HYGIENE

VOLUME II

OCCUPATIONAL MEDICINE
INDUSTRIAL HYGIENE
OCCUPATIONAL DISEASES

EDITED BY
Prof. Dr. Dimitar Tsvetkov, DSci

2019
HYGIENE
VOLUME II

OCCUPATIONAL MEDICINE
INDUSTRIAL HYGIENE
OCCUPATIONAL DISEASES

© Prof. Dr. Dimitar Tsvetkov, MD

© FLAT Ltd.

ISBN
 LABOUR MEDICINE

PROF. DR. DIMITAR TSVETKOV, MD

EDITOR

Prof. Dr. Dimitar Tsvetkov, MD graduated in medicine in 1961 from 1990 to 1999 was head of
the Department of hygiene, ecology and professional MF diseases Sofia. MD happened in 1972
and Doctor of Medical Sciences in 1991. He was a deputy. dean and vice. Rector of the Medical
University Sofia member of the Academic Board and a member of the senior educational council of
Education, Director National Center of Hygiene.
His research interests are in the field of occupational medicine, in particular Physical work en-
vironment factors. Developing methodology for research risk role of physical stressors on cardio-
vascular diseases and dyslipidemia. There are numerous studies on working conditions and health
of workers in mining, ferrous and nonferrous metallurgy, production of building materials, etc.; in
the field of communal hygiene, nutrition, occupational toxicology, hygiene of children and adoles-
cents, ergonomics.
Prof. Tsvetkov is a member of the leadership of the Scientific Society of hygiene Bulgaria, Bulgar-
ian National Academy of Medicine, a member of New York Academy of Sciences, Polish Society of
Hygiene, the leadership of Atlanto Euro Mediterranean Academy of Medical Sciences and Bulgarian
Lipid league. Editor and member of the editorial boards of numerous scientific journals at home
and abroad.
Author of over 190 scientific publications. He has participated in writing and edition of 5 text-
books, 3 manuals on hygiene and occupational diseases, one monograph.

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 OCCUPATIONAL MEDICINE
Prof. Evgeniya Hygiene, ecology and Prof. Diseases” of Prof. Dr. Zlat-
G. Dincheva, DSci, MF - Sofia. There are over 135 scientific ka Stoyneva, PhD,
in 1961, graduated publications and reports in the field of er- graduated in 1979 at
in Medicine at the gonomics, hygiene and safety. He has au- the Medical Acade-
Medical Institute in thored over 15 scientific and popular bro- my, Sofia. From 1980-
Sofia. Since 1969 she chures, 2 educational film on ergonomics 1983 she is a regular
is a research fellow, postgraduate at the
and hygiene, co-author in the manual of
since 1982 - Assoc. Clinic of Occupa-
Hygiene and Professional Diseases.
Prof. Since 1985 she tional Diseases - MA,
has been a Prof. in Sofia. Since 1983 she has been a PhD III-I
Chief Assist. Dr.
the Department of Physiology at the NCH- degree assistant, chief assistant at the Clin-
Ftyana Y. Kalburova
MEN. She has been PhD since 1969 and ic of Occupational Diseases. He has been
graduated from high-
since 1984 has been a Doctor of Medical Head of the Clinical Neurovegetology Lab-
er education in 1971
Sciences. From 1989 to 1992 she was the oratory since 1996. Associate Professor -
at the Higher Institute
director of the NCMEN. Member of BNAM, 2005. Specialist in Neurology and Occupa-
of Mathematics - Plo-
IBRO, Scientific Society of Hygiene. He is a tional Diseases. She has been a PhD since
vdiv. Since 1974 she
specialist in the field of occupational med- 1983. Professor - 2016. She has specialized
has been an assistant
icine and more closely in the field of phys- in Russia, Sweden, Japan. Her scientific
in the Department of
iology and psychophysiology of labour. interests are in the field of professional
Hygiene at the Higher
More than 150 scientific papers, papers on pathology and neurology, working on vi-
Medical Institute - Sofia. In 1978-1985, she
occupational medicine and monographs brational disease, occupational pathology
was a research associate at the Joint Aero-
in physiology and psychophysiology of la- of overintension and microtraumatism of
medical Institute at the Military Medical
bour have been published. the nervous and musculoskeletal system,
Academy. Since 1985 she has been a gen-
diagnostics of autonomic neurovascular,
eral assistant in the Department of Hygiene
Ass. Prof. Bistra thermoregulatory, sudomotor, microcir-
at the Sofia Medical University. She has a
M. Tsenova, PhD, culative and trophic disorders in acrial
specialty in occupational hygiene - 1982
graduated from the syndromes and diseases. Its main scientific
and occupational diseases - 1993. Scientific
Humboldt Universi- contributions are in the field of neurovege-
interests are in the field of physical factors
ty in Berlin in 1976. tology and microcirculation. She is the au-
of the working environment - noise, vibra-
She defended her thor of more than 100 scientific publica-
tions, electromagnetic fields, microclimate.
doctorate in psychol- tions, monographs, textbooks and guides
She has over 70 scientific works, rational-
ogy at St. Petersburg on occupational diseases and neurology.
izations, and participations in manuals and
State University in
monographs on Hygiene and Occupational
1982. She received a Assoc. Prof. Nestor Mitrev, PhD,
Medicine.
degree in Medical Psychology and Peda- graduated from the
gogical Rehabilitation. She has specialized Higher Institute of
psychosocial factors and stress resistance, Prof. Dr. Bozhi- Medicine - Plovdiv in
psychotoxicology, modern epidemiology dar Stefanov DSci. 1961. Since 1969, he
and health promotion (Germany, Russia, graduated in medi- has been an assistant
Finland). For more than 20 years she has cine at the Medical professor, since 1984
worked as a research fellow at the Nation- University Donetsk an associate profes-
al Center for Hygiene, Medical Ecology and - Ukraine in 1970. sor at the Depart-
Nutrition. It deals with the psychological as- Two years later he ment of Hygiene at
pects of the analysis and evaluation of work completed disser- the Higher Institute
activities (content and conditions) and their tation - PhD. He has of Medicine - Plovdiv. Since 1988 he has
consequences for health, personal devel- worked in HEI Varna and at the Medical been head of the same department. PhD
opment and organizations. She has partic- University of Varna as an assistant. Since (1979). Co-author of many practical man-
ipated in international projects - research 1977 he is Associate Professor and Head uals and hygiene textbooks for medical
on the motivation for achievement and of Department “Hygiene, Medical Ecol- and dental practitioners, author of three
neurobehavioural effects of lead in children monographs, two inventions and one ra-
ogy and Occupational diseases” at the
(WHO). There are over 120 publications and tionalization. His scientific interests are in
Medical University - Pleven. Since 1984, the field of occupational medicine - mainly
reports to international and national scien-
tific forums in the fields of work psychology, Doctor of Medical Sciences and Profes- the impact of noise and vibration.
stress, psychotoxicology, individual differ- sor. During the period 1980-1987, and
ences, and more. the 1989-1991, he was vice Rector of the Prof. Dr. Dimitar
Medical University - Pleven. Since 2001 he G. Dimitrov, DSci,
Assoc. Prof. is Chairman of the General meeting of the graduated in med-
Zachary K. Ivanov, Medical University - Pleven. There are spe- icine in 1961 at the
PhD, graduated in cialties of general hygiene occupational, Higher Medical Insti-
medicine in MU - So- hygiene and communal hygiene. Since tute - Sofia. Aviation
fia and then a doc- 1988 a member of the Global Environ- doctor from 1962 to
mental Epidemiology Network (GEENET). 1965. Since 1966 he
torate in NIHPZ in
He published over 200 scientific papers in has been a research
1967 PhD from 1968.
the field of hygiene, ergonomics, medi- associate at the Joint
Worked as a Assis- Aeromedical Research Institute - Sofia. It
tant and Ass. Prof. in cal ecology and medical informatics, 10
passes through all the scientific degrees
Scientific Institute of labour and Institute brochures and monographs, including.
(PhD and DSci) and titles. There are over
of economy and organization of engi- “Glossary of Hygiene”, “Radio waves and 330 scientific publications, 5 monographs,
neering (where is chief of the “Ergonom- magnetic fields (hygienic aspects).” a significant part of which are printed and
ics and physiology of labour”) until 1990. popularized in other countries. His main
Since 1990 Ass. Prof. in the department“

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scientific interests are in the field of phys- of pesticides and the toxicology of heavy of work environment factors, screening to
iology of dynamic flight factors, brain cir- metals and nitrites. He authored over 170 detect early abnormalities in the worker's
culation in extreme situations, the role of scientific publications in the fields of hy- liver status. Her scientific output covers
human factor in the origin of aviation ca- giene, ecology and toxicology. Co-wrote more than 140 publications, monographs,
tastrophes and accidents. 10 monographs and textbooks on hygiene scientific conferences, and symposia.
and occupational diseases.
Chief Assist. Dr. Prof. Emil
Adriana Iv. Agovs-
Vodenicharov, PhD,
ka, PhD graduated
Prof. Dr. Mar- graduated in medi-
from higher medical
education in 1989 at garita Koleva, DSci., cine at the Institute
the Medical Faculty graduated in med- of Medicine - Sofia
in Sofia. From 1989 to icine in 1970 at the in 1980. He is a grad-
1991 he was a doctor Higher Medical Insti- uate of the Depart-
at HEI - Vratsa. Since tute - Kharkiv. Since ment of Hygiene,
1991, she has been 1976 is assistant in Ecology and Occu-
an assistant at the Department of Hygiene, the Department pational Diseases, Medical University, So-
Ecology and Occupational Diseases at the of Hygiene - Sofia. fia since 1981, since 1984 is an assistant
Sofia Medical University. Her scientific in- Since 1990 - Associate Professor, 2006 since 1989 - Chief Assistant in the Depart-
terests are in the field of psychophysiology - Professor PhD from 1976; DSci - 2004 ment, since 2004 - Associate Professor,
and school medicine - nutrition of children Member of Medichem (Occupational and and since 2008 - Head of the Department.
and socially significant diseases, problems Environmental Health in the Chemical In- Professor -2013.
of training of chronically ill students, as- dustry), EAA (European Anthropological Since 1984, he has been PhD. In 1996-
sessment of working capacity and stress in
Association), EASO (European Association 1997 he specialized in France. There are
different age and professional groups, etc.
for the Study of Obesity), BASORD (Bul- two recognized rations in the field of ex-
Since 2000 she has been a PhD. More than
50 scientific and research papers have been garian Association for the Study of Obe- perimental medicine.
published in Bulgaria and abroad. sity and Related Diseases), member of the His scientific interests and publica-
leadership of the Bulgarian lipid league, tions are in various areas of hygiene, but
Chief Assist. Dr. Bulgarian Society for Hygiene, Vice Ch. mostly in occupational medicine, exper-
Sabina S. Sabeva, editor of the magazine. “Hygiene and imental medicine, and the impact of the
PhD, graduated from Public Health”. dust factor in the work environment.
the Medical Acade- Her scientific works are mainly in field More than 100 scientific papers and con-
my in Sofia in 1982. of toxicology, occupational medicine and tributions to monographs and textbooks
She started her pro- professional diseases, the assessment of have been published and reported.
fessional career as a working conditions and health risk, an-
pediatrician in Sliven. thropological characteristic and obesity Ass. Prof. Maya
From 1989 to 2002 in workers, toxicological assessment of Lyapin, PhD gradu-
she is an assistant
heavy metals, pharmaceuticals, pesti- ated in medicine at
- chief and senior at the Department of
cides and organic solvents. the Higher Medical
Hygiene, Ecology and Prof. Diseases at the
Medical Faculty - Sofia. He has been a PhD She has authored more than 130 Institute - Sofia in
since 1999. She holds a Master's degree in scientific publications in Bulgaria and 1989. Since 1996 she
Public Health from Geneva University in abroad, co-author of monographs, text- has been an assistant
2002. She has over 40 scientific publica- books and manuals. at the Department
tions and reports in Bulgarian and foreign of Hygiene, Ecology
scientific journals and congresses. Ass. Prof. Anna and Occupational Diseases, Medical Uni-
K. Mihailova, PhD, versity, Sofia. In 2015 PhD. In 2017 Ass.
Ass. Prof. Den- graduated from the Prof. She has specialized in Sweden - Car-
cho Tsonevski, DSci. Higher Medical In- oline Institute and Belgium. Her scientific
He graduated in stitute, Sofia. Since interests and publications are in the study
medicine in 1961 at 1975 he has been a of the effects of physical and chemical
the Medical Universi- research associate at factors on the working environment on
ty - Plovdiv. PhD hap- the National Center neutrophil function and activation, im-
pened in 1974. From of Hygiene, Depart- munology and immunotoxicology. She
1979 he was Ass. ment of Production Toxicology, PhD since has specializations in occupational med-
professor and Head 1975, Associate Professor - 1993. She is icine and clinical immunology.
of the Department a member of NS in Hygiene the Union
of Hygiene and Occupational Diseases of Scientists, MEDICHEM, the Society of Prof. Rachamin
at the Medical University - Varna (branch Pharmacology and Toxicology. Works Shekerdjiyski, DSci,
- Dobrich). From 1985 to 1990 he was Di- in the field of: experimental toxicology: graduated from the
rector of the “Prevention and State Sani- study of the toxic effects of chemicals, Pharmaceutical Fac-
tary Control” at the Ministry of Health, and pesticides, biopreparations and drugs on ulty at the Medical
from 1990 he is Associate Professor at the critical organs and systems, on different Institute Sofia in
Department of Hygiene, Ecology and Prof. routes of administration and modes (mo- 1956. Since 1973 he
Diseases - Sofia. Doctor of medical sciences notonous and intermittent), isolated or in has been an Assis-
- 1996. In 1997 he was elected an extraordi- combination, toxicokinetics, action and tant at the Depart-
nary professor at the University of Ruse. His cumulation and adaptation processes; ment of Technology
research is related to the combined effects risk assessment for workers in the impact of Pharmaceuticals at the Faculty of Phar-

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 OCCUPATIONAL MEDICINE
macy. PhD - 1972. DSci - 1990. Habilitated Assoc. Prof. An- 1978 he has been head of the Depart-
in 1980. Professor - 1992. Head of Depart- toaneta MANOLO- ment of Sanitary and Technical Expertise
ment of Industrial Pharmacy - 1992 - 2002. VA, PhD, graduated at NCHMEN - Sofia. In 1984 he acquired
Dean of Pharmaceutical FacultyAuthor of in medicine at the a specialty "Sanitary Engineer". Special-
over 150 scientific publications, 2 text- Higher Medical Insti- ized in the World Health Organization
books and 2 monographs in the field of tute in Sofia in 1977. in France, Belgium, Italy in 1971-73. He
formulation and testing of pharmaceuti- In 1978-82 she was a passed an Environmental Assessment
cal forms. Member of the European Asso- regular post-gradu- Course organized by the US Environmen-
ciation of Faculties of Pharmacy. ate student in Mos- tal Protection Agency in 1993. His depart-
cow, where she defended a PhD thesis in ment carried out at national level expert
Ivan N. Denev 1982. Since 1982 she has been a research activity in the preliminary sanitary control
graduated from the associate in the child health direction at of the hygienic requirements and rules in
Faculty of Pharma- NCHMEN. Ass. Prof. at 2008. Specializes the project documentation. Eng. Nikolov
cy of the Medical in the issues of maternal and child health participated in the preparation of envi-
University - Sofia in care in France and healthcare marketing ronmental and health assessments in the
2003. He participat- in Switzerland. Its research activity is re- development of hygiene standards. He is
ed in national and lated to the assessment of the health, a representative of the Ministry of Health
international stu- environmental and social risks in children in expert councils of ministries and de-
dent scientific con- and adolescents and the development partments, participates in the training of
ferences. Since 2004, he has been doing of strategies and programs for risk man- NCHMEN in the training and postgradu-
research work in a Bulgarian company agement and prevention. She is involved ate qualification of medical and technical
(Natstim) for the production of antioxi- in developing legislation on child health specialists from the preliminary sanitary
dant and immunostimulating food sup- issues, vocational training and adolescent control.
plements. orientation in various areas of work.
Assoc. Prof. Dr.
Assoc. Prof. Prof. Mira Tz- Nedyalka Kole-
Tsanka Voditsche- ve t kov a - A r s ov a , va Stamova, PhD,
va, DSci, graduat- DSci, graduated graduated from the
ed in medicine in from Sofia University Medical Institute in
1963 at the Kharkov "St. Kliment Ohrid- Sofia in 1963. PhD
Medical Institute - ski "specialty" Spe- since 1969. In 1986
Ukraine. Since 1973 cial Pedagogy "in she became an As-
she has been a se- 1989. Since 1990 sociate Professor at
nior and chief assis- she has been a reg- the Department of Hygiene - MU - Sofia.
tant in the Department of Hygiene - Sofia. ular post-graduate student at the Sofia The main and scientific interests are in the
Since 1988 she has been a senior research University and since 1991 an assistant field of occupational medicine. She is the
associate. She was a PhD in 1970 and a of pedagogy for the visually impaired author of more than 100 scientific papers,
Doctor of Medical Sciences in 1997. Ass. at the Department of Special Pedagogy co-author and editor of three textbooks,
Prof. in 1992. Her scientific work is in the of the Faculty of Primary and Pre-school four guides, one monograph.
field of community hygiene and in partic- Pedagogy of Sofia University. Chief assis-
ular on the problems of hygiene normal- tant since 1997, associate professor since Chief Assist. Nina Gincheva, PhD,
ization, atherogenic and co-toxic effect of 2006 PhD since 1998, DSci - 2014. Profes- graduated from the
chemical components of drinking water; sor -2016. She has specialized in Boston Higher Institute of
environmental pollution with heavy met- College and the Perkins Blind School in Medicine - Sofia in
als and research on the transport status Boston, USA, and at institutes for visual- 1966. In 1967-1968,
of the population in industrial areas; hy- ly disabled with additional disabilities in Head of Department
gienic assessment and normalization of Finland. She is the author of more than of Labour Hygiene at
microclimate in hospital rooms and living 120 publications in Bulgarian and foreign HEI - Sofia, branch of
quarters; epidemiological studies and specialized publications and six indepen- Blagoevgrad. Since
development of a concept of the impor- dent textbooks on orientation and mobil- 1968, she has been
tance of chemical composition of drink- ity for the blind and on the education of assigned to a regular postgraduate at
ing water for the spread of cardiovascular visually impaired with multiple disabili- Laboratory of Industrial Toxicology in the
diseases in Bulgaria. There are also studies ties and a monograph. She has participat- Department of labour Hygiene at the In-
in the field of occupational hygiene, child ed in a number of international projects stitute of Hygiene of Labour and Prof. Dis-
health and prevemtive nutrition. She is with partners from USA, Germany, Great eases at the Academy of Medical science
the author of over 200 scientific publi- Britain and others. - USSR. PhD - 1972 In the same year she
cations, co-author of monograph, three was appointed as a research fellow at the
textbooks and 6 hygiene tutorials. Eng. Kalcho Ni- National Center of Hygiene, Section "Pro-
kolov graduated in duction Toxicology". Since 1978 he has
1963 at MEI Sofia. been Ch. assistant at the Department of
From 1967 to 1972 Hygiene at the Higher Medical Institute -
he worked as an ex- Sofia. She has a specialty in occupational
pert at the Research medicine. Its main scientific interests are
Institute of Hygiene in the field of occupational medicine -
at the Ministry of production and experimental toxicology
Health Sofia. Since and labour hygiene in industries of vari-

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 LABOUR MEDICINE
ous branches. Her occupational hygiene Ass. Prof. Ves- ities of the Nervous and Musculoskeletal
and epidemiological studies are mainly selin Bliznakov, System at the CPD - Sofia. Her scientific
in the chemical and petrochemical in- PhD, graduated interests are in the field of occupational
dustries - organic synthesis, polymers, in medicine at the nerve diseases and vibrational disease.
synthetic fibers, etc. There are over 90 Higher Medical In- She is the author of more than 100 sci-
publications and reports in Bulgaria and stitute - Sofia in entific publications and scientific reports.
abroad. Co-authored in 2 manuals and 2 1969. Since 1975 She participated in the writing of 3 text-
hygiene textbooks. he working at the books and guides on occupational diseas-
National Center for es and 1 independent monograph.
Dr. Ivan N. Radiobiology and Radiation Protection,
Paunov, PhD, grad- Head of the Department of Medical Ra- Ass. Prof. Dr.
uated in medicine diological Protection and Epidemiology Anton St. Savov,
in 1976 at the Medi- at the NCRRP. He has specialized in Russia, PhD, graduated in
cal Institute in Sofia. Austria, France and the Czech Republic. medicine in 1968
From 1979 to 1994 PhD since 1981, Associate Professor since at the Higher Medi-
he was a research 1986. He has over 100 scientific publica- cal Institute - Varna.
associate at the tions in the field of radiation medicine Since 1976 he has
Transport Medical and protection, nuclear energy, uranium been assistant in the
Institute - Sofia. Doctor of Medicine since mining, radiation carcinogenesis and epi- Clinic of Occupa-
1990. From 1994 to 1998 he was Director demiology, health monitoring, etc. Chair- tional Diseases at the Center of Hygiene
of Transport HEI. Occupational Hygiene man of the Bulgarian Nuclear Society and - Department of Occupational ORL Dis-
Specialty since 1980. There are about 80 the Bulgarian Scientific Society for Radio- eases and Otoneurology. PhD since 1979.
scientific publications in Bulgaria and biology and Radiation Protection. He is Since 1992 he has been Head of the Clinic
abroad in the field of transport hygiene, a member of the Managing Board of the of Occupational ORL Diseases and Oto-
impact of noise, vibrations and infra- European Nuclear Society and the Man- neurology at the University Hospital "St.
sound on transport drivers. agement Board of the Bulgarian Atomic Ivan Rilski "- Sofia, and since 2000 he has
Forum. been head of the Center for Occupation-
Ass. Prof. Lil- al Diseases at the Medical Faculty - Sofia.
anda T. Elenkova, Chief Assist. His scientific work is mainly in the field of
PhD, graduated Latinka G. Nako- clinical, diagnostic, expertise, prophylaxis
from the Faculty of va graduated from and rehabilitation of occupational and
Law at the Sofia Uni- Medical Universi- para-professional diseases of the upper
versity in 1977. She ty in Sofia in 1972. respiratory tract and ears. He has written
defends her PhD in Since 1975 she has more than 120 scientific publications,
1986. Ass. Prof. in been an assistant at participations in monographs, textbooks,
1991. She special- the Clinic of Occu- and guides in the field of professional pa-
ized in economic management in 1992. pational Diseases at thology.
Chief Legal Advisor of the University hos- the Department of Hygiene and Occu-
pital "Ivan Rilski ". She has participated in pational Diseases at MA Sofia. There are Prof. Elisave-
the development of laws and regulations two clinical specialties - neurology and ta Petrova, DSci,
in the field of health and social security. occupational diseases. Her scientific inter- graduated from the
ests are focused on the problem of neu- Medical University in
Prof. Nevena ro-vegetative reactivity and specialized Sofia in 1973. Since
Tsacheva - Hristo- sensitivity in electromagnetic influences 1980 she has been
va, PhD, graduate of the working environment. In this field senior assistant as-
in medicine at the and other problems of professional neu- sistant and Ass. Pro-
Higher Medical Insti- rology she has over 50 publications in fessor at the Clinic
tute - Sofia in 1976. Bulgaria and abroad. She has specialized of Pulmonary Occupational Diseases at
Since 1978 she has in France - Paris. the National Center of Hygiene and oc-
been an assistant in cupational diseases. Head of the Clinic of
Medical Institute - Ass. Prof. Ve- Occupational Diseases at the University
Pleven, Department of Social Medicine. neta Kostova, PhD, Hospital "St. Ivan Rilski" at 1997. She has
Since 1983 she has been a research fel- graduated from written over 130 scientific publications
low at the Institute of Hygiene and Oc- Medical University in in Bulgaria and abroad, 3 independent
cupational Diseases. PhD since 1987, Ass. 1971. Since 1974 she monographs and over 70 papers at scien-
Professor since 1991. Professor in 2008 at has been a regular tific congresses, conferences and sympo-
the Faculty of Public Health at the Medical post-graduate at the sia. She is a specialist in "pneumology and
University - Sofia. Since 1994 he has been Clinic of Occupation- phthisiatry" and "occupational diseases".
Head of the department "Organization of al Diseases - Sofia. PhD in medicine since 1988, DSci - 2005,
the Scientific, Educational and Method- In 1980 he defended his doctorate on professor - since 2007. She has taken part
ological Activities" of the NCHMEN and "Some Changes in the Hypothalamus-Pi- in qualification courses in Poland, USA
since 2000 has been the Head of the Na- tuitary-Adrenal Cortex System in Patients and Bulgaria. Member is the Scientific So-
tional Register of Professional Morbidity. with Vibrational Disease". Since 1981 she ciety for Lung Diseases and the Hygiene
is a research associate, since 1998 - Ass. Society.
Prof. and Head of the Department of Gen-
eral Neurology and Occupational Disabil-

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 OCCUPATIONAL MEDICINE
Prof. Dr. Todor Chief Assist. monograph on occupational diseases.
Burilov, DSci. He Dr. Daniela G.
graduated in med- Medzhieeva, PhD Prof. Ivan
icine at the Higher graduated in medi- Dikov, DSci, gradu-
Medical Institute - cine at the Medical ated from the High-
Sofia, in 1951. From Faculty in Sofia in er Medical Institute
1965 to 1989 he 1986. Since 1988, - Sofia in 1956. Since
worked as a research she has worked as a 1968 he has been
associate - professor research associate at working in the de-
in the Clinic of Occupational Diseases at the Department with Clinic of Occupa- partment of Inf. dis-
the Hygiene Center. PhD (1961) and Doc- tional Diseases at the Scientific Center of eases, epidemiology
tor of Medical Sciences (1983). Works in Hygiene in the Clinic of Occupational ORL and parasitology as an assistant, associate
the field of occupational pulmonary dis- Diseases. PhD -2002. She is a member of professor and professor. Doctor of med-
eases, silicosis, silicotuberculosis, asbes- the European and Bulgarian Society of ical sciences since 1985. Specialized in
tosis, exogenous allergic alveolitis and Otorhinolaryngology and the Headache Lyon and Paris. Honorary Assistant of the
granulomatosis. Specialized in Germany Society. There are publications and re- Faculty of Medicine in Lyon. Many years
and Poland. Author and co-author of six ports in Bulgarian and foreign magazines lecturer, and researcher in infectious dis-
monographs in the field of pulmonary and congresses in the field of professional eases. There are over 180 scientific pub-
pathology. There are over 200 scientific ORL and otoneurological diseases. lications, 10 monographs and three text-
publications in Bulgaria and abroad. For- books.
eign member of the German Society of Prof. Dr. Venc-
Ecology. Awarded by the French Medical eslav Hr. Bosnev, Assoc. Prof.
Academy. DSci He graduated Dr. Violina Boe-
from Medical Uni- va-Bangyozova,
Chief Assist. Dr. versity in 1952. Since PhD, graduated
Krasimira Dinko- 1960 he has been from Higher Medical
va, PhD, graduate working in the field Institute "I. P. Pavlov
in medicine at the of neurology - neu- "- Plovdiv in 1965.
Higher Medical Insti- rovegetology, neural Since 1972 she has
tute - Sofia in 1974. therapy, diseases of been a research as-
Since 1977 she has kinematic hand-arm chain. He created a sociate in medical parasitology at NCIPD.
been a post-gradu- Laboratory of Clinical Neurovegetology From 1991 to 2003 she was head of the
ate of occupational at the First Neurological Clinic at the Alex- Parasitology Department at the Depart-
diseases at CPD in NCHMEN. Since 1980 androvska Hospital and later at the Neu- ment of Infectious Diseases, Epidemiolo-
she has been an assistant in clinic of rology Clinic at the University Hospital "St. gy, Parasitology and Tropical Medicine at
occupational lung diseases. PhD since Ivan Rilski ". He was the head of the Clinic the Sofia Medical Faculty. PhD since 1979,
1987. Since 1996 he has been head of a of Occupational Diseases at the Medical senior research associate since 1988. She
intensive care department in COPD at Institute in Sofia and a national consul- has more than 130 scientific publications,
"St. Ivan Rilski" hospital. She has more tant on occupational diseases. He is the 4 monographs and 6 textbooks in the
than 60 publications in Bulgaria and in- author of 240 scientific papers, including field of clinical parasitology. She has spe-
ternational congresses, mainly related to 4 monographs and 20 collective mono- cialized in Moscow, Athens, Hanoi.
occupational diseases of the respiratory graphs. President of the Atlantic-Eu-
system. Co-author of textbooks, guides ro-Mediterranean Academy of Medical Ass. Prof. Dr.
and monographs on hygiene and occu- Sciences, member of American, Europe- Maria Demirova,
pational diseases. an, Bulgarian scientific societies and ed- PhD, graduated from
itorial colleges. Specialist in neurology, Medical University in
Ass. Prof. Dr. occupational diseases, neurovegetology. 1967. Since 1968 she
Lilyana Dimitrova, has been working as
MD, graduate from Chief Assist. Dr. a research associate
the Medical Institute Gergina Oncheva, at the Clinic of Oc-
in Varna in 1974. She PhD, graduated in cupational Diseases
was a 1974 train- medicine in 1982 at at the National Institute of Hygiene and
ee-assistant of oc- the Medical Faculty Professional Diseases in Sofia. PhD since
cupational diseases - Sofia. She has been 1977, Ass. Prof. in occupational diseases
and a regular assis- working as a special- since 1985. Since 1990 he has been the
tant at the Clinic of Occupational Diseas- ist researcher at the head of a clinic for occupational pulmo-
es MU - Varna since 1977. PhD since 1984. Electrophysiology nary diseases, since 1996 - of the Center
Since 1988 she has been Head of the Laboratory at the for Occupational Diseases at the Medical
Clinic of Occupational Diseases at Medi- Institute of Brain Research at the Bulgar- Faculty - Sofia. Republican Consultant at
cal University - Varna. Her main research ian Academy of Sciences and since 1988 the MH, for prof. pathology in 1995.
work is on the problems of heavy metal has been a post-graduate student at the
intoxication and occupational pulmonary Neurological Clinic of the Department for
and allergic diseases. Occupational Diseases in Sofia. PhD and
Chief Assistant at the Neurological Clinic
since 1991. She is the author of more than
40 scientific papers and a co-author in the

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 LABOUR MEDICINE
Prof. Dr. Vanko Prof. Dr. Todor University - Sofia. PhD - 1984, Ass. Profes-
Nichev, DSci. grad- Meshkov, DSci. sor and Head of Internal Medicine Clinic
uated from medicine Born in 1935, he at the Transport Medical Institute since
at the Higher Med- graduated in Sofia 1992. Scientific interests and publications
ical Institute - Sofia in 1960. Since 1963, - over 100 are in the field of internal dis-
in 1953. Since 1959 after a competition, eases, professional pathology and trans-
he has been an assis- he has been a re- port medicine.
tant at the Institute search fellow at the
of Pulmonary Diseas- National Center of Prof. Mois Nis-
es - Sofia. PhD of 1972, Doctor of Medical Hematology and Transfusiology (III, II and sim Melamed, DSci.
Sciences-1987. Associate Professor-1975, I degree). In 1980 he was habilitated as He graduated from
Professor-1988. Since 1984, he has been Sen. res II deg., and in 1988 as Sen. res. I Medical University -
Head of the Clinic of Pneumophthisiatry degree. He was elected Professor of He- Sofia in 1954. In 1961
and, Director of the Institute of Pulmo- matology in 1991. Director of the Nation- he became an inter-
nary Diseases - Sofia, since 1994 is the Di- al Center of Hematology and Transfusion nal at the ORL clinic
rector of the Pneumophthisiatric Hospital (1989-1997). He defended Ph.D. in 1976 of Medical Universi-
- Sofia. National consultant of the Ministry and Doctor of Medical Sciences in 1988. ty - Sofia. Since 1968
of Health in pneumology and phthisiatry. He is the author of the Atlas of Hematolo- he has been a research associate at the
Author and co-author of over 200 scien- gy, 5 monographs and over 100 scientific Institute of Oncology. Selected for Assoc.
tific publications, monographs, textbooks papers on haematological cytology, bone Prof. and Professor of Otorhinolaryngolo-
and guides in the field of pulmonary pa- marrow regeneration, preleukemic con- gy and Oncology. Doctor of Medicine and
thology. ditions (myelodysplasia ), problems with Doctor of Medical Sciences. He has more
leukemias and lymphomas, membrane than 160 publications in Bulgaria and
changes in drug resistance. He has spe- abroad. He participated in 8 monographs.
Dr. Daniela Ni- cialized in Germany, Poland, Russia and Member of the Scientific Society of Oncol-
kolova-Baltadzhie- the United States. Member of Bulgarian ogy and Otorhinolaryngology.
va, PhD, graduated and foreign scientific societies.
in Medicine at the Dr. Hristo
Medical Academy in Prof. Dr. Dimi- Damyanov, PhD,
Sofia in 1982. From tar Todorov, DSci graduated in 1974
1986-1991 she was He graduated from at the Higher Med-
a researcher at the Higher Medical Ed- ical Institute - Sofia.
Laboratory of Aller- ucation in Sofia in Since 1980 he has
gies at the NCIPD Medical Academy. PhD 1962. Since 1972 he been working in a
since 1997. Since 1999 he has been work- has been working at urological ward at
ing at the Central Laboratory of Clinical the National Oncolo- the Military Hos-
Immunology at the University Hospital gy Center as founder pital - Sliven. From 1984-1993 he leads
"Alexandrovska". Specialized Immunolo- and head of Lab. for oncopharmacology. a urological department in the Military
gy and Allergology in Belgium, USA and PhD since 1970, Doctor of Medical Scienc- Academy - Sofia. Since 1994, he has been
Portugal. es - 1986, Professor - 1987. Specialized in chairing a urological department at the
England (London, Solsburne) and Germa- National Cancer Center. PhD - 1998 Mem-
Chief Assist. ny (Heidelberg). He was Deputy Director ber of the National Society of Urology
Dr. Yuri Simeonov and director of the NOC. His baseline - Bulgaria, World and European Urology
graduated in medi- studies - over 200 scientific publications, Associations, Balkan Cancer Association.
cine at the Medical are in the field of pharmacology and tox- Scientific studies in the field of urooncol-
Faculty in Sofia in icology of antitumor agents, liposomal ogy - kidney and bladder tumors, prostate
1983. Since 1986 he carriers, molecular mechanisms of ac- cancer, immunotherapy, endourology.
has been an assis- tion, combined drug therapy (including
tant, and since 1996 molecular biotherapy), pharmacological Prof. Dr. Petar
has been a Chief as- approaches to overcoming multiple drug Mihaylov, PhD,
sistant at the Department of Propedeutics resistance (MDR) of tumors. He was chair- graduated from the
of Internal Diseases at the Medical Univer- man of the Bulgarian Oncology Society, Medical Faculty of
sity - Sofia. He has clinical specialties in member of the American and European the Sofia University
internal and lung diseases. His scientific Cancer Association, editor-in-chief of Bul- in 1945. Scientific
interests and publications are in the field garian Oncology Magazines. associate at the Insti-
of diagnostics and therapy of bronchial tute of Dermatology
asthma and atypical pneumonia. Member Ass. Prof. Dr. and Venereology,
of the Scientific Society of Pneumology Ekaterina Stoino- 1951; PhD - 1960; Associate Professor -
and Phthysiatry. va, PhD, graduated 1963; Senior Research Associate - 1973;
in medicine in 1969 Professor - 1975 Specialized in Hungary,
at the Higher Med- Russia, Germany, Switzerland. In 1975-
ical Institute - Sofia. 1985 he was Head of the Department of
Since 1980 she has Skin and Venereal Diseases and Director
worked as assistant of the Scientific Institute of Dermatology
- ch. assistant at the and Venereology at the Medical Acad-
Clinic of Occupational Diseases at Medical emy - Sofia. Prof. Mihailov has been a

9
 OCCUPATIONAL MEDICINE
long-standing national consultant in der- sciences - 1992. Her research activities versity - Sofia. She has over 120 scientific
matology and venereology. His scientific cover over 100 publications (scientific publications in our and foreign journals,
interests are in the field of allergy and pro- works, monographs, textbooks and man- participations in collective monographs,
fessional dermatoses, medical cosmetics, uals), in the field of professional obstetric- textbooks of hygiene and occupational
climatic treatment, sexually transmitted gynecological pathology mainly on the diseases, participation in international
diseases. He has published more than damaging effect of chemical and physical scientific projects. She has specialized in
350 scientific papers - messages, mono- factors on genitals and female reproduc- Russia, Ukraine, Poland, USA. She was a
graphs, textbooks and guides. He is the tion. WHO expert on professional pathology.
author of the first monograph in Bulgar-
ia "Professional Skin Diseases". President Dr. Ivan Dorothea Tsvet-
of the Bulgarian Dermatological Society, Grozdev, PhD, kova graduated in
honorary member of the societies of graduated from the Biology - Gene and
France, Austria, Germany, Poland, Israel Faculty of Dentistry Cell Engineering at
and others. in Sofia in 1951. He Sofia University "St.
works for 25 years as Kliment Ohridski "in
Chief Assist. Dr. Head of Professional 2000. Since 2001 he
Dilyana Nyagolova Dentistry at the Clin- has been working
- Smilova graduated ic of Occupational in the Department
from Medical Univer- Diseases of the Medical Academy in Sofia. of Structural Biology at Memorial Sloam
sity in Sofia. For more PhD - 1971. He has over 50 scientific pub- Kettering Cancer Center, New York. There
than 30 years she lications and reports of international and have been developments and publica-
has worked in the national congresses in the field of occu- tions in the art of elucidating the struc-
Department of Der- pational dental diseases. ture of receptor proteins involved in tu-
matology and Vene- mor angiogenesis and testing of active
reology as an assistant, senior assistant, Dr. Kornelia Ko- macromolecules to inhibit tumor growth.
chief assistant. Author of more than 50 tseva, PhD, graduat-
scientific articles, guides and textbooks ed from the Higher Ass. Prof. Ivan-
in the field of dermatology and venereol- Medical Institute ka Kirova, PhD,
ogy. There are studies mainly in the field in 1977 - Sofia. She graduated from
of sexually transmitted diseases - their works as a Chief as- Higher Medical In-
clinical course, diagnosis, treatment and sistant in the clinic stitute-Sofia, in 1961.
prophylaxis, social significance. of occupational dis- Since 1991 she is
eases of the National Ass. Professor at the
Chief Assist. Hygiene Center - Sofia. PhD since 1984, Department of Phys-
Dr. Reni Toncheva since 2003 is a senior researcher in the iotherapy and Re-
graduated from the Department of Cardiovascular Medicine habilitation at Medical University - Sofia.
Medical University - of the National Heart and Pulmonary In- Specialized Physical Medicine in Poland.
Sofia in 1982. Since stitute, London. She has developed over Author of more than 100 scientific papers,
1988, she has been 70 scientific papers, co-authored in 7 10 monographs and textbooks. He works
an assistant, senior monographs on risk factors, epidemiolo- in the field of treatment and prophylaxis
assistant and chief gy, professional dependens, primary and with natural physical factors, reflexology
assistant at the Clinic secondary prophylaxis, clinical trials of (especially acupressure), physical therapy
of Occupational Dis- new drugs for cardiovascular diseases. of occupational and internal diseases.
eases at the Department of Hygiene and Member of national and international
Occupational Diseases. She has partici- scientific societies of cardiology and oc- Ass. Prof. Mar-
pated in over 250 scientific publications cupational medicine. garita Neykova,
and reports in Bulgaria and abroad in the PhD, graduated in
field of occupational diseases of the eye. Assoc. Prof. 1973 from the Fac-
She has specialized in Belgium, Hungary, Vera Petkova, PhD, ulty of Kinesithera-
Italy. He is a member of the Societies of graduated from the py at the NSA and
Eye and of Ergoophthalmology, Society Kharkiv Medical In- started work at the
of the International Eye research Associ- stitute - Ukraine in Department of Phys-
ation. 1970. Since 1971 she iotherapy and Reha-
has been working bilitation of MA - Sofia. PhD - 1982, Ass.
Prof. Dr. Zlatka as a research asso- Professor since 1987. He has over 100 sci-
Panova, DSci. She ciate in the Clinical entific studies in kinesitherapy, co-author
graduated from the Department of Occupational Diseases of of monographs and textbooks. She is au-
Higher Medical Insti- the National Hygiene Center. In 1982, she thor of 1 invention and 7 rationalizations
tute in Sofia in 1955. defended in St. Petersburg dissertation for new diagnostic and therapeutic meth-
Since 1970 she has on the combined effects of pesticides ods and apparatuses in medicine.
been working as a and vibrations in mechanics. In 1991 she
research associate at was habilitated in the field of chronic
the Clinic of Occupa- professional intoxications. Since then he
tional Diseases at the Medical Academy has been leading the Clinic for Chronic
in Sofia. Ass. Professor in 1983, Professor Occupational Intoxications at the Center
- 1993. PhD - 1986 and doctor of medical for Occupational Diseases of Medical Uni-

10
 LABOUR MEDICINE
Prof. Tanya Kun- diseases. Author and co-author of scien- dissertation on the role of immunological
eva, PhD, graduated tific publications and communications, processes in the clinic of noise-vibration
in medicine at the 1 guide for medical students and 2 text- pathology. Since 1984 Ass. Professor in
Higher Medical Insti- books. the Clinic of Occupational Diseases at
tute - Varna in 1976. NCHMEN. Head of Department of Hy-
In 1978 she joined Prof. Dr. Yordan- giene, Med. Ecology and Prof. Diseases in
the Clinic of Occu- ka Hadjieva, DSci, Medical University - Pleven at 2008. She
pational Diseases as graduated in med- has specialized in Portugal and the Unit-
a post-graduate stu- icine in 1966 at the ed States. Major scientific interests in the
dent. He has been a PhD since 1981 and Higher Medical In- field of occupational medicine and occu-
since then has worked as an assistant, stitute - Sofia. Since pational allergy diseases, where there are
Senior and Chief Assistant at the Clinic 1976 she has been a over 80 publications.
of Chronic Occupational Intoxications at postgraduate at the
CPD. In 1986 she was elected associate Clinic of Occupation- Ass. Prof. Sonia
professor. Since 2000 he has been head al Diseases. Ass. Professor - 1984, Doctor Pavlova, PhD, grad-
of the Center for Occupational Diseases at of Medical Sciences since 1991, Profes- uated in biology, in
the Medical Faculty - Sofia. At 2016 - Pro- sor of Occupational Diseases since 1996. 1968 at the Faculty of
fessor. She has specializations in internal Head of Department of Occupational Biology at Sofia Uni-
diseases, occupational diseases and clini- Diseases Clinics at the Department of versity. Since 1968
cal toxicology. Her scientific work is in the Hygiene and Occupational Diseases from she has worked as a
field of chronic occupational poisoning. 1990 to 1994. She has developed 250 sci- specialist in the field
She is the author of more than 100 sci- entific papers in the field of clinical and of biochemistry and
entific publications, has participated in occupational diseases diagnostics (early asistent III-I degree. At 1999 as Ass. Prof.
monographs, textbooks and guides. laboratory diagnostics of chemical dam- in the Center for Occupational Diseases at
ages - self and combined action), physical the Medical Faculty - Sofia. PhD since 1982
Prof. Dr. Valen- damage, treatment of occupational intox- Author of more than 170 scientific publi-
tina Zlateva, DSci, ications, work capacity and morbidity of cations and reports, including studies
graduated in Med- occupational diseases. Co-author of 10 on toxicochemical and clinical-chemical
icine at the Higher monographs and textbooks in the field changes occurring under the influence of
Medical Institute of occupational diseases. National Con- various professional injuries. Co-author of
in Sofia in 1963. In sultant on Occupational Diseases in 1999 monographs and guides on hygiene and
1970-1973 she was - 2001 Member of Bulgarian and Foreign occupational diseases.
assistant at the Oph- Scientific Societies of Occupational Dis-
talmologic Clinic eases, Hygiene and Clinical Laboratory. Ass. Prof. Dr.
at the Higher Medical Institute in Varna. Rouzhka Stefano-
Since 1974 Head of Eye department of Prof. Konstan- va, PhD, graduated
CPD at MA-Sofia. PhD - 1977, Doctor of ta Timcheva, DSci, in medicine in 1963
Medical Sciences - 1991 Associate Pro- graduated medicine at the Higher Med-
fessor - 1983, Professor of Ophthalmolo- in Medical Univer- ical Institute - Sofia.
gy - 1998 Specialized in France, Germany, sity-Sofia in 1975. Since 1967 she has
Ukraine, USA, Japan. She has developed Since 1982 she has been a postgradu-
over 160 scientific publications, mono- been working in a ate at the Clinic of
graphs, textbooks and manuals on oc- chemotherapy de- Occupational Diseases of the Institute of
cupational ophthalmology. Member of partment at the Na- Hygiene and Preofessional Diseases - So-
national and international ophthalmic tional Cancer Center. PhD - 1982, Asso- fia. PhD since 1972, since 1973, is assis-
scientific societies. ciate Professor of Oncology - 1997, Head tant - chief assistant in the CPD. She has a
of chemotherapy clinic at NOC - 2000, specialization in biochemistry. Since 1991
Chief Assist. Dr. professor - since 2010. There are over 100 she has been habilitated as Assoc. Prof. at
Shiboy Kuzmov, scientific publications in the field of che- CPD (Medical Diagnostic Laboratory). Her
PhD, graduated in motherapy at oncological diseases. She scientific work - over 120 articles and re-
medicine in 1988 in is a member of the European Oncology ports, is mainly for clinical and laboratory
Sofia. From 1988 to Research Association. European Society research in chronic intoxications with or-
1990 he worked in of Chemotherapy, New York Academy of ganic solvents, pesticides, heavy metals,
distribution in Pernik Sciences. ecological problems and others. She is a
as a workshop ther- member of the International Association
apist. From 1990 to Assoc. Prof. Dr. of Agricultural Medicine (AMIEF) and the
1991, he was assistant at the Institute of Mariana Stoynovs- Balkan Society of Clinical Laboratory.
Pulmonary Diseases at MA - Sofia. From ka, PhD, graduated
1991 to 1994 he was a post-graduate in medicine in 1975
student for occupational diseases to the at the Higher Med-
National Institute for Hygiene and Pro- ical Institute - Sofia.
fessional Diseases, and later also to the From 1979 to 1983
hospital "St. Yves. Rilski "- Sofia. PhD in she was a post-grad-
1995. Since 1996 he has been assistant uate student at the
III-I degree, Head of FID office. He has spe- Department of Occupational Diseases of
cializations in internal and occupational the LSGMI - St. Petersburg. She defends a

11
 OCCUPATIONAL MEDICINE
Prof. Vladimir Ass. Prof. Dr.
Radulov, DSci, Naiden I. Mirchev, Prof. Dr. Al-
graduated in 1969, PhD, graduated in exander Monov,
Sofia University "St. medicine in 1959 in DSci, graduated
Kliment Ohridski Med. University "Iv. from the Medical
specialty" Special P. Pavlov "- Plovdiv. Faculty in Sofia. He
Pedagogy. In 1976, Since 1970 he has is the founder of the
he defended doctor- been working in the Bulgarian School of
al dissertation and Department of Clin- Clinical Toxicology,
in the period 1977-1991 he worked as a ical Toxicology at NIUMA "N. I. Pirogov ". the Scientific Society and the National
research associate in pedagogy of the vi- In 1976 he defended a dissertation in the Toxicology Center (at the Pirogov Insti-
sually impaired at the NIE. In 1991 he was field of acute and occupational poisoning tute), whose head has been for 30 years.
elected Associate Professor at the Depart- with benzodiazepine preparations. Since He has over 200 scientific publications
ment of Special Pedagogy at the Faculty 1977 he has been the head of the Chil- and monographs in the field of emer-
of Primary and Pre-school Pedagogy of dren's Section in the Clinical Toxicology gency medicine, poisoning and allergies
the Sofia University. In 1999 became Doc- Section. Ass. Prof. from 1988, from 1991 , ecological disabilities of man. Chairman
tor of Science and from 2000 was elected to 1999 - head of Clinical Toxicology Sec- and member of the management of sci-
Professor. He is the author of more than tion. Chief expert of Clinical Toxicology at entific societies of medicine and clinical
120 publications in Bulgarian and foreign the Ministry of Health - 1997-99 There are toxicology in Bulgaria and abroad, chief
specialized publications on the problems over 100 scientific papers in the field of editor of scientific medical journals.
of training and rehabilitation of the visu- toxicology.
ally impaired. He is the President of the Prof. Dr. Iskra
Bulgarian Association for the Education Ass. Prof. Dr. Altinkova, DSci,
of Visually Impaired Children and a mem- Stanka G. Andono- graduate in medi-
ber of the European Regional Commit- va, PhD, graduated cine at the Higher
tee at the International Council for the from the Higher In- Medical Institute -
Education of Visually Impaired Children. stitute of Medicine - Varna in 1974. Since
He has participated in numerous inter- Plovdiv in 1963. She 1974 she has been
national conferences and in a number of works in the district working as an as-
international projects with partners from health service, then sistant of immunol-
USA, Germany, Great Britain, Belgium and in the intensive sec- ogy at the Department of Nephrology,
others. tor of the First Municipal Hospital - Plo- NINUTH, Medical Academy - Sofia and
vdiv. Since 1973 she has been an assistant since 1977 as a research associate of Clin-
Prof. Dr. Dobrin at the Higher Medical Institute - Plovdiv. ical Immunology at the Department of In-
Charakchiev, DSci, PhD in 1982. Habilitated as Ass. Professor ternal Medicine, NIID, MA - Sofia. In 1984,
graduated from the and Head of Occupational Diseases Clinic, she defended PhD, and in 1998 DSci. Since
Higher Medical In- Plovdiv, since 1984. She has specialized 1994 she has been the Head of the Clinical
stitute in Sofia in in internal diseases, occupational diseas- Immunology Laboratory at the University
1956. Since 1960 he es and clinical toxicology. She has over Hospital "St. Ivan Rilski ". Since 1999 he
has been a research 100 scientific publications, participation has been a professor at the Department
fellow at the Clin- in scientific forums and monographs on of Clinical Laboratory and Immunology,
ic of Occupational toxicology. Medical University - Sofia. She has spe-
Diseases - Sofia. Since 1972 he has been cialized in Great Britain, Austria, Russia,
Assistant Professor and since 1991 - Pro- Chief Assist. Germany, France and Belgium. She is a
fessor. Since 1968 he has been PhD, and Diana Apostolo- member of the European Association of
since 1989 he has been a doctor of medi- va, PhD, graduated Nephrology, Dialysis and Transplantation.
cal sciences. He has specializations in Oc- from Higher Medi- Her scientific interests and publications
cupational Medicine, Occupational Dis- cal Education at the are related to the development and im-
eases, Internal Diseases and Biochemistry. Medical Academy in plementation of new, modern diagnostic
He has specialized in occupational diseas- Sofia in 1979. Since immunological methods in nephrology
es in Russia and the Czech Republic. There 1999 she has been and gastroenterology practice and to the
are over 200 publications in Bulgaria and working in the Clin- study of the pathogenetic mechanisms of
abroad, 6 monographs. His work covers ic of Occupational chronic glomerulonephritis and inflam-
all major sections of occupational dis- Diseases at the Medical University in So- matory diseases of the kidneys. There are
eases. His main scientific theoretical con- fia. He has specializations in occupational over 100 scientific publications in our and
tributions are in the field of homeostasis medicine and occupational diseases. PhD foreign magazines.
(alkaline-acid regulation in the body and since 2000. Her research activities cover
its clinical significance). He is a member of problems of the combined effect of the Prof. Dr. Zhel-
the European Society of Clinical Physiolo- working environment factors (ionizing yazko Iv. Hristov,
gy, the European Society of Pulmonology and non-ionizing factors) on the health of PhD. He graduated
and the International Aerosol Society. workers from the metallurgical, chemical in medicine in 1976
and uranium mining industry. at the Higher Medi-
cal Institute - Plovdiv.
Since 1982-1996 he
has been assistant

12
 LABOUR MEDICINE
- Chief Assist. at the Higher Medical Insti- itary healthcare and health management Ass. Prof. Ivan
tute - Plovdiv. PhD since 2005, Associate in national and foreign scientific journals. Popivanov, PhD. He
Professor - 2006, Dean of FPH at MU - Plo- He has specialized in Austria, USA, Germa- graduated in 1995 at
vdiv - 2007. Professor - 2008. Since 1997 ny and others. He participated in NATO, Medical University
he has been Chairman of CIUB. There are EU and NATO conferences and work- - Pleven. Since 2004
over 100 scientific publications, the latest shops in Bulgaria and abroad, related to he has been work-
of which in the field of stress. Specializing the military provision of troops. Head of ing at the Military
in social and medical problems related to Department of Military Medicine since Medical Academy, as
work in the USA, Argentina, France. 1998. Deputy Chairman of the Bulgarian a consecutive assis-
Scientific Society for Military Medicine. tant, senior assistant and chief assistant
Ass. Prof. Dr. An- President of the Bulgarian National Board in the Department of Military Epidemi-
drey Milchev, PhD, and Member of the Board of the Balkan ology and Hygiene at the Department of
graduated from the Military Medical Committee since 2003, Military Medicine. He has a recognized
Medical University in Member of the Association of American specializations in "Epidemiology of Infec-
Sofia in 1988. Since Military Doctors. tious Diseases" and "General Medicine".
1992 he has been PhD in 2013, Ass. Prof. - 2015, is scientific
a researcher at the Dr. Andrey Ran- interests are in the field of preventive mil-
Radiation Medicine gelov Galev, PhD. itary medicine, with over 70 publications
Laboratory of the graduated in Medi- in national and international specialized
National Center for Radiobiology and Ra- cine at the Medical periodicals and participation in textbooks
diation Protection. He has specializations Academy in Sofia in and manuals. He participates in NATO
in internal diseases and radiobiology. He 1986. Head of Med- and MD working groups. Member of the
has specialized in Italy and the Czech Re- ical Service at outfit BNS on Epidemiology of Infectious and
public. His scientific publications are in 26620 - Sliven (1989- Non-infectious Diseases.
the field of health monitoring and occu- 1990). From 1990 to
pational disabilities of persons working 2004, he worked at the MMA Infectious
in the environment of ionizing radiation. Diseases Clinic, where he served as as- Chief Assist. Dr.
He is a member of the Scientific Society sistant, head of department, and clinic Vlayko Vodenich-
of Radiobiology and Radiation Protection. head. Since 2004 he has been Head of arov, PhD, grad-
the Center for Military Epidemiology and uated in 2014 in
Prof. Dr. Assen Hygiene. In 2003 he defended disserta- Medical University
Petkov Petkov, tion. In 2004 he was elected expert of the - Sofia. From 2015
DSci. He graduated Republic of Bulgaria to the UN on the is- he worked as assis-
in Medical Universi- sues of combating bio-terrorism. He has tant, senior and chief
ty in Sofia in 1979. specialties in skin and venereal diseases, assistant in Depart-
Since 1983 he has infectious diseases and tropical medicine. ment of Hygiene, med. ecology and nu-
been in the Military Dr. Galev is the author and co-author of trition of Medical University - Sofia. PhD
Medical Academy over 250 publications in the field of der- - in 2018. He participate in scientific con-
and graduated from matology, epidemiology, prevention, ferences of labour medicine in Fukuoka -
the academic positions as Assistant, Assis- clinic and treatment of infectious and 2014, and Groningen - 2015; of bioethics -
tant, Chief Assistant, Ass. Professor (1998) parasitic diseases of social and military Basel and Napoli - 2013. There are more of
and Professor (2010). PhD since 1988, significance. There are publications in the 30 scientific publications in bulgarian and
Doctor of Medical Sciences since 2009. field of occupational medicine. In 2010 he foreign journals. Chief editor of scintific
There are a number of publications on established a Bulgarian Association for magazine "Praemedicus".
military medicine, the organization of mil- Preventive Medicine.

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 OCCUPATIONAL MEDICINE

CONTENT

FOREWORD...................................................................................................................................................................................... 27
A. OCCUPATIONAL HYGIENE..................................................................................................................................................... 29
1. DEVELOPMENT AND PRESENT STATE OF THE ORGANIZATION, FORMS AND
WORKING CONDITIONS
D. Tsvetkov........................................................................................................................................................................................ 29
1.1 Evolution of concepts for organization (structure of tasks) of labour ................................................31
1.1.1. Earlier systems of labour organisation .............................................................................................................31
1.1.2. The movement for “humane treatment” ..........................................................................................................32
1.1.3. Restructuring tasks ..................................................................................................................................................33
1.1.4. The importance of the physiology of labour and ergonomics ................................................................33
1.1.5. Electronics and modern labour ...........................................................................................................................34
1.2. Factors of working environment ...............................................................................................................36
1.2.1. Work environment factors – industries and professions ............................................................................36
1.2.2. Work environment - health status and performance ..................................................................................37
1.2.3. Hygiene standardization and health risk .........................................................................................................38
1.3. Forecasts for the development of postindustrial society .....................................................................41
1.3.1. Industrial society ......................................................................................................................................................41
1.3.2. To postindustrial society. .......................................................................................................................................42

2. PHYSIOLOGY OF LABOUR
E. Dincheva...................................................................................................................................................43
2.1. Physical work .................................................................................................................................................43
2.1.1. Types of physical work ............................................................................................................................................43
2.1.2. Categorization of labour ........................................................................................................................................44
2.1.3. Changes in organs and systems during physical work ...............................................................................45
2.2. Non-physical or mental work .....................................................................................................................48
2.2.1. Classification of mainly intellectual work ........................................................................................................48
2.1.2. Changes in organs and systems in mental work ..........................................................................................49
2.3. Working capacity...........................................................................................................................................50
2.4. Fatigue ............................................................................................................................................................53
2.4.1. Classification of fatigue ..........................................................................................................................................53
2.4.2. Overwork .....................................................................................................................................................................54
2.4.3. Signs and symptoms of fatigue ...........................................................................................................................54
2.4.4. Prevention of fatigue and overwork ..................................................................................................................55
2.5. Professional stress ........................................................................................................................................56
2.5.1. Work-related stressors ............................................................................................................................................57
2.5.2. Symptoms of stress. Other stress-similar states. ..........................................................................................58
2.5.3. Stress and illness .......................................................................................................................................................59
2.5.4. Prevention and stress management .................................................................................................................60
2.6. Modern approaches and methods to assess the state of mental stress and intervention
Zhel. Hristov, B. Tsenova......................................................................................................................................62

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 LABOUR MEDICINE
2.6.1. Modern psychological theories of occupational stress ..............................................................................62
2.6.2. Practice for research on workplace stress .......................................................................................................63
2.6.3. Studies in Bulgaria ...................................................................................................................................................65
2.6.4. Strategies and policies to limit stress - modern practices .........................................................................66
2.6.4.1. Monitoring of stress .......................................................................................................................................66
2.6.4.2. Types and levels of intervention in companies and organizations ..............................................66
2.6.4.3. Fighting burnout syndrome .......................................................................................................................67
2.6.4.4. Prevention of mental violence (mobbing) ............................................................................................67
2.6.4.5. Proactive approach - an overall policy to limit and reduce stress ................................................68

3. PSYCHOLOGY OF LABOUR
B. Tsenova.....................................................................................................................................................70
3.1. Stages of development by psychology of labour ...................................................................................70
3.2. Criteria for psychological assessment of work activities ......................................................................71
3.3. Methods for psychological analysis of the content of the work and
its impact on humans ..........................................................................................................................................73
3.4. Methodological approaches to psychological analysis of labour .......................................................74
3.5. Psychological states at work .......................................................................................................................75
3.6. Psychological study of occupations ..........................................................................................................79
3.7. Professional success and motivation to work .........................................................................................82
3.8. Psychosocial factors of labour and health................................................................................................83

4. ERGONOMICS
Z. Ivanov.......................................................................................................................................................86
4.1. Workplace and anthropometric characteristics of man. .......................................................................86
4.2. Workplace and working posture. ...............................................................................................................89
4.3. Working furniture and tools .......................................................................................................................94
4.4. Working movements ....................................................................................................................................94
4.5. Means of presenting the information (MPI) and controls (MC) ...........................................................95
4.6. Lighting and vision .......................................................................................................................................97
4.6.1. Elements of physics .................................................................................................................................................97
4.6.2. Physiology and functional possibilities of vision in labour........................................................................98
4.6.3. Optimization of visual activity at work. ......................................................................................................... 102
4.6.4. Lighting in the workplace .................................................................................................................................. 104

5. BIOLOGICAL RHYTHM AND REGIMEN OF WORK AND REST

Z. Ivanov.....................................................................................................................................................108

6. PHYSICAL FACTORS..............................................................................................................................112
6.1. Thermal conditions of environment (microclimate)
Ft. Kalburova, D. Tsvetkov ................................................................................................................................108
6.1.1. Thermal factors........................................................................................................................................................ 112
6.1.2. Thermal condition of the body ......................................................................................................................... 113
6.1.3. Influence of thermal conditions – pathological disorders and diseases. .......................................... 117

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6.1.4. Hygiene regulation of thermal conditions ................................................................................................... 117
6.1.5. Prevention of adverse effects of uncomfortable microclimate............................................................. 118
6.2. Non-Ionizing radiation ..............................................................................................................................121
6.2.1. Infrared radiation
F.Kalburova, D. Tsvetkov ................................................................................................................................................. 122
6.2.1.1. Biological effects........................................................................................................................................... 123
6.2.1.2. Hygiene normalization............................................................................................................................... 124
6.2.1.3. Prevention of adverse biological effects.............................................................................................. 124
6.2.2. Ultraviolet radiation
D. Tsvetkov ........................................................................................................................................................................... 127
6.2.2.1. Sources to UV-radiation ............................................................................................................................. 127
6.2.2.2. Absorbtion and general biological action .......................................................................................... 128
6.2.2.3. Health effects (risk) under irradiation with UV-rays ........................................................................ 129
6.2.2.4. Endangered professions ........................................................................................................................... 131
6.2.2.5. Hygiene standards ...................................................................................................................................... 131
6.2.2.6. Prevention of adverse effects .................................................................................................................. 132
6.2.3. Radio-frequency electromagnetic fields (radio waves)
B. Stefanov ........................................................................................................................................................................... 134
6.2.3.1.General characteristics ............................................................................................................................... 134
6.2.3.2. Main sources of radio waves..................................................................................................................... 134
6.2.3.3. Biological action. Clinical manifestations............................................................................................ 135
6.2.3.4. Prevention of damages.............................................................................................................................. 136
6.2.4. Low-frequency electromagnetic radiation. Magnetic field
B.Stefanov ............................................................................................................................................................................ 138
6.2.4.1. General characteristics .............................................................................................................................. 138
6.2.4.2. Main sources .................................................................................................................................................. 138
6.2.4.3. Biological activity ......................................................................................................................................... 138
6.2.5. Static electricity
B.Stefanov, D. Tsvetkov ................................................................................................................................................... 141
6.2.5.1. General characteristics .............................................................................................................................. 141
6.2.5.2. Main sources .................................................................................................................................................. 141
6.2.5.3. Biological action ........................................................................................................................................... 141
6.2.5.4. Prevention ...................................................................................................................................................... 142
6.2.6. Laser
D. Tsvetkov, M. Lyapina ................................................................................................................................................... 144
6.2.6.1. Use of lasers.................................................................................................................................................... 144
6.2.6.2. Occupational risk factors........................................................................................................................... 144
6.2.6.3. Classification of lasers in the degree of occupational risk............................................................. 145
6.2.6.4. Biological action............................................................................................................................................ 145
6.2.6.5. Prevention of laser impact........................................................................................................................ 146
6.3. Air ionization
Ft. Kalburova .......................................................................................................................................................150
6.3.1. Main characteristics and sources ..................................................................................................................... 150
6.3.2. Ionization of the air environment of indoor and outdoor ...................................................................... 150

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6.3.3. Biological effects of air ionization.................................................................................................................... 151
6.3.4. Prevention of adverse effects. ........................................................................................................................... 152
6.3.5. Artificial ionization of air. Ion generators. .................................................................................................... 153
6.4. Noise
N.Mitrev, D.Tsvetkov, Zl. Stoyneva ..................................................................................................................154
6.4.1. General condition, basic characteristics and sources .............................................................................. 154
6.4.2. Specific - hearing, effects of noise.................................................................................................................... 155
6.4.3. Nonspecific - extraaural, effects of noise ...................................................................................................... 156
6.4.4. Prevention of adverse noise effects ................................................................................................................ 156
6.5. Infrasound
N.Mitrev ...............................................................................................................................................................161
6.5.1. Effects of infrasound on the body ................................................................................................................... 161
6.5.2. Prevention of adverse effects ............................................................................................................................ 163
6.6. Ultrasound
N.Mitrev, D.Tsvetkov ..........................................................................................................................................165
6.6.1. Impact of ultrasound on the human body .................................................................................................. 166
6.6.2. Prevention of adverse effects ............................................................................................................................ 167
6.7. Vibration
N.Mitrev, D.Tsvetkov, Zl.Stoineva.....................................................................................................................169
6.7.1. General and basic features ................................................................................................................................. 169
6.7.2. Impact of local vibrations on the body ......................................................................................................... 171
6.7.3. Effect of general vibration on the body ........................................................................................................ 173
6.7.4. Prevention of adverse effects. ........................................................................................................................... 175
6.8. Reduced atmospheric pressure
D. Dimitrov, A. Agovska.....................................................................................................................................179
6.8.1. Physiological effects of reduced atmospheric pressure .......................................................................... 179
6.8.2. Pathological conditions and diseases............................................................................................................. 181
6.8.3. Prevention of altitudinal disabilities ............................................................................................................... 184
6.9. Increased atmospheric pressure
D.Dimitrov, S.Sabeva..........................................................................................................................................185
6.9.1. Toxic effects of increased atmospheric pressure ....................................................................................... 185
6.9.2. Other effects of the increased pressure ........................................................................................................ 186
6.9.3. Decompression ...................................................................................................................................................... 187
6.9.4. Prevention of compression and decompression disabilities ................................................................. 189
6.10. Gravity, acceleration, and micro-gravity (weightlessness)
D.Dimitrov, S.Sabeva..........................................................................................................................................191
6.10.1. Gravity and acceleration .................................................................................................................................. 191
6.10.2. Preventive measures .......................................................................................................................................... 192
6.10.3. Microgravity (weightlessness) ........................................................................................................................ 193

7. CHEMICAL FACTORS.............................................................................................................................195
7.1. Industrial Toxicology - basic assumptions, parameters of toxicity.
Prevention of occupational poisoning
D. Tsonevsky.........................................................................................................................................................195

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7.1.1. Factors determining the toxicity of substances ......................................................................................... 196
7.1.2. Toxicocinetics .......................................................................................................................................................... 198
7.1.3. Toxicometrics........................................................................................................................................................... 200
7.1.4. Toxicodynamics (mechanisms of toxicity) .................................................................................................... 203
7.1.5. Prevention of occupational poisonings. General principle..................................................................... 205
7.2. Metals and non-metals
M. Koleva..............................................................................................................................................................207
7.3. Alkalis and acids
M. Koleva..............................................................................................................................................................232
7.3.1. Alkalis ......................................................................................................................................................................... 232
7.3.2. Acids ........................................................................................................................................................................... 232
7.4. Alcohol
M. Koleva..............................................................................................................................................................234
7.5. Aromatic hydrocarbons
M. Koleva..............................................................................................................................................................236
7.6. Gases
A. Mihaylova........................................................................................................................................................238
7.7. Ketones
M.Koleva...............................................................................................................................................................245
7.8. Nitro - and amino derivatives of benzene and toluene
M.Koleva...............................................................................................................................................................246
7.9. Polycyclic aromatic hydrocarbons (PAHC)
M.Koleva ..............................................................................................................................................................248
7.10. Chlorinated hydrocarbons
M.Koleva...............................................................................................................................................................250
7.11. Containing Fluorine chlorine hydrocarbons
M.Koleva ..............................................................................................................................................................252
7.12. Other organics
M.Koleva, A. Mihaylova......................................................................................................................................253
7.13. Pesticides
D.Tsonevsky, M. Lyapin......................................................................................................................................261

8. DUST AEROSOLS
E.Vodenicharov..........................................................................................................................................274
8.1. Classification of the aerosols ....................................................................................................................274
8.2. Deposition of dust particles into the respiratory system ...................................................................275
8.3. Chemical composition of the dust and fibrogenIC action ..................................................................276
8.4. Exposure to dust and the risk of lung damage .....................................................................................277
8.5. Express experimental methods to determine the extent of fibrogenity and silicosis hazard
of powders ...........................................................................................................................................................277
8.6. Health risk from exposure to dust ...........................................................................................................278
8.7. Adverse health effects from exposure to dust ......................................................................................278
8.8. Prevention of adverse effects ...................................................................................................................279

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9. CHEMICAL FACTORS WITH CARCINOGENIC EFFECT
D. Tsonevski................................................................................................................................................281
9.1. Methods for evaluation and classification .............................................................................................281
9.2. Mechanisms of carcinogenesis ................................................................................................................282
9.3. Dose and health risk ...................................................................................................................................282
9.4. Modifying factors .......................................................................................................................................283
9.5. Carcinogens in production .......................................................................................................................284

10. FACTORS ACTING ON THE IMMUNE SYSTEM

I. Altankova, M. Lyapina............................................................................................................................287
10.1. Immune system ........................................................................................................................................287
10.2. Basic mechanisms of immune damage ..............................................................................................288
10.3. Health effects of immunotoxicity effects ...........................................................................................288
10.4. Allergens causing professionally-dependent sensitization ............................................................289
10.5. Immuno-dependent occupational diseases ......................................................................................290
10.6. Diagnosis of immune impairment .......................................................................................................291
10.7. Impact of physical factors on the immune system
M. Lyapina, E. Vodenicharov.............................................................................................................................294
10.8. Possibilities for treatment of adverse factors by antioxidant supplements
R. Shekerdjiiski, I. Denev....................................................................................................................................298

11. HYGIENE REGULATION OF ENVIRONMENTAL FACTORS. ASSESSMENT AND MANAGEMENT

OF OCCUPATIONAL RISK - APPROACHES AND MODELS
Ts. Vodichenska, D. Tsvetkov....................................................................................................................303
11.1. Environmental factors .............................................................................................................................304
11.2. Work environment factors ......................................................................................................................305
11.3. Assessment and management of occupational risk - approaches and models. .........................307

12. PRODUCTION TRAUMATISM

Z. Ivanov ....................................................................................................................................................313

13. WORK - AGE AND SEX

E. Dincheva.................................................................................................................................................316
13.1. Changes in physical performance with age ........................................................................................316
13.2. Changes in neuro-psychic performance with age .............................................................................317
13.3. Adaptation of women to work ...............................................................................................................319
13.4. Osteoporosis
A. Manolova.........................................................................................................................................................322

14. PROFESSIONAL TRAINING AND WORK OF PERSONS WITH DISABILITIES

M.Tsvetkova-Arsova, Vl. Radulov.............................................................................................................325
14.1. Vocational rehabilitation of persons with disabilities .......................................................................326
14.2. Labour for people with disorders ..........................................................................................................326

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15. MANUFACTURING ENTERPRISES - ARCHITECTURAL BUILDING CONCEPTS AND
REQUIREMENTS. VENTILATION
K.Nikolov....................................................................................................................................................329
15.1. Architectural and planning. Solutions and requirements ................................................................329
15.2. Ventilation..................................................................................................................................................332

16. PERSONAL PROTECTIVE EQUIPMENT

Z.Ivanov .....................................................................................................................................................334

17. MANUFACTURING AND PROFESSIONS - BASIC TECHNOLOGIES, HEALTH RISK,

PREVENTION.............................................................................................................................................338
17.1. Agriculture
D.Tsonevsky.........................................................................................................................................................338
17.1.1. Labour hygiene in plant-growing ................................................................................................................. 338
17.1.2. Labour hygiene in livestock breeding ......................................................................................................... 340
17.2. Mining
N. Stamova...........................................................................................................................................................342
17.2.1. Mining ..................................................................................................................................................................... 342
17.2.2. Ore processing and dressing .......................................................................................................................... 350
17.3. Ferous and non-ferous metallurgy
Z.Ivanov, M.Lyapin, Em. Vodenicharov...........................................................................................................350
17.3.1. Ferous metallurgy ............................................................................................................................................... 350
17.3.2. Non-ferrous metallurgy .................................................................................................................................... 352
17.4. MECHANICAL ENGINEERING
N. Gincheva..........................................................................................................................................................358
17.4.1. Foundry production ........................................................................................................................................... 358
17.4.2. Forge-press production .................................................................................................................................... 362
17.4.3. Mechanical machining of metals .................................................................................................................. 363
17.4.4. Assembly production ........................................................................................................................................ 365
17.5. Chemical industry
N. Gincheva..........................................................................................................................................................371
17.6. Textile industry. Manufacture of cotton fabrics
N. Stamova...........................................................................................................................................................375
17.7. Construction and production of building materials
N. Gincheva, M. Lyapina.....................................................................................................................................380
17.7.1. Construction ......................................................................................................................................................... 380
17.7.2. Production of building materials .................................................................................................................. 385
17.8. Labour hygiene when working with computer equipment
B. Stefanov............................................................................................................................................................391
17.9. Electricity production
E. Dincheva...........................................................................................................................................................396
17.9.1. Thermal power plant ......................................................................................................................................... 396
17.9.2. Hydroelectric power plants ............................................................................................................................. 397
17.9.3. Nuclear Power Plants ......................................................................................................................................... 397

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17.10. Transport
Iv. Paunov.............................................................................................................................................................400
17.10.1. Water transport ................................................................................................................................................. 400
17.10.2. Rail transport ...................................................................................................................................................... 402
17.10.3. Metro .................................................................................................................................................................... 404
17.10.4. Road transport .................................................................................................................................................. 405
17.10.5. Air transport ....................................................................................................................................................... 406
17.11. Chemical-pharmaceutical production. Pharmacies
M. Koleva..............................................................................................................................................................410
17.11.1. Production buildings ...................................................................................................................................... 411
17.11.2. Working environment and production process .................................................................................... 412
17.11.3. Fermentation (production of antibiotics) ................................................................................................ 416
17.11.4. Synthesis of Medicines ................................................................................................................................... 417
17.11.5. Biological (natural) extraction ..................................................................................................................... 418
17.11.6. Production of ready-to-use pharmaceutical forms .............................................................................. 419
17.11.7. Pharmacies ......................................................................................................................................................... 422
17.12. Armed Forces
As. Petkov, An. Galev, Iv. Popivanov................................................................................................................426

B. PROFESSIONAL DISEASES.....................................................................................................................431

1. OCCUPATIONAL DISEASES. INTRODUCTION

J. Hadjieva, L. Elenkova.............................................................................................................................431
1.1. Occupational diseases – basic characteristics .......................................................................................431
1.2. Occupational disease and occupational accidents. Social Risks Provided. .....................................437

2. EPIDEMIOLOGY OF OCCUPATIONAL DISEASES

N. Tsacheva.................................................................................................................................................441

3. OCCUPATIONAL POISONING...............................................................................................................446
3.1. Metals............................................................................................................................................................446
3.1.1. Antimony - J. Hadjieva.......................................................................................................................................... 446
3.1.2. ArsenIc - V. Petkova, S. Pavlova.......................................................................................................................... 448
3.1.3. Beryllium – T. Кuneva............................................................................................................................................ 451
3.1.4. Kadmium - T. Kuneva............................................................................................................................................. 453
3.1.5. Chromium - J. Hadjieva........................................................................................................................................ 454
3.1.6. Cobalt - J. Hadjieva................................................................................................................................................. 456
3.1.7. Lead - D. Charakchiev, St. Andonova............................................................................................................... 457
3.1.8. Manganese - V. Petkova....................................................................................................................................... 459
3.1.9. Mercury - St. Andonova....................................................................................................................................... 460
3.1.10. Nickel - J. Hadjieva............................................................................................................................................... 461
3.1.11. Phosphorus - T. Kuneva...................................................................................................................................... 461
3.1.12 Selenium - S. Pavlova........................................................................................................................................... 463
3.1.13. Tellurium - S. Pavlova.......................................................................................................................................... 464

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3.1.14. Thallium - V.Petkova............................................................................................................................................ 465
3.1.15. Vanadium - T. Kuneva......................................................................................................................................... 465
3.1.16. Zink - J. Hadjieva................................................................................................................................................... 466
3.1.17. TIN - J. Hadjieva..................................................................................................................................................... 467
3.1.18. Copper - T. Kuneva............................................................................................................................................... 468
3.1.19. Aluminum - S. Pavlova....................................................................................................................................... 470
3.2. Organic solvents..........................................................................................................................................473
3.2.1. Benzol - J. Hadjieva................................................................................................................................................ 475
3.2.2. Alcohols - R. Stefanova......................................................................................................................................... 476
3.2.3. Ethylene Glycol - D. Apostolova........................................................................................................................ 477
3.2.4. Phenol - J. Hadjieva................................................................................................................................................ 478
3.2.5. Ketones - D. CHarykchiev, St. Andonova........................................................................................................ 479
3.2.6. Chlorinated hydrocarbons - D. Apostolova, J. Hadjieva........................................................................... 480
3.2.7. Amino- and nitro derivatives of benzene. Trinitrotoluene - J. Hadjieva............................................. 482
3.2.8. Gasoline - R. Stefanova......................................................................................................................................... 483
3.2.9. Carbondisulfide - St. Andonova, S. Pavlova.................................................................................................. 485
3.3. Polymers........................................................................................................................................................488
3.3.1. Acrylamide - V. Petkova........................................................................................................................................ 489
3.3.2. Acrylonitrile - T. Kuneva........................................................................................................................................ 490
3.3.3. Styrene - T. Kuneva................................................................................................................................................. 491
3.3.4. Vinylchloride - V. Petkova..................................................................................................................................... 492
3.3.5. Ethylene - T. Kuneva............................................................................................................................................... 492
3.3.6. Methyl methacrylate - T. Kuneva....................................................................................................................... 493
3.4. Pesticides......................................................................................................................................................495
3.4.1. Cholinesterase-inhibiting pesticides - St. Andonova, R. Stefanova..................................................... 495
3.4.2. Chlororganic pesticides - V. Petkova, St. Andonova................................................................................... 497
3.4.3. Mercury pesticides - V. Petkova......................................................................................................................... 498
3.4.4. Dipyridyls - St. Andonova.................................................................................................................................... 499
3.4.5. Nitrophenols (dinitro compounds) - V. Petkova.......................................................................................... 499
3.4.6. Pyrethroids - St. Andonova................................................................................................................................. 500
3.5. Toxic gases....................................................................................................................................................502
3.5.1. Carbon monoxide - St. Andonova, D. Charakchiev.................................................................................... 503
3.5.2. Hydrogen cyanide and cyanides - V. Petkova.............................................................................................. 504
3.5.3. Hydrogen sulphide - St. Andonova.................................................................................................................. 505
3.5.4. Arsine (hydrogen arsenide) - T. Kuneva.......................................................................................................... 505
3.5.5. Chlorine - St. Andonova....................................................................................................................................... 506
3.5.6. Fluorine, hydrogen fluoride - St. Andonova................................................................................................. 507
3.5.7. Ammonia - St. Andonova.................................................................................................................................... 508
3.5.8. Sulfur gases - St. Andonova................................................................................................................................ 508
3.5.9. Nitrogen Oxides - T. Kuneva............................................................................................................................... 509
3.6. Other chemical compounds......................................................................................................................511
3.6.1. Acids - S. Pavlova.................................................................................................................................................... 511
3.6.2. Bases - T. Kuneva..................................................................................................................................................... 512
3.6.3. Chloromethyl ethers - R. Stefanova................................................................................................................. 513

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3.6.4. Formaldehyde - R. Stefanova............................................................................................................................. 514
3.6.5. Surfactants. - R. Stefanova................................................................................................................................... 514
3.6.6. Ethylene oxide - J. Hadjieva................................................................................................................................ 516
3.6.7. Tetraethyl-lead - J. Hadjieva................................................................................................................................ 516
3.6.8. Polycyclic aromatic hydrocarbons - D. Apostolova.................................................................................... 517
3.7. Mass acute poisoning - toxochemical traumatism. Mass poisoning from industrial poisons
Al. Monov..............................................................................................................................................................520

4. OCCUPATIONAL DISEASES BY PHYSICAL FACTORS............................................................................................ 524

4.1. Professional cryopathology
Zl. Stoineva...........................................................................................................................................................524
4.2. Professional thermopathology
Zl. Stoineva...........................................................................................................................................................528
4.3. Radio-wave disabilities
L. Nakova..............................................................................................................................................................531
4.4. Radiation illness
Ves. Bliznakov, A. Milchev..................................................................................................................................533
4.4.1. Acute radiation illness ......................................................................................................................................... 533
4.4.2. Chronic Radiation Disease ................................................................................................................................. 537
4.5. Vibrational disease
V. Kostova.............................................................................................................................................................540
4.5.1. Vibratory disease from local vibrations ......................................................................................................... 541
4.5.2. Vibrational disease of general vibrations ...................................................................................................... 543
4.6. Professional deafness
A. Savov ................................................................................................................................................................547
4.7. Occupational disability of the vestibular analyzer
A. Savov.................................................................................................................................................................553

5. OCCUPATIONAL DUST DISEASES OF THE RESPIRATORY SYSTEM..................................................556

5.1. Pneumoconiosis. Silicosis
E. Petrova..............................................................................................................................................................556
5.1.1. Pneumoconiosis. General part. ........................................................................................................................ 556
5.1.2. Silicosis ...................................................................................................................................................................... 557
5.2. Silicotuberculosis
T. Burilkov, Kr. Dinkova.......................................................................................................................................568
5.3. Asbestosis
T. Burilkov, Kr. Dinkova.......................................................................................................................................569
5.4. Silicatoses
L. Dimitrova..........................................................................................................................................................571
5.5. Anthracosis
E. Petrova..............................................................................................................................................................575
5.6. Metalconiosis
Kr. Dinkova...........................................................................................................................................................577
5.7. Mixed pneumoconiosis
Kr. Dinkova...........................................................................................................................................................579
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5.8. Organic powder
D. Charakchiev.....................................................................................................................................................580
5.9. Professional chronic bronchitis
Sh. Kuzmov, M. Demirova, Kr. Dinkova...........................................................................................................583
5.10. Occupational diseases of URT
D. Medjidieva.......................................................................................................................................................587

6. OCCUPATIONAL OVERTENSION DISEASES

V. Bosnev, G. Oncheva, Zl. Stoyneva........................................................................................................590
6.1. Diseases of peripheral nervous system overtension............................................................................590
6.2. Vegetative polyneuropathy from overintension or microtraumatism (ICD-X-90.0).......................595
6.3. Diseases of overtension of the musculoskeletal system.....................................................................596
6.4. Coordination dyskinesias...........................................................................................................................599

7. PROFESSIONAL INFECTIOUS AND PARASITIC DISEASES

Iv. Dikov, V. Boeva......................................................................................................................................601
7.1. Bacterial and viral infectious diseases
Iv. Dikov................................................................................................................................................................601
7.2. Professional parasitic diseases
V. Boeva.................................................................................................................................................................609

8. OCCUPATIONAL ALLERGIC DISEASES................................................................................................614

8.1. Introduction. Classification
M. Demirova.........................................................................................................................................................614
8.2. Allergic diseases of the respiratory system............................................................................................616
8.2.1. Allergic diseases of the upper respiratory tract
A. Savov, M. Stoynovska.................................................................................................................................................. 616
8.2.2. Professional bronchial asthma
M. Demirova......................................................................................................................................................................... 618
8.2.3. Hypersensitive pneumonitis
M. Demirova, Y. Simeonov, M. Stoynovska, D. Baltadjieva.................................................................................. 621
8.3. Professional allergic conjunctivitis
V. Zlateva, R. Toncheva, M. Stoynovska..........................................................................................................624

9. PROFESSIONAL MALIGNANT NEOPLASMS.......................................................................................626

9.1. Oncological diseases - basic situations
D. Todorov............................................................................................................................................................626
9.2. Malignant neoplasms of the respiratory system...................................................................................633
9.2.1. Pulmonary cancer
M. Demirova, Y. Simeonov, E. Stoynova..................................................................................................................... 633
9.2.2. Larynx, nasal and laryngeal cavities cancer
M. Melamed......................................................................................................................................................................... 637
9.3. Bladder cancer
Hr. Damyanov......................................................................................................................................................641

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9.4. Myeloproliferative diseases
T. Meshkov............................................................................................................................................................644
9.5. Modern approaches to chemotherapy of oncology
D. Todorov, K. Timcheva, D. Tsvetkova............................................................................................................649
10. PROFESSIONAL SKIN DISEASES
P. Mihaylov, D. Nyagolova.........................................................................................................................656
10.1. Irritant contact dermatitis ......................................................................................................................656
10.2. Allergic contact dermatitis .....................................................................................................................657
10.3. Phototoxic contact dermatitis ...............................................................................................................660
10.4. Allergic contact photodermatitis ..........................................................................................................661
10.5. Skin pigmentation ....................................................................................................................................661
10.6. Chloracne ...................................................................................................................................................662
10.7. Professional dermatoses from plants (Phytodermatitis) ..................................................................662
10.8. Occupational skin infections ..................................................................................................................662
10.9. Professionally determined skin tumors ...............................................................................................662

11. PROFESSIONAL DISEASES OF THE VISUAL ANALYZER.....................................................................665

11.1. Physical and chemical agents and load
V. Zlateva..............................................................................................................................................................665
11.2. Acute occular traumas
V. Zlateva, R. Toncheva.......................................................................................................................................672

12. OCCUPATIONAL DISABILITIES OF FEMALE REPRODUCTION

Zl. Panova...................................................................................................................................................675

13. OCCUPATIONAL IMPAIRMENT OF THE ORAL CAVITY AND TEETH

Iv. Grozdev.................................................................................................................................................679

14. OCCUPATIONAL DISABILITIES OF THE CARDIOVASCULAR SYSTEM

K. Kotseva...................................................................................................................................................682

15. PHYSIATRICS AND REHABILITATION OF PREFESSIONAL DISEASES AND INTOXICATIONS

Iv. Kirova, M. Neykova...............................................................................................................................687
15.1. Occupational intoxications .....................................................................................................................687
15.1.1. Rehabilitation of professional metal poisonings ..................................................................................... 687
15.1.2. Physiotherapy and kinesitherapy in organic solvents intoxication .................................................. 688
15.1.3. Physiotherapy and kinesitherapy in polymers intoxication ................................................................ 688
15.1.4. Physiotherapy and kinesitherapy in pesticides intoxication ............................................................... 689
15.1.5. Physiotherapy and kinesitherapy in irritant gases intoxication ......................................................... 690
15.2. Occupational diseases by physical factors ..........................................................................................690
15.2.1. Physiotherapy and kinesitherapy in cold angioneuropathy ............................................................... 690
15.2.2. Physiotherapy and kinesitherapy in thermal shock, thermal cramp, thermal exhaustion ...... 691
15.2.3. Physiotherapy and kinesitherapy in radiowave damages ................................................................... 691
15.2.4. Physiotherapy and kinesitherapy in radiation disease .......................................................................... 691

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15.2.5 Physiotherapy and kinesitherapy in caisson disease .............................................................................. 692
15.2.6. Physiotherapy and kinesitherapy in mountain sickness...................................................................... 692
15.2.7. Physiotherapy and kinesitherapy in vibration disease .......................................................................... 692
15.2.8. Physiotherapy in professional deafness...................................................................................................... 693
5.3. Professional dust respiratory diseases ...................................................................................................693
15.4. Occupational over-tension......................................................................................................................694
15.4.1. Physiotherapy and kinesitherapy in musculoskeletal diseases......................................................... 694
15.4.2. Physiotherapy and kinesitherapy in peripheral neurvous system diseases .................................. 695
15.4.3. Physiotherapy and kinesitherapy in vegetative polineuropathy at the upper limbs ................ 696
15.4.4. Physiotherapy and kinesitherapy in occupational dyskinesias .......................................................... 697
15.5 Occupational allergic diseases - bronchial asthma .............................................................................697
15.6. Professional malignant neoplasms .......................................................................................................698
15.7. Occupational disorders of the visual analyzer ...................................................................................698
15.8 Occupational cardiovascular damage ...................................................................................................699
15.9. Occupational disabilities of the vestibular analyzer .........................................................................699

26
 LABOUR MEDICINE

FOREWORD

Medicine includes three key areas-prevention, treatment and rehabilitation. This division is provisionally,
since they are interconnected, and the main purpose of medicine is health (not disease), which determines
its preventive orientation. Among numerous of medical disciplines-fundamental, clinical, rehabilitation, hy-
giene is the primary preventive science. It is a new science in the modern sense and at the same time one of
the oldest units of human knowledge and practice related to medicine.

Like any modern science hygiene constantly enrich their knowledge and dynamic besides interacting
with medical and other sciences.

The relationship of hygienic science with other preventive medical sciences (social medicine, epidemiol-
ogy, microbiology and parasitology) show that unity of integration and differentiation. From one historical
aspect of science, now they have their specificity in mutual relations and penetration into each other in
some areas. Hygiene is directed to the health of the individual, but above all to the health of the larger pop-
ulation groups. Achievement of its objective-studying, preserving, strengthening and improving the health
and human performance, is done by optimizing the interaction of to “man-environment”, to determine the
most favorable parameters of the environment and increased adaptation capabilities of the organism.

The proposed volume of Hygiene guide includes two volumes: Hygiene and ecology Volume I; Hygiene
and occupational diseases (Occupational Health) Volume II. In writing they involved a large number of Bul-
garian authors mainly from higher medical institutes and also authors from abroad. In his writing we have
tried not only to present hygiene in its modern light, as a wide and comprehensive preventive science, but
to direct its contents to more training and knowledge needs students of medical specialties and doctors.

Compared with previous textbooks of hygiene, content now is not only voluminous, but many altered.
Processed entirely all sections, it is mainly emphasized changes in health (biological action, diseases, chang-
es in the adaptation) under the action of environmental factors.

In focus-for doctors and students, and voluminous, this guide in Hygiene is the modern successor of
issued more than 40 years two volumes Textbook hygiene first and second parts, ed. Prof. Dr. L. Tsvetkov
(1958) and Occupational medicine ed. Prof.. Dr. M. Lukanov (1984). Now in the second volume is on and
discipline professional diseases.

We are grateful for the quality requirements of higher education concerning environronment, and sup-
port the project JEP 2154-91/94 program “Tempus” with the Head Professor Andre Pavia , University of
Montpellier II, France.

The guide can be used by other nonmedical professionals. Gratefully we will accept all criticism and views
on quality.

Prof. Dr. D. Tsvetkov, DSci

27
 OCCUPATIONAL MEDICINE

PREFACE

La médecine comprend trois directions fondamentales-prophylaxie, traitement médical et réhabi-

litation. C ‘est une division relative puisque ce sont des partie mutuellement liées, et le but principal de la
médecine est la santé (non pas la maladie), qui détermine son orientation prophylactique. Parmi les nom-
breuses disciplines de médecine: fondamentales, cliniques et de réhabilitation, l’hygiène est une des mo-
derne, mais en même temps une des branches les plus anciennes de la connaissance et de la pratique hu-
maines, liées a la médecine.
Comme chaque science contemporaine, l’hygiène enrichit constamment ses connaissances et sa
coopération avec les autre sciences de médecine ainsi que avec des sciences dans les domaines homolo-
gues.
Les relation réciproques entre l’hygiène et les autres sciences medico-prophylactiques-mèdecine
sociale, èpidèmiologie, microbiologie et parasitologie, progressent surtout durant les dernières décades.
Elles témoignent d’une unité d’intégration et de différenciation. Etant parties, historiquement d’une seule
science, actuellement elles présent une specifite sur le fond des liens réciproques et d’une interpénétration.
L’hygiène est orientée vers le santé de l’individu, mais avant tout vers celle de large groupes de la popula-
tion. L’hygiène envisage la réalisation de son but – l’étude, la protection, la promotion, l’amélioration de la
santé et de la capacité de travail par l’optimisation de l’interaction entre l’homme et l’environnement, c’est a
dire, par l’identification les plus favourables paramètres de l’environnement et la promotion de la capacités
d’adaptation de l’organisme.
Le présent manuel d’Hygiène est constitue de deux volumes: „Hygiène et écologie“ – v.l et,,Hygiène
du travail et maladies professionnelles» (Médecine de travaille)-v.11 a ètè rédigé par des nombreux auteurs
bulares – surtout des Instituts supérieurs de médecine, et d’étranger. Comparant ce cours avec les ma-
nuels précédents d’Hygiène on constate un changement ainsi bien au point de vue volume et composition
que d’amélioration d’approche et de quantité. Toutes les parties sont remaniées et revissées. L’accent est mis
principalement sur les changements de l’ètat de santé (influence biologique, maladies, modification d’adap-
tation) sous l’influence des facteurs de l’environnement.
Dans son esprit, contenu de base, but et destination le cours est un continuateur contemporain de
Manuel en deux volumes du prof. L. Tzvetkov (1958-1958) et de Medicine de Travail, sous la dir. de prof. M.
Loukanov (1984). Le nouveau v. Il comprend aussi la discipline maladies professionnelles.
Nous sommes reconnaissants pour les exigences a l’égard de la qualité de l’éducation supérieurs
dans le domaine de l’environnement et l’assistance du Projet JEP 2154 – 91/94 du programme TEMPUS sous
la direction du prof. André Pavia , l’Université de Montpellier II (France).
L‘ouvrage peut être utile a nombre de spécialistes qui travaillent dans des secteurs qui ne sont pas
en liens étroits avec la médecine. Les auteurs seraient contents de recevoir des critiques et de commentaires
concernant les qualités de cette publications.

Prof. D. Tzvetkov, D.Sc

28
 A. OCCUPATIONAL HYGIENE

1
D. Tsvetkov

DEVELOPMENT AND PRESENT STATE

OF THE ORGANIZATION, FORMS
AND WORKING CONDITIONS

Hygiene is part of hygiene science, studying la- mercury, lead and

bour activity and working environment, with a view coal smoke. In the
to their impact on the employees - their health con- sixteenth century.
dition and performance. Hygiene develops hygien- Paracelsus(Para-
ic norms, rules and various preventive measures to celsus-Philipus The-
create favorable for health and performance work ophrastus Bombast,
conditions. 1493-1541) In the
Occupational medicine is wider medical disci- three-volume work
plines related hygiene of labour with occupational (1530) describes in
diseases and more broadly with other diseases - detail the working
paraprofesionals and everyone else involved in the conditions and oc-
so-called general morbidity, i.e. occupational med- cupational diseases
icine connects preventive and curative aspects of in miners in Tyrol
medicine in the area of humans labour activity. (acute and chronic
Early and late history. Hygiene of labour and oc- mercurialism) and
cupational medicine have their beginning from the Paracelsus (Paracelsus-Filippos
time of Hippocrates and before him. Individual ideas Teofrastus Bombast, 1493-1541 years)
of occupational diseases and the role of the favora-
ble conditions of work in the miner, metal produc- in 1556. Agricola (G. Agricola, 1494-1555 years) in his
tion and the need for correct labour regimen for the work “De re metalica”, describe in detail silicosis and
preservation of health, has in ancient Egyptian and other dust disabilities in the e silver and gold mines
Chinese script, in the works of scientists and writers Yoahimstal in the
of ancient Greece and the Roman Empire in ancient Harz mountains.
Jewish collection of Judaism “Talmud”. Inhabited in Ramazini (Ber-
the Balkan Peninsula thracians (later the proto-bul- nardino Ramazini,
garians) have left also written and other archaeolog- 1633-1714 years),
ical data about high at this time health culture. called the father
Hippocrates (Hippokrates, 460-377 to S.J.) Is de- of occupational
scribed in his treatises damaging effects of dust in medicine, a doc-
mining, toxicity of lead ( “lead” colic). Pliny the Elder tor and professor
(Gaius Plinius Secundus, about 23-79 to J.C.) and of medicine in
Galen (Claudius Galenus, 129-201 to J.C.) are indicat- Modena, pub-
ed harmful effects of dust, in mining of sulfur and lished in 1700 his
cinnobar (mercury paint). Ovidius (Publius Ovidius treatise “De mor-
Naso ‘43 to - and about 18 after J.C.) and Plutarch bis artificum dia-
(Plutarchos about 46-127 years) have described the triba” ( “For diseas-
hazards at tanners and metallurgists, and diseases in es to craftsmen”),
miner described by Carr Lucretius (Lucretius Carus in which systema-
Titus, about 99-55 to J.C.) and Juvenal (Decimus Јu- tize all knowledge
nius Јuvenalis, about 60-127 y.). to that time in the
Early Middle Ages not bring new knowledge in field of occupa-
the field of occupational medicine. Only in 1473 tional medicine
Ulrich-Elenbok describes poiso­ ning by fumes of based on about
29
 OCCUPATIONAL MEDICINE
70 different professions (“diseases of pharmacists,” guidance on “Occupational Hygiene” (1927). He was
“diseases of writers and scientists,” etc.). He points the first professor of hygiene in Bulgaria and head
out that “when the doctor visited the sick worker of the first Department of Hygiene (1919) In 1944
... .. to Hippocrates recommended questions at ex- Hr. Hadzhiolov established the first clinic for occu-
amination should add another - what is your profes- pational diseases. In the area of hygiene
​​ of labour
sion?”. In 1742 the founder of Russian science and and occupational
culture M. V. Lomonosov (1711-1765) has exhibited pathology work L.
in detail the problems associated with hygiene and Tsvetkov (lead poi-
safety at work in miners - mine ventilation, organiza- soning), B. Slavkov
tion of work and rest, work wear, extraction of mine (mining), V. Kuzmin
water, air pollution, etc. (microclimate), Kr.
In the mid-nineteenth century and early twenti- Kirjakov (trans-
eth century development of industrial production port medicine), M.
on the one hand, and scientific knowledge in the Spasovski (occu-
field of exact sciences (physics, chemistry, mathe- pational toxicol-
matics), biology and medicine on the other, gives a ogy) D. Dimchev
new development of research and practical activi- (vibration, noise)
ties in the field of hygiene of labour and occupation- Vl. Boyadzhiev
al pathology. (branch hygiene,
In Russia in 1847 A. N. Nikitin published the first heavy metals), N.
book on labour hygiene and occupational diseases Tsaneva (physi-
(“Diseases of workers with instructions on preven- ology of labour),
tive measures”) and in 1877 F. F. Erisman published M. Dobreva and T.
the first original guidance “Professional hygiene or Burilkov (dust, sili-
hygiene of the mental and physical labour.” Appear cosis) At. Kehaiov (hearing and vestibular analyzer),
many new books G. Bobev (sanitary
and specialized chemistry) and
journals on vari- others. In 1948 is
ous issues of occu- created Institute of
pational medicine. hygiene of labour
Famous scientists with founder Iv.
in this field are M. Ivanov (occu-
then Lehmann pational hygiene),
(K. Lehmann) and and in the 50s of
Teleki (L. Teleky) in XX c. create Sci-
Germany; Simon entific research
(J. Simon), Hill (L. institute of occu-
Hill), Breadford, pational safety
Ledge (T. M. Leg- and occupational
ge - the first in- diseases with long
spector of labour time director M.
Alice Hamilton (1869-1970) hygiene, 1898) in Lukanov (physi-
England; Bruardel (P. Brouardel) in France. In 1910 in ology of labour)
Milan Devoto (L. Devoto) establish, existing and now and head of the clinic for occupational diseases Ts.
(named on him), the first specialized clinic for occu- Aleksieva (poisoning metals, organization of profpa-
pational diseases. Institutes of occupational medi- tological activity).
cine were opening in Japan, Finland, Spain, USA. The Later (early 80s) Institute developed as Research in-
founder of occupational medicine in the US is Alice stitute of hygiene and occupational diseases with
Hamilton (1869-1970 years) published in 1925 the longtime director F. Kaloyanova (occupational tox-
book “Occupational poisons in the US,” professor of icology, pesticides). Create and Transport medical
medicine at Harvard from 1919. institute, Aviation medicine institute, Institute for ra-
In Bulgaria in the early and mid-twentieth c. in diobiology and radiation hygiene and Laboratories
the field of occupational medicine worked G. Zlatar- of physiology of labour and ergonomics to branch
ski, L. Vankov, Hr. Piyanechki who carried out re- institutes.
search on silicosis in miners. T. Petrov issued the first

30
 LABOUR MEDICINE
1.1 EVOLUTION OF CONCEPTS FOR workforce like Philadelphia, wrote Taylor, the rhythm
ORGANIZATION (STRUCTURE OF TASKS) of work should be higher.”
OF LABOR1 Ÿ Working movements and the smallest gestures
are defined with precision by engineers. The work-
Over the last two centuries, the process of labour er has no right to change them, i.e. it turned into a
has undergone major changes in the principles and machine.
practice of labour. A little by little craftsmanship Ÿ Workers who can not follow the required
gives way to mass production and ever more so- rhythm, removed.
phisticated machines replace workers, leading to a This system contains no real study of fatigue. De-
division of tasks and specialization. This evolution in spite careful selection workers exhibit obvious phys-
the content of labour reaches a “rationalization” of ical fatigue and after several years of intensive work
the worker’s activities in the production process. removed from the workshops. The system Taylor
Labour is the subject of numerous studies, that survived only because the wear of labour in America
led to the “scientific organization” of labour, aimed was offset by immigration.
at applying scientific methods to control human la- Moreover, in the United States workers actively
bour in disregard of psychological approach and so- protested. US Congress appointed a committee of
cial consequences. In response, appeared new forms three members, which makes careful study, result-
of work organization, developed by researchers in ing, in the following active protest of workers, the
psychology and sociology of labour and specialists parliament of the United States decided - the credits
in ergonomics. voted in 1913 for government contracts, can not be
used in enterprises where used the system of Taylor.
1.1.1. EARLIER SYSTEMS OF LABOUR Ford (H. Ford - 1863-1947). – His name is asso-
ORGANISATION ciated primarily with the concepts of work conveyor
and the theory of high wages. His contributions to
Taylor (F.W. Taylor - 1856-1915). Examine is the organization shall consist of:
the implementation of labour operations of various • Mass (or large series) production;
workers and is determined after analysis and syn- • Interchangeability of parts and appliances;
thesis best method that removes unnecessary or • Replacement of transport by hand of the con-
too lengthy movements and replacing them with veyor;
more-efficient (spary) in terms of effort and time re- • Balancing the work places of the conveyor
quired by workers for their implementation. (uniform loading);
This type of study has been widely known as tim- • The creation of tools and machines with high
ing and consists of dividing the work of elementa- performance;
ry motions and measuring the duration of each of • Higher wages and replacing the work at piece
them. Disposed with the time required for elemen- with the imposed rhythm.
tary movements, can determine precisely the task Bedeaux. – Before the last war the influence of
that must be completed for a fixed time. Bedeaux lead to a revision of the methods for study-
Knowing the time allows for the introduction of ing the labour market.
salary depending on performance. This, however, is Bedeaux offers measurement unit Bedeaux (B),
differentiated wage, as a worker is paid per piece: which represents the amount of work, that is nor-
the more you make, the more you receive, but with mally done by a worker for 1 min, taking into ac-
a minimum number of manufactured items (deliber- count the proportion of time spent on rest.
ately difficult attainable for working day). The maximum pace of the average worker is
The physiological risks of implementing the sys- equal to 80 B, and normal 60 B. Such a pace reached
tem Taylor is connected to: the average worker without much effort and it cor-
Ÿ “Requiring, said Taylor, must always be well responds to the wage specified in the collective
above the productivity of the average worker.” agreement. In pace 80 B premium is 33% of the ba-
Ÿ The system of remuneration no account the sic wage. An extremely handy and energetic worker
“cost” of workers. Workers from densely populated can no problems to reach 100 B.
areas, should make much more effort for the same The positive contribution of Bedeaux system,
wage. “If businesses are in a country with a large that is integrated in the French methods of work
organization, is the assessment of the pace of work
1
In Leplat J., H. Monod - Evolution de conception d, organisa- and rest, as factors offsetting fatigue.
tion du travail. Precis de medicine du travail, sous la dir. De H. Gilbreth - 1868-1924. - His influence is felt slow-
Desoille, J. Sherrer, R. Truhaut, 6 ed., Masson, Paris, 1992. er in industrial environments (system implemented

31
 OCCUPATIONAL MEDICINE
first at masons), but nowadays it prevails due to the Ÿ With regard to the division of tasks and content
new direction, which gives research of professionals of work. - Tasks more and more repeat, that leads to
of psychotehnology and physiology. All organizers monotony imposed rhythm and significant mental
now know that reducing the execution time of a task stress. Physical load is associated with maintaining
is a function primarily of the used method, not by a specific posture, while high speed and accuracy of
the speed of movement. Efforts in the organization gestures when working with objects in motion.
should be directed towards a better adaptation of Ÿ This Labour Organisation has social conse-
machines and tools to people and creating a work quences. Unemployment among young, who refuse
process that matches their needs (posture, environ- functions unattractive for received vocational train-
ment, movement, rhythm ...) ing and an influx of immigrants.
A.G. Stahanov. - Miner, a specialist in the extrac- Ÿ Social effects, which are individual (more ab-
tion of ore with a hammer for breaking into the Sovi- sences from work in enterprises with monotonous
et Union, which, after analyzing his work, separates work, irresponsibility, indifference to the quality of
the two operations - supported by a beam and dis- the product) or collective (conflicts between man-
lodge and achieved record results in digging coal. agement and workers).
The method created in 1935 reveals the importance
of the contribution of the worker in case of favorable 1.1.2. THE MOVEMENT FOR “HUMANE
organizational conditions, ie contractors can active- TREATMENT”
ly make good proposals and give new ideas after
critically analyze technology and working methods. It originated in the US in the thirties of last cen-
Total consequences of these systems for “scientif- tury Mayo (Elt. Mayo) and occurs as a reaction
ic” organization of labour are: against the excesses of the “scientific” organization
Ÿ In the field of payment - The number of work- of labour. It pleads for return of intolerable working
ers without qualification, without meet the needs of conditions created by taylorism, with good physical
skilled workers. Increases range of no labour cate- and psychological environment in the enterprise.
gories related to planning, testing, supervision and The purpose of human respect is better integration
recruitment. of the worker in the enterprise.
Ÿ In the field of premiums - They are very impor- The heads of enterprises rely on the appeal of
tant to compensate for the fixed basic salary, that human respect, to change the behaviour of work-
corresponds to the minimum rate, and are typical ers, without aiming to change their own behaviour,
for simple work, that is not of interest to the worker. or the organization of work and even do nothing to
Tabl. 1. New forms of work organization

Principle Benefits Difficulties and limitations

Rotation of Dislocation of operators holders of Reduced monotony of Alternating plain and unmotivated tasks can
tasks different jobs within a workgroup labor not create real interest in labor
or conveyor for assembly or 0+0+0=0
manufacture. (Herzberg)

Extending the Extending the cycle time without - Reducing the number Adding ordinary and unmotivated tasks can
tasks changing the nature of the work. of jobs not create real interest in labor
- Decrease mental fatigue
of operators
Enrichment of Inclusion in the tasks to perform - Increased responsibility, - The need for additional training
tasks tasks associated with the the ability to identify with - Too often increase funds for salaries in the
preparation (regulation, supply, the end product, more enterprise
etc.) and control. Accompanied in respect
many cases with the organization - In many cases:
of space and jobs or improve the qualification and payment
safety and comfort of workers.

Semi- Groups of workers who take - A good solution for some - A system limited to the manufacturing
autonomous collective responsibility for a basic needs of workers, process and allowing the formation of small
teams production with more or less as an initiative, teams
rights for assessment the responsibility, - Is needed too long preparation
objectives. relationships. - Multiplying the risk of tensions and conflicts:
- Frequently increase of interpersonal or between teams (since the
qualification tension increases with the increase of contacts)
and remuneration - Need additional training
- Often, excessive increase in funds for
salaries in the enterprise

32
 LABOUR MEDICINE
change the unfavorable material conditions of la- • abolishing the incentive remuneration (ne-
bour. oteylorizam)
As workers, they adopt generally manifestations • greater responsibility and autonomy of the
of human respect and the fact, that work in a factory, performers
of which benefit, but realize that more and more are • reducing staff absenteeism and instability
involved in a model developed without their partic- • improving quality and productivity.
ipation, in an organization that used them as a nec- This requires, however, large investments that
essary object. again raise questions about the role of leadership
and the principle of hierarchy of authority. On the
1.1.3. RESTRUCTURING TASKS other hand, trade unions fear of overexploitation for,
psychological manipulation of workers.
Following the problems of previous forms of
work organization, began to talk about restructur- 1.1.4. THE IMPORTANCE OF THE
ing tasks to revive interest in the work. PHYSIOLOGY OF LABOUR AND
Restructuring tasks stems from two trends that ERGONOMICS
deal with the theory of human needs at work. Ac-
cording to Maslow (A. Maslow), operating there is One important perspectives for the development
a danger man be deprived not only of social needs, of general physiology is the study of people at work.
but also entire hierarchy of needs - physiological, Possible aspects here:
which are the basis of the rankings, to the need for 1. Physical (muscle) activity of the worker.
implementation (ie the ability to exercise their own 2. Psychosensory, mental activity
creativity at work), which is located on top of the 3. The impact of the work environment (mainly
“pyramid of Maslow.” Requests workers covering all physical factors - microclimate, lighting, sound, in
steps of the pyramid. the presence of undergoing work).
Herzberg used the conclusions of Maslow and Whether it is for primarily psycho-sensory or mus-
creates a new theory of human needs at work. He cle activity, or to study the working environment,
distinguished: physiology of labour deals mainly with elementary
1. needs, which if not implemented lead to dis- or integrated functional responses of individuals in
satisfaction, but if you realize, do not provide the certain working conditions. Ergonomics can be seen
necessary satisfaction - hunger, safety ... as primarily practical development of physiology
2. needs, the realization of which gives some and psychology of labour. It is usually defined as the
satisfaction and arising from the specific nature of science of adaptation of man to work.
human nature . Workers express them through their Changes in the economy in the twentieth cen-
demands for the content of labour, responsibilities, tury are significant. Of mostly craft a system where
promotions and more. generations used the same methods and tools,
As a result, they proposed and experimented which produce the same products, proceed to this
new forms of work organization (Table. 1). stage of industrialization, namely to produce sig-
After various forms of restructuring tasks are nificant quantities of products through integrated
enriching tasks and the formation of semi-autono- production structures. At present, it is important in
mous groups that are positively and give the work any preliminary study of a production to take into
a more human nature - the employee can influence account the following two issues:
his work. Some workers, however, accustomed to re- • Whether the product is adapted to the needs
petitive work operations is hostile like restructuring, of the individual, who should use it?
yielding new tensions and increases the effort. • Whether the jobs are adapted to the needs of
The most often cited example of semi-autono- workers?
mous groups of Volvo plant in Kalmar, Sweden. The For example, it makes no sense to produce cars
car conveyor is removed and is replaced with small that can not be used conveniently and securely from
groups, each of which assembles a separate car. people or to build a plant in which in some places
In France, Renault management has applied this can work only under exceptional stress. These prob-
experience and is followed by other companies lems must be solved at the stage of design.
(more than 300 in total), mainly from the production Social evolution greatly reduced and continues
of electric appliances and machinery. to reduce the level of allowable stress. In the XIX cen-
The results for employees are: tury working conditions are often unfavorable and
• need of professional training and improve- enforcement, and working time – longer. Adverse
ment factors progressively reduced, but the requirements

33
 OCCUPATIONAL MEDICINE
of social progress include continuous reduction of of types of automatic machines, as occurred a year
their level. dozens of new types.
So in the middle of the twentieth century. Work- They can be distinguished two phases of infor-
ing conditions are sufficiently studied as effects on matization with very different technical and social
workers to build ergonomics as an independent characteristics.
discipline. The need for it is felt both in society and Phase of centralization is characterized on the
in the economic sphere. Along with the physiology one hand centralized computing, which is owned
and psychophysiology of work, dealing with human by large organizations, and the other a substitution.
functioning at work, discipline was formed (begin- The last is to replace some devices (such as process-
ning as so-called “corrective ergonomics”), which ing equipment) of mechanical components with
aims to modify the tools or the task of labour for to electronic. Originally used for scientific calculations
adapt to the individual. Thus reducing the load with (especially in warfare), informatics progressively
which has to cope the body and increases produc- begin to apply in the management of enterprises.
tivity, quality and reliability of work. Informatization of management focuses primarily
large enterprises and less in administration.
1.1.5. ELECTRONICS AND MODERN LABOUR Gradually this “elitist information” gives way to
mass informatization - ie. “Informatization boom.”
Development of modern electronics is many ap- The second phase is characterized by a multiplici-
plications. These include computers and machines ty of applications and users of automatic machines
for automatic processing of information, operated and foremost with their integration into “automated
by programs when performing arithmetic logic op- systems”.
erations, enabling not only to produce multiple re- Today distinguish at least 7 types of machines:
ports, but also for decision-making. Two large tech- - PMNC.
nical advantages are miniaturization that allows to - Automatic machines for continuous production
record a large number of data (created term mem- of large series. Besides robots in this category in-
ory) and speed of operation (eg. In program chess cludes manipulation devices, integrated systems of
game, the computer can calculate three million data robots and programming machines.
and more for 3 minutes). • Machinery for process automation. Refineries
Electronic devices can replace humans in many or water power plants are an example of the
areas: statistical reporting, monitoring and control use of machines for the automation of contin-
of machines, allowing more high level of automatic uous processes.
operation. • Design with computer. Currently used mainly
Contribution of electronics allows the man to re- in aerospace, automotive, shipbuilding, this
place the machine, suggesting earlier availability of method allows to automatically do all the cal-
information, hence the terms automation and in- culations required for the design of a product.
formatization, or robotics. • Automatic devices for optical reading: these
The robot is a machine composed of two parts: are automated distribution of letters or sys-
a device performing operations and software that tems for processing checks in banks.
manages the sequence. • Machine tools for word processing (typewrit-
Guittet defines it as “an automatic machine that ers with memory). They are connected to a
can be adapted to a complex environment and to computer, which allows for automatic paging
replace or extend one or more functions of a per- and corrections.
son being able to influence the environment.” The- • Fax - system that enables you to transmit pho-
oretically there are three generations of robots with tocopies of distances on the phone lines.
different levels of complexity (from monovalency to • Database - computerised libraries that can be
complex robotic systems). used with a computer (terminal).
Stages of informatization. A review of the his- Can indicate other applications that are less likely
tory of technics over the last 50 years makes it pos- to be classified. These are mini terminals and micro-
sible to distinguish three main periods of informati- computers, which are found almost everywhere, and
zation. By the early seventies are known two main differ only in program management. Microcomput-
types of automatic machines, computers of large ers are used in workshops and offices for accounting
enterprises and automatic controls of fixed produc- and inventory management. Another form of infor-
tion processes (chemical, petrochemical, etc.). Then matization, which has developed very fast, electron-
appear processing machines with numerical control ic payment, which is used in various fields such as
(PMNC). Later seen extremely rapid multiplication selling tickets, selling merchandise and ATMs.

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 LABOUR MEDICINE
Qualitatively new phase of mass information is reversal of the tendency to split the tasks. The share
the creation and development of the global infor- of workers it however less because it is “unable” to
matization system (Internet). Form a futuristic con- perform alone the various operations carried out by
cept of teleworking by telecommunications, which the machinery, but only controls the execution. So
will put the issue of working from home. the worker has no direct contact with the product
New working conditions. Informatization often of their labour.
presented as the safest way to release the man from Preparation: Regardless of the type of automatic
some difficult production tasks associated most of- device preparation is associated with program de-
ten with removal of intense physical effort in a hos- velopment. This includes three categories of staff:
tile environment, performed by robots or operations • Analysts who determine the logic of Informa-
that are characterized by no uniformly and repeata- tion systems;
bility. • Programmers who transcribed this logic, the
In informatization however, new problems ap- language of machines;
peared associated with psychosensory tension. • Operators, who make this transcription reada-
Studies have shown that the operation of the ter- ble by computer.
minal, there are lots of symptoms associated with The very existence of information services leads
the visual fatigue, such as headache (80% of cases), to so-called deskilling/excessive qualification by M.
blinding (70%), burning of the eyes (70%) and re- Freyssenet, namely that technical progress is linked
duction of visual acuity (50% ). to the reduction of qualification for the majority (op-
On the other hand psychological factors also erators) and qualification for the elite, the one that
change. Before the master commanded the team. programe.
Placed in front of the controls, however, it no longer Centralization of information has resulted in large
does. Moreover, this transformation may at first lead enterprises to increasingly teylorism in the process
mainly in older workers to emotional instability and of preparation of labour with machines. At this stage
psychosomatic disorders due to fear of dismissal in there was no real break from previous forms of work
reducing staff, into another category with a change organization.
of perspective for development and the possibility B) “Boom of informatization.” Three trends
of moving to another post not complying with the characterize in the beginning of the 80s the arrival
skills and professional experience. of a new “era”, that of “ informatic without informat-
Studies in these workers indicate tendency to ics”, namely:
a high incidence of psychiatric symptoms: anxiety • The creation of a “generator of programs” and
(40%), insomnia (20%), depression (25%). the multiplication of “library for programs”,
Informatization not lead, however, to a uniform leading to a substantial reduction the role of
deterioration of working conditions. Informatiza- programmers.
tion is primarily a heterogeneous from mental per- • The increasing simplification of languages​​
spective phenomenon. For carrying out an order is (creation of APL - conversational language
appropriate and inappropriate automation systems and specialized languages), facilitating the
and devices. In informatization can and should be use of IT by non-specialists.
selected, ie to apply the requirements of ergonom- • The integration of the program into program-
ics. ming package.
Consequences of the organization of work The development of integration is closely linked
(structure of tasks). The consequences of informa- to the progress of the operation of the terminal. The
tization in the field of labour organization vary de- specifics of the operation of the terminal is in the dia-
pending on the phase of informatization. logue between man and machine. Therefore among
A) A centralized information - Each automatic operators, supervisors, and those dealing with the
machine consists of two separate elements: the de- introduction of data, need to add a new category -
vice and software. In this phase of informatization operators working with interactive keyboard.
most significant changes undergoes work with the The progress in the integration of automated sys-
machine, and preparation (development program) tems increases the need for teamwork. The team of
continues to be organized in a fairly traditional way. workers in this case is composed of three sub-teams
Working with the machine: the big novelty at - control; surveillance; guidance, maintenance and
this level is the emergence of an entirely new func- transportation. First team of which depends mostly
tion, control and surveillance. By automatic devices on the proper functioning of the enterprise is char-
worker involved in the implementation of several acterized by very high stability in the workplace,
operations that were previously separated. This is a while the other two are “peripheral” and have tem-

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 OCCUPATIONAL MEDICINE
porary status - provisionally performed functions 1.2.1. WORK ENVIRONMENT FACTORS –
and subcontractors. INDUSTRIES AND PROFESSIONS
Based on all the consequences to man of infor-
mation it is necessary to conduct adequate social In the modern labour massively entering high-per-
protection and maintain good health psychoso- formance machines and equipment, processes, in-
matic condition. Indicate four priority areas: strumentation, using and which are the sources of
Ÿ information: full and early information is the physical factors (hazards) of the working environ-
only way not to multiply the phenomenon of rejec- ment. Most diverse industries, and especially textile
tion by continuous influx of new information tech- production (spinning and weaving mills), metallurgy
nologies in the enterprise and machine-building, logging and wood process-
Ÿ prevention: 1) thanks to the development of ing, ore mining and others characterized by intense
ergonomics and the intervention of specialists in noise; intense local vibrations are typical for logging;
occupational medicine (SOM) may to adapt the ma- “general” vibration - for transport; adverse microcli-
chine to the man and so to improve working condi- mate (excessive heat, cooling) - when working out
tions; 2) psychological factors change in the period (agriculture, construction, metallurgy, shipping).
of transition and SOM must scrutinize the cases of For contemporary work are characteristic radio fre-
transfer to a new job. quency electromagnetic fields (induction furnaces
Ÿ training: informatization create jobs, but also in metallurgy, radar, telecommunications); laser ra-
led to the closure of others. Vocational training al- diation (holography, radio electronics, automotive);
lows for adaptation to new knowledge and a guar- ultrasound in the air (in high speed machines) and
antee against mass unemployment. ultrasound in liquids (cleaning of metal parts); infra-
Ÿ negotiations: They allow for controlled oppos- sound (large machinery and equipment in metallur-
ing interests and through them over time, thanks to gy, transport). The atmospheric pressure (high, low
mass informatization to create social democracy, i.e. and rapidly changing) is a “classic” and present harm
benefit of all. at work under water and under water pools or at
high altitude. Typical of contemporary work is, and
1.2. FACTORS OF WORKING so-called “chemization of labour.” Y.V. Sanotskiy
ENVIRONMENT (1987) states that the rapid development of chem-
istry and the growing needs, currently is character-
Working conditions, affecting the health and per- ized by existing over 5 million chemical compounds,
formance can be divided into two groups. weekly synthesis in the world of 5-6 thousand new
Work environment factors, which include: the compounds and now use over 60 thousand chemi-
microclimate factors (temperature, humidity, speed cals and more - an annual introducing in production
of air movement and infrared radiation), production of over 1000 substances. “Chemical industries” can
radiation (ionizing, non-ionizing, laser), industrial be called the production of plastics, fertilizers and
lighting (i.e. visible light), mechanical oscillations pesticides, paints and varnishes, chemical-pharma-
(noise, vibration, infra- ultrasound), atmospheric ceutical industries, petrochemistry, production of
pressure; chemical factors (gases, vapors, liquids, acids, paints, detergents and others. Chemical fac-
aerosols with toxic action); dust (physico-chemical) tors related to technological processes as hazards
factors, biological factors.1 in the working environment can be released in a
Factors of labour process related to heaviness variety of industries - metallurgy, machine building,
and tension of labour; regime of work and rest; textile industry, transport, construction, mining, etc.
working posture; workplace and working move- Characteristically, however for modern technology
ments; psychosocial factors. and procedures is the mass automation of techno-
Some authors indicate indirectly acting on the logical processes, replacement of highly toxic chem-
health status and factors related to labour envi- icals with less toxic or non-toxic (eg. replace organic
ronment: planning, design and technical solution solvents with water) and ultimately higher degree of
in production premises; location and connections protection of labour and the environment by chemi-
of technological machinery and equipment, manu- cal hazards. A major problem with them still carrying
facturing furniture and furnishings; sanitary equip- out repair works on the equipments and especially
ments (industrial heating, ventilation). the cases of accidents - eg. accident at the chemical
plant in Bhopal - India in 1984, where divisions gas
(methyl isocyanate) affected over 20 thousand peo-
2
l here may also be included traumatic factors (mechanical, ple and caused two thousand deaths.
chemical, electrical, etc.).

36
 LABOUR MEDICINE
Dust such as harmfulness of the working envi- disorders and diseases of the body, but also high re-
ronment changes its meaning in modern working sistance to various diseases and high performance;
conditions. The high degree of dust with roughly - opportunities to restore and enhance the cul-
dispersed and with high crystalline SiO2 (fibrosogen- tural and intellectual level;
ic) dust is rare meet now state (often in the past in - state of health, as a constant process of com-
underground mining - i.e. “dry” drilling in the manu- plete adaptation of the organism to changing con-
facture of building materials). Currently actual effect ditions of environmental and working environment
is of finely divided dust (mining, construction, agri- (labour).
culture), dust with allergenic effect (agriculture, con- Factors of working environment and labour
struction materials - cement, pharmaceuticals), with process, as adverse health factors, influencing per-
carcinogenic effects (asbestos, aerosols containing formance (reducing it, and quickly led to fatigue),
nickel, chromium, etc.). cause the development of professional and para-
Forty years of the twentieth century. It is charac- professional diseases, affect the general morbidity
terized by rapid development of manufactures for (increased frequency, heaviness, altered structure).
so-called biologically active substances - antibiotics, Now, a person is subjected to adverse effects of
amino acids, proteins, enzymes etc., based on micro- many factors in production and the environment.
biological synthesis. Working conditions in modern Typical for them now is that:
enterprises of the chemical-pharmaceutical industry • Usually are with less intensity;
(antibiotics); microbiological industry (production • Act combined, sequential, continuous or in-
of a food protein, microbial fertilizer, insecticides, termittent with constant or variable intensity;
etc.); textiles; agriculture (livestock, poultry farming, • They are of a different characteristics (nature)
husbandry) pointed to the forefront and so-called with similar or different effects on the body;
“adverse biological factor“. Biological factors are • The combined presence of chemical factors
expressed now hazards and for working with liq- leads to the physico-chemical reactions and
uid and solid waste (cleaning of settlements), in the the formation of new substances, and condi-
leather industry, working in places with vectors (car- tions, also acting on the body;
riers - eg. Insects) of infectious diseases - geologists, • Acting chronic, and combined with a healthy
logging, working with biological materials in human or not lifestyle - proper daily regimen, nutri-
and veterinary medicine. Now and in the near future tion, physical activity, alcohol use and smok-
biological factor is a major adverse for health and ing, drug addiction.
caused high mortality factor in countries of warm cli- When work environment factors are of less in-
mate in their main industries of agriculture (farming, tensity, but act chronic and combined with other
husbandry), mining and others. Biological factors - adverse factors and lifestyle (healthy or not), they do
micro- and macro organisms, viruses and products not cause development of the occupational diseas-
of their metabolism (biologically active substances) es, but reduce efficiency and immunological reactiv-
are the causes of infectious and parasitic diseases; ity.
dysbacteriosis; mycosis (eg. candidiasis - Cand. albi- Adverse effects herein are characterized by the
cans) and others.; intoxications (eg. mycotoxicosis so-called small and “hidden” symptomatology (oc-
when working in silos, in wood processing); aller- curring after provocation), affects the whole organ-
gic diseases (eg. hypersensitivity pneumonitis or so ism, the reactions are mostly phases2. In this case
called “farmer’s lung”, first described by Ramazini in the work environment factors appear (with varying
1713); malignancies (eg. angiosarcoma of the liver in degrees of probability) as one of the risk factors for
aflatoxicosises - toxins of the fungus Aspergillus fla- formation the general morbidity.
vus). Modern ventilation systems (air conditioning For example, epidemiological studies of diseas-
systems) with recirculation of air in rooms (offices) es of the cardiovascular system and conditions of
with closed windows or no windows workshops are dyslipidemias in workers in contact with carbon di-
important for the growth of mold into the air. sulfide or affect of noise levels below those causing
specific disorders (decrease in auditory sensitivity)
1.2.2. WORK ENVIRONMENT - HEALTH showed that as at relatively low concentrations (be-
STATUS AND PERFORMANCE low and about MAC) of carbon disulphide and the
noise factor is the risk factors for development (high-
Enacted in 1949 by the WHO definition of health 2
Place in three phases: Ist - functional or weak structural chang-
as “a state of physical, mental and social well-being” es (i.e. a biochemical “adaptation”); IInd - a period of “hidden” de-
implies: compensation (apparent adaptation); III th - deterioration, with
- not only the absence of somatic and psychiatric lasting changes and clinical signs of damage

37
 OCCUPATIONAL MEDICINE
er incidence) of cardiovascular pathology (together of professional factors for developing cancer is de-
with other risk factors for it, with production and scribed for the first time by Percival Pott in 1775 in
non-production character). Such studies, combined London (cancer of the scrotum in chimney sweeps
with experimental studies have shown through use - soot) later, at the end of the nineteenth century,
of more sophisticated methods of statistical analysis high incidence of lung cancer in miners of mines for
(factorial, discriminant, logistic regression) the im- uranium and nonferrous metals in Czechoslovakia
portance of vibration factor in the higher incidence (radon combined with dust containing quartz, nick-
of dyslipidemia, coronary heart disease and hyper- el, haematite).
tension in workers with and without specific clinical In the second half of the twentieth century vari-
manifestations of vibration damage. ous authors already indicate that 4 to 40 percent of
Also is known the cumulative effect of factors of cancer cases are caused by occupational hazards.
working environment with less intensity, with such Many modern productions at risk of developing
of the labour process, resulting in reduced perfor- cancer by work environment factors - chemical and
mance - eg. noise factor of intensities much lower chemical-pharmaceutical, petrochemical, work with
than 80-85 dB increase significantly neurosensorial ionizing radiation, metallurgy and machine build-
tension in operators. ing, agriculture, mining, production of plastics, rub-
Occurrence or not of these “non-specific” effects ber industry.
of work environment factors is closely related to the International Agency for Research on Cancer
functionality of the body’s systems of workers to (IARC) divides agents (factors), depending on the
maintain homeostasis (opportunities conditioned presence or absence of the carcinogenic effect of
as genetic and as of lifestyle - healthy or not). the 5 groups, the first 3 groups (1, 2a and 2b) have
Factors of working environment with less inten- such effects.
sity and chronic effect, on impact on small or large The first group, known to be carcinogenic in
populations (groups of workers in industries) often humans are 22 chemicals, such as arsenic, asbestos,
cause the development of allergic reactions and dis- benzene, beryllium, cadmium, chromium and their
eases and are factors for carcinogenesis. compounds, mineral oils, nickel compounds, vinyl
Currently around 10% of general morbidity are chloride, wood dust and others. It also includes ra-
various allergic disorders (US indicate for the gen- don, solar radiation, some biological factors (hepa-
eral population about 50% slight and 10% with titis B and C virus, Helicobacter pylori, Schistosoma
more serious allergic reactions). A typical and severe hematobium). All of them, without biological factors
damage to the respiratory system - asthma is often present real production risk. In the second group
a professional etiology (5-15% of cases). Contact (probable carcinogenic risk) are 20 chemical factors
dermatitis is about 90% of all cases of occupation- - benzidine, formaldehyde, polychlorinated biphen-
al dermatoses (in 80% affect the main body part of nyls crystalline SiO2, tri- and tetrachlorethylene, etc.,
work - hands). Typical occupational allergic diseases and UV-radiation. In the third group (2b) - a possible
are also farmer’s lung; bagasosis; byssinosis; aller- carcinogenic risk, included 62 chemical substances
gic rhinitis (pollen fever) and conjunctivitis. Global and their compounds - diesel fuel, hydrazine, lead,
trend is a steady increase in the incidence of allergic methylmercury, nickel, some dyes (o-toluidine,
disabilities. ponceau), styrene, vinyl acetate, foundry smoke, etc.
Chemical factors in the work environment are of- Separately, in the above groups are also included 22
ten allergens - phenol and its derivatives, benzene, pesticides (eg. DDT, heptachlor) and 31 drugs (phen-
arsenic, mercury, zinc and manganese compounds, acetin, cyclosporine, estrogens, oral contraceptives,
chromium, cobalt, aromatic- nitro and amine com- chloramphenicol, etc.). This variety of chronic rele-
pounds, isocyanates, detergents, organic solvents. vant factors with proven or possible carcinogenic ef-
Also such factors are dust factors - cement, flour, fect in humans, involving many industries and large
vegetable; biological factors - antibiotics, food yeast, groups of workers, shows great medical and social
microbial insecticides and fertilizers; physical factors - importance of preventions in the occupational can-
cooling microclimate, intense insolation, UV-radiation. cer.
Modern production of chemical-pharmaceutical
industry, plastics, building materials, paints and var- 1.2.3. HYGIENE STANDARDIZATION
nishes, petrochemistry, agriculture, textile industry AND HEALTH RISK
have a higher incidence of allergic disabilities.
It is noted that 30-40% of the population of de- Modern definition of hygienic standard of chem-
veloped industrial countries develop cancer, as one ical agents in the air of the working environment
person in five is dying of cancer. The importance was “such a limit concentration (MAC), which in

38
 LABOUR MEDICINE
everyday work (8h) during the working week and These criteria reflect the relationship man-envi-
throughout the all service can not cause deviations ronment. In observing hygienic standards (concen-
in health (established by the most modern methods trations, levels) are not followed:
and knowledge), over the full lifetime of the work- • Acute or chronic occupational diseases and
er and his offspring. “ This definition is basically the poisoning;
same for other factors of working environment. • Does not increase the susceptibility of the or-
Generally hygienic standardization, as manda- ganism to the development of other diseases
tory and recommended separate regulations and - cardiovascular, cancer, allergic, etc .;
standards starting in the second half of the nine- • Not lowering reproduction capabilities and
teenth century and in early twentieth century - per- worsen the health status of the offspring;
haps first for the qualities of drinking water - i.e. • No accelerates aging and shortens life expec-
“Limit values” - the Brussels Commission in 1853, and tancy.
the first standard for water - USA, 1914 The devel- Dose's approach is fundamentally correct, but
opment of hygienic norms and standards for work there are features associated with the pathway of
environment factors starts during the first half of the chemical substances in the body, different exposure
twentieth century. It is known that the process of hy- time (shift, day, week, year, total length of service),
gienic normalization is continuous, despite the vast area of ​​exposure and others. Eg. in chemical factors
accumulated material, due to the continuous devel- determine the maximum-single time and mid-shift
opment of human knowledge, both in the field of allowable concentrations, similar is a normalization
production and technology, and the impact of fac- of non-ionizing electromagnetic fields (allowable
tors on the body. energy for work shift and allowable maximum in-
Basic concepts (criteria) for hygienic normali- tensity).
zation of working environment factors are: It is especially difficult in normalization to: low
• “Medical” - avoiding damage to health; doses, different path ways of entrance, entrance and
• “Publicly acceptable risk” - comparing with by environmental (not only by labour environment),
the situation in a “successful” (compared to combined and intermittent action. More exactly and
others) production in relation to health, or to easy is normalization using experimental models of
the so-called “natural background”; animals and humans (but the latter is very limited),
• “Economic criteria” - funds for the improve- but it is difficult interpretation in the obligatory ep-
ment of working conditions and the econom- idemiological study of people in real working con-
ic losses from diseases, retirement and reas- ditions and taking into account the influence of fac-
signment; tors of lifestyle and nutrition.
• “Zero levels” - non-factor and reduce it to that It was pointed out that in the field of hygienic
in “natural” conditions of the environment. standardization has gained vast material. Although
Since in the base of hygienic normalization is the it is an ongoing process, established productions
concept of so-called “threshold” (quantify) of the ad- now it will be done only in the emergence of new
verse action - to remind the definition of Paracelsus factors, qualitatively distinct from previously known
“Everything is poison, only the dose makes the - eg. now for evaluating the toxic effects of con-
poison invisible” health criteria are the main. Cer- stantly emerging chemicals and compounds, used
tainly in specific cases, linked to the other conditions quick "account" methods followed by monitoring
of work - eg. time of exposure, combined with other the health status of people working with them. Now
hazards, path ways of entry, time for practical imple- normalization will target in two main areas:
mentation, etc., into account are also the other con- Ÿ the impact of factors with less intensity on
cepts (criteria). This applies also and in a stochastic efficiency in modern forms of work and on com-
factors (no-threshold action) - eg. ionizing radiation fort - eg. and now standards for production micro-
with regard to gene mutations in somatic and sex climate are admissible and optimal (providing com-
cells. fort and high performance), with Fanger's indicator
The theory and practices of hygiene standards is (ISO-7730) is defined thermal comfort/discomfort;
based on two sets of criteria: the standard of ISO-2631-1 for general vibration
• Evaluation of biological action - indicators defines three levels of permissible impact, two of
of health status, performance, psychological which ensure “no influence of performance” and “no
state; disturb comfort”; permissible sound levels in mainly
• Assessment of factors - the degree of ex- mental work are much lower (50-65 dB/A) than for
pression (intensity, concentration), exposure enterprises - 85 dB/A (with a view harmless auditory
(shifts, total length of service). senses).

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 OCCUPATIONAL MEDICINE
Ÿ connecting hygiene standards with determi- the presence of the effect (biological response) rel-
nation (evaluation) of the health risk. Until now, ative to this factor, or by epidemiological studies an
existing data accept the position, that the joint ac- increased incidence (i.e. a dose-effect) of cases with
tion of factors prevails so-called total action. It re- adverse health condition (disease or other).
flected in a widely known formula to chemical fac- Ÿ Certain factors have no threshold effect - eg.
tors C1/TLV1 + S2/TLV2 + ... .. Cn/TLVn ≤ 1, but it turned ionizing radiation and carcinogenic effects. With
out that it is only applicable to xenobiotics with a mathematical models here are account of the risk
similar action (eg. substances with narcotic effect). of increased incidence of fatal malignancy in large
The enormous variety of factors in the working en- populations irradiated with an appropriate dose,
vironment and conditions of the employment pro- compared with natural (background) rate of the
cess with less intensity (about hygiene standards), general population. In these so-called stochastic
combined with the conditions of lifestyle and nutri- health effects can not determine at what dose will
tion, does not require continual introduction of new arise a disease (and with what degree of damage) in
and new standards for the individual factors but a the individual (with probability p ≤ 0.05), but how
new approach to the assessment of their adverse many cases will increase the frequency of the dis-
impacts. These impacts are associated primarily ease, according to the number of impacting people.
with a reduction in immunological reactivity of the When factors of low intensity or in those who are
organism and hence with increased incidence of unable to establish a dose-response relationship
general morbidity - cardiovascular, cancer, allergic, (shown dose-effect) are used multi-factor complex
respiratory and others. Also with reduced capacity methods for statistical analysis - factorial, discrimi-
and with the states of discomfort. In the 80s of the nant, logistic regression and the like. Create models
twentieth century studies by NIOSH (USA) and de- that seeks significance more than 3/4 (75%) - ie, that
velopment of the expert group of the WHO intro- a combination of adverse health factors (including
duced the term “building associated ilness", which studied by us) in over 75% of people (employees)
occurs when working in modern buildings (offices, will develop this condition (disease). Basic statisti-
administrative premises, control services, etc.), sub- cal method here is the definition of so-called. odds
jected to the action of many factors with a small ratio (OR) and relative risk (RR) based on method x2
intensity. Described are real and potential adverse for non-parametric statistical analysis - i.e. assess
conditions with short and long latency period and the reliability of differences in incidence (diseased/
is not always associated with certain exactly agent - non-diseased) when operating in industries with re-
i.e. “syndrome of confined office” “mass psychogenic search risk factors and those with absence of this risk
illness,” “hypersensitivity pneumonitis” and others. factor. Use also other methods of statistical analysis -
All this necessitates for the health risk assessment variance, correlation, regression, and make compar-
of action to already normalized factors in the work isons of data obtained through them. An interest-
environment. ing feature (not a contradiction!) here is justified
Health risk assessments is relatively new, cur- combination of proven probability p ≤ 0.05, with
rent, and prospective area of ​​hygiene science and the importance of forecasting (participation in
occupational medicine in particular. The risk assess- model) phenomenon (illness or other) at 75% or
ment includes an evaluation of the ability of the fac- more of the people.
tor (s) to participate for the occurrence of adverse The so-called “philosophy of health risk assess-
health conditions. The risk assessment includes ments” based primarily on the so-called principle
the so-called four main paradigms - identification ALARA (As Low As Reasonably Achievable). “Philos-
of risk; determining the dose/response; exposure ophy” is based on the following situations:
assessment; risk characterization. They are interre- - “Zero” risk does not exist - each activity is associ-
lated and include both experiments on laboratory ated with some degree of risk;
animals and humans (when possible) and epidemi- - Safety (full) no - relative safety is related to ac-
ological studies for working in industries with health ceptance of some degree (level) of risk;
risk factors (including that/those of whose effect will - The level of risk is manageable with appropriate
be demonstrated). Here should be forecast some personal and collective preventive measures;
specifics: - Health risk varies between two conditional lim-
Ÿ Not always found exact dose-response relation- its - from 0 to 1 or 1 ≥ R ≤ 0, where R = 1 when the
ship. In operation at low intensities (doses) or factors risk is unacceptably high, and when R = 0 - very low;
with expected fewer degree to contribute to the - In all cases (values) of R, take appropriate pre-
occurrence of a condition (eg. a toxic factor and hy- ventive action based on the principle ALARA;
pertension) is sought, most often in the experiment - The safety level of the system (B) - B = 1 - R.

40
 LABOUR MEDICINE
Applying ALARA principle shown in Fig. 1, where
the cost to compensate the effects of risk “Y” are costs to costs to

”
“Y
compensate for the “Y” safety “X”
costs to compensate victims (temporary disabili-

es
ex

ens
p en

unacceptable risk

exp
ses
ty, occupational diseases, prolonged work, work at

negligible risk
tolerable risk
“Y
”

requirements
to BZR)
high risk, etc.), property damage, unrealized pro-

(min
duction, worsened quality and rejects etc. These costs to costs to

optimum
safety “X” compensate for the “Y”
costs are a linear function of the magnitude of the
risk. Cost (X) to enhance safety (B) are exponential safety level B = 1 – R

curve. Curve “S”, expressing the sum of the cost “X” Fig. 1. Scheme for implementation of the “ALARA”
and “Y” has its optimum, which can be associated (by D. Dimitrov, 2002)
with the application of the principle ALARA. The ap- extraction, agriculture and services. Economy and
plication, however, is closely related to the setting active population of each country are distributed in
of minimum requirements for safety, ie hygienic different sectors.
norms and standards, which should not be exceed- In industrialized countries, such as France and
ed. Moreover, there intervene a number of health, Germany, for example, employed in industry are
ethical and humane considerations in the valuation about 40-50% of the active population. But in each
of “reasonable eligible costs”, especially when con- of these countries has a modern agricultural sector,
sidering prevention and health promotion. which is industrializing and services sector (respec-
In the diversity of the relevant factors, health risk tively around 6-9% and 45-50% for France and Ger-
assessments, as current prospective area of ​​occupa- many in the 80s).
tional medicine has its very great practical value for The part of industry in relation of employment
the introduction of mass control for health workers. of the active population and the economy is a key
Solving the problems caused by the influence and explains the use of the term industrial society
of work environment factors on health in contempo- although the balance between the different spheres
rary work focuses on: of employment and activity is not final and chang-
• technical facilities and technology - mas- es. Beyond the differences between countries due
sive automation (computerization) of produc- to differences in their resources at the beginning
tion lines (processes) and use of non-waste and their successful use, in developed countries is
technology with low emergency risk; a tendency for informatization of the active popula-
• training of workers - higher profession- tion and economy, and with a significant reduction
al qualifications; training for maximum safe in the agricultural sector at the expense of industry.
operation of facilities repair and emergency The latter initially developed rapidly after it reaches
situations; creating sustainable habits for a a level and no progressed (or progressing too weak
healthy lifestyle; and tends to regress), while the services sector has
• health risk assessment in the specific work- steadily increased. As a result, the term industrial
ing conditions in modern productions. Estab- society rather reflected a balance of activities in the
lishment of the organization and participation economy, built on high technology and informatiza-
of the occupational doctor into it permanent tion (electronization).
comprehensive monitoring of the health sta- Evolution of industrial society. The transition
tus of workers; from craft to industry in the early nineteenth cen-
• health policy - to favorably resolve problems tury led to profound changes in working conditions
related to workers’ health. and put its mark on modern society.
The main characteristics of the artisanal work,
1.3. FORECASTS FOR THE DEVELOPMENT conceived and carried out by the same person, using
OF POSTINDUSTRIAL SOCIETY3 the technology and knowledge that are the result of
a long process, and motivation, whose ultimate goal
1.3.1. INDUSTRIAL SOCIETY is creativity, largely removed from industrial labour.
The division of tasks, hierarchy functions, collec-
This society is often defined as industrial for tive framework of the production units, typical of
countries that have reached a high degree of eco- industrial labour leads to dehumanization of work.
nomic development. This name covers other activi- Technological progress deepens the discomfort
ties, including unless industry itself also raw material of the transition from craft to industry in the grow-
1
In Leplat J., H. Monod - Evolution de conception d, organisa-
ing replacement of manual labour with mechani-
tion du travail. Precis de medicine du travail, sous la dir. De H. zation. Fragmentation and complexity of manufac-
Desoille, J. Sherrer, R. Truhaut, 6 ed., Masson, Paris, 1992. turing operations makes human subject, crafted a

41
 OCCUPATIONAL MEDICINE
article with tools or machines, in person – object, and social relations in the enterprise, account
connected or even subordinated to the machine. So that the operators (or at least most of them) will have
artisan who became a worker, loses his creative free- a full and broad education and new responsibilities
dom and functional autonomy, despite the fact that related to the need for automation and organiza-
social life offers more knowledge and opportunities. tional and managerial functions. The transition from
These are all conditions for “industrial disadaptation.” mechanization to automation, from manual labour
Its manifestations in the form of labour conflicts, ab- to more intellectual tasks, that require control and
senteeism and increasing disrespect for industrial regulation of processes, allows for a return to auton-
labour. Connected with this, and characteristic of omy and initiative specific to artisanal labour. Inter-
industrial society is still relatively high frequency of personal and intergroup relations is also determined
accidents (whose importance and seriousness were by the greater autonomy and responsibility of peo-
denied), but also disease (professional or not), wear ple, teams and manufacturing units. So strictly hier-
the organism and premature aging. archical relationship lost its advantage, in order to
reach what is referred to as “industrial democracy.”
1.3.2. TO POSTINDUSTRIAL SOCIETY. Primary evolution towards postindustrial so-
ciety is marked by the importance given to the
Most modern enterprises and government explore human factor. His place will grow in proportion to
means of eliminating more obvious disadvantages of the complexity of production processes, whose ca-
working conditions in industrialized countries. pacity (quantity and quality) will depend again by
In technical terms the changes that lie ahead the operator, as before by the machine or working
should lead to the development of automation in movements. The importance attached to human
industrial production (to free the worker from me- factors will allow to balance professional life with so-
chanical tension) as well as research in areas where cial (reduction of working hours, work at home, etc.).
automation is not yet implemented. However, before the period of transition to a postin-
To relieve labour and increase its attractive- dustrial society, which will be prolonged, it should
ness to introduce systems of work, aimed alterna- be expected inevitable tension. It will be mainly due
tion task by staff rotation to break the monotony or to internal reorganisations and conversions of en-
reduce physical effort; be grouped again fragment- terprises; uncertainty in the productive sectors; the
ed small operations to obtain a work task with more discrepancy between the process of adaptation to
importance for the worker; to re-evaluate their pro- the labour and relevant training tools and process-
fessional activity, as it integrate organizational and ing, etc. Because of this transition to a new form of
managerial functions. society will include largely scientific predictions,
In this connection, the more likely it is the smaller based not only on existing methods and disciplines
production units with greater autonomy to progres- in the field of exact sciences, but also the disciplines
sively displace the larger. of human science, such as psychology, physiology
With regard to professional qualifications, this and sociology.
evolution will lead to a significant reduction in the As far as the interdependence between labour
proportion of unskilled workers and back increase and the environment will increase, they will converge
the technical staff, engineers, researchers. There is ergonomics as a scientific approach to labour and
for example the emergence of a new category of ecology as a scientific approach to the environment.
workers working with industrial equipment or oper- This multidisciplinary perspective of the postin-
ators to surveillance. Their work is primarily intellec- dustrial society, participation of sciences who study
tual, not excluding some manual operations. human will be mainly, and occupational medicine
These changes will lead to a change in hierarchy will takes its place.
REFERENCES:
1. Apostolov, M., History of Medicine - Sofia, Med. and phys., 1977. (in bul.)
2. Encyclopaedia of Occupational Health and Safety, ed. J.M. Stellman, v I, 4 th ed., ILO, Geneva, 1998.
3. Environmental and Occupational Medicine - ed. W.N. Rom, Little, Brown and Co, Boston, 1 st ed., 1983.
4. Guide for hygiene of labour - ed. Krotkov, G., Moscow, Medicine, 1, 1965. (in russ.)
5. Guide for hygiene of labour - ed. Izmerov, N.F., Moscow, Medicine, 1987. (in russ.)
6. Guide fo hygiene and occupational diseases - ed. D. Tsvetkov, Sofia Med. and phys., 1994. (in bul.)
7. Hygienic standartization factors of working environment and labour process - ed. Izmerov, N. F. and
Kasparov, A.A., Moscow, Medicine, 1986. (in russ.)
8. Nikolova, S.Y., Health and safety conditions at work - Sofia, Bulgarian Chamber of Commerce, Fund
“Working Conditions”, 2005. (in bul.)
9. Occupational Medicine - ed. J. La Dou, Appelton / Lange, Norwalk, California, 1990.
42
 E. Dincheva

2 PHYSIOLOGY OF LABOUR

Human in its existence is in constant interaction fense mechanism, whose physiological function is
with the environment. The whole existence of the to prevent the occurrence of pathological changes;
organism is a continuous chain of stimuli and re- problems of intellectual labour and occupational
sponses to these stimuli. The framework in which stress; individual abilities and personal characteris-
these changes in the body in response to external tics; problems of shift work and night work and oth-
conditions do not lead to pathological changes are ers.
physiological limits or conditions of existence. In Physiology of labour is the object of a num-
his work the person meets specific changes in en- ber of science-practical tasks: the standardization
vironmental conditions and with different types and categorization of severity of labour; develop-
and weight loads. For this reason, in general physi- ing science-based regiments of work and rest; de-
ology as a science, departed branch or department velopment of ergonomic requirements for work
studying processes in the body in the course of bal- equipment, furniture; rationalization of working
ancing his work environment and requirements of movements, etc.
the workload. On the other hand knowledge of the
many factors of working environment and labour 2.1. PHYSICAL WORK
process is important in assessing the response of the
body. Therefore, currently, the physiology of labour Depending on mostly what body systems are in-
is accepted as part of hygiene/or medicine of labour. volved in the implementation of the work the work
In the last 2 decades of technological progress is divided into physical and non-physical or mental
have even more complex relationship between in the most general sense. In any kind of physical
body, working environment and social environment. work involved and nervous system and in any men-
In industry the tools undergo not only enormously tal work - and sceletal-muscular system. Therefore
development and of appendage of the human hand it is more correct to speak of mainly physical and
became a leading unit, but the development of new mostly mental work.
technologies led to the “extension” of the human
brain or enhance its “capacities”. The highest forms 2.1.1. TYPES OF PHYSICAL WORK
of work organization associated in a functional com-
plex large groups of people and machines, to build According to physiological characteristics of
complex systems and networks pokrivashi major re- muscle contraction work can be dynamic or stat-
gions and parts of the Earth. Employment in these ic. As a physiological phenomenon, dynamic work
systems and networks is subject to the same re- is a isotonic muscle contraction, that involve various
quirements, sometimes a rhythm, responsibility, etc. units of kinematic chain, i.e. moving relatively to
All this puts the man in front of new requirements each other, to carry and mechanical work. It is ac-
in the process of balancing his employment. These cepted that dynamic work is divided into two types:
changes in the nature of work, place issues of psy- “positive” and “negative.” Usually the first is associat-
chology and psychophysiology of labour as a part in ed with concentric contraction of the muscles and
the general labour - hygienic problems. the second with extension of the muscles actively
Physiology of labour used physiological, bio- resisting to the stretching force by developing ten-
chemical, psychological and occupational hygienic sion. For example, when climbing stairs extensors of
methods. Subject to the study of the physiology of feet made positive work, and when he came down
labour are: problems that occur on the organism they stretch and made a negative work. Energy con-
in different types of workloads and performance sumption in the negative job is much smaller.
issues; the problem of fatigue as an important de-

43
 OCCUPATIONAL MEDICINE
Static work we have in isometric muscle contrac- movement optimal time for performing the move-
tion in which the muscle does not change its length ments should be 0.3-0.4 s, which corresponds to a
and growing its internal tensions. In static tense rate of about 2.4 movements s., and for large classes
muscles blood irrigation is insufficient due to con- - 0.7-0.9 s. Another classification proposes to distin-
striction of blood vessels, creating conditions for the guish three degrees of rhythm of work:
accumulation of acid products, delays in the release Moderate rate - up to 20 movements of the arms
of metabolic products and fatigue occurs rapidly. or legs and the body 10 for 1 min.
Static work occurs with less energy expense, but Average rate - from 21 to 40 movements of the
immediately after stopping its oxygen consump- arms or legs and 11-20 body movements for 1 min.
tion and the amount of evolved carbon dioxide High rate - more than 40 movements of the arms
increased and the recovery process due to oxygen or legs and over more than 20 of the body for 1 min.
accumulated debt is slower.
Static working there is when the muscle is unable 2.1.2. CATEGORIZATION OF LABOUR
to overcome the load. In practice these are all work-
ing operations in which there are elements of main- Dosing workload is an important issue through
taining weights, tools or uncomfortable posture. The which reach major labour hygienic purposes - main-
static operation leads not only to the development taining performance at an optimal level long, dis-
of fatigue, but has pathogenetic factor for diseases tances to the development of fatigue, avoid the
of the skeletal muscular system - myositis, tendinitis, development of overstain and that related illnesses.
tendovaginitis and the like. For example, in tiling of Dosing of the workload is important, especially for
teared fibers hands of spinners are extremely unfa- the so called vulnerable groups - persons after have
vorable posture - raised up and this static tension, ill in the recovery period, women, new or young
repeated a hundred times in the course of the work- workers, subjected to reassignment. The categoriza-
ing day is pathogenetic factor for the development tion of physical labour is legally governed and great-
of professional damage to the shoulder joint. ly assist in solving these issues. Classification of work
Different types of physical work require differ- is important for the standardization and remunera-
ent muscle strength and hence the inclusion of tion of labour.
different strength and amount of muscle (mus- The criteria for the degree of physical labour is
cle mass). Physical work is defined as common as mainly based on indicators of energy consumption,
2/3 of muscles are engaged to perform it. Typically, pulse rate and indicators of external breathing.
such work requires great energy expense and often Energy consumption is very accurate quan-
refers to the category of heavy physical labour. In lo- titative indicator to determine the heaviness of
cal muscle work involved mainly the muscles of the labour for severe and moderate loads and less ac-
hands. This kind of work is widespread - meeting at curate at light loads and in static operation. Energy
different manipulative activity, at work on convey- consumption can be measured in kcal/kJ / for 24h,
or, assembly work and many others. Very often, the for 8h, for 1h or for 1 min. Daily balance of energy
effort required to perform labour operations is not consumption is the sum of power consumption dur-
consistent with the smaller muscle groups of hands, ing sleep (average for 8 h about 560-600 kcal - 2300-
working often with great pace and rhythm imposed. 2500 kJ, i.e. approximately basal exchange), energy
Occupational injuries sceletal-muscular system in consumption in their free time (1100-1200 kcal -
this type of work are common. In the expert opinion 4,600-5,000 kJ, or twice the basal exchange for 8h)
of work, to take professional nature of the disease, and energy consumption for 8 h work (in heavy and
using the following classification of working move- very hard work can reach 2500-3000 kcal - 10500-
ments: 12500 kJ). This is an estimate of energy consumption
1st class - are involved muscles of the fingers and in uniform for the whole day activity.
wrist; In practice, the most common classification of
2nd class - are involved muscles of the fingers, work is based on a reading of energy consumption
wrist and forearm; for 1 min. This involves measuring the energy con-
3rd class - are involved muscles of the fingers, sumption at the main operating procedures and
wrist, forearm and elbow; calculation of averages based on timing research.
4th class - includes muscles and arms; Thus in addition to the average energy expense for
5th class - in movement is included and shoulder. a given profession we can have and details of peak
For prevention it is important to know that with moments and worst working operations in a profes-
the increase of the class of movement their rate must sion. On Table. 1 is a classification of work adopted
be reduced. It is considered that for small classes of in our country.

44
 LABOUR MEDICINE
Tabl.1.
Man Wemen
Category kJ/min kJ/min
kcal/min kcal/min
1 Light work up to 3 up to 12.57 up to 2.4 10.04
2 Moderate work 3-5 12.57-20.95 2.4-4 10.04-16.72
3 Hard work over 5 over 20.9 over 4 over 16.72
4 Very hard work over 6.5 over 27.3 it is not allowed it is not allowed
Note: Power consumption is presented in gross values.

The data presented in Table 1 are average for In our country has adopted the following catego-
both sexes. When we need to assess the possibilities rization of labour according to pulse frequency:
of a person to perform a certain kind of work best • Light work - up to 90 beats/ min.
to use categorization consistent with individual pos- • Moderate work - from 90 to 100 beats/min.
sibilities. This approach is particularly important in • Hard work - from 100 to 110 beats/min.
reassigned workers. The assessment is made on the • Very hard work - over 110 beats/min.
basis of maximum aerobic capacity (or maximum Pulse rate can reach up to 200 beats/min. at sport-
working capacity - MWC). It is believed that person ing events in well-trained athletes. It is believed that
for a long time may perform work that is 30% of its above these values ​​begin to suffer supply the heart
MWC. For example, if the person at its maximum muscle with blood. In workload heart rate should
load (to failure) can reach energy expense 12 kcal/ not exceed 130-135 beats/min. On Table. 2 shows
min (50 kJ/min), then work with energy expense 3.6 the valaes of the pulse rate in one of the most hard
kcal/min (15 kJ/min) is practically no fatigue him. operations in same professions.
Based on the MWC’s work is classified as follows: 1. But by working pulse rate, the heaviness of labour
Light work - load is 10-20% of the MWC; 2. Moder- can be characterized by the dynamics of the heart
ate work - load is 20-30% of the MWC; 3. Hard work rate during recovery. It is estimated that in the first
- load 30-40% of MWC. 4. Very heavy - load over 50% minute of recovery pulse rate should not exceed 110
of MWC. beats/min and the third can be below 90 beats/min.
Tabl.2.
№ Profession Business operations Pulse in beats/min
Perforate 125-135
1. Miner (underground) Caving 132-138
Fastening 130-135
Drilling 114-120
2. Miner (open pit)
Bomber 125-130
Felling trunk (manual chainsaw) 130-135
Limbing 120-130
3. Woodcutters
Measuring and sorting 120-125
Landslide logs (with animal traction) 128-135

In assessing indirectly for energy consumption In assessing the physical load by pulse rate, should
can be judged by oxygen consumption, but also be borne in mind and the influence of factors such
by lung ventilation. It is believed that oxygen con- as age, sex, fatigue, emotional state, diurnal rhythm
sumption to 0.5 l/min. meets the light work, from 0.5 and more.
to 1.0 l/min - moderate work and oxygen consump-
tion over 1.0 l/min corresponds to the very hard 2.1.3. CHANGES IN ORGANS AND SYSTEMS
work. The determination of energy consumption on DURING PHYSICAL WORK
lung ventilation can be done only in those activities
in which are included large muscle groups. 1). Changes in the cardiovascular system
The ability pulse to be accepted as an indica- Changes in the cardiovascular system during
tor of the heaviness of labour stem from the fact physical load is important for the adaptation of the
that oxygen consumption and heart rate showed a organism to labour. The state of the cardiovascular
high correlation coefficient up to the critical values​​ system is largely the factor that limits the efficiency.
of oxygen consumption around 3.0 l/min and heart External and tissue respiration have a significantly
rate around 200 beats/min., then the increase of the larger reserves and oxygen deficiency is determined
pulse is greater. by the ability of the cardiovascular system to pro-

45
 OCCUPATIONAL MEDICINE
vide necessary for a physical effort circulation. In same level or may drop slightly. In this regard, the
the resting pulse rate at 70 beats/min and stroke pulse pressure increases and serves as the sign of
volume 80 ml, minute volume is 5.6 l/min, systolic the stroke volume of the heart. Of this normoton-
index (the ratio of stroke volume on 1 kg of body ic kind of reaction differ hypertonic type, asthenic
weight) is 1-1.5 and cardiac index (minut volume on and dystonic type of reaction, that sign of untrain-
1 m2 of body surface) is about 2.8. When loads stroke ing of the cardiovascular system or pathological
volume gradually increases, but upon reaching the changes in heart muscle or peripheral vascular sys-
oxygen consumption up to 2 l/min remains constant tem. In static working increases the maximum blood
- about 150-170 ml. These values show that the max- pressure significantly, but are also being increased
imum amount of blood that can pass through the and the minimum blood pressure, pulse pressure
circulatory system is approximately 30 l/min. This showed no significant increase.
allows maximum transport of oxygen 3.5 l. Mean- At muscular work cardiovascular activity passes
while, the lungs can pass about 100 l air to deliver through two stages: the period of inworking and a
5-5.5 l oxygen. period of steady state. The period of inworking of
Functional setting of the cardiovascular system the cardiovascular system is short - from 20-30 s to
is aimed at creating adequate circulatory balance to 2-3 min. We must distinguish between the period
ensure the necessary substantial humoral exchange of inworking at physical load and the period of in-
of tissues, according to the increased requirements working at the beginning of the work shift, which is
in connection with the work performed. In hemo- considerably longer and its mechanism lies the prin-
dynamically terms this means to deliver relevant ciple of formation of dynamic stereotype, and adap-
inflow of arterial blood and out flow in the vein of tation to the complex working conditions.
the working body and flow of venous and arterial Especially important is the recovery period af-
blood to the heart. The setting of the circulatory sys- ter the termination of the load. We distinguish ear-
tem becomes by neuro-reflex tract, allowing greater ly stage of recovery and stage of actual recovery.
speed of changes. The implementation of neuro-re- Early recovery takes 30-60 s and is characterized
flex regulation includes a series of mechanisms in by a steep drop in the pulse rate and the maximum
which the main factor is the heart, but along with blood pressure. In the second stage of the recovery,
it however no small role playing and peripheral cir- the parameters of the cardiovascular system is clos-
culatory system, the movement of muscles and res- er to the initials. The development of recovery has
piratory system. exponential curve and depends on load. In samples
First with the start of a movement (or before him with dosed exercise at the end of the third minute to
- conditional reflex reaction) becomes redistribution reach full recovery. In static work immediately after
of blood volume. It is pushed from blood depot in switching, pulse rate remains unchanged and the re-
the abdomen to working muscles. Abundant blood covery process proceeds more slowly.
supply to the muscle allows for their contraction to In well-trained individuals the response of the
push a significantly greater quantity of blood to the cardiovascular system to a moderate load is charac-
veins. Thus muscles act as an additional pump that terized by a smaller amplitude changes - pulse rate
assists the heart in particular with respect to venous is rising less, and the recovery is faster compared to
flow. Respiratory movements also assist venous flow the untrained individuals (Fig. 1). At maximum load
through sequential decrease and increase intraab- (denial) untrained persons meet with greater fre-
dominal pressure. These mechanisms provide quick quency pulse.
and plentiful supply of blood to the heart. 2). ECG changes
Filling of the heart depends on the duration of Physical work needs increased myocardial ox-
diastole. In fast heart rate reduces its duration, so ygen and blood flow in the coronary vessels. This
harmonious consistent output of venous flow and can lead to a inconformity between the demands
duration of diastole is essential for efficient and eco- of the myocardium of oxygen and entering in coro-
nomical cardiac output. This is achieved by a com- nary vessels blood. Electrocardiography allowed to
plex neuro-reflex regulation featuring baroreceptors express themselves inadequate in terms of myocar-
of v.cava and proprioreceptors to working muscles, dial loading. ECG changes also reflect the modified
and also with the participation of humoral regula- speed and direction of blood, changes in neuro-veg-
tion of simpatico-adrenal system. etative tone. These changes can be visualized pri-
When exercise the maximum blood pressure is marily through two approaches - classic when ECG is
generally increased in healthy people, with this in- recorded at the time of load (although difficult using
crease is the greater, as the intensity is greater. Min- no standard - leads) and is registered in the first 15 s,
imum blood pressure rises slightly, remains at the after loading, of the first, second and sixth minute of

46
 LABOUR MEDICINE
Load Recovery tachycardia after 3 minute break; 3). ECG changes in
the conduction system; 4). ECG changes in the inter-
val ST and T wave.
well 3). Changes in muscle
trained
average
One of the important conditions for effective
trainee work and out of fatigue is good blood flow to the
working muscle. If the muscle has good conditions
Puls- beats/minutes

for the supply of oxygen, anaerobic decomposition

processes may even before the formation of lactic
acid being switched to aerobic cycle of tricarbo-
xylic acids. Thus, if observe to specific conditions,
such as the supply of carbohydrates, the work can
be performed for a long time. The maximum flow
rate of muscle depends on vasodilatation and the
minimum of force of muscle contractions. Maximum
flow of muscles in a dynamic work is determined by
140-200 ml/min per 100 g muscle against 2-3 ml/
min at rest. In static operation, if the force of mainte-
Minutes
nance does not exceed 20% of the maximum capac-
Fig. 1. Effect of training (on Brua)
ity of the muscle, increase blood flow can reach 15-
recovery, or at conditions of employment and recov- 30 ml/min per 100 g muscle mass in which work can
ery, by recording of Holter systems. continue for a long time. Above 70% of maximum
Important for assessing the state of the myocar- opportunities blood supply is extremely limited and
dium is the application of samples of dosed exercise the work can last only a short time.
intensity and duration, as submaximal and maximal 4.) Changes to the respiratory system.
loads are achieved gradually or stepwise with con- The respiratory volume increases linearly with
tinuous monitoring of changes in pulse rate, blood the increase of the load and of 500-600 ml/min can
pressure and ECG. Ergometry bicycle allows to ac- reach up to 2000 ml/min. The effectiveness of the in-
curately implement dose and standard load and be crease is limited by the increase of respiratory dead
quickly terminated at the appearance of indications. space. Minute respiratory volume of 6-8 l/min can
It is generally accepted that in order to provoke the grow up to 100 l/min, as its limitation comes from
cardiovascular system and manifest ECG changes, increased respiratory dead space with shortness and
pulse rate with loads should reach 160-170 beats/ frequency of breath. At that oxygen consumption
min. Most often and best manifest ischemic chang- increases linearly with breathing minute volume to
es in left precordial leads (V5). They are expressed certain values -​​ up to 2 l/min, after which the growth
by lowering ST-segment associated mostly with re- of minute respiratory volume is ahead of that of ox-
duction or inversion of the T wave. Decreases in ST ygen consumption. Maximum oxygen consumption
below 2 mm horizontaly and/or descending, sure in well-trained men can reach up to 3.5 l/min, which
evidence of myocardial ischemia, occurred as a re- is limited by the cardiovascular system.
sult of a discrepancy between physical activity and Reduced physical activity
opportunities of coronary vessels. In a number of modern professions (operators
Close by informative are ECG recordings imme- of control desks, apparatuses, working on a video
diately after the implementation of the two-staged display, workers in offices, management staff and
test steppe Master or other standard workloads that many others, are increasingly present adverse ef-
do not require sophisticated equipment. Step Test fects of factors hypokinesia (reduced physical ac-
Master successfully used both in dynamics during tivity). In another large group of professions carried
the working day, and in assessing the degree of re- out a large number of manual operations, mainly
duction of physical efficiency in workers spent some from small muscle groups of the arms - hypody-
somatic, infectious or diseases of the cardiovascular namia (occupation of the conveyors, installers,
system. This is particularly important for workers en- workers from the electronics, textiles and clothing,
gaged in moderate or hard physical activity. As an etc.). Because the consequences of hypodynamia
expression of pathology accepted criteria: 1). Occur- and hypokinesia of the body slightly differ, used the
rence of dyspnea, cyanosis, cardiac pain; 2). Sinus general term “reduced mobility”. At the professions
tachycardia with heart rate above 120 beats/min, reduced physical activity is added and the deficit of
paroxysmal tachycardia or arrhythmia, extrasystole; the social-mode of life physical activity.

47
 OCCUPATIONAL MEDICINE
The changes in the body as a result of reduced rests must comply with the specificity of the work
physical activity in less movable and less dynamic and the dynamics of the performance.
professions often arise on background of the pro- In addition of intersfifts prevention of the effects
longed static exertion of muscles, providing forced of reduced physical activity it is particularly impor-
standing or sitting posture, resulting in changes in tant and conducting activities outside working
performance due to both factors. hours, aimed at improving the physical training of
The main factor in the mechanism of hypokinetic the body.
and hypodinamic changes is to minimize the load
on the cardiovascular and musculoskeletal system. 2.2. NON-PHYSICAL OR MENTAL WORK
This led to a decrease in the level of functional status
of these systems and their detraining and reduced Mainly issues related to determining the weight
capacity. Detraining of cardiovascular system is ex- and classification of non-physical or mental work
acerbated by postural fluid redistribution in the are much more complex than in the physical. More
body where the blood circulating in vessels lost complex are the problems of mental fatigue and ex-
their normal tone. Under these conditions humoral haustion and health consequences of them. If phys-
regulation of the cardiovascular system is not able ical work can accurately determine by the energy
to provide a influx of the required amount of blood expended and on this basis or on the basis of the
(oxygen) to the brain, which is one of the main pre- working pulse can be categorized and normalized
conditions for the reduction of mental performance labour, it is impossible in mental work. First, it fol-
and development of fatigue. By a number of authors lows from the fact that as the increasing intensity of
found that the immobilization results in a reduction metabolic processes in the brain, due to the relative-
of the activation process and from there to consider- ly small volume to the body, they insignificantly af-
able disturbances in the central nervous system, the fect the total energy expense. Secondly this “work-
hormonal changes, water-salt and energy metabo- ing” organ is incredibly complex and many sides of
lism. its operations are still in the area of ​​hypothetical ex-
Detraining in conditions of reduced physical planations. On the other hand mostly mental work,
activity leads to sharply reduce the possibilities of because of the different requirements for the basic
functional systems. Very common are inadequate neural processes, analysts, psychomotor, varying de-
reactions - increased intensity of muscle work irrele- grees of involvement of hormonal mechanisms, and
vant to the physical load, unproportion movements. emotional sphere is very diverse. Therefore, one of
Violations in coordination functions of locomotori- the approaches for studying the workload and strain
um in turn make it difficult to adapt to working con- in this kind of work is it to be classified based on
ditions and workload. In these professions it is hard mainly involved in its work processes and on this ba-
to staff at the beginning of the working day and sis to analyze and evaluate the intension of labour.
slowly reaching steady working condition.
Decreased physical activity in modern socie- 2.2.1. CLASSIFICATION OF MAINLY
ty leads to so-called hypokinetic disease. In it are INTELLECTUAL WORK
characteristic changes in the central nervous system
(reduced activity of excitation processes, anxiety, 1. Work with predominantly sensorineural in-
drowsiness, emotional instability), disorder in the tension.
metabolism, disorders of the gastrointestinal tract In this type of work they are loaded mainly sen-
and the like. Decreased physical activity and neu- sory organs, mainly the visual and auditory. These
ro-psychological tension in contemporary profes- are so called observer occupations such as opera-
sions are and etiology of cardiovascular diseases. tors, equipment operators, proofreaders and others.
Most important for the prevention of adverse ef- Of course, observation activity involved and central
fects of reduced physical activity are events aimed at parts of the analysts, basic neural processes and es-
creating a rational regime of work and rest in which pecially processes of attention, but if the work is not
the principal is the implementation of active inter- complicated, the load is mainly on visual or respec-
shifts rests. Lengthy period of inworking gives base tively auditory analyst. Usually when evaluating this
to propose the introduction of a regulated rest at type of work are examined changes in hearing sensi-
the beginning of the work. This is so-called opening tivity of the analyzer, fatigue accomodation mecha-
or introductory active recreation. The complex of ex- nisms, changes in the electrical sensitivity of the eye
ercises performed before or 10-15 min. after starting (ocular reobasis), critical frequency signal mergence
work, contributes to more rapid introduction into and others. From the degree of change at the end of
the labour rhythm. Later during the work shift active the day assessing the intension of labour. Further-

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 LABOUR MEDICINE
more, in the physiology of labour there are classifi- a large amount of information during the workday.
cations of the intension of the labour on the basis Here goes the work of students, researchers. In these
of number and size of observed objects, changing professions is engaged more and visual analyzer,
their perimeters per unit time, the relationship be- and also processes of directed attention. The eval-
tween relevant and “noise” signals etc. uation of the intension of work is done on the basis
2. Mostly sensoryneural and psychomotor of changes occurring in the course of the working
work. day in the visual analyzer, the maximum amount of
In this type of work, to the reflex arc includes mo- processed information per unit of time, changes in
tor reply. In practice very often a signal requires a fast the sustainability of attention, pulse rate and more.
motor response. The most typical example of this 5. Mostly creative work requires the involve-
kind of work is the work of drivers, crane operators, ment of higher thought and associative processes,
dispatchers, machine-operators. Besides intension a large amount of stored information and mobil-
of sensing systems and load on the same kinematic ity of memory processes. This type of work related
chains, these professions require rapid differentia- professions of architects, engineers, doctors and
tion of signals and decision, brought great demands others. The basis of creative work lies formation of
on attention processes and more specifically to its dominant. This creates a selective and purposeful
two main qualities - distribution and sustainability. mental activity. All mental creation, all associations
The assessment of load is based on a changes, in the and knowledge are directed to a particular site and
course of the day occurred in the sensitivity of sen- the stream of thoughts is not diverted to adverse
sory organs, in time for the implementation of sim- events. Moreover, in permanent employment, dom-
ple and complex sense-motor reactions changes in inant thought process can even be supported by
attention and working frequency pulse. adverse stimuli. On this occasion Uhtomsky wrote:
3. Work with mostly emotional stress. “The mind burdened with an idea suddenly finds
Emotional stress is most pronounced in occupa- mechanism for resolving its, among side impres-
tions with greater responsibility. It is believed that sions on a trip in the mountains, on a sunny day or
the responsibility is least if the worker is responsible walk in the street crowd.”
only for products providing his salary. It is greater In this type of work, there is another very charac-
if he is responsible for ensuring the work of many teristic. This is the fact that a strong dominant pecu-
people, even more if mistakes can cause accidents liarity can not be easily extinguished. Working day in
or loss of life. The greatest degree of responsibility in many professions is far from finished with the com-
occupations that are responsible for many lives. As pletion of work time. These features make it difficult
an example of working with great responsibility may to apply the regimes of work and rest in creative pro-
indicate the work of drivers of motor vehicles, airline fessions. Fatigue and stress often arising in solving
pilots, air traffic, drivers of locomotives, operating difficult and important tasks are important health
personnel in nuclear plants and others. and social problem here.
In professions and activities with greater respon-
sibility very often require rapid decisions, decisions 2.1.2. CHANGES IN ORGANS AND SYSTEMS
on choice of several alternatives, which implies IN MENTAL WORK
knowledge and experience, flexible memory and
thinking processes. Making decisions in conditions Main characteristic of the condition of the body
of deficiency of time makes this work particularly in mental work is low gas exchange. In intensive
stressed. Significant emotional intension exists in neuro-psychological work maximum oxygen con-
professions that require contact with many people sumption increases about 6% and the evolved car-
- teachers, managers, working with clients. The eval- bon dioxide - by 2%. These relatively small changes
uation of the intension is performed by assaying the in total gas exchange is not respond, however, for
level of excitation processes in the CNS, the amount low intensity of metabolic processes in the brain
of excretion of stress hormones - adrenaline, no- (the intensity of metabolism per 100 g of brain sub-
radrenaline, corticosteroid hormones, evaluation of stance is much higher than that of 100 g muscle).
the reaction of the stress of the person, the dynam- Changes in the frequency of the working pulse
ics of the working pulse rate and the like. and blood pressure depend on the type of mental
4. Work with mostly informational load. work. The pulse rate increases significantly at neuro
In this type of work load is mainly in terms of emotional intension. Conversely, the difficult mental
information and the memory processes. Work in a tasks run optimally at lower levels of activation, so
variety of occupations such as bank clerks, account- that the pulse rate even showed a downward trend.
ants, cashiers and others such processing, requires In many professions that require a focus, inclusion

49
 OCCUPATIONAL MEDICINE
of memory and thought processes, pulse rate is low The frequency response of the background
adapted indicator of labour tension (Fig. 2). The EEG activity gives a real idea of the
​​ level of excita-
same is largely true for changes in blood pressure. tion processes in the central nervous system. The
Undoubtedly the most significant changes occur picture of EEG activity is very complex, it becomes
in the nervous system. First are the changes in the even more complex with active mental work and
activation process. The effective implementation to assess the changes required complex machining
of each task requires a certain level of activation. analysis. Therefore, this method has not yet been
Above and below this level efficiency is reduced. entered in the broad practice of the physiology of
The low level of tonic nonspecific activation during labour. The same can be said of methods of induced
night shift work is a major cause for difficulty main- brain activity - induced in response to a stimulus or
taining attention. Furthermore, the inclusion of spe- task potentials (evoked potentials). In practice, to as-
cific physiological activation processes as a result of sess the changes in the nervous system successfully
external stimuli, depends on what condition they apply a range of behavioural methods such as time
found the nerve centers in relation to activation. of simple and complex sense-motor tests, threshold
In actively functioning system of self-regulation sensuosness of sensory analysts, tests to assess the
(by way of descending projection system) achieves quality of attention and others.
necessary, according to the task, level of activation.
Where tasks or relevant signals occur rarely, such as 2.3. WORKING CAPACITY
when working on some control desks, the level of
activation decreases, develops so-called monoto- The definition of efficiency performance, as the
nous due to deficiency of information. ability of man to maintain longer a level of produc-
tivity without occurrence of pathological changes
Limits 120, 100, 80 pulse/min in organs and systems is valid for both physical and
Interval 60 s mental performance. The factors which determine
pulse/min performance are also valid (of varying severity) for
one or the an other kind of work. Efficiency can be
determined by indicators of productivity (qualita-
tive and quantitative), or by changes in the function-
al state of organs or systems. As a result of the work,
performance varies over the course of the working
day and working week, as well as during the length
of service.
The factors, that determine the efficiency can be
included in the following groups: 1. factors associat-
ed with severity and organization of work - duration,
mode of work and rest, shift work, working move-
ments, posture; 2. factors in the workplace and en-
vironment - microclimate, noise, toxic factors, light-
ing, etc .; 3. individual qualities of man - age, gender,
length of service, experience, motivation, health
status, etc .; 4. psychosocial factors, associated with
working team.
The dynamics of the performance during the
workday depends primarily on the type and level
of work performed. In moderate physical work, ma-
nipulative or instalation work for example, usually in
Over line 1 6%, 16 min the dynamics of performance detect three phases.
Between line 1 and 2 35%, 92 min
Between line 2 and 3 50%, 131 min The first phase is the period of the inworking, over
Over line 3 8 %, 22 min who is restored or develop dynamic stereotype, pro-
ductivity increases and operating frequency pulse
Fig. 2. Changes in pulse rate during student
exam: gradually decreases. The period of the inworking
- More frequent pulse rate when towing a ticket (80/min) may continue until 2 h. The second phase is the pe-
- Reducing the pulse rate frequency pulcovata riod of steady performance, which in a rational or-
between thinking (90-150/min)
ganization of labour is the longest and is character-
- Increase the frequency in responses (150-180/min)
ized by stable production indicators and pulse rate.

50
 LABOUR MEDICINE
The third phase is set at the end of the working day duced capacity due to chronic illness or period of
when performance begins to fall and pulse rate as a rekovalestsentsiya. To determine the physical abili-
result of coming fatigue increases (Fig. 3). ty to apply different functional samples loaded the
In this classic curve of performance, some au- body in varying degrees. There are two main groups
thors distinguish 7 phases or periods: 1. Period of function tests - with moderate load with submaxi-
the inworking; 2. Period of maximum performance; mal or maximum load.
3. Period of full compensation when there are al- 1. The tests with moderate load refer orthostat-
ready tired but it is offset by willful effort or high ic test, Martynez test, step test Master, Harvard step
motivation; 4. Period of unsteady compensation - test. To them - before, during exercise and during
sometimes performance increases, then decreased; the recovery account the reaction of the cardiovas-
5. Period of final revival - efficiency decreases, but cular system (pulse rate, blood pressure, ECG chang-
productivity can be increased; 7. Interruption of es). The results of the reaction of the body are more
work and development of fatigue. favorable as the changes are less marked.
2. Tests with submaximal and maximal loads are
aimed at determining the maximum aerobic capac-
pulse/min

Day shift
Night shift
ity and should be applied only in healthy people.
Determination relates to the application of loads to
fail, and as the capacity is greater, the higher values​​
reaching oxygen consumption, heart rate, maximum
blood pressure. Even with well-trained persons max-
imum oxygen consumption rarely exceeds 3 l/min,
while during the same time through the lungs can
pass 6 l/min oxygen. It is believed that the load is
optimal when the person works with 30% of their
consecutive study maximum capability.
Fig. 3. Changes in pulse rate while working Physical performance can be significantly in-
in day and night shifts
creased as a result of training. During the training,
the body goes a number of morphological, physi-
In many modern forms of work, the classic curve ological and biochemical changes that lead to bet-
of performance has not been established. For exam- ter adapt to the work and increase efficiency. The
ple, in many automated activities, basic intension changes affect the whole organism, the most signifi-
develops in the beginning of work, followed by an cant are expressed in respect of muscular and cardi-
extended period of monitoring. The period of inten- ovascular system.
sion can be delivered before the work commences. As a result of system loads the size of the work-
The so-called anticypatic stress (or intension) is as- ing muscles increases, a to account of thickening of
sociated with thinking, planning, making important the muscle fiber. However, in the muscle grow more
decisions related to the work ahead. capillaries and blood circulation improves, which is
Regularity in changes in performance are iden- a prerequisite for improving metabolic processes in
tified and during the working week. The first day muscle contraction. Transmission of nerve impulses
somewhat conform to the inworking. The highest in the motor plate also improved, while each pulse
performance is in the middle of the week and at the triggering more fiber. All of this leads to increase
end already feels fatigue. strength, endurance and speed of muscle. Due to
the unevenness in the pass of processes these prop-
Physical performance erties can be achieved before the apparent increase
The level of physical performance depends on the in muscle mass.
functional state of the respiratory and cardiovascular Significant changes in the process of training oc-
system, the morphological and functional proper- cur in the heart muscle. In an untrained organism in-
ties of the muscle, the adaptation capabilities of the creasing needs of oxygen to working organs are sat-
muscle metabolism, i.e. of efficiency performance or isfied mainly by accelerates the heart rate. In trained
physical capacity. Second rank factors of work envi- individuals, sending more blood to the muscles to
ronment such as microclimate, dust, toxicochemical account of increasing stroke volume of the heart. It
impacts, motivation, psychosocial factors. is also affected and blood pressure. In untrained per-
To preserve the health and performance, it is es- sons continued work leads to progressive decline in
sential workload to match the capacity of the work- systolic blood pressure, which is an expression of ex-
er. This even more largely true for persons with re- haustion, while trained persons that effect recedes.

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 OCCUPATIONAL MEDICINE
During the training participate most actively and rapid fatigue. For performance of the visual system
nervous system. Repeated exercises lead to proper are also important adaptation options to light and
interaction between the CNS receptors, motor or- to different brightness, color vision, disturbances in
gans, respiratory and cardiovascular system. Based accommodation.
on the improvement of basic neural processes and Reduction in auditory sensitivity to noise expo-
conditional - reflector links, being set up and dy- sure, deteriorated speech clearness, difficult the
namic stereotype, resulting in improved coordina- adoption of useful information and leads to faster
tion and automation of movements. nervous fatigue.
On the basis of the new features of the trained Optimal tonus of the brain cortex is essential for
body, are and significant biochemical changes. In- optimal functioning of mental activity. Above and
creases energy potential (macroergic phosphate below this optimum effectiveness is reduced (Fig.
groups, liver glycogen), changing the amount of 4).
myoglobin. Increase in the enzymatic activity, the Typing
destruction and the formation of glycogen. The in- Painting
Lifting weights

creased buffering properties of the blood lead to a

Performance
better toleration of acidosis. The training becomes
by special programs that rely on such basic princi-
ples as repeatability, gradually increasing the loads,
complexity, consistently, etc. These principles are
basic in the manufacturing training. Level of activation

Fig. 4. Level of activation of the various in

Mental performance complexity tasks
Though the basic principles of efficiency are
Optimal levels
generally valid for mental performance, it has some
important features compared to physical. Firstly
it is pronounced interindividual differences in the In active functioning of the system of self-regula-
course of major psychiatric processes and activities, tion (the path of the descending reticular formation)
and hence the different capabilities of individuals for is achieved requested, according to the task level of
the performance of one or another kind of task. Sec- activation. It is considered that the effect of self-reg-
ondly this is its strong influence on the motivation, ulation underlies at U-shaped relationship between
which often leads to masking advancing fatigue. the level of activation and performance - and at low
In mental performance, there is another important and at very high levels of activation performance
feature, this is the great flexibility and the ability to deteriorate. In this, complex and complicated task
change the strategy in a change in functional status, requiring a lower level of activation as compared
which often mask fatigue. with the simplest task.
Taking a slightly different aspect of mental per- Circadian rhythm is a major factor that affects the
formance is reliability. It is seen as probability to activation processes. In connection with the exist-
readiness for flawlessly, faultlessly and timely exe- ing two main types of curves in body temperature
cution of a task and in extreme conditions, as and - a peak in the early afternoon and peak in late af-
opportunities for fast recovery. The reliability of the ternoon hours, shaped and so-called evening and
human unit in the system “man-machine” in condi- morning types of people. Evening (introvert) type is
tions of a large production risk is essential. Factors unable to work in the morning and morning (extra-
that lead to reduced mental performance and devel- verted) - in the afternoon. Introvert persons starting
opment of fatigue, adversely affect reliability. day with a higher level of activation as compared
At the level of perception mental performance de- with their morning extraverts and their performance
pends on the functional state of auditory and visual in the same task is higher (Fig. 5).
system. Functional state of the visual system in the Mental performance also depends on a number
first place is determined by visual acuity. Visual acui- of properties of the nervous system such as strength
ty for near is particularly important parameter, since and agility of the main nerve processes, capabilities
many manipulative professions, assembly services, of supporting sustained attention. The rapid switch
working with texts, the distance from the object to over of attention from one object to another is par-
the eye is 30-40 cm. For occupations requiring moni- ticularly important in some professions such as op-
toring moving objects (eg. monitoring radar screens erators, equipment operators, dispatchers, drivers of
by flight head) is important kinetic visual acuity. motor vehicles and others. For mental performance
Uncorrected hypermetropia and presbyopia lead to are important the memory capabilities of person,

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2.4.1. CLASSIFICATION OF FATIGUE

Depending on the nature of the work fatigue is

usually: physical (local and general), sensory (visual
or auditory) and mental fatigue, which can also be
several subspecies.
1. Physical fatigue
General physical fatigue occurs at the inclusion
in the work of the large muscle groups of 3, 4 and
5th class of movement. In modern forms of work this
type of fatigue occurs rarely, than local physical fa-
tigue, which is very common in manual work and at
load the same muscle groups and joints. This fatigue
is mostly associated with the depletion of macroer-
Introvert
gic compounds and failure of anaerobic reactions. It
Extravert
is generally believed that the accumulated catabolic
products (lactate, pyruvate), stimulate nerve end-
ings and generate specific sense of diffuse pain in
Morning Afternoon
the muscle tissue.
Fig. 5. Daily dynamics of performance at intro- Incorrect performance of the actions of tired
and extraverts
muscles most likely is the result of wrong afferent
information from muscle receptors, which in turn
hampers the control of the central nervous system
profound mental and associative processes. High and leads to a distortion of the dynamic stereotype
performance especially in creative tasks are based 2. Sensory fatigue
on the principles of building dominant. This largely For practice is important fatigue of visual and au-
explains why in many modern forms of work perfor- ditory system. Visual fatigue meet primarily in activ-
mance curve is different from the classic. ities requiring intension and concentration of eyes
when working at close distance, in frequent chang-
2.4. FATIGUE es of focal distances (eg. installation of small details,
correction of texts, entering data into a computer,
For many authors fatigue is a major protective etc.), activities that require intension of the muscles
phenomenon that exists in all living beings and from involved in the process of accommodation, conver-
this perspective should be seen as an important link gence, reduce the effects of spherical and chromat-
in the system of self-regulation. One of the classic ic aberration. Very often at the end of the working
definitions assume that fatigue is temporary and re- day workers complain of headaches, flushing, itch-
versible decrease the ability of the body to carry out ing, watery eyes. These complaints are more fre-
physical, mental or psychological activity as a result quent and more degree at hypermetrops, and per-
of previous work. Unlike fatigue, over work regard- sons after age 40. Some of the symptoms, such as
ed as prepathological condition that occurs after headache, dizziness and general fatigue not due, of
the strong loads, or when the work is started again, course, only by fatigue of eye muscles, and are one
without being resolved phenomena of fatigue and integral effect of overload of exceptionally complex
has reached a state of complete recovery. mechanisms involved in visual perception. Fatigue
Usually classical theories to explain the fatigue may be a result of excessive psychosensorial work or
can be divided into two large groups. To the first forced maintaining wakefulness.
belong humoral-localistic that explain fatigue by Auditory fatigue develops as a result of high noise
exhaustion of energy resources, accumulation of levels - 70-90 dB, depending on the nature of work
catabolic products. Another group of theories based (degree of sensorineural load). The most character-
on the principles of neurism and consider fatigue as istic manifestation of auditory fatigue is temporary
a condition that is associated primarily with CNS - deterioration of auditory sensation. In this connec-
imbalance of processes of excitation and detention, tion, it must first be distinguished from the adapta-
violation of regulatory mechanisms and more. tion, which is also a protective reaction of the body.
It is assumed that for adaptation can speak in raising
of hearing threshold by 10-15 dB and recovery peri-
od to 3-10 min. Changes in hearing sensitivity and

53
 OCCUPATIONAL MEDICINE
time to recover above these values ​​are regarded as 2.4.2. OVERWORK
fatigue. Again, as mainly visual fatigue, are appear
other signs and symptoms of “general fatigue”. Overwork is seen as prepathological condition
3. Nervous fatigue that occurs after very high load or as a result of oper-
Nervous fatigue can be mostly sensorineural, psy- ating in an incomplete recovery of the body. In this
chomotor, intellectual, depending on which mainly connection distinguish: hyper overwork, acute over-
units of the CNS are engaged in labour activity. Much work and chronic overwork.
of the features of neuro-sensory covered with ocular The classic example of hyper overwork is the his-
and auditory fatigue. Psychomotor fatigue develops torical fact of the death of the Greek warrior run a 40
in work that besides the load on the sensor system km by Athens to announce the victory of the Greeks
requires quick decisions and psycho-motor effects over the Persians in the village of Marathon (490 to
(drivers of motor vehicles for example). J.C). There is also in the pursuit of hunting. The an-
Mental fatigue in the broader sense or intellec- imal stopped, it has an extremely strong dyspnea,
tual fatigue are obtained in actions demanding pro- tachycardia, fever. Death occurs in a few minutes,
cessing and storage of information (the memory followed by a post-mortem numbness. Establish hy-
processes), requiring solving creative problems by poglycemia, increased lactate in the blood, hyper-
engaging the higher mental activity. The most char- thermia.
acteristic feature of mental fatigue is that develops Acute overwork develops in hard loads or un-
slowly and imperceptibly and signals for rest come trained body. Typical is vibrate weakness. Accom-
later. The strong positive motivation to complete a panied with anorexia, insomnia, agitation. Can be
task, for a long time can mask fatigue. On the other monitored and other unwell-defined conditions,
hand what makes mental fatigue less favorable than and also renal disorders. In healthy people, who do
physical is that physical work after its termination not have any kidney disease is established albumin
process of recovery begin immediately, while at the in urine, can have hematuria or cylinders. This re-
mental work extinction of the dominant excited fo- quires close monitoring of individuals. Eg. in sport-
cis can not start immediately. Burdened with solv- ing activities with hard and very long loads or at
ing a task brains “still working” long after the formal short, but with maximum intensity exercises often
working hours. Strong dominant focis do not go out appears albuminuria. It is believed that it is due to
and through the night sleep. Therefore the recovery the permeability of the capsule of Bowman, result
process run more slowly, and breaks especially if are of lactic acid in blood and hypoxia, as a result of re-
shorter, are ineffective. duced blood flow. Sports albuminuria can last up to
Mental fatigue is manifested by general weak- 24 hours.
ness, headache, often appears tinnitus due to con- Chronic overwork, occurred as a result of system
traction of the peripheral vessels and invasion of load after incomplete recovery, is characterized by
blood to the head. In severe mental fatigue appears somatophysical exhaustion and a number of disor-
palpitations and hyperesthesia, appears irritability, ders, such as severe sleep disorders, developments
weakened self-control. Sleep disorders are also in- neuroses, neurasthenic symptoms, weight loss, loss
dicative symptom of nervous fatigue. of appetite. If you do not take serious measures
Mental fatigue should be distinguished from could lead to the development of psychosomatic
adverse psychic states of boredom and monotony. diseases. So to chronic fatigue should also be treat-
They arise as a result of specific working conditions, ed as a prepathological state that needs of prophy-
monotony, lack of stimulus or deficit of informa- lactic and therapeutic means.
tion, repetition of activities with little difficulty and
complexity and are an expression of the decrease 2.4.3. SIGNS AND SYMPTOMS OF FATIGUE
in activation processes. Characterized by lethargy,
decreased alertness, drowsiness. Monotony can de- Is generally accepted, the changes in fatigue can
velop into mental satiation, leading to a reduction in be divided into objective and subjective. Besides
productivity, emotional disorders and others. the subjective feeling of tiredness, fatigue and de-
Reduced capacity may not be the result of work, pression, other symptoms specific to the type of fa-
and also can expressed as fatigue by decrease the tigue were described above. Objective criteria can
functionality of an organ, system, or whole organ- be divided into 3 groups: production indicators;
ism - in condition of an irrational diet, lack of oxy- physiological indices and psychological indicators.
gen, strong emotional agitation and other adverse 1. Deterioration production quality is the earliest
factors. manifestation of the objective manufacturing indi-
cators. Reduced coordination of movements and

54
 LABOUR MEDICINE
violations dynamic stereotype, led to an extension 1. Measures of the first group placed first in fight-
of time for individual working operations, of micr- ing fatigue. They are always specific, depending on
opauses and reducing the quantity and quality of the nature of work and the characteristics of the par-
production. Increased errors and accidents. One ex- ticular professional group. The events may relate to
planation of this fact is that the conflict that plays solving these important problems.
out between the subjective symptoms of fatigue a) Improvement of the working environment and
and obligations which the worker must perform on furnishings. These include measures to reduce the
behalf of overcoming fatigue leads to anxiety and intensity and exposure factors such as noise, vibra-
nervousness, haste and wrong actions. Moreover tion, adverse microclimate, dust, toxic hazards, in-
nervous fatigue, leads to deterioration of attention surance as required by the work, required illumina-
(concentration and distribution of attention), to re- tion of the workplace, heating, ventilation, personal
duced vigilance, which also increases the risk of ac- protective equipment, etc.
cidents and deterioration. b) Rational organization of the labour process,
2. Physiological indicators. The assessment of the which is particularly important proper organization
level of development of fatigue is done by assess- of the working movements and work to the maxial
ing the functional status of the involved organs or and optimal work area, posture, appropriate mode
systems or changes in the functional state of the of work and rest. These include also ergonomic re-
systems, ensuring their work and, in particular, these quirements at the workplace, working furniture, ma-
are changes that occur in the cardiovascular and res- chinery and equipment.
piratory system. c) Optimizing workload - optimal regime of work
The first group performance related reduction in and rest. Optimal workload means not to cross the
muscle strength and endurance (muscle strength line behind which quickly comes “exhaustion” and
in the arms, or waist muscle strength), raising the occurs fatigue, but also on the other hand it must
threshold of auditory sensitivity, changes in eye not be below a certain lower limit beyond which ad-
reobasis or frequency of critical fusion of signal, aptation to the labour are difficult, develop adverse
changes in accommodative and others. Of course, psychic conditions such as monotony, due to defi-
these indicators provide information not only for ciency of information, boredom, dissatisfaction with
the working body, but also for functional state of the job.
the CNS. 2. Means to increase physical and neuro-psycho-
The second group of indicators related changes logical capacity refer to targeting specific to employ-
in the cardiovascular system - increase in pulse rate ee events. An important condition is the physical
and longer recovery time, increase the variability and mental work to respond of the physical capacity
of heart rate, blood pressure changes, indicators of and neuropsychic features of the person.
external breathing, increased metabolism energy. It Adopted in our country physiological norms and
also covers a s of indicators that provide information rules for manual handling of loads (Decree № 16/
about the functional state of the endocrine system. 31.05.1999) state that:
3. Psychological indicators. This group includes a 2.1. The distance for regular manual weight car-
series of tests and methods that provide information rying is limited to 2 m in women and 30 m in men
about the various neuro-psychological processes - (when moving on stairs - 1 step = 1 m distance);
time of perception, time of simple and complex neu- – In carrying 2 m distance allowed weight up to
ro-sensory reactions, pass of complex thought and 15 kg for women and 50 kg for men for single load
decision-making processes, processes of attention. and consequently to 4 t for women and 10 t for men
- a total shift;
2.4.4. PREVENTION OF FATIGUE AND – When carrying up to 30 m (only for men) - 30 kg
OVERWORK single load and 6 t total at shift.
2.2. Indicate also the requirements for permissi-
When considering means to combat fatigue ble laden weight for group carrying - less than the
must be considered, as some common general per- sum of those for individual loads as well as the inter-
formances and also specific measures depending vals at repetitive operations - not less than 30 s.
on the type of fatigue and its stage of development. 2.3. Prohibit regular manual work of loads, includ-
Measures to combat tiredness and overwork, can ing also vehicles, by young people from 15-16 years
generally be divided into 3 groups: of age. In a single lifting the load is limited to 8 kg for
1. Prevention of fatigue women and 15 kg for men (age 16-18 years values
2. Means of increasing the efficiency are 10 kg or 20 kg, and regular work is forbidden).
3. Treatment of overwork. For increasing the efficiency are widely used:

55
 OCCUPATIONAL MEDICINE
a). Exercises and training. They are particularly gastrointestinal complaints, agents for improving
important for physical work and manipulative activ- sleep, means for increasing activation processes in
ity. In the process of training whose basic principle the central nervous system, or vice versa means of
is the gradual increase in load achieved the desired inhibiting these processes in case of agitation and
changes in the structure of muscles and metabo- anxiety.
lism of body. By improving coordination of move-
ments and build a dynamic stereotype movements 2.5. PROFESSIONAL STRESS
become more efficient and require less energy con-
sumption. Of great importance is to increase the ca- Stress is characterized by a set of physiological,
pacity of the cardiovascular system. psychological, and endocrine responses. Hans Se-
A number of neuro-psychological processes are lye explains stress by the theory of general adap-
also subject to training - memorable processes, tation syndrome, including obligatory non-specific
processes of attention, increases sensitivity to the response of the body as a result of any external ir-
perception of the relevant signals. Upon exercise ritation. The reaction of stress is regulated by sim-
increases lability of CNS, conditional reflex connec- patico-adrenal and hypothalamic-pituitary-suprare-
tions become more sustainable, improving relation- nal system, through complex feed-back. In an open
ships between I and II-signal system. state reaction takes place in three basic stages: 1).
b). Healthy nutrition, in certain cases and protec- Alarm stage, characterized by shock and anti-shock
tive-professional nutrition, are also important to re- phase; 2). Stage of resistance associated with the
cede fatigue. activation of regulatory processes, which performs
c). Raising the general resistance of the organ- the recovery of the imbalance and increases resist-
ism by hardening and gymnastics is also one of the ance of the organism: 3). Stage of exhaustion and
means to recede fatigue. depletion of adaptation options as a result of strong
3. Means for removal and treatment of overwork. or long-acting stressors. In this connection, where it
The best is the removal of overwork going will expand the response to stress, is distinguished
through physiological means - providing adequate of two qualitatively different effects identifying
rest, good sleep, rational nutrition. Recently widely such as: 1). “Eustress” - a condition in which there
discussed and application of chemicals to enhance is adaptation and mobilization of defenses and 2).
performance and prevent overwork. Chemical stim- “Distress” - a condition characterized by disadvan-
ulants are generally divided into two groups: meta- tageous reactions, exhaustion and development of
bolic and neurogenic. pathological conditions.
a). Metabolic stimulants included in intensive Within the general concept of stress, a number
metabolic processes that accompany muscular work of theories, etc. theories of interaction underline the
and reduced adverse humoral changes that lead to importance of the mode of interaction between the
fatigue. To this group stimulators belong, glucose person and the environment.
phosphate, vitamins that affect oxidation process- The model of professional stress, called Model
es - vitamins of group B, vitamin C, as well as trace matching personality - environment (French et
elements necessary for the enzyme system and co- al. 1982), perceived stress as an imbalance between
enzymes. These and similar means are physiological work environment factors and work tasks on the one
and can be used in practice at an appropriate dos- hand and individual capabilities to perform work ac-
age and individual control. tivities. This theory rests on two basic parameters
b). Neurogenic stimulants act primarily the nerv- and their mismatched. The first is the objective reali-
ous system. These include fenamine, caffeine, gin- ty (Environment - OR) and the second perception by
seng (Eleutheroccus senticosus, Panaxia ponicum), the individual (Personal perception - P). Variables OR
echynopsine al., whose effect is manifested primar- and P may be subjectively or objectively presented
ily through increased efficiency of cortical cells and and accepted. Based on these 2 by 2 combinations
weakening processes of inhibition. Regardless of the can be obtained no sufficiently matching, at the re-
effect of these substances to enhance performance sult of that develop stress responses. Individual pos-
they recede protective effect of inhibition and oper- sibilities bring elements of subjective perception of
ations realized at account of the exclusive consump- the whole complex of working conditions and they
tion of energy resources. They are not harmless and become a very important factor in occupational
should be applied only in rare cases. stress.
c). Depending on the symptoms of overwork In 1979, Karasek, developed a model of profes-
are selected and other means of treatment such as sional stress whose basis is the notion that the char-
agents improving existing anemia, or treatment of acteristics of labour may not be in linear relation to

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the health of workers and that they can combine pends and on the individual characteristics. Also
and interact differently. Based on a meta-analysis “impaired relaxing ability” (impaired relaxation)
of results from studies of workers from the US and can model the health effects at the scheme of the
Sweden, found that workers with high job require- model. For example. “Impaired ability relaxing” very
ments (complicated and responsible work) and often found in conditions of very hard work, com-
low decision-making have definitely worse health. bined with homework (less time for rest and sleep,
Lowest rate of disease and death was found among no enough time for personal needs), leading to neg-
groups of workers engaged in labour with moderate ative health effects.
intension combined with a high possibility of deci-
sion-making and control of tasks and working con- 2.5.1. WORK-RELATED STRESSORS
ditions. The combined effect of these two character-
istics of working conditions is called Model “Control In conditions of employment, there are numer-
over decisions - Requirements of operation“ (Fig. ous stressors, which generally can be grouped as
6). follows:
In 1991, Johanson et al. expand the model by 1. Stressful work environment factors.
adding a third dimension and formulated as “Con- The physical factors of work environment, along
trol over decisions - Requirements of work - So- with its specific action could lead to the develop-
cial support “. Dimension “Social support” comes ment and response to stress. For example, in addi-
from the attitude of colleagues and managers. In ex- tion to the specific hearing impairments in excessive
ceptional mental requirements (eg greater responsi- noise levels often diagnosed sleep disorders, hyper-
bility in decision making) it serves as a buffer in the tension, headache and others. Other physical factors
development of distress. Conversely, high demand- such as vibrations, high or low temperatures may
ing of the task, low control over the situation and also cause a disease-specific, but in no high intensity
low social support (or social exclusion) are accompa- to lead to discomfort that can result in mental stress.
nied by internal anxiety, psychosomatic complaints Exposure to chemicals can also lead to stress
and high cardiovascular risk. through a variety of mechanisms - direct stimulant
The interaction between the three dimensions effect on the central nervous system, operating in
in the model and the output of this interaction de- a high risk of poisoning and explosions, unpleasant

Requirements of task
low high Activity level

Small strain Active

reaction behavior
high
Control over decisions

High strain
reaction
Passive
behavior
low

Fig. 6. Model “Control over decisions/requirement of the task” (Karasek, 1979); strain
- intension

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 OCCUPATIONAL MEDICINE
odor and others. The possibility of infections in con- same stressors, stress reaction reaches different de-
tact with biological factors can also lead to mental gree and distress reach a limited number of persons.
tension and stress. Work environment factors can Moderators of stress response are different sides of
act as stressors alone or acts combined effect (po- the individual characteristics, social protection and
tentiated or additive). social class (group) associated with a different per-
2. Organizational factors and relationships. ception of the stress factors and possibilities to sup-
Currently many people in industrial and even press stress.
more so in post-industrial society are engaged in Over the past 30 years, much attention was paid
organizational or managerial activities. These activi- to the individual vulnerability in relation to coro-
ties can be stressful factors as for managerial teams, nary heart disease and the role of psychological and
and in performers. Factors such as political conflicts, behavioural factor in the development and suppress
authoritarian imposition of decisions, transfer of stress. The concept of type A mode of behaviour was
responsibilities, etc. may be strong stressors. Inter- originally developed by Friedman and Rosenman. It
personal and intergroup conflicts, conflicts with defines the type A as a major risk factor for cardio-
managers also reinforce dissatisfaction of work and vascular disease. According to a large-scale studies,
lead to stress. Conversely, support from colleagues, people with high risk for coronary heart disease de-
family and especially by the heads can prevent the fined as type A (Friedman, Rosenman) are: strongly
development of distress. Here may refer a number associated with work and dedicated to the profes-
of stressful situations as badly defined task, not well sion; with a strong sense for urgency of tasks; with
defined responsibility, failure qualifications and skills a strong sense of competition and the tendency for
of performers, inability to training and advancement aggressiveness.
in the hierarchy etc. Indicators that assess the state of hostility and
3. Labour task angrylity of persons, are also referred to as predic-
Overload and under-load, the ability to make de- tors of cardiovascular disease.
cisions, the level of responsibility are factors of par- The relationship between type A behaviour or
ticular relevance to occupational stress. hostility and angrylity of persons on the one side
Load in both qualitative and quantitative terms is and cardiovascular risk than another is moderated
pointed out as a reason for stress-related illnesses. In by several factors such as age, sex, socio-economic
quantitative overloads worker carried a lot of work, and educational status.
and in qualitative overloads functional require- Group differences and the creation of vulnera-
ments are high, ie tasks are very difficult. Quantita- ble groups, reflects the effect of individual differenc-
tive overload often associated with cardiovascular es and social status, which are common and charac-
disease, and quality - of adverse psycho-physiolog- teristic of certain groups and/or affect the general
ical changes. model of reaction in response to exposure to stress-
Insufficient quantitative and qualitative load also ors. A number of studies identify various vulnerable
adversely affect the functional state. Simple, ele- groups, such as young workers, older workers, wom-
mentary tasks and activities, especially if performed en, immigrants, incapacitated.
by qualified and skilled employees, leading to frus-
tration and stress. 2.5.2. SYMPTOMS OF STRESS.
Responsibility at work is also a factor for stress. OTHER STRESS-SIMILAR STATES.
The highest degree of responsibility when it comes
to responsibility for human life or the lives of many Subjective complaints depend on a number
people - surgeons, guiding of flights, pilots, dis- of factors and conditions. First except intensity and
patchers, etc. exposure to the stress factors, to consider is how
4. Shift work stressors is new, unexpected or expected, quick-
Shift and night work is widespread stressor that is changed, etc. Subjective symptoms depend on the
impossible to avoid in enterprises with a continuous state of development of stress reaction - at a sense
cycle of work, transport, rescue teams and others. of mild tension to complaints related to the devel-
Health problems are the result of disturbances in cir- opment of distress and stress-related illnesses. Emo-
cadian rhythms of the body and frequently chang- tional reaction to stress is characterized by anxiety,
ing dynamic stereotype. They are most pronounced intension, stuttering speech, impaired motor coor-
in subjects with continuous sequence of night shifts dination, errors in performing the work. Vegetative
and transcontinental flights. changes that occur as a result of the activation of
5. Individual, group and social factors. the hypothalamic-pituitary-suprarenal and simpati-
It is known that among workers exposed to the co-adrenal system is reflected in an increase in blood

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pressure, shortness of heart rate, increase cerebral and friends. Other adverse mental states, which
blood flow, flushing, mydriatic pupil, sweating of must be distinguished from stress and occur fre-
the hands, muscle weakness. The excretion of stress quently in modern forms of work are mental
hormones can repeatedly be increased. The state of satiation and monotony. (See section 3.5).
distress should be distinguished first of nervous fa-
tigue and of some adverse psychic states. 2.5.3. STRESS AND ILLNESS
The problems concerning the quality and du-
ration of sleep may be also be related to occupa- Impact of stress on mental health ranges from
tional stress. Sleep disturbances are frequent in early slight changes to the express mental illness. Sub-
rising, which reduces REM sleep and in later bedtime, jective changes in terms of self-esteem are some of
which reduces the duration of slow wave sleep. Dif- early manifestations of stress - very often symptoms
ficulty falling asleep or frequent awakenings, are ac- are anxiety, intension, anger, irritability. These com-
companied by anxiety, the sense of no relaxing and plaints are often a precursor to more serious illnesses.
can lead to neuro-psychical disorders. At stress can A number of behavioural changes also often oc-
be seen opposite effect - sleep is extended to 9-10 cur in occupational stress. The reduced participation
hours or more as a means to overcome stress - ie. in family and community life, apathy or unreason-
“withdrawal by sleep.” ably aggressive behaviour towards others are com-
Stress-similar states. Although there are many mon symptoms. Individuals in high-stress state and
common features between stress and nervous fa- dissatisfaction with work often resort to excessive
tigue, it is considered that they are completely dif- use of alcohol and high consumption of cigarettes.
ferent states. Stress is associated primarily with veg- Other behavioural changes relate to variations in
etative changes and mental fatigue - changes in the appetite - from very large to the complete disap-
CNS. When stress the fundamental experiences are pearance of desire for eating; assessment of risk sit-
threats, fear, uncertainty, excitement, anxiety. In the uations that most often develops a tendency to take
nervous fatigue person feels tiredness and weak- unreasonable risks; decreased interest in recreation-
ness. Fatigue develops at the end of the working day al activity.
until symptoms of stress are not directly related to The next level changes are prominent psycholog-
the timing of the work. ical dysfunctions. These include prominent clinical
Stress has some common characteristics with depression, anxiety disorders, psychosomatic disor-
other adverse mental states among the most impor- ders (hypochondria, for example), and exacerbation
tant is burnout (burnout - burning) or syndrome of pre-existing illnesses. Established a statistically
of professional exhausting. This condition devel- significant link between these illnesses and stressors
ops as a result of continuous professional stress or such as job loss, lack of opportunity to improve the
distress and is regarded as one of the most impor- social situation and others.
tant consequences. Characterized by: So-called post traumatic stress disorders is a
consequence of significant traumatic episode in
• Physical exhaustion. Going back to the mod- working conditions affected colleague. The patient
el H. Seley, this is the third stage of the general consistently “experiencing” the traumatic event and
adaptation syndrome, or state of distress. Peo- developed symptoms of reduced ability to respond
ple complain about reduced energy, weakness, adequately to the outside world. Fear anxiety, de-
severe fatigue, which often leads to frustration. pression, avoid actions that cause memory of the
tragic incident, emotional lability are often accom-
• Emotional exhaustion. Workers in the state panying symptoms.
of burnout have a sense of helplessness and Mass psychogenic illness (mass psychosis) is a
hopelessness. Satisfaction that previous- collective manifestation of symptoms that affect
ly had in their spare time or when are with two or more persons sometimes covering the en-
their family or among friends disappears. tire team. Symptoms are always subjective such as
Disappears and general satisfaction of life headache, dizziness, vertigo, heaviness, fatigue or
and people may fall into a deep depression. weakness. There is a small or absent objective symp-
toms. The disease is more common among women’s
• Dehumanization and cynicism. Negative groups in offices of various kinds and spread by au-
assessment of the work has dehumanizing ef- ditory or visual chain. Factors and conditions such as
fect on worker and he often can not respond boredom, monotonous and unsatisfying work, mis-
to the feelings of others. This negative attitude management, isolation and poor communication
and dehumanization can be extended to family are often in this disease.

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General assessment of occupational risk

risk assessment reduce the risk

including translation
verification

feedback

organizational learning
and training

Fig. 7. A structural model for managing work-related risks (in Cox, T. et al., Work related stress, 2000).

Stress control programs Stress-reducing programs

Autogenous training
Defending workers' rights
Biofeedback
Deep breaths Resolving conflicts
Physical exercise Ability to make decisions and resolve conflicts
Free activity Interpersonal skills
Massages Work planning and time management
Meditation Psychotherapy
Progressive relaxation Psychotherapeutic means
Social support
Yogism
Tab.3. Programs for prevention and stress management

Professional stress is a risk factor for cardiovas- traffic controllers, dispatchers and other professions
cular disease. It is known that atherosclerosis, coro- with high responsibility. The relationship between
nary artery disease and myocardial infarction, insult, stress and peptic ulcer can be explained in that the
in large part, the result of such risk factors like dys- autonomic nervous system has essential role for
lipidemia, hypertension, smoking, unhealthy life- stomach secretion. Stomach secretion also increases
style. Stress contributes to heart disease in two ways and as a result of the catecholamine excretion.
- either individually or through potentiation of other Other gastroinestinalni problems, such as diseas-
risk factors. Very high workload associated with in- es related to appetite (bulimia and anorexia), gas-
creased incidence of myocardial infarction. When tritis, ulcerative colitis, and enterocolitis, functional
workers engaged in mental work establishes a close biliary dyskinesia, endocrine diseases (eg. thyrotox-
link between job satisfaction, conflict and coronary icosis) and immune systems, also often associated
disease. In strong stress response was an increase with stress.
in serum cholesterol. And increases the excretion
of stress hormones - adrenaline, noradrenaline and 2.5.4. PREVENTION AND STRESS
cortisol, androgens, thyroid function, increases and MANAGEMENT
blood pressure.
Diseases of the digestive system, especially Prevention and management of occupational
ulcer disease long associated with stress. Epidemi- stress is one of the biggest challenges of modern in-
ological data show an increased incidence of gastric dustrial and post-industrial society. This stems from
and duodenal ulcer among executive directors, air the fact that more and more growing stresogenic

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professions and activities, and the difficulties asso- Most of stress managing programs are aimed at
ciated with the disclosure of the stress factors and the individual and aim to develop in him the knowl-
diagnosis manifestations of distress. Available mod- edge and skills of management and reduction of
els (Cox T. et al; 2000), which emphasizes that stage stress. These programs can be offered to all employ-
“reduction stress” ( “risk reduction”) includes not ees or to a particular group or individual. Skills can
only prevention of the stress factors, but also activi- be classified as managing stress and stress reducing
ties aimed at health and well-being of the individual techniques (Table. 3).
(Fig. 7). Managing techniques are directed to methods
Prevention of stress begins with disclosure and to help individuals cope with the psychological and
assessment of the stress factors, passes through the physiological effects of stress. Stress reduction pro-
understanding by the leaders of the need to imple- gram developed interpersonal skills and strategies
ment measures for their removal and understand- that aim to reduce the stressful nature of work-relat-
ing of the worker by developing its own strategy, ed psychosocial environment and the stress factors
behaviour and lifestyles aimed at overcoming stress. arising from specific labour organization and those
The doctor is obliged to seek targeted and reveals arising from factors in the work environment and
the earliest symptoms of distress, to establish as far employment. In the prevention of stress in some
as possible the causes and to offer workers means cases can lead to proposals and developing health
and methods to reduce stress. In the prevention and and hygiene regulations, industry regulations or ini-
management of occupational stress using two basic tiating legislative activity.
approaches - individual and organizational.

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 Zhel. Hristov, B.Tsenova

2.6 MODERN APPROACHES AND METHODS TO ASSESS

THE STATE OF MENTAL STRESS AND INTERVENTION

Modern approaches and methods to assess the siders that it can not cope with the requirements set
state of mental stress and stress intervention contin- him or something that threatens his well-being, ie
ues to be defined in different ways and at different stress with unpleasant state of intension that occurs
levels of analysis - and as a stimulus and as response, when a situation is assessed as hostile, deflecting
and as recapitulate the interaction and the imbal- of habitual and a threat to self. The arguments in
ance between the individual and the environment. favor of the negative definition of stress are numer-
ous. Only negatively rated events can be expected
2.6.1. MODERN PSYCHOLOGICAL THEORIES harmful consequences, and only when the intensity
OF OCCUPATIONAL STRESS and duration exceeds a critical limit. Typical of stress
that is associated with the individual’s psyche, as
Transactional theories and models. These decisive is the assessment of the individual, not only
theories about stress are based on the conceptual its physiological reactions, movements or behaviour
structure of the interactive models, with a focus on (although for it is often judged on the basis and of
the structural characterization of the interaction these effects).
between the individual and the surrounding work Stressors are events that increase the probability
environment. It, however, puts more emphasis on of stress conditions. Potential stressors are different
the psychological mechanisms underlying this inter- loads of work: from labour task, of job role, of the
action - emotional reactions, cognitive assessment physical and social environment, of the conditions
and reassessment, and stress management (coping) of behaviour - isolated jobs or “overpopulation, of
– Model imbalance “effort-reward” (Siegrist J. professional (non) availability, inefficient style of ac-
et al., 1990). According to this model the survival of tion, lack of experience. These effects cause stress
chronic stress can better be explained in terms of the - response, including uncontrolled and uncontrol-
ratio of high cost - low gain. Conditioned by labour lable physiological, psychological and behavioural
stress is a consequence of the discrepancy between changes. It can be short or long with negative con-
the magnitude of the effort, with sources of external sequences for both work performance and health.
demands and internal motivation and the amount – Burnout is an individual experience, specifi-
of the consideration received, either monetary, so- cally in the context of work. The worker is no longer
cio-emotional payoff or position control, related able to engage in normal work. Exhaustion causes of
to career prospects and security at work. Adverse action for withdrawal (emotionally and mentally) of
health outcomes such as cardiovascular risk preva- their work as a way to deal with overload.
lent in professions where situational constraints do Burnout is determined with questionnaires, the
not allow workers to reduce the imbalance between most widely used of which is the Maslach Burn-
effort and reward. out Inventory (MBI, 1981), including 22 questions
– Cognitive - phenomenological transaction grouped into subscales: “Emotional exhaustion” (EE)
models for assessing and coping (Lazarus R.S. et al., - emotional overload and exhaustion of their work;
1981), according to which stress is a negative mental “Dehumanization” (DH) - indifference and cynicism
state with cognitive and emotional sides. The prima- regarding dependent of professional people; “Em-
ry assessment involves constant checking interac- ployability” (E) - a subjective sense of competence
tions personality-environment in terms of require- and efficiency in their work.
ments, possibilities, capabilities, limitations and Contemporary theoretical framework of burn-
support (the question is: “Do I have a problem?”). out syndrome clearly integrates individual and sit-
Establishing a problematic situation is usually ac- uational factors based on the model “work-person”
companied by unpleasant experiences and a gen- with a focus on the correlation between worker
eral feeling of discomfort. The secondary assessment and six key areas of work environment: workload,
after the establishment of the problem involves a control, reward, community, justice and conflict
thorough analysis to determine the coping strategies between valuables. These six areas of life in an or-
(“What do I do?”). Stress occurs when a person, con- ganization are frame preceding the development of

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burnout organizational characteristics. The greater conventional risk factors (hypertension, smoking)
is the chronic disparity, the greater the likelihood and changes in autonomous and neuroendocrine
of burnout. Understanding the specifics of burnout mechanisms. High demands of work associated
syndrome requires distinguishing it from similar and with a 7-times increased risk of emotional exhaus-
related states such as frustration from work, stress, tion and low social support at work - 2 times higher
depression, poor mental health, mental violence, risk of problems and pain in the back and shoulders.
absorption of the work (Table. 1). Type of work and freedom of decision-making
are important for the formation of the risk of cardio-
2.6.2. PRACTICE FOR RESEARCH ON vascular, gastrointestinal, skin, allergic and other dis-
WORKPLACE STRESS eases. There are sufficient evidence that the major
risk factors for these diseases are psychosocial and
As indicators of long-term effects of stress on their action is limited to: l Depletion of adaptation
health most often studied markedness of psychoso- mechanisms; l An imbalance in terms of “Require-
matic complaints and depressive tendencies, cardi- ments-Control” in the workplace l Imbalance “Ef-
ovascular diseases (CVD) and digestive system, back forts-reward.”
pain (low back pain). The presence of psychosomatic complaints is an
Numerous recent studies clearly show that high important indicator of overall prosperity. In an anal-
demands and intension of the job are the main risk ysis of registered complaints should be taken into
factor for CVD. As etiological links, psychosocial and account personal circumstances and factors related
behavioural configurations (responsibility, dedica- to motivation as they changed causal relationships.
tion to work, chronic fatigue) play a role, as well as Complaints include various neurological and vege-

Table 1. Burnout and related conditions - similarity and distinction

Related conditions Burnout
● related to the specific situation of work
● all areas of life ● decrease in efficiency due to negative
● emotional, physical and behavioral symptoms, attitudes
Depression weakness ● emphasis on the emotional and behavioral
● predisposed to depression (with high scores in symptoms rather than physical
neuroticism scale) are more vulnerable to ● under normal people without previous
develop burnout psychopathology
● clinically healthy people
● in all professions and people
Impaired ● form of poor mental health, closely linked
● linked not only to work to the work performed, "work-related
mental health
● more pronounced pathological profile neurasthenia" (ICD 10)
● all jobs ● in social professions, emotionally
Mental
● extreme psychosocial stressor demanding work with people
violence ● with victims and affected organizations similar ● consequence of unresolved chronic stress
at work state as in burnout
● social professions, emotionally
● in all professions
Stress loading
● prerequisite for burnout ● result of chronic no overcome stress
● positive emotional and motivational state of ● negative wealth with low levels of
satisfaction and fulfillment, positive antithesis independent dimensions - activation
of burnout and pleasure
● high activation and pleasure associated more
with the resources of the work (job control, ● more connected with the demands of work
Connectivity feedback, learning opportunities) – load, emotional demands
with work ● main components:
- Energy, without fatigue put effort, stabity ● main components:
- Devoted - dedication, involvement, - exhaustion
enthusiasm, pride - cynicism and alienation
- Pleasant absorption - the operating time - reduced efficiency
passes imperceptibly
● in all professions ● social professions
Dissatisfaction ● extent that work is a means and source of ● connected to itself performed work
with work satisfying the needs and exemption from ● closely related to DFW, but causation
(DFW) creating displeasure factors has not yet been clarified
● does not include personal connection with the ● contagious and self-powered through
work itself (content and meaning) informal interactions at work

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 OCCUPATIONAL MEDICINE
tative symptoms and disorders, leading to depres- rather than strictly deterministic. Professional work
sion, isolation, alienation. is only one of the possible areas of life, which can
As an indicator of the general health being used cause stress and illness respectively. Much of the
individual number of symptomatic response and stressors associated with family, unfulfilled expec-
the comparison of different subgroups and the per- tations for tomorrow, insecurity, poor ratio expecta-
centage of persons with an increased number of tions-realistic reality, leading to so-called “stress of
complaints. The distribution of responses to individ- wear.” It is essential the influence of family history of
ual questions, as well as their configuration depend- a disease.
ing on individual criteria for forming subgroups to Appropriate is division of investigated stressors
compare, sex, occupation, experience, etc. - is a basis according to their origin to several factorial areas:
for comparison. • Factors of socio-economic environment -
Special attention should be paid depressive ten- economic development and stability, stand-
dencies, because although the psychological price ard of living, unemployment, crime and ag-
of such problems is mainly at the expense of the gression, structural reforms, ethnic problems,
individual and his family, society pays an enormous etc .;
price in the form of loss of work time, inefficient in- • Factors of family environment - financial
terpersonal contacts and their multiple organiza- problems, unemployed in the family, difficul-
tional implications and other mutualities effects. ty in caring for parents and children, health
According to the hypothetical model for risk fac- problems, relationship and support between
tors and pathogenic mechanisms for the develop- family members and others.
ment of diseases hypotheses about the emergence • Factors related to the profession as complexi-
of the CVD, diseases of the digestive and the mus- ty, responsibility, qualifications, workload and
culoskeletal system should integrate clinical meth- rhythm and more.
ods with labour - social and psychological causes • Factors of working environment, including:
and physiological mechanisms. Synthetic model of • Physical, chemical and biological factors;
stress, various events and consequences that cause • Psychological factors - social support from
in their dynamics is presented in Figure 1. management, opportunities for communica-
In analyzing the etiopathogenetic relationship tion and expression;
between experiences stress and disease, must al- • Factors of work organization - working hours,
ways be in mind that the relationship is probabilistic variable schedule and mode of work and rest,
staff shortages, emergencies.
Sources Symptoms Diseases/states • For determination using val-
of stress of stress
idated questionnaires and spe-
cial questionnaires containing
Individual
Related to the symptoms Coronary different numbers of questions
nature of work
High blood pressure
cardiopathies with possible answers.
Mental illness
Each stressor is assessed re-
Depressed state
garding 1) the existence and 2)
Remuneration Excessive alcohol use Weakened by a factor of weighted average
immune
Irritability potency. The potency is deter-
system
Thoracal pains mined in degrees awarded by
Labour relations
and role in the the respective grading value. For
organization
Men each type and group of stressors
Perspectives for
determine the types and group
growth Symptoms factor potency (0.1-1 odds). The
in company
ratios of potency can be cal-
A large number Prolonged strikes culated and depending on the
Organizational of absences
structure and individual and personal charac-
High turnover Frequent and
psycho-climate
Interpersonal severe accidents teristics of the respondents - ex-
conflicts
Apathy perience, gender, age, position,
Weak quality
Interaction control stress stability, resources for cop-
life - work ing.
Depending on availability,
Fig. 1. Model Cooper for dynamics of the labour stress duration and transience of the stress state, the re-
(adapted from Cooper & Marshall, 1976) spondents refer to:

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 LABOUR MEDICINE
• The state of constant stress - provided the The ratios of the potency of socio-economic fac-
“permanent” presence of not less than two or tors are significantly higher connected with profes-
more symptoms sion and reflect the attitude towards public events
• State of intermediate stress - not less three (economic development, crime and violence, re-
symptoms, referred to “often” with a break forms in education, health, etc.) from a professional
• Fast transitional state of stress - “rarely” (1-2 point of view. Highest stressful action has low living
times) indicates the presence of symptoms, standard.
regardless of their number. Profession and gender of individuals influenc-
• It is important data for these factors to be as es the perception of various factors and perceived
specific as possible and be focused on the per- strength of their action - in teachers is a higher rel-
formance of the work (absenteeism, delays, ative part of highly effected factors in comparison
decrease efficiency, omissions, causeless ac- with doctors.
cidents), or abnormal repetitive behaviours They studied two main forms of stress - affective
(alienation, inappropriate humor, superficiali- and depressive. Affective symptoms of stress were
ty, big mood swings, more and more careless observed in 98% of investigated, and by high levels
appearance, alcohol, etc.) for a longer period of this form of stress amounted to 31% doctors and
of time. 37% for teachers.
• The strength of the existing relationship be- Depressive symptoms are common to more than
tween the listed diseases and studied stress- one-fifth of investigated, and by the high level of
ors is estimated by calculating the odds ratio these are 8 to 14% in different professions - doctors,
(OR) of the studied factors or relative risk (RR) respectively teachers.
by method of single- and multi logistic regres- Nearly a quarter of doctors and teachers are in a
sion. state of constant stress and fast transitional stress is
distributed to a third of them. When teachers, reg-
2.6.3. STUDIES IN BULGARIA istered a greater frequency and greater part of the
constant and often presence of stress-related psy-
Studies of stress in teachers, doctors, social work- chosomatic symptoms. Women in both profesions
ers show that in our country they are at increased have a greater number of psychosomatic events
risk of stress-related diseases. Changes in the ba- compared to men.
sic principles, rules and norms of the device in so- Digestive system diseases and stress. The
ciety, related to socio-economic transition create study of the probability of occurrence of such dis-
new stressful situation that causes serious changes eases due to various stressors at doctors and teach-
in the psycho-emotional state of people and their ers shows that the highest prevalence among cases
health. This situation is characterized by: 1) Increase are the stress factors:
the sources of stressful impacts, 2) Diversity in the • Poor sanitary conditions;
structure of factors and the appearance of new, 3) • Unemployed in the household;
Increase the intensity and duration of action of dif- • Work associated with monotony, non-ergo-
ferent stressors, 4) Reduce the stress stability of the nomic requirements, forced posture;
population. • Eating habits-, number of meals throughout
Stressors and state of stress for doctors and the day, malnutrition, opportunities for sup-
teachers. With a starting hypothesis that the profes- plying quality food.
sion and the work of doctors and teachers in condi- Much of stressors in which the risk of diseases
tions of socio-economic transition are subjected to of the digestive system increases statistically signif-
numerous and with greater intensity stressful fac- icantly associated with family and social environ-
tors, leading to the occurrence of psycho-emotional ment, the influence of family history, the problems
reactions that adversely affect their health has made in the health and educational systems. They increase
epidemiological characteristics. the risk of developing these diseases from 1.4 to 3.5
A comparison of different groups stressors shows times.
that psychological factors generally have highly They are identified and specific, increasing the
stressful effect (second only to socio-economic fac- risk occupational factors - for doctors - work and
tors in both professions). Foremost among them is contact with specific contingent and contagious
“bad balance in the estimates of official capacity and patients, in teachers - uniformity and monotony of
the work done”, i.e. non-conformity personality - en- work and poor sanitation.
vironment, followed by “lack of support and cooper- Burnout. Research on the prevalence of burnout
ation from the leaders.” in recent years have shown that early and middle

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stages of burnout are widespread among teachers, tion and choice of work methods and technologies,
medical and other support staff. Different profile and with a view, in particular, to alleviate monotonous
markedness of the dimensions of burnout in pro- work and work with a given rate and reduce their
fessional groups connected with the specific con- unfavorable health effects;
ditions and load of work. Analysing the correlation – Harmful stress can be avoided.
of burnout symptoms and indicators for common Monitoring of stress requires the development of
intensity and frequency of load and social support sufficiently reliable, informative and efficient meth-
by the head, displayed on the base on of established ods for identifying and evaluating its, applicable to
stressors indicates that: various professional communities.
– the total amount of stress, frequency and load,
determine the development of emotional exhaus- 2.6.4.2. TYPES AND LEVELS OF
tion; INTERVENTION IN COMPANIES AND
– the frequency of experienced of work stressors, ORGANIZATIONS
especially the lack of support from the head, associ-
ated with the development of indifference, cynical Any organization that seeks to establish and main-
attitudes dehumanization. Dehumanization reliably tain the best state of physical, mental and social health
correlated with burnout indicators for the situation of employees, needs a rate policies and procedures
of working, which in turn have associated with mar- that comprehensively cover health and safety. This
ital status; company policy includes procedures for stress man-
- the sense of reduced efficiency and perfor- agement based on the needs of the company and
mance is related to the intensity of the load; its collaborators. There are many choices that need
- the greater the frequency and experienced sig- to be taken into account in the prevention of stress
nificance of individual stressors, as of the stronger - primary level of prevention (eg. Reducing stressors),
is expressed burnout symptoms, emotional distress secondary (eg. Stress Management) and tertiary (eg.
and dehumanization. Programs to help contributors-consultation) and are
aimed at different phases of the stress process.
2.6.4. STRATEGIES AND POLICIES TO Primary prevention deals with the organization
LIMIT STRESS - MODERN PRACTICES of activities to modify or eliminate sources of stress
present at the work environment. Possible strategies
2.6.4.1. MONITORING OF STRESS are:
• re-design of task;
Main reasons why you should be paying special • re-design of the work environment;
attention to work-related stress, to monitor and su- • establishing flexible work arrangements
pervise the extent and spreading him are: (schedules/time-table);
– stress is a problem both for the user and the • stimulating the management with broad par-
enterprise. Stress-related disorders and diseases lead ticipation of all employees;
to decreased productivity, absenteeism, disability, • inclusion of employees in the planning of pro-
poor psychological climate; fessional development;
– related employment dependent stress prob- • analysis of the roles of work and setting goals;
lems are growing - the nature of work is changing • providing social support and feedback;
in recent years due to increased requirements for • building cohesive teams;
mental labour, technological changes, flexibility of • promote fair conditions and relationships at
production and services, constant reorganizations, work - a policy of the employer;
leading to a growing need for retraining and in- • distribution of salaries and incentives.
creasing insecurity; The organization’s activities in the primary in-
– legal obligations. Framework Directive of the tervention include changes in communication,
European Community for health and safety, requires meetings and discussion processes, changes in the
an employer to recognize and correct the exist- methods and style of work organization, changes in
ing stress factors. It stipulates that the employer is corporate culture.
obliged to ensure the safety and health of workers Any intervention should be guided by a previous
in relation to any aspect related to work, following diagnosis or test of identification specific workplace
general principles of prevention - risk avoidance, risk stressors, interviews and questionnaires to detect
assessment (which can not be avoided), anti-source stressors associated with fatigue and burnout.
of risk, adaptation of work to the individual, particu- Secondary prevention is mainly engaged in the
larly in terms of workplace design, equipment selec- discovery and management of experienced stress by

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raise awareness and improve skills for stress manage- • interpersonal: colleagues are mutually rein-
ment of the individual through training and educa- forcing and help to cope with stress, creative
tion. Key factors that influence individual suscepti- supervision, submitting feedback, listening,
bility to stress are: individual personality, individual group training, communication training;
coping strategies, age, gender, attitudes, training, • workplace: changes in the workplace to elimi-
past experience, level of social support from family, nate or reduce stressors.
friends, colleagues. • organizational level: long-term political and
Secondary prevention can focus on learning structural changes in/on whole organizations
different relaxation techniques. Activities in health or institutions, rules and regulations.
promotion and programs to change lifestyles relate Activities at each level can have different general
to primary prevention. Education on the problem of objectives:
stress and learning for stress management help in- • identification of the existence of burnout,
dividuals: to recognize symptoms of stress; build causes and its consequences at every level;
skills to change their lifestyle or work (eg. training • preventing on any level;
for management and distribution of time or self-af- • intervention: reduce burnout or reversed de-
firmation); acquisition of resources to cope, as with velopment if the process is started;
both inherent in the working environment stressors, • crisis intervention: therapy for persons, who
which can not be removed (e. uncertainty of oper- are in an advanced stage of burnout.
ation), as well as other in extraprofessional sphere. Specific measures to deal with stress loads aim
The role of secondary prevention is inherently pri- to:
marily limit the damage (often directed more at the • implement active strategies to overcome
consequences, rather than the sources of stress). The stress, such as changing the situation itself or
main objective is to improve the adaptation of the its individual aspects, personally or together
individual to stress. with other colleagues;
Tertiary prevention is concerned with the care, • expand own capabilities and competence to
rehabilitation and recovery process of those individu- respond more adequately to the stress;
als who have suffered or are suffering from serious • providing social support where together with
health damage due to stress. Interventions include other colleagues seek a solution and under-
specialized psychological counseling on the issues of standing of experienced professional difficul-
employee in professional and personal spheres. They ties.
are effective in helping workers to cope with stress- Main in preventing burnout is the attention and
ors in the workplace, which can not be changed, and care to preserve the health of staff, awareness of
with stressors outside the professional sphere, which the existence of the problem, definition of respon-
spread and affect activity in the profession. Such ser- sibilities in prevention of burnout, improving coop-
vices and consultations are strictly protected, they are eration and mutual support and the support of the
subject to medical confidentiality. head.
Psychological consultation (therapy) is possibly
effective in terms of improving mental well-being 2.6.4.4. PREVENTION OF MENTAL VIOLENCE
of workers, and in terms of economic impact. There (MOBBING)
are data showing significant economizing in such in-
vestment - on the order of 3: 1 to 15: 1. Depending on the phase of escalation of the
conflict and the reasons apply different measures:
2.6.4.3. FIGHTING BURNOUT SYNDROME changes in the design of labour, changes in the
behaviour of the head, protect the social position
Most effective approach is a combination of of the individual and raising the level of ethics and
changes in management practices and training. In- standards in working group and the company as a
terventions in the leadership needed to change in whole.
any of the six areas of working life, but not sufficient, An appropriate strategy for the prevention of
as long as no changed the consumed individual workplace violence involves four steps:
skills and attitudes. • policy for prevention of workplace violence
Common strategies for preventing or reducing - supported by management, with annual
already occurred burnout vary according to the level training and complete (if necessary);
and type of four goals of the intervention: • realization of the first weak manifestations
• individual level: helping individuals to operate and potentially violent behaviour in the work-
more effectively with occupational stress; place;

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 OCCUPATIONAL MEDICINE
• intervention demonstrating the importance as a process, for analyzing and managing risk and
of the problem, encourage early notification protecting workers, recommended cycle of action,
of potential violence, which is a better out- running through several phases: identifying injuries,
come in a timely care; assessment of risk, implement appropriate control
• networking - an interdisciplinary team ana- strategies, monitoring of their effectiveness, reas-
lyze signals of violence, which contributes to sessment of risk, analysis for needs of information
maximum benefit from interventions in low and education at risk.
potential risk. Perspective is spreading throughout the world
Justify its effectiveness in cases of psychological since 2002 SOLVE methodology of ILO for manage-
harassment in the workplace are the promotion of ment of psychosocial questions in the workplace
knowledge on the problem mobbing through pe- and related health problems through integration
riodicals and scientific-popular publications, radio into overall company policy.
and television broadcasts. The International Labour Organisation, the World
Health Organisation or by joint working groups
2.6.4.5. PROACTIVE APPROACH - AN and specialized agencies and commissions of the
OVERALL POLICY TO LIMIT AND European Union, develop programs to prevent the
REDUCE STRESS harmful consequences of the development of men-
tal stress and workplace violence. In our country this
There is a change to the old style, where experts base model is built on prevention and limitation
react to already arising problem of management, of stress with the strategic goal of reducing mor-
providing for the possibility of problems and finding bidity and mortality from diseases associated with
solutions through a proactive approach. According stress and improve health in a variety of professional
to EU directive 1996 y. for consideration of stress groups in the country (Fig. 2).

Collecting
information
on the main
stressors

Assessment
Мonitoring of the state
of stress

Evaluate the
performance
and the state
of stress

Determination
Execution and action
planning

Distribution of
planned actions

Fig. 2. The algorithm of model to limit stress (Zhel. Hristov, 2004)

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REFERENCES

1. Basic on physiology of labour - ed. M. Lukanov, Med. and phys., Sofia, 1963 (in bul.)
2. B. Tsenova Spread of burnout syndrome in education and service.: Coll. “The challenges of stress,” Ed
“St. George “, Sofia, 1998, 61-62. (in bul.)
3. B. Tsenova Strategy and approaches to deal with stress and mental violence. J. Phys. Med., Reh., Hlth,
2005, 1, 12-18. (in bul.)
4. Causes, cooping and consequences of stress at work, Ed. by C. L. looper and R. Payne. Joohn Wiley
and sons, Chichester, New York, Brisbane, Toronto, Singapore, 1989.
5. Cooper, CL, Luikkonen, P., Cartwright, S. Stress prevention in the workplace: assessing the costs and
benefits to organizations. European Foundation for the improvement of living and working conditions. Lux-
emboutg, Office for official publication of the European Communities, 1996.
6. Decree № 16 for physiological norms and rules for manual handling with loads. SG. 54, 5.06.1999 (in
bul.)
7. Di Martino V., Gold D., Schaap A. Managing emerging health-related problems at work. ILO, Turin,
2002.
8. Ergometrie - Mellerowicz. H., Munchen - Berlin, 1962.
9. Guide for Physiology of labour - ed. Z. M. Zolina and N.F. Izmerov, Medicine, Moscow, 1983. (in russ.)
10. Guide for hygiene and occupational diseases - ed. D. Tsvetkov, Med. and phys., Sofia, 1994. (in bul.)
11. Guide for electrocardiography, Moscow, Medicine, 1983. (in russ.)
12. Guide for labour hygiene - ed. N. F. Izmerov, I, Moscow, Med., 1987. (in russ.)
13. Hristov, G. Epidemiology of stress for doctors and teachers in the transition period. Doct. thesis. S.,
2004, 209 p. (in bul.)
14. Human Physiology (first part) - ed. Dr. Mateev, Med. and phys., Sofia, 1962. (in bul.)
15. Information stress and overcome it. Balichev J., ed. “PablishSaySet - Eco”, Sofia, 2002, 248 (in bul.)
16. Intervation in occupational stress. R. R. Rooss and E. M. Altmaier, SAGE publication, London, New
Delhi, 1994.
17. Lazarus R. S., Launier R. Stressbezogene Transaktionen zwischen Person und Umwelt. In: J. Nitsch
(Hrsg.), Stress. Huber, Stuttgart, 1981, 213-260.
18. Leiter, M.P., Maslach, C. Preventing Burnout and Building Engagement: A Complete Program for
Organizational Renewal. San Francisco: Jossey-Bass, 2000.
19. Maslach C., Jackson S. E. The measurement of experienced burnout. J. Occup. Behav. 1981, 2: 99,113.
20. Organisation physiologique du travail. Precis de medicine du travail, Sous la dir. H. Desoille, J. Scher-
rer, R. Truhaut, Masson, Paris, Milan, Barcelone, Bonn, 1991.
21. Occupational medicine. Ed. by J. La Dou, Appleton & Lange, Norwalk, Connecticut / San Mateo, Cali-
fornia, 1990.
22. Occupational medicine - ed. M. Lukanov, Med. and phys., Sofia, 1984. (in bul.)
23. Psychophysiology of labour - ed. N. Tsaneva, Med. and phys., Sofia, 1988 (in bul.)
24. Psychophysiology of labour - ed. N. Tsaneva, Med. and phys., Sofia, 1982 (in bul.)
25. Regime of work and rest - ed. G. Ganchev, Med. and phys., Sofia, 1976 (in bul.)
26. Siegrist J., Peter R., Junge D., Cremer P., Seidel D. Low status control, high effort at work and is-
chemic heart disease: prospective evidence from blue-collar men. Soc. Sci. Med., 1990, 31 (10), 1127-34.
27. Stress, Coll. First National tripartite conference of the Bulgarian Society for Study and combat stress.
S., CISB, 2003 (in bul.)
28. Stress. Basic mechanisms and clinical implications. Ed. by G. P. Chrousos et al. Ann. of the N. Y. Acad.
Scien. vol. 771, 1995.
29. Stress research and stress management: Putting theory to work. Cox T. Sudbury: HSE Books, 1993.
30. Stress and its importance for organism Science, Moscow, 1988. (in russ.)
31. Work related stress, Cox, T., A. Griffths and E. Rial-Gonzales, Belgium, 2000.

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3 PSYCHOLOGY OF LABOUR

Psychology of labour study the experiences and uation of regulating psychic structure of work in
attitudes of people in the labour process, psycholog- shaping the articles, especially the means of labour,
ical conformities, mental processes and properties decision-making on the organization of work and
of the individual in their relationship with the sub- also for general working conditions such as work en-
ject and work tools, with physical and social environ- vironment, regime of work and rest.
ment, i.e. mental regulated employment of individu- 2) Improve the individual conditions and opportu-
als with regard to its conditions and consequences. nities for successful work, covering the opening and
It covers these achievements and methods of the development of the psychological foundations of
various psychological disciplines, that are relevant professional training, including diagnostics of indi-
to the analysis and optimal design of employment. vidual prerequisites for achievement as a basis for/
The main objectives of the psychology of labour or a result of the training.
at applied research are the humanization of labour 3) A separate group tasks of the psychology of
and increasing its productivity. Under the humani- labour associated with the development and evalu-
zation of labour is of course prevention of fatigue, ation of methods for labour psychological research.
occupational diseases, prevention of industrial acci- These are the methods of assessment and analysis
dents and professional deformation of the person, of the activity, for diagnosis and prediction capabil-
raising the thoughts of labour, creating conditions ities, methods for studying social structure and psy-
for multilateral personality development and de- chological climate in the team, methods for assess-
ployment of its abilities. ing work-related mental conditions.
To solve these tasks using a variety of measures:
technical, technological, sanitary, organizational. Psy- 3.1. STAGES OF DEVELOPMENT BY
chology solves tasks for humanization of labour with PSYCHOLOGY OF LABOUR
its own means taking into account the psychological
characteristics of employees. All these events come Psychology of labour is a relatively young science
into the structure of scientific organization of labour. whose formation began in the late nineteenth cen-
General psychology of labour study basic prop- tury. The main stages of development of work-psy-
erties of psychic structure and regulation of work chological theories differ in the definition of man’s
involved in solving any single task in any type of place in the production process - “economic”, “social”,
work activity (Hacker, 1998). It deals with particular “own-developing” and “complex” human, under-
processes of aim-formation and motivation, the cre- standing for the organization and the organizational
ation of an indicative basis, the design of the pro- structures, the purpose of changing labour activities
grams of action, of deciding on the modalities of and the criteria for their evaluation. The main direc-
implementation and controlling it using a relatively tions of its development - teylorism, psychologi-
stable operating forms, resulting in the execution of cal aptitude, the movement of human relations,
specific activities. Its subject are the process of acti- business, industrial and engineering psychology
vation and psychic automation that alter mental reg- - are associated with the development of econom-
ulation of work. Special psychology of labour takes ic life, industry and public relations. Based on the
into account the characteristics of different types of study of individual elements of the movement in the
work and prepare the psychological foundation for late nineteenth century american engineer F. Taylor
solving several specific tasks that can be attributed developed a system for rationalization of movement
to the following areas: and attempted to justify scientific organization of
1) Psychological design of activities, i.e. improv- labour. The recommended its system of strict pro-
ing working conditions, covering design and eval- fessional selection boils down to choosing the fast-

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est and best candidates on the basis of work tests tion of personnel in industrial production, the psy-
to maximum performance, regardless of the needs chological issues of furniture and shaping the work
and interests of workers and the consequences for environment. Since this area is a separate business
their health. psychology with typical tasks - socio-psychologi-
During the first three decades of the XX centu- cal and economic-psychological issues of market,
ry especially became known psycho-technique. supply and demand, the relationship between peo-
Its occurrence is associated with the names of fa- ple and production. In the 60s it was formed engi-
mous german psychologists-psychotechniques neering psychology dealing with the complicated
William Stern, introduced the concept in 1903 and interrelationships between man and machine in
Hugo Myunsterberg worked mainly in the US. Psy- modern terms of technical progress and automat-
cho-technique, understood as practical use of psy- ed production. It gives psychological foundations
chology in different areas of life and culture, brings of programming, design and management of auto-
to the fore issues of professional selection and orien- mated systems. It is also known under the name of
tation, studying individual differences in profession- “human engineering” (Human Factors engineering).
al ability and demand for appropriate methods for The need for coordination of a number of biological,
the detection capabilities (with orientation mainly technical, economic, social and psychological pa-
to test method ). rameters in the optimization of labour in the system
The study of the process for implementation of “man-machine” (SHM) led to the development of er-
work and determinants for achievement is linked to gonomics.
the development of experimental psychology and
psychophysiology. Current problems are fatigue 3.2. CRITERIA FOR PSYCHOLOGICAL
and efficiency and strive to fully cover the employ- ASSESSMENT OF WORK ACTIVITIES
ment process. Differentiated by its specific tasks in-
dustrial or production psychology, which studies In determining the purpose of changing labour
the forms, methods and organization of work, selec- activities essential issue is the system of criteria by
Tab. 1. Hierarchical system for psychological assessment of work activities (Hacker, 1998)
Level of
Degrees Screening methods Possible criteria (examples)
assessment
♦ development of  TBS* on Hacker (1989) • time for independent action
4. Encourag- selected Abilities  Satisfaction of labor with control of • time for creative activities
ing personal and Attitudes covarianted values also possible: • necessity of learning
development ♦ preservation of Labour subjective analysis
certain A. and A. (SAA Udris & Alioth, 1980)
♦ reduction of Diagnostic examination of the activity
certain A. and A. (JDS, Hackman & Oldham, 1974)
3. Preserva- ♦ no or addmissible  Screening of mental intension with cards for • negative changes in psychophysiological
tion of violations CEAL ** indicators (ECG, EEG, catecholamines)
violations of ♦ tolerable  Scales to assess subjective health • disorders of mental condition, deterioration
the mental conditionally complaints also possible: of self-confidence
condition eligible violations  Scale to assess own status • dynamics of achievement
♦ malfunctions (Nitsch, 1976)
 AET *** (Rohmert et al., 1978)
 Comprehensive analysis of the workplace
and mental stress
 Ergonomic assessment by Schmidtke (1976)
2. Safety Damage to health  Brief methods for assessing working • values of threshold and a maximal
♦ excluded conditions and workload, represented a health concentration of harmful substances
♦ possible risk from CEAL ** complemented by • occupational diseases
♦ they are very  Analysis of morbidity and separation • accidents
probable of covarianted variables
 Psychoneurologic questionnaire for toxic effects
 General analysis of labor
Ergonomic assessment of labor

1. Implemen- ♦ unlimited General ergonomic analysis of work

 • anthropometric standards
tation ♦ partially restricted (AET *** by Schmidtke) • psychophysical parameters of CNS and
♦ reliable perception - labor - hygienic standards
implementation • psychophysiological limit values for
no exists processing of information
* TBS (Tätigkeitsbewertungssystem) - evaluation system for activity
** CEAL - complex ergonomic analysis of labor
*** AET - Arbeitswissenschaftliches Erhebungsverfahren zur Tätigkeitsanalyse Rohmert, Landau, 1979)
- scientific research method for analysis of work

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which they are measured. One of the most com- follow its implementation and changes in personal-
monly used systems today to assess the level of psy- ity over the course of one shift. Essential in this as-
chological shape (design) of labour activities devel- sessment are changes in the term structure of the
oped by Hacker W. It contains four hierarchical levels work shift, the organization and the combination of
of evaluation (Table. 1). different activities. Also important is the assessment
Hierarchy means that: 1) the implementation of of the physical and mental work correlation, which
the minimum requirements of the first level is a pre- has no standards. It is known that the purpose of
requisite for the transition to the next higher level the design work process is balanced participation of
of assessment of work and 2) higher levels provide physical and mental work, for reasons of health and
possibility for further and fuller realization of lower. optimum degree of activation.
Eg. the possibility of individual work style and use Under the potential of employment to boost de-
of intellectual abilities may prevent the onset of fa- velopment of personality understand the opportu-
tigue, to prevent violations of the mental condition. nities for further development of the usual activity
Assessment in terms of safety is primarily occu- regulating psychological conditions: attitudes and
pational health and hygiene problem with (or not) abilities.
damage to health. The main conditions to encourage personal de-
Fluctuations and deficiencies in the implemen- velopment in employment, which are evaluated in
tation of the action may be general information the analysis of activity are:
about the existence of problems with its realization. • Providing sufficient activity.
Identification of such problems is possible by the • Providing opportunities for application and
analysis of the performance of the particular task. storage of the acquired premises for work.
Restrictions on the performance of an activity can The concept of overall employment activities by
be determined by: Hacker is based on the consideration of this prob-
1) the design of tools and working environment lems. The characteristics of the overall labour activ-
that does not meet the anthropometric and physio- ities are: w self goal setting, w independent training
logical properties of man. of the actions taking functions of planning, w inde-
2) cognitive feasibility of actions, ie overload ca- pendent choice of the means of action and the nec-
pacity for processing information of the person or essary interactions to achieve the goals, w perform
difficulty mastering of leading for activity signals activities by providing feedback its passing, w control,
due to lack of feedback or unclear purpose. incl. possibility to verify the compliance of the results
In the assessment of work in terms of preser- of their actions for posed goals. In partial activities
vation of violations of mental health problems absent any of these characteristics, mainly the possi-
associated with load, tested primarily negative ef- bility of self goal setting and decision-making or for
fects of stress. They depend primarily on the infor- individual courses of action. Integrity of work activi-
mational characteristics of activity and occur as re- ties has two sides: cyclic integrity associated with the
versible deterioration of mental preconditions for consistent performance of all business functions and
achievement, for ex. fatigue and similar conditions hierarchical integrity associated with the use of var-
such monotony, satiation, etc. The emergence of ious levels of psychic regulation of the activity. Op-
negative consequences of stress involves a change timal structures are covering preparatory, perform-
in the level of claims (personal goals for a specified ing and controlling phase with changing of different
quantity and quality of performance change), or levels of psychic regulation - from sensmotor to the
by change of put in efforts. During prolonged and level of solving intellectual problems in the activity.
intensive load compensation by raising efforts it „„ Provide opportunities for application and ex-
becomes impossible and leads to distortion in the pansion of the variety of conditions for activi-
structure of activity and dysregulation. In psycho- ties by learning.
motor regulated activities occur violations of coordi- „„ Provide self goal setting, decision making and
nation, increase is additional and hidden breaks and selection methods.
interruptions. In mainly perceptual regulated activ- „„ Provide creative potential opportunities to
ities, eg. tasks of monitoring, the effects of load are change working methods.
pass signals and prolonged reaction. In intellectual „„ Provide opportunities for collaboration with
regulated as processing information, fatigue wors- others.
ened short-term and operative memory, changing „„ Provide assessment of the significant achieve-
and defining them motivation. For the assessment ments of the performers.
of the potential negative consequences of load, as- Three components - complete structure of ac-
sociated with a particular activity, it is necessary to tions, learning opportunity and partly jointly per-

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formed work, provided the activity of people at jective” method with a similar goal is method for
work, which in turn is a prerequisite for adequate detecting regulatory requirements in employment
activity and success. (MURI, VERA of Volpert et al., 1983), ie the require-
Measurable effects on the developing potential ments in terms of planning, thinking and decision
of the work is established in two areas: a) maintain- making. “Subjective” method with such goal is the
ing and developing intellectual abilities through method by Ulich (1981). Another example is a sys-
continuous employability with higher cognitive de- tem to evaluate the performance TBS by Hacker
mands (Fig. 1) and b) motivation for own work task (1989), which is a differentiated system of sorting
and work for public purposes and problems. and separating meaningful for assessment of work
characteristics: organizational and technical condi-
tions that determine the completeness of the activ-
ity; cooperation and communication; arising from
job responsibility; required cognitive performance;
Achievements in IQ tests%

requirements for qualification and training. Another

higher education
method of psychological analysis of the labour pro-
professional training cess in a workplace is a methodology for analyzing
workloads as a result of regulatory obstacles (AWRO,
unskilled work
RHIA of Leitner et al. 1987).
2) Expert assessment of the task and activity.
For this purpose there are standardized universally
applicable methods, regardless of the activity, of
which the most widespread is the questionnaire for
the analysis of labour McCormick et al. (PAQ, Posi-
Age tion Analysis Questionnaire, 1969). They are more
Fig. 1. Age changes in the performance of the IQ tests depend- suitable job classification and definition of require-
ing on the qualification level of activity performed * ments for employability than for the justification
of the proposals for activities related to the design
3.3. METHODS FOR PSYCHOLOGICAL of the activity and qualification requirements. PAQ
ANALYSIS OF THE CONTENT OF THE questionnaire consists of 6 modules: receiving infor-
WORK AND ITS IMPACT ON HUMANS mation, information processing, work performance,
significant work for connections to other individuals,
Most commonly used methods of analyzing the environmental influences and additional conditions.
perception of objective employment situation and 3) Appraisal in attitude of global dimensions.
analysis of the impact of work on the general state This category methods analyze the perception of
and self- confidence. In psychological analysis of objective work situation in order to explain and
activity uniting different methods, allowing reliable forecast the impact of events on the work design.
and valid conclusions in one way amending various The most widely known and distributed is a ques-
parameters set by them. tionnaire for diagnostic examination of the activities
Numerous areas of application of the results of by Hackman & Oldham (Job Diagnostic Survey - JDS,
labour - psychological studies, that range from the 1974). It revealed scores of workers objective char-
design of the work system to professional selection acteristics of their work, and emotional reactions to
and professional guidance, explain the variety of the work and its conditions, and readiness for posi-
methods used. tive motivation to work (Table. 2).
1) Psychological analysis of tasks assigned, According to the authors the emergence of inter-
the conditions of implementation and operation nal motivation for work is related to the experience
in order to detect their determining employment of “critical psychological states,” which are defined by
factors. These methods are analytical procedures the five dimensions of activity. Intrinsic motivation is
that are modified depending on the class of stud- determined by human needs of personal develop-
ied business and target (rationalization and design ment. People with high need for personal develop-
of business or screening for specific industry). “Ob- ment react more positively to the changes related
to increasing the degree of markedness of the five
* Amthauer test for structure of intelligence IST (Schleicher, characteristics of the activity, ie better quality per-
1973). Special studies have shown that by the same starting
formance, higher satisfaction of employment by re-
level of education, differences in mental performance increase
with age and length of service, depending on the cognitive de- ducing absenteeism, higher intrinsic motivation.
mands of the activity.

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Tab. 2. The design and structure of the questionnaire for diagnostic study activity by Hackman & Oldham

Dimensions of activity Psychological states Effects for work

• A variety of activities ♦ Experienced importance of work ∗ High motivation to work
♦ Experienced responsibility for ∗ High quality employment
• Integrity task
performance achievement
• Importance of the task of one's own
life and for others ♦ Knowledge of current performance, ∗ High satisfaction with labor
the quality of own work
• Autonomy (independence)
• Feedback on performance inherent ∗ Less absenteeism and low
♦ Need for personal development
in business fluidity of labour

Widely known is the method of subjective analy- Fig. 2. Stages of psychological analysis of labour.
sis of the activity of Ulich, E. (STA, 1981) to stimulate
the motivation of workers, where they are regarded ANALYSIS OF DATA FROM ENTERPRISE
as “experts” in relation of their activities. Result: Targeting study, hypotheses about
4) Estimation of work related to required pro- cause / effect relationships
fessional qualities. In this type of expertise differ 
two approaches: with an emphasis on the necessary PSYCHOLOGICAL ANALYSIS OF LABOUR TASK
for implementation of the action properties and ca- AND CONDITIONS OF IMPLEMENTATION
Result: Hypotheses about the structure of work,
pabilities, and focusing on the required cognitive
its psychological assessment and the nature of the
processes. For a description of activities by data on
necessary and feasible interventions, design
cognitive processes Miller (1971) compile a list of activities for labour task
terms such as detection, search, identification, cod-
ing, interpretation, categorization, transmission. An- 
other group of methods described business with the PSYCHOLOGICAL ANALYSIS OF THE ACTIVITY
necessary behaviours, like Job Activities Checklist of AND METHODS FOR PSYCHOLOGICAL
Palmer, McCormick (1961). EVALUATION OF ACTIVITIES
5) Analysis of the effect of work on the self
confidence of workers. Labour situation works by Result: Psychological assessment of
Hypothesis about
reflecting it and processing it, in relation with the activities and suggestions for the shortcomings
experience, goals and own claims. As confirmed psychological improving to study of the cognitive
by the results of research into stress, the process is activity or the design of similar bases of
three stage - perception, assessment, action. The work activities regulation
processes of perception and evaluation are available
by revealing experience, consisting of: motivation; 
various aspects of job satisfaction and its conditions; DETAILED ANALYSIS OF COGNITIVE
use and raising of qualification; different dimensions FUNDAMENTALS OF REGULATION BY
EXPERIMENTAL METHODS
of intension; difficulties in implementation of labour.
Result: Identification of incomplete or
For their study used various questionnaires. Some of incorrect cognitive bases of
the most commonly used are the scale Bartenwerf- regulation and output measures, eg.
er (1969), screening of intension by Meister (1976), training methods
scale of states by Nitsch (1976), a questionnaire for

determining the intension, monotony and satiation METHODS FOR CONTROL OF EFFECT
by Plath, Richter (BMS, 1978), polar profile by Math- OF MEASURES
esius (1972).
qualifications required for various types of activities
3.4. METHODOLOGICAL APPROACHES in jobs, error analysis, an analysis of the inworking
TO PSYCHOLOGICAL ANALYSIS OF of newcomers, morbidity, fluidity of labour and ac-
LABOUR cidents. These data allow quick orientation and are
necessary for the preparation of labour psycholog-
Psychological analysis of work is carried out suc- ical analysis and activities, for two reasons: a) The
cessively in stages (Fig. 2): implementation of anthropometric, labour-hygienic
1) Preliminary analysis of the documentation and medical requirements is a prerequisite for em-
of enterprise in terms of interpersonal differences ployment-psychological designing of activity. This
and dynamics of individual annual performance, means that an activity must be feasible and does

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not lead to disabilities and to optimize in relation Structure of employment is characterized by a)
of the consequences of mental load and opportuni- the content of labour, expressed in the needs, mo-
ties for personal development. b) The effectiveness tivations and targets and determined by the means
of the work depends not only on external factors and conditions of work and b) the hierarchical el-
(distribution of functions, means and labour condi- ements of activity - actions, operations and move-
tions) but also by personal characteristics. Cards for ments. The action is an essential element of the work
complex ergonomic analysis of the workplace, allow and is characterized by relative autonomy.
for a differentiated assessment of the state of labour The psychological analysis of activity is always
hygiene and many other characteristics of work. Fur- going according to the particular job. Labour activ-
thermore, there are specific methods of analysis and ities, and actions for their designing and improving,
evaluation of occupational hygiene and anthropo- assessed according to how well they execute the
metric characteristics of the workplace (ergonom- requirements in relation of their enforceability and
ic assessment of the labour system by Schmidtke, safety, eligibility of load and conditions for progress
1976, and the system AET by Rohmert et al., 1975, of personality (Hacker, 1998). Depending on this, is
that reveal and evaluate all factors associated with defined, as subject of study variables and parame-
feasibility and safety of work process). ters, and also methods for their determination.
2) Psychological analysis of work activity and 4) Planning of psychological analysis of work.
conditions of employment on the basis of tech- To remove possible sources of error in collecting
nological documentation, description of operating necessary to evaluate the performance data, need-
systems and facilities, interviews with experts from ed to ensure their representation in several respects:
the enterprise and individual workers, observations a) representation on work assignments for the
in the workplace and, if necessary, - monitoring the workplace (hampered at varying tasks, eg. the pro-
passing of the activity. The analysis of the working duction of small series).
activity comprises the following steps: b) representation in relation of time conditions
a). technological division of the manufacturing in the workplace, which may change depending on
process and separation of humans tasks. the mode of shift work.
b). identifying the work process, within the pro- c) representation in relation of the groups of
duction process: for the entire enterprise. workers (level of qualification, experience, operating
c). description the qualities of the product to be mode).
treated or the process that must be managed with In all studies of human behaviour must be tak-
reporting capabilities for impact by workers; en into account effects associated with conscious
d). analysis of the distribution of labour between or unconscious influence of behaviour. Errors of this
workers and labour conditioned cooperation and kind due to the “conscious participation in the ex-
communication, based on documentation, inter- periment” called Houtorn effect. The possibilities for
viewing the immediate managers and workers; reducing such reactive effects are few:
e). description of the rough structure of individu- w awareness lectures and providing assistance to
al work activity (in relation of stability, and complex- workers for their participation in the experiment,
ity); determining the sequence of individual opera- w testing methods and approaches in pilot studies,
tions, identifying the key points for decision-making wopportunity to control and verify the stability of
and operations in different work situations, deter- the routine individual ways of work.
mine the number of signals and managing impacts,
of listing rules and criteria that must be respected; 3.5. PSYCHOLOGICAL STATES AT WORK
f). establishing objective possibilities for choice
between different ways of working. Choices that Mental state of man is relatively stable structural
have worker (= degrees of freedom), refer to the organization of all components of the psyche and
sequence of individual operations, goals and objec- serves as an active human interactions with the ex-
tives, means and ways to achieve them. ternal environment presented at a time of particular
g). Characteristics of the individual activity in rela- situations. “Psychic” in this sense refers to the emo-
tion of the time factor - duration, frequency (repeat- tional and cognitive processes in humans associated
ability) during a working day/shift. Similar objective with the acceptance and processing of information.
activity can lead to various activity (redefinition of ac- The characteristics of a mental state caused by the
tivity) depending on the subjective perception of the same stimulus may be different depending on the
individual and the qualities of the individual. individual characteristics of personality and its as-
3) Psychological analysis of the activities and sessment in relation to the stimulus.
methods of its psychological assessment.

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Fig. 3. Scheme of the “mental load - mental intension”
INFLUENCE OF ENVIRONMENT ON MENTAL LOAD, for example:
S REQUIREMENTS OF THE PHYSICAL
SOCIAL AND
ORGANIZATIONAL
SOCIAL FACTORS
(OUTSIDE THE R
LABOR ACTIVITIES AND TASKS FACTORS
FACTORS ORGANIZATION)
U For example: For example: For example: For example:
Continuous attention Lighting Type of Social requirements

R (continuous monitoring
radar screen)
(brightness,
contrast,
organization
(structure of
(accountable to public
health or social care)
blinding the control structure E
R Processing of information
brilliance)
Weather
of communications)

(number and quality of the conditions Organizational Sociocultural

O signals to be detected,
decision, conclusion on
(temperature, atmosphere (per-
relative humidity, sonal acceptance,
standards (acceptable
working conditions,
incomplete information, air velocity)
U the choice between
interpersonal
relations)
values, norms)
A
alternative courses of action)
Group factors Economic situation

N Noise (sound (structure of (state of the labor

Responsibility (health and pressure level, group cohesion) market)
safety of employees, loss character)

D of production)
Weather
Manual (constant
close supervision, S
Duration and temporal conditions authoritarian
I characteristics of action
(working hours, rests,
(rain, storm) leadership style)

shift work)
N Smell Conflicts (between
Contents of the task (aromatic,
unpleasant)
groups or between
individuals) O
G
(controlling, planning,
implementation,
evaluation) Social contacts
S Hazardous work
(transportation, work
(work in isolation,
relationships with
underground, work with customers)
explosives) N
P INDIVIDUAL PERFORMANCE,
E MODIFIED LINKAGES "LOAD-INTENSION", for example
R Level of claims, faith in their General condition,
Abilities, skills, Instant state,
S
O
own abilities, motivation,
relationships, coping style
knowledge,
health, physical
build, age, diet
baseline level S
experience of activation
N
A E
L MENTAL INTENSION F
I F
T POSITIVE EFFECTS NEGATIVE EFFECTS OTHER EFFECTS
E
Y Effect "heating", activation Mental fatigue and exhaustion, Effect of education
C
conditions like fatigue (monotonous, and training
reduced alertness, mental satiation) T
S

Emerging in the labour process mental states of psychophysiological parameters.

people can be classified (staged) on several counts: Most important for the psychology of labour
duration, a leading component, level the overall classification of states by level of intension, as this
tone, degree of active awareness, dominant in the feature is most significant in relation of their impact
structure properties of personality, etc. In any psy- on business performance. Moderate intension is
chological state there is a certain level of activity of normal operating condition, occurring in mobiliz-
an organism which can be detected by change of ing impact on employment. It is necessary for the

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normal implementation of the action and is accom- Mental fatigue - a temporary disorder of the effec-
panied by moderate modification of physiological tiveness of mental and physical functional capacity,
reactions manifested in good spirits, stable and depending on the strength, duration and course of
moderate implementation of the action. Increased the prior mental intension. Reduced functional ca-
intension accompanies the activities taking place in pacity occurs eg. in feelings of fatigue, a more un-
extreme conditions. favorable ratio between achievement and put in
1. Psychological states and working effort, type and frequency of errors, etc. The compo-
conditions nents of tiredness as a mental state are:
Each activity, even primarily physical work can lead „„ Feeling weak, oppressive intension and un-
to mental stress. According to the European standard certainty;
(EN ISO 10075-1, 2000) mental stress is a term to de- „„ Attention deficit disorder characterized by in-
scribe the set of all external influences on people who stability, low mobility or chaotic;
influence him mentally and can be evaluated. Mental „„ Disorders in the sensory area of ​​receptors in-
load causes an increase or decrease in mental inten- volved in such work as ex. “smearing” of the
sion in humans. Depending on your previous activi- text after prolonged reading or weakening
ty or baseline and the qualities of the individual, the of tactile sensitivity after prolonged manual
same situations can constitute mental load leading to work;
increased or decreased mental intension. „„ Disorders in the fields of motility, resulting
Mental intension is a direct nolong-lasting effect in delay or unorganized movements, rhythm
of psychological load on people. The consequences disorder, reducing accuracy, coordination and
of mental intension can vary in shape and strength automation of movements;
depending on the individual characteristics and situ- „„ Defects in thinking and memory in the field
ation. Adverse factors that increase the intension, re- which is related to work, lowering their wits;
fer to the following groups: physiological discomfort „„ Loss of will, determination, persistence and
or non-compliance of the conditions of living and self-control;
regulatory requirements; biological fear and danger „„ Drowsiness as an expression of the develop-
to life; lack of time; increased difficulty of tasks; in- ment of protective inhibition.
creased significance of potential improper actions; Tagged psychological indicators of fatigue occur
presence of significant side factors; failure due to depending on its extent. Low fatigue (first stage),
objective circumstances; deficit of information for without significant changes in the psyche, signaled
decision making; sensory deprivation; information the need for measures to avoid a decrease in per-
overload; conflict conditions and others. The degree formance. The second stage of the fatigue is char-
of mental intension, which is carried out, depends acterized by a marked and enhancing deterioration
also on motivation and assessment of the objective. of productivity, often only in relation of quality. The
The high assessment of the purpose of the action, third stage is characterized by an acute experience
requires more energy and effort to implement its, of fatigue in the form of strain at which sharply de-
mobilization. creases the efficiency.
The links between mental intension, individual Similar fatigue states - monotony, reduced vig-
characteristics, experienced mental intensiont and ilance and mental satiation.
its immediate effects are shown in Fig. 3. „„ Monotony is slowly evolving state of reduced
The immediate effects of mental intension are activity, which may occur during prolonged,
positive or negative. The positive effects of mental uniform, repetitive tasks or activities and
stress are: which is mainly characterized by drowsiness,
Effect of “heat” - a common consequence of men- fatigue, decrease and fluctuations in produc-
tal intension that soon after the commencement of tivity, a reduction in the adaptability and re-
operations reduces the effort to carry it out. activity.
Activation - inner state with varying degrees of „„ Reduced vigilance is slowly developing condi-
mental and physical functional capacity. There are tion characterized by reduced signal detec-
areas where activation is optimal and provides the tion in uniform tasks of monitoring (eg. moni-
best functional capacity. The sudden increase of in- toring of screens or indicator devices).
tension can lead to undesired hyperactivation and To overcome the negative impact of boring and
worsening of the results. monotonous work is very important motivation.
The negative effects of mental stress should be Mental satiation is a state of nervous, periodically
differentiated depending on the time needed for re- Increasing, strongly emotional rejection of repeti-
covery and ways to achieve this. These include: tive task or situation that is experienced as “not get-

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ting anywhere” or “leading to a dead end.” Addition- of frequent, repeated very high or very low men-
al symptoms of mental satiation are anger, reduced tal stress: psychovegetative disorders, increased
performance and / or sensations of fatigue and a irritability, depression, psychosomatic complaints
tendency to withdraw and business interruption. and diseases, permanent disability, stress, burnout
Mental satiation in contrast to the monotony and “burnout” (Tsenova B., 1993). According to mod-
reduced vigilance is characterized by unchanged or ern concepts of stress he was uncomfortable state
even increased level of activity, but associated with of intension arising from the assessment of a given
negative emotions. It is caused primarily by repeat- situation as unfavorable for the individual and the
ing the operation, while monotony are needed and resulting need to remove this imbalance individu-
other objective data - narrow of irritants, uniformity, al- environment in which he can not cope. Richter
narrowness of the observed field. & Hacker (1998) propose a system of nine criteria to
As an indirect consequence of mental satiation distinguish most researched forms of negative ef-
may occur effects of training related to repeated fects of mental stress (Table. 3).
overcome the mental strain. The state of negative emotional intension that
Other effects are boredom, feelings of overload occurs in humans at the meeting of a substantial
where there is great interpersonal differences. The barrier on the way to achieving a significant goal for
same applies for possible adverse long-term effects him is described as frustration. It is usually accom-

Table 3. Criteria for Negative effects of mental intension

distinguishing the
Criterion Mental Mental
different forms fatigue Monotonous satiation Stress
of the negative effects
Configuration Prolonged Insufficient use Experienced Objectively overload
of mental stress triggers demands on the of PA as a a lack of without the possibility
(Richter & Hacker 1998) prerequisites for necessity in sense in of avoiding and/or by
achievement (PA); narrow range readiness for experiencing overload
accelerated when of observation realization congestion of caused
exhausted and of the task negative emotions;
overloaded PA frustration of goals

Leading Exhaustion, disinterest, marked excitatory troubling

signs of tiredness boredom, irritability and intension, anxiety,
experience, without accompanied by discontent, concern the feasibility
phenomenal boredom a sense of fatigue disgust of the task

Time to Occurs after a occurs after a it is also it is also possible in

business continuous continuous possible in advance and during
activity; constant activity; undulating advance and the operation
process course during the
operation

Change small improving ? probably permanently

activities - achievement lower achievement
effect
Depending on small small high high
assessments
Activation Initially downgraded increased increased
compensatory
increased, later
downgraded
Individual Missing abilities Missing PA and none increased
dispositions and skills a limited variety of vulnerability to
strengthen tasks favourable emotional lability
mental fatigue for usual
hypoactivation
Restore Constantly, possible ? persistent violations
passing requires time intermittent of recovery

Precautions Design of labor, enrichment of individual reduce emotional

distribution of tasks, reducing sense, stress by expanding
functions man- the requirements pricing, goals, the field of activity,
technique, training for continuous changing treatment of
regulatory PA, attention activity emotional lability
regime of work
and rest

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panied by negative emotions - fear, anger, insecurity vanic reaction, reflex of the pupil). To psychological
and the formation of a negative attitude towards the methods belong tests measuring mental functions
cause. In frustration behaviour manifests as aggres- in humans, volume, distribution and switching of
sion, marked hostility, rudeness, malevolence or di- attention: the tests on Kraepelin-Schulze, Nechaev,
rected at himself aggressiveness, or on the contrary Schulte-Platonov, Bernstein, tachyometrical survey
- depression and lower activity. and others. Only using various methods, including
Human behaviour in extreme conditions of ac- subjective report can give an accurate description of
tivity is an expression and a result of his psychological the state of fatigue.
readiness for activity. The total and situational psycho-
logical readiness includes the following components: 3.6. PSYCHOLOGICAL STUDY OF
a) motivational (need for achievement, interest OCCUPATIONS
in the operation); b) cognitive (understanding the
obligations, task, assessing its relevance, knowledge 1) Professiography
of the means to achieve the objective); c) emotional For many professions are developed professio-
(sense of responsibility, enthusiasm, confidence in grams - description of socio-economic, industrial
success); d) volitional (self-control, focus on the task, and technical, hygiene, psychological and other
overcoming doubts). characteristics of the profession. An important part
Rationalization of working conditions in the of professiograms is psychogram - feature the re-
broadest sense is a means to combat the negative quirements of the profession to the human psyche.
mental states. Development professiograms and psychograms first
Some examples of solutions and approaches to descriptive stage of psychological study of activity.
prevent the negative effects of mental stress at work Professiography principles are: complexity, pur-
at different levels are: distribution of breaks for rest; posefulness; principle of social activity, suggesting
avoiding monotonous noise; shift work; periodic inclusion in professiograms elements of profpropa-
replacement of the operations carried out; combi- ganda; principle of the personal approach; principle
nation of tasks of varying complexity; distribution of reliability (concerning stability of a person under
of tasks; avoid fragmentation of the operating time unfavorable conditions); principle of differentiation,
and continuous attention; variety of tasks; identifi- providing different disciplines entering a profession
cation of signals; changes in the modality of signal; and principle of typification requiring aggregation
lighting; temperature; coloring; the possibility of in- of occupations in certain groups; and finally the
dividual approach in carrying out tasks etc. principles of perspectivity and reality.
2. Methods for assessment of mental states In accordance with the first of these principles,
To evaluate the effectiveness of rationalization in the complex analysis of the profession suggests: -
certain working conditions using different methods production characteristics of the profession and its
to study the states. In many cases, only the combina- specialties; - data on the economic importance of
tion of more methods may allow diagnosis of men- the profession; - sociological and socio-psycholog-
tal state. To determine its use monitoring of human ical characteristics (incl. features of interpersonal
behaviour, natural and laboratory experiment. Mon- relationships, the collective, the social prestige of
itoring results can be supplemented with the ob- the profession); - listing of knowledge and skills re-
jective data as: timing, photographs, camerawork, quired for successful professional activity with the
measuring some physiological functions (heart rate, release of those defining professional mastery, in-
breathing, blood pressure, sweating, skin-galvanic volving and terms of training and perspectives for
reaction, etc.). This approach is called a methodolo- career development; - hygienic characteristics of
gy for visual assessment of the situation in external working conditions with the release of so-called “oc-
signs and somatic indices. cupational hazards”; - review of requirements of hu-
Mental state of fatigue is a complex phenom- man, point of view of physiology and medical con-
enon which depends not so much on the severity traindications to exercise a profession; - Compiling
of labour but also by a number of subjective condi- psychogram.
tions: increased excitability, asthenic emotions, lack The sequence of the research in the use of pro-
of planning. Used today methods can be divided fesiographycal method is presented in Fig. 4. De-
into two groups: methods oriented to physiology pending on his appointment professiograms are
and to psychology. In physiological methods in- divided into universal, containing information and
vestigate the physiology of the muscles (electro-my- specifications apply to all types of work, and special
ography), central nervous system (EEG), autonomic containing specialized features needed to solve spe-
nervous system (pulse rate measurement, skin-gal- cific labour tasks.

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Fig. 4. Continuity of research of work using professiographycal method

Study and description of the work by methods of the individual sciences and disciplines

Physiology Hygiene Psychology Sociology Economy

Analysis, systematization and generalization of data on employment

PRIVATE PROFESSIOGRAMS
economic and
physiological sanitary psychological sociological
organizational

Summary of private professiograms

Complete professiograms

Universal complex professiograms

Purposeful use for the specific needs of the practice

SPECIAL PROFESSIOGRAMS
optimization to improve the to solve the the formation for the
conditions and socio-hygienic social and of lifestyle and purposes of
regimen of conditions and psychological management economic
work safety issues assessment
and stimulation
of labour

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The content and volume of psychogram depend In the case of own account workers are instruct-
on the purpose for which studied the profession. ed to think aloud on the job, to explain to the viewer
Such an objective can be professional selection and as a student all necessary actions and operations.
orientation, occupational training, rationalization of In the second option of using introspection in
the regime and working conditions, optimization of professiography himself psychologist became a
labour, increased safety, standardization and evalu- student and studied the profession by participat-
ation the hardness of labour, etc. ing directly in the work and gradually acquire the
2) Methods of psychological study of the pro- required skill and habits. Such an approach called
fessions working method is applicable only for relatively sim-
On the psychological study of professions meth- ple jobs, whose adopt does not require much time.
ods are used to gather information about the pe- In other professions, this approach can be applied in
culiarities of the professional environment and the the form of labour tests when adopt only some, the
resulting demands on people, properties of the most important or accessible areas of activity.
subject of labour and its demands on the business Experimental method
environment, as well as methods for processing and In professiography experiment serves to verify
systematization of information received. the already constructed psychogram. When enough
Analysis of the documentation. match (high correlation coefficients) between ex-
Of technological documentation, manuals, in- perimental evaluations and practical performance
structions, periodicals can obtain initial information data of professiographical analysis can be recog-
about the structure of the workplace and the cir- nized as correct and justified.
cumstances of: basic professional tasks, operations, The main experimental productions in the study
performance for mode of work. Knowing these and analysis of the occupations are:
characteristics of the business and professional ter- „„ finding experiment aimed at ascertaining
minology is a prerequisite for the development of whether the respondents have certain quali-
monitoring plan and talk scheme with specialists. ties (sens-motorial, intellectual, personality),
Talk and survey methods. „„ production experiment, which involves the
These are aids, but can be used at the provision- introduction of changes in the organization
al stage of familiarization with the profession or the and execution of work in aim to studying their
study of refractory for monitoring and experimental influence and also role of individual psycho-
verification parts of professional activity. The study logical factors to cope with the requirements
can be in the form of verbal discourse or using the of professional activities,
inquiry forms. „„ modeling experiment in which models are
The survey - receipt of written answers to ques- made, reproducing complex conditions and
tions - can have a “free response” and type “selected labour operations by analogy with the real.
response”. We should'nt, instead careful preliminary analysis
The reliability of the information received in the of the profession, at the outset, to try an experimen-
lecture and the survey depends on the belief of re- tal evaluation of by chanse taked mental properties,
spondents, that reported their data will not be used associated with a profession, because they can pro-
to the detriment of themselves and their colleagues. duce false conclusions.
Method of monitoring. Personality methods
Monitoring work-process and behaviour of spe- The properties and relationships of personality
cialists (operating with tools, materials, communi- can be assessed from the examined person as in
cation) enables a more accurate description of the most personality questionnaires, or colleagues who
actions and movements of workers in accordance know him well - a method of independent charac-
with production tasks and the results of labour and teristics. Widespread personality questionnaires are
enable the detection of critical moments. of Eysenck questionnaire to determine neurotism,
Monitoring is usually combined with timing. Tim- extroversion-introversion and psychotism; sixteen
ing and photography of the working day is conven- factorial questionnaire Cattell (16 PFI); MMPI (Min-
ient to use specially prepared blanks with vertical nesota multifactor personality questionnaire). Ex-
scale of time on the left side. The main elements of pression of a factor in a person is determined by
the activity coded in advance. The monitoring data 10-15 questions whose answers in implicit form
is usually complemented with objective data ob- characterize these factors (properties).
tained with the help of measuring methods. Using these questionnaires assessing personal-
ity, suggests their adaptation (taking into account
Introspection and own account socio-cultural differences) and standards for the

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population. It should be taken into account that ob- Consultant for professional orientation can greatly
tained using these questionnaires “diagnosis of per- contribute to the creation of proper motivation and
sonality” is unsustainable and change significantly peaceful reorientation.
by environment and lifestyle of the individual.
In the method of independent characteristics by 2) Motivation to work
Platonov a trait of personality evaluated by the im- There are many studies and attempts to classify
mediate supervisor and workers who know better individual needs that motivate people. A. Maslow
research specialist (of 5-7 people) on a 5-point scale. releases 5 basic levels of human needs: 1) basic
The received average assessment show formed in physiological needs, ensuring survival (hunger,
the working collective opinion about a person. thirst, sleep, etc.). 2) need for safety and security; 3)
need for love, friendship and social activity; 4) need
3.7. PROFESSIONAL SUCCESS AND for respect, recognition and self-esteem; 5) need for
MOTIVATION TO WORK self-fulfillment, achievement and personal growth.
Only after satisfying the needs of lower-level, person
1) Definition and criteria for professional strives to meet the needs of a higher level. Maslow
success believes that the need for realization of their oppor-
Concept of “success” is not unambiguous. It in- tunities, continuous self-improvement and creativi-
cludes primarily labour productivity but also prod- ty in a broad sense, dominate the little people.
uct quality, making mistakes, the necessary neu- The motivation for work is influenced by how
ro-psychical efforts to achieve a result (its “cost” ), work contributes to addressing the needs of work-
and employee satisfaction. ers. Obviously, unmotivated behaviour is harmful to
When the degree of markedness of any individ- an organization, such individuals are absent often,
ual-mental property corresponds to the high level do not comply with working time, distinguished by
of professional success, this property can be regard- neglect, cynicism, apathy, lack of interest, sometimes
ed as professionally significant, ie ability. Abilities aggressive attitudes and reactions to his colleagues.
can be as individual properties (peculiarities of his They themselves are in a state of stress and provoke
cognitive, emotional, volitional activity) and the re- the occurrence of stress in others. Conversely, it has
lationship of personality (interest, passion, respon- been proven that highly motivated workers come in
sibility, debt). A prerequisite for success in a profes- regularly to work, work diligently, with more readi-
sion not just a collection of the necessary properties ly and are more flexible. Motivation is a critical ele-
and a certain structure - “functional group” capabili- ment for any organization.
ties (combination of various components). The level Specific opportunities to increase motivation
of the capability development depends on the re- vary, but generally it can be said that: To provide the
lationship between the possibilities of man and his best possible payment and job security - at least on
motivation and interest in the profession. average somewhere existing payment and favours
Individual sustainable system of psychological for similar work. To bring style and practice of super-
means, personal approaches and methods of work vision that encourage motivation to work and set up
that one uses consciously or spontaneously to adapt working groups (team) of compatible personalities.
to objective conditions and requirements, called in- Endeavour in the selection, recruitment, distribu-
dividual style of activity. tion and evaluation of staff reaching out to better
Strong motivation and the existence of a conflict match between individual capabilities and offer job
between the properties of the individual and the re- opportunities; periodically to check whether people
lationship of personality capabilities to structure can continue to feel that they are treated fairly and are
be removed through the development of under-ex- assigned a suitable job and responsibility. To use
pressed significant professional property. all means possible to maintain good and open re-
The second option to overcome this contradic- lations with all contractors. These include: friendly
tion is expressed compensation of insufficient prop- supervision of consultation character; regular joint
erty or set of properties with other habits and skills. consultations with senior executive staff; regular
In real terms it is difficult to determine whether the discussions with employee representatives / unions;
basis of professional success are certain abilities or effective assessment of individual performance and
new forming experts skills. achievement based on disclosed properly justified
This contradiction can not always be overcome and validated criteria; briefing groups; periodic ex-
even partially. In this case, the outcome is the for- amination/screening perceptions and attitudes to-
mation of positive attitudes towards other activities. wards work.

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 LABOUR MEDICINE
3) Predicting the success of the activity 3.8. PSYCHOSOCIAL FACTORS OF
Developing a system to predict the success of the LABOUR AND HEALTH
activity involves the following stages:
„„ Psychological study of activity. The psycho- Related health and mental well-being issues
logical structure of activity gives an idea of ​​the include psychosocial stressors at work, in family
necessary structure for capabilities of person- and social life. They affect health and self-esteem
ality for this activity; through 4 types of closely interrelated mechanisms:
„„ Selection and development of methods for emotional, cognitive, behavioural and physiological.
collecting baseline information. Optimal de- Psychosocial factors are associated with social
sign of diagnostic methodology combines structures and processes are mediated by percep-
analytical - study of individual mental prop- tion and experience and include: 1) structures and
erties, and synthesis approach, i.e. imitation, processes in the environment (incl. and work) eg.
creation of simplified models of the activity; rapid social change, destruction of cultural tradi-
„„ Developing criteria, objective measure of the tions that may cause pathogenic or, on the contrary,
success of the activity. Used for this indicators improving health effects; 2) individual determinants
must comply with the basic principles: ade- of human capabilities to respond to such stimuli
quacy purposes of forecasting; use primarily (personality characteristics, habits, attitudes); 3) psy-
on objective indicators; using several indica- chosocial conditioned physiological, psychological
tors with separation of the lead or generalizet- and social mechanisms (functional disorders in the
ed evaluation of success; excretion of hormones, anxiety, increased willing-
„„ Conversion of output information in an inte- ness to risk); 4) psychosocial conditioned mental or
grated diagnostic evaluation. Used in systems physical illness; 5) lowering of self-esteem, satisfac-
for predicting the success of the activity sta- tion, quality of life; 6) various aspects of the health-
tistical methods are: comparative analysis of care system, including events promoting health and
final groups, a method of correlation pleiads, efficiency of health care (Levi, 1979).
factor analysis, sequential analysis, regression The common forms of psychosocial determined
analysis; ill health and self-esteem is: a mismatch between
„„ Definition of validity of the system for fore- individual needs and offer environmental opportu-
casting and assessment of its acceptability for nities for their satisfaction, mismatch between the
practical use. Comparing formed on the ba- capabilities of human and environmental demands,
sis of informative indicators forecast with the discrepancy between individual expectations and
objective characteristics of the success of the perceived situation.
work of the same sample of persons is called One of the most significant psychosocial stress-
verify the prediction. ors in employment are: insufficient or too high load
If the system is valid, it is formed as a guide. and pace of work, monotony, role conflict, limited
Used in procedure for professional selection opportunity for social contacts in the workplace,
methods are evaluated according to the criteria: pre- autocratic style of leadership, lack of social support
dictive value (informative) - probability of correctly from the supervisor, poor interpersonal relations
predicting the professional efficiency of the studied, and workplace violence (psychological terror), in-
measured by the coefficient of correlation between sufficient motivation to work and achievement, shift
the survey results and success of operations; reliabil- work, insufficient participation of workers in deci-
ity - stability of the results obtained with a method sion-making at work, lack of autonomy and control
in repeated studies of the same persons; differentia- capability of the work performed, job insecurity and
tion (specificity) - orientation of each methodology redirection, risk of unemployment.
for assessing the specific function or set of functions. Can be distinguished two groups work character-
Diagnosis and prediction capabilities, assess- istics affecting mental health:
ment of employability, must be carried out only by a) a permanent effect (absence deteriorating
persons with special psychological training. health, but their presence over the required not im-
Privacy, prevention of psychological disability prove it): physical security and safety; recognition of
and discrimination, require full information of the social status; have the necessary financial resources;
evaluated candidate and ensure agreement prior to b) the effect of further deterioration, when there
the dissemination of information, data or diagnoses is a negative relationship between high doses and
for him to others. health: control options; opportunity to use skills; for-
eign targets; diversity; clarity regarding the environ-
ment; the possibility of interpersonal contacts.

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 OCCUPATIONAL MEDICINE
The negative effects of labour activities affecting Mental violence in the workplace - mobbing
fundamental and diverse areas of human life, so in Mental violence in the workplace, reaching down
literature speaks of “the long arm of the work.” These to psychological terror, is an extreme form of psy-
include: short-term disturbances of psychosomatic chosocial stressors at work. It involves systematical-
condition and subsequent long-term deterioration ly targeted, objectively unreasonable maltreating,
of physical and mental health of workers; reduce hostile and unethical behaviour by one or more
intellectual capacity, especially the mobility of persons in respect of an individual who behaves in a
thought; passivity leisure and social sphere; educa- position of helpless and defenseless with consistent
tion of children in a spirit of obedience and passivity; repeat (at least weekly) discriminatory actions for
changing valuable orientations of the individual. several months. The term is indicated severe harass-
Adverse effects of the different characteristics of ment horizontally (by colleagues) and vertical (head,
the work for the mental well-being is expressed in: bullying) to workers in different organizations with
anxiety associated with the subjective assessment negative consequences for affected (increased irri-
of events and demands as a threat; depression, as tability, psychosomatic complaints, reduced abili-
an indicator of loss of control over the situation; low ty to complete nervous breakdown and diseases)
self-esteem, resulting from constant comparisons and the organization as a whole (worsening labour
with others; psychosomatic complaints as a sign of morale and motivation, poor production, decline in
poor coordination between body and psyche; irrita- productivity and waste, turnover) and society (re-
bility, as an indicator of depletion of mental resourc- duced competitiveness, higher costs for health care,
es, a common frustration. loss of work-day).
The model of P. Warr related to labour welfare and Main causes of mental violence are factors relat-
mental health includes five components: emotional ed to labour organization and management of work.
well-being, with basic dimensions “pleasure (joy)” Usually starts with a conflict, that has long been ob-
and “activation”; subjective competence, which is scure or no clarify.
seen as the capacity to cope with external and inter- A quarter of workers in Western Europe have
nal requirements and overcome emerging difficul- been subjected to systematic humiliation and psy-
ties; autonomy as an individual feature to counter- chological harassment in recent years. Mental har-
act the effects of environment and independently assment in the workplace is increasing rapidly and is
determine their own beliefs and actions taken; aspi- a problem in all EU countries. The consequences of
rations and claims reflected in motivated behaviour this phenomenon is expected to become the most
in search of new opportunities and efforts to meet widespread occupational disease of the future.
the significant challenges; integrally functioning of New guideline regarding “organizational charac-
the individual as a whole, relating to the complex in- teristics - stress and burnout” is the transition from
terrelationships and balance between the first four situational context to organizational and mana-
components. gerial environment (in which works) to the impor-
New directions in research and practical work in tance of the valuables that
​​ form the emotional and
the field of psychosocial factors are organizational cognitive connection of people with their work. They
health, mental violence in the workplace, psy- are defined as a psychological contract, ie belief,
chological contract. what is required to give the employer, based on the
Organizational health perceived promise of reciprocal exchange. Today,
Improper organization and management of the employees are expected and required to give more
work require that the creation of unnecessary ten- with respect of time, effort, skill, flexibility, while in
sion and stress, which is a breeding ground for the return they receive less in relations of opportunities
development of burnout and the emergence of psy- for career development, job security, etc. . Violation
chological torment in the workplace. Organizational of the psychological contract leads to burnout, be-
health is defined as the quality (general condition) cause it destroys the idea of ​​reciprocity, decisive to
the structure and function of the organization, its maintain prosperity. For this particular focus of de-
system of governance and its culture. Healthy are velopment programs and boost staff, motivation
these organizations, “in which the differently com- and finding meaning in work performed at any level
ponents that determine their general condition, of emotional intelligence of managers.
make them able to fulfill its goal, successful and Management of psychosocial problems. Work-
adaptable and which are perceived positively by its related psychosocial factors are managed through
workers” (Cox T., 2000). Therefore, preventing its im- control programs and reduce mental intension and
portant task falls to the executives who are respon- stress in the workplace, including improved ergo-
sible for the “health of the organization.” nomic working conditions, psychological design of

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 LABOUR MEDICINE
work, reorganization of tasks, improve communica- abilities of employees to cope with potential stress-
tion within the organization, professional selection ors through various techniques for psycho-vegeta-
and staff training, incl. managers, raise individual tive unloading and training in social skills.

REFERENCES
1. BS EN ISO 10075-1 “Ergonomic principles related to mental stress at work. Part 1: General and terms “;
BS EN ISO 10075-2 “Ergonomic principles related to mental stress at work. Part 2: Principles of design “, 2004.
(in bul.)
2. Caruso, D., Salovey P. Managen mit emotionaler Kompetenz. Die vier zentralen Skills fuer Ihren
Fuehrungsalltag, Campus Verlag, 2005.
3. Cox T., Thomson L. Organizational healtiness: work-related stress and employee health. In: P. Dewe, M.
Leiter, T. Cox (eds.) Coping, health and organizations. London, Taylor & Francis, 2000.
4. Dmitrieva M.A., A.A. Kryilov, A.I. Naftulyev. Psychology of labour and engineering psychology. LGU,
L., 1979. (in russ.)
5. Guelpen, B. Mitarbeiter foerdern. Programme zur Personalentwicklung. Schaeffer-Poeschel, 2004.
6. Hacker W. Allgemeine Arbeitspsychologie. Psychische Regulation von Arbeitstätigkeiten. Huber, Bern,
1998.
7. Hacker W. Arbeitsanalysehilfsmittel: Die Verfahrensgruppe TBS und BMS. In: Greif S., Holling H., Ni-
cholson, N. (Hg.) Arbeitsund Organisationspsychologie. Internationales Handbuch in Schlüsselbegriffen.
Psychologie Verlags Union, Munchen, 1989, 94-98.
8. Hacker W. Spezielle Arbeitsund Ingenieurpsychologie. Band 2: Psychische Fehlbeanspruchung. VEB
Deutscher Verlag der Wissenschaften, Berlin, 1980.
9. Ivanova A., What work is needed to man? AI “Prof. M. Drinov “S., 2000. (in bul.)
10. Landau K., W. Rohmert (eds.) Recent Developments in Job Analysis. Taylor & Francis, London et al.,
1989.
11. Levi L. Psychosocial factors in preventive medicine. In: Healthy people, General report, DHEW Publi-
cations No. 79-55071A, Washington, 1979.
12. Maslow A. Motivation and personality. 2-nd ed. Harper & Row, New York, 1970.
13. Matern B. Psychologische Arbeitsanalyse. Spezielle Arbeitsund Ingenieurpsychologie - Lehrtext 3. Dt.
Verlag d. Wiss., Berlin, 1983.
14. Nitsch J.R. Die Eigenzustandsskala (EZ-Skala) - ein Verfahren zur hierarchischen mehrdimensionalen
Befindlichkeitsskalierung. In: J.R.Nitsch, I.Udris (Hrsg.) Beanspruchung im Sport, Training und Beanspruchung.
Bd.4. Bad Homburg, 1976.
15. Oesterreich R. & K. Leitner. Handlungspsychologische Arbeitsanalyseverfahren “VERA” und “RHIA”.
In: Greif S., Holling H., Nicholson, N. (Hrsg.), Arbeitsund Organisationspsychologie. Internationales Hand-
buch in Schlüsselbegriffen. Psychologie Verlags Union, Munchen, 1989, 240-244.
16. Richter P. & W. Hacker. Belastung und Beanspruchung. Asanger, Heidelberg, 1998.
17. Rouseau, D. Psychological Contracts in Organizations; Understanding Written and Unwritten Agree-
ments. Thousand Oaks, CA: Sage, 1995.
18. Rusinova V., R. Rouhou (ed.) Psychosocial problems of employment. AI “Prof.. M. Drinov “, S., 1995.
(in bul.)
19. Schabracq M.J., J.M.Winnubst & C.L. Cooper (eds.) Handbook of Work and Health Psychology, Wiley,
Chichester, 1996.
20. Sonntag K. (Hg.) Personalentwicklung in Organisationen. Psychologishe Grundlagen, Methoden und
Strategien. Gottingen, Hogrefe Verlag fur Psychologie, 1992.
21. Tiandis, H., Dunnette, M., Hough, L. Handbook of Industrial and Organizational Psychology: 4 (2nd
ed) Gilmour Drummond Publishing, 1994. 894.
22. Tsenova B., Phenomenon” burnout. “ Bul. J. Psych., 1993,4,35-56. (in bul.)
23. Tsenova B., Stress at work - empirical research. J. Safety and Health at Work, 2003, 1, 65-87. (in bul.)
24. Tsenova B., Psychological harassment in the workplace - contemporary issues. J. Safety and Health
at Work, 2003, 3, 33-50.1 (in bul.)
25. Tsenova B.,Psychosocial issues at work: stress, burnout, psychological harassment. J. Physical Medi-
cine, Rehabilitation, Health, 2004, 3-4, 18-27. (in bul.)
26. Wilbers, G. Sinnfindung im Beruf, Kamphausen, 2005.

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 Z. Ivanov

4 ERGONOMICS

The rapid development of modern production, the correct adaptation of the machines and work
automation and centralization his ubiquitous use place to man.
of information and computing equipment, com-
plication and increase the speed of technological 4.1. WORKPLACE AND
processes, the emergence of more and more profes- ANTHROPOMETRIC
sions, associated with dynamic social progress, cre- CHARACTERISTICS OF MAN.
ated the need for new interdisciplinary science of la-
bour. She should summarize all the more valuable of Crucial element in ergonomic design or correct
the theory and methodology of various disciplines workplace is complying with basic anthropomet-
for human work, while immediately decided purely ric characteristics of human - operator. It should be
practical problems arising in specific employment taken into account: a) linear (static) anthropometric
situations. This interdisciplinary science is ergonom- data, b) the maximum amplitudes of movement in
ics (from Greek: Ergon - work and nomos - law) - Fig. the joints, c) the maximum area the reach of hands
4.1. Its aim is the adaptation of labour to the physio- d) the maximum muscle strength.
logical and psychological possibilities of man, with a a) The anthropometric data according to BS
view to securing the most efficient operation, with- 14386-77 regarding 5%, 50% and 95% of the pop-
out creating danger to his health, at minimal cost ulation (i.e. men and women fifth, fiftieth and nine-
to biological resources. Ergonomics is divided into ty-fifth percentiles). Eg. man fiftieth percentile P 50
correction (or classical) and projective (or ergonom- is a typical representative of the average individual
ics systems). Classical ergonomics studies already who has values of performance equal to the cor-
created systems - a man - machine - working envi- responding P 50 and P 5 man size is typical for the
ronment and considering mainly certain elements small person. For Bulgarian population basic anthro-
of the line of interaction between man and machine pometric indicators are presented in Table. 4.1.1.
(mainly means for control - MC and means for pre- b) The maximum amplitude of movement
senting information - MPI) strive to adapt to the char- joints are required in the ergonomic design and
acteristics of operator. As a result formulate separate control necessary to optimize working space and
one-dimensional models, respectively requirements freedom of movement in employment. On Table.
for workb instruments, working furniture, environ- 4.1.2. data are presented for upper limb (by Demp-
ment, etc. Ultimately corrective ergonomics as a re- ster).
sult represents the sum of one-dimensional models
(requirements) of the individual labour sciences (eg.
hygiene of laboour, psychology of labour, etc.). Of-
ten these requirements are contradictory and it is
almost impossible truly optimize the human work. Аnatomy Anthropometry Organization of production

Projective ergonomics participate more in the Orthopedy Biomechanics Biotech

development of a system man - machine - working Physiology Physiology of labor System tech

environment and implement multifactor synthesis Medicine Occupational Health Safety technique

of joint system - i.e. - recognize interrelated impact Psychology Management Military engineering

on human activity of psychological, anthropometric Sociology Labor relations Computer Aided Design (CAD)

and hygienic factors, defined by the corresponding

parameters of the machines and work environment.
In narrow aspect since its creation in the 40s of the
twentieth century (also called human engeneering
or human factors in the US) ergonomics deals with Fig. 4.1. Sources and applications of ergonomics

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 LABOUR MEDICINE
Tab. 4.1.1. Basic anthropometric indicators

Name of index Female Male

P5 P 50 P 95 P5 P 50 P 95

Indicators standing posture - in mm (except №2 in kg and №49 to 54 in °)

1. Growth 1488 1586 1675 1602 1707 1810
2. Body weight - kg 49 64 83 57 72 90
3. Height - pupils 1383 1478 1567 1488 1591 1697
4. Height - shoulders 1203 1294 1381 1300 1398 1495
5. Height - elbow 927 1000 1071 996 1081 1165
6. Height - clenched fist 645 702 761 683 747 814
7. Height to the fingers of the hand 547 601 657 574 637 698
8. Maximum width of the shoulders in arms 383 425 472 418 460 499
9. Maximum sagittal diameter of the chest 162 188 219 186 216 251
10. Maximum width of the hips 316 352 394 306 337 369
11. Length - upper limb 636 694 752 700 760 822
12. Length, armpit 258 294 328 282 316 353
13. Length, forearm 189 219 256 209 245 282
14. Length of palm with fingers 159 180 204 177 198 223
15. Maximum width of the palm 86 93 102 98 106 116
16. Thickness of palm 20 24 29 24 28 33
17. Length - foot 818 890 960 880 960 1035
18. Length - hip 408 459 513 436 493 547
19. Length - shank 308 347 390 329 376 425
20. Sole - height 73 82 96 76 90 105
21. Sole - length 224 242 261 245 265 286
22. Sole - width 89 97 107 96 107 118
23. Maximum reach forward 722 799 878 793 869 949
24. Maximum span of arms 1481 1598 1709 1625 1746 1876
25. Maximum span elbow 796 868 941 862 935 1020
26. Maximum reach up 1863 1994 2120 2032 2179 2324
27. Maximum reach up with bent fingers 1767 1898 2018 1928 2068 2212
Indicators sitting posture
28. Popliteal height 369 402 439 407 450 494
29. Growth in sitting posture 788 838 890 843 899 953
30. Height of pupils 646 700 749 682 740 796
31. Height shoulders 522 564 607 557 602 646
32. Height - elbow 218 252 288 226 262 295
33. Height of the third lumbar vertebra 168 198 227 178 204 234
34. Depth of sitting 436 474 518 444 481 524
35. Distance between the plane of
recline and top of the knee 526 570 621 545 592 641
36. Length of straight leg 858 942 1020 910 1000 1080
37. Maximum reach forward 737 802 874 801 870 950
38. Maximum reach up 1174 1259 1336 1279 1364 1451
39. Maximum reach aside 728 794 865 801 868 938
40. Maximum width of elbows 359 422 496 388 454 519
41. Maximum width of the seat 314 368 424 302 341 383
42. Maximum width of the hips 328 374 429 299 333 375
43. Maximum width of the knees 158 188 233 164 188 222
Indicators head
44. Length 168 178 189 176 188 201
45. Maximum width 139 148 159 144 155 166
46. Front head height 192 212 232 207 229 253
47. Length of the ear 53 60 66 57 64 72
48. Width ear 28 32 39 30 35 41
Indicators of angular deflection - in plain degree
49. Maximum angle of deflection of the foot - up 16 28 45 15 27 39
50. Maximum angle of deflection of the foot - down 22 37 52 29 39 51
51. Maximum turning angle of the hand - external 116 149 185 117 149 183
52. Maximum turning angle of the hand - internal 23 50 77 20 42 72
53. Maximum angle of rotation of the head - right 50 67 83 52 71 84
54. Maximum angle of rotation of the head - left 51 68 84 54 71 84

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 OCCUPATIONAL MEDICINE
Tab. 4.1.2. Amplitude of the joint movement of the upper limb in degrees
Type joint motion Average For percentile For percentile
P 50 Р5 Р 95
Wrist:
flexion 90 114 66
extension 99 125 73
total 189 231 147
abduction 27 45 9
adduction 47 61 33
total 74 100 48
Forearm:
supination 113 157 69
pronation 77 125 29
total 190 250 130
Elbow:
flexion 142 162 122
Shoulder:
flexion 188 212 164
extension 61 89 33
total 249 287 211
Horizontal:
abduction 134 168 100
adduction 48 66 30
total 182 222 142
Rotations
internal 34 60 8
total 131 179 83
c) The maximum area of reach, hands are dif- In ergonomic design or correct workplace max-
ferent for sitting posture (BS 15371-81) and working imum work areas comply with the dimensions of a
right (BS 15262-81). When sitting posture for the woman P5, separately for right and left hand. This
basic of the cylindrical coordinate system which provides convenience for 95% of likely working (in
have maximum working areas of the hands is cho- other words, MC for example should not be placed
sen point of sitting posture - the intersection of the beyond the maximum working area woman P5).
plane of the seat, backrest and the symmetry of the For sitting position provided horizontal sections of
human body - Fig. 4.1.1. maximum working areas at different levels of 0 (the
plane of the seat) to the level of 1100 or upwards
through 100 mm - Table. 4.1.3. and 4.1.4. For pos-
ture straight reach zones in vertical and horizontal
planes for a man of medium size they are deter-
mined by figures 4.1.2. and 4.1.3.

Fig. 4.1.1. Basic planes for ergonomic design of maximum

areas to the reach of hands in a sitting posture Fig. 4.1.2. Area of reach, in a vertical plane

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 LABOUR MEDICINE
In all cases the aim is the implementation of man-
ual operations, especially those that occur very fre-
quently and frequently is within the optimal operat-
ing zone or within the normal reach - figures 4.1.4.
and 4.1.5.
d). Maximum muscle strength is determined by
the maximum effort that can support an individual
for a few - 5-10, seconds.
On Table 4.1.5. are the values of maximum force
exerted by hand at different angles at the elbow
and different types of muscle actions. It should be
added that the maximum muscular strength varies
Fig. 4.1.3. Area of reach horizontal plane depending on: the relative position of the parts of
the active limb, muscular effort type and stability of
posture, and is facilitated by the use of various types
of supports.

4.2. WORKPLACE AND WORKING

POSTURE.

Working posture (WP) is an essential element of

human work, respectively in the workplace. Fixing
the body in a certain position enables hands, feet
and eyes to perform certain movements on the im-
plementation of an action. Maintaining appropriate
posture leads to an increase in static muscle work.
1 - area available to the most important and many frequently used The smaller is the proportion of static muscle ten-
controls (optimal workforce) sion, the more rational is WP. The main positions in
2 - area available to frequently used controls (zone normal reach) the labour process are listed in Table 4.2.1.
3 - area available to the rarely used controls (zone reach)
The aim is to seek optimal WP for the specific
Fig. 4.1.4. Areas for the implementation of manual operations work. Since in practice distinguish two basic pos-
and positioning of controls in a horizontal plane tures - standing and sitting, we will look at the basic
features. In terms of biomechanics and physiology of
labour sitting posture has many advantages: greater
stability, small muscular efforts, low energy expense,
optimum conditions for fixing the body, the shoul-
der girdle and upper parts of the arms, which allow
for precise operation. Its disadvantages are mainly:
limited motor freedom, static tension of the muscles
(in unpleasing ergonomic work furniture) and stag-
nation of blood in the legs and pelvis (especially at
constant sitting position - to the fifth, sixth hour of
work).
Ergonomic optimization to sitting requires WP:
A. The implementation of operating procedures
very often and often in optimal work area, or within
a zone of normal reach - Fig. 4.2.1.
B. The construction of production equipment to
create an opportunity to reduce static muscle work
1 - area available to the most important and very frequently used by regulating the height of the work surface, seat,
controls (optimal workforce)
backrest, space and footrests.
2 - area available to frequently used controls (zone normal reach)
3 - area available to the rarely used controls (zone reach)
The adjustable parameters are determined by
nomograms, and if this is impossible - according to
Fig. 4.1.5. Areas for the implementation of manual operations the requirements, set out in Tables 4.2.2. and 4.2.3.
and positioning of controls in a vertical plane and Fig. 4.2.2.

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 OCCUPATIONAL MEDICINE
Table 4.2.1. Types of job positions

Free Coercive
1. Sitting normal 1. Sitting

2. Standing normal 1.1. Leaning

3. Sitting-standing 1.2. Hands up

2. Standing
2.1. Hands forward
2.2. Hands up
2.3. Inclined (to 30o)*
2.4. Strong inclined (up to 30o)*
3. On knees
3.1. Normal
3.2. Inclined (to 30o)*
3.3. Strong inclined (to 30o)*

3.4. Hands up

4. Squatting
4.1. Normal

4.2. Hands up

5. Lying with his hands up

* Tilt the body from the vertical

Table 4.1.3. Maximum work areas - right-handed women 5 P in mm

Polar
angle * Level

0 100 200 300 400 500 600 700 800 900 1000 1100
-90 - 290 303 307 312 310 310 300 295 280 266 246
-80 - 300 320 399 343 341 340 334 318 299 267 253
-70 290 325 356 372 381 385 385 377 358 339 307 284
-60 313 352 391 421 439 445 441 432 406 378 341 304
-50 348 399 444 478 500 510 510 500 473 438 396 345
-40 399 448 498 530 557 568 570 558 585 500 455 395
-30 451 500 545 582 607 618 618 607 581 542 500 440
-20 296 543 588 626 658 658 653 638 618 585 542 480
-10 520 568 616 656 682 695 632 675 643 607 561 518
0 541 595 643 685 710 718 715 708 772 630 578 525
10 547 617 668 708 723 730 728 715 680 639 582 522
20 559 632 680 715 732 738 738 722 698 650 585 518
30 568 639 690 720 738 740 740 732 710 667 600 510
40 570 640 690 720 742 745 745 735 719 673 600 510
50 558 638 687 720 735 740 740 737 718 667 598 506
60 540 628 678 709 727 738 740 730 708 660 598 506
70 590 620 670 700 720 730 730 722 700 660 595 495
80 507 598 650 682 702 710 710 705 690 648 579 490
90 480 575 628 659 675 680 680 678 665 636 570 490
* Divergence angle of the hand in front position: (-) on the other hand, (+) to the same hand

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Table 4.1.4. Maximum work areas - left hand for women 5 P in mm
Polar
angle * Level

0 100 200 300 400 500 600 700 800 900 1000 1100
-90 480 575 628 659 675 680 680 678 665 635 570 490
-80 507 598 650 682 702 710 710 705 690 648 579 490
-70 530 620 670 700 720 730 730 722 700 660 595 495
-60 540 628 678 709 737 739 740 730 708 660 598 506
-50 558 638 687 720 735 740 740 737 718 667 598 506
-40 570 640 690 720 742 745 745 738 719 673 598 506
-30 568 639 690 720 738 740 770 732 708 667 600 510
-20 559 632 680 715 732 738 738 722 698 650 585 518
-10 547 617 668 708 723 730 728 715 680 639 582 522
0 541 595 643 685 710 718 715 703 672 630 578 525
10 520 568 616 656 682 695 692 675 643 607 561 518
20 496 542 588 626 653 658 658 638 618 585 544 480
30 541 500 545 582 607 618 618 607 581 542 500 400
40 399 448 493 530 557 568 570 558 535 500 455 395
50 348 399 444 478 500 510 510 500 473 438 392 345
60 312 352 391 421 439 445 441 432 406 378 341 304
70 290 325 356 372 381 385 385 377 358 333 309 284
80 – 300 320 339 343 341 340 334 318 299 267 253
90 – 290 305 307 312 310 310 300 295 280 264 246
* Divergence angle of the hand in front position: (-) on the other hand, (+) to the same hand

C. To assure optimal angle of comfort for body D. When work allows it to provide support arms
parts. For example, for a job of truck driver comfort by armrests installed on the operating chair or work
angles that provide minimal static tension of the surface.
body are presented in Fig. 4.2.3.

Table 4.1.5: Maximum muscle strength at different angles at the elbow and different muscle actions

Angle at the Percentiles (kg) Percentiles (kg) Percentiles (kg)

Type of action
elbow - degrees Р5 Р 50 Р 95
Propulsion 60 15.4 41.7 68.0
90 16.3 39.0 69.8
120 16.3 46.7 78.0
150 19.0 55.8 88.0
180 22.7 62.6 95.3
Tow 60 10.9 28.6 33.6
90 16.8 39.9 61.2
120 19.0 47.2 69.8
150 25.4 55.3 85.7
180 23.6 54.4 77.6
Lifting 60 9.1 22.2 37.2
90 9.1 25.4 48.1
120 10.9 27.2 56.2
150 8.2 25.4 53.5
180 6.3 19.5 39.9
Descent 60 9.1 23.1 40.4
90 11.8 24.0 39.9
120 11.8 26.3 44.4
150 9.1 21.3 36.3
180 7.7 18.6 37.2
External rotation 60 9.1 23.6 39.5
90 8.2 22.7 44.0
120 10.0 24.0 45.4
150 9.1 24.5 47.2
180 9.1 22.7 47.2
Internal rotation 60 7.7 19.0 37.2
90 7.3 16.8 30.8
120 6.8 15.4 28.1
150 6.8 15.0 29.0
180 6.3 15.4 28.1

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Table 4.2.2: Recommended parameters for the height of the work surface in mm

Height work surface

Types of work
female male female and male
1. Many fine visual work (assembly of watches,
engraving, cartography installation of small 930 1020 975
details)
2. Fine work (assembly of small parts machining
operations requiring high precision, etc.). 835 905 870

3. Light work (installation of medium machine

parts, activities no requiring high accuracy, etc.). 700 750 725

4. Rough work (light assembly work at a large

parts, printing machine, topographic machines, 630 680 655
etc.).

1 - area available to the most important and frequently used

controls (optimal workforce)
2 - area available to frequently used controls (zone normal
Reach) Angles of comfort
3 - area available to the rarely used controls (zone Reach)
1 - between 10 ° and 20 °
2 - between 90 ° and 110 °
Fig. 4.2.1. Areas for the implementation of manual operations 3 - between 95 ° and 120 °
and positioning of controls in a horizontal plane 4 - between 90 ° and 110 °
5 - 15 ° (extension) and 45 ° (flexion) *
6 - between 80 ° and 160 ° *
7 - between 180 ° (radial inclination) and 190 ° (cubital inclination)
*
7 - between 170 ° and 190 ° (flexion-extension)
* With support arm

Fig. 4.2.3. Recommended angles of comfort

WP standing preferred: when performing hard

and medium physical work; technological condi-
tioned sizes are large manufacturing equipment;
serve several machines. It has the following advan-
tages: provides greater motive freedom and force;
the worker can move into the work area allowing to
d - distance from the seat to the lower edge increase the working field of arms and legs, while
of the work surface, not less than 150 mm expands and the visual field. Its disadvantages are
h - height leg area
mainly: increased energy consumption (an average
Fig. 4.2.2. Recommended parameters of the workplace in the of 10-12%, while bending forward up to 47%); in-
course of work sitting creased muscle tension especially the pelvic girdle,

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legs, spine and neck; increase local muscular fatigue Table 4.2.4: Recommended height of the work surface for put
of the legs and in the waist; difficulties in the blood on shoes operator (heel = 3 cm.), posture standing
circulation of the lower limbs; deformations of the
sole arch and possibly knee and intervertebral joints Category Height work surface of workplace - in mm
work
- with longer standing; ptosis female genital under women men women&men
similar working conditions, especially combined Light 990 1060 1025
with the individual characteristics of the female Average 930 980 955
Hard 870 920 895
body; reducing the threshold of external stimuli, the
speed of reflexes and level of attention - as a conse-
quence of general fatigue.
Ergonomic optimization of the WP standing re-
quires: C. It must provide space for entry of soles with
A. Ensuring the standings and freedoms position dimensions not less than 150 mm deep and 550 mm
of working with tilt forward up to 0.2618 rad (15 de- in width. D. Whenever it is possible to use the chair-
grees). seats for support the seat. In terms of physiology and
B. Adjust the height of the work surface (or foot- psychology of labour optimate is free seated-stand-
rests). The adjustable parameters are determined by ing posture. Example of unfavorable with significant
nomogram, and when this is impossible - according static tension is forced to knees (squatting) posture
to the requirements set out in Table 4.2.4. in operation welding - Fig. 4.2.4.

Fig. 4.2.4. Muscles of the body (static and dynamic loads) in working position of welder

8. abdominal external oblique muscle

9. average gluteus
10. gluteus muscle
11. stretching the general fascia
12. sunny muscle
13. the three-headed calf muscle
14. inner broad muscle of the thigh
15. right thigh muscle
16. the semi tendinous muscle
17. adduction, large muscle
18. thin muscle
19. long adduction muscle
20. sewing muscle
21. inner broad muscle of the thigh
22. triceps shoulder
23. rectus abdominis muscle
24. elbow extensors wrist
Legend 1. chest - claviclous- 25. wrist extensors
mastoid muscle 26. extensors fingers
Dynamic load 2. trapezius muscle 27. the short thumb extensors
3. small round muscle 28. the long thumb extensors
Significant static load 4. muscle below the crest 29. the short radial wrist extensors
of the scapula 30. the long radial wrist extensors
Negligible static load 5. the large circular muscle 31. the brachial-elbow muscle
6. broad back muscles 32. biceps
Relaxed state 7. front toothed muscle 33. deltoid muscle

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4.3. WORKING FURNITURE AND TOOLS The main requirement for ergonomic tools is
their size, shape and weight to create optimal con-
Working furniture is extremely essential for er- ditions for the implementation of the work moves at
gonomic optimization of work (especially in terms the rational posture. Below are given some basic re-
of anthropometric characteristics and working pos- quirements for the most commonly used hand tools:
ture). Her includes chairs, seat devices, tables, desks, Hammers used to work with one hand must not
countertops and others. weigh more than 3 - 3.5 kg (without handle) length
A. Chairs and Seat devices. Commonly for pro- of the handle is between 250-350 mm.
ductions, the main requirement is the chairs have Shovels may be of different lengths (900-1300
adjustable dimensions of height and position of the mm), while their selection is better to comply with
seat and backrest and not to restrict the mobility the requirement standing to body shovel to reach
of the body (though it depends on the specific re- the lower limit of the chest.
quirements of the activities - eg. fixing body when Places to catch tools is to be constructed after ac-
pilots). For proper distribution of buttocks seat can curate mechanical analysis of catch - Fig. 4.3.1.
be upholstered soft fabric or slightly concave, and
avoid stagnation of blood in the pelvis should have a 4.4. WORKING MOVEMENTS
gentle slope in front-rear position of 3 to 5 degrees.
The backrest should be adjustable incline. It is Optimum locomotor activity of man - operator is
right to secure and support legs by pedestal. Rec- achieved with correct organization of the working
ommended sizes of chairs and armchairs are listed movements based on the following principles:
in Table 4.3.1. 1. Saving movement. The aim is to achieve the
The design of office chairs, seats and more it is effect using the most appropriate class movements
best to select the specific work.
Table 4.3.1: Basic dimensions of the working chairs
Dimensions in mm
Parameter Chair Armchair
firm semi soft firm semi soft soft
Height seating 440 450 440 430 380-420
Height of seat from the floor 850-870 850-870 850-870 850-870 800-1000
Seat width front 450 470 540 570 600
Width of the seat back 410 - 400 - -
Full depth 520 520 400 600 750-880
Height of the armrests of the seat - - 130 - -

B. Desks, Countertops others. The height of the for activity. There are 5 classes movements - see Ta-
working surface is the most significant parameter. In ble 4.4.1.
general rule, it is at the height of the elbow, both in 2. Achieving optimal force working move-
straight and in a sitting posture. It is best that height ments for a given job and the class of movements.
is adjustable. The depth of the work surface should Those with smaller class have less power. In general
be at least 700, and the width - at least 1000 mm.
When on a surface (table, countertop) work more
persons, the minimum distance between seats
should be 300 mm, and the space for each of the
workers (in depth and width) - minimum 675 mm.
The shelves are convenient when easily reach and
can be seen from the workplace. Ergonomic require-
ments are: a) top shelf at a height of up to 1900 mm,
and the bottom - at least to 1000 mm from the floor;
b) the depth and dimensions are determined by the
size of the stored material. It is recommended that
the depth of the above is smaller than that of the
bottom shelf, as the minimum distance between
two shelves is 250 mm for the upper and lower to Fig. 4.3.1. Design) of pliers to avoid abduction of the wrist and
375 mm. a better positioning of the fingers

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Table 4.4.1. Characteristic of work movements *
Class Axis motion Moving parts
I Knuckles Fingers
II Joints of the wrist Fingers + wrist
III Elbow joint Fingers + wrist + forearm
IV Shoulder joint Fingers + wrist + arm + forearm
V Trunk Fingers + wrist + forearm + arm + trunk
* Optimal movements are to III class.
strength should not exceed 33% of the maximum tion - such as noise engine, the smell of substance,
strength of working muscles, and must be used bi- hardness of a surface, color of material or process (of
omechanical working conditions. For example, op- molten metal, flame, electric arc), etc. The reception
timum strength of the hand is achieved at an angle and interpretation of these signals requires almost
between arm and forearm 120 - 150 degrees. Foot always considerable experience and excellent psy-
this angle is about 120 degrees (sole, lower leg and chophysiological state - high perceptive capacity of
thigh). the sensory organs of the working man.
3. The speed of movement must be between B. Coding information, provided by appropri-
120 and 190 cm/s at a load up to 15 kg, the load at ate means (MPI).
45 kg - less than 25 cm/s. Moreover, movements to The most commonly used visual and auditory
himself in the horizontal plane, forward - backward MPI. Their choice depends on a number of charac-
are faster than those of himself, in the vertical plane teristics of the transmitted information and work
and away. The speed of the rotating movements is process - Table 4.5.1.
1.5 times faster in comparison with the progressive Visual MPI must meet the following basic re-
(a straight line). quirements:
4. The rate of movement depends on the ampli- 1. To be clear, legible inscribe and properly labe-
tude and class, and accuracy requirements. The opti- led, in compliance with distance monitoring. Usually
mal rate in production is about 2 moves per second the size of the scales, digits etc. provides monitoring
of I-II class movements. Fewer tiring is a little faster of about 694-700 mm (length of the hand of a wom-
than slower rate. an P 50 or man P 50). For other distances these sizes
5. Both hands should begin and end their must increase or decrease.
movements at the same time, but in the opposite 2. The information that give to read quickly and
direction, symmetrically and simultaneously. This without hesitation.
leads to a reduction in eye movements as they are 3. Give only necessary to process information (no
fixed in one area or move slightly. Very often the excess).
work is organized so that when one hand takes a 4. The information to be given to them in the
piece, while the other leaves the treated article or most direct form.
taking tool. Thus the time to perform certain opera- 5. To be clearly distinguishable from each other
tions may be reduced to 40%. and from the background of the machine.
6. Circular and continuous movements are 6. Layout, grouping and their subordination to be
more economical for the body than those in a in the comfort zone - the best in the center of the
straight line and interrupted movements. Ballistic visual field, as required for priority, frequency and
movements are faster, more accurate and easier consecutivity of their use.
to implement, because usually involving only one 7. Scales “open window” and the round is read by
group of muscles (flexors or extensors). For this they at least mistakes and should be preferred in accura-
should be preferred. cy requirements.
8. With the best readability are scales that use
4.5. MEANS OF PRESENTING THE natural sequential order of the numbers - 0, 1, 2, 3
INFORMATION (MPI) AND CONTROLS (MC) ...; 0, 10, 20, 30.
9. To meet the stereotypes of human behaviour.
To manage the majority of modern machines hu- For example, to mark the intensification of a process
man operator is necessary information is obtained to use the principle of movement of the clock-clock-
without transformation from sensory organs to the wise, or from left to right.
operator. The nature and complexity of the means of 10. When is possible to use MPI with pictorial
obtaining information is divided into: images. They are perceived very easy (especially if
A) Direct emitted by the machine informa- combined with inscriptions designation) without

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Table 4.5.1.

Hearing MPI Visual MPI

1. Simple message 1.Complicated message
2. Short message 2. Long message
3. The message is not related to subsequent messages 3. The message will be associated with subsequent
messages
4. The communication talk about events taking place 4. The communication about position in space
in time
5. The message requires immediate action 5. Communication does not require immediate action
6. Visual system of operator is overloaded 6. Auditory system operator is overloaded
7. The point of obtaining the information is too brightly lit 7. The point of receiving the message is very noisy
or require full dark adaptation
8. The work of the operator impose constantly moving 8. The work allows the operator to remain in fixed position

hesitation and do not require large production ex- c) is necessary to guarantee secrecy of the mes-
perience - Fig. 4.5.1. sage. (The speech can be understood easily by side
Of course there are different degrees of pictorial- listener, while encoded sound or noise signals can
ity - such as photography or television images are at be formed so, that they are not clear to unwanted
one end of pictoriality, and maps, radar indicators, listener.)
mimic, especially compasses that show some of the d) is necessary flexibility of connection and/or
spatial relationships of presenting information that rapid bilateral exchange of information (especially if
they, are on the other end of pictoriality . you use the MPI base on human speech).
11. MPI are compatible with the corresponding e) it is necessary to identify those who submitted
controls (MC). Ideally, MPI and MC must be designed information (the source of the message).
and located so that the operator no/or small training MC, allowing the operator to change control of
can choose corresponding MC and work with him. processes and machines, can also be sources of in-
formation - most often visual, tactile, kinesthetic and
auditory. Thus they may allow the operator to exer-
cise retroactive control of employment.
In the modus operating differ two major classes
MC: those pressures (mainly buttons - hand and foot)
and such a move (handles, levers, cranks, wheels,
pedals, etc.). - Fig. 4.5.2.

Fig. 4.5.1. Combined pictograms and inscriptions designation

for emergency exit

Hearing MPI must meet the following basic require-

ments:
1. To hear well in the work area and work place
- i.e. be selected with appropriate intensity and fre-
quency response of the acoustic signal.
2. Use to transmit signals mostly acoustic origin -
especially for human speech.
3. To always prefer when:
a) the visibility is limited or impossible
Fig. 4.5.2. The most common MC of pressure or by moving
b) work in conditions of hypo- and anoxia, as
man continues to hear good signals until the vision When choosing a MC usually consider: the pur-
was seriously exacerbated by hypoxia (as in pilots pose, function, as well as some ergonomic and de-
and others.). sign features - Table 4.5.2.

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Table 4.5.2: Principles for selection of controls

Construction Ergonomic
Functions Designation Type of control
considerations considerations
natural direction of
start and stop equipment; "Hammering" when
choosing movement; rational
sequence start and stop; tumbler; switch lever; switching; visually well
between estimate of efforts;
temporary submission of foot switch differing various
alternatives correct position, form
the signal positions of MC
comfortable to hold

choice of communication
choice of switch with indicator
channel; range selection;
three of more fixing position; fixation positions same as above
set the operating modes
options tumbler, switch lever
of the equipment
same as above plus
continuous adjustment compatibility
accurate fluency in the execution
of parameters; fine tuning knob movements MC
adjustment of operations; friction
and calibration whereabouts of the
MPI
continuously controlled
(choke); change the knob; joystick;
crude tuning same as above same as above
characteristics of the pedal; helm
channel; faucet
fluency in the execution
quickly of operations; small or
for example, adjusting the tumbler or switch same as above
adjusting the medium resistance
electronic directory of the lever, enforcement plus optimal speed
values of the (friction) depending on
course on a plane electrical translation of MPI device
parameters the size of the MC

applying steering control; clutch; joystick; wheelhouse;

optimal size same as above
great effort brake pedal (without pedal foot control
booster)

MC must meet the following basic requirements: mainly through standardization of their coding and
1. To have the reach areas. position. The main and emergency MC need to iden-
2. To be well distinguished from the background tify well as visual and as tactile.
of the machine and each other by color, tactile, form, 9. When dealing with MC in any case to seek a re-
inscriptions and combined coding. duction in the part of optic retroactive control at the
3. Their dimensions conform to the anthropo- advantage of increasing touch and proprioceptive
metric characteristics of the operator to meet its one.
physiological capabilities (especially strength and
biomechanical characteristics). 4.6. LIGHTING AND VISION
4. The drive can be carried out as follows: a) for-
ward - inclusion; move forward - enhancing b) to the In 80% of cases human-operator perceived by
left - off; move left - reduction) to the right - inclu- sight, and in some types of work eye left only its en-
sion; move right - strengthening trance. That is why one of the most important sci-
5. Emergency levers are in the direction of move- entific and practical problems of hygiene and ergo-
ment “to myself.” nomics is the continuous adaptation of the physical
6. When requirements for greater accuracy, nature and hygienic qualities of lighting, physiolog-
speed and low power use manual, while demands ical characteristics of vision and the specific require-
for greater strength and inaccurate movements - ments of the type of visual work.
foot MC. Foot MC only be used when possible sitting
posture. 4.6.1. ELEMENTS OF PHYSICS
7. Their distribution in work areas is even and
compatible with the requirements for priority, se- 1. Definition and properties. For visible light
quence and frequency of their use, the direction of is usually accepted that part of the spectrum of
their movement is co-ordinated with muscle coor- electromagnetic radiation having a wavelength be-
dination. tween 400 and 800 nm. According to some authors
8. To elect MC, which can easily be recognized this limit varies from 380 to violet - to 1050 nm - a

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 OCCUPATIONAL MEDICINE
red - or rather on short infrared rays. It should not fatigue, etc.
be overlooked, however, its dependence as irritant Besides the static meaning in ergonomics and
central nervous system and synchronizer of circadi- occupational medicine there, so-called kinetic or
an biological rhythms. dynamic visual acuity. It is particularly important for
2. Intensity or power of light of a light source is professional activities related to monitoring or de-
measured by unit candela - cd. A candela is 1/60 the tection of moving objects (working with video dis-
power of light emitted in the direction perpendicu- play, oscilloscopes, radar screens, in conveyor, trans-
lar to the surface of the absolutely blackbody area of portation, military, etc.).
1 cm2 at the temperature of solidification of platinum 2. Adaptation of vision according to the lighting
(1760° C). and brightness is one of the most important fea-
3. The luminous flux emitted by a light source tures of the visual system as a self-regulating system
is measured by unit lumen - lm. A lumen is the lumi- in the labour process. On the base of phenomenon
nous flux emitted in a solid angle of 1 steradian (sr) of adaptation lie physiological, biochemical and
by source of light intensity 1 cd (1 lm = 1 cd. 1sr). photochemical processes that lead to changes in
4. Lighting is the ratio of the magnitude of the the threshold of sensitivity to light in a huge range
luminous flux fall on a surface to its area. Measured - 1 to 105.
in lux (lx). It is one lx, when on a surface of 1 m2 fall 1 The adaptation takes place in a complex of visual
lm. The lighting increases with increasing luminous system, but can differentiate such levels of pupil and
flux. the retina. Pupila adaptation is extremely fast. A few
5. The brightness is the brilliance of a surface. tenths of a second pupil shrinks harshly reduces the
Measured in cd/m2: 1 cd/m2 = 1 nit (nt - unit not in- light beam to the retina and thus protects it from
cluded in Sl). For a given lighting it depends on the overlighting.
reflectance (see part 4.6.4) of the illumination sur- Adaptation of the retina level include (depend-
face expressed in the following equation: ing on the amount of light falling on it) double pro-
brightness = 0.32 x lighting x reflectance cess of regulation: more nervous - relatively quick
Table 4.6.1. Dependens of the visual acuity by brightness
Lighting in lx Visual acuity Lighting in lx Visual acuity
0.01 0.14 4.4 1.35
0.055 0.22 11 1.62
0.11 0.27 22 1.93
0.22 0.90 55 2.00
1.1 1.20 110 2.10

4.6.2. PHYSIOLOGY AND FUNCTIONAL and photochemical road - slow. The time for adap-
POSSIBILITIES OF VISION IN LABOUR tation to darkness is long: in the first 5 minutes, it
is fast enough, then slowed down and after about
Visible objects emit light rays that pass through 35-40 minutes sight almost completely adapted to
the pupil and the optical system of eye and fall on the darkness (recent studies have shown that this
the retina. Its cells transform light energy into nerve process is completed after about 60 minutes).
impulses that pass through the optic nerve and brain Adaptation to light is much faster, but to be fully
structures reach the cerebral cortex. There occurs the effective it also requires time from 30 to 60 minutes.
phenomenon of awareness of visible images. They distinguish two phases: rapid - about 0.05 s,
1. Visual acuity is one of the most important which reduces the sensitivity of the retina to 1/5 of
visual parameters for the pursuit of the occupation. its initial value, and slower, which is based on the re-
The static visual acuity is determined by the mini- actions of degradation - regeneration of photosensi-
mum distance between two points can still be seen tive substances. In practice, for better adaptation to
separately. It improves for the same size monitored light are needed 8-10 minutes, as the higher speed
by raising the level of brightness within certain lim- observe the first 2-3 minutes. Closely related to the
its - Table. 4.6.1., also by increases the differences in adaptation is process of glare, which occurs when
the brightness of the subject and the background. poorly designed conditions of visual labour. At
Visual acuity (excluding age) influence though to a blindness brilliance of the light source is such that it
lesser extent, other factors such as the color of the is impossible any adaptation. The relative blindness
object, in real time - day or night - for the perfor- may be due to too large contrasts in the visual field.
mance of work tasks, general condition of the body 3. Accommodation to distance plays a signifi-
- especially the supply him with vitamins A and B1, cant role in the implementation of labour activities.

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 LABOUR MEDICINE
Accommodation is realized by changing the projec- view from an ergonomic point of view is considera-
tion lens of the eye under the influence of the ciliary bly larger. Here are these important concepts:
muscles. Punctum proximum (PP) is the nearest to a). Standard line of observation. Starting from
the eye point that is clearly visible. For children, it is the base of the nose and is perpendicular to the
6 cm, and for adults after the age of 40 - 15 cm. Punc- transverse (to the line of the ears) and the vertical
tum remotum (PR) is the most distant point that is axis of the head of the worker, irrespective of the
clearly visible in the absence of any accommodation movements of the eyes. Since the vertical axis of the
(ie completely relaxed ciliary muscles). head of the seated or standing operator is slightly
In unfavorable from an ergonomic standpoint tilted forward (about 5 °), the standard line of obser-
conditions for visual work - especially in poor light- vation is 5 ° below the horizontal (see Fig. 4.6.1.).
ing and little distance to the observed object - suf-
Fig. 4.6.1. Standard line of observation
fers speed and reducing distance of accommodation
(the distance that separates punctum remotum and
punctum proximum). Therefore, when designing
the system man - machine - working environment,
depending on the distance to the visual object 3 dif-
ferent categories of visual work: A. Work at distanc-
es of the observed object over 183 cm. Practical in
these cases there is almost no intension of accom-
modation and convergence. B. The distance to the
visual object is between 30 and 182 cm (most often
about 56 cm). Accommodation and convergence
are loaded, especially if the distance to the subject is
less than 50 cm. From the ergonomic point of view
can be located, on the indicator devices at least 33
cm, but most preferably they are at least 50 cm from
the eye. C. The distance of observation below 30 cm. 1. The vertical axis of the head
2. Standard line of observation
Very high load convergence and accommodation 3. Transverse axis of the head
whose intension can reach 8. D. By increasing the
contrast between object and background accom- b). Normal line of observation. It is a line of ob-
modation efficiency grow. servation in fixed eyes, passing 10 ° lower than the
4. In binocular vision accommodation runs standard line of observation, since as is usually the
jointly with proportional reflex convergence of the eyes look down (seated man - 15 ° below horizontal).
eyes. Surely monocular vision is sufficient in some c). Distance of observation is the distance from
cases to assess the objects of observation in space, the base of the nose to the visual object.
but only stereoscopic vision allows real assessment of d). Optimum angle of vision. The angle horizon-
depth. Both eyes stand each other about 5,6 cm and tal and vertical line of standard line of observation
therefore see objects not quite the same. The brain within which the operator can see the observed tar-
combines the images of the two eyes in one which get only with movement of the eyes.
has a depth of image. This process is performed by e). Maximum angle of vision. In its borders per-
convergence, while nearby objects, lines of sight in son can see objects with eye movement and head.
both eyes converge until they meet on him. Viewing The data for the optimum and maximum angles of
far apart the lines of sight, while too distant targets vision are given in the Table. 4.6.2.
the lines of sight of both eyes are almost parallel. For The visibility of an object in the visual field also
the needs of ergonomics and occupational medi- depends on: its size (category visual work), lighting,
cine is important so-called threshold of stereoscopic brightness, contrast with the background and the
vision, which decreases with increasing lighting (i.e. lighting of the background, exposure time. If insuffi-
stereoscopic vision is improving). cient lighting eg., should increase the size of the ob-
It should be noted that about 5% of adults do not ject, and back if necessary to distinguish the object
have quality depth vision, which limits their ability in a very short time (0,1 s) lighting should be very
to exercise many of professions from transport, war- high.
fare and more. The boundaries of the visual field narrows with
5. Peripheral vision and visual field. This is the age, wearing glasses, fatigue vision, and in some
part of space that can spread fixed eye. Due to the special cases (eg. when driving increases the speed
movements of the head and binocular vision field of of the vehicle).

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Tab. 4.6.2. Angles of vision (visual perimeter) for sitting, standing, lying on their backs operator
Horizontal Horizontal Vertical Vertical
Movement Direction angle * angle * Direction angle * angle *
Optimum Maximum Optimum Maximum
Left 0 60 Up 0 50
Only head
Right 0 60 Down 0 50
Left 15 35 Up 0 25
Only eyes
Right 15 35 Down 30 35
Head and eyes Left 15 95 Up 0 75
together Right 15 95 Down 30 85
* In degrees from the line of observation, lying in a horizontal plane
Many of jobs in transportation, construction, mil- the curve shifts to the left (almost 40-50 nm) and
itary, with the task of monitoring and control require best seen is green-blue radiation, the relative visi-
a very good peripheral vision. This should be con- bility of red radiation is reduced to virtually zero (all
sidered in ergonomic workplace design, as well as subjects looks colorless - gray) .
professional guidance and selection.
The brightness contrast is essential for good
visibility under certain lighting. It show how the
brightness of the object is distinguished from the
background. It is expressed by the following equa-
tion:
Contrast = (B1 - B2) / B2, where B1 is the bright-
est, and B2 darker part of the two contrasting areas.
At low contrast visual acuity is lower - eg. black
object on a gray background will be visible harder
than on white. The dependence of the perceived
brightness contrast of lighting is presented in Table.
4.6.3. 1 - Night C - green
Example: The reflectance of white paper 0.8 2 - Day D - Yellow
(white paper reflects about 80% - i.e. white retain A - Violet E - Orange
20% of the light), the dark green paper - 0.1-0.2 and B - Blue F - Red
black letters - with 0.01. The visual task is reading Fig. 4.6.2 Curves of relative visibility depending on the color

Tab. 4.6.3. Depending minimum distinguishable contrast of lighting

Lighting lx 500 100 50 20 10 5 2 1 0,5
Maximum distinct
4,5 6,0 6,5 8,5 11 14,5 20 25 30
contrast

black letters on a white background with lighting 50 The main distinctions of colour from another is
lx. The brightness of the white paper is 50.0,8 = 40 limited to distinctions in tone, saturation and bright-
lx, and the letters 50.0,01 = 0,5 lx. The difference be- ness and colour contrast.
tween the two luminance is 40 – 0,5 = 39,5 lx. If the The colour tone is determined by so-called selec-
paper is dark green, difference is 50. 0,1-0,5 = 4,5 lx. tive reflection of light from the object, i.e. its ability
It is clear that for the text to be read as well, as white to selectively reflects and absorbs falling on it light
background lighting level should be increased to beams with different wavelengths. Selective reflec-
400 lx (400. 0,1 - 0,5 = 39,5 lx). This example shows tion of light from the objects of a different colour is
that one sees objects because of differences in measured in percentage and is expressed by coeffi-
brightness and/or in colour. cient of reflectance (Δ) - Table. 4.6.4.
Color vision is primarily a function of the macula Saturation is the degree of visibility of the colour
lutea, as it is in this part of the eye are concentrated tone (the degree of dash of white to a colour). Rec-
heel ends that perceive the basic three colours - red, ommended use of colours with a considerable de-
green and violet. The eye is not equally sensitive to gree of saturation, thus improving the perception of
different colours (Fig. 4.6.2). During the day most the visual object. The colour contrast is the change
-well visible yellow-green part of the spectrum with in colour perception depending on the simultane-
a wavelength of 555 nm. In times of dusk or night, ous secondary coloured irritants, that exacerbate in

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him (the colour perception) its quality, or diminish a) red, yellow, orange colour and their shades rem-
their quality in a given sense (this is so called the iniscent of the colour of the heated metal, sun and
phenomenon of contrast). are associated in the minds of human warmth; this is
The lack of colour contrast or brightness in the called warm colours. These are dynamic colours that
colour of the manufacturing premises, machinery pulsed action (increasing productivity) and improve
equipment causes difficulty in distinguishing the spirits. Red increases in respiratory rate, muscle ten-
contours of them, resulting in visual apparatus in- sion and blood pressure and pulse quickens. Yellow
tense and tired quickly. Strong contrasts too tired stimulates the eye and brain, causing nice and cheer-
eyes and therefore must be avoided. ful spirits, calms the nervous system. Orange im-
In this connection, it is recommended that the proves digestion, creates a warm feeling and a stim-
background color of the mashinery, the walls, the ulating effect. In most cases, irritating and signalling.
Tab. 4.6.4. Approximately reflection on the surfaces of a different color
Colours and surfaces ∆ Colours and surfaces ∆
Purple-light 0,65 Beige (oil-based) 0,78
Ultramarine 0,08 White (clay) 0,76
Sky blue 0,66 Light Grey 0,44
Blue 0,55 Gray 0,30
Dark blue 0,11 Silver gray 0,35
Light green 0,48 Stone grey 0,48
Green 0,28 Zinc gray 0,12
Dark green 0,13 Zink 0,55
Yellow green 0,39 Dark gray 0,14
Light yellow green 0,68 Gray black 0,12
Light yellow 0,65 Black 0,10
Dark yellow 0,44 Black (oil-based) 0,06
Light orange 0,48 Black (matte) 0,04
Dark orange 0,35 Ivory 0,70
Orange 0,23 Cream 0,70
Brown 0,43 Light oak 0,33
Dark brown 0,32 Dark oak 0,18
Light pink 0,60 Grey dry concrete 0,32
Pink 0,47 Yellow brick 0,32
Light red 0,32 Red brick 0,25
Red 0,25 Asphalt 0,20
Tight red 0,13 Stucco 0,50
Dark red 0,09 Gypsum plaster 0,77
Chartreuse green 0,54 Lime plaster 0,51
White (zinc weis) 0,83 Pine boards 0,39
Paneling (natural plywood) 0,42 Human skin-average 0,63

floor to choose depending on the colour of worked b) green, blue, blue-green colour and its shades
pieces. reminiscent expanse of sea, the colour of the sky and
So in processing gray details, as iron, steel, lead, are called cool colours. Calming effect and promote
aluminum and other preparations, recommend- a lasting increase its productivity of labour. They in-
ed background is in yellow-cream colour. When crease the spatial idea. The green colour is soothing,
processing workpieces with white (paper, etc.) the fresh and a sense of humidity. Act relaxed. The blue
background is blue. Treat yellow details, such as colour is light, reduces muscle tension, slows heart
bronze, copper, brass ware, wood, yellow plastic, rate and respiration, lowers blood pressure.
recommended background to be blue sky saturated c) light colours create a sense of lightness and joy.
colour, in contrast, if treated with details blue, back- Increased lighting, incite to maintain cleanliness;
ground should be yellow or beige. When processing d) dark colours work hard, depressing, reduce the
red, brown or black details, at - suitable brick red or reflection of light;
beige background. e) saturated and bright colours pulsed sensitivity,
The colour design of the work environment af- spirits and enliven the workplace;
fects the psyche. For example: f ) low saturated colours calm.

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Some colours can create and taste sensations. take into account the vertical (E v.) lighting. It is be-
For example, the green colour creates a sense of lieved that the ratio E x.: Ev = 4: 1 ensures the best
salty flavor, of sour yellow, blue for bitter. hygienic conditions for visual comfort. The lighting
Colours influence to create work habits when of the workplace already comply with the age fac-
used with the same purpose - to begin and com- tor. A number of authors believe that reading print-
plete the work, danger, etc. ed text by 60 year old individual it needs 15 times
Colour vision is an essential condition for the more lighting compared to 10-20 years and about
exercise of many professions in transport, military, 10 times more lighting compared to the 20-30 year
photography, television, chemical, textile, leather, old individual.
printing industry. Visual comfort. It includes anti-brightness, anti-
sharp contrasts, creating a uniform lighting in the
4.6.3. OPTIMIZATION OF VISUAL visual field and others.
ACTIVITY AT WORK. 1. Remove the brightness and stroboscopic ef-
fect. When relatively bright light source or its reflec-
It is implemented using ergonomic and labour - tion appeared in the visual field, creating brilliance
medical measures. decreases sharply visibility. Direct luster due to the
Increasing the level of lighting. The impor- presence of direct light source and reflected (mirror)
tance of good lighting is evident from the following shine - the presence of highly reflective surfaces in
examples: the field of vision (Fig. 4.6.3).
A. Copy of the same typewritten text is per- Direct shine may be reduced as follows:
formed depending on the level of lighting (other - By not dispose bright light sources within 60 °
things being equal - experience typist, workplace from the centre of the visual field (or above 30 ° from
organization, etc.), as follows: the horizontal plan) - Fig. 4.6.4.;

Level of Time for retype

lighting (lx) on 1 line, (s)
40 16
100 14
300 13
B. Turning a cover for petrol pump in mechanical
engineering:
Lighting Time Increasing
level (lx) - processing productivity
average 1 piece (min) in %
52 108 –
136 95 14
351 90 20 Fig. 4.6.3. Direct and reflected shine

Level the least lighting is determined by several - Using light-protetive appliance, suitable for
parameters, normalized in BS 1786-84 - Table. 4.6.5. specific workplace;
1. Contrast (k) is high at over 0.5; average - in k 0,5 - Using the reflected light;
to 0,2; low for k to 0.2. - By using several light sources with less power
2. The background is bright in diffuse reflection instead a more powerful.
factor of the surface (Δ) over 0.4; average - 0.4 to 0.2 The reflected shine may be reduced as follows:
and dark in 0.2. - Using diffused light;
3. Assumed the realized value of lighting differ - By applying a matte, instead polished surfaces
from normal plus 15% and minus 5%. of avoiding the mirror effect - Fig. 4.6.5.;
When necessary lighting to over 500 lx, is recom- - Through the deployment of the light sources so
mended to organize local artificial lighting. In these that the viewing angle of the working surface does
cases it is necessary to keep a balance between lo- not coincide with the angle of incidence on it of
cal (El.) and total (Ec.) lighting - the latter to provide light rays - Fig. 4.6.6.
lighting of not less than 10% of the combined. Stroboscopic effects due to the pulsation of lumi-
Lighting is typically measured in horizontal (E x.) nous flux (these are for discharge lamps) is removed
plan, but in a number of occupations is necessary to through proper networking of luminaires.

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Tab. 4.6.5. Norms for the least light (lx)
Contrast (k) Characte- Lighting (lx)
Size
Category object/ ristics Combined General
Character of visual work object to
visual background of the lighting lighting
distinguish,
work backgr.
mm
1 2 3 4
To 0,15 Ia small dark 5000 1500
Ib small average 4000 1250
average dark
Extremely high accuracy Ic small bright 2500 750
average average
great dark
Id average bright 1500 400
great bright
great average
from II а As I а 4000 1250
0,16 II b As I b 3000 750
Very high accuracy
to II c As I c 2000 500
0,30 II d 1000 300
from III а As I а 2000 500
0,31 III b As I b 1000 300
High accuracy
to III c As I c 750 300
0,50 III d As I d 400 200
from IV а As I а 750 300
0,51 IV b As I b 500 200
Average accuracy
to IV c As I c 400 200
1,00 IV d As I d 300 150
Vа As I а 300 200
from 1,01 Vb As I b 200 150
Small accuracy
to 5,00 Vc As I c – 150
Vd As I d – 100
Regardless of
Rough working Over 5.00 VI contrast and – 150
background
Working with self-luminous
Over
materials and products VII Also – 200
5.00
in hot workshops
General observation of the
VІІІ а Also 75
process - permanently
Periodically, at a constant
presence of people in the – VIII b Also 50
room
Periodically during a
temporary stay of people VIII c Also 30
in the room

1. Matte surface - diffuse reflection

2. Polished surface - mirror reflection
3. Semi-gloss surface - mixed reflection
1. - The eye is not affected by light sources located above Fig. 4.6.5. Reflection from various surfaces
30 ° from the horizontal plan
2. Providing uniform illumination in the field.
2. - The eye is not influenced by the light source located at
an angle of less than 30 °, but provided with a light-protec- To achieve such a desirable ratio of brightness be-
tive appliance tween the four areas of the visual field is as follows:
A: B = 3; A: C = 10; D = 100 - Fig. 4.6.7. Light, bright
Fig. 4.6.4. Reduced shine through appropriate positioning of
the light source to the horizontal plan surfaces is desirable to have in the center and dark
at the periphery of the visual field. Avoid sequential
appearance of bright and dark surfaces, mobile and

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reflection - D (Table. 4.6.4), respectively the correct
coloring of various surfaces in operating rooms. It is
recommended to be as follows: for floors of 0.1 to
0.5; for work surfaces - 0.2-0.6; walling - 0.3-0.8; ceil-
ing - 0.6-0.9.
4. The viewing comfort improves if you take into
account the types of artificial lighting and its im-
pact on the perception of color.

4.6.4. LIGHTING IN THE WORKPLACE

1. Reflected by light source S1, beam coincide at view direc-
tion (bad performance) Generally modern architectural trends for more
2. Reflected beams of light sources S1 and S2 no reach eye extensive use of natural lighting, in combination
(good performance) with the various sources of artificial light (ie setting
Fig. 4.6.6. Observed object and reflected light up of so-called mixed lighting), comply with the
guidelines in hygiene standards to increase the lev-
el of lighting and creating visual comfort. This leads
also to increased levels of productivity and reflected
in the reduction of overall morbidity, accidents and
absenteeism.
Natural lighting based on external lighting at
least 5000 lx and depends on: the time of day, sea-
son, method of implementation and others. It is es-
timated by the coefficient of natural lighting (CNL)
percentage formula:
CNL% = Evi / Ee x 100
where
A - object; B - central zone;
C - peripheral field ≈ 30O; D - total visual field E i. = Brightness of the interior lighting, lx;
E e. = Brightness of external light, lx.
Fig. 4.6.7. Lighting - areas of the visual field (by H. Desoile) Hygiene requirements of CNL depending the
with different shine objectives in the field, and light professional activity are different (Table. 4.6.6)
from a light source with a pronounced pulse flux. Side lighting is more efficient at higher than at
Breaking evenly lighting causes relatively dazzle wide windows (with the same glazed area).
the eye, causing discomfort, rapid visual fatigue and Overhead lighting has three varieties - Fig. 4.6.8.
should be avoided. Shedovoto lighting is oriented north to avoid
3. Impact of surrounding objects. It also affects the massive flow of infrared radiation and fonari -
brightness and depends on the coefficient of diffuse east-west. To ensure visual comfort (mainly in terms
Tab. 4.6.6. Hygiene requirements to CNL

Coefficient of natural lighting

Category of visual work
In rooflights In side lighting
CNL average, % CNL min, %
I 10 3,5
II 7 2,5
III 5 2,0
IV 4 1,5
V 3 1,0
VI 2 0,5
VII 3 1,0
VIII
а 1 0,3
b 0,7 0,2
c 0,5 0,1

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Fig. 4.6.8. Type rooflights

of brightness) visible part of the sky should not be parts of the walls) provides uniform lighting without
located in the visual field. Anti-glow of infrared ra- shadows and glare. It creates the best visual com-
diation is appropriate to use blinds - best vertical fort and is suitable for low rooms with bright walls.
lift. Index glazing (with a view to reducing solar heat Disadvantages: sometimes distorted perception of
radiation and improving the microclimate) is limit- depth (relief ) of the image; it is not economical.
ed to 20-30%, which requires setting up of artificial Diffused light requires less energy consumption
lighting to achieve the necessary illumination (espe- compared with the reflected, but sometimes creates
cially during transitional seasons, in dim days and at shadows and glare (for lighting by discharge lamps
different times per day). - if fit with light-protectors, almost completely liqui-
Artificial lighting. The light sources are divided dated glare).
into three categories depending on the method of Artificial lighting in production use several basic
lighting work zone - direct, reflected and diffused types of lighting. Those with heated lamp (light bulb)
light. are the oldest tool used now, although according to
In direct lighting 90-100% of the light is directed BS 1786-84 is recommended discharge lamps - fluo-
downward. Easy to concentrate on the field. A major rescent lights, mercury and sodium lamps (mercury
disadvantage: high brightness contrasts, shadows, lamps can be combined with such a heated wire, or
reflections. Lighting reflected light (when 90-100% be a luminescent layer which corrected spectrum
of the light is directed toward the ceiling and upper thereof ). Heated filament lamps with a continuous

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spectrum and contains all colors, but they dominate productivity, many small details, low contrast, very
the yellow and especially red. Heated filament lamps long period of time, or vice versa - a very large size
are suitable for colored in warm tones rooms. Since of details, high contrast, very short period of time)
they are still used most widely, it should be added in the recommended scale of lighting - 20-30-50-75-
that in light of heated lamps light levels given in the 100-150-200-300-500-750-1000-2000-3000-5000 lx.
Table. 4.6.5 should be reduced as follows: a) one Maintained lighting on surfaces with continuous
degree for a system of combined lighting in produc- work should not be less than 200 lx. In certain specif-
tion and auxiliary premises of industrial enterprises ic activities required lighting level can be very high
when normalized lighting is equal to or more than - eg. in health facilities of the operating field in op-
750 lx; lighting in public and residential buildings, erating rooms - 10 000 to 100 000 lx; dental offices
when normalized lighting it is equal to or more than - illumination of the oral cavity - over 5000 lx, tables
300 lx; b) one degree on the scale of the lighting for autopsy and dissection - over 5,000 lx. The lighting
system for general lighting categories I to V and VII of the immediate surrounding areas shall not be less
(but not more than 300 lx); c) two degrees on the than one step (on a scale of lighting) than the work
scale of lighting for system for general lighting cat- surface (range 200-750 lx on the working surface).
egory VI and VIII and in public and residential build- The extent of light on the work surface must be ≥
ings, with the exception of the cases described in a). 0.7, and the immediate surrounding areas ≥ 0.5.
Fluorescent lamps are several types according The degree of brightness discomfort determine
to the spectrum of light emitted from them. Lights by a logarithmic index UGR (Unifed Glade Rating -
“daylight” are best suited for artificial lighting, be- aggregated level of glare). Its value depends on the
cause at least change available color (as spectrum brightness of the background in cd x m-2; the bright-
closest to them - close to that of daylight). ness of each luminaire in the direction of the eye of
When lighting using fluorescent lamps type the worker - cd x m-2; solid angle (in steradians - sr),
“white hot” to color the rooms are recommend- under which are visible luminous parts of the lumi-
ed warm colors, and illuminated with fluorescent naire; positional index Guth, associated with the lo-
lamps, illuminated with blue light - cool colors. cation of illuminant bodies to line of sight. The val-
Mercury lamps when they are equipped with lu- ues of UGRL - usually in the range of 19-25, should
minescent layer for color adjustment (emitted light not be exceeded. Designated UGRL presented in
beams) are very suitable for the production aesthet- project documentation.
ics. In their use should take into account certain hy- Color or so-called “Light color” of the light source
giene requirements, the most important of which (lamp) is reproduced color of the light emitted.
is that it can only be used in large rooms with high Lamps with correlated color temperature (Tm) below
ceilings of 6-7 m from the floor. With sodium vapor 3300 K (Kelvin) is a warm light color; from 3300 to
lamps have very good performance, large luminous 5300 K - neutral, and over 5,300 K - cold. Light sourc-
flux and suitable for vision no fatigue yellow color. es (lamps) are evaluated with the so-called color
The new Bulgarian standard for lighting work rendering index Ra of up to 100. In workplaces
places - BS EN 12464-1: 2006 (identical with the Eu- used lamps index Ra ≥ 80. Lower values are possi-
ropean EN 12464-1: 2002) indicates values of light- ble for example in passable tunnels, high halls, etc.,
ing, discomfort from glare and color rendering, but there is a safety color must be well recognized.
guaranteeing good visual performance and visual Required values (minimum) for lighting (Em), UGRL
comfort, associated with safety and health of work- and Ra are presented for a variety of areas (surfac-
ers. es), tasks and activities, grouped into eight major
The values for the lighting of the work surface in groups (tables) - for example. Table 5.7. - Health
different types of activities may increase or decrease institutions.
by one step (respectively eg. high accuracy and

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REFERENCES

1. BS 15371-81, Ergonomic design data for maximum work areas of hands in a sitting posture. S., 1981.
(in bul.)
2. BS 1786-84, Lighting, naturally and artificially. S., 1984. (in bul.)
3. BS EN 12464-1: 2006. Light and lighting. Lighting jobs. Part 1: Indoor work places. (in bul.)
4. BS 14386-77, Anthropometric indicators basic for ergonomic design. S., 1977. (in bul.)
5. BS 15262-81, Workplace in carrying out the work standing. S., 1981. (in bul.)
6. BS 15263-81, Workplace in carrying out the work seated. S., 1981. (in bul.)
7. Cassou H., Fichez R., La charge visuelle, essai d’evaluation en medecine du travail., Arch. Mal. Prof.,
169-177, 1976.
8. Decree №7 SG. 32/2003 (amend. 2005) on requirements for health and safety in workplaces and work
equipment. (in bul.)
9. Dempster W.T., Space reguirements of the seated operator., W.A.D.C., Techn. Rept., 55-159, Wright Air
Development Center, Wright Patterson Air Force Base, Ohio, 1955.
10. Ergonomics., ed. of Venda C. F., Mir., 1971. (in bul.)
11. Environmental and Occupational Medicine., ed. Rom W.N., First Edition, Boston, 1983.
12. Ergonomie., ed. Noulin M., Techniplus , Paris, 1992.
13. Ergonomics and Health in Modern Offices - ed. Grandjean E., Taylor s Francis, 1984.
14. Fundamentals of industrial Hygiene, ed. Plog B.A., Benjamin G.S., Kerwin, M.A., Third Edition, Na-
tional Safety Council, USA, 1988.
15. Ivanov Z. Complex assessment of working conditions. Ergonomic evaluation of working movements
and posture. In Guide to hygiene and occupational diseases ed. D. Tsvetkov, MF. S., 1994. (in bul.)
16. Medical problems of ergonomics., Ed. of Boshev N., MF, S., 1974. (in bul.)
17. Precis de Medicine du Travail., sous la dir de Desoille H; J. Scherrer, R. Truhaut., Masson, Paris, 1991.
18. Physiologie du Travial, Notions d’ergonomie. Masson, Paris, 1981.
19. Thompson D.A. - Ergonomics the Prevention of Occupational Injuries. in Occupational Medicine, ed.
J. La Dou, Appleton Lange, Norwalk, Connecticut, 1990.
20. Woodson W.E. - Human Factors Design Handbook, Mc Graw - Hill, 1981.

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 Z. Ivanov

5 BIOLOGICAL RHYTHM AND

REGIMEN OF WORK AND REST

The rhythm (from the Latin transferred from the tion that rhythm underpins the scientific modes of
Greek “rhytmus”) is a universal biological phenom- work and rest, whose deeper meaning is to achieve
enon that can be expressed with quantitative and adaptive balance between state of action and break,
qualitative indicators and covers all forms of living thereby not only counteract fatigue, but also sup-
matter - of subcellular structures and the cell to ports high sustainable performance.
complex behaviours of individuals and even pop- Rhythm “work - rest“ has the following general
ulations and ecosystems. The basis of biological characteristics: a) it is an obligate condition for any
rhythms lies rotation of fluctuate changes in matter kind of labour; b) arises and is determined by the
and its functions that are inherent in every rhythm course of the work from the beginning to its end; c)
three major components: frequency fluctuations, has specific characteristics depending on the type of
size (amplitude) and phase. Biorhythmology is a work intension and stress of labour conditions and
relatively new science, often identified with hron- labour organization.
obiology, but it is assumed that the general prob- At the beginning of the worker productivity is
lem of biorhythmology include: hronobiology, relatively low. In the course of the work process ef-
hronopathology, hronomedicine, chronothera- ficiency gradually grow. That its ascendant curve
py, hronopharmacology etc. The complexity of the associated with the gradual inclusion of the overall
shape of the curve biological rhythms define them physiological functions and depending on the spe-
as simple (sinusoidal or cosinusoidal) and complex. cific type of work is a process vrabotvane. Reaching
In humans, by virtue of biological requirement to a certain level in work performance occurs stabiliza-
keep the existence adapting to environmental con- tion reflected in uniform or with small fluctuations
ditions, rhythms of a number of physiological func- productivity. In the rhythm of work this is known as
tions have been “copied” from those of the environ- “permanent plateau of sustainable performance.”
ment itself. In this respect especially wide popularity After a time starts drop in performance and appear
has rhythm “day - night” (light - dark) or so-called signs of fatigue. If it is substantial, it may necessitate
circadian rhythms (from the Latin. “circa” - and about termination of the work. The insertion of a longer
“dies” - day). There are also weekly, seasonal, annual break (usually lunch - at day shift) caused repeat-
and multiannual (with periods of 11 and 22 years) ed increase in productivity, which again belongs to
rhythms, but they have much less impact on human closing work time.
performance. Thus, the rhythm of working day consists of
Circadian rhythm has a strong impact on em- at least two waves, and depending on the type of
ployment and its rhythm, which in turn can be ex- work (including the loadness and the intension of
pressed with the two-phase process: action (labour) labour) and more pauses may occur several succes-
- break (pause). The operation determines the occur- sive waves of varying amplitude. This is the typical
rence of a number of changes in the whole organism work rhythm for day shift, which usually coincides
(mostly in the locomotorium, the cardiovascular, res- with the circadian rhythm of performance, driven
piratory and nervous system and brain). The pause determine by its lower level in the afternoon - indi-
is preparing for the next work phase and serves to cate that performance between 14 and 16 hours is
restore biochemical balance and lost neuro-psycho- about 20-30% more lower compared to the morning
logical and muscle power in the labour process. It hours.
should be explicit that rhythm “work - rest “ is almost Rhythm of work achievenments (respectively
perfect physiological mechanism built into human performance) has as weekly, as seasonal aspect - the
evolution, whose main task is counteracting fatigue lower the productivity on Monday and during the
and wear on the body. In modern labour organiza- hot summer months, and more in Tuesday, Wednes-

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day and Thursday, as well as in winter, although work and night work. Night work is reversing the
that mental performance not seen such a distinct course of circadian physiological rhythms in which
rhythm. the phase of rest and sleep are replaced by active
Interestingly, although many debatable bio- intension of work phase. Because of the rough vi-
rhythmological problem is the so-called macrobi- olation of encoded in human evolution habitual
orhythms - physical, emotional and intellectual rhythm (especially that of the nervous system, au-
cycles and their importance for employment. All tonomic functions) night work is more tiring and
these three cycles provides a common rhythm with lower productivity. Even long - weeks, months, night
maxima and minima every 4-5 months, which con- work is not able to completely alter the course of
tinues throughout the life of man. circadian physiological rhythms. All this requires the
The physical cycle - also called male, lasts 23 creation of specific science-based regimens for work
days. It determines the energy, the strength, endur- and rest in these types of work. Intershift modes of
ance, coordination of motor manifestations of the work and rest, which include rest within a regulat-
individual. His first half (the uplift) lasts 11 days and ed working hours, i.e. these rests are regulated, be-
is characterized by increased activity, especially be- come part of the real (for manufacturing activities)
tween the 2nd and 9th day. In the second half thereof, time (unfortunately neither our nor in the European
the decrement of those functions. labour laws rests are not included in real work time,
The emotional cycle, also called female, lasts except for meal breaks in continuous production -
about 28 days. In his first half - to 13-14 th his day, a European legislation, however, identifies the need
man is cheerful, optimistic, aggressive mood. In the statutory rests be subject to negotiation between
second half made a critical reassessment of the re- employers and employees).
sults, there is increased irritability. First question is when to introduce statutory
The intellectual cycle lasts 33 days. In his first rests. It is believed that they are effective in angage-
17 days mental functions in humans are on the rise, ment of the worker over 75-80% of their working
memory is very accurate, clear logic; after 17 days time in direct production activities, ie when oper-
was observed impaired memory and noticeably de- ational (real) time is over 75-80%. In this case, it is
crease the intensity of the brain function. considered generally that rests should be not less
It was found that the combination of the three than 15% of operating time, while at many work
macrobiorhythms defines so-called critical days and activities they have to be bigger - 20-30%, and very
periods in the life of every person (even in 1780 on hard work, especially in conditions of excessive heat
27 May Goethe wrote in his diary: “Watching cycle production microclimate they can reach more than
of good and bad days that are repeated in a specific 50% of the effective time.
order ... “). In those days the resistance of human and The determination of the total time for vacations
there performance decreased, attention and memo- is specifically for different types of work. It is realize
ry are weakened, the thought is rigid. Then possibly by assessing the type and extent of factors influ-
arise accidents, to do our work worse than usual. So enced on labour and/or by evaluation of changes
for people engaged in certain activities (especially in labour efficiency in production, physiological and
in military affairs, transportation, aviation, etc.) has psychophysical indices. The minimum total time for
recently made calculations to establish these indi- statutory breaks during the work shift is 10 minutes
vidual cycles in order to “critical days” to work with for men and 15 minutes for women.
more attention, with more caution . Described the The number and length of breaks is determined
most common features of labour rhythm on the by the nature and severity of occupational activities
impact of the biological clock gain in any particu- and changes in performance over the course of the
lar work its specifics. When conveyor forms of work day, they should be given just before the onset of
organization, for example, there is the so-called im- symptoms of fatigue.
posed work rhythm with great repeatability of par- The minimum duration of each break is five min-
tial and small operations. This requires adjustment utes, the maximum - 20 minutes. Longer breaks dis-
of personal biorhythm of workers to the course of tort the rhythm of work and require re period of the
the conveyor. Coincidence of both rhythm flow of inworking to enter the economy (sustainable) op-
work processes can be satisfactory and productive, eration regimen. It is therefore recommended first
but significant deviations occur negative phenom- break to give 120-150 minutes after the start of the
ena of the nervous system throughout the body - working day and break in the afternoon, 60-90 min-
monotony, manifested most commonly as an early utes after lunch (for light work in day shift).
onset of fatigue. Significant disruption of normal It is desirable that 30-40% of the rest period is in
physiological rhythms is very characteristic at shift the first half, and 60-70% - in the second half of the

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 OCCUPATIONAL MEDICINE
work day. At an mean rate dynamic exercise break high physical exertion; significant mental stress and
is given after 60-90 min, in heavy physical work - af- mental fatigue; high pace of work; significantly rout-
ter 30-60 min, and at very heavy physical work - af- ing load; forced and standing working postures; un-
ter 30-45 min job. In activities with loading of small favorable sanitary conditions.
muscle groups and expressed monotony are effec- It is best regulated rests take place outside the
tive the short and frequent breaks. production environment, in specially designed for
In evening and night shifts introduce additional this purpose recreation recesses and recreational
rests. Morning shift is not more than 6 h, and the centres.
night starts at 22 h. Not allowed more than 4-5 con- On Table 5.1. are given schemes - examples for
secutive night shifts and rest between two succes- allocation of breaks depending on the nature of
sive shifts is not less than 12 h. work.
Extended shifts - 12 h, they are allowed only In practical development of inter-change regi-
when working with a medium level of physical and mens of work and rest are evaluated all the factors
mental intension and admissible levels of work envi- of the working environment and workflow in ac-
ronment factors and employment. In the extended cordance with the requirements of the country Or-
shifts are introduced at least two breaks with a dura- dinance on a comprehensive assessment of working
tion of 30 min each. conditions - 1991 Additional evaluate ergonomic
Statutory rests by type are: active, semi-pas- compliance of control means, means for presenting
sive and passive. information, production equipment, and also work-
Active rests include physical exercise, kalanetics, ing posture and working areas. On this basis it is esti-
aerobics and more. They apply to professional ac- mated whole load of workers in labour and calculate
tivities with hypokinesi, mild to moderate exercise, the time needed to restore capacity. Then develops
work in forced sitting posture and / or moderate a specific regimen of work and rest, and determine
neuro-psychological intension. the duration and distribution of breaks within the
Semi-passive rests include walking, self-mas- working shift - Fig. 5.1. It is represented graphical-
sage, light sports games, etc. Apply when operating ly scientific and reasonable inter-shift mode of work
at an average rate, sitting posture, increased visual and rest for the profession of ironing presses in the
load, average level of physical and mental intension, garment industry - first shift. The impact of all factors
in workers over the ‘35 and under unfavorable sani- of the working environment and working process,
tary conditions. whose parameters are outside of existing regula-
Passive rests are carried out in a sitting, lying or tions - overheating microclimate unfavorable work-
semi- lying postures and may include reading news- ing position (standing), physical load, ergonomic in-
papers, listening to music, sessions of psychological adequacy of equipment, control devices and display
unloading, etc. They are suitable for activities with: devices to human - operator opportunities.

Tab. 5.1. Example schemes to determine the duration and distribution of breaks according to the nature of work

1 2 3
1. Light exercise and minor mental intension (eg. 2 breaks 5-10 min: Ist - 130 min after
Short and rare
work in offices, semi-automatic lines in machine- the start of the working day; II nd -
breaks
building). 90 min after the pause for meal
2 breaks 10 min: Ist - 110 min, after the
2. Moderate physical and mild mental intension (eg. Average duration
beginning of the working day; II nd -
work turners, fitters, miller, painters, etc.). and rare breaks
80 min after the break for a meal.
3. Heavy physical loading (eg. Core activities in Frequent and
20-25 minutes every hour.
heavy engineering, metallurgy, construction, etc.). long holidays
2 rests: Ist 120-130 min after the
4. Minor physical loading and pronounced Medium-length
start of the working day of 10 min; II- nd
psychological intension (work of accountants, and frequency
100 min after the timeout for feeding, of
cashiers, operators TPS and NPS, etc.). breaks
15 min.
5. Work with great monotony, visual and motor
Frequent and
intension (operation pipeline, in cigarette production, 5 min each hour or 10 min for two hours.
short breaks
installation of small articles, in engineering, etc.).

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 LABOUR MEDICINE
Characteristic of the regimen of work and rest:
1. Total duration shift time - 510 min.
2. Total duration of the statutory rests - 54 min.
3. Distribution of breaks during shifts:
I-st break from 7.50 to 8.10 - for rest and meal
II-nd break from 9.20 to 9.25 - for recreation
III-th break from 10.35 to 10.40 - for recreation
IV-th break from 11.50 to 12.08 - for rest and meal
V-th break from 13.18 to 13.24 - for recreation Fig. 5.1. Inter-shift regimen of work and rest for ironing press-
es - I-st shift

REFERENCES

1. Decree № 15 of the terms and requirements for the development and introduction of physiological
regimens of work and rest during work. SG, 54 / 5.06.1999 (in bul.)
2. Ganmy et al. La semaine de travail de 40 heures en 4 jours. Arch. Mal. Prof., 1981.
3. Hronobiology and hronomedicine - ed. F.I. Komarov, Medicine, Moscow, 1989. (in russ.)
4. Ivanov Z., Vodenitcharov E. Ergonomically design regimens of work and rest in the garment industry.,
VI National Congress of hygiene, S., 1994. (in bul.)
5. L’Epee, Les horaires variables, reflexions a propos de quelques realisations de la region bordelaise.,
Arch. Mal. Prof., 1976.
6. Lille F., Andlauer P., Rythmes circadiens., In: Precis de Physiologie du Travail., Notions d’Ergonomie.,
Ed. Scherrer J. Masson., Paris, 1981.
7. Medical problems of ergonomics., ed. Boshev N. Med. and phys., S., 1974. (in bul.)
8. Occupational Medicine, ed. Lukanov M. Med. and phys., S., 1979. (in bul.)
9. Occupational Medicine, ed. Lukanov M. Med. and phys., S., 1984. (in bul.)
10. Piorel C., Les rythmes circadiens en psychopathologie., Masson, Paris, 1975.
11. Precis de medicine du travail., Sous la dir. de Desoille H., J. Scherrer, R. Truhaut, Massson, Paris, 1991.
12. Sartin P., Les horaires libres, Travail et Methodes, Paris, 1973.

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 6 PHYSICAL FACTORS
Ft. Kalburova, D. Tsvetkov

6.1 THERMAL CONDITIONS OF

ENVIRONMENT (MICROCLIMATE)
In its daily household and work activity the human
THERMAL CONDITIONS
body is exposed of different weather environment
outdoors or indoors - residential, public, industrial,
school and others. Productive human activities oc- CLOTHING
cur or outdoors - agriculture, construction, forestry,
outdoor ore and non-metallic minerals, etc., or more
often indoors - engineering, metallurgy, chemistry WORK WORKER
and petrochemistry, pharmaceutical industry, food
and others (in some of the industries operating pro-
cedures can run, both indoors and outdoors). INDIVIDUAL
PERFORMANCE
The thermal conditions (microclimate) include a
set of physical environmental factors that have an Fig. 1
impact mainly on the thermal condition of the body.
These are - air temperature, humidity and speed of and glass: the work of a number of mechanisms of
air movement, and heat, by infrared radiation, par- technological equipment: workers carrying out in-
ticipating in heat exchange of human body, and tense physical labour and others. The air tempera-
determine the thermal environment of a space out- ture in these conditions can exceed 35 ° C, in which
doors or indoors. the heat in the environment for an hour to surpass
The production microclimate has a number of 84 kJ/m3h are so-called “hot” production conditions.
features: considerable intensity of its individual “Hot” productions are also chemical, production of
components, combined with other adverse factors rubber, deep mines, ceramic production.
in the workplace - the physico-chemical, chemical, For industries where temperature and humidity
biological and by labour process - the intension and are a prerequisite for quality of production is formed
stress of work, regimen of labour and so on. That can so-called technological microclimate - example tex-
aggravate its impact on self-esteem, employability tile industry, microelectronics.
and health of influenced. When outdoor air temperature and other thermal
The thermal state of man is a function of fac- factors resulting from climate of the region and can
tors with thermal and non thermal nature (Fig. 1). range from very low (below zero or subnormal val-
Thermal factors include air temperature, humidity, ues) to excess, overheating. Such nature air temper-
speed of air movement, radiation heat, non thermal ature has on jobs in the food industry, restaurants
include by one side the characteristics of the human (kitchens), fishing, agriculture, bakeries, laundries, at
body (surface, size, physical activity, skin colour), on sporting events, military training and others.
the other - clothing (thermoresistance, air and va- 2. Humidity
pour permeability, colour). Humidity is the amount of water vapor contained
in the air or pressure of water vapor in the air. It is in
6.1.1. THERMAL FACTORS a very direct correlation with the air temperature. In
terms of the combination of the high temperature
1. Air temperature and high humidity, when the heat through evapo-
Air temperature is a result of heating the air from ration of sweat is the only effective mechanism for
various sources in the environment: hot manufactor- keeping the heat balance is established states of
ing materials, metallurgical furnaces, molten metals “overheat” the body. A more accurate indicator of

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 LABOUR MEDICINE
humidity in this regard is so-called relative humidity To what extent thermal radiation will change
or deficit of saturation. the thermal condition of the bodies from the envi-
High levels of relative humidity over 65-70% than ronment depends on the capabilities of intrusion
in the open, where it can reach and 100%, are typi- or takeover of the emitted energy. It is known that
cal for a number of industries indoors - mines, paint most oxidized and dark colored surfaces absorb the
shops, laundries, textile industry, fur industry and emission from 750 to 9000 nm. Short-wave (1400
others. nm) penetrates the tissue to a few cm, and that of a
3. Air movement wavelength of 1 to 8 μm is absorbed by the surface
Movement of the air depends on the air flows skin layer.
from production equipment (operation of electric Upon passage of infrared radiation through the
machines, mechanisms, etc.) and the influence of air she did not warm. Radiation heat exchange takes
external air currents. The increased speed and air place between bodies at different temperatures,
movement raises the possibility of the human or- and depending on the temperature gradient is de-
ganism to release heat through convection and termined and the direction of flow of heat - from the
evaporation. When so-called “Hot” industries air is environment to the human body or vice versa (i.e.,
considered “almost stationary”, which trouble this heating or cooling of the body).
type of heat exchange. When working outdoors are
essential characteristics of prevailing air currents 6.1.2. THERMAL CONDITION OF THE BODY
on the geographical area and who may be at high
speeds. 1. Heat balance - determinants
4. Heat (infrared) radiation. Thermal balance of the human body is a function
Heat radiation is electromagnetic radiation of a of a number of both thermal and no thermal charac-
wavelength of 760 nm to 1 mm, divided into three teristics of the environment and the organism itself.
ranges: A - short-rays with a wavelength of 760 to Thermal environmental conditions are the compo-
1400 nm: C - average between 1400 nm and 3 μm nents of the microclimate (air temperature, humid-
and C - long between 3 μm and 1 mm. A source of ity, speed of air movement, thermal radiation), and
infrared radiation is any heated body. Thermal ra- no thermal - hardness and intension of labour,
diation is governed by physical laws; depends only characteristics of the clothing, regime of work and
on the state of the emitting body, not by the envi- rest, food and drinking regime, physical , physiolog-
ronment (the law of Kirchhoff ) and is proportional ical and physical-physiological mechanisms of heat
to the fourth degree of the absolute (K) its temper- transfer (conduction, convection, radiation, hemod-
ature (E = T4W/m2 - law of Stefan-Boltzmann): ratio ynamics, sweating, metabolism).
between the maximum wavelength of emission and The heat balance can generally be expressed in
absolute temperature is constant the equation:
(law of Vin-C = ml) ± S (Q) ± W = E ± R ± C ± K + M,
T
where S or Q is accumulated in the body heat:
It is obvious that even with a small increase in
W - the energy required to overcome the external
temperature of the body, heat-transfer through ra-
physical resistance (useful work ) M-level of heat
diation increases significantly. By the temperature of
production (metabolic heat), E-heat loss through
the source can determine the wavelength of maxi-
evaporation of diffuse moisture (perspiration) from
mum emission - eg. for bodies heated to a tempera-
the skin and through more intense sweating, R-ra-
ture of 400-500 ° C are typical longwave radiation, in
diation heat transfer, C-convection heat transfer,
molten metal - temperature 1600 ° C - 22% of energy
K-heat transfer by conduction (all indicators ex-
is at the expense of shortwave, at 2700 ° C -43% are
pressed in W or W/m2 body surface area). The equa-
short-wave rays.
tion is not included heating losses through evapora-
Outdoors major source of infrared radiation is the
tion of moisture from the upper respiratory tract and
sun and human exposure is significant. In conditions
heating the inhaled air, but it is of little value, as well
of indoor production sources are numerous - from
as the heat by conduction (under certain conditions
ordinary light bulbs and torches to electric furnaces,
and for useful work)*, whereby the equation takes
molten metal and glass. Typical industrial processes
the form of a more practical matter:
with infrared radiation are bread and production of
pasta (ovens), ceramic, porcelain industry, installing ± S or Q = E ± R ± C + M
protective coatings, adhesives and paints, drying * In some conditions however, eg. work outdoors in conditions
textiles, paper, leather, meat, vegetables, welding, of cold and polar climates or underwater work they have very
machine building (foundry), metallurgy. high values.

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 OCCUPATIONAL MEDICINE
2. Physiological response of the body to ther- Physical mechanisms
mal effects. Heat transfer by conduction. It consists in car-
Thermal homeostasis is maintained by ther- rying out the heat from the warmer to colder surfac-
moregulatory system of the body, which consists of es depending on the temperature gradient:
a number of elements with interrelated functions K = hk (T1-T2), where hk is the coefficient of con-
and their work is similar to the system of automatic duction in Wm-2. ° C-1, and T1 and T2 - the temperature
control with negative feedback (Fig. 2). of the contacting bodies.
Conduction is less important for heat transfer
Afferent nerves Efferent nerves Venous outflow Feedback except when taken very hot or very cold foods and
Termoretseptori CNS Effectors Thermal mixer
drinks and in proceedings requiring body contact
with refrigerated or heated surfaces.
Peripheral
termoretseptori
Heat loss Heat through convection. When the air of the
environment has a temperature lower or higher
Hypothalamus Heart and lungs than that of the surface of the skin warmth is giv-
en or taken from the body by convection. The rate
of heat transfer depends on the temperature differ-
Central
thermoregulators Heat production
ence and the coefficient of convection:
Feedback termoreceptors and blood C = hc (T1-T2), wherein C is the heat transfer by
convection Wm-2, hc - convection coefficient Wm-2.
Fig. 2
° C-1, T1 and T2 respectively air temperature and the
Thermal information is from the surface or deep surface of the body. The main factors that affect the
temperature receptors by afferent nerves to the rate of the convection is air movement and the tem-
center of thermoregulation within the hypothala- perature gradient between the skin and the ambient
mus then activate various mechanisms to ensure air, for most activities it is 8.3. √V. W.m-2 C-1, wherein V
the heat production or heat. The mechanism of is the velocity of the air in m.s-1.
feedback involving the nervous system and blood The degree of heating losses by convection de-
flow alter the sensitivity of temperature receptors pends on the difference between the temperature
and thus the system is closed. of the body surface and the air, and the greater is,
Temperature receptors are distributed over the the greater the transfer of heat. The normal skin
entire surface of the body and in the internal organs, temperature is around 31-32 ° C and if it equals the
and the temperature sensitive nerve cells in the cer- ambient air temperature, respectively equalizing
ebral cortex and Auerbach plexus, hypothalamus, the temperature of clothing to that of the ambient
reticular formation, preoptic area of the brain trunk, air by convection heat is not transferred.
the spinal cord. Heat by radiation. Heat transfer through radia-
Heat production and heat loss vary under the in- tion (R) depends on numerous factors - coefficient of
fluence of many nerve centres. radiation hr, the skin temperature Tsk, radiation tem-
The heat loss is regulated by the motor centres of perature Tr or R = hr (Tsk-Tr) wherein the variables
the anterior hypothalamus, and heat production by are as above, but Tsk can refer both to skin tempera-
centres in the hypothalamus back. ture, and the surface temperature of clothing.
The centres of the anterior hypothalamus regu- When the radiation energy from the longer wave-
late the vasodilatation, sweat and respiration in re- length range is absorbed by the relevant body then
sponse to temperature irritation of flowing blood. it is transformed into heat. Heat radiation has the
There is data that the functioning of the hypo- same type of feed energy as visible and is independ-
thalamus important is the flow of sodium and potas- ent of the presence of air and its condition - tem-
sium ions, possibly setting the presset temperature perature, humidity, speed. The thermal radiation fall
level. on the respective surface can be absorbed, to pen-
Removal of heat from the interior of the human etrate deeply, depending on the wavelength or to
body (so-called “core”) to the periphery or body sur- be reflect. Dark bodies (leather, clothing) absorbed
face area (so-called “shell”) is effected by changes in radiation energy, bright and polished reflecting it to
vasomotor tone, which is regulated by adrenergic 90-95%.
sympathetic nerve fibres, varying flow of blood into Heat transfer by convection and radiation at
the periphery. comfortable thermal conditions or cooling is 70-
3. Thermoregulatory mechanisms of thermal 88% of the total heating losses (respectively 20-30%
equilibrium and 40-60%).

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 LABOUR MEDICINE
Physiological mechanisms bution of the blood and release of blood depots for
Heat production (metabolism). It is necessary skin blood flow. This mechanism of compensatory
to maintain a constant temperature of the body can response, however, has high biological value.
be assumed as heat tempering of the body to the The initial response of the thermal impact is the
environmental conditions. The maximum metabol- release of vasoconstrictive tone synchronous by in-
ic heat includes basal metabolisme an additional creasing blood flow to the extremities. Lower limbs
heat produced as a result of thermal environmental supported higher vasoconstrictor tone in compar-
effects. The basal exchange correspond at so-called ison with the above. Upon reaching a maximum
area of prevalence of chemical thermoregulation inhibition of vasoconstrictor occurs secondary dila-
and forms lower and upper critical body temper- tation accompanied by sweating. The secondary dil-
ature. Subject to overheating observed also two atation is the result of the action of the sympathetic
zones: a zone of secondary chemical thermoregula- cholinergic nerve fibres, together with a vasodilat-
tion and area of prevalence of physical thermoregu- ing substance bradykinin and potassium.
lation. Outside these areas develop or hyperthermia
and death from overheating or hypothermia and
death from overcooling.
When the ambient temperature reaches a max-
imum value (upper critical limit), i.e. level, wherein
the compensatory mechanisms for increasing the
heat loss is insufficient, the body temperature began
to rise. If this process continues long enough, it will
die from heatstroke. The range between the upper
and lower critical limits of ambient temperature is
called metabolic indifferent zone.
The peculiarities of chemical thermoregulation
is a taxonomic sign characterized as the systematic
position of the species and its ecology. The peculiar-
ities of chemical thermoregulation are conditioned
by long evolutionary adaptation of way of life.
Cardiovascular mechanisms of heat transfer
Output of the heat from the interior (the “core”) of
the body to the peripheral tissues ( “coat”) is the first
adaptive mechanism at work in conditions of over- Fig. 3. The temperature of the different areas of the body at an
heating, wherein an increase in blood flow through air temperature of 20 ° C / A / C and 35 ° C / B /.
the skin and mucous membranes increases 10 to 30
times. For proper functioning (adaptation) of the At air temperature 20 ° C, there are sharp falls in
body during exercise and in conditions of high air temperature between the inside area of the body
temperature primary condition is good functional and limbs (Fig. 3A). At 35 ° C the temperature of the
state of the cardiovascular system. inner area and is distributed to the extremities (Fig.
In terms of overheating increases blood flow to 3B).
the skin and the excess heat is dissipated to the pe- In response to a strong cooling the common vas-
riphery. The maximum increase in blood flow can omotor response reduces blood flow to the periph-
provide multiple increase of heat loss - 0.34 at 25,5 ery by the effector vasospastic therein. The cooled
° C of 2,58 l.m-2. min-1 at 50,5 ° C. Peripheral vasodi- venous blood is returned into the interior of the
lation accompanied by vasoconstriction in other tis- body by vessel, located near the arteries and takes
sues and increased of the pulse to 180-200 for min., most of the heat transmitted from the arterial blood.
and minute volume of blood circulation increased When air temperature close to zero this system
by 50-70%. for reduced heat is not always effective, because of
In the event of failure of hemodynamics, physi- the intense heat exchange between arterial and ve-
ological compensation occurs in the following se- nous blood, skin temperature may drop significantly
quence - an initial increase of peripheral blood flow, - up to freeze.
causing a new failure of the circulation, followed by Heat content changes in the body associated and
an increased pulse rate and increased cardiac output with body mass. So imbalance in the heat to the en-
of blood circulation, as a result of which occurs again vironment body temperature of people with higher
failure of the circulation, which is offset by redistri- levels of body mass will vary less.

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Physical and physiological mechanisms 2/3 by skin, clothing). With increasing values - 40%
Heat through evaporation of sweat. The phys- or more, the environment is perceived as “warm”
ical nature of this mechanism is expressed by the and “hot”.
equation E = he / Psk - Pa), where E is the heat of 4. Role of clothing for thermal condition of the
evaporation of sweat, W. m-2, he coefficient of evap- body.
oration Wm-2.Pa-1, which depends exclusively on air One adapts to environmental conditions through
movement, Psk water vapour pressure at the surface clothing and, if possible, by adjusting the temper-
of the skin in kPa, Pa - water vapour pressure in the ature, humidity and velocity of the ambient air,
ambient air in kPa, ie heating losses through evapo- wherein skin temperature is maintained around 33 °
ration is determined by relative humidity and speed C without tension on the thermoregulatory mecha-
of air movement. nisms. The role of the clothing to heat transfer from
Upon evaporation of sweat 1g (surface of the the body surface to the environment is determined
body, clothing, breath) released 0.59 kcal of heat. by three determinants: index of air permeability, co-
This is a powerful mechanism for heat loss from the efficient of “ventilation” in the layers of the clothing
body under conditions of high air temperatures of and the impedance of the clothing for sweating.
the environment and normal or low relative humid- Sweat between the skin and clothing depends on
ity. the nature of the clothing, water vapor pressure on
Evaporation of sweat become from all the body the skin surface and aerial environments, air tem-
surface. In human skin has more than 2 million. perature and metabolic heat. Heat loss (E- in Wm-2. °
sweat glands, the function of which is regulated by C-1) through sweating is defined:
the sympathetic nervous system. Mediators of sweat Psk – Pa
are sympathetic cholinergic nerve fibres. Postgangli- E=
on axons have the terminal branches of axon every 6 (Re ,T),
to 10 sweat glands. Sweat gland in response to puls- where Psk Pa is the difference in water vapour
es from the anterior hypothalamus and their num- pressure between the skin and ambient air (in kPa),
ber increases with the increase in body temperature Re, T - heat secreted thanks to clothing in arbitrary
in response to the rise in skin temperature above 40 units (clo) - from 0 to 1.0.
° C. At high air temperatures and physical work the The participation of the clothing in the heat ex-
amount of sweat can reach 1,7-2 l/h. change connected to the “ventilation” of the air be-
Skin cooling inhibits sweat loss even when body tween the layers of clothing. In different combina-
temperature is high, which translates into a notice- tions of clothes and velocity of ambient air creating
able subjective sensation to reduce fatigue and re- conditions clothing to act as a “pump” to direct air to
covery of thermal comfort at work. or from clothing.
Water losses from the surface of the body has At calculation is determined the relationship be-
in the absence of a visible sense of sweating due tween the degree of need sweating (SW req - 120 W/
to passive diffusion of moisture through the skin. m2 or 180 g/h, standard ISO-7243) as a function of
This “invisible” sweating is about 20 to 50 g.m-2.h de- the permeability of clothing for water vapor at dif-
pending on the pressure of the water vapours in the ferent ambient temperatures in order to protect by
environment and the values of skin temperature. In condensation.
physical labour of sweat excreted in terms of ther- The role of the garment in the heat transfer by
mal comfort - if not separated, the environment is convection is related to its resistance. Any clothing
perceived as “cool” (Table. 1). still in the manufacturing has definitely thermore-
In comfortable thermal conditions heat loss by sistance - TR. TR unit is “clo” - is determined to 0,155°
evaporation is about 23-27% of the total heating C.m-2.W-1 that provides thermal comfort at rest and
losses (besides about 1/3 is heating losses from air temperature 21 °C, 50% relative humidity and
evaporation from the upper respiratory tract and speed of air movement 0,1 m/s.
Tab. 1. Moisture separation by the human organism, g / h, at a relative rest
Warm feeling
Very hot Hot Warm Comfortable Coolness Coldly Very coldly

500-2000 250-500 60-250 50±10 40

a significant a significant sweat sweat is sweat is Moisture separation
portion of the portion of the does not not released not released is not typical as
sweat runs down sweat runs flow an indicator for
down warm feeling

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 LABOUR MEDICINE
The total thermal resistance between the skin notonous stimulus (ex. in radio and microelectron-
and the air environment is the sum of that of the ics) leads to a reduction in capacity.
clothing and the ambient air and is dependent on The health effects of working in a condition of
the speed of air movement. The air permeability of overheating or cooling resulting from the influence
clothing markedly reduces thermoresistance - so of multiple factors - duration of exposure, type of
for example at fast walking can reduce by half ther- clothing, heaviness of the work, mode of work and
moresistance to moderately thick clothing. This ef- rest, age, gender and health status of workers.
fect is partly due to the mechanical effect of “pump”
of the moving body, which ventilates microspace 6.1.4. HYGIENE REGULATION OF THERMAL
between clothing and skin surface, i.e. due to the in- CONDITIONS
creased speed of air movement.
Clothing can absorb or reflect heat radiation. Evaluation of thermal conditions should include
Radiation heat transfer for dressed man is between all elements that are relevant to their formation:
the skin and the inner surface of the clothing and microclimate components, rated complex as act
between the outer surface of the clothing and the in real life, burden and intension of labour, regime
environment, but here he has a small role in heat of work and rest, features clothing and others. The
balance than convection and evaporation of sweat. physiological response of the organism is evaluated
respectively by the state of metabolism, of the he-
6.1.3. INFLUENCE OF THERMAL modynamic system (heat transfer by convection and
CONDITIONS – PATHOLOGICAL radiation) and of sweating.
DISORDERS AND DISEASES. Those considerations in hygienic regulation of
thermal environmental conditions are included in
The thermal conditions can be described as com- the international standards ISO - 7243, ISO - 7730
fortable and uncomfortable (overheating, cooling, and ISO - 7933, in which the main indicators that
static, etc.). summarize most parameters of thermal protec-
Overheat conditions caused severe (acute hy- tion-effective temperature, WBGT index, index fore-
perthermia, heat stroke, cramps disease, “sunny” casting subjective heat sensation (PMV), an index
stroke) and chronic (heat exhaustion, heat fatigue, for predicting thermal discomfort (PPD) index of
myocardio- and vasopathics, poor performance and heat stress (HSI), which indicators allow assessments
poor function of the gastrointestinal tract and the such as thermal comfort, level of discomfort, warn-
urinary system, decreased resistance to other ad- ing of the danger, zone of thermal tolerance, regime
verse environmental factors), disorders and diseas- of work and rest and others.
es. Comprehensive evaluation of thermal conditions
They cause skin damage and local - miliaria, in- by a WBGT index (BS EN 27243; ISO - 7243) allows
tertrigo, heat erythema and dermatitis, burns (in- to determine its reference values at different inten-
frared radiation). Also ocular lesions - heat cataract sity of work (metabolic heat in W or W/m2) and at
(infrared radiation) and occupational diseases - early rest, in acclimatized or no acclimatized persons to
atherosclerosis (up to 40). overheating conditions, at a speed of air movement
The cooling conditions also cause acute gen- above or below 0,1 m/s, standard clothing-0,6 clo.
eral (acute hypothermia - "white" death, colds and Depending on the values of WBGTi and meta-
upper respiratory tract, myositis, neuralgia), acute bolic heat can determine the mode of work / rest
local (frostbite) disorders and diseases and chronic for every hour of work, in acclimatized individuals,
(decreased performance, lowered immunity, allergic speeds of air movement over 0,1 m/s (as the rest is
reactions, decreased resistance to other unfavora- the same or close to the microclimate conditions as
ble environmental factors - ex. very often and more in the workplace - the same values WBGTi).
quickly develop vibration disease by activity of local By the method of Fanger (ISO-7730) based on
vibrations. data of exercise intensity (in units met - 1 met = 58
A special place holds so on static or monoto- W/m2), thermoresistance of clothing (clo), tension
nous microclimate, characterized by minor modi- of water vapor (kPa) and air temperature and on
fications to its parameters in time. On the one hand surfaces (average radiation temperature), are deter-
- has a stimulating effect on termoretseptorniya mined subjectively predicted heat sensation (PMV)
apparatus resulting in no trained organism is more and predicted percentage of subjects with discom-
sensitive to changes in weather conditions outside fort under the given conditions (PPD). The thermal
manufacturing - more easily vulnerable to cause comfort is at PMV ± 0,5 and PPD to 10%.
infectious diseases, colds, the other - being the mo-

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 OCCUPATIONAL MEDICINE
In terms of overheating more informative and - Rational regime of work and rest
more important for the essence of preventive meas- - Rational feed - and drinking regime
ures is heat stress index (HSI) ISO - 7933. - Thermal adaptation (heat acclimatization and
In the index of heat stress can be defined and its training)
degree (mild to moderate, strong, very strong, max- - Technical means - shielding, remote control,
imum), its impact on affect people, the necessary ventilation and others.
preventive measures and contraindications for work - Personal protective equipment - protective
(Table. 2). clothing, head protection, eyes, hands.
The method of heat stress index is used to deter-
mine the permissible exposure and work with rele- 1. Medical control
vant thermal conditions. The preliminary medical examinations in appro-
Used and analytical (separately) regulation of mi- priate volume of research and testing, providing in-
croclimate parameters (BS 14776-87), in depending formation on the health status of job applicants with
on the intensity of physical labour, seasons (hot and adverse climate, it is particularly important to ensure
cold) and the release of convection heat in the work- the reliability of the physical and psychological real-
ing space (above and below 23,26 J. m-3.s-1). Stand- ization without overintension of thermoregulatory
ards are optimal and acceptable (with some inten- mechanisms, i.e. biosocial low price.
sion of thermoregulatory mechanisms and decrease Discovering or presence of acute or chronic dis-
in efficiency). eases (current or past history), of cardiovascular sys-
In recent years, it is recommended to create a tem, kidneys, liver, endocrine system, lungs and skin
strategy for evaluating the thermal conditions, un- are contraindications to work after prolonged heat
der which studies and assessments made in stages exposure.
(preliminary, working, in-depth analyzes), indicate Attention should be paid and to clarify the used
the most informative indicators and the most ap- drugs for the cardiovascular system - diuretics, an-
propriate solutions for the protection of influenced. tidepressants, sedatives, tranquilizers, and also nar-
cotics, alcohol, reducing opportunities for adapta-
6.1.5. PREVENTION OF ADVERSE EFFECTS OF tion to thermal environmental conditions.
UNCOMFORTABLE MICROCLIMATE The scope of research must include glucose toler-
ant test, renal clearance, X-ray of the lungs, abdomi-
Main directions of prevention activities are: nal ultrasound scan, pulmonary function tests, ECG,
- Controlling microclimate parameters and other complete blood count and urine.
related factors that are relevant to the thermal state All persons subject to heat stress are subject to
of the body. periodic medical examinations - for persons 45 years
- Control of the state of the acting organism - an of age every two years and over 45 - every year (NI-
assessment of physiological mechanisms of thermal OSH). The scope of such reviews shall include a set of
equilibrium and medical control on health (prelim- preliminary examinations.
inary medical examination, professional selection, Persons over 45 are also subject to extensive
periodic medical examinations) studies of the functional state of the cardiovascular,
Tab. 2. Index of heat stress (HSI) at 8 h exposure
Index Effects, protection
0 Comfort
10 Mild to moderate heat stress, exercise capacity is reduced, difficulties are intellectual
20 activity, dexterity and vigilance
30
40 Strong heat stress, reduced working capacity; application of rational regime of work
and rest; medical control on the status of workers; contraindications - mental activity,
50 people with diseases of the cardio- and respiratory system and skin

60
70 Very strong heat stress in which even minor ailments in workers can affect the
physical capacity to inability to perform the job; application of technical means of
protection; rational regime of work, rest and feed- drinking regime (filling of water-salt
80 losses); medical examinations (preliminary and periodical); conducting heat adaptation
(in real terms or artificial heat-training)
90

100 Maximum stress, that can be borne only by young men acclimatized
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 LABOUR MEDICINE
respiratory, urinary systems, basal metabolism and By hormones in the process of thermal adapta-
skin state. tion, mainly to water balance, prevailed aldosterone
For individuals who are loaded heat only sporad- and antidiuretic hormone. Aldosterone promotes
ic (seasonal workers in the summer heat), reviews the reabsorption of sodium chloride from the sweat
conducted before the campaign starts. And when glands, and kidneys. Conversely, aldosterone secre-
the thermal stress is constant (year-round) examina- tion is stimulated by the negative salt balance.
tions are carried out by seasons. Antidiuretic hormone (ADH) leads to water reten-
2. Thermal adaptation (acclimatization, heat tion by the kidneys. In thermal impact and adoption
trainings) of water reduces the secretion of ADH. In acclimati-
The purpose of conducting acclimatization (ad- zation increases the rate of production of ADH and
aptation to real environmental conditions) is to im- aldosterone.
prove the general condition, the easy tolerance to After 4-6 weeks in an overheating conditions
heat or cold stress, shortening the recovery of func- there are signs of good adaptation, characterized by
tional status and performance, and depends of indi- less strain on thermoregulation and cardiovascular
vidual characteristics of the organism. system, increasing efficiency. For full stable acclima-
Acclimatization to heat is a process that in- tization to overheating conditions take years.
volves complex physiological (and pathological may Adaptation speak on condition that the fluctu-
temporarily) mechanisms that occur during the first ations of the parameters of thermal environmental
weeks of real work in state of overheating or artificial factors trigger response does not go beyond com-
conditions (heat chambers). pensatory possibilities of the organism. Emergency
Initial effects from exposure to overheating en- actions - high intensity for a long time, lead to the
vironmental conditions are fatigue and discomfort, collapse of adaptation. The latter is associated with
irritability, difficulties in the implementation of lowered immune reactivity, and the appearance of
physical and mental activity, susceptibility to mus- a variety of disease disorders, respiratory diseases,
cle cramps. peripheral nervous and cardiovascular system (my-
The process of acclimatization is carried out in a ocardiopathy, miocardyodistona, vazopathy, ather-
certain consecutivity. First increases skin temperature osclerosis, hypertension, coronary heart disease),
as a result of the maximum dilatation of the cutane- gastrointestinal tract (chronic gastritis , colitis, pep-
ous vessels. This was loaded cardiovascular system, as tic ulcer disease), of ENT diseases (pharyngitis, laryn-
demonstrated by a decrease in pulse rate, an increase gitis, chronic tonsillitis, rhinitis), allergic diseases. Ac-
in stroke volume, reduction in body temperature. climatization is a constant process. Only after a week
The first adaptive response to thermal effects of absence from overheating conditions needed
is to increase the degree of sweating to two times four days to re-acclimatization, and after 3-4 weeks
compared with the usual values of unadapted per- of cooling acclimatization is completely lost.
sons. Exercise and workouts lead to the amplifica- Artificial acclimatization (heat workouts).
tion function of the sweat glands. Reduced sweating Physiologically natural and artificial conditions for
on thermal effect shows a deficit of physical capaci- acclimatization are similar, but in natural there are
ty and behavioural adaptation to heat, i.e. these are mitigating factors - choice of dress, work stoppage
persons with reduced tolerance. in the hottest time of the day, the adoption of wa-
Potential risks of significant sweating are dehydra- ter-salt solutions, relaxation in state of thermal com-
tion and salt loss (also and separation of water-soluble fort.
vitamins - C, B1, B2). Reducing water capacity does not In artificial conditions, in special heat chambers
increase tolerance to thirst or dehydration, but oth- create microclimate parameters imitating a produc-
erwise deteriorated thermoregulation and reduced tion with a certain intensity of work and using gar-
work capacity and immunological reactivity. ments with different TR. It is believed that it is bet-
The loss of salts, however, is considerably less af- ter when worn clothing preventing the release of
ter acclimating - whereas previously the salt concen- sweat. Skin temperature increases significantly (due
tration is 3 g/l, is then reduced by more than half in to difficult sweating) and the application of light ex-
sweat. The excretion of salts and reduces in the kid- ercise for 1h, leads to increase in body temperature
neys. above 38 ° C. After a period of 2-3 weeks the adap-
The adaptation of the cardiovascular system to tive response is characterized by acclimatization to
heat impact is related to the degree of sweating. thermal impact and increased physical condition.
Changes in metabolism by thermal effects to- Acclimation to cooling. It will not matter so
wards the reduction was not observed or is it slight- much as overheating as much more easily retained
ly - to about 10%. skin and body temperature by appropriate clothing,

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 OCCUPATIONAL MEDICINE
mode of operation, nutrition and drinking regime. be removed with the adoption of drinking water or
Increasing heat production in cold-effect can be in- weakly mineralized, not necessarily salted, improved
creased by proper diet to include more protein, fat taste with ascorbic or citric acid. Use and specially
and vitamins. prepared drinks for working in hot shops.
In the adaptation of the worker to cooling in- 4. The role of workers in overheating condi-
creases metabolism, increases in heat production, tions
faster restores skin temperature, less is expressed Acclimatization to heat impact requires above
spasm of dermal vessels, increased’s blood supply, all a positive motivation of workers who, through
is increased volume of circulating blood, activates appropriate behaviours can reduce adverse effects
thyroid gland, increasing the excretion of corticos- and accelerate the process of adaptation. To fulfill
teroids and catecholamines. this role, working under conditions of overheating
3. Drinking mode in the conditions of thermal must maintain a good level of physical and mental
load health, to conduct endurance treatments, gymnas-
Intense sweating under thermal stress causes a tics and implement appropriate preventive meas-
loss of sweat of a significant amount of water and ures. For this purpose, workers must be informed of
mineral salts, mainly sodium chloride, but the same the thermal conditions in production, the impact on
and potassium, calcium, trace elements - copper, the body and preventive measures.
zinc, iodine, water soluble vitamins - C B1, B2. The re- 5. Rational regime of work and rest
duced inventory of the salts in the body cause the 6. Technical and technological protective
acceptance of larger quantities of liquids, whereby means
sweat increases, but also the salt losses. Despite the 7. Protective clothing - features to meet the
adoption of large amounts of fluids exist constant thermal conditions and technological process to re-
feeling of thirst, dry mouth and nasopharynx. flect the thermal radiation, to facilitate the effect of
If the loss of sweat is up to 5% of body weight no no- “pump” and the heat loss from the surface through
ticeable correlation between sweat and water intake. evaporation of sweat, for retaining body heat, etc. Per-
The question of the necessary intake water (flu- sonal protective equipment (goggles, gloves, shoes)
id) has not yet been resolved. Unlimited fluid intake are also in line with the thermal conditions and ma-
in conditions of intense sweating no overloading jor adverse component. In the prevalence of the risk
the cardiovascular system to 8-9 l. Usually it recom- of damage from infrared radiation - metalling with a
mends the adoption of 2-3 l cold water. Thirst can highly reflective clothing, spectacle lenses, gloves.
REFERENCES

1. Allan B. et al. - Heat - in Industrial Hygiene, N. Y., USA, 1976.

2. Alpaugh E. - Temperature Extremes - in Fundamentals of Industrial Hygiene, ed. BA Plog, part I, NSC,
ISBN 0-87912 - 7, 1988.
3. Base of physiology ed. Sterki P. (translated from English.), M., Mir, 1984. (in russ.)
4. Beatjer A. - Temperature - in Preventive Medicine and Public Health, ACC, 1973.
5. BS 14776-87 - Protection of Labour. Jobs in the manufacturing premises. Sanitary standards for temper-
ature, relative humidity, speed of air movement and heat radiation. (in bull.)
6. BS EN 27243: 2002 (ISO-7243: 1989) Hot environments. Evaluation of the thermal load of a working
man based on an index WBGT. (in bull.)
7. Chaleur et froid - in Precis de medicine du travail sous la dir. H. Dessoille, Y. Scherrer, R. Truhaut, Mas-
son, Paris, 1991, 569-573.
8. Fuller F. et al. - Evaluation of heat stress in a hot workshop by physiological measurements, AIHA, 1981,
1, 32 - 37.
9. Guide for labour hygiene. V.I. ed. F.G. Krotkov, Moscow, Medicine, 1965. (in russ.)
10. Guide for labour hygiene V.I. ed. N.F. Izmerov, Moscow, 1987. (in russ.)
11. Heins A. - Hot and cold Environments - in Physical and Biological Hazards of the work place, ed. P.
Wald, G. Stave, Van Nostrand Reinhold, NY, 1994.
12. Hygiene of labour ed. S.V. Alexeyev, V. R. Usenko, M. Med., 1988, 70-95. (in russ.)
13. ISO - 7730 - Moderate thermal environments - Determination of the PMV and PPD - indices and spec-
ification of the conditions for thermal comfort, 1984-08 - 15
14 . ISO - 7933 - Hot environments - Analytical determination and interpretation of thermal stress using
calculation of required sweat rate, 1989-07 - 15.
15. Manual of Hygiene and Occupational Diseases, ed. D. Tsvetkov, Sofia Med. and physics., 1994. (in
bull.)
16. Production microclimate - V.M. Kuzmin, Sofia Med. and phys., II ed., 1981. (in bull.)
17. Todorova - Vasileva L. - Production microclimate - in. Physical environmental factors ed. E. Efremov,
Sofia Med. and phys., 1988. (in bul.)
120
 6.2 NON-IONIZING RADIATION

Electromagnetic radiation includes oscillat- frared radiation (IR), “microwaves” and radio waves,
ing (wave) electric and magnetic field. The electric low frequency waves ( transmission of electricity)
waves are distinguished by their frequency (Hz), lasers. These radiations cause a variety of changes to
the wavelength (m) and energy (eV). Non-ionizing the substance - changes in vibrational and rotation-
electromagnetic radiation is one that under normal al energy of molecules (thermal effects); excitation
conditions can not cause ionization in biological ob- of the ions and molecules (electrons passing from
jects (in the tissues of humans and animals) due to one orbit to another); photochemical, phototoxic
low power - less than 12,4 eV. These radiations are of and photosensitizing effects. In air and in gaseous
a longer wavelength from ionizing (X-rays, gamma environment they can cause and ionization (short
rays) and with less energy. Depending on their phys- wave UV radiation). A general rule is that the smaller
ical characteristics (wavelength, frequency, method the wavelength, the higher the frequency and ener-
of radiation) and their biological effects, they are di- gy of the radiation (Table. 1).
vided into ultraviolet radiation (UV), visible light, in-

Tab. 1. Non-ionizeing rays - frequency, wavelenght, energy

Type of radiation Frequency (Hz) Wavelength (m) Еnergy (eV)

Ionizing >3000 THz <100 nm >12.40 eV
Ultraviolet (non-ionizing) 3000-750 THz 100-400 nm 12.40-3.10 eV
UV-vacuum 3x105 to 30000-1580 1 to 10-190 1240 to 124-6.53
Far 1580-1000 190-300 6.53-4.13
Near 1000-750 300-400 4.13-3.10
UV-C 3000-1070 100-280 12.40-4.43
UV-B 1070-952 250-315 4.43-3.94
UV-A (black light) 952-750 315-400 3.94-3.10
visible light* 750-385 THz 400-780 nm 3.10-1.59 eV
Infrared (IR) 385-0.3 THz 0.78-1000 µm 1590-1.24 meV
IR-A 385-214 0.78-1.4 1590-886
IR-B 214-100 1.4-3 886-413
IR-C 100-0.3 3-1000 413-1.24
Near 385-100 0.78-3 1590-413
Middle 100-10 3-30 413-41.3
Far 10-0.3 30-1000 41.3-1.24
Laser 1500-15 0.2-20 6200-62
Class 1 - no risk
Class 2 - low risk, low power
Class 3a - low risk, medium power
Class 3b - medium risk, medium power
Class 4 - high risk, high power
Radio frequency (RF) 300GHz-0.1MHz 1mm-3000m 1240µeV-0.41neV
Extremely high frequency (EHF)
Super high frequency (SHF)
Ultra high frequency (UHF)
Very high frequency (VHF)
} "microwaves" (MW)
300-30GHz
30-3
3-0.3
300-30 MHz
1-10 mm
10-100
100-1000
1-10 m
1240-124µeV
124-12.4
12.4-1.24
1240-124 neV
High frequency (HF) 30-3 10-100 124-12.4
Medium frequency (MF) 3.03 100-1000 12.4-1.24
Low frequency (LF) 300-30 kHz 1-10 km 1240-124 peV
Very low frequency (VLF) 30-3 10-100 124-12.4
– 3-03 100-1000 12.4-1.24
Extremely low frequency (ELF) <0.3 kHz >1000 km <1.24 peV

* The limits of the human eye varies individually from 380-400 nm to 750-780 nm

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 F.Kalburova, D. Tsvetkov

6.2.1 INFRARED RADIATION

Infrared rays were discovered by English astron- trum of radiation moves towards shorter rays and
omer William Herschel in 1800 when studying the the intensity of the emitted power increases. For
spectrum of solar radiation and received its name bodies heated to a temperature 400 500 ° C, is char-
from Becquerel in 1869. acterized by long-wave radiation; in molten metal
Infrared region of the spectrum lies between the (temperature 1600 ° C) - 22% of energy is at the ex-
red limit of visible light (750-780 nm) and range of pense of shortwave and at 2370 ° C - 43% shortwave
radio waves ( “microwaves” - 1-10 mm). broadcasts. Even with no large increase in the tem-
The biological properties of infrared rays are perature of the body, letting the heat by radiation
closely related to their wavelength. Depending on significantly increased. At the temperature of the
three set parts of the IR spectrum: (A) - near the re- source may tentatively to determine the wavelength
gion with a wavelength of 0.76 to 2.5 μm; (B) - middle of maximum radiation and assess the biological ef-
- from 2.5 to 25 μm and (C) - far - from 25 to 1000μm fect (Vin’s law
(division is arbitrary and different authors indicate max. l
various levels of the three ranges). C=
T
Another characteristic of infrared waves is their
density - the amount of radiation passing through a where C - constant Vin is 2880, T - degrees K, λmax
1 cm2 area (W/cm2). - μm). By raising the temperature of the emitting
Infrared radiation (IR) as all electromagnetic radi- body power of radiation is directly proportional to
ation has characteristics - radiation, absorption, re- the fourth degree of absolute temperature - E = δ T4
flection, diffraction, transmission. Like other broad- (W/m2) - law Stefan-Boltzmann, where δ = 5.775.10-9,
casts it can be absorbed by the body over which T - degrees K.
falls and is converted into heat (hence the name of There are numerous sources of infrared radiation.
their “heat rays”). Heat radiation is of all bodies at The most intense natural source of IR is the Sun and
a temperature above absolute zero, and character the number of exposed persons and the duration of
(spectrum) depends on the physical state of the sub- exposure is significant. The radiation energy of the
stances. While passing through the air (unpolluted), sun falling on the Earth’s surface is approximately
IR radiation, it no heats. 1.355 kWh/m2, half of this energy is due to infrared
Radiation heat transfer between the bodies de- radiation. The radiation from the sun comparable to
pends on the so-called temperature gradient - ra- that of a black body heated to about 6000 ° C.
diating - absorbing body. Different objects absorb Artificial sources are also numerous in recent
infrared rays in varying degrees. The lens is transpar- years greatly increased use of IR in different indus-
ent to wavelengths from 2.5 to 27 μm, water - about tries - bread, ceramic industry, heat treatment of
1.5 or more μm. There are different opinions on the various materials, drying of various products and
permeability of skin to infrared rays with different the like, rose and exposed contingents and duration
wavelength. Indicate - Gersten, Mellete, Strow et of exposure.
al., the skin is transparent to infrared rays having a The intensity of the heat radiation of work places
wavelength of 0.7 to 1.5 μm and relatively opaque in and people depend on: the nature of the process,
the range of 1.5 to 5 μm. Conversely, Taylor, Rucket the temperature of the radiation source, the dis-
et al., Indicate strong absorption by the skin of IR- tance from the source, the degree of thermoinsula-
rays having a wavelength of 3-6 μm - close to the tion, collective and individual preventive means.
transparency of the water. To hot workshops relate those that are heat (con-
Thermal radiation is subject to the physical laws vection heat) over 23 J/m3. In the main workshops of
that are important hygienic matter - depends only the steel industry (blast, converter, martin furnace,
on the condition of the emitting body, not from the blooming, electrical steel etc.), the intensity of IR is
environment (Law Virchow) and is proportional to 348 to 13 920 W/m2; engineering (foundry, black-
the temperature of the radiating surface. When in- smith workshops and workshops for processing
creasing the temperature of the source, the spec- details) intensity of radiation from 1392 to 3480 W/

122
 LABOUR MEDICINE
m2. With the intense heat radiation are characterized Several factors are important in determining the
and working conditions outdoors in summer heat - exposure of the retina: pupil diameter, the spectral
construction and agricultural activities. Endangered transmission in the middle segment of the eye, the
contingents are involved in the production of glass spectral absorption of the retina and choroid, and
- intensity 2100-2800 W/m2, electric welders - inten- the size and quality of the image. Adapting to dark-
sity about 3 W/m2. In the latter, however, it is a small ness pupil has a 7 mm diameter compared with nor-
area of the radiating surface and health problems mal - 2-3 mm in normal sunlight. This allows the en-
are related primarily to UV-radiation. try of a greater amount of energy into the eye. Some
short-wave radiation to 1.4 μm reach the retina
6.2.1.1. Biological effects through absorption of the middle segment (cornea,
vitreous, lens). The optical transmission is greater in
Thermal (infrared) radiation is an important com- length from 0.5 to 0.9 μm, reduced by 50% at 1 μm
ponent of the microclimate (see Section 6.1). and reached the lowest levels in the 1.2-1.4 μm. With
Biological activity of IR has a number of features the increase of incoming energy and its absorption
that are directly dependent on the wavelength ex- by the retina and choroid increases the risk of their
posure dose, duration of exposure, repetition rate of defeat.
impact, peculiarities of influence tissues. Iris. - It is very sensitive to the IR due to the high
Effects on eye structures absorption of dark pigment. Moderate doses cause
Ocular structures are particularly sensitive to constriction of the pupil (hyperemic miosis) and for-
the action of IR. Under natural conditions of human mation water secretion - two protective mechanism
(non-production exposure) there are safeguards to against IR.
reduce the adverse effects - blink, pupillary light re- Cornea. - Upon exposure to high intensity long
flex. In production conditions damage to the ocular infrared rays cornea reacts painfully and includes
structures are mostly made of shortwave range: safeguards - reflex closing of eyelids and turning
Lentils. - The exceptional exposure in this range his head in the opposite direction of the source. It
leads to the development of so-called. heat cataracts is assumed that the primary is the response of the
(first described in workers in the glass industry as a thermal irritation (it is for a parts of a second and is
“cataract of the glass blowers”). It is expressed in tur- obtained and at low temperatures - approximately
bidity of the posterior surface of the lens, such as at 45 ° C, corresponding to the power level absorbed
a wavelength of 1.2 to 1.4 μm is more pronounced at by the cornea about 100 kW/m2), because of the
the periphery. The temperature of the lens can be in- high sensitivity of sensory corneal nerve, after which
creased directly (rays having a wavelength of 0.8 -1.2 arises and pain reflexes. Under normal production
μm) depending on its spectrosorption characteristic exposures of IR does not observed burns. At high
or indirectly by heat transfer of the iris. It is believed intensities burns occur in corneal epithelium, and
that at energy levels of about 1.4 kW/m2 for many sometimes may even develop opacities.
years the development of cataract is not certain. In Conjunctiva. - Cases of conjunctivitis with re-
modern technologies sources IR risk of developing duced lacrimation were observed in exposure to
cataracts is less or cataract is less pronounced. The near IR - effective wavelength of 0.98 μm and inten-
development of cataracts important are the energy sity of the radiation 650 W/m2. Continued exposure
levels of impact, exposure, age. Heredity, race, use to IR is associated with increased evaporation, lead-
of drugs, diseases, immune and climatic factors may ing to tear deficiency and development of so-called
predispose to cataractogenesis. “dry” eyes.
For now adopted two theories about the devel- Eyelids. - Flashing protects the eyes from the ef-
opment of cataracts by IR. One that cataract due to fects of IR and move liquid to the front surface of the
direct absorption of thermal energy or by transfer of eye - double protection from the heat. Anatomical
heat from other ocular structures (iris, chamber flu- structures of the eyelids are similar to those of the
id) and the other that the initials are photochemical skin and thus to damage on them will also be similar
damage of the lens, which are depending on the en- - erythema, edema, vesicles.
ergy dose (energy level and exposure). Effects on the skin.
Retina. - It absorbs short infrared rays, which do Damage the skin depends on its thermal and op-
not differ in penetrating from visible and have a pre- tical characteristics, of its ability to absorb radiation
dominantly thermal effect. Sudden exposure to high energy. On reflection and absorption characteristics
energy levels of IR causes temporary blindness and can be determined and the effects - in IR below 2
chorioretinal burns as a result of which occur scotoma μm reflective properties depend on skin pigmenta-
- eg. when using electric arc and unprotected eyes. tion and blood flow, and the maximum reflection is

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 OCCUPATIONAL MEDICINE
between 0.7 and 1.2 μm, which corresponds to the of risk of burns (Table. 2) should not exceed:
maximum intensity of infrared effect. The lesions of 1400
the skin depend on the degree of difraction which Σ L(λ). R(λ) ≤ 5/α.t1/4
385
is determined by the microstructure of the skin
and of penetrating ability of IR (i.e. a transmissible Where Lλ is the spectral radiation in W (cm2.
spectrum, dependent on the water content, which sr.nm); R (λ) - measured risk of burns associated with
is about 60-70%). Typically, the skin is impermeable the range of the wavelength Δλ source; t - time (ex-
to lengths of less than 2 μm, but the shorter IR radia- posure) in s, but a period of 10 μs to 10 s; α (in rad)
tion can cause burns. Medium and long-rays are im- = l/r, wherein l is the distance to the source, r - the
portant factors as thermal load in the manufacture visible average size (diameter) of the source (and the
exposed persons. Manifest signs of skin lesions by two dimensions in cm or m).
short infrared rays at chronic effects are erythematic, 2. To protect the cornea and lens (cataract-gen-
skin pigmentation and burns. Short-wave radiation esis) of thermal injury from IR - 770 nm-3 μm, expo-
penetrates to a few cm into the tissue and causes sure to hot proceedings should be limited to 1000 s,
skin burns and persistent skin pigmentation. and up to 10 mW/cm2 or:
Other effects. 3000
Besides lesions to so-called 0rgans targets for Σ Eλ. Δλ ≤ 1.8-3/4 W/cm2 (for t < 1000 s)
770
IR (eye structures, skin) were observed also in hu-
mans and experiment: vascular congestion of the 3. To protect the retina from a near IR (IR-A-770-
spleen and kidneys; changes in the immune reactiv- 1400 nm), the absence of a strong light stimulus of
ity (phagocytic index, bactericidal properties of the source of - brightness under 10 -2 cd/cm2, the effect
skin); damage to the upper respiratory tract (chronic is limited to
rhinitis, laryngitis and sinusitis - 10 times more com- 1400
mon in persons exposed to IR); temporary reduction Σ Lλ. Δλ ≤ 0.6/α
770
in sperm production; genetic effects - chromosom-
al aberrations by short IR rays; mutagenic effects in a period over of 10 s. For periods of less than 10 s
experimental animals; probable carcinogenic effect. is used first equation (but for Δλ - 770-1400 nm). This
Typical heat effect of IR on the brain in intensive limit is based on pupil diameter of 7 mm. Both equa-
direct irradiation of unprotected head is so-called tions are empirical and for accuracy introduces spa-
“Sunstroke” (see labour microclimate). tial correction factors to their right part - respective-
ly K1 = 1W. rad. s1/4/(cm2. sr) and K2 = 1W. rad/(cm2. sr).
6.2.1.2. Hygiene normalization Normalization of IR as thermal environmental
factor is performed as a complex acting with other
Safe exposure to IR on the eyes is offered by a thermal factors (temperature, humidity and air ve-
number of authors. According to some acute ocular locity) by standarts ISO 7730; 7243; 7933. For exist-
changes (on the cornea) were observed at exposure ing BS 14770-87 value of the IR in the workplace are
to the energy levels of 40-80 kW/m2 (however, ig- standardized separately - up to 350 W/m2.
nores the duration of effect in acute cases) and are
recommended as safe levels in chronic effects - 4 to 6.2.1.3. Prevention of adverse biological
8 kW/m2. Other authors indicate as safe levels for effects
chronic exposure in attitude of ocular 0.1 kW/m2,
and a few minutes of exposure is allowed up to 10 Medical control. - Preliminary medical examina-
times more. tions are conducted with particular attention on the
To protect the eye safe levels for sources of short- state of the eye and skin structures and contraindi-
wave IR and visible light - 385-3000 nm, recommend- cations for work in conditions of intense IR. Periodic
ed by the WHO, ILO, the United States Conference medical examinations to be aimed at establishing
of Labour Hygienists (ACGIH) and the International early, subclinical changes in view to implement
Commission on Non Ionizing Radiation Protection timely protection of vulnerable groups - removal
(ICNIRP), in manufacturing exposure for 8 h working from the working environment, differentiating the
day, at known radiation spectrum (Lλ) and total radi- age of the professional changes.
ation from the source (E), measured at the position To refine the biological effects is neccessary anal-
of the eyes of the worker: ysis of specific subclinical abnormalities, study of
1. To protect against retinal thermal damage, late effects - mutagenic, carcinogenic and clarify the
spectral radiation from sources of visible light, basic mechanisms of the injured on biological sys-
weighted against function R (λ), showing the degree tems.

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 LABOUR MEDICINE
Technical control. - Regularly performing con- ly aluminum foil; IR filtering goggles and shields,
trol measurements of the sources of IR; specifying gloves, and at very high intensities and reflective
the distance from the source; shaping separated costumes. Glasses unless protective qualities must
cabins and work places; shielding of the sources have a good aesthetic design, are comfortable to
(metallic curtains, which reduce the intensity of the wear and do not become a secondary source of heat
radiation by 80%); installation of glass or plastic in- effects on the cornea. The choice of metal coatings
termediate doors; application of special signaling for glasses depends on the type of radiation - length,
systems for locking; ensure effective ventilation and intensity and are different for different industries -
water circulation. eg. in foundries advised cobalt blue glass, to control
Personal protective equipment. - Protective the temperature of the metal combined with glass
clothing with a reflective metallic coating - most- absorbing heat.

Tab. 2. Spectral weighting functions for determining the risk of photochemical and thermal damage
to the retina of radiation in the range 305-1400 nm
Wavelength Lensectonomy "Blue light" Thermal damage
(nm) Risk Risk Risk
Function А(λ) Function В(λ) Function R(λ)
305-335 6.00 0.01 –
340 5.88 0.01 –
345 5.71 0.01 –
350 5.46 0.01 –
355 5.22 0.01 –
360 4.62 0.01 –
365 4.29 0.01 –
370 3.75 0.01 –
375 3.56 0.01 –
380 3.19 0.01 –
385 2.31 0.0125 0.125
390 1.88 0.025 0.25
395 1.58 0.050 0.5
400 1.43 0.100 1.0
405 1.30 0.200 2.0
410 1.25 0.400 4.0
415 1.20 0.800 8.0
420 1.15 0.900 9.0
425 1.11 0.950 9.5
430 1.07 0.980 9.8
435 1.03 1.000 10.0
440 1.000 1.000 10.0
445 0.970 0.970 9.7
450 0.940 0.940 9.4
455 0.900 0.900 9.0
460 0.800 0.800 8.0
465 0.700 0.700 7.0
470 0.620 0.620 6.2
475 0.550 0.550 5.5
480 0.450 0.450 4.5
485 0.400 0.400 4.0
490 0.220 0.220 2.2
495 0.160 0.160 1.6
500 0.100 0.100 1.0
505 0.079 0.079 1.0
510 0.063 0.063 1.0
515 0.050 0.050 1.0
520 0.040 0.040 1.0
525 0.032 0.032 1.0
530 0.025 0.025 1.0
535 0.020 0.020 1.0
540 0.016 0.016 1.0
545 0.013 0.013 1.0
550 0.010 0.010 1.0
555 0.008 0.008 1.0
560 0.006 0.006 1.0
565 0.005 0.005 1.0
570 0.004 0.004 1.0
575 0.003 0.003 1.0
580 0.002 0.002 1.0
585 0.002 0.002 1.0
590 0.001 0.001 1.0
595 0.001 0.001 1.0
600-700 0.001 0.001 1.0
700-1050 – – 10 [(700-λ)/500]

1050-1400 – – 0.2
Note: To protect the retina from photochemical damage in the so-called sources "Blue Light" (305-700 nm) - fluorescent lamps,
halogen lamps, film projectors, arc lamps, etc., using other equations depending on the exposure time (over or under 104s),
spectral radiation - L blue, over 10 mW / (cm2.sr), viewing angle up to 0.011 rad, working with the lensectonomy.

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REFERENCES

1. American Conference of Governmental Hygienist (ACGIH) - TLVs and BELs for Chemical Substances and
Physical Agents. Light and Near - Infrared radiation, 153-157, Cincinati, Ohio, ACGIH, 2008.
2. Curtis R., Nichols M. - Nonionizing Radiation, in Environmental and Occupational Medicine, ed. Rom
W.N., Little, Brown and Co, Boston, 1983.
3. Hathaway J. A et al. - Visible light and infrared radtation - in Physical and Biological Hazards of the
workplace, ITRA, NY., 1994.
4. Labour hygiene ed. Alekseev S.V., V.R. Usenko, M., Medicine, 1988. (in russ.)
5. Labour hygiene ed. Kasparov A.A., M., Medicine, 1988. (in russ.)
6. Largent E.J. et al. - Nonionizing Radiation, in. Fundamentals of Industrial Hygiene, ed. Plog B.A., Nat.
Saf. Council, N.Y., 1988.
7. Maliisheva A.E. - Infrared radiation, in. Guide for labour hygiene V. I, ed. Krotkov F.G., M., Medicine,
1965. (in russ.)
8. Matthes R. - Infrared Radiation, in Encyclopedia of Occup. Health and Safety, ed. J.M. Stellman ILO -
office, Geneva, v.2, 4th ed., 1998.
9. Nosse C.E. et al. - Infrared radiation - in Nonionizing radiation protection, ed. M.J. Suess, D.A. Benwell,
sec. edit., WHO Publ. Ser. 25, 1989.

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 D. Tsvetkov

6.2.2 ULTRAVIOLET RADIATION

Ultraviolet radiation includes the spectrum of pheric oxygen, nitrogen and hydrogen) and lower -
non-ionizing radiation between visible light and from molecular oxygen resulting in the formation of
ionizing radiation - a wavelength of 100-400 nm (in- ozone - O3). Producing photochemical ozone, with
dicate and lower values - up to 1-4 nm). Due to the a maximum concentration at a height of about 50
relatively high photon energy when it has a wide km (35-70 km) absorbs radiation with a wavelength
variety of biological effects on the one side and on of 220-290 nm (Fig. 1). The formation and disinte-
the other - its lowest penetration limited its direct gration of ozone is a dynamic process dependent on
biological activity to surface tissues and organs of natural conditions - latitude, annual and diurnal var-
the body (skin, eyes). iations and human activities. Separating the hydro-
By their physical characteristics and biological chlorofluorocarbons (CFCs) in the atmosphere (gas
effects UV-radiation is divided into near range - 300- refrigerant in refrigerators, sprays, etc.), as well as
400 nm range and far - 180 (200) - 300 nm. Ray short- nitrogen oxide, catalytic reduces ozone. The possi-
er than 180/200/nm are absorbed by the air and can bilities for reducing ozone can predict the expected
not practically exhibit a biological effect (they exist increase in the incidence of skin cancer. Indicate that
in a vacuum or in a non-swelling them gas). Since expected reductions in the thickness of the ozone
this division is associated primarily with the penetra- layer by 1% will increase by 3% cases of basal cell
tion of the UV-rays into the skin and of air absorb, by skin cancer and by 5% - of planocellular skin cancer.
biological point of view used their division: range A It should be pointed out, however, that the pollu-
-320(315)-400 nm (predominantly pigmentforming tion of the Earth’s atmosphere with dust, soot, gases
action); range - 280-320 (315)nm (predominantly er- - ammonia, sulfur gases, also nitrogen oxides, lead-
ythema and vitamin D forming action) and a range ing to strong absorption of UV-radiation, so now air
- below 280 nm (bactericidal action). The biological pollution is associated primarily with absorption of
effect is determined not only by the wavelength of UV-radiation, not by its increasing resulting of effect
the UV-rays, but also by the radiation power (W/ on the ozone layer. Absorbtion to UV-rays depends
cm2), the exposure time and their penetration into generally on the thickness and “transparency” of the
the tissues, so that using both classifications. For ex- atmosphere (air layer) through which they pass - so
ample, a low bactericidal effect is visible light, but that altitude, season, far geographic latitude, time
under irradiation with the same intensity of test cul- of the day strongly influence the intensity and spec-
tures Esh. coli they perish for 2-30 s in exposure to trum. The contaminated air, low standing in the sun
radiation 210-280 nm and above 1900 s - with rays above the horizon (latitudes, winter season, early
300-330 nm, ie varying the degree of expression (or and late hours during the day) not only greatly re-
practical presence) of these biological effects.

6.2.2.1. Sources to UV-radiation Black body

Outside atmosphere
Sources to UV-radiation are all bodies with a tem-
Relative intensity

perature of over 2500 K. Sea level

The main source of UV-radiation is the sun. As
a absolutely blackbody at temperature of 5600 K,
it emits UV-rays by wavelength substantially below
290 nm, but on earth ground reached rays only over
this length, making and all life on earth in its present
state (short-wave UV-radiation it is lethal to most or- visible near IR

ganisms on the surface of the earth). Short UV-rays Wavelength (nm)

are absorbed by Earth’s atmosphere, at an altitude
of about 200 km and an lower absorbed rays with Fig. 1. The solar spectrum in the upper atmosphere and sea
a wavelength below 220 nm (240 nm) (from atmos- levels (by Giese A.C., 1976)

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 OCCUPATIONAL MEDICINE
duce the total intensity of UV-radiation, but absorb primarily in the cornea. To reach the vitreous rays
much stronger its shortwave ingredient (increases with a wavelength exceeding 295 nm, and the ret-
the lower limit of reach the earth’s surface UV-radia- ina - up 330 nm.
tion). For example, in the summer in 12 h lower limit At absorbtion of body tissues (skin, eye) high
to UV-radiation in Sofia is 302 nm, and the Black Sea energy of UV-rays causes primary photoelectric
coast - 297 nm. processes followed by photochemical reactions (in-
In rooms UV-radiation is almost entirely absorbed cluding phototoxic reactions and hypersensitivity).
by ordinary clear glass (containing traces of iron and Photoelectric processes are related to the excitation
titanium oxides). of atoms and molecules, after they give their energy
Artificial sources of UV-radiation are numerous. by the formation of photoproducts or give it to an-
Discharge lamps - mercury at low-, medium- and other receptor.
high pressure, metalhalogen lamps, xenon lamps, Basic acceptor to UV-radiation are cellular pro-
lamp “lightnings” have different lumination power teins and nucleic acids. UV-radiation induces non-
and spectral composition. These by low pressure specific (uncharacteristic for UV-rays) denaturation
emit interrupted UV-spectrum (with determinate of cellular proteins and subsequent by enzymatic
wavelengths). Arc welding (metal electrodes with proteolysis, autolysis and formation of biogenic
protective coatings) emits a continuous spectrum amines - histamine and histamine like substances.
UV-rays, depending on the metal surface, its cover It has been shown formation in vitro (althogh in a
and the gas protection during welding (nitrogen, very small percentage) and in vivo histamine from
carbon dioxide). Carbon electrodes (arc) are also a histidine at UV-irradiation. General reactions of the
powerful source to UV-radiation. Fluorescent lamps body and the formation of UV-erythema explained
used for lighting have retentive filter for the UV-rays by local and total action (after entering the blood) of
(usually glass), while those emitting UV-rays (UV-B these products on protein disintegration - direct and
and UV-A range) are made of quartz glass. The spec- indirect effect of UV-rays. UV-radiation causes and
trum of the UV-rays depends also on the kind of disturbances in the structure of nucleic acids, which
the fluorescent substance. They are also used lasers can be recovered by enzyme systems, but may also
emitting UV-rays - in nitrogen lasers (337 nm), heli- cause the death of the cell or the development of
umcadmium lasers (325 nm) and others. The wave- rare diseases (xerodermia pigmentosum, etc.), and
length here depends on the active base and the op- skin cancers.
erating mode of the laser. Heereditary changes due to genetic, chromo-
somal and gene mutations are possible in lower or-
6.2.2.2. Absorbtion and general biological ganisms not in humans and animals due to the low
action penetration of UV-radiation.
Specific photochemical effect of the UV-radiation
Penetration of UV-radiation in biological tissues is the formation of vitamin D by irradiation of ster-
is limited (Fig. 2). In the skin near UV-radiation (300- ols. In skin cells of humans and animals under the
400 nm) penetrate to a depth of 0,1-1 mm - in str. influence of UV-rays (primarily from range B) of 7-de-
corneum and str. Malpigii the epidermis. Far UV-ra- hydrocholesterol formed cholecalciferol (Vit D3) - an
diation (200-300 nm) penetrates only to 0,01-0,1 important factor for calcium-phosphorus metabo-
mm (greater part is absorbed by str corneum, and lism and prevention of rickets and senile osteoma-
low fraction penetrates into str. Malpigii). A similar is lacia.
penetration to UV-rays in the eye. They are absorbed Upon irradiation of ergosterol (in vegetable oils -
in vitro) is obtained Vit D2 (ergocalciferol) - no matter
Fig. 2. Penetration to UV and visible radiation in lightly
pigmented skin in Europeans - in% compared to
the prevention of rickets in humans (not absorbed
perpendicular radiation (in Bruls W.A. - 1984). by the digestive tract). Another characteristic ef-
fect of UV-radiation is the formation of melanin in
cells of the str. basale of the epidermis. The UV-rays
catalyzed oxidation of tryptophan to dihydroxyphe-
nyl-L-alanine (DOPA) which forms melanin under the
influence of DOPA-oxidase. The formation of mela-
nin pigment is a protective reaction of the organism
against UV-rays, associated with the condition and
reaction of sympathicoadrenal system. Cutting the
sympathetic nerve fibers in the experiment causes
depigmentation of the skin. Conversely, the skin irri-

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tation (mechanical, thermal, and primarily to UV-ra-
diation) leads to enhanced production of adrenaline Bactericidal, mutagenic, cell division

(vasoconstrictive action). Melanin is also such (like

Cataractogenic
adrenaline) action, i.e. they have antagonistic activ-
ity on histamine and histamine like substances, re- Kataraktogenen
lated to the generation of UV-erythema. In addition,
melanin (pigmented skin) has a higher reflectance Keratitis

(albedo) of the incident on the skin UV-radiation.

Antirahitic (Vit. D3)
Also in persons with more highly pigmented skin at
the same other conditions is less risk of skin cancer Пигментация
upon irradiation with UV-rays.
Hypersensitive (photosensitive) effects are of Erythema

two types - phototoxic (non-allergic) and photo-al- 250 300 350 400 nm
lergenic. In the first type UV-radiation is absorbed wavelength
by the photosensitive substances to an exogenous Fig. 3. Ultraviolet radiation - wavelength and biological
or endogenous origin. Such as: medication - griseof- effect: as in black and bar have a maximum effect
ulvin, tetracycline, chlorpromazine, sulfonamides, (by Curtis R. and Nichols M. - 1983)
acridine, methoxsalen, furocoumarines, tar (con- penetration; passing in pigmentation (tanning).
taining anthracene and other photosensitive sub- Higher doses of UV-radiation reduces latency and
stances) bergamot oil (in many cosmetics) as well as increases the duration and degree of erythema. As
chromophores - lactic acid, hematoporphyrin. The most effective UV-rays and identifying those in the
occurrence of hypersensitivity phototoxic reactions range 300-307 nm in sunlight and 254 nm and 297
need simultaneous action to UV-radiation and pho- nm - in artificial sources. UV erythema has a charac-
tosensitizing agents. In photoallergic reactions need ter of an inflammatory response - increased capillary
not be present (except the initial) of chemicals - only permeability, edema, lymphocytic infiltration, which
irradiation with UV-radiation may cause them. We reaches a maximum on the second day after irradia-
need a little exposure and the effect usually occurs tion. At high doses of radiation, non-pigmented skin,
in individuals with acquired previously altered reac- young children, are possible and general reactions
tivity of type antigen-antibody or cellular immune such as fever, chills, headache, vomiting, rare vascu-
response to a particular substance. lar collapse. Erythema followed by desquamation
Photochemical reactions can be suppressed by rarely leads to ulceration due to microorganisms
substances such as vit E, β-carotene, vit C, which either (secondary infections in impaired skin protection).
resulted, excited by the UV-rays molecule to baseline Erythema minimum dose (MED) is individual, very
or neutralize formed photochemical products. different and also depends on the exposure area of
skin. In lightly pigmented skin MED is about 200 J/
6.2.2.3. Health effects (risk) under irradiation m2 on body (chest, abdomen) in UV-rays in 250-300
with UV-rays nm, rises sharply in lengths exceeding 310 nm, and
is 2.105 J/m2 at radiation in the range 330-400 nm.
These can be divided as follows: early and late Third skin reactions pigmentation (tanning). It
non-stochastic effects; stochastic effects; indirectly is related both to the migration of pigment granules
affecting health. (melanin) of the adjacent deeper lying cells (from str.
Early non-stochastic effects. They occur on the Malpigii to str. corneum) - initial phase and also by
skin and eyes (in rare cases describe effects on oral increased formation of melanin. To the extent that
mucosa using faulty older models of apparatus for the pigmentation is mainly due to UV-erythema, the
UV-photopolymerisation in the dental practice). most effective UV-rays here are the same as those
Skin describes four types of reactions: of the UV-erythema. But as mentioned in the long
Fast skin pigmentation, stronger occurring in UV-rays - over 315/320/nm induce pigmentation in
people with pigmented skin. This effect manifests a much weaker erythemal reaction.
itself in the maximum irradiation with long UV-rays UV-radiation affects the division of the skin cells.
- maximum at 360 nm and is reported for radiation Immediately after irradiation (up to 24-36 h, de-
with a wavelength of 400 nm and above (visible pending on dose) there is inhibition of cell division
light) - Fig. 3. followed by amplification - up to 72 h and continu-
The ultraviolet erythema is characterized by: ing (at single exposure) 5-6 days. This hyperplasia of
sharply defined borders (only where the skin is ir- the epidermis combined with dropping the highly
radiated with UV-rays); latency period - 1-8 h, its damaged cells (desquamation).

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On eye the acute (once) action to UV-radiation ly in the head and arms (hands and fingers) for the
occurs on the superficial tissue - conjunctiva, cornea prevention of rickets in children.
and deep lying - vitreous and retina. Late non-stochastic effects to UV-radiation also
The most frequently observed effect is photoker- occur on the skin and eyes.
atitis and fotoconjuctivities. It is caused by UV-rays On the skin continuous UV-radiation causes the
with a wavelength below 315 nm, and is most pro- so-called skin aging - reduced elasticity, degenera-
nounced at 270 nm (similar to the ultraviolet erythe- tion of collagen fibers, hyperpigmentation, telangi-
ma). Minimum degree of manifestation to UV-kera- ectasia. No dose for occurrence this condition (ac-
titis (conjunctivitis) is required irradiation of 50 J/m2 tinic skin), but it often goes into precancerous, such
at 270 nm, 550 J/m2 at 310 nm and 22500 J/m2 at 315 as solar keratosis, keratoacanthoma and Hatchinson
nm. The effect is manifested 2-24 h after irradiation melanosis.
and lasts 1-5 days. The symptoms are photophobia, On the eyes repeated UV-radiation in the range
feeling of a foreign body (“sand”) in the eye, blepha- 295-400 nm causes photochemical cataracts. Epide-
rospasm, pain, lacrimation. Observed erosions of the miological studies indicate an increased incidence
cornea. The events resolved without sequelae. This of so-called senile cataracts in living near the equa-
effect can be manifested in the range of UV-A, but at tor (intensive UV-radiation) or working outdoors.
very high doses of radiation. The effect is also called Stochastic effects are non-threshold, they are
fotooftalmiya (ophthalmia electrica in arc welding). not related to the severity of the lesions, but with a
Another acute effect is a ultraviolet cataracts probability of development and an increased inci-
caused by UV-rays in the range 295-400 nm, which dence of disability - at irradiation with UV-radiation
pass through the cornea and about 80% is absorbed that is a skin cancer. Three types of skin cancer have
by the lens (lens crystalina). Especially relevant prob- been associated with UV-radiation - basal cell car-
lem became acute UV-cataract after introduction to cinoma, squamous cell carcinoma and melanoma.
UV-lasers (powerful sources of UV-rays with specific All ranges to UV-radiation can induce skin cancer,
wavelengths). UV-cataract is of two types. The first but believes that a more pronounced effect was
relates to thermal effects, to greater lengths UV-rays erythema range B. Long and higher doses of radia-
- maximum at 365 nm. In the second type are ex- tion increases the incidence of skin cancer. It is rare
pressed photochemical reactions associated with in people with highly pigmented skin and more
the formation of pigment (melanin) of tryptophan often in albinos, in people with precancerous skin.
(the so-called “pigment” cataract). Maximum this Indicate in US, much of the approximately 400 thou-
effect occurs in the range of 295-320 nm UV-rays. sand cases of skin cancer annually due to exposure
Acute UV-cataract occurs at high radiation doses at to UV-radiation from the sun (in production is not
which pass both types of reactions (heat and pig- exactly proven this effect). Upon irradiation open-
ment) to varying degrees. air demonstrated increased incidence of basal cell
Damage to the retina by intense UV-ray at A range and squamous cell carcinomas of the skin, while
established in an experiment on animals. In humans, melanoma malignum in humans is considered to be
it is possible the removal of lens crystalina (aphakia) demonstrated increased its frequency of exposure
and replacing it with a synthetic one (permeable to to UV-radiation only in individuals suffering from xe-
UV radiation below 300 nm). It is possible that such roderma pigmentosum.
an injury when working with powerful lasers in the Some authors indicate that strong exposure to
UV-long-wave range. UV-radiation in children (with frequent sunburns) is
Another early non-stochastic effects unrelated to associated with an increased risk of melanoma. On
the exact dose of irradiation with UV-rays is hyper- the other hand, melanoma develops more often in
sensitivity - phototoxic and photoallergic effect to the trunk rather than on exposed parts - hands, face,
UV-radiation. neck exposed much more to UV-rays.
Non-stochastic early effect associated with the Stochastic effects in the eye are also associated
dose of UV-irradiation is the formation of vit D3 with the development of precancerous (pterigium)
in the skin. With the high efficiency of this effect is of the conjunctiva, but also with melanoma malig-
erythema range (280-320 nm). The formation of vit num on anterior eye - chamber and iris (more com-
D3 is very important biological activities to UV-radi- mon in people with blue eyes). These and other
ation of phosphor-calcium metabolism, prevention malignancies have been observed in experiment
of rickets and osteomalacia senile, but the doses re- animals. In humans it is found at a higher frequency
quired for this are very low. Indication of necessary in people in tropical regions.
daily doses of about 5% of the MED of the skin sur- UV-radiation indirectly affects on health
face of 200 cm2 or about 60 MED irradiation annual- through its photochemical effects into the air and

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foremost on air pollutants. The most typical exam-
ple is the formation of Los Angeles smog. Under the
influence UV-rays with a wavelength below 380 nm

Concentration - ppm
was carried out the most important primary reaction
to the formation of this photochemical smog - decay
of the liberated with exhaust gases from motor vehi-
cles nitrogen dioxide to nitric oxide and atomic oxy-
gen, and the last form ozone. In this nitrogen oxide August 30.1995

with atmospheric oxygen again returns to nitrogen hour

dioxide and the reaction is repeated throughout, Fig. 4. - daily concentrations of ozone and oxidants in Los
while there is direct sunlight (Fig. 4). Angeles on various methods - at Renzetti and Romanovski
Second in importance primary reaction is the (1956)
photo-dissociation of aldehydes; ketones; alkilaum Prophylactic irradiation (in the so-called Photariums
and peroxyacyl nitrates; hydrogen peroxide and or- Fotarii) in miners and workers in windowless work-
ganic peroxides; nitric and nitrous acid to form free shops during the winter season; in children and other
radicals - OH, NO, RCO, RO. These primary photoox- contingents in situations with increased epidemiolog-
idants - ozone, nitric oxide and free radicals, enter ical risk to respiratory infections showed no significant
into complex chain reactions with formation of sec- differences with irradiated with UV-rays contingents in
ondary photooxidants or other substances - olefi- the incidence of diseases or resistance to cold. As far re-
nozonides, nitroolefines (nitropentan, nitrohexane), ceived some differences in incidence is explained pri-
peroxyacyl nitrate (PAN), alcohols, ethers, acids. All marily by reduced air microflora in rooms - bactericidal
these substances are highly irritating damaging ef- effect of UV-rays. Not recommended the use of artifi-
fect on the skin, the mucosa of the airways and lung cial sources of UV-rays ( “erythema” UV-lamps) at home
and eye, damage plants, degrade plastic and rubber for this purpose. Increased general immune defense of
products. Ultraviolet and less and the visible radia- the body during the warm seasons (summer) is associ-
tion, involved and other photochemical reactions in ated with a complex of factors - recreation, physical ac-
the atmosphere, such as excitation of the molecules tivity, nutrition, physical and chemical factors of the air
of the oxygen and of other primary pollutants - hal- environment, etc. where needed quite moderate (even
ogens, condensation metal aerosols, are also includ- lower) UV-radiation doses.
ed in the other chain of chemical reactions with the
formation of a skin irritant , mucous membranes and 6.2.2.4. Endangered professions
lungs substances.
UV-rays have an indirect health effects, and the Endangered professions at risk of damage by UV-
formation in the air with negatively charged light rays are first all working and staying long outdoors,
ions and ozone (from atmospheric oxygen), but this affecting intensive solar radiation - working in agri-
effect have radiation with a wavelength below 280 culture, construction, forestry and logging, open pit
nm, i.e. these are the effects of artificial sources of mining, water transport, professional sports, working
UV-radiation (outdoor influence to UV-radiation of in tropical regions and many others. Here it is impor-
air ionization is very small). tant that not only the profession, but also prolonged
A large number of experimental studies have exposure to the sun during the holiday periods.
shown that UV-radiation to change the response of Intensive UV-radiation are subjected electric
the immune system alone or in combination with welders and metallurgists in electric steel produc-
other factors impact. Indicate suppression of skin sen- tion. Also affect individuals have used UV-lasers;
sitivity and changes in the distribution of sub-popu- working in rooms with UV-bactericidal lamps (oper-
lations of lymphocytes in humans and experimental ating units, microbiological boxes); UV-sterilization
animals irradiated with UV-rays, and also suppression of food and water; in physiotherapy departments
of defense against tumors implanted in experimen- using UV-A radiation in the treatment of certain
tal animals. The popular belief that UV-radiation and skin diseases - herpes, psoriasis; in some laboratory
obtained through her leather tanning increases the equipment (spectrophotometers) and apparatus for
immune system, increase the resistivity against in- graphic reproduction using UV-lamps.
fectious agents and are an obligatory moment in the
annealing procedure is not necessary scientific confir- 6.2.2.5. Hygiene standards
mation. Studies in humans and experimental animals
no showed significant positive effect of irradiation with Standards for permissible exposure to UV-radia-
UV-rays for insensibility to acute respiratory infections. tion have been proposed by the American Confer-

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Wavelength (nm) Norm (mJ/cm2) Relative spectral efficiency (Sλ/
200 100.0 0.03
210 40.0 0.075
220 25.0 0.12
230 16.0 0.19
240 10.0 0.30
250 7.0 0.43
254 6.0 0.5
260 4.6 0.65
270 3.0 1.0
280 3.4 0.88
290 4.7 0.64
300 10.0 0.30
305 50.0 0.06
310 200.0 0.015
315 1000.0 0.003
Tab. 2. UV-radiation - norms

ence of Industrial Hygienists (ACGIH). They do not narrow spectral band (5-10 nm width); Sλ - relative
apply to exposure outdoors or in people with pho- spectral efficiency (whichever takes the highest val-
tosensitive reactions. This includes persons exposed ue in spectral band with a width of 5-10 nm); Δλ -
in production with artificial sources of UV-rays (with- the spectral width in nm (5-10 nm). The permissible
out UV-lasers) and standards are based on the ef- exposure (s) is obtained by dividing 0,003 J/cm2 of
fects on the eye (photokeratitis) and skin (erythema) Eeff (W/cm2). These rules do not give quite precise
in people with normal pigmented (white) skin and boundary between safe and dangerous levels of ir-
repeated exposure. radiation with UV-rays primarily in terms of stochas-
According to this standard allows irradiation with tic effects (they occur in exposure to solar radiation).
UV-A-rays (320-400 nm) is not more than 1 mW/cm2 It is believed that the permissible irradiation with
for a period of 103 s (about 17 min), and for the short- UV-radiation from the sun should be limited to the
er periods - up to 1 J/cm2. At irradiation with UV-rays dosages needed for the production of vit D3 (about
in the range 200-315 nm values for a period of 8 h 60 MED per year). These doses are considered suffi-
are shown in Table 2 - these values are used directly cient for maintaining the “tolerance” of the skin to
only by irradiation with UV-rays with a precisely de- increased UV-radiation during the summer months
fined wavelengths (eg. only 290 nm). When sources (Table. 3)
with a wide spectral range (also in this area - 200- At 2010 in accordance with the European Di-
315 nm) is determined so-called effective irradiation rective 2006/25/EC on the protection of optical ra-
(Eeff ), relative to the peak spectral efficiency (1.0) at diation in Bulgaria introduced regulation of UV ra-
a wavelength of 270 nm according to the formula: diation for workers in risks related to exposure to
artificial optical radiation - limits for the energy dose
Eeff = ΣΕλ.Δλ.Sλ (H) in Jm-2 and the density power (L) in Wm-2 sr-1 at
different wavelengths (nm), and permissible of ex-
wherein: Eλ is the measured intensity in W/cm2 posure (s).
for the corresponding wavelength or more often
6.2.2.6. Prevention of adverse effects.
Tab. 3. Protection against exposure to ultraviolet rays
The months of the year that need protection from Prophylaxis against UV-radiation from the sun in-
sunlight depend on latitude
Months in which sunscreen
clude: limiting direct exposure; wearing appropriate
Latitude
is necessary clothing - light but maximum covering all parts of
600N до 700N From May to August the body; use of protective (filtering UV-radiation)
500N до 600N From April to September creams and lotions. Use of appropriate glasses. It
400N до 500N From March to October should know, however, that reflected from the sky
300N до 400N From February to November
UV-radiation can reach 50% of total UV-radiation
reaching the Earth’s surface in the presence of high,
300N до 300S All year
feathery clouds and reflected UV-radiation from the
30 S до 40 S
0 0
From August to May
snow reaches 85% of falling on it up to 20% of the
400S до 500S From September to April
sand, to 6% of water and only 2% of the grass (in this
500S до 600S From October to March short UV-rays reflected better in a smaller angle of

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 LABOUR MEDICINE
incidence, but generally more strongly reflect more
long UV-rays), i.e. by certain conditions only protec-
tion from direct UV-radiation is not always enough;
also very thin textiles (cotton) and synthetic are par-
ticularly permeable to UV-rays; protective creams
and lotions should not only moisturize the skin and
grease, and contain UV-rays absorbing substances -
r-aminobenzoic acid and β-carotene; glasses except
dark (reduce visible light) must be made of glass
(not synthetic).
In artificial sources defense includes engineer-
ing tools and personal protection. Sources to UV-ra-
diation must be shielded and maximum production
process automated. Use goggles, shields (protection
of face and eyes), clothing and gloves. In arc welding
required and ventilation (removal of ozone, nitro-
gen oxides and metallic aerosols), painting the walls
with paint containing ZnO absorbing the reflected
UV-radiation, away of other workers from the source
(Fig. 5).
Fig. 5. - Recommended maximum exposure based on
distance from arc welding (ICNIRP - International commission
on Non-Ionizing Radiation Protection).
REFERENCES

1. American Conference of Governmental Industrial Hygienists: Treshold Limitit Values for Physical Agents,
Cincinati, Ohio, 1984.
2. Baetjer A. M. - Ultraviolet Radiation; in. Prevantive Medicine and Public Health ed. P.E.Sartwell, tenth
edition, Appl. Century - Crofts, N.Y, 1997, 854-858.
3. Chuchkova M. - Solar radiation. Physical environmental factors, ed. E.Efremov, Med. and phys., S. 1988,
157-170. (in bul.)
4. Cohen R. - Injuries Due to Physical Hazards - nonionizing radiation injuries; in Occupational Medicine,
ed. J. La Dou, Appleton & Lange, Norwalk, 1990, 116-121.
5. Curtis R., M. Nichols - Nonionizing Radiaion; in Euvironmental and Occupational Medicine, I ed., ed.
W.N. Rom, Little, Brown and Co, Boston, 1983, 693-705
6. Daynes R.A. et al. - Experimental and clinical photoiommunology, Boca Raton, FL, CRC Press, 1983, 373
7. Dragiev T. L.Tsvetkova - Ultraviolet radiation and reactivity Med. and phys., S., 1980, 191. (in bul.)
8. Faber M. - Ultraviolet radiation; in Nonionizing Radiation protection, Sec. ed. WHO Regional publica-
tions, European Series, N 25, 1989,13-48
9. Farr P.M., B.L. Diffey - The erythemal response of human skin to ultraviolet radiation, J. invest. dermat.,
84, 1985, 449-450
10. Galanin N.F. - Luminous energy; Sun radiation and it hygiene importance; in Guide for communale
hygiene I. ed. V.A. Ryazanov, Medgiz, 1961, 55-118. (in russ.)
11. Haagen - Smith A.J., L.G. Wayne - Atmospheric Radiations and Scavenging Processes; In Air Pollu-
tion (sec ed.), Ed. by A.C. Stern, Acad. Press, N.Y., V. I, 1994, 149-183
12. Hathaway J.A., D.H. Sliney - Ultraviolet Radiation; in. Physical and Biological Hazards of the Work-
place, ed. P.H. Wald and J.M. Stave, Van Nostrand Reinhold, N.Y., 184-188, 1998.
13. Kurzel R.B. et al. - Ultraviolet radiation effects on the human eye, Photochemical and Photobiological
rewieus, 2,133, 1977
14. Largent E.J., J. Olishifski - Nonionizing Radition; in Fundamentals of Industrial Hygiene, III ed., ed.
B.A. Plog, National Safeti Council, USA, 1988, 227-257.
15. Ordinance №5/SG. 49 2010 of MLSP and MH on the minimum requirements for ensuring the health
of workers from the risks related to exposure to artificial optical radiation. (in bul.)
16. Tsvetkov D., R. Andreychin - Studies on solar radiation in the Black Sea resorts, Mod. Med., 3, 1967,
249-255. (in bul.)
133
 B.Stefanov

6.2.3 RADIO-FREQUENCY ELECTROMAGNETIC FIELDS

(RADIO WAVES)

6.2.3.1. General Characteristics Intensity - at relatively low frequencies are deter-

mined separately tension of the electric field in volt/
Radio waves are electromagnetic oscillations with meter (V/m) and the magnetic field in ampere/me-
a frequency of 1 kHz to 300 GHz and occupy the long ter (A/m).
wave part of the electromagnetic spectrum to the Energy - Ultra-High Frequency waves (UHF, SHF)
border area with infrared rays. The configuration of measured density of energy flow (DEF), i.e. falling
the radio field (RF) in the space depends on the dis- energy per unit time per unit area (in W/m2, mW/m2
tance from its source. Are distinguished three zones: or μW/m2).
- near (area of induction) - with a radius from the For the purposes of medicine and biology using
source up to a distance much less than 1/6 of the the classification is presented in the Table. 1.
wavelength;
- intermediate (interference zone) - between the 6.2.3.2. Main sources of radio waves
near and distant;
- a distant (wave zone) - with a radius of at least Radio waves most widely used in various in-
10 times greater than 1/6 of the wavelength. dustries, transport, communications, science and
In the area of induction EMF is not yet formed, the medicine. The ability of EMF quickly heated mate-
two components of the field do not match in phas- rial is used for heat treatment of metals (precision
es and not in a specific quantity ratio. This requires smelting, volumetric heating, surface treatment) of
in assessing the intensity of the field to determine semiconductors and dielectrics. The thermal effect
the values of the electric and magnetic components of EMF on the metals is determined by the eddy cur-
separately. In the zone of interference is as noform- rents that are induced in a given environment of the
ing field and also formed electromagnetic waves. In magnetic component of the EMF.
the wave zone field now is formed and spread as a High-frequency induction heating units are used
"running" wave. in metallurgy, metal processing, mechanical engi-
Practical when working with sources of radio neering, in the manufacture of electronic compo-
Table 1: Classification of radio waves used in medicine
Range Frequency Wave Wavelength
ultra-low frequencies (ULF) under 1 кHz Ultra-long over 30000 km
low frequencies (LF) 1 – 100 кHz Ultra-long 3 – 300 km
Long 1 – 3 km
high frequencies (HF) 100 kHz-30 MHz Average 100 – 1000 m
Short 10 – 100 m
ultra-high frequencies (UHF) 30 – 300 MHz Ultrashort 1 – 10 m
decimetered 1m -10 cm
super-high frequencies (SHF) 300 MHz-300 GHz centimetered 1 – 10 cm
millimetered 1 – 10 mm
waves employees are always to near or intermediate nents and others. Radiating elements of such plants
zone. In service of sources SHF fields (microwaves) are oscillating circuits, transformers, feeder lines (in
jobs are in distant (wave) zone. ineffective shielding) and working inductors.
The main features of radiofrequency EMFs are: Heating dielectrics used the energy of the electri-
Frequency - express the number of complete os- cal component of EMF. RF generators are applicable
cillations per unit of time; measured in Hz, respec- to the drying of wood, yarn and other materials, to
tively kHz, MHz and GHz. adhere to plastic, compression of the synthetic pow-
Wavelength - the distance between the two clos- ders, vulcanization of rubber, and the like. In these
est points of the wave with the same phase of oscil- generators the greatest radiation of the working ca-
lation; measured in m, cm and mm. pacitor.

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 LABOUR MEDICINE
Radio waves are the most widely used radio, ing of microstructures of heterogeneous biological
television, navigation and location, for telephone tissues. The rich phenomenological material witness
connections (mobile phones), Internet connection for expressed changes in the human and experi-
(radio modems) and others. Except through station- mental animals at intensities far below the thermal
ary radios, radio communications are carried out by effect. Namely non-thermal effect of radio waves is
means of transport (water, air, rail and road). Ships the starting point for its normalization.
and aircraft mounted and radar equipment. When It is believed that the main “target” on exposure
effectively shielding the transmitter, feeder lines and to radio waves is the brain, respectively nervous sys-
antenna switches hygiene problems do not arise. If tem - arise reversible phase changes in the bioelec-
there are defects in the shield possible radiation not tric activity, of the brain, in conditioned reflex activ-
only operators but also indirectly personal involved. ity, in certain biochemical reactions ensuring nerve
RF fields and used to ionize the gas to obtain processes.
plasma for flaw detection and the like. Intensive EMF Acute effect of radio waves is possible only in an
emitted by the laser installations in some working emergency or gross violation of the rules for safe
areas of radio-electronic industry. Microwave ener- operation. It is characterized by adinamiya, feelings
gy is used in chicken, beer, dairy, meat and fish in- of anxiety, expressed vegetative and vascular dis-
dustry to heat, freesublimationze drying, defrosting, orders, diencephalic crises, episodes of paroxysmal
sterilization and pasteurization products. The same tachycardia, nosebleeds, leukocytosis. There are re-
energy is used in microwave ovens in bits. In imper- ports of cataracts of the eyes and infertility.
fect construction or insufficient sealing of the work- Chronic effect of radio waves occurs mostly func-
ing chambers and waveguides possible leakage of tional changes in the central nervous system (espe-
microwave energy. cially its vegetative sections) and the cardiovascular
The feature EMF to heat tissue is used in physio- system. These may with some conditionality to unite
therapeutic practice. Apply different methods and three main syndromes: asthenic, asthenovegetative
frequencies: diathermy, darsonvalization, inducto- and hypothalamic (diencephalic).
thermy, UHF therapy, microwave therapy and others. Asthenic syndrome is initial. There is after work
experience of 3-5 years. It is expressed by a number
6.2.3.3. Biological action. of subjective complaints: headache, dizziness, fa-
Clinical manifestations tigue, irritability, reduced working capacity, general
weakness, sleep and menstrual cycle disorders, low-
The nature and severity of biological effects on ered sexual potency and others. Vegetative chang-
exposure to radiofrequency EMF is determined by es nosharply expressed by vagotonic predominant
the following factors: reactions, hypotension and bradycardia. The syn-
1) wavelength, respectively frequency of radia- drome occurs favorable, performance does not de-
tion; crease significantly.
2) Intensity of EMF; With the continuation of the work in an envi-
3) Nature of field - sinusoidal, pulsed, modulated ronment with radio waves (5-10 years of exposure)
etc.; asthenia increases, join and cardiovascular disor-
4) Polarization of the wave; ders. It becomes astenovegetative syndrome with
5) Mode of radiation - continuous or by breaks; vegetative-vascular dysfunction (neurocirculatory
6) Method of radiation - local, general; dystonia). The latter may be of hypotensive or hy-
7) Duration of irradiation; pertensive type depending on the baseline func-
8) Location man against vectors of EMF; tional status. Vascular tone is increased, observed
9) Availability of environmental factors that can functional angiospastic changes, are registered ab-
modify (potentiate or weaken) the effect of radio normal oscillograph, reograph, reoencephalograph
waves. and ECG curves.
It found that inequal conditions SHF EMF are An increase in the pathological phenomena
most pronounced biological activity, followed by (continuation work of intensive EMF) arises vege-
UHF and HF fields, ie biological effect is in direct de- tative-vascular form of hypothalamic syndrome. It
pendence on the frequency. is characterized by diencephalic crises expressed
In a high intensity radio waves are expressed agitation, tremor, sharp headache, astringent chest
thermal action, which is manifested in an integral pain, hyperhidrosis, acrocyanosis, low-grade fever.
increase of the temperature of the body or of its Blood pressure is significantly increased, particular-
individual parts. In less impact on the field are only ly diastolic. Electrocardiographic changes deepen,
possible microthermal effects due to uneven heat- are possible conduction abnormalities, ventricular

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 OCCUPATIONAL MEDICINE
extrasistoly and others. The changes are usually re- stitution, age, preceding diseases, exposure and in-
versible. In advanced stages of the disease develop tensity of the impact and others. It is obligatory and
clinical picture of ischemic heart disease and hyper- reliable exclusion the role of others (professional
tension. Working capacity of patients is permanent- and no-professional) risk factors.
ly and significantly impaired.
Typical of paraclinical changes is their instability 6.2.3.4. Prevention of damages
and phase nature. Predominant trend towards cy-
topenias - leukopenia, thrombocytopenia, relative To avoid damages to the health of workers ap-
lymphocytosis, reticulocytosis. Often defined mod- plies a system of measures of a different nature:
erate dysproteinaemias with an increased propor- planning, organizational, technical, structural, tech-
tion of globulins, so albumin-globulin ratio decreas- nological, medical, biological and others.
es. Changes and quantity of mediators: histamine in The indispensable is hygienic standardization.
the blood increases, the content of acetylcholine is Under Decree № 7 of 1999 in work places when op-
changed to a lesser extent, but cholinesterase activ- erating in conditions of electromagnetic radiation of
ity substantially reduced. Possible further endocrine radio frequency and microwave range observed the
disorders, ovarian hypofunction, impotence. established norms according to BS 14525-90 and BS
Other biological effects found primarily in exper- 17137-90.
imental impacts of microwave (MW) and radio fre- When working with low frequency electromag-
quency waves (RF) are: death by hyperthermia (tem- netic fields requiring maximum permissible value of
perature of the brain 70-90°C) at very high power the intensity of the electric field does not exceed the
(described cases in humans); reduced relative weight following values (Table. 2):
of adrenals, pituitary and thyroid gland and secret-
Table 2: Hygiene standards for low frequency EMF
ed by these hormones; changes in the EEG, with
an increase of the alpha rhythm and its amplitude; Frequency Emax
changes in the immune system-lowring of antibod- from 0 to 100 Нz 25 kV/m
ies generating cells, antibody titre, disturbances in 100 Нz to 4 kНz 2,5.10 6/f (Нz) V/m
the nucleus of lymphoblasts; mutagenic activity - es- 4 kHz to 60 kНz 625 V/m
tablished chromosomal aberrations, teratogenic and
embryotoxic effects in pregnant animals - increased Maximum permissible value of the flux density of
fetal mortality and decreased fetal weight, increased the magnetic field must meet the following relation-
postnatal mortality and altered behaviours; changes ship: Emax = 60/f, mT, where f is the frequency in Hz.
in male reproduction - decreased spermatogenesis, BS 14525-90 for high-frequency and ultra high
sperm motility and osmotic resistance and other bio- frequency range regulates the maximum energy pa-
logical effects, incl. and possible carcinogenesis. All of rameters and intensities individually to electric and
these effects, however, besides being observed main- magnetic field (Table. 3).
ly in an experiment are not enough epidemiological In the presence of VHF radio maximum permissi-
confirmation at people, are not always confirmed by ble density of energy flow (DEF) should not exceed
similar studies are often used in high power - over 10 1,000 μW/cm2. This value is reduced 10 times, if the
mW/cm2, with pronounced thermal effect. In chronic working environment is ionizing radiation, or the air
exposure to the UHF radio waves is possible occur- temperature is above 28 °C.
rence of cataracts. Recent studies in this direction The maximum permissible energy load of the
have shown that this is possible only when the action body (En) for one shift is 200 μW.h/cm2. Upon irra-
of the radio waves at a frequency of 1.5 to 10 GHz. At diation with rotating and scanning antennas is al-
frequencies around 35 GHz can be observed keratitis lowed up to 10 times higher value of En. The per-
and damage to the stroma of the cornea. missible exposure is determined by the formula En
Some authors propose to separate independent = DEF. T where T is the time in hours. For example, if
nosological unit “RF disease.” This proposal is not the workplace is measured values of DEF 50 μW.h/
supported by the majority of scientists mainly due cm2, maximum permissible time is 200:50 = 4 h.
to the nonspecific nature of the changes caused by Prevention when working with sources of radio
radio waves. In Bulgaria professional conditioned by waves based on the principles: reducing intensity
action of microwave radiation are considered cata- and exposure, protection by distance and screens.
racts, arterial hypertension, coronary heart disease, Applied power source should be minimal,
leukemia, cancers of the CNS. enough for that process. Reducing exposure seek
Of course polyetiologicality of these diseases re- at higher values of RF EMF to reduce the radiation
quires reporting of hereditary predisposition, con- dose. In norms is a possibility of working with repairs

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 LABOUR MEDICINE
Table 3. Standards for exposure with SHF and UHF in production
Maximum energy parameters Maximum intensity
Frequency range (W) (Е and Н)
in MHz el. field E
el. field WE(E2T) mag. field WH(H2T) mag. field H (A/m)
(V/m)
0,06 – 3 20000 – 500 –
3 – 30 3200 – 200 –
30 – 300 800* – 60 –
0,06 – 10 – 200 – 50
* For rotating and scanning antennas a maximum of 10 times the value of WE

generators and emergency to operate at higher DEF, Medical prophylaxis, along with hygienic normal-
but for a limited time and with the use of personal ization, includes preliminary and peridichni medical
protective equipment. This principle of protection examination.
also includes various compensations and privileges Medical contraindications for employment with
of workers (reduced working hours, extra days off sources of electromagnetic waves are:
etc.). 1) Diseases of the cardiovascular system (arterial
Protection by distance is through the creation hypertension and hypotension, ischemic heart dis-
of sanitary-protection zones around the antenna ease, angina pectoris).
equipment with application of automatic machines 2) All diseases of the blood and secondary ane-
and robots and remote monitoring and manage- mia (hemoglobin less than 14 g% for men and 12
ment of processes at high intensity EMF. g% for females).
The most common method of protection is 3) Organic diseases of the central nervous sys-
shielding. It is used both to sources and to protect tem, incl. epilepsy.
personnel or unprofessional exposed persons. Win- 4) Expressed autonomic dysfunction.
dows for monitoring processes must be shielded. 5) Expressed asthenic condition.
Used tinned wire-net, spacing between the threads 6) Diseases of the endocrine glands with perma-
no more than 3 mm. Recommended command and nent impairment of their function.
display bodies are bring out to the screen. Particular 7) Expressed neuroses (neurasthenia, hysteria,
attention requires grounding the screens. The wire psychasthenia).
should be as short and with a greater section. Oth- 8) Cataracts.
erwise, he could become a source of EMF. 9) Durable and expressed abnormalities in ovari-
Failing to reduce the intensity of the field to the an - menstrual cycle.
standards, is obligatory use of personal protective 10) Psychiatric illness.
equipment radioprotective glasses with fine metal 11) Chronic skin diseases.
(brass) net or from a special glass with pressed net, Periodic reviews are conducted every 24 months.
shields and overalls with woven metallic threads. In The review must take part therapist, neurologist and
our country we have developed a new type of radio ophthalmologist. Make a determination of hemo-
protective tissue on the basis of chemically metal- globin, red blood cells, platelets and proteinogram;
lized polyester textile with very good hygiene indi- in indications and ophthalmoscopy, biomicroscopy,
cators. In local irradiation may be used gloves and ECG, oscillography, determination of serum electro-
aprons of metallised tissue. lytes.

137
 B.Stefanov, D. Tsvetkov

6.2.4 LOW-FREQUENCY ELECTROMAGNETIC RADIATION.

MAGNETIC FIELD

6.2.4.1. General characteristic 6.2.4.2. Main sources

Magnetic field (MF) is a form of existence of mat- Constant magnetic field is more prominent factor
ter, force field, thereby realised the interaction be- in the work environment in the manufacture of mag-
tween moving electric charges or currents. MF is a nets, in quality control and assembly of magnetic sys-
constituent of EMF. When changing value in the time tems of individual magnets, installation of magnetic
always arises electric field. Self-existence is possible parts (generators, DC motors, gauges and more.).
only if its value is constant in time. Permanent mag- Electromagnets have the most diverse applica-
netic field (PMF) is created by the direct current - DC tion: devices for magnetization (in preparation of per-
(uniformly moving charges) or by substances hav- manent magnets), for fixing parts in metal machining,
ing properties of permanent magnet. Low-frequen- in cranes, magnetic separators, devices for focusing
cy electromagnetic radiation is in the lower end of the electron beam, installations for nuclear magnet-
the electromagnetic spectrum - frequency 0-300 Hz, ic (NMP) and electron paramagnetic resonance (EPR)
mostly in alternating current (AC) - 50-60 Hz, and it and others. Magnetohydrodynamic effect upon the
forms a variable magnetic field. interaction of moving charges with MF is used to gen-
The main characteristics of the magnetic field are: erate electricity - magnetohydrodynamic generators
1. Tension - it does not depend on the properties with superconducting cryogenic electromagnets.
of the medium, and is determined by the current Sources of the MF in production conditions are
strength and the shape of the conductor. Its meas- and electrolysis baths, the conductivity belts and
urement unit is the SI ampere/meter (A/m). Out-of- other electrical devices, which direct current flows.
SI unit, which occurs in the older literature is oersht- Low-frequency MF are used in magnet impulsive
ed (Oe) - 1 Oe = 79,58 A/m. and electro hydraulic installations.
2. Induction - a vector quantity that depends on MF is used in medical practice. Natural magnets
the properties of the medium. The direction of the are used relatively rarely. Artificial MF are generated
magnetic induction vector coincides with the direc- by the solenoids of different shapes, which are fed
tion of the magnetic field. It is measured in Tesla (T), with a sinusoidal current at a frequency of 50, 100 or
endeavored unit is gauss (G) - 1 G = 10-4T; 1m T = 5000 Hz. These are eg. apparatus Biopuls (Germany)
10G. produced in our country apparatus Magnet-H-80
3. Stream - physical quantity, numerically equal apparatus Pole-1 Alfa-pulsar, MAG-30 and others.
to the product of the magnitudes of the magnetic Exposure to low frequency electromagnetic fields
induction and the area perpendicular to the vector have anywhere using electric power (AC/DC) - pow-
of induction. Determine units in Weber (Wb) - 1 Wb/ er lines, electric motors, electrical in household, pro-
m2 = 1 T. duction, education, transport and so on.. With high
The magnetic field penetrates easily into many intensity (A/m) and induction (T) magnetic field are
substances, including biological matter and is very working with arc welding in power plants, electri-
difficult to shield. Variable magnetic fields with low cal transport, maintenance of electrical lines and
frequency of great interest in view of their relation- transformers, metallurgists in electric arc furnaces,
ship with molecular biocurrents and health effects. television and radio-engineers (Fig.1). Working with
The source of such fields are all appliances and sys- video displays are also subjected to a low-frequency
tems using alternating current and the electrical electromagnetic field, but they must be at a distance
lines. In contrast of the magnetic field electrical no under 10 cm. to it in order to have a field strength
significant penetration of the human body.1 comparable to those mentioned above.
1
Man is constantly subjected to the action of the Earth’s mag-
netic field ≈ 450 mG, changing slightly - ± 0,5 mG day due to 6.2.4.3. Biological activity
changes in solar activity (but there is a sudden change - “Mag-
netic Storms”). Earth’s electric field is ≈ 120-150 V/m (compara- Biological effects of MF are determined primarily
ble to that of 12 kV power line), but the bad weather (thunder-
storms) reaches 3-5 MV/m. by: a) the type of field - constant, sinusoidal, pulsed

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 LABOUR MEDICINE

Electric arc furnaces -

steel, electric welding
Industry with electric
motors
Offices with electric
appliances
Control rooms 400 kV

Power-plants
directly to power lines
Power-plants
remote to power source
Power lines - 15 m away

Power lines - 50 m
Power lines - 100 m

Offices without electric

appliances

Intensity - μT

Fig. 1. Magnetic fields at the electric current (50 Hz) and steam turbine generators -
1800 and 3800 rev./min (according to H. Lundren, 1992).
or impulsed; b) the magnitude of the magnetic in- es do not always confirm, they are not links “dose /
duction, respectively the field tension; c) the gradi- effect” (most messages are in action on “low-dose”)
ent of the field, respectively extent of its inhomog- does not indicate pathogenetic mechanisms ex-
enous; d) the duration of the effect; e) modes of plaining found changes. Indicate: the presence of
radiation - continuous or with breaks. persons “hypersensitivity to electricity” - established
The first changes that precede any other reac- in Sweden (1993) 10 000 people with subjective
tions of the body are changes in bioelectric activity symptoms and complaints, working with video dis-
of the brain. In the initial stages of excitatory effects play and other electrical equipment; epidemiologi-
processes prevail. The further impact of CMF leads cal studies in people living near power lines (but low
to a slowing of the electrical rhythms of increase in magnetic induction - 0.2 mT) for increased frequen-
the intermediate EEG amplitudes and slow waves. cy of cases of leukemia in children and brain tumors;
Subjective complaints in intensive impact with increased incidence of premature pregnancy and
the MF most frequently: headache, recurrent verti- malformations in some working in power plants or
go, tinnitus, increased irritability, anxiety and worry. using electric warming blankets in the night; a high-
Under the influence of the CMF in the body of er incidence of certain types of leukemia - acute my-
workers observed vegetative-vascular changes, eloid leukemia and chronic lymphocytic leukemia,
which are characterized mainly by phenomena of when operating in industries with large electric
vasodilatation. The disorders in the various regions motors; have been developed and theoretical mod-
of the vascular system does not occur simultaneous- els for changes in cell membranes (transmembrane
ly. At first they cover arteries and arterial part of the potential), explaining found reduced melatonin and
capillary network, and then spread in the parts of permeability of the calcium ion.
venous capillaries and veins. In some of those chron- Prevention. Regulations for low ER and magnet-
ic staying in an environment with MF has a tendency ic component of EMF are listed (see Radio frequen-
to arterial hypertension. cy electromagnetic fields). In our in manufacturing
Changes in the activity of the cardiovascular sys- processes and work equipment, which are a source
tem, morphological composition of blood and me- of constant magnetic field, magnetic induction is
tabolism are usually transient, reversible and of a regulated in the workplace to 60 mT (equivalent
functional nature. to 600 Gs) per shift. The maximum value of the flux
It is noted that in the body induced by the mag- density of the magnetic field should not exceed 2 T
netic field biocurrent in persons standing in the vi- regardless of exposure time
cinity of the power line - 5OHzAC, is much less than In our legislation are not regulated contraindica-
those induced by the electric field. In addition in- tions to work with constant magnetic fields and pe-
duced MF biocurrent significantly weaker and those riodic examination of such categories of workers. (In
caused by normal heart and brain activity - respec- view of the similarity in physical nature and biolog-
tively 10 mA/m2 and 1mA/m2. ical activity should be regulated on the radio waves
Like the biological effects of action of EMF in the applies to the magnetic field).
radio frequency range and here reported chang-

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 OCCUPATIONAL MEDICINE
REFERENCES

1. Cohen R., P. Wald - Microwave, Raddiofrequency and Extremely Low - Frequency Energy. in Physical
and Biological Hazards of the Workplace, ed. P. H. Wald, G. M. Stave, N. Y. VanNostrand Reinhold, 1994, 203-
215
2. Curtis R., M. Nichols - Nonionising Radiation. in. Environmental and Occupational Medicine, ed. W. N.
Rom, Boston, Little, Brown and Co, 1sth ed, 1984, 693-706
3. Electromagnetic Fields 300 Hz to 300 GHz. Environmental Health Criteria № 137, World Health Organ-
ization, Geneva, 1993.
4. Knave B., J. Niland, C. Zenz - Nonionizing Radiation. in Occupational Medicine, ed. C. Zenz, Mosby, 3th
edition, 1994, 384-392
5. Mild, K.H. Radiofrequency Field and Microwaves. In Encyclopaedia of Occupational Health and Safety,
ed. J.M. Stellman, International Labour Office, Geneva, 1998, 4th edition, vol. IV, 49.18-49.31.
6. Ordinance № 7 for minimum health and safety requirements in workplaces and the use of working
equipment. SG. No. 88 of 08.10.1999, amended. and supplemented. by 2004. (in bul.)
7. Ordinance on reporting, registration, confirmation, appeal and account of occupational diseases. SG.
No. 33 of 4.04.2001. (in bul.)
8. Stefanov, B. Radio waves and magnetic fields (hygienic aspects). S., Med. and Phys., 1990, 144. (in bul.)

140
 B.Stefanov

6.2.5 STATIC ELECTRICITY

processing - in warp, spinning, drawing, twisting,

6.2.5.1. General characteristics finishing operations and others. End spinning and
weaving machines is determined static field inten-
Static electricity is a set of phenomena associat- sity of 100 kV/m.
ed with the occurrence of electrical charges on the High intensity of the electrostatic field and is reg-
surface or volume of dielectrics or isolated conduc- istered in the processing of dried wood, which has
tive bodies. Static electricity occurs upon contact of a high dielectric constant, which makes easier its
two different materials, which becomes a redistribu- electrization occurs. This factor is typical for paper
tion of the electrons or ions them and form a dou- pulp industry, which are widely used materials with
ble electric layer with opposite signs. Depending on pronounced dielectric properties - cellulose, rosin,
how and source of formation electrostatic field can paraffin, wood and others. At separate technologi-
exist as their own (field of fixed charges) or station- cal operations are measured values of the field from
ary electric field (electric field of the DC). 60 to 150 kV/m.
Main indicators of the electrostatic field are its in- Increased level of static electricity can be estab-
tensity and potential of point charges. Intensity is a lished and workplaces equipped with computers.
ratio of the force F, with which field acts on the point To speed the flow of electrons in the picture tube of
charge Q, to the magnitude of this charge: E = F/Q. a video monitor serves electrode, which is fed very
Unit for intensity is volt/meter (V/m), and a potential high potential. He became a source of electrostatic
- volt (V). field. In falling electronic beam on the luminopho-
rous layer of the screen also create electrostatic
6.2.5.2. Main sources charges. Their presence can be felt by touching the
monitor screen if he has no special anti-static coat-
Electrostatic field on work places as a result of us- ing.
ing any electronic-ion technology or adverse effect Source of static electricity are electrifying syn-
of a production process. thetic materials that abound modern business inte-
In the first case using the opportunities provid- rior - carpets, plastic coatings, incl. and clothing (un-
ed by static electricity for purification of gases (in derwear and outerwear) and shoes from synthetic
electro filters) for electrostatic separation of ores fabrics.
and other materials for electrostatic application of
paints, varnishes, and polymers. These technologies 6.2.5.3. Biological action
are widely used in chemical, grain feed, food and pa-
per industries - for rubberise of tissues, production Static electricity could have harmful effects on
of plastic foils, paper, flooring textile base (linole- the human body not only in direct contact with the
um), processing and production of granular materi- charges, but due to the action of the electric field
als and powders and others. that occurs around the charged surfaces.
As an unintended consequence static electricity Experimental animal studies have shown that the
may occur in the process friction, spraying, crush- most sensitive to electrostatic fields are nervous
ing, blending, movement of liquids through pipe- and cardiovascular systems. There are changes in
lines and others. Generating electrostatic charges the conditional reflex activity and electrical activity
are observed in production, processing and storage of the cortex and deep structures of the brain. Upon
of powders (bulk materials with particle size of fine prolonged exposure to the electric field in the ani-
powders to granules) and to electroinstallations and mals is determined reduced reactivity of the auto-
high voltage direct current lines. nomic nervous system with transient characteristic
Significant electrostatic fields arise in the textile (Table. 1).
industry in the processing of chemical fibers with Working for long periods in an area with intense
high dielectric properties. The acetate and synthet- electrostatic fields complain of increased emotion-
ic fibers are hydrophobic, have high specific resist- al excitability, irritability, headache, rapid fatigue,
ances and load in the process of production and weakness, sleep disorders and appetite. It should

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 OCCUPATIONAL MEDICINE
Tab. 1. Experiments on animals exposed to static electricity
Biological changes Effects observed Terms of exposure
Haematological and Inconstant changes in serum albumin and Permanent exhibition on fields between 2.8
immunological globulin fraction in rats and 19.7 kV / m from 22 to 52 days of life
There were no significant differences Exposure to 340 kV / m for 22 hours a day
in blood cells count, serum proteins and for a total of 5000 hours
biochemical parameters in mice

Nervous system Reliable EEG changes in rats, but the Exposure to electric fields with intensities
effect is not permanent up to 10 kV / m
There were no significant changes in the Exposure to fields with intensity 3 kV / m
concentration and rate of implementation to 66 hours
of various neurotransmitters in the brain
of male rats

Behavioral reactions There were no effects on behavioral Exposure to HVD electric fields from 55
responses in rodents to 80 kV / m
Occurrence of dose-dependent Exposure to fields with an intensity
behavioral abnormalities in male rats, of 12 kV / m
no change in the air ionization
Reproduction and There were no significant differences in Exposure to 340 kV / m for 22 hours a day
development the total number of offspring and per cent before, during and after pregnancy
survivors mice

be noted that the static electricity presents a danger 2. The use in some technological processes of
not only to health but also to life. Following the blast neutralizers of static electricity, which ionize the air
power of electrostatic discharges, there is a high and thereby relax charge.
probability of explosions and fires - particularly for 3. Use of other antistatic additives, and the coat-
inflammable, combustible and explosive materials ing material for reducing the specific volume and
in contact with metal unearthed facilities (Table. 2). surface resistances of the materials to values corre-
sponding to a low degree of electricity.
6.2.5.4. Prevention 4. Maintain a high relative humidity in the work-
ing environment - up to 65-75%.
Recommended that workplaces limit value of 5. Reduce speed and turbulence of movement of
electrostatic field is 60 kV/m for 1 h. If the contact liquids in pipelines.
with static electricity is over 1 h, was used the formu- 6. Floors and floor coatings must be electrocon-
la E = 60/√ T, where T - time in hours. For example, 4 ductive;.
h, regulates the intensity E = 60/2 = 30 kV/m. 7. Use an alarm and (or) blocking at risk of elec-
The general requirements for protection from trostatic discharges due to high intensity electro-
static electricity in Bulgaria are regulated in BS static field.
15969-84 and in Regulations on labour safety and 8. Use personal protective equipment - anti-static
operation of electrical installations and equipment shoes and more.
(D-01-008). Fighting electrostatic fields is carried by To prevent sparks from static electricity in haz-
a number of technical, technological, structural, or- ardous areas and external systems, with belt drives
ganizing and other events. The most important of must be used antistatic belts or flat belts of semi-
them are: conducting material in the required coating with
1. Grounding electrostatic conductive parts of antistatic paste. It is prohibited flammable liquids to
machines, equipment, piping, ventilation systems, pour in containers by flowing stream. Rightly pour-
tanks, etc., where generate electrostatic charges. ing liquid drip on the walls of the tank. For work in

Tab. 2. Typical lower limits of flammability of dusts, gases and vapors

Substances Limit
Some powders Some joules
Very fine sulfur and aluminum aerosols Some joules
Vapour from hydrocarbons and other organic liquids 200 micro joules
Hydrogen and acetylene 20 micro joules
Explosives 1 micro joule

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 LABOUR MEDICINE
hazardous areas and environments are not allowed
to use clothes made of synthetic material which can
accumulate electrostatic charges.

REFERENCES

1. BS 15969-84. Static electricity. General requirements for protection. (in bul.)

2. Grandolfo M. Static Electric and Magnetic Fields. in Encyclopaedia of Occupational Health and Safety,
ed. J.M. Stellman, International Labour Office, Geneva, 1998, 4th edition, vol. II, 49.25-49.29.
3. Hygiene of labour at electromagnetic field action. ed. V.E. Kovshilo. M. “Medicine” , 1983, 176. (in russ.)
4. Menguy Cl. Static Electricity. in Encyclopaedia of Occupational Health and Safety, ed. J.M. Stellman,
International Labour Office, Geneva, 1998, 4th edition, vol. II, 40.5-40.16.
5. Regulations on labour safety and operation of electrical installations and equipment (D-01-008). News-
letter for Labour, Min. labour and social care. № 10, 1996. (in bul.)

143
 D. Tsvetkov, M. Lyapina

6.2.6 LASER

One of the most remarkable discoveries of mod- 6.2.6.1 Use of lasers

ern times are optical quantum generators or laser
- Light Amplification by Stimulated Emission of Ra- Described characteristics of the laser beams
diation. make them widely used in industry (in the process-
Nikolay Basov and Alexander Prokhorov and ing of high temperature stable metals and alloys,
Charles Townes (1954) first developed the physical for drilling, cutting and welding under high pres-
foundations of the so called Maser (Microwave Am- sure, calibration, in instrumentation, etc.), Military
plification by Stimulated Emission of Radiation) or equipment, construction (mining, road, buildings),
a generator that works in the range of microwaves. communication and communication systems, in
Optical maser is a laser. In 1958, Charles Townes various research apparatus and methods in spec-
and Arthur Schawlou offer the principle of the laser. trophotometry holography. Lasers are becoming
The first ruby laser was created in 1960 by Theo- more widely used in medicine - surgery, oncology,
dore Maiman (in 1964 Nikolay Basov and Alexander ophthalmology, dermatology, gynecology, dentistry
Prokhorov and Charles Townes become Nobel Prize and in bits (CD-ROM components, PC drives and CD
in Physics). music systems). Increasingly used and various ther-
The lasers are quantum generators of electro- apeutic laser systems for conducting physiotherapy
magnetic waves of infrared, visible and ultraviolet and acupuncture.
range using the phenomenon of stimulated emis-
sion. In general, any laser device consists of an active 6.2.6.2. Occupational risk factors
medium (solid, liquid, gaseous, semiconductor, etc.),
A system for excitation of the active medium with Persons working a long time with lasers can be
a source of energy -optical, electrical, chemical, gas exposed to a complex of adverse factors in the work
dynamic, electronic and resonator device - element environment - direct, reflected or diffuse laser ra-
which makes laser of quantum amplifier in a quan- diation, ultraviolet and infrared radiation, impulse
tum generator. noise, toxic dusts and gases separately from laser
In Table. 1 shows the main types of lasers and process materials. As a result of electrical discharg-
their characteristics. es or ionization of the air environment around the
high power laser devices, in the air of the working
Tab. 1. environment is ozone. Cooling of solid-state lasers
Active Wavelength Mode of
are sometimes used liquefied
Type Power nitrogen and helium that skin
medium transmission
Ruby 694 nm pulse solid 100,000 W contact can cause burns. These
Neodymium 1060 nm continuous solid 3W refrigerant gases at their expiry
Helium-neon 632,8 nm continuous gas 0,2 W in closed (unventilated) room
Argon 488-514 nm continuous gas 2W
CO2 + N2 + He 10 600 nm continuous gas 10 – 300 W
replace oxygen and there is a
Gallium arsenide 840 nm continuous semiconducting 2W risk of hypoxic damage. It is
possible defeat of high voltage
Pulse lasers emited energy as single or series of electricity using laser equipment. In some manufac-
pulses with a duration of less than 0,25 s. turing operations using flammable organic solvents
Laser radiation has several extremely important and materials, that can be easily ignited by the laser
and specific properties, namely: high monohroma- beam. Often lasers used in medical practice have
tism - a very narrow range of frequencies or wave- such power characteristic, that if no observing the
lengths, coherence - sinhronous in time and space rules for working with lasers can cause tissue dam-
emitted from the laser source light waves, high di- age not only applies them medical staff but also for
rectivity and minimal divergence, which determines patients.
the largest concentration of energy in the section of
the beam.

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 LABOUR MEDICINE
ated with the following main effects: thermal, me-
6.2.6.3 Classification of lasers in the degree of chanical, electrical, photochemical and biostimulat-
occupational risk. ing.
Typical of the thermic effect is the formation of
Occupational risk assessment of laser radiation is large amounts of heat (up to hundreds of degrees)
carried out using a classification system (Decree № 9 in a small volume of tissue in a very short time. In-
for sanitary rules when working with lasers SG. 95 of creases were mainly the temperature of liquids, so
1986 .; American National Standards Institute - ANSI suddenly increases and intracellular pressure. Me-
Z136.1-1986), based on the baseline characteristics chanical or hit, the devastating effect of laser radi-
of laser radiation (power features, impulse duration ation is the result of kinetic and ultrasonic changes.
and frequency of repetition, duration of radiation, The resulting shock wave is the result of descriptions
wavelength, etc.) and limit levels (LV) for exposure thermal effect on cellular fluids and is most pow-
to laser radiation (Decree № 8 for hygiene standards erful when it is formed in the deep-seated tissues.
laser radiation SG. 92 of 1986). The electric effect is related to the electric field that
Since the main risk of laser radiation results from accompanies radiation and may affect influence
damage to the visual system and, to a lesser extent, on molecular structure and permeability of the cell
to skin lesions, classification is based on the ability of membrane. Photochemical effect is the result of
a laser radiation to cause these injuries (classification stimulation of photochemical reactions and the se-
of the lasers must be done by the manufacturer). lective absorption of laser radiation by some cellular
Class I belong a class of lasers and laser devices components (eg. photocoagulation of colored, light
with the lowest power or some lasers emitting in ful- absorbent tissue). This effect is also the therapeutic
ly enclosed space (fully shielded laser). They do not use (eg. In oncology), as in the tissue prior to inject a
cause eye damage, even in direct directing the laser specific photosensitizer. Biostimulates effect is typ-
beam to the eye at duration maximum for type of ical for treatment (low energy) lasers. In these cases,
laser (sometime unlimited). laser radiation given quantum energy without pur-
Class II includes low power lasers and laser de- suing destruction. The cell uses the resulting energy
vices visible range. Do not cause damage to the eye for the “management” of its own metabolism.
by direct observation of the laser beam for a time The described biological effects are the basis of
t < 0.25 s. the mechanisms involved in the pathogenesis of ra-
Class III includes average power lasers and laser diation-induced damage the laser. However, often
devices emitting in the infrared, ultraviolet or visi- the action of these radiations is not limited to these
ble area. These lasers can cause ocular damage by effects. To specific biological effects of laser radiation
direct entry of the beam into the eye, such as beams relate changes in the genetic apparatus, in enzymat-
with certain wavelengths and can damage the skin. ic and biochemical systems, in some components
Lasers of this class are divided into class IIIa and IIIb of the blood (hemoglobin) and the like. The basis
class. Class IIIb lasers belong, in which the risk of of specific biological action lie complex processes
causing damage to the eye is higher. caused by selective absorption of electro-magnetic
Class IV belong lasers and laser devices with high energy from the tissues.
power where even diffusely reflected laser light cre- Occupational exposure are possible as severe
ates a risk of eye damage. Direct laser beam causes (more common), and caused by distracted, reflected
skin lesions and create a fire hazard. rays chronic disabilities. Last expressed as functional
Control measurements of laser radiation are car- disorders in the nervous and cardiovascular system
ried out mostly using laser class IIIb and IV. - increased fatigue, headache, tremor of the hands
and eyelids, poor self-esteem, dizziness, lability of
6.2.6.4. Biological action pulse and blood pressure. Formed astheno-vegeta-
tive syndrome.
Peculiarities of the biological action of laser radi- Most sensitive and susceptible to acute injury
ation is determined by: from laser radiation organ is the eye; relatively rare,
- The characteristics of radiation - wavelength but also are possible skin damage.
mode of radiation, pulse duration, energy and pow- Damage to the cornea by laser radiation in the
er of radiation; infrared region(1400 nm - 1 mm).
- Properties of biological object - absorption coef- Depending on the power of laser equipment
ficient and reflection, thermal conductivity and heat damage to the cornea can vary - from minimal,
capacity, content of certain chemical compounds. affecting only the epithelium to the massive de-
The biological action of laser radiation is associ- struction of the cornea with severe burns adjacent

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 OCCUPATIONAL MEDICINE
conjunctiva and eyelids. The injuries are a result of to non-coherent sources of ultraviolet and infrared
absorption of energy from tears and corneal tissue radiation induced cataracts. It is theoretically pos-
fluids (thermal effect). Recovery after minimal dam- sible occurrence of the same pathology and by ex-
age can occur within 48 hours, but heavy damage posure to laser radiation with a similar wavelength.
causing lasting consequences. In real production conditions, it is unlikely chronic
Damage to the cornea by laser radiation in the exposure to laser radiation without presence of per-
UV region (100-400 nm) sonal and collective protective equipment. Chronic
Radiation damage by laser in the ultraviolet re- effects of laser radiation on the lens have not been
gion is similar to that caused by other natural or ar- studied.
tificial sources of ultraviolet radiation. Clinical symp- Skin damage
toms include photophobia, redness and tearing. The Skin damage occurred at impact of laser radiation
damage caused by ultraviolet radiation was not due with more energy. The laser radiation is absorbed se-
to thermal effects, but rather to a photochemical de- lectively by the pigment of the skin structures and
naturation of proteins and other macromolecules, therefore advantageously damaging pigmented
such as DNA and RNA. cells. In connection with the increased absorption
Retinal damage from laser radiation in the vis- of laser radiation by hemoglobin possible rupture
ible and near infrared region (400-1400 nm) of the blood vessel with bleeding, and the develop-
Laser radiation within the visible region mostly ment of thrombosis in small blood vessels and skin
pass through the cornea, the lens and the ocular capillaries.
media without damaging them. Almost all the en- Laser radiation in the ultraviolet region in acute
ergy of laser radiation reaches the retina, where he exposure cause photochemical damage to the skin,
practices harmful effects. Due to the focusing pow- similar to acute sunburn. Theoretically, chronic ex-
er of the lens density of the energy that reaches the posure to these radiations can lead to premature ag-
retina is increased, thereby it becomes possible laser ing of the skin and the increased risk of developing
radiation with a lower energy to cause localized, is skin cancer.
often substantial damage. The clinical presentation Laser radiation in the visible and infrared range
varies - from minimal, often asymptomatic and re- can cause thermal burns in acute exposure.
solved within 24 hours ophthalmoscopic disabilities, In production terms, particularly in respect of the
in small focal degenerative changes in the macula rules for working with lasers, a real risk of skin dam-
and paramacularic area of the retina, occurring in age is unlikely.
immediate loss of vision and retinal hemorrhag- Table 2 provides a summary of eye and skin le-
es. Generally, the degree of organic and functional sions caused by the laser radiation in the ultraviolet,
damages depends on the area of the lesion and its visible and infrared regions.
localization.
The mechanisms participated in the pathogene- Tab. 2.
sis of injuries caused Injuries:
Wavelength
by laser radiation in eyes skin
the visible region are 100-280 nm (UV-C) photokeratitis erythema, skin cancer
different, depending 280-315 nm (UV-B) photokeratitis, photo-chemical hyperpigmentation, skin cancer,
on the type of laser cataracts accelerated skin aging
315-400 nm (UV-A) photokeratitis, photo-chemical pigmentation, photosensitive
device. Discusses
cataracts reactions, skin cancer,
the role of thermal accelerated skin aging
effects (by denatur- 400-780 nm (visible) photo chemical and thermal pigmentation, photosensitive
ation of proteins), as damage to the retina reactions, skin burns
well as that of the 780-1400 nm (IR-А) cataract, retinal burns skin burns
1400-3000 nm (IR-B) corneal burns, cataracts skin burns
mechanical and pho-
3000 – 106 nm (IR-C) corneal burns skin burns
tochemical effects.
Other ocular lesions 6.2.6.5. Prevention of laser impact
Laser radiation in the near ultraviolet region and
a near infrared region to have characteristics allow- Prevention involves complex events. Developed
ing the absorption of large amounts of energy in rules and requirements for protection against laser
ocular structures, arranged between the cornea and radiation (Decree № 9 for sanitary rules when work-
the retina (including in the lens and the iris). Acute ing with lasers SG. 95 of 1986).
injuries of these structures are possible under the ef- To ensure safe operation with lasers apply safe-
fect of high power laser devices. Chronic exposure guards based on the class of laser system - the level

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 LABOUR MEDICINE
of occupational risk, the specific operating condi- from the target, cryogenic liquids and the process-
tions of the laser, environment, presence of other ing of different materials with the laser beam should
harmful environmental factors, path of the laser not exceed the MAC by simply build appropriate lo-
beam, constructive features of the laser device, type cal and general ventilation. Protection emitted from
target and others. power radio frequency devices, electromagnetic
Not allowed intra ray monitoring of the laser fields, X-ray radiation or optical radiation of pulse
beam (laser class I) and directing the laser beam to lamps are carried out through shielding. When ex-
the eye (for lasers of classes II and III). It is shielding cessive amounts of noise is necessary to implement
the laser beam for laser class II, III and IV, for lasers individual and/or collective protection.
from third class shield and the reflected rays and The coloring of the premises with laser systems
those from class IV is shielded completely and the must be tailored to the wavelength of emitted radia-
path of the laser beam and remove any reflective tion in them, to absorb them and prevents mirror re-
objects and surfaces. The premises for laser devices flections. The lighting in workrooms should provide
should not be located mirrored surfaces. the requirements of hygiene standards, except when
Technical safety also includes the use of filters, ab- the process having to work in a darkened room.
sorbers and attenuators to the outlet of the laser to Medical prevention. In preliminary medical ex-
reduce power and energy, automatic locks, remote amination contraindications for work with lasers are:
control - for lasers class IV and others. Lenses, prisms eye damage - reduction of visual acuity, cataracts
and other optical elements should have blinds and and other diseases whose course can be aggravat-
accessories for the adjustment of the radiation be ed when exposed to laser radiation; skin diseases, in
fitted with protective filters with a range of absorb- particular malignant; organic diseases of the central
tion, which coincides with the length of the laser nervous system; expressed neuroses and autonomic
beam. On laser head and the doors of the premises dysfunction; all blood disorders and secondary ane-
must be sign for laser class, with signs warning of mia; diseases of the cardiovascular system (perma-
the danger. An important preventive measure is the nent arterial hypertension, coronary heard disease,
formation of a controlled area marked with special angina pectoris); endocrine diseases; pregnancy.
signs (for lasers of classes III and IV), access to which Workers in the production and application of lasers
have only specially trained persons. Staff not direct- subject to obligatory periodic medical examinations
ly involved with the operation of the laser allow at once every 12 months. They should participate ther-
safe distances from laser danger zone, to ensure the apist, neurologist and ophthalmologist. Required
safety shall require the presence of light and sound tests include ophthalmoscopy and determination of
signal during the radiation. hemoglobin and leukocytes, and at indications - bi-
Of utmost importance is the use when working omicroscopy, ECG, platelets and red blood cells.
on goggles fitted with passport and selected based Hygiene standardization. Under Decree № 8 on
on their spectral characteristics, the optical density hygiene standards for laser radiation are established
and the period of prevention, resistance for demo- limit values (LV) of work places with the use of la-
lition of absorbing medium by laser beam or other sers with continuous wave and pulsed mode. Limit
environmental factors, comfort wear, ventilation values apply to occupational risk assessment of the
and others. Protective clothing applies when there primary effects of radiation on humans and does not
is danger of radiation on skin with values above lim- apply to chronic exposure of human continuous or
it levels for skin. Used clothing dark colored, laser pulsed low-intensity laser radiation for extended pe-
radiation absorbing tissues and gloves, shields and riods (months or years). Justify limit levels for expo-
more. Laser class IV protective materials must be fire sure of the skin (Table. 5) and eyes (Table. 3 and 4)
resistant and protect from heat. with continuous radiation.
Rules and requirements for the protection of
other harmful factors. Toxic substances emitted

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 OCCUPATIONAL MEDICINE
Tab. 3. Limit levels in radiation monitoring - α <α o
Wavelength, λ (μm) Duration of radiation, t (s) Limit levels
0,200 – 0,302 10-9 – 3.104 3 .10-3 J . cm-2
0,303 10-9 – 3.104 4 .10 -3
J . cm-2
0,304 10-9 – 3.104 6 .10 -3
J . cm-2
0,305 10-9 – 3.104 1,0.10 -2
J . cm-2
0,306 10-9 – 3.104 1,6.10-2 J . cm-2
0,307 10-9 – 3.104 2,5.10-2 J . cm-2
0,308 10-9 – 3.104 4,0.10-2 J . cm-2
0,309 10-9 – 3.104 6,3.10 -2
J . cm-2
0,310 10-9 – 3.104 1,0.10 -1
J . cm-2
0,311 10-9 – 3.104 1,6.10 -1
J . cm-2
0,312 10-9 – 3.104 2,5.10 -1
J . cm-2
0,313 10-9 – 3.104 4,0.10-1 J . cm-2
0,314 10-9 – 3.104 6,3.10-1 J . cm-2
0,315- 0,400 10-9 – 10 0,56 t ¼
J . cm-2
0,315- 0,400 10 – 103 1 J . cm-2
0,315- 0,400 103 – 3.104 10 -3
W . cm-2
0,400- 0,700 10-9 – 1,8.10-5 5.10 -7
J . cm-2
0,400- 0,700 1,8.10-5 – 10 1,8 t¾ . 10-3 J . cm-2
0,400- 0,550 10 – 104 10-2 J . cm-2
0,550- 0,700 10 – T 1,8 t¾ . 10-3 J . cm-2
0,550- 0,700 T – 104 10CB . 10 -3
J . cm-2
0,400- 0,700 104 – 3.104 CB .10 -6
W . cm-2
0,700- 1,050 10-9 – 1,8.10-5 5CA . 10 -7
J . cm-2
0,700- 1,050 1,8.10-5 – 103 1,8CA t¾ . 10-3 J . cm-2
1,051- 1,400 10-9 – 5.10-5 5.10-6 J . cm-2
1,051- 1,400 5.10-5 – 103 9 t¾ . 10 -3
J . cm-2
0,700- 1,400 103 – 3.104 320CA .10 -6
W . cm-2
1,4 – 103 10-9 – 10-7 10 -2
J . cm-2
1,4 – 103 10-7 – 10 0,56 t¼ J . cm-2
1,4 – 103 > 10 0,1 W . cm-2
Tab. 4. Limit levels eyes when irradiation with divergent laser radiation - viewing angle - α> α o
Wavelength, λ (μm) Duration of radiation, t (s) Limit levels
0,200 – 0,302 10-9 – 3.104 3 .10-3 J . cm-2
0,303 10-9 – 3.104 4 .10 -3
J . cm-2
0,304 10-9 – 3.104 6 .10 -3
J . cm-2
0,305 10-9 – 3.104 1,0.10 -2
J . cm-2
0,306 10-9 – 3.104 1,6.10-2 J . cm-2
0,307 10-9 – 3.104 2,5.10-2 J . cm-2
0,308 10-9 – 3.104 4,0.10 -2
J . cm-2
0,309 10-9 – 3.104 6,3.10 -2
J . cm-2
0,310 10-9 – 3.104 1,0.10 -1
J . cm-2
0,311 10-9 – 3.104 1,6.10 -1
J . cm-2
0,312 10-9 – 3.104 2,5.10-1 J . cm-2
0,313 10-9 – 3.104 4,0.10-1 J . cm-2
0,314 10-9 – 3.104 6,3.10 -1
J . cm-2
0,315- 0,400 10-9 – 10 0,56 t ¼ J . cm-2
0,315- 0,400 10 – 103 1 J . cm-2
0,315- 0,400 103 – 3.104 10 -3
W . cm-2
0,400- 0,700 10-9 – 10 10 t⅓ J . cm-2 . sr-1
0,400- 0,550 10 – 104 21 J . cm-2 . sr-1
0,550- 0,700 10 – T 3,83 t¾ J . cm-2 . sr-1
0,550- 0,700 T – 104 21CB J . cm-2 . sr-1
0,400- 0,700 104 – 3.104 2,1CB . 10 -3
W . cm-2 . sr-1
0,700- 1,400 10-9 – 10 10CAt⅓ J . cm-2 . sr-1
0,700- 1,400 10 – 103 3,83CA t¾ J . cm-2 . sr-1
0,700- 1,400 103 – 3.104 0,64CA W . cm-2 . sr-1
1,4 – 103 10-9 – 10-7 10-2 J . cm-2
1,4 – 103 10-7 – 10 0,56 t ¼ J . cm-2
1,4 – 103 > 10 0,1 W . cm-2

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 LABOUR MEDICINE
Tab. 5. Limit exposure levels of the skin with laser light

Wavelength, λ (μm) Duration of radiation, t (s) Limit levels

0,200 – 0,400 10-9– 3.104 Same values as in Tables 3 and 4

0,400- 1,400 10-9 – 10-7 2CA . 10-2 J . cm-2
0,400- 1,400 10-7 – 10 1,1CA . t ¼ J . cm-2
0,400- 1,400 10 – 3.104 0,2CA W . cm-2
1,4 – 103 10-9 – 3.103 Same values as in Tables 3 and 4

REFERENCES

1. Decree № 9 for sanitary rules when working with lasers SG. 95 1986 (in bul.)
2. Decree № 8 on hygiene standards for laser radiation SG. 92 1986 (in bul.)
3. Goldman L., S. M. Michaelson, R. J. Rockwell et al. Optical radiation, with particular reference to la-
sers. In: Nonionizing radiation protection, sec. ed., ed. M. J. Suess, WHO, series № 25, 1989, 49-85
4. Hathaway J. A., D. J. Sliney. Laser Radiation. In: Physical and Biological Hazards of the Workplace,
1994, Van Nostrand Reinhold, 196-202
5. Largent E. J., J. Olishifski, L. Anderson. Nonionizing Radiation. In: Fundamentals of Industrial Hy-
giene, third edition, 1998, National Safety Consil; 245-255
6. Sliney D. J. et al. Laser hazards bibliography. Aberdeen Proving Grounds, UD, US Army Environmental
Hygiene Agency, 1984.
7. TLVs and BEL’s - Lasers, American Conference of Governmental Industrial Hygienists, Cincinnati, OH,
2008, 134-141.
8. Zhohov V.P. et al. Hygiene of labour and prevention professional pathology in work with lasers. M.:
Medicine, 1981, 208 p. (in russ.)

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 Ft. Kalburova

6.3 AIR IONIZATION

The electrical conductivity of the air is related to The size and mobility of its ions are divided into
the presence therein of particulate carriers of elec- small (light), medium (intermediate) and heavy or
tric charges. Modern research has shown that crucial very slow (Langeven ions) cleave to particulate mat-
to the electric state of the air have its ions. ter and so-called eitkin nuclei - Table. 2.
Ionizer air environment are natural and artificial
6.3.1. MAIN CHARACTERISTICS AND origin. Natural are: radioactive radiation from the
SOURCES earth’s crust; UV radiation; cosmic radiation; thun-
der activity; disintegration of water droplets (baloe-
Under air ionization means disintegration of gas- lectronic effect - i.e. hydroaero ionisation); for rap-
es from air environment with the release of elec- id passage of large air masses over the mountains;
trons from electrically neutral
molecules and atoms under the Mobility(cm/s/V/cm) Diameter (μm) Characteristics
Lightweight, great mobility,
influence of external factors of 3.0-0.1 0.001-0.003
short life
different nature (natural and ar- 0.1-0.005 0.003-0.03 Intermediate, slower
tificial, physical and chemical), Heavy (Langevin ions) associated
which gives electro charged 0.005-0.002 >0.03 with larger particles (dust)
particles - positive and nega-
tive. Tab. 2. Characteristics of ions - mobility diameter
Ionization requires the transfer of energy - ener- sand (disintegration of particulat,e matter) and
gy ionization (Vi), and is expressed in electron volts air storms; some plants that produce essential oils
(1 eV = 1,6.10-12 erg). The minimum energy causing and phytoncides. Artificial are highly heated metal
ionization of a gas molecule is called the critical po- surfaces (i.e. thermo electronic emission), with the
tential (Vil), which depends on the nature of the gas use of ionizing radiation in various industries and in
(Table. 1). medical practice, electric motors, copiers, monitors,
presses and others.
Critical The characteristics of the ionization of air, that
Gas composition of air
potential eV
Oxygen molecule 12.5
are important for the sanitary conditions of the air
Oxygen and hydrogen atoms 13.6 environment and its biological effects are: absolute
Nitrogen atoms 14.5 number of ions of each sign per unit volume (cm3);
Nitrogen molecules 15.5 unipolar ratio (q) - the ratio of the number of posi-
Hydrogen molecules 15.6 tive to the number of negative ions (qlight = n+ /n- and
Tab. 1. Critical potentials qheavy = N+/N-); ion indicator of air pollution (the ra-
tio of the number of heavy to the number of light
The easiest process of ionization is carried out at ions); the relationship of the ionization of air with
these gas components which have the lowest ener- other parameters of the air environment - weather
gy of binding. In the atmosphere it is the molecule complex gaseous and particulate pollutants, antro-
of oxygen. potoxins, vegetation, ozone - ion state.
In the ionization of air primary molecular ion
the s-6 form stable secondary so-called light ions. 6.3.2. IONIZATION OF THE AIR
Light ions carry an elementary electric charge ENVIRONMENT OF INDOOR AND OUTDOOR
(eo = 1,6.10-10 coulomb (C)). Light ions at normal hu-
midity represent a complex of an ionized molecule, Normally the number of ions in the ground layers
and 4-12 polarized molecules of water. The most of the atmosphere is about 400-500 for positive and
typical are: H+(H2O); O-2 (H2O); O-3 (H2O); OH-(H2O); 400 negative (according to other sources respective-
H3O+ (H2O); CO-4 (H2O) – n ranges from 4-8. Air nitro- ly 1,000 and 3,000 pairs in cm3).
gen does not form a stable positive ions. The air in the mountains is clean (free of dust
and gaseous pollutants) and has improved airi-

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 LABOUR MEDICINE
shops and underground sites with full recirculation
of air, reduces the amount of ozone - a factor for air
ionization.
In the air mainly contain light negative ions of
ozone and positive - nitrogen. After the irrigation
chamber of climate systems, ozone ions decreased
71 times, and nitrogen - 6.3 times. A major share
of light ions in these rooms are ions of water vapor
(H2O-, H2O+). In residential premises without air con-
ditioning ozone ions also decreased - 10 to 30 times,
and nitrogen (NO+) - 3 to 5 times. Unpleasant sub-
jective sensation at low concentrations of air ions or
deionized air environment are not due only quanti-
tative but also qualitative changes in the ionic com-
Fig. 1. Ionization of airspace position (in their chemical nature) and is considered
oned characteristics. In residential and especially more appropriate to monitor the impact of the so-
in the industrial areas, the number of positive and called ion-ozone mode of the premises (i.e., and the
heavy ions strongly increased. This is related to the concentration of ozone).
availability of large amounts of water vapor and air
pollutants (Fig. 1). In the free atmosphere near the 6.3.3. BIOLOGICAL EFFECTS OF
Earth always has an excess of positive ions and the AIR IONIZATION
coefficient of unipolarity is slightly above 1.0, at 1.22
to 1.5 in resort areas, but in industrial centers it may Biological effects under natural conditions.
reach 4-6. Epidemiological studies found that some people
Found direct dependence on the degree of ion- develop specific responses to weather conditions
ization of air with temperature and humidity and when ion concentration is amended sharply and
reverse to atmospheric pressure - reduced atmos- significantly in the so-called “bad” winds as Sharaf
pheric pressure and increased air temperatures con- (Middle East), Sirocco (North Africa), Saint An (West-
tribute to increase the release of radon (222 Rn) from ern USA), foehn (Europe). It was also at that time in-
Earth. Larger quantities of heavy ions in the fall, as- creased crime, suicides, road accidents, accidents at
sociated with increased relative humidity and lower work - i.e. “serotonin syndrome”.
speed of air currents (windlessness). Observed conditions are associated with the total
Light ions are more in good visibility and winds, increase in the concentration of ions and particularly
and reduced in fog, high humidity and air currents positive 24-48 h before the advent of “bad” wind. At
from the mainland (in coastal regions) - except in that time, 30% of people develop particular symp-
industrial areas where the wind carries heavy ions toms: nausea, migraine headaches, blood flow in the
and nuclei. Heavy ions decrease with altitude. Light head, palpitations, anxiety, intestinal hyper-peristal-
ions are growing in conditions of air in high trees, sis. These symptoms are more pronounced in older
particularly one that emits phytoncides (eg. siberian people and women to form three main syndrome:
and white fir). serotonin excitable syndrome (increasing the con-
Smoking adversely affects aeroioning composi- centration of serotonin); adrenaline exhausting syn-
tion of the air. When smoked one cigarette increas- drome (diminished adrenal function) and syndrome
es the concentration of heavy ions, and decreases thyroid gland hyper function. In conditions of nat-
intermediats, with both positive and negative sign. ural ecosystems, however, it is difficult to precisely
Ion indicator of pollution increases 4.5 times. determine which of environmental factors in these
The nature of the ionization of air in residential situations is a priority.
rooms and public buildings is significantly altered Biological effects in experimental studies with
by his conditioning. Light negative ions in the rooms laboratory animals. Conducted studies have found
are twice more than in ambient air and light positive various effects of air ionisation such as reduced
retain concentration. Filtration and humidification, mortality in mice infected with influenza virus after
however, increase the coefficient of unipolarity. The prolonged exposure (48-72 h) with negative light
transport of the air ducts decreases the concentra- ions and back, under the action of positive ions; ac-
tion of ions (ions recombination), and also increas- celerated wound healing with negative ionization
es the coefficient of unipolarity. Heavy ions in the of air, also increasing the amount of total protein
presence of people grow 2-3 times. In windowless and alpha-globulins in blood serum; increase the

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 OCCUPATIONAL MEDICINE
regenerative ability of the liver tissue on exposure (“clean” rooms). In conducting bipolar ionization (up
to ionized air of experimental animals with induced to 5-6.103 pairs cm3) subjective symptoms and func-
carcinogenesis; decreased EEG activity during con- tional changes are less pronounced and morbidity
tinuous action of positive ions; reduced oxygen is reduced.
consumption, reduced partial pressure of oxygen in Effects observed in unipolar ionization can be ex-
the muscles and the uptake in liver tissue in the ac- plained by changes in natural immunity; in strength-
tion of high concentrations bipolar air - 1,8.105 cm3 ening bactericidal (barrier) function of the skin; re-
and coefficient of unipolarity 0.88; increasing con- duction in air microflora.
centrations of blood glucose, pyruvate and lactate Aeroionization and air quality protection. Aer-
in blood serum in the effect of positive ions at high oionic state of air has a certain relation to microbial
concentration - 5.105 cm3 and the like. characterization of the air environment. It is known
Biological effects in experiments with volun- that air ions possess bacteriostatic and bactericidal
teers. Surveys were conducted in varying degrees effect - with the use of artificial ionization in weaving
of air ionization (ions from one sign; doses - optimal, sheds the number of microorganisms is 2.5 times
high and ultrahigh; deionized air), created in special smaller and 2-3 times lowered the number of staph-
chambers with options for dosing and thermal com- ylococci, streptococci and fungal microflora.
fort. Bipolar ionization - 5-6.103 cm3 and q-1,2-0,8, lead
It has been found that de-ionised air leads to fluc- to changes in gas composition of indoor air electron-
tuations in titer of lysozyme and diminished of the ics - ozone and nitrogen oxides exceed the MAC. Ar-
phagocytic activity of neutrophils in saliva, changes tificial ionization, however, in rooms with dust-sepa-
in hemogram. rating and inadequate ventilation (extraction of the
Was established antagonism in effects of ions in dust), leads to a 50-100 rate increase of the suspended
physical activity - in positive increases oxygen debt, substances in the air, thereby increasing significantly
pulse rate, systolic pressure. The continued impact the dose dust entering the body. Also artificial ioniza-
of positive ions is adversely affects the self confi- tion increases the toxic properties of the substances.
dence and performance. Mechanism of action of air ions. Roads for pen-
When studying subjective reactions to negative etration of air ions in the human body are inhalation
ionization, back establishes that supports relaxation and dermal. In lung, besides gas and water exchange
of the body - reduces fatigue and improves mental takes place and electro exchange of electric charges.
state (according to some authors "causes mental This connects the primary effect of air ions - chang-
and emotional upsurge “). Saturation of the air with es in the electrical properties of the blood, and the
negative ions reduces complaints of shortness of secondary action is explained by transport of electro
breath, headache, heaviness in the heart area, im- charged colloidal systems to tissues. Along with this
proving quality of attention, visual-motor response electrohumoral mechanism exists and neuro-reflex.
- a total mental activity. Electric load bearing gas atoms irritate the nerve
In real working conditions among staff to mon- receptors and nerve impulses reaching the centers
itor complaints of headache and temperature sensi- in the cerebral cortex form appropriate biological
tivity exacerbated by the impact of positive ions. In response. Other studies biotropic effect of ions lies
rooms with an air conditioning describes increased in the effects of electromagnetic impulses arising
irritability, nervousness, headache, somnolence, of- from the irritation of the skin receptors and interore-
ten nasal catarrh, etc. disorders which may be asso- ceptors of lung. In general accept is a positive effect
ciated with the shortage of negative ions in the air. of negative ions, but it still needs further studies.
Saturation of the air with negative ions, back reduc-
es complaints of headache, shortness of breath and 6.3.4. PREVENTION OF ADVERSE EFFECTS.
weight as well as reducing the number of mistakes
at work. Aeroionic assessment of the state of air environ-
In microelectronics high psycho-sensory tension ment, hygiene standardization under natural at-
combined with static microclimate and ionized air, mospheric conditions or conditions of the working
creating conditions adversely affects the functional environment at this stage is difficult, because the
state of the nervous and cardiovascular system. In results of the studies were not sufficiently substan-
compensate aeroionic deficiency is achieved bal- tiated yet. For norms matter: the determination of
ance between the two parts of the higher nervous the minimum and maximum allowable limits of air
activity and the cardiovascular system expands the ions dosage; unipolar ratio; length of sessions and
functional reserves. Increased incidence of working the rate of application in use for treatment; type of
in radioelectronics associated with aeroionic hunger regimen - static or dynamic.

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 LABOUR MEDICINE
As a biological unit for ionization of air is recom- influence of negative ions only, i.e. it is advisable dy-
mended 8.109 negative ions, ie the number of ions namic aeroionic regime, creating conditions close to
that adult takes per day. Other recommended norms natural.
(optimal and acceptable) are light positive ions re- Studies have shown that ionization of air and has
spectively - 0,5.103/cm3 to 6.103/cm3 and negative a therapeutic effect - favorably influenced suffering
light - 0,6.103/cm3 to 6.103/cm3, with a coefficient of from cardiovascular diseases, allergic and immune
unipolarity from 0.8 to 1.2. diseases, with neurotic conditions, dyslipidemias.
Russian standards for manufacturing premises Positive results were obtained in the treatment of
using sources ionizing air (X-ray rooms, departments tuberculosis, asthma, hypertension, certain types
for physical therapy) are: minimum - a positive 400/ of sinusitis, diseases of endocrine glands, skin dis-
cm3, the negative - 600; optimal respectively 1500 eases of hard healing wounds and burns, silicosis,
and 3000/cm3 and maximum - to 8000 and 50000/ vibration disease. With regard to the number and
cm3. In cases with concentrations around and above duration of the sessions is generally recommended:
the exposure necessary control the content of ozone duration of one session of 10 to 30 min, with a total
and nitrogen oxides. dose (for medicinal purposes) from 75 to 180 billion
negative ions and duration of the course of 15 to 25
6.3.5. ARTIFICIAL IONIZATION OF AIR. days.
ION GENERATORS. There are various air ions generators using
different principles - sealed sources of ionizing
Artificial ionization of air improves the quality radiation (eg. tritium - alpha rays)*; baloefekt (hi-
of air environment - oxidation of organic matter, droaeroionizatsion); UV-rays; thermoelectric effect;
reducing suspended matter (dust and microorgan- high-voltage electric current (50/60 Hz). The latter
isms). It indicates that the artificial ionization in ad- are the most prevalent. It is necessary to them using
ministrative buildings reduces the dust to 3.5 times multiple electrodes (cathodes) and a lower voltage -
and bacterial contamination - 2-3 times. In produc- up to 8-10 kV, since the one electrode and the higher
tion premises, however, high dust and other chemi- voltages increases much emission of ozone and ni-
cal factors (gases and vapors), artificial ionization of trogen oxides. Also for even distribution of air ions
air counterproductive, adverse effect. in the room is needed fan to generator and proper
Artificial ionization of air is also a means to in- disposal of the unit - the ceiling, walls or other open
crease efficiency and immunological reactivity of space.
the organism. It is believed that short-term treat-
ment with negative ions, followed by a short posi- * Aeroionizatori using sealed sources of ionizing radiation are
tive has a more favorable effect than the continuous banned in most countries.

REFERENCES

1. Bioclimatology - Chubinskiy S.I., Moscow, Med., 1965, 113-127. (in russ.)

2. General hygiene ed. Rumyantsev G.I., M.P. Vorontsov, M Med., 1990, 76-81. (in russ.)
3. Hedge H, A. Eleftheraxis - Air ionization an evaluation of its physiological and psychological effects,
Occup. Hyg, 1982, 25, 4, 409-419.
4. Hedge A., M.D. Collis - Do negative air ions affect human mood and performance ?, Occup. Hyg., 1987,
31, 285-290.
5. Instructions on compensation aeroionic insufficiency in premises of industrial enterprises, M., MH-
USSR, 1977. (in russ.)
6. Kalburova F. - ionization of air - ecological factor, Hyg. and publ. health., 1989, 5, 104-107. (in bul.)
7. Kalburova F. - Biological effects of ionization of air, Mod. med., 1990, 1, 6-9. (in bul.)
8. Liebana E.A., J.G. Farras - Indoor Air: Ionization, in. Encyclopaedia of Occup, Health and Safety, 4th ed.,
V.II, ed. J.M. Stellman, ILO, Geneva, 1998, 45.23-45.25.
9. Marinov V., I. Angelov - Air ionization, in Medical climatology, S, Med. and phys., 1980, 130-136. (in
bul.)
10. Tocheva V. - Ionization of air, in Physical environmental factors, ed. E. Efremov, S., Med. and phys.,
1988, 245-274. (in bul.)

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 N.Mitrev, D.Tsvetkov, Zl. Stoyneva

6.4 NOISE

6.4.1. GENERAL CONDITION, BASIC measurement unit used relative intensity unit - dec-
CHARACTERISTICS AND SOURCES ibel (dB). Decibel is a unit that reflects the logarithm
(decimal logarithm) the ratio of the measured to
Objectively noise is a chaotic set of sounds, de- the reference amount of sound energy - W or pres-
void of musical properties, but the sounds are me- sure - Pa. The scale covering 0-140 dB. Increase by
chanical vibrations of elastic medium, physical form 3 dB means a doubling of sound energy: the 0 dB
of motion of the wave due to movement of particles corresponds to the threshold of normal hearing at
in the elastic medium (usually air). Noise is a subjec- a frequency tone 1000-2000 Hz, and 140 dB is the
tive sensory perception of the central nervous sys- threshold of pain. Minimum change the intensity of
tem caused by unwanted and unpleasant sounds. the noise that the human ear perceives is about 1
According to the generally accepted definition dB. The slight rustle of the trees is about 20 dB, calm
of noise is regarded as an acoustic phenomenon speech - about 40-50 dB, transport noise - from 75
(sound) that causes auditory sensation evaluated to 80 dB, the metal press or riveting machines reach
as unpleasant and adverse health. Under normal 100 to 115 dB, and pneumatic tools - up to 130-140
conditions, the sound accompanying most human dB level sound pressure.
activities is a characteristic feature of life and is one In certain dimension of sound pressure severi-
of the most effective signal systems of the physical ty of the response of the auditory organ varies de-
environment surrounding the man. Continued ab- pending on the frequency of sound. According to
sence of sound, for example soundproofed cham- the dominant sound pressure level of a frequency
ber, causes disorientation in time and space and band noise conditionally divided into: low frequen-
psycho-emotional disorders. cy to 400 Hz; mid - from 400 to 800 Hz and a high
Noise is not a new risk factor for health. It is indi- frequency - over 800 Hz. The sensitivity is at a max-
cated from B. Ramazzini in “De morbis artificum dia- imum in the frequency range of 1000-4000 hertz
triba” (1700) in copper mining, the cause of “hard of (Hz). The frequency range determines the noise con-
hearing” at miner reaching for continuous operation ditioned irritation. The more high-frequency noise
even to deafness. Before the Industrial Revolution, is, the more perceived as unpleasant and faster dam-
however, relatively few workers impacted by intense aging auditory sensation. The narrow band or pure
noise. tones (single frequency) are also more harmful to
Currently, few industrial areas no less or more hearing than the broad band noise. The lowest hear-
pronounced noise. Values apply risk of noise dam- ing threshold at a frequency of 1000 Hz.
age exists in the mining industry, mechanical engi- Depending on the change in intensity over time
neering, metalworking, metallurgy, textile industry, noises are permanent (stable) and no permanent
transport, logging and wood processing, chemical (unstable). Permanent noises are those whose tem-
industry, mechanized tillage (Fig. 1). Indicate that poral change of intensity (sound pressure level) is less
now the US 1/3 of workers in the manufacturing and than 5 dB/A. In same conditions intermittent noises
services impacted by noise levels of over 85 dB/A are more harmful than permanent. Intermitent noises
and more than 8 million workers suffer from occupa- in turn can be: impulsed - noise, composed of one or
tional hearing loss, which would require more than several sound pulses, each lasting up to 200 ms, in-
20 bln. dollars compensation for them. tensity above the background - more than 6 dB, and
Physiological and pathophysiological responses intervals - more than 10 ms; discontinuous - noise
of the body to manufacturing noise is determined alternating sudden drop in level to the background
by its physical parameters (sound pressure level, noise and the duration of the intervals is greater than
character, etc.) and individual characteristics of peo- 1 s; fluctuating - noise with continuously variable lev-
ple (age, sex, psycho-emotional status, intellectual el - differences over 5 dB, and others (“white” noise,
and cultural level). Auditory perception increasing broadband noise, tonal noise, etc.).
logarithmically of increasing the sound pressure, Hearing-related injuries are parallel to the inten-
ie stimulus intensity (Weber-Fechner law), so as a sity and length of exposure of the noise. The inten-

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 LABOUR MEDICINE
sity of the noise, spectrum and its noise exposure tion of the sounds as more unpleasant (higher and
varies too much during the work shift, which is why stronger) . After the rest auditory fatigue disappears.
a realistic assessment of the risk of disability, applies The recovery of hearing becomes advantageously
dose method or so-called equivalent noise level, ie from 1 to 24 hours after impact (but can continue in
sound energy level relative to 8 h impact. The ade- a weaker degree and up to 1 week).
quacy of dose approach is proven mainly for hear- Some authors indicate the acoustic adaptation
ing loss. Reactions to noise depends, however, and - decrease in hearing threshold by up to 10 dB, and
its information content - pleasant or unpleasant, recovery to 10 min after inreruption of noise impact.
expected or unexpected, conditions and nature of Prolonged exposure to high noise levels occurs
work (mainly psycho-sensorial or not). so-called professional ear hearing hard - profes-
sional noise damage to hearing function in which
Fig. 1. Graduated in descending row industries
there are three stages. Hearing loss is sensoneural,
with excessive noise bilateral. Concern is the sensory hair cell (cellulae
pilosae), located on the basal membrane of organ
of Corti. The initial stage is characterized by slight
but definitive lesions of sensory cells. Localization
Logging of hearing impairment in the area of high frequen-
Woodworking cies, especially around 4-6 kHz and is not noticed by
Texle industry the infured (in some cases violate the possibility of
Oil and coal
Metalworking differentiation of consonants, especially in the pres-
Public services ence of background noise). In a continuation of the
Extracon of paper noise impact occurs manifest stage with deepening
Chemical industry
Prinng & Publishing
and broadening of hearing impairment - beginning
Metalworking to 2000, then at 1000 and finally to 500 Hz. If the per-
Food industry son is not removed from noisy environments may
Engineering
Transport
develop late-stage practical and complete deafness
Furniture industry (hearing loss - 60-90 dB and more).
Producon of res and plascs Although acute overstimulation of acoustic ener-
Tobacco industry
Masonry, glass producon
gy can cause a short time irreversible hearing loss,
Electrical Industry usually in the production noise-induced deafness is
Dressmaking related to duration of exposure. Permanent hearing
Leather
deficiency occurs in the acoustic levels exceeding
6.4.2. SPECIFIC - HEARING, 85 dB, for a longer period - depending on the sound
EFFECTS OF NOISE level (Fig. 2).

Hearing impairment due to noise exposure at

work is one of the most important occupational
diseases. The effects of noise impact on auditory or-
gan may be physiological and pathological. Among
the physiological effect is masking noise or difficult
to distinguish sounds (music, speech, telephone,
sound signals) in the presence of background noise.
The stronger the masking effect at the same intensi-
ty noise in coincidence or near the frequency com-
position of noise and that of the useful acoustic sig-
nals (eg. speech - 300-800 Hz).
Auditory fatigue is a transient decrease in the
activity of auditory receptor as a result of non-con-
tinuous noise impact. The degree of hearing thresh-
old increase is more pronounced at higher intensity А Normal hearing
B and C Early stages of the disorder
noise, higher frequency and more prolonged expo- D Advanced hearing loss
sure. It occurs in the first 3-4 weeks of service in a E Late stages of violation
noisy environment and results in hearing loss, tinni- Fig. 2. Audiogram characterizing different stages
tus, whistling, feeling occupancy ears and percep- of hearing loss in noise impact

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 OCCUPATIONAL MEDICINE
Tinnitus is a condition that often accompanies tion of functional type.
professionally conditioned temporary or permanent In very intense noise possible vertigo events due
hearing loss. Described as mild to strong ringing to dysfunction of the vestibular system with transient
in the ears. Reflects irritation of sensory cells of the dizziness and gait disorder, originating a threat to
inner ear and often precedes hearing loss. Causes individual and collective security. The intense noise
irritability, anxiety, sleep disturbances, and is more causes a narrowing of the field of vision, loss of vi-
common in impulse noise. sion in darkness and in stereoscopic vision, spasm of
May and acute acoustic trauma that occurs the branches of a.centralis retinae. Established high-
when a sudden impact of very intense noise exceed- er rates of gastritis, anorexia and pylorospasm in sys-
ing the threshold of pain (explosion, shooting with temic exposure to intense noise, as a manifestation
powerful weapons and others) on unprotected ears. of autonomic dysfunction.
It is characterized by acute pain and ringing in the Noise causes increased secretion of adrenaline and
ears, hearing loss, occurs occasionally rupture of the aldosterone, changes in electrolytes with a credible
tympanic membrane, lesions of the auditory bones increase in serum calcium and magnesium and an
in the middle ear, less damage organ of Corti. increasing trend of serum phosphorus. And increas-
Synergies of noise with infrasound and vibration es excretion of magnesium and phosphate.
augment auditory effects of noise. Excess noise increases cardiovascular risk. Pre-
Many believe that any prior damage to the mid- dominant opinion of a positive correlation between
dle ear predisposes to hearing damage from noise. hypertension and noise exposure. Reliable increased
Previous damage to the middle ear, lesions in recep- serum cholesterol and triglycerides. They have been
tor system, otosclerosis, prior treatment with oto- described in experimental studies, immunological
toxic medications - antibiotics, etc., or postcomotio changes, and embryotropic action of intense noise.
cerebro astenic syndrome, increase the vulnerability The noise worsened qualitative and quantitative
of hearing. Some endogenous (uremia, uricemia) indicators of the labour activity.
and exogenous (with carbon monoxide, carbon di- In recent years (1999), some authors describe vi-
sulfide, lead, organic solvents - toluene, xylene, ben- broacoustic disease with a variety of pathological
zene, etc.) intoxications reinforce individual sensitiv- changes in flight technicians and aeronaut exposed
ity to noise. Vulnerability of hearing is significantly to noise intensity 90 dB, and low frequencies - below
higher after 40 years of age. 500 Hz, and general vibrations.

6.4.3. NONSPECIFIC - EXTRAAURAL, 6.4.4. PREVENTION OF ADVERSE NOISE

EFFECTS OF NOISE EFFECTS

Violations in the nervous, cardiovascular, endo- Guidelines for the prevention of adverse effects
crine and other systems due stressful nature of noise of noise include: programs for noise control through
form nonspecific or extraaural its effects, giving rise engineering and administrative measures and per-
to Andreeva - Galanina E.Ts. in 1957 to introduce the sonal protective equipment; conservation programs
concept of “noise disease” including aural and ex- for hearing and extraaural effects with focus on pre-
traaural effects. vention. Consideration of the actual situation, usu-
The impact of noise on the central nervous sys- ally requires the implementation of comprehensive
tem (CNS) may cause disturbances in psycho-motor preventive measures.
area (as a rule at intense and very intense noise) Programs for noise control. Engineering noise
and general disturbances in the mental sphere. The control methods include precise localization of noise
first result of impaired functional balance in CNS sources, determine the quantitative parameters of
and express themselves in difficulty simultaneously noise and analyzing its spread. The most rational
perform mental and motor activities, imprecision of is necessary a noise effect can be provided by re-
motor actions, no economical spending of energy, ducing the noise formation. Easily applicable and
changes in facial expression, laughter, speech and cost-effective measures such as: regular and ongo-
gestures. To general disruption in mental sphere ing overhaul and maintenance of noisy machines,
refer insufficient alertness, reduced willingness and aggregates and instruments; replacement of out-
initiative, feelings of insecurity and discomfort, dif- dated equipment; grinding and lubrication of the
ficult recovery after work, sleep disorders, agitation friction parts; maintenance of vehicles and their
and intolerance against others, characteristic and silencing devices; precision static and dynamic bal-
intellectual changes that some call “noise psychopa- ancing machines and engines; replacement of worn,
thy “. Establish tendon and supraosteal hyper reflec- unbalanced parts, etc.

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Due to technical features and defects in the ma- remote controlled, but is difficult in presses, ham-
chinery and equipment mentioned current meas- mers, punches, etc., requiring interrupted or contin-
ures sometimes are uneffective. Then to reduce uous manual operation.
the intensity of noise apply changes in engineering It is the encapsulation of various lightweight
design through major construction or simple solu- construction detachable and portable, where sound
tions. With good results have been the replacement isolation combined with sound absorption through
of metal parts with plastic, textolite, wood and the acoustic treatment of the inner surface of the struc-
like. Effectively reducing the clearances between ture.
mating parts by materials that increase the resist- Another type of sound barrier between the
ance and weaken vibration. Thus air-cushion of vi- source and the worker are screens, portable semi-
bration be increased by coating the vibrating surfac- fixed booths, soundproofed booths for monitor-
es with material having high friction such as rubber, ing and remote control of technological processes.
resinous substances, felt and the like. Suitably, the There have been studies on the use and so-called
replacement of large and slow to smaller and faster interference noise reduction by microphone to per-
machines, hydraulic to mechanical press, etc. ceive noise, amplifier, phase inverter and speaker.
Results were obtained by changing the processes Sound emitted from speaker reverse of the 180o
in a manner which eliminates the blow (welding in- phase creates a “zone of silence”. It is also possible
stead hammer, compression rather than stamping, acoustic noise reduction using placed in the air-
unshuttle weaving machines, and so on) or reduce space bodies of different geometric shape.
the number and power of the blows. Suitable planning, urbanization and architec-
Limiting noise is possible by absorbing (acous- ture to prevent the spread of noise to less noisy
tic) materials and structures such as mineral wool, rooms through rational planning of the production
some highlyporous materials, swelled perlite, cer- building. Creation of premises soundproofing is
amist, vermiculite, frothy fabrics of high-molecular greater as a massive wall and higher frequency of
compounds, soft porous woody-fiber boards and noise. This law for the mass can be changed in order
others. to improve fuel economy by a double wall with an
Sound absorbing structures are combinations
of sound absorbing material and protective and Brick wall 22 cm cement of 1.5 cm
decorative coatings - perforated gypsum, plywood, Block of gypsum and slag cement (11 cm thick)
woody-fiber, plastic, metal and other plates or pan- Wood- 10 cm cement of 1.5 cm
els. The lining of the premises with acoustic material Block of plaster 10 cm

is economical and effective method primarily with

respect to high-frequency noises.
The noise emitted by pneumatic tools, compres-
sors, blowers and the like, can be isolated with si-
lencers - active and reactive. Complicated reactive
silencers based on the principle of the acoustic fil-
ter, are more effective against low-frequency noise. Window glass A wall of concrete
with a 3 mm
Active filters absorb sound energy with them ef- 20 cm cement of 1.5 cm
Window with double A wall of concrete 14 cm
fectively lower high-frequency component of the glass - 4 cm distance cement of 1.5 cm
noise. The most suitable tubular mufflers that have Window with two
panes - 15 cm
Brick wall 11 cm
cement of 1.5 cm
little aerodynamic resistance. Important is the sig- 5 mm glass Solid brick 5,5 cm
nificance of vibro isolation of compressors, engines 12 mm glass cement 1.5 cm
and other units by placing them on shock absorbers
(steel springs or layers of rubber, felt, etc.), and sta- Fig. 3. Noise reduction various by building materials
and structures. Law of the mass.
ble base.
Inhibit the spread of noise is achieved by reflec- air space between the two walls (Fig. 3).
tion of sound waves from different partitions. For Noise from infactory transportation may be lim-
this purpose, so-called encapsulation with acoustic ited by a ban on audible signals, landscaping and
hoods on noise sources or using partitions, screens, asphalting the territory, construction of highways
shields and so on. For sources with high sound pow- parallel to the factory walls - barriers, earth mounds
er encapsulation is often the only effective means and others.
of suppressing noise. Encapsulation is made easier The program for noise control covers a number
with turbines, motors, compressors, diesel engines, of administrative measures to shift work, alternating
fans and other equipment, which are automated or types of activities with a view to reducing individual

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noise exposure time. It is the reduction of the dura- to impede speech and other signal-acoustic com-
tion of noise exposure and/or transforming it from munication of workers between them and the envi-
continuing in intermittent by shortening the peri- ronment; do not cause foreign body sensation and
ods of noise impact, extension and/or increasing the painful pressure in the ear; they are made of easy to
number of breaks, periodically passing to operation clean, without irritating properties materials; shape
unrelated to the noise impact. It is recommended and structure them to comply with the morpholog-
that breaks take place in a quiet room with a com- ical characteristics of the ear and skull, maximizing
fortable microclimate. Our legislation provides for
an additional six-day leave at work in conditions
of excessive noise in continuation more than four
hours a day. American authors propose a scheme
for the duration and number of periods of rest in a
quiet room to periods of noise with varying intensity

Number of cycles (period with noise and without

noise) per shift (480 min)
Duration of the rest period

Spectrum (average) in 22 type external ear muffs

Spectrum (average) in 31 type internal earmuffs

Fig. 5. Loss of noise in internal and external ear muffs

Duration of the period with noise impact adherence to them.

Fig. 4. Scheme of the duration and number of periods of In practice, use internal and external ear muffs
intense noise and rest during the work shift most varied form, structure and efficiency. The inner
(in Desoille H., J. Scherrer, R. Truhaut - 1991) ear muffs (bushings, obturators) are made mostly
of plastics or rubber, but can be successfully used
throughout the work shift - 480 min (Fig. 4). those made of cotton, mixed with wax, sponge and
Without a generally accepted, opinion exists for others. Good adhesion of ear sleeves sometimes is
beneficial effects on mental state of low-frequency more important than the quality of material used.
music with less intensity. Auditory stimuli to soften The outer ear muffs are made in the form of ear-
by proportional rhythmic contrast of color combina- phones, headset and helmets. Earphones only re-
tions of interior. duce air conduction noise and like bushings, lower
Individual protection. For protection from the mainly high frequency components. Apply at high
adverse effects of intense noise apply different types intensity noise (over 100 dB) and in cases where the
of antiphons. bushes are underperforming or hardly usable be-
The choice and use of hearing protection are de- cause of ear infections, decubitus and itching in the
termined primarily by the intensity, frequency spec- ears.
trum and nature of the acting noise, the duration In the more intense noises requires the use of
of noise exposure, microclimate conditions of the headset or helmets that prevent both air and bone
working environment and the need to maintain ver- conduction noise, but they are expensive, heavy and
bal and other acoustic communication. To justify the bulky.
production and use on their merits, hearing protec- To overcome resistance to the use of hearing pro-
tion must satisfy a number of requirements, basic of tection, often associated with an underestimation of
which are: to descend into optimum noise (Fig. 5); the risk of noise effects are required individualized
their use does not lead to a rapid sweating, macera- preparation and training for proper use. Individual
tion and infection of the external auditory canal; not tools are an important part of prevention programs

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for noise disabilities, in many cases they are only ef- the nature of work, the use of PPE may cause greater
fective mean, but they should not replace technical risk to health and safety, they can no be used.
solutions to noise sources. These normative values and BS/ISO 1999-2004
The program for the conservation of hearing and concerning the impact of noise on hearing sensitivi-
extraaural noise effects include: evaluation of the ty and appropriate prophylaxis.
worker exposure - average daily, weekly and gener- In business activities related to greater stress -
al; profpathological assessment of the risk, of setting mental work, the greater is the importance of noise
maximum noise levels for a certain period of time; as a factor inducing a state of psychic discomfort,
hearing protection; educational programs for staff. decreased work capacity and leading quickly to fa-
Sparing hearing programs apply to all workers in tigue. In Decree № 6 MH and MEW in 2006, for indi-
noise over 85 dB/A, used accordinaly noise charac- cators of environmental noise, taking into account
teristics. The intervention includes multicomponent the degree of discomfort indicates that limits noise
educational strategies and features of storing indus- - equivalent level for consulting rooms in hospitals
trial strategy. are 40 dB/A during the day and 35 dB/A during the
Control at noisy environment. Only on the basis night; in classrooms and auditoriums in schools,
of systematic analysis of the parameters of the noise reading rooms, facilities for research - 40 dB/A. (day
made by means of precision instrumentation and and night); workplaces in office buildings - 50 dB/A
detailed knowledge of the origins and causes of the (day and night). Here at the impact of tonal and
emergence and spread adequately possible deci- impulsive noise values are reduced by 5 dB/A. Also
sion on measures to lessen the noise, the frequency states that production and storage areas and zones
of prophylactic examinations and selection of per- limits are 70 dB/A (day and night).
sonal protectors. Dose investigations with the use of Medical control. In our country these contrain-
individual dosimeters precise data on noise loading. dications apply to work in conditions of intense
Risk assessment for hearing loss induced by pro- noise: permanent hearing loss regardless of etiol-
duction noise offers standard ISO 1999 (1990), who ogy; otosclerosis and other chronic diseases of the
relate the effect of the intensity of the noise and the ear with apparently poor prognosis; expressed dis-
total time of exposure. It is assumed that equivalent turbances in the function of the vestibular appara-
(about 8 h) noise level of 85 dB/A and less, will no tus irrespective of the genesis; expressed autonomic
damage auditory sensitivity at 95% of influenced dysfunction; organic diseases of the CNS, including
persons for period of impact over 30 years (whole epilepsy; neuritis and polyneuritis; mental illness
service). BS 14478-82 allowed noise at work places and psychopathia; diseases of the cardiovascular
also up to 85 dB/A (equivalent level). system (hypertension, coronary heart disease, angi-
Since 2006 (Decree № 6 of MH and MLSP) the na pectoris and hypotension); ulcers of the stomach
minimum requirements for ensuring the health and and duodenum in the acute stage. In conducting
safety of workers from the risks related to exposure audiometric testing to establish the state of audito-
to noise as hygiene standards is introduced con- ry adaptation. The more pronounced is the increase
cepts exposure limit values and exposure limits. in the auditory threshold after noise loading (direct
Exposure limit values is Lex.8h = 87 dB/A at mo- adaptation), the higher the resistance to noise; more
mentary peak sound pressure (P peak) - 200 Pa or convincing indicator however, for resistance to noise
140 dB/A. is readaptation (recovery time of hearing threshold
Upper exposure limits for action is Lex.8h = 85 to baseline).
dB/A at P peak - 140 Pa or 137 dB/A. Mandatory screening of risk contingents aimed
Lower exposure limits for action is Lex.8h = 80 at early diagnosis of noise disability. In Bulgaria was
dB/A at P peak - 112 Pa or 135 dB/A. adopted in carrying out their compulsory participa-
Upon exposure limits actual exposure of workers tion ENT specialist and a neurologist, at indications
report with noise reduction used personal protec- - and therapist and gynecologist. In excess of the
tive equipment, ie allowed in noisy proceedings in limit of not more than 20 dB is conducted every 24
mandatory use of PPE impact of noise intensity Lex months, and over 20 dB - 12 months in compulsory
.8h
= 87 dB/A. audiometric testing and electrocardiogram - at in-
Exposure to noise greater than Lex.8h = 80 dB/A, dication. Audiometric changes in hearing threshold
workers also provide personal protective equip- over -15 dB impose measures to prevent further de-
ment, while Lex.8h = 85 dB/A PPE now they should terioration of auditory function, adequate therapeu-
be used. tic behaviour and monitoring of audiometric status
It is not permissible noise exposure above the lim- of the worker.
it values (87 dB/A). Only in exceptional cases where

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REFERENCES

1. Andreeva-Galanina, E.Ts. etal., Noise and noise disease. L., Medicine, 1972. (in russ.)
2. Angelova M., Production noise, in. Physical factors of the environment ed. E. Efremov, Med. and phys.,
Sofia, 1988, 108-124. (in bull.)
3. BS ISO 1999: 2004. Acoustics. Determining the impact of noise at work and assessing the damage to
hearing caused by noise. (in bull.)
4. Castelo Branco N.A.The clinical stages of vibroacoustic disease. Aviat Space Environ Med 1999 Mar;
70 (3 Pt 2): A32-9
5. Decree № 6 of MLSP and MH on the minimum requirements to ensure the health and safety of workers
from the risks related to exposure to noise. SG. 70, 2005 (in bul.)
6. Decree № 6 of MH and MEW on indicators of environmental noise, taking into account the degree of
discomfort, limits, methods for assessing the parameters for noise and harmful effects of noise on human
health. Bulletin of the Ministry of Health, № 11 2006 (in bul.)
7. Desoille, H., J.Scherrer, R.Truhaut. Precis de medicine du travail. Ambiance sonore. Masson, Paris,
1991, P, 1119, 154-162.
8. Dimchev D., At. Gyulev N. Mitrev. D. Simeonova, B. Simov, D. Stamatov - Noise as a factor of the
living environment, Plovdiv, Hr. Danov, 1976, 160. (in bul.)
9. Dobie, R.A. Noise. In: Physical and biological Hazards of the Workplace. Eds. P.H Wald, G.M Stave, Van
Nostrand Reinhold, NY, Albany. Etc., 1994, 215-224.
10. Infrasound, ultrasound, noise and vibrations - ed. D. Tsvetkov, M. Angelova, Med. and phys., Sofia,
2007, 280. (in bul.)
11. Malinskaya N.N., G.A. Suvorov, L.N. Shkarinov - Noise, vibration ultra- and infrasound. in Guide for
labour hygiene, V. I Med., Moscow, 1987, 168-204. (in russ.)
12. McCandless G.A, G. Butler. Noise. In: Environmental and Occupational Medicine, Ed.W.N Rom, Little,
Brown & Co, Boston, 1983, 707-718.
13. Mocci F., Canalis P., Tomasi P.A, Casu F, Pettinato S. The effect of noise on serum and urinary mag-
nesium and catecholamines in humans. Occup Med (Lond) 2001 Feb; 51 (1): 56-61.
14. Olishifski, J.B. Industrial noise. In: Fundamentals of Industrial Hygiene. ed. B.A. Plog., National Safety
Council, NY, 1988, 163-203.
15. Sulkowski W., Kowalska S., Lipowczan A., Prasher D., Raglan E. Tinnitus and impulse noise-in-
duced hearing loss in drop-forge operators. Int J Occup Med Environ Health 1999; 12 (2): 177-182.
16. Suter, A.H. The Nature and Effects of Noise. In: Encyclopedia of Occupational Health and Safety, ed.
J.M.Stellman, 4th ed., International Labour Office, Geneva, 1998, 472-475.
17. Suvorov G.A., L.N. Shkarinov, E.I. Denisov. Nygienic standartisation production noise and vibration
- Med., Moscow, 1984, 239. (in russ.)
18. Thompson S.J. Review: extraaural health effects of chronic noise exposure in humans. Schriftenr Ver
Wasser Boden Lufthyg 1993; 88: 91-117
19. WHO. Environmenatl Criteria, Noise, Geneva, 1980.

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6.5 INFRASOUND

A powerful subsonic wave generated by Per- 6.5.1. EFFECTS OF INFRASOUND

buatan volcano on the island of Krakatoa was de- ON THE BODY
scribed in 1883. Later, during First World War were
created infrasound detectors guns. More systematic It is believed that infrasound is irritant receptors
research in the 30 years of the twentieth century to at organ of Corti, vestibular system, Vater-Pacini skin
infrasound phenomena relate to their many natu- receptors. In phenomena of resonance and stimu-
ral sources - earthquakes, volcanic eruptions, hurri- late pain receptors in the internal organs, intero- and
canes, sea waves, storms and strong winds, water- proprioreceptors, mechanoreceptors are activated
falls, landslides avalanches, demolitions, blowing in different autonomous neural and neurovascular re-
the wind buildings, trees, bridges, etc. flex mechanisms. Allowed and auditory detection of
Objectively infrasound and noise have the same infrasound, without this constituting a real hearing.
physical nature with different frequency response. Probably from the middle ear are perceived periodic
Infrasound represents mechanical oscillations and pressure changes caused by infrasound.
waves of elastic medium in the frequency range When it comes to the mechanisms of the biologi-
between 0.1 and 20 Hz, which is lower than the cal action of infrasound, utmost importance is given
minimum audible frequencies perceived by the hu- to induced resonance - coincidence of infrasound
man ear as an acoustic signal. The features of infra- frequencies with the natural frequency of some or-
sound waves are spherical forme and amplitude of gan is irritate its inter- and proprioreceptors which
the wave. Their distribution is low absorption, and information is transmitted to the nerve centers. Res-
therefore can travel large distances. Moreover infra- onance of internal organs is infrasound at a frequen-
sound waves bypass the barriers that stop noise and cy of 2-8 Hz, and head - about 17-25 Hz (Fig. 1). It is
ultrasound, and easily penetrate into the premises established the interaction between the frequency
because they expressed diffraction phenomenon. of brain alpha rhythm in humans and frequency of
The latter is all the more manifested, the greater is infrasound emitted by marine and ocean waves. In-
the wavelength. Characteristic of infrasound waves tense infrasound at a frequency of 7 Hz, coinciding
are and their resonant manifestations that are capa- with the frequency of alpha rhythm brain, is very
ble of causing vibration of large objects. dangerous, even deadly. Some authors, depending
There are numerous art manufacturing technical on the intensity and the frequency characteristic of
sources of infrasound: compressors, turbines, blast infrasound define “zones of danger/safety” (Fig. 2).
and rotary furnaces, industrial fans, excavators, bull- Adverse psycho-physiological effect is reduced
dozers, cranes, pneumatic tools, means of transport work capacity directly dependent on the intensity
(trains, planes, buses, trucks, ships), acoustic warn- and length of exposure to infrasound. Infrasound
ing devices (sirens), space equipment and others. acts directly on the nuclei of VIII and X CBN and in-
Intense infrasonic waves also arise in chemical and directly on other organs and systems. Described are
nuclear explosions. weakening auditory sensitivity, balance disorders,
Designed are: subsonic steams (France) for heat nystagmus, worsening the parameters of attention,
demonstrators, which generates five miles infra- the accuracy of movement and orientation. The
sonic field, causing severe pain and vibration to the impact of infrasound at a frequency of 20 Hz for 8
human body; subsonic projector (USA), damaging minutes and intensity up to 144 dB causes unpainful
vision and causing a feeling of fullness and fear. pressure in the middle ear, which relieves by the test
There are infrasonic generators for ore dressing, of Valsalva or termination of exposure. Morphologi-
cleaning vegetables and metallic and synthetic fil- cal changes in the receptor cells of the three semi-
ters, studies of geological structures and others. circular canals and of the inner hair cells of the spiral

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Fig. 1. Own (resonant) frequencies of the human body:

1-head (20-30 Hz); 2 - eyes (40-100 Hz); 3-vestibular system
(0,5-13 Hz); 4-heart (4-8 Hz); 5-vertebrae (4-6 Hz); 6-stomach
(2-8 Hz); 7-intestine (2-4 Hz); 8-kidney (6-8 Hz); 9-hands (2-5
Hz)

death zone death zone

very dangerous area zone of potential danger

trying area

danger zone
area of psychophysical disorders

zone of potential occurrence

of psychophysical disorders
lack of obvious reactions

safe area

(by A.Stan, 1974) (by E.N.Malishev, 1979)

Fig. 2. Areas in danger of infrasound impact

canal after the subsonic exposure were observed by tion and vibration of internal organs (liver, stomach,
electron microscopy, with reversible changes in the spleen and chest wall), difficulty breathing, decrease
endoplasmic reticulum and mitochondria. in visual acuity, increase auditory threshold, tinnitus,
Biometric indicators for infrasound biological impaired speech intelligibility and others. The res-
effects, of exposure to infrasound - parameters 4 onance range of brain structures between 5 and 9
Hz and 130 dB, in show prevalence of general re- Hz, makes these frequencies especially noxogenics.
sponses of the human body. Infrasound waves with Upon impact of infrasound allow participation of
intensity above 100 dB cause headache, pallor, nau- limbic-reticular complex, hypothalamus and other
sea, weakness, fear, increased sweating, feeling fric- subcortical structures with sensomotor and auton-

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omous visceral symptoms. Infrasound is a stressor. ding is minimal. Better are reactive silencers range in
It impairs the functions of the pituitary, thyroid and subsonic spectrum. Deployment of sources of infra-
gonads. The intense infrasound change frequency sound in separate and isolated areas may also give
and the rhythm of cardiac contractions with tachy- a certain result. Vehicles to be as distant as possible.
cardia in the beginning and bradycardia after. Also It takes frequent (at least once a year) meas-
disclosed is a peripheral vasodilatation with increase urements of infrasound level and good technical
in skin surface temperature and reduced systol- maintenance of machinery and vehicles. Different
ic blood pressure. In the experiment established, authors offered, and in some countries there are
however, spasm of peripheral vessels and increases very different levels of infrasound. Nixon C.W. rec-
blood pressure in unchanging values of the pulse. ommended level of 120 dB at a frequency of 20 Hz,
Studies of the effects of infrasound at a frequency with an increase of 3 dB for each subsequent lower
of 8 and 16 Hz with a intensity of 120 to 140 dB in frequency octave (16-1 Hz). In short duration (up to
3 hours a day for 1 to 40 days established an in- 8 min) recommended up to 150 dB for frequencies
creased functional activity of the myocardium and 1-7 Hz; 145 dB-8-11 Hz and up to 140 dB-12-20 Hz.
absence of destructive changes. The acute effects Hygiene standards in Russia (1980) indicate values
of infrasound (frequencies 6, 12, 16 Hz and intensi- up to 105 dB for the range of 2-16 Hz, 102 dB-31,5
ty 95, 110, 125 dB (lin) in the experiment at people Hz and total infrasonic pressure - 110 dB. Similar
establish reliably increase in diastolic blood pres- regulations in Poland and Sweden, and in Norway
sure and the decrease in systolic without changes in general infrasonic levels up to 120 dB for 8 h shift. In
heart rate. This suggests peripheral vasoconstriction psycho-sensorial labour (CP, administrative offices,
with an increase in blood pressure, thus allowing the design offices) and residential buildings offer lower
influence of chronic infrasound exposure at predis- levels - 80-90 dB (Poland).
posing to hypertension people. In the system of prevention find a place and a
Infrasounds and noise inhibit contractility of the number of medical measures. In preliminary medical
lymphatic vessels. examinations are recognized contraindications for
A combination of subsonic impact to that of elec- work in the sphere of intense infrasound impact:
tromagnetic fields, noise, vibration, ionizing radia- the vestibular and hearing violations, expressed
tion, biological effects are enhanced. neurotic conditions, autonomic dysfunction, organ-
There are publications that do not show chang- ic changes in the central nervous system. In annual
es in behaviour of exposed to noise and infrasound medical examinations attention focuses on the con-
in aviation and are considered unreliable opinions stellation of subjective symptoms (headache, fa-
about behavioural changes in exposed human and tigue, dizziness, weight, sleep disorder, unmotivat-
manifestations of nystagmus. ed fear, etc.) and objective data on changes in the
vestibular and auditory, nervous and cardiovascular
6.5.2. PREVENTION OF ADVERSE EFFECTS system. The establishment of these changes require
appropriate vocational rehabilitation. In the periodic
Prevention adverse effects of infrasound is diffi- medical examination of the risk contingent involved
cult, due to these characteristics. Antiphons create neurologist, ENT specialist and internist (Decree №
weak protection. The most promising way is to re- 3/1987, the Ministry of Health).
duce infrasound through structural changes in the Relatively good results are obtained and ration-
sources - machinery, equipment, tools, vehicles. The al regime of work and rest (20-minute rest in a quiet
effect of efforts to reduce the level of infrasound in room every 2 hours). It is also periodically endan-
the way of its distribution through soundproof en- gered stay in prophylactic places and sanatoriums
closures and housings and sound-absorbing clad- in ensured conditions for recreation.

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REFERENCES

1. Angelova M., - Infrasound. in Physical environmental factors - ed. E. Efremov, Med. and phys., Sofia,
1988, 152-157. (in bul.)
2. Harris C.S., Sommer H.C., Johnson D.L. Review of the effects of infrasound on man. Aviat. Space En-
viron. Med., 1976 Apr; 47 (4): 430-4
3. Hygiene standards of infrasound of work places № 2274-80, MH-USSR, 1980. (in russ.)
4. Ising, H. Psychological, ergonomical and physiological effects of longterm exposure to infrasound and
sound. Mat. Conf. “Sound & Vibration”, 1980, Bulgaria, 168-174.
5. Izmerov, N.F., G.A. Suvorov, N.A. Kuralesin, V.G. Ovakimov. Infrasound: body effects and hygienic
regulation. N. Russ. akad. med. scien, 1997; (7): 39-46. (in russ.)
6. Karpov, N.I., Z.N.Malshev. Low frequency acoustics fluctuations in production. M., Medicine, 1981,
192. (in russ.)
7. Nekhoroshev, A.S. Investigations on mechanisms of effects low frequency acoustical vibrations. Med.
lab.prom. ecol. 1998; (5): 26-30. (in russ.)
8. Nikolaeva D., Iv. Paunov - Infrasound. in Infrasound, ultrasound, noise and vibrations - ed. D. Tsvetkov
and M. Angelova, Med. and phys., Sofia, 2007, 11-43. (in bul.)
9. Pawlaczyk-Luszczynska M. Evaluation of occupational exposure to infrasonic noise in Poland. Int. J.
Occup. Med. Environ. Health, 1999; 12 (2): 159-76
10. Tempest, W. Infrasound and low frequency vibration. London, Academic Press, 1976.

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 N.Mitrev, D.Tsvetkov

6.6 ULTRASOUND

The term “ultrasound” means those mechanical ophoresis), obstetrics and gynecology, neurology,
oscillations whose frequencies exceed the limit of ophthalmology (eg. for the treatment of cataracts),
perception by the human ear*, namely those in the dentistry (for removal of tartar) and the like.
range from 20 (16) Hz to 1 GHz. The frequencies in A number of noise sources in production and
the range above 1 GHz is designated as hypersound transport are both generators and of ultrasonic fre-
(1-100 GHz). In nature, ultrasound is generated by quencies - pneumatic tools, turbines, plasmotronics,
earthquakes, volcanic eruptions. Many animals, compressors, textile machinery (in rotation spin-
mostly inhabiting the underground (caves) and un- dles), gas burners, jets and more. In hygienic assess-
derwater or at night, produce and perceive ultra- ment of the risk of damage than the ultrasound in-
sound - birds, rats, bats, dogs, fish, etc., for exchange tensity (measured in dB with a reference level 2.10-5
of information or echolocation. Eg. dogs perceive Pa or W/m2) and spectrum, matter and conducting
ultrasonic frequencies up to 44 kHz, bats - 115 kHz, ultrasonic oscillations in different environments. In
rats - 72 kHz. this aspect talk about air and contact ultrasound. Air
Although relatively new source of energy, multi- absorbs ultrasound. Therefore, the risk for harmful
ple properties of ultrasound determined its widely effects of ultrasound by air is more limited but not
used for industrial, medical and scientific purposes. negligible. The higher is the frequency of the ultra-
The first attempts to use are associated with Paul sound waves, the higher the rate of absorption of
Langevin (1918) - during the First World War for the the air environment.
purpose of hydrolocation. Sources of this type of Conversely, the ultrasound waves are conducted
mechanical fluctuations are varied ultrasonic sirens, better in a liquid medium (water, biological fluids)
magnetostrictive and piezoelectric transducers and and spread easily from water in biological fluids. In
others. Ultrasound is applied for cleaning and pro- such cases, talk about the impact of contact ultra-
cessing of hard materials and plastics, for the drying sound. The degree of penetration and conduction
of fine powders, preparation of emulsions, ultrason- the ultrasound in biological tissues depends on their
ic fault detection, in hydrolocation and many others. structure (type) and functional status and is greater,
In medicine (Table. 1) ultrasonic equipment is used the lower is its frequency. Attenuation constant α/in
for both diagnostic and therapeutic purposes in sur- Np/m/ for ultrasound at a frequency of 1 MHz is: air -
gery (eg. lithotripsy), gastroenterology, cardiology, 15; water - 0.02; liver - 8; fatty tissue - 5-25; blood - 2;
angiology, urology, physical therapy (eg. drug ion- skeletal muscle - 10-35; bones of the skull - 115.

Tab. 1. Medical ultrasound equipment - characteristic (C.R.Hill, 1989)

Spatial - Spatial -
Frequency Area Coefficient of Average temporal peak
range source power temporal variations
Apparatus - kind efficiency intensities in pressure
(MHz) (mm2) (mW) (kW/m2) (MРa)*.
Diagnostics
Pulse-echo (pulsed 1-20 100-3000 0,001 0,01-80 1-10000 0,1-7,4 (+)
Doppler) 0,1-3,9 (-)
Permanent Doppler
stomach / 2-4 100 1 5,0-240 200-18000 0,01-0,11 (±/
heart vessels 5-10 100 0,01-1 0,01-40 30-19500 0,003-0,12 (±)
Treatment
permanent 0,75-3 500 1 0-15000 0-100000 0-0,25 (±)
pulsatile 0,75-3 500 0,2 0-3000 0-20000 0-0,25 (±)
* Positive (+) or negative (-) relative to the mean value

* According to various surveys the lower limit of auditory perception is 5-16 Hz, and the upper - 16-25 kHz. These limits depend on
the age, individual characteristics, methods of research. For practical purposes (audiometry) set thresholds of audibility for tones
with frequencies above 12 kHz is also without relevance - very high and variable values

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6.6.1. IMPACT OF ULTRASOUND ON THE fluids and high vapor pressure in them. Cavitation
HUMAN BODY occurs in intensity of ultrasound over 0,3 W/cm2,
there is a strong destructive (mechanical) effect and
Arises from the ultrasound biological effect de- is considered that it provokes and chemical effects
pends mainly on the intensity, frequency and dura- - formation of new compounds (eg. hydrogen per-
tion of impact. Low-intensity ultrasound in the range oxide) and a free radical. In intensity of ultrasound
of 80-90 dB influence stimulating (positively) on over 1 W/cm2 the resulting electrical potential is
the body, while high intensity (120 dB) is negative, comparable to that of cell membranes and induced
harmful effects. The low-frequency ultrasound pro- depolarization change their electoral permeabili-
duced effects similar to those of the noise. High-fre- ty. Ultrasound with the suitable power there is and
quency ultrasound induces changes similar to those thermal effect - eg. This effect is used in the treat-
of radiofrequency electromagnetic radiation or ex- ment of malignancies (destruction of cancer cells by
traauralic noise impacts. hyperthermia - 42-45˚S), or in physiotherapy.
The pathogenic action of ultrasound can be Biological action of ultrasound has been found
explained by four main and interrelated effects: in studies on: isolated biomolecules, cells, tissues,
mechanical, thermal, chemical (biochemical) and multicellular organisms (plants, insects, mammals),
electrophysical. The mechanical effect is associated epidemiological studies in humans (Table. 2).
with both mechanical stress of intense ultrasound In humans, pathogenic action of ultrasound is
perceived by mechanoreceptors and the phenom- explained mainly by caused the mechanical and
enon of “cavitation” - the formation of small bubbles thermal effect, occurring disorders in tissues in
(diameter in micrometers) in water and biological the form of inflammation, heromagiya, denatura-

Tab. 2. Biological effects of ultrasound

Object Biological effects / mechanisms
1. Isolated molecule - DNA - 1. rupture and destruction / cavitation
solution 2. genetic changes have not been established
2. Isolated cells and cell cultures 1. demolition / cavitation
2. unaffected cell proliferation / without cavitation
3. greater influence in mitosis and relative resistance after mitosis / cavitation

- Genetic effects 1. chromosomal aberrations in joint action on X-rays and ultrasound

2. lymphocytes and lymphoblasts - no comfirming data on chromatid

exchanges (mutagenesis)

- Structural changes 1. nonlethal changes - in the cell membranes of tumor cells, thymocytes,
endothelial cells / cavitation, electric potential
2. changes in mitochondria, and destruction of lysosomes, cell death / cavitation

1. changes in membrane permeability

- Functional changes 2. the inhibition of motor function in aquatic microorganisms
3. boost: protein synthesis in fibroblasts; restoration of bone structure;
angiogenesis in ischemic tissue / non-thermal and nocavitation mechanisms

3. Multicellular organisms 1. no evidence of gonadotrophic and embryotropic action in single doses

under 7,5 kW/m2 (non-thermal action)
- mammals 2. prolonged exposure - reduced fetal weight and increased mortality

3. ocular lesions - cataracts, in intensity from 30-400 W/cm2 and

1-9,8 MHz frequencies
4. stimulate: blood flow in the vessels; tissue regeneration

- insects 1. not established mutations in the gene apparatus of Drosophila melanogaster

2. the increased mortality of larvae of Drosophila in intensity over
100 kW/m2/cavitation, heat above 42°C

- plants 1. destruction of cells, tissues, chromosomes in the intensity of more than

3 kW/m2, more strongly manifested effects of cavitation

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tion, necrosis, but there are reflex mechanisms and sonic transmitting on arms. Standards ACGIH (1999)
changes in hormonal regulation due to other effects indicate levels of: 88 dB - 10 kHz; 89 dB-12,5 kHz; 92
- chemical, electrophysiological. As adverse effects dB-16 kHz and 94 dB-20 kHz, also for 8 h exposure
of ultrasound waves concern astheno-vegetative and threshold of 105 dB for this range. If ultrasound
syndrome, hypothalamic syndrome, vestibulopaty, is narrowband (tonal) subjective discomfort can be
lower visual acuity and changes in peripheral vi- obtained at levels of 75-105 dB for frequencies 10-
sion, vasomotor instability, dysesthesia, paresthesia, 20 kHz and must be taken measures for hearing pro-
gastrointestinal dyskinesia. There is evidence of ab- tection and engineering solutions. To contact ultra-
normal biochemical parameters (protein fractions, sound are offered values of 110-115 dB at range of
enzymatic changes), blood changes - transient eo- 25-100 kHz (all these values for air and contact ultra-
sinophilia, decreased blood pressure and others. sound are at Po-20 μPa). When working underwater
Furthermore, the presence of ultrasounds in the thresholds for ultrasound are 167-177 dB at range of
mixed industrial noise sensitize the inner ear and 10-100 kHz (but Po-1 μPa).
can contribute to faster development of hearing Prevention of adverse effects of ultrasound in-
damage - described temporarily decrease in audito- cludes a number of measures of organizational,
ry sensitivity of action of low-frequency ultrasound technical and medical nature. It is appropriate devic-
(17-37 kHz) and very high intensity - 148-154 dB, and es, sources of powerful ultrasound, be placed in sep-
noise in the ears (tinnitus). arate and insulated rooms and even better in cabins
All these aural and extraaural effects of air ul- with remote control. Ultrasound generators need
trasound in the production or related to the joint to procure passport data on power and frequency
action of sound (noise), or similar changes may be spectrum.
caused by other physical factors, toxic agents or Limiting exposure is an important measure for
stress. prevention as well as in industrial and in medical use
In action of contact ultrasound are described: in of ultrasound. Here, as in noise, gradually requires
ultrasonic polyneuritis; skin changes - hyperemia, the application of the approach to dosing by meas-
hemorrhage, increased skin temperature, aseptic in- uring the shift and all service dose and their limita-
flammatory reactions; changes in the cardiovascular tion. In the medical use of ultrasound must strictly
system - tachycardia/bradycardia, arrhythmias, angi- comply with the emission limit power, energy den-
na pectoris attacks. sity and exposure, which is important for both staff
Studies on the risk of genetic, carcinogenic and and patients.
embryotropic effect in humans no show a statisti- When working with ultrasonic cleaning baths
cally significant increased incidence of birth defects is forbidden any contact of hands and other body
and malignant tumors using ultrasound for diagnos- parts with fluid; the same applies to the contact with
tic purposes during pregnancy. ultrasonic tools and workpieces. Charging the baths
should be performed at off equipment, and it is best
6.6.2. PREVENTION OF ADVERSE EFFECTS that this be done automatically.
Personal protection using gloves with air and pin-
Limit levels of sound pressure over 11,2 kHz at cers (working with ultrasonic baths) and multilayer
work places for 8 h exposure (industrial ultrasound), antiphones type “sandwich” designed to protect the
according to BS 12.1.001-79 are for third octave auditory organ. In consider includes protective pro-
bands with geometrical mean frequencies: 12,5 kHz- fessional nutrition and rational regime of work and
75 dB; 16 kHz-85 dB; 20 kHz and more - 110 dB. The rest of the risk contingents.
measurement is linear ( “lin”, not included “A” filter) Contraindicated for work in conditions of ultra
and does not affect the contact ultrasound. Russian sonication are persons with diseases of the central
standards from 1983 (GOST 12.1.001-83) indicate nervous system, auditory, paranasal sinuses, auto-
levels: 12,5 kHz-80 dB; 16 kHz-90 dB; 20 kHz-100 dB; nomic nervous system and hematopoietic organs,
25 kHz-105 dB; 31,5-100 kHz - 110 dB for air ultra- eye lens, cardiovascular system.
sound and 110 dB or 0,1 W/cm2 for contact ultra-

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REFERENCES

1. Angelova, M. Ultrasound. In: Physical environmental factors ed. E. Efremov. S., Med. and phys., 1988,
143-151. (in bul.)
2. Baker K.G, Robertson V.J., Duck F.A. A review of therapeutic ultrasound: biophysical effects. Phys.
Ther., 2001 Jul; 81 (7): 1351-8
3. Cartwright, R.A. et al. Ultrasound examinations in pregnancy and childhood cancer. Lancet, 2, 1984,
998-1000.
4. Hill C.R., G. ter Haar. Ultrasound, in Nonionizing radiation protection, 2 ed., ed. M.J. Suess, D.A. Benwell
- Morison, WHO - publication №25, 1989, 245-292.
5. Malinskaya N.N., G.A. Suvorov, L.N. Shkarinov. Noise, vibration, infra - and ultrasound. In: Guide for
hygiene of labour. ed. N.F. Izmerov, Moscow, Medicine, 1987, V. I, 196-200. (in russ.)
6. Melkumova, A.S., E.S.Lisichkina, S.I.Gorshkov. Ultrasound, M., Medicine, 1975. (in russ.)
7. Roshtin, A.V. Ultrasound. In: Handbook on hygiene of labour. L., Medicine, 1979, 100-105. (in russ.)
8. Sagalovich B.M. Hearing perception of ultrasound, M., Science, 1988, 287. (in russ.)
9. Stark, C.R. et al. Short and long term risks after exposure to diagnostic ultrasound in utero, Obstet and
gynecology, 63, 1984, 194-200.
10. Topalova, V., Ch.Donev. Ultrasound. In: Infrasound, ultrasound, noise and vibration, ed. Tsvetkov D.
and M. Angelova, Med. and phys., S., 2007, 44-65. (in bul.)
11. Valcic, J. Le bruit et ses effets nocifs. Paris, New York, Barcelone, Milan, 1980.

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 N.Mitrev, D.Tsvetkov, Zl.Stoineva

6.7 VIBRATION

In 1911 G. Loriga first described the Italian work- of vibrations in the contact area amount mechani-
ers with pneumatic vibrogenerating tools, who show cal (vibration) energy. This quantity is proportional to
symptoms of the disease type Raynaud*, and in the intensity of vibration, the contact area (receptive
1918 A. Hamilton and associates established in hew- area) and the time of exposure (exposure). The in-
ers in Indiana a high incidence of “spastic anemia of tensity of the vibrations is dependent on the speed
arms” that relate to the cold-impact, compression (m.sec-1), the acceleration (m.sec-2) and amplitude
and vibration of the arm. Subsequently, the com- (mm). Another important feature of vibration is re-
prehensive mechanization of almost all production petitive or periodic motion, ie frequency (Hz).
activities and the pronounced trend of continuous The vibrations are felt as such at frequency to
increase in the number and diversity of introduced about 8 kHz - higher frequencies are perceived as
in use vibrating machinery and equipment have the heat. The vibrations are measured in the range of
effect of increasing the number of vibroinflenced 1-1000 Hz, or 8-1000 Hz - for local vibrations and
persons. Currently, over 70 occupational groups ex- 1-63 Hz for general (these values are the mean of
posed to vibrations (Table. 1). The vibrations are ex- octave bands). Based on frequency vibrations are di-
pressed factor in road, rail, water and air transport. vided into low frequency, mid- and high frequency,
It pointed out that in the 70s and early 80s in the which are respectively at general and local vibration
United States about 8 mil. workers impacted by vi- 1-4 Hz, 8-16 Hz and 31,5-63 Hz; 8-16 Hz, 31,5-63 Hz
bration, of which about 6.5 million in transport oper- and 125-1000 Hz. Low frequency vibrations prop-
ations (transport, agriculture, construction). Indicate agate more intensely in the human body from the
there also 194 thousand impactful people with gen- point of contact and high-frequency local vibrations
eral vibration in foundries. In Bulgaria during the pe- lead more quickly to vasospasm.
riod 1975-91, the annual reported cases of vibration Possible resonance hardening (even repeated-
disease were held 4-5 place in the structure of occu- ly) of own vibration of the tissues, organs or whole
pational diseases, half were miners, and the next five body under the influence of low frequencies vibra-
professional groups in frequency were: tractor driv- tion, i.e. increasing the risk of vibration damage. The
ers, drivers, crane operators, turners , logging. Over resonant frequency of the whole body in a sitting
the past 15-20 years, however, there is a strong trend posture is 4-6 Hz, and in standing - 5-10 Hz; head 20-
for reducing the incidence of vibration disease in de- 30 Hz; heart and liver - 4-6 Hz; stomach - 6-8 Hz.
veloped countries - up to 64% in England to 1982, Depending on the direction of oscillation vibra-
85% in Japan for the period 1978-1991, the 1/3 to tions are horizontal, vertical, rotational and so on.
half of them working in logging - combined effect The vertical general vibrations have a more negative
of vibration and low temperature air (work outdoor). impact on the human body in an upright and a sit-
ting position and horizontal general vibrations - in
6.7.1. GENERAL AND BASIC FEATURES lying. Vibrations characterized depending on the
time being - periodic, aperiodic (strokes), stochas-
The term vibrations mean mechanical vibrations tic (random), declining and short-term (pulse).
of the material bodies or points removed from equi- Most often in production are complex - the result of
librium position under the influence of external forc- superimposing very simple (harmonic or sinusoi-
es. dal) vibrations with different characteristics at the
The nature and severity of vibration-related inju- time, direction, movement and regime. According
ries are caused mostly transmitted from the source to the contact between man and vibrational sources
influential vibrations are local (segmental or even
hand-arm vibration), general and mixed (local and
* Maurice Raynaud (1862) doctoral thesis “Local asphyxia and
symmetrical gangrene of the extremities” - attack and perma- general). In the first case the transmission of vibra-
nent white - fingers (or “dead hand”), with subsequent atrophy tions going through your hands when working with
and gangrenous changes, now called Raynaud’s disease or pri- hand-held vibrating tools, and the second - they act
mary Raynaud’s syndrome. on the body in standing, sitting or lying position.

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Tab. 1. Sources of above the standards vibrations in production *
Production Source Type vibration Mean rate exceeding standards - K

1. Mining drills lv 2-3,5

breakers lv 4-14
loaders lv 1,5-3
Gv 2-3
2. Coal drills lv 2-3,5
breakers lv 3-10
electrobores lv 1-2,5
loaders lv 1,5-2,5
Gv 1-2
3. Open mine excavators Gv 1-2,5
boring machines Gv 3-8
electric carrier Gv 3-10
bulldozers Gv 3,5-4
cargo vehicle Gv 3-4,5
4. Machine-building pneumatic hand lv 2-4
instruments
grinding machines lv 1-1,5
presses Gv 2-2,5
molding presses Gv 2
compressors Gv 1-1,5
cold treatment lv 1-1,3
cranes Gv 1-3
5. Logging chainsaw lv 2-5,5
tractors Gv 1,5-2,5
cargo vehicle Gv 2-3,5
6. Production of ready vibrators lv 2-3
vibroelements for building vibroplatform Gv 1-1,5
7. Agricultural tractors Gv 1-3
lv 1-2
tractor-driven Gv 2-3
bulldozers Gv 2-3
8. Textiles textile machinery Gv 1-1,5
* The data represent mean values from different measurements and should be regarded as tentative. The parameters
of vibration strongly influence various factors (mainly technical) and they can be very different under the same machinery
and manufacturing processes.

For hygienic assessment of vibration they are Determine also the exposure time of the work
measured in three orthogonal directions (x, y and shift.
z). In local vibrations into account the highest meas-
ured value in different frequency bands (Fig. 1). In
general vibrations (Fig. 2) are evaluated separately
vertical (z) vibration and the highest values in differ-
ent frequency bands from both directions (x and y)
of horizontal vibrations.*

A vibrating surface A vibrating surface

Fig. 1. Standardized position of the axes

x, y and z in local vibrations

* Now at local vibrations into account the amount of simulta- A vibrating surface
neously frequency-weighted values in all three axes, and in
general - also frequency - weghted values, but separately for Fig. 2. Standardized position of the axes
the three axes. x, y and z with general vibrations

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Besides vibrations for the occurrence of vibra- exposed suffering to cooling. Outside workers are
tion mediated pathology significance have other most exposed to early morning attacks. Advanced
adverse factors. Most important in this respect are occurring serious difficulties in the performance of
static tension of muscles, reverse shot tool, awkward work duties, social activity and entertainment.
posture, cold impact (local or general), noise, toxic There are also atypical forms - describe attacks by
noxal (nicotine, aerosols of heavy metals, organic graying of the top half of the ear shells and ischemic
solvents, carbon monoxide, etc.). coronary events in some vibration disease patients.
It can be observed development of cerebral angiod-
6.7.2. IMPACT OF LOCAL VIBRATIONS ystonic syndrome, characterized by headache, neu-
ON THE BODY rasthenic manifestations, due to functional dysregu-
lation of brain circulation.
Local vibrational energy is absorb primarily by Pathophysiology of vascular disorders. On Fig. 3
upper limb and that is why they are affected most presents the pathophysiological mechanisms of vi-
when working with hand-held vibrating tools, but bration disease from local vibroimpact.
cause and generalized damage. Damage is primarily Vasoconstrictor response is determined by the
functions and structure of the nervous, cardiovascu- increased activity of sympatho-adrenal system or
lar and osteo-articular system. parasympathetic depression caused by overstimu-
Vascular disorders are one of the earliest and lation of Vater-Pacini corpuscles. There was also in-
dominant manifestations of vibration damage. creased receptor activity in arterioles and arteries to
Based on these in Anglo-Saxon literature vibration vasoactive substances with functional dominance
disease is described as a vibration-induced phe- of a2-adrenergic receptors in acral parts. Activation
nomenon of Raynaud, vibration induced white fin- of serotonin (5HT2) receptors in the digital vessels
ger, traumatic vasospastic disease, work-related also plays an important role in provoked by cold
phenomenon of Raynaud. Since 1983 according to events type Raynaud. The vibrations damaging local
international consensus called vibration-induced dermal perivascular nerves containing the powerful
hand-arm syndrome. In Southeast Europe, Japan vasodilator calcitonin gene-related peptide (CGRP).
and the Scandinavian countries talk about vibra- Endothelial vasodilator substances - nitric oxide
tion disease. (NO), vasoactive prostaglandins (prostacyclin) and
In local vibrations occur varying degrees of mark- endothelium-derived hyperpolarizing factor (EDHR)
edness changes in the tone of the arterial bed. Dis- modulate vasoconstriction driven by adrenergic
orders in the regulation of increased vascular tone of nerves, originating from the blood cells substances
arteries of medium and small-caliber in upper limb and local autocoides. Endothelial cells produce and
has been proven repeatedly by a number of meth- vasoconstrictor substances, such as prostanoids,
ods, including. arteriography, infrared thermog- thromboxane A2, superoxide anions, endothelin-1
raphy, Doppler sonography, fotopletismography, (ET1). Numerous factors secreted by the endothe-
laser-Doppler flowmetry. Expression of these viola- lium and the complex interactions between them
tions has decreased skin temperature of the hands and noendotel mediators determined local vasomo-
sometimes and asymmetrical, while at generaliza- tor control on vascular smooth muscle cells.
tion of process and in lower limbs, not only during Humoral dysregulation alter hemostasis, fibrinol-
ischemic crises “dead fingers”, but in intercrises peri- ysis and haemorheology.
ods. Attacks are preceded by a latency period whose It was found impaired permeability of the capil-
duration is much shorter, the more intense the vi- lary walls for plasma proteins, increased blood vis-
brations, ranging from years to weeks. The shorter cosity (hypercoagulable), increase the concentra-
this period is, the progression of the phenomenon tion of plasma hematocrit and hemoglobin.
is more severe and attacks - more frequent. In the Vibration exposure causes and intravascular
initial period the graying covers skin of the distal platelet activation which can enhance the release of
phalanges of III and IV, less II and V of the fingers, as thromboxane A2 (TxA2), whose metabolite throm-
the attack is short - from seconds to several minutes. boxane B2 is a potent vasoconstrictor. In places of
In advanced cases, the attacks become more fre- vascular stenosis leukocytes and platelets are sub-
quent and longer, sometimes up to two hours and jected to extremely large hemodynamic stress from
cover fully all phalanges of the fingers. Classic at- blood flow (shear stress), which further activates
tacks of sudden blanching and numbness of the fin- them. Leukotrienes, chemotaxis factors and cy-
gers with sharp demarcation are often provoked by tokines secreted by damaged endothelium, activat-
cooling. Early attacks occur mainly in the early morn- ed leukocytes further, on a background of reduced
ing in winter, at home or on the way to work, when production of prostacyclin.

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Fig. 3. The pathophysiological mechanisms of vascular injury

VIBRATION Cardiovascular system

Cold Central nervous system Hypothalamus,
Noise limbic system
Other
Stressors Vegetative nerve system
Adaptation

ACTH, cortisol, adrenaline, noradrenaline, dopamine, T3,

Vessels T4, cAMP, cGMP, and other neuro humoral and
neuroendocrine factors
Bradycardia, enlarged
heart, increased left
Local ventricular stroke
dysregulation 1. Receptor dysfunction - 1-receptor damage, 2- receptor dominance, 5HT2-receptor sensitivity, volume, low blood
damage to mechanoreceptors, temperature, pain receptors pressure
2. Damage to nerve endings - loss of perivascular nerves containing CGRP, nerve fibers vibration
and painful perception

Histomorphological 3. Endothelial dysfunction, reduction or degradation of EDRF (NO, PG12, EDHF), an increase of EDCF (ET1,
enndoperoxids, TXA 2, superoxide anions). High hemodynamic stress. Duration
changes and
ischemia 4. Increased oxidative stress

5. Impaired response of smooth muscle fibers.

6. Leucocyte activation (hypodeformation, hyperagregation, hyperadhesion, release of free radicals and

lytic enzymes, cytokines, chemoattractants) erythrocytes (hypodeformation, hyperagregation), platelets
(adherence, aggregation and release of mitogenic mediators such as PDGF, vasoconstrictors
TxA2 → TxB2; 5HT2) Disadaptation
7. Increase of sICAM-1, a reduction in IL-8
Vasospasm
Microangiopathy 8. Vascular remodeling, altered gene expression, promotion of the inflammatory proceses
Thrombosis in Hypertension,
peripheral 9. Proliferation of media
dyslipidemia
arteries

Histomorphological changes in vessel wall grow the threshold of vibrosensitivity. A similar combined
in the more advanced stages of the vibration dis- effects of vibration and physical load, probably as
ease. There have been intense thickening of the connected with vibroreceptors fatigue and impaired
muscle layers of the digital arteries, with a strong local circulation. On the functional status of special-
hypertrophy of smooth muscle cells without intimal ized mechanoreceptors perception of vibration in-
fibrosis, but with the peri-arterial fibrosis and some- fluenced and some chemical (adrenaline, acetylcho-
times changes with atherosclerotic foam cells, lipid line, novocaine, drugs, caffeine, fenamin etc.) and
deposition and fibrous sclerosis. Development of physical factors (ultrasound, noise, ionizing radia-
severe morphological changes in the vascular wall tion, etc.), age changes (atherosclerosis, hypotrophy
with pregangrenous and gangrenous condition of of the skin, changes in mechanoreceptors, etc.). The
the fingers, described mostly in the past due accord- earliest notable and most pronounced is hypopal-
ing to some authors less impact vibration as other estesy under the influence of vibration frequency of
accompanying them nonspecific risk factors - trau- 125-250 Hz, probably due to the increased vulnera-
ma, infection or intoxication. bility of specialized FAII receptors (i.e. inclusion Vater
Peripheral nerve disorders. In local vibrations Pacini corpuscles), who perceive these frequencies,
has expressed peripheral and central neural pathol- and later affected and low-frequency range per-
ogies. Especially pronounced polyneuritic syn- ceived by the FAI and SAI receptors (cell complexes
drome with sensory and autonomic vasomotor, su- Merkel and corpuscles of Meissner). Hypopalestesy
dosecretory, thermoregulatory, neurovascular and is most pronounced in the distal sections of limbs,
dystrophic disorders. The symptoms of vibration especially volar side of the tips of the fingers and
disease is exept microcirculatory but senseneural - plantar of foot.
prickling, tingling, burning, numbness, insensibility The vibrations harm the superficial sense of touch
of fingers with intermittent character initially and and pain. Hypesthesy (hypalgesia) of distal type
subsequently permanent accompanied by pain. and unlike of hypopalestesy is more pronounced
Local vibration damage mainly peripheral nerves at impact of low frequency vibrations. In the early
of the upper limbs, and sensory nerve fibers are stages of the vibratory disease hypalgesia settled
more sensitive and vulnerable than motor. in the fingertips, during disease progression “climb”
Establish lowered vibration sensation (hypopa- proximal covering successively wrist and lower third
lestesy) even before the onset of other symptoms of of the forearm (type “gloves”). In the third stage can
vibration disease. The combined impact of vibration acquire segment character and cover the shoulder
factor with cold increase the risk of an increase in girdle and part of the chest (type “short jacket” or

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Vascular Neurological Tab. 2. Clinical and
laboratory tests
Tests Adson and Alain Tests of Tinel and Fallen
Hyperabduction and bone-clavicle movement Abduction-external rotation
Doppler sonography Muscle strength into a fist
Laser-Doppler flowmetry Deep sensibility
Finger blood pressure before and after a cold Discriminatory sense
provocation Manipulative dexterity
Plethysmography before and after the cold stress test Palestesiometry
Cold test Temperature perception
Capillaroscopy Nerve conduction

“breastplate with sleeves”). Tactile sensation is less sis flashes (24.5%), deforming osteoarthrosis of the
disturbed, but according to some authors, exposure interphalangeal and metacarpo-phalangeal joints
to high-frequency vibrations can cause a temporary (31.1%). More frequent and aseptic necrosis of carpal
decrease in the sense of touch even full loss. Dam- bones on the type of disease Kienbock.
age and complex sensation- discriminatory sense to In the insertions of muscles and tendons grow
the extent of the incapacity of the patient to per- hardening and calcium deposits.
form fine manipulation. On Table. 2 are recommended clinical and labo-
In local vibrations occur, and abnormal temper- ratory tests to diagnose pathology of overstrain and
ature sensitivity with an increase in the thresh- vibrations in working conditions.
olds for thermal and, to a lesser grade to the cold. In the differential diagnosis in patients with vibra-
In patients with vibration disease is established and tion disease should be excluded a number of diseas-
hypotermestesy hypotermalgesia not only in the es as the primary phenomenon of Raynaud; second-
points of direct contact with the vibrations, but also ary Raynaud’s phenomenon with different etiology
in other body parts. In some cases termanestesy may - collagenoses (scleroderma), endocrine, metabolic,
create a risk of burns on contact with hot objects. cardiovascular diseases, intoxication (vinyl chloride);
A study of the functional state of the neuromus- polyneuritis and polyneuropathy with other gene-
cular apparatus in most patients is established and sis, syringomyelia, disseminated sclerosis, cerebro-
reduction of the lability and increase in the thresh- vascular disease, pernicious anemia, compression
olds of excitation. In the early stages decreased mus- and neuro-vascular syndromes in upper limbs.
cle tone and endurance. Muscle strength changes On Table 3 presents senso-neural, microvascu-
phase - increased at the beginning and progressive- lar and musculoskeletal criteria for determining the
ly reduced. Possible trophic muscular changes in stage of vibration disease.
upper limbs and shoulder girdle and painful hard-
enings type myofasciculus or fibromyositis. In ad- 6.7.3. EFFECT OF GENERAL VIBRATION
vanced stages are possible hypo- to atrophy of indi- ON THE BODY
vidual muscles or muscle groups.
For musculoskeletal disorders have a dominant General vibrations are regarded as non-specific
importance and accompanying vibration static and common stressors that can act multiform on a parts
dynamic intension, return punch tool, heavy phys- and organs of the human body depending on the
ical labour that lead to mechanical traumatisation. vibration characteristics. In addition to musculoskel-
Be established tendovaginitis most of the flex- etal system general vibrations affect the reticular
ors of the hand, radial and ulnar epicondylitis, peri- formation, cerebellum, spinal cord and brain and en-
arthritis predominantly humeroscapular joint it. A docrine glands and cause various psycho-sensory,
common finding is tendomyositis of extensor group neurovegetative and somatic reactions of the body.
muscles of the hand. The main approaches to the evaluation of the re-
An important place in the clinic of vibration lationship cause/effect of general vibration is most
disease hold degenerative-dystrophic changes often limited to: subjective assessment of tolerance
in the osteo-articular system in the upper limbs, to vibration and a feeling of comfort; reliability of
shoulder girdle and spine. The character of bone-ar- the tasks (a performance); integrated assessment of
ticular changes too diverse - among the most typ- functional status of the human body with the objec-
ical are enostosis, regional osteoporosis, osteochon- tive physiological indicators.
drosis and deforming spondylosis, bone cysts and Intensive general vibration impact and duration
deforming osteoarthosis. Surveys indicate most com- of exposure worsen proportionally results of the
mon degenerative-dystrophic changes enostosis visual-motorial tasks.
(63.3%), cystic flashes (58.3%), regional osteoporo- Subjective evaluation of vibration is based on the

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Stage Symptoms Tab. 3. Stockholm criteria for
1SN Intermittent numbness and tingling in fingers diagnosis of vibration disease
2SN Intermittent or persistent numbness, tingling and hypoesthesia of hands (1987) *
3SN
Intermittent or permanent numbness and tingling, grown hypoesthesia in the
hands of pain in the fingers and upper extremities, decreased sensation
discriminatory
1V Cold fingertips with or without numbness, attack after provocation
2V
Attacks phenomenon of Raynaud (RP), comprising the distal phalanges of
3V one or more fingers with numbness
4V RP expressed all phalanges of the fingers, frequent ischemic attack in
summer and in winter
Graying full of all fingers of both hands in summer and in winter, trophic
changes
1M Intermittent or persistent numbness and pain in the fingertips
2M
Impossible fine movements in everyday life such as fastening buttons or
3M handling small objects. Expressed pain in the upper limbs.
Constant pain in the arms, upper limbs and elbows.
* О [SN, V, M] – exposed to vibration, without clinical symptoms

threshold of sensation, tolerance and discomfort changes in reographic and Doppler sonographic in-
(pain, anxiety and fear). Studies in production condi- dicators, increased tone of cerebral vessels in tractor
tions established a number of subjective complaints drivers and combine operators, peripheral vascular
- pain in the lumbar and cervical spine, epigastralgia, disorders in the legs with operators of excavators
nausea, decreased visual acuity, insomnia, spasms in and tractor drivers. One reason for gynecological pa-
the colon, neurotic symptoms. thology in women exposed to intense general vibra-
Changes in the functional state of the central tion are disorders in blood circulation to the organs
and peripheral nervous system - increased fatigue, in the pelvis.
headaches and dizziness, sleep disorders and irrita- General vibrations cause a number of endocrine,
bility, tremor of the eyelids and hands anisoreflec- hormonal and neurohumoral effects. They affect
tion, disturbed cerebral hemodynamics, activation adreno-cortical system, increase of testosterone
of the reticular formation, mesodiencephalic and and growth factor and reduction of cortisol, as well
brain stem structures. Damage to the peripheral as higher concentrations of glucose and insulin, and
nerves and the formation of vegetative polyneural many others.
syndrome are possible in general vibration impact. More common among women of professions
Damages and musculoskeletal system (MSS). with vibration exposure are the emergence and ex-
When exposed to intense general vibration estab- acerbation of inflammatory gynecological diseases,
lish degenerative changes in the spine (lumbar and spontaneous aborts and premature births, gesta-
cervical segments), osteoarthritis of the radio-ul- tional toxicosis and post-natal complications. Ani-
nar joint, aseptic necrosis of semilunar bone, pain mal experiments suggest disabilities and in fetus.
syndrome in the lumbar-sacral part of the spine, is- To assess the impact of general vibrations during
chioneuralgia pain, reduced muscle strength, mus- the last 10-15 years, many researchers use indicators
cle cramps and myalgia. of morbidity with temporary disability. In such ana-
Common in general vibration impact are the lyzes an increased frequency of accidents and dis-
reactions of the vestibular and auditory analyzer - eases MSS, gastrointestinal, cardiovascular, urinary
occurrence of discomfort, dizziness, nausea and and reproductive system of tractor drivers, opera-
drowsiness at the end of the workday, changes in tors of excavators and steam-navvy machines and
the regulation of posture in stabilography, greater disc disease in tractor drivers and crane operators. In
increase in hearing threshold in exposed to noise the structure of the cardiovascular pathology most
and general vibrations. common are hypertension, followed by chronic is-
General vibration can also affect the function of chemic heart disease.
the visual analyzer with signs of decreased sharp- The presence of numerous themselves nonspe-
ness of vision and worsening of peripheral vision cific changes in the impact of general vibrations
and color vision. have their further study with a view of complex eval-
There are changes on the part of the cardiovascu- uation and forecasting the state of the body.
lar system - slowing heart rate, lower blood pressure,

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6.7.4. PREVENTION OF ADVERSE EFFECTS. calculated the three axes.
Workers should not be exposed to levels exceed-
Preventing vibration pathology includes control ing the exposure limit values of general or local vi-
and regulation of vibration, measures to weaken the brations. The employer is obliged to take action (or
vibrations at source and limit their spread; measures change them) in order to avoid exceeding them.
against other factors and conditions of the working Allowed some exceptions (eg ships, helicopters, air
environment of etiological significance for vibration screw planes) when possible accidental increase,
pathology; rationalization of the regime of work and but with a proven lower risk than that of excess. Also,
work organization in vibro dangerous professions; the employer provides health surveillance in accord-
measures with medical prophylactic character. ance with Ordinance № 3/1987 on mandatory test-
Control and standartisation of vibration. Un- ing of workers in the presence of a health risk (con-
der Decree № 3 of MLSP and MH (2005) in accord- tact vibration), while exceeding the daily exposure
ance with BS ISO 5349-1:2004 and BS ISO 2631- values is obliged to provide it, and exceeding the
1:2004 (identical to ISO 2631-1:1997) - according to limits (at specified exceptions) is obliged to provide
local vibrations (vibration transmitted to the hand) enhanced health surveillance.
and general vibration (vibration on the whole body) According to BS/ISO 5349-1:2004 (identical to
on the health hazards of workers exposed to vibra- ISO 5349-1:2001) evaluation of local (hand-arm) vi-
tions, states: bration changes:
In local vibrations (hand-arm system): 1. Estimated total value of vibrations, while in
1. The daily exposure limit value for a period of 8 the previous standard ISO 53491:1985 permissible
h - to 5 ms-2 vibration acceleration of 2 ms-2 is compared to the
2. The daily exposure value for taking action, for a direction (x, y and z axis), where frequency-weight-
period 8 h - to 2.5 ms-2 ed rms value is greatest.
In general vibration (whole-body): Therefore now the measured value (total value)
1. The daily exposure limit value for a period of 8 is greater by 1.0 to 1.7 times (typically 1.2-1.5 times)
h - to 1,15 ms-2 than the highest, but only one of the axes (respec-
2. The daily exposure value for taking action for a tively in comparison with previously measured val-
period 8 h - up to 0,5 ms-2 ues they must be multiplied by the appropriate fac-
The above values to local vibrations are com- tor - mostly 1.3 to 1.4).
mon (ahv) vibration values, determined by the sum of 2. The daily assessment of the impact of vibration
together reported frequency weighted square root is based on the equivalent energy (vibration accel-
values of acceleration (in ms-2) measured on three eration) for 8 h. In ISO 5349-1:1985 it treated the
axes - x, y and z, of the vibrating surface. period of 4 h. Transforming 4 h equivalent values to
For a period of 8 h (vibrations actually do not ef- those for 8 h requires multiplication by a factor of
fect 8 h, and the fewer, but similar to the effects of 0.7.
noise or chemical noxae here use “time-weighted 3. Retain in general showed in standard ISO 5349-
averaging”) the daily exposure value A(8) is defined 1:1985 compliance between the development of
as: the syndrome of “white fingers” and the impact of
vibration (vibration acceleration), but correction are
A(8) = ahv T/TO made due of reference now to the equivalent period
of exposure 8 h and multiplication values by a factor
where T - total daily exposure s (h) of 1.4.
TO - exposure 8 h (28.800 s) According to BS (ISO 2631-1:2004 (identical to
In general vibrations daily exposure A(8) is de- ISO 2631-1:1997) estimate of general vibration (on
fined as: the while body) changes compared to the first edi-
tion of ISO 2631-1:1985, as:
A(8) = k. aw T/TO 1. The evaluation is based more on frequen-
cy-weighted mean square (rms) acceleration value
where aw is the vibration magnitude (square root) of the vibrations and their impact on health, comfort
of the weighted average frequency accelerations in and perception, as well as diseases of the travelling
each of the three axes - x, y and z. (malaise travel - vomiting, nausea, headache, dizzi-
TO - 8 h (28.800 s) ness and etc.). Not included: “exposure limit”, but
T - real duration of exposure in h (s) assessment methods can be used as a basis for the
k - factor of 1.4 in x and y axes and 1.0 on z axis limits with appropriate action (measures); also the
Daily exposure is regarded as the highest of the concept of “decreasing performance (fatigue)” under

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 OCCUPATIONAL MEDICINE
the effect of vibrations because it much depends on principle, with those that exclude the stroke, found-
ergonomics and working conditions of the operator. ing in molds with liquid self-hardening mixtures, al-
2. The range of vibration is extended under 1Hz: lowing it to be discarded pneumatic rammers and
– from 0.5 to 80 Hz - for health, comfort and per- molding machines; attaching the processed details
ception on vibration pad, etc.
– from 0.1 to 0.5 Hz - for diseases of the travelling. The most radical way to combat the harmful ef-
3. The main method of assessment is frequency fects of vibration is a remote control vibrating ma-
weighted square root value (rms) of acceleration. chinery and equipment, thereby limiting the influ-
When vibration ratio peak above 9 (including acci- ence of noise, cooling and physical load.
dental shots) is optionally available using two other Meaning have such measures as compulso-
methods: ry passport of vibration sources, inclusion in their
– method for assessing the current r.m.s values or documentation rules for installation, operation and
determine the so-called MTVV (maximum value of maintenance.
the previous vibration); Measures against other factors and conditions at-
– method of fourth degree of vibration dose VDV. tendant vibrations. To eliminate the cooling apply
Emphasize that the risks to health impairment various methods: using warmth- and moisture pro-
always evaluated by using the main method, but tective gloves, clothing and shoes; making handles
in case of suspicion of misjudgment to use and the and other parts of contact with hands on materials
aforementioned methods. of suitable coefficient of heat or lining the same with
Measures to weaken the vibrations at source and such materials; create a comfortable microclimate
limit their spread outside source. The weakening of conditions on the premises; ensure during the cold
vibrations in the source of their generation can be seasons of heated transport and space heating for
achieved in the way of constructive and technolog- outdoor work; change the direction of the exit of the
ical measures: change of kinematic scheme and the exhaust air of pneumatic tools, cooling hands and
working cycle of hand power tools; improving the others.
production of components, their installation and To reduce the physical load required handles and
the parameters of vibrating machines and tools; the levers have a shape that is not only comfortable for
use of materials with high internal friction; careful the job, but also evenly distributes the force of pres-
balancing of moving parts and so on. sure, reduce the contact area with the tool and the
The elastic suspension of part of corps of the machine and preventing jams.
chainsaws eg., playing the role of dynamic vibration Rationalization of the regime and work organi-
reducer leads to significant damping effect and re- zation. The organization of complex brigades and
duce the frequency of vibration damage. Appropri- rotation of manipulations, performed significantly
ate suspension or isolation systems in machines and decrease the incidence of vibration disease, by re-
vehicles with fixed base by inserting elastic springs ducing the exposure time. In Bulgaria are distribut-
or other damping material between the source and ed special instructions for prophylactic regimen of
the person, reduces vibrations significantly. Such work in jobs threatened by local vibrational effects;
solutions include springy seats in vehicles with determinated admissible exposures of a single time
rough ride and airplanes. vibrations, duration of pauses and limit a total ex-
The spread of vibrations outside their source posure per shift, depending on the intensity of vi-
may be hindered more by anti vibration processing bration; a total maximum exposure for shift should
bases of machines and foundations using rubber be up to 90-120 min. When operating vibrating tool
pads, insulating joints of vibroisolated materials, re- should stick slightly loose, avoiding large static ef-
moving the solid connection between the vibrating fort and optimal angle of supination between the
platforms and structural elements of the premises, arm and forearm between 90 ° and 150 °.
isolation of workshops with vibrating machines and Measures with medico- prophylactic character.
equipment, etc. The professional selection for work in conditions of
To isolate the hands of workers in condition of vibrations is held in strict observance of contraindi-
vibration effects often used gloves of vibration-ab- cations: organic diseases of the central nervous sys-
sorbing materials, that protect from moisture and tem, incl. epilepsy; marked autonomic dysfunction,
cold. diencephalic events; Raynaud’s disease and Ray-
Results in the fight against vibration are achieved naud-like syndromes, autonomic polyneuropathy;
and the way of improvement of technological pro- neuritis and polyneuritis; diseases of musculoskele-
cesses. In this regard, consideration includes the re- tal system, disorders of motor function; diseases of
placement of machines and tools, working on stroke the cardiovascular system; diseases of the endocrine

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glands with permanent impairment of their func- ologically active substances, vitamins B1, PP and C);
tion; ulcer; permanent hearing loss, otosclerosis and must be eliminated smoking, alcohol abuse.
other ear diseases with unfavorable prognosis for Among the means of individual prevention of in-
hearing; chronic diseases and expressed anatomical juries from local vibration most recommended are
changes in the female genital area. warm hydroprocedures. Recommended and gentle
At risk and affected by vibration disabilities self-massage after the procedure and wearing warm
should be cautious in order to avoid extra work vi- gloves during the cold seasons.
brations (i.e. long riding a motorcycle, operating mo- Prophylactic examination is held once a year
tor mowers, power saws, drills, etc.), and in particular (oto-rhino-laringological - at two years) by a neurol-
in conditions of cooling, soaking and moisture. It is ogist, therapist, orthopedic and ORL specialist, and
also using the beneficial effect of specialized pro- at indication - and by obstetrician and rheumatol-
duction gymnastics, regular nutrition and suitable ogist.
professional diet (diet A - rich in animal protein, bi-

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2. Angelova, M. Vibrations. In Physical environmental factors. ed. E.Efremov, S, Med. and phys., 1988,
125-142. (in bul.)
3. Bovenzi M, Hulshof C.T. An updated review of epidemiologic studies on the relationship between
exposure to whole-body vibration and low back pain (1986-1997). Int Arch Occup Environ Health 1999 Sep;
72 (6): 351-65
4. Decree № 3 of the Ministry of Health on the minimum requirements for ensuring the health of workers
from the risks related to exposure to vibration. SG. 40/2005 (in bul.)
5. Dupuis H., G. Zerlett. The effects of Whole-Body vibration. Berline, Springer-Verlag, 1986.
6. Gemne G. Pathophysiology and pathogenesis of disorders in workers using hand-held vibration tools.
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Taylor, D. E. Wasserman, 1992, New York: Van Nostrand Reinhold; Chap. 4, pp 41-64.
7. Goranova L., D. Tsvetkov, M. Angelova, E. Ivanovic, Iv. Paunov, N. Mitrev V. Bosnev. Production
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phys., 1995, 133-244. (in bul.)
8. Griffin M., H. Seidel, M. Bovenzi, A. J. Benson. Vibration. In. Encyclopedia of Occup. Healt and Safety.
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9. Issley D. W., D.Greenstein, I.C.Chetter, R. C.Kester. Alpha-2 adrenoreceptors in Vibration White Fin-
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10. Ivanovic, E. Labour hygienic problems of the general vibration and noise impact on the body. Doc-
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11. Karastanev I., K. Yazov, N. Mitrev. Vibration disease, Plovdiv, Hr. G. Danov, 1974, 93. (in bul.)
12. Malinskaya N.N., G.A. Suvorov L.N. Shkarinov. Noise, vibration, ultra- and infrasound. Guide for
hygiene of labour ed. NF Izmerov V. 1, M., Medicine, 1987, 168-205. (in russ.)
13. Menshov A.A. Influence of production vibration and noise on human body. Kiev, Zdorovya, 1977, 12
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14. Mitrev, N. Some aspects of the problem of vibration pathology in miners. dis., Plovdiv, 1979. (in bul.)
15. Nakamura H, Ariizumi M, Okazawa T, Nagase H, Yoshida M, Okada A, Involvement of endothelin
in peripheral circulatory change induced by hand-arm vibration. Cent. Eur. J. Public Health 1995; 3 Suppl:
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16. Pelmear P., Taylor W. Clinical picture (Vascular, Neurological and Musculoskeletal / m In: Hand-arm
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serman. 1992 New York: Van Nostrand Reinhold.
17. Pyykko I, Starck J. Pathophysiological and hygienic aspects of hand-arm vibration. Scand. J. Work
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18. Rumyantsev G. I. Hygiene of labour in the production of reinforced concrete panels, Moscow, Medi-
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19. Seidel H., R. Heide. longterm effects of whole-body vibration: A critical survey of the literature. Int.
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21. Suvorov, G.A. Hygiene standartisation of labour noise and vibration. in Hygienic standartisation of
work environment and labour process factors. ed. N.F. Izmerov and A.A. Kasparov, M., Medicine, 1986, 104-
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22. Tsvetkov D., Vibrations - occupational hygiene importance of nonspecific changes in the body (char-
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D. Tsvetkov, Sofia, Med. and phys., 1994, 143-153. (in bul.)
24. Tzvetkov D. Effect of vibrations on the organism - possibilities for development of non-specific dis-
eases and their prognostication. Cent. Eur. J. Public Health. 1993 Jun; 1 (1): 10-15.
25. Wilder D.G., D.E. Wasserman, M.H. Pope, P.L. Pelmear, W. Taylor. Vibration . in: Physical and Biolog-
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6.8 REDUCED ATMOSPHERIC PRESSURE

Globally noted an increasing number of people ops in conditions violating O2 transport to the tis-
who work and live in conditions of reduced atmos- sues - eg. reduced inflow of arterial blood in cardio-
pheric pressure. That is due to the rapid develop- vascular disease.
ment of aviation and aerospace, and also the con- Histotoxical hypoxia - is determined by the re-
duct of a number of economic activities in heights duction in the utilization of O2 tissues (arterial blood
- construction and mining sites, scientific expedi- PO2 is normal and venous PO2 is increased). The
tions, weather stations, mountain tourism, farming main indicator for the development and severity of
and agriculture and others. At the present time over the hypoxic condition is the magnitude of the par-
25 mln. people live and work at altitudes above 3000 tial pressure of oxygen in the alveolar air - PaO2 and
m above sea level, most of them are not adapted to closest to him magnitude of PO2 in arterial blood.
height. Reduced atmospheric pressure found in nat- The critical value of PaO2 according to a number of
ural conditions when climbing in height and in arti- authors from 27 to 33 mmHg.
ficial conditions (eg. in hyperbaric chambers). Altitude hypoxia is acute or chronic. In rapid-
With increasing altitude, barometric pressure ly climbing high altitude (4000-5000 m.) the body
(PB) reduces, the temperature dropped by about does not have time to adapt and acute hypoxia
6,5° C at 1000 m. (Table. 1), reduce the cloud, dust, occurs. Of such are threatened primarily aviators
and the pressure of the water vapors. Ultraviolet ra- and mountain rescuers. In a smooth ascent to high
diation increases by about 4% at 300 m. (additional (hikers, climbers and others.) provides time for ac-
snow reflect UV rays) climatization, which is a protection against acute
hypoxia. By appearances of chronic hypoxia threat-
6.8.1. PHYSIOLOGICAL EFFECTS OF REDUCED ened longer or permanent residents of height. As a
ATMOSPHERIC PRESSURE result of acute hypoxia occurs altitude sickness, and
as a result of chronic - mountain sickness. Despite
With elevation of the height due to the reduced the importance of acclimatization, training, inherit-
barometric pressure, as a result of the decreased ed properties, speed of ascent, a major factor in the
partial pressure of oxygen in the air occurs different- occurrence of adverse effects and the ability to ex-
ly pronounced hypoxia in the tissue. According to perience remains altitude (Fig. 1).
the etiology and pathogenesis are 4 main forms of
hypoxia:
Hypoxic hypoxia - Causes Height Atmospheric pressure Temperature
can be diseases violating oxy- (m) (mb/hPa) (torr/mmHg) (°C)
genation of venous blood in the Sea level 1013 760 15.00
lungs. In healthy people this oc- 100 1001 751 14.35
curs in elevation height without 200 989 742 13.70
300 977 733 13.05
extra breathing oxygen - i.e. so-
400 966 724 12.40
called altitude hypoxia. 500 954 716 11.75
Chemical hypoxia - occurs 1000 898 674 8.50
when a drop content of hemo- 2000 795 596 2.00
globin in the blood (blood loss, 3000 701 525 - 4.49
poisoning, etc.). It is character- 4000 616 462 - 10.98
ized by a reduction in the PO2 in 5000 540 405 - 17.47
10 000 264 198 - 49.90
the venous blood and tissues in
15 000 121 90 - 56.50
a normal PO2 of arterial blood. 20 000 55 41 - 56.50
Circulatory hypoxia - devel- 25 000 25 19 - 51.60
30 000 11 8 - 46.64
Tab. 1. Relation between altitude, air 40 000 2 2 - 22.80
pressure and temperature 50 000 0.8 0.6 - 2.50

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Height increases (Fig. 3).
On the other side, however, an increased release
of CO2 reduces the concentration of hydrogen ions
(H +) in the blood, determining the development of
alkalosis. This “protective” alkalosis, respectively. dis-
turbed acid-base balance (ABB) inhibit hypoxic ven-
tilatory response.
Ability to compensate for respiratory acidic loss-
es and balancing the ABB has increased excretion by
the kidneys of bicarbonate, but this is a slow process
- a few days. This explains less pronounced increase
of ventilation with increasing altitude. The time that
is necessary to complete (full) ventilatory acclima-
tization increased progressively with increasing
height (Fig. 4). Note and individual differences in
time for acclimatization.
A longer period of residence (several years) in
height can be determined reduced hypoxic venti-
latory response associated with the development
of other adaptive mechanisms for preserving tissue
oxygenation: increasing capillary density, increased
the capacity of tissues for gas exchange, increasing
the number of mitochondria.
When height acclimatized people return to sea
level, the process is “turned” - PO2 increases to this
sea levels and ventilation decreases. Reduced PO2
at high altitude greatly reduces O2 diffusion in the
Fig. 1. Zones of tolerance height blood - Fig. 5. At sea level is counterbalanced ter-
minal capillary PO2 to alveolar PO2 while at Everest
The decrease in the partial pressure of O2 in the (8848 m) for example full equilibration is not real-
arterial blood causes irritation chemoreceptor cells ized. This difference leads to greatly reduced diffu-
- a highly sensitive neuro-similar cells in carotid bod- sion gradient between alveolar and venous PO2.
ies of synocarotid and aortic vascular reflex zones. With exercise or sport cardiac output and blood flow
Hard afferentation of chemoreceptor is trigger of can rise and thus reduce the transport time of blood
very reflective adaptive responses, that indicate the cells in the alveolar capillaries.
increase in cardiac output, stimulation of the pitu- Difficulty in oxygen delivery to the tissues can be
itary-adrenal system and bulbar formations of the enhanced through: the adaptation of the cardiovas-
brain, including the cortex of the hemisphere. cular and circulatory systems; increased production
The impulses sent through ninth cranial nerve of erythropoietin and an increased concentration of
directly turn to the respiratory control center in the Hb; increased tendency of O2 to bind to hemoglobin;
cerebral cortex (the brain stem-medula oblongata). displacement of the oxyhemoglobin dissociation
The last effect is to increase the frequency and depth curve to right - the accelerated release of oxygen to
of respiration, respectively quantity of ventilation air tissues; increased acceptance and utilization of O2;
through the lungs, which helps restore arterial PO2. by biochemical changes that lead to increased mito-
The complex functional changes to increase the chondrial function (increased levels of myoglobin).*
ventilation is called ventilatory acclimatization - Research shows and other physiological effects
Fig. 2. Ventilatory acclimatization protects arterial of high altitude such as: changes in brain function -
PO2 against the effects of reduced oxygen levels in delayed motor, sensory and cognitive abilities, incl.
the ambient air. reduced ability to learn new tasks, difficulty in pres-
On the one hand, increased ventilation is a way to entation of verbal information, which leads to poor
raise the arterial PO2 to its values at sea level. Howev- self-esteem and irritability; when residents of height
er, increasing the release of CO2 as a result of which
the blood, and then the alveolar partial pressure of * Myoglobin concentration increases with exercise (at sea level)
CO2 falls. The decrease in alveolar PCO2 allows to in- and correlated with the aerobic capacity of the muscle cells.
crease alveolar PO2 and as a result, arterial PO2 also

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Fig. 3. Ventilatory acclimatization at 4300 m above sea level
Increase height (by J. T. Reeves)

Acclimatization

Hypoxia (low PO2)

Decreased PCO2

Carotid stimulation

Stimulation of the
respiratory center

Increased
ventilation

Improved hypoxia

Fig. 2. Course of
acclimatization
(by J. T. Reeves)

settled periodic (Cheyne-Stok's) breathing often dur-

ing sleep - characterized by periods of increased
respiratory rate (hyperpnoea) followed by periods
of cessation of breathing (apnea), leading to hypox-
ia. This is more pronounced in subjects with higher days
ventilation
ventilatory sensitivity to hypoxia. In acclimatization alveolar CO2
periodic breathing improves. The use of drugs and alveolar O2
alcohol that suppress ventilation exacerbate hypox-
ia during sleep.

6.8.2. PATHOLOGICAL CONDITIONS

AND DISEASES
Days for full acclimatization

Decompression disorders. Occurred in very

quickly climb over 8000 m. The reason is the transi-
tion of tissue nitrogen from liquid to gaseous state.
Characterized by pain in the large joints in the tis-
sues around them, which disappear in lowering
height. They also establish puffiness of the skin, rash
erythematous character, itchy skin as from insect
bites, neurological symptoms - headache, pallor,
increased sweating, heaviness in the heart area and
others. This condition is typical for working under in-
creased pressure with subsequent decompression.
Explosive decompression. That is a peculiar
form of decompression disorder, ie decompression Height (km)
occurring in a very short time (seconds), most often Fig. 4. Height and time for acclimatization (by J. T. Reeves)

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Mount Everest Sea level

inspired aspirated

Аlveolar Аlveolar

End capillary РО2

intravenous
End capillary РО2

intravenous

Transportation time Transportation time

in alveolar capillaries (s) in alveolar capillaries (s)
Fig. 5. Oxygen diffusion in the alveolar capillary

in sudden dehermetisation in the aircraft and space- curs at high altitude subcutaneous emphysema. The
craft. The sudden transition from high (incabin) to size and shape of the body will change, but clinical
low (outcabin) pressure occurs sharp expansion of manifestations are often insignificant.
gases in the body and mechanical damage to tissues Retinal haemorrhages - many spread and
and organs. self-injury at high altitude - sometimes affecting
Disbarizam. In impaired hermetisation of the up to 40% of people at height 3700 m. Most often
aircraft is possible sharp drop in atmospheric pres- no symptoms, more common in people with oth-
sure, which can lead to increased pressure in a cavity er symptoms (most commonly headache) and at a
spaces of the bodies containing gas, with develop- sharp physical loading. No can prevent from Aceta-
ment of meteorism, aerosinusitis, aerootitis, also al- zolamide or Furosemid. Most often the absorption is
titude tissue emphysema (vapors in the tissues). spontaneous and occurs in about 2 weeks.
In a quick and chronic repeated decompression Altitude sickness (AS).
arise states of disbarizam long latency period as This concept join all the pathological conditions
aseptic osteonecrosis and increased threshold of in humans quickly raised at altitude (mountain
auditory sensation. These conditions are charac- climbing, high-altitude flights, rise in hyperbaric
terized mainly during decompression from high to chambers, etc.) associated with reduced PO2. Ap-
normal atmospheric pressure. As manifestations of pearance depends on many factors, such as fre-
chronic disbarizam (but insufficient epidemiological quency of ascents, length of stay, level of physical
support) must also disclose: signs of emotional in- activity, individual susceptibility.
stability and impaired short-term memory; EEG ab- The development of AS to establish a number
normalities; changes in the pigment and the vessels of disturbances in metabolism, with accumulation
of the retina; reduced vital capacity. in the cells of lactic and pyruvic acid and violation
At the height meteorism stomach swells, dia- of intracellular homeostasis- decrease in pH and
fragmeta shifts up, the heart takes a horizontal changes to the selective permeability of cell mem-
position, breathing is difficult; reflex irritation of branes, which determines the early development
mechanoreceptors in the gut causes various gastro- of morphological changes. AS occurs most often in
intestinal and autonomic disorders - infringement of the first few hours after rapid ascent to a height of
coordination of movements, pallor, sweating, palpi- over 2,500 m. Described are two main forms of alti-
tations and others. tude sickness: precolapse, which occurs at relatively
Boiling of the liquid (blood). At a height of moderate deficit of O2 - at height 5000-6000 m, at
19,200 m in lowering the air pressure to 47 mmHg and a collapse - occurring in significant deficit O2 at
and a temperature of 37 ° C water (resp. blood) boil. heights around and above 7000-10000 m.
Boiling occurs more quickly in regions of the body Precolapse form of AS occurs in healthy people
with low pressure - veins, right ventricle of the heart, of the 5th to the 30th minute after climb 4000-6000
the pleural cavity, subcutaneous tissue, which oc- m. Persons noted poor self-esteem, headache, ma-

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laise (fatigue); “warm feeling” in the body or head, irritability, insomnia, ataxia, hallucinations, paresis,
vertigo, tinnitus; shortness of breath, wheezing; loss coma. Ophtalmoscopic examination may show pap-
of appetite, often accompanied by nausea and vom- illoedema, retinal haemorrhages. Brain edema can
iting. Changes in appearance and behaviour, facial be combined with pulmonary.
features sharpen, eyes appear sunken, increased in Treatment of AS: The most effective is lowering
early locomotor activity and euphoria are replaced the patient at a lower height and to be carried out
with common inhibit, posture became rigid, all com- at a moderate speed. At impossibility is necessary
mands and instructions are perceived slow and per- to ensure oxygen or carbogen (oxygen with 3-7%
form reluctantly. If you do not provide O2 feeding CO2) to overcome hypoxemia and restore breathing.
status could sharply deteriorate in loss of conscious- Humidified oxygen therapy with 100% oxygen be-
ness. Serious indications of deterioration are the re- gins initially with a mask or nasopharyngeal probe.
duction in heart rate and blood pressure, a decrease In severe cases are shown endotracheal intubation,
in cerebral blood flow. artificial or assisted mechanical ventilation for a pro-
Collapse form. In the mechanism of the devel- longed period.
opment of the collapse response, plays an essential Upon occurrence altitude pulmonary edema is
role and hypocapnia, which may explain the ab- shown giving large doses of corticosteroids - 30 mg/
sence of therapeutic effect within the first minutes kg Urbazon (Methylprednisolone) for 6 hours for 48
after O2 feeding. to 72 hours. We need a proper water balance, nor-
Loss of consciousness occurs suddenly or may be mal import of liquids and in increased pulmocapil-
preceded by clonic cramps. Around and over 15,000 lary pressure-diuretic.
m hyperacute disease occurs, with loss of conscious- Mastery of hypercapnia (if any) is achieved by
ness of 12-15 s after the rise. A height of 7000-7500 correct disobstruction, applying respiratory ana-
m course of the disease depends on the individual leptics - eg. Mikoren 1-4 ampoules at 250-350 ml.
resistance - from 2-3 to 20-30 min or more. glucose-salt solution. Good effect is achieved with
Collapse form of AS develop without expressed novphylline - 1-3 ampoules added to this mixture.
harbingers - person loses adequately respect to the Cardiotonics should be used carefully, since in
surrounding environment, does not notice the mis- hypoxemia their therapeutic width narrows - recom-
takes made in the implementation of psychophysi- mended that about 1/3 of the normal dosage.
cal tests or solve simple arithmetic problems, noted To reduce the risk of thromboembolic compli-
a violation of the handwriting. Often found retro- cations are recommended anticoagulant agents
grade amnesia - do not remember the circumstanc- - heparin 5000 E in 6:00 h under the skin for 8-10
es prior to loss of consciousness and even reported days, after which continues with indirect coagulant
that they felt better. - antistenocardin 3x2 table or 3x1/2 tablets. Symp-
Serious complication of AS is high-altitude pul- tomatic drugs - analgesics and vitamins of the E, C,
monary edema. It affects 0.5 to 2.0% of those over B1, B6, PP (for stimulation of the oxidation processes
2700 m, and is the most common cause of death and to facilitate the resynthesis of codehydrase and
from altitude sickness. It grows 6 to 96 hours after cocarboxylase systems in the brain).
the climb. The pathogenesis associated with in- Mountain sickness.
creased pressure in the pulmonary vessels and in- For the first time - in 1590, data for this disease
creased permeability of the same (pulmonary hy- presents J. de Acosta to residents in the Andes at
pertension as a result of altitude hypoxia, is present 4000 m - now called Monge’s disease * - chronic
in all individuals of high altitude, incl. and those who mountain sickness at insufficient acclimatized resi-
did not develop pulmonary edema). dents, but not in permanent Andes residents. Men
The symptoms are like in AS, combined with re- are affected more often than women. It is character-
duced tolerance to physical loading and prolonged ized by a plethora, cyanosis, an increase in the mass
recovery period, shortness of breath, persistent of red blood cells, neurological symptoms - head-
cough, cyanosis of nails and lips. Early diagnosis of ache, dizziness, somnolence and memory impair-
pulmonary edema is very important to reduce mor- ment. Sufferers often develop corpulmonale, due to
tality. increased pressure in pulmonary vessels and reduc-
The most severe complication of altitude sickness tion of oxyhemoglobin saturation. The pathogen-
is a high-altitude cerebral edema. The pathogen- esis is not fully understood - studies show low hy-
esis is the same as AS - hypoventilation, increased poxic ventilatory response, pronounced hypoxemia,
cerebral blood flow and intracranial pressure, lead-
ing to cerebral edema. During disease progression * Carlos Monge Medrano (1884-1970), Peru. Institute of Biology
was added neurological symptoms, incl. increased of the Andes

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increasing during sleep, high-HB concentration and the climb high ASL is useful adoption of Diamox (Ac-
increased pulmonary artery pressure. Many of the etazolamid) - it inhibits the action of carbonic anhy-
symptoms can be managed when driving at sea lev- drase in the kidneys, which lead to acidosis in the
el. This change (decrease) hypoxic stimulus for the blood and stimulate breathing.
production of red blood cells and pulmonary vaso- Health considerations in organizing work
constriction. The therapy involves the submission of in high altitude. Workers at high altitude have to
O2 during sleep (to control the hypoxia), Medroxy- spend a few days of 3000-4000 m, and then a few
progesteron (respiratory stimulant) - at 10 weeks days at sea level. The most acceptable options to
therapy of it improves ventilation, hypoxia and re- shift modes are: 7 days work and seven days rest (or
duces the number of red blood cells. 10 days working with 10 days rest). Thus not reached
full acclimatization at high, and also full disaclimati-
6.8.3. PREVENTION OF ALTITUDINAL zation at sea level.
DISABILITIES Medical contraindications for work at high alti-
tudes are chronic bronchitis, COPD and asthma; hy-
Increasing resistance to human hypoxia means pertension, anemia, polycythemia; diseases of the
preliminary training in natural and artificial hypox- gastrointestinal tract; mentally unstable persons.
ic conditions - alpine climbing or training in hyper- Appropriate tests are: spirometry, lung X-ray, assess-
baric chambers. Stay in alpine conditions for several ment of physical fitness, ECG when resting and after
days or weeks to develop height resistance allowing physical load. Altitudinal testing the flight staff car-
trained to rise to a height of 8500 m without oxygen ried out in hyperbaric chambers. Assess tolerance to
and also endure oxygen starvation of height 7000 m moderate hypoxia, imitate the conditions of a height
within a few days. So acquired acclimatization in in- of 5000 m. The rating is “good” and “reduced - I, II, III
dividual fluctuations kept for relatively short period degree.” At a reduced assessment is not allowed air-
of time and gradually disappears. Before or during manship and repeat the test.

REFERENCES

1. De Hart, R.L. Low-Pressure and Hypoxic Environments. In: Physical and Biological Hazards of the Work-
place. Ed.P. H. Wald, G. M. Stave, Van Nostrand Reihold, N.Y., 1994, p.148-156
2. Dummer W. Barometric Pressure, Reduced. In: Dempsey, J.A., H.V.Forster. Mediation of ventilatory ad-
aptations. Physoil. Rev., 1982, 62, 2622-346
3. Gazenko, O.G. Phisiology of Man at High Altitudes. Moskow: Nauka, 1987 (in russ.)
4. Heath D., Williams D. R. Man at High Alitude: The Pathophysiology of Acclimatization and Adaptation.
Edinburg, Scotland: Churchill Livingstone, 1977
5. Kosmolinskiy F.P., EI Kuznits. Influence of body of low barometric pressure. In: Guide for hygiene
labour V. 1 ed. F.G. Krotkov, Medicine, 1965, 473-506 (in russ.)
6. Rom, W.N. High-altitude Environments. In: Environmental and Occupational Medicine. Ed.W.N.Rom,
Little, Brown & Company, Boston, 1983,725-732
7. Tocheva V. Diseases conditioned by the decrease in atmospheric pressure. In: Physical environmental
factors. ed. E. Efremov, Med. and phys., Sofia, 1988, p. 74-76 (in bul.)
8. Ward, M.P., J.S. Milledge and J.B.West. High Altitude Medicine and Phisiology. London, Chapman &
Hall, 1995

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 D.Dimitrov, S.Sabeva

6.9 INCREASED ATMOSPHERIC PRESSURE

The normal functioning of the human body is in the lungs (the effect of Lorrain-Smith). Symptoms
a relatively narrow range of barometric pressure. At of this toxicity are substernal chest pain; dry, non-
high atmospheric pressure leading to physiologi- productive cough; decline in vital capacity; loss of
cal stress and related illnesses are subjected and production of a surfactant. In continuing exposure
ground workers at digging tunnels requiring use of establish microhaemorrhage with subsequent for-
compressed air or operating caissons (laying foun- mation of permanent fibrosis in the lung. All stages
dations of bridges, water towers, oil drilling, etc.). of oxygen toxicity to microhaemorhagic state are re-
Also personnel of hyperbaric chambers used to versible formation of fibrosis, the process becomes
treat patients (operations with hyperbaric oxygena- irreversible.
tion, presence of treatment with recompresion etc.). Oxygen can be breathed at a pressure lower than
More common is the high barometric pressure un- 0,6 ata* without ill effect. When 100% oxygen is in-
der water - divers (eg. removing the pearl mussels, haled under 2 ata (10 m pressure seawater), early
athletes) divers using aqualungs, divers performing signs of oxygen toxicity is manifest after about 6
various activities at different depths (eg. 300 m, and hours. The measurement of vital capacity seems to
more in the exploitation of oil drilling in the sea). be the most sensitive indicator of early oxygen tox-
Historically one of the first practical methods for icity.
underwater work are created by Smeaton (1778) At a pressure higher than 2 ata, pulmonary oxy-
underwater bells predecessors of current caissons gen toxicity loses its primary importance on account
- used then and now as laying the foundations of of cerebral oxygen toxicity, a major manifestation of
bridges (vertical caisson), and in digging of under- which seizures. If one should breathe 100% oxygen
water tunnels (i.e. horizontal caissons). In 1819 in at a pressure of 3 ata for more than 3 h, the proba-
England created the first suits with air supply pres- bility to get fit type grand mal is significant. There
sure - from the surface to perform underwater work are some factors that enhance the toxicity of oxygen
by divers. At the same time appeared the first mes- and reduce the seizure threshold: physical exercise,
sages (Triger, 1841) for decompression disabilities use of steroids, temperature conditions, cooling, ac-
(caisson disease) when working in horizontal cais- ceptance of amphetamines, hyperthyroidism.
sons. In 1908 the English physiologist J.S. Haldane Taking medicines that suppress the production
developed the first decompression tables for the of seizures, such as phenobarbital or phenytoin, did
prevention of caison disease, known as the DCIEM not reduce damage to the brain and spinal cord, if
tables * - based and currently used tables. the pressure or time are exceeded (Table. 1).
Carbon monoxide can be polluting the atmos-
6.9.1. TOXIC EFFECTS OF INCREASED phere at work in caisson or under water. Most often
ATMOSPHERIC PRESSURE sources of internal combustion engines used for
compressors or other devices near them.
It is normal atmospheric air contains 20.93% oxy- Early symptoms of carbon monoxide poisoning
gen. The human body is adapted to breathe atmos- include headache, nausea, dizziness and general
pheric oxygen at a pressure of about 760 Torr (760 weakness. Carbon monoxide binding to hemoglo-
mm Hg) (160 Torr partial pressure of O2) at sea level. bin block oxygen transfer and has a lethal effect.
The organism is able to withstand a relatively wide Recent studies indicate, however, the direct effect of
range of variations in pressure of oxygen without CO on cell membranes, and induced lipid peroxida-
significant disability for a short period of time. Pro- tion (a major cause of death) can be interrupted only
longed exposure can lead to oxygen toxicity. by inhalation of oxygen.
On the surface of the earth person can breathe
* Ata - absolute atmosphere equal to the sum of the pressure
continuously without risk 100% oxygen between 24 of the air column at sea level and that of the water column (ie.
and 36 hours. Then oxygen exerts its toxic effect on additional pressure - ati). 1 atm (physical or normal) = 1,013 at
(technical) = 1,033 kg/m2 = 10,33 m of water column = 760 Torr
* DCIEM - Defence and Civil Institute of Environment Medicine (760 mm Hg) = 1,013 bar = 1013 hPa (unit SI)

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It must be ensured taking air at a height above By increasing the atmospheric pressure, the con-
the tailpipe of the compressor. To monitor for possi- centration of nitrogen in the blood increases, and it
ble change in wind direction. acts as an aliphatic anesthetic (nitrogen narcosis),
Carbon dioxide is a normal product of metabo- the level of anesthetic effect depends on the ratio
lism and is eliminated through the lungs. Different of the solubility of the oil/water. Nitrogen causes a
types of respirators, however, can disrupt its separa- slight swelling of the cell membrane of the neurons,
tion or cause high concentrations in the breaths of which increases its permeability with respect to the
air divers. ions of sodium and potassium. Violations during
At high concentrations (above 3%) it can cause normal depolarization/repolarization is the basis of
errors in the ability to assess what initially appears clinical symptoms of nitrogen narcosis.
as unjustified euphoria, while prolonged exposure Work in water depths up to 50 m can be achieved
such as depression. If the concentration continued with compressed air (78% nitrogen). At depths
to increase (above 8%) could be observed loss of greater than 50 m, for avoiding effects of nitrogen
consciousness (Table. 1). At a partial pressure above narcosis is most commonly used mixture of helium
40 mm Hg, carbon dioxide and deteriorating exacer- and oxygen.
bating the effect of the impact of nitrogen narcosis.
When breathing 100% oxygen at a pressure above 6.9.2. OTHER EFFECTS OF THE
2 ata, with the increase of the CO2 concentration INCREASED PRESSURE
the risk of obtaining a seizure (convulsion oxygen)
greatly increases. In the pressure change in the external environ-
Nitrogen is an inert gas that is related to the nor- ment during compression there occur the so-called.
mal metabolism in the body. disbarizam - no mean while change in the pressure
Table 1. Toxic effects of gases on divers
Gas Reasons (sources) Symptoms
Narcosis of inert ■ Increased partial pressure of inert gas ■ Dizziness
gas ■ Diminished ability to think clearly
■ Loss of fine dividing power

■ Euphoria
■ Slowed reflexes
■ Impaired ability to assess
■ Paresthesia
■ Progressive depression
■ Auditory/visual hallucinations
■ Memory loss
■ Loss of consciousness
Oxygen toxicity ■ > 1,3 ata partial pressure of oxygen ■ Disturbances in vision
■ The risk increases with increasing partial ■ Reduced visual acuity
■ CNS (acute) pressure ■ Nausea/vomiting
■ Twitch
■ Irritability/fatigue
■ Dizziness
■ Convulsions (may occur without prodromal
symptoms; no long-term consequences)

■ Pulmonary ■ Prolonged exposure of> 0,5 ata oxygen ■ Chest pain when inhaling
(chronic) ■ Breathing difficulties
■ Cough
Progressive dyspnea
Hypoxia ■ Hyperventilation prior to diving and hold air ■ Loss of consciousness (without symptoms)

■ Wrong gas mixture

Toxicity ■ Constructioin of tools ■ Increased respiratory rate
СО2 ■ Increased gas density ■ Asthma
■ The increased partial pressure of oxygen ■ Headache
blunted response to CO2 ■ Loss of consciousness
■ Increased content of CO2
■ Using inappropriate means to grease the ■ Headache
compressor (flammable) ■ Nausea/vomiting
Toxicity
■ Error compression ■ Loss of consciousness
СО
■ Incorrect position of the hole for air intake
(eg. near the compressor)

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of the external environment and cavities of the hu- During the compression tension of breaths and
man body - primarily in the middle ear and the skull located in the arterial blood inert gas (mostly nitro-
as a whole. This is expressed with symptoms - pain in gen) increases. The inert gas (es) is transferred to the
the ears, in the eyebrows and forehead, barotrauma tissues until a balance between its tension in the
- bleeding and rupture of m. tympani, bleeding from inspired air, arterial blood and tissues. The time for
the nose and ears. These conditions of the middle this ranges from 30 min to more than one day, de-
ear occur most frequently in abnormal conduction pending on the tissue type and the inert gas, and
of the Eustachian tubes (inflammation, allergy). The also depends on:
earliest symptoms are decreased auditory sensa- ü Blood supply to the tissue;
tion, followed quickly by severe pain in the ears (to ü The solubility of the inert gas in the blood
intolerance). It may also be observed and dizziness, and in the tissue;
headache, nausea, irritation as a consequence of the ü The spread of inert gas through the blood
inner ear. to the tissue;
When operating at high pressure (and its align- ü The temperature of the tissue;
ment) man adapts relatively quickly, but there are ü The workload of the tissue;
changes in voice timbre (tone deaf ), a decrease in ü Tension of tissue carbon dioxide.
auditory sensitivity, as well as skin sensitivity, dry- In subsequent decompression process is re-
ness of mucous membranes of the upper respirato- versed, and the rate of release of gas is determined
ry tract. The diaphragm is lowered, increased vital by the above factors, but the process proceeds more
capacity, reduce the frequency of breathing, heart slowly compared with its receipt. In slow decom-
rate and cardiac output (at rest). Efficiency is slight- pression gas is exhaled, but in fast form bubbles in
ly increased, there was a slight increase of muscle the tissues and blood vessels.
strength and endurance. The second primary mechanism by which de-
As regards the influence of compression on the compression can cause disabilities is barotrauma (it
cardiovascular system describes a decrease in sys- can occur both compression and decompression).
tolic pressure and increase in diastolic (during de- Classification. Until recently decompression dis-
compression - back). Are described and ECG chang- eases are classified as:
es with reversible character - bradycardia, a decrease – barotrauma
of P and T increases peak. – cerebral arterial gas embolism
Studies on the blood changes establish so-called – decompression disabilities – 3 types: Type
caisson anemia - reduced content of HB, eryth- 1 (pain and rashes on the skin); Type 2 (all other
rocytes in an increased number of leukocytes and events); Type 3 (appearances as cerebral arterial em-
lymphocytes and the development of reticulocyto- bolism, and the decompression disabled) - Table. 2.
sis. These results, however, not always be confirmed. A new classification of decompression illness was
There are also conflicting results regarding changes in established because of the difficulty in the distinc-
metabolic processes with high atmospheric pressure. tion between cerebral arterial gas embolism and
Some authors reported and amplified gastric motili- brain decompression complaints and between de-
ty at a reduced secretory activity; reduced diuresis at compression disabilities Type 1-3. Now all decom-
relatively low compression (1-2 ati) and increased at pression illness only be classified as such (Table. 3).
higher pressure (4-5 ati); changes in the absorption of Barotrauma. During each compression space
phosphorus and glucose in the small intestine, etc., filled with gas can be included in barotrauma and
i.e., a variety of changes, but not always verified and this applies particularly to the ears. Most often dam-
substantiated pathogenetically exactly. age the tympanic membrane and the middle ear.
This type of injury occurs more frequently in work-
6.9.3. DECOMPRESSION ers with pathology of the upper respiratory tract
and Eustachian tube dysfunction. The possible con-
Decompression disorders may impair working sequences are increased pressure in the middle ear
under high pressure through one of two primary and/or rupture m. tympani. Often occur ear pain and
mechanisms. The first is due to the adoption of the conduction deafness. Upon entering the cold water
gas during compression and formation of bubbles in the middle ear in impaired membrane can occur
in the tissues and vessels (venous, arterial) during nausea, vomiting and dizziness transient. More of-
and after subsequent decompression. It is generally ten, vertigo (and possible also sensoneural deaf-
accepted that metabolic gases, oxygen and carbon ness) is the result of barotrauma of the inner ear.
dioxide have no attitude (and relevant) to the forma- Paranasal sinuses are also often affected, usually
tion of blisters. due to blocked foramen. To local pain here is added

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Tab. 2. Clinical picture of the main types of decompression disorders
Type 1 Type 2 Type 3
Mainly affects the limbs It affects the central and peripheral nervous system. Aseptic necrosis of bone, the
and skin. The most frequently manifests as: most common
The most frequently ■ Stabbing and needles "paresthesia ■ The head or the body of the
manifests as: ■ Hypoesthesia humerus
■ Acute pain around the ■ Dizziness ■ More rarely, the long end of
big joint. Can begin ■ Hyperreflexia the femur or tibia head
immediately or 12th hour ■ Ataxia
after decompression. ■ + Babinska It was found 6 to 60 months
■ Paralysis or weakness in the limbs after decompression and is
■ Sometimes it is ■ Headache asymptomatic, the inclusion
accompanied by hives ■ Seizures of the joints - mostly
and itchy skin ■ Vomiting symmetrically.
■ Loss of vision or visual field deficit ■ Increased frequency of
violations in memory
■ Incontinence ■ Retrograde amnesia
■ Impaired speech ■ Emotional instability and
■ Tremor others neurotic and psychotic
■ Coma symptoms in divers spent
decompression sickness
Pulmonary System:
■ Substernal pain
■ Chest tightness
■ Severe cough
■ Dyspnoea
■ Pulmonary edema

Cardiovascular:
■ Arrhythmia
■ Hypertension

May have significant consequences such as:

■ Obstruction of vessels and tissue infarction, which is
sometimes accompanied by:
– haemoconcentration,
– changes in osmotic pressure or fat emboli,
– hypercoagulable blood

and epistaxis. Rarely are damaged lung, teeth, intes- Decompression disorders (“caisson disease”)
tines and others. due to blistering in the tissues or blood vessels, is
Decompressive barotrauma occurs rarely com- typically manifested within a few minutes or hours
pared with compressive, but there heavily conse- after decompression. The natural history of many of
quences. It operates primarily in the lung and inner these decompression illness ends with spontaneous
ear. The gas discharged from the damaged lung improvement. In some cases, however, spontaneous
may pass through the interstitium to the hilus of the recovery is partial and needs treatment.
lungs, mediastinum and even to the underlying tis- The most common manifestation of decompres-
sues of the neck and head. This interstitial gas can sion disease is a form of influenza-like illness. Oth-
cause dyspnea with substernal pain and cough with er common complaints are different sensory dis-
sputum with blood. The compression of the heart is turbances, local pain, especially in the extremities
extremely rare. Gas from the traumatized lung can and other neurological symptoms associated with
pass also in the pleural space (pneumothorax) or in sensory and motor fatigue (fewer prejudice skin
the pulmonary veins (and possibly to obtain arterial and lymphatic system). For some groups, the most
gas embolism). common complaint is pain - in fixed joint or joints,
Tab. 3. Revised classification system for decompression illness (in Dees F. Gorman, 1998).
Duration Evolution Symptoms
Acute Progressive Musculoskeletal
Chronic Spontaneous recovery Skin
Static Lymphatic Decompression
Repeated Neurological disease + or -
Vestibular Availability of
Cardiac and respiratory barotrauma

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back pain and rarely can be observed unspecified Compression early to be slow by systemic pressure
crumble pains. equalization airways cavities with external pressure.
Manifestation of decompression illness is diverse. In manifestation of deaf or ear pain, compression
Any disease of working in conditions of high pres- stops and reduced. It is repeated when symptoms
sure that occurs to 24-48 h post decompression may disappear. At the reappearance of complaints com-
be associated with decompression (until proven pression is terminated.
otherwise). To prevent the occurrence of decompression
The development of treated decompression barotrauma to the lungs is necessary to meet the
illnesses is different. In some cases the residual phe- following requirements:
nomena can be overcome in the next 6-12 months, • use of properly scuba equipment;
while others complete recovery does not occur. • do not hold breath at exits on surface;
The treatment of the majority of decompres- • do not allow people under water with cough,
sion illness is rekompresiya in hyperbaric chambers. regardless of its nature;
An exception to this rule is barotrauma (when not • be strictly observed decompression schemes.
cause arterial gas embolism). In patients with ear Medical prevention. Underwater work allowed
barotrauma required number of outpatient exam- people practically completely healthy, high physical
inations, application of means, ability to relax the and neuro-psychological resistance. Current medi-
nose, pain, and suspicion of barotrauma and inner cal examinations were 12 months. The commission
ear - compulsory treatment of bed. includes therapist, ORL specialist, neurologist and
In barotrauma to the lung of applying 100% ox- ophthalmologist at indication and orthopedist and
ygen at the level of the atmospheric pressure has a radiologist. It must be investigated Hb, by indication
beneficial effect. - leukocytes, B.S.R., X-ray of lung and large joints, os-
The pressure (rekompresiyata) to treat decom- cillography.
pression sickness it is not definitely known, al- Decompression. Schemes of decompression
though a conventional first choice is 2,8 bar abso- (Table. 4) determine the time for decompression of
lute pressure (282 kPa). In low affect of symptoms a person who has been exposed to high pressure,
is prolonged by a further compression of 4 to 6 bar depending primarily on the depth, and duration of
absolute pressure. Mixtures of oxygen and helium exposure, the gas mixture and others. None scheme
may be more effective in comparison with ambient of decompression can not guarantee absolutely
air or 100% oxygen. avoid decompression sickness (bubbles form in any
Again exhibiting symptoms of decompression normal decompression), but the longer full decom-
sickness are frequent and most workers have to be pression is, the more rare is decompression sickness.
recompressed. This continues until deviations are Most modern decompression schemes are based
removed or until two consecutive courses of treat- on mathematical models that anticipate the develop-
ment had no positive effect. One year after it is held ment of decompression sickness <1-5% for workers.
X-ray search disbaric osteonecrosis (aseptic necro- Habituation or acclimatization was observed in
sis) of long bones. divers and those working with compressed air, which
As a general effects of decompression sickness makes them less sensitive to compression and de-
can be identified (in decreasing frequency): depres- compression effects after repeated exposures. Toler-
sion; problems with short-term memory; sensory ance can be seen in daily exposure for one week and
symptoms; micturition and sexual offenses; and lost after an absence from work between 1-4 weeks
vaguely aches and pains. or at sudden increase in pressure ( “addiction” does
Many of those working in conditions of high pres- not mean a complete adaptation of the body).
sure can return to their work at least one month after Other preventive measures here are: quantity
decompression sickness. They should not be allowed and quality of supply air pressure to meet the regu-
to work but workers with pulmonary barotrauma or latory requirements, the use of pure oxygen or heli-
evidence of chronic severe injury to the inner ear. um-oxygen mixture to a rapid decompression and re-
moval of nitrogen narcosis; preventing cooling of the
6.9.4. PREVENTION OF COMPRESSION body; annealing and training; technological and sani-
AND DECOMPRESSION DISABILITIES tary-technical means for removing other harmful - oil
vapors and aerosols, dust, metal aerosols (welding),
To prevent compression barotrauma of the insufficient lighting, noise, vibration, risk of physical
ear and paranasal sinuses should not be allowed injury, fire, etc .; protective professional nutrition with
compression at inflammation of nasopharynx, weight control; the possibility of constant medical su-
poor conduction of the Eustachian tubes, rhinitis. pervision and use of hyperbaric chambers.

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Tab. 4. Decompression tables. Norms for decompression in one-shift operation in caisson
(a S.V. Alexeyev and V.R. Usenko, 1988; V.K. Navrotskiy, 1974)

Pressure in the First phase of decompression Second phase of decompression

Total time
working chamber Up to what level is reduced Duration Duration in minutes in minutes
in ati pressure in ati in minutes
1,3 0,3 4 8 12
1,4 0,4 4 10 14
1,5 0,5 4 12 16
1,6 0,6 4 14 18
1,7 0,6 4 16 20
1,8 0,7 5 18 23
1,9 0,7 5 21 26
2,0 0,8 5 24 29
2,1 0,8 5 27 32
2,2 0,9 5 30 35
2,3 1,0 5 33 38
2,4 1,0 5 36 41
2,5 1,1 5 39 44
2,6 1,1 5 42 47
2,7 1,2 5 45 50
2,8 1,3 5 48 53
2,9 1,3 5 51 56
3,0 1,4 6 54 60
3,1 1,4 6 57 63
3,2 1,5 6 60 66
3,3 1,6 7 63 70
3,4 1,7 7 66 73
3,5 1,7 7 69 76
3,6 1,8 7 72 79
3,7 1,9 7 74 81
3,8 1,9 7 76 83
3,9 2,0 7 78 85

REFERENCES

1. Alekseev S.V., B.P. Usenko. Increased atmospheric pressure. in: Hygiene of labour, 1988, M., Medicine,
124-133. (in russ.)
2. Calder, I.M. Dysbarism: A review. Foresenic Sci. Int., 1986, 30: 237.
3. Elliott D.H., R.E. Moon. Long term health effects of diving. eds.: Bennette P.B., Elliott D.H., in. The phys-
iology and medicine of diving, 4th ed., Philadelphia: W.B. Saunders, 1993, 585-604.
4. Farmer, J.C. Vestibular and auditory function. eds.: Shilling, C.W., C.B. Carlston, R.A. Mathias, in. The
physician’s guide to diving medicine. New York, Plenum, 1984, 192-198
5. Gorman, Dees F. Decompression Disorders. In: Encyclopedia of Occupational Health and Safety. Fourt
edition. ed. J.M. Stellamn. International Labour Office, Geneva, 1998, pp. 36.9-36.13.
6. Kindwall E. Working under Increased Barometric Pressure. In: Encyclopedia of Occupational Health
and Safety. Fourt edition. ed. J.M. Stellman. International Labour Office, Geneva, 1998, pp. 36.2-36.9.
7. Kizer, K.W. Diving medicine. Emerg. Med. Clin. North Am., 1984, 2: 513.
8. Navrotskiy V.K. Increased atmospheric pressure. in: Hygiene of labour (sec. edition), 1974, M., Medi-
cine, 106-113. (in russ.)
9. Precis de medicine de travail. Atmosphère comprimée. Sous de dir. H. Desoille, J. Scherrer, R. Truhaut.
Masson, Paris, 1991, pp. 555-568.
10. Rozanov L.S. Increased atmospheric pressure. in: Guide for hygiene of labour V. I, ed. F.G. Krotkov, M.,
Medicine, 1965, 415-472. (in russ.)
11. Smith D.J. High - pressure environments. In: Physical and Biological Hazards of the Workplace, eds
Wald P.H., G.M. Stave, N.Y., Van Nostrand Reinhold, 1994, 125-147.
12. Tocheva V. Atmospheric pressure. in: Physical environmental factors. ed. E. Efremov, 1988, Sofia Med.
and phys., 68-74. (in bul.)

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 D.Dimitrov, S.Sabeva

6.10 GRAVITY, ACCELERATION, AND

MICRO-GRAVITY (WEIGHTLESSNESS)1

Nowadays, aviation and spaceflight are essen- The direction of acceleration against a human
tial high technological international activities. Data body is described through the three axes – x, y, z,
show that from 1960 to 1989 the average annual where z is a vertical axis (parallel to the long axis of
number of passengers in civil aviation regular un- the body), x is pointing forehead/nape and y is ori-
derway flights has increased from 20 to 900 mil- ented from side to side. Accelerations can be catego-
lion. people. Now data are: 928 mill. in EC for 2015 rized into two main types: permanent and transient.
- growth 22% to 2009; 1,7 bill. in World for 2012 - an- Constant acceleration. Prolonged changes in
nual growth 5%. Air Force Aviation is a high part of velocity leading to acceleration lasting more than 2
the armed forces of most nations. Advances in avia- s may be established for changes in the direction of
tion technology contributes to the development of flight and speed of the aircraft.
space programs involving humans. The biological effect of constant acceleration is
Impact on the health of the crew, passengers and the result of deformation of the tissues and organs
astronauts than the reduced oxygen concentration of the body, changes in blood flow and the distribu-
in the air, have a number of physical factors such tion of body fluids.
as reduced air pressure, heat stress, acceleration, In civil aviation acceleration axis z (Gz) can occur
gravity, weightlessness, vibration, noise, ionizing randomly and moderately during take-offs or land-
radiation and others. ings or flying in turbulent environment. In these
cases, passengers may fall short in a state of weight-
6.10.1. GRAVITY AND ACCELERATION lessness, due to sharply downgrade (negative Gz). In
unfastened seat belts that can lead to injuries.
Combination of gravity and acceleration occur- Positive or directed to head acceleration axis z
ring during flight in the atmosphere has a variety of (+Gz) is the largest physiological problem.
physiological effects on the crew and passengers. Management of high-speed military aircraft and
On the surface of the Earth gravitational forc- aerial acrobatics can generate much higher linear,
es act on all forms of human physical activity. The radial and angular accelerations. Indicated are the
weight (mass) per person corresponds to the force positive accelerations - from 5 to 7 G lasted for 10 to
with which the earth’s gravitational field acting on 40 s. The crew can experience a sense of increasing
it. The magnitude of the acceleration of freely falling the weight of the tissue and limbs even at relatively
object on Earth’s surface g = 9,8 m/s2. low levels of acceleration of +2 Gz.
Acceleration occurs when an object in motion in- The most important system of the body to de-
creases his speed (accelerated). Deceleration leads to termine its tolerance limit in response to + Gz is
acceleration of the opposite direction. cardiovascular. The impact of positive acceleration
There are three types of acceleration: on vision and mental performance due to reduced
1. Linear - changes in speed without a change in blood supply to the eyes and brain. This can cause
direction; temporary loss of peripheral vision to complete loss
2. Radial - change in direction without a change in of vision or complete loss of consciousness. Cardi-
the speed - an example of this type of accelerations ac arrhythmias occur after exposure to high levels
are those that arise in the course of virage (flight in a of persistent + Gz acceleration, but they are usually
closed circle) or making figures of the complex and minimal clinical importance in healthy and trained
aerobatics example loop. people.
3. Angle - changes in speed and direction. Negative Gz rarely establishes for the design and
In aviation applied accelerations most often ex- implementation of aircraft. Physiological effects as-
pressed in the unit G, expressing the attitude of the sociated with -Gz originally lead to an increased vas-
applied acceleration to the gravitational constant cular pressure in the upper half of the body, head
(9.8 m/s2). and neck.
Constant accelerations acting at right angles to
1
As a problem of aviation and aerospace medicine the long axis of the body are called transverse ac-

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celerations and are relatively rare in most situations 6.10.2. PREVENTIVE MEASURES
in aviation - for example in ejection. Accelerations in
these operations are relatively small and the effects To enhance crew tolerance to the effects of ac-
are less pronounced than those of the acceleration celeration and hyper gravitation use complexes of
Gz. physical and physiological methods and means:
The lateral accelerations axis ± Gy are much rarer Physical (mechanical) methods:
than those in experimental aircraft. • safety (anti over load) clothings;
The biological effects of acceleration on the de- • adjustable seats;
gree of markedness are minor functional changes • systems for breathing oxygen under pressure;
to severe functional and structural damage, loss of • immersion systems.
consciousness and death. There is a variety of sub- Physiological methods:
jective symptoms - feeling overrides, difficulty in • hardening and physical training;
movement to impossible to move, pain sensations, • training in a centrifuge;
etc. Change are functions of external breathing - • muscle tension;
shortness, increased pulmonary ventilation, but can • procedures (maneuvers) M-1 and L-1 (con-
be monitored and atelectasis and puffiness in the troled intension breathing);
lower parts of the lungs, decreased blood saturation • adaptation to hypoxia;
with oxygen, developing hypoxia. As a stress fac- • pharmacological agents;
tor acceleration causes early changes in the central • professional selection and medical supervi-
nervous system - changes in EEG with phase char- sion.
acter and appearance of delta waves. Described are Preliminary medical examination of crew mem-
the early phase changes in the functions of: endo- bers to detect diseases are essential in aeromedical
crine glands - an increased level of catecholamines program.
and norepinephrine; gastrointestinal tract - changes Crews must be trained to recognize different
in the secretory and motor functions; urinary system physiological conditions, which can reduce their tol-
- oliguria, but and polyuria; biochemical and mor- erance to G stress - fatigue, dehydration, heat stress,
phological blood changes. hypoglycemia and hypoxia.
Transient acceleration. Many factors influence The crews of high-speed aircraft used three types
the tolerability of man to short accelerations. These of procedures (maneuvers) to reduce the harmful
are: the magnitude and duration of the applied forc- effects of constant acceleration during the flight.
es; initial magnitude of the applied force; its direc- Forced contraction of the muscles, especially in the
tion and site of application. People can withstand legs, abdomen and shoulder girdle increases pres-
much greater forces when they are perpendicular to sure on blood vessels, contributing to a return ve-
the long axis of the body (the axes of x and y). nous blood, reducing its landfill in the lower half
Physiological responses of the crew and passen- of the body, resulting in increasing resistance to
gers of brief (transitional) accelerations are essential accelerations in 1.5-2.0 G. Exhaling against a closed
for the prevention of air accidents and to protect the glottis, called the Valsalva maneuver (or M1 proce-
crew and passengers. dure) can increase the pressure in the upper half of
Human tolerance to sudden deceleration (often the body and increase it in the chest. These results,
less than 1 s) of occurrence of mechanical* disabili- however, are short-lived and may even be harmful if
ties resulting for deformation of tissues and organs the procedure lasted longer due to reduced return
and consequently for blow to the structural parts of venous blood to the heart. Breathing against
of the aircraft’s is variable value. The nature of the positive pressure (50-70 mm Hg of air mixture with
mechanical trauma depends on the applied forces 40-50% oxygen) is another method of enhancing in-
(whether involve penetration or blunt impact). The trathoracic pressure. Through it increases blood flow
forces are divided into manageable, traumatic and to the eyes and brain and reduces hypoxia.
fatal. Tolerated forces lead to mild traumatic injuries Military crews use a range of training methods
(scrapes and bruises) and traumatic forces - to mod- to increase the G-tolerance as a spin in a centrifuge
erate or severe injuries, which, however, does not that generates different + Gz acceleration. This work-
always lead to complete loss of capacity. It has been out helps to increase tolerance to accelerations with
found that acceleration of 25 G for approximately 1,6-1,8G. Hardening of the body and physical exer-
0,1 s are tolerated limit for the axis + Gz, those of 15G cise, and especially to increase the endurance of the
for 0,1 s are limit to the axis - Gz. body are also considered effective.
* Mechanical damage (injuries) are essential in the short-term
Adaptation to hypoxia (in alpine conditions or
accelerations hyperbaric chambers) also supports resistance to

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acceleration - indicate elevations up to 2.0-2.4 G. De- serious (even fatal).
veloped methods and criteria for professional selec- Preventive measures for these conditions of the
tion of persons with individual qualities of reduced cardiovascular system are primarily focused on phys-
susceptibility (increased resistance) to accelerations. ical exercise during the flight of a walking path, ex-
Developed and protective clothing (pneumatic ercise bike and simulator rowing, they are combined
inflatable anti-G suits) to reduce the effects of ex- with creating a negative pressure in the lower half
posure to + Gz. Under the impact of the inflated air of the body (in astronaut spacesuit). Used appropri-
in the suit is increased tissue pressure on the lower ately designed and drinks with high saline content.
limbs. This keeps the peripheral vascular resistance, Musculoskeletal system. In all astronauts set-
decreases the collection of blood in the abdomen tled a loss of muscle mass (atrophy) irrespective of
and the lower limbs and the displacement of the di- the duration of the flight. Particularly affected are
aphragm down, which prevents an increase in the the muscles of the arms and legs - decrease mus-
vertical distance between the heart and brain. Sur- cle strength and endurance. Explanation for these
vival in plane crashes depends on efficient restraint changes is that work in conditions of weightlessness
systems and maintain the integrity of the cabin and are carried out almost no muscle effort.
cockpit. Seats that reduce energy and lining on the Prevention here include: exercise during the
back of the seats are part of the structure of the air- flight, electrical stimulation of the muscles and an-
craft, which restricts injuries. Another technology in- abolic drugs (testosterone or testosterone-like ster-
volves creating components that absorb energy and oids). These means, however, only postpone muscu-
improve the structure of the seats in order to reduce lar atrophy.
mechanical damage, and improving tolerance to ac- It establishes a slow but continuous loss and
celerations. bone mass (about 300 mg per day, or 0.5% of the
The use of pharmacological agents (vasocon- total content of calcium in the bones, in a month).
strictors and vasodilators, ganglioblockers, stimu- Calcium loss and bone erosion may be a limiting
lants CNS, hormones) as well as of immersions sys- factor during the flight. Bone loss may lead to an in-
tems (insertion of the body into a container with creased risk of fractures, and the release of calcium
liquid - water) are experimented and has not found in the urine increases the risk of lithiasis.
practical application. So far, not been found effective measures for
preventing the loss of calcium. Have tried a number
6.10.3. MICROGRAVITY (WEIGHTLESSNESS) of means including exercise (walking path, exercise
bike and rowing simulator) and additional intake of
As a result of spaceflight has published a large calcium, vitamins and medications (eg. diphospho-
amount of literature that reflects the physiological nates - drugs helps prevent bone loss in osteopo-
changes at teams during and after the flight. The rosis). The most effective, but practically difficult to
reason for these deviations indicate exposure to achieve is the creation of an artificial gravitational
weightlessness or microgravity. These changes are field, either continuously or temporarily turning the
transient - a full recovery from several days to sev- aircraft.
eral months after return to Earth, however, can not Neuro-vestibular apparatus. More than half of
predict the consequences after a flight lasting 2-3 the astronauts and cosmonauts suffer from a con-
years and more. The most significant deviations can dition called motion sickness in space (SMS - Space
be categorized into several major groups - cardio- Motion Sickness). Symptoms arise due to violation
vascular; musculoskeletal; neuro-vestibular; haema- of the functional interaction between analyzers.
tological and endocrinological. Neuro-vestibular complaints are caused by disor-
Cardiovascular system. Microgravity can induce ders in the function of the inner ear due to micro-
instability of blood pressure and pulse, but they are gravity. CNS to be sent wrong signals by analyzers
not very significant - not harms or work crew during or recent interpreted incorrectly. Symptoms include
the flight. Almost half of the astronauts, however, heartburn, nausea, vomiting, headache and drows-
immediately after the flight complained of dizziness iness. The complaints are exacerbated when rapid
and stunning, some receive fainting (syncope) or movement of the head. SMS is manifested several
are near to fainting (pre-syncope). The reason is the minutes to several hours after start and recover fully
drop in blood pressure in vertical position due to the within 72 hours. Therefore, the first three days of the
impact of the Earth’s gravitational field and abnor- flight is not planning any work in outer space.
mal compensatory mechanisms of the body. These Increasing adaptation of astronauts before flight
conditions are transient and without consequences, by training with rotating chairs with little effect by
but after a very long flight, they can be much more preventing SMS. Antihistamines administered by in-

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jection, are particularly effective as a treatment, but deepen, which would lead to disorders in the im-
its efficacy as a prophylactic is not proven. mune system. It has been described in some cosmo-
Other neuro-vestibular symptoms are dizziness, nauts changes in haemostatics and thrombocytope-
balance disorder, illusions of astronaut himself for nia in post-flight period.
time, spatial perception, movement, colors, making Endocrine system. It was found that during the
it difficult to work during the flight and its move- flight occurs several changes in the liquid medium
ment for a short time after the flight. The mecha- and minerals in the body, which are due to changes
nisms for these phenomena are complex and not in the endocrine system. In general, there is a loss
fully understood. They have not been found effec- of the total volume of liquids in the body, as well as
tive preventive measures. sodium, calcium and potassium. Although the ex-
Hematologic. Microgravity effect on red and act mechanism of this phenomenon has not been
white blood cells. Astronauts decreased by 7-17% defined, some explanation give found changes in
of the number of red blood cells at the beginning the levels of various hormones - growth secretion
of the flight. This condition remains to normal 4 to of adrenaline, renin and aldosterone, but as the re-
8 weeks after the flight. This phenomenon is not of sults of the tests at various astronauts are not unidi-
clinical significance, but would become a serious rectional, it may be formed single hypothesis about
problem during long flights, as it will lead to the de- the causes of these physiological disorders. It is not
velopment of anemia. proven and deterioration of health of astronauts and
Microgravity also affects white blood cells. There quality of their work on the basis of the changes de-
is an overall increase in their number, mainly of neu- scribed. It is not known and what could be the con-
trophils and reduction of lymphocytes. There were sequences of these violations in a very long flight.
no illnesses directly related to them. It is not known
whether also at a long flight of these changes will

REFERENCES

1. De Hart, R.L. Aerospace Medicine, In: Public health and Preventive Medicine, 13rd edition, M.L.Last
and R.B. Wallace (eds.), 1992, Norwalk, CT, Appleton and Lange
2. Dimitrov D. Comprehensive evaluation of adaptation of the organism to accelerations and decom-
pression of the lower half of the body, for the purpose of aero-medical examination and selection. Doct.
disert., S., 1984. (in bul.)
3. Glaister, D.H. The effects of long duration acceleration. In: Aviation Medicine, 2nd edition, J. Ecnsting,
P. F. King (eds.), 1998, London, Butterworth.
4. Miyamoto, Y. Eye and respiratory irritants in jet engine exhaust. Aviation, Space and Environmental
Medicine, 1986, 57 (11), 1104-1108
5. Nicogossian, A.E., C.L. Huntoon, S.L. Pool (eds.). Space Physiology and Medicine, 3rd edition, 1994,
Philadelphia, PA: Lea and Febiger.
6. Patterson, R., R. B. Raymon. Aerospace Medicine: Effects of Gravity, Acceleration and Microgravity
in the Aerospace Environment. In: Encyclopedia of Occupational Health and Safety. Fourth edition. Ed. J.M.
Stellamn. International Labour Office, Geneva, 1998, pp. 102.16-102.20
7. Poitrast, B.J., de Treville. Occupational Medical Considerations in the Aviation Industry. In: Occupa-
tional Medicine, 3rd edition, edited by C.Zenz, O.B. Dickerson, E.P. Hovarth, 1994, St. Louis, MO: Mosby
8. Valdez, C.D. Ten years survey of altitude chamber reactions using the FAA training chamber flight pro-
files. Aviat. Space Environ. Med., 1977, 48: 718

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 7 CHEMICAL FACTORS
D. Tsonevsky

INDUSTRIAL TOXICOLOGY - BASIC

7.1 ASSUMPTIONS, PARAMETERS OF TOXICITY.

PREVENTION OF OCCUPATIONAL POISONING

Impact of chemicals on workers is possible in ease, depending on specific conditions, ie to assess

many professions during the production and pro- the health risk.
cessing of raw materials in the preparation of indus- In toxicology distinguish between the concepts
trial production, operating in transport, in agricul- degree of toxicity and health risks. Highly toxic sub-
ture. Effects of toxic substances on the health status stances that are hermetically sealed, creating little
of workers studied the production toxicology. risk or presents no danger. When these substanc-
Toxicology is a science that studies the interac- es are used by workers in a confined space in im-
tion of toxins in the body (from toxicon - poisons and paired pressurization of equipment, without proper
logos - knowledge). In practical terms toxicology sci- precautions, the health risk becomes significantly
ence that prevents, detects and removes early prox- larger. Ie. how dangerous a substance in the envi-
imal and distal consequences of the action of harm- ronment is determined by technical equipment,
ful substances. All substances are potentially toxic. processes, pressurization of equipment, ventilation
The concept of poison defined more by Paracelsus of production premises, subject to the requirements
(1493-1541), which states that “All substances are relating to technical safety, the use of personal pro-
poisonous and nothing is devoid of toxicity. Only tective equipment, etc.
the dose makes the poison unnoticed. “ Poisons Manufacturing poisons are substances that can
are defined as substances that come through phys- be raw materials, intermediate or finished products
iological pathways in the body in relatively small must waste from industry and agriculture. Health
amounts, enter the chemical or physico-chemical in- risk are exposed workers of: the metallurgical indus-
teraction with tissues and under certain conditions try (CO, sulfur gases and metal aerosols); ore mining
violate health*. American Association of Industrial ( “explosive gases” - CO, CO2, NOx); metal products
Hygienists - ACGIH gives quantitative valuation of and machinery (toxic gases, vapors and aerosols in
poison. According to experts the association, of poi- acid treatment of metals, galvanization, nickel, chro-
sons are accepted substances which, after treatment mium); chemical industry (chlorine, ammonia, sulfur
of experimental animals (white rats weighing 200- gases, toluene, phenol, formaldehyde, styrene, ni-
300 g) for the solutions and emulsions in doses of trogen oxides, acids and bases); agriculture (differ-
50 mg/kg of weight or in smaller quantities, and to ent types of pesticides, as PhOC, ChlOC, carbamate
gases and vapors that at concentrations of 2 mg/l air and dithiocarbamate preparations, nitrophenols,
and exposure of 60 min, after 48 hours causing the mercury compounds) and others.
death of 50 percent or more of the animals treated. Classification (in Ch. Becker). For this purpose,
The objectives of clinical and experimental stud- the following important criteria: a) their origin - the
ies in toxicology are to determine: a) the harmful manufacturing poisons are mineral and biologi-
effects of substances, their toxicity; b) doses, when cal-plant, animal, microbial; b) a chemical structure
occurring toxic effects i.e. the relationship between (primary classification) are divided into inorganic
the dose-response; c) the potential for injury or dis- and organic substances. Among the most com-
monly occurring inorganic substances - metals and
* Poisons are marked also as xenobiotics (from Greek: xenos - non-metals, in manufacturing concern: halogens
foreign and bios - life) (chlorine, bromine, fluorine), sulfur compounds

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(sulfur dioxide, hydrogen sulfide, sulfuric acid), com- constitutes no threat to workers unless it is heated.
pounds of nitrogen (ammonia, nitrogen oxides, 2. Environmental factors. The toxicity of the
nitric acid), the compounds of the cyano acid (hy- substances are influenced by temperature, humidity
drogen cyanide, potassium cyanide), heavy and rare and atmospheric pressure. High temperature vio-
metals (lead, mercury, manganese, chromium, cad- lates the metabolism in the liver, increases lung ven-
mium, vanadium, etc.). The most common organic tilation, reduces imunnobiologichnata reactivity of
substances include: hydrocarbons: aromatic com- the body, and combined with high humidity acceler-
pounds (benzene, toluene, xylene, phenol), butyric ates the absorption of toxic substances. In this con-
compounds (gasoline, methane, ethane, ethylene, nection, as a rule, high temperature and humidity
acetylene, chlorinated aliphatic hydrocarbons) and enhance the toxic effect. Low temperatures in some
alcohols of butyric row ( methyl, ethyl alcohol, ethyl- cases enhance the effect of toxins (CO, benzene, ac-
ene glycol, etc.); c) a physical condition are divided etone, dichloroethane), in others - reducing toxic ef-
into: solids, powders, gases, vapors, aerosols, liquids fects due to inducing the activity of OMF* (naphthyl-
(lead for example is harmless in the solid state, with amine, aniline). The increased atmospheric pressure
intermediate toxicity is as a powder and is highly also associated with an increased partial pressure of
toxic as an aerosol) d) in the medium of the action. the substances promote the entry of more poison in
Some toxic substances are found in specific environ- the body (eg. nitrogen oxides). Under reduced pres-
ments. For ex. sulfur and nitrogen oxides - into the sure, however, is often also observed to potentiate
air, trihalomethanes - in water and nitrosamines - in the toxic effects - eg. hypoxic poisons (CO, benzene,
food. Mid of action to some extent determines the benzine) as a result of reduced oxygen partial pres-
degree of risk and risk population; e) specific tox- sure.
icity - substances are divided primarily neurotoxic, 3. Individual factors. Individual factors that in-
hepatotoxic, nephrotoxic, cardiotoxic etc. f ) mecha- fluence the body’s sensitivity to poisons are: gender,
nism of effect on the body - toxins are divided into age, race, genetic background, body weight, diet,
cause: tissue asphyxia (cyanide, CO), hypoxia (inert lifestyle, immunological and hormonal status, tran-
gas), blocking enzyme systems (PhOC, carbamates), sitional diseases, stress. These factors are depend-
etc .; g) as the dominant health effects are divided ent on one another. For example, genetic factors
into: toxic active (acute or chronic poisoning); aller- determine a significant number of other individual
gic acting (chlorinated hydrocarbons, mineral oils, factors, and diet can significantly affect the immu-
diisocyanate, toluene); gonadotropic(chloroprene, nological status. Gender - women establish more
manganese, carbaryl, formaldehyde, phenol, lead, sensitive to some poisons (lead, mercury, benzine,
mercury, dichloroethane, carbon disulfide, grano- benzene, PhOC), particularly during pregnancy, lac-
zan, sevin, etc.); teratogenic (dioxins, lead, mercu- tation or menstruation; compounds of boron are se-
ry, manganese, chloroprene, vinyl chloride, thio- lectively toxic action to the male gonads. A number
carbamates, derivatives of phthalic acid, ethanol, of studies have shown that the fetus, children and
etc.); mutagenic and carcinogenic (3,4-benzpyrene, the elderly have a greater sensitivity to a variety of
nitrosamines, urethane, benzene, acrolein, vinyl poisons as a result of the lower efficiency of meta-
chloride, formaldehyde, aflatoxin, lead organic com- bolic poisons. On susceptibility to toxins can also
pounds, naphthylamine, asbestos, vinyl chloride, ar- affect the length of service and intensity of physical
senic, chromium, nickel, beryllium, benzidine, chlo- labour.
rinated hydrocarbons, etc.). Malnutrition usually alter the normal response
of the body to toxins by influencing the absorption,
7.1.1. FACTORS DETERMINING THE TOXICITY storage and bio-transformation. Individual sensitiv-
OF SUBSTANCES ity also depends of health status, functional activi-
ty of different systems, the character of work - eg.
The toxic effect depends on the condition of the heavy physical work enhances the processes of
organism during its interaction with the toxins in respiration and circulation and thus accelerates the
environmental conditions. On these processes affect entry of toxins in organs and tissues. Increased sen-
these groups of factors: sitivity to certain toxic substances - vicyanin, arsenic,
1. The duration, frequency and route of expo- naphthalene, described in subjects with deficiency
sure. The severity of toxicity impairment most often of glucoso 6-phosphate-dehydrogenase, sickle cell
related to the duration and frequency of exposure. anemia, alpha-antitrypsin deficiency.
Route of administration of substances in the body
are also often determines the toxicity - eg. ethylene
glycol is toxic when ingested, but of work places * The OMF - mixed function oxidases

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In the reactions of the organism in toxicity of poi- of its effect. There are many examples which show
sons observed stages: Stage 1. The primary reaction; that two completely different chemical structure
2. Stage of “adaptation”; 3. Stage of compensation/ substances can have similar toxic effect and vice
decompensation. The described adaptation of the versa. The reason for this is that very often the body
organism to some poisons- chlorine, ammonia, for- responds with a non-specific, universal effects of
maldehyde, is often apparent and is connected to the action of substances that are quite different in
the intension of the biochemical and physiological chemical structure. By practical standpoint impor-
responses, which leads to hidden damage to tissues tance have dependencies that allow to predict the
and organs. These lesions can be detected some- change in the toxic action of the substances in a
times after adequate functional load. type of modification of the chemical structure. Most
4. Physical properties of toxic substances. The manifest the relationships between chemical struc-
toxicity of the substances exert certain influence ture and biological activity in homologous series.
their solubility, volatility and physical condition. As Some of the established patterns between chem-
a substance is more soluble, it is more toxic. Particu- ical structure and toxicity are: 1. The rule of branched
larly important to assess toxicity has solubility in chain. This rule is fully valid as a homologous series
water, biological fluids and fat. The effect of drugs of unspecified fatty hydrocarbons and the aromat-
depends on the distribution of their distributing ic hydrocarbons - ex. propylic and butylic alcohol
coefficient (DC) = solubility in oil/solubility in water are stronger drugs from isopropylic and isobutylic;
- rule of Overton and Meyer. As this ratio is larger, 2. Substances with higher atomic weight are more
the penetrating ability and their accumulation in toxic as compared to substances with less atomic
lipid-rich tissues is larger. Physical condition is also weight; 3. The toxicity of the organic compounds
important for toxicity - metallic mercury as a liquid increases with increasing number of double bonds
is non-toxic, but in the form of vapour is very dan- - eg. acetylene is more toxic than ethane and eth-
gerous. The same applies to a finely dispersed solids. ylene. Narcotic effect increases at acyclic hydrocar-
In equally other conditions higher volatility - with a bons with an increase of double bonds (cyclohexane
lower boiling point, determines most toxic of sub- → cyclohexaene → cyclohexadiene). 4. By increas-
stances. For example parathion and sistoks have the ing the number of carbon atoms in the homologous
same toxicity but sistoks is much more volatile and rows of methane is increased toxic effects of the
therefore is much more dangerous than parathi- compounds (rule of Richardson). For example, there
on*. In this connection, in toxicological practice has are pentane CL50 - 300 mg/l, the hexane - 100 mg/l,
been introduced the concept of effective toxicity. hectan - 40 mg/l, and octane - 30mg/l; 5. The spatial
It is determined by the product of absolute toxicity location of the radicals in the molecule also affects
and volatility and well-characterized manufacturing the strength and character of toxicity - paraisomer
health risk. In case a particular appears introduced have the highest biological activity, follow by meta-
by I.V. Sanotskiy term - coefficient of possible inha- and ortoisomers. This dependence is observed for
lation poisoning (CPIP), which is determined by the example in the isomers of nitrophenol, nitrotolu-
ratio C20°/ CL50120, where C20° is the maximum real con- ene, nitrobenzene and nitroaniline; 6. The molecu-
centration at 20°C, and CL50120 is the concentration lar symmetry is also important for the toxicity of the
causing 50% mortality of white mice in single expo- substances. It is understood that the compounds
sure of 120 min. which have a symmetrical structure of the molecule
5. Chemical composition and structure of sub- are more toxic than the compounds of asymmetri-
stances. To a large extent the toxic action of the sub- cal construction; 7. The organic compounds of low
stances is determined by their structure and chemi- valency when combined with metalloids - sulfur, ar-
cal composition. Thanks to that today can largely be senic and phosphorus, increase their toxicity; 8. The
predicted toxicity and pharmacological activity of character of the action of the substances is altered
newly synthesized chemical compounds, based on by introduction of halogen atoms, methyl, amine,
some known their physical and chemical properties hydroxyl, and nitro groups. The introduction of chlo-
and determine their tentative MAC in the air of the rine, bromine and fluorine in a molecule increases
environment or the working environment. the irritating and their general toxic action and the
It should'nt, however, be absolute opinion that introduction of amino and nitro groups converted
knowing the chemical structure of a substance can into methemoglobinferous compounds, increases
quite accurately determine the nature and intensity their allergic action. 9. The change in the valence
of the elements may change their toxicity and the
* above applies to the toxicity of the substances entering the nature of the action. Trivalent arsenic compounds
inspired air for example are more toxic than quinquivalent, and

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in chroma, contrast, hexavalent are more toxic than all hydrocarbons from aromatic and fatty rank and
trivalent (trivalent chromium compounds, howev- their derivatives such as gasoline, benzene, ether,
er, have a carcinogenic effect); 10. Dependence of acetone, acetylene and others. They enter the blood
toxicity by electronic stability. It was found that a through the lungs under the law of diffusion, ie
reduction of the electronic stability increases the due to the difference in partial pressure of gas at
toxicity of inorganic compounds; 11. Depending on the alveolar air and blood. At the beginning of ex-
the type of crystal lattice. Substances with a volume posure saturation of blood is fast, then gradually
centered cubic lattice are the least toxic, and those slows down and eventually terminates (the partial
with low grade symmetry of the lattice are less toxic. pressure equalization). It is important to conduct in
As examples can be mentioned titanium and tung- providing first aid to the victims, since their export
sten, which have a weak pneumosclerosis effect and on fresh air will quickly come desorbtion. The toxic
free silica (with hexagonal lattice) is a high pneumo- effect of these toxins depends mainly on their solu-
sclerosis effect. bility in the blood (water) and much less than their
exposure. Their solubility in the blood is determined
7.1.2. TOXICOCINETICS by the partition coefficient (K) of Henderson and
Hagar.
Toxicocinetics studied the movement of toxic K = substance concentration in arterial blood /
substances in the body, ie their absorption, distribu- substance concentration in the alveolar air.
tion, metabolism and excretion and the relationship For example, K ethanol is 2000, 12.9 of the ether,
between the dose which is received and the level of benzene - 10.3, benzine - 2.1, acetylene - 0.84. As
toxic substances in biological media. smaller this ratio, the faster the poisoning occurs.
Ways of penetration of toxins in the body. Poi- Dermal absorption of toxins is limited. Ability to
sons enter the body in three main ways: through the pass through an intact or damaged skin have only
lungs, the skin and the gastrointestinal tract. By air- lipoidsoluble substances such as organic solvents,
way penetrate gases, vapors and dusts. By penetrat- some pesticides, chlorinated hydrocarbons (dichlo-
ing the skin mostly organic substances and through roethane, trichlorethylene, carbon tetrachloride),
the gastrointestinal tract - emptied poison on your amino- and nitro compounds (nitrobenzene, trini-
hands (in production gastrointestinal tract have the trotoluene, TNT, dinitrobenzene) and others. The
least importance for receipt of poisons). absorption increases with larger contact surface
Basic and the most dangerous way for receipt with the poison, in moist skin, substances that cause
of poisons in the body is still breathing. The large increased blood supply to the skin. It depends on
surface of the lungs from 90 to 120 m2, and their the individual and racial characteristics of the skin
rich blood supply, allowing toxic substances to do and the skin area of the body (skin structure). For
quickly in the blood and quickly spread to all the the action of toxic substances penetrating through
organs and systems. It is estimated that 80-90% of the skin matter and their solubility in water, ie it
acute poisoning in the industry are due to gases and depends on the partition coefficient (K) of the sub-
vapors. Their entry into the body through the lungs stance in the oil and water: K = solubility in the oil/
is subject to certain mechanisms. Gases and vapors water solubility - (law of Overton and Meyer)*.
according to their absorption in the body is divided Some electrolytes such as lead and mercury in
into reactants and non-reactings. To the reactants small quantities can penetrate through the follicles
refer sulfur oxides, nitrogen oxides, ammonia, chlo- of the skin. Major importance for skin penetration
rine, phosgene, diphosgene, acids, bases. Their prac- are the consistency and volatility of the substanc-
tical saturation of the blood with the poison does es. For example substances of low volatility, and an
not occur, as is always the amount of the received oil-like consistency, such as aniline, nitrobenzene, or
gas is directly dependent on the volume of respira- readily volatile, but incorporated in oily creams and
tion (as a consequence, the risk of poisoning is much pastes, easily penetrate the skin and be retained
greater as greater exposure). Very well soluble and longer on it.
chemically reactive in water, gases and vapors such In ophthalmic absorption toxic substances
as ammonia, acids and bases, damaging mainly the within the body, through the conjunctiva, in which
upper respiratory tract and have irritation. Slowly bypass the liver and can cause severe intoxication
soluble chlorine and sulfur gases totally damaged (PhOC).
airways and slowly soluble - nitrogen oxides, phos- The presence of toxins in the body through the
gene, diphosgene, reach the lung alveoli and cause
toxic bronchopneumonia and pulmonary edema. * For substances with low K, ex. gasoline - 2.1, poisoning through
To non-reacting gases and vapors includes the skin does not occur, due to its rapid excretion via the lungs.

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digestive tract is possible for non-rules of personal the body do not occur, regardless of the duration of
hygiene, such as nutrition and smoking with con- exposure. A typical example in this respect are or-
taminated hands. Some poisons can be absorbed ganophosphorus pesticides (PhOC) who gradually
already in the mouth, for example lipophilic com- penetrates into the body inhibits cholinesterase ac-
pounds, such as cyanide, nicotine, phenols and tivity (CheA). The clinical manifestations of toxic ac-
the like. A number of substances undergo chem- tion of PhOC are registered in inhibiting CheA more
ical transformations in the stomach - for example than 50%. Lowering CheA 30-50% is seen as premor-
iron passes from the two-to-trivalent, insoluble bid condition.
salts of lead in more soluble, and other poisons un- Metabolism of toxins in the body. Only a minor
der the action of acid medium pass into more tox- part of become trapped in the body substances is
ic compounds. In certain specific conditions in the removed unchanged (inert gases, acids and alkalis,
digestive tract (elevated pH values, the presence some aliphatic hydrocarbons).
of nitrites more) low or medium-toxic amines, and Enzymatic reactions performed in metabolic bi-
dithiocarbamates may be nitrosated to carcinogenic otransformation of xenobiotics can be divided into
nitrosamines. four basic types: oxidation, reduction, hydrolysis and
Distribution of poisons in the body. The toxic conjugation (conjugation is always final reaction).
substances are transported to the various parts of The reduction and hydrolysis usually prepare
the body predominantly from the blood (some of toxics substances make harmless, while oxidation
them can be transformed by the lymph, and oth- reactions are the most common. The oxidation in
er by macrophages). The distribution depends on the body is subjected to alcohols, aldehydes, acids.
the physicochemical properties but affect cardiac Benzene, for example is oxidized to phenol and py-
output and regional especially blood flow. In tissue rocatechol, alcohols of the fatty rank to water and
distribution and penetration into the cells toxins are CO2 (with the exception of the methanol, which is
divided into two groups: non-electrolytes and elec- oxidised to formaldehyde and formic acid). The
trolytes. Non-electrolytes are distributed mainly in salts of the metals typically form insoluble com-
the organs with good circulation. As the partition plex compounds with tissue albumin. In the liver is
coefficient of the substances in the oil and water is done conjugation of toxins with glucose, cysteine,
greater (law of Overton and Meyer), so their pene- methionine, sulfuric acid - sulfates, glutathione. As
tration capability through lipoproteinic cell mem- a result of the biotransformation of toxins in the
branes is greater. Electrolytes penetrate into the body to form less toxic and less soluble compounds
cells, depending on the charge of their membranes. that are readily excreted by the kidneys. Known are,
If the surface of the cells is negatively charged, they however, many cases where products of metabolic
do not miss anions and a positive charge not miss biotransformation are more toxic than the parent
cations. Therefore, distributions of electrolytes in compound, for example tetrachloromethane me-
the tissues is very unequable. As a feature consid- tabolized to more toxic radical trichloromethane,
ered their ability to accumulate in some tissues and methyl acetate hydrolyzed to methyl alcohol and
organs and form deposits - material accumulation. acetic acid and methyl alcohol to high toxical for-
This creates an opportunity for the introduction of maldehyde and formic acid. In the oxidative desul-
small amounts of a poison in the body occur chronic furation of tyophosphates (PhOC) is obtained P = 0
intoxication (eg. entrance of 0.2 to 1mg of lead per analogs which are also hundreds of times more tox-
day at about six months exposure leads to chronic ic. The biotransformation of xenobiotics in the body
poisoning). Lead in larger amounts accumulate in (reduction, hydrolysis and oxidation) is carried out
bones, manganese - in the liver and heart, mercury in most cases involving hydrolyzing enzyme system,
- kidney, cadmium - in the kidneys and liver, arsenic known as a mixed function oxidases (OMF), mainly
- in nails and hair, etc. Material accumulation is as- in the liver and to a lesser degree in blood plasma,
sessed by factor of accumulation (Kk). kidneys, skin, lung or other tissues. In OMF includes
Kk = DL50chr (for 3 months)/DL50ac (single expo- about 25 enzymes (cytochromes, esterase, reduc-
sure). tase), at which leading importance for cytochrome
When Kk less than 1 there is overcumulation, at - P-450. Biotransformation reactions without involv-
odds of 1-3 - a high accumulation of 3-7 - medium ing OMF are distinguished by pronounced substrate
and 7-10 - weak and over 10 - very weak. specificity - eg. histaminase only participate in the
Besides the material accumulation is known and metabolism of histamine, serotoninase - serotonin,
functional cumulation, which showed accumulation monoamine oxidase - primary amines and catecho-
of physiological effects, ie if the concentration of the lamines, alcohol dehydrogenase - methanol and
toxic substance is below the threshold, changes in ethanol, etc.

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Excretion of toxins from the body. The excre- common method of J. Litchefield and F. Wilcocxon -
tion of toxins from the body is carried out by the defined doses at low and high mortality - DLI6, DL50,
kidneys, lungs, gastrointestinal tract and skin. Toxic DL84.
substances excreted as metabolites or unchanged. 5. Threshold of acute effect in a single treatment
Excretory organs except the lungs eliminate more of experimental animals - Limac - represents the min-
efficient water-soluble compounds. Kidneys are the imum dose or concentration causing in acute effects
most important organs that eliminate most polar changes in some (most sensitive to specific condi-
compounds and their metabolites. The excretion of tions) of those of surveyed indicators for body vital
toxic substances in the urine going through glomer- activity (integrated, immunological, biochemical,
ular filtration, active secretion and passive tubular historadiographycal etc).
reabsorption. Alkalization or acidified urine can sig- 6. Threshold of chronic effect (Limch) - represents
nificantly alter excretion of some toxic agents - eg. the minimum dose or concentration that causes
when the primary urine is alkaline, weak acids are chronic effects change of surveyed indicators. Based
excreted faster because they are ionized and passive on the threshold of chronic effect of substances in
tubular reabsorption is reduced. Many toxic sub- inhalation exposure is determined experimental ad-
stances metabolised in the liver is excreted in the missible limit concentration (MAC).
bile and then excreted in feces or reabsorbed into 7. Ratio of the stock (RS) - the ratio of the thresh-
the blood and are eliminated through the urine. old of chronic effect to the relevant MAC.
Trans-lung eliminate inert gases and vapors. The 8. Factor of accumulation (FA) - the ratio between
rate of release depends on the distribution coeffi- total DL50, determined in one month oral experience
cient oil/water. As this ratio is smaller, so the poison with the daily introduction of 1/5 - 1/20 and less of
is removed faster at organism. For example, much DL50 single (defined in single time experience) - to
faster are separated gasoline, benzene and chloro- DL50 single. The more big FA, so the risk of accumula-
form and much slower ethanol and acetone. tion and toxic effects is smaller (back in FA <1 - “over
In the stomach and intestines were removed in- accumulation”).
soluble metabolites, metals, bipolar ions which can 9. Zone of acute action Zac = CL50/Limac - is the ra-
not cross the epithelial barrier. tio of median lethal concentration to the threshold
In the skin and mucous membranes may be of acute action.
eliminated mercury, cyanides, arsenic, chromium, 10. Zone of chronic action Zch = Limac/Limch - is the
serodovorod etc. . Some toxic substances in small ratio of the threshold of acute action on the thresh-
amounts can be separated, and in breast milk, saliva, old of chronic action.
sweat glands (lead, mercury, manganese, etc.). The determination of these areas is important for
occupational risk. As the area of the acute effect is
7.1.3. TOXICOMETRICS smaller and the area of chronic effect is greater, the
toxicant is more dangerous, respectively for deaths
Toxicometrics studied quantification of potential in acute impact and intoxications - in chronic.
and actual risk from the effects of toxic substances. The maximum admissible concentration
Toxicometrics parameters include: lethal, thresholds (MAC) represents the maximum amount of a sub-
and limit doses and concentrations coefficients dig- stance in the air of the working environment, which
itally define specific damage in certain path of ad- in everyday work, but also throughout total service
ministration and level of impact: does not cause among workers, except in cases of
1. Zero lethal dose or concentration DL0/CL0/ - hypersensitivity, somatic or mental illness or chang-
represents the maximum tolerated dose or concen- es in their health state out of the limits of adaptive
tration, that does not cause death in any of the test physiological reactions, identified with the modern
animals. methods of investigation, immediately or in remote
2. Minimum lethal dose or concentration DLmin/ periods of life, on present or future generations.
CLmin/ - lowest dose or concentration that causes In determining the MAC starting from:
death of at least one of the treated animals. 1. Physico-chemical properties of substances -
3. Medium lethal dose or concentration DL50/ they justify tentative MAC, valid for two years or to
CL50/ - is that dose or concentration that causes carry out the necessary toxicometrics experimental
death of at least 50% of the tested animals. studies of toxic agent.
4. Absolute lethal dose or concentration DL100/ 2. The results of experimental studies - they justi-
CL100/. This is the minimum dose or concentration fy the temporary MAC.
that causes death of all treated animals. They are 3. Data of hygiene observations of conditions in
set using a statistical treatment of results, the most the manufacturing and health of workers for a peri-

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od of three years after the introduction of the sub- database relating to the toxic chemical (Table. 1).
stance into production are use if necessary for cor- MAD = no effect dose/uncertainty factor x mod-
rection of the temporary MAC. ifying factor
In justifying tentative MAC account the structur- Basically, MAD is level (reference dose - RfD) with
al formula of the substances, molecular and specific uncertainties, lying within one order of magnitude
weight, melting and boiling point, volatility, solubil- of daily exposure of the population (including and
ity in different media. sensitive groups), causing a noticeable risk of disa-
Output value for determining temporary MAC is a bility throughout life.
threshold of a chronic effect or dose-effect. Most of- The reference dose is expressed in mg/kg per day.
ten MAC is set at 10-100 times lower than the thresh- Determining the MAC of inhaled pollutants is
old of chronic action - i.e. ratio of the stock (RS). more complex than determining the MAD - in oral
The stock factor increases with increase in the ab- exposure. In determining the MAC should keep in
solute toxicity, with increasing volatility, by reducing mind the differences in anatomy and physiology of
the area of the acute effect, by increasing the area itself respiratory system in animals and humans, and
of chronic action, to reduce the rate of accumula- the physicochemical properties of the chemical. Fur-
tion, with an increase in skin-resorption action, with thermore, the critical health effects for the respira-
the presence of teratogenic, embryotoxic , gonad- tory system depends more on the kind of chemical
otrophic, mutagenic or carcinogenic effects - in re- deposition in it, than the concentration of the sub-
cent cases, RS can reach 1000 or xenobiotic no per- stance in the air.
mit to the production (eg. asbestos). Doses or exposures lower than the MAC and MAD
In experimental studies in recent years, is select- most often not associated with significant health
ed exposure level based on the critical effects which risks which are not taken into account in the stand-
is the highest level investigated, whereby it is not ardization, but the last (ie compliance with regula-
established “any adverse effect.” No effect (level tions) does not mean the absence of a health risk.
of no observed adverse effects - LNOAE) is the high- According to the duration of the impact of toxic
est experimental dose of a chemical substance in substances, under Regulation N 13 (SG. 81/1992) the
which there are no statistically proven and biolog- limit concentrations are divided into:
ically significant alterations in the frequency and 1. Mean-shift MAC (MSMAC) - this is the average
severity of adverse effects among individuals in the concentrations of harmful substances 8.5 h work
group subjected to exposure, as compared with a time of no more than 40 h work week;
suitable control group. A toxic agent can cause more 2. Short-time maximum MAC (STMMAC) - this
than one toxic effect. Used indicator for the critical is the highest allowable concentration for up to 15
effect in the evaluation of toxicity dose/response is min., no more than 4 times per work shift, at inter-
deviation showing the lowest value in determining vals over 60 min. (for substances without specific
the no active dose. STMMAC allow one-off increase over 3 times MS-
MAD is the standard dose, derived from no effect MAC for 30 min.);
dose by the application of magnitude of the fac- 3. Exposure MAC (EMAC) is used to work time
tors of uncertainty (FU), which reflect the different over 8,5 h. Determined by the formula:
types of data sets, used to determine the limit levels. EMAC = (MSMAC x 8)/h. (h. - have extended hours
Sometimes used and modifying factor (MF), which of working day);
is based on the professional judgment of the entire
Table 1. Factors of uncertainty and modifying factor
Uncertainties factor (FU)
Question for discussion Value
1. Take into account the biological variability of the whole population in order to protect
sensitive groups 10
2. When extrapolating from animals to humans 10
3. When the no-effect dose was established as a result of subchronic instead of
chronic studies in determining chronic MAD
10
4. When used threshold of chronic action instead-no effect dose (LNOAE)
10
Modifying factor (MF)
1. To take into account other deficiencies, which are not included in previous factor of
uncertainties (mutagenic, carcinogenic, etc.). < 0 до 10

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4. Biological MAC (BMAC) - the maximum content Limit Values) by ACGIH (American Conference of
of harmful chemicals or their metabolites in blood, Governmental Industrial Hygienists); RELs (Recom-
urine or breath, which does not expect any damage mended Exposure Levels) from NIOSH (National In-
to the health of workers and their offspring (BMAC stitute for Occupational Safety and Health) and PELs
is assigned to the value of the MSMAC). BMAC gives (Permissible Exposure Limits) from OSHA (Occupa-
important information about occupational risk for tional Safety and Health Administration), which are
the introduction of xenobiotic more than one of the officially authorized, recommended limits for vari-
three physiological path way; ous chemicals in the air of working environment and
5. Limit concentrations of chemical irritants, con- in biological media and accepted in many countries,
tact allergens and substances with skin-resorbtive incl. in Bulgaria with/or without some adjustments
systemic action in stocks and raw materials that to specific chemicals.
have direct contact with people; The essence of this approach is that there is no
6. Concentration immediately dangerous to environment without health risk but “safe” is the
health (CIDH) - the maximum concentration of the environment where the level of risk is acceptable
toxic substances that no-threaten the health and life under specific conditions, ie applied the principle
in case of emergency, in effect no more than 30 min. ALARA (As Low As Reasonably Achievable).
(CIDH determines the need for appropriate use of In the production Toxicology to measure expo-
masks). sure through biological monitoring more often used
An ordinance № 13/2003 in place to limit concen- biological markers that are three types: markers of
trations (MAC) for the protection of workers from exposure, effect markers and markers of sensitivity.
the risks related to exposure to chemical agents at Markers of exposure are exogenous substances,
work, introducing concepts: their metabolites, interaction between xenobiotic
• limit of chemical agents in the air at the agents and target molecules or cells, tested in any
workplace (in mg/m3 or number of particles/ part of the body. For example, the concentration of
cm3) exposure 8 h or 15 min; lead in blood reflects the exposure as a result of in-
• biological limits of the chemical agents and/ halation of lead in the air, and as a result of the direct
or their metabolites in biological media, as or indirect absorption through food, water, dust or
well as biomarkers of effect. soil. Also, there is a linear relationship between ex-
The values for various chemical agents under this posure to CO and carboxyhemoglobin levels in the
ordinance do not differ from those indicated in De- blood. It is assumed that usually the marker of expo-
cree № 13/1992 years - respectively mean-shift MAC sure is more useful for appraiser if in biological ma-
(about 8,5 h and 40 h the work-week); MAC short- terial is measured the substance, not its metabolite.
time maximum (to 15 min); biological MAC (BMAC). Markers of efficiency are measurable biochem-
The values of chemical agents in the air at the ical, physiological or other change in the body that
workplace and in biological media (them or their depending on its magnitude is recognized as an es-
metabolites) should not exceed the limits. tablished or potential deterioration of health. Mark-
The presence of hazardous chemical agents in ers of effect can be useful for assessing exposure, if
the working environment requires the employer to signal for preclinical or presymptomatic stages in
be informed of their existence and take various ade- the development of the disease (eg. inhibiting the
quate measures to reduce the health risk to workers. ChEA of PhOC) that are specific to the substance.
These include technological and technical changes Other markers of effect can report only adaptive
to reduce the amount of their, replacement with changes that by themselves are not pathological.
other less toxic or the removal thereof; awareness of Markers for sensitivity are indicators of inherent
workers about risk, training for the safeguards, their or acquired limiting the body’s ability to appropriate
health status; health surveillance of occupational response to exposure to systemic toxic substance.
health services, etc. The main responsibility for this For example, the measurement of the reactivity of
is the employer, of course, and persons (including the airways to inhaled bronchoconstrictors can be
workers), the relevant authorities and agencies in- used as a marker for susceptibility - the increased
volved in reducing health risks among workers ex- non-specific reactivity of the airways is a characteris-
posed to chemical agents. tic of most asthmatics and plays a role in the devel-
This approach to hygiene regulation of chemical opment of the disease.
agents at work - ie. occupational exposure standards In recent years there has been great progress
for airborne contaminants, developed in the United in developing a new class of biomarkers, namely
States and is accepted in European and other coun- measuring the labeled DNA molecules and pro-
tries. Developed in the US called. TLVs (Threshold teins. These new techniques are only possible under

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these chemicals or their metabolites which can bind cant (the range is much smaller in poisons that hav-
covalently with biological molecules (eg. DNA and en't distinct effects). Exposure leading to subcritical
proteins) - i.e. labeled molecules into target or pe- concentrations in critical organ can cause biochem-
ripheral tissues. For detection and quantification of ical changes (subcritical effects) associated with a
labeled molecules using methods of gas and liquid compensatory intension. They are a manifestation
chromatography/mass spectrometry, as well as im- of premorbid condition of the body and serve as a
munological assays with labeled with radioactive or harbinger of danger of causing critical effects - that
fluorescent molecules antigens. defines great importance to the prevention of occu-
pational diseases.
7.1.4. TOXICODYNAMICS The critical effect is a biological change caused
(MECHANISMS OF TOXICITY) by certain exposure. It is connected to the primary
toxic effect, as may coincide with it, or be the result
Toxicodynamics study the impact of toxic sub- of its development eg. primary toxic effect of PhOC
stances on the body, ie studies the relationship be- is the inactivation of ChEA. When the degree of inac-
tween the received dose and the measured biologi- tivation reach 50% there is a critical effect.
cal response, the latter is linked to the concentration The critical effect directed to investigate the
of toxic substances at the place of action eg. where most sensitive to the toxic effects function of critical
the toxic agent received through the mouth causes organ - eg. critical effect for occupational exposure
vomiting and diarrhea, it is rapidly eliminated and to cadmium is proteinuria - the result of the devel-
does not reach the existing level so-called toxic bi- opment of the primary toxic effects in cells critical to
oavailability. the critical organ (the epithelial cells of the proximal
In recent years, when literature deals with the renal tubules).
mechanism of action of poisons, toxic effects are dis- To adopted today molecular mechanisms, spe-
cussed at various levels - from primary effect at the cific to the operation of the whole groups of toxic
molecular level to the highest levels - cells, tissues, substances include: a) forming in the body of ox-
systems, organism. idants - free radicals by lipoperoxidation (carbon
All these events constitute toxicodynamics, tetrachloride, iodoform, dibromomethane, dimeti-
which in turn determines the clinical picture of in- laminoazobenzol etc.), b) coupling with the sulfhy-
toxication. dryl groups of enzymes (i.e. thiol poisons - metals
In critical cell concentration occurring biologi- - mercury, lead, cadmium and their compounds,
cally significant adverse functional changes in the arsenic, styrene, benzene, dithiocarbamates, chloro-
cell due to damage at sensitive to toxic substanc- prene, etc.), c) changes in the enzyme activity (heavy
es structures (usually these are organelles in which metals, PhOC, carbamates, and ChlOC etc.). These
the receptor is a structural element). Critical cells changes are divided by the authors of the prima-
and is the first population of cells in which poison- ry and secondary. The primary changes are mostly
ous substance reaches a critical concentration (due linked with structural modifications in the molecule
to readaptation changes next populations are less of the enzyme, leading to partial or complete loss of
sensitive).Critical tissue concentration is the aver- function. Secondary changes may be manifested by
age concentration reached in the organ (tissue) for an increase or decrease in the activity of enzymes, d)
the period during which in the corresponding cells a biologically alkylation and decupling of oxidative
is a critical concentration. Critical organ is the first phosphorylation (dinitrophenols, arsenic, aluminum
organum in which the poison reaches toxic concen- salts, dieldrin, etc.), e) changes in the regulation of
tration under specific conditions of exposure. His biochemical processes in the intoxication (ethanol,
knowledge is important for determining the thresh- nitroglycerin, etilenglikoldinitrat etc.). Changes in
old of chronic action, hygienic standardization and the regulatory mechanisms here are associated
early diagnosis of occupational diseases. most often with a change in the content of biogenic
Selective impairment of the critical organ is amines - adrenaline, noradrenaline, serotonin and
also used for the characterization of toxins such others.
as: hepatotropic (carbon tetrachloride, halothane, Received in the body manufacturing poisons
ChlOC, etc.), neurotropic (organic solvents, certain cause acute, subacute and chronic poisoning.
compounds of bromine), damaging hematopoiesis Acute poisonings often occur in groups and in ran-
(benzene, aniline, etc.), Nephrotropic (compounds dom accidents. They are characterized by the follow-
mercury, cadmium). In all these cases range be- ing important features: a) short-term effect of the
tween doses of the substance damaging the critical poison; b) the poison enters the body in relatively
organ and other organs and body systems is signifi- large amounts, often at high concentrations in the

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 OCCUPATIONAL MEDICINE
air of the working environment, after mistakenly in- in which the observed death of the cells of the fe-
gestion or heavily contaminated skin and mucous tus occurs in exposure to higher doses or concen-
membranes; c) a clear clinical picture immediate- trations of chemical substances, or when they enter
ly after receipt of the poison in the body or after a the body through the first 15-20 days of fertilization.
short-lived latent period. As a rule, in development The teratogenic effect was found in exposure of
of acute poisoning has two phases: the first phase is pregnant women at low concentrations and after 15
nonspecific and is manifested by headaches, gener- days from the beginning of fertilization.
al weakness, dizziness; the second phase - specific, Mutagenic effect associated with the occur-
which showed symptoms characteristic of the poi- rence of changes in the hereditary information that
son. can be transmitted to future generations. Mutagenic
Chronic poisonings occur after long duration ex- activity have several hundred inorganic and organ-
posure and at significantly lower concentrations of ic compounds - organochlorine pesticides (DDT,
toxic substances, particularly those with cumulative hexachloro, dieldrin, aldrin), organic mercury com-
properties. pounds, derivatives of dithiocarbamic acid, chlorin-
Poisons occur mainly general or mainly local ated hydrocarbons, polycyclic aromatic hydrocar-
action. In local reactions (in the place of receipt of bons, nitroso compounds and others.
the poison) always establish common events - leu- The carcinogenic effect is associated with two
kocytosis and fever at chemical burns, histamine major mechanisms of action: genotoxic and epitox-
- like reactions, etc. Poisons have mostly general re- ic. It is estimated that 80-85% of malignant tumors
sorption action that occurs after the release of sub- are caused by exogenous chemical substances: 1.
stances in the blood and tissue fluids. This is due to Polycyclic aromatic hydrocarbons - more than 100
the disruption of cell and tissue metabolism result- substances of a basic agent 3,4-benzpyrene, which
ing impact of toxins on enzyme systems. are contained in petroleum, coal tar, soot, smoke ;
Production poisons may cause not only a specif- 2. Aromatic amines - naphthyl amine, benzidine,
ic acute, subacute and chronic poisoning, but also amino derivatives of stilbene; 3. Azo- and nitro com-
reduce imunnobiological reactivity of the organism, pounds; 4-metilaminoazobenzol, nitrozodialkila-
may contribute to the development of non-specif- min, nitrosamines; 4. Other carcinogens - beryllium,
ic diseases - catarrh of the upper respiratory tract, nickel, chromium, arsenic, epoxy resins, radioactive
tuberculosis, diseases of the kidneys, cardiovascular substances, vinyl chloride, acrolein, mycotoxins, sac-
system and so on. A number of industrial poisons charin, hydrazines, safrole, benzene and the like.
cause allergic diseases, have gonadotropic, terato- In production conditions very often found com-
genic, mutagenic and carcinogenic effects. bined effect of certain chemicals on the body. In
Allergens belong to various chemicals - inorgan- metallurgy frequent combinations CO and content
ic (nickel, cobalt, mercury, arsenic, chromium, beryl- of sulfur dioxide, the CO and NOx, in the chemical
lium); organic compounds (heterocyclic turpentine, industry - vapour from benzene with toluene and
aldehydes, aromatic nitro- and amino- compounds. hydrogen sulphide, in agriculture - combinations
Very strong allergens are diamines as paraphenyl-di- between PhOC and dithiocarbamates, PhOC and
amine (yrsol). Other chemicals have the ability to ChlOC, PhOC and nitrophenols or synthetic pyre-
sensitize the skin to UV radiation, so-called photo- throids . There are three main types of combined ac-
sensitizers - anthracene, coal tar. tion: a) synergy - when one substance potentiates
Gonadotropic effect relates by changes in gen- the action of the other; b) antagonism - where a
ital tissue and gonads, with a change in their ability substance attenuates the other; c) total or additive
to reproduce. Gonadotropic activity have a number effect (mostly) - where the effect of the substance
of xenobiotics such as carbon monoxide, sulfur ox- added. The mechanism of action in the potentiation
ides, nitrogen oxides, lead, mercury, benzene, nico- or reduction of toxic effects is associated with the
tine, acrolein, tetrachloroethane. ability of certain substances to inhibit or induce the
In embryotoxic and teratogenic effect ob- enzyme systems involved in metabolic biotransfor-
served damage to the fetus in the uterus after trans- mation. For example, as inducers OMF appear some
fer of the placental barrier to chemical substances. of ChlOC's - lindane, melbex. Their combination with
This effect was observed in the exposure during the PhOC reduces the toxic effect - antagonism.
first trimester, the most common in: lead, mercury, For hygienic evaluation of air environment under
manganese, derivatives of carbamic and dithiocar- conditions of additive effect of toxic gases (eg. sul-
bamic acid, phenol, formaldehyde, benzene, dini- fur oxides and nitrogen oxides) apply the formula of
trobenzene, chlorinated hydrocarbons, a number Averyanov.
of drugs, ethanol and the like. Embryotoxic effect

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 LABOUR MEDICINE
K = C1 + C2 + C3 + Cn ≤ 1 On today much of the main aggregates, like elec-
MAC1 MAC2 MAC3 MACn tro-filters, steam-utilitarisators, cameras for combus-
tion, columns of synthesis and precatalysis are out in
where the sum of the relationship of the actual the open, away from production areas and employ-
concentrations to their MAC must be equal to or less ees control their work remotely, i.e. from a control
than one. room through appropriate instrumentation. More
dangerous places need setting up of alarm with si-
7.1.5. PREVENTION OF OCCUPATIONAL ren or warning lights, related to the control room.
POISONINGS. GENERAL PRINCIPLES. 5. Regular monitoring of the content of poisons -
gas and dust in the air of production premises. This
Most effective measures for the prevention of can provide by using gas analysers and detectors for
occupational poisoning can take place in the design automatic control.
phase of industrial enterprises. 6. Organization of effective measures for person-
To hygiene failures associated with acute and al prevention. This includes providing employees:
chronic poisoning of workers in manufacturing most reliable personal protective equipment and special
often include: disruption of the normal technologi- clothing, protective professional nutrition, resourc-
cal regime, failure of equipment, ventilation, tools es for maintaining personal hygiene - bathrooms,
and apparatuses, violating occupational safety and wardrobes, laundry for cleaning and maintenance
hygiene, poor instruction and insufficient training of clothing, rooms for personal hygiene of women.
of workers coming into contact with toxic substanc- In chemical plants, metallurgy and mining sites is
es, improper work organization and workplace, ab- mandatory setting up of gaz-saving stations.
sence or malfunction of personal protective equip- 7. Organization of effective therapeutic and
ment and special clothing. In this connection, the prophylactic measures. These include mandatory
main measures for the prevention of occupational conducting preliminary professional selection of in-
poisoning can be grouped as follows: coming work in harmful and dangerous industries,
1. Introduction of new technology and preserv- conducting periodic preventive examinations and
ing optimal technological regime. Here importance dispensary of diseased, registration and analysis of
is the replacement of more toxic substances with occupational diseases and poisoning. The registra-
less toxic (eg, the use of gasoline instead of benzene, tion of professional poisonings - acute and chronic,
of zinc paints instead of lead) and hygiene stand- inquiry of each case and the analysis of their causes
ards of the most important chemical raw materials are mandatory.
in order to prevent highly toxic substances in basic 8. Organizational and administrative measures.
composition of chemical products (plastics, paints). They are regulated by labour legislation and include:
Violation of normal technological regime not only shortened working day, additional leave, reduced
leads to failure of machinery, but serious accidents total length of service, preliminary and ongoing san-
causing acute group poisonings. itary control, technical and labour hygiene instruc-
2. Provide complete seal hermetically of equip- tion for newcomer workers. Instruction includes
ment and communications. introduction with harmful production factors and
3. Provide sufficient air exchange in manufactur- prevention measures, proper use of personal pro-
ing premisses. This is achieved with natural and arti- tective equipment, methods of self-help and mutual
ficial ventilation as the most dangerous places sepa- assistance in the poisoning, health-education meas-
rate high concentrations of gases must be installed ures.
local hoods or aspirators. In the workshops, which In all industries where possible poisoning, re-
emit heavier than air gases and vapors it is necessary quires extreme readiness of medical personnel and
to provide additional aspiration of air into the lower adequate basis for fast rendering first aid to the vic-
part of the premises. tims of acute poisoning.
4. Continuous mechanization and automation
of production, including remote control and regu-
lation of processes, accurate and reliable operation
of CMG (check-measuring gauges) and automation.

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REFERENCES

1. Beker C.E., Rosenberg J: Clinical Toxicology. In Occupational Medicine, edi. J. LaDou. Norwalk, Apple-
ton and Lange, 1990, 131-139.
2. Decree № 13 on the protection of workers from the risks related to exposure to chemical agents at
work. SG. 8/2004 (in bul.)
3. Desoille M., J. Scherrer, R. Truhaut. Precis de medicine du travail. Facteurs chimiques, Masson, Paris,
1991, 445-507.
4. Doull J, Klaassen C. D, Amdur M. O (editors): Casarett and Doyll’s: Toxicology: The Basic Science of
Poisons, 3 rd ed. Macmillan, 1986. 1
5. Fowler D. P. Industrial Hygiene. In Occupational Medicine, ed. J. LaDou. Norwalk, Appleton and Lange,
1990, 499-513.
6. Hayes A. W (editor): Principles and Methodes of Toxicology, Raven Press, 1982.
7. Kaloyanova F. (ed.). Hygienic Toxicology - general section. Sofia. Med. and phys., 1981. (in bul.)
8. Kaloyanova F. (ed.). Hygienic Toxicology - Manual. Sofia Med. and phys., 1985. (in bul.)
9. Kamrin M. A: Toxicology. Lewis, 1988.
10. Kasparov A. A.: Hygiene of labour and industrial sanitary. Moscow. Medicine, 1997. (in russ.)
11. Korbakova, AI, Sanotskiy I. C. I. P. Ulanova. Hygienic standartisation chemical substances. Guide for
hygiene of labour V. I, ed. NF Izmerov, Moscow, Medicine, 276 - 311, 1987. (in russ.)
12. Lukanov M. (ed.): Hygiene of the main sectors of production. Sofia Med. and phys., 1978. (in bul.)
13. Lukanov M. (ed.). Occupational medicine II ed., Med. and phys., Sofia, 1984. (in bul.)
14. Monov A. et al .: Clinical Toxicology, Sofia Med. and phys., 1981. (in bul.)
15. Navrotskiy V.K. Hygiene of labour, II ed., Moscow, Medicine, 1974. (in russ.)
16. Popov, T., V. Hristeva, Bainova A. et al. Toxicology. in. Occupational Health - a collection of teaching
materials, Ministry of Health and NCHMEN, S., V. I, 1999, 306-406. (in bul.)
17. Rodricks J. V, Tardiff R. G (editors): Assessment and Management of Chemical Risk, Amer. Chemical
Society, 1984.
18. Sielbergeld E. K. (editor). Toxicology, in Encyclopedia of occupational Health and Safety, ed. J. M.
Stellman 4th ed., Vol. I, 33.2 - 33.42., ILO, Geneva, 1998.
19. Williams P. L., Burson J. L. (editors): Industrial Toxicology: Safety and Health Applications in the Work-
place. Van Nostrand/Reinhold, 1985.

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 M. Koleva

7.2 METALS AND NON-METALS

Antimony (Sb) used for the treatment of parasitic diseases distrib-

HYGIENE STANDARDS uted in tropical countries.
Air of the working environment: Mean-shift PROFESSIONAL AND UNPROFESSIONAL
MAC - 0,5 mg/m3 EXPOSURE
GENERAL CHARACTERISTICS Occupational exposure is mainly related activi-
Antimony is a silvery-white metal with a pro- ties upon receipt of antimony compounds and pure
nounced sparkle and crystalline structure. Atomic metal.
weight - 121.75; density 6,69 g/ml at 20°C, a melting Markedly toxic to humans is antimony trichloride.
point of 630,5°C, boiling temperature - according to The nature of toxicity is determined by the forming
different authors vary from 1325 to 1635°C. in hydrolysis hydrochloric acid.
Chemical is poorly active element. Low migrates High toxicity features is SbH3 (stibine) - gaseous
into the environment. Diffuse dispersed metal with an compound. There are reports of poisoning workers
average content in the lithosphere 4-5.10-5%. In na- with stibine. It is experimentally proved that stibine
tive condition is very rare. There are over 90 mineral induce acute inflammatory changes in the trachea
containing antimony: complex sulphide, oxides and and bronchi, pulmonary edema, necrobiotic chang-
oxichlorides. Manufactured has mineral antimonyt es in the myocardium, toxic dystrophy and necrosis
(Sb2S3 - antimony 70%, sulfur 28%). In ores as a rule of the renal tubules and others.
except antimony containing gold, silver, lead, copper Unprofessional exposure concerns individuals
and arsenic. The average content of antimony ranges using antimony preparations for treatment.
from 5 to 20%. The largest deposits of antimony in the The presence of antimony in ambient air is asso-
world are located on the territory of the former USSR. ciated with anthropogenic pollution and settled in
His most famous organic compound is antimony po- areas of extracting antimony and lead companies.
tassium tartrate (Antimony) that causes vomiting. It is With waste gases from production in the atmos-
used as a medicament. The majority described antimo- phere is ejected dust with a complex composition
ny poisoning are caused precisely by him. (antimony, arsenic, iron, lead, carbon, silicon diox-
In natural conditions, the largest quantities of an- ide) and spread over large distances (up to 20 km
timony are found in the waters of the mineral springs from the source).
(up to 0,5 mg/dm3) and at sea. The main sources of pollution of the aquatic en-
USE vironment with antimony are wastewater from con-
World annual production of antimony is about centration plants containing more than 10 mg/dm3
100 thousand tons. In pure antimony is not used antimony.
except for the semiconductor ultra-high purity METABOLISM AND MECHANISM OF ACTION
(impurities no more than 1.10-4%). Antimony alloys Antimony is a nonessential toxic ultramicroele-
are very hard, corrosion-resistant, excellent friction ment to humans. For pentavalent its compounds
properties and the ability to expand during harden- supposedly essential role.
ing. Used for the production of bearings, plates for Enters the body by inhalation (for workers) and
batteries, parts for pumps, equipment for the chem- oral (mainly food). In the gastrointestinal tract are
ical industry, in typography. absorbed only 5-15% of the amount absorbed. For
Antimony trioxide is used in the chemical indus- about two hours, the antimony passed from the
try, textile and glass industry, the manufacture of blood into tissues. In a study of the distribution of
paints and varnishes. Antimony pentoxide is used in the antimony in the body it has been found that an-
the chemical and pharmaceutical industry. The com- timony is rapidly detected in the liver, kidney, lung,
pounds of antimony with sulfur is used to produce thyroid, adrenal, pancreas. Regardless of the path of
rubber (coloring agents and plasticizers), matches, entry into the body, the nature of the distribution of
in pyrotechnics. Halogenated antimony are used for the antimony is uniform, differences were observed
the preparation of rubber, synthetic fiber and drugs. only in the level. This pattern was also observed in
A number of preparations containing antimony is complex receipt of antimony in the body (in all pos-

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 OCCUPATIONAL MEDICINE
sible ways of simultaneously penetration). Pentava- copper, zinc, lead, gold and silver of amounts to 5-10%
lent antimony is deposited in bones. It is assumed (in the richer of arsenic ores). Under natural conditions
that in the body antimony subject of biomethyla- formed arsenates (As 5+ - salts of arsenic acid), arsen-
tion. ite (As 3+ - salts of arsenous acid). Alloys of arsenic with
Excreted primarily in the urine and faeces, but metals called arsenide.
in the stools amount of antimony is 2-3 times more Arsenic is a multivalent element, formed over 180
than in urine. minerals. Manufactured are: arsenopyrite (FeAsS),
Exposure assessment recommended determina- auripigment (As2 S3), with an average arsenic content
tion of antimony in urine, blood and hair. 46% and 61%. Vigorously migrates into the environ-
Individual medicinal preparations (organic com- ment. When volcanic activity in the composition of
pounds) have a pronounced antigenic and cause volcanic gases off into the air. With deep thermal wa-
skin reactions. ter is exported to the surface simultaneously with iron,
PREVENTION sulfur, selenium, antimony, cobalt, nickel, copper and
Specific prevention of chronic poisoning with others. and precipitated.
antimony in production include: technological and There are several allotropic forms of arsenic. The
technical measures to limit dust- and gas emission most common form are grey crystals with metallic
in the production, isolation and hermetisation; pre- luster that are oxidized by air. The density of the arse-
liminary and periodical medical examinations in- nic is 5.727 (at 14°C), melting temperature of 817°C to
volving therapist, neurologist, radiologist and der- 615°C sublimate. Insoluble in water is. When heating is
matologist; dispensary of persons in contact with oxidized to As2O3. Aqua regia and nitric acid oxidated
antimony; testing for the presence of antimony in arsenic to arsenates.
the blood, urine and other biological media; per- Arsine (AsH3) is a colorless gas. In its pure form is
sonal protective equipment (clothing, dust masks or odorless, in the presence of impurities has a charac-
respirators) and good personal hygiene. teristic smell of garlic that probably due to dietilarsine
- AsH (C2H5)2. The density of arsine is 3.50, dissolved in
ARSENIC (As) water. When heated above 500°C is decomposed into
HYGIENE STANDARDS hydrogen and arsenic.
Air of the working environment.* Arsenic and White arsenic (As2O3) is an amorphous, glassy or
inorganic compounds (diarsenic trioxide, diarsenic crystalline solid, with melting point 313 ° C (crystal
pentoxide, gallium arsenide) - Mean-shift MAC - 0,05 form), a boiling point of 456 ° C, density 4,15. Slightly
mg/m3. Carcinogenicity to humans (Group 1) terato- soluble in water, the aqueous solution has an acid re-
gen for animals. action.
Arsine (AsH3) - Mean-shift MAC - 0,05 mg/m3. USE
Air settlements: arsenic (inorganic compounds Arsenic is used to obtain a semiconductor (gal-
without arsine calculated as arsenic) - Daily average lium arsenite), as an additive in the alloys, in glass
MAC - 0,003 mg/m3. industry, leather industry, the chemical industry
Arsine - Daily average MAC - 0,002 mg/m3. (initiator, catalyst), in paints for underwater installa-
Drinking water (BS 2823-83): Arsenic 3+ in mg/ tions, in pyrotechnics, for the preservation of wood,
dm3 no more than 0,05 mg/dm3. in dentistry and medicine (currently limited).
Flowing surface water: I category - 0,02 mg/dm3, PROFESSIONAL AND UNPROFESSIONAL
II category - 0,05 mg/dm3, III category - 0,2 mg/dm3. EXPOSURE
Food products: from 0,05 mg/kg in infant food Arsene form and paid in the following cases:
milk-based, to 5,0 mg/kg in the sea fish. • In contact with metals contaminated with
Soil: 25 mg/kg. arsenic acids, in electroplating and metal ex-
GENERAL CHARACTERISTICS traction by electrolysis;
Arsenic is widely distributed in nature element, • Contact FeSi with water (in warehouses for
though rarely occurs in native form. The average con- storage); metal containing arsenic with water
tent in the earth’s crust is 1,7.10-4%. Opened as an im- in the metallurgical industry; in the prepara-
purity (average 2%) in all the sulphide ores in complex tion of acetylene by calcium carbide; at con-
iron and manganese, precious and non-ferrous metals: tact of aluminum arsenite with water if alumi-
num is used for cleansing lead from arsenic;
* Here and further for work environment, according to Decree № • In the chemical industry in the manufacture
13/2004 on be used instead mean-shift MAC, short-time maxi-
mum MAC, biological MAC, respectively - limit for 8 h, limit for of aniline;
15 min., a biological limit. Specific values are the same - for • In wet rooms painted with arsenic paint under
MAC/for limit. the influence of developing fungus.

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 LABOUR MEDICINE
Conditions of increased absorption of arsenic by everyday entry - about 47 μg.
workers exist in the extraction of metal ores and es- In pure state arsenic is insoluble and poorly ab-
pecially in their heat treatment during the produc- sorbed in the body. Arsenic compounds are ab-
tion of copper, lead, zinc, iron. sorbed easily in the gastrointestinal tract (80-100%),
A major pollutant of the environment with ar- and therefore oral entrance is the most important
senic are metallurgical enterprises. In less arsenic is quantitatively way of penetration. The work environ-
released during combustion of coal (TEPP). Arsenic ment arsenic enters the body mainly by inhalation.
is present as an impurity in some superphosphate About 35% of infiltrating the lungs arsenic stays and
fertilizers and detergents. 50-80% is absorbed. It is possible penetration and
In the air of clean areas contained by 0.0009 to skin contact.
0,003 mg/m3 arsenic. In the area of source of air pol- Repeated absorption subtoxical doses of diarse-
lution with arsenic concentration reaches 0,006-0,026 nic trioxide leads to the development of tolerance,
mg/m3. In surface and groundwater contaminated possibly by way of reduced absorption of intestinal
with arsenic amount is about 0,010 mg/dm3, in min- contents.
eral waters reached 0,125 mg/dm3. In anthropogenic Arsenic in serum is protein bound and his frac-
polluted areas arsenic in surface waters varies wide- tion in erythrocytes is almost entirely associated
ly: from 0,20 mg/dm3 to 10,4-89 mg/m3. Soils in un- with globin. Metalloid quickly passes from the blood
contaminated areas in the country contain arsenic into the organs. In exposed workers have shown ele-
average of 5-10 mg/kg. Round sources of pollution vated levels in the lungs, liver and kidneys.
(ironworks) soil layer of 30 cm contain 8-200 mg/kg Arsenic accumulates partially (about 30%) in the
arsenic, soil layer 60 cm - 4-55 mg/kg arsenic. skin, hair, nails and skeleton. Is eliminated mainly by
The natural content of arsenic in food is up to 1 the kidneys in urine (70% of absorbed arsenic) and
mg/kg: vegetables and fruits - from traces to 0,5 mg/ to a lesser extent by the hair, nails, feces, sweat and
kg, beans - from 0,016 to 1,210 mg/kg. An excep- failing epithelial cells. Arsenic crosses the placental
tion to this rule are fish of the sea and some types barrier and is secreted in milk. Blood brain barrier is
of mushrooms that concentrate arsenic in amounts impermeable to the inorganic forms.
corresponding to 166 mg/kg and up to 356 mg/kg. Determination of inorganic and organic forms of
In our established the following amounts of arsenic arsenic in urine is recommended as a specific and
in food products of anthropogenic polluted areas: sensitive method for biological control.
corn - 0,250-0,400 mg/kg of raw product; potatoes PREVENTION
- 0,007-0,1 mg/kg of raw product; pears - 0,017-0,60 Integrated application of all known measures to
mg/kg and maximum in alfalfa - 1,175-2,250 mg/kg. reduce exposure to arsenic in the workplace is re-
Industrial discards arsenic is more toxic trivalent quired by proven its carcinogenic potential.
form which has a greater carcinogenic activity. In Preliminary and periodic medical examinations
the soil, it is oxidized to the pentavalent form weak- are required. It recommended diet D for protective
ly active, which is found normally in the surface soil professional feeding and giving additional vitamin C
layer. Increasing the trivalent form is a direct indi- 100 mg, vitamin E 20 mg, vitamin B2 - 2 mg, enriched
cation of intense contamination with arsenic and with pectin, fruit drinks and fruit purees, mousses.
violation of the processes of self-purification in soil.
These changes in biotope affect and biocoenoses, as BERYLLIUM (Be)
occurs phytotoxic action, suppresses to the growth HYGIENE STANDARDS
of microorganisms, higher organisms die. Due to Air of working environment: Mean-shift MAC -
the selective accumulation of arsenic in the body of 0,002 mg/m3.
aquatic life, possible inclusion in the food chain. Surface water: I category - 0,0002 mg/dm3, II cat-
METABOLISM AND MECHANISM OF ACTION egory - 0,0002 mg/m3, III category - 0,002 mg/dm3.
Arsenic is nonessential and toxic to human ele- GENERAL CHARACTERISTICS
ment. The toxicity of arsenic compounds depends Beryllium is a light, pale-grey metal. In the com-
on the degree of oxidation of the metalloid, its pounds is divalent. Are known isotopes of beryllium
chemical form and its solubility in biological media. having an atomic mass 7, 8, 9, 10, and 11. Melting
It decreases in the following order: arsine, inorganic point 1284°C, a boiling point of 2970°C, a density of
and organic compounds of trivalent arsenic (arsen- 1,85 g/cm3 at 20°C, insoluble in water. Forms salts that
ites), inorganic and organic compounds of pentava- are soluble in water.
lent arsenic (arsenates), metallic arsenic. In the lithosphere and crust contain from 6.10-4 to
The total amount of arsenic in the body under 4.10-4% beryllium. Currently, there are known 54 be-
normal conditions amounts to about 1 mg, due to ryllium minerals, most silicates, phosphates, oxides,

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 OCCUPATIONAL MEDICINE
borates, arsenates and carbonates. The most common companies extracting or using beryllium and its
is berilat, also known as emerald, aquamarine, etc., compounds. The content of beryllium in the air of
Containing 10,5-14,3% Be. Manufactured significance cities reached 0,0009 μg/m3. The total import of be-
have more: fenakit (45,5% BeO), chrysoberyl or alex- ryllium in the body for 24 hours is around 10-20 μg.
andrite (18.1 to 20.7% BeO), bertrandit (39.6 to 42.6% METABOLISM AND MECHANISM OF ACTION
BeO) and others. Beryllium is a nonessential ultramicroelement,
Typical satellites of beryllium in these minerals are toxic in extremely small quantities. Critical toxicity
opal, chalcedony, gypsum, mica, quartz and others. has Be2+ which has general toxic, allergic, carcino-
The natural content of beryllium in the ore is less than genic and embryotoxic action. For soluble com-
1%, and therefore must be subjected to enrichment for pounds is typical irritation. The most toxic are the
the production. Pure beryllium (99.98%) was obtained following beryllium compounds: chloride, fluoride,
by distillation. oxyfluorides, acetate, sulfate and oxalate.
Beryllium vigorously migrated in the environmen- Beryllium enter in the body mainly by inhalation
tal objects. Concentrated beryllium is found in coal and or through skin. At inhalation of beryllium in lung
oil. By products of their combustion spread into the en- develop process of formation of specific granulomas.
vironment. The contents of beryllium at objects with The disease is called berylliosis. Observed changes
low pH (acidic pH): soil, mineral waters, containing in the immunological condition of the body and the
sulphates and fluorine, is higher. Rarely found in sites activity of enzymes catalyzing energy processes in
with pH above 7.5 to 8.0. Around deposits of beryllium the body, since beryllium enter into competitive
are formed biogeochemical provinces with a surplus of and often antagonistic relationship with ions of bi-
beryllium, which was observed growth of malformed ologically important divalent metals (magnesium,
conifers. calcium, manganese, etc.) which are natural activa-
USE tors of enzymes. Attempts to quantify toxic effects
Production of aircraft, missiles and spacecraft is shown that beryllium is a potent, tissue necrotizing
unthinkable without beryllium and its alloys. They substance without correlation between dose and re-
are used in all elements of the construction of space- sponse of the body.
craft, compressors, air- and gas turbogenerators, Inhalation of soluble compounds principal
brake systems of airplanes. Beryllium is recognized amount of beryllium by lung passes into the blood
as the most suitable material for making VHF anten- and deposited in bone. After oral ingestion absorp-
nas of radars, telemetry devices to transmit signals tion is negligible.
and mirrors of telescopes. “Transparent” for X-rays, Beryllium crosses the placenta and harms the
it is used in the manufacture of windows of X-ray fetus. Secreted by the mammary glands and is dan-
tubes. In nuclear reactors used for reflection and gerous for infants. Easily overcome and hematoen-
slow flows charged particles and radiation. cephal barrier.
In the machinery used beryllium bronze (4%) PREVENTION
for the production of electricity contacts, explo- To prevent chronic professional and non-profes-
sion-proof tools and bearings. sional poisonings apply complex preventive meas-
PROFESSIONAL AND UNPROFESSIONAL ures: cut off sources of air pollution to Be; insulating
EXPOSURE buildings, which works with Be or its alloys contain-
Due to the high biological activity, high toxicity ing more than 20 percent Be; maximum mechaniza-
and specificity of the biological action of beryllium tion, automation, effective ventilation, preliminary
(allergen and a carcinogen group 1), the profession- and periodic medical examinations, personal pro-
al contact with a high risk. Especially dangerous are tective equipment.
the professions and jobs associated with obtaining Containing beryllium solid waste reprocessed. If
beryllium and it's alloys; welding beryllium alloys; processing is impossible, they are collected and dis-
production and processing of beryllium windows posed of appropriately, mostly buried in concrete
for X-ray tubes. Through automation and pressuriza- repositories.
tion of equipment and production processes possi- Industrial wastewater containing beryllium sub-
ble content of beryllium in the air of the working en- ject to compulsory treatment.
vironment is reduced to 0,01-0,36 μg/m3 (at hygiene Protection of ambient air on beryllium apply pol-
standard 2 μg/m3). lution systems of multistep purification of air with
Sources of pollution of Be in air, water, soils are the mandatory use of high efficiency electrostatic
power plants (of coal and oil), motor vehicles and precipitators as a last step.

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VANADIUM (V) environment of condensation and disintegrating
HYGIENE STANDARDS aerosols whose total amount fluctuated from 0.03
Air of the working environment: Mean-shift to 1,0-2,0 mg/m3.
MAC for vanadium - oxides and inorganic com- In the preparation of pure reagents (vanadium
pounds - 0,05 mg/m3. salts and vanadium pentoxide), their concentration
Air settlements: Daily average MAC of vanadi- in the air reaches 2,0-6,0 mg/m3. Production of fer-
um pentoxide - 0,002 mg/m3. ovanadium accompanied by intensive formation
Surface water: I category - 0,01 mg/dm3, II cate- of aerosols with a complex composition. In general
gory - 0,1 mg/dm3, III category - 1 mg/dm3. concentration of metal aerosols 10-30 mg/m3 con-
GENERAL CHARACTERISTICS tent of vanadium in the air at melting fluctuated
The pure vanadium is greyish-blue malleable from 0.05 to 3,0-4,0 mg/m3.
metal with a specific gravity of 5.688 and a melting When cleaning steam generators of TEPP, fueled
point of 1735°C. Vanadium exhibits high reactivity by fuel oil, the concentration of vanadium in the
and forms a number of complex inorganic and or- breathing zone of workers fluctuates widely and
ganic compounds, but the most characteristic is a reach tens mg/m3.
chemical bond V-O. The main source of vanadium in the environment
The average content of vanadium in the Earth’s are central fueled by oil, fuel oil and coal. Remains
crust is 5.10-2%. He is distracted element occurs in of burning oil contains more vanadium than coal. In
the composition of titanoiummagnetitic and sedi- oil refining vanadium entirely goes into mazut oil,
mentary iron ores and oxidized ores containing cop- where its content reaches 1,400 g/t mazut. When
per, lead and zinc. Natural concentrates of vanadium burning fuel oil 90% of vanadium be disposed of
are coal and oil. with smoke.
Upon heating vanadium forms oxides with var- Source of pollution of air, water and soil with va-
ying degrees of oxidation: VO - insoluble in water nadium are metallurgical and chemical plants where
but soluble in acids, naturally rapidly passes into the they receive vanadium compounds or using them to
trivalent vanadium; V2O3 - soluble in acids, slowly ox- obtain alloy steels. In the area of metallurgical plants
idises under the influence of the air; VO2 - exhibits concentration of vanadium pentoxide range from
amphoteric properties, easily oxidized to pentox- 0.98 to 2 μg/m3.
ide; V2O5 - most wide spread vanadium compound, Wastewater from producing vanadium plants
moderately soluble in water, well dissolves in bases contain up to 700 mg/dm3 vanadium and after treat-
forming salts: ortho-, para- and metavanadates. By ment - 0,34 mg/m3.
number of compounds formed, vanadium concede The natural content of vanadium in fresh produce
only to carbon. is about 2 μg /%. Most rich in vanadium are beans -
USE 203 μg%, cabbage and carrots - 111-112 μg% and
Vanadium is used in metallurgy for the prepa- apples - 21 μg%.
ration of a variety of steels and alloys with other METABOLISM AND MECHANISM OF ACTION
metals. V2O5 is a raw material for the preparation of Vanadium is essential ultramicroelement in
metal vanadium and vanadium alloys of aluminum, mammals, but the evidence that is the same for peo-
titanium, and iron. From it are prepared, and vanadi- ple still are not enough. The amount of vanadium in
um catalysts necessary for the production of sulfuric the body is harmless to a certain level, above which
acid. As chemical reagents used various salts of va- the observed manifestations of toxicity.
nadium. Body content of vanadium is 100-200 μg no ten-
Metavanadat is used in the production of aniline dency for accumulation. The main source of vanadi-
paints, colorful ceramics and glass. Furthermore, the um is food, daily admission intake is around 10-30
vanadium pentoxide and its salts have been used μg. The level of absorption of vanadium contained
for catalysis in the production of phthalic and maleic in food is not known.
anhydride, vinyl acetate, cyclonexilamine and vari- The importance of the respiratory route of ad-
ous oxidation reactions. Ferovanadium be used to ministration of vanadium in the body increases in
obtain high-quality steel. pollution of environment and production condi-
PROFESSIOINAL AND UNPROFESSIONAL tions. It is believed that the absorption of vanadium
EXPOSURE in the lungs is faster and higher than intestinal and
Concentration of dust in vanadiumcontant slag reaches 25 to 100 percent of inhaled and retained
at crushing reaches tens mg/m3. The process of re- amount of vanadium. Absorption through the skin
ceiving and processing of vanadium pentoxide ac- has no practical significance.
companied by the release into the air of the working Absorbed vanadium is evenly distributed in the

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body. Briefly retained in bone, liver, kidney, muscle, mg/m3. Mercury vapours are 7 times heavier than air.
spleen, endocrine and sexual glands. Excreted pri- Its solubility in water is low, increases with the increase
marily in the urine, particularly with increased expo- of the oxygen content in it. Dissolve in hydrochloric
sure. acid, hot concentrated sulfuric or nitric acid and so-
In the biological control of the exposure can be called. “aqua regia”. Mercury dissolves number of met-
used the following tests: urine vanadium, vanadium als (gold, silver, zinc, lead, tin, etc.) to form amalgams.
in the blood (serum), plasma, vanadium in hair and In normal conditions it is not oxidized by atmospheric
in faces. oxygen.
PREVENTION Mercury is distracted element. Natural concentrates
To optimize working conditions is particularly of mercury are sulfide ores. Small amounts are found
important introduction of continuous and central- in native condition. The average mercury content in
ized production processes. To reduce air pollution the Earth crust is 8.10-6%. The total amount of mercury
using scrubbers and electrostatic precipitators, and in seawater is 206 mil. tons, and the above-ground bi-
the processes of crushing, grinding and roasting of omass - 0.5 mil. t. The total amount of mercury in the
vanadium slag takes place in pressurized equipment air is 300-350 t, as the concentration over the land is in
with effective local ventilation and remote control. an order higher than that over the ocean. It is believed
The presence of a powerful local ventilation is espe- that the reason for this is mainly agricultural work.
cially important in the production of vanadium met- With 1 m3 of rainwater falling on the ground 200 μg
al and the vanadium chlorides. mercury, per 1 year the total exceeds 100 000 t, which is
To protect the inhalation is recommended to use 15-20 times more than the global annual production.
respirators. To protect the body and arms are recom- Mercury intensively included in the so-called water
mended suits of special suitable materials and rub- migration, characterized by a high absorption coeffi-
ber gloves. cient of brown algae (200.0). This coefficient for terres-
In prophylactic medical examination must par- trial plants is 7.58. Stably fixed in the soil by forming
ticipate therapist, ORL specialist and radiologist. In- complexes with humic acid. The half-life of the soil was
dividuals diagnosed with pneumoconiosis, diffuse 250 years. From land to ocean waters annually in the
pneumosclerosis, anemia, liver damage is vocation- form of soluble organic compounds pass 2.6 thousand
al rehabilitation. The same recommendation is valid tons of mercury; from the soil to the air - 1000 t; in the
for workers with allergic diseases of the airways and biological cycle includes 40 thousand tons.
bronchi. The sources of mercury in the environment are
anthropogenic and natural. Natural are divided into:
MERCURY AND ITS COMPOUNDS (Hg) global (Earth’s mantle, ocean, underground and sur-
HYGIENE STANDARDS face water, biosphere), regional (mercury deposits - ore
Air of the working environment: zones and regions) and local (ore fields). In environ-
• Mercury - vapour of metal in the elementary mental and working environment mercury is present
state - mean-shift MAC 0,05 mg/m3; in a wide range of physico-chemical conditions and
• Inorganic and aryl compounds - mean-shift compounds, each of which has specific chemical and
MAC - 0,1 mg/m3; toxic properties. They are classified as follows:
• Organic and alkyd compounds - mean-shift 1. Inorganic mercury forms:
MAC - 0,01 mg/m3, a) the vapour of mercury in elemental state,
• Short-term maximum MAC - 0,03 mg/m3. b) inorganic compounds of mercury (II) and mercu-
Air settlements: Mercury and metal compounds ry (I), which in the body is converted to Hg2+
- daily average MAC - 0,0003 mg/m3. 2. Organic mercury compounds:
Surface water: I category - 0,0002 mg/dm3, II cat- a) alkyl mercury compounds: methylmercury, ethyl
egory - 0,001 mg/dm3, III category - 0,001 mg/dm3. mercury and propyl mercury
Food: From 0,005 mg/kg for milk and infant food, b) alloxy alkyl mercury compounds
milk-based to 0,1 mg/kg for guts and dried vegeta- c) aryl mercury compounds as phenyl mercury and
bles; maximum of 0,4 mg/kg for mussels and 0,6 others.
mg/kg of freshwater fish (0,7 mg/kg - sea fish). Vapour of mercury in elemental state are the most
GENERAL CHARACTERISTICS common contaminants in the work environment and
Mercury is a silvery liquid metal with a molecular alkyl mercury compounds (methylmercury) - in the en-
weight of 200.59 and density of 13,546 g/cm3 at 20°C. vironment. They are the most toxic compounds.
At temperatures below -39°C becomes white and mal- Technogenically dispersed mercury compounds
leability. At normal temperature, was evaporated. The (soluble salts, organic compounds) are distinguished
maximum possible concentration at 20°C was 15,2 by pronounced geochemical mobility as compared

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with natural (mainly sulfides, hardly soluble and weak- tion of inorganic mercury compounds in the gastro-
ly volatile), and therefore are environmentally hazard- intestinal tract is estimated at about 7%, depending
ous. on the solubility of the absorbed compound.
USE Alkyl mercury short-chain compounds (meth-
The mercury is used in various industries: prepa- ylmercury) are more volatile and dangerous if in-
ration of chlorine and caustic soda (mercury cath- haled by aryl mercury. Pulmonary their absorption
ode electrolysis); synthesis of inorganic and organ- is about 80%.
ic mercury compounds (including organomercury A significant part of the mercury in the diet (the
pesticides); in electrical engineering and instrumen- main source of population) in the form of methyl-
tation; the extraction of precious metals (gold) from mercury, especially in fish. Provide the toxicity of
ore; for steel alloy materials; heat transfer; catalyst mercury, WHO recommended provisional tolerable
in the chemical industry; to obtain amalgams and weekly submission of mercury 300 μg, at it methyl
amalgamation (incl. in the dental practice); as an mercury maximum of 200 μg. Practically all of the
anti-rot wood; in laboratory and medical practice; received in the gastrointestinal tract methylmercury
production of lamps - quartz and fluorescent lamps, is absorbed - 95%. The skin can pass toxic acting
X-ray tubes and explosives. amounts of alkyl mercury.
PROFESSIONAL AND UNPROFESSIONAL Resorption of aryl mercury compounds after in-
EXPOSURE halation and skin contact is weak. The absorption in
Mercury is a classic example of how at occupa- the gastrointestinal tract is almost complete.
tional exposure critical effect and critical organ in In the division between organs mercury show af-
the same substance may change depending on the finity for scaly epithelium of the skin, hair, sweat, and
chemical form, route of administration, duration salivary glands, thyroid gland, gastrointestinal tract,
and object of impact. In short-term exposure to high liver, pancreas, kidney, testes and prostate.
concentrations of mercury vapor critical organ are The retention time of the accumulated mercury
lungs. In long term (chronic) exposure to mercury fluctuated widely for different organs. It is the long-
vapor critical organ is the brain. est in the brain, kidneys and testes.
Critical organ of inorganic salts and aryl deriva- Main excretory organs for mercury are the kid-
tives of mercury are kidney. Critical organ of alkyl neys (by tubular excretion in the urine) and liver (by
mercury short-chain compounds (methylmercury, bile secretion in faeces). With less importance are
ethyl mercury) is the brain and at pregnant women - the secretions of the gastrointestinal tract, sweat,
the brain of the child. excretion of hair and nails.
Mercury is absorbed by the building materials Mercury content in blood and urine are informa-
and structures in working and living areas, wooden tive toxicokinetic tests during nearby exposure, but
items of equipment, furniture, clothing and more. did not clarify the problem of mercury content in
The quantity of absorbed mercury depends on the the brain. Exposure assessment of an individual by
time of impact, the amount of mercury in the air, mercury in urine is possible only at several analyzing
the properties of the absorbent material and the 24-hour urine samples for several days at prior expo-
temperature. Contaminated with mercury elements sure over one year.
of the interior at desorption turn into a secondary PREVENTION
source of mercury vapor in the room. The main events for the prevention of chronic
Mercury has a pronounced ability to bioconcentra- mercury poisoning are:
tion (i.e. food chain), which explains the cases of poison- • Eliminating possible sources of mercury in
ing by organic mercury compounds from fish as food. the working environment; proper storage of
METABOLISM AND MECHANISM OF ACTION mercury and its salts; changes in technology
Mercury is nonessential cumulative, a toxic for aimed at the exclusion and replacement with
body element. Body content of mercury in adult is some less toxic or non-toxic substances;
about 13 mg. • Location of sources of pollution of the work-
Vapour of mercury in elemental state (as a con- ing environment by mercury vapor;
taminant in the work environment most common) • Protection of structures, equipment and work
enter through the airways. The absorption in the furniture;
lungs is high (80%), which includes about 80% re- • Compliance with the rules for safe work and
tention and 100% absorption. Absorbed mercury personal hygiene when work with mercury;
quickly passes into the bloodstream. After acciden- • Efficient processing of clothing;
tal ingestion of metallic mercury absorption in the • Preliminary and ongoing instructions on safe
gastrointestinal tract is negligible - 0,01%. Absorp- work for all persons in contact with the mer-

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cury. cadmium content in the Earth crust is 1,3.10-5%. In
Preliminary and periodic medical examinations small amounts are found in all objects of the environ-
involving therapist, neurologist, dentist and at in- ment, mainly in soils with alkaline pH, sea waters, bot-
dications a psychiatrist and gynecologist, are re- tom sediments. It tends to bioconcentration in plank-
quired. If signs of mercurialism persons temporarily ton.
removed from contact with the mercury, with sub- USE
sequent treatment in ambylatory or clinical setting. The most widely used cadmium is in electroplat-
When operating in contact with mercury is rec- ing and production of the alloys. Cadmium coatings
ommended that workers receive than diet B more: are more resistant than zinc in aggressive environ-
Vitamin C - 100 mg, vitamin E - 20 mg, vitamin B ments. Therefore, electrical and chemical industry
complex - 1 dragee every other day, vitamin B12 - 3 equipment are covered with cadmium or cadmi-
μg, folic acid - 300 μg, enriched of pectin fruit drinks um-zinc alloy. Cadmium plating to airline and ship-
and fruit purees, mousses, 1 l mineral water Kavarna ping details.
or Gorna Banya, Targovishte, Ivanyane, Belovo Iz- Cadmium is a component of many alloys: fast
vorishte, Varshetz, Varna. melt, special, with precious metals and for produc-
tion of bearings. Alloy of copper and 1% cadmium
CADMIUM (Cd) (cadmium bronze) used for telegraph and tele-
HYGIENE STANDARDS phone cables. An alloy of cadmium (20%) with lead
Air of the working environment: Mean-shift and tin is used for typography plates. Copper-zirco-
MAC cadmium and inorganic compounds (such as nium-cadmium alloy is used for high-voltage lines.
cadmium) - 0,05 mg/m3. Specific effects: embryotox- In the jewelry industry used double (gold and cad-
ic and teratogenic for animals. mium), triple (gold, silver and cadmium) and quad-
Mean-shift MAC for cadmium stearate - 0,1 mg/ ruple (gold, silver, copper and cadmium) alloys.
m3. Cadmium of high purity is used for the preparation
Air settlements: Average annual MAC - 0,00001 of alloys with semiconductor properties (cadmium
mg/m3, average daily MAC - 0,00002 mg/m3. arsenide, antimonid, tellurite) for opto-electronics
Drinking water: Cadmium in mg/dm3 not more industry.
than 0.01. Cadmium is used as a neutron absorber in nucle-
Surface water: I category - 0,005 mg/dm3, II cate- ar reactors. Enter into the composition of the cata-
gory - 0,01 mg/dm3, III category - 0,02 mg/dm3. lysts for the chemical industry. Cadmium sulphide
Food: From 0,01 mg/kg in milk and infant food, (red and yellow paint) is used in the paint industry
milk-based; to 0,5-1,0 mg/kg in the guts of farm ani- for decorating porcelain and in painting. Cadmium
mals (liver, kidney, etc.). chloride is used in the manufacture of paints, cad-
Soil: 5,0 mg/kg. mium oxalate - in ceramic, cadmium carbonate - in
GENERAL DESCRIPTION battery production, cadmium stearate - stabilizer in
Cadmium is greyish-white, silver, soft and malleable the production of plastics, cadmium iodide and bro-
metal having an atomic weight 112.40, melting point mide - in photography.
321°C, a boiling point of 767°C, a density of about 8.63 Cadmium is needed in the glass industry for the
to 8.69 depending on the processing. Insoluble in wa- production of colored glass. It comes in numerous
ter, slightly dissolved in hydrochloric and sulfuric acid. fungicides as zineb, maneb and some superphos-
At ambient temperature its surface layer is oxidized to phate fertilizer. Its content in superphosphates rang-
cadmium oxide. es from 50 to 170 mg/kg. Enriching the soil with cad-
Of the compounds of cadmium industrial impor- mium is precisely on account of mineral fertilizers.
tance are: cadmium oxide, cadmium sulfate, nitrate, Nickel-cadmium batteries are used in satellites,
carbonate, sulfide, sulfoselenid and salts with halo- spacecraft and automatic meteostations.
gens (chloride, bromide, iodide). Recently, introduced PROFESSIONAL AND UNPROFESSIONAL
in production organic compounds of cadmium with EXPOSURE
fatty acids (caprylic, stearic, lauric) and intermetallic Upon manufacture of cadmium in all industries
compounds of tellurium and selenium. where it or its compounds are used, to detect cadmi-
Cadmium is an distracted element and does not um aerosols in the air of the working environment.
form separate ore deposits. In nature, cadmium and In the hydrometallurgical method of manufacture of
compounds thereof are found in sulphidic polymetalic cadmium in zinc plant, the cadmium content in the
ores, most often zinc, in an amount of 0.1 to 5%. The air of the working environment ranges from 0.01 to
ratio of cadmium/zinc fluctuated from 1:350 to 1:100. 0,062 mg/m3. In modern technologies of manufac-
Rich in zinc ores contain more cadmium. The average ture in all stages of the technological process, cad-

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 LABOUR MEDICINE
mium in the air of the working environment is under ited to about 200-400 μg/g tissue. Above this critical
MAC. In termovakuum cadmium plating amount of concentration renal dysfunction occurs- firstly pro-
cadmium aerosols up to 0,9 mg/m3. Unprofessional teinuria.
exposure is formed by the amount of cadmium en- In cells cadmium is associated mainly with metal-
tering the body with food, air pollution settlements lothionein - a protein containing a plurality of sulfhy-
of motor vehicles and tobacco. The cadmium content dryl groups, which bind the metals (cadmium, zinc,
of tobacco is about 200 μg%. The amount of cadmi- iron, copper) and thus protects the sensitive enzyme
um in the body increases with age up to 50 years. At systems of the cell. Its synthesis in the liver, kidney
this age it reaches 9-40 mg, varying depending on and intestine was induced by cadmium.
the geographical area and smoking - at smokers it Cadmium is excreted primarily in the urine and
is twice as high. The main sources of environmental less bile. Small amounts are excreted through sweat
pollution by cadmium are technogenic: enterprises and hair.
of non ferrous metallurgy and mechanical engineer- Cadmium is accumulated poison with a half-life
ing, electrical, chemical, chemical- pharmaceutical of the whole body around 10-30 years, of kidney -
industry, in agriculture - plant protection agents and 15-40 years, 4-19 years liver and blood - 2.5 months.
mineral fertilizers, in the cities - mainly road trans- Exposure assessment and biological control in
port. It is, however, particularly to note that in areas professionally exposed individuals using toxicoci-
with intensive anthropogenic pollution cadmium netic tests to determine cadmium in urine, blood
content in humus soil horizon of soil is 3-5 times the and hair.
background and in the green aboveground plant PREVENTION
parts amount of cadmium 20-30 times exceeds the Radical technological measures against cadmium
background - bioconccentration. intoxication is restricting the use of cadmium and
METABOLISM AND MECHANISM OF ACTION its compounds. Since it is not always possible it is
Cadmium is nonessential highly toxic accumu- important to know that the recommended central-
lated metal. To prevent toxic effects on workers and ization of the manufacture of cadmium-containing
the population must take into account all possible materials within the same industry. It is appropriate
sources and routes of administration of cadmium in cadmium products and compounds are produced
the body. in the physical state that prevents or limits to max-
Food is the main source of cadmium for pop- imum release of aerosols in the air of the working
ulation. Crabs, fish and animals (mainly in the kid- environment. Also recommended: comprehensive
neys and liver) accumulate relatively large amounts mechanization and automation of processes with
of cadmium. Daily amount of cadmium in the diet remote control, introduction of vacuum technology
ranges from 10 to 85 μg, but in some countries, es- in production processes, equipment with increased
pecially where marine fish are a major food, report- hermetisation and efficient aspiration, mechanical
ed higher values. FAO WHO proposed allowable loading and pneumatic transport.
amount of cadmium intake - 70 μg, but generally ac- Rational architectural and planning solutions are
ceptable - only 20-50 μg. The absorption in gastroin- of great importance. Workshops and departments
testinal tract is about 5% (from 1 to 12%). Deficiency for the production of cadmium and its compounds
of calcium, iron, and protein in the diet increase the should be isolated rooms. In mechanical engineer-
absorption of cadmium. ing, instrumentation and others sectors such isola-
Airway is a major occupational exposure. Depo- tion should be provided for termovakuum cadmium
sition of particles having a diameter below 5 μm is plating and galvanic baths.
about 25%. About 60% of the delayed cadmium is To protect inhalation should be ensured dust
absorbed, ie absorption after inhalation is approx- respirators, masks, pnevmohelmet. Through appro-
imately 15%. It reaches 50% in persistent smokers. priate clothing to protect the skin. It is also recom-
Coarsely dispersed particles are propelled by the mended the use of creams and shampoos for wash-
cilia of epithelial cells into the pharynx and be swal- ing hands, complex-contained.
lowed. Preliminary and periodic medical examinations
Skin absorption is found only in contact with or- are required. Workers in contact with cadmium is
ganic compounds. recommended to ensure diet B of the professional
Cadmium is retain briefly in the blood. It accumu- safety catering. Additionally provide: vit. C 100 mg/
lates mainly in the kidneys and liver, which in steady day, vitamin E 20 mg, vitamin B complex 1 dragee
state contain 80% of the body weight of metal. In every other day vitamin B12 - 3 μg, folic acid 300 μg,
the kidney cadmium is primarily concentrated in the fruit drinks, purees and mousses, mineral water 1 l of
crust whose capacity to accumulate cadmium is lim- Gorna Banya, Varshets, Varna, Targovishte, Ivanyane

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 OCCUPATIONAL MEDICINE
or Belovo. The content of tin in food products is as follows: po-
The role of health education for the prevention of tatoes - 0,19-0,65 mg/kg, wheat - 5,6-7,9 mg/kg, peas
toxicity of cadmium is exceptional. Compliance with - to 18,7 mg/kg. Total by food intake in the body enter
the rules of personal hygiene is required. It is prohib- from 187 μg to 8,8-17,14 mg/day, and if used for food
ited in the workplace persons in professional con- cans - up to 38 mg/day.
tact with cadmium to eat, drink and smoke. Given USE
the role of tobacco it is desirable to motivate work- Up to 40% of the amount produced in the world
ers to minimize smoking or completely abandon it. tin is used for tinning of sheet metal for cans. The re-
maining quantity of tin is used for the production of
TIN AND ITS COMPOUNDS (Sn) solders and alloys. As a rule solders are alloys of tin,
HYGIENE STANDARDS lead and cadmium. Unleaded solders except tin con-
Air of the working environment: Mean-shift taining silver, antimony, zinc or indium. Antifriction
MAC for tin and inorganic compounds, oxides (as properties is an alloy of tin, antimony and copper -
tin) - 2,0 mg/m3; Mean-shift MAC for tin-organic “babit”. Alloy of tin and zinc foil packaging known as
compounds (as tin) - 0,1 mg/m3. tin-foil (silver-paper).
Food: preserved food and drink in cans - 200,0 Tin dioxide used for producing heat-resistant
mg/kg. enamels and glazes. Crystal tin sulfide is a compo-
Canned foods and beverages in glass container - nent of paints, imitating gold plating. Niobium sta-
50,0 mg/kg. nid is one of the most famous superconducting ma-
Baby foods in metal packaging - 100,0 mg/kg. terials in the world. Tin component of titanium alloys
Baby food in glass container - 25,0 mg/kg. for avio-industry, of zirconium - for nuclear reactors.
Other food products in addition to the above - Used for the production of automotive radiators, air
25,0 mg/kg. conditioners, heat exchangers and electronics, den-
Drinks without canned in metal packaging - 5,0 tistry (amalgam).
mg/kg. The excellent properties of tin in casting, as well
GENERAL DESCRIPTION as its malleability, susceptibility for carving, noble
The tin is white brilliant soft and plastic metal with a gray-white color explain the use of tin in decorative
molecular weight of 118.69, density 5,85 g/cm3 at 20°C, art from ancient times.
a melting point of 231,9 ° C, a boiling point of 2620°C. Halogenated organic tin (acrylates, acetates,
In the compounds is of 2+ and 4+ valence. maleates, and their hydroxyl compounds) are po-
Tin is a characteristic feature for the upper Earth tent insecticides. Used to impregnate textiles, wood
crust. Its content in the lithosphere is 2,5.10-4%. The structures, vessels as protection against biological
concentration of tin in the earth layers is associated destruction due to development of fungi, microor-
with magmatic and hydrothermal processes. Known ganisms, algae, mussels, snails and others. They are
are 24 natural mineral, with the greatest industrial im- processed ponds against excessive multiplication of
portance are cassiterite (SnO2) and statins (Cu2FeSnS4). phytoplankton and other aquatic organisms.
Tin migrates slightly. The dry or moist air having a tem- PROFESSIONAL AND UNPROFESSIONAL
perature of to 100°C not oxidize tin (it protects thin, EXPOSURE
but dense and stable layer of tin dioxide). Insoluble No evidence of acute inhalation profession-
in water is poorly dissolved in dilute hydrochloric and al poisonings. Acute poisoning mainly from food.
sulfuric acids. With halogens formed di- and tetrahal- Symptoms of acute poisoning affecting the gastro-
ogenides such SnX2, SnX4. intestinal tract are registered with canned food and
In the air of large cities tin content varies from 3 to drinks. The lowest toxicity dose tin as component
300 ng/m3, in rural areas is even lower, but anthropo- (impurity) in food is 250 mg/kg. Especially danger-
genic polluted areas reaches 0,8 μg/m3 (in Boston). ous are canned foods and beverages in corrosion
Emissions from electric tin concentration reaches and migration of tin by packaging. Corrosion of the
640 μg/m3. 700 m away from the plant - the source of package depends on the type and quality of food
tin content in the air is about 4,0 μg/m3. The most in- products, the duration and the storage temperature,
tensive polluting tin heating coal and oil. the pH and the amount of air in the can. Oxidizing
In the aquatic environment (rivers and lakes) the agents (nitrates, copper and iron compounds) an-
average concentration of tin 0,5 μg/dm3, a maximum thocyanic pigments, methylamine, sulfur dioxide
of 2,5 μg/dm3. In industrial wastewater are established intensified corrosion, and soluble salts of tin, sug-
concentrations of tin to 530 mg/dm3. ars and colloids (gelatin) will suspend. Vegetables,
The concentration of tin in soils vary from a few to accumulating nitrates are unsuitable for canning in
several hundred mg/kg (data - up to 410 mg/kg).

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 LABOUR MEDICINE
cans. The storage of preserved food under unsuita- Air settlements: Daily average MAC for manga-
ble temperature and the temperature increase with nese and its compounds (calculated as manganese
1°C increase the content of tin in foodstuffs with 2 dioxide) - 0,01 mg/m3.
mg/kg per month. The content of tin in canned food Drinking water: Manganese in mg/dm3 not
products is increasing, and it is stored in already more than 0.1.
open cans. Surface water: I category - 0,1 mg/dm3, II cate-
METABOLISM AND MECHANISM OF ACTION gory - 0,3 mg/dm3, III category - 0,8 mg/dm3.
There is no consensus about the relationship tin GENERAL CHARACTERISTICS
- human organism. Opinions vary on nonessential Manganese is a brittle grey metal which on con-
to essential alleged, even if proven essential ultra- tact with air easily oxidized, especially if it is frag-
mikroelement. Its content in the body of the person mented state. It has a melting point 1244 ° C, a boil-
generally up to about 17 mg. ing point of 2095 ° C and a density of 7.44. It dissolves
He joined mainly oral and, in production - of in- in acids. Is reacted with a halogen, sulfur, phospho-
halation. Trialkyltin compounds with short chain rus, carbon, silicon. When melting manganese his
penetrate the skin. Absorption of tin and inorgan- vapours in high-temperature furnace zone associat-
ic compounds is low (about 5%). Better absorbed ed with oxygen from the air to form brown smoke,
organic compounds. Absorbed amount of tin for mainly from MnO and Mn3O4. Element variable
a short time circulates in the blood, 80% bound to valence (from 2+ to 7+), manganese oxides formed
erythrocytes. Most large amounts of tin found in a large number of which most known as air pollut-
the kidneys, liver and bones. Its content in still-born ants are: manganese oxide (MnO), trimanganese te-
babies is negligible, indicating that does not pen- troxide (Mn3O4), dimanganese trioxide (Mn2O3) and
etrate the placenta. With age, the amount of tin is manganese dioxide (MnO2). The average content of
increased only in the lung, in other organs and tis- manganese in the Earth crust is 0.1% spread is dis-
sues after 10-12 years of age concentration of tin tracted state. It is found in ore deposits most often in
are hardly changed. Excreted rapidly from the body combination with iron. Vigorously migrates in all ob-
mainly by the kidneys and a small part in bile. The jects of the environment. The most flexible in acidic
low absorption, poor retention in the tissues and waters. Concentrated in soils and bottom sediments
rapid elimination from the body explain the low tox- forming iron-manganese concretions.
icity of tin and its inorganic compounds. Organic tin USE
compounds undergo biotransformation in the liver Manganese and its compounds are widely used
with the participation of mixed function oxidases, in steel production for ferro-manganese, mechani-
especially cytochrome P-450. cal engineering, chemical industry, glazes, enamels,
PREVENTION paints, batteries (dry items), welding electrodes, in
Prevention of increased receipt of tin in the body the textile industry and in agriculture in the compo-
of canned foods requires strict control over the en- sition of pesticides and microfertilizers, antidetona-
tire chain: compliance with the requirements for tor for production of environmentally clean (unlead-
agrochemical use of nitrogen fertilizers in agricul- ed) gasoline.
ture, manufacturing and storage of cans. PROFESSIONAL AND UNPROFESSIONAL
In an industrial environment is mandatory ef- EXPOSURE
fective ventilation. High dust respirators are recom- All the literature of chronic occupational manga-
mended, in contact with tin hydride and tin chloride nese poisoning are associated with the operation
- filtering mask. When working with organic com- of its oxygen compounds (oxides) in the mining
pounds requires special measures to protect the and processing of manganese ores; casting of high
skin. quality steels and alloys; production of dry galvanic
elements (batteries); electrodes and fluxes for doing
MANGANESE (Mn) arc and oxygen welding. In these high-temperature
HYGIENE STANDARDS processes the disperse phase of the aerosol con-
Air in the work environment: Manganese ox- densation contains substantially pure oxides of 2-
ide and inorganic compounds (such as manganese) and 3-valent manganese. In the composition of the
- mean-shift MAC 0,3 mg/m3; short maximum MAC welding aerosols manganese content reaches 30%
3,0 mg/m3. of trivalent chromium - 10%, nickel - 6%. The great-
Manganese cyclopentadienyl tricarbonyl and est solubility differs manganese, which explains the
others organic manganese compounds (manganese prevalence his resorptive toxic effect.
talat) - additives to gasoline (such as manganese) - Manganese is an essential trace element with
mean-shift MAC 0,1 mg/m3. high biological activity. Found in the composition

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 OCCUPATIONAL MEDICINE
of many proteins, DNA, heparin and more than 100 tact with manganese and manganese content in
vital enzyme systems. Receipt of manganese in large blood and urine also not been established. Weak is
quantities can cause both acute and chronic poison- the correlation between manganese in blood and in
ing, because manganese is polythrop cell poison, urine.
damaging many organs and systems. Most likely
this is due to the complex interplay of biological and PREVENTION
toxic effects of the metal, reflecting the complex re- Main in the prevention of manganese poisoning
lationship between manganese dependent enzyme is the protection of respiratory organs: effective ven-
systems and homeostasis of trace elements. tilation and the mandatory use of PPE - dust masks
The main source of non-professional exposure and respirators, goggles, and at welding in closed
to manganese for population is food. Of ingested spaces - gas masks of insulating type.
through food and drinking water in manganese at Preliminary and periodic medical examinations
gastrointestinal tract is absorbed only 3%, probably are required featuring neurologist, therapist, derma-
as divalent manganese. The level of absorption de- tologist and ORL specialist.
pends on the reciprocal of the level of manganese Recommended diet B of safety professional nu-
in the diet and is controlled by homeostatic mech- trition.
anisms. The amount of iron in the diet and in the
body affects the absorption of manganese. In ele- COPPER (Cu)
vated doses manganese and iron are antagonists. HYGIENE STANDARDS
Iron deficiency leads to increased transport of active Air of the working environment: Copper - met-
manganese in the duodenum and small intestine. al vapor (such as copper) - mean-shift MAC 0,1 mg/
The level of calcium and phosphorus also affect the m3, irritating; copper - oxides and inorganic com-
absorption of manganese. pounds (such as copper) - mean-shift MAC 1,0 mg/
METABOLISM AND MECHANISM OF ACTION m3; copper oxychloride - mean-shift MAC 0,5 mg/m3.
It is believed that the normal, usual diet contains Air settlements: Copper - Daily average MAC
enough manganese to prevent lack condition. 0,01 mg/m3;
A major toxicological problem is occupation- Copper oxide - Daily average MAC 0,002 mg/m3.
al exposure, particularly in inhalation admission of Drinking water: Copper is not more than 0,2
highly-dispersion manganese aerosols. Secondly, it mg/dm3. Surface water: I category - 0,05 mg/dm3, II
should be borne in mind ingesting rough- dispersed category - 0,1 mg/dm3, III category - 0,5 mg/dm3.
particles from the nasopharyngeal region. Dermal Food products: from 0,4 mg/kg for milk, to 50,0
enter only organic compounds of manganese. mg/kg of dried vegetables, cocoa powder, 60,0 mg/
The metal accumulates primarily in the liver. kg of offal (liver, spleen, kidney, etc.) and 100, 0 mg/
When exposed in workers were identified elevated kg for tea.
levels of manganese in the lungs, liver and kidneys. GENERAL DESCRIPTION
Manganese may accumulate in the hair (especially Copper is pink or reddish metal with a high plastici-
in the dark hair) and other pigmented areas of the ty (ductility), warmth conductivity. Temperature of its
body (retina, pigmented conjunctiva, dark skin, oth- melting point is 1083° C, a boiling point of 2543° C and
er areas rich in melanin incl. brain formations). a density of 8.92 to 8.94. Dissolved in 0.3% solution of
The metal ions are emitted almost completely hydrochloric acid in gastric juice. The chemical activity
(98%) of the bile in faeces probably related to bile is not very high. In the compounds is the first or second
acids. Only about 0.1-1.3% of the daily receipt of valence. When heated above 185° C is carried out sur-
manganese is excreted through the urine. In ex- face oxidation by air. With wet chlorine forming copper
posed workers hair can be considered as a way to chloride, easily interact and with other halogens. Salts
eliminate manganese of the body. of monovalent copper (I) are practically insoluble in
A specific feature of manganese is its neurotoxic- water, while those of copper (II) have a high solubility.
ity (manganese parkinsonism). Forms numerous complex compounds.
There are currently no generally accepted toxi- The average copper content in the Earth crust is
cokinetic indicator of exposure to manganese. The about 4,7.10-3%. Total world reserves of copper ores
determination of metal in blood, serum, urine and amounted to 465 mil. t. Among minerals predominate
feces so far not demonstrated its capacity as expo- sulfides, sulfates, phosphates, chlorides, native copper,
sition test to assess the level of exposure. Increased carbonates and oxides. Native copper occurs in com-
excretion after provocation did not correlate with bination with malachite (CuOH)2CO3, with azurite and
the degree of toxicity. On the other hand significant other minerals.
correlations between the specialized service in con- The average copper concentrations in the waters

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 LABOUR MEDICINE
of rivers and lakes is about 7 μg/dm3, at sea - 0,9 μg/ metals, environmental pollutants (molybdenum,
dm3. An important role in the migration of copper in cadmium, mercury), influence copper metabolism
the hydrosphere have plankton - zoo- and phytoben- and can cause a relative deficiency of copper in the
thos. Certain types of plankton concentrate copper to body.
90,000 times.
The copper content in the soil is on average about METABOLISM AND MECHANISM OF ACTION
15-20 mg/kg. More than 90% of the copper in the soil Copper is an essential element in a complex role
in the form of organic complex compounds. Migration in the body’s functions. Toxicity it is relatively low.
capability of copper depends on the acid-base status The human body contains 100-150 mg of copper;
and redox reactions of the environment. about 10% in the liver and about 50% in the muscles
The total copper content in phytomass on the plan- and the bones.
et is 25 mil. t. Copper is one of the catalysts necessary Daily admission of copper intake is about 2-3
for the existence of plants, which contain copper in the mg and fully meets the needs of the body. The ab-
range of 8,4-24 mg/kg dry matter. sorption in the gastrointestinal tract is an average
The copper content in the air ranges from 10 to 100 57% in children is higher. Depends on the content
μg/m3. and the chemical form of the copper in the diet,
Bio-indicators of environmental pollution with cop- the rate of gastrointestinal passage, the presence
per compounds can serve birds that accumulate cop- of antagonists such as zinc, mercury, silver, cadmi-
per in feathers. Well copper concentrate and can serve um, molybdenum and the ingredients of the food
as bio-indicators of pollution marine blue-green algae which reduces the absorption of copper (sulfate,
and mussels. phytates, ascorbic acid, fiber). It is realized mainly in
USE the stomach, duodenum and upper small intestine.
Copper is used in refrigeration, electrical engi- The absorption of copper from the gastrointestinal
neering, powder metallurgy and communications. A tract is regulated homeostatic. In this process in-
significant part of the produced copper put in the volved metallothionein, which performs the follow-
production of alloys (brass, bronze, etc.), which are ing functions: carrier of copper; freeboard form in
used as structural, antifriction, corrosion-resistant, the cells and mucosal block, which was saturated at
warmth- and electrical conductors in mechanical high concentrations and prevent excessive resorp-
engineering, vessel industry, aerospace and auto- tion. High doses are absorbed in progressively less-
motive industry, device and others. Copper salts are er degree, depending on the saturation of the body
used in the manufacture of synthetic fibers, glass with copper.
and enamel, in electroplating, the preservation of The data on the absorption of copper by inhala-
wood in ore dressing and production of mineral tion are scarce.
paints. Many copper compounds are used as pesti- Absorption in skin contact is possible for some
cides in pure form (copper sulfate) or in the compo- organic compounds of copper.
sition of complex products (cuprozin, cuprozan etc.). After the release of metallothionein copper pass-
PROFESSIONAL AND UNPROFESSIONAL es in plasma in a free state or linked to amino ac-
EXPOSURE ids. In the portal circulation, it is transported to the
Main sources of environment pollution by copper liver, primarily related to albumin. In blood copper
are the enterprises of ferrous metallurgy, transport, is distributed equally between red blood cells and
copper-containing fertilizers and pesticides, plating plasma.
processes and the burning of oil and coal in various The liver is the central organ in homeostasis of
industries. The annual volume of technogenic con- copper in, that it be temporary deposited.
tamination of copper is distributed in the following Excreted through the bile. Small amounts are ex-
way: in the air disposed of 56 thousand tons, of cop- creted in sweat, urine, hair and nails. Copper crosses
per, solid waste - 77 thousand tons, of pesticides - 94 the placenta and is secreted in milk.
thousand tons, of chemical plants - 155 thousand The half-life of the whole body is four weeks.
tons. Copper contaminated soil changes its struc- The copper content in serum (plasma), urine,
ture - decrease its porosity, water permeability is vi- blood, in hair, nails and can be used for evaluation
olated, deteriorates water-air regime of the soil. of exposure.
Although exposure to copper is common in in- PREVENTION
dustry, are not reported chronic toxic effects charac- To prevent the effects of local irritation on UAP
teristic of metal, other than local irritation. workers recommended after work to make alkaline
There are no known health effects associated and oil inhalations.
with environmental pollution with copper. Many

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 OCCUPATIONAL MEDICINE
NICKEL AND ITS COMPOUNDS (Ni) Atmospheric air, water, soil and plant food con-
Carcinogen for humans (Group 1) Nickel met- taminated by nickel mainly from enterprises (mining
al (Ni); Soluble salts: nickel sulphate (NiSO4), nickel or processing nickel) and TEP (using fuel oil or coal). In
chloride, (NiCl2), nickel nitrate [Ni (NO3)2], nickel car- heavily anthropogenic contaminated by TEP regions
bonyl (Ni tetracarbonyl) - Ni(CO)4. are formed artificial biogeochemical provinces, as oil
HYGIENE STANDARDS: and coal are natural concentrates of nickel.
Air working environment: Mean-shift MAC: In acidic and neutral waters nickel vigorously mi-
0,05 mg/m3 for nickel metal soluble compounds, grates. Concentrated in bottom sediments of contam-
nickel sulphide, nickelchromphosphat (such as nick- inated ponds forming hard soluble organometallic
el); 0,007 mg/m3 - nickel carbonyl. complexes.
Air settlements: Daily average MAC: 0,0002 mg/ The nickel content in the plant products is higher
m3 nickel - soluble salts; 0,001 mg/m3 - metallic nick- than in animal products. It depends on the geochem-
el and nickel oxide. ical characteristics of the region, the intensity of ferti-
Surface water: I category - 0,005 mg/dm3, II cate- lization with superphosphats, use of nickel contents
gory - 0,2 mg/dm3, III category - 0,5 mg/dm3. fungicides and anthropogenic pollution. In cereals and
Food products: from 0,1 mg/kg (milk) to 3 mg/ pulses content of nickel reaches 0,089-1,09 mg/kg raw
kg (pulses) and 8 mg/kg (cocoa powder and tea). grain, in fruits and vegetables - from 0,1 to 2,0 mg/kg
GENERAL DESCRIPTION fresh weight.
The nickel is resistant to water, the nickel carbonyl USE
- insoluble in water, other compounds are soluble in Nickel is used for the preparation of alloys with
water in varying degrees (most soluble - nickel nitrate). other metals: iron, chromium, copper and the like.
Nickel is a silvery white metal with a characteristic Copper-nickel alloys are characterized by high plas-
luster, very malleable and ductile. It occurs in two mod- tics and corrosion resistance. Ferromagnetic alloys
ifications: alpha- and beta. The transition from alpha are especially valuable for production of elements
to beta-modification occurs at heating to 250-300°C. sensitive to changes in the magnetic field. Alloys of
Both versions have different crystal grid. The treated nickel with cobalt are used for making feroacustical
metal nickel (sheets, wires, etc.) is a beta-nickel. apparatus. By nichrome (nickel and chromium) and
Nickel is ferromagnetic, at a temperature of 358°C, feronichrom (iron, chromium and nickel) is made re-
loses ferromagnetic properties. Valence is inconsistent active technology, gas turbines and construction of
(in simple compounds is divalent). Characterized by nuclear reactors.
an average chemical reactivity. It is resistant to atmos- Alloys of nickel with molybdenum and nickel
pheric gases, water, halogens, sulfur and others. Slight- with molybdenum and chromium are used for mak-
ly soluble in dilute acids, resistant to strong alkalis. By ing chemical apparatus operating in hard agressive
reacting with acids forming salts of divalent nickel. environment. Significant amounts of nickel are used
The soluble salts of nickel are different in color and for the production of batteries and anti-corrosion
characteristic crystals. Nickel carbonyl is a colorless coatings: details of the chemical equipment, med-
easy flowing liquid with a characteristic sharp odor. ical instruments, apparatuses, dishes, gauges and
Natural nickel component of the Earth’s core, is a more. Nickel and its salts are catalysts in the chemi-
mixture of five stable isotopes. The nickel content in the cal industry.
Earth crust is 8.10-3%. It occurs as sulphide copper-nick- PROFESSIONAL AND UNPROFESSIONAL
el, oxidized silicate and arsenic ores. 53 minerals EXPOSURE
formed. In anthropogenic clean areas nickel content Main source of nickel for the body of persons
of the soil is constant. Between migration into ground- without professional contact is food. The total
water, surface water and plants and imports into the amount used with diet is about 250 μg/day.
soil at the account of the destruction of soil minerals, The absorption of nickel in the gastrointestinal
decomposition of dead plant and animal organisms, tract is low - around 5%. It is assumed that a home-
fertilize the soil with fertilizers and precipitation from ostatic regulated.
the air, there is a natural equilibrium.
Substance Molecular weight Melting point Boiling point Density g/cm3
Nickel metal 58,71 1453°С Around 3000°С 8,9 (20 оС)
Nickel sulphate 154,78 – – 3,652 (25 оС)
Nickel chloride 129,62 – – 3,508 (22 оС)
Nickel nitrate 182,72 – – –
Nickel carbonyl 170,71 liquid 1,361 (0 оС)
–
hard 1,78 (-55 оС)

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 LABOUR MEDICINE
In production conditions nickel joined mainly PREVENTION
by inhalation. Inhaled amounts are absorbed better Prevention of chronic professional intoxication
than ingested orally and directly affect by the sol- with nickel carbonyl and in electrolysis workshops
ubility of the compound. Along with general toxic based on the maximum hermetisation of processes
action dominate the complaints and symptoms and equipment, automation and mechanization of
of irritation and necrotizing effect on the mucosa nickel-plated.
of the upper respiratory tract. The most frequently In preliminary medical examination is recom-
observed chronic sinusitis with anosmia (84.1%), mended to conduct a skin test. Periodic medical ex-
acute sinusitis (5.6%), cysts and cystyc like forma- aminations involving dermatologist, ORL specialist
tions (10.3%). Under the influence of nickel sulphide and oncologist are required.
and oxides develop nickel pneumoconiosis. Serious In chronic allergic skin diseases and bronchial
problems by carcinogenic activity of nickel and its asthma workers were removed from contact with
compounds (nickel carbonyl). Latency period - be- nickel, chromium and cobalt. Cross-allergenicity is
ginning of professional contact - occurrence of lung- possible.
or paranasal sinuses cancer is 13 to 31 years. Also provided strict controls on air quality of the
Sensitizing activity of nickel has been proven working environment and use of PPE. If you need to
both in professional contact and in living condi- operate at high concentrations to use filtering or in-
tions. Improvements in technology limited profes- sulating type masks, waterproof suits and gloves.
sional contact and reduce the spread of professional
nickel dermatitis. Recently nickel dermatitis is more LEAD (Pb)
common among atypical professions (surgeons, HYGIENE STANDARDS
dentists, shop assistants, cashiers, waitresses, hair- Air of the working environment: Mean-shift
dressers). Due to the widespread use of nickel-plat- MAC - 0,05 mg/m3; Specific effects: Gonad-toxicity,
ed objects in life, sensitization and allergic derma- probably carcinogenic to humans - 2 group. Mean-
titis and eczema in population increase. Dermatitis shift MAC for working adolescents (15-18 years) -
have been described in contact with nickel-plated 0,005 mg/m3.
frames of glasses, rings, watches, buckles, clasps and Air settlements: Average annual MAC for lead
safety pins, nickel coins, tableware, disinfectants and and its compounds (except TEL), calculated as lead -
detergents containing nickel compounds. There is a 0,001 mg/m3, average daily MAC - 0,001 mg/m3.
trend towards worsening the problem, since the use Drinking water: Lead not more than 0,05 mg/dm3.
of nickel products is increasing steadily - by an aver- Surface water: I category - 0,02 mg/dm3, II cate-
age of 10% per annum. gory - 0,05 mg/dm3, III category - 0,2 mg/dm3.
METABOLISM AND MECHANISM OF ACTION Soil: From 20 to 80 mg/kg, depending on the pH
Nickel enters the body by inhalation and oral of the soil.
route. In studies of the conditions and mechanism Food: From 0,1 mg/kg in margarine, vegetable
of the occurrence of skin sensitivity was shown that and animal fats to 10,0 mg/kg in mussels, crusta-
the sensitization of the organism is associated with ceans and tea.
penetration of nickel through the skin. The lead content must be determined in the fol-
In blood, the metal is distributed between leuko- lowing foods: milk, canned meat, sea fish, flour, spin-
cytes and serum. Found in three forms: - Ni (II) com- ach, fruit juices and nectars, sugar, candy, chocolate,
plex with albumin; - Ni - metaloprotein complex and cocoa powder, infant food of milk, vegetable, fruit
Ni - α1 - glycoprotein complex; - ultrafilterable Ni (II) and meat-based and soft drinks.
complexes with amino acids or polypeptides. GENERAL DESCRIPTION
Body nickel content is about 10 mg, divided in Lead is greyish-blue metal with atomic mass 207.2,
decreasing concentration in bone, lung, colon, small high density (11,35 g/cm3 at 20°C), melting tempera-
intestine, skin and others. With age, increasing the ture 327.4 ° C, a boiling point of 1740 ° C, practically
amount of nickel only in the lung. insoluble in dilute acids, soluble in nitric acid, acetic
Absorbed nickel is excreted primarily in the urine acid and hot concentrated sulfuric acid. The solubility
(90%). In the sweat concentration is 20-fold higher of lead (TEL) in soft water in the presence of O2 and CO2
than in urine. Biliary excretion is no-significant. Ex- has a great hygienic importance.
cept through sweat glands, secreted by the mam- Upon heating the lead is oxidized to form oxides,
mary glands and thus falls in milk. are associated with halogens, sulfur, and tellurium.
Professional and non-professional exposure is By organic lead compounds greatest relevance are
evaluated by determination of nickel in blood and tetraethyl-lead (TEL) and tetramethyl. They are insolu-
urine. ble in water. Dissolve well in organic solvents and fats.

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 OCCUPATIONAL MEDICINE
Have moderate volatility. duced and lead-manufacturing enterprises. Large
The average content of lead in the earth’s crust is populations are threatened by non-professional ex-
1,6.10-3%. Extraction of lead-zinc ores or containing posure to lead through leaded paint, emissions from
mainly copper, zinc and iron. Formed around 80 natu- road transport and drinking water.
ral minerals: sulfates, carbonates, phosphates - galenit Emissions from non-ferrous metallurgy contain-
(PbS), anglesite (PbSO4), cerusit (PbCO3). ing more than 0,2 mg/m3 of lead, pollute the air of
Lead vigorously migrates into the environment, open space far above hygiene standards. Within a
more active in acidic environments. Through its ability radius of up to 4 km. ground lead manufacturing
to bioconcentration included in biocircle. Accumulates enterprises the lead content in the soil reaches 80-
in great quantities in clay soils, humus and bottom sed- 3500 mg/kg, at natural background levels, ranging
iments. on average from 2.6 to 43 mg/kg.
USE The impact of road transport as a powerful source
Globally, 55% of extracted lead is used for the of contamination of soils and growing crops on
production of batteries, lead pipes, acid-resistant them settled in wide strip 150-200 m on both sides
mechanization for the chemical industry, protection of highways. The most intensive pollution (from 3
against X-rays and other ionizing radiation. About to 6 times above background) at a distance of 60
22% is used in the form of alloys and 23% as chemi- meters from the roadway. A significant proportion
cal compounds: paints for glass and ceramic indus- (50%) have surface contamination by dust contain-
try, stabilizers in the manufacture of polymers and ing large quantities of lead compounds.
rubber, alkylating organic compounds, antidetona- Apart from the non-ferrous metallurgy and trans-
tion graft to gasoline and the like. port soil contaminated by lead and by micro- fertiliz-
PROFESSIONAL AND UNPROFESSIONAL ers containing up to 1% lead.
EXPOSURE It has been found that lead migrates from the
In the air of the working environment lead is material of the water pipes in quantities from 0,09 to
present as vapor and aerosols. Particularly danger- 0,58 mg/dm3, depending on the pH, water temper-
ous to the health of workers are condensing, fine ature, the amount of lead-containing stabilizer (for
disperse aerosols that are formed during casting or pipes made of polyvinylchloride), material thickness
high-temperature processing of the metal. Risk oc- and diameter of the tubes. Migration continues from
cupations and industries are: founders and metallur- 1 month to 2.5 years, the amount of lead in the water
gists in casting and refining of lead; miners of lead level can reach hundreds of times over the hygiene
mines; plumbers; fitters in water and canalization standards.
systems (WCS); fitters; shipbuilders; printers; police Natural lead content in food products is negligi-
- street regulators; welders; electric welders; install- ble - from 1.1 to 10,7 μg%. In areas with intensive
ers of special equipment for the chemical industry; anthropogenic pollution levels of lead can reach
workers from the production of plastics, rubber and from 0,558 mg/kg in wheat to 3,67 mg/kg in some
caoutchouc; workers of gas stations; decorators of vegetables at the rate of 0,5 mg/kg.
glass and ceramics; workers from the production of Source of lead can also be drugs, theatrical make-
batteries; workers for repair of bridges and others in up and some cosmetics.
direct contact with lead. METABOLISM AND MECHANISM OF ACTION
At concentrations of lead in the air of the working For human lead is a nonessential trace element,
environment about 0,01 mg/m3 content in the blood typical xenobiotic at high toxicity and pronounced
of exposed workers ranges from 6 to 140 mg% (aver- tendency to material accumulation. Particularly sen-
age 32-41 mg%), which is more than 2 times higher sitive to lead are children and pregnant women. As
than the control level in unexposed individuals. a rule, the signs of chronic lead poisoning in chil-
Source of lead can be other activities, professions dren were detected at lower concentrations of lead
or hobbies for individuals: applied artists potters, in blood (Fig. 1). Priority damaging the central and
masters of unique ceramic and glassware; manu- peripheral nervous system, blood cells, metabolism
facturers of lead shot and fishing weights; lovers of vitamin D and calcium, reproductive function. The
of electronic equipment performing consistently injuries may be irreversible. Lead penetrates placen-
lead solder; collectors of pottery, swept to prepare tal, which explains the high risk to the fetus. The im-
“healthy” food in them. perfections of the blood-brain barrier in children un-
Given the long history (centuries) of lead as a der 3 years of age makes them the most vulnerable
companion of human in life and production, cur- population groups. Very often in childhood signs of
rently lead is ubiquitous environmental pollutant. chronic lead poisoning are limited to unusual hyper-
Local sources of pollution with lead are lead-pro- activity and lightly mental retardation.

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 LABOUR MEDICINE
In the body, inorganic lead and its compounds tion (low caloric and low protein), calcium, iron and
fall through inhalation and ingestion. Inhaled way phosphorus deficiency.
of penetration is very important in professional con- Up to 35% of inhaled lead particle of size 0,1-1,0
tact with lead. Digestive pathway is essential for the μm are deposited and held in the lungs. Pulmonary
whole population. Only organic lead compounds absorption is about 30% and depends on the size
(eg. tetraethyl lead) penetrate through the skin. of the particles, the solubility of the compound, the
The daily amount of lead incoming by diet is individual physiological characteristics and the pres-
mostly about 100-200 μg, but in some regions it ence of pathological changes in the organism. Ris-
ing to 50 percent by inhalation of exhaust gases or
soluble lead compounds, smokers and people with
Children Concentration in Adults chronic diseases of the respiratory organs. In bones
the blood (g Pb/dl)
and teeth concentrate 95% of the total content of
lead in the body - a typical material accumulation.
Death Only 2% is lead in blood and it is distributed so - al-
Encephalopathy
most 99% of the circulating lead is associated with
Encephalopathy
the erythrocytes and only about 1% remains in the
Nephropathy Anemia plasma. It is experimentally found that after a single
Anemia
Shortening of life treatment period of half-life from the blood in adult
expectancy individuals is about 25 days of soft tissues - about 40
Colica abdominalis
The synthesis
days, from the bones - more than 25 years. Accumu-
of hemoglobin lated bone lead is a potential endogenous source
The synthesis of Peripheral neuropathy - physiological conditions (pregnancy, lactation),
hemoglobin Sterility (men)
Nephropathy stress (alcohol ‘hit’) or chronic illness activate inert
Metabolism Systolic lead in the bones and the level in the blood rises.
arterial pressure
of vitamin D
Hearing acuity
Lead is excreted primarily in the urine (75-80%),
Protoporphyrin in to 15% of the bile secretions and faeces of the GIT,
erythrocyte (Men) less than 8 percent with sweat and horny formations
Nerve conduction
- hair and nails. By mammary glands falls in milk in
Protoporphyrin in Protoporphyrin in
small but proportionate content of blood lead lev-
erythrocytes erythrocytes (Women) els.
Metabolism of The exposure assessment is done by convention-
vitamin D
Changes in development al toxicokinetic tests: lead in blood, urine, hair and
Ratio intelig. (IQ) teeth.
Hypertension (?)
Hearing PREVENTION
Growth
Placental entry
When operating in contact with lead in order to
limit the exposure is recommended:
• maximum mechanization of production pro-
Overactive function Reduced function cesses,
• encapsulation of places with intensive dust and
Fig. 1. Influence of inorganic lead on children and adults - the
lowest level of observed adverse changes
spraying water on powdery materials
• wet cleaning of the premises
reaches 500 μg/day. According to WHO recommen- • a device of hermetic cabins for workers at the
dations for daily amount for adults is to 400 μg/day. casting of lead,
Given the high sensitivity of children US Agency for • improving the design of furnaces for high-tem-
Control of Food and Drug Administration (FDA) pro- perature processing of lead,
vides for measures to reduce aggregate imports of • introduction of a continuous process of refining
lead in children 1 to 5 years to 100 μg/day. lead and closed production cycles
Incoming by inhalation and oral - inorganic tract • increasing the volume of ventilation to 15-20
lead is not metabolized. Metabolic transformation is m/s and more.
characteristic of the organic lead compounds. Preliminary and periodic medical examinations
The absorption of lead in gastro intestinal tract are required. Workers in contact with lead are pro-
(GIT) is about 10-15% of ingested quantity. For preg- vided: the diet B as a safety professional nutrition,
nant women and children resorption is increased to vitamin C 100 mg, vitamin E 20 mg, vitamin B com-
50%. Features in the feeding significantly affecting plex 1 dragee every other day, vitamin B12 - 3 μg, fo-
the absorption of lead. It is increased by malnutri- lic acid 300 μg, enriched with pectin fruit drinks and

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 OCCUPATIONAL MEDICINE
fruit purees, mousses, 1 l mineral water from Kavar- PROFESSIONAL AND UNPROFESSIONAL
na or Gorna Banya, Targovishte, Ivanyane, Belovo, EXPOSURE
Varshetz, Varna. Occupational exposure to selenium with signs of
damage to the health of workers is observed in the
SELENIUM (Se) copper production; melting of aluminum, coated
HYGIENE STANDARDS with selenium and in the manufacture of steel.
Air of the working environment: Selenium and Chronic toxic effects in increased exposure of the
compounds (such as selenium) - Mean-shift MAC - selenium from the environment are unspecific.
0,2 mg/m3, teratogen for animals; Hydrogen seleni- The content of selenium in the air near the copper
um (such as selenium) - Mean-shift MAC 0,03 mg/m3. enterprises and the territory of the factory reaches
Air settlements: Selenium dioxide - Daily aver- 0,0004-0,0005 mg/m3. Much more intense polluting
age MAC - 0,00005 mg/m3, maximum single MAC - the air with selenium in volcanic activity (in volcanic
0,0001 mg/m3. gas content of selenium is a thousand times more).
Surface water: I-III category - 0,01 mg/dm3. In surface water content of selenium rarely ex-
GENERAL CHARACTERISTICS ceed 1 μg/dm3. Maximum values have been estab-
Selenium exists in crystalline and amorphous forms. lished in the mineral waters (acidic and hydro car-
It represents grey-dark with brown hue substance. Un- bonic) - 6 to 8 μg/dm3.
der normal temperature most resistant hexagonal High ability to accumulate selenium is character-
crystal grey or metallic selenium. The temperature of istic of soil bacteria, actinomycetes and fungi. In the
the melt was 217°C, a boiling point of 685°C, a density selenium content of 0,4 mg/kg in soil in edible and
of 4,79 g/cm3. Does not dissolve in water. Under ordi- poisonous mushrooms concentration of selenium
nary conditions it is resistant to the action of air, oxy- ranges from 2 to 12 mg/kg dry matter.
gen, water, hydrochloric acid and dilute sulfuric. Well The content of selenium in plant products de-
dissolved in nitric acid and “aqua regia”. With fluorine, pend on the geochemical characteristics of the
chlorine and bromine formed haloides with hydrogen region, in environmental pollution with selenium.
at 350-440°C - hydrogen selenium. At high tempera- In legumes contain 0,24-0,73 mg/kg dry seeds. In
ture, dissolved in organic substances. wheat, rye, barley, oats and peas content of sele-
The content of selenium in the earth’s crust averag- nium varies around 0,257-0,304 mg/kg dry mass.
es 6.10-5%. Pure selenium minerals and native selenium Significantly less amount of selenium contained in
are very rare. More often there are small selenium- sul- potatoes, corn, cabbage, onions, carrots, cucumbers
phide hydrothermal deposits. There are 38 minerals: and apples - from 0,004 to 0,142 mg/kg dry mass.
selenide (compounds with selenium metals: claustalit The meat of bovine animals contain 0,929 mg/kg
PbSe, timanit HgSe, naumanit AgSe etc.); selenites selenium eggs - 0,022 mg/kg, dairy products - 0,100-
(salts of selenious acid) and seleniates (salts of selenic 0,298 mg/kg dry matter.
acid). METABOLISM AND MECHANISM OF ACTION
In slightly alkaline selenium vigorously migrates Selenium is an essential trace element that is
and is able to form selenium biogeochemical provinces toxic to mammals and man when he entered the
or biosphere subregions. One of the factors determin- increased amounts of diet or inhaled air. Toxic dos-
ing the absorption of selenium from the plant is the es are 100-300 times higher than those needed for
amount of water-soluble selenium in the soil. life. Human body contains from 3 to 15 mg seleni-
USE um. Daily admission to the diet varies from 60 to 300
Selenium is mainly used for the production of μg, depending on the characteristics of the area, the
rectifiers and photopiles. It synthesized various se- composition and preparation of food. The absorp-
lenides with semiconductor properties that are tion in the gastrointestinal tract is up to 90% (50-
applied in the manufacture of thermo elements, 100%), influences significantly from the content of
photoresistors and cathod-luminofores. Selenium is methionine in the diet - this amino acid inhibits the
used in the glass industry as a colorant, in the vul- absorption of selenium-containing amino acids.
canization of rubber and in metallurgy to form a fine Newly admited selenium is found mainly in plas-
grain structure of the steel. ma associated with the α2 and β1 - globulin fraction
Selenium is used as a catalyst in the process of and the free amino acids (cysteine, methionine, leu-
hydrogenation. In organic synthesis is used seleni- cine).
um dioxide as the oxidant and the starting material After tissue distribution maximum levels found in
for the preparation of organic and selenites com- the kidneys and liver; lower - in the retina, spleen,
pounds which are used as extractants, antioxidants lung, myocardium, skeletal muscle and brain. Sele-
and drugs. nium accumulates in hair. At occupational exposure

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elevated levels are found in the lung. compounds which are superior in stability at those of
In tissue selenium undergoes biotransforma- bismuth, antimony, iron, chromium and aluminum.
tion: reduction, methylation and connection or di- With metals forming alloys.
rect involvement in proteins (Se-cysteine instead of The content of thallium in the earth’s crust is from
cysteine, Se-methionine instead of methionine). 0.43% to 1.0.10-4. Occur in the composition of rare min-
Selenium cross the placental barrier and is secret- erals, manganese, copper, zinc and arsenic ores. The
ed in milk. Emitted mainly in the urine, but also in content of thallium in soil is 1.0.10-5% in seawater - 0,01
sweat, feces, hair and exhaled air. μg/dm3, freshwater 0,01-14,0 μg/dm3, and in the air -
In biogeochemical provinces livestock (cows, from 0.04 to 0.48 ng/m3. In areas of minefield thallium
sheep, pigs, dogs, horses) have so-called “alkaline” content in groundwater reaches 2,7 mg/dm3.
disease - chronic selenium toxicity. In the same ar- USE
eas in medical examinations of the population are Thallium and its compounds are used to manu-
established changes in the enamel of the teeth, sub- facture semiconductors, electronics and electrical
icteric skin, chronic inflammation of the joints, rash, engineering; for doping germanium, silicon and
nail diseases, anemia, gastrointestinal diseases and cadmium compounds; for the preparation of pho-
nervous disorders. toresistors and photoelements with high sensitiv-
A characteristic sign of increased exposure in ity; in atomic engineering for different scintillation
chronic selenium toxicity is the smell of garlic in counters; for activation of luminescent crystals; in
expire air, due to the generated in biometilation di- optics, instrumentation and mechanical engineer-
metilselenid. ing. Thallium salts are used as octane antidetona-
PREVENTION tors, catalysts to produce luminous paints, artificial
Technological events are the most important and semi-precious stones, pearls and diamonds, in the
radical measures for the prevention of chronic intox- composition of depilatory creams and pastes, and
ications in production: hermetisation of equipment; rodenticides.
mechanization of operations for loading the reactor PROFESSIONAL AND UNPROFESSIONAL
with technical selenium; isolation of operations re- EXPOSURE
lated to the separation of selenium in the air of the In the production of thallium - metal and its ox-
working environment in premisses. ides, the concentration of thallium in the premises
Preliminary and periodic medical examinations reaches 0,18 mg/m3, in casting metal - 13-17,4 mg/
are required. Pregnant women vocational rehabil- m3. The production of salt, content of thallium in the
itation immediately - without contact with seleni- air of the working environment is about 0,136-0,354
um. At work should use personal protection: rubber mg/m3, in the synthesis of mono- crystals - 0,004-
gloves when working with a solution of selenium 0,007 mg/m3.
thiosulfate; dust respirators and masks in packaging The most significant sources of environmental
technical selenium; if necessary, gas masks and skin contamination with thallium are thermal power
protection. plants of oil, coal and fuel oil and enterprises of non
ferrous metallurgy, mining copper, lead and zinc.
THALLIUM AND ITS COMPOUNDS (Ti) Thallium can get into the drinking water and food
HYGIENE STANDARDS in highly anthropogenic of contaminated areas and
Air of the working environment: Thallium and of excessive fertilization with potassium fertilizers.
its compounds (such as thallium) - Mean-shift MAC METABOLISM AND MECHANISM OF ACTION
- 0,05 mg/m3. Thallium is a nonessential ultramicroelement
GENERAL DESCRIPTION characterized by properties similar to those of lead:
Thallium is a soft light gray metal with a molecu- material accumulation and toxicity. In the body pen-
lar weight of 204.37, a meltin point of 303,5°C, a boil- etrates in all possible physiological pathways: enter-
ing point of 1472°C, a density of 11,82 g/dm3 at 20°C. al, inhalation of aerosols and through the skin.
Crystallizes in two modifications. Its surface is oxidized Under normal conditions with food and drinking
by air at normal room temperature. Insoluble in water water daily take 1.6 to 2,0 μg, by inhalation - 0,05 μg.
and bases. Easily react with mineral acid (nitric, sulfu- The thallium content in hair was 4,8-15,8 ng/g, in the
ric), but not with hydrochloric acid due to the forma- urine - 0,13-1,69 μg/dm3, in nails - 0,72-4,93 ng/g.
tion on the surface coating of thallium chloride. Medium in body contained 100 μg thallium.
Slightly soluble halides, sulfides, chromates of mon- Thallium is rapidly absorbed through the all
ovalent thallium it closer to monovalent silver, copper, mucous membranes - enteral and UAP, as well as
gold and divalent lead and mercury. Trivalent thallium through the skin. Peaks in the blood after 12 hours
is readily reduced to the monovalent, form complex and soon disappears. Distribute the internal or-

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 OCCUPATIONAL MEDICINE
gans, especially kidneys, salivary glands, testes, liver, lotropic states: hexagonal crystals and dust. With met-
spleen, prostate, brain. The next redistribution in the als form tellurides.
body is deposited in bones and hair. Tellurium is one of the rarest distracted elements.
Because of the similarity with potassium possible It is represented by eight stable isotopes. The average
biological interaction between two elements: thalli- content in the earth’s crust is about 1.10-7%. 40 mineral
um can replace potassium and compete with him in forms: tellurides and their oxidation products. Typical
the construction of biological membranes. The infu- impurity to pyrite or in a polymetallic, copper- zinc and
sion of potassium increases the clearance of thalli- lead- zinc ores.
um and extraction of the tissues. USE
Thallium is excreted in urine and faeces. Excre- Telluride and its alloys are used for the produc-
tion is long, can reach 1 year. Excretion through sali- tion of semiconductors. Pure tellurium is alloying
vary glands is substantial, up to 15 times higher than additive to lead, steel and cast iron; component of
by the kidneys. alloys with a high resistance; used in the vulcaniza-
Depending on the individual sensitivity the le- tion of rubber; coloring glass and ceramics industry
thal dose for humans ranges from 0.5 to 3 g, mini- in the production of reddish glass and ceramics and
mum lethal dose is 12 mg/kg body weight. in the manufacture of latex mixtures.
PREVENTION PROFESSIONAL AND UNPROFESSIONAL
In all manufacturing processes where possible EXPOSURE
contamination of the premises with thallium are re- Professional exposed to tellurium and its com-
quired mechanization and automation of manufac- pounds (mainly TeO2) are workers of workshops for
turing processes, hermetisation of equipment and electrolysis and obtaining pure metals from ore with
effective ventilation. impurities of tellurium.
It recommended the introduction of closed cy- When workers in ferrous metallurgy (steel) ex-
cles excluding manual operations. Machining and posed to tellurium in concentrations of 0.01 to 0,1
polishing crystal should be carried out only under mg/m3 shall be established: the smell of garlic in ex-
local ventilation. pire air and sweat, metallic taste in mouth, anorexia,
Particular attention should be paid to the dispos- rhinitis, somnolence, these content in urine up to
al of solid waste that are extremely dangerous for 0,06 mg/l.
the environment and the population. Working with METABOLISM AND MECHANISM OF ACTION
thallium after the shift must take a shower, and if Tellurium is a nonessential ultramicroelement per
necessary to organize sanitization of the body and human. From the known tellurium - metal, tellurides
clothing. Frequent change of clothing is obligatory, (compounds of metals), tellurites and telurates (salts
while repair and emergency works it is used only of telluric and telurorouse acid), at a weak toxicity
once. In addition of moisture- and dustproof suits, has tellurium metal. Most toxic are water-soluble tel-
are provided: respirators, goggles, rubber gloves. lurites. Tellurium and its compounds enter the body
Preliminary and periodic medical examinations are mainly through inhalation and in limited quantity
required. Recommended monthly survey of thalli- by digestive. Intestinal absorption is low due to poor
um in urine. solubility. Only organic compounds penetrate intact
skin. Tellurium accumulates in all parts of the body,
TELLURIUM (Te) most in the kidneys, liver, brain and testes. Internal
HYGIENE STANDARDS organs and mucous membranes of the mouth and
Air of the working environment: Mean-shift the stomach or upper respiratory tract, specifically
MAC - 0,1 mg/m3 stained dark green to black with earthy nuance. This
Air of settlements: Daily average MAC - 0,0005 staining was due to the reduction of the compounds
mg/m3 (tellurium dioxide). to tellurium metal. Restored tellurium is methylated
GENERAL CHARACTERISTICS to dimethyl tellurium, which is the reason for the
Tellurium is a silver-gray brittle metal with a pro- specific smell of garlic. Excretion from the body of
nounced sparkle, molecular weight of 127.60, density tellurium is very slow, performed mainly by the kid-
6,64 g/cm3 at 20°C. When heated burns with a blue neys. Small amounts are excreted via the bile and
flame and forms TeO2. React with halogens, hydrogen stool (dimethyl tellurium and tellurium metal); by
formed telluro-hydrogen - colorless, poisonous gas lung and sweat (garlic breath from the mouth and
with a sharp odor. Insoluble in water and organic sol- the smell of garlic from the body); by salivary glands
vents. Dissolved in concentrated nitric acid, in “aqua re- (metallic taste in the mouth).
gia” (a mixture of concentrated nitric and sulfuric acid), The mechanism of toxicity is not fully understood.
low in hydrochloric acid and alkalis. It exists in two al- It is believed that the observed sleepiness and other

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 LABOUR MEDICINE
Air of the working environment
Chemical Empirical formula Mean shift MAC Short maximum MAC
1. Phosphoric anhydride P2O5 1,0 mg/m3 -
2. Phosphorus pentachloride PCl5 1,0 mg/m3 -
3. Phosphorus trichloride PCl3 1,5 mg/m3 3,0 mg/m3
4. Phosphine PH3 0,1 mg/m3 0,2 mg/m3

Air settlements
Pollutants Daily average MAC Maximum single MAC
1. Phosphoric anhydride 0,05 mg/m3 0,15 mg/m3
2. Phosphine 0,001 mg/m3 0,01 mg/m3

Drinking water
Phosphates in mg/dm3 not more than 0.5
Surface water I category II category III category
1. Phosphates (PO4) 0,2 mg/dm3 1,0 mg/dm3 2,0 mg/dm3
2. Phosphorus - the total content as РО 4 0,4 mg/dm3 2,0 mg/dm3 3,0 mg/dm3

neurological symptoms are due to a reduction of the density of 2.2. Red phosphorus is less active than white
cortical excitability. It is also known to cause growth phosphorus, at normal temperature with water vapor
failure, hair loss, paralysis. and oxygen react slowly.
PREVENTION Phosphorus is one of the main elements that make
Workers in contact with tellurium subject to pre- up living organisms. As an essential component of pro-
liminary and periodic medical examinations. toplasm, nervous tissue and bone, the phosphorus is
Protection of workers is ensured by effective ven- present in significant amounts in molecules with great
tilation in the working premises. In the presence of biological importance: nucleotides and phospholipids.
tellurium aerosols need to wear respirators. Workers In nature, phosphorus is the main factor limiting the
in contact and tellur-hydrogen should use filter-type growth of autotrophic organisms both in the water
masks. To provide clothing and rubber gloves. It is and on land. It is assumed (for the nitrogen has been
imperative to observe the rules of personal hygiene. shown) that phosphorus is the main regulator of all
other biogeochemical cycles. The amount of nitrate in
PHOSPHORUS COMPOUNDS (P) the water and oxygen in the atmosphere depends on
HYGIENE STANDARDS (Table) the state of the cycle of phosphorus.
GENERAL CHARACTERISTICS Human activity has significantly increased amounts
Phosphorus freely in nature does not occur. Was de- of natural phosphorus. Annually in wastewater of ur-
tected in the form of phosphates in the composition of ban sewerage fall 2 kg of phosphorus for each resident
the minerals: chlorapatite, fluorapatite, vivianite or phos- of the settlement used to maintain personal hygiene
pharite. Its content in the earth’s crust is about 0.12%. modern shampoos and detergents. The majority of the
Phosphorus exists in three allotropic states: white phosphorus used as fertilizer remains in the soil, be-
phosphorus (highly toxic), red phosphorus - low toxic cause of the high content of calcium, aluminum and
due to insolubility in biological fluids and black phos- iron, which forms a phosphorous compounds. Part of
phorus. the excess falls in freshwater pools, playing a major
White phosphorous is a colorless soft crystalline role in the occurrence of eutrophication (aging and
form, lighting in the darkness and quickly yellowing complete disappearance of aquatic fauna due to accu-
under the influence of light. The melting point of white mulation of minerals, primarily phosphorus and nitro-
phosphorus is 44,1°C, boiling temperature - 275°C, gen, and intense growth of aquatic plants).
flash point 34°C, density - 1.83. Vapour of phosphorus USE
is 4.3 times heavier than air. At ambient temperature White phosphorus is used for obtaining red
is low volatile, in the air form a white fog, containing phosphorus, phosphorus compounds and alloys;
phosphorus and its oxides. Slightly soluble in water. pesticide is used for rodent control; as fume forma-
When access of light and air very easily oxidized and tive and incendiary means. Specially purified phos-
self-igniting. Therefore, it is stored in the dark and un- phorus is used in the electronics and semiconductor
der water. Reacts violently with sulfur, halogens and industry.
metals. Red phosphorus is used in the manufacture of
The red phosphorus is powder with dark red to matches, agriculture and metallurgy.
brown. Melting point - 600°C, a flashpoint of 240°C, a

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 OCCUPATIONAL MEDICINE
PROFESSIONAL AND UNPROFESSIONAL CHROMIUM AND ITS COMPOUNDS (Cr)
EXPOSURE Chromium oxide (III) - Cr2O3,
Acute poisoning with phosphorus are described Chromium trioxide (VI) - CrO3 - proven carcino-
exclusively by ingestion of white phosphorus, al- gen for people - 1 group,
though possible and acute poisoning with phos- Sodium chromate - Na2 CrO4,
phorus steam. Potassium chromate - K2CrO4,
Chronic poisoning of phosphorus vapours are Sodium dichromate - Na2Cr2O7.H2O,
described in concentrations of white phosphorus in Potassium dichromate - K2Cr2O7,
the air of the working environment 0,2-1,2 mg/m3 Chromium trichloride - CrCl3.
in the manufacture of matches, also at concentra- HYGIENE STANDARDS
tions 0,1-0,16 mg/m3 (but at the same time vapour Air of the working environment: Mean-shift
of phosphoric anhydride, phosphine and hydrogen MAC 0,5 mg/m3 for chromium - dust from metal,
fluoride). ores and concentrates; 0,05 mg/m3 for chromium
Being on the skin white phosphorus ignites, compounds.
develops high temperature, causing slow healing Drinking Water: Chromium (VI) - not more than
burns. Local adverse effect on the site of combus- 0,05 mg/dm3.
tion provide the forming phosphoric acid. Air settlements: Daily average MAC for hexava-
In metallurgy, metal processing, containing im- lent chromium calculated as CrO3 - 0,0015 mg/m3;
purities of phosphorus, with concentrated acids lib- Maximum single - 0,0015 mg/m3.
erates highly toxic gas phosphine (PH3). Surface water: I category: trivalent chromium -
Accidental or suicidal ingestion of phosphorus 0,1 mg/dm3, hexavalent chromium - 0,02 mg/dm3;
compounds (mostly pesticides) causes unprofes- category II: trivalent chromium - 0,5 mg/dm3, hex-
sional poisoning or death. avalent chromium - 0,05 mg/dm3; category III: triva-
METABOLISM AND MECHANISM OF ACTION lent chromium - 1,0 mg/dm3, hexavalent chromium
White phosphorus enters the body through the - 0,1 mg/dm3.
respiratory, mucosa of the gastrointestinal tract Food products: from 0,1 mg/kg (in milk, fruit) to
after ingestion and through damaged skin from 0,5 mg/kg (in the intestines of animals and birds).
burning. Upon receipt of phosphorus in the body at GENERAL CHARACTERISTICS
large quantities it is possible to detect in the blood Chromium is gray hard melting metal with molec-
in elemental state. When phosphorus poisoning, oc- ular weight 51.99, density 7,19 g/cm3 (20°C), melting
cur disturbances in the metabolism of proteins and point 1890°C. Chromium and chromium oxide are in-
carbohydrates, in the deposition of glycogen in the soluble in water; chromium trioxide, chromates and
liver. And increases fat deposition in the liver. bihromatite are soluble. Pure chromium metal is plas-
The excretion of inorganic phosphorus is carried tic. Chemical is less active. Under ordinary conditions
out mainly by the kidneys. it is resistant to oxygen. Formed compounds with flu-
PREVENTION orine and salts with oxygen-containing acids. In the
Manufacturing processes in obtaining and use compounds is from 2+, 3+ or 6+ valency. Derivatives
of white phosphorus must be hermetisated and of bivalent chromium are very strong restorers; of tri-
the premises equipped with efficient ventilation. At valent chromium - can be restorers or oxidizing agents.
work use respirators or filter masks. Special attention The most resistant are the compounds of trivalent
is paid to personal hygiene, carefully washing hands, chromium.
face and body shower. Compulsory oral hygiene and USE
teeth. Persons with carious teeth are not allowed to Wide use of chromium due to its thermal stabili-
work in contact with phosphorus. Strictly forbids ty, hardness and corrosion resistance. Best known is
eating and smoking in workplaces. Limited to man- as an alloying addition to steel, stainless steel, heat-
ual manipulation of phosphorus (in proceedings and acid resistant. Chrome-nickel alloy (nichrome,
provides mechanical loading with phosphorus). It is nimonik) are used for the manufacture of reactive
recommended that workers who performed several equipment, gas turbine and nuclear reactors. Signif-
professions frequently change jobs in contact with icant amounts of chromium are used for decorative
phosphorus. Preliminary and periodic medical ex- corrosion - chrome-plating. Chrome powder is used
aminations are required to X-ray of jaws and others in metal ceramics and production of welding elec-
bones by indications. Recommended diet D of the trodes. Trivalent chromium alloy is used for the jew-
safety professional nutrition. elry industry and ruby laser technique. Chromium
oxide is a raw material to produce chrome, paint for
glass and ceramics, chrome catalysts. Obtained from

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 LABOUR MEDICINE
chromium trioxide. than those of adults. The chromium content in the
Chromates is used as chemical reagents in the heart, lung, aorta and spleen decline in the first 10
textile industry, leather industry (tanning solutions), years of life, in the liver and kidneys had been held
wood (wood preservatives) and agriculture (decon- during the second decade. Lungs is the only organ
tamination of seeds). with increasing concentration over time.
Bichromates are widely used in metal, leather, The chromium content is significantly reduced in
textile, ceramic industry, for the production of paints ischemic heart disease, particularly myocardial in-
and varnishes and in pyrotechnics. farction, and also in the duodenal ulcer disease and
PROFESSIONAL AND UNPROFESSIONAL liver disease.
EXPOSURE The content of chromium in hair, nails, blood and
Lithosphere chrome is 0.055%. In the free state lymph nodes of persons in professional contact with
does not occur. The basic form is a natural chromium chromium is significantly higher.
oxide. Chromium forms a 20 minerals, mainly com- Trivalent chromium is an essential trace element,
pounds of oxygen and iron: chromite, kemerit etc. hexavalent chromium is highly toxic. Intracellular its
In 0,5-2 km radius of chromworking enterprise conversion to trivalent chromium is the basis of the
ambient air contains chromium 10 to 30 times more critical toxic effects.
than sanitary norm. Chromium enters the body by inhalation and di-
The natural content of chromium in open res- gestive tract and through the skin. The absorption of
ervoirs fluctuate widely, up to 0,112 mg/dm3. In chromium in the lung (mainly soluble compounds
seawater chromium content is about 0,05 μg/dm3, of hexavalent chromium) can be significant and fast.
in the oceans - 0,28 μg/dm3. In drinking water, the Chromium accumulates in the lung into insoluble
average chromium content is about 0,0023 μg/dm3. compounds.
In unpolluted soils natural chromium content is The absorption of chromium in the gastrointes-
about 1,8.10-3% depending on the type of soil. Con- tinal tract is about 1% on average, for the trivalent
centrated in the topsoil horizon. chromium ranges from 0.1 to 1.2%, for hexavalent
Chromium was detected in all the plants in con- chromium - 2%, for GTF - up to 10%. Cell membranes
centrations of up to about 5 mg/kg. Up to 95% of the are readily permeable to the chromium (VI), but not
total was concentrated in roots. to the chromium (III). In mitochondria and nuclei of
Chromium is found in all foods of plant or ani- chromium (VI) is reduced to chromium (III) and re-
mal origin. Presented in the form of inorganic com- mains in this form in the tissues and in the connect-
pounds or as coordination complex with nicotinic ed state.
acid and amino acids so-called glucose-tolerant Chromium, probably as GTF passes transplacen-
factor (GTF), with pronounced influence on carbo- tal and in the same form secreted in milk.
hydrate metabolism. Urine is the main route of excretion of chromium.
Acute inhalation intoxication in production are Faeces contain mainly unabsorbed from food metal.
described in concentrations of 20 mg/m3. Concen- In biological control using the following toxicoki-
trations in the range of 4-5 mg/m3 cause perfora- netic tests: urine chromium, chromium in blood, se-
tions of the septum nasi in more than half exposed rum (plasma) and chromium in hair.
persons for a period of six months to three years. In PREVENTION
all workers observed rhinitis and pharyngitis, and for The most important and radical measures for the
some individuals it is possible to detect an enlarged prevention of chronic professional intoxications are
liver and kidney dysfunctions technological and technical: replacement of toxic
METABOLISM AND MECHANISM OF ACTION hexavalent compounds with low toxic; full herme-
Chromium enters the body mainly by the food in tisated equipment; maximum mechanization and
an amount of 25 to 282 μg/day, usually 50-150 μg/ automation; effective local ventilation.
day. Deficiency in the diet of trivalent chromium, Entering on work subject of preliminary medi-
which is an essential trace element for the body, is a cal examination. In periodic medical examinations
topical issue for some countries (recommended in- involved and oncologists. Persons with pneumo-
troduction of chromium in the amount of 50 to 200 sclerotic changes in the lung and/or recurrent skin
μg/day to overcome the deficit in food). lesions are vocational rehabilitation.
In the human body contains 6-12 mg chromium. It is necessary to ensure strict monitoring of com-
With age the amount is reduced. pliance with individual protection measures: respi-
The greatest amount of chrome settled in her rators or masks of insulating type; rubber gloves;
hair, liver, lung, kidney, endocrine glands and intes- suits with hoods, and for galvanotechnicians and
tines. Tissues of newborns contain more chromium handling solutions - waterproof clothing; protective

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ointments, creams and pastes for hands of the type Significantly higher concentrations of zinc are found in
“biological gloves”. To clean the skin of the hands the waters of the regions of ore deposits - up to 20-35
and decontamination of chromium, recommended mg/dm3.
special protective ointments containing EDTA and The zinc content in the groundwater outside the ore
ascorbic acid. Handwashing is appropriate to use areas averaged about 10 μg/dm3, rarely reaches 50 μg/
the 5% solution of sodium thiosulfate or 10% sodi- dm3, while the waters draining the deposits amount of
um bisulfite. zinc is 1000 times more.
Importance is the prevention of skin trauma, and Zinc is essential bio-element and is contained in all
inflammatory diseases of the upper respiratory tract. the tissues of plants and animals. The average content
in the body of reptiles and amphibians is about 1-3
ZINC (Zn) mg%, and in the body of mammals and birds - 23 mg%.
HYGIENE STANDARDS Ability to accumulate zinc have forage grasses (al-
Air of the working environment: Zinc oxide falfa), natural grass vegetation and some poisonous
(such as zinc) - Mean-shift MAC - 0,5 mg/m3, maxi- plants. In the food content of zinc ranges from 0,47
mum short MAC - 10,0 mg/m3. mg/kg in egg white to 58,2 mg/kg in meat. From plant
Air settlements: Daily average MAC - 0,05 mg/ products as much zinc is in the parsley, carrots, pota-
m3. toes, beets, cabbage; of cereals most zinc contained in
Drinking water: Zinc not more than 5,0 mg/dm3. the rye; the maximum amount of zinc found in pome-
Surface water: I category - 1,0 mg/dm3; category granates.
II - 5,0 mg/dm3; category III - 10,0 mg/dm3. USE
Soil: from 20 to 370 mg/kg depending on the pH The most important is zinc as galvanoplasty
of the soil. (58.8% of all plating) to protect iron from corrosion.
Food: from 5,0 mg/kg for milk and infant food Zinc is used in industry for the preparation of alloys:
milk-based to 200,0 mg/kg of mussels, crustaceans with copper (brass); copper and lead (bronze) and
and others. copper and nickel (melchior). Expanding the use of
GENERAL CHARACTERISTICS its anti-friction alloys containing 5-10% aluminum
Zinc is a silvery blue shiny metal, stronger reducer, and 5-10% copper. Zinc sulfide activated with sil-
able to shift much of divalent metal from its salts. In ver and aluminum have fluorescent properties and
compounds always of the second valency. The temper- mixed with cadmium sulfide is used for making tele-
ature of melting is 419,5°C, the boiling temperature of vision tubes and displays (kinescope). Zinc parts ob-
906°C and a density of 7.133 at 20°C. tained by smelting under pressure is widely used in
Zinc - metal readily soluble in dilute acids. In water aerospace, automotive, and others industries. Zinc
well soluble following salts of zinc: chlorides, bromides, is used in stabilizing devices that correct deviations
iodides, nitrates, sulphates and acetates. Low soluble of satellites in space and its compounds (zinc-silver
are zinc sulfide, carbonate, fluoride, phosphate, arse- oxide batteries) are a source of energy in spacecraft.
nate, arsenite, chromate, oxalate, silicate, cyanide, fer- Anhydrous zinc chloride is used as dehydrating
rocyanide. agent in reactions in organic chemistry, in the pro-
Zinc is widely distributed in nature element, its con- duction of paints, viscose and as flux in hot dip gal-
tent in the Earth's crust is 1,5.10-3%. It enters into the vanizing, tin plating and soldering.
composition of a large number of minerals. Pure zinc Zinc antimonid used in devices for converting
ores in nature as a rule hardly meet. For obtaining zinc, electrical energy into heat, spot cooling detectors
polymetalic ores are processed, wherein the initially and as a component of electronics and instrumen-
obtained concentrates comprising: zinc - 48-58%, lead tation in space ships.
- 1-2%, copper - 2%, iron - 5-10% and sulfur up to 30%. Zinc selenide is used in the semiconductor and
The zinc content in the air of cities around 0,040-0,047 fluorescent technique for producing photoresistors,
μg/m3. photoelements, photosensitive layers and transpar-
Zinc content of the soil depends on the nature of ent ceramic.
the sediments, organic matter content, the texture of Zinc oxide is a raw material in the production of
the soil and its active reaction (pH). Ranged from 15 to powder, glass, ceramics, matches, celluloid, paints,
80 or more mg/kg, in the areas of ore deposits reached dental face cement, cosmetics, rubber.
n.10-2 - 1%. Zinc salts are used in agriculture as fertilizers (sul-
In sea waters the amount of zinc fluctuated from phates, nitrates and chlorides) and polimicrofertiliz-
2 to 50 μg/dm3. In surface freshwater pools zinc con- ers that enhance the growth of root system of plants
tent varies more widely: from 0.6 to 120, and in some and improve their protein metabolism, accelerate
regions of Siberia to 577 μg / dm3, average 1,3 μg/dm3. redox reactions, stimulate the synthesis of chloro-

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 LABOUR MEDICINE
phyll, vitamins C and vitamin P. nificant pollution, to toxic levels, monitoring should
Zinc is used as a stimulator for fish roe and larvae include a hygienic analysis of water and bottom sed-
of carp. Zinc compounds are widely applied in med- iments.
ical practice: zinc sulfate as antiseptic at conjuncti- METABOLISM AND MECHANISM OF ACTION
vitis, laryngitis, urethritis and vaginitis; zinc oxide in Zinc is an essential element. It is relatively
the composition of ointments and pastes for exter- non-toxic to a wide range of tolerance (from normal
nal use. to toxic levels). Some authors consider that besides
PROFESSIONAL AND UNPROFESSIONAL acute inhalation poisoning, occurring as so-called
EXPOSURE “Foundry fever” or chemical pneumonitis, and acute
Zinc is one of the most common anthropogen- oral toxicity after ingestion of a high dose of zinc
ic pollutants. His technophylity (the ratio of annual with function disorder of the gastrointestinal tract,
production to the average content in the Earth's chronic poisoning with zinc by the working or envi-
crust) is 108-9. Zinc dig from the earth in an amount ronment does not exist.
exceeding five times the natural removal of the sur- The main source of zinc for the body is food. The
face by the waters, as land (soil) annually adds 3.1 daily need of zinc reached 5 mg. In the adult body
mln. tons of zinc. contains 2-3 g of zinc. The amount of zinc in various
The main source of environmental pollution are organs and tissues varies - about 3 mg% on average.
enterprises of non ferrous metallurgy. Composition The levels of zinc in the skin, hair and nails depends
of their waste is determined by the composition of on nutritional status.
processed ores, if are copper-zinc, per ton of copper Absorption of zinc after ingestion also varies
accounts for two tons of zinc. From the air by precip- widely - from 5 to over 90%. It depends on the sta-
itation annually on 1 km2 area is allocated an aver- tus of the body and the composition of food: amino
age of 72 kg zinc. acids in proteins bind zinc and amplify the oral ab-
Wastewater from metallurgical enterprises, con- sorption; calcium, phytates and fiber reducing them.
centrating factories, electroplating factories, chemical In the process of distribution between organs and
plants and enterprises for artificial silk, contain zinc tissues, does not indicate a trend towards accumu-
compounds from 0,25 to 4,4 mg/dm3 (such as zinc). lation of zinc. Excreted primarily through the intes-
The soil is contaminated with zinc through at- tines. Relatively small amounts are excreted through
mospheric precipitation, in treatment with zinc urine. Substantial amount of zinc can be eliminated
phosphide against rodents, at fertilization with zinc from the body through sweat. Under normal condi-
fertilizers. Increased zinc content is found near TEP tions (adults with daily average receiving of food),
due to its high content in oil and coal. the half-life time of the whole body is about 1 year.
The content of zinc aerosols in the air of the Information about zinc metabolism in the body is
working environment in the metallurgical and elec- obtained by determining the concentrations in the
troplating workshops ranged from 0.3 to 5-7 mg/m3. plasma (serum), urine, hair and sweat.
Zinc refers to the elements tend to bioaccumula- PREVENTION
tion. In grass the zinc content is up to 13 times more Main direction to improve working conditions in
than in the soil. Lichens, which actively absorb at- metallurgical plants is the improvement of process-
mospheric precipitation with dissolved therein ele- es and equipment, mechanization and automation
ments, accumulate zinc 84 to 153 mg/kg dry matter of manufacturing operations. Moreover, the com-
and can serve as indicators of environmental pollu- plex remedial measures in the production of zinc
tion with zinc. include: - complete hermetisation of equipment; -
Under normal conditions (soils non contami- establishing an effective ventilation system; - mech-
nated with zinc) the intensity of absorption of zinc anization of cleaning processes in scrubbers and
is high, soil-plant coefficient of zinc is from 3 to 30 electro filters; - use of vacuum pumps for submission
(sometimes reaches 50 or more). High content of of raw materials and others.
zinc in soil reduces this ratio, which proves the ex- To protect the UAP recommended special respi-
istence of a physiological barrier in plants of zinc ab- rator, including filtration and ion-exchange padding
sorption. with an efficiency of 99% protection and operation
According ability to migrate aquatic zinc refers time up to 72 hours.
to easily removable elements. In neutral and acidic Preliminary and periodic medical examinations
water easily migrates, in the alkali - form precipitates are conducted with the participation of a therapist,
of hydroxides and salts. In minor contamination of ORL, ophthalmology and radiology. Recommended
the rivers, the most sensitive objects, convenient for regular sanitation the oral cavity.
biomonitoring are freshwater invertebrates. In sig-

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 M. Koleva

7.3 ALKALIS AND ACIDS

7.3.1. ALKALIS into the tissues of the eye and can cause severe pa-
GENERAL CHARACTERISTICS thology including blindness.
HYGIENE STANDARDS The powder of calcium oxide acts on UAP not
Air of the working environment
Chemical Mean-shift MAC Maximum single MAC Specific effects
1. Potassium hydroxide 2,0 mg/m3 – Caustic effect
2. Calcium hydroxide 5,0 mg/m3 – Irritation
3. Sodium hydroxide 2,0 mg/m3 –

Potassium base is white opaque highly hygroscop- only as a mechanical irritant, causing discomfort and
ic substance. Outdoor passes in potassium carbonate sneezing. On wet skin, especially the mucous mem-
(potash). Calcium hydroxide (slaked lime) is an aque- branes occurs and caustic action.
ous solution of CaO (quicklime), which is a white METABOLISM AND MECHANISM OF ACTION
amorphous powder with a melting point of 2580°C, a Alkalis are irritating and caustic effect on the skin
boiling point of 2850°C, density 3.16. And slaked quick and mucous membranes. They gel tissue in contact,
and lime absorb carbon dioxide from the air. Sodium dissolving proteins which form albuminates. Pene-
hydroxide is a white opaque solid, highly hygroscop- trate deeply and cause painful and difficult healing
ic, having a melting point of 320°C, a boiling point of burns.
1378°C, density 2.13. A strong base, in store outdoors These solutions operate depending on concen-
gradually turns into sodium carbonate. tration and temperature.
USE Especially dangerous and very serious conse-
Potassium hydroxide are used to produce liquid quences are burns with bases at esophageal acci-
soaps, potassium salts, printing ink, in the textile in- dental engulfment and accidents.
dustry and printing industry. PREVENTION
Sodium hydroxide is used in the manufacture of To prevent of basics is imperative to ensure work-
fibers, soaps, paper and textile industry, descaling ers with special work clothing, rubber gloves, boots
and cleaning of oils and oil fractions. and goggles or a transparent helmets. The use of
The calcium base used in the production of ce- hydrophobic ointments and creams to protect the
ment, construction, metallurgy, food and leather exposed areas of skin.
industry, glass industry, agriculture and ecological
objectives - wastewater treatment. 7.3.2. ACIDS
PROFESSIONAL AND UNPROFESSIONAL Nitric acid - HNO3
EXPOSURE Orthophosphoric acid - H3PO4
Alkaline aerosols are a common factor in the work Acetic acid - CH3COOH
environment given the widespread use of mainly Picric acid - C6N3O6OH
potassium and sodium hydroxide in various sectors Sulfuric acid - H2SO4
and industries. Basics itself have strong local caustic TCA - CCl3COOH
(burning) effect on skin and mucous membranes. Hydrogen chloride and hydrochloric acid - HCl
Dissolved proteins and penetrate into the depth of
the skin. After skin burn of base remain permanent GENERAL CHARACTERISTICS
scarring. In constant contact with hot alkaline solu- Concentrated inorganic acids containing sulfuric
tions stratum corneum of the skin softens, swells acid are chemical mixtures carcinogenic to humans
and gradually falls of. This condition is known in the (Group 1).
literature as “hands of laundress”. Nitric acid is a colorless liquid with a boiling point of
Especially dangerous is falling solution (drops, 83,4°C and a density of 1.502. Vapour of nitric acid were
spray) of bases in the eye. Lesions rapidly spreading 2.2 times heavier than air. A strong acid and an oxidiz-
and not only affect the cornea but penetrate deeply ing agent - oxidizes all metals except gold, platinum,

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 LABOUR MEDICINE
HYGIENE STANDARDS
Air of the working environment
Chemical Mean-shift MAC Maximum single MAC Specific effects
1. Nitric acid 5,0 mg/m3 – Irritation
2. Acetic acid 25,0 mg/m3 37,0 mg/m3
3. Picric acid Allergen, irritation
0,1 mg/m3 –
(2,4,6-Trinitrophenol)
4. Sulfuric acid 1,0 mg/m3 – Irritation
5. Trichloroacetic acid solution 7,0 mg/m3 –
6. Hydrogen chloride and hydrochloric acid 8,0 mg/m3 15,0 mg/m3 Irritation

Air settlements
Pollutants Daily average MAC Maximum single MAC
1. Nitric acid 0,15 mg/m3 0,40 mg/m3
2. Acetic acid 0,06 mg/m3 0,20 mg/m3
3. Sulfuric acid (in the molecule of the acid) 0,10 mg/m3 0,30 mg/m3
4. Sulfuric acid (a hydrogen ion) 0,002 mg/m3 –
5. Hydrochloric acid (a molecule HCl) 0,20 mg/m3 0,30 mg/m3

rhodium and iridium. Straw, sawdust and other porous Orthophosphoric acid is a colorless easy melting
organic materials in contact with nitric acid and spon- crystals with a melting point of 42,35 ° C and a density
taneously in flame and emit nitrogen dioxide. Alcohol of 1,834 at 18 ° C. Well dissolved in water, with hot wa-
and turpentine in contact with nitric acid to detonate. ter mixed in all ratios.
Under the influence of light and heat yellowing as a re- USE
sult of formation of nitrogen dioxide. Dissolve in water Nitric acid is used in the manufacture of fertiliz-
in any proportion. ers, explosives, film tape, rayon, nitrocellulose lac-
Acetic acid is a liquid having a boiling point 118.1°C quers, nitrates, acids, aniline dyes; in printing; in non
and a density of 1.04 at 20°C. Mix with water in all pro- ferrous metallurgy, an oxidizer for rocket fuel.
portions. Sulphuric acid is used to produce a variety of salts
Picric acid is a solid - yellow crystals in the form of and acids, fertilizers, explosives, in organic synthesis
sheets or prisms with a strong bitter taste. Upon gentle for hydration, sulfuration, alkylation; in petrochemi-
heating to evaporate without being decomposed. Dis- cal, metal, textile and leather industries.
solved in water - 1.22% at 20°C. Very well dissolved in Hydrochloric acid is used for preparing chlorides
alcohol. Explodes at detonation, but much dangerous of metals, organic products - chloropropane, dyes,
its salts, exploding on heating, friction or shock. Tem- alcohol, glucose, sucrose, gelatin and glues, for the
perature of outbreak 300-310°C. tanning and coloring of leather, the saponification
Sulfuric acid in its pure form is oleiferous liquid, of fats, coloring fabrics, purification of metals, in
transparent, colorless, slightly volatile, highly hygro- electroplating and oil production.
scopic and odorless. Boiling point 330°C, density 1,834. Orthophosphoric acid is used in the production
At ambient temperature (about 18-20°C) no smoke, of phosphate fertilizers, salts of phosphorus, gental
when heated to 50°C and more separated sulfur tri- and special types of cement (for protection against
oxide vapor that with humid air form aerosols - white ionizing radiation), to remove limescale, for anti-cor-
haze. With the water is mixed in any proportion, re- rosion coatings, for impregnating fabrics with fire re-
leasing a considerable amount of heat. Concentrated sistant mixtures, in the production of photographic
sulfuric acid is a strong oxidizer. Technical sulfuric acid film and photoreactive, in electroplating, and as a
contains impurities of arsenic and in contact with met- catalyst.
als form highly toxic arsenovodorod (arsine). A large number of organic acids are used in the
Trichloroacetic acid is a white or slightly yellowish, textile industry, production of synthetic rubber, indi-
hygroscopic powder with a melting point of 59.2 ° C, go, plasticizers, drugs, pesticides and in food indus-
boiling point 197.5 ° C and a density of 1.617 at 46 ° C. try.
Dissolve well in water, ether and alcohol. The solution PROFESSIONAL AND UNPROFESSIONAL
is a strong acid. EXPOSURE
Hydrochloric acid is an aqueous solution of hydro- It is very difficult to list all the professions from
gen chloride. At a concentration of 38% density is 1.19. all sectors. Wherever used acid is a risk of acute poi-
Dissolve most metals except gold, silver, platinum, tan- soning with acid spill, and almost constant (chronic)
talum, niobium and the like. Technical hydrochloric acting concentrations typical for production.
acid contains impurities including arsenic. All acids have a local effect on skin and mucous

233
 OCCUPATIONAL MEDICINE
membranes. The effects range from annoying to se- cause eczema.
verely burning action, later development of difficult Under the influence of vapour on chromium, sul-
healing inflammatory lesions of the skin and mu- furic and phosphoric acid occurs erosion of dental
cous membranes. enamel. For prolonged chronic exposure are possi-
METABOLISM AND MECHANISM OF ACTION ble manifestations of general toxic action.
Due to its solubility in water and coming electro- PREVENTION
lytic dissociation organic and inorganic acids dam- Protect skin, eyes and mucous membranes of
age the skin and mucous membranes in direct con- UAP through masks filter type, goggles, transparent
tact. The dimensions and the extent of the damage shields or masks, special clothing of anti acid-treat-
depends on the acid concentration and the time of ed polymer fabrics, gloves, aprons and boots made
contact with the tissue. Inhalation of vapor mixtures of acid-resistant materials.
of acids (acid mist) damage to the lining of the UAP Mechanization of operations transport, transfu-
depends on the properties of aerosols in the com- sion and charging with acids. Full hermetisation of
position of fog. the technological equipment.
Aerosols of sulfuric acid are more toxic of sulfur For people in contact with acids required prelim-
dioxide. inary and periodical medical examinations involving
Nitric acid causes severe skin burns. Diseased tis- ORL specialist, dermatologist and dentist.
sue colored yellow because of upcoming xanthop-
roteinic reaction. The diluted nitric acid solution may

M. Koleva

7.4 ALCOHOL

METHYL AND ETHYL ALCOHOL cides; varnishes and lacquers; in the pharmaceu-
Empirical formula: CH3OH (methanol); tical industry as extracting agent and as reagents
C2 H5OH (ethanol) in organic synthesis. One quarter of the produced
Structural formula: H HH methanol is used as solvent, the remainder is dis-
H-C-OH H-C-C-OH tributed mainly for dilution (denatured) ethanol and
H HH the production of formaldehyde. Much of the work
Methanol Ethanol ethyl alcohol used in the manufacture of alcoholic
beverages.
HYGIENE STANDARDS PROFESSIONAL AND UNPROFESSIONAL
Air of the working environment: Methyl alco- EXPOSURE
hol - mean - shift MAC - 50,0 mg/m3; Ethyl alcohol Occupational exposure to methanol and ethanol
- mean - shift MAC - 1000 mg/m3. is typical for operators and workers in the chemical
Air settlements: Methanol - daily average MAC - industry, distillery, pharmaceuticals (mainly phyto-
0,5 mg/m3; maximum single MAC - 1,0 mg/m3; chemistry) and furniture industry.
Ethanol - daily average MAC - 5,0 mg / m3, maxi- METABOLISM AND MECHANISM OF ACTION
mum single MAC - 5,0 mg/m3. In production conditions the main road of pene-
GENERAL CHARACTERISTICS tration in the body is inhaled. Possible and absorp-
Monovalent (monohydric) alcohols are hydrocar- tion through the skin. The absorption is prolonged,
bons containing a hydroxyl group. They have a char- and the accumulation is continuously throughout
acteristic pungent odor. Mixed with water in any pro- the period of exposure because of the high solubil-
portion (totally soluble in water). They are volatile. The ity of the vapour of methanol and ethanol in water.
lower limit of ignition of methanol in the mixture with Tissue distribution is dependent on their water con-
air is 3.5%. tent.
USE The methanol is oxidized to formaldehyde and
Alcohols are used as solvents, paints and pesti- formic acid, which are highly toxic. The oxidation is

234
 LABOUR MEDICINE
slower than that of ethanol. Connects with glucu- in the tobacco, textile, leather, pharmaceutical and
ronic acid. cosmetics industry, raw material in the production
Ethyl alcohol is oxidized to acetaldehyde and of polyester fiber, lubricant in production of high
acetic acid. density synthetic fibers, based on caproate, a plas-
The alcohols are eliminated from the body as CO2 ticizer in the production of plastics and cellophane.
in the composition of exhaled air and as metabol- PROFESSIONAL AND UNPROFESSIONAL
ic products in the urine composition (mainly formic EXPOSURE
acid in methanol). EG does not create excessive concentrations
PREVENTION in the working environment due to its low vapor
At high concentrations of methanol in the work- pressure at ordinary temperature. Risk of acute and
ing environment is recommended to use a gas mask chronic poisoning inhaled gone. Barely penetrate
filter type. It is desirable in all technologies methanol the skin and poses no risk of dermal absorption in
can be replaced with ethanol or other suitable sub- direct contact. EG represents a danger to the body
stituents. Along with raising health awareness and when ingested per os. Endangered are large num-
the information of workers about toxic properties of ber of workers because of its wide use, but the most
methanol, necessarily labeled containers contain- common acute fatal poisoning register with drivers
ing methanol. Pipelines for methanol are indicated and fitters. Takes as mistake, because it resembles
with signal paint and warnings. It is also necessary alcoholic drink.
to ensure maximum hermetisation of technological Concentrations in ambient air as a rule does not
equipment. create, as has a short half-life and is not volatile.
It is believed that acute inhalation poisoning with MECHANISM OF ACTION AND METABOLISM
ethanol in production without further oral ingestion Oxidation of EG by alcohol dehydrogenase to
is no possible. glycoaldehyde is a critical step in the metabolism
which leads to oxalic acid - cause of acute renal fail-
ETHYLENE GLYCOL (Glycols; Diols) ure, metabolic acidosis and fatal outcome in most
Empirical formula: C2H4 (OH) 2 cases. About 60 cm3 a lethal dose of man. Chief path-
Structural formula: way leads to the formation of CO2 by glycoaldehyde,
HH glycolic acid and glyoxal. There is also so-called mi-
HO-C-C-OH nor path, which leads to oxalic acid with limit level of
HH excretion to 16% at low doses EG.
Under the same conditions the amount of CO2 ex-
HYGIENE STANDARDS haled reaches 84%. Pure EG is much less toxic than
Air of the working environment: Mean-shift the metabolites that are formed in the body. This
MAC - 60 mg/m3, maximum single - 125 mg/m3. fact has been used successfully to prevent the fatal
GENERAL CHARACTERISTICS outcome ingestion of large doses of EG. If blocking
Ethylene glycol (EG) is a colorless, nearly odorless alcohol dehydrogenase by introducing another sub-
liquid with a sweet taste. M.m. 62.07, a boiling point strate (specifically - ethyl alcohol) elimination of EG
of 197,2°C, completely soluble in water, well was dis- unchanged in the urine increases and the patient
solved in ethyl alcohol, acetone, glycerin, lower in overcomes renal failure and metabolic acidosis.
ether, chloroform and benzene. Almost incombustible, PREVENTION
without corrosive activity and less volatile. In the presence of high concentrations in the air
USE of the working environment is recommended to use
Synthesized in 1859. Discovered as a substitute a respirator or gas mask filter type.
for glycerin, EG attracted the attention of military ex- If used as a solvent, a plasticizer, an electrolyte,
perts and its use increased sharply in some sectors especially under heat and the formation of aerosol -
of the defense industry in I-World War. It is widely local aspiration ventilation.
used in the airline and road transport, and in various If used as antifreeze and in the composition of
industries such as: basic component of antifreeze, other non-freezing liquids must be followed accept-
brake fluids and anti-refrigerating liquids. Currently, ed rules for safe handling: informing workers for the
65% of the production of EG used for the prepara- safe transportation, labeling packages with the ap-
tion of antifreeze. Substitute for glycerin production propriate labels.
of frost resistant dynamite, electrolyte in the pro- Workers in contact with ethylene glycol subject
duction of capacitors and radiodetayli, a constituent to periodic check-ups.
of fibre glass building materials resin-based, solvent

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 M. Koleva

7.5 AROMATIC HYDROCARBONS

Benzene possible, be replaced by less toxic solvents because

Alkylbenzenes: toluene, xylene, ethyl benzene, of proven carcinogenic properties. Still applied in
styrene and isopropylbenzene. organic synthesis to obtain: phenol, styrene, cy-
The aromatic hydrocarbons are compounds clohexane, caprolactam, fibers, plastics, detergents
with one or more benzene rings. They include: Ben- and pharmaceuticals. It is also used for extraction
HYGIENE STANDARDS
Air of the working environment:
Maximum
Chemical Mean-shift MAC Specific effects
single MAC
1. Benzene 3,25 mg/m3 Carcinogenicity to humans (group 1).
2. Toluene 150 mg/m3 300 mg/m3
3. Xylene 221 mg/m3 442 mg/m3 Irritation
4. Ethylbenzene 435 mg/m3 545 mg/m3
5. Isopropylbenzene (Cumene) 100 mg/m3 250 mg/m3 Skin-resorptive effect
6. Styrene 85 mg/m3 215 mg/m3 Possibly carcinogenic to humans (group 2B)

Air settlements:
Pollutants Daily average MAC Maximum single MAC
1. Benzene 0,1 mg/m3 1,5 mg/m3
2. Toluene 0,6 mg/m3 0,6 mg/m3
3. Xylene 0,2 mg/m3 0,2 mg/m3
4. Ethylbenzene 0,02 mg/m3 0,02 mg/m
5. Isopropylbenzene 0,014 mg/m3 0,014 mg/m3
6. Styrene 0,003 mg/m3 0,003 mg/m3

Surface water:
Indicator I category II category III category
1. Benzene 0,5 mg/dm3 0,5 mg/dm3 1,0 mg/dm3
2. Styrene 0,1 mg/dm3 0,2 mg/dm3 0,5 mg/dm3
zene and so-called alkylbenzenes, namely: Toluene of protein, skiming bone and solid waste. Relatively
(methylbenzene), xylene (o-, m- and p-isomers of di- new field of application of benzene are laser tech-
methylbenzene), ethyl benzene, isopropylbenzene nologies.
(cumene) and styrene (vinyl-benzene). Toluene is used for the preparation of capro-
GENERAL CHARACTERISTICS lactam and TNT (trotyl), in the production of dyes,
Benzene is a colorless liquid with a specific smell. pharmaceuticals, plastics, resins, varnishes and the
Mix without restrictions with non-polar solvents: hy- like.
drocarbons, turpentine, ethers; dissolved fat, rubber, Air-gasoline and high-octane automobile gas-
resins and the like. Explosive concentrations of ben- oline contains aromatic hydrocarbons in limited
zene vapors vary from 1.5 to 8%. In almost the same quantity.
range (from 1.27 to 7%) are explosive concentrations PROFESSIONAL AND UNPROFESSIONAL
of toluene in a mixture with air. The specific sweet smell EXPOSURE
is common organoleptic feature of most aromatic hy- Benzene settled in air of the working envi-
drocarbons. All of them are obtained directly or indi- ronment in enterprises of oil, petrochemical and
rectly mostly of crude oil and less than coal tar. coke-chemical industry as a constant intermediate
USE product. Aromatic hydrocarbons are volatile and
Despite the exceptional qualities of benzene use create concentrations similar to hygiene standards
as solvent restricts and wherever technologically is in the air of the working environment, and in use of

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 LABOUR MEDICINE
products containing them. The number of persons alternation of mineral water 1 liter two months of
exposed, significantly exceeds directly employed in Mihalkovo, Shipkovo 1 month of Gorna Banya, Tar-
various industries, because of the universal charac- govishte, Ivanyane, Belovo, Varshetz or Varna.
ter of aromatic hydrocarbons such as solvents and
theirs general use. STYREN1
Source of water pollution with benzene and aro- Possibly carcinogenic to humans (group 2B)
matic hydrocarbons are all industries that use these Empirical formula: C8H8
compounds, petroleum storage depots, refineries Structural formula: CH = CH2
and petrochemical plants, and on navigable rivers -
river transport.
Aromatic hydrocarbons (particularly benzene)
weakly oxidized under the influence of biological
processes in the water and have no impact on the
oxygen content in it. GENERAL CHARACTERISTICS
It was found that the underground and Styrene (vinyl-benzene) is a colorless liquid with a
aboveground parts of higher plants (roots, shoots, sweet (at low concentrations) and unpleasant (at high
leaves, fruits) have the ability to absorb and metab- concentrations) smell. Melting point 30.6°C, the boil-
olize benzene. ing temperature of 145.2°C, insoluble in water and is
METABOLISM AND MECHANISM OF ACTION soluble in ethanol, acetone, benzene, ether. Reacts vi-
The main route of entering of benzene and tolu- olently with strong oxidants. Highly flammable. Flash
ene in the body is inhaled, in proven high respirato- temperature 30°C. Temperature of self-ignition 530°C.
ry absorption: 50-90% for benzene and 57-72% for Generate electrostatic charges when pouring, shaking
toluene. Skin absorption of benzene vapor is negli- and blows. Above 65°C spontaneously polymerize with
gible. Steam of toluene not penetrate the skin. the danger of fire and explosion. With air form explo-
Benzene and toluene are distributed unevenly in sive mixtures.
the tissue, in the greatest amount is found in the ad- USE
ipose tissue, bone marrow and nervous tissue. It is widely used in industry. Significant quantities
The major metabolite of benzene is phenol - 50- are consumed in polymerization, and for the prepa-
90% of the amount of benzene. With the exhaled ration of polystyrene, styrene-acrylonitrile resin, sty-
air is eliminated from 3 to 45% of the total amount rene-butadiene rubber, polyester resins. Polystyrene
of benzene in the body, 89% of the total adsorbed and its co-polymer akrilnitrilbutadien styrene are
amount of benzene is eliminated within 2-3 days. used for the production of packaging for food prod-
Exposition test for benzene in the air is content of ucts.
phenol in urine. PROFESSIONAL AND UNPROFESSIONAL
The main quantity of toluene metabolized to ben- EXPOSURE
zoic acid (80-100%). Benzoic acid reacts with glycine Risk of occupational exposure exist in the pro-
to form hippuric acid. About 10-20% of the benzoic duction of styrene and polystyrene and use dis-
acid conjugated with glucuronic acid and sulfuric solved in styrene unsaturated polyester resins. Ex-
acid to form benzoilglyucoronic acid and sulfates. posure varies greatly and depends on the task being
With the exhaled air is eliminated from 8 to 31% performed. High concentrations in the air of the
of the received in body toluene. The remaining working environment is created for cleaning and
quantity is rapidly excreted in the urine (half-life pe- maintenance of the facilities.
riod of 2-3 hours) as benzoic and hippuric acid. The biggest polluter of the environment with
PREVENTION styrene is the petrochemical industry. Significant
The main preventive measure is the ban benzene amounts are released in breach of distillation col-
to be included in the formulation of solvent. umns, leakage and spillage from containers during
Healing working conditions is achieved through storage and transportation. Emission sources are
maximum hermetisation of process equipment. polymerization processes, the burning of polymers,
Preliminary and periodic medical examinations in exhaust gas mixtures from motor vehicles. Tobacco
contact with benzene are required. Pregnant wom- smoke contains 18-48 micrograms styrene/ciga-
en vocational rehabilitation immediately. Avoid con- rette.
tact of adolescents (before age 18) with benzene. The use of styrene as a solvent in life is a potential
Appropriate organization of professional protec- source of emissions.
tive nutrition (diet D), giving extra vitamins: vitamin.
C - 100 mg, vit. B12 - 3 μg, folic acid - 300 μg, and the 1
A. Mihaylova

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 OCCUPATIONAL MEDICINE
METABOLISM AND MECHANISM OF ACTION Expressed narcotic phenomena occur less fre-
It has been found that 50-90% of the inhaled quently, as strong irritation of styrene forcing work-
styrene metabolized. The biotransformation is car- ers to evacuate the workplace. Irritative effect occurs
ried out by oxidation of the double bond in the in concentrations over 408 mg/m3.
cytochrome P-450 and P-448. The formed styrene PREVENTION
oxides (styrene-7-8-oxide and styrene-3-4-oxide-2) It is not allowed women in fertile age have con-
included in the coupling reaction with glutathione tact with styrene. Performed compulsory check-ups
and using the transferases form conjugates. The ma- with a focus on hematopoiesis, liver, respiratory and
jor metabolites in humans are mandelic acid and nervous systems. To pay attention to personal hy-
fenilglioxsalic and in smaller quantities hippuric and giene of workers. At elevated concentrations in the
4-vinylphenol. Styrene oxides have short half-life. air of the working environment, accidents and fires,
Studies in recent years show that the toxicity of sty- workers to provide: clothing from coated fabrics, air-
rene is mainly related to the effects of styrene oxides. tight goggles or face shield, mask filter, latex gloves
Styrene has a narcotic effect. There is a strong irri- and footwear - boots with leather face and a rubber
tant effect on skin and mucous membranes. Damag- sole.
ing haemopoieses and the liver. Deposits in adipose
tissue. Violates the permeability of the blood brain
barrier.

A. Mihaylova

7.6 GASES

Gases, vapors and smoke may cause lung dam- HYGIENE STANDARDS
age in five main mechanisms: Air working environment
1. Replacement of oxygen from inhaled air with Nitrogen dioxide -
subsequent asphyxia mean-shift MAC - 4.0 mg/m3
2. Absorption into the systemic circulation with Nitrogen oxide -
obstruction of transport and utilization of oxygen mean-shift MAC - 20.0 mg/m3
(chemical asphyxia) Atmospheric air of settlements
3. Exercise of systemic toxicity without affecting Nitrogen dioxide: Annual average
the supply of oxygen MAC - 0.05 mg/m3
4. Direct irritative effects or damage to the res- Daily average MAC - 0.10 mg/m3
piratory tract, such as the site of the damage de- Maximum single MAC - 0.20 mg/m3
pends on the solubility of gases. Gases with the Nitric oxide:
highest solubility are absorbed by the mucous Average annual MAC - 0.06 mg/m3
membranes of the nose, upper respiratory tract and Maximum single MAC - 0.60 mg/m3
conjunctiva (eg. Ammonia), and the more sparingly
soluble exert harmful effects especially on the lower GENERAL CHARACTERISTICS
respiratory tract (eg. Nitric oxides) Nitrogen oxides are intermittent gas mixture that
5. Inducing allergic effects directly damaging the includes nitric oxide (NO), nitrogen dioxide (NO2), dini-
lung or disrupting gas exchange (Table. 1). trogen tetroxide (N2O4), dinitrogen trioxide (N2O3) and
dinitrogen pentoxide) N2O5), and vapor of nitrous, hy-
NITROGEN OXIDES ponitrous and nitric acid, that of air are reduced by the
NO organic substances and pass into nitrogen oxides. Rel-
NO2 atively constant components of the mixture are nitro-
N2O4 gen oxide, nitrogen dioxide, and dinitrogen tetroxide.
N2O3 In production conditions the most common is ni-
N2O5 trogen dioxide, which is a reddish-brown gas with a

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 LABOUR MEDICINE
Tab. 1. Mechanisms of toxic effect on lung from gases (by Charles E.Becker, 1997)
Substance (gas) Source
Simple asphyxiants
Carbon dioxide Fires
Methane Underground mining of ore and coal
Nitrogen Work for hyperbaric conditions
Chemical asphyxiants
Carbon monoxide Fires
Cyanide Gold Mining; Galvanization; Fires
Hydrogen sulfide Oil refining; Decay of organic matter
Systemic toxicants
Arsin gas Microelectronics
Phosphine Microelectronics
Paraquat Agriculture
Metal aerosols pyrogenic action
Melting of metals; Production of alloys
(causing "Fondry fever")
Irritants direct irritation
Chlorine Production of bases, disinfectants and detergents
Ammonia Production of mineral fertilizers; refrigeration manufacture
Nitrogen oxides Melting of metals; Exhaust gases
Sulphur dioxide Production of paper; Refining
Hydrogen fluoride Microelectronics
Allergens
Isocyanates Production of polyurethane
Aerosols of platinum compounds Production of catalysts; electroplating
Aerosols of solders and flux Soldering

strong irritating odor and is heavier than air. Temper- 3800 mg/m3 create bins in the fermentation of the
ature (T°) of melting 11.2°C, T ° of boiling point 20.7°C. cereal seeds.
In case of contact with metals, chlorinated hydro- Yearly over 53 mln. tons of nitrogen oxides re-
carbons and ammonia cause explosions. Does not leased into the atmosphere. Sources of emissions
burn, but it increases the combustibility of other sub- are vehicles (internal combustion engines), the use
stances. It manifests as a strong oxidizing agent. Espe- of solid and liquid fuels for heating in TEPP and
cially dangerous is at temperatures above 21°C. household, production of explosives and nitric acid,
Nitric oxide is a colorless volatile gas with a sharp as well as tobacco smoke. The content of nitrogen
sweet smell. Melting point 163.7°C, T° of boiling 151, monoxide in tobacco smoke ranges from 98-135
solubility in water 73.40 cm/dm3. At high concentra- mg/m3, and nitrogen dioxide - from 150-226 mg/m3.
tions stained brown in the air. With water forms corro- METABOLISM AND MECHANISM OF ACTION
sive vapours. In contact with ozone and chlorine com- Nitrogen dioxide metabolized to nitrites and ni-
pounds is explosive. It is explosive when heated, and trates, which are excreted in the urine.
fire - by improper storage. Nitrogen oxides have a local effect - irritation of
USE the mucous membranes of the respiratory tract and
They are used in the production of celluloid, pho- eyes and general resorbtive, predominantly affect-
toplates, sugar refining. Nitrogen dioxide is used as ing the nervous system and blood. They are methe-
a nitrating agent and a catalyst in the production of moglobin generating, consequently arise hypoxia
sulfuric acid. and anoxaemia. When connecting 70% of hemoglo-
PROFESSIONAL AND UNPROFESSIONAL bin into methemoglobin death occurs. Exhibit and
EXPOSURE vasodilatory activity (nitrite effect).
Nitrogen oxides are found in the production of Their irritative action provokes the release of
nitric, sulfuric, chromic and picric acid, nitrates, ni- large amounts of histamine, which favors the devel-
trogen fertilizers, explosives (nitrocellulose, nitrotol- opment of pulmonary edema.
uene, nitroglycerin), toluene. Are formed in oxygen- PREVENTION
and electric welding, when blasting in mines and Total technical measures include automation,
others. Released in large quantities when pouring hermetisation and effective ventilation. Workers
nitric acid and in contact with metals and organic must be provided clothing from coated fabrics, latex
substances. High concentrations of the order of 300- gloves and rubber/PVC boots, while accidents, ex-

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 OCCUPATIONAL MEDICINE
plosions and massive chemical contamination - gas sonal protective equipment.
masks with filter for acid gases. In cesspool cleaning (leather industry), tanks and
Preliminary and periodic medical examinations more, workers must use clothing from coated fab-
with focus on blood, respiratory and nervous sys- rics, gas masks filter ammonia, long latex gloves and
tems. rubber or PVC boots.
In preliminary and preventive medical examina-
AMMONIA (NH3) tions focus be in terms of the respiratory system,
HYGIENE STANDARDS nervous system, skin and blood.
Air of the working environment:
Mean-shift MAC - 18.0 mg/m3. ARSINE (AsH3)
Atmospheric air of settlements: HYGIENE STANDARDS
Daily average MAC - 0.04 mg/m3, Air of the working environment:
Maximum single MAC - 0.20 mg/m3. Mean-shift MAC - 0.05 mg/m3.
GENERAL CHARACTERISTICS Atmospheric air of settlements:
Ammonia (ammonium anhydrite, ammonia aqua) Daily average MAC - 0.002 mg/m3.
is a colorless, volatile gas with a strong irritating odor.
Melting point 77.75°C, Boiling T° 33.35°C, a density GENERAL CHARACTERISTICS
of 0.771 g/l (0°C) and 0.59 g/l (25°C). Soluble in water Arsine, arsenic trihydride is a colorless gas with a
and organic solvents. The aqueous solution is highly characteristic odor, heavier than air. Melting point
alkaline and acids react violently. Causing corrosion of 113.5 ° C, T ° Boiling - 62.5 ° C. When light, moisture and
metals. With air form explosive mixtures. high temperatures (300 ° C) decomposes. By reacting
USE with the chlorides and nitric acid can cause explosions.
It is widely used in the production of nitric acid, With air also form explosive mixtures. Combustion re-
nitrogen fertilizers, urea, caustic soda, cleaners for leases arsenic trioxide.
the household. Feedstock for obtaining explosives USE
and artificial fibers. It is used in metallurgy, rubber, Used for preparation of arsenic as an absorbent
paper, textile, leather and food industries, as well as in the production of semiconductors.
for purification of water. PROFESSIONAL AND UNPROFESSIONAL
PROFESSIONAL AND UNPROFESSIONAL EXPOSURE
EXPOSURE Arsine is a factor in the work environment in the
Increased emissions are registered in the synthe- production of semiconductor chips in microelec-
sis of ammonia, coking and dry distillation of coal, tronics. Small amounts of gas are released from the
the production of fertilizers and explosives. treatment with acids arsenic contented rocks and
In the air is released in the decomposition of or- burning of fossil fuels. Risk of exposure exists in the
ganic substances from animal excrement, canals and processes of electro plating and engraving. High
wastewater, fertilization of soil and volcanic erup- concentrations are created when working in con-
tions. Large quantities are released during accidents fined spaces - cleaning of tanks, reservoirs, vats and
in production and transportation, as well as fires. accidental release of stored arsine.
Opportunities for contamination of surface water METABOLISM AND MECHANISM OF ACTION
exist in the use of fertilizer and manure in areas with In the biotransformation of arsine form elemen-
a strong livestock, the decomposition of organic tal arsenic or arsenic dihidrid. Trivalent arsenic at
materials and natural accumulation of air. chronic exposure may be a carcinogen.
METABOLISM AND MECHANISM OF ACTION Arsine was dissolved in plasma. In red blood cells
Ammonia metabolized to glutamine and urea forms insoluble complexes. Coming hemolysis is
in the liver. The released nitrogen of glutamine is multifactorial. Inhibits catalase and blocks the sulf-
involved in protein synthesis. It is believed that glu- hydryl groups of enzymes in erythrocytes. Provoke
tamine is the first metabolic product. oxidative stress similar to that observed in G6PhDh
There are irritating and corrosive to the eyes, skin deficiency. Developing renal impairment may be
and upper respiratory tract. It damages the cell di- due to direct involvement of the renal tubules, sec-
rectly, as manifested alkaline corrosive and causes ondary hypoxia reaching to anemia or precipitation
burns on all mucous membranes. of hemoglobin-haptoglobinic complex in tubular
PREVENTION lumen.
Includes hermetisation and automation of man- PREVENTION
ufacturing processes, replacing ammonia with other In gassed premises includes individual protec-
compounds (in refrigeration production), use of per- tion clothing from coated fabrics, fuel gas masks

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 LABOUR MEDICINE
with oxygen bottles, gloves (rubber) and boots (rub- includes about 200 chemicals. In combination with
ber or PVC). Preliminary and periodic medical exam- these CO exhibits a pronounced toxic effect as com-
inations to be oriented to the nervous and digestive pared to the isolated action.
systems, liver, skin and blood. Recommended diets METABOLISM AND MECHANISM OF ACTION
rich in protein and lipotropic factors with restriction In the body, CO is associated with compounds
of fats and increase the content of thiamine, refresh- containing in the molecule a divalent iron (myoglo-
ing drinks and more fluids. bin, cytochromperoxidase, cytochromoxidase, cat-
alase) and mainly by hemoglobin. Separated in the
CARBON MONOXIDE (CO) urine as a complex compound with iron.
HYGIENE STANDARDS The affinity of hemoglobin to CO is 240 times
Air of the working environment: higher than to oxygen. Linking CO with hemoglo-
Mean-shift MAC - 40,0 mg/m3 bin, formation carboxihemoglobin and lowering
Short-term maximum MAC - 200,0 mg/m3 the oxygen capacity of the blood is the main mech-
Atmospheric air of settlements: anism of action of the noxa. The formation rate of
Daily average MAC - 10,0 mg/m3 carboxyhemoglobin depends on the concentration
Maximum single MAC - 6.0 mg/m3 and duration of exposure, locomotor activity (which
increases the amount of air inhaled per unit time)
GENERAL CHARACTERISTICS and the ambient temperature, as well as the health
It is a gas, colorless and odorless, lighter than air. status of the exposures. The formation of carboxy-
Burns with a blue flame. and is oxidized to carbon diox- hemoglobin is a reversible process, but the time for
ide. Ignition temperature 610°C. In contact with strong half-elimination (T1/2) is sufficiently long - from 2 to
oxidizers risk of fires and explosions. With air form ex- 6.5 hours and depends on the initial levels of COHb.
plosive mixtures. This may lead to accumulation of COHb and increase
USE its content in the blood, when exposed to relatively
Carbon monoxide is a feedstock for many organic low concentrations of CO.
syntheses. It is used for producing metal from them The carbon monoxide blocks cellular enzymes,
oxides, carbonyl chloride, carbonyl sulfide, aromat- and it causes tissue hypoxia. Hypoxemia and hypox-
ic aldehydes, formamide, formic acid, hexahydroxi- ia determine violations in metabolic processes, such
benzen, methyl alcohol, synthetic gasoline, and the as hyperglycemia, glucosuria, accumulation of lac-
like. tic acid, lowering the alkaline reserve, disruption of
PROFESSIONAL AND UNPROFESSIONAL protein synthesis, development of acidosis.
EXPOSURE PREVENTION
Carbon monoxide is the most common industrial Special attention should be paid to ventilation,
gas. Formed in all processes where there are condi- hermetisation and personal protective equipment.
tions of incomplete combustion of substances con- Fire and explosions to provide protective clothing,
taining carbon. complete with front apron, gas masks and filter,
As a result of human activity into the atmosphere cold-protective gloves and shoes. Medical surveil-
annually spend 350-600 106t CO. Domestic sources lance of workers to be targeted at the nervous sys-
of CO are incomplete combustion of fuel, failures tem and blood. To organize periodic monitoring of
in pipelines and gas equipment, fires and smoke. the content of carboxyhemoglobin.
Carbon monoxide is a component of various gas
mixtures (gases) as a blast furnace, coke, water, gas HYDROGEN SULFIDE (H2S)
generators, explosive and others. The concentration HYGIENE STANDARDS
of CO under ground after blowing reach 350 mg/m3. Air of the working environment:
In the chemical industry emitters of CO are the Mean-shift MAC - 14 mg/m3,
production of ammonia, catalytic cracking, formalin, Short-term maximum MAC - 21 mg/m3
the synthesis of hydrocarbons, phosgene, methyl Atmospheric air of settlements:
alcohol, methane, formic acid. CO is formed in the Daily average MAC - 0.003 mg/m3,
production and processing of synthetic fibers. Met- Maximum single MAC - 0.005 mg/m3.
allurgical enterprises ejected into the atmosphere
daily 320-400 t CO. GENERAL CHARACTERISTICS
More than half of CO entering the atmosphere Hydrogen sulfide (channel gas) is a colorless gas
separated from road transport. CO content of the with a characteristic odor, melting point - 122°C, boil-
unburnt gases emitted from the engines is about ing temperature - 46.3°C, a density of 1.26 (20°C), solu-
12%, taking into account that their composition bility in water 0.26/100 g (0 ° C), vapor pressure 127.3

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 OCCUPATIONAL MEDICINE
mm Hg (0 ° C) and 297.5 mm Hg (20 ° C). Reacts violent- SULFUROXIDES (SO2) (SO3)
ly with strong oxidizing agents (risk of fire and explo- HYGIENE STANDARDS
sions). With air form explosive mixtures. Decomposes Air of the working environment:
during combustion to form sulfur dioxide. Sulfur dioxide mean-shift MAC - 5.0 mg/m3,
USE Maximum Short MAC - 10.0 mg/m3.
Hydrogen sulfide was used to produce sulfur Atmospheric air of settlements:
and sulfuric acids, thiol compounds, sulfides, as a Sulphur dioxide
reducing agent in analytical chemistry. It is used in Average hourly rate - 0.350 mg/m3,
the manufacture of gunpowder, matches, in leather, Average daily rate - 0.125 mg/m3,
sugar, paper and textile industries. Standard to protect natural
PROFESSIONAL AND UNPROFESSIONAL ecosystems - 0.020 mg/m3.
EXPOSURE
Large quantities of hydrogen sulphide are re- GENERAL CHARACTERISTICS
leased during the extraction and exploration of nat- Sulphur dioxide (SO2) - a colorless gas with a char-
ural gas and crude oil. The sulfur content of crude acteristic odor, while in cooling - a colorless liquid.
oil is 0-5%, in the earth gas reaches 42%, in coal - 80 Melting point - 75.5 ° C, boiling temperature - 10.1 °
g/kg. Sources hydrogen sulfide are and geother- C, solubility in water 22.8 g/100 g (0 ° C). Heavier than
mal springs. High concentrations were measured in air. With water forms sulfurous acid, in the presence
plants using geothermal waters. of strong oxidizing sulfur passes into sulfur trioxide,
Hydrogen sulfide is removed by some industrial respectively in sulfuric acid. When moisture is highly
processes, as a result of the reaction of elemental corrosive.
sulfur or sulfur containing compounds with organic Sulfur trioxide (SO3) - separated mainly by vapour
substances at high temperatures. from fuming sulfuric acid. In humid environments
Hydrogen sulfide is an intermediate product in quickly becoming aerosols of sulfuric acid.
the production of carbon-disulphide, artificial silk, USE
leather tanning, sugar refining, production of coke The sulfur dioxide is a feedstock for the prepa-
of sulfur-containing coal and others. Separated into ration of sulfuric acid. Used in the vulcanization of
septic tanks, wells and canals in the anaerobic de- rubber, production of cellulose and ultramarine,
composition of organic matter. bleaching of fabrics (wool and silk) and cellulose,
METABOLISM AND MECHANISM OF ACTION disinfection of premises, preservative food.
Hydrogen sulfide belongs to irritating gases. The sulfur trioxide is used in the manufacture of
Odor is felt at concentrations of 1-2 mg/m3, and irri- sulfuric acid, organic and inorganic substances, bat-
tation has at concentrations above 6 mg/m3. Metab- teries, cleaning of metals.
olized by oxidation to thiosulphate and sulfates. Like PROFESSIONAL AND UNPROFESSIONAL
cyanide inhibits cytochrome -C-oxidase and other EXPOSURE
enzymes containing heavy metals in a molecule. Sulfur dioxide in combination with SO3 is one
Causes intracellular hypoxia and asphyxia. Especial- of the most widespread pollutants in the working
ly sensitive organ for acute effects are brain - causes environment in metallurgy (processing of zinc, cop-
coma and death. In chronic effects are typical eye per, lead and others ores), in obtaining sulfuric acid,
(conjunctivitis and keratitis) and lung (chronic bron- burning liquid and solid (sulfur-containing) fuels in
chitis) disabilities. thermal power plants, foundries and forge shops,
PREVENTION boiler rooms, production of superphosphates.
Systematic control of concentrations of hydro- High concentrations of sulfur oxides are created
gen sulfide in the air of the working environment in the mines with blasting, the individual amounts
(getting used to the smell occurs rapidly). It is rec- depend on the used explosives and mining devel-
ommended that periodic changing of jobs by those opment.
who are not contaminated with hydrogen sulphide. Sources of emissions of sulfur oxides are:
Use personal protective equipment: clothing made - liquid and solid fuels used in industry and
of coated acid resistant fabrics, breathing mask, households;
rubber gloves and boots. Preliminary and periodic - Industrial plants;
medical examinations to be oriented to the nervous, - Motor vehicles.
respiratory and cardiovascular systems, and eyes. METABOLISM AND MECHANISM OF ACTION
Dietary modes include lipotropic (methionine, lec- The biotransformation of sulfur dioxide occurs
ithin, etc.) and biologically active substances, and with the formation of sulfuric acid that was separat-
vitamins E, B6 and nicotinic acid (PP). ed as sulfates. Part of the sulfur metabolites bind to

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 LABOUR MEDICINE
form S-cysteine, S-sulfoglutation and S-sulfonates. USE
In metabolism may include L-acetylcystein group It is used for synthesis of rubber, synthetic fibers,
and to form alkyl- and aryl-S - N-acetylcistein deriva- methylmethacrylate, sodium cyanide, ferrocyanide,
tives - mercapturic acids and their derivatives. for the preparation of plastics, plexiglass, pharma-
Sulphur dioxide causes local damage with irri- ceuticals and the like. It is used as an insecticide, ro-
tant and corrosive nature. Facilitates the formation denticide and fumigant.
of methemoglobin. Blocking thiol enzymes and po- PROFESSIONAL AND UNPROFESSIONAL
tentiate hypoxia. EXPOSURE
Sulfur trioxide causes severe burns to the skin. In the air of the working environment is released
PREVENTION during the production of hydrogen cyanide, ben-
Compulsory technical measures are the intro- zene, toluene, xylene, thiocyanate, cyanides, in elec-
duction of effective ventilation and hermetisation of troplating processes, heating the polymer composi-
the production process. For reduction of risk prior to tions.
detonating the mines must be carried out spraying The biggest emitters are producing methyl meth-
with water downhole, as well as the removal of the acrylate, acrylonitrile and hydrogen cyanide. Present
excavated ore, filling the blast holes with wet clay in in wastewater from ore-dressing factories, mines,
order to reduce the risk of incomplete combustion, metal plating shops, metallurgical and metalwork-
the sampling air for concentrations of CO and NOx ing plants, gas generators stations, coke-chemical
no earlier than 15 minutes and no later than 30 min- plants and others. The content of hydrogen cyanide
utes after the bombing. in the smoke is 0.002 g/10 g of tobacco.
Workers to be provided with personal protective METABOLISM AND MECHANISM OF ACTION
equipment, such as at high risk (explosions, massive Hydrogen cyanide (cyanides) is one of the fastest
chemical pollution) to use the clothing of acid re- acting known fatal poisons. Cyanides is not essential
sistant, coated fabric, mask with filter for acid gases, to the human body, but their presence in food, air,
rubber gloves and acid resistant shoes. Preliminary water, the workplace makes them significant, not
and periodic medical examinations to be oriented to only at high concentrations, especially in smokers
the respiratory system and skin. (Table. 2).
It is assumed that in the body is transformed to
HYDROGEN CYANIDE (HCN) low toxic thiocyanates (rhodanides), released by the
HYGIENE STANDARDS kidneys.
Air of the working environment: Cytochrom-C-oxidase inhibited by the mitochon-
Mean-shift MAC - 1.0 mg/m3, drial respiratory chain. Disturbing oxidative process-
Maximum short MAC - 5.0 mg/m3. es in the cell, resulting in severe hypoxia develop.
Atmospheric air of settlements: Cytochrom-C-oxidase in the brain is the most
Daily average MAC - 0.01 mg /m3, sensitive to cyanide, which determines the dysfunc-
Maximum single MAC - 0.01 mg/m3. tion of the central nervous system for major in acute

Tab. 2. Content of thiocyanate and cyanide in the blood of smokers and nonsmokers (by Charles E. Becker, 1997)
Substance / Group Level Quantity in μg/ml Type sample
Cyanide
No smokers Average value 0.02 Whole blood
Smokers Average value 0.04 Whole blood
Acute poisoning >0.1 Whole blood
Fatal poisoning >1.0 Whole blood
Thiocyanate
No smokers 1-4 Plasma
Smokers 3-12 Plasma

GENERAL CHARACTERISTICS lethal effects. Chronic effects of hydrogen cyanide in

Hydrogen cyanide (formonitril, Prussian acid, cy- occupational exposure are controversial (smokers,
anic acid) is a colorless gas or liquid with a charac- receipt of cyanides by food). Described are: inhibi-
teristic odor. The gas is lighter than air. Polymerize in tion of thyroid function (hypothyroidism), as a re-
the presence of water as emits heat and increases the sult formed rhodanides; atrophy of the optic nerve;
pressure (risk of fires and explosions). The fluid is com- astheno-vegetative syndrome; changes in EKG and
bustible. Ignition temperature 538°C. With air form ex- clinical laboratory blood values (reduced blood sug-
plosive mixtures. ar, increased lactate and Hb), skin lesions in contact

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 OCCUPATIONAL MEDICINE
with sodium or potassium cyanide. Are possible In a massive emergency (accidents, explosions)
birth defects (especially in smokers) - low weight in causes chemical burns to the lungs, blocking the
newborns. respiratory center, causing reflex death.
PREVENTION Chlorine molecule is a strong oxidizing agent
Hermetisation of process. and reacts with many functional groups in the cell.
Workers use special work clothes from coated In chronic exposure are described damage to the
fabrics, dust mask, gloves and boots. Disposal of respiratory system (chronic obstructive and restric-
waste and cleaning of polluted areas to use breath- tive bronchitis); skin; ocular mucosa and cornea; rhi-
ing apparatus with oxygen bottle. Periodic medical nitis and frequent development of anosmia.
examinations (conducted annually) be oriented to PREVENTION
the nervous system, liver and skin. It is recommend- Production processes to be automated and used
ed that a diet rich in lipotropic (methionine, lecithin hermetically equipment. To exercise constant con-
etc.) and biologically active substances, vitamins E, trol of concentrations of chlorine in the air of the
B6, B1 and C. working environment. Workers to provide personal
protective equipment. At elevated risk of using ac-
CHLORINE (Cl2) id-resistant, fire resistant clothing, boots of PVC or
HYGIENE STANDARDS rubber, latex gloves, respirator with oxygen bottle or
Air of the working environment: an entire gas masks with filter for acid gases. Medi-
Mean-shift MAC - 3.0 mg/m3. cal surveillance of workers to be targeted at the res-
Atmospheric air of settlements: piratory system, skin, eyes and blood. Prophylactic
Daily average MAC - 0.03 mg/m3, nutrition include lipotropic and biologically active
Maximum single MAC - 0.1 mg/m3. substances, with the addition of vitamins (E, B1 and
Drinking water: 0.3-0.4 mg/dm3 residual chlo- C), refreshing drinks and more fluids.
rine in a 30-minute contact with water.
GENERAL CHARACTERISTICS HYDROGEN FLUORIDE (HF)
Chlorine is a yellow-green gas with a pungent odor, HYGIENE STANDARDS
pressure liquefies. Melting point - 101.3°C, boiling tem- Air of the working environment:
perature - 34.05°C. Heavier than air. Dissolve in water Mean-shift MAC - 2.5 mg/m3
and organic solvents. Reacts violently with organic Atmospheric air of settlements:
compounds and metal dust it can cause fires and ex- Daily average MAC - 0,001 mg/m3,
plosions. Form hydrogen chloride on contact with air. Maximum single MAC - 0.01 mg/m3.
Corrodes plastic, rubber, textiles and metals in the
presence of water. GENERAL CHARACTERISTICS
USE Hydrogen fluoride is a colorless gas. Melting point -
It is used for the preparation of 1,2-dichlo- 87,2 ° C, T ° boiling 19,9 ° C, density - 0.9885 (13 ° C). The
roethane, vinyl chloride, hydrochloric acid, chloriat- aqueous solution is a strong acid. Reacts with metals
ed lime, chloride, pesticides, plastics and bleaching to form hydrogen in the presence of water or moisture.
agents. It is used in metallurgy, paper, textile, chem- In contact with air are obtained corrosive fumes, heav-
ical- pharmaceutical and rubber industries, for the ier than air. Destroys the glass.
disinfection of drinking water and disposal of waste- USE
water. It is used in the production of aluminum, super-
PROFESSIONAL AND UNPROFESSIONAL phosphate chlorofluorocarbons hydrocarbons, lu-
EXPOSURE bricants, hydrogen peroxide, heat-resistant plastics,
Risks from exposure to chlorine exists in the pro- insecticides and fungicides; as the solvent of the al-
duction of 1,2-dichloroethane and vinyl chloride. cohols and aldehydes, a catalyst in polymerization
Chlorine is transported primarily in pipelines and processes and alkylation; in engraving and polishing
tanks. Solid contaminants are possible breakout in the of glass.
pipelines. Known quantities are released during load- PROFESSIONAL AND UNPROFESSIONAL
ing and unloading of tanks. Emission source are and EXPOSURE
the process of electrolysis of chlorine compounds. Professional risk exists in the production of alumi-
METABOLISM AND MECHANISM OF ACTION num and phosphate fertilizer, production and use of
Chlorine occurs irritating and corrosive action. pesticides, micro - silicon chips, as well as engraving
Upon contact with the mucous membranes form and polishing of glass. At high levels of exposure are
hydrogen chloride and with tissues - hydrochloric monitored by local disabled of mucous membrane
acid. irritation to skin burns.

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 LABOUR MEDICINE
Emission sources are aluminum and superphos- - dermatitis. Deposite fluoride in bones and teeth,
phate production. Natural source of fluoride are vol- which is released slowly by the kidneys.
canoes. PREVENTION
METABOLISM AND MECHANISM OF ACTION Recommended replacement of HF with less tox-
Hydrogen fluoride is irritating and corrosive ef- ic compounds, its use in closed systems in effective
fect on the skin and mucous membranes. ventilation. Workers must be provided special work
It occurs as a direct cellular poison. Violates cal- clothes fabric of neoprene and gloves at increased
cium metabolism and enzymatic mechanisms. With risk (accidents, explosions, massive pollution) - mask
calcium forms insoluble precipitates and lowers its brand B and goggles from organic glass. Preventive
plasma level. medical examinations to be oriented to the respira-
In chronic exposure occur trophic disorders of the tory system, eyes and skin. In works related to the
mucous membranes - inflammation of the nasal mu- separation of hydrogen fluoride vapor women are
cosa, bleeding, perforation of septum nasi, anosmia; not allowed, regardless of their age.
laryngitis, bronchitis, pneumonia; conjunctivitis and Recommended enrichment of dietary regimen of
keratitis. Disabilities: tooth enamel - tan pigmenta- vitamins C, A and D and involving calcium supple-
tion, caries; digestive system - frequent gastritis; skin ments.

M.Koleva

7.7 KETONES

ACETONE AND METHYLETHYLKETONE: of paints, varnishes, acetate rayon, photographic

Empirical formula: acetone - CH3COCH3, film and celluloid.
methylethylketone - CH3COCH2CH3 PROFESSIONAL AND UNPROFESSIONAL
Structural formula: EXPOSURE
H H High volatility determines the presence of ac-
acetone H-C-C-C-H etone in the working environment whenever it is
H O H H HH used. Concentrations ranged from 200-400 mg/m3
methyl ethyl ketone H-C-C-C-C-H to tens of thousands mg/m3.
H-O-H-H Acetone is a natural metabolite of man. The con-
HYGIENE STANDARDS tent in the blood normally around 0,7-0,8 mg%, and
Air of the working environment: urine - 20-30 mg/24 h. The content of acetone in the
Acetone: Mean-shift MAC - 600 mg/m3, exhaled air is about 0,2-0,3 mg/m3. Under normal
Maximum single MAC - 1400 mg/m3. conditions, a person exhales 16,1 ± 1,2 mg of ace-
Methyl ethyl ketone: tone for 24 hours. Therefore, acetone is detected in
Mean-shift MAC - 590 mg/m3, maximum single the air of hermetic chambers - the concentration of
MAC - 885 mg/m3, irritating effect. acetone in the air of the spacecraft “Soyuse-22” was
Air settlements: 5,2 to 7,8 mg/m3, and the orbital station “Skylab-4” -
Daily average MAC - 0,35 mg/m3, of 6,5 to 18,7 mg/m3.
Maximum single MAC - 0,35 mg/m3. In the air, at 100, 300, 500 and 1000 m away from
the plant for acetone are found excessive amounts.
GENERAL CHARACTERISTICS In air samples from residential premises in 7 of 10
Colorless liquids with a distinctive odor, highly vola- samples acetone is not found, and the remaining 3
tile, soluble in alcohol and other solvents. The acetone maximum concentration is 0,13 mg/m3.
was mixed with water. Methyl-ethylketone with air In the industrial wastewater from acetone pro-
forms explosive mixtures in concentrations from 1.97 duction is evidenced in the amount of up to 16 mg/
to 10.2 volume %. dm3.
USE METABOLISM AND MECHANISM OF ACTION
It is used as a solvent of nitrocellulose and cellu- In production conditions ketones (mainly ace-
lose acetate synthetic, rubber, rubber, resins; dena- tone) penetrate primarily by the inhalation route.
turing of alcohol; as raw material for the manufacture There is a possibility of penetration of liquid aerosol

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 OCCUPATIONAL MEDICINE
through the lining of the gastrointestinal tract and acetone in the blood exceed 400 mg/l (at a norm of
through the skin. Through analysis of the acetone in about 10-20 mg/l, maximal 25 mg/l).
the exhale air it has been shown that liquid acetone Chronic poisoning with acetone is manifested
permeates through the skin in the same amount by atrophic catarrhal changes in the lining of the
as well as vapor at a concentration of 5000 mg/m3. UAP, anemia and left shift of the leukocyte formula.
Isolated skin has been found that the rate of perme- Changes in protein fractions of blood are also con-
ation through the skin of liquid acetone was 0,002 sidered characteristic of chronic effect of acetone.
mg/cm2/h, and a vapor (at a concentration of 20000- Acetone has a local irritant to the skin. Hours af-
30000 mg/m3) - 0,059 mg/cm2/h, i.e. over 20 times ter application on intact skin establish redness with
faster. transient character after removing the irritating
At low levels of exposure to 50% of the dose ab- agent. Exposed areas skin is dry due to significantly
sorbed is oxidized to CO2 and exhales. The high co- depressed function of the sebaceous glands.
efficient of partition blood/air (338.9 for man), deter- Methyl-ethylketone also is narcotic. After the first
mines the slow release of acetone absorbed by the 3-5 min. in the majority exposed under the influence
body. The rest ketones are rapidly eliminated. of concentration around 1000 mg/m3 was observed
Except through exhaled air ketones are eliminat- irritation of the mucous membranes of the eyes,
ed through urine (metabolized and unmetabolized) nose and throat. In short inhalation of concentra-
and up to 10% through the skin. tions 10 000 mg/m3 feels strong odor, irritation of
The amount of acetone in the urine used for ex- mucous membranes of the eyes and nose, at 30 000
position test. mg/m3 irritation becomes unbearable. In the com-
The content of acetone in blood is about 50% bined action of the acetone and methyl ethyl ketone
higher than that in the tissues. The distribution in or- in a concentration from 2300 to 3000 mg/m3 was re-
gans and tissues is as follows: brain, liver, pancreas, corded case of acute poisoning.
kidneys, lungs, muscles and heart. The effect of methyl-ethylketone on skin is poor-
Acetone is narcotic that harms all sections of the ly manifested, but in constant contact observed oc-
central nervous system. With prolonged inhalation cupational dermatitis. Pre-drying of the skin slows
accumulates in the body. The slow excretion increas- and damping increases skin absorption.
es the possibility of chronic poisoning. PREVENTION
The odor threshold varies around 1.1 mg/m3. Individual protection of skin and UAP through
Concentrations 500 times above that level mark appropriate personal protective equipment: work-
threshold of specific action proven electroenceph- ing suit, goggles, gloves.
alographic by disrupting the formation of a condi- Special attention should be paid to nutrition. To
tioned reflex. At concentrations above recommend- limit fats, especially animal, to take more proteins
ed MAC register irritating effect on the mucous containing glutamic acid, a large amount of lipo-
membranes of the eyes, nose and throat. Concen- tropic substances and methionine, easily digestible
tration 100-120 mg/m3 do not induce any signs of carbohydrates, lactic acid foods, vitamins.
toxicity in the body of the workers. In operation, for It is also recommended to train workers to con-
one week at 10 times higher concentrations is estab- duct breathing pauses with gymnastics and stick to
lished acetone in the blood. If the concentration of increased physical regime.
acetone in the air reach 5000 mg/m3, the amount of

M.Koleva

7.8 NITRO - AND AMINO DERIVATIVES

OF BENZENE AND TOLUENE
Nitrobenzene - C6H5NO2 o-, m- and p- nitrotoluene - CH3C6H4NO2
Aniline. Empirical formula - C6H5NH2: o-, m- and p- Toluidines (Aminotoluens) -
Structural formula - CH3C6H4NH2
GENERAL CHARACTERISTICS
NH2 Nitrobenzene. Yellow lubricous liquid smelling
of bitter almond and sweet-tannic flavor. Molecular

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 LABOUR MEDICINE
weight 123.11, boiling point 210,9 ° C. Slightly soluble Inhalation absorption is high. For some indus-
in water, insoluble in acids and alkalis. Flammable and tries, especially in direct contact with liquid product
explosive substance with a lower explosive limit 1.8 skin resorption plays a major role. Are described and
volume %. household intoxications through clothes, dyed with
Aniline. Lubricous liquid, colorless, but quickly aniline.
darkening of light in contact with air. There aromatic Because lipoidorsolubility of compounds the
odor. Boiling point 184,4 ° C, slightly soluble in water greatest amount is found in adipose tissue.
(3.4% at 20 ° C and 6.4% at 90 ° C), well dissolved in Sources of environmental pollution are mainly
alcohol, ethers and other organic solvents. enterprises for the production of aniline dyes. Only
O-, m- and p- nitrotoluene. O- and m-nitrotolu- one such object for 24 h discarded 3600 m3 effluent
ene are sallow, lubricous liquids, p-nitrotoluene a crys- containing approximately 17 organic compounds,
talline solid. Slightly soluble in water, mixed with alco- primarily aromatic nitro derivatives.
hol in any proportion. Following exposure to nitrobenzene in water it
O-, m- and p- Toluidines. O- and m-toluidine are changes color, smell and taste of the water. At a con-
liquids, p-toluidine a crystalline solid. Slightly soluble centration of 4 mg/dm3 yellowish water at 100 mg/
in water, dissolve well in organic solvents. dm3 becomes almost black with black sludge. The
Nitro- and amino derivative of benzene and tolu- odor threshold for water at 12-24 ° C is 0,6-1 mg/
ene are characterized by lower volatility and high lipoi- dm3, and disagreeable flavor occurs at a concentra-
dosolubility, which is why most frequent poisoning tion of 0,03 mg/dm3.
caused by dermal penetration of substances, but rare
- occurring by the inhalation route.
HYGIENE STANDARDS
Air of the working environment
Chemical Mea-shift MAC Maximum single MAC Specific effects
1. Aniline 2,0 mg/m 3 – Skin-resorptive effect
2. Nitrobenzene 5,0 mg/m 3 – Skin-resorptive effect
3. p-nitrotoluene 11,0 mg/m 3 – Skin-resorptive effect
4. n-toluidine 9,0 mg/m 3 – Skin-resorptive effect

Air settlements
Pollutants Daily average MAC Maximum single MAC
1. Aniline 0,03 mg/m 3 0,05 mg/m 3
2. Nitrobenzene 0,008 mg/m 3 0,008 mg/m 3
USE METABOLISM AND MECHANISM OF ACTION
Nitrobenzene is the main raw material for the Substantially all of the absorbed aniline metab-
production of aniline: 90% is used for the prepara- olized to p-aminophenol, determination of which
tion of aniline, 2% - for the synthesis of other dyes, in urine serves as a exposure test. Major metabolic
7% - as intermediates in organic synthesis, and 1% pathways is aromatic hydroxylation. The second-
for other purposes, ex. in the perfume industry, in ary roads are: N-hydroxylation, N-sulfoconjugation,
the manufacture of soaps and more. N-glucuronidation, binding to glutathione to form
The most widely used of aniline in the textile in- aminoglutation and degradation to carbon dioxide.
dustry for the production of aniline dyes and plas- Is eliminated primarily through the urine as
tics, in the rubber and pharmaceutical industries, as p-aminofenol small part unchanged.
well as for production of aromatic substances and The biotransformation of nitrobenzene (by ex-
semi-finished products of naphthalene and aromat- perimental data) occurs in 2 ways: a) reduction to
ic order. the aniline followed by hydroxylation of the aniline
Nitrotoluenes is used for the preparation of tolui- to the aminophenols; b) direct hydroxylation of ni-
dines, in the perfume industry and low part as herbi- trobenzene with formation of nitrophenols and
cides. Toluidine are used for the production of paints partial reduction of nitrophenols to aminophenols.
and in organic synthesis. In the composition of many Certain metabolic products are highly toxic. Is elim-
corrosion inhibitors. inated through the urine as 20-30% of the dose ap-
PROFESSIONAL AND UNPROFESSIONAL pears in the urine as sulfates and glucuronides of
EXPOSURE p-aminophenol and p-nitrophenol. Urinary excre-
In production conditions nitro- and amine deriv- tion is slow - up to 3 weeks.
ative of benzene and toluene was mainly via inhala- Nitro- and amino compounds by the mechanism
tion and through the skin. of action and clinical picture of poisoning are very
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 OCCUPATIONAL MEDICINE
similar, because in the body to metabolize the same allergy.
products, but have some peculiarities. Some amino compounds induced benign and
For example, the nitro compounds act more ex- malignant tumors of the urinary tract and bladder.
pressed on the nervous system, while the amino A classic example is aniline, but also β - naphthyl-
compounds are stronger methemoglobine forming; amine, benzidine, α - naphthylamine, o - toluidine.
toxicity of nitro compounds is not increased by in- Amino- and nitro compounds easily penetrate
creasing the number of nitro groups; joining chlo- the skin, making this path way most dangerous of
rine to the molecule of aniline and nitrobenzene re- entry into the body in real production conditions,
sults in a more aggressive action on the blood. where their low volatility could not create high con-
A feature of the toxic effect of the nitro- and centrations in the air.
amine derivative is its polytropism, but the chang- PREVENTION
es in the blood remains in the clear pathognomic In contact with aniline and other compounds
sign of poisoning. Violations of the features of ox- necessary protection of UAP and skin. Achieved
yhaemoglobin are associated with the formation through the introduction of continuous manufac-
of methemoglobin and develops anemia. Chronic turing processes, hermetisation of equipment, effi-
poisoning results in increased regenerative capacity cient ventilation and purification of emissions, that
of hematopoietic organs, leading to reticulocytosis. cause air pollution.
Emerging hypoxia and hypoxemia cause dysfunc- Workers must be provided clothing, underwear,
tion of all organs, primarily in the CNS. CCC disor- shoes, gloves and respirators. Organized regular re-
ders are due to the direct effect on the heart muscle, placement of clothing and underwear. Recommend-
nerve centers, blood vessels and by the emerging ed PPE are made from materials nonsorbent harmful
hypoxia. substances and easy to clean. When spills and acci-
Nitro- and amino compounds damage the liver. dental contamination of clothing is recommended
In acute poisoning observed expressed pathology, worker immediately to change. Especially careful to
while chronic poisoning are most often observed keep the skin from pollution during the summer. It
changes in the metabolism of pigments, due to in- prohibited in spillage and contamination of the skin
jury of liver and hemolysis of erythrocytes. Clinical to take a hot shower.
signs of damage to the gastro-intestinal tract ob- Workers are entitled to preliminary and period-
served. Renal impairment are also characteristic of ic medical examinations. Required control of blood
the toxic effects of amino compounds. values. Recommended diet D and providing addi-
Some of dinitro compounds affect metabolism by tional vitamins E - 20 mg and Rutascorbin - 1 dra-
violations, that cause in oxidative phosphorylation. gee and 1 l mineral water Gorna banya, Targovishte,
In contact with skin cause dermatitis and ecze- Ivanyane, Belovo, Varshetz, Varna.
ma, are possible general and local manifestations of

M.Koleva

7.9 POLYCYCLIC AROMATIC

HYDROCARBONS (PAHC)
Anthracene - C12H10 Benz (a) pyrene - C20H12 Naphthalene - C10H8

HYGIENE STANDARDS
Air of the working environment
Chemical Mean-shift MAC Maximum single MAC Specific effects
1. Anthracene 0,1 mg/m3 –
2. Benz(a)pyrene 0,00015 mg/m3 – Possibly carcinogenic to humans (Group 2A)
3. Naphthalene 50,0 mg/m3 75,0 mg/m3

Air settlements
Pollutants Daily average MAC Maximum single MAC
1. 3-, 4-benzpyrene 0,1 μg/100 m3 –
2. Naphthalene 0,003 mg/m3 0,003 mg/m3

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 LABOUR MEDICINE
Foods: METABOLISM AND MECHANISM OF ACTION
3-, 4-benzpyrene - 0.03 mg/kg. PAHC enter the body through inhalation, inges-
tion and contact with skin. So far there are no ac-
GENERAL CHARACTERISTICS curate data on the metabolism of PAHC in humans.
Polycyclic aromatic hydrocarbons (PAHC) are or- All information on the absorption, distribution and
ganic compounds containing 3 or more conditioned elimination of the PAHC from the body is based on
(glued) benzene rings made of carbon and hydrogen. experimental studies with experimental animals. Af-
Are formed in pyrolysis and incomplete combustion ter absorption PAHC penetrate the lymph, circulate
or other type of heat treatment under high pressure of blood, metabolized primarily in the liver and kid-
organic matter: coke, coal tar and resins, asphalt, oil neys and is excreted via the bile and urine. Due to
and petroleum products or contaminated with these its lipophilicity accumulate in milk (by the mammary
solid waste disposal, destroyed by combustion in incin- glands) and adipose tissue. Sometimes excretion in
erators. There are hundreds of polycyclic aromatic hy- faeces (via bile) and urine is effective enough due to
drocarbons. They are a natural component of natural the prevalence of enzymes transform PAHC in polar
fuels: coal and oil. metabolites.
At room temperature are solid substances of low Furthermore, in the liver and kidneys PAHC me-
volatility. Dissolved in organic solvents. Do not dissolve tabolized in the adrenal glands, testis, lung, skin,
in water. The majority of PAHC are degraded to simpler sebaceous glands and intestine. Perhaps initially
compounds under the influence of light. converted into epoxides, which are transformed into
PROFESSIONAL AND UNPROFESSIONAL dihydrodiolic derivatives and phenols.
EXPOSURE Persons with genetically determined high induc-
Percival Pot (surgeon) for the first time in 1775 ibility of the enzyme arilhydroxylazse (oxygenase of
associated profession with cancer. He described an mixed function in the composition of the microso-
unusually high incidence of cancer of the scrotum in mal fraction) form probably the group at high risk of
chimney and explains the origin of the disease to ex- cancer due to contact with PAHC - believes that this
posure to soot and ashes. Subsequently experimen- is a decisive factor for incidence of lung and larynx
tal repeatedly observed carcinogenesis induced by cancer.
coal tar. Many PAHC have carcinogenic potential, First epidemiological studies on mortality from
most often it is contained 5 or 6 benzene rings. lung cancer in workers from coke factory in Japan
Professional risk exists for all workers of enter- and England published in 1936. Until nowadays
prises producing or using coke, coal tar, bitumen many epidemiological data reveal increased inci-
(asphalt) and others petrochemicals. dence of skin cancer, lung cancer, bladder and gas-
PAHC are ubiquitous environmental pollutants. trointestinal tract when exposed to PAHC workers.
Set aside in the air in forest fires and volcanic erup- In our sanitary legislation coal tars and resins are
tions. Found in room air for combustion of coal, primarily in chemical mixtures as carcinogenic for
wood, oil and petroleum products in fireplaces and humans.
stoves on solid or liquid fuel. The air in urban areas Technical anthracene is significantly more toxic
is contaminated with PAHC from motor vehicles and than pure. Inhalation of dust containing anthracene,
city incinerators. appears swollen eyelids, irritation of mucous mem-
Benz (a) pyrene has the highest potential carcin- branes and erythema, which is exacerbated by light
ogen. Coal tar and creosote, which are a complex - photodermatitis with burning and itching skin.
mixture of liquid and solid hydrocarbons, contain Prolonged contact is observed pigmentation with
significant amounts of benz (a) pyrene and PAHC. hornification the surface layers of the skin and telan-
Cigarette smoke contains a many of PAHC. A ciga- giectasia. Photodynamic action of technical anthra-
rette is source of 10-50 ng benz (a) pyrene, chrysene cene was associated with the presence of impurities
- 18 ng, 40 ng dibenz (a, h) anthracene and 12-140 from carbasole, acridine and others.
ng benz (a) anthracene. Cigarette filters retain some, The naphthalene affects the nervous system,
but not all PAHC from the smoke, other inhaled by gastrointestinal tract and kidneys. Typical are the
smokers. changes in the blood: hemolysis, leukocytosis, ane-
The concentration of the PAHC in food products mia. Technical naphthalene is more toxic than pure
varies widely. Fried peanuts and coffee, refined veg- because of the presence of impurities in thionaph-
etable oils, smoked meat, fish and sausages contain thene, phenols and other.
PAHC. To 2 μg/kg benz(a)pyrene is prove in smoked Contact with skin causes erythema, eczema,
fish. Some grains and pulses such as wheat, rye and appearance of red spots. There are reports of skin
lentils synthesize PAHC. illness with redness, diffuse infiltration and pigmen-

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tation of nails with general signs of poisoning. Acute need to minimizing individual exposure of workers.
dermatitis are frequent in workers in contact with By appropriate personal protective equipment to
naphthalene. completely eliminate direct contact with skin.
PREVENTION It is also necessary to enhance the health educa-
Through complex preventive measures need- tion of the population and through effective meas-
ed to limit emissions from coke-chemical industry, ures to restrict smoking, especially among pregnant
ferrous and non-ferrous metallurgy. In work places women and nursing mothers.

M.Koleva

7.10 CHLORINATED HYDROCARBONS

Methyl chloride - CH3CI (Chloromethane, Fre- Carbon tetrachloride. Liquid with a boiling
on-40) point of 76.8°C. Partition coefficient oil/water - 1000.
Methylene chloride - CH2CI2 (Dichloromethane, Non-flammable, but in contact with open flames and
Freon-30) high heated objects decomposes to form phosgene. As
Chloroform - CHCl3 (Trichloromethane, Fre- impurities contains carbon disulfide, hydrogen chlo-
on-20) ride, hydrogen sulfide, organic sulfides. Slightly soluble
Carbon tetrachloride - CCI4 (Perchlorometan, in water, soluble in chloroform, alcohol, ether and ben-
Freon-10) zene.
HYGIENE STANDARDS
Air of the working environment
Chemical Mean-shift MAC Maximum single MAC Specific effects
1. Methyl chloride 50,0 mg/m3 100,0 mg/m3
Possibly carcinogenic to
2. Methylene chloride 100,0 mg/m3 517,0 mg/m3
humans (group 2B)
3. Chloroform 10,0 mg/m3 – Carcinogen Group 3
4. Carbon tetrachloride 12,6 mg/m3 –

Air settlements
Pollutants Daily average MAC Maximum single MAC
1. Methylene chloride 1,5 mg/m 3
3,0 mg/m3
2. Carbon tetrachloride 1,0 mg/m 3
–
GENERAL CHARACTERISTICS USE
Methyl chloride. Colorless gas with a slight sweet Methyl chloride is used in the chemical industry
smell. Partition coefficient oil/water - 25.3. Explosive as a methylating agent in the production of methyl-
- and fire product with a self-ignition temperature of chlorosilanes, siloxanes, methylcellulose, tetrame-
632°C, region of ignition of vapours in air from 7.6 to thyl lead; as a solvent in the production of butyl rub-
19.0 volume %. ber, pesticides, oils and resins; as cooler and mixed
Methylene chloride. Colorless transparent liquid with carbon tetrachloride as fire extinguisher.
with a sweet smell, boiling point 40.1°C and partition Methylene chloride is used as solvent in the
coefficient oil/water - 26. Upon contact with an open production of cellulose (particularly triacetyl cellu-
flame decomposes and forms irritating and toxic sub- lose), fats, resins, rubber, plastics; as cooler and for
stances. Under the influence of light decomposes and extraction of etheral oils.
emits hydrogen chloride. Chloroform. More than 90% of the produced
Chloroform. Transparent colorless liquid with a chloroform is used for the production of freons and
sharp sweet smell. Boiling point 61.2°C. On light, where fluorine-containing polymers; a small part as a sol-
free access of air easily decomposed. Upon contact of vent for fats and varnishes, in the pharmaceutical
vapour chloroform with fire form phosgene. Partition industry, production of alkaloids and rayon, as a fu-
coefficient oil/water - 7.3. migant in agriculture.

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 LABOUR MEDICINE
Tetrachloromethane was widely used as a in- The biotransformation of carbon tetrachloride is
flammable solvent for fats and alkaloids, in the man- low. About 20% of the absorbed carbon tetrachlo-
ufacture of refrigerants, fire extinguishers, electri- ride metabolized turning into chloroform, which in
cal insulators, in dry cleaners and a small part as a turn is oxidized to formic acid and CO2. The main
means of deratisation. amount absorbed tetrachloride is eliminated by the
PROFESSIONAL AND UNPROFESSIONAL lungs unchanged.
EXPOSURE Saturated chlorinated hydrocarbons, cyclopar-
Possibility of contamination of the working en- affins and cycloolefins (methyl chloride, methylene
vironment by chlorinated hydrocarbons exist wher- chloride, chloroform, carbon tetrachloride) are vol-
ever work with them in non-hermetic conditions. atile narcotics. The strength of the narcotic effect of
There are reports of occupational poisoning (mostly the derivatives of the same hydrocarbon increases
of carbon tetrachloride), and household poisonings with the number of chlorine atoms. Furthermore,
most often when trying to dry cleaning of clothes. chlorinated hydrocarbons increase the sensitivity of
Wastewater from the production of chlorine the myocardium to adrenaline.
containing complex chlorinated hydrocarbons, es- Chronic action, and sometimes single exposure
pecially methylene chloride. Such waters are not to high concentrations of chlorinated hydrocarbons,
amenable to biological treatment and a risk of pene- causing considerable damage to the internal organs
tration of methylene chloride in open reservoirs. For as a result of fatty infiltration of the liver, kidney,
now, the release of water is only through evapora- heart muscle, pancreas. The most pronounced are
tion after 3-4 days. these changes under the influence of carbon tetra-
Chloroform is formed in drinking water disinfect- chloride.
ed with chlorine as a result of reaction of free active Prominent among chlorinated hydrocarbons is
chlorine with organic compound of natural (humic methyl chloride, which is relatively weak drug, but
acids, proteins, amino acids, carbohydrates, etc.) and is highly toxic to the central nervous system. This is
anthropogenic origin (high molecular compounds). most likely due to the formation of methanol, which
METABOLISM AND MECHANISM OF ACTION accumulates in the body, separated slowly and pro-
In production conditions general way of penetra- duce toxic metabolic products (formaldehyde and
tion in the body of the chlorinated hydrocarbons is formic acid). Described cases of severe acute poison-
inhaled. Due to the affinity for fat is possible pen- ing with methyl chloride (Freon-40) with prolonged
etration through the skin and mucous membranes, loss of consciousness (over 24 hours), clonic and
particularly if theirs integrity is impaired. tonic convulsions, and absence of reflexes. Possible
Quickly absorbed and distributed in organs rich residual changes in the psyche, chronic depression
in fat (bone marrow, adipose tissue). Most small and others. Ethanol and other higher alcohols po-
amounts are found in the lungs and bones. Metab- tentiate the toxicity of chlorinated hydrocarbons in
olized in the liver with the participation of the OMF. a combined action.
One of the possible metabolites of methyl chloride The effect on skin of chlorinated hydrocarbons is
is formaldehyde. The methylene chloride refers to less pronounced than that of the corresponding sat-
non-reacting substances, in the body are not me- urated hydrocarbons (although they also penetrate
tabolized practical. through intact skin). Under the influence of chlorin-
Chloroform and tetrachloromethane are drugs ated hydrocarbons is observed irritation of the skin
with marked toxic effect (less in chloroform) in rela- and development of allergic dermatitis.
tion to their ability to form free radicals. The methylene chloride was relatively less tox-
Absorption of vapour of chloroform at inhala- ic. Chronic effect present with the symptoms of CNS
tion reaches 60-80%. The content in the blood is the damage, gastrointestinal tract, liver, and other in-
same as the concentration in the brain, in the fat con- ternal organs, but after an interruption of contact
centration was almost 10 times higher. It is believed changes are reversible.
that increasing the concentration of chloroform in There are pronounced cooling effect on the skin
the blood over 10,4-12,5 mg% can cause death. 30 due to rapid evaporation (the likelihood of dermal
to 50% of the received amount in the body chloro- absorption in toxic doses is unlikely).
form metabolizes. There is data that single metabo- Chloroform is also a powerful drug with toxic
lite is CO2, an amount that corresponds to 50% of the action. Chronic professional poisoning occurs with
absorbed dose. About 10% of chloroform absorbed lesions in the liver.
is excreted unchanged until one hour after the ex- Tetrachloromethane there is less drug action
posure. The remainder is eliminated slowly (up to 10 than chloroform, but is much more toxic. Regardless
days), especially in persons with obesity. of the manner of entry into the body causing severe

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 OCCUPATIONAL MEDICINE
damage to the liver - centrilobular necrosis and fat- It is necessary to provide a high degree of auto-
ty degeneration. Both damaging and other paren- mation and a good balance between general and
chymal organs: kidneys (renal proximal tubules) and local ventilation to remove vapour of chlorinated
lung (alveolar membranes and blood vessels). Alco- hydrocarbons or products of their destruction in the
hol intake, cooling the body and increased concen- place of release. When working with methyl chloride
tration of oxygen in the air amplify its toxic effect. is recommended mixing with strong-smelling sub-
Tetrachloromethane has a severe irritant action stances to quickly detect gaps in hermetisation. At
to the skin, causing dermatitis and eczema. high concentrations and fighting fires it is best to
Ingestion per os developing severe hepato-renal work with insulating gas masks or filter type. An im-
syndrome, with possible exitus. portant preventive measure is to avoid direct con-
PREVENTION tact with skin. Mandatory preliminary and periodic
Compliance with the general rules for safe han- medical examinations.
dling of organic solvents is required. Do not ignore
the danger of formation of phosgene.

M.Koleva

7.11 CONTAINING FLUORINE CHLORINE

HYDROCARBONS
Trichlorofluoromethane (Freon-11) - CFCI3 of the “ozone hole” - thinning the complete disappear-
Dichlorodifluoromethane (Freon-12) - CF2CI2 ance of the ozone layer of the stratosphere (currently
Difluorochloromethyl (Freon-22) - CHF2CI “ozone hole” over Antarctica extends over an area of 14
Difluortetrachloroetan (Freon 112) - CCI3CF2CI million square kilometers). Two scientific expeditions,
Trichlorotrifluoroethane (Freon-113) - CF2CICFCI2 in 1986 and 1987 found that this is due to the chlorine
Dichlorotetrafluoroethane (Freon-114) - atoms emitted from CFCH and other chlorinated hy-
CF2CICF2CI drocarbons such as methyl chloroform (1,1,1-trichlo-
Pentafluorchloroetan (Freon-115) - CF3CF2CI roethane) and carbon tetrachloride. According signed
HYGIENE STANDARDS
Air of the working environment
Chemical Mean-shift MAC Maximum single MAC Specific effects

1. Trichlorofluoromethane (F-11) 5600,0 mg/m3 – –

2. Difluorochloromethyl (F-12) 3000,0 mg/m3
– –
3. 1,2-difluoro - tetrachloroethane (F-112) 1000,0 mg/m3 – –
4. 1,2,2-trifluoro – 1,1,2-trichloroethane (F113) 7600,0 mg/m3 9500,0 mg/m3 –

GENERAL CHARACTERISTICS in 1988 in Montreal Protocol, by the end of the last cen-
Chlor-fluoro containing hydrocarbons (CFCH) were tury the annual production of CFCH had to be reduced
synthesized for the first time in 1937 in Germany and to half of the output in 1986 CFCH.
soon find application as originally coolers and aero- Some are gaseous (Freon-12, Freon-22), other liquid
sol propellants. After 1950 and until mid-60s annual (Freon- 11) substances soluble in organic solvents and
production increased by 100,000 tons, resulting in se- lubricating oils, practically insoluble in water. Under
rious pollution of the atmosphere with all the negative ordinary conditions not burn, does not form explo-
consequences. In the early 70s for the first time spoke sive mixtures with air. Relatively chemically inert, but
USE
Use Type freon
Dry cleaning, cooling Freon-113, Freon-11
Refrigerators, air conditioners Freon-22, Freon-12, Freon-11
Foam fire extinguishing Freon-11
Aerosol propellants Freon-12, Freon-11, Freon-14
Production of plastics Freon-12, Freon-22

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 LABOUR MEDICINE
in contact with open flames decompose and form dif- ter several cases of sudden death in individuals ex-
luoro- and fluorochlorophosgene. posed to very high concentrations of Freon-11 and
Their properties make them sustainable in the low- Freon-12 in the 60s of last century.
er layers of the troposphere - half-life 40-80 years of According to the National Institute of Cancer
Freon-11 (average 50 years) and 75-150 years, an aver- Research in the United States Freon-11 showed no
age of 100 years of Freon-12. carcinogenicity in experiments on mice, as Freon-22
METABOLISM AND MECHANISM OF ACTION slightly increased incidence of tumors of the salivary
As a rule, mixed halogenated hydrocarbons are glands in male white rats. Twice less, commonly used
less toxic than chlorine- or bromine-containing Freon-31 and Freon-133a, show limited carcinogen-
compounds. Represent a high risk that the products ic potential in experimental conditions. Freon-22
of their thermal decomposition containing phos- (one of the more commonly used refrigerants) is
gene, hydrohaloid acids, etc. Often contain impuri- genotoxic and weak bacterial mutagen. Numerous
ties sharply increasing toxicity. The introduction of CFCH are tested for teratogenicity but different de-
chlorine atoms in the fluorine-containing hydrocar- sign studies does not allow to adequately interpret
bon chains increases the toxicity of the compounds, the results and make a general conclusion. There is
which is in connection with the process of dehalo- data that Freon-22 has teratogenic in rats, but not
genation (dechlorination) and the formation of free in rabbits, which is manifested by microophthalmia
radicals. and anophthalmia at concentrations of 50,000 ppm
CFCH enter the body by inhalation and is rapid- (176 899.96 mg/m3).
ly and completely separated then by breath. During REVENTION
inhalation itself is eliminated 95%, and in the next Preventive measures are concentrated around
30-45 min, and the remaining 5% of the respirable the protection of UAP, as well as skin contact with
dose. Rarely, but there are refrigerants that form in liquid CFCH.
the body of toxic metabolites. To operate at moderate high concentrations can
Chlor-fluoro containing hydrocarbons are less be used a gas mask filter type. At high concentra-
toxic compounds. They have a narcotic effect, but at tions, risk of thermal destruction, accidents, use a
high concentrations, in normal practice of their ap- mask insulating type. Provides complete hermetisa-
plication rarely reach. No evidence of neurobehav- tion of technological equipment, protection against
ioural abnormalities under the influence of CFCH. contact with hot surfaces, sparks, effective ventila-
They are not strong irritants, though prolonged or tion of rooms.
frequent action on the skin can cause typical for or- Workers are entitled to preliminary and periodic
ganic solvents dermatitis. medical examinations.
Increased sensitivity of the cardiac muscle under
the influence of CFCH reported for the first time af-

M.Koleva, A. Mihaylova

7.12 OTHER ORGANICS

AKRILAMID1 GENERAL CHARACTERISTICS

Possibly carcinogenic to humans (2B gr.) Acrylamide (propenamide, acrylamide monomer)
Empirical formula, Structural formula is a colorless crystals with a characteristic odor. Melt-
C3H5NO H O H ing point 84,5°C, T° boiling - 87°C at 0.267 kPa, 103°C
at 0.667 kPa. It is well dissolved in water, acetone and
H2C= C – C – N – H alcohols. Polymerizes when heated by ultraviolet rays
HYGIENE STANDARDS with the danger of fire and explosion. Burning decom-
Air of the working environment: pose toxic gases and vapors (NOx). Reacts violently
Mean-shift MAC - 0.03 mg/m3 with oxidants. Superfine particles form explosive mix-
Atmospheric air of settlements: not standardized. tures with air.
1
A. Mihaylova

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 OCCUPATIONAL MEDICINE
USE odic medical examinations with focus on peripheral
Acrylamide is the main raw material for the and central nervous system, liver and kidneys
preparation of polymers and copolymers. The poly-
mers used in the manufacture of building materials, ACRYLONITRILE
emulsions, varnishes, paints, adhesives, plugging Structural formula: (CH2 = CHCN);
materials in dentistry for hardening compositions Empirical formula: C2H3CN
with high adhesion. Copolymers and butadiene are HYGIENE STANDARDS
used to produce polyurethane. Significant amounts Air of the working environment:
of acrylamide are used in the textile industry and in Mean-shift MAC - 4,5 mg/m3.
the manufacture of food packaging. Specific effects: skin resorption action, possibly
PROFESSIONAL AND UNPROFESSIONAL carcinogenic to humans, 2A group.
EXPOSURE Air settlements: Daily average MAC - 0,03 mg/
The use of closed systems in the production of m3.
acrylamide reduces the possibilities to create condi-
tions for occupational exposure. Extreme situations GENERAL DESCRIPTION
may arise in breach of reactors, in the accumulation Acrylonitrile is a colorless volatile liquid with a
of large amounts of dust from acrylamide, shipping slight smell, a melting point of 83 ° C, a boiling point
and cargo handling activities. of 77.3 ° C and a density of 0.806 at 25 ° C. Typical is
Potential source of emissions is polyacrylamide, his ability to spontaneously polymerize. Can be stored
used in the purification of water supplies, sewage, only after adding polymerization inhibitors. Slightly
industrial wastewater and flotation ore. soluble in water - 7.3%. And is insoluble in all classical
Minor amounts are released into the atmosphere organic solvents (acetone, benzene, ether, carbon tet-
in the production of synthetic rubber and organic rachloride, ethanol, methanol, ethyl acetate, toluene,
synthesis. xylene, etc.). His vapour is heavier from the air, forming
In the United States has limited the content of explosive mixtures - limit content in the air - 3-17 vol.%
monomers in food supplements (1 mg/kg), stored in acrylonitrile. Burning forming hydrogen cyanide.
the acrylamide packaging. USE
METABOLISM AND MECHANISM OF ACTION Acrylonitrile is known from 100 years ago, but un-
In experimental conditions biotransformation of til World War II almost did not use. By the war sharp
acrylamide occurs by conjugation. Binding of mon- increases in the production of nitrile rubber.
omer to glutathione can be carried out in the liver In the modern chemical industry is the starting
and brain. Biliary excretion of glutathione conju- material (monomer) for the synthesis of polyacry-
gates was observed in intravenous administration. lonitrile, which are produced by the known poly-
In urine identified four metabolites: mercapturic acrylonitrile fibers. Used also as an insecticide under
acid and three non-containing sulfur compounds. the trade name Ventox. Acrylonitrile containing pol-
As a major metabolite shows mercapturic acid. ymers, mainly rubbers - acrylonitrile-butadiene-sty-
About 2% of the introduced in body acrylamide is rene rubber, acrylonitrile-styrene rubber, are used
excreted unchanged in the urine. for the production of pipes and building structural
Acrylamide occurs locally irritant in contact with elements, and in the automotive industry. Acryloni-
skin. It has expressed neurotoxic effects. Damag- trile is used for the preparation of acrylamide.
es the peripheral and central nervous system (the PROFESSIONAL AND UNPROFESSIONAL
mechanism has not yet been elucidated). There is EXPOSURE
evidence of violation of axon transport, suppress Professional acute and chronic poisoning are
the growth of neural and neuroglia cells, inhibition possible in production given the volatility of the
of mitochondrial respiration, reducing the level of compound. Risk are mainly working in the chemical
dopamine, noradrenaline and 5-HP (5-hydroxy- industry.
tryptamine). The inclusion of vitamin B6 to the food The literature describes serious forms of poison-
ration of experimental animals reduces the toxicity ing of unprofessional character in children occurred
of the monomer. after rubbing detergent in hair.
PREVENTION METABOLISM AND MECHANISM OF ACTION
Preventive measures include automation and In production conditions acrylonitrile penetrates
hermetisation of production processes; provide per- mainly by the inhalation route. Acrylonitrile liquid
sonal protective equipment - face mask, while ac- and vapors penetrate also through the skin.
cidents and explosions - filtering industrial aerosol In the body are absorbed from 20 to 40% of the
mask with filter; conducting preliminary and peri- inhaled quantity. Metabolized in the liver with the

254
 LABOUR MEDICINE
participation of the enzyme rodanase - specific for cohol), in the metal industry for degreasing of com-
cyanides. End products of biotransformation are thi- ponents and parts, washing engines in transport,
ocyanates and mercapturic acids. extraction of fat, in dry cleaning and more.
With breath eliminate 15-20% of the inhaled PROFESSIONAL AND UNPROFESSIONAL
amount of acrylonitrile. In production conditions EXPOSURE
complete elimination is complete after 72 hours. As Possibility of poisoning exists when used in prac-
rhodanates were removed 14% of the dose during tice as fuel in garages, at petrol stations, cleaning
the first 4-6 hours after entry into the body. By 2-3 of tanks, pipelines, in emergency conditions, when
days after single exposure is an increased content of using distillation and oil-extraction apparatus, clean
sulfhydryl groups in serum. clothes, and in any case their use as solvents.
Acrylonitrile has irritating effect on mucous METABOLISM AND MECHANISM OF ACTION
membranes at high concentrations (acute effect), Penetration of gasoline in the body occurs main-
but these effects are described and in chronic ef- ly through inhalation in the form of vapour. Absorp-
fects. Also described are skin lesions in contact; CNS tion of petrol vapour in professional skin contact is
disorders, and acute poisoning with lethal similar to negligible. The absorption of liquid fuel through the
cyanide poisoning. skin is greater, but in comparison with that of ben-
For exposition test can serve the determination zene is weaker.
of acrylonitrile in the blood, the determination of Due to the low solubility of gasoline in the blood
the rhodanates in the urine, the determination of even at lethal acute inhalation poisoning amount
sulfhydryl groups in the serum and mercapturic ac- of gasoline in the blood is negligible - 0.3-0.4% (in
ids in urine. experimental animals). Saturation of the blood and
PREVENTION central nervous system is very fast. Received the
Conduct preliminary and periodic medical exam- body gasoline is released through the lungs un-
inations necessarily, as strict observance of contrain- changed also very fast. This is crucial for the preven-
dications for contact with acrylonitrile: organic CNS tion of acute inhalation poisoning.
diseases, mental diseases, endocrine, respiratory Gasoline is highly irritating to mucous mem-
system and CHD. branes (especially respiratory), damages the skin on
contact, affects the central nervous system (lipoido-
PETROL dissolvent, narcotic). Described are morphological
Petrol products from the distillation of crude oil changes of blood - anemia, basophil pointed red
(mineral oil) or formed by thermal and/or catalytic blood cells.
cracking of its individual factions. According to their PREVENTION
purpose is customary to divide into: Prevention of chronic poisoning by inhaled gas-
Aviation gasoline - a mixture of high-octane oline required to ensure hermetisation of the tech-
gasoline fractions and hydrocarbon components, to nological equipment in all manufacturing processes
be added octane enhancers and antioxidants. and dynamically track the concentrations of gaso-
Automobile gasoline - a mixture of products of line in the air of the working environment.
direct distillation and cracking process having a boil- Cleaning and repair of containers must be done
ing point not more than 205 ° C. in advance with purge by air or steam. Workers
Petrol - solvents and extractants - a mixture of performing cleaning and repair of tanks should be
low boiling fraction of oil in commonly property - trained to perform artificial respiration. It is forbid-
very high volatility. den singly to work in tankers.
HYGIENE STANDARDS In professional contact with gasoline, containing
Air of the working environment: an increased amount of aromatic hydrocarbons rec-
Mean-shift MAC 900,0 mg/m3 for gasoline - sol- ommended periodic monitoring of blood indices.
vent and 300,0 mg/m3 for gasoline - cracking.
Air settlements: Gasoline (petroleum with low VINYL CHLORIDE
sulfur content, calculated as carbon) - Daily average Carcinogen humans (Group 1)
MAC - 1,5 mg/m3, maximum single MAC - 5,0 mg/m3; Empirical formula: C2H3CI;
Gasoline (slate, calculated as carbon) - Daily average Structural formula: (H2C = CH-CI)
MAC - 0,05 mg/m3, maximum single MAC - 0,05 mg/ HYGIENE STANDARDS
m3. Air of the working environment:
USE Mean-shift MAC - 2,5 mg/m3.
It is extremely broad application except as a fuel GENERAL DESCRIPTION
and as a solvent of rubber, oils, varnishes (White-al- Vinyl chloride is a colorless gas with melting point -

255
 OCCUPATIONAL MEDICINE
153,8 O C and molecular mass of 62.5. Slightly explosive is controversial.
in a mixture with air, even at 4-22% of the mixture dif- Inhalation absorbed about 40% of the amount
ficult to ignite. Easy joins a molecule of halogens form- inhaled. At low exposure metabolism is accom-
ing trihalogenetanes. Under the influence of light po- plished by alcohol dehydrogenase, and high - with
lymerizes easily. On combustion (950-1466oC) smoke the aid of microsomal enzymes (cytochrome P-450).
consists of: 27 parts of hydrochloric acid, 581 parts of The first metabolite is chloroethylenes oxide, which
CO2, 9 parts of CO, and 0.04 parts of phosgene. is converted into an active intermediate epoxide. For
USE it has been shown to bind to RNA and DNA in vivo,
Monomer of polyvinyl chloride, which is widely and most likely it is due to carcinogenesis observed
used in industry and households for production of in experimental animals and humans.
building materials and products shaping the interior In intact through the lungs remove about 60% of
of the house (linoleum, tile flooring, decorative cur- inhaled vinyl chloride. Remainder metabolized and
tains and panels, washable wallpaper, ledges, hand- eliminated in the urine as metabolites whose con-
rails for stairs and others); water and sewage pipes, tent does not depend on the concentration of vinyl
artificial leather, toys, food packaging. chloride in the air. Not developed exposition test.
PROFESSIONAL AND UNPROFESSIONAL In addition carcinogen (angiosarcoma of the liv-
EXPOSURE er) vinyl chloride is irritating to mucous membranes
Due to the widespread use of vinyl chloride direct of the respiratory tract and inhibition functions of
professional contacts have over 100 000 workers in the central nervous system (depression) at high
the world (in the US alone there are more than 27 concentrations (acute poisoning). Chronic effects
000). Over 1/3 of the world population daily contact are detailed and other biological effects such as liver
with products of polyvinylchloride resins. damage - fibrosis, hepatomegaly (and hepatosple-
Sources of vinyl chloride in the environment are nomegaly); vascular damage - Raynaud’s syndrome;
plants for the production and processing of pol- skin lesions - scleroderma, thinning of the skin;
yvinylchloride resin and various polymer materi- acro-osteolysis; pneumoconiosis; impaired repro-
als based on polyvinyl chloride which contain free duction.
monomer and during the operation to liberate it. PREVENTION
Depending on the specifics of the technological The reduction of exposure and reduce risk for
processes in the production of vinyl chloride and people in contact with vinyl chloride is achieved
polyvinyl chloride in the air of the working envi- through maximum mechanization, automation and
ronment of vinyl chloride concentrations can reach remote control of production processes. In case of
values significantly exceeding hygiene standards failure to provide workers with appropriate cloth-
(during the period 1960-70, the - 22-24 mg/m3, and ing from coated fabrics, protective eye (maximum
before that, and more). When processing a lining sealed goggles covered type) and UAP (gas masks
made of polyvinyl chloride occurs termodestruction with oxygen bottle or gas mask filter type), latex
and air in working environment is polluted with sig- gloves and waterproof boots.
nificant amounts of vinyl chloride - 28-105 mg/m3. In
the production of artificial leather and leather prod- ETILEN1
ucts are found vinyl chloride concentrations in the Empirical formula: C2H4
range of 2,4-5,6 mg/m3. Structural formula:
Polymeric construction materials based on poly- CH2
vinyl chloride for several months at ordinary temper- ||
ature (18-22 ° C) emit volatile components including CH2
vinyl chloride. At high temperature the migration of
toxic substances increases. HYGIENE STANDARDS
Vinyl chloride migrated from bottles to storing Air of the working environment:
therein alcoholic beverages in quantity 10-20 mg/ Tentative safe level of exposure -
dm3. The rate of migration depends on the duration 3.0 mg/m3
of storage. It was found that the monomer migrates Atmospheric air of settlements:
into water, vinegar, arachis oil and corn oil, orange Daily average MAC - 3.0 mg/m3,
puree and konjac in concentrations of 0.01 to 33 Maximum single MAC - 3.0 mg/m3.
mg/dm3.
METABOLISM AND MECHANISM OF ACTION GENERAL CHARACTERISTICS
In production conditions highway penetration of Ethylene (ethene) is a colorless gas with a charac-
vinyl chloride in the body is inhaled. Skin absorption 1
A. Mihaylova

256
 LABOUR MEDICINE
teristic odor. At elevated pressure and low temperature PREVENTION
is liquefied. Temperature (T °) of melting 170 ° C, T ° of It is performed with technical events: automation
boiling 104 ° C. The chilled gas is heavier than air. Does and hermetisation of the production process and
not dissolve in water but is soluble in organic solvents. provide personal protective equipment for workers.
Reacts violently with strong oxidants. Flammable is to a In case of fire, explosions or mass chemical contam-
distance. At high temperature and pressure polymerized. ination to benefit from clothing coated textiles, gas
In its rapid evaporation creates a lower temperature. masks oxygen bottle, latex gloves and rubber or PVC
USE boots. Periodic medical examinations to be target-
Used as a feedstock in the production of polyeth- ed at central, peripheral and autonomic nervous
ylene, ethylene oxide, ethyl alcohol, ethanolamine, system, cardiovascular system and liver. Workers re-
polyvinyl chloride, thyokol and others. It is used as ceive vitamins B1, B6, E and C.
a drug in surgery. Ethylene is a component of gas
mixtures used in welding, lighting and more. ETHYLENE OXIDE
PROFESSIONAL AND UNPROFESSIONAL Molecular formula: C2H4O; Synonyms: ethylene
EXPOSURE oxide, 1,2-epoxyethane, oxirane.
Professional risk exists in the production of eth- HYGIENE STANDARDS
ylene. Main sources of gas removal are leaky flange Air of the working environment: Mean-shift
connections, gaps in the bearing devices, operations MAC - 2,0 mg/m3. Possibly carcinogenic to humans
sampling for analysis, in the prevention and repair of (group 2A).
equipment. Air settlements: MAC daily average - 0,03 mg/
Ethylene is formed in all plant tissues in signifi- m3, maximum single MAC - 0,3 mg/m3.
cant amounts and acts as an endogenous regulator
of growth. Is produced by soil microorganisms. GENERAL CHARACTERISTICS
Sources of pollution are producing organic com- Ethylene oxide is a colorless, flammable gas with
pounds, chemical and pharmaceutical industry, a smell of ether. At low temperature, is a colorless
metal processing enterprises, gases emitted from low-viscosity liquid with a characteristic odor of ether,
motor vehicles and aircraft. the temperature of boiling10,7°C and a density of
METABOLISM AND MECHANISM OF ACTION 0.887 at 7°C. It is well dissolved in water, alcohol and
Ethylene biotransformation occurs in the liver. ether, has a tendency to polymerization and reaction
By microsomal epoxidation to form ethylene ox- with many organic and inorganic substances. Lower
ide, which undergoes hydrolysis to ethylene glycol. limit of flammability in air mixture with 3% by volume.
Biodegradation of ethylene glycol is carried out by Upon heating to 400°C is converted to acetaldehyde,
known circuits - conversion to oxalic acid or by the by heating with water to form ethylene glycol.
formation of intermediate metabolites (glycolic and USE
hippuric acid), with the end product - oxalic acid. All The ethylene oxide is used for the preparation of
metabolites are eliminated in the urine. ethylene glycol as an intermediate in the manufacture
Ethylene is manifested as asfiktant and narcotic. of polyester fibers, polyethylene (film, and various bot-
Asphyxia, as a result of mass entering of ethylene, tles), surfactants, washers and detergents for industri-
is proportional to the reduced content of oxygen in al and domestic purposes. As ethanolamine is used for
the air. the preparation of soaps, detergents and chemicals
Narcotic effects of ethylene occurs at lower con- for textile and cellulose industry, such as glycol ethers
centrations and does not depend on the lipid level, for the production of surface coatings. It is used as a
but on the content of water in tissues (the brain con- fumigant and disinfectant (dry sterilization) in agricul-
tains 78% water and 12% lipids). ture, medical and dental practices, libraries, museums,
Detected in animal experiment, induction of tu- gassing and disinfection of vehicles, production of
mors (sarcomas) upon implantation of the polyeth- milk and dairy products, and spices.
ylene, is not associated with the action of the mon- PROFESSIONAL AND UNPROFESSIONAL
omers - ethylene. EXPOSURE
Ethylene interacts with biosubstratum in account Envisage the technological and technical char-
of Vander-Valss connections. In biomedya of body acteristics of the chemical industry (mechanization,
does not undergo changes in its structure. In suf- automation and hermetisation of production pro-
ficient partial pressure of water to form a complex cesses), the most serious risk of occupational expo-
- latticed microcrystals hydrates by a fixed config- sure exists for workers in the operations associated
uration. The system is unstable and pressure drop with loading installations with ethylene oxide and
process is reversible. repairs.

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 OCCUPATIONAL MEDICINE
Although less than 1% of the total production of signal to raise vapour in the working environment and
ethylene oxide is used for dry sterilization, profes- the associated danger.
sionally exposed to ethylene oxide are a large num- USE
ber of persons in all health institutions, responsible Carbon disulfide is mainly used for the produc-
for the sterilization of medical instruments. tion of viscose (rayon) and cellophane. It is a good
METABOLISM AND MECHANISM OF ACTION solvent for rubber, phosphorus, sulfur, fats and wax-
Ethylene oxide penetrates into the body by inha- es. It is also used in the vulcanization of rubber as a
lation or through the skin. A specific narcotic toxic- raw material for the production of rhodanate com-
ity that is most likely related to forming metabolic pounds (thodonides), xanthogenates and potassi-
products are: formaldehyde or ethylene glycol. It is um thiocarbonate. In agriculture is used as a pesti-
possible the formation and trimethylamine. Ethyl- cide.
ene oxide is irritating and sensitizing effect. It is an PROFESSIONAL AND UNPROFESSIONAL
alkylating agent and mutagen, damages male and EXPOSURE
female reproduction. Described are carcinogenic Vapour of hydrogen sulfide detected in the air of
effects in animal experiments and in workers: mon- the working environment in the production of rayon
onuclear leukemia, stomach cancer, peritoneal mes- in the amount of 1 to 10, and in exceptional circum-
othelioma, cerebral glioma. stances and up to 20 mg/m3.
PREVENTION Modern viscose plants eject into the air from 1.5
Main prophylactic measure is the hermetisation to 40 tons of carbon disulfide per day.
of the equipment and communications, wherever In the area up to 2000 m around the plant detect-
possible the formation and separation of ethylene ed concentrations in the range of 0,49-0,03 mg/m3,
oxide. At elevated concentrations in producing ex- but sometimes up to 2 mg/m3.
ceptional measures to protect the UAP, eyes and It is possible contamination of surface water from
skin. Clothing, gloves and boots are waterproof and wastewater plants for artificial leather and rayon.
resistant to ethylene oxide. To protect the UAP used In the treatment of the soil with a 50% emulsion
a gas mask filter type. of carbon disulphide (as a fumigant) creating air-
When dry sterilization is required to comply with borne concentrations from 2,5 to 6,7 mg/m3. After
all requirements of the instructions. After fumiga- 24 h of carbon disulfide is not evidenced.
tion the premises must be ventilated mandatory. METABOLISM AND MECHANISM OF ACTION
The predominant route of entry into the body in
CARBON DISULFIDE manufacturing conditions is inhaled. Important and
Empirical formula: CS2 dermal route - for 1 h through the skin can be ab-
Structural formula: S sorbed 17 mg hydrogen sulfide.
C Inhalation of hydrogen sulfide vapour initially ab-
sorbed 60-80% and 20-30% at the end of inhalation.
S Equilibrium is reached quickly (within 1 h). The majori-
HYGIENE STANDARDS ty of the absorbed amount is associated with proteins,
Air of the working environment: Mean-shift peptides, amino acids, biogenic amines and sugars.
MAC - 10 mg/m3, proved gonadotrophic and embry- Are formed dithiocarbamic, thiocarbamic and xanto-
otoxic action for animals. genic acid. 10 to 30% of the absorbed carbon disulfide
Air settlements: Daily average MAC: 0,005 mg/ exhaled and less than 1% is excreted unchanged in the
m3, maximum single MAC: 0,03 mg/m3. urine; 70-90% is subjected to biotransformation and
is eliminated from the body as metabolites: thiourea,
GENERAL CHARACTERISTICS thiocarbamic acids, sulfates, 2-mercapto-2-thiazo-
Carbon disulfide is a colorless liquid with a pleas- line-5-on. The formation of chelates of thiazolidines
ant smell. It has the following properties: a molecular with zinc and copper, as well as the binding of CS2
weight of 76.14, a melting point of - 112°C, a boiling with SH-groups interfere with the normal function of
point of 46,3°C, a density of 1.26 (at 20°C). Insoluble many enzyme systems (in microsomes, cytochrome
practical in water, in ether, alcohol and chloroform P-450). Carbon disulfide violates catecholamines me-
were mixed in all ratios. tabolism - an inhibitor of dopamine- betahydroxylase
When heated to 100°C sulfide vapour igniting. (copper-containing enzyme), which increases dopa-
Combustion releases CO2 and sulfur dioxide. With the mine and reduced norepinephrine. Another possible
air forms explosive mixtures in concentrations from mechanism is the impact on vitamins - established a
1.25 to 50 volume %. reduction of vitamin B6, as a result connecting dithio-
The odor threshold is below MAC, which is a good carbamic acid with pyridoxamine.

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As lipoidosolvent carbon disulfide is narcotic, PROFESSIONAL AND UNPROFESSIONAL
causing toxic encephalopathy (acute or subacute poi- EXPOSURE
soning) can result in death. Chronic action features in Content of phenol in the air of production facili-
addition to damage to the central nervous system ties and into the air, water and soil varies widely.
and with pronounced effects on lipid metabolism - In the production of phenol are registered con-
dyslipidemias; atherosclerosis; increased incidence centrations from 1 to 6 mg/m3; in impaired hermeti-
of ischemic heart disease and arterial hypertension; sation of equipment increased to 2 times and more.
retinal microangiopathy; reproduction - mostly sper- Obtaining phenol by carbonization of coal is accom-
matogenesis, but also female reproduction. panied by a concentration in the main workshop of
To assess the degree of exposure is determined: 10-25 mg/m3, in the workshop of distillation - 50-90
carbon disulfide in exhaled air, carbon disulfide in mg/m3.
blood and urinary metabolites (iodine-azide test). The concentration of phenol in ambient air
PREVENTION around the ferrous metallurgy off 500, 1000, 2000
In addition to sanitary and technical measures to and 5000 m is respectively: 0,1-0,4 mg/m3; 0,2-0,36
reduce the concentration of carbon disulfide in the mg/m3; 0,04 mg/m3 and 0,03 mg/m3. At this level of
air of the working environment through maximum air pollution in the belt of about 2500 m away from
hermetisation, production automation and effective the source of contamination phenol in soil varies
ventilation for workers in contact with carbon disul- from 0.06 to 19,2 mg/100 g of dry soil. Autotransport
phide recommended: optimal regime of work and also a source of phenol - in the air of the settlements.
rest, quenching procedures safety professional nu- High concentrations of phenol settled in waste-
trition to enhance the body’s resistance, mandatory water during thermal processing of solid fuel for the
preliminary and periodic medical examinations with production of phenol phtalein, salicylic acid, salol,
the participation of a neurologist, obstetric-gyne- where regeneration of tires and others.
cologist, if necessary and psychiatrist. METABOLISM AND MECHANISM OF ACTION
In production conditions phenol penetrates the
PHENOL (carbolic acid, oxybenzene) body mainly by the inhalation and dermal route. Res-
Empirical formula: C6H5OH piratory absorption is high - 70-80% of the amount
Structural formula: inhaled. Vapour of phenol pass directly through the
skin. Absorbed phenol is rapidly distributed uneven-
OH ly in the tissues: kidney, liver, heart, blood, muscles.
HYGIENE STANDARDS The phenol and diphenol metabolites conjugat-
Air of the working environment: ed with sulfuric acid and glucuronic acid.
Mean-shift MAC 7,8 mg/m3. With breath eliminate traces of unchanged phe-
Air settlements: Daily average MAC 0,01 mg/m3, nol. Small amounts are released as CO2. The basic
maximum single MAC 0,01 mg/m3. amount (over 90% of absorbed) is excreted in urine
Surface water: I category - 0,01 mg/dm3, II cate- as free and bound phenolics - in the form of sul-
gory - 0,05 mg/dm3, III category - 0,1 mg/dm3. phates and glucuronides.
GENERAL CHARACTERISTICS The amount of total phenol in urine is exposition
Phenol is one of the most widespread pollutants. test.
Colourless crystalline solid with a characteristic Like other lipoido-solvents, phenol impairs the
(specific) odor. Molecular weight 94.11, a melting point function of the CNS, more pronounced at higher
of 40,9°C, a boiling point of 188,7°C, a density of 1.0576 concentrations in acute impact. Phenol is highly ir-
(20°C). The crystals of the phenol by the action of oxy- ritating to mucous membranes and skin. Binding to
gen in the air are stained in pink color is due to the qui- protein and subsequent denaturation and precipita-
none - a product of the oxidation. In 100 cm3 of water tion makes cytotoxic to all cells - causing tissue ne-
at 16°C was dissolved 6,7 g phenol - form is a hydrate. crosis, in addition to skin and mucous membranes,
The phenol was dissolved well in chloroform, ether, oils also in liver, kidney, heart, urinary tract with appro-
and organic solvents. Technical phenol is a rust-red to priate functional disabilities.
black viscous liquid. Described is carcinogenic effects - skin cancer, in
USE contact with phenol in experimental animals, but
The phenol is widely used for the preparation has not been confirmed in humans.
of phenol-formaldehyde and other resins (bakelite, PREVENTION
carboline), caprolactam, aromatics, medicinal sub- Preliminary and periodic medical examinations
stances, antiseptic and tanning agents, plastics, dyes are required. All workers receive in advance instruc-
and direct for disinfection. tion for individual precautions and safe handling.

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In the presence of phenol vapour in excessive or consuming formaldehyde. Contained in exhaust
amounts in the air of the working environment it is gases of diesel vehicles. It may be formed as a by-
necessary to use a gas mask filter type and the pres- product as a result of a complex photochemical re-
ence of aerosols - the same mask with filter or res- action, a catalyst which is UVR.
pirator. Mandatory take precautions to protect eyes By wastewater possible contamination of
and skin from liquid phenol. Recommended suits groundwater and water of open reservoirs.
of thick, impregnated fabric, gloves and overalls. It On the territory of industrial enterprises pollution
prohibited the export of work clothing outside for of soil can reach 18-72 mg/100 g of dry soil, which
washing at home. In the medicine cabinet of work- can also lead to significant pollution of groundwa-
shop should have always diluted alcohol (10-40%) ter. Persistent in the environment at 20 ° C to 5 days.
for washing the skin after pouring of phenol. METABOLISM AND MECHANISM OF ACTION
It recommended for workers to organize safety Formaldehyde is highly irritating and sensitizing
professional nutrition (diet D) and include vit. B1 and effect. Central nervous system depression and es-
calcium pantothenate. pecially ocular hills, which most likely is due to its
metabolites: methyl alcohol and formic acid. It has
FORMALDEHYDE mutagenic and carcinogenic effects of chronic ex-
Empirical formula: HCHO posure. Described are also the development of neu-
Structural formula: rasthenia syndrome, bronchial asthma, neuritis n.
O
opticus, effects on reproduction.
H-C
Formaldehyde is an important intermediate me-
H tabolite of the body. Formed intracellularly as 5-,
HYGIENE STANDARDS 10-metilentetrahydrofolic acid.
Air of the working environment: Exogenously penetrates into the body by inha-
Mean-shift MAC - 1,0 mg/m3, lation, ingestion or skin absorption. About 95% of
Maximum single MAC - 2,0 mg/m3. Irritation, pos- inhaled quantity absorbed and rapidly metabolized
sibly carcinogenic to humans (Group 2A). to formic acid under the influence of formaldehyde
Air settlements: Daily average MAC - 0,003 mg/ dehydrogenase. The majority of the received formal-
m3, maximum single MAC 0,035 mg/m3. dehyde in the body is transformed by intermediates
Surface water: I category - 0,5 mg/dm3; Catego- (formic acid and methanol) to CO2, low fraction of
ry II - 0,5 mg/dm3; Category III - 1 mg/dm3 formaldehyde is excreted in urine.
Formaldehyde reacts with macromolecules:
GENERAL CHARACTERISTICS DNA, RNA and proteins (pathogenetic mechanisms
Formaldehyde is a gas with a sharp odor. Syno- of carcinogenic effect).
nyms: formic aldehyde, methanal oxomethane. Mo- For exposition test serve concentrations of for-
lecular weight 30.03. Easily soluble in water - 35-40% maldehyde in blood and urine.
aqueous solution is called formalin. Gaseous formal- PREVENTION
dehyde burn and with air and oxygen form explosive To reduce exposure in industrial settings is rec-
mixtures. ommended: hermetisation of technological pro-
USE cesses, introduction of continuous processes, work
It is used as a monomer in the production of ar- on vacuum apparatus, remote control. If possible
tificial (synthetic) resins and polymers on their basis: replacement of formaldehyde as a preservative with
urea, phenol-formaldehyde and melamine-formal- low toxic substances.
dehyde resins; synthesis of methenamine, drugs For personal protection recommended airtight
and explosives, dyes (indigo, rosemary, auras, acrylic goggles, waterproof suit, boots and gloves to pro-
paints); in leather, paper-pulp, textile industry. Ex- tect UAP: gas mask filter type, but at high concentra-
cellent preservative properties of formaldehyde are tions - insulating type.
used in photography and storage of plant and ana- Absolute contraindications for work are diseases
tomical preparations. from asthma and others allergic states and viola-
PROFESSIONAL AND UNPROFESSIONAL tions of the indicators of external breathing.
EXPOSURE
Formaldehyde is one of the best known muta-
gens and this requires strict control in professional
contact with the substance.
A constant source of environmental contamina-
tion with formaldehyde are enterprises producing

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 D.Tsonevsky, M. Lyapin

7.13 PESTICIDES

In agriculture and forestry pesticides1 used to compounds, chlorfenoxy herbicides, contaminat-

combat plant pests - bacteria, viruses, acarides, ed with dioxins, some of thiourea derivatives. Also
worms, rodents, weeds. To the group of pesticides ChlOC and dioxins can for months and years to keep
concern and means for defoliation and destruc- unchanged in the environment and accumulate in
tion of shrubs and trees, for regulating growth. This the body.
group includes means for disinsection and deratisa- Deficiencies that have chemical agents used
tion used in households, industry and healthcare. in agriculture led to an increased demand for new
Pesticides are generally chemical compounds products, safer for the environment, people and an-
which are artificially synthesized or derived from imals. These are biological means for plant protec-
vegetable products. Recently they have been creat- tion. Failure to comply with the rules when working
ed and pesticides of biological agents such as bacte- with them, however, they can also cause chronic
ria, viruses, fungi and the like. In this connection, the poisoning, hypersensitivity, imbalance of the natural
term pesticide includes both chemicals and micro- microflora of body, contact dermatitis.
organisms used for pest control. There are several criteria for the classification of
The oldest pesticide agents were organic sub- pesticides:
stances of natural origin such as tobacco, piretrium, 1. According to its use pesticides are divided
petroleum derivatives. Later began to be used, and into:
inorganic compounds such as the salts of copper, acaricides - against ticks;
mercury, arsenic - eg. yet in 1860 successfully used algaecides - to destroy algae and other vegeta-
so-called Paris green - copper acetoarsenite, against tion in the basin;
Colorado potato beetle. In 1930, there were 30 pesti- antihelmintics - to struggle with parasitic worms;
cides for agriculture - are most commonly used lead antiresistantes - special additives that reduce the
arsenate, pyrethrum and nicotine, and in the world resistance of insects to certain substances;
today use about 1,400 pesticide active substances, antiseptics - prevention of microorganisms;
included in about 60 000 commercial preparations. attractants - substances that attract insects;
In world production of over 4 mln. tons of pesticides aphicides - to combat aphids;
annually, the primary user is the US - 35-40% of the bactericides - anti-bacteria and bacterial plant
total. In our country are used on average 120-140 diseases;
pesticide, as an annual average in the country ap- gametocides - substances causing sterility in
plied to 20-25 000 tons of active substances. Sys- weeds;
tematic use allows for increased production in ag- herbicides - weed control;
riculture by an average of 60-80%. Conversely, only desiccants - the destruction of shrubs and low
a few years a greater spread of pests can cause the vegetation;
destruction of hundreds of thousands of acres agri- defoliants - to cause early loss and drying the
culture cultures. leaves;
Widespread application of pesticides, however, rodenticides or zoocides - for rodent control;
lies the potential for disruption of the ecological insecticides - to combat harmful insects;
balance in nature and may have serious - direct and larvicides - to destroy the larvae and caterpillars
indirect effects on health. This translates into direct insects; nematocides - against round worms;
or indirect, professional or household intoxication ovocides - chemicals, killing eggs of insects;
- acute, subacute and chronic poisoning, lowering growth regulators - substances affecting the growth
the reactivity of the body, sensitization, early and and development of plants;
late genotoxic effects (teratogenesis, embryo- and repellents - to repel insects;
gonadotoxicity, mutagenesis and carcinogenesis). fumigants - substances applied in vapour or gas-
In this respect especially dangerous organochlorine eous (gas, mist, smoke);
fungicides - to combat fungal diseases of plants.
1
Pesticides - lat. pest - wracker and cido- destroy, kill

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 OCCUPATIONAL MEDICINE
In the nature of penetration insecticides (most ability of antidotes, irritation of skin and mucous
used pesticides) are divided: contact insecticides membranes, allergic action. Furthermore, they can
- that kill insects on contact with the body; gastro- be considered: the type of formulation (pellets, liq-
intestinal - that penetrate the body of the insect uid, aqueous solution), available emulsifiers, the vol-
through the digestive organs; systems - that have atility of the pesticide.
the ability to move in the vascular system of plants To avoid acute and chronic poisoning with pes-
and insects destroyed after use of plants for food; ticides necessary knowledge of the following posi-
fumigants - that penetrate the body of the insect tions:
through the bodies of breathing (many preparations 1. Methods of application.
may come in different ways, but determining what is 2. Paths of penetration in the body.
a main route) 3. Toxicological and hygienic characteristics.
2. Chemical classification. In their chemical 4. Preventive measures in transport, storage and
composition pesticides are divided into 22 groups use.
(Table. 1). Any substance in the group has its own Methods for application of pesticides are de-
characteristics and different from other mostly by pendent on certain agrochemical requirements and
pesticides and toxic action, but generally they are hygiene rules. The most commonly used: dusting,
similar and often with the same mechanism of ac- spraying of solutions, suspensions or emulsions; de-
tion. contamination in liquids, laying of poisoned baits;
Table № 1 fumigation of rooms etc. Spraying with solutions
CHEMICAL CLASSIFICATION OF PESTICIDES (the most commonly used method) is done, by
Chemical group back-pack sprayers, mechanical tractor sprayers and
1. Phosphorganic specially equipped aircraft and helicopters.
2. Chlororganic Workers are exposed to contact with the active
3. Carbamates and thiocarbamates ingredients in the preparation of working solutions
4. Dithiocarbamates during charging of the sprinklers, in the direct treat-
5. Triazines ment of crops, during cleaning of the machines.
6. Dichlorfenoxyacetic acid derivatives Routes of the penetration of pesticides into the
7. Derivatives of urea body are: through the skin, visible mucous mem-
8. Derivatives of amides and anilides branes, respiratory system and through the gas-
9. Dinitrocompounds trointestinal tract. The methods of application of
10. Coumarin derivatives pesticides determine opportunities for penetration
11. Copper preparations in the body, but believes that a leading path in pro-
12. Sulphur preparations fessional poisoning is skin (possible are both three
13. Benzoilphenylureic ways). In some cases, the exposure through the skin
14. Dipyridilic derivatives is 100-1000 times higher compared with that by the
15. Pthalimides respiratory tract, such as the highest skin permea-
16. Sulphates, sulfones and sulfonates bility have emulsified concentrates, as a result they
17. Benzimidazoles contain organic solvents and emulsifiers. Easily solu-
18. Synthetic pyrethroids ble in lipids PhOC, ChlOC, mercury preparations and
19. Triazoles nitrophenols quickly penetrate caught on exposed
20. Phosphides parts of the body, but it can be done and contam-
21. Methyl bromide inated clothing. Spraying with knapsack sprayers
22. Other preparations and mixes creates the greatest risk of passing the pesticides
3. Hygienic classification. This classification through the skin.
includes criteria for evaluating pesticides from a By respiratory pesticides penetrate the body in
health and environmental perspective. Pesticides all cases of their application, but the highest pro-
are divided into 4 groups (Table. 2 and 3) depend- fessional risk when used indoors, when working in
ing on their toxic parameters - acute toxicity and sloping terrain, wind or falling into a cloud of pesti-
early and late neurotoxic and genotoxic damage cide spraying in jet.
(most often a limiting criteria is DL50 in rat after oral Penetration of pesticides through the gastroin-
treatment). The criteria also include: percutaneous testinal tract, most commonly seen in suction mouth
toxicity, inhalation toxicity, cumulation, sustainabili- of working solutions, nutrition and smoking with un-
ty in the environment, mutagenic, carcinogenic and washed hands, improper use of personal protective
teratogenic action, embryotoxicity, the possibility equipment, ingestion of concentrated preparations
of acute poisoning, treatment options such as avail- (criminalized cases). Poisonings have been observed

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Table № 2. Criteria for classification of pesticides
May be used only Work certificate is Allow for wider use
Not registered
by specialists required Category III
Criteria Extremely dangerous
I category Category II Slightly dangerous
Zero category
Very dangerous Moderately dangerous
Acute toxicity
Oral – DL 50
Solid form To 10 mg/kg 11-30 mg/kg 31-150 mg/kg Over 150 mg
Liquid form To 50 mg/kg 51-100 mg/kg 101-500 mg/kg Over 500 mg/kg
Inhaler
To 200 mg/m 3 201-1000 mg/m3 1001-2500 mg/m3 Over 2,500 mg/m3
CL50 (4 h)
Irritation of skin
Highly corrosive Corrosivity Irritation No irritation
and eyes
Allergens in humans,
Pronounced in humans
Sensitization non-sensitizing effects in Supposed effect No sensitizing effects
and guinea pigs
guinea pigs

Proven abnormalities in Abnormalities in

Teratogenic effect Proven abnormalities Lack of teratogenesis
experimental animals - animals with less than
in people
in 50% of them 50% of the treated
Proven in humans and Demonstrated in a
Carcinogenic effect No carcinogenic effect No carcinogenic effect
in more than one species laboratory animals
and suspicious for people

Table 3. Criteria for classification of pesticides proposed by the Agency for Environmental Protection (EPA) - USA
Criteria Class pesticides
І ІІ ІІ ІV
Oral LD 50 50 mg/kg 50-500 mg/kg 500-5000 mg/kg 5000 mg/kg
(for rat)
Inhaler CL 50 0,2 mg/l 0,2-2 mg/l 2-20 mg/l 20 mg/l

Dermal LD 50 200 mg/kg 200-2000 mg/kg 2000-20000 mg/kg 20000 mg/kg

Eye effect Corrosion; corneal Corneal opacity, which is Corneal not darkens No inflammation
opacity, which did not restored to 7 days. inflammation is restored was observed.
recover to seven days. to 7 days.

Skin effect Corrosion. Strong inflammation Medium inflammation Low inflammation

at 72 h. at 72 h. at 72 h.
Preventive Fatal after ingestion, Can be fatal after ingestion, Damage after ingestion, Low inflammation
measures inhalation or absorption or absorption through the inhalation or absorption at 72 h.
through the skin. Do not skin. Do not breathe vapors through the skin. Do not Not required
breathe vapors or dust. or dust. Do not fall into the breathe vapors or dust. precautions.
Do not fall into the eyes, eyes, skin or clothing. Avoid contact with eyes,
skin or clothing. skin or clothing.

in the consumption of treated food without compli- - lindane, keltan, melbecs) assist both accelerated
ance with the guidelines (quarantine, etc.), or if used detoxification and to accelerate the “lethal synthe-
for food decontaminated with mercury preparations sis” - eg. for some PhOC (parathion, metilparathi-
cereal seed. on, ftalofos) wherein in the metabolism are formed
Metabolism much more toxic (hundreds of times higher anticho-
The biotransformation of pesticides is carried linesterase activity). It has been found that certain
out by mixed function oxidases (MFO) mainly in liv- pesticidal mixtures consisting of PhOC, ChlOC, de-
er endoplasmic reticulum. The rate of metabolism rivatives of carbamic and dithiocarbamic acid can
affect a number of factors affecting the activity of have a highly toxic effect in comparison with the
enzymes involved in the MFO as: age, sex, genet- individual components, but in most cases (suita-
ic predisposition, general diseases, nutrition, daily ble mixtures thereof ), decrease the toxicity of the
routine, alcohol, substances inducers or inhibitors combinations containing PhOC and ChlOC. (Some
of the MFO. The MFO induction (eg. of some ChlOC medications (phenobarbital) are also strong induc-

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 OCCUPATIONAL MEDICINE
ers of the MFO and can be used as a prophylactic zymes like other esterase, oxidase, lipase and pro-
exposure to pesticides or treatment of intoxication.) teinase.
Basic requirement when choosing a pesticide and For preliminary and ongoing sanitary control in
evaluation of selective toxic action, involving high working with PhOC importance is the study of se-
efficiency respect to insects and maximum safety rum ChE. In lowering the ChE more than 30% from
for warm-blooded animals and man. For example, baseline, workers must be removed from work.
pesticides Actellic, Hortet, Valekson, Antio have up Symptoms of poisoning occur in lowering ChE with
to 10 times more effective than Metafos for insect more than 50%, while chronic exposure due to ad-
(by CL50) and at the same time have from 200 to 2000 aptation processes symptoms can occur at very low
times less toxic to warm-blooded animals and man. levels of ChE - 15-20% from baseline. A specific anti-
dote for PhOC is atropine.
ORGANOPHOSPHORUS COMPOUNDS
First organic phosphate - tetraetilpyrophosphat CARBAMATES
(TEPP) was synthesized in 1854, but the develop- General characteristics. Specimens of this
ment of PhOC was in the thirties of the twentieth group are used as insecticides, fungicides and her-
century when in Germany synthesized the so-called bicides. Carbamate pesticides are complex esters
“Nerve paralytiq gases” - zarin, tabun and zommer of N-methylcarbamate (baygon, dekrezil, sevin,
(chemical warfare). During the 40s and 50s are syn- mezurol) and N-dimethylcarbamic acid (pyrrolyl,
thesized many new PhOC-insecticides, mainly in RP-62). Naphthyl and cresyl esters of methylcarba-
Germany (Schroeder). mic acide are less toxic to warm-blooded, compared
General characteristics. Organophosphorus with dimethylcarbamic acid derivatives which con-
pesticides due to a number of benefits have largest tain in their molecule heterocyclic radicals (pyrrolyl).
application. In agriculture, used as insecticides, aca- Carbamates do not accumulate in the environment
ricides and defoliants. Some of them apply for disin- and not general phytotoxicity.
section - in domestic animals, on premises. PhOC, Toxicological characteristics and mechanism
are complex esters of a number of acids - phosphor- of action.
ic acid, dithiophosphoric, thiophosphoric, pyroph- Carbamate compounds mainly enter the body by
osphoric. The main advantage over other pesticide inhalation and dermal route. They can cause acute
that decompose relatively quickly in the environ- poisoning, and, like PhOC inhibit the activity of ChE.
ment. The resistance varies depending on the type of This explains the similarity of the clinical picture in
compound - from one day to several months. Some both groups pesticides. Unlike PhOC reactivation
of systemic insecticides, however, can be saved and of the enzyme it is very fast and occurs and after
up to one year (sayfos, formothion). having taken blood (this requires analysis of ChE be
Toxicological characteristics and mechanism carried out within 2-3 hours of taking the sample).
of action. Upon termination of exposure to carbamate prepa-
Organophosphorus pesticides are compounds of rations symptoms disappear mostly after 1-2 hours
varying toxicity to humans and warm-blooded an- and there are no known cases of chronic poisoning.
imals. They enter the body by inhalation, skin and In toxicodynamics esters of methylcarbamate (se-
digestive tract. Typical of these compounds that can vin) are essential damage to the endocrine organs,
enter the body through intact skin without causing disruption of oxidative process and nucleic acids
irritation (this represents a great danger to work- metabolism.
ers). After absorption in the body of larger amounts
of PhOC was observed inhibition of cholinesterase DITHIOCARBAMATE COMPOUNDS
(ChE) - an enzyme that hydrolyzes acetylcholine to General characteristics. Dithiocarbamate com-
choline and acetic acid. Specific AChE (acetyl cho- pounds are widely used in agriculture mainly as
linesterase) locates in ganglionic and myoneural fungicides in the treatment of fruit, vegetable and
synapses in the central brain structures and in eryth- cereal crops, or in seed treatment. The derivatives of
rocytes, and pseudo-cholinesterase - mainly in plas- dithiocarbamic acid (DTCA) as pesticides are used
ma and liver. PhOC generally inhibit both enzymes, the salts of methyl-DTCA (karbation), dimethyl DT-
which resulted in nerve ganglia, in myoneural syn- CA(TMTD, ferbam, ziram), ethyl-bis-DTCA (zineb,
apses and brain structures accumulate acetylcho- maneb, nabam, policarbazin) and ethyl- and methyl-
line. Occurring endogenous acetylcholine poison- esters of DTCA (preparation 23, zistogon). Further-
ing, which determines the main clinical syndromes more, in agriculture are widely used different mix-
of poisoning: muskarinic, nicotinic and cerebral. tures of dithiocarbamates (cuprozin - a mixture of
Organophosphorus pesticides inhibit other en- zineb and copper salt of ethylene-bis-DTCA), deptan

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 LABOUR MEDICINE
C-45 (mixture of zineb and maneb) and mixtures of years, they are the most widely used insecticides,
dithiocarbamates and other compounds such as DDT, aldrin, dieldrin, chlordane, heptachlor, lindane
kuprozan and miltoks, maneb and nickel sulphate. and toxaphene. Their high persistence in the envi-
In the environment dithiocarbamates decompose ronment (around 20 years half-life) and their accu-
relatively rapidly, whereby toxic volatile compounds mulation in warm-blooded animals and humans
(carbon disulfide, hydrogen sulfide, dimethylamine). however, have led in recent decades to ban many of
Upon destruction of the dithiocarbamate into the them.
environment and form stable compounds (dime- ChlOC represent chlordeviratives of polycyclic
thyl-DTCA, tetramethiltiourea, ethylenethiourea, hydrocarbons (DDT), compounds of cyclodiene row
dimethylamine). Ethylenethiourea is removed after (tioneks), bicyclic aromatics - bichlorfeniles (keltan,
heat treatment of food products treated with dith- methoxy), cycloparaffins (lindane), chlorinated ter-
iocarbamates. penes and camphenes (toxaphene).
Toxicological characteristics and mechanism A distinctive feature of many ChlOC is the so-
of action. called process of biomagnification. This phenom-
Dithiocarbamates may enter the body through enon is characteristic of compounds with much
the respiratory system, skin and through the diges- greater stability in the environment and in organ-
tive tract. Acute poisoning when they enter through isms and is characterized by a gradual accumulation
the mouth and skin are not observed, given their along the food chain (ex. content of DDT in meat
low toxicity. Upon their receipt by the inhalation water gulls can exceed a million times its content in
route are possible poisoning both the starting com- water ponds).
pounds of DTCA, and the products of their destruc- Toxicological characteristics and mechanism
tion (carbon disulfide, hydrogen sulfide, methyltioi- of action.
socyanate). The majority of dithiocarbamates do not Organochlorine pesticides can enter the body
have a local irritating effect in single application on through the respiratory system, skin or mouth. Un-
the skin, but often repeated contact sensitization is like PhOC and carbamates penetration through the
observed (cineb, maneb, TMTD, ciram) - dermatitis, skin is less stringent, (depending on the solvent
bronchial asthma. used). When ChlOC greater the risk of chronic poi-
In animal experiments are established early and soning (accumulation). Degrades predominantly in
late genotoxic effects (embryotoxicity, teratogenic- liver (inducing the MFO), central nervous system and
ity, gonadotoxicity, blastomogenic and mutagenic). gastrointestinal tract. Symptoms of acute toxicity is
These effects occur in entering the body of amounts largely determined by the way of administration of
greatly exceeding the real ones. It is believed that the poison in the body. The mechanism of action of
these effects are due to their degradation products pesticides are associated with impairment of several
(ethylenethiourea, etilentiouram disulfid). enzyme systems (of the respiratory chain, carbohy-
Dithiocarbamate compounds are distinguished drate metabolism), which often leads to tissue hy-
by high reactivity to metals, which form metal poxia. Hydrocarbons of the aliphatic range block the
complexes and thus influence the activity of many sulfhydryl groups of enzymes and deplete protein
enzymes. They block the enzymatic conversion of synthesis, and ChlOC diene synthesis by inhibiting
inorganic iodine in an organic, and at chronic oral the activity of cytochromoxidase.
administration to experimental animals, can cause In chronic exposure to ChlOC described cases
hyperplasia of the thyroid gland. of aplastic anemia in workers, and in animal experi-
ments found carcinogenic effects of chlordane, hep-
ORGANOCHLORINE COMPOUNDS tachlor, toxaphene, aldrin and dieldrin.
In 1874 synthesized DDT (dichloro-diphe-
nyl-trichloroethane), but only in 1939, Paul Mueller SYNTHETIC PYRETHROIDS
discovers the insecticidal qualities and its commer- Pyrethrum (extract from color chrysanthemum)
cial production, production of other ChlOC, and is one of the oldest and high insecticidal activity of
their use at 1945. natural pesticides. It contains 6 active ingredients -
General characteristics. Organochlorine com- pyrethrins (pyrethroids) - esters of pyrethrinic and
pounds (ChlOC) is applied in agriculture and forestry jasmine acids. After World War II synthesized pyre-
and for health purposes as insecticides, acaricides, thrins (synthetic pyrethroids) with molecules similar
fungicides. Their importance for elimination or re- to natural but modified for stability.
duction of yellow fever, malaria and other parasitic General characteristics. Synthetic pyrethroids
diseases transmitted by insects is extremely high, are among the most active insecticide (with low
especially in tropical climates. In the past - 50-60 toxicity for humans). They are analogues of cyclo-

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 OCCUPATIONAL MEDICINE
propanecarbonic acid. There are hundreds of com- DINITROPHENOLS1
mercial preparations containing pyrethrum and General characteristics. Nitrophenols are
synthetic pyrethroids, often in combination with preparations with a relatively high toxicity, is very
synergists - PhOC or carbamates. Apply for seed versatile in agriculture (such as insecticides, acari-
treatment, in vegetable and fruit growing, viticul- cides, ovicides, fungicides and herbicides). In fact,
ture, rooms, in minimal concentrations - 0.01-0.1% they are one of the oldest insecticidal agents - are
active ingredient. Compared with PhOC at ten-rate used as such in the 19th century, and as herbicides
lower concentrations they have the same effect on applied by about 50 years. The most widely spread
different insects. In the environment are degraded are selinon (4,6-dinitroorthocresol - DNOC) karatan,
rapidly from 1 to 3 weeks after application. For ex- acricide and acrecs. Selinon contain 50% dinitroor-
ample, in some of them (karate vastak, detsis) one tocrezol and 50% fillers and has a insecticidal, fungi-
day after treatment of fruit and vegetables remain cidal and herbicidal activity.
negligible amounts of preparation. Toxicological profile and mechanism of ac-
Toxicological characteristics and mechanism tion.
of action. Dinitrophenol have different toxicity to humans
Synthetic pyrethroids may enter the body and warm-blooded animals (Table. 4)
through the respiratory system and digestive tract Dinitrophenol enter the body by breathing, di-
and fall on the skin. In humans, they decompose gestive tract and through the skin, emit relatively
and emit much faster than in insects and fish - it also slow (3-4 days) in the urine, unchanged or associat-
defines the very most toxicity to insects. Acute and ed as glucuronide. Hepatic metabolism is negligible.
hard poisoning in humans have not been report- DNOC accumulates in the body. In blood this
ed. While exposure to pyrethrum are typical and preparation is combined with plasma proteins and
frequent allergic contact dermatitis (described and form compounds, kept for some time in the body.
allergic rhinitis, bronchial asthma, hypersensitivity In warm-blooded animals is reduced to amino com-
pneumonitis, etc.) In synthetic pyrethrins allergic re- pounds. Emits significantly slow in the urine, where
actions have not been reported. If on skin can cause find as amidofenol.
itching and burning, with no evidence of local in- The mechanism of action of dinitrophenols
flammation. In rare cases can cause eczema, or skin comprises impairment of enzymatic systems and
inflammation. blockage of oxidative phosphorylation. As a result,
The mechanism of their action is not fully under- increased oxygen consumption and production of
stood. To clarify the causes of neurological disorders heat, impairs thermoregulation and increased body
in mammals (seen only at high doses pyrethroids) temperature. In poisoning by DNOC increases aer-
were studied neural mediators and an increase in obic glycolysis due to hyperglycemia to yield a de-
some of them (in insects, however, the main mecha- cline of glycogen in muscle and liver. During the
nism of their action is neurotoxic). summer days the risk of poisoning is greater, be-
The toxicity of some pyrethroids is enhanced by cause the heat caused the increase in basic cellular
inhibitors of MFO in mice, and they themselves to metabolism.
varying degrees induce mixed function oxidases. Characteristic of systemic poisoning with these
Some pyrethroids (permethrin, respethrin) cause preparations is the total hypermetabolism, which is
carcinogenicity in experimental animals. reflected in the clinical picture - profuse sweating,

Tab. 4. Dinitrophenols - administration and toxicity

Designation Dosages and concentra- DL50 mg/kg Quarantine -
Name Active substance Antidote
tions of application per os day
Karatan dinoxan fungicide 1-2 kg/ha
acaricide 0,1-0,2% solution 980 – 21

Akreks dinobuton acaricide 7 kg/ha

0,1% solution 140 – 20

Selinon DNOC acaricide 10-20 kg/ha

insecticide 3% solution 20-50 – 45
fungicide

Acricide binapacryl 40% acaricide 0,1-0,2 % 150 – 21

1
M. Lyapina

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 LABOUR MEDICINE
thirst, flushing, fever, anxiety or euphoria, tachycar- dangerous and they are used less frequently. Table
dia, hypertension and others. 5 presents some organic herbicides with relatively
Conflicting data on local irritation of DNOC. It weak health effects.
is known, however, that commercial preparations The herbicides are degraded in the environment
based on DNOC irritate the skin and mucous mem- to 1-2 years and in plants hardly found in good agri-
branes, and one of the chronic effects of these cultural practice.
preparations is the development of dermatitis. Yel- Toxicological characteristics and mechanism
lowing of the skin, nails and hair is observed upon of action.
contact with dinitrophenols; coloring of the sclera The major route of penetration in the body when
and urine is a sign of systemic absorption. applying herbicidesis is dermal; possibly penetrate
into the body of individuals without occupational
HERBITCIDES2 exposure - in the form of impurities in food or resi-
General characteristics. dues on crops. Herbicides generally possess low tox-
Herbicides are pesticides that prevent or control icity to mammals. There is relatively little informa-
the growth of weeds, or destroy them after their tion on the pharmacokinetics and their mechanism
appearance. This chemical method of weed control of action in humans. Certain herbicide formulations
largely replace mechanical (committed fewer peo- containing organic solvents, surfactants, emulsi-
ple). The herbicides are now the most widely used fiers, and other additives and binders, which may
pesticides - they make up 60% of total sales of pesti- cause irritation of eyes, nose and throat (spray with
cides in the US and 40% of those worldwide. herbicides), as well as dermatitis in prolonged skin
In the group of the herbicides include plant contact. Some of the herbicides exhibit allergenici-
growth regulators, defoliants, and desiccants. De- ty and photosensitizing effect. There is evidence of
pending on the activity spectrum herbicides are carcinogenic effects of some herbicides (alachlor) in
non-selective, total, affecting all plants and selective the experiment.
affecting specific target weeds. In connection with
the mechanism of action they have contact (attack PHENOXYACETATIC ACID - DERIVATIVES
plant parts in direct contact) and systemic (are ab- General characteristics. The herbicides of this
sorbed by plants). group include 2,4-dichlorophenoxyacetic acid - (2,4-
The herbicides are mainly the following groups: D - the most widely used in Bulgaria), 2,4,5trichlor-
salts of phenoxyacetic acid and phenoxypropano- fenoxyacetic acid (2,4,5-T), 2-methyl-4-chlorophe-
ic, nitro- and chlorophenols, dipyridyls, triazines, noxyacetic acid (MCPA), as well as their salts and
carbamates and the like. Inorganic herbicides are esters. Formulations silvex, kuron and fenac are
homologs of 2,4,5-T and 2,4DB, MCPB, MCPCA and
Tab. 5. MCPP are homologs of 2,4-D and MCPA, respective-
Name DL 50 (mg/kg) per os ly. These are systemic herbicides relatively selective
Alachlor 1,000 for deciduous plants used against weeds of cereals.
Amitrole 1,000 2,4,5-trichlorophenoxyacetic acid and its ho-
Ammonium sulfamate 4,000
mologs are no manufactured in the USA, because
Atrazine 3,000
Bifenox 6,500 combining these drugs with chlorinated dibenzodi-
Dalapon 6,500 oxins (2,3,7,8-tetrachlorodibenzo-p-dioxin), known
Dicamba 1,000 as strong carcinogens and mutagens. In some batch-
Diuron 3,500 es of 2,4-D is also found to be contaminated with
Etfluralin 10,000
less chlorinated dioxins, ex. dihlordibenzo-p-dioxin,
Glyphosphate 4,300
Linuron 1,500 but has not been established toxicological signif-
Monuron 3,500 icance of any of these contaminants. On the other
Oryzalin 10,000 hand, the experimental data for the teratogenic and
Oxadiazon 3,500 mutagenic action of 2,4-D are associated with con-
Picloram 8,000 tamination of the preparation with dioxins.
Prometon 3,000
Pronamide 5,500 2,4-D is rapidly decomposed in the environment;
Propham 9,000 water pollution with this preparation does not con-
Propanil 1,500 stitute a health problem.
Simazine 5,000 Toxicological characteristics and mechanism
Terbutryn 2,000 of action.
Tertrifluralin 3,500
Herbicides in this group mainly enter the body
2
M. Lyapina through the skin by direct contact with them (in the

267
 OCCUPATIONAL MEDICINE
preparation of mixtures, loading, etc.), inhalation Dipyridyls cause tissue damage as well as in
and digestive tract. 2,4D, and most of the prepara- plants and in mammals, by the generation of oxy-
tions of this group, not cumulative and excrete un- gen free radicals.
changed, easily and quickly through the urine. These herbicides (especially paraquat) have a
The putative mechanism of herbicidal action pronounced irritant effect regardless of the route of
of chlorophenoxyacetic acid includes simulated entry into the body. They damage the epithelial tis-
growth hormones (auxins) of the plants and their ef- sues such as skin, nails, cornea, gastrointestinal and
fects on metabolism. The mechanism of the adverse respiratory tract, and kidneys and liver. Contact of
impact on humans is not yet fully understood. It is concentrated solutions with nails can result in break-
assumed weak blocking of oxidative phosphoryl- ing up and their fall. Aerosols of paraquat entering
ation, which is in extremely high doses resulted in up in the lungs, causing irritation and inflammation.
increased production of heat and hyperthermia. Ingestion of paraquat clinical picture develops
Some formulations of these compositions are in three phases: early - abdominal pain, nausea,
strong irritants to the skin, eyes, nose, throat and vomiting, a second phase with symptoms of liver
respiratory tract and the gastrointestinal tract when and kidney damage and late phase - dyspnea due
ingested. In workers cause dermatitis and chlorac- to pulmonary edema, which quickly evolved into
ne, discoloration or hyperpigmentation. There have pulmonary fibrosis (the ingestion of diquat does not
liver, kidney damage and pancytopenia. There are lead to the development of lung fibrosis). Described
reports of peripheral polyneuropathy, after dermal are also the occurrence of the development of pul-
exposure to 2,4-D in relatively high doses for a few monary fibrosis after exposure to paraquat by skin.
days. Experimental studies suggest that at a dose The development of lung damage is facilitated by
of 40 mg/kg per day for a month 2,4-D resulted in the active accumulation of paraquat in the lungs
an increased incidence of cerebral tumors. Cases of and its slow transmission thereof. In the mechanism
lung cancer, soft tissue sarcomas and lymphomas in of the described effects lies infringement of leucine
humans is also associated with exposure to herbi- metabolism of the alveolar epithelium and the sur-
cides of this group. factant. Impaired integrity of lipid membranes and
phospholipids is due to lipid peroxidation.
DIPYRIDYLS Were reported hundreds of deaths worldwide
General characteristics. The main represent- due to ingestion of small amounts of paraquat. In
atives of this group of herbicides are paraquat order to reduce their frequency is exploring the pos-
(gramoxson is an aqueous solution of technical sibility of adding an emetic to formulations of para-
paraquat dichloride, used and methylsulfate of pa- quat.
raquat) and diquat (trade names reglon and agral).
These are non-selective contact herbicide, widely PREVENTIVE MEASURES DURING
used (especially paraquat) against weeds of vine- TRANSPORTATION, STORAGE
yards, orchards, as defoliants and desiccants, clean- AND USE OF PESTICIDES
ing of weeds in ponds. Paraquat is less stable in
the environment. Diquat absorbed intensive in soil From hygiene measures are particularly impor-
where dissociate under the influence of soil bacteria. tant replacement and banning of persistent and
However, some quantities of preparation, are found, highly toxic pesticides from the first and second
and the seventh month after treatment. group and the introduction of effective but with low
Toxicological characteristics and mechanism toxic action and quickly degradable pesticides (eg.
of action. synthetic pyrethroids).
Occupational exposure dipyridyls can enter the To improve working conditions for loading and
body through skin in contact with solutions, as well unloading of the preparations required mechaniza-
as breathing and digestive tract. The penetration of tion of the main processes. Workers must wear work
paraquat through the skin is facilitated when it is clothing and personal protective equipment. During
compromised the integrity. The contact of concen- the journey and work is forbidden to drink, smoke
trated solution with the skin for a few hours, severe or eat. Provide bathe and change clothes after the
disability and symptoms of general toxic action - are completion of transport.
described cases of acute toxicity and effect of aero- Pesticides stored in warehouses. Built on no less
sols of the preparation on the skin. Overall, paraquat than 100 m away from residential buildings, barns or
is of the stronger toxicity of diquat - acceptable daily warehouses to forage, 200 m away from ponds and
intake for paraquat is 0,002 mg/kg body weight for water sources, 50 m away from the main and 25 m
diquat - 0,005 mg/kg bodyweight. of secondary irrigation canals. The floors need to be

268
 LABOUR MEDICINE
adapted so quickly and easily cleaned and washed. ers should be a distance of at least 5 m apart (prepa-
Wash down water are discharged into a special built rations first category should never be applied using
shaft. Highly toxic and volatile preparations can be knapsack sprayers). Tractors used in plant protection
stored in separate rooms from less dangerous. It is in practice must be tightly closed cabins. Processing of
the stores to have ventilation, running water, over- aircraft allowed to land located at least 500 m away
flow and recuperation of preparations to become from the last buildings of the settlements and 200 m
mechanized. The staff of the store should work re- away from livestock farms. Treatment of areas with
quired with special clothing and personal protective airplanes inhabitants of settlements, adjacent blocks
equipment. shall be notified by the respective municipal coun-
Pesticide products under hygienic requirements cils at least three days pore (specify the day, time,
must be placed in special metal or plastic containers place and used pesticides). For use of pesticides in
or containers with hermetic closure to have durable personal holdings are allowed only preparations III
labels in Bulgarian, contain the exact name of the and IV class.
pesticide, data on his toxicity instructions on how Work clothes are deactivated for 2-3 hours in a
to use precautions and first aid for intoxication. Me- 3% solution of bicarbonate of soda or concentrat-
tallic and plastic packaging can be reused only for ed soap solution, then launder. After each spraying
storing pesticides. workers must provide mandatory bathing or wash-
The preparation of the working solutions is car- ing.
ried out in pre-prepared containers intended for Working with pesticides undergo preliminary and
this purpose. Empty containers are treated with 5% periodic medical examination. At work are allowed
caustic soda and burned in furnaces for solid waste. only healthy persons and 18 years old. Do not allow
The application of volatile products (PhOC, deriv- people with skin, respiratory, infectious diseases,
atives of chlorophenoxyacetic acid and the like.) in neurological disorders, mental disorders, chronic re-
the warmer seasons of the year must be carried out nal and hepatic disease, or used before alcohol. Also
mainly in the morning hours when the air tempera- not allowed pregnant women and nursing mothers.
ture is not higher than 28 ° C and a wind speed of 3 Periodic check-ups are carried out 2 times a year by
m/s. the therapist, neurologist and dermatologist (work-
Always before work is tested functionality of ma- ing with PhOC is compulsory control of ChE in blood
chines. Workers who sprayed with knapsack spray- serum).

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Acids and bases Akrilamid

1. Encyclopaedia of Occupational Health and Safety, 4th 1. Bambang, W., I.Joshihise. N-acetylcystein fails to
ed., Edit. In chief J.M.Stellman, ILO, Geneva, 1998, vol. 4, Ac- protect rats from acrylamide neurotoxicity. J.Occup. Health,
ids, Inorganic, Hinkamp D.L., 104.5-104.11; Alkaline Materi- 1999, 41, 3, 181-182.
als, Hinkamp D.L., 104.57-104.72. 2. Handbook of poisoning, ed. R. Dreisbach and W.Rob-

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 LABOUR MEDICINE
ertson, 12th ed., Appleton & Lange, Los Altos, California, ertson, 12th edition, Appleton & Lange, Los Altos, California,
1987, 142, IPCS. Acrylamide, EHC 49, WHO, Geneva, 1985. 1987, 35, 216
3. Toxicological review of selected chemicals. Acrylamide. 2. Hygienic Toxicology. A special part. ed. F.Kaloyanova,
OSHA, June 19, 1988. Med. and phys., Sofia, 1983, 110-113. (in bul.)
4. Occupational Medicine, ed. J. LaDou, Appleton & 3. Patty, s Industrial Hygiene and Toxicology, 4th edition,
Lange, San Mateo, California, 1990, 331-334. vol.II Part B, ed. G.Clayton & F. Clayton, John Wiley & Sons
Inc.NY, 1994, 1241-1242.
Ammonia 4. Popov, T., Z.Zapryanov, I.Benchev, G. Georgiev. Atlas
1. Handbook of poisoning, ed. R.Dreisbach and W.Rob- of toxicokinetics., Medic. and phys., Sofia, 1984, 123. (in bul.)
ertson, 12th edition, Appleton & Lange, Los Altos, California,
1987, 214. Hydrogen sulphide
2. Occupational Medicine, ed. J.La Dou, Appleton & 1. Handbook of poisoning, ed. R.Dreisbach and W.Rob-
Lange, San Mateo, California, 1990, 441. ertson, 12th edition, Appleton & Lange, Los Altos, California,
3. Patty's Industrial Hygiene and Toxicology, 4th edition, 1987,35, 256
vol. II Part B, ed.G.Clayton & F. Clayton, John Wiley & Sons 2. Hygienic Toxicology. A special part. ed. F.Kaloyanova,
Inc.NY, 1994,1089. Med. and phys., Sofia, 1983, 138-139 p. (in bul.)
4. Popov, T., Z.Zapryanov, I.Benchev, G. Georgiev. At- 3. Occupational Medicine, ed. J.LaDou, Appleton &
las of toxicokinetics, Med. and phys., Sofia, 1984, 144-145. (in Lange, San Mateo, California, 1990, 436-437.
bul.) 4. PCS. Hydrogen sulfide, EHC 19, WHO, Geneva, 1981.
5. Toxicological profile for Ammonia, TP-90/03, US De- 5. Popov, T., Z.Zapryanov, I.Benchev, G. Georgiev. Atlas
partment of Health & Human Services, Public Health Service, of toxicokinetics., Med. and phys., Sofia, 1984, 146 p. (in bul.)
December 1990. 6. Toxicological review of selected chemicals. Hydrogen
6. Toxicological review of selected chemicals. Ammonia. sulfide. OSHA, June 19,1888
OSHA, June 19,1888
Sulphur oxides
Arsine 1. Handbook of poisoning, ed. R.Dreisbach and W.Rob-
1. Handbook of poisoning, ed. R.Dreisbach and W.Rob- ertson, 12th edition, Appleton & Lange, Los Altos, California,
ertson, 12th edition, Appleton & Lange, Los Altos, California, 1987,35, 209
1987,125l 2. Hygienic Toxicology. A special part. ed. F. Kaloyanova,
2. Hesdorffer C.S. et al. Arsine gas poisoning. The impor- Med. and phys., Sofia, 1983, 138 p. (in bul.)
tance of exchange transfusions in severe cases. Br.J.Ind.Med. 3. IPCS. Oxides de Soufre et particules en suspension,
1986,43, 353. EHC 8, WHO, Geneva, 1980
3. Occupational Medicine, ed. J. LaDou, Appleton & 4. Popov, T., Z.Zapryanov, I.Benchev, G. Georgiev. At-
Lange, San Mateo, California, 1990, 437-438. las of toxicokinetics. Me. and phys., Sofia, 1984, 145 p. (in bul.)
4. Patty, s Industrial Hygiene and Toxicology, 4th Edition, 5. Toxicological review of chemicals. OSHA, June 19,1888.
vol.II Part B, ed. G.Clayton & F. Clayton, John Wiley & Sons
Inc.NY, 1994, 1351-1358. Cyanide
1. Handbook of poisoning, ed. R.Dreisbach and W.Rob-
Carbon monoxide ertson, 12th edition, Appleton & Lange, Los Altos, California,
1. Emst A., J. D.Zibrak Intoxication par le monooxyde de 1987,35, 251, 252, 432.
carbone. Energ. - Sante, 1999,10, 2, 244-246 2. Hydrogen cyanide Noxious chemical substances. Non
2. Hamilton R.J., M.I.Greeberg. Epidemiology of US organic compounds of elements I-IV grupp, Handbook V.A.
workplace Carbon Monoxide. J.Toxicol. Clin. Toxicol., 1998, Filov, Leningrad “Chemistry” Leningrad department, 1988,
36, 468-469. 331-341 p. (in russ.)
3. Handbook of poisoning, ed.R.Dreisbach and W.Rob- 3. Patty, s Industrial Hygiene and Toxicology, 4th edition,
ertson, 12th edition, Appleton & Lange, Los Altos, California, vol.II Part B, ed. G.Clayton & F. Clayton, John Wiley & Sons
1987,35, 259. Inc. NY, 1994, 1092.
4. Hygienic Toxicology. A special part. ed. F. Kaloyanova, 4. Toxicological profile for Cyanide, TP - 92-09, U.S., Public
Med. and phys., Sofia, 1983, 136-139. (in bul.) Health Service, April 1993.
5. Noxious chemical substances. Non organic compounds 5. Toxicological review of selected chemicals. Hydrogen
of elements I-IV grupp, Handbook V.A. Filov Leningrad cyanide. OSHA June 19,1888
“Chemistry” Leningrad department, 1988, 303-324 (in russ.)
6. Occupational Medicine, ed. J.LaDou, Appleton & Chlorine
Lange, San Mateo, California, 1990, 433-437. 1. Handbook of poisoning, ed. R.Dreisbach and W.Rob-
7. Popov, T., H. Zapryanov, I.Benchev, G. Georgiev. Atlas ertson, 12th edition, Appleton & Lange, Los Altos, California,
of toxicokinetics., Med. and phys., Sofia, 1984, 146. (in bul.) 1987, 199.
8. Williams. L. Atmospheric pollution: Contribution of 2. Hygiene Toxicology. A special part. ed. F.Kaloyanova,
automobiles. Rev. fr. allergol. et immunol. clin. 2000.40, 2, Med. and phys., Sofia, 1983, 135-136. (in bul.)
216-221. 3. IPCS. Chlorine and Hydrogen Chlorine, EHC 21, WHO,
Geneva, 1982
Ethylene 4. Occupational Medicine, ed. J. LaDou, Appleton &
1. Handbook of poisoning, ed. R.Dreisbach and W.Rob- Lange, San Mateo, California, 1990, 440-441.

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5. Toxicological review of selected chemicals. Chlorine ment of health and human services. ATSDR, Atlanta, Georgia,
OSHA, June 19,1888 1998, 241 pp.
8. Tooxicological profile for methylene chloride. U.S.
Fluoride Department of health and human services. ATSDR, Atlanta,
1. Handbook of poisoning, ed. R.Dreisbach and W.Rob- Georgia, 2000, 271 p.
ertson, 12th edition, Appleton & Lange, Los Altos, California,
1987,35, 216 Chlorine-fluorine containing hydrocarbons
2. Occupational Medicine, Ed. J.LaDou, Appleton & 2. Hygienic Toxicology. A special part. ed. F.Kaloyanova,
Lange, San Mateo, California, 1990, 441. Medi. and phys., Sofia 1983. 304 p. (in bul.)
3. Toxicological review of selected chemicals. Hydrogen 1. Sherwoord R. Ozone. Change of atmosphere. Our
fluoride. OSHA, June 19,1888 planet. UNEP, v.9, 2, 1997, 4-6.
4. Toxicological profile for fluorides, Hydrogen Fluoride
and Fluorine. Draft., U.S., Public Health Service, July, 1991. Other organic compounds
Acrylonitrile
Ketones 1. Hygienic Toxicology. A special part. ed. F.Kaloyanova,
2. Popov T., Z.Zapryanov, I.Benchev, G. Georgiev. Atlas Med. and phys., Sofia 1983. 304 p. (in bul.)
of toxicokinetics, Med. and phys., Sofia, 1984, 189 p. (in bul.) 2. Popov T., Z. Zapryanov, I. Benchev, G. Georgiev. Atlas
1. Acetone (97). ed. N. Izmerov, Series “Scientific survey", of toxicokinetics, Med. and phys., Sofia, 1984, 189 p. (in bul.)
UNEP, MRPTHV, Ed. CMP GKNT, Moscow 1986, 46 p. (in russ.)
Vinyl chloride
Nitro- and amino derivatives of benzene and toluene 2. Popov T. Z.Zapryanov, I.Benchev, G. Georgiev. Atlas
1. Popov T., Z.Zapryanov, I.Benchev, G. Georgiev. Atlas of toxicokinetics, Med. and phys., Sofia, 1984, 189 p. (in bul.)
of toxicokinetics, Med. and phys., Sofia, 1984, 189 p. (in bul.) 1. Hygienic Toxicology. A special part. ed. F.Kaloyanova,
2. Hygienic Toxicology. A special part. ed. F. Kaloyanova, Med. and phys., Sofia 1983, 304 p. (in bul.)
Med. and phys., Sofia 1983. 304 p. (in bul.) 4. Vinyl chloride (37). ed. N.Izmerov, Series “Scientific
3. IV nitrobenzene (51). ed. N.Izmerov, Series “Scientific survey” UNEP, MRPTHV, Ed. CMP GKNT, Moscow 1983, 16 p.
survey” UNEP, MRPTHV, Ed. CMP GKNT, Moscow 1984, 21 p. (in russ.)
(in russ.) 3. Toxicological profile for vinil chloride. U.S. Department
4. Aniline (53). ed. N.Izmerov, Series “Scientific survey” of health and human services. ATSDR, Atlanta, Georgia, 1995,
UNEP, MRPTHV, Ed. CMP GKNT, Moscow 1984, 19 p. (in russ.) 225 pp.

Polycyclic aromatic hydrocarbons Hydrogen sulfide

1. Benzo (a) pyrene (43). ed. N.Izmerov, Series “Scientific 1. Hydrogen sulfide (41). ed. N.Izmerov, Series “Scientific
survey” UNEP, MRPTHV, Ed. CMP GKNT, Moscow 1983, 31 p. survey” UNEP, MRPTHV, Ed. CMP GKNT, Moscow 1984, 28 p.
(in russ.) (in russ.)
2. Hygienic Toxicology. A special part. ed. F.Kaloyanova, 2. Hygienic criteria environmental condition 10. SHydro-
Medicine and Sports, Sofia 1983. 304 p. gen sulfide, Geneva, 1982. 108 p. (in russ.)
3. Popov T., Z.Zapryanov, I.Benchev, G. Georgiev. Atlas 3. Hygienic Toxicology. A special part. ed. F.Kaloyanova,
of toxicokinetics, Med. and phys., Sofia, 1984, 189 p. (in bul.) Med. and phys., Sofia 1983. 304 p. (in bul.)
4. Tooxicological profile for polycyclic aromatic hydrocar- 4. Popov T., Z.Zapryanov, I.Benchev, G. Georgiev. Atlas
bons (PAHs). U.S. Department of health and human services. of toxicokinetics, Med. and phys., Sofia, 1984, 189 p. (in bul.)
ATSDR, Atlanta, Georgia, 1995, 458 pp. 5. Reasoning unify MAC for hydrogen sulfide in work
zone air. in: Problems of industrial toxicology, V.2. ed. F.Ka-
Chlorinated hydrocarbons loyanova-Simeonova, A.Korbakova, Ed. CMEA, Moscow
1. Case Studies in Environmental Medicine. Carbone Tet- 1986, 55-101. (in russ.)
rachloride Toxicity 18. U.S. Department of health and human 6. Toxicological profile for carbon disulfide. U.S. Depart-
services. ATSDR, 1992, 21 p. ment of health and human services. ATSDR, Atlanta, Georgia,
2. Halogenic methanes (59). ed. N. Izmerov, Series “Sci- 1996, 219 p.
entific survey” UNEP, MRPTHV, Ed. CMP GKNT, Moscow 1984,
32 p. (in russ.) Phenol
3. Hygienic Toxicology. A special part. ed. F.Kaloyanova, 1. Hygienic Toxicology. A special part. ed. F. Kaloyanova,
Med. and phys., Sofia 1983. 304 p. (in bul.) Med. and phys., Sofia 1983, 304 p. (in bul.)
4. Popov T., Z.Zapryanov, I.Benchev, G. Georgiev. At- 2. Phenol (61). ed. N.Izmerov, Series “Scientific survey”
las toxicokinetics, ed. “Med. and phys.”, Sofia, 1984, 189 p. (in UNEP, MRPTHV, Ed. CMP GKNT, Moscow 1984, 36 p. (in russ.)
bul.) 3. Popov T., Z. Zapryanov, I. Benchev, G. Georgiev. At-
5. Tetrachlor carbon (27). ed. N. Izmerov, Series “Scientif- las of toxicokinetics, Med. and phys., Sofia, 1984, 189 p. (in
ic survey” UNEP, MRPTHV, Ed. CMP GKNT, Moscow 1983, 20 bul.)
p. (in russ.) 4. Toxicological profile for phenol. U.S. Department of
6. Tooxicological profile for chloroform. U.S. Department health and human services. ATSDR, Atlanta, Georgia, 1998,
of health and human services. ATSDR, Atlanta, Georgia, 1997, 206 p.
293 pp.
7. Tooxicological profile for chloromethan. U.S. Depart-

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Formaldehyde 1-5. (in russ.)
1. Formalydehyd (13). ed. N.Izmerov, Series “Scientific 4. Kaloyanova F., A. Bainova, V. Bogdanov et al. - Guide
survey” UNEP, MRPTHV, Ed. CMP GKNT, Moscow 1982, 18 p. to health and the environment protection in the use of pes-
(in russ.) ticides. Sofia Med. and phys., 1993. (in bul.)
2. Hygienic Toxicology. A special part. order. F. Kaloyano- 5. Kaloyanova F. et al. - Pesticides. in Hygienic Toxicology
va, Med. and phys., Sofia 1983, 304 p. (in bul.) - special part. Sofia Med. and phys., 1983, p. 149-190. (in bul.)
3. Popov T., Z. Zapryanov, I. Benchev, G. Georgiev. At- 6. Kaloyanova F. et al. - Guide for safe use of pesticides.
las of toxicokinetics, Med. and phys., Sofia, 1984, 189 p. (in Sofia Med. and phys., 1984. (in bul.)
bul.) 7. Moses M. - Pesticides. in Environmental and Occupa-
4. Tooxicological profile for formaldehyde. U.S. Depart- tional Medicine, edit. WN. Rom, Little, Brown and Com., Bos-
ment of health and human services. ATSDR, Atlanta, Georgia, ton, I ed., 1983, 547-572.
1999, 423 p. 8. Page G. A. - Agricultural Chemicals. Pesticides. in Ency-
clopaedia of Occupational Health and Safety. IV ed., edit J.M.
Pesticides Stellman, ILO, Geneva. vol. 3, 62.7-62.41., 1998.
1. Browver R., H. Marquaret et al. - Risk assessment of 9. Rosenberg J. Pesticides, in Occupational Medicine /
dermal exposure workers to pesticides after reentry. - Arch. Editor J. LaDou /, Norwalk, Appliton, Lange, 1990.
Environ Contam. And Toxicol., 1992, 23, 3, 237-280. 10. Svetlyi S.S. Hygienic use, toxicology and clinic of poi-
2. Hutson D., P. Milburn. - Enzyme mediated selective soning. Moscow, 1974, p. 92-95. (in russ.)
toxicity of an organophosphate and a pyretroide. Some 11. Tsonevski D. - Hygiene toxicological study on the
examples from arrange of animals. - Biochemm: Soc. Trans, complex application of pesticides. Dissertation, 1974 (in bul.)
1991, 19, 3, 737740. 12. Tzonevski D., V. Dokov, et al. - Study of the acute tox-
3. Kagan U. S. Principal results and tasks for investigation icity and combined action of the pesticides acrex and actelic.
of pesticides toxicology J. Hyg. labour and prof. dis. 1986, 8, Scripta scientifica medica, 20, 1983, 33-35.

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8 DUST AEROSOLS

In his life and work the man is inevitably exposed ygen welding, etc. Condensation aerosols are distin-
to dust impacts. Dust is one of the most important guished by disintegration in a smaller size, a narrow
and universal influencing factors of the environ- range of dispersion, usually have regular spherical
ment, which harms not only millions of industrial shape and have a tendency to form agglomerates
and agricultural workers in the world, but a large confluence of a large number of particles. Second-
part of the population living in contaminated areas. ary are those powders that at some stage of pro-
Collective term dust (dust aerosol)1 includes a duction or end in packaging, transport and bulk
variety of organic and inorganic substances with materials are in powder or sedimented on working
the different in nature and force damaging impact, equipment, floor, windows, etc., and at work and
united by common physical property - highly frag- in creating air currents pass again in the air of the
mented particles that because of its small size and working environment.
mass and relatively large surface stay in the air for Basic parameters of dust aerosols necessary for
differently long periods of time. hygienic health risk assessment and prevention of
A huge number of manufacturing industries in adverse effects are: type of dust; dispersibility and
which the person is exposed to the dust factor. To other physico-chemical characteristics of the pow-
so-called dusty proceedings concern the open and der; duration of exposure; concentration and path-
underground mines for ore- and coal mining; the ex- ogenic properties.
traction of raw materials and the production of con- Type of powder. Type dust is divided into organic,
struction materials - stone, gravel, sand, etc.; met- inorganic and mixed.
allurgy; mechanical engineering; textiles; glass and The organic powders in turn are natural - plant
porcelain-faience industry, agricultural production, (pollen, flower powder, seeds, cotton, linen, etc.)
construction and others. and animal (animal dandruff, hairs, microorganisms
and their spores, mites, parasitic elements leaking
8.1. CLASSIFICATION OF THE AEROSOLS by urine and feces of infected animals and people
or formed during the process of decomposition and
According to the mode of preparing the aerosols decay of organic matter, etc.) and resulting from hu-
are primary - (by disintegration and condensation) man activity - synthetic powders (paints, plastics,
and secondary. Disintegration are obtained by me- pesticides, pharmaceuticals, synthetic fibers, deter-
chanical grinding of solids, such as carrying out drill- gents powders and so on..).
ing works, blasting, seizure of extracted mass - in Inorganic powders are classified as:
mining, hydro- and road construction, demolition, – metal (metal oxides and condensation aerosols)
construction and repair of furnaces, logging and Metal powder and metal oxides are formed in
woodworking. A characteristic feature of disinte- the metal industry, such as condensation aerosols
gration particulate matter is that most of them have in welding, melting and casting. The natural mineral
an irregular form. Condensation aerosol form in the powders belong rock, coal, mining dust, dust of no
condensation of vapour or gas after high tempera- – nonmetallic
ture effects on substances that are in solid form at
mineral salts, alkalis, acids
ambient temperature - dust-processes of melting
metal and silicate minerals, in industries like metal- natural artificial
mineral mineral
lurgy, glass and porcelain industry, electric- and ox-
containing SiO2 noncontaining SiO2
1
The dust in the air is referred to as a colloid system in which the
fragmented particles were dispersed phase and the dispersing containing free containing combined
medium is air, and therefore also means the concept of a dust SiO2 SiO2
aerosol. (crystalline, amorphous)

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 LABOUR MEDICINE
ore minerals and others. To artificial mineral pow- glomeration and slows them precipitation. Another
ders belong ceramic fibers, glass wool, stone wool. feature is the hydroscopic capacity of dust particles
Aerosols of salts, acids and bases are formed in the - absorbs moisture they increase its mass and faster
production of mineral fertilizers, cement, condensa- settle.
tion silicic acid and the like. Dusts rich in SiO2 are free The solubility of the powder particles - its speed,
quartz, cristobalite, tridimit, and by synthetic - with as well as the adsorption properties are closely relat-
crystal structure - for ex. koezit and with amorphous ed to the dispersibility and the total surface area of
- aerosil, vulkasil, silica gels and the like, causing dis- the powder aerosol. By reducing the size of particles
ease silikoza1. Exposure of powders rich in SiO2 lead and increases their surface accelerates dissolution.
to develop silicatoses - asbestosis, talkosis, olivino- Many organic powders which mechanically trauma-
sis, nefelinosis, apatosis, caolinosis and others. Expo- tize and damage the mucosa of the upper respira-
sure to dusts containing no SiO2 leads to the devel- tory tract, if it were soluble would have such effects,
opment of aluminosis, baritosis, stanosis, berylliosis, i.e. their insolubility is unfavorable, but the opposite
manganoconiosis, pneumoconiosis of oxygen- and - eg. it is at toxic acting aerosols.
welders and others. Prolonged inhalation of nefibro-
genic dusts leads to dust pneumonia - hammer man 8.2. DEPOSITION OF DUST PARTICLES
lungs and others. INTO THE RESPIRATORY SYSTEM
In real terms the most commonly found mixed
powders, for example: mineral-metal (a mixture of From the dispersibility of the powder (particle
iron and silicon) - when welding; organic and inor- size) depends on the depth of penetration into the
ganic - in textile production powder is mostly herbal, respiratory system and the nature of the particulate
but contains impurities of mineral (soil) powder and damage.
so on. Dust particles can be carriers of the microflora “Precipitation” is the amount of dust that settle in
(eg., grain dust can contain spores of various fungi). different areas of respiratory in inhalation and exha-
Dispersion. The degree of dispersion powders are lation (expressed as the difference in the concentra-
divided into: dust - the size of dust particles above tions of dust in inhaled and exhaled air). “Clearing”
10 μm (these particles are precipitated under con- is the elimination of particles by ciliated epithelium,
stant acceleration in static air according to Newton’s lung macrophages depending on where the deposi-
second law (G = m.g) and rapidly sediment); cloud tion. “Retention” is the accumulated amount of dust
(microscopic dust) - the size of dust particles from 10 in the alveolar region for a specified time after com-
μm to 0,1 μm, which precipitate significantly slow- pletion of primary bronchial purification, or 20 hours
er with constant speed2; smoke (ultramicroscopic after the last inhalation.
dust) - the size of dust particles below 0,1 μm - in Dust particles inhaled with the air can reach,
static air they perform Brownian motion and practi- and accumulate in various areas of the respiratory
cally no precipitation. system, depending on their aerodynamic size, of ge-
The greater is the dispersibility of the powder ometric dimensions and shape of the airways, which
aerosol, the greater is its physico-chemical activi- carry and characteristics of breathing (in through,
ty (this especially applies for the degree of adsorp- the nose, mouth, mixed, depth of breathing). A
tion). Dust tend to adsorb ions from the air, gaining large part of them back to the breath, while others
positive or negative charge (dust acquire an electric are eliminated by treatment mechanisms of the res-
charge and the formation of dust - in the process of piratory system. Important in terms of pneumoco-
weeds, crushing etc.). Electric charge status increas- niosis danger are those which are able to penetrate
es with increasing temperature and decreases with deep into the lungs and form there lasting depot.
increasing humidity. Electric charge status powders This fraction of the total suspended in the air of the
is important for their stability. working environment dust is referred to as respirable
The property of dust particles to adsorb gas mol- - this dust particles with a size of 0,5-5 μm.
ecules in the air results in the formation of a kind The first protective barrier for dust were upper
of buffer strips around dust which prevents the ag- respiratory tract - so eg., almost all particles larger
than 10 μm are held primarily in the nasal cavity,
1
Disease described from Paracelsus - in 1530, Agricola - 1556, and breathing through the mouth only a very small
Ramazini - 1700. Term silicosis is proposed by Visconti - 1870, percentage of them to penetrate the bronchi of the
from latin silicium - silica.
2
Now it is considered that the particle sizes up to 100-200 μm second order. In the nasal cavity main sewage safe-
are precipitated at a constant speed by the law of Stokes. Effect guards are nasal hairs, released from the lining of
on the rate of precipitation and has a flocculation process of the
powder aerosol, depending on the humidity and the velocity of nasal mucus, rich in lysozyme, in which stick dust,
the air, the type and size of particulates. vibrating cilia of the epithelium and the nasal con-

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 OCCUPATIONAL MEDICINE
cha, creating a highly undulating topography of the action. Fibrogenity of dust particles is determined
inner nasal surface. This air moves circularly with the primarily by the content of free silica.
greatest speed (120-150 cm/s) and therefore plays Silicon is prevalent element in the earth’s crust,
a major role inertia precipitation, called impaction. occurring mainly in the form of silica. Quartz is a
Precipitated particles are exported by the secretions mineral composed entirely of free silica, but its crys-
of the pharynx and are eliminated either by absorp- tals are mixed. Differ α- and β-quartz, α- and β- cris-
tion or by expectoration or mechanically cleaned tobalit, α- and β- and γ- tridimit - these are high-tem-
(blowing, sneezing, etc.). Breathing through the perature crystal modifications of both the crystalline
mouth of the particles precipitated mainly by im- and the amorphous silica. Crystalline quartz (sand)
paction in the oral cavity and pharynx, and eliminat- is almost insoluble in water, even more slowly dis-
ed by ingestion. solves its deep layer, which has a great importance
With the advent in the trachea and in bronhi in for the development of fibrosis. The amorphous sil-
deeper parts of the respiratory system, where the ica has a greater solubility and is unstable at high
air is moving at a slower speed (in bronchioles ve- temperature effects, it passes in tridimit, which in
locity up to 1 cm/s) a major role in the precipitation turn is converted into cristobalite at higher temper-
of the powder play sedimentation and diffusion. As ature impacts. Calcination of the amorphous silica
it is less than the speed of the inhaled air and thus increases the amount of free silica in it by 20-30%.
longer path, and as a greater mass of particles, the Various modifications of the quartz vary in their
greater their sedimentation. Diffusion is important fibrogenity. Amorphous silica does not provide in-
for particles with a diameter lower of 0,5 μm. They tense fibrosis. Cristobalite and tridimit have a more
perform unruly (Brownian) motion, bump into walls potent fibrogenic effect than quartz. Some crystal-
of the airways and are precipitated thereon. Airway line modifications of silicon dioxide (stishovit) are
to the terminal bronchioles are covered with ciliary biologically inert. Much fibrogenic activity to the
epithelium and mucus glands whose secretions is lungs show crypto- (micro) crystalline forms of free
moved proximally from the ciliated epithelium. This silica (flint, chalcedony).
is an effective means of eliminating dust particles Fibroactivity of free silica was increased signifi-
before they reach the alveoli - so-called muco-cili- cantly in the presence of components such as lead,
ary escalator (function is difficult in inflammation copper, arsenic, mercury, manganese, uranium and
or hypersecretion - smoking, irritating gases). In the the like. Dust exposure required for the occurrence
alveolar region, lacking the ciliary epithelium, clear- of the disease is reduced. There are particulate in-
ing of particles is relatively slow. An important role gredients with antagonistic activity (reducing fibro-
here play phagocytic cells. In the tracheo-bronchial activity of free silica) - iron, coal, aluminum, hema-
tree to retain 10-15% of the particles size of 3 μm, tite, limestone and the like.
and 40% of them reach the alveolar region. Almost Organic powders contain specific biologically ac-
all particles smaller than 0,5 μm reach the alveolar tive components (Table. 1).
region but of which approximately 20% are preip- The relative role of each of these components, ei-
itated (some of them are absorbed by phagocytes ther individually or in combination with each other,
and are transported by muco-ciliary escalator, oth- has not been fully studied. Relatively more data is
ers cross the alveolar walls and penetrate the lym- the role of the present in most organic powders bac-
phatic lung system, rest is excreted in exhaled air). terial endotoxins. Endotoxins are lipopolysaccharide
Around 80% of the inhaled dust is eliminated due to components of the cell membrane of Gram-nega-
a combination of defense mechanisms. In persons tive bacteria. The biological response of the human
who perform heavy physical work (large volume of body upon inhalation them is expressed in an acute
breathing air), or who breathe mostly through the inflammatory reaction in the mucosa of the res-
mouth are greater amount of large particles in dif- piratory tract with invasion of neutrophils and the
ferent sections of the respiratory system. subsequent activation of other cells and secretion
of inflammatory mediators. Another specific com-
8.3. CHEMICAL COMPOSITION OF THE ponent of the organic powder is (1 → 3) - β-D-gly-
DUST AND FIBROGENIC ACTION can contained in the cell wall of molds and certain
bacteria - it enhances the inflammatory response to
In the proceedings are most often heterogene- endotoxins and alter the function of inflammatory
ous particulate aerosols, including ingredients with cells, especially macrophages and T-lymphocytes.
different chemical and biological action. The chem- Some of these biologically active agents in organic
ical composition of the dust determined biological dusts - eg. proteins and enzymes, are allergen caus-
activity - its fibrogenic, allergenic, toxic and irritation ing development of hypersensitivity pneumonitis.

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Tab. 1 Main biologically active agents in organic dusts ers. Generally may indicate that the greater amount
Type organic dust Biologically active agent of powder has gone into the lung and longer dust
is stored, the greater the likelihood of damage. Also
Vegetable powders Tannins, histamine, alkaloids (nicotine), however, the massive “dust stroke” lead rapidly to
cytochalasin
disease, especially in highly toxic dusts. The amount
Animal powders Proteins, enzymes of the deposited quartz (Q) in the lungs is calculated
Endotoxins, proteases, mycotoxins as follows:
Microorganisms
(1 → 3) - β-D-glucans
Q = k. c. t,
8.4. EXPOSURE TO DUST AND THE
RISK OF LUNG DAMAGE where k is a factor depending on the individual
characteristics of the respiratory system, c - the con-
Important factor in assessing the risk of dust centration of fine (respirable) fraction of dust in the
impact was the exposure (E), which is equal to the worker’s breathing zone and t - the duration of dust
multiplication of the time - T (working shifts in days, exposure.
months and years, the whole service), in which man The risk (R) of disease of the lungs is a function
it has been exposed to dust and average concentra- of the amount of the powder depot (Q), its specific
tion - Cavr. of total inhaled dust and fine (respirable - biological effect (a) and the time of his stay in the
below 5 μm) fraction in the breathing zone of work- lung (T):
ers during this period. R = f. (a. Q. T)
E = Cavr. .T
8.5. EXPRESS EXPERIMENTAL METHODS
(This formula is valid for non-toxic powders with TO DETERMINE THE EXTENT OF
predominantly fibrosogenic action). FIBROGENITY AND SILICOSIS
In assessing the impact of the so called powder HAZARD OF POWDERS
depot (cumulative exposure) in late silicosis or sili-
cotuberculosis essential to have “average stay of For predicting disease risk in exposure to sili-
dust in the lungs,” which is calculated by the follow- ca-containing powders production are developed
ing formula: express experimental methods to determine the
extent of fibrogenity and silicosis hazard them. This
AS = E/2+ DP, is the method of “subcutaneous pocket” in which 50
mg of studies powder suspended in a suitable nutri-
where : AS is the average stay of dust, E - the time ent medium, is administered subcutaneously in the
of dust exposure (in years) and DP - dust-free period. back of the test animal. In place of the application of
Concentration (mass) of dust into the air, along the powder to form a body of oval shape, which dis-
with the exposure time is of primary importance for section at 7th day of the experience and its diameter
the emergence of powder pathology and is an indi- is measured linearly (to 0.01 cm of the dimentions).
cator of the efficiency of the preventive measures. On the basis thereof calculate the area (S) of the pro-
Adverse effects of dust on the health depends both jection of the cavity filled with connective tissue, as
on its total mass (the concentration of total dust) and determined and the amount of oxyproline (connec-
the concentration of fine powder - less than 5 μm tive amino acid) in it - in mg/g tissue.
(determined by weighing method and expressed in According to these indicators powders can be
mg/m3). graded on silicosis hazard:
Data necessary for assessing the actual exposure First grade - very high silicosis hazard with an
to dust for each worker and for risk assessment of area of subcutaneous pocket over 10 cm2 and con-
damage to health are available on individual sam- tent of oxyproline in the tissue above 70 mg/g.
pling. It is realized with personal sampling devices Second stage - high silicosis hazard, an area of
located in the worker’s breathing zone and provides the subcutaneous pocket of 6 to 10 cm2 and con-
information on its dust load for one shift. taining oxyproline in the tissue of 45 to 70 mg/g.
Other significant factors for the occurrence of Third stage - medium silicosis hazard, an area of
lung disease are the parameters of breathing de- the subcutaneous pocket of 4.5 to 6 cm2 and oxy-
fining of: anatomy and functional condition of the proline content in the tissue of 35 to 45 mg/g.
airways, way of breathing - in through the nose or Fourth stage - low silicosis hazard, an area of the
through the mouth, posture, microclimates, the hard subcutaneous pocket of 1.5 to 4.5 cm2 and oxypro-
of labour, individual characteristics of body and oth- line content in the tissue of 20 to 35 mg/g.

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Fifth stage - no-silicosis hazard, an area of the 8.7. ADVERSE HEALTH EFFECTS
subcutaneous pocket to 1.5 cm2 and oxyproline con- FROM EXPOSURE TO DUST
tent in the tissue to 20 mg/g.
Although the powders have very different phys-
8.6. HEALTH RISK FROM EXPOSURE icochemical properties and chemical composition,
TO DUST their adverse health effects can be classified into the
following guidelines: toxic action, locally irritable
Health risk is considered as a function between and corrosive, allergenic effect, specific action, car-
the severity of possible injury (degree of silicosis cinogenic action.
hazard) and the likelihood of its occurrence. The The main disease caused by exposure to dust are:
probability in turn is a function of the incidence of Lung disease - are caused by the accumulation
professional diseases and the exposure time. of dust in the lungs and include the development of
Using the formula for the definition of risk (R) as a fibrosis, bronchitis, asthma and lung cancer.
value determined by three parameters - probability The dust pathology is primarily pulmonary pa-
(P) exposure (E), consequences (damage) (D) thology causing occupational disease pneumoconi-
osis4. Initially as pneumoconiosis are designated all
R = P x E x D, dust lung disorders, but subsequently only include
those where there is development of pulmonary fi-
on propose risk assessment of lung damage from brosis (of varying degree and nature). In etiological
exposure at certain type of dust or powders with un- sign has 6 major groups pneumoconiosis: silicosis
explained biological effect on humans. The proba- - the most typical and fast growing pneumoconio-
bility (P) is equivalent to the frequency (F): sis caused by dust containing free crystalline silica;
F = number of persons with proven professional silicatoses - by powder comprising salts of SiO2
disease of lung/100 workers. (bounded silica), for example. asbestosis, talkosis,
Exposition (E) is calculated as: olivinosis, nefelinoza etc.; carboconiosis - carbohy-
E = N x T, where N is the value expressing the drate meals - eg. coal dust (anthracosis), powdered
ratio of the measured concentration of dust in the graphite, carbon black, coke, etc; metaloconiosis
breathing zone of workers to MAC, and T is the ex- - powdered metals (metal oxides), for example alu-
posure time minosis, baritosis, siderosis, manganoconiosis etc.;
T = T1 x T2, where pneumoconiosis of mixed powders with differ-
T1 is the exposure time of the powder during the ent content of free and bounded silicon dioxide, for
working day/week, for which are adopted the fol- example siderosilicosis, antracosilicosis etc.; pneu-
lowing ratios: moconiosis from organic powder (plant, animal,
0.1 - very low (up to 1 h weekly) synthetic) eg. tabacosis (tobacco powder) bagaso-
0.2 - low (up to 1 h per day) sis (reed), byssinosis (cotton), amylosis (flour), from
0.3 - medium (to 1/3 of working days) wood dust, plastics, etc. In these pneumoconiosis
0.4 - high enough (1/2 of the working day) can occur and dominate other effects besides fibro-
0.6 - continuous (all the day) sis - ie. asbestosis is often combined with lung can-
T2 is the total duration of dust exposure (in years) cer (mesothelioma, cancer of the bronchus), silicosis
Consequences (damage) (D) equalizing by S (area (less silicatosis) combined with pulmonary tuber-
of the ellipse of subcutaneous pocket) in determin- culosis - silicotuberculosis; in pneumoconiosis from
ing silicosis hazard of dust in cm2. organic dust prevalent allergic reactions - hypersen-
The risk (R) on the development of dust pathol- sitivity pneumonitis, bronchoconstriction, bronchial
ogy: asthma; in carboconiosis (anthracosis etc.) is a very
1. to 7.5 - very limited, acceptable risk common lung emphysema and slowly developing
2. from 7.5 to 30 - a small risk, it is necessary at- interstitial diffuse fibrosis, etc.
tention Systemic effects - occur with absorption in the
3. 30 to 60 - measures are needed to reduce risk blood of inorganic toxic dusts containing elements
4. from 60 to 260 - need immediate improvement such as lead, manganese, cadmium, mercury, as well
of working conditions as absorption of certain components (also with toxic
5. 260 - leave off work to eliminate the risk action) of the organic powders.

4
Pneumoconiosis - a term first introduced by F.A. Zenker in 1866
from greek pneumon - lung and konis - dust.

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Metal fever - is observed at inhalation of finely Radiotoxic action - stochastic and non-stochas-
dispersed condensation aerosols of oxides of zinc, tic damage to organs and tissue from inhaled radio-
magnesium, copper, derived from the melting of nuclides.
metals. It has been reported that inhalation of aer-
osols, resulting from the melting of aluminum, an- 8.8. PREVENTION OF ADVERSE EFFECTS
timony, cadmium, copper, iron, manganese, nickel,
selenium, silver and other also cause metal fever. Basic preventive directions can be classified as:
Allergic and hypersensitivity reactions - in the 1. Technological 2. Sanitary-technical 3. Hygienic 4.
inhalation or skin contact with vegetable powders Medico- prophylactic.
(flour, cereals, certain types of wood dust, medicinal The most effective and radical are the techno-
plants), as well as some organic and inorganic mate- logical and sanitary-technical solutions limiting
rials (chromium, nickel, drugs, enzyme preparations dust formation and dust scattering.
used in the rubber industry as auxiliary materials ac- These include:
celerators, stabilizers, etc.). – radical changes in technological processes with
Bacterial and fungal infections - exposure to intensive dust: maximum avoid dry techniques pro-
dusts containing live microorganisms (anthrax in cessing- eg. introduce of water perforators in Bul-
woolen powder) or powder of cereal, nuts, contain- garia in 1956 .; implementing effective means of wet
ing pathogenic fungi. dedusting - using tools and methods for increasing
Irritative action - such effect have acids, bas- the wettability of water - placing in blasting holes in
es, etc. It is well known that chrom containing dust the plastic cartridges filled with water or pastes pre-
cause ulceration and perforation of the nasal sep- pared on the basis of cellulose or bentonite (which
tum. led to a reduction of dust in underground mines
Another very common occupational lung pathol- from 20 to 80%); implementation of uninterrupted
ogy - chronic dust bronchitis is also associated with work precesses managed automatically, mechaniza-
irritation of dust on the mucous membranes of the tion and hermetisation.
airways - mechanical, chemical, allergenic effect of – the use of powders and raw materials can be
the dust aerosol. These effects start from the nasal minimized by introducing pasty and granular (eg. in
cavity, pharynx and larynx, especially aggressive plastic production).
is silica containing powder (rapid development of – encapsulation and placement of local exhaust
hypertrophic and atrophic catarrh of the upper res- ventilation with mandatory dust hold before the re-
piratory tract, followed by atrophic sclerosing bron- lease in the atmosphere.
chitis with frequent metaplasia - after 15-20 years of – the transport of raw materials is carried out by
service). Potentiating effect have other production shorten the path, using the band sealed, screw or
factors - excessive heat or cooling microclimate, ir- pneumatic, applying periodic spraying with water.
ritant gases, work loading, also available respiratory – isolated in separate premises processes, ma-
diseases and smoking. chinery and equipment with intensive dust.
Injury to the eye mucosa - conjunctivitis and ker- – establishment of effective general exchange
atitis, caused by the mechanical and chemical action ventilation of descending type and local aspiration
of metal and mineral dust aerosols on the eyes. or encapsulation also from descending type accord-
Skin contact various kinds of dust cause a variety ingly particularities of production.
of local disability - eg. eczema, dermatitis of allergic – in ventilation with recirculating air, content of
nature; argirosis and anthracosis in skin due by im- dust in the recirculating stream can be up to 10% of
pregnation of dust particles of coal and silver; der- MAC for work environment.
matitis and eczema, acne, furuncles, injuries to the The group of hygienic and medical preventive
sweat glands, sores, etc. activities include:
Carcinogenic effects - inhalation of asbestos – removal of the settled dust in workplaces, best
dust (mesothelioma, cancer of the bronchi); met- by pneumatic suction with industrial vacuum clean-
al aerosol - nickel, chromium, arsenic, etc.; powder ers.
with enhanced natural radioactivity, or a combina- – use of appropriate personal protective equip-
tion of powder with the radioactive effect of radon ment (masks, goggles) and dust protection clothing.
and smoking (potentiating effect). – organizing systematic control of dust in the air*.

* air in work environment: - at higher SiO2 or other substances - lower MAC - 3-8 mg/m3
- mean-shift MAC for dust to 2% free crystal SiO2 air settlements:
- inhalable fraction - 10 mg/m3 - dailly average MAC - 50 μg/m3 FDP10
- respirable fraction - 4 mg/m3 -average annual MAC - 30 μg/m3 FDP10

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– conducting preliminary and periodic medical bathrooms, laundry, etc.).
examinations - every 12 or 24 months involving – organizing photiriums - with UV-exposure, indi-
therapist, ORL, dermatologist, ophthalmologist. vidual inhalations with saline and sodium carbonate
– ensuring the safety professional catering for solutions (5% solution of NaCl, 2% soda solution) to
workers (diet B) - rich fat (PUFA), proteins (cystine, restore the self-cleaning function of the bronchial
cysteine, methionine), calcium and vitamins (vit A) tree.
food, inhibits the development of silicotic process.
– providing conditions for good personal hygiene
(two-sector cabinets for work and personal clothing,

REFERENCES

1. Alpaugh E. Particulates. in Fundamentals of Industrial Hygiene ed. B.A. Plog, National Safety Council,
1988, IIIth ed., Pp. 123-144.
2. Alvear Galindo M.G. et al. Risk indicator of dust exposure and health effects in cement plant workers.
J. Occup. Environ. Med. 1999 Aug; 41 (8): 654-61
3. Alwis K.U., Mandryk J., Hocking A.D. Exposure to biohazards in wood dust: bacteria, fungi, endotox-
ins, and (1 -> 3) -beta-D-glucans. Appl. Occup. Environ. Hyg. 1999 Sep; 14 (9): 598-608.
4. Brisman J., Jarvholm B., Lillienberg L. Exposure-response relations for self reported asthma and rhi-
nitis in bakers. Occup. Environ. Med. 2000 May; 57 (5): 335-40.
5. Burilkov T., M. Dobreva St. Ivanova. Mineral dusts in the workplace (hygienic and epidemiological
characteristics), Sofia, Med. and phys., 1983, p. 241. (in bul.)
6. Gandev V., I. Ivanov. Applied occupational hygiene, Sofia Med. and phys., 1982, 74-85. (in bul.)
7. Imbus H. R. Wood Dust. in Physical and Biological Hazards of the Workplace, eds. P. Wald and G. Stave,
Van Nostrand Reinhold, 1994, pp. 488-492.
8. Joyce S. Major issues in miner health. Environ. Health-Perspect. 1998 Nov; 106 (11): A538-43.
9. Kotela I., Laskowicz K., Plezia B. Consequences of exposure to asbestos dust. Przegl Lek. 1996; 53 (8):
631-3.
10. Mandryk J., Alwis K.U., Hocking A.D. Effects of personal exposures on pulmonary function and
work-related symptoms among sawmill workers. Ann. Occup. Hyg. 2000 Jun; 44 (4): 281-9.
11. Navrotskiy V.K. Industrial dust, dust pathology and prevention, in Hygiene of labour ed. V.K. Navrot-
skiy, II ed., Moscow, Medicine, 1974, p. 137-160. (in russ.)
12. Petrova E. Silicosis and silicotuberculosis, Sofia Med. and phys., 1993, 13-16. (in bul.)
13. San L.N. et al. Pulmonary function of workers in the aluminum industry. Am. J. Ind. Med. 1998 Mar;
33 (3): 305-7.
14. Taylor L., Reist P.C., Boehlecke B.A., Jacobs R.R. Characterization of an aerosol chamber for human
exposures to endotoxin. Appl. Occup. Environ. Hyg. 2000 Mar; 15 (3): 303-12.
15. Velichkovskiy B. T., E.I. Vorontsova, V. B. Latushkina. Industrial dust, in Guide for labour hygiene, V.
I, ed. Izmerov N.F., Moscow “Medicine”, 1987, 133-167. (in russ.)
16. Vodenitcharov E., Express methods for determining the fibrogenic action of silica-containing indus-
trial aerosols, Dissertation, Sofia, 1984. (in bul.)
17. Wang X., Yano E., Nonaka K., Wang M., Wang Z. Respiratory impairments due to dust exposure: a
comparative study among workers exposed to silica, asbestos, and coalmine dust. Am J Ind Med. 1997 May;
31 (5): 495-502.

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9 CHEMICAL FACTORS WITH

CARCINOGENIC EFFECT

Carcinogenic effect as general biological phe- developed on the basis of certain basic character-
nomenon is a process of converting a normal cell istics of chemical carcinogens: induction of chro-
into a tumor under the influence of carcinogens. Tu- mosomal aberrations and reparative DNA synthesis
mor transformation is observed under the influence in cell cultures, the use of bacterial systems, blast-
of three main groups of carcinogens: chemicals, ra- transformaion of cell culture, disruption of the cell
diation and oncogenic viruses in all species. genotype in the form of point mutations. Practical
It is estimated that currently 30-40% of the pop- most widespread testing methods have mutagenic
ulation in industrialized countries developed malig- action of chemicals as an indicator of carcinogenic
nancies during their life. The main part of cancer in activity. Systematic studies have found that 90-95%
humans are caused by environmental factors (70- of chemical carcinogens tested on bacterial test sys-
80%), as a leading place among them have chemical tems from mutant strains (Salmonella typhimurium
pollutants (70-85%). Today, modern man consumes - 5 strain, method of B. Ames et al. - 1975) are proven
more than 60 000 chemical substances. Around 16% mutagenic item, i.e. disclosed is a high correlation
of them were tested for carcinogenic activity on ani- between the ability of a substance to induce muta-
mals. Till now experimentally found carcinogenic ac- tions in microbial test systems and the development
tivity of more than 1,000 chemicals, of which more of cancer in experimental animals (potential carcino-
than 40 have proven carcinogenic to humans. gens in humans). According to the modern concept
of the mechanisms of tumorigenesis, carcinogens
9.1. METHODS FOR EVALUATION with mutagenic effect are genotoxic unlike of epi-
AND CLASSIFICATION genetic which acting by others, often not well de-
fined biological effects, associated with functional
Carcinogenic risk of chemicals and industrial pro- changes in the genome - violation of physiological
cesses are evaluated using the following basic meth- and regulatory processes in cells, disrupting perme-
ods: ability cell membranes and the interaction between
1. Epidemiological studies: include descrip- the cells. Prognostic significance of rapid screening
tions of individual cases or observations of large test systems does not exceed 90-95%, ie they are
groups of people for an extended period of time binding, but can not replace experimental studies
(15-30 years) exposed to certain chemical substanc- (allowing, however, be screened).
es. Data from these studies are most important, be- Based on the data of the main methods for as-
cause through them is estimated actual carcinogen- sessing the carcinogenic risk of chemicals and in-
ic risk in humans. dustrial processes, WHO experts offer their division
2. Experimental studies. Data from experimen- into three groups:
tal animal studies are essential in assessing the car- 1. First group - chemical substances, mixtures
cinogenic risk because epidemiological studies are and industrial processes that are carcinogenic to
possible only after 20-40 years of presence of chem- humans (asbestos arsenic, chromium, 2-naphth-
icals in the environment. The study of a substance ylamine, benzidine, vinyl chloride, benzene, etc.).
for carcinogenicity lasts from 3 to 5 years and takes In them a causal relationship between exposure to
place in three stages: preparatory, chronic experi- the agent and the development of cancer in man.
ment and evaluate the results. Development of tumors in various types of lines or
3. Express tests. The classical methods of ex- animals using various dosages and routes of admin-
perimental oncology are labour-intensive and ex- istration of the test substance.
pensive, and therefore in recent years have been 2. The second group - chemical substances,
proposed more than 100 express test. They were mixtures and industrial processes that are proba-

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bly carcinogenic to humans. In subgroup 2A are tors. The second stage is the stage of the promotion,
included substances, and industrial processes for and the agents are called promoters. The sequence
which the evidence is relatively strong by those of is obligatory (if initially treated with promoter tumor
subgroup 2B (aflatoxins, acrylonitrile, diethyl sulfate, can not be obtained). The stage of initiation is short
beryllium, etc.). In the evaluation of carcinogenicity - from minutes to the time required for passing of a
of the substance of this subgroup main are results cycle of cell division. In this stage, a normal cell turns
obtained in the experimental studies. into a neoplastic, most likely through cell mutation,
3. A third group - chemical substances, mixtures without excluding the participation of epigenetic
and industrial processes that can not be accepted mechanism. As a result, yielding the so-called latent
or rejected as carcinogenic to humans (aniline, di- or dormant tumor cells. Stage of promotion is long -
chlormethane, dieldrin, saccharin, lead and its com- from weeks to two years. During this stage the latent
pounds, reserpine, hematite, etc.). The available data tumor cell begins to divide and eventually leads to
are insufficient in quantity and quality. the appearance of tumors. Promoters in most cases
realize its effect at two levels - by influencing the reg-
9.2. MECHANISMS OF CARCINOGENESIS ulatory genes via interaction with cell membranes,
i.e. their action is paragenetic. Known combination
According to current studies carcinogenesis of agents that cause the two successive stages, and
associated with the most common and basic life a biological model is the one with urethane as the
events and characteristics of the species, rather than initiator, croton oil - promoter and the mouse skin
separate and specific to a particular type or tissue as a system for developing the effect - skin tum-
structures and functions. In chemical carcinogenesis ors. As initiators in animal experiments have used
establish some basic laws; 1) the chemical induction many chemicals (carcinogens) - polycyclic aromatic
of cancer process is a result of too specific interac- compounds aminoazo compounds, aflatoxins, aro-
tion between the carcinogen and cellular targets; 2) matic amines, nitrosamines, and as promoters - sur-
the cancer has monoclonal character, ie the tumor factants, phenols, bile acids, DDT, phenobarbital,
arises from changes in one cell and its progeny; 3) saccharine and the like.
the progression from normal to malignant pheno- Two stages not the only mechanism for the
type comprises a plurality of phases with varying development of carcinogenesis. In many cases, this
degrees of stability and reversibility; 4) carcinogenic occurs after contact with an agent. This is a char-
effects depend on the dose, they accumulate and acteristic of exposure to sufficiently high doses of
are almost reversibilic; 5) modifying factors can ac- chemicals - strong carcinogens, as well as with ion-
celerate or inhibit the process of carcinogenesis. The izing radiation, possibly with oncogenic viruses. In
mechanisms of action of carcinogens associated some production conditions this mechanism of
with their metabolism. Some of these are direct act- carcinogenesis can be leading, while in pollution of
ing, but most require metabolic activation by cellu- ecosystems to chemical pollutants and unhealthy
lar enzymes (MFO), which results in highly reactive lifestyles, leading can be combined action of the ini-
so-called carcinogens. The isolation of the final car- tiators and promoters.
cinogens is difficult because of their high volatility Carcinogenesis is not a one-way process. It is pos-
and reactivity. These activated metabolites interact sible reversibility of every stage of its development
with the nucleophilic centers of cellular macromole- before the emergence of a malignant tumor. This re-
cules (DNA, RNA, proteins) and form covalent bonds gression is observed in both experiments, and in hu-
with them. mans in a clinical setting and is the more common
Experimental and epidemiological studies of car- as more initial stages of carcinogenesis is. Rare cases
cinogenesis indicate a latent period and phasic na- of reverse development of already occurring malig-
ture of tumorigenesis. For people duration of latent nant tumors have no relevance.
period varies from 4-6 years for leukemia induced
by ionizing radiation to 40-50 years on some cases of 9.3. DOSE AND HEALTH RISK
mesothelioma induced by asbestos, for most tumors
that period averaged 12 and 25 years. The duration Carcinogenic effects are dose-related, such as: 1)
of the latent period showed comparability in various the higher doses give a higher percentage of tum-
experimental animals and humans, according to life origenesis and decrease latency; 2) repeated mul-
expectancy. tiple smaller doses, regardless of the timing of the
In the process of carcinogenesis often differ two different exposures lead more often to tumorigen-
main stages. The first stage is the initiation and the esis compared to a single (or a few) large dose; 3)
respective agents that cause it are so-called initia- a combination of several carcinogenic factors more

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frequently causes on the target tissue the synergis- as in toxic substances the introduction of ratio of
tic or additive effect (less antagonistic action); 4) any safety, but with larger values - 100 and more.
exposure to carcinogenic creates a risk of cancer for
all the life. 9.4. MODIFYING FACTORS
For many toxic action substances is a threshold
dose below which there are no adverse changes (ie. Carcinogens do not operate in isolation on bio-
non-stochastic effect). logical systems. Many of on biological factors (ge-
When factors of carcinogenic effect is difficult to netic, immune, sexual, age, nutrition, enzyme induc-
determine whether there is a threshold dose - it is tion) can have a stimulating or inhibiting effect on
assumed that they have stochastic effects on linear carcinogenesis.
(non-threshold) depending dose - response. A num- Species and genetic specificity. Some species
ber of arguments, however, are held against the are relatively resistant or more susceptible to the
concept of non-threshold carcinogen - eg. agents effects of certain carcinogens. These differences are
may react with other cellular nucleophiles (proteins, most often a result of certain genetically determined
non-critical segments of DNA); be rapidly metabo- properties of the type - eg. in underdeveloped seba-
lized when passing through the liver; occur off of ceous glands of the skin, thereby hindering the pen-
mutations in the DNA or destruction of the neoplas- etration of the carcinogen; inability to induce the
tic cell by the immunogenic mechanisms, prior to MFO, due to not forming carcinogenic metabolites,
the occurrence of tumor cloning. Also, for cancer to etc.
occur under the influence of a number of carcino- A number of tumor localizations can be observed
gens is necessary to have previously tissue damage more frequently in blood relatives (brothers and sis-
(hyperplasia, necrosis), which is the threshold effect ters). These are cancers of the breast, colon, bladder,
- i.e. then there is a threshold for an initial toxicity kidneys, lungs, prostate gland, stomach; melanomas
below which there was no damage, it should have and some sarcomas. The risk of developing some of
and the threshold for secondary formation tumors. these tumors in blood relatives is 3-4 times higher
These arguments, however, are not generally ac- than that seen in control families or among the gen-
cepted because they can not prove accurate in ex- eral population of the inhabitants. This is explained
periments on animals and studies in humans. with genetically determined metabolic competence
Regardless of whether there are threshold dos- of the hepatocytes and the cells of other organs to
es or not, today there is much evidence of dose-re- metabolizable fallen into the body chemical sub-
sponse effects of carcinogens - eg., that large doses stances, wherein the active carcinogens degrade to
lead to a greater probability of developing tumors; harmless products, or vice versa, from the inactive
to a higher incidence of mortality and a shorter la- chemical substances are formed intermediate and
tency period compared to lower doses or concen- final carcinogens.
trations. In this connection, a number of authors In connection with this modification of carcino-
consider that the threshold concentrations of chem- genesis are important factors that induce enzyme
ical carcinogens can be established. For this purpose systems associated with metabolic processes of
comes in experiments with a variety of experimen- carcinogens. Here are some essential polycyclic ar-
tal animals, in a variety of ways of introducing and omatic compounds (methylholantren), organochlo-
gradually decreasing the dose to establish the dos- rine pesticides (lindane), food (spinach, cabbage,
es or concentrations that do not cause tumors and salads), drugs (luminal), smoking and chronic con-
pre-tumor proliferation during the life of the exper- sumption of alcohol.
imental animals; also identified in the experiment Experimental established a number of inhibitors
noblastomogenic doses to be compared with the of carcinogenesis contained in fruits and vegetables,
results of the quantification of carcinogens in the cereals and legumes, such as vitamins A, E, C, PP, B2,
environment in which they live or work certain pop- carotenoids, indoles, coumarins, aromatic isothiocy-
ulation groups, as well as the frequency of relevant anates, flavones, plant sterols, protease inhibitors.
cancers in them. Gender differences. Different sensitivities of
Transfer of results of animal experiments on hu- sexes to carcinogens can be explained by differenc-
mans is quite naturally taking into account a series es in hormonal profile, anatomical structure of some
of factors - eg. the body mass of the various organs tissues and organs and their physiological activity. It
of animals and humans, their physiological and bio- is known for example that estrogens stimulate and
chemical characteristics, etc. It is recommended that testestosterone inhibit carcinogenicity of chemical
the use of various mathematical models and appro- substances, MT-virus, ionizing radiation in tumori-
priate formula. After all the calculations is required, genesis of breast cancer.

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Age differences. Experimental and epidemio- fibers with a diameter less than 3 μm and a length
logical studies have shown that adolescents individ- below 5 μm. Established a synergy when combined
uals are much more favorable terrain for the course action of asbestos and smoking.
of carcinogenesis in action of carcinogenic factors. Arsenic and arsenic compounds. In miners in-
Most likely, this is due to high proliferative activity of volved in the extraction of gold, cobalt and copper
tissues, the relative immaturity of the immunolog- ores, that are high in inorganic arsenic compounds
ical defense of the organism, of the immaturity of is detected an increased risk of lung cancer. The risk
certain structures and enzyme systems. of lung cancer is greatly increased in the metals re-
fineries, where workers inhale high concentrations
9.5. CARCINOGENS IN PRODUCTION of arsenic (Table. 3). In literature there are not a few
reports of skin and lung cancer in growers used ars-
Professional chemical carcinogens are major en containing insecticides.
sources of air pollution, food, water and soil. Initial Chromium and chromium compounds. In the
assumptions about the low incidence of occupa- workers involved in the production of chromates,
tional cancer of 1-3% were not compliant with such there was about a 20 times higher risk of developing
factors as the prolonged latent period and synergies lung cancer compared to the corresponding control
in the combined action of some carcinogens. Now, groups. In experimental studies have induced tum-
according to some authors 20-40% of cancers are or ors in laboratory animals after treatment with vari-
will be in the coming decades professionally condi- ous chromium compounds (calcium, strontium and
tioned (Table. 1). zinc chromate).
Data from epidemiological studies indicate the Nickel and nickel compounds. Cancer mortali-
presence of an increased risk for occupational expo- ty in the nasal cavity at workers in nickel refineries
sure to inorganic and organic compounds (Table. is 150 times higher, and lung cancer 5 times higher
2): than in the general population. In these workers is
Asbestos. In workers of asbestos productions increased and the risk of cancer of the larynx and
register an increased incidence of lung cancer and stomach, as well as various sarcomas. The risk now
mesothelioma. It is noted that asbestos is over 3,000 associated mainly with the powdering of nickel ores.
different applications in industry and households. For carcinogens adopt nickel sulphide, nickel ox-
High concentrations of asbestos in the environment ide and carbonate. Intramuscular administration of
are found around manufacturing industry and en- these substances to rats leads to the development
terprises. It is experimentally demonstrated that of fibrosarcomas and by inhalation - tumors of the
the incidence of tumors is influenced by the shape lungs.
and dimensions of the fibers. Most are carcinogenic
Tab. 1. Productions in which the possible development of cancer (in M.L. Fischman et al., 1995)

Production Probable or suspected agent Target organ

Production of aluminum Polycyclic aromatic hydrocarbons Lung, bladder
Production of auramin Auramin Bladder
Manufacture and repair of
Benzene Leukemia
footwear (some professions)
Gasification (coal) Polycyclic aromatic hydrocarbons Lung, bladder, skin, scrotum

Production of coke Polycyclic aromatic hydrocarbons Lung, ?kidney

Furniture production Wood dust Nasal cavity (mainly adenosarcomas)
?Polycyclic aromatic hydrocarbons,
Casting of iron and steel Lung
silicon, metal aerosols
Production of isopropyl alcohol Diisopropyl sulfate, isopropyl oils Paranasal sinuses, ?Larynx
Fuchsin, ?precursors
Production of fuchsin Bladder
(incl. Ortotoluidin)
Purification of nickel Nickel oxides, nickel subsulfid Nasal cavity, lung, larynx
Bladder, leukemia, stomach, lung, skin, colon,
Rubber industry Aromatic amines, ?solvents
prostate, lymphoma
Underground mining of
?Radon Lung
hematite (exposure to radon)

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Tab. 2. Production carcinogens (by Encyclopaedia of Occup. Health and Safety, 1998)

Carcinogen Target organ

4-aminobiphenyl Bladder
Arsenic and its compounds * Lung, skin, ?liver angiosarcoma
Pleura and peritoneum (mesothelioma), lung, ?larynx,
Asbestos
gastrointestinal tract, kidneys
Benzene Leukemia
Benzidine Bladder
Beryllium and its compounds Lung
Bis (chloromethyl) ether ** Lung
Vinyl chloride Liver (angiosarcoma),? brain, lung
Coal tars and resins Skin, scrotum, lung? bladder
Wood dust Nasal cavity
Ethylene oxide Leukemia
Mustard gas Larynx, lung
Ionizing radiation Leukemia, skin and others.
Cadmium and its compounds Lung
Mineral oils, raw or slightly processed Skin, scrotum,? lung
β-naphthylamine Bladder
Nickel and its compounds (? Oxide and sulfide) Lung, nasal cavity
Radium Bones (sarcomas)
Radon Lung
Soot, tar * Skin, lung,? bladder
Talc containing fibers azbestformeni Lung? mesothelioma
Ultraviolet radiation Skin
Chromium (VI) compounds * Lung, nasal cavity
* Compounds with a carcinogenic effect in humans are not well defined
** And technical chloromethyl ether which contains 1-8% bis (chloromethyl) ether

Tab. 3. Carcinogenic risk in the copper production - CP (by Tzolova S., 1995)

Number of Common
CP Type of study Follow-up period Exposure
persons relative risk (%)
Таcоmа,
Cohort 525 1949-1973 AsY 304.8*
USA
-“- -“- 2802 1940-1976 AsY 194.9*
-“- -“- -“- -“- AsA -“-
Anaconda,
-“- 8047 1938-1963 AsA 329*
USA
-“- -“- 8045 1938-1977 AsA - **
-“- -“- 1800 1938-1979 AsA -
Garfield, Proportional
244 died 1959-1969 - 481*
USA mortality
Ooita,
Cohort 2675 1949-1971 - -
Japan
Sweden -“- 3916 1928-1981 AsA 372*
-“- -“- 3710 1958-1982 - 232*
29 dead of
-“- Case-control 1960-1976 AsA 510*
lung cancer
9 workshop
copper electrolysis Cohort 4802 1946-1975 - 97
USA

* р<0.05 ** Relative risk in contingent no-estimated

AsY - Arsenic in urine; AsA - Arsenic in air

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Aromatic amines. Of aromatic amines with un- Vinyl chloride. Epidemiological studies show
derlighted carcinogenic properties to induce blad- that exposure of workers to vinyl chloride increases
der tumors are β-naphthyl amine and benzidine. the carcinogenic risk of developing angiosarcoma
Epidemiological studies have found that the high- of the liver, brain tumors, lung cancer, chemo- and
est risk in workers exposed to β-naphthylamine - 61 limphopoetic system. Following oral or inhalative
times more than in the whole male population and treatment of experimental animals with vinyl chlo-
benzidine - by 19 times. Carcinogenic amines are ap- ride are observed most frequently angiosarcoma of
plied in cable production, the paper industry, in the the liver.
production of pigments and dyes. With increased Benzene. When workers having prolonged
carcinogenic risk and are working with benzidine in contact with benzene establishes an increased risk
publishing laboratories. of acute no-lymphocytic leukemia. Relatively few
Heterocyclic and polycyclic aromatic hydro- however, successful attempts to induce tumors with
carbons in soot, coal tar and mineral oils. A num- benzene in an experiment with animals.
ber of experimental studies have shown that con- Several studies have established an increased risk
tact with soot, coal tar, creosote, shale oils, asphalt, of cancer of the paranasal sinuses in the wood-pro-
smoke that is produced by burning organic matter, cessing and furniture industry, production of shoes.
carries a high risk of developing skin cancer (cancer The increased cancer risk associated with release
of the scrotum in chimney sweeps, and workers ex- of large amounts of wood dust in the wood-pro-
posed on tar and mineral oils), and in fewer degrees cessing industry and the use of several chemicals
of lung cancer, bladder and digestive system. These in other industries that are carcinogenic to humans
substances are produced experimental tumors in and experimental animals (chromium and chromi-
many animal species of both sexes of almost all or- um salts, arsenic and arsenic compounds, asbestos,
gans and systems. Polycyclic aromatic hydrocarbons benzene, mineral oils, tars, isopropyl alcohol, etc.).
exhibit strong carcinogenic and for cells and organs,
cultured in vitro.

REFERENCES

1. Ames B.N., Magaw R., Gold L.S. - Ranking possible carcinogenic hazards. Science, 1987, 236-271.
2. Boeva M.N. - Mechanisms of carcinogenesis. Sofia Med. and phys., 1977. (in bul.)
3. Boffetta P. ed. Cancer in: Encyclopedia of Occupational Health and Safety, ed. J. M. Stellman 4th ed.,
Geneva, JLO, 1998, Vol. I, 2.2-2.14.
4. Fichman M., Cadman E., Desmond S. - Occupational Cancer. in Occupational Medicine, edit. J. La Dou,
Norwalk, Appleton & Lange, 1990, 182-208.
5. Hoel D.G et al. - The impact of toxicity on carcinogenicity studies: implications for risk assessment.
Carcinogenesis, 1988, 9, 2045.
6. INTERNATIONAL AGENCY FOR RESEARCH ON CANCER: Overall Evaluations of Carcinogenicity: An
Updating of IARC Monographs Vol. 1-42, IARC Monographs Suplement 7, WHO / IARC, 1987.
7. Kaloyanova F. et al. - Hygienic Toxicology, Sofia Med. and phys., 1985. (in bul.)
8. Mitrov G., I. Chernozemski, L. Shabad. Carcinogens in the environment and human cancer. Sofia
Med. and phys., 1982. (in bul.)
9. Mitrov G., I. Chernozemski - Nutrition and cancer. Sofia Med. and phys., 1985. (in bul.)
10. Nicolson W.J.: Research issues in occupational and environmental cancer. Arch. of Env. Health, 1984,
39, 190.
11. Schottenfeld D.: Chronic Disease in the Workplace and Environment: Cancer. Arch. of Env. Health,
1984, 39, 150.
12. Tennant R.W. et al: Prediction of chemical carcinogenicity in rodents from in vitro genetic toxicity
asseys. Science, 1989, 236, 933.
13. Tsonevski D., N. Donchev, R. Enikova, V. Jarova - Modification of experimental carcinogenesis of
cadmium in terms of different diets. Hyg. and Pub. Hlth., 1994, 3-4, 43-46. (in bul.)
14. Vainia H.: Carcinogenesis and teratogenesis may have common mechanisms. Scand. J. Work Environ.
Health, 1989, 15, 13.

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 I. Altankova, M. Lyapina

10 FACTORS ACTING
ON THE IMMUNE SYSTEM
The latter normally are destroyed by macrophages,
10.1. IMMUNE SYSTEM but a small part of them is processed and presented
to the lymphocytes which are activated. T-lympho-
Object of the immune system is to protect the cytes bear on their surface receptors, through which
living body from external aggressors (bacteria, vi- recognize foreign materials. Activation of B-and T
ruses, fungi, nutrients, chemicals) through the con- lymphocytes by clonal proliferation leads to ampli-
struction of a protective immune response against fication of the immune response. Upon stimulation
foreign macromolecules (called antigens). Large bi- part of T-lymphocytes differentiate into cytotoxic
ological macromolecules are natural antigens, while T-lymphocytes, while others respond by formation
smaller molecules can not induce an immune re- of soluble mediators, termed lymphokines, possess-
sponse if they are not associated with a carrier (usu- ing an extremely broad spectrum of activity. Most
ally proteins) - haptens. of the newly immunocompetent cells involved in
Immune competence has two main components: the development of an immune response, but some
1. Humoral immunity - immunoglobulins, anti- of them remain “dormant” as memory cells. Upon
gen-specific antibodies, B lymphocytes re-exposure to the specific antigen, the memory
2. Cellular immunity - T lymphocytes, sub- cells are activated and generate a large number of
populations of their, T-cell recognition, lym- responsive cells (via IL-2), leading to intense im-
phokines, T-B cell cooperation and regulation mune response.
of immune response. The selectivity of the humoral response against
Immune defenses of higher organisms is done on foreign molecules or pathogens is mediated by
two levels: antibodies. Antibodies are gamma globulins that
a) antigen nonspecific, primary implemented by identify foreign antigens and activate certain pro-
polymorphic-nuclear leukocytes, macrophages, nat- tective systems of the body. They consist of heavy
ural antibodies, opsonization and phagocytosis and light chains making up the functional domains
b) antigen-specific - characterized antigen recog- and are formed by plasma cells. There are five classes
nition, primary or secondary immune response of immunoglobulins (IgG, IgA, IgM, IgE, IgD) each of
All of these, called immunocompetent cells de- which has a specific heavy chain (Table. 1).
rived from pluripotent stem cells. A portion of the Despite large differences in the nature of the
precursor stem cells are “brought up” in the thymus humoral and cellular immune response, various
and are transformed into T-lymphocytes, which are Tab. 1. Human immunoglobulin classes
present in thymus-dependent areas of spleen, and
Mean serum Half-life in
lymph nodes and constitute 60-85% of peripheral Type concentration
Molecular
plasma
Biological
weight function
blood lymphocytes. Precursor B cells mature under (mg/dl) (days)
the influence of the fetal liver and bone marrow and Fix complement
IgG 1200 150 000 23 precipitin
make up 7-23% of human lymphocytes. Genetical-
ly defined cell surface markers allow you to identi- Secretory
160 000
fy and distinguish lymphocyte types. Stem cells are IgA 280
550 000
6 antibodies, anti-
also precursors of the monocyte-macrophage and virus protection
Fix complement,
polymorphs-nuclear lines of cells that play an im- IgM 120 900 000 5 agglutinins
portant role as in non-specific and like wise in anti-
gen-specific immune defense. In lymphocyte
IgD 3 180 000 3 receptor in
Lymphocytes can be activated, either directly by
newborns
the antigen or indirectly by macrophages (via inter- Reagins
IgE 0.03 190 000 2.5
leukin-1, IL-1) which were exposed to the antigen. antibodies

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 OCCUPATIONAL MEDICINE
cell types cooperate with each other and through plement cascade.
complex mechanisms set and the two arms of the The demonstration of type II reaction going
immune response. Certain subpopulations of T-lym- through the test of Coombs, who demonstrated IgG
phocytes (T-helper and T-suppressor) exert a positive antibodies on the surface of red blood cells.
and negative control and on B- and on T-lympho- Type III - immunocomplex reactions
cyte function. Other lymphocytic cells called natural They occur when the binding of soluble antigen
killer (NK cells) participate in non-specific defense of and free IgG and IgM antibodies in immune com-
the body and are potentiallycy cytotoxic for various plexes, which leads to complement activation. May
malignancies and virus-infected cells, and another develop as local, Arthus reaction (immune complex-
subpopulation T cells involved in antibody-depend- es are formed in situ in the skin) and systemic serum
ent cell-mediated cytotoxicity. Furthermore, in the sickness (circulating complexes are deposited in dif-
effector phase of the immune impairment involved ferent tissues). The deposition of immune complex-
and other components (biological systems, cells, es leads to the development of the effects of chronic
etc.): complement, prostaglandins, cyclic nucleo- inflammation with the inclusion of the coagulation,
tides, eosinophils, platelets, hormones, neuro-endo- complement and other systems, the secretion of
crine links, psychological stress, which determines vasoactive amines, cytokines, oxygen radicals and
the complexity of the immune response. other factors and cells that lead to the death of the
tissue and fibrosis.
10.2. BASIC MECHANISMS The presence of antibodies of type III immune re-
OF IMMUNE DAMAGE actions can be demonstrated through the establish-
ment of circulating immune complexes and comple-
Currently defined at least 4 major types of im- ment activation in the conventional way.
mune responses conditioned tissue damage, de- Type IV - cellular immune responses
pending on the effector mechanisms. In many dis- This type of immune response, also called de-
eases, however, operate more than one effector layed-type hypersensitivity, occurs when the an-
immune mechanism. tigen binds to the sensitized T lymphocytes and
Type I - quick type hypersensitivity form a series of cytokines. It does not require hu-
Reaction develops in sensitized individuals im- moral antibodies and complement. Located in skin
mediately after contact with the antigen, most of- Langerhans cells absorb and processing fall antigen
ten in people with a history of IgE-mediated asth- and present it to the CD4 + T lymphocytes. Upon
ma or rhinitis (atopics). Fc-portion of the formed IgE repeated exposure, they are activated and secrete
binds to surface receptors on basophils and mast lymphokines. Lymphokines exert its effect mainly in
cells, resulting in the release of vasoactive medi- the neighborhood surrounding environment by en-
ators. Depending on the organ involved clinical hancing a number of biological activities, but their
manifestations are rhinitis, bronchospasm, urticar- main function is to attract and activate macrophag-
ia, angioedema or hypotension (by this mechanism es and new immune cells. Clinically occurs most
occurs occupational allergic asthma and rhinitis). By often as contact dermatitis. At 24-48 hr immune in-
IgE-mediated mechanism than fast, immediate re- filtrate manifests itself as erythema, induration and
actions can occur and late-phase reactions - 12-24 itchy, and sometimes vesicles and skin necrosis.
hours after the initial reaction, and are characteristic Demonstration of delayed type hypersensitivity
of occupational asthma when using detergents, in in vivo done by skin test by standardized antigen.
bakers and others.
The fast type hypersensitivity evidenced by skin 10.3. HEALTH EFFECTS OF
tests with relevant allergens in vivo and immune IMMUNOTOXICITY EFFECTS
tests which prove specific IgE in serum.
Type II - cytotoxic effects Known and relatively well known are as innate,
In them a cell antigen is a protein or is attached genetically determined T-, B- or combined immuno-
to the cell surface. Low-molecular substances (eg. deficiency, and diseases associated with acquired
haptens) can induce the formation of IgG or IgM immunodeficiency. Possible health effects of immu-
antibodies with anti-hapten specificity. Upon re-ex- notoxicity effects can be related both to suppress or
posure on the cell surface to form antigen-antibody enhance the normal immune response, and the de-
complexes. The destruction of target cells (mostly velopment of aberrant one. The most typical clinical
erythrocytes or pulmonary basic membranes) is manifestations of abnormal immune response can
realized by killer cells that have receptors for the be summarized as follows:
Fc-portion of IgG, as well as activation of the com- 1. Suppressed resistance to infections.

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 LABOUR MEDICINE
Several harmful environmental factors can lead 4. Hypersensitivity reactions.
to suppression of the immune response: ionizing Well known that most of the immunomodulating
radiation, metals (lead, cadmium, cobalt, beryllium, agents may also cause hypersensitivity reactions.
gold), polychlorinated biphenyls, chemotherapeutic Clinically, the most common are fatigue and febrile
and immunosuppressive drugs. They may be affect- conditions and are the expression of a pharmaco-
ed various components of the immune system: logically immunomodulation associated with acti-
• immunodeficiency of T-cell subpopulations vation of macrophages and release of interleukins
- mainly associated with severe viral and op- IL-1 and TNF. Chemical immunostimulation can also
portunistic infections due to intracellular increase the risk of a true allergic diseases, regard-
pathogens and fungi (chicken pox, tuberculo- less of the allergen. There is evidence for increased
sis, listeriosis, aspergillosis, etc.). production of IgE antibodies in the action of chem-
• deficient in B-cellular functions - most often icals and drugs. Each of 4 effector mechanisms of
associated with severe bacterial infections immune damage (but most likely in combination
(streptococcus, Klebsiella pneumoniae, Neis- with others) may underlie of clinical-proven allergic
seria, etc.) reactions as a result of toxic pollutants in working
• impaired phagocytosis and intracellular kill- and environmental surroundings.
ing - may manifest as recurrent purulent in- 5. Altered hepatic metabolism.
fection, chronic skin disease Inhibition or stimulation of liver enzymes from
• deficiency of the complement system - man- harmful chemicals or immunomodulatory thera-
ifested by recurrent infections with strep- peutic agents leads to distortion in the normal bio-
tococci, Haemophilus influenzae, Neisseria transformation in the cells, which may lead to an ac-
meningitis cumulation of active metabolites, abnormal toxicity
2. More frequent occurrence of carcinomas. and interleukin production. For similar mechanisms
Congenital immunodeficiency, such as Ataxia for example affect phenobarbital and polycyclic aro-
telangestasis, syndrome Wiskott-Aldrich and severe matic hydrocarbons that damage cytochrome P450
acquired immunodeficiency diseases are associated monooxygenase functions. Immunostimulation is
with a high incidence of lymphoreticular malignan- also a factor that can modulate hepatic enzymatic
cy, Kaposi’s sarcoma and others. Prolonged treat- metabolisation of chemicals.
ment with immunosuppressants on transplant pa-
tients or patients with autoimmune diseases is also 10.4. ALLERGENS CAUSING
associated with a higher incidence of malignancy. PROFESSIONALLY-DEPENDENT
In cancer patients after prolonged chemo- or radi- SENSITIZATION
ation therapy occurs more frequently second ma-
lignancies such as leukemia, macroglobulinemia, Professional allergen is any substance present ex-
myeloma, another cancer, associated probably with clusively or predominantly in the workplace, which
immunodepression. can cause by immune or non-immune mechanisms
3. Emergence of autoimmune diseases. hypersensitivity reaction in exposed workers. With
Currently the emergence of autoimmunity as a the development and introduction of new technol-
consequence of immunotoxicity effects is quite de- ogies is constantly increasing and the number of po-
batable. Described are a number of drug-induced tential allergens.
autoimmune diseases-lupus-similar syndrome, my- Plant allergens. Herbal ingredients, oils, resins
asthenia gravis, autoimmune hemolytic anemia. and juices can cause asthma, rhinitis, urticaria or
There are many similarities between idiopathic and contact dermatitis. Pollen from grasses and trees
drug-induced autoimmune diseases, but there are can sensitize agronomists, florists grain-producers,
significant differences between them. In the past gardeners. Known role of gluten - a common anti-
there are two characteristic features: gradual onset gen for various types of flour (wheat, corn, barley)
- 3-6 months after exposure, and clear remission fol- for occupational asthma among millers, bakers,
lowing termination of exposure to harmful agents. confectioners. Inhalation of wood dust from oak,
Possible mechanisms of induction of autoim- pine, beech and some exotic trees - mahogany, teak,
mune response of chemical hazards are: a) simple western red cedar and others can cause occupation-
activation of latent disease or cross immune reac- al allergic diseases. Some medicinal plants - primula,
tivity to chemical, b) directly imunopharmacological valerian, aloe, lime, causing the occurrence of bron-
or immunotoxicity effects on the immune response chial asthma in pharmacists and herbalists. Castor
- eg. in action of chlorpromazine, hydralazine, seed, oil plants cake, tobacco, soya flour, cotton, flax,
methyldopa, penicillamine, procainamide. hemp, jute, dust from raw coffee have similar effects

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 OCCUPATIONAL MEDICINE
on exposed them workers (interesting is that during nickel is one of the most common causes of contact
firing of green coffee are destroyed macromolecular dermatitis. Allergenicity have also chromium, plati-
substances, play a role allergens). num. It is believed that the metals and the salts act as
When workers in the textile industries inhalation haptens, causing subsequently immune response.
of dust from cotton, linen or hemp causes so-called Lawrence (1981) graded heavy metals accord-
byssinosis. The pathogenesis of the disease is not ing immunotoxic properties as follows: mercury >
yet fully understood, but it is assumed that develops copper > manganese > cobalt > cadmium > chro-
histaminoliberation without prior sensitization of in- mium. According to him, zinc and iron showed no
haled dust. significant effects, while lead and nickel, lead to an
Animal antigens. By epidermal waste (dandruff increase in antibody-forming cells.
and hair) come epialergens. They include dandruff The metals can affect the immune system in
and hair of man and animals, feathers and down several directions: to influence natural immune re-
of birds, fish scales. Secretions, mucus, urine, feces, sistance (antigen - nonspecific immune response);
insect venoms may also be allergens. Endangered cause immunosuppression; to connect to its own
professions are those of veterinarians, breeders, proteins and make them autoantigens (gold- and
workers in vivariums, zoologists, poultry-farmers. mercury induced nephritis in humans and animals);
Ingredients of cuticle (artropodin), haemolympha, to induce reaction of respiratory hypersensitivity
excrement (proteins and glycoproteins) a number of (chromium and development of asthma in atopics).
parasites - ticks (home, flour), insects (corn beetle), Occupational lead exposure shows that the main
moths (wheat moth) and sericin - protein cover fib- immunotoxicity effects are most likely associated
ers of silk, are also professional allergens. Allergenic- with proliferative ability of lymphocytes (amplified)
ity of sheep wool and unrest dust increases during without major changes in humoral immune indica-
their storage in humid and warm rooms due to the tors (except for a reduction in secretory IgA in saliva).
development of fungal and bacterial microflora. The mechanisms by which heavy metals exert
Pearl dust causes sensitization and asthma among their immunomodulatory effects are noth entirely
jewelers. clear. It is generally accepted that metalothioneins
Bacteria, fungi and their spores. Most impor- - small, cysteine-rich proteins (6-8 kDa) which bind
tant for professional pulmonary pathology as anti- heavy metals have Immunosuppressive properties.
gens are thermophilic actinomycetes, enzymes of Drug allergy. Professional are exposed workers
Bacilus subtilis and fungi - Alternaria, Penicillum, human and veterinary medicine, pharmacists, work-
Aspergilus and others. Risk are workers employed ers in the chemical and pharmaceutical plants. The
in the production of wood flour, leather, detergents, most common allergens are antibiotics, anesthetics,
cheese, beer, mushrooms and more. Inhalation of al- sulfonamides, analgesics, corticosteroids, neurolep-
lergens causes hipersensitiv pneumonitis. tics and others. The mechanisms of sensitization to
Chemical allergens. A huge number of organic drugs can be immune or pseudo- and non-immune
and inorganic substances can cause occupational and clinical manifestations - local or generalized,
sensitization. Of organic matter allergenicity have systemic.
gasoline, naphtha, chloramin, formaldehyde, acr- Food additives and impurities are common al-
olein, trichloroethylene, benzene, phenol and de- lergens - the different colors of food (eg. tartrazine),
rivatives, mineral oils, coal tar, aniline, organic dyes preservative (benzoic acid, sodium bisulfite, acetyl-
used in the textile industry (indigo-, azo-, nitro- and salicylic acid), antioxidants (ascorbic acid, lactase,
nitrozo dyes) , epoxy resins, etc. Ursol and in particu- salt of citric acid), impurities (metals, pesticides, in-
lar derivative hinondiamin causes symptoms of res- gredients of plastics, detergents, etc.).
piratory allergy in working with hair dyes. Pesticides, The work environment various antigens are
especially chlor- and organophosphorus also have found in various combinations with one another
allergenic potential. In many professions - workers and with the physical factors, impacting on the body
in the chemical industry, painters, bookbinders, pro- complex. The induced immune response can be car-
ducers of shoes and handbags, workers in wood- ried out in more than one immune mechanism.
working and furniture production risk of sensitiza-
tion in contact with lacquers, paints and adhesives. 10.5. IMMUNO-DEPENDENT
In the production of plastics etiologic factors for OCCUPATIONAL DISEASES
the occurrence of occupational allergy can be used
monomers, accelerators, plasticizers and colorants. Most common occupational diseases in the
Metals. Metals and their salts are important eti- pathogenesis of immune mechanisms involved are
ologic factor for allergic conditions. Working with allergic asthma and rhinitis, hypersensitivity pneu-

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monitis and contact dermatitis. Their development confirm the assumption that the primary pathoge-
depends on the individual predisposition, the type netic mechanism engages the effector T-cells.
of allergen, and the extent of exposure. Clinical manifestations, the latest experiments
Allergic asthma and allergic rhinitis are some of conducted on animals, epidemiological data and
the manifestations of I-type IgE-mediated allergy. research samples from bronchoalveolar lavage
Generally, genetically predisposed individuals (atop- showed a complex mechanism of disease with in-
ics) are prone to sensitization by inhalation of aller- volvement of specific cell-mediated immunity, and
gens of high molecular weight (proteins), while the nonspecific biological effects of inhaled material
inhalation of small molecule antigens, no-connec- and only a small role (if can speak of such), circulat-
tion with the presence of atopy in the individual and ing antibodies.
sensitization. Still not fully understood the mecha- Contact dermatitis is erythematous skin disease,
nisms of pathogenesis of non-allergic (non-immu- classic manifestation of cell-mediated immunity,
nological) asthma. wherein the main pathogenetic role is played by sen-
Hypersensitivity pneumonitis were known in sitized T-lymphocytes. It is assumed direct contact of
1713, were described by Ramazzini as pneumo- the allergen with the skin. There are numerous aller-
nia-like illnesses occurring after contact with pow- gens leading to disease - metals (chromium, nickel,
ders in some productions - i.e. as occupational cobalt), and organic compounds - ingredients in
diseases. Subsequently, they are disclosed various cosmetics, detergents (enzyme preparations), pre-
forms - farmer’s lung, bagasoza disease, cheese pro- servatives (formalin), cutting oils, drugs, used in the
ducers disease, lung of mushrooms, etc. rubber industry as auxiliary materials accelerators,
Hypersensitivity pneumonitis is an allergic dis- anti-oxidants, vulcanizators, stabilizers. The majority
ease of the lung parenchyma by inflammation of the of them are haptens, but the source and nature of
alveoli and the interstitial spaces, induced immuno- the vectors in the skin are not known.
logically from acute or chronic inhalation of various As a special case here is regarded photoallergy
organic powders or of occur in these bacteria or - manifestation of cell-mediated hypersensitivity to
fungi (thermophilic actinomycetes), as and animal some substances which are converted into immuno-
products (dried excrement). The allergen enters as gens under the action of sunlight. Photosensitising
particles that do not exceed 3 μm, and reaches the considered as being phototoxic reaction, associated
alveoli in normal breathing. with changes in pyrimidine bases of DNA or changes
Many of the allergens associated with hypersensi- in its double helix. It is known photosensitizing ef-
tivity pneumonitis, except immunogenicity possess fect of some medications - sulfonamides, phenothi-
other biological properties relevant to pathogene- azines (endogenous activity) and phototoxic effect
sis. Such are the adjuvant properties, which is due to of coal tar, tar and derivatives (exogenous action).
additional non-specific activation of macrophages Unlike the typical effects of some occupational
and non-immunological activation of the alternative hazards and drugs on the immune system, relation-
complement pathway. ship immune response- harmful substances from
A long time as a major pathogenetic mechanism the environment are unclear. It was found that the
of hypersensitivity pneumonitis was assumed III- total load of antigens from the environment sup-
type - reaction of Arthus, caused by immune com- presses the immune system leading to an immune
plexes of inhaled allergen by precipitating IgG an- abnormalities, multisystemic and psychological dis-
tibodies and subsequent complement activation. eases. Typical symptoms are impaired self-esteem,
Evidence in this direction are found in more than chronic fatigue and neurotic symptoms. Harmful
90% of patients antigen - specific precipitating an- agents of the environment include exhaust from
tibodies. However, in 50% of persons with similar road transport, smoke, perfumes, solvents, formal-
exposure and without clinical symptoms were also dehyde, chlorine and fluorine compounds in drink-
detected precipitating antibodies, suggesting that ing water, chemical additives to foods and more. No
these antibodies are associated with the effects (ex- exact mechanisms of damage to the immune sys-
posure) to the allergen, and not necessarily by the tem by these agents, but it is the role of IgE, immune
presence of lung disease. complexes, and other yet unidentified mechanisms.
There is also an opinion that the disease is me-
diated predominantly by IV-type - T-lymphocyte ef- 10.6. DIAGNOSIS OF IMMUNE
fector mechanisms. In support of this are histologi- IMPAIRMENT
cal studies showing the infiltration of lymphocytes,
neutrophils and macrophages, interstitial fibrosis, Study of immune changes in humans exposed to
granulomas. Experimental studies in animals also potentially harmful agents is much more complicat-

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ed compared to that in the experimental animals. It mites, feathers, pollen and extracts of suspected
is necessary to comply difficulties as logistical prob- high-molecular-weight antigens of working envi-
lems, appropriate controls, magnitude and nature of ronment. Low-molecular materials usually do not
exposure, drug abuse, illness. give positive rapid skin response until are no-conju-
The human population is heterogeneous and ge- gated with carrying protein- ex. serum albumin. The
netically different and individual variation affects on initial positive reaction from a redness and vesicles
results. People are exposed continuously to stimuli may be followed after 4-6 hours of IgE-mediated late
from the environment, and their ability to meet the response, expressed by erythema, induration, pruri-
foreign materials is supported by immunological tus on application site.
memory. For some infectious microorganisms, eg., Testing by patches. Patches used in the proof of
the immune response, however, does not lead to contact skin sensitization. The test was performed
their complete elimination, and more likely to their with standard impregnated with antigen patches,
“soft” integration into the genome (Herpes, cyto- which are applied to the skin and results were read
megalovirus, Epstein-Bar viruses, etc.).
Table 2. Methods recommended by WHO for the
Essential are limitations of methodological ap- study of immunotoxicity
proaches to the study of people. Applied noninva-
sive methods carry less information, and method- 1. Blood cell counts and differential counts
ology established by WHO to study the immune 2. Antibody-mediated immunity (one or more of
the following)
response was built to demonstrate abnormalities
- a primary antibody response to protein antigens
of the immune system in prominent medical con- (eg. epitope tagged flu vaccine)
ditions - immunodeficiencies and more discreet - serum immunoglobulins IgG, IgA, IgM, IgE
departures are difficult ascertainable. For some im- - a secondary antibody response to a protein anti-
mune parameters are essential and age, gender, ad- gen (diphtheria, tetanus or poliomyelitis)
ditional disease therapy - factors which, if not com- - natural immunity to blood group antigens (an-
ply can be a source of misinterpretation of results. ti-A and anti-B)
Obtaining usable data for immunotoxicity effects 3. Phenotypic analysis of lymphocytes by flow
of some environmental factor and its use for risk cytometry
characterization begins with initial epidemiological - superficial analysis of CD3, CD4, CD8, CD20
study. The most common model is a cross-section 4. Cellular immunity
study in which exposure and disease state (in this - skin testing for delayed type hypersensitivity by
Multitest Biomerieux R
case a change in immune function) are measured
- primary reaction of delayed-type against the pro-
once or within a short period. Immune function of tein (keyhole limpet haemocianin)
“exposed” individuals was compared with that of un- - proliferation by permitting antigens (secondary
exposed, appropriately selected group. response)
Actual laboratory studies of the immune re- 5. Autoantibodies and inflammation
sponse are usually selected standard and are aimed - C-reactive protein
at characterizing the overall immune competence Titers of autoantibodies against nuclear (ANA),
(first stage) and to characterize specific immune DNK, mitochondrial antigens
response to toxic materials and mechanisms of oc- - IgE against allergens
currence of aberrant immune response (subsequent 6. Measurement of non-specific immunity
stages). There are some differences in the combina- - the number of NK cells (CD56 or CD60) or cytolyt-
tions of methods applied in different countries, such ic activity against K562
- phagocytosis (NBT or chemiluminescence)
studies are combined in one-moment scheme or se-
7. Clinical Chemistry
quential-deepening order. On Table. 2 is a combina-
tion of methods recommended by the World Health
Organization (EHC 180). after 24 h. A positive reaction consists of erythe-
Tests for the study of immune competence ma, induration, and in some cases and a vesicle. In
After detailed and focused history and initial addition to standard commercial kits comprising a
studies of: blood (blood count), pulmonary function set antigens (American Academy of Dermatology)
tests (FEV1, FVC, EFF25-75, PEFR) or provocative sam- in the same manner can be applied and suspected
ples (eg. with methacholine) is directed to proceed harmful antigens from the environment.
laboratory testing of the immune response. Examination of antibody-mediated immunity
Skin tests. Scarification and intradermal skin in vitro. The study of the humoral immune response
tests are useful in identifying sensitization to num- include measurement of serum concentrations of
ber of inhaled protein antigens such as ticks, dust immunoglobulins, antibody formation after immu-

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nization and screening of natural immunity. transformation and newly synthesized DNA and the
For the determination of serum total and aler- expression of some activation markers IL-2R (CD25),
genspecifically IgE antibodies are most popular ra- CD69, HLA-DR, etc.
dio-immunosorbent (RAST) and the enzyme-linked Tests for the study of non-specific immune de-
immunosorbent (ELISA) methods. In these, inert fense. Studied the number of so-called NK cells (by
particles/surfaces are coated with antigen and in- flow cytometry) or their cytolytic function through
cubated with serum. The formed antigen-antibody their ability to cell line K562. A significant role in
complexes were visualized by an anti-human conju- non-specific immune defense play and polymor-
gate with isotopes or enzymes. The latter are meas- phonuclear leukocytes, whose function phagocyto-
ured by suitable apparatuses-counters or spectro- sis is frequent object of study. The activation status
photometers. of neutrophils and platelets can be examined by
The common IgG, IgM and IgA antibodies in se- flow cytometry with appropriate labeled antibodies:
rum most often were measured by radial immuno- CD11b, CD14, CD16, CD54, CD63, etc.
diffusion in gel or turbidimetry. The demonstration The classical complement system is composed of
of precipitating IgG can be done by test Ouchterlony 9 components (C1-C9) and a number of regulatory
- cross-diffusion in gel, where antigens and antibod- proteins. Many important biological activities in the
ies from serum diffuse against each other and form inflammatory response and in natural resistance to
a precipitation line. This test is useful to define the III infection are disclosed at various times of the clas-
type immune responses. sical and alternative pathway activation of the com-
Tests for cellular immune response. Various plement system. Laboratory testing of serum hemo-
tests in vivo and in vitro are used for the study of lytic complement activity (CH50) is a useful test, but
cellular immunity: number of T- lymphocytes and similar and focused information can be obtained
their subpopulations, cutaneous delayed hypersen- through the study of fragments of complement - C3,
sitivity, lymphocyte proliferation in vitro and blast C4, C1 - inhibitor, C2 and others.
transformation under the influence of antigens and The classification of the immune response in pre-
mitogens. dominantly Th1 or Th2 type of cytokine secretion
The modern approach to determine the number (Mosmann & Coffman 1989) and modulation from
of lymphocytes and their subpopulations, as well as harmful environmental opens new perspectives
some of their functions is by flow cytometry. Using for the characterization of immune mechanisms by
specific monoclonal antibodies against different which damage occurs.
characteristic epitopes of a cell surface, associated
with fluorescent substances, labeled mononuclear
cells from peripheral blood and account their % or
absolute number of an automated flow cytometer.
Deviations in the number of cells or in their ratio may
be associated with defects in their ability to recog-
nize antigens and the regulation of T-cell function,
leading to immune incompetence or autoimmunity.
Delayed type hypersensitivity indicates the
ability of the individual to manifest pre-built T-cell
response and in vivo was examined by cutaneous
application of antigens which normally induce such
a response. Is used to demonstrate T-cell-mediated
immune deficiency (i.e. performed with a commer-
cial kit Multitest R, Institute Merieux, Lyon, France,
containing 7 standardized antigen, positive and
negative controls, placed in a special applicator).
The results were evaluated after 48 h by measuring
the diameter of the hardening and calculating the
sum (scoore).
The proliferation of mononuclear cells in addition
to the authorizing (recall) antigens is an way for the
study of delayed hypersensitivity in vitro and proof
of type IV immune reactions as pathogenetic mech-
anism of immunotoxicity disabilities. Measure blast-

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M. Lyapina, E. Vodenicharov

10.7 IMPACT OF PHYSICAL FACTORS

ON THE IMMUNE SYSTEM

Relatively scarce and conflicting data about the liferation ability of splenic lymphocytes and NK-ac-
impact of physical factors on the immune system. tivity reduced.
The biological effects of physical factors are due to INFRASOUND AND ULTRASOUND. Scarce and
the direct impact on the cell and subcellular struc- conflicting data about the effects of infrasound on
tures and by means of - by neurohumoral and neu- the immune system. Eg. experimentally it has been
roreflex mechanisms. Recent advances in the study found that the effects are dependent on the levels of
of the interaction between the nervous and immune sound pressure - frequency infrasound with 8 Hz and
systems show bidirectional links between them sound pressure of 80 dB has an immunostimulating
through common receptors and biologically active effect, and at 130 dB induce immunodeficiency.
substances, cytokines and neuropeptides. It is known that the smaller the intensity of the
NOISE is one of the most common environ- ultrasound has a positive biological effect, stimu-
mental stressors and in working environment. Ad- lating the vital processes. Therapeutic applications
verse effects on the immune system can be either have resorption, fibrinolytic, vegetonormaliziation,
by means of neuroendocrine disorders, and directly desensitization and immune stimulating effect of ul-
immunity. In both cases extremely important clini- trasound. In conditions of experiment it was shown
cal implications are distortions in common to neu- that exposure to low frequency ultrasound to stim-
roendocrine and immune system mediators. ulate the functional activity of macrophages and
It is considered that the noise impact on the im- their metabolism, as well as the specific immune
mune system manifests itself in the following bio- response.
logical effects: Larger intensities have a destructive effect on the
1. Reduction of anti-infective immunity cell protoplasm. It highlights the importance of free
2. To promote the development of autoimmune radicals, that could mediate the production of yet
and allergic processes unidentified organic radicals, also cause DNA dam-
3. Reduction of antitumor immunity. age found during exposure to ultrasound.
Exposure to noise distorts the function of cell THE VIBRATIONS are a physical stressor that by
membranes and biological barriers, increasing their afferent and efferent connections with the partici-
permeability, which leads to entry into the blood- pation of the central nervous system and affects the
stream of antigen-carring scars of another origin immune system.
and opportunity for development of autoimmune The assumption of a possible link between occu-
response. pational exposure to vibrations and development
In experiments carried out on animals exposed to of scleroderma was first expressed back in 1914 by
a short-time (30 min to 1 h) exposure to noise levels Bramwell. Currently it has formed the hypothesis
of 100 dB report decreased secretion of superoxide that the possible development of collagen and be
radicals from neutrophils and IL-1 from macrophag- professionally conditioned. Similar is the patholog-
es. Increased titers of serum thymulin, increase the ical picture of the vascular damage in vibration dis-
weight of thymus and the number of thymocytes. ease and scleroderma-rupture of the inner elastic
In experiments with 3 weeks of exposure to noise, membrane of the vessels with subsequent focal cell
it was found that the tested immune parameters are proliferation and regenerative formation of collagen
changed in the direction of immunostimulation or and elastin. In addition, endothelial damage caused
immunosuppression, depending on the exposure directly from the vibrational impact may cause
duration: after 24 hours increased serum levels of platelet-adherence, activation and the release of
IgM, decreases in the phagocytic activity and in- mitogenic mediators - such for example platelet de-
creased activity of NK-cells, after 7 days, a decrease rived growth factor (PDGF), which enters the vessel
of the proliferation ability of spleen lymphocytes wall and causes local smooth muscle proliferation.
upon stimulation with mitogens and NK-activity is Studies in the field of vascular pathology indicate
increased: after 3 weeks increased slightly the pro- the important role of leukocytes. Main role in micro-

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vascular occlusion is attributable to polymorphonu- Quantitative assessment of lymphocyte subpop-
clear leukocytes (PMN), which are the most numer- ulations, defining their functional activity, of serum
ous, considerably larger than lymphocytes. immunoglobulins, phagocytic indicators and an-
In subjects with a phenomenon of “white fin- tinuclear antibodies in professionally exposed to
gers” (VWF) found subpopulation harder and hard- Ultra-High Frequency (UHF) electromagnetic fields.
er deformable therefore activated leukocytes. It is The majority of controlled indicators show dyna-
considered that the vibration exposure causes local mism and expressed phase character in its quanti-
activation of leucocytes and increase their adhesion tative variation depending on length of service and
to the endothelium. The release of leukotrienes, the trend in the first five years is to increase.
cytokines and chemoattractants by damaged en- Sets are an increase in IgM - primary immuno-
dothelium, and ischemic and “captured” PMN en- globulin in the primary immune response, which
hances the development of a pathological process gives base to assume the role of microwave electro-
by increasing the expression of adhesion molecules magnetic fields as antigen non-specific immunos-
on endothelium and leukocytes, and further recruit- timulant.
ment and activation of PMN - there is a vicious circle. There are changes in lymphocyte subpopula-
In support of the hypothesis of activation of tions, as total T-lymphocytes are reduced, and sup-
leukocytes in vibration exposure is established in- pressor-cytotoxics - increased. There have been re-
creased production of leukotriene B4 and free rad- ports of generating an autoimmune response upon
icals by PMN in patients with VWF. LTB4 is a potent exposure of the test animals.
chemotactic and aggregation mediator and a rise in In studies carried out on peripheral blood mon-
plasma levels, in turn, further activated leukocytes. onuclear cells, exposed to extremely low frequen-
In the latest research has explored the role and cy electromagnetic fields was an increase in pro-
defined serum levels of intercellular adhesion mol- duction of IL-1 and IL-6 from monocytes. Express
ecule-1 (sICAM-1) and interleukin-8 (IL-8) in patients assumption is that it is possible monocytes are the
with VWF. Found a significant increase in the levels target of these EMF.
of sICAM and reduction of IL-8 in persons with VWF. Interest is the possible carcinogenic effects of
Elevated levels of sICAM-1 reflect the increased leu- EMF with frequency 50Hz, sources that can be pow-
kocyte adherence and extravasation in the extracel- er lines and household appliances. In the studies
lular matrix which may contribute to the develop- on isolated human lymphocytes is not apparent in-
ment of microcirculatory pathology. The reduction crease in the frequency of spontaneous emergence
in levels of IL-8 in these patients probably reflects of “micronucleus” and genotoxic effect.
slow blood flow in the microcirculation. In booming fields of application of high-frequen-
It is known that the development of vibration cy EMF (3-30 MHz) and increasing the number of
disease, the severity and nature of its course may radio sites (mainly antenna systems of broadcasting
be different in people working under identical con- stations) more people are exposed to their action.
ditions. Perhaps it depends on biological, genet- Scarce and conflicting data about the impact of
ically determined characteristics of the organism these EMFs on the human immune system. Exper-
determining unequal susceptibility to the effects iments on animals have shown: establishment leu-
of industrial vibration. Not exclude that the autoim- kopenia and lymphopenia with monocytopenia; in-
mune component is basically a negative course of creasing the number of basophils and reducing the
vibrational disease with the development of degen- number of neutrophils; There is a clear correlation
erative-dystrophic permanent damage. Susceptibil- between the effect and degree of the impact (field
ity to immunodeficiencies and autosensibilization strength).
associated with antigenic determinants related to Higher voltages field (400V/m at 24 MHz) stim-
HLA-system. It has been found that the antigen HLA- ulate autoimmune reactions in the body and lower
DR5 may have a role as a prognostic marker indica- (200 V/m) induce delayed-type hypersensitivity.
tive of increased risk of adverse course of vibration IONIZING RADIATION. Studies were carried
disease. Conversely, antigens HLA B35, B40 and DR2 out on changes in humoral and cellular immune re-
perform protective function to the impact of indus- sponse upon exposure to ionizing radiation. Chang-
trial vibration. es in the humoral immune response is characterized
ELECTROMAGNETIC FIELD (EMF). The accu- by: 1. extending between an antigenic stimulation
mulated data are still insufficient and contradictory, and antibody production 2. reducing the rate of
but identifying certain trends in the immune re- increase in serum antibody levels 3. reduction of
sponse depending on the type and duration of ex- their maximum concentration. The study of serum
posure and the type and intensity of exposure. IgG, IgA and IgM in workers in uranium mines show

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phase character and dynamics in its quantitative considered that the strongest immunosuppressive
variation depending on the time of exposure. There effect have the UV-rays in the range 260-270 nm.
is a suppression of cell-mediated immune response. They studied the effects of ultraviolet radiation
Detected is a difference in sensitivity of different on the immune system and activation of viral and
lymphocyte subpopulations, the most sensitive to other infectious diseases. Assumed probability of
the effects of ionizing radiation are CD 8 + suppres- exposure to ultraviolet light to activate the HIV virus
sor T cells. Increased interrelation helper-suppressor and to accelerate the onset of the disease.
(CD4/CD8) speaks for selective recovery of CD4 cells TEMPERATURE. It is known that physical fac-
after irradiation in occupational exposure. tors such as sunlight, heat, cold, mechanical injury
They found data of the role of immune chang- can cause urticaria. These are 15-20% of its chronic
es for the occurrence of some diseases of the pop- forms.
ulation in areas contaminated with radionuclides The physical forms of urticaria are divided broad-
(Chernobyl accident). It is found interrelation of an ly into primary (IgE-mediated) and secondary. For
autoimmune response to antigens of thyroid, micro- reagin-mediated solar urticaria is assumed that an-
somal and thyroglobulin to the observed thyroid hy- tibodies react with modified or synthesized de novo
perplasia. There are also antibodies to the antigens antigens under the influence of the sun. The origin
of the lens, which also implies involvement of au- of antibodies of class IgG and IgM in cold urticaria
toimmune mechanisms in the development of cat- are associated with the occurrence of cold-induced
aracts in humans exposed to chronic effect to low neoantigens (by exposure of new antigenic determi-
doses of ionizing radiation. nants or modified proteins).
ULTRAVIOLET RADIATION. Ultraviolet radia- ATMOSPHERIC PRESSURE. The conditions of
tion affects human health in different ways. Acute reduced atmospheric pressure and hypoxia, cause
reactions are skin erythema and photodermatoses marked changes in the immune system, increasing
and by eye-keratitis and conjunctivitis. In chronic the amount of lymphocytes, monocytes, functional
exposure to UV radiation increases the risk of devel- activity and the concentration of NK-cells, a reduc-
oping various types of skin cancers and cataracts. tion in CD4 + and CD8 + lymphocytes. It is assumed
Damaging the immune system and DNA. that NK-cells are particularly sensitive to hypoxia.
Experimental studies have shown that radiation With prolonged stay under increased atmospher-
in the UV-B range cause suppression of contact hy- ic pressure observed phase reaction in the function-
persensitivity reactions, reduction in the number al activity of polymorphonuclear cells and monocy-
and functional activity of the Langerhans cells in the tomacrophagic row - after initial increasing should
skin, and changes in the distribution of lymphocyte decrease. There is also an increase in aberrant meta-
subpopulations in peripheral blood. Repeated expo- phases of lymphocytes.
sure of mice with radiation in the UV-B range induce The study of the mechanisms and processes, un-
immunological changes, leading to suppression of derlying the immune response, allowing to look for
rejection induced by radiation in the UV-B range new approaches to assess the impact of physical fac-
tumors in syngenic mice. The impact of the rays in tors on the body, and to take appropriate preventive
the UV-B range and leads to suppression protection measures.
against of primary, induced by radiation in the UV-B
range tumors in the skin of influenced animals. It is

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REFERENCES

1. Adams M. R., Jessup W., Hailstones D., Celermajer D. S. - L-Arginine reduces human monocyte ad-
hesion to vascular endothelium and endothelial expression of cell adhesion molecules. Circulation, 1997;
95: 662-8
2. Ambach, W., M. Blumthaler. - Biological effectiveness of solar UV radiation in humans (review). Experi-
atia, 49, 1993 (9): 747-53.
3. Basic and Clinical Immunology; - Eight Edition, D. Stites, A. Terr and T. Parslow (EDS) 1994, Prentice
Hall International Inc.
4. Bozhkov B. - Applied Allergy, Sofia, VenelOOD, 1996 (in bul.)
5. Coombs R.R., Gell R.G. - Classification of allergic reactions responsible for clinical hypersensitivity and
disease. In: Clinical Aspects of Immunology, Gell R.G., Coombs R.R., Lachman (EDS) 1975, Blackwell Scientific
Publications.
6. Demirova M., B. Petrunov - Occupational asthma, Sofia Med. and phys., 1988 (in bul.)
7. Essencials of immunotoxicity assessesment in humans. - In EHC 180: Immunotoxicology, 1993.
8. Fisher T. C., H. J. Meiselman. - Polymorphonuclear leukocytes in ischemic vascular disease. Thrombo-
sis Research, Vol. 74, Suppl. 1, pp. S21S34, 1994
9. Greenstein, R. C. Kester. - The role of leucocytes in the pathogenesis of vibration white finger. Angiol-
ogy, 1998, 49 (11), 915-922
10. Grishina, T. I., O. K. Suvorova. - Immmunomodulated impact of noise (overview of bibliography).
Med. lab. prod. ecol., 1997, 3: 26-29. (in russ.)
11. Immunotoxicity of Metals and Immunotoxicology. - A.D. Dayan et al (EDS), 1990, Plenum Press, New
York
12. Klokker, M. et al. - Influence of in vivo hypobaric hypoxia on function of lymphocytes, neutrocytes,
natural killer cells, and cytokines. J. Appl. Physiol., 74, 1993 (3): 1100-6.
13. Lau, C. S., A. O’Dowd, J. J. Belch. - White blood cell activation in Raynaud’s phenomenon of systemic
sclerosis and vibration induced white finger syndrome. Ann. Rheum. Dis., 51, 1992 (2): 249-52.
14. Nagata, S. - Stress-induced immune changes and brain-immune interaction. Sangyo. Ika. Daigaku.
Zasshi., 15, 1993 (2): 161-171.
15. Pelmear, P. L., J. O. Roos., W. M. Maehle. - Occupationally-induced scleroderma. J. Occup. Med., 34,
1992 (1): 20-5.
16. Sidelytseva, E.V. and al. - Immunogenetic markers in vibration disease. Med. Lab. and prod. ecol.,
1993, 11-12, 27-29. (in russ.)
17. Tsvetkov, D. Non-specific effects of vibration impact. In Infrasound, ultrasound, noise, vibrations. ed.
Tsvetkov, D., M. Angelova. S., Med. and phys., 2007, p. 215-229. (in bul.)
18. Van Raaij, M. T. et al. - Time-dependent differential changes of immune function in rats exposed to
chronic intermittent noise. Physiol. Behav., 60, 1996 (6): 1527-33.
19. Zarev, P. - Characterization of immune status and assessment of ongoing changes in persons occupa-
tionally exposed to VHF electromagnetic fields. Dissertation, 1995. (in bul.)

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R. Shekerdjiiski, I. Denev

10.8 POSSIBILITIES FOR TREATMENT OF ADVERSE

FACTORS BY ANTIOXIDANT SUPPLEMENTS

Number of environmental factors, physical, Dietary antioxidants reduce oxidative damage

chemical, biological, social (stress), affect human by:
health and have markedly deleterious effect on the • inhibiting the processes of formation of reac-
immune system. This effect is the reduction of its tive oxygen species;
own resilience to a variety of bacteria and viruses, • regeneration of antioxidant vitamins;
the greater possibility of sensitization of the body, a • supporting and inducing effect on antioxi-
predisposition to the development of autoimmune dant enzymes and detoxifying agents.
diseases and malignant. Numerous epidemiolog- To increase the antioxidant defenses of the body
ical and clinical studies prove the primary role of may further be included in the diet increased intake
prophylactic nutrition to reduce the harmful effects of antioxidants in the form of dietary supplements.
of these factors and prevention of many chronic and This is especially exposed to adverse chemical envi-
degenerative diseases. ronmental factors (eg. production of petrochemicals,
The increasing knowledge of the reactive forms plastics, synthetic fibers). Where are limited oppor-
of oxygen, oxidative stress and the role of antioxi- tunities for primary prevention of risk management
dants in the diet showed that feeding can modify, strategies to enhance adaptation capabilities of the
positively or negatively, oxidative damage to the cell organism are fully appropriate. The antioxidant vi-
structures are involved in the pathogenesis of many tamins E, C, beta-carotene are a necessary compo-
diseases. nent of a safety professional catering. In prophylac-
The active oxygen species are produced as tic purposes are accepted and some trace elements
by-products during normal cellular metabolism, (selenium, zinc, manganese), directly involved in the
mainly in mitochondria. These are hydroxyl radical, enzymes metabolizing toxic substances.
superoxide anion, hydrogen peroxide, nitrous oxide
and others. Under normal conditions, the cells have VITAMIN E
a well-developed antioxidant protection reduces Vitamin E is the main antioxidant in the lipid
the impact of reactive oxygen species. When pro- phase of biological membranes and lipoproteins.
duction of these reactive species has increased to The name vitamin E includes eight compounds (four
the degree that overcomes the antioxidant cellular tocopherols and four tocotrienols). Alpha-tocopher-
protection are talking about oxidative stress. Be- ol is the most biologically active. Natural alpha-to-
cause these molecules are partially reduced oxygen copherol (d-α-tocopherol) is a single stereoisomer
products, they are highly reactive and interact with and is 2 times more biologically active than the syn-
other biomolecules, which may lead to lipid perox- thetic form (dl-α-tocopherol), which is an equimolar
idation, oxidation of the nucleic acids and proteins. mixture of eight stereoisomers. Their different bio-
Therefore, oxidative stress plays an important sub- logical activity due to the differences in their incor-
sidiary, role in the pathogenesis of numerous chron- poration in LDL- and HDL-cholesterol, affinity of tis-
ic and degenerative diseases. sue to the natural form and much faster metabolism
Antioxidants are substances that directly or indi- for synthetic form.
rectly protected the cells against the harmful effects In membranes tocopherol is reacted with a lipid
of xenobiotics, toxins, drugs and carcinogens. Anti- peroxyl and alkoxyl radicals to give a relatively sta-
oxidants are divided into three groups: ble lipid hydroperoxide and tocopheroxyl radical,
• antioxidants in food - vitamins C, E, carote- interrupting the chain reaction of lipid peroxidation:
noids, flavonoids and other plant polyphe-
nols;
• metallo-enzymes such as catalase, superoxide
dismutase, glutathione peroxidase, etc .;
• molecules such as glutathione, albumin, bili-
rubin and uric acid.

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Various studies suggest that the protective effect important antioxidant function as deactivated sin-
of vit.E in terms of chronic diseases, can be attrib- glet oxygen, formed during photosynthesis as high
uted not only to its powerful antioxidant action but effective is lycopene.
also to other poorly understood mechanisms such Laboratory studies show that carotenoids in-
as participation in cell signaling mechanisms. hibit lipid peroxidation. The system of conjugated
In addition to maintaining the integrity of cell double bonds determined absorption in the visible
membranes, alpha-tocopherol protects the unsatu- spectrum. This is of particular importance to the eye,
rated fatty acid in LDL-cholesterol from oxidation. It wherein the lutein and zeaxanthin effectively absorb
has been shown that the changed oxidized LDL-cho- the blue light, preventing the photoreceptor cells of
lesterol plays an important role in the development the retina from damage.
of atherosclerotic changes in the blood vessels. Although the results of epidemiological studies
Several epidemiological studies have shown that have shown that a high dietary intake of rich in ca-
low consumption of vitamin E increases the risk of rotenoids fruits and vegetables reduces the risk of
cardiovascular diseases. WHO sponsored studies to cardiovascular disease and certain types of cancer,
determine the presence of low serum levels of vita- high doses of beta-carotene does not reduce the
min E as a very important risk factor for developing risk of these diseases in large randomized clinical tri-
heart disease. als. Back, two such studies found that high doses of
Conversely, use of high doses of vitamin E in the beta-carotene (more than 20 mg/day) increases the
treatment of patients already diagnosed with heart risk of lung cancer in smokers and former workers in
disease show conflicting results. In 1996, Cambridge the asbestos industry.
Heart Antioxidant Study conducted with more than Beta-carotene has vitamin A activity and includ-
2,000 patients with proven coronary atherosclerosis, ed in multivitamin preparations as 2 μg beta caro-
indicates that supplementation with 400-800 UI/day tene (suplemented) provides 1 μg retinol (3,33 UI
synthetic alpha-tocopherol, for 2 years, reduces the vitamin A). The recommended daily intake of retinol
incidence of non-fatal myocardial infarction by 77%, is 1000 μg (3330 UI vitamin A)
but generally total mortality from heart disease has Epidemiological studies have shown that men
not changed significantly. with high intake of dietary lycopene (tomatoes and
It is believed that many cancers are the result of derivatives) have a lower risk of developing prostate
oxidative DNA damage. Placebo-controlled study cancer. As a dietary supplement lycopene is availa-
in Finland seeking preventive effect of vitamin E in ble in doses of 5 to 15 mg.
lung cancer in male smokers demonstrated 32% de- Lutein and zeaxanthin are carotenoids in the
crease in the incidence of prostate cancer in patients retina and lens of the eye. Scientific evidence shows
receiving 50 mg of synthetic alpha-tocopherol, over that consumption of at least 6 mg of these can re-
a period of 5 years. duce the development of age-related macular de-
Main sources of vitamins. E are vegetable oils, generation and cataracts.
nuts and grains. The recommended dietary intake
for adults of alpha-tocopherol is 15 mg/day (22,5 ASCORBIC ACID
UI). This amount is primarily necessary to prevent Vitamin C is the most effective water-soluble an-
the symptoms of deficiency (neurological), rather tioxidant and most important for extracellular fluid.
than for prevention of chronic diseases. It’s hard to Ascorbate effectively binds to a variety of reactive
consume more than this amount of food without oxygen species. Vitamin C has and tocopherol re-
increasing the intake and fat. To prevent chronic generating effect by reducing tocopheroxyl radical
diseases such as cardiovascular, neurodegenerative to tocopherol.
and some types of cancer is recommended intake of To prevent deficiency recommended daily intake
200 UI (133 mg) natural vitamin E daily during meals. for adults is 70 mg. Numerous, mainly prospective
However, vitamin E affects the clotting process at cohort studies have shown that the amount of vita-
very high doses can lead to bleeding. On this basis min C necessary for the prevention of chronic dis-
calculated maximum allowable daily intake of vita- eases is significantly higher (100-300 mg). The allow-
min E (natural and synthetic) - 1000 mg. able maximum daily intake for vitamin C is 2 g.

CAROTENOIDS METALLOENZYMES ANTIOXIDANT

In the human diet most often present carote- Enzymatic antioxidants - superoxide dismutase
noids alpha/beta-carotene and beta cryptoxanthin (SOD), catalases and peroxidases, have emerged as
which are pro-vitamin A activity as well as lycopene, early as the evolutionary development and are es-
lutein and zeaxanthin. In plants, carotenoids play an tablished in all eukaryotes.

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SOD are a family of metalloenzymes contain- epicatechin and epicatechingalat.
ing copper, zinc and manganese. They catalyze the Epidemiological WHO studies show that at com-
conversion of superoxide radicals to hydrogen per- parable levels of plasma cholesterol and other risk
oxide and oxygen. Daily recommended dietary in- factors, the incidence of heart diseases in France is
take for adults of zinc, copper and manganese, re- more than half lower than in North America. This
spectively - men 11 mg, 900 μg, 2,2 mg; women 9 discrepancy known as the “French paradox” is con-
mg, 900 μg, 1,6 mg. The maximum allowable daily firmed by other studies indicating that moderate
intake of these elements is 40 mg, 10 mg, 11 mg. consumption of red wine (rich OP) probably reduces
Prolonged intake of zinc in doses above 50 mg/day the risk of cardiovascular disease.
cause a shortage of copper and iron in the body. OP used clinically for half a century they have
Selenium dependent enzyme glutathione held very in-vitro and in-vivo studies demonstrat-
peroxidase is of primary importance to eliminate ing their powerful antioxidant, collagen stabilizing,
peroxides (hydrogen peroxide and lipid hydroper- anti-thrombotic, anti-inflammatory and vasodilat-
oxides) in the cell, while forming water and alcohols, ing action. OP have affinity for blood vessels, which
and using reduced glutathione. Its importance to accumulate in the greatest concentration and exert
the body as demonstrated by Keshan disease - car- vasoprotective effect.
diomyopathy that develops in endemic areas of Kes- Their antioxidant activity involves direct interac-
han province in China, where the soil and hence the tion with various radicals, storing and regenerating
food is very low in selenium. It is assumed that oxi- effect of alpha-tocopherol, inhibition of xanthine
dative stress caused by selenium deficiency leads to oxidase, chelating iron and copper ions. In vitro
emergence of more virulent strains of some viruses studies have shown that OP are significantly more
that affect the heart muscle. potent antioxidants from vitamin C and vitamin E.
There is a reverse correlation between cancer This has led to numerous, and conducting in vivo,
incidence and selenium content in soil, water and studies demonstrating that administration of OP
food in different geographic areas. Other studies significantly increased plasma antioxidant activity
also show inverse correlation between cancer inci- and reduce the tendency of LDL to oxidation by free
dence and level of selenium in serum and nails. In radicals.
the US in a placebo controlled clinical trial proves With prophylactic dosage is 50-100 mg/day, and
that selenium intake of 200 μg/day for an average of for therapeutic purposes (problems in blood circu-
7.4 years reduces the risk of prostate cancer by 51%. lation such as varicose veins, edema, etc.) is 150-300
Furthermore, increased activity of antioxidants mg/day.
selenoenzimes and other mechanisms have been It is known that a high consumption of green tea,
proposed for the protective effect of selenium in re- in some areas of Japan is associated with a signifi-
spect of cancer diseases. Such are improved immune cant reduction in the case of cancers. Green tea con-
function, influenced metabolism of carcinogens, in- tains a significant amount (up to 30% of the dried
creased levels of selenium metabolites suppressing drug) monomer catechins (epicatechin, epigallo-
tumor growth. catechin, epicatechin gallate, epigallocatechin gal-
The recommended daily intake for adults of sele- late):
nium is 55 μg. Average diet provides about 100 μg.
High doses can be toxical-maximum tolerable daily
intake of 400 μg.

FLAVONOIDS
Flavonoids are a diverse group of polyphenolic
compounds of plant origin. It is believed that many
of the biological activities of flavonoids due to their
antioxidant potential.
With used as food additives are used oligomer-
ic proanthocyanidins, monomeric catechins from
green tea, kvertsetin, extract of ginkgo biloba, sily-
marin and others.
Industrial oligomeric proanthocyanidins (OP) In addition to the strong antioxidant activity in
are obtained as extracts from grape seeds (92-95% vitro conditions are proven and various other mech-
OP) and mediterranean pine bark (80-85% OP). They anisms (stimulation of detoxification enzymes, etc. .)
represent dimers, trimers and tetramers of catechin, contributing to the anti-cancer activity of green tea.

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With prophylactic dose is 100-300 mg/day of a blood - a biomarker of lipid peroxidation. It is also a
standardized extract (60-80% polyphenols). significant decrease in antioxidant status - measured
Quercetin is the most common flavonoid in activity of the enzyme glutathione peroxidase and
plants such as occurs in the form of glycosides (rutin, reduced glutathione concentrations.
kvertsetrin, hesperidin, etc.). In comparative in-vitro Studied is the ability to counteract oxidative
studies it shows the strong antioxidant properties stress by using a food supplement "Oxiprevent “(sup-
as compared with other flavonoids. It has a strong plement contains a complete blend of antioxidants).
anti-inflammatory and antiallergic action, making it As a result, the intake significantly improved antiox-
useful in complex therapy of asthma, allergic rhini- idant status of exposed workers as all biochemical
tis, rheumatoid arthritis and the like. Quercetin is a indices recovered to normal values.
potent inhibitor of the enzyme aldose reductase in An increasing number of immunocompromised
the eye lens and has a protective significance in the people and the frequency of individuals with an an-
development of cataracts in diabetic patients. Apply tibiotic resistance in the treatment of various acute
in high doses (1,2-1,5 g/day) due to a very weak ab- and chronic infectious diseases. Also common are
sorption in the gastrointestinal tract. Recently, using hypersensitivity reactions to antibiotics and the
an analogue thereof - quercetin chalcone in a lower manifestation of their immunosuppressive effect.
dose (750 mg/day) due to its high bioavailability. One way to overcome this problem is prophylac-
Standardized extract of Ginkgo biloba contains tic use of immune stimulating agents.
22-27% flavonol glycosides and terpene trilacotones Food additive “Respistim plus” (an improved ver-
5-7%. Many clinical studies have confirmed its effec- sion of Oxiprevent) is a combination of strong im-
tiveness in subjects with symptoms of impaired cer- mune-stimulating lyophilized bacterial lysate and a
ebral blood flow (impaired memory, tinnitus, etc.). full range of antioxidants. The bacterial extract con-
The extract was administered at a dose of 120 mg/ tains lipopolysaccharides, peptidoglycan, muramyl
day. The effect is observed after several months of dipeptide, tayhoic acids of the most common bac-
supplementation. terial cause of respiratory diseases. In experimental
Proven hepatoprotective effect (chemical dam- and clinical studies have demonstrated a general
age, viral hepatitis) has extract of milk thistle, con- stimulant properties on various immune system
tains flavonoid mixture silymarin, the effect is due components such as phagocytosis, complement,
to the antioxidant action. interferon, secretory IgA, alveolar surfactant, B- and
The intake of flavonoids is well tolerated without T- helper lymphocytes and others. and specific im-
side effects. As a general problem of all flavonoids mune stimulation - synthesis of antibodies to the
is their low and unpredictable resorption. Devel- bacterial species from which it is isolated lysate.
oped extracts of grape seeds, green tea and ginkgo Administration of “Respistim plus” fell nearly 10
biloba, in which the flavonoid compound has been times respiratory infections in soldiers, exposed dai-
associated with soya phospholipids, leading to sig- ly on stress and overheating weather.
nificantly higher absorption and effect. Other combination preparations with antioxi-
Drugs with antioxidant activity dant activity are: Enogriyn instant drink Oxibor forte,
Conducted in our research in petrochemical plant Triovit, Phytophanere solaire.
have shown abnormalities in antioxidant defenses Drugs with eye protective effect containing a
and a health risk to those exposed. It has been found combination of lutein and other antioxidants:
that by increasing the concentration of benzene in Stel and Stel forte, Eyelut, ICaps, Vitalux, Vitavi-
air, increasing the level of malonic aldehyde in the sion.

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11 HYGIENE REGULATION OF ENVIRONMENTAL

FACTORS. ASSESSMENT AND MANAGEMENT OF
OCCUPATIONAL RISK - APPROACHES AND MODELS

Throughout his life, a person is under the constant tions on animals pathological reactions man and ex-
influence of various environmental factors. Modern trapolation of the results of experimental studies on
hygiene justify preventive measures is based on people1. The threshold values are the smallest con-
the concept of the primary role of environmental centrations (dosage levels) that lead to statistically
factors (OS) in the etiology of human diseases. Bal- significant deviations of indicators of vital activity
ancing the relationship of the “Environment-man” of animals (people) in chronic (acute) experiment.
for the purpose of primary prevention of diseases is In determining the threshold of action is neces-
reached with hygiene regulation of environmental sary to establish physiologicaly permissible fluctu-
factors, which is the theoretical foundation of hy- ations of indicators and to distinguish the “norm”
giene and has important practical significance. It is of “prepathology" and to obtain information about
used in solving the events of technological, sanitary prepathological state in experimental and clinical
and urban character and is the basis for health leg- studies, were used adequate functional tests with
islation. load. The threshold value of the factor is needed in
The basis of hygiene standardization standing order to determine the maximum no-effect dose
notion that only certain combination of various en- (concentration, level). Eg. for each toxic substance is
vironmental factors is optimal for humans. In a sig- determined limit of effective concentrations (doses)
nificant change in the composition and intensity of under which does not occur harmful effects. These
environmental factors disturbing the unity between safe concentrations usually are several times lower
body and environment. In such conditions, or com- than the threshold. To justify the limit concentra-
pletely exclude the possibility of existence of the or- tions (MAC) or doses (MAD) of harmful substances
ganism or therein develop pathological alterations are conducted experimental toxicological studies
occurring in the form of acute and chronic diseases. in acute, subacute and chronic experiments on an-
In less deterioration of the environmental qualities imals and epidemiological studies.
observed mobilization of protective-adaptive mech- From acute experience obtain information about
anisms of the body, in which adaptive reactions can the degree of toxicity, range of toxicity, the magni-
go in pathologies. tude of the DL50, species and gender sensitivity of
Hygiene norm is the maximum safe quantitative experimental animals to the test substance. The re-
physiological level, which is set for factors in differ- sults of subacute experiment allow to judge the de-
entiated levels (minimum, maximum and optimum). gree of expression of the cumulative properties of
It ensures the preservation of health in the broadest the substance. In the chronic experience are estab-
sense, including genetic and reproductive health of lished threshold (threshold of chronic exposure to
both the individual and the entire population. Sub- the substance) and sub-threshold (maximum no-ef-
ject to the hygiene standards, human performance fect) concentration. The maximum dose no-effect of
is not reduced and not worsen the conditions of life the test substance is used to justify the MAC (MAD).
and work. Experimental studies carried out on sensitive for test
In different sections of the hygiene norms of en- substance, type laboratory animals. In epidemiolog-
vironmental factors has its own specifics. Moreover, ical studies, studied the health status of the popula-
modern methodical approaches to hygienic nor- tion exposed to this toxic substance.
malization factors in different environments based
on general theoretical principles. Theoretical basis
of hygienic normalization is general biological sta-
tus of the threshold effect on the body of the factors
of the environment and the theoretical possibility 1
Possible experiments (modeling) and people under strict con-
of reproduction (modeling) in experimental condi- ditions that guarantee non-injurious to health

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11.1. ENVIRONMENTAL FACTORS (prevalence of dental caries) and optimal necessary
parameters (ONP) are 0,7-1,0 mg/l.
The problem of hygiene regulation of environ- Existing hygiene and are temporary and need
mental factors is complex, as opposed to factors of systematic reassessment and improvement based
work environment, they are characterized by low on monitoring of environmental factors and studies
intensity, but operate continuously throughout the their effects on the body.
life of the individual, irrespective of age and profes- In hygienic regulation of air pollutants is taken
sion, there is diverse combination of factors that act into account that their impact is at the entire pop-
simultaneously on the body in a complex interac- ulation, including and the most sensitive part of it
tion between them. - children, the elderly, chronically ill and in through-
Historically may be noted three areas of hygiene out the day and throughout their lives. In this pos-
standardization environmental factors: sible reflex action, resorptive effect and indirect ef-
1. The basis of hygiene standardization adopt fects of chemical compounds on the environment
the characteristics and parameters of a factor in the and living conditions of the population. Therefore
clear (without anthropogenic impact) environment. hygiene standards for ambient air are lower than
It should be borne in mind, however, that “pure na- those quantitative levels of harmful factors that can
ture” does not always offer optimal conditions for lead to reliable diversion of some of the indicators
the organism. For example, in some areas settled for normal vital activity of the body in this popula-
natural deficiency or excess of micro- and macro- el- tion. Experimental studies to assess the biological
ements that need to be adjusted. On the other hand, activity conducted in two stages. The first stage
many so-called harmful factors in certain quantita- being studied in humans (volunteers) threshold of
tive relations appear as bioelements. odor, irritation and reflex reactions in short-term ef-
2. Regulation of communal factors to comply fects of the substance. The information obtained is
with the technical parameters achievable, accord- used to justify the maximum single concentration.
ing to the development and capabilities of techno- The second stage is held to justify daily average con-
logical progress. From the hygienic point of view centration for preventing resorption effects of harm-
maximizing this approach it is also unacceptable as ful substances during their prolonged inhalation en-
these parameters may incidentally coincide with op- tering the body. To determine the MAC experiments
timal conditions and harmless to the body. Modern are conducted on laboratory animals undergoing
equipment and technologies enable a high degree round-the-clock inhalation effects of the test sub-
of purification in relation to a number of factors, the stance over the course of 3-4 months, which is deter-
achievement of which in some cases is not neces- mined threshold and sub-threshold concentration
sary and beneficial for the body, while in terms of from resorption activity of chemical compounds. In
other factors still no workable solutions to achieve this case, if the MAC does not establish by reflex ac-
optimal parameters. tion, sub-threshold concentration is justified MAC of
3. Physiologically justify hygiene standards for this substance in the air. In hygienic regulation of air
determining harmless to the body and generations pollutants accepted the principle of the limit (most
parameters active factors. This is the basic and cor- sensitive) indicator. For example, if the smell of the
rect modern approach. substance is felt at concentrations that do not have
Important from a methodological standpoint is a harmful effect on humans (resorptive activity) and
acceptance of certain parameters for harmful sub- environmental, norms becomes by the threshold of
stances and factors in the environment not as norm, perception of smell.
but as MAC, i.e. concentrations that are not normal, MAC substances in the waters of the reser-
but are the limit- i.e. not distort hygiene comfort, voirs are established based on medical and biolog-
have no direct or indirect adverse effects on the man ical research, starting from the priority of hygiene
and his descendants, not decrease performance requirements to ensure the safety and welfare of
and his confidence, no harm plants and animals. It the population for water. Development of hygiene
is therefore necessary to move from the definition standards provides comprehensive research of the
of the minimum levels of environmental factors, to substance in 3 major signs of harm:
the next stage - and from the optimum parameters. 1. toxicological studies of the influence of the
For example, a MAC (maximum value according to substance on the body;
Decree № 9 of 2001 on the quality of drinking water 2. influence on organoleptic properties of water;
in the country) for the content of fluoride in drinking 3. impact on the sanitary regime of the basin.
water is considered 1,5 mg/l (risk of developing fluo- In establishing standards for drinking water can
rosis); the minimum concentration (MIC) is 0,5 mg/l be tested only the first two signs of harm.

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 LABOUR MEDICINE
The study of the effects of substances on the the harmful effects of the poison. It is considered
organoleptic properties of water aims to establish sufficient justification to be assessed as harmful al-
a threshold concentration for their impact on the terations that go beyond the physiological norm for
smell, the taste, color, transparency (turbidity). one or other indicator (it being understood exit out-
The study on the sanitary regime of reservoirs side the normal range 1,5-2,0 Sx or in many cases - 3
aims to establish a threshold concentration in their Sx) . For the most reasonable approach to adequate
influence on the processes of biochemical oxygen assessment of the significance of detected changes
necessity, mineralization of nitrogen-containing or- currently considered complex complete characteri-
ganic substances and develop of aquatic saprophyt- zation of the state of the organism as a whole, which
ic microflora. recognizes the dynamics of the process in time.
The study of toxic effects of chemical aims to Many important now is the question of criterial sig-
establish the maximum no-effect concentration nificance of the observed changes in the assessment
(MNC), ie of sub-threshold concentrations of sani- of the effects of compounds in low concentrations.
tary-toxicological sign of harmfulness. This happens Prolonged contact with chemical compounds often
in toxicological experiment on laboratory animals or no-leads to the formation of a symptom character-
by predicting the value of MNC with subsequent ex- istic of chronic intoxication with industrial poisons,
trapolation of data on humans. but working under those conditions there are signs
Guiding principle in regulation of toxic substanc- of a decrease in the general resistivity of the body,
es into water is the principle of limiting indicator of increase the level of non-specific morbidity, changes
harmfulness, i.e. accepted for MAC lowest set of val- in immunological reactivity. Criterion for assessing
ues from above 3 (2) symptoms of harm. the harmful effects of chemical compounds is the
Security of scientifically based hygiene norms is preservation or enhancement of adverse effects af-
checked in practice through comprehensive studies ter the recovery period, which is typical for poisons
of reservoirs under natural conditions using epide- having far in the time type of action (carcinogenic,
miologic methods to study the health of the popu- gerontogenic effects).
lation. The methodology of the hygienic regulation of
In hygienic regulation of toxic substances in chemical compounds in the air of the working area
the soil examine their impact on these harmfulness provides specific staging that enables:
indicators: translocation, air-migration, water-mi- • quick scientific prediction of the degree of
gration, and general-sanitary. For those indicators danger and toxicity of chemical compounds;
are established permissible concentrations of sub- • establishing safe levels of exposure to experi-
stances that do not affect the process of self-purifi- ment on animals;
cation of soil, onto her microbiocenoses and exclude • clinical- hygienic approbation for established
the possibility of passing the test substance into in experiment MAC.
groundwater and surface water, plants and air in The first stage is held justify approximate safe
quantities exceeding hygienic norms for each of the levels of influence, with the help of calculations
mentioned objects of the environment. In normal- for various physico-chemical properties of the sub-
ization of substances in soil, as normalization of air stance and experiment on animals - on indicators
pollutants and water, decisive is the principle of lim- of toxicity in single and repeated (up to 1 month)
iting indicator of harm - for MAC is considered the impact. The calculation methods are based on the
smallest of the four values established in the above relationship between the parameters of the toxicity
indicators for harm. of the substances identified in short-term trials and
established MAC of these substances in the environ-
11.2. WORK ENVIRONMENT FACTORS ment. It was found that on the basis of dependence
“dose-time” and “dose-effect” it is possible to predict
Possibility of hygienic regulation of chemical the effects of chronic action using the results of the
factors in the work environment is based on the acute experience, and also to identify the relevant
existence of dependency “dose-time-effect” and hygiene standards for harmful substances.
threshold for harmful action. Many known muta- The second stage of the hygiene regulation of
gens and carcinogens as are necessary for normal harmful substances are exploring their toxicity by
vital activity - trace-elements, for example selenium, inhalation effects on the body of laboratory ani-
arsenic, chromium and others. These compounds mals, but also evaluate skin resorption and irritating
are dangerous only at a certain quantitative limit properties, the nature of the action and the rate of
in the body when the protective systems are inad- accumulation of the substance in re-entering the
equate. This level corresponds to the threshold of body. Studies completed by conducting chronic

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toxicological experiment, which aims to determine of labour. The degree of harmfulness of noise and
the threshold of chronic exposure to the substance. vibration judging by the results of the assessment
For the determination of MAC threshold value of a of the health status of workers: morbidity and clin-
chronic effect dividing by ratio of the stock (uncer- ico-physiological studies in dynamics during the
tainty factor, modifying factor). The modifying factor working day and the recovery period. Starting from
is different for different substances (typically 10 but the nature of the effect of noise on the whole or-
can be 100 and more) and depends on the charac- ganism, is establish concept of bioequivalence to
teristics of the biological activity of the substance, its the effects of the influence of noise and nervous
cumulative properties and others. load (confirmed in manufacturing and experimental
Conducted the third phase clinical- hygienic and studies). In their joint action, their adverse impact on
epidemiological studies in working in endangered the body is additive.
industries are criteria for prognostic value of experi- 3. The adverse effects of noise and vibration
mentally established MAC. is estimated as by their direct effect on adequate
The basis of the norms of physical factors is functions of analysts, and in mediated reactions
also thersholdness. In the hygiene regulation of the throughout the body. The selection of adequate and
negative high levels of physical factors (noise, vi- informative methods for testing must be based on
bration, electromagnetic energy, ionizing radiation, modern ideas about ways of receiving information in
etc.) are justified safe for body-limit levels (LV) or the body of the current stimulus, but along with the
doses (LD). study of hearing, skin and vestibular analysts to also
The purpose of the hygienic regulation of include indicators of functional state of nervous, car-
noise and vibration to determine the permissible diovascular and endocrine systems having general
dayly (or weekly) dose of energy for relevant factors, biological significance. About the dangers of noise
which provides in terms of employment (taking into or vibration is judged by the degree of fatigue on-
account the gravity and tension of labour) preven- set and severity of remote consequences. Assessing
tion of functional disorders or diseases caused by the impact of noise is performed by specific changes
these factors. in the auditory organ and nonspecific changes that
To assess the physiological changes resulting appeared before them, which occur in disorders of
from the effects of noise or vibration are two ap- neuro-psychic sphere - fatigue, dizziness, headache,
proaches. The first is generally accepted and can sleep disorders and others. In assessing the impact
be called concept of “eligible” change - change of general vibrations into account the extent of vio-
compared with criterial permissible alterations (not lations comfort when working near (immediately) to
causing severe intensions and restore normal). The sources of vibration.
second approach can be called concept of “zero” 4. The criterion for harmful effects of factors shall
changes when changes in the indicators do not go be established by changes in indicators of phys-
beyond the physiological norm, i.e. dose is no-effect. iological functions compared with the norm and
Given the specificity of noise-vibration factor, taking into account the prediction of irreversible
defined the basic principles of hygiene standardiza- changes in the magnitude of temporary changes
tion, including physical, medico-biological, and so- the threshold of analyzer systems - used to assess
cial-hygienic aspects: the changes in physiological indicators during the
1. The hygiene regulation of noise and vibration 8-hour day, compared with their level before work
in the production environment must be taken into (eg. it was found that the temporary reduction in
account interaction is system “man-machine-pro- hearing sensitivity after 8 h noise impact is equal in
duction environment.” Scientific and technological rank - in dB, of sustainable decreased auditory acuity
revolution reduce manual labour in manufacturing, after 10 years of working in continuous effect noise
increased role of knowledge workers. While previ- with the same intensity; such are the changes in vi-
ously in the “human-machine” focuses on the coor- bration sensitivity and indicators of peripheral blood
dination of the design of the machine with anato- circulation in local vibrations). A distinctive feature
my-physiological characteristics and parameters of of the hygiene regulation of noise and vibration is to
the body, it is currently leading conformity of the conduct experimental studies on volunteers to ex-
machinery and labour microenvironment with neu- clude masking or enhancing effect of other factors
ro-psychic possibilities of man. of production.
2. Hygiene regulation of noise and vibration is Microclimate normalization of production
based on health and performance criteria to assess is based on the results of studies for heat transfer
the impact of factors on the whole organism in the from man to the environment and conditioned by
process of work, given the intension and hardness his functional status of various systems of the body,

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and the biological effect of various weather factors. Important practical matter the justification of
Normalization is aimed at ensuring the two levels of norms, consistent with the simultaneous effect on
the human heat condition (optimal and acceptable), the body of multiple environmental factors. In this
taking into account its level of energy consumption account: the nature of the action - complex, com-
and period of the year. Provides standardized re- bined or coupled effect of various environmental
quirements for individual microclimate parameters factors; bioequivalence (izoeffectiveness) of hygien-
(temperature, humidity and speed of air movement) ic norms established for different environments and
that in their joint action to provide the required others. In the combined action of harmful sub-
thermal condition of the body. stances can be observed different effects - an addi-
As standards for optimal production microcli- tive effect (the most common), the potentiation and
mate accepted levels of individual components, antagonism. Upon receipt of a harmful substance
which in systemic and lasting effect on the human in the body by both inhalation and oral route (in-
body does not lead to significant changes in phys- complex action) toxicity becomes higher than the
iological status, help to preserve confidence and receipt of this substance only once route. In terms
health of workers and create prerequisites for high of the coupled action of factors of different nature
performance and labour productivity. can be observed strengthening (most common) or
Hygiene standards for microclimate must ensure weakening of their action.
levels of thermal conditions in the body of workers,
where there is no tension on the mechanisms of 11.3. ASSESSMENT AND MANAGEMENT
thermoregulation or the same is weak. Developed OF OCCUPATIONAL RISK -
a special classification of thermal conditions, at the APPROACHES AND MODELS.
basis of which are criteria to evaluate the function
of thermoregulation and cardiovascular system, tak- Risk assessment is a process in which data from
ing into account indicators for the energy value of experimental studies and epidemiological studies
labour. “Optimal” thermal condition is characterized on humans are combined with information about
by a lack of intension by thermoregulatory mecha- the degree of exposure, to be able to quantitative-
nisms, comfortable heat sensation, preserve human ly predict the probability of specific adverse health
health and a high level of performance. In “permissi- effects that would have occurred in exposed pop-
ble” heat condition has been some tension of ther- ulation. Health risk assessments is divided into four
moregulatory mechanisms, uncomfortable heat stages: risk identification, evaluation of dose-re-
sensation, is possible decrease in performance, but sponse relationship, exposure assessment and risk
there are no violations of health. characterization (Fig. 1).
It is preferred that the complex evaluation of the Risk identification is the first and most easily
microclimate in general; determining the degree of step in assessing the health risk. This is a process of
thermal discomfort/comfort; the risk of heat stress determining whether exposure to certain profes-
in acclimatized/noacclimatized, taking into account sional agent could increase the likelihood of adverse
the intensity of work (metabolic heat) and thermo effects on the health of the exposed population. It
resistance (insulation) of clothing. is based on experimental animal studies and epide-
In the hygiene regulation of the ionizing radia- miological studies of exposed persons in order to
tion factor takes into account the specifics of its bi- determine the health side effects when exposed to
ological impact on the body. Dependence “dose-ra- certain occupational hazards.
diation-biological effect” occurs in two forms of The evaluation of the dose-response depend-
biological effects: threshold (non-stochastic) and ence defines the relationship between the dose of
non-threshold (stochastic) effects. Normalization of exposure and the possibility of specific side effects.
non-stochastic effects is based on the concept of a It requires information on methods of extrapolat-
threshold effect, i.e. determine a maximum physi- ing the effects from high to low exposure and from
ologically harmless, quantified level of impact. In a experimental studies in animals to humans. There
study of stochastic (non-threshold) effects departing are some problems in extrapolating data from ex-
from the principle of probability of occurrence and perimental studies to humans: the various possi-
not from the severity of the violations, which causes ble mechanisms of action of some occupational
radiation. Specific hygiene regulation of stochastic hazards are not fully known; doses used in exper-
effects is that in developing the system of radiation imental animal studies are often very high and
protection is considered the concept of non-tresh- these doses are not commonly found in exposed
old action whereby theoretically each dose ionizing individuals; there is a difference between animals
radiation have mutagenic action. and humans in relation to the metabolism of toxic

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substances; dose that is released in specific target Approaches to prove the causal link between
organs of animals is different from that in humans. work-related CVD and professional factors include:
The most accurate model for assessing human ex- 1. Detailed occupational history to establish re-
posure based on data from experimental studies are lationships over time between the occurrence and
physiologically based pharmacokinetic models for development of cardiovascular symptoms and risk
the effects of chemical factors. factors of the working environment.
Exposure assessment determines the magni- 2. Establishment of exposure to occupational fac-
tude and probability of accumulation of the toxic tor - daily, weekly, annual and cumulative (over the
agent from the environment in the body. It is de- entire service).
fined as an external (the concentration of different 3. Detection and evaluation of others (profes-
toxic agents in the environment and working envi- sional and domestic) risk factors.
ronment) and internal exposure (accumulation of 4. Perform a general clinical examination with fo-
these substances in the body). For some chemicals, cused study of the cardiovascular system.
the actual exposure is determined directly by meas- 5. Use of diagnostic tests to identify the type and
uring the content of the toxic agent or its metabo- the degree of cardiovascular damage - ECG; 24-hour
lites in certain body fluids, feces, hair, etc. ECG monitoring; step test, possibly coronary an-
The most important part of the assessment - the giography; 24-hour monitoring of blood pressure
risk characterization summarizes and interprets and others. In epidemiological studies, WHO recom-
the information collected during the previous stag- mends the use of ECG and its interpretation by the
es and identifies the limitations of this evaluation. It code of Minnesota and Rose questionnaire for angi-
requires to determine whether in the specific work- na pectoris and myocardial infarction.
place, there are significant health effects. Complete 6. The determination of the risk of impact of
characterization must discusses previous levels of working factor under certain conditions of the work-
production factor in the environment and work en- ing environment requires sufficient continuous and
vironment and in the body, the pharmacokinetic dif- controlled epidemiological studies (case-control
ferences between experimental research and stud- and cohort retrospective and prospective studies)
ies in humans, the effect of the choice of the specific and analysis of results through advanced methods
parameters for the exposure, statistical analyzes, as of biostatistics.
well as other factors that may affect the magnitude Epidemiological studies and constantly perfect-
of the evaluated risk. ed methods of biostatistics are of great importance
The influence of chemical and physical factors in the assessment of occupational risk. There are
in the workplace on the cardiovascular system is three main types of epidemiological studies: de-
one of the current problems of preventive medicine. scriptive, analytical and experimental. Descriptive
The difficulty of diagnosing cardiovascular injuries studies can be used to prove the hypotheses and
from professional hazards arising from a number are relevant only for the characterization of the de-
of reasons. These injuries (so-called. "Work-relat- velopment of certain diseases. Analytical studies
ed" cardiovascular disease) are not specific and are enable testing specific hypothesis and by calculat-
expressed at increased risk for the development of ing the degree of risk, to determine whether the
hypertension, ischemic heart disease, cardiomyo- etiologic factor associated with the development of
pathy or heart rhythm and conduction disturbanc- disease: (1) What are other risk factors for this disease
es. Due to the multi-risk nature of these diseases, in the exposed population? (2) Whether the existing
demonstrating the role of occupational exposure is occupational exposure increases the risk of disease
very difficult. In addition, non-invasive methods to (using relative risk for measuring excessive risk)? (3)
study the cardiovascular system recommended by How many cases of the disease could be prevented
WHO for epidemiological studies do not allow for if exposure is eliminated (using the methodology
safe diagnosis of CHD. In most of the studies used for calculating the attributive risk)? Experimental
different methodologies, so the results can hardly studies aim demand a strategy to influence the nat-
be compared. ural history of the disease, for example intervention-
Production factors most likely damage the cardi- al studies to reduce risk factors, screening studies to
ovascular system are: some metals (lead, cadmium, identify the early stages of the disease, etc.
mercury, cobalt, arsenic, antimony, yellow phospho- Fig. 2, 3, 4, 5, 6 and 7 presents an exemplary
rus), nitrates, carbon monoxide, hydrocarbons, car- model for demonstrating a causal link between ex-
bon disulphide, pesticides, noise, vibration, high and posure to certain professional factor - vibration, and
low temperature, non-ionizing radiation and others. the probability of developing disease caused by it

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(cardiovascular diseases and dyslipidemias). The fect of other factors of production on the cardiovas-
proposed approach is based on research for health cular system.
risk assessment and can be applied to study the ef-

STUDIES RISK ASSESSMENT RISK MANAGEMENT

Laboratory and field studies of Identification of the Development of

adverse health effects and risk (whether the regulatory means
exposure to certain agents agent causes side
effects?)

Assesment of dose
Information from extrapolation Assessment of the
response relationship
of methods from high to low health, economic,
(what dose -
dose and from animals to Risk social and political
response)
humans characterization consequences of
(What is the regulatory resources
frequency of
side effects in
a population?)
Field measurements, exposure
assessment, characterization of Exposure assessment
populations

Decisions and actions

of the responsible
institutions

Fig.1. Elements for assesment and managing risk (of National Academy of Sciences, 1983)

APPROACH TO PROOF CAUSATION - FACTOR / DISEASE

Experimental productions with
experimental animals

Studies in people - professional

groups / patients - 300-500 people

Multidimensional statistical analyzes. Approaches for

forming groups / sub-groups.

1. Practical Approaches
2. Opportunities for a new decision - case/control

ANALYSIS OF RESULTS

Fig.2.

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Fig.3.

I. EXPERIMENTAL RESEARCHES ON ANIMALS

VIBRATIONS DURATION AVAILABILITY AND NATURE STATISTICAL
OF CHANGES METHODS

Frequency Intensity TOTAL – 2-4 months THERE ARE / NO Variational

(Hz) m.s-2
Correlation analysis
permanent (Most commonly used)
DAILY – 2-3 h
increasing

decreasing

Phase character
Variable on:
- degree
- disappeared
- appeared

RESULTS ANALYSIS

Type and nature Statistical Correlations between Influence of frequency Recovery

of change reliability individual indicators and intensity there are / no

Fig.4.

II. STUDIES IN HUMANS - professional groups / patients (vibration disease)

(Single retrospective, cohort) - min. 300-500 people
PROFESSIONAL AVAILABILITY AND
INDICATORS STATISTICAL METHODS
HISTORY NATURE OF CHANGES

biochemical service there are / no If it uses a control group

biophysical industrial hazards: or has subgroups
immunological type (exposure) (age, training, etc.)
physiological intensity (concentration), Incidence (%) - Variance analysis
clinical dayly/training dose of cases in and - Non-parametric analysis
questionnaire: outside the - Dispersion analysis and others.
- feeding reference
- alcohol
limits
- physical activity
- sleep and relaxation
- smoking
- personal and family RESULTS ANALYSIS

Type and nature Statistical reliability Correlations between Frequency of Changes in age and
of change indicators and outside reference training groups
age / length of service values

Fig.5.

III. MULTIDIMENSIONAL STATISTICAL ANALYSES

Determination of the phenomenon (the group) of factors

FACTOR ANALYSIS Analyzing the relationship between the primary variables and the main
factors

Distinguishing between two or more sets (groups) on a certain number

of indicators. Construction of discriminative function.

Exploring the links between initial indicators and

DISCRIMINANT ANALYSIS discriminative function for studying aggregates

Percent probability (> 75%) of differentiation (prognosis).

LOGISTIC REGRESSION Regression analysis in dichotomous dependent variable (assuming non-

Gaussian distribution of the variables)

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Fig.6.

IV. APPROACHES FOR FORMING GROUPS AND ANALYSIS

GROUPS / SUB GROUPS ANALYSIS

Influence of vibrations Mean values (x) / outside reference values

GROUPS

(frequency) of indicators at separate subgroups

or

Ill
Vibration disease I-III degree Less favorable mean values of indicators -
in why subgroup?

with CVD without CVD A higher frequency of adverse izvanreferentni

values - in which subgroup?
INDICATORS

Influenced of vibration and noise, In the subgroup with the CVD prevalence

positive answer
influenced of noise; GENERAL GROUP of biochemical, biophysical, physiological
GROUPS

- Control group indicators with less favorable values

Noise / vibration and noise - higher intensity

with CVD without CVD (or over / under normes) for subgroup with CVD

INDICATORS

Noise
Vibration and noise

Fig.7.

V. PRACTICAL APPROACH AND NEW SOLUTION

Practical approach to identified risk (I-IV) New decision

RISK FACTOR?

CHOICE ? CASE / CONTROL

Vibrations - no? Vibrations - yes?

Prevention on Control of health -

factors - sub norm lipid profile, RR, EKG,
surveys Vibration - yes, in combination with other factors!

Accumulation of data

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REFERENCES

1. Barnthouse L.W. - The role of models in ecological risk assesment: A 1990s perspective. Environ. Toxi-
col. Chem., 11 (12), 1992, 1750-1761.
2. Burger J., M. Gochfeld - Paradigms for Ecological Risk Assesment, in Preventive Strategies for Living
in a Chemical World, ed. E. Binghamand, D.P. Rall, Annals of the N.Y. Acad. of Scienc. V. 837, 1997, 372-386.
3. Dimitrov D., Management of health and safety at work, Sofia, “Sindiprevantiva”, 2002, 223. (in bul.)
4. Izmerov NF, A .A. Kasparov (ed.). - Hygienic normalisation factors of working environmental and pro-
duction process. - Medicine, Moscow, 1986, 239. (in russ.)
5. Guide to hygiene and occupational diseases. - ed. D. Tsvetkov, Med. and phys., Sofia, 1995, 246. (in bul.)
6. Methods for assessing the risk to humans; Sanitary regulation of toxic substances. in: Hygienic Toxicol-
ogy - ed. F. Kaloyanova, Sofia Med. and phys., 1985, 291-328. (in bul.)
7. National Research Council - Issues in Risk Assessment. National Academy Press, Washington, DC, 1993.
8. Occupational hygiene, ed. R.F. Herrick; in: Encyclopaedia of Occup. Health and Safety, ed. J.M. Stell-
man. vol. I, 30.4-30.34, ILO, Geneva, 1998.
9. Tsvetkov D., Statistic-mathematical models to predict the conditions and diseases in impact of vibra-
tion. In Infrasound, ultrasound, noise and vibrations, ed. D. Tsvetkov, M. Angelova, S., Med. and phys., 2007,
230-252. (in bul.)
10. Tsvetkov D., K. Kotseva, M. Boev - Occupational diseases and risk assessment - cardiovascular dis-
ease, dyslipidemias and occupational risk assessment, Actual Lipidology 1, 2001, 9-19. (in bul.)
11. Vodichenska Ts. - Experimental and sanitary-epidemiological studies for atherogenic effect and im-
portance of the chemical components of drinking water (heavy metals, etc.) on the prevalence of cardiovas-
cular disease in Bulgaria - Dissertation, Sofia, 1996. (in bul.)

312
 Z. Ivanov

12 PRODUCTION
TRAUMATISM

Production trauma are injuries to the body, oc- lost working days - B (on this indicator accidents are
curred suddenly under the influence of external fac- divided into led to the loss of working days: to 3; 4 to
tors, directly related to production conditions, that 17; over 17 and invalidity); the number of accidents
disabilities violate anatomical integrity of organ/ occurred during the reporting period (C).
tissue, and damage physiological functions. Possi-
Cx1000 B(total days)
ble mechanical, electrical, thermal, by ionizing and Kf = Kg =
non-ionizing radiation, or chemical manufacturing A A
traums1.
For industrial accidents are all traumatic inju- Reasons for production injuries can be grouped
ries, occurring during or in connection with work as:
performed (and any damage to health occurs as a Technical inherent in the technology and use
result of working in an emergency or abnormal con- of technically outdated and dangerous production
ditions for a profession), if it led to temporary disa- processes. Serious reasons are: inadequate equip-
bility, invalidity or death of the employee. ment, lack of blocking devices on dangerous jobs,
Some non-industrial accidents are assimilated failure of machinery and equipment, lack of auto-
to production and recorded and reported as them. matic and remote control units, imperfection of
These are injuries occurring during any work done fences and protective devices and others.
on the order or not, but in the interest of the enter- Organizational reasons in the first place are the
prise, during breaks spent in the enterprise; when result of incorrect manipulation by workers due to
saving human life or public property; in outward or inadequate instruction, training and supervision, or
return of work; from the feeding place during the due to non-compliance with the rules of technical
working day and the place to payment; in the per- safety. After injury due to shortcomings in the work-
formance of public duties in connection with the place, poor order, poor maintenance of internal fac-
operation of the enterprise. tory communications and transport, long working
Production injuries are lightly, heavy, emergen- time, failure of or no-use personal protective equip-
cy and deadly. Lightly are those that do not lead to ment and more.
disability. Heavy lead to disability and emergency Reasons for not complying with the require-
affects more than three people. ments of occupational hygiene and sanitation,
Following the production injuries (accidents) ergonomics and psychology of labour. For exam-
may experience temporary or permanent disability ple excessive heat production microclimate signifi-
(invalidity). When permanent disability the victim cantly reduces the speed of reactions, distributy and
usually retire. sustainability of attention, loaded significant cardio-
All production injuries and treated as non-pro- vascular and respiratory systems, which influenced
ductive ones, which have caused loss of perfor- to increase production traumatism. Low tempera-
mance for one or more days, subject to registration tures in addition to the general impact on the psy-
within three days. cho-physiological functions can often be indirect
The analysis and study of the production trauma- cause of accidents - because wearing uncomforta-
tism is carried out using two basic coefficient. The ble and heavy clothing and restricting freedom of
coefficient of frequency (Kf ) and the coefficient of movement. Significant impact on accidents at work
gravity (Kg) is calculated based on: average number and have the status of lighting, color dynamics, in-
of personnel during the reporting period (A); total dustrial aesthetic. Studies show that as improved
brightness can be lowered in some cases by 40-50%
1
Similar in nature/reason are household injuries, but they are the number of accidents and rational coloring of
not linked to production.

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the interior, plant and equipment - by 4-12%. Pulse incidence of injuries, accidents, but are generally
and high-frequency noises interfere with workers to less severities, etc. Age to 30 years was also “cause”
hear sounds (especially suffers perception of speech of more frequent injuries, as it is associated with a
due to the masking effect of noise mostly on the reduced self-control, impulsiveness and conceit,
perception of consonants). Along with that, caused reluctance to seek help from colleagues. Frequent
by noise, fatigue and reduced efficiency of 30-60%, injuries seen with elderly workers associated with
it is also one of the reasons for the increase in inju- age physiological and psychological changes. There
ries in noisy industries. Fatigue and changes in the are hypotheses about “personal predisposition” to
functional state of higher nervous activity under the injuries - found that people with more accidents are
impact of excessive concentrations of toxic gases, very fast psycho-motor reactions, respond quickly
vapours and dust also contribute to increasing the and accurately to psycho-physiological tests. Such
level of trauma. General and local vibrations (espe- a “predisposition” however, is rather temporary -
cially in transport, military, vibration technologies under the influence of emotions, stress, personal
in construction) lead along with objective changes problems (very rare to meet people with enduring
in sensation (vibration, touch, pain, temperature) predisposition to injury). “Left-handing” can also af-
also to pronounced phenomena of subjective dis- fect the level of trauma - about 22% of workers with
comfort and fatigue, which increases the risk of ac- frequent accidents are left-handed, while workers
cidents. In a significant physical strain, the level of with less accidents only 5% work with his left hand.
fatigue and as a consequence of injuries and is also Other reasons - marital status, ethnicity, ex-
considerably overstated. There is also a strong cor- perience and training, operation, use of alcohol,
relation between the level of accidents and a num- motivation (satisfaction) of work and more. Family
ber of ergonomic indexes. This is incorrect posture workers have fewer accidents than single people,
no-compliance requirements for working in the which is explained by the increased sense of re-
areas of accessibility, irrational design and mainte- sponsibility. Described are differences in the level
nance of controls and means of presenting infor- of trauma depending on ethnic (racial) identity, but
mation, non-ergonomic work furniture, etc. It is be- it is associated primarily with the family and social
lieved that because of the failure to the ergonomic environment and conditions, not heredity. People
requirements and those of the psychology of labour with more experience and training allow fewer acci-
arise about 18-20% of accidents. Important are the dents - believes that after the first two to four years
relationships within the workers. Studies show that of work accidents decreased significantly. The mode
9 to 15% of an accident persons they have poor re- of operation a day also has implications for injuries.
lations with colleagues, insufficient adaptation and Studies show that the risk of accidents in three-shift
non-inclusive to a group (eg. working together in operation, as determined factor 1 for morning shift,
difficult operations requires not only rational and is 1.79 for the afternoon and to 1.37 for night. Also
synchronized interaction between all participants, highlight of accidents occur between the third and
but constant attention with a heightened sense of fourth working hour, at the end of the shift accidents
responsibility for the safety of others). are less frequent, but more weight. In only mechani-
Reasons of the human factor. By 1960 almost cal working operations, even with medium and high
equal importance has been serving the technical physical activity, occupational safety is higher dur-
and human factors of production traumatism (till ing night shifts, while dealing with constant atten-
after 1929 began to recognize the importance of tion and focus on complicated problems is the op-
human factors). Now, however, Heinrich attached posite. Alcohol undoubtedly increases the severity
88% of accidents in the US industry “personal dan- and frequency of accidents.
gerous actions”, Barbier stated 90% of accidents Motivation (satisfaction) of the work is also an im-
in the French metallurgy and Coppee-Bolly - 98% portant factor for the occurrence or not of injuries.
of Belgian industry. Health is an important factor The nature of work, working conditions and friendly
(among human reasons) to increase traumatism. relations in team had a high influence for positive
It was found that the chronically ill (ulcer disease, motivation to work, than wages and working hours.
diabetes, cardiovascular diseases - mainly hyper- Workers who are satisfied with the work and occu-
tension, neurosis) were observed more frequently pied position, assuming accident cited as reason for
accidents. Gender also affects of trauma - women more frequent personal reasons, while unsatisfied
experience greater difficulty to adjust in a moment cited as the more common “objective” reasons, relat-
of danger; their bodies are more susceptible to ed to the profession and the work team.
poisoning; immediately before and during the first Prevention of production accidents is aimed at
four days of the menstrual cycle, they sharply rising eliminating or reducing the risk of multiple factors

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(reasons) for injuries, it is directed primarily towards of production (profession) and training (if necessary
the most important of them - conditions the risk and individual insurance) of workers for safe and
factors associated with the nature and conditions trouble-free operation.

REFERENCES

1. Cavigneaux A., Antissier R., Porcher B., La réparations des accidents du travail et des maladies pro-
fessionnelles, Masson, 1984.
2. Code of compulsory social insurance - SG. 110/1999. (in bul.)
3. Folliot D., Les accidents d’origine électrique, Masson, Paris , 1982.
4. Hachet J. Urgences en medicine du travail, Masson, Paris, 1987.
5. Labour Code - SG. 26 and 27/1986, with the last amendment in SG. 18/2003. (in bul.)
6. Law on Health and Safety at Work - SG. 24/1997 SG. 86/1999 SG. 64/2000 SG. 92/2000 SG. 111/2001. (in
bul.)
7. Ordinance on the establishment, investigation, registration and reporting of accidents SG. 6/2000 SG.
61/2000. (in bul.)
8. Précis de medicine du travail. sou la dir. Desoille H., J. Scherrer, R. Truhaut., 6 ed. Chap. III Importance
et causes des accidents du travail, Masson, Paris, 1991, 38-42.

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13 WORK - AGE AND SEX

Study of aging changes in relation to the work- of age development, led to the gradual decline of
load has its place in the prevention of many diseases his physical abilities. Body mass of men over 45
associated with overloading the body and the devel- years begins to decline (women this process began
opment of stress. It is not possible to optimize work- about 55 years). Height after 40 years also began to
load, without complying with the age of the worker. decline. Reducing absolute muscle strength starts
The problem becomes even more complex, taking even earlier - after 30 years, these changes are more
into account the fact that the rapid changes in the pronounced for the large muscle groups of the legs
structure of production capacities and introduction and body and less in the smaller muscle groups of
of new technologies requires frequent retraining hands. Changes and endurance to static muscular
and changing jobs. Opportunities for requalification effort. In aging form a peculiar muscle tone.
and training of new job also depend on the age. Ac- Along with the offense of supraspinal control
tuality of the problem is increasing and of advanc- due to changes in the CNS are observed and compli-
ing recent demographic changes in the population cated changes in segmental motoneuron apparatus.
structure. It was found that in the elderly activity of alpha mo-
Based on age-related changes and the integra- toneurons (rapid, phases motoneurons) is reduced,
tion of the individual in the social environment are and this at gamma motoneurons (slow, tonic moto-
many classifications of periods of working age. One neurons) increases. Imbalance between alpha and
of the most common classifications is that of D. gamma motoneuron apparatus led to increased ten-
Bromley (1974). According to her, working age divid- sion in skeletal muscles, which reduces the possibil-
ed into the following periods: 1). Young age - from ity of quick phases movements. With these changes,
20 to 25 years; 2). Middle mature age - from 25 to as well as degenerative changes in bone and joint
40 years; 3). Late mature age - from 40 to 60 years; system is explained reduced possibility of elderly to
4). Before retirement age - from 60 to 65 years; 5). work at a rapid pace.
Retirement age - after 65 years and 6). Old age - over Advancing in age changes in psychomotor ac-
70 years. This classification does not always coincide tivity have some essential peculiarities. Typically,
with the adopted legal decrees for retirement. the ability to perform simple and uniform motion
The large interindividual differences in the pro- to a much lesser extent distorted as compared to
cess of reducing the functional capabilities of peo- the changes that occur in the execution of complex
ple with respect to age, resulting mainly from the movements and actions. For example, actions in the
impact of environmental and social environment led course of which movement has to change speed and
to the formation of the concepts of “biological and direction, usually, with increasing age, significantly
functional age”, ie the actual biological status of cells delayed. It has been found that with age changes
in various organs and systems and functional ca- and strategy of execution a movement or action. As
pacity, compared at the same chronological group. the extended time is mainly on account of exten-
There is no clear correlation between biological and sion of time pass of central nervous processes (less-
chronological age, and are pronounced individual or not for the motor time), usually the general bal-
functional differences in aging. ance of time is shortened. To the changed strategy
goes that on account of the reduced speed allowed,
13.1. CHANGES IN PHYSICAL however fewer mistakes. It was also found that with
PERFORMANCE WITH AGE age, change (slow down) the most significant, such
movements and actions with which the worker has
Morphological and functional changes that oc- at least experience. At age, unfavorable changes in
cur in all organs and tissues in the body in the course terms of speed of movement is established when

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Fig. 1. Results for different age groups depending Tab. 1. Vital capacity (x ± std in l)
on the pace and complexity of work
Age Male Female
20 - 24 4,3 ± 0,3 2,8 ± 0,3
25 - 29 4,2 ± 0,4 2,8 ± 0,3
30 - 34 4,1 ± 0,3 2,7 ± 0,3
free pace
35 - 39 3,9 ± 0,4 2,6 ± 0,3
imposed pace
40 - 44 3,7 ± 0,4 2,4 ± 0,2
imposed pace
45 - 49 3,4 ± 0,3 2,3 ± 0,3
and high accuracy
50 -54 3,2 ± 0,4 2,1 ± 0,3
55 -59 2,9 ± 0,4 1,9 ± 0,3
Effectiveness

is due to changes in heart - vascular system, and the

change of the hemoglobin content of the blood, the
smaller arteriovenous differentiation of oxygen, the
low efficiency of cell respiration. All these changes
result in a decrease in physical capacity with age.
The maximum aerobic capacity (MAC) is highest
around age 25 and then gradually decreasing. Char-
acteristically, at the age grow increasing and interin-
dividual variation in physical fitness. This is associat-
ed with both genetic and with a number of factors
such as health, fitness level, diet and not least the
Age (years) influence of the profession and working conditions.
Studies in workers in Bulgaria showed the high-
the worker has to work with precise movements in est indicators of MAC in occupations with signifi-
terms of the imposed rhythm, for example. when cant physical load - miners and forestry workers, the
operating the conveyor (Fig. 1). lowest values in workers from the chemical indus-
Established facts regarding age changes in lo- try, which most often missing dynamic exercise and
comotor activity are important for the organization strong toxic-chemical factor (Table. 2). Clarifying
of labour. It should be borne in mind that changing the impact of the occupation on physical capacity is
labour task is detrimental to the worker. When this important in two aspects - to seek professional fac-
change is necessary, the new psycho-motor task tor that may modify age-related changes, and sec-
should not be more complicated and more difficult ondly how age limits in physical performance make
than previously exercised. It is a new activity in the it difficult for older workers to perform their profes-
older worker to start after a period of training and sional duties and affect health them.
adaptation to changed working conditions. For prevention it is important that the load of
It is well known that lung volumes and capaci- older people should be dosed with great care and
ties, in addition to gender and height and are highly caution, strictly differentiated according to individ-
correlated with age (Table. 1). Along with the vital ual opportunities, avoid fling movements, spins and
capacity and decreased respiratory reserve volume. large static efforts. To maintain exercise capacity and
In this is typical and relatively increased residual vol- delay aging changes it is very important that physi-
ume to total lung volume. Moreover, changing some cal activity in young and middle age. This is particu-
basic indicators of the exchange of gases in the larly important in professions with marked hipodi-
lungs. With age increases alveolar-arterial oxygen namiya and hypokinesia.
differentiation resulting in a reduced partial pres-
sure of oxygen in arterial blood. The latter is most 13.2. CHANGES IN NEURO-PSYCHIC
often associated with non-compliance of alveolar PERFORMANCE WITH AGE
ventilation and blood flow to the lungs.
Well-known are also changes that occur with age Age-related changes in visual functions are es-
with respect to the cardiovascular system. These are: sential for adaptation in work requiring sensorineu-
reducing the efficiency of the heart as a pump, slow ral and neuro-mental activities. This is mainly due
heart rate, decreased blood flow in the coronary to the fact that although slowly they start too early,
vessels and the heart’s ability to use oxygen. Rigidity when the total neuro-mental performance is high.
of the large and small blood vessels and capillaries Knowing their first symptoms and their impact on
alter blood flow to the organs. Furthermore, consid- the performances and the condition of the worker
erable changes in the oxygen carrying capacity. This is important for rational organization of labour and

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Tab. 2. Maximum oxygen consumption (x-l / min) and a maximum pulse rate (x-beats min-1) at various professions

Study group Age Мах.O 2 consumption Pulse rate Authors

20 - 25 2,37 174
Workers from chemical
26 - 30 2,50 165 N. Тsaneva at all.
industry
31 - 35 2,29 158
to 20 3,12 187
Workers of engineering 21 - 30 3.00 184
G. Ganchev
31 - 40 2.80 181
over 40 2.60 180
21 - 30 2.90 180
Mechanics in agriculture 31 - 40 2.80 172
L. Mincheva
41 - 50 2.70 168
51 - 60 2.40 168
to 30 3.26 172
31 - 35 2.88 167
Forestry workers I. Hadzhiolova et al.
36 - 40 2.96 170
41 - 45 2.81 159
21 - 30 3.40 –
Miners 31 - 40 2.54 – L. Mintcheva et al.
41 - 50 2.49 –

maintaining the health and performance. Moreover, near distance. To form a clear image on the retina
many modern professions and activities related to accommodation apparatus is under constant ten-
monitoring small objects and details or require con- sion. This leads to the development of fatigue, which
tinuous visual control, the great quantity of informa- manifests with visual discomfort, tearing, redness of
tion, which requires a over-loading the visual system. the eyes, headache. Decrease in visual performance
Age-related changes in front of the visual system after 40-45 years requires special measures for work
mainly relate to the changes in the transmittance places. First, it is to improve the brightness and con-
of light (change in the thickness and shape of the trast and reduce glare. It is important to avoid over-
cornea changes in the vitreous, etc.) And to changes loading the visual system, which usually happens at
in accommodation functions (change in the thick- the end of the month. Working with small details in
ness and density of the lens, reduction the elasticity older workers is very tiring. Recommended periodic
and mobility thereof, atrophic changes in the cili- eye examinations to detect the changes occurring in
ary muscle, etc.). These changes begin between 35 visual acuity and prescription needed glasses. When
and 45 years of age and consist mainly of changes working on a video display with workers over 45
in visual acuity, which is one of the main demon- years recommended visual correction be of seeing
strated indexes for the capacity of the visual system. the so-called semi-near distance.
For hygiene of labour is important determination of Reducing the hearing with age - presbycusis, also
visual acuity for near distance, as a large number of has importance for the employability of older work-
occupations associated with manufacturing, assem- ers. The deterioration of auditory function consists
bly or observation of small details and objects, the in raising the hearing threshold in the range of 4000-
distance to the eye is 30-40 cm. In addition to visual 5000 Hz. Changes in hearing sensitivity in exposure
acuity of static objects in employment matter and to excessive noise levels in industrial conditions
kinesthetic visual acuity, ie the perception of ob- initially were approximately at the same frequency
jects that move. Time perception of static and more range and are an expression of such pathological
of moving objects with age progressively increases. changes - degeneration of hair cells and damage to
Undoubtedly, aging changes in time perception is relevant cochlear structures, i.e. both factors have an
also due to the changes that occur not only in the additive effect and older workers are more sensitive
front parts of the visual system, but also to circulato- to noise impacts. Later, with age auditory sensitivity
ry and metabolic changes in the retina that lead to decreases and in the lower frequency bands which
narrowing of the visual field. leads to deterioration and speech intelligibility, re-
With age the elasticity of the lens decreases spectively hinder workers communication.
with which the nearest point of clear vision are in- Problems with aging changes in the neuro-psy-
creasingly moving away from the eyes. Develops chological performance are very complicated be-
so-called presbyopia (age hypermetrophia). Uncor- cause of the fact that with age the various psycho-
rected or improperly corrected hyperopia leads to physiological indicators do not change equally and
difficulties in the execution of work performed at depend on a number of factors. Firstly these are indi-

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vidual characteristics and type of labour. It is known Fig. 2. Age changes in SVMR and in RC
that most-exert neuropsychological functions re-
main preserved for a long time. Moreover, along
with progressive degenerative changes develop a
number of compensatory mechanisms that allow
a long time to perform neuro-psychic activity. For
example, the time to implement simple sense (vis-
ual)-motor reactions (SVMR) starts increasing with
age, compared to the time for performance of com-
plex tasks requiring engagement processes of dis-
crimination signals, decision-making and more. Hor-
monal changes also play a role. Studies show that
for example in all age groups after 20 years of age, SVMR RC
men have a shorter response time than women. In
men, at period of the working age, changes in time
of simple reaction are negligible, while the chang-
es in time of complex reactions (RC - reactions of
choice) after age 40 are more pronounced. In wom-
en, both reactions in this age group are delayed. It
should be emphasized that in both groups of per-
sons age changes are more pronounced at the end
of the day, when already there are signs of develop-
SVMR RC
ment of fatigue (Fig. 2). Many authors highlight the Start of the working day
I group - 20-30; II group - 31-40; III group - 41-50; IV group - 51-60;
fact that while older workers to perform more slowly female male
neuro-sensory task, they make fewer mistakes in the
appearance of distracting attention factors and the
end result may not be worse. 13.3. ADAPTATION OF WOMEN TO WORK
The memory processes with age are not altered
in equal measure. The primary memory (when the The need of special attention to women’s work
material is still repeated and is the focus of atten- stems from the fundamental physiological differ-
tion), age changed insignificantly, while changes in ences between the sexes and the underlying mech-
long-term memory are demonstratively expressed. anisms that determine biological links between en-
Reducing the ability to memorize in the process of vironment and health status. Moreover, the woman
aging is also related with adaptability responses - there are special periods such as period of pregnan-
age begin to prevail components of semantic and cy, lactation, hormonal changes of sudden exit of
logical memory than mechanical. Semantic compo- fertile age when they are more vulnerable. Besides
nents are stored longer and acquire a relatively large professional commitment, housework and upbring-
share of total memory. ing of children, and a number of psychosocial prob-
Higher intellectual processes also show dynam- lems are additional stressors.
ics with age, but the changes occur relatively late. A The woman has less physical strength than men
number of authors find that they are kept and even - it has a smaller skeleton, shorter limbs - an average
improved to 50 years of age. As has been shown im- of about 7% of men. The smaller muscle strength is
provement in solving arithmetic problems in 60-69 due to the smaller muscles and the greater amount
the men, and 50-57, the women. The explanation of of fat. The heart is at least about 10-15%, which re-
this fact is most often associated with improving the sults in the smaller stroke volume. In load stroke
functional condition of the body after completion of volume increased less and compensation at the ex-
climacteric processes in previous decades and stabi- pense of fast heart rate. At the same load women in-
lization of the neuroendocrine regulation. creased almost twice pulse rate. When thermal load
The age changes in neuropsychological perfor- woman also corresponds with a higher pulse rate.
mance should be considered in addressing issues For physical efficiency is important, and the fact that
such as education, training and retraining of work- the woman has a smaller chest and lower indices of
ers, ergonomic problems of work places, the prob- lung capacity by about 15%. Hemoglobin in wom-
lems associated with the normalization of labour, en is about 25% less quantity compared to men and
which is directly related to preserving the health the absorption of oxygen from the lungs is less.
and employability of workers.

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These differences determine the lower working cial situation of women doing night work with them
capacity of women - about 20-25%. The woman has especially tiring, and therefore should be limited.
only 55-65% of males opportunities for lifting and In terms of accidents in the industry, there is ev-
carrying weights. Therefore, women should not per- idence that women make fewer mistakes and acci-
form heavy physical work. In Bulgaria norms for dif- dents than men. Normally accidents in enterprises
ferent categories of physical work are about 0.5 kcal/ are found in younger and older women compared
min lower than those for men. During pregnancy, to those of middle age. In domestic accidents, things
women have certain restrictions for heavy work due are opposite, which again is due to their social en-
to fatigue. After diagnosis of pregnancy a woman gagement with family.
should be transferred to lighter work. For women in There are no data to suggest that outside of
production this problem exists, in connection with their particular periods, women are more suscepti-
pregnancy and in relation to the menstrual cycle. ble to diseases. On the contrary, men have a higher
Also early initiation of hard work is harmful to the incidence of mortality in all age groups - higher in
young girl. Forced work posture leads to stagnation them and fetal and infant mortality, the greater the
in the pelvis and favour the development of the re- mortality of inborn disorders. These differences in-
productive system diseases. dicate a role of genetic factors as well as in suscep-
No reliable data to show significant psycho-phys- tibility to the development of certain diseases and
iological differences between men and women. Indi- certain hereditary diseases associated with a single
vidual authors emphasize some mental instability in chromosome in men, such as color blindness. It is
women, greater emotionality and irritability, as well also known that men risk of cardiovascular disease
as no-precision approach when dealing with some is greater than for women. It is considered that the
individuals. It is known that women have a longer younger women risk of cardiovascular disease due
response time and a slower rate of voluntary move- to the protective role of female sex hormones, espe-
ments. However, as all these activities largely depend cially estrogen. This explains the fact that the inci-
on training and professional training, it is difficult to dence of cardiovascular diseases in early menopause
argue that these differences are physiologically deter- after ovariectomy after menopause is higher. It also
mined (known practice, both in our and other coun- assumes that a large amount of lipoplasmic proteins
tries that workers take jobs in industry often without with high density in women have a protective effect
any prior training and qualifications). In terms of skill, on the development of cardiovascular diseases.
there is evidence that activities requiring fine adjust- Significant interest is answering the question
ment attach better on women. whether there are differences between men and
In literature there are no data to suggest that women regarding the development of reaction to
women are more sensitive to various toxic and stress. During the rest or inactive state no differenc-
chemical substances - toxic powders, aerosols, gas- es in urinary catecholamines, but in situations of
es, compared with men. It has been shown, how- experimental stress - implementation of frustrating
ever, that during pregnancy and during lactation, cognitive tasks, tasks that measured the response
certain toxic substances are particularly harmful for time, after exams, etc., excretion of adrenaline in
women. It is known adverse effect of lead, mercury, men increases to a greater extent than women.
organic solvents and the like. These substances pass Regarding the excretion of norepinephrine absent
through the placental blood flow and harm the fe- such differences. There are data showing that there
tus. So there are laws and regulations that protect were no differences between men and women in
women during pregnancy and motherhood. the development of stress responses in certain psy-
A number of factors in the work environment cho-social conditions. For example, in cases where
may adversely affect the female body to a greater women exercise so-called male professions - drivers,
degree. Important are the issues of security of wom- responsible management activities, etc., differences
en working in the conditions of ionizing radiation, in cortisol levels between the two groups were in-
particularly during the period of organogenesis in significant. It is suggested that psychosocial factors
pregnant. The genital area of a woman apart from play an important role in the regulation of endo-
hard work affected by general vibration, infrasound, crine activity.
intense electromagnetic fields. Given, more active involvement of women in dif-
With regard to night work is considered that ficult and responsible jobs, these data are important
there is no physiological causes women to suffer to physicians and psychologists of work in the de-
harder than men. That women in night shift work velopment of medico-preventive measures - modes
decreased productivity more than men, is associat- of work and rest, stress control and stress reducing
ed mainly with insufficient and disturbed sleep - so- programs, and to solve the problems of each case.

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REFERENCES

1. Hadzhiolova J. et al.,Employability and age. Sofia Med. and phys., 1984. (in bul.)
2. Hall E.M., Women’s work: An injury into the health effects of invisible and visible labour. Stocholm,
1999.
3. Navatikyan, A.O., Kryizhanovskaya, V.V., Age performance in persons with mental labour Kiev,
Zdorovya, 1979. (in russ.)
4. Precis de medicine du travail. sous la dir. H. Desoille, J. Scherer, R. Truhaut. 6 ed. Travail feminine;
Travailleurs ages. Masson, Paris, 1991, 1028-1054.
5. Psychophysiology of labour. ed. N.Tsaneva, Med. and phys., Sofia, 1988. (in bul.)
6. Sheprard R., Physical activity and aging. London, Croom Helm, 1978.

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 A. Manolova

13.4 OSTEOPOROSIS

onadism, hyperparathyroidism, hyper-tireoidism,

Osteoporosis (OP) is the most common meta- hypopituitarism, insulin-dependent diabetes); med-
bolic bone disease that according the World Health ication (glucocorticoids, heparin, anticonvulsants,
Organization occupies fourth place after cardiovas- thyroid hormones, high doses of aluminum-con-
cular diseases, cancer and diabetes in medical, social taining antacids, immunosuppressants); diseases
and economic significance. of the digestive tract, cancer and genetic diseses
OP is defined as the systematic osteopathy char- (malabsorption, chronic hepatitis, primary biliary
acterized by reduced bone mass per unit volume cirrhosis and alcoholic, rheumatoid arthritis, leu-
and violation of microarhitectonics of bone tissue. kemia, myeloma, lymphoma, and other neoplasms,
Histomorphometric OP is defined as a reduction osteogenesis imperfecta, homocystinuria, Marfan
of the total amount of normal bone formed. Record syndrome and Ehlers-Danlos).
the simultaneous reduction of the mineral sub- Epidemiology of osteoporosis and related
stance and the bone matrix, and the ratio between fractures. Medical and social consequences. OP
them remains unchanged. The bones become po- can develop individuals of all ages, but most affect-
rous and fragile, skeletal strength and endurance ed are women after menopause. Epidemiological
decline, which in turn significantly increases the risk studies indicate that 45% of women over 45 years
of fractures with minimal trauma. Bone loss, most of age and 15% of men over 50 suffer from osteo-
often occurs without symptoms at the onset of the porosis.
first fracture. The spread of OP grow worldwide. In the US, for
Classification of osteoporosis: Osteoporosis is example, according to the NHANES III cases diag-
defined as primary or secondary based on the ab- nosed OP at 5-8 million for the period 1988 to 1994,
sence or presence of certain diseases, surgery inter- rose to 10 million in 2000, and another 18 million
vention, and/or taking certain medications. Americans are at increased risk due to osteoporosis
• Primary osteoporosis (involutional) because diagnosed osteopenia (low bone mass).
Given the clinical features, hormonal changes In the countries of the European Union suffer
and the relationship of the disease with age from osteoporosis 40 million, representing 12% of
and menopause are distinguished two types the population.
of involutional OP: In Bulgaria, according to a representative epide-
Type I - postmenopausal osteoporosis - it man- miological study osteoporosis determine at 20.5%
ifests itself in women 50 years of age and is associ- and osteopenia in 32.5% of the surveyed postmen-
ated with acute estrogen deficiency in menopause. opausal women. Extrapolating these data on the
Determined by the accelerated bone turnover, usu- general population, the authors assume that about
ally resulting in increased bone resorption. 820,000 women with low bone mass and increased
Type II - senile osteoporosis. Occurs with age, af- risk of fractures.
fecting equally men and women over the age of 70. It is assumed that 50% of women and 25% of
Determined in age-related decrease in the body men over age 60 will suffer at least one fracture dur-
of the functionality of osteoblasts and secondary ing the remainder of his life. Patients over the age of
hyperparathyroidism, probably dependent of im- 70, the curve of dependence - reduced bone / frac-
paired calcium absorption in the small intestine. It ture risk is already exponential. It is important that
is characterized by reduced bone turnover - relative- in over 50% of the osteoporosis fractures are the re-
ly unchanged or reduced absorption, coupled with sult of a minor or moderate injury, as in the majority
low bone formation (76%) are due to a fall from a standing position or
• Idiopathic Osteoporosis - rare forms of oste- lighter falls.
oporosis in children and adults (juvenile, pre- Compared to the 70s, during the period 1989-
menopausal in women and senile in men) 1991 fractures of the limbs have increased by 14%
• Secondary osteoporosis, which is mainly to: (22% of women and 1% of men). It is assumed that
Hormonal disorders (amenorrhea, hypog- if in 1990 worldwide were registered 1.7 million frac-

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tures due to osteoporosis, then in 2050 they are ex- duration) in the menopause and/or at a later age.
pected to reach 6.3 million and in the European Un- The level of bone mass, both in childhood and in
ion predicts that over the next 50 years will increase later life is determined by a number of interrelated
hip fractures more than 2 times - from 414 000 to genetic, hormonal and behavioural factors affect-
972 000. ing varying degrees accumulation of PBM or subse-
The high prevalence and subsequent osteoporo- quent bone loss.
tic fractures determine the clinical and social signif- • Phenotypic and genotypic characteristics.
icance of the OP (reduced bone mass, itself no clin- As highlighted female sex was significantly af-
ical signs). fected by the OP and related fractures. These dif-
The most frequent and severe complications are ferences can be explained by the fact that men first
hip fractures. It more than 50% of cases require pro- accumulate significantly greater PBM because the 2
longed hospitalisation, and 10% - permanent home additional years of prepubertal growth and long pe-
patient care over a period of year. After severe hip riod of pubertal maturation. On the other hand the
fracture, approximately 11% of patients become dis- absence of menopausal equivalent leads to a signifi-
abled completely (only 30-50% recover completely). cantly later and weak age related bone loss.
The established high lethality due OP and frac- Studies in children and adults demonstrate not
tures is associated mostly with that of the femoral only sexual but also expressed racial disparities that
neck fractures - 5-20% of patients die from compli- persist throughout life and set higher OP and frac-
cations during the first year. Generally such a frac- ture risk in individuals of Caucasian and Asian pa-
ture reduces life expectancy by 12-20%. tients compared with those of Negroid.
Second in severity and significance are compres- Bone mass is under strong genetic control, evi-
sion fractures of the vertebral bodies. Established dence of which are based both on surveys of pairs
at 36% of older women. Spinal deformities due to of twins, as well as data from family studies. Accepts
compression fractures are the cause of persistent that up to 70% (50-90%) of the variability in bone
back pain, limited physical activity, expressed chest density due to heredity. Made attempts to deter-
hyperkyphosis (“widow’s hump”), loss of height, and mine polymorphisms in several genes related to
5% - reaching total disability. bone mass and / or fracture risk. These are: vitamin
Complications after fracture of the radius in D receptor gene (VDR); collagen type 1 α1 gene (CO-
loco tipico not so heavy, but in 29% to 44% of these L1A1) and connecting it proteins; estrogen receptor
patients establishes much pain, and 36-40% of them alpha gene (ER-alpha); transforming growth factor
complain of weakness and numbness of the hand beta gene (TGF-beta); interleukin-1 beta gene and
and after a year of trauma. the like.
Due to the high frequency and severity of com- • Body constitution:
plications of osteoporosis fractures, economic loss- Increased osteoporosis and fracture risk is asso-
es associated with OPs are huge and are increasing ciated with lower body weight, reduced thigh cir-
every year. cumference, decreased muscle and fat mass and so
In 1999, medical costs for treatment of fractures on. For example, women with a higher body weight
due to osteoporosis (without working day losses) have lower bone loss, as weak and tall women devel-
common to Europe and the United States were 27 op more frequently osteoporosis.
billion USD. In the next 50 years is expected to dou- • Factors of lifestyle:
ble these costs. Nutrition - inadequate import of calcium and
Risk factors for osteoporosis. Bone mass is ac- vitamin D, as a number of other minerals and vita-
cumulated in childhood, rising to a peak in late ado- mins - Mg, Zn, Cu, F and vitamins K, C, B6, also the
lescence (so called peak bone mass - PBM) and after reduction in Ca absorption in the digestive tract due
a period of stability began to decline. In this regard, to decreased synthesis of vitamin D with age, a vio-
two major pathogenic determinants of OP: lation of the ratio of Ca/P due to excessive intakes of
1. Gaining a relatively low peak bone mass (PBM) phosphorus in the diet.
in the years of childhood and adolescence. In this Reduced physical activity and immobilization:
case, even minimal bone loss with age will lead to Already in 1892 J. Wolff proves insufficient physical
low bone mass and high osteoporosis risk. It was exercise (gravity or mechanical) adversely affects the
found that PBM set at 50-70% (respectively for tra- bones, and bone strength and bone mass increases
becular and cortical bone) bone mass in adulthood in response to increased physical activity. Today it
and is therefore predictive of the first order in etio- is assumed that the adaptation of the bone to the
pathogenesis of osteoporosis. effects of mechanical impacts occurs with changes,
2. Significant bone loss (such as value, speed and both in its size and in its structure. It is also under-

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lined that bone mineral density in a certain skeletal the normal average mass of bone in young healthy
point is associated with muscle strength in regional women in white race1.
tissue mass. Known is also the larger osteogenic ef- to -1 SD - standard
fect of locomotor activity during growth in compar- on - 1 SD up to - 2,5 SD - osteopenia
ison with that during adulthood. below - 2,5 SD without fractures - osteoporosis
Some negative behaviours (smoking, alcohol- below - 2,5 SD with fracture - advanced severe
ism): Smoking is a proven risk factor for bone me- osteoporosis
tabolism. Women who smoke regularly are lower Prevention of OP. Osteoporosis is a disease of
bone mass compared with nonsmokers. Smoking old age, but it has its genesis in childhood and ado-
has been associated with lower levels of estrogens lescence, and therefore primary prevention of OP is
and early menopause. And it assumed that nicotine aimed at optimal skeletal growth and mineralization
inhibits the function of osteoblasts. from an early age. It is accepted that one standard
The negative impact of large amounts of alcohol deviation (10%) higher PBM reduces the risk of os-
on the one hand due to a toxic effect on bone cells, teoporotic fractures in elderly people by about 50%.
the other-coming in from alcoholism nutrient defi- Secondary prevention is necessary for all women
ciency, malabsorption syndrome and expressed he- after menopause, elderly people of both sexes, and
patic impairment. for people with chronic diseases, provoking reduc-
• Features of hormonal status: tion of bone mass.
These are related to estrogen deficiency before Prevention of OP is complex and includes:
and after the onset of menopause (amenorrhea, hy- – A balanced diet, providing important for main-
pogonadism, menopause); taining bone metabolism nutrients (minerals, vita-
• Some chronic diseases or drug therapy: mins, proteins); failing that, supplementation of the
Endocrine, rheumatic, hematological, gastroen- diet with preparations of calcium and vitamin D, or a
terological, nephrological and other diseases, organ combination supplements containing besides calci-
transplantation, treatment with glucocorticoids. um and vitamin D, Mg, Zn, vitamins C, B6.
Diagnosis of osteoporosis: The World Health – Exercise
Organization has established diagnostic criteria for – Correction of some behavioural risk factors:
osteoporosis and osteopenia, based on measure- smoking cessation and reducing alcohol consump-
ment of bone mineral density (g/cm2) with DEXA tion.
(dual-energy-X-ray-absorbiometry) at the femoral
neck - so-called “Gold standard”.
The presence of osteoporosis is demonstrated by
means of densitometry established indicator T-in- 1
Men diagnostic use the same absolute values of bone density
deks - magnitude of the standard deviation (SD) of and T-index as in women.

REFERENCES

1. Bachrach L.K. Acquisition of optimal bone mass in childhood and adolescence. Trends in Endocrinol.
and Metab. 2001, 12: 22-28. (in bul.)
2. Manolova A., Ribarova F., Cider L. The Osteoporosis problem today. Scripta Medica. 2002, V, 2: 1728.
3. Obermayer-Pietsch B., Chararas C., Kotschan S. et al. Genetic background of osteoporosis. Acta
Med. Austriaca. 2000, 27: 18-22.
4. Report on Osteoporosis in the European Union-Osteoporosis, 2000. Signal number, November: 17-20.
(in bul.)
5. Rizzoli R., Bonjour J.P. Determinants of peak bone mass and mechanisms of bone loss. Osteoporos.
Int. 1999, 9 Suppl 2: S17-23
6. Sheytanov J. Osteoporosis. 2nd ed .. C., 2000, 120. (in bul.)

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 M.Tsvetkova-Arsova, Vl. Radulov

14 PROFESSIONAL TRAINING AND WORK

OF PERSONS WITH DISABILITIES

In different countries around the world there is a tailed interview of person with violations. If the per-
different age limit for completing school students in son is nonverbal or for other reasons can not only
disorders - in some countries it is 18 years in most 21 participate in the interview, then the necessary in-
years. In many countries also permitted and attend- formation is collected from parents or others who
ing additional class (i.e. extra class), thanks to which know him well - the class teacher, other teachers,
students with disabilities who are not yet ready to neighbors, parents, etc.
leave school, work hard to master the important Besides conducting the interview, the assess-
skills for independent living and focus on the utili- ment should undertake a study of a number of doc-
zation of labour and professional skills and habits uments and materials such as:
(Sweden, Finland, USA, etc.). • school diaries, individual curriculum and pro-
With the creation of the first educational institu- gram of person for the last few years.
tions for children with disabilities, placed and early • the medical file of the person - recent survey
labour training and the fundamentals of vocation- of vision, hearing, intelligence, general physi-
al guidance. In the first school for the deaf opened cal and neurological condition.
in 1760 in Paris, in the school for the blind, founded • psychological record of a person - is there
in 1784 in Paris and in the school for children with documented behavioural problems and what
mental disorders, also discovered in France in 1841, therapy is conducted, how the person per-
began to teach subjects like needlework, modeling, ceives their own violations, is there a realistic
etc., which are directly related to the future profes- idea of their limitations, are there adequate
sional development of persons with disabilities. So expectations for the future.
gradually began systematic preparation for future
professional activity in children with disorders. Model list of questions to assess
In 1984, Madeline Will (USA) developed a model a person with disabilities
for categorization of graduate school students with
violations. They are divided into three main groups 1. Tell me about yourself and your family.
according to their needs at graduation and transi- 2. Where are you going to live after graduation?
tion to adulthood: 3. What are you going to do after graduation?
1. Students who will no need of extra care and 4. What job would you like to do?
service after graduation and can alone successfully 5. How are you going to get a job?
make the transition to adulthood and exercise pro- 6. What skills mastered in your school?
fession - students with one disorder usually mild: for 7. What skills have yet to learn?
example, visually impaired, hearing impaired, stu- 8. What do you do best?
dents with mild intellectual disability, students with 9. What are you doing worst?
mild neuro-somatic disabilities. 10. Please describe how and to what extent do
2. Students who will require special care and at- you see / hear / move, etc.
tention for making the transition to adulthood and 11. Have you worked before? Where? What have
addiction professional activity for a period of time - you done?
students with combined disorders or with moderate 12. What are the obligations you have at home?
and severe disability. 13. What are your goals for this year? And the fu-
3. Students who will need protracted, perhaps ture?
permanent care and services for the transition to 14. What help will you need to achieve your
adulthood and can not be completely autonomous goals?
and independent in the performance of profession- 15. How would you describe yourself (use 5-10
al duties - students with multiple disabilities. adjectives that suit you)?
Appropriate vocational guidance includes de- 16. Which activities you like in school?

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 OCCUPATIONAL MEDICINE
17. What activities outside school you like? Suitable professional schools: music school and
18. What do you do in your spare time? medical college to master the massage of persons
19. Own you prefer to work or among other peo- with visual impairment, trade schools for people
ple? with hearing disorders, etc.
20. What work do you prefer - inside a building or Through short university programs. This is a
outdoors, in the open? new form of professional training, popular in West-
21. Which do you like more - to work with people, ern Europe and the USA. By university program aims
with data, with the animals or objects? acquiring knowledge and experience in a specific
22. Describe how you imagine the perfect job for profession, such as computer technology and oth-
you. ers.
Through vocational courses. These courses are
14.1. VOCATIONAL REHABILITATION created for people with a certain type of disability
OF PERSONS WITH DISABILITIES and have the task to teach students specific skills.
Examples of such professional courses are: sewing,
Appropriate vocational rehabilitation requires knitting, carpentry, piano tuning, repair of appli-
practice good professional training. At the same ances, upholstery, etc. Usually these courses are or-
time it is important to know the possibilities for ob- ganized by an organization of disabled people - for
taining it. In modern society there at least seven op- example, the Union of the Blind, Association of the
tions for obtaining professional qualification: Deaf, Union of Disabled People.
Special schools for children with disorders. Through international programs. A number of
This is the oldest form to master the profession both educational and rehabilitation facilities around the
internationally and nationally aspect. For example, world offer training to master a profession or quali-
the creation of the first schools for deaf, blind and fication of persons with disorders, and exchange of
mentally retarded in Bulgaria respectively in 1898, students. Thanks to this form of vocational training
1905 and 1936 is advocated the absorption of var- disabled people can master entirely new profession
ious crafts. The school for the blind learn basketry or improve their skills in their profession known as
and brush-making, later introduced the study of familiarize themselves with modern trends in its ex-
massage and tuning of pianos, in school for mentally ercise - for example, to gain an idea of the innova-
retarded taught needlework. Today, besides the tra- tions in computer hard- and software for the blind
ditional crafts, to master the basics and of advanced and others.
professions, working with computers and modern
special equipment. 14.2. LABOUR FOR PEOPLE WITH
Rehabilitation centers. They are intended pri- DISORDERS
marily for persons where violations occur in old age.
It provides both elementary rehabilitation, master- In Bulgaria at the end of 2000 the number of per-
ing living skills and vocational rehabilitation. sons with permanent disability (disabled) is 240,000.
Specialized centers for vocational rehabili- For Sofia only their number is more than 30 000
tation. This form of professional training enjoyed people. The basic legal documents regulating their
success in many countries - especially in the Nordic rights and social benefits are: the Law on Protection,
countries. It involves creating a special center for Rehabilitation and Social Integration of Disabled (as
persons with certain types of disabilities or a combi- amended and supplemented by the 38th National
nation thereof, where to teach different professions Assembly in March 2001), the Code of compulsory
suitable for the type of disability. In Bulgaria these social insurance from January 2000, the social assis-
are social educational and professional institutions tance act and its implementing rules, the Regulation
(SEPI) for persons with intellectual disability. In our on expertise of efficiency.
country there are a total of 10 such institutions Career development is a “Process by which the in-
where people with intellectual disabilities master dividual defines their professional values and carries
professions like tailoring, upholstery, cooking, paint- significant professional activities. This process also
ing, printing, furniture, women knitting, agricultural includes the assessment of interest and the detec-
activities and more. tion of potential “(Simpson F., 1986). It creates a feel-
Mass vocational schools. This form is applicable ing of satisfaction, allows free communication and
for persons with visual, light neuro-somatic some- not living in isolation, ensure financial stability and
what with hearing disorders. In her disabled do in independence, creates self-esteem.
ordinary vocational education and master the pro- The main factors that determine employability of
fession on a par with persons without disabilities. persons with disorders are:

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Personal adjustment. To be a personal adjust- cuss with them any problems, to mediate between
ment, the person must be able to observe good per- the individual with disorders and employer.
sonal hygiene, dressing appropriately, have good Working in special enterprise or special envi-
manners and behaviour. ronment for people with disorders. This system
Social adjustment. It requires mastering the of vocational rehabilitation is the oldest historically
face of such skills will make him an effective mem- - emerged in Europe in the late eighteenth century
ber of a group or team. when to different schools for children with disorders
Public adjustment. This factor implies adapta- (mostly blind and deaf ) are created workshops (lat-
tion of the person to the basic rules of society. For er created special autonomous workshops). Now in
this purpose, it must be able to handle money, shop- Bulgaria special enterprises (from 1952 for the blind)
ping, using public resources, etc. exist at the Union of Blind - i.e. “Success” and the Un-
Professional adjustment. The person to master ion of the Deaf - i.e. “Quiet work”. In practice, the first
all those work skills and habits that allow him to effi- special enterprises in the country occur around the
ciently perform the professional activity. middle of the twentieth century. They should be re-
Employability of people with disorders are a few: cruited only individuals with one disorder without
Job's working place together with persons additional disabilities.
without violations. This means that the person Working in “enclave”. This is a system in which
is increasingly competitive and able to deal inde- a small number of persons with impaired work to-
pendently with various professional tasks as well as gether in an ordinary working environment, among
persons without violations. In support of this oppor- people without disabilities, are responsible for a
tunity in different countries apply support measures certain part of the production process, eg., man-
in the face of two systems: a quota system and the ufacture or assembly of certain detail. They work
volunteers. The quota system is an obligation of collaboratively with others with a similar condition,
the employer to set aside a certain number of jobs but get in continual contact with colleagues without
for the disabled. This system has been successfully disabilities. These enclaves are guided by a person of
applied mainly in the 70s of XX c., but then began rehabilitation facility or institution for professional
to decline. In Germany, for example the legislation training, but could this be a person from enterprise
provides each company with more than 16 work with some training in special education.
places to allocate 6% of persons with disabilities. Traveling work teams (groups). These are
The system of volunteers is more flexible. Her goal working groups of people with similar disorders
is to encourage employers naturally to employ per- who travel together and perform certain work un-
sons with disabilities, without being obliged by law. der contract with various employers. Usually they
For example, if an employer hire a disabled person, include “professional adviser” or a social worker.
for one year his salary is paid by social funds. During In a modern world for people with disorders
this time invalid has the opportunity to demonstrate should constantly seek new ways to professional
their professional skills and be approved. After the appearance. The change of society towards persons
first year, if the employer decides to keep working with disabilities, as well as modern scientific-tech-
person with violations, he had himself assumed the nological and information revolution, undertake in
payment of his earnings. the search for new directions and strategies. Their
Job's working place with persons without dis- implementation is necessary:
turbances, but with help and support. This is an • Studying the experience of different coun-
alternative form of work in a company, institution tries.
or workplace with persons without disabilities, but • Compliance with national traditions and
provide additional assistance from a specialist. This possibilities of updating.
extra help can have different dimensions - for exam- • Analysis of the status and trends and de-
ple, a one-time demonstration of the performance velopment of professions.
of a specific task or activity in the workplace, to • Understand and use the experience of suc-
continuously supervise and monitor the work. Spe- cessfully realized in the profession persons
cialists who can provide this extra help are usually: with disabilities.
specialist for vocational training, social worker, spe- • Introduction of employers with profession-
cial education teacher. There is a post “professional al capacity and realization of persons with
adviser” (job coach) in the US, Germany and others, disabilities.
whose task is to open new employment opportuni- • Promoting the professional capabilities of
ties for persons with disabilities, to help them accus- the disabled in society.
tomed to tasks which perform in the workplace, dis- Although often in the media are exported some

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common issues related to persons with disabilities relevant information for the professional training
is very low emphasis on their ability or success pro- of disabled people through visual demonstration
fessionally. This creates a false idea in society that of coping with the mastered their profession, can
disabled people are helpless, unable to work or vice change incorrect perceptions of society for persons
versa - there is a lack of conversance about their po- with disabilities.
tential. By consistently delivering in the media of the

REFERENCES

1. Holbrook MC, Koenig A.J.(eds.), Foundations of Education (2nd ed.): Instructional Strategies for Teach-
ing Children and Youths with Visual Impairments, AFB, New York, 2000
2. Kisiov M., Disability and temporary disability New, Star Bulsoft-1 Ltd., Sofia. 2001 (in bul.)
3. Ponchillia PE, Ponchillia S.V. Foundations of Rehabilitation Teaching with Persons who are Blind or
Visually Impaired, AFB, New York, 1996.
4. Radulov Vl., Rehabilitation of the visually impaired, DARS, Bourgas. 1999 (in bul.)
5. Simpson F. Transition to adulthood, In: Foundations of Education for Blind and Visually Handicapped
Children and Youth, G.Scholl (ed.), AFB, New York 1986
6. Tsvetkova M., Blind in antiquity and the Middle Ages, Pedagogy, 11, 84-93 ,. 1996 (in bul.)
7. Wolffe K., Transition planning and employment outcomes, In: Educating Students who have Visual
Impairments with other Disabilities, S. Sacks & R. Silberman (eds.), Paul H. Brooks publ. Co., Baltimore, 1998

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 K.Nikolov

15
MANUFACTURING ENTERPRISES -
ARCHITECTURAL BUILDING CONCEPTS
AND REQUIREMENTS. VENTILATION.
15.1. ARCHITECTURAL AND PLANNING lute environment and at objects identified by de-
SOLUTIONS AND REQUIREMENTS tailed plans), water catchment areas, nature reserves
and protected areas of dams, historical and archae-
Creation of favorable working conditions at pro- ological monuments, resorts, areas around special
duction enterprises is determined largely by the ap- objects.
propriate planning and architectural and structural Positioning itself industrial area is done by design
design solutions. The last created material organized aiming at appropriate functional zoning of the in-
environment, the object of spatial resolution are dustrial area - such disposal of the main workshops,
linked in a single system factors in the production auxiliary, service, warehouse and administrative
process and the conditions of work and rest, that are buildings, in which should not create conditions for
created for employees. Industrial architecture that harmful effects on workers of manufacturing pro-
is highly targeted technological certainty, observe cess and the emergence of ecological failures to the
and reflect the diversity in the formation of the pro- natural environment.
duction environment. By developing a general plan of enterprise now
The design is based on mandatory construc- solve issues in planning the routes of the railways
tion-technical norms in line with hygiene standards and internal factory roads, underground and above
and sanitary requirements and rules. Architectural ground installations, the profile of the area and the
and planning solutions in determining the loca- overall development of the territory - landscaping
tion of the manufacturing enterprises of structure using plants with sanitary-protective qualities and
schemes and plans of the territories in the coun- sustainable to harmful substances.
try in compliance with current regulations. The The buildings of the individual subobjects can
structure schemes providing arrangement of area, be deployed separately, to block, to form a semi-en-
corresponding to socio-economic development closed courtyards or enclosed on four sides yards,
guaranteeing environmental protection. The struc- while besides technical and economic feasibility of
ture plans include: general - determining the pre- such decisions into account and hygiene, fire protec-
dominant purpose and method of development of tion requirements and those in occupational safety.
the different structural parts of the territories; and Compliance with the construction-technical
detailed - specifying spatial planning and develop- norms precludes adverse shading of two opposite
ment of settlements and lands, and settlement for- buildings.
mations. In functional and spatial architecture design of
In determining the most appropriate location of the Industry building itself and is looking imple-
production area reflect a number of factors: topog- menting all hygiene requirements and conditions
raphy of the area, the direction of prevailing winds, for safe operation in terms of:
so called “Wind rose”, weather conditions, existing 1. Ensuring adequate natural lighting in accord-
background concentrations of prevailing harmful ance with the envisaged category of visual work.
substances. Natural lighting in industrial buildings is carried
It requires compliance with the permissible san- by side (through windows) and upper (through
itary-protection zones (distances) of production or glazed roof panels or glazing of different height
service facilities or sources of harm to the nearest roofing sheets).
housing, food, health, education, children and oth- Overhead lighting is only possible in one-storey
ers objects, subject to health protection or to the buildings in the upper floors of multistory buildings
border of the settlement regulation depending on (Fig. 1).
the nature and capacity of the specific proceedings. Side lighting using windows with different de-
Do not allow the construction of industrial plants sign that depending on the nature of the industri-
in: residential areas (except for small objects no pol- al building is mounted on the front walls as targets

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tivities for effective protection against noise and
vibration: walls with the necessary sound insula-
tion qualities, separation of areas with high levels of
noise through the buffer stock and other areas, de-
sign of lightweight insulating partitions and screens,
separation of soundproof cabins for remote control
of technological processes.

Fig. 1. Schemes of three-navicular-hall buildings

with steel structures Fig. 2. Basic forms of upper lighting
1) transverse caterpillar lighting; Regulatory norms pose significant requirements
2) direct caterpillar lighting;
3) with ridge and attic lighting.
for construction products. Construction products
for use in construction are usable only if it does not
glazed surfaces, vertical or horizontal glazed strips, endanger the safety and health of people, possess
single holes arranged in rows or checkerboard. Their characteristics, that suitable the envisaged for them
dimensions are selected according to specific archi- use in construction for reasonable working life, are
tectural construction decision and the basis of ex- properly designed and executed and meet the es-
isting regulations. The windows can be opened in sential requirements for buildings. These require-
different ways, such as open windows whole or in ments which may affect the characteristics of con-
part. Widely use a glazing of glass bricks and glass struction products are: mechanical resistance and
profiled panels that besides giving diffused light, stability, fire safety, safe operation, health and en-
have good insulating properties. vironmental protection, hygiene, noise protection,
In large-area buildings is arranged overhead energy saving and heat insulation.
lighting, which may be in the direction of the roof 4. Ensuring legally necessary premises for sani-
ridge, transverse to the ridge or in combination. Re- tary service of workers.
alized with the aid of fonari superstructures of vari- Manufacturing buildings can be one-story, mul-
ous forms with respect to a certain width and height ti-story, combined.
and inclination of the glass plates from 45 ° to 90 °. The advantages of one-story buildings (Fig. 3)
Envisaged so-called shedovi (saw-formed) roofs that are: pass of the production process at one level, cre-
give through vertical or inclined glazing uniformly ating facilities for maintenance, repair and reorgan-
good natural lighting (Fig. 2). izing; maximum load-bearing capacity of the floor;
The ceiling lights have great advantages and the possibility of creating lightweight structures for
are widely applied in the construction of industrial the building; providing good natural lighting, place-
buildings. It should not however be allowed direct ment of lighting openings in the roof; convenient
entry of solar rays on work places, constituting a transportation and conditions for the rapid evacua-
threat of overheating microclimate and intolerance tion of personnel; possibilities for maximum spatial
for the body of the worker. combining of the premises.
1. Create conditions for natural ventilation of The disadvantages of the one-story buildings can
production buuildings through appropriate struc- be underlined: the need for larger construction areas
tures of openable windows. within the industrial area, longer installation networks
2. Selection of appropriate construction sys- and communications, greater heat loss and more.
tems and materials for achieving hygiene stand- Multi-storey buildings are with smaller floor area,
ards for microclimate of work places, create optimal with more compactness of production facilities, with
heated volumes and avoid air flows. lower heat losses, better insulation and drainage of
3. Anticipate architectural and construction ac- roof construction.

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The coloring of machines and equipment, except
in accord with the interior, should help to create safe
working conditions - creating a contrast between
control and working organs and the background on
which projected.
According to statutory requirements, stained in
certain colors technological pipelines, communica-
tions for heating, fixtures and more.
Architectural decisions relating to the exterior of
the industrial building, as an additional treatment
of the facades, surface treatment of fencing and
Fig. 3. Inner view of low one-story building construction elements, the color of the facades, pro-
As their disadvantages are: greater difficulties to vided lighting, signs and logos associated with aes-
achieve the parameters of natural lighting, limited thetic searches of the designer to create unity be-
height of floors and installation of heavy machinery tween the material nature of industrial architecture
and equipment, a greater percentage of additional and aesthetic form. When designing the production
service area, greater difficulties in evacuation, sup- project dropped self-demandable of in itself unnec-
plying and repairs. essary and extraneous architectural forms and dec-
The one-storey buildings are designed and im- orations, but works well thought out and rational
plemented if the assessment proves that the floor composition, while aiming at the most appropriate
construction is contrary to the technology, unrea- and most economical solution.
sonably expensive construction works and contrary Safe operation of objects depends on the proper-
to hygiene and fire safety requirements. ties and quality of building materials. Architectural
The production buildings are designed in rectan- and construction solutions must take into account
gular or square shape without unnecessary bends. the fact that the implementation of a number of
Avoid designing of prominent building elements, building materials emit harmful substances, that are
canopies, window steps - especially in enterprises expressed most strongly in a specific process. Also,
with dusty processes. in case of fire some materials emit highly toxic gases,
The architectural design on the height of pro- leading to a threat to health and life and rise to seri-
duction premises into account the dimensions of ous environmental pollution.
the machines that will be installed, at the required Construction materials as the most common
height for installation and repairs, heights required classification can be divided into:
for crane and lifting equipment, requirements for 1. Natural stone (granite, rhyolite, syenite, marl,
safety at work and fire safety. dolomite, limestone, marble, etc.), used in cladding,
The floors in the production premises must be some floor coverings, aggregates for concrete , mo-
secured against slipping, are incombustible and saic and more. In the application emit dust contain-
current no conductivity (in explosive processes and ing different percentages of free silica, sand, small
using flammable liquids), are resistant to abrasion fragments.
(movement of vehicles on them), are not damaged 2. Ceramic building materials and products -
by aggressive substances (when work with acids, bricks, tiles, shutters, cladding tiles, acid resistant
chemicals, oils, petroleum products, etc.). and fireproof products, stoneware pipes, tiles, por-
Essential to create favourable working conditions celain and more. Harmful emissions released during
is appropriate decision of interior furnishing of pro- their application are: dust, pieces of undegraded
duction baildings and exterior. waste, ionizing radiation (such as zirconium sand).
The interior determines the impact of composi- 3. Materials of glass melts (flat glass, profiled glass,
tional structure of the premises, the colour of vari- glass vials, glass fibres, gas-glass) and of molten rock
ous elements, lighting, visual communication (signs, (basalt, marl, slag pumice). Detached dust and un-
directories), the distribution of mobile equipment. degraded pieces.
The coloring of the premises must comply with the 4. Inorganic binders - plaster, lime, cements,
positive impact, that should be on the psyche of the ashes of TEPP, inert additives, waste from asbestos
worker. The floors are stained in neutral tones and production. Release dust containing silica, dust with
the columns and walls - in brighter. toxic action, dust containing asbestos.
Premises with cold mode of production are 5. Concrete and solutions, asbestos cement prod-
painted with warm, mostly yellow tones and in hot ucts. Release dust containing silica, asbestos, glass
industries avoid staining in bright colors. and mineral fibres.

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6. Metals - ferrous and non ferrous. Emit different in temperature between two opposite walls.
hazards depending on their application - dust, metal In all cases, natural ventilation is unstable and
aerosols. depends on the weather.
7. Wood and wood construction materials-planks, • Vertical - through the upper windows, using
flooring, doors, windows, beams and more. Set the elevating power of heated air.
aside in their application dust, sawdust, vapour from • Mechanical - air supply and suction - two
paints, varnishes and others. ventilation working together.
8. Synthetic building materials - resins, plastics, • Air conditioning - looking not only provide
paints, hardeners, stabilizers and others. Separate fresh air in the room, but maintaining micro-
vapors, aerosols, smoke, soot, gases with toxic, irri- climate parameters within certain limits - tem-
tating and carcinogenic effects. perature and humidity in the room (these pa-
Continuous development and improvement of rameters vary according to the type of work).
technology in the world determines the appearance Certain procedures require dry air (installa-
of new and new construction, insulation, acoustic tion of electrical apparatus), and another case
and decorative materials that are more widely used moist (spinning, weaving).
in the construction of manufacturing and service Dust in the workplace strongly affects the qual-
buildings. ity of the environment. To avoid it is necessary to
Ministry of Health exercises state sanitary con- prevent facilities that emit dust, no-work without
trol through its specialized authorities. The prelimi- local exhaust ventilation. Regularly clean working
nary health checks involving medical professionals - environment and to prevent secondary dust in the
doctors, sanitary engineers and architects who give air. This can only be achieved with well-organized
opinions on all relevant hygiene standards, build- maintenance and good condition of the machines
ing codes and regulations for prepared projects for and ventilation equipment, maintained by staff.
construction, reconstruction and modernization of 1. Aspiration. It is done using a local exhauster
production buildings. Opinions shall be submitted connected to the suction duct (under vacuum). We
to the parts. Preliminary health checks are carried have to take into account the fact that the speed of
out and in the construction phase of the project suction rapidly decreases with distance from the
and ends with an opinion authorizing the use of the hole. For example, a circular suction opening - off
building in operation, which is provided by PIPCPH one diameter - speed drops 10 times. Where the
state acceptance committees and permission for us- place of separation of dust is mobile (eg mine where
ing buildings in the Republic of Bulgaria. dust activity moves continuously), mounted mobile
suckers associated with the intake air duct with flex-
15.2. VENTILATION ible connection. If dust emission is at the level of the
worktable it is appropriate to provide lower local
Aeration is a reliable and economical way of suction (dust tends to settle due to gravity).
ventilation of industrial buildings. Used in buildings 2. Transportation. Dust extraction in the work-
with higher heat load, because under these condi- place is transported by pipeline to the dust-catcher.
tions it is reliable in all seasons. Used elevating pow- There are two basic ways to avoid jam on pipelines
er of heated air, which tends to the above aeration transporting dust mixtures: while maintaining high-
holes. For well organized aeration is required great- speed transport and while not allowing sharp cor-
er height of the building - exceeding 5 m and aera- ners, that support the layering of dust and jam.
tion holes are located on strictly defined places. The 3. Dust-catcher. Dust catchers are different
most commonly used two-way aeration when the types:
air enters on both sides of the housing through the Ÿ Mechanical - gravity: ordinary settling chamber
lower aeration openings (windows with a particu- where the section is significantly increased and the
lar manner of opening and exits through the upper speed of dust mixtures suddenly falls and the dust
openings (fonari). Wide area buildings are inconven- settles by gravity. Adverse is that these dust catchers
ient to use on aeration because in their inner part are very large and inconvenient to use in most cases.
can not do enough fresh air. To reduce their length are used mixed precipitators
Multiplicity of air changes in workplaces is deter- where dust mixtures moves in a zigzag and thus pro-
mined according pollution and dimensions of the longs the path of the particles to can settle. Precipi-
rooms. tated mainly larger particles.
Types of systems and ventilation: Ÿ Filtering. Filtering it through a filter fabric - cot-
• Natural - horizontal (windows and doors). It is ton, paper or synthetic nonwovens. To avoid the
more active as greater pressure difference and accumulation (stratification) of dust on the filter

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 LABOUR MEDICINE
material, leading to a strong increase in resistance, moderate speed through a bundle of vertical pipes
applied the following means: increases strongly with a diameter of 20 to 30 cm and about 5 m long,
the surface of the filter material by making multiple through which passes a metal rod with a diameter of
folds or multiple sleeves that are shaken by period- 2 to 3 mm, acting as a negative electrode. Pipes are a
ic strikes on filters to unstick the accumulated dust. positive electrode and at a differential tension of 25
Perform and increasing the porosity of the material to 100,000 V., particulates are first ionized and then
used by various artificial materials that are electri- precipitate and adhere to the surface. In another
fied (static electricity attracts dust particles). type electrostatic, called wet, dust mixtures is suita-
Ÿ Centrifugal - used the high speed of suction fan, bly wetted at the inlet and after the sticking on the
the spray tangents to the inner side of the cylinder wall of the filter, it was washed with running water.
which in its lower part becomes an inverted cone. This principle is very effective and it gets cleaning
Ÿ Cyclone. A cylinder mounted on an inverted from the order of 99.9%, but is too expensive.
cone. Dust mixtures enters in the upper part of the In gas polluted working environment aspiration
cylinder tangential with high-speed, rotated and its is used in the same way to capture, as in the dust. As
movement becomes helically, along the way dust in dust the local aspiration combined with general
particles lose their speed, by friction in the walls of exchange (of the whole room) ventilation. The exact
the cone. They precipitated at the bottom of the in- design and implementation (for maximum efficien-
verted cone (there are discharged through a valve in cy) of ventilation, into account the conditions and
the container for dust), and the cleans air changes its characteristics of the technological process: the type,
direction and is directed upward leaving the cyclone quantity and physico-chemical characteristics of the
at the top. It is possible to increase the efficiency emitted gases and vapors, heat generation, etc.
of these dust-catchers by reducing their diameter, What precautions should be taken before bring
while in same time not increasing its resistance. This out the polluted air in the atmosphere? Incorrect
is achieved by using a greater number of cyclones usually sucked from the workplace or technologi-
with smaller diameters, called multicyclones. cal facility polluted air to throw directly out into the
Ÿ Water dust-catchers. Dust mixtures are sub- atmosphere without purification. Where are bring
jected to the action of water - or in the form of a liq- out into the atmosphere many harmful substances,
uid or in the form of a condensable vapor, such as such as hydrofluoric acid, sulfur dioxide, etc., should
resulting in wetting of the powder and create larger be undertake preliminary purification before throw
particles that are separated in the inner part of the out. This can be done for example by bubbling in
apparatus in the form of a middling slime (silt). water or a neutralizing solution. Since these purifi-
Ÿ Ultrasound. The issue of continuous ultrasonic cation of exhaust air are expensive, require consoli-
waves from a single source support consolidation of dation of a group of gases in general or purifier such
particulates and they can significantly easier to cap- capture in which to use caught substances again in
ture the classic dust-catchers, such as dry cyclones production. Therefore, in most of these cases the use
or even settling chambers with partitions. of charcoal filter, in which obtained absorption of
Ÿ Electric or electrostatic filters used for the first gases, and then they are recuperated by separation
time of Cottrell in the US. The principle of dust col- with steam.
lection in them is the passage of dust mixtures at

REFERENCES

1. BS EN 12464-1: 2006 Light and lighting. Lighting of work places (in bul.)
2. Conception architecturall de lieux de travail. Aeration. Precis de medicine du travail. sous la dir. H. De-
soile, J. Scherrer, R. Truhaut, Masson, Paris, 1991, 133-140.
3. Ivanov V., Krapchev B., Heating and Ventilation, S., Technique, 1991 (in bul.)
4. Kostov K., Architecture of industrial interior. S., Technique, 1977 (in bul.)
5. Markowski P. Architecture of civil and industrial buildings and engineering structures. Technique,
1959 (in bul.)
6. Norms for design of heating, ventilation and air conditioning systems. Bulletin of Construction and
Architecture, issue. 6 and 7 CTVS, 1986. (in bul.)
7. Ordinance № 7 of the MH - Hygiene requirements for health protection of the urban environment - SG.
46, 1992 (complementary.: №46, 1994; № 89анд №101, 1996, №101, 1997, №20, 1999). (in bul.)
8. Ordinance № 7 of the МH - For minimum health requirements and safety in workplaces and the use of
working equipment. SG. 88, 1999 (amend. and suppl. to 2004). (in bul.)

333
 Z.Ivanov

16 PERSONAL PROTECTIVE
EQUIPMENT

Personal protective equipment (PPE) is used For special purposes

when risks can not be avoided or reduced sufficient- there are other different hel-
ly by means of collective protection or by means of mets. To protect the head
methods and procedures for organizing the work. and face during the opera-
The general requirements for PPE are: tion of fire departments, the
• to provide protection against the risks in helmet (Figure 1.2) is very
which they are applied, without themselves good, protecting against:
leading to an increase in any risk; mechanical and thermal im-
• be eligible at the appropriate workplace; pacts; water and precipita-
• comply with the ergonomic requirements and tion; aggressive substances;
health of workers; organic solvents, paints, var-
• match the user's dimensions, if necessary, af- nishes, adhesives; oil, lubricants and fats.
ter appropriate adjustment; 2. PPE to protect hearing organs.
• where, due to more than one hazard, it is nec- These PPE are divided into two sub-groups: in-
essary to use more than one personal protec- ternal antiphoning; external earphones and helmo-
tive equipment, they must be compatible and phones.
continue to be effective against their respec- They are designed to protect against effects of
tive hazards when used together. noise exceeding 85dB (A).
PPE are divided into: The internal antiphonics
1. PPE for head protection. are most often made of a
This PPE group includes the following subgroups: soft, sound absorbing mate-
helmets; hats; bonnets or under helmets; head cloth rial that can be gradually ex-
and kerchiefs. panded to take the form and
These devices are designed to protect the head size of the hearing channel
(without the eyes, ears and respiratory organs) from (Figure 2.1).
mechanical impacts - shock, contact with open Internal antiphonics can
electrical wires, unfavourable climatic effects - cold, reduce the noise to the or-
rain and wind below +12°C, pollution with no-toxic der of 30-34 dB for the most
and toxic powders, to protect hair from moving ma- dangerous, High noise rates.
chines and mechanisms, solar radiation and other Some anti-phonics are also anti-allergic and are
harmful radiation and hazardous thermal effects. comfortable for people with narrow ear canals.
Of the above-mentioned PPE group, the helmets The external anti-phon-
are the most important for maintaining health and ics can: be fitted with hel-
safety for workers. They can prevent serious acci- mets (Figure 2.2); to re-
dents at work (having a lethal finis) caused by the ceive and transmit speech
impact of falling objects and materials. with built-in microphones
Classical in this and headphones; to reduce
regard is the INTR- noise with certain charac-
CAP MK 1A (weigh- teristics. External antiphon-
ing 320 g), which ics are used at a noise inten-
also protects against sity above 102-105 dB/A, and the helmphons at an
electric current with intensity above 112-120 dB/A.
a voltage above 24V. Antiphonics can not be used in cases where
(Figure 1.1.) sound signals have to be received to ensure safe

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 LABOUR MEDICINE
work. In this case, you must use anti-phonics with a pressed air supply; breathing
device for receiving the sound signals. apparatus isolating with an
3. PPE for eye and face protection open system; breathing appa-
Various types of spectacles and shields are used ratus isolating with a closed
for this PPE group. system; space-suit and pneu-
They are designed to protect against mechanical mo-suit (Figure 4.3); filters
damage - blowing away particles, harmful radiation, designed to clean the air by
spraying with aggressive toxic and hot liquids and retaining toxic substances.
irritating eyes powder. The main requirements for Particularly essential re-
this PPE group are not to reduce the viewer's field quirements for this type
of view, to avoid sweat, not to fall when performing of PPE are: not to impede
different movements, to be able to combine with breathing, to diminish the
other PPE and in particular, to be able to use glasses field of view, not to smash
, correcting vision. the visual screen, to resist of
In order to guarantee the protection qualities of impacts and aggressive sub-
glasses and shields, it is particularly important to stances. The body of the mask
have the materials from which the glass is made - does not irritate the skin of
the various types of light-filtering lenses and view- the face, stick tightly and has
ing screens that are resistant to blow, splashing with good airproofness.
aggressive and hot liquids. 5. PPE to protect the up-
Such wide-field eye- per limbs
glasses (Figure 3.1) pro- This PPE group is designed to protect the hands,
tect against: a strike of including the elbow joints from mechanical impacts,
objects and particles; from dangerous chemical substances, from thermal
non-toxic dust; splashing and adverse climatic influences and from electrical
water; toxic solids and currents.
dust; toxic liquid sub- Predominant in this group are protective gloves,
stances and solutions, re- which have a large assortment depending on their
spectively splashes of acids, bases, solvents, paints, purpose, construction and the materials and tech-
varnishes, adhesives, oil, petroleum products and nologies used.
mineral oils; toxic aerosols and gases - class 1-4. Besides gloves for this group, sleeves and prophy-
The front protective lactic wrist straps are included.
helmet (Figure 3.2) pro- To ensure work safety, dielectric gloves, heat-re-
tects against: sparks; sistant gloves and gloves protecting against aggres-
splashes of molten metal, sive and toxic substances are particularly important.
slag and broken particles; For example, nitrile gloves "Soflex" protect against:
ultraviolet radiation; light blow away from objects and particles; piercing, cut-
rays with intense shine - ting or scraping action; contaminated surfaces with
over 200 nits. non-toxic materials and contaminated surfaces with
4. PPE for respiratory oil, petroleum products and mineral oils; non-miner-
protection al oils and fats.
These PPEs are of particular Gloves for workers in slaughterhouses, sausages
importance for the protection and butchers are also special (Figure 5.1).
of the health and safety of work- Protective leather cuffs pro-
ers. This PPE group consists of Fig. 5.2. tect against: piercing, cut or
the following subgroups: mask scratching; sparks, splashes of
whole; semi mask (Figure 4.1); molten metal, etc. (Figure 5.2).
respiratory
insulating Fig. 5.1.
apparatus
(Figure
4.2);breath-
ing apparatus insulating with
pure atmospheres; breathing
apparatus insulating with com-

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 OCCUPATIONAL MEDICINE
6. PPE to protect the lower limbs rials, special working gar-
They are used to protect legs to the knee joint. ments with different pro-
Include the following subgroups: boots; half-shoes; tective qualities are made.
sandals, slippers and To prevent of low air tem-
prophylactic shoes; boots perature (+12° to –20°C),
and galoshes; dielectric static electricity and water
boots and galoshes. splashes, wet surfaces are
Personal lower leg most often used with half-
guards are designed to fur coats.
protect against mechan- For welding works to
ical, thermal, climatic, protect against sparks and
strong aggressive and toxic substances, vibrations splashes of heated parti-
and harmful radiation. In most cases, personal lower cles, welders' suits (Fig.
leg protection should protect against the combined 7.1) are recommended,
effects of several hazards and dangers. Very often which have a leather front, sleeves, back panels,
used with slip-resistant front of the trousers and the saddle. When work-
soles. ing near a fire, used costumes
In a standing position, made of aluminized materi-
shoes with low or high leg al impregnated with cotton
are recommended (Fig. cloth. For example, the suit
6.1). They also prevent "Inter safe fire suit" (Fig. 7.2)
slipping as well as convec- suit has a very good perfor-
tion heat from + 25 °C to mance: it protects the body
+ 37 °C. and face from sparks, molten
To protect the legs metal splashes, slag, heated
from intense mechanical particles; thermal radiation up
impacts, shoes with steel to 15x1000 W/m2; heated sur-
plates in the bombs can face above 100 ° C.
be used to withstand up to two tons of pressure. The To protect against: toxic
shoes are lightweight and comfortable. and aggressive substances,
Boots protect against: slipping; contaminated organic solvents and mineral
surfaces with non-toxic substances; watering and oils, suits are recommended,
rainfall; water splashes and wet surfaces; splashes some of which are completely
and wet surfaces with acids and/or bases. air-proof.
To protect against: piercing or pricking effects; At risk of splashes and dirty surfaces of acids, bas-
sparks, splashes of molten metal, slag and hot par- es, solvents, paints, varnishes and adhesives, as well
ticles are very practical in the case of leggings (Fig. as from water and from contact with contaminated
6.2.) or leather gussets. surfaces of non-toxic substances, use seamless, one-
Knee-pads is used for creep work (pavers, par- piece aprons with sewn ties for binding on the waist
quet floors, etc.). Against skidding in snowy and icy and for hanging on the neck.
terrain, very useful work is done by special shoe cats. When working in an area of severe radioactive
Their steel teeth have a height of 10 mm. contamination, workers must wear knitted under-
7. Special workwear and PPE for body and tor- wear, socks, gloves and slippers under the other
so protection special workwear. All items of knitwear are cleaned
This group of protective equipment has a wide (deactivated) after each use. They can not be used
range of applications. In most cases, special work outside the work area.
wear is designed to protect against the simultane- 8. Protective safeguarded equipment
ous impact of several hazards and dangers. These safeguarded equipment is designed to
The following subgroups are included in this protect workers from potentially dangerous risk.
group: fur coats and half-fur coats; costumes; jack- This group includes the following protective means:
ets, jerkins and bodies; trousers, cami-knicks and dielectric carpets; anti-vibration mats; safety belts
half-aprons; shirts; underwear; cloaks, mantles and against falling from a height; cats for climbing; work-
mackintoshes. ing seats in a hanging position; dielectric rods; pro-
Subgroups are based on type of constructions. tective support strips for attaching or lifting loads.
When combining different constructions and mate- Due to the large variety of these safety devices, and

336
 LABOUR MEDICINE
especially the great re- The right choice and use of protective creams,
sponsibility they incur, pastes and biological gloves leads to a reduction of
they must be provid- professional dermatoses and limits the penetration
ed with the necessary of toxic substances into the body.
instructions for use, Depending on their solubility and character,
pre-training and train- these PPEs are divided into:
ing of the workers with a) oil-no soluble (water-soluble) - they serve to
them, quality certifi- protect the skin against mineral oils, fats, hydrocar-
cates, shelf-life for pre- bons and organic substances (solvents, varnishes,
serving and operation, resins, etc.) free of water. Washing agents include
methodology for ver- water and soapy water emulsions. Marked with O/W:
ification of safety fea- b) water-insoluble (soluble in organic solvents) -
tures during operation. serve to protect the skin against water and aqueous
For example, there solutions of acids, bases, salts and other substances,
are special require- as well as water-oil emulsions. Washing agents are
ments for the belts to organic solvents with subsequent skin lubrication
fall from a height. The with softening and lubricating creams. Marked with
support in the event of W/O;
a fall should be in the c) silicone based protective substances. Silicones
seat area (to protect the kidneys from tearing). In ad- are organic substances resistant to acids, alkalis, wa-
dition, a special braking device is also provided which ter and high temperature. They are easily attacked
absorbs part of the energy (Figure 8.1). by organic solvents (trichlorethylene, carbon tetra-
9. PPE for skin protection - dermatological chloride) and petroleum derivatives (petrol). They
protective equipment have good coverage - they form a monomolecular
This group of protective devices are designed film. Washing agents are active - binding substanc-
to protect against skin damage by chemical agents es and highly alkaline aqueous solutions. They are
and harmful radiation. Dermatological protective not recommended for use in the furniture indus-
agents are subdivided into the following subgroups: try, paint coatings and galvanotechnics as they can
barrier creams; protective preparations; restorative damage the quality of the product.
preparations; disinfectants. REFERENCES
1. Acoustics - Hearing Protectors - Part 2: Estimation of Effective A - Weighted Sound Pressure Levels When
Hearing Protectors Are Worn ISO 4869-2: 1994 (E). Geneva: ISO, 1994.
2. American Industrial Hygiene Association (AIHA). Respiratory Protection: A Manual and Guideline. Fairfax,
Va: AIHA, 1991.
3. British Standards Institute (BSI). Hearing Protectors - Recommendations for Selection, Use, Care and Main-
tenance - Guidance Document. Document No. BSI EN 458: 1994. London: BSI, 1994.
4. Enchev M., et. al. Guidebook for personal protective equipment, clothing and shoes, Profizdat, S., 1970.
(in bul.)
5. European Economic Community (EEC). Directive 89/686/EEC on the approximation of the laws of the
Member States relating to personal protective equipment. Luxembourg: EEC, 1980.
6. Eye and face protection. In the Encyclopaedia of Occupational Health and Safety, 3rd edition. Geneva: ILO,
1983.
7. Herrick R. F. ed. Personal protection. In Encyclopaedia of Occupational Health and Safety, ed. J. M. Stell-
man, 4th edition, v.I, ILO, Geneva, 1998, 31.2-31.21.
8. Lundin A. M., Respiratory Protective Equipment, Chapter 23, in Fundamentals of Industrial Hygiene,
Third Edition, Washington, 1988.
9. Lundin A. M., Personal protection. National Safety News, USA, 1971
10. Ordinance № 3 of the Ministry of Labour and Social Protection and the Ministry of Health on minimum
safety and health requirements for protection of workers health when using personal protective equipment
at the workplace; SG. 46/2001 (in bul.)
11. Personal protective equipment approved for use in the Republic of Bulgaria, items I and II, Labour
Conditions Fund at MLSP, Sofia, 2000 (in bul.)
12. Protection individuelle. In Précis de médecine du travail, sous la dir. Desoille H., Scherrer J., Truhaut
M., Sixième édition, Masson, Paris, 1991.

337
 17
MANUFACTURING AND PROFES-
SIONS - BASIC TECHNOLOGIES,
HEALTH RISK, PREVENTION

D.Tsonevsky

17.1 AGRICULTURE

Agriculture is one of the main branches of the some major activities. An intense load, for example,
economy. The object of its production is the vegeta- occurs during ploughing, sowing, harvesting, and in
ble and animal raw materials needed mainly for the livestock - during the period of shearing, the sheep's
functioning of the food industry but also of many birthing period. The duration of the working week
other branches of the economy. and the use of the rest day during a harvest cam-
To improve and optimize working conditions in paign is determined only by the weather conditions.
modern agriculture, it is essential to meet the basic The working day at the mechanic most often lasts for
requirements of hygiene, physiology of labour and 11-15 hours, and in livestock breeding work begins
ergonomics. The introduction of new technologies at 3-4 in the morning and ends with small interrup-
and new equipment, the mechanization and auto- tions at 21-22 hours; 3. Frequent changes of opera-
mation of the basic labour-intensive processes, the tions - irrespective of the internal specialization in
optimization of the relations in the ergonomic sys- each sub-sector of agriculture, individual operations
tem - man/machine/environment, in the agricultural often change; 4. Agricultural activity is most often
production led to the creation of new professions - done outdoors under the influence of day and sea-
operators, mechanics, etc. sons-specific weather factors; 5. Biological factors.
Major branches of agriculture are plant and live- Direct contact with domestic animals, plants, insects
stock breeding. The broad range of agriculture in- poses a high health risk to professional, infectious,
cludes sub-sectors such as grain production (grain parasitic and allergic diseases among all categories
and technical crops), vegetable growing, fruit grow- of farm workers; 6. Chemical factors. The widespread
ing, viticulture, etc. Livestock breeding includes use of chemical preparations such as pesticides, fer-
sub-breeding cattle, sheep, pig, poultry farming. tilizers, biostimulators, etc., creates conditions for
Each industry is characterized by general and specif- acute, sub-chronic and chronic intoxications, for aller-
ic labour-hygiene problems. gic diseases, to reduce the reactivity of the organism;
The general characteristics of all agricultural ac- 7. Factors related to labour mechanization. Here is
tivities in the different sub-sectors of agriculture, added the adverse effects of factors such as noise, vi-
distinguishing them from the working processes in bration, air pollution with harmful gases, contact with
the industry, are: 1. Higher physical workload and fuel-lubricants, overheating, non-ergonomic-work
intensity of labour. The problem of the complete re- place and posture; 8. Other factors and peculiarities.
placement of manual labour in key sectors of agricul- The considerable remoteness of the workplace from
ture has not yet been resolved, operations connect- the place of residence is adversely affected. Also, the
ed with ploughing, sowing, harvesting of greenery aging of agricultural workers as well as female labour
crops are mechanized, other activities such as forage, in unskilled labour operations associated with heavy
special operations in viticulture, vegetable produc- physical labour is also significant.
tion, tobacco production are still not mechanized . In
livestock farming, much of the labour is still heavily 17.1.1. LABOUR HYGIENE IN PLANT-GROW-
physically; 2. Particularities in the rhythm of work and ING
the duration of the working day. Agricultural labour
is characterized by irritability, both in terms of an- Labour hygiene in mechanics. The work of the
nual seasons and in the twenty-four-hour rhythm of mechanics - tractors, combine harvesters, mechan-

338
 LABOUR MEDICINE
ics, agricultural machinery and tractors mechanics, The mechanics are exposed to the harmful effects
is very diverse. It depends on the different stages of of toxic chemical agents - pesticides, exhaust gases
agricultural production. from engines (carbon monoxide and dioxide, nitro-
The main machine in agricultural work is the trac- gen oxides, sulfur oxides, methane, aldehydes, 3-4
tor, which, combined with various attachments, is benzpyren, ammonia, hydrocarbons, mineral ferti-
involved in a variety of operations in soil cultivation, lizers, fuel lubricants The formation of toxic gases is
sowing, cultivation of agricultural crops. The con- related to the type of agricultural machines, the type
struction features, the differences in the type of fuel, of engines - petrol or diesel, the term of operation,
the type of the chassis determine to the greatest ex- their technical and operational characteristics, etc.
tent the labour-hygienic conditions of work. To limit the impact of the main harmful factors in
During operation, the tractor is subjected to a the mechanics-noise, vibration, dustiness, adverse
continuous impact of a set of unfavorable factors. microclimate, etc., suitable solutions are made in
Microclimatic conditions of operation depend on the construction and operation of agricultural ma-
the presence or absence of a cabin, its constructive chines - provision of cabin with conditioning devic-
solution. The microclimatic conditions in the cabs of es, sound insulation, vibration reduction measures.
the machines used are significantly different from The ergonomic position of the seat, levers and other
those of the atmospheric air. In the tests of different devices In the cabs also have their influence, and the
brands of tractors during summer, the temperature organization of the working day, ensuring a correct
of the internal surfaces of the walls between 36 and working and rest regime, healthy eating are of great
55 ° C and the air in it between 28 and 44 ° C, which importance.
exceeds the outside temperature by 5-14 ° C. Labour hygiene in the field of grain-produc-
What matters for noise is the type of engines and tion. The work of the grain-producers is reduced to
the mode the cabs are mounted. Diesel engines gen- carrying out operations such as fertilizing the soil
erate higher-intensity noise than gasoline. The noise with natural and artificial fertilizers, loading and
tests of the agricultural machines used in Bulgaria unloading, soil mowing, weeding, irrigation, grain
show that it is high frequency, with an intensity of decontamination, etc. Nowadays almost complete
75 to 105 dB / A and hygienic norms exceeding 4-14 mechanization is carried out in the different types
dB/A for different tractors, 6-12 dB/A in mowers, and of soil treatment (plowing, bending, harrowing),
with 5-10 dB/A in harvesters. sowing, fertilizing, irrigation, crop cultivation with
The vibrations of working with agricultural ma- pesticides, harvesting of grain crops. Lesser oppor-
chines are mostly general - aperiodical with pushing tunities exist in some sub-sectors such as viticulture,
nature. Meanwhile, periodic, local vibrations of con- fruit growing, vegetable growing, and the cultiva-
stant character are also important in the operation tion of certain technical crops.
of engines and gears. The vibrations measured on In spite of mechanization in the field of grain-pro-
the seats of used tractors in the different activities duction, the problem of intensive physical work
exceed the hygienic norms for the mean frequencies is still a problem, especially in manual operations.
from 2 to 21 times and for the high ones - up to 1.5 Their energy costs can be categorized as medium
times. and heavy-duty occupations. In agriculture too of-
The combined effect of noise, vibrations and ten are the forced posture - inclined body, squatting,
their combination with forced posture leads to in- kneeling, etc. The physiological performance of the
creased morbidity of the locomotory system, to an- work indicates that it is carried out with some strain
giospastic injuries, hypertension, angina pectoris, on the cardiovascular and nervous system and on
gastric motor disorder, vegetative dystonia, hearing the locomotory system. Grain farmers, especially in
and vestibular disorder. the summer, lose a lot of fluids, have a fast heartbeat.
Dust is one of the most significant unfavorable During the work, the farmers are exposed to the
factors in the working environment of mechan- constant influence of changing meteorological fac-
ics. Air pollution in the respiratory area depends tors - outdoor work. Even within one season, the
on the nature of the work performed, the weather temperature often varies considerably, allowing for
conditions and the soil humidity, the design of the overheating or over cooling.
machinery, the height and position of the seat, the Pollution of air in various field works also fluc-
sealing of the cabins, etc. The powder with which tuates considerably. The main source of dust is the
mechanizers are exposed is non-toxic, with an or- soil in its mechanized treatment, as its humidity has
ganic-mineral character and is finely dispersed. Me- a major impact. The character of the operations is
chanics complaints are particularly frequent during often associated with permanent irritation of the
harvest when the air dust in the work area is highest. skin. During weeding, irrigation and other manip-

339
 OCCUPATIONAL MEDICINE
ulations skin microinjury, macerations, pyoderms, growing is a complex process involving about 53
dermatitis can be produced. Failure to comply with operations. The main stages are soil preparation,
hygiene requirements, lack of prior instruction, and seed planting, seedling cultivation in greenhouse,
handling of faulty machines and tools often lead to plant planting, cultivation, harvesting, tobacco
injuries. There is also a danger of biting from rep- racking, drying. Along with meteorological and mi-
tiles and insects, and from some transmissible in- croclimatic unfavorable factors, seasonal workload,
fections (Crimea hemorrhagic fever, Haemorrhagic unfavorable working position, there are some spe-
nephrosonephritis, Lyme Illness, etc.). cific dangers to tobacco drying. In the air of the dry-
Farming activities are often also associated with a er, concentrations of nicotine vapours of 0.94 to 8.1
health risk from the use of pesticides. Failure to meet mg/m3, methyl alcohol - from 7.1 to 30 mg/m3, ae-
hygiene requirements during seed decontamina- theric oils - from 0.3 to 3 mg/m3, ammonia - 10 mg/
tion, spraying and dusting crops, failure to observe m3, as well as traces of phenol, organic acids, CO and
quarantine deadlines causes acute, sub-chronic and others.
chronic intoxication. The complex effects of working conditions here
Several specific features are also found in some lead to diseases of hypertension, gastritis, cholecys-
sub-branches in the field of agriculture. In a study titis, bronchitis, radiculitis, rheumatic polyarthritis,
the parameters of the microclimate in the green- female genital diseases.
house vegetable production in Bulgaria show that
during the hot season the air temperature varies 17.1.2. LABOUR HYGIENE IN LIVESTOCK
from 25,6 to 38,5 ° C, the relative humidity - from BREEDING
74 to 100% and the air velocity - from 0, 0 to 0.60
m/s, and during the cold period, respectively, of 14 In the different sub-sectors of animal husband-
to 27 ° C; from 61 to 96% and from 0.5 to 1 m/s. This ry, common unfavorable factors are: dustiness, air
shows that the microclimate by temperature factor pollution with harmful gases, unfavorable microcli-
during the cold period of the year is within the per- mate, heavy physical labour.
missible norms, and in the warmer it is overheating, The differences between the different livestock
within the limits of the unfavorable and especially breeding sectors - sheep, cattle breeding, pig farm-
unfavorable conditions. The adverse effects of the ing, fish farming, etc. are distinguished from the bi-
discomfort microclimate are exacerbated by the sig- ological characteristics of the different livestock and
nificant physical load, the heavy load carrying (10 to the aims of their cultivation - meat production, milk
22 kg of single load), the high labour intensity and production, etc.
the forced posture. The microclimate in livestock farms depends on
Of the toxic-chemical factors, pesticides are also the type, construction, and extent to which they
important here, using widely and in large quantities. meet modern requirements. A microclimate, mainly
It has been found that about 30-35 pesticides and dependent on the weather conditions and the sea-
several pesticide mixtures of PhOC, ChlOC, carba- son, is established in the farms. Conditions for over-
mates and dithiocarbamates are found to be used cooling or overheating are formed therein.
in greenhouses for vegetable crops. Significant is In livestock farms, constantly acting are the harm-
the high relative part (55-65%) of preparations with ful factors as of ammonia, CO2, SH2, mercaptans, al-
medium and high toxicity and their pronounced dehydes, ketones, and others, eliminated by animals
skin-absorption and irritation effect. organism. In the aeronautical environment of farms
Fruit growing and viticulture are important of an earlier type, for example, the concentration of
sub-sectors in agriculture. Work here is also predom- ammonia has been found to reach 2.4-80 mg/m3,
inantly seasonal, outdoors, and the microclimate, as carbon dioxide - 0.20.4%, hydrogen sulphide - from
well as other factors in the work environment, are 8 to 30 mg/m3 - significant exceedance of the MAC
similar to those in the field of grain-production. The for these gases.
processes in fruit and vine-growing have specific Major occupational hazards in livestock breed-
mechanization - small tractors, machine spraying, ing are also some biological factors. The possibility
etc. And are characterized by uneven rhythm and of transmission of a number of zooanthropogenes
many manual operations. This leads to increased up- such as brucellosis, anthrax, foot-and-mouth disease
per respiratory tract morbidity, to frequent conjunc- is high.
tivitis, dermatitis, allergic reactions. There is more Dust is a significant adverse factor in the work-
frequent pyoderma and microtraumatism here. ing environment. The degree of dustiness varies de-
Tobacco production also has a number of spe- pending on the season, humidity, the nature of the
cific factors in the working environment. Tobacco food mix, etc. The powder is predominantly organic

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in nature and can serve as a factor in the transmis- shoulder joints are most commonly affected. The
sion of many causative agents of infectious and al- second place is chronic bronchitis and emphyse-
lergic diseases and mycoses. ma, followed by cardiovascular diseases, often with
Hygiene measures in livestock breeding should damage to venous vessels (varicose veins). Substan-
be directed to maximum mechanization and auto- tial place in the structure of morbidity also includes
mation of the working processes, daily cleaning of gynecological diseases related to the widely used
the premises, daily provision of the breeders and female labour.
carrying out periodic prophylactic examinations, For mechanics, the structure of the morbidi-
good lighting and good natural and artificial ventila- ty is different. Diseases of the digestive system are
tion of the premises, regular and effective veterinary the first place, followed by production traumatism,
control of the animals and organizing healthy eating colds, diseases of the vegetative and peripheral
for workers. nervous system. Among the breeders, first of all, is
Illness and traumatism in agricultural work- production traumatism, followed by colds, pulmo-
ers. For the non-mechanized and partly mecha- nary chronic diseases, diseases of the locomotory
nized agricultural labour, the diseases of the loco- system and various infectious diseases related to
motor apparatus are characteristic. The spine, knees, contact with animals.

REFERENCES

1. Kundiev Y., V. Chernyuk. Planting and Grouing Operation. In the Encyclopaedia of Occupational.
Health and Safety, ed. J.M. Stellman, Geneva, ILO, 1998, 64. 17-19.
2. Methner M., A. Miles. Greenhouse and nursery operations. Encyclopaedia öf Occupational. Health
and Safety. Ed. J.M. Stellman, Geneva, International Labour Office, 1998, 4th 64. 10.
3. Murphy D. Mechanization. In the Encyclopaedia of Occupational. Health and Safety, Ed. J.M. Stellman,
Geneva, ILO, 1998, 64, 29-33.
4. Peedin G. Tobacco Cultivation. In the Encyclopaedia of Occupational. Health and Safety, ed. J.M. Stell-
man, Geneva, ILO, 1998, 64, 48-50.
5. Sechanov Iv., T. Dimitrov. Hygiene of the modern village. Med and phys., Sofia, 1981. (in bul.)
6. Tsonevski D. Hygienic, toxicological and ecological problems of industrial vegetable production. Com-
bined action of chemical contaminants. Doctoral dissertation, Sofia, 1996. (in bul.)

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N. Stamova

17.2 MINING
17.2.1. MINING Drilling of blast holes is most often done with
vibrating tools - drill bits that work with com-
Mining is carried out in two ways - open and un- pressed air. The most commonly used so-called
derground. rapid drill hammers (2700-3700 beats/min) of dif-
The open method of extraction of ore and ferent weights: hand weights of about 20 kg and
non-metalliferous minerals from an economic and telescopes weighing 50 to 75 kg. Drilling, includ-
hygienic point of view is more appropriate and ing self-propelled drilling machines is also applied,
progressive, but not in all cases it can be applied in where mining conditions allow.
practice. The open mines (quarries) in the mining in- Explosives such as ammonites and dynamites,
dustry generally represent stepped valleys reaching and detonators are used for the explosion. Explo-
a depth of 100 to 400-700 m. Technological equip- sives are placed in cylindrical cartridges. The correct
ment is located outdoors on horizontal platforms. choice of explosives determines to a great extent
The open-cast mining process consists of the the safe operation and the amount of explosive
following main operations: 1) drilling and blasting gases generated by the explosion. The strengthen
operations; 2) excavation and loading of the rock of mining work is necessary due to the presence
breed and ore in transport vehicles; 3) transporta- of continuous rock pressure. The strengthening is
tion of the ore to the enrichment plant, and the rock made with wooden or metal frames, reinforced con-
breed to the discharge; 4) road construction and crete and others.
road maintenance activities; 5) repairs. The loading of weighed rock or ore is done man-
The most common method for drilling-blasting ually and/or with pneumatic loading machines.
operations in open-cast mining is drilling. Boreholes The transportation of the weighed rock and ore
are filled with explosives, most often of the ammo- mass on the horizontal mining works is done by rail
nite type. Filling with explosives is done manually or with electrowelds, and by the vertical shafts - by
with special machines. means of cells loaded with full/empty wagons.
The excavation and loading of rock and ore is Auxiliary activities provide ventilation ducts,
done by excavators or "mechanical shovel" excava- plumbing, railways, equipment repairs, etc.
tors. For the conditions of the working environ-
The transportation of the ore to the filling facto- ment in ore mining is a characteristic complex of
ries and to the rock mass to the discharge is most work place factors: specific microclimate, noise and
often done by dumpers with a lifting capacity of up vibrations, dust, toxic gases, absence of solar radia-
to 200 t. The application of road transport has the tion in the underground mines, etc.
advantage of avoiding heavy and labour intensive The microclimatic conditions in the opencast
operations for the construction of a railway lines, but mines depend on the climate and the time of the
on the other hand the gases emitted by cars contain geographic area where the mine is located. In the
toxic substances. summer, continental climate regions can create ad-
In the underground mining process different verse microclimatic conditions due to the combina-
systems for the ore deposit are applied. The system tion of high air temperatures and intense insu lation
chosen must meet the mining and technical con- with secondary reflection. Moreover, with the dehu-
ditions and provide the most favourable and safe midification of the mine the temperature rises every
working conditions. 100 m depth by 1-1,5 ° C and above, due to adiabatic
The underground mining process consists of the heating, insulating and raising the temperature of
following production operations: 1) boring of blast the ore breeds. In evening, night and morning hours
holes or drilling; 2) filling them with explosives and as a result of inversions, the air temperature in the
blasting; 3) strengthen of mine workings1; 4) load- lower places of the open pit is lower by 1-2 ° C than
ing; 5) scraping and transporting weighed ore and on the surface. Inverse air streams lead to the forma-
rock mass; 6) auxiliary and repairs. tion of fogs.
1
Mine workings is each "empty" area worked in underground The air movement in the deep opencast mines
mines, generated after taking away weighed ore or rock mass. becomes a complex aerodynamic scheme with low

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ventilation efficiency and a sharp reduction in air ve- Noise and vibrations in mining are generated
locity. by the operation of machinery and equipment, es-
The relative humidity in bottom places of the pecially for those using compressed air.
open-cast mines compared to the open surface var- In the open-cast mines, sources of noise and vi-
ies slightly, with its gradient in the diurnal range of brations are the different types and brands of drills,
5-10%. diggers, bulldozers, excavators, dumpers and oth-
In the winter and transition seasons of the year ers. The most characteristic features of the noise-vi-
the meteorological conditions in the open pit are bration exposure in these cases are the following:
characterized by low temperatures, often combined transmission of vibrations to the worker through
with strong wind and rainfall. the floor, seat, levers and pedals; a combination of
When assessing the microclimate in opencast common with local vibrations; frequency variability
mining, it must be borne in mind that some profes- of vibrations coupled with thrusts and in combina-
sional groups, such as sonders, bombers, roadmak- tion with noise. The exact characteristics of noise
ers, repairers, are all throughout the shift or most of and vibration depend most on the type of machine,
it outdoors. Another part - excavators, bulldozers, the operating conditions, the degree of wear of the
diggers and dumper drivers are in cabins and pro- mechanisms, the hardness of the breed, the design
tected from external weather conditions, but if the of the cabin, etc. (The modern models of these ma-
cabins are not appropriately upgraded (without ef- chines are designed to meet the requirements of
ficient thermal insulation), drivers is cooled to even international standards for noise and anti-vibration
freezing temperatures in winter, and summer - heat- protection - noise and vibration levels usually do not
ing the air to temperatures 5 to 15°C higher than exceed the permissible values). When operating ma-
outside. The operation under the described micro- chines in soft breeds, 4 to 16 times lower vibration
climatic conditions is associated with a pronounced intensities are measured on the control levers, 2 to 5
overtension of thermoregulation, abundant water times on the seats, and 2 to 8 times on the floor.
loss and possible acute overheating of the body. In the case of heavy-duty dumpers, bulldozers
In underground mines, microclimatic condi- and auto-graders, the level of general vibrations
tions are mainly determined by the depth of mine also depends greatly on the state of the roads, their
workings and the efficiency of ventilation. In the speed of movement and their load. Vertical vibra-
main mining works (crossbeams, shroud, mining tions are most intense, with maximum values rang-
yard, galleries), there is considerable fluctuation in ing from 1-4 Hz; when moving with a load the vibra-
the air temperature, and in the stopes - it is relatively tions are weaker.
stable. In the vast majority of the Bulgarian under- In the case of underground mining, the main
ground mines the temperature in the main works is sources of noise and vibrations are pneumatic ham-
from 10 to 15°C, and in props, chambers and stopes mers, drills, loaders, scrapers, etc. Highest noise lev-
- 20-25°C; In deep mines (over 500 m depth) can els are measured for drilling activities (Table 1). The
reach 30-34°C. The speed of air movement is also professional risk here is also conditioned by the high
different - it can reach up to 5-6 m/s-1 and more in frequency nature of noise and exposure over most
main mining works, and in deaf stopes - 0.1-0.3 m/s-1. of the working time.
Relative humidity is very high - 85-95%, which de- The local vibrations generated by the different
pends primarily on the water content of the rock types of drills typically exceed the hygienic norms -
breed. It can be summed up that an unpleasant, from 8 to 14 times for the average frequencies and
uncomfortable microclimate
Level to noise in dB/A
is formed in the underground Process / Machine
By S. Maksimov By Altynbekov and all.
mining. The worker's consist-
1. Pneumatic hammers 105-127 114-127
ent exposure to microclimatic
2. Drills 75-102
conditions with the opposite
3. Loaders 88-106 95-110
effect on thermoregulation – loading of ore 92-104 95-110
is important - in the stopes – feeder ore 83-88 –
of overheating - and, in the 4. Scrapers 93-98 94-97
event of a departure from 5. Electric carrier 85-87 –
them - significant cooling. – in purifying wagons – 108-110
Specialised sanitation stand- 6. Fans 92-105 70-75
ards for mine microclimate do 7. Lifts 89-92 68-97
not allow operation at tem-
peratures above 32 ° C. Tab. 1. Noise levels in different mining processes and machines

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 OCCUPATIONAL MEDICINE
from 2.5 to 5 times for the highs. The contact time of is capable of causing dust in the stope up to 1600
the master-digger or his assistant with the vibrating mg/m3. Before the introduction of the wet drilling,
punch takes about 25% of the working time. The na- the average dust in the ore mining in Bulgaria was
ture and intensity of the vibrations depend on the 500 mg/m3, and after its introduction the dustiness
pressure of compressed air in the net, the stiffness of decreased to 3-5 mg/m3 (Figure 2). Another highly
the breed, the technical condition of the instrument. dusting process is the explosion, but with effective
When assessing the occupational risk for the occur- ventilation equipment and other anti-dusting meas-
rence of a vibration disease, the potentiating effect ures a concentration of 2 mg/m3 is reached. Loading
of the static effort of the upper limbs (to maintain is also a powder-generating process, the most in-
the instrument and the posture) as well as their cool- tense in the stope, the characteristic here being that
ing from the water used for the water drilling, must fine fractions occur less frequently.
be taken into account. General and constant source of dusting in the
Dust, the most widespread and dangerous pro- underground mines is the settled dust in galleries
duction hazard in mines, is released in all manufac- and stopes that maintains a constant dusting back-
turing operations. ground.
In the opencast mines the most intense dust The silica content of mine dust is most often
source is blasting. As the blasting is carried out once high. In many countries, incl. and in our country, for
a day (2-3 times a week) and during interruptions silico-dangerous are defined, mines with dust con-
between shifts, until the start of the new work shift taining more than 10% free crystalline silica.
the dust dissipates and precipitates and at the start The dispersion of mining dust, whether in open
of work the dust corresponds to the average dust or underground mining, is extremely high - dusts
of the mine - 0.3 to 2 mg/m3. When updepthing the up to 5 μm in excess of 90%. The harder the breed,
mine, reduced natural ventilation helps to increase the more fine the powder is formed. Compressor air
dustiness. Usually, in summer, dust is higher than pressure or wearing of the drill bits also increase the
in winter - then the ways in the mine are a serious finely divided powder fraction.
source of dust. In addition to the dust, a significant amount of
Local dust contamination in digger cabins, bull- oily aerosol is excreted in the mining air during the
dozers, excavators and auto-mowers is also depend- operation of pneumatic hammers. Depending on
ent on freight, mining roads, wind, etc. (Figure 1). the used lubricating oil, more or less carcinogenic
In the case of underground mining, drilling of substances can be found in this aerosol. In the air
explosive holes is the largest share of dust mining. in the workplaces also particles of the mechanical
When drilling 1 m of rock or ore mass, an average of impurities contained in the water used in the wet
about 150 g of finely dispersed dust is formed which drilling and the various methods of irrigation, falled.
Toxic gases in mine work-
ings can come from the ore
loading that is being processed; as a
loading loading result of the explosion; from
road transport, from under-
Concentration of dust - mg/m3

ground fires, rot processes,

from compressor air, etc.
In open mining, the dust
cloud raise at 100-150 m dur-
ing blasting. Removing this
cloud beyond the mine limits
depends on the speed and
direction of the wind, the size
of the mine, etc. Normally, af-
ter 5-6 minutes, the concen-
trations of carbon monoxide
and nitrogen oxides fall to
the limit values. Higher and
longer (up to 6-7 h) gaseous
Time - min state can be expected with
Fig. 1. Dynamics of the dust content of the excavator cabin in an open cast mine temperature inversions and
(S.V. Aleksiev, V.R. Usenko) windlessness. It is possible

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manually, and the relative share
of manual labour, especially in
concentration of dust underground mining, is high.
quartz content in total dust In the open cast mine,
the main professions are: drill-
ing, digger, bulldozer, digger,
heavy truck driver, bomber,
mine maintenance worker.
Their main production activ-
ities are characterized by a
moderate burden of labour,
but in the case of repair and
auxiliary work, the physical
load, especially of the diggers,
bulldozers and drills, is great.
In all occupations, the static
load on the musculoskeletal
system is considerable. Signifi-
cantly nervous-mental tension
Year is experienced by the work of
diggers, drills and bombers -
Fig. 2. Powder-hygienic characteristics of the Gorubso mines (by E. Petrova) the most pronounced it is for
heavy-truck drivers.
further extraction of gases from the demolished rock In the underground mines the different types
and ore mass. of activities are related to dynamic physical load,
Autotransport in the open cast mine constant- which does not differ significantly in the basic min-
ly pollutes the air. Car exhaust gases are a complex ing professions from the so-called "stope group" -
mixture of toxic gases depending on the type of fuel, master-digger, assistant master, driller, bomber, and
the type of engine, its operating mode, the degree of cap (strengter). Almost all work operations (without
wear, etc. Their concentrations vary widely and are drilling the blast holes) are performed by hand tools.
higher when the mine is deeper. The static physical load in this group of miners is
In the conditions of the underground mines, also expressed. The working posture is often com-
carbon monoxide and nitrogen gases are of hygienic pulsive, inconvenient, in a limited space with raised
importance and their quantity depends on the type hands, and so on. Maintenance of the boring ham-
of explosives used. With the modern organization mers is also associated with a static effort.
of blasting mining at the end of the shift and subse- The work of miners requires constant attention,
quent two-hour or one-hour ventilation before the speed, dexterity, operational and long-term memo-
next shift, the blasting gases are usually not a serious ry associated with visual tension. High labour risk re-
hygiene problem. It is possible to accumulate larger quires responsibility for occupational safety, as well
quantities of these gases in the extracted material as discipline and emotional sustainability.
and to release them at the start of loading. Policyclic A major occupation in the underground mine
aromatic hydrocarbons resulting from the thermal is also the electric driver. His work is not associated
destruction of mineral lubricating oils can also be with a heavy physical load, but requires a large and
found in the precipitated dust and as vapors. continuous visual load, good hearing, caution, speed
In the polymetal mines (mainly in lead-zinc), the and security in driving, resulting in pronounced
air of the working environment can also be contami- nervous-sensory stress. Besides the professions that
nated with radon. are directly connected with the implementation
Mining lighting is one of the factors for safe and of the basic technological processes, workers from
high-performance work. Stationary and portable the so-called repair staff. Depending on the nature
lighting (acetylene or rechargeable lamps) is used, of the work performed, it may be associated with
but it is often inadequate in intensity or with a high mild to high physical stress, with static effort, with
contrast object/background. significant but not continuous visual tension. Work
The labour process of the main professional requires accuracy, attention and speed, very good
groups in miners is varied. Some of the technologi- qualifications.
cal operations are mechanized, others are performed General and occupational morbidity. The most

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common occupational diseases among miners are marily of the cervical and lumbar spine.
silicosis, vibrational disease, auditory nerve neuri- Neuritis of the auditory nerve is most often
tis. Occupational toxicities are also acute poisoning found in diggers and their auxiliaries in underground
with toxic gases, especially in emergency situations. mines, and in individual cases in the presence of un-
Silicosis is a typical pneumoconiosis for under- derground repair personnel, machine-tool opera-
ground mining and, most importantly, for miners tors, and others.
from the "stope-group". The estimated number of In addition to the nature of work and social-liv-
silicosis and silicotuberculosis patients in Bulgaria in ing factors, the incidence of temporary incapacity
1990 was 5,200. About 90% of them have late forms. for work (ITIW) in the ore extraction, also affects the
The dust-exposed workers in danger to silicosis are age-gender structure - only men are employed in
23504 in the country in 1990. The problem of silico- the main occupations, and their age is usually be-
sis remains on a global scale. tween 20 and 40 years.
There are peculiarities in the clinic of silicosis In the case of underground mining, the struc-
from the various mines. Workers in the gold mines ture of ITIW in miners is mainly formed by chronic
during the "dry" drilling of the blast holes form "egg diseases of the respiratory system, skin and subcu-
shell" changes in the hyloxic lymph nodes and "pea taneous tissue infections, diseases of the peripher-
disease". Zinc mining silicosis occurs late after a long al nervous system (cervical and lumbosacral rad-
dustless or latency period of dust extinction, and iculitis, the locomotory system (osteochondrosis,
is typically characterized by macular shades type deforming spondyloarthrosis), from gastrointestinal
"snowstorms", which are scarcely delimited. Silicosis tract diseases (acute gastritis, gastroenterocolitis)
in the copper mines has a favorable slow motion, and from labour traumatism. For the open-cast min-
low morbidity and a picture of mixed pneumoconi- ing, the structure of the ITIW is similar, but from the
osis. In the iron mines, silicosis or siderosilicosis with diseases of the respiratory system leading are acute
a favorable run can be expected. Uranium mining infections of the upper respiratory tract, of gastroin-
causes progressive silicosis, arising as a result of high testinal diseases are ulcerative disease and chronic
quartz concentrations in the air aerosol from the gastritis. Hypertension is also high. Diseases of the
working environment and the potentiating effect of locomotory system, peripheral nervous system and
radon impact. hypertonic disease have a higher relative share in
Pneumoconiosis in open-cast mines miners is less those over 40, and younger workers are more likely
frequent. Pneumoconiosis in these cases is benign to suffer from acute upper respiratory tract infec-
and progresses very slowly. In individual opencast tions and gastrointestinal tract infections.
mines, signs of chronic bronchitis with combined Prevention of work. In the opencast mines, it
etiology (from dust, adverse weather conditions, is important to ensure the hygienically acceptable
toxic exhaust gases) can be found after work over values of the microclimatic factors in the cabins of
15 years. mining machines and road transport. The walls and
Vibrational disease. In the underground mines, their floors must be lined with heat-insulating mate-
the contingent is the digger-makers and their as- rial. The best option is conditioning them.
sistants. The adverse effects of local vibrations gen- For workers all year in the open environment, it is
erated by pneumatic hammers are potentiated by important to provide work-wear suitable for winter
general and local cooling and static physical over or summer, as well as winter warming premisses and
tension of upper limbs. In the vertical drilling of blast for rest periods during the summer. It is also neces-
holes, diggers are exposed not only to local but also sary to consume hot liquids in the winter and cool
to general vibrational action. mineral water and fruit drinks in the summer.
Vibrational disease incidence among workers in In underground mines, the main precaution
opencast mines is less frequent. Separate cases of vi- against the discomfort microclimate is working
brational pathology have been found in crawler ex- clothes: a wet-protected top coat and trousers, woo-
cavators after 10-15 years of work experience, with len underwear, socks and boots. Hot bath after work
symptoms typical of general vibrations, combined is mandatory.
with angiospasm manifestations of the hands. The complex of measures to reduce noise and
Drillers, diggers, bulldozers and heavy-duty truck vibrations in mining and their impact includes or-
drivers may also be at risk of developing a vibratory ganizational, technical and medical means. Organi-
disease. The pathology of the nervous system may zational considerations include: observance of spe-
be accompanied by lumbalgia, lumbar-circulatory cial rules for the operation and repair of machines,
radiculitis, and diseases of the locomotory system rational working regiment, extended annual leave,
- osteochondrosis and deforming spondylosis pri- etc. The most important organizational measure is

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to reduce the time of exposure through the inter- at each stage of the mining technology. The main
changeability of workers from different professions. place is dedicated to the so-called "wet drilling" of
The technical means of reducing noise and vibra- explosive holes. The efficiency of dust extraction
tions from mining equipment should be taken as a and retention of dust is increased by adding to the
rule by the producer companies, but only as an ex- water the so-called wetters and foams.
ception, by the users. Full elimination of the noise-vi- In cases where mining conditions do not allow
bration effect can be achieved by remote control of the use of water drilling, dry dust collection is used,
mining machines wherever is possible. which has a number of advantages over water drill-
In the open-cast mines, the general principle of ing-capture and the finest particles of dust, as well
limiting vibration and noise is, above all, the vibra- as reduced humidity in the workplace and wetting
tion and sound insulation of the machinery cabs. In of clothes, shoes and hands.
order to reduce the vibrations and impulses of the Removal dust in mining is also carried out by dis-
heavy-duty trucks it is important to have the roads persing water (irrigation) at the dusting sites. Water
in the open-cast mine with concrete or reinforced cartridges, water balloons, water curtains are used.
concrete slabs and the right choice of the speed of Dew is subject to the walls and ceiling of mine work-
movement. ings at the pre-blasting work, the gas dust cloud
In underground mines to reduce the harmful itself after blasting, the weighed rock mass after
impact of vibrations, the use of "self-driving" drilling blasting and preloading, the dusty ventilation flow
machines, including automatic and remote control, coming out of the debris and loading/unloading
will be very effective. Vibrocarretes and vibrating points in the mine.
handles are used for the commonly used hammer Reducing concentrations of toxic gas from road
drills. Vibrocarretes are designed to protect hands transport in open-cast mines can be achieved by
when drilling horizontal and sloping holes (they are using catalysts. It is very important to keep engines
spring shock absorbers and reduce vibration at all in good technical condition (regular repairs, adjust-
frequencies). In order to reduce the vibrations of the ments, etc.). In case of inversion and windlessness, if
load machines, shock absorbers for the chassis are there is accumulation of toxic gases, work in the pit
used. should be stopped.
Substantial noise reduction is achieved by sound- In the underground mines the blasting must be
proofing the engines of various mining machines, done at the end of the working shift; between every
including and pneumatic hammers. two working shifts a mandatory ventilation time of
It is also mandatory to use individual anti-noise 1-2 hours was established.
and vibration protection devices - anti-phones and The main purpose of avoiding the formation of
impermeable and oil-resistant gloves with vibrat- large quantities of explosive gases in the mining
ing lining. In the complex of medical measures and industry is the use of explosives having a correctly
means, apart from preliminary and periodical exam- estimated oxygen balance allowing their full (no res-
inations, dispensary, labour readjustment, protec- idue) burning.
tive meals, physiotherapeutic measures - self-mas- Correctly conducted ventilation in under-
sage, gymnastics and hydroprocesses should not be ground mines is essential for: normalization of the
overlooked. mine microclimate, reduction of dust and toxic gas-
In the open-cast mines the dust control is car- es to the MAC. There are powerful stationary venti-
ried out in several directions: application of dust lation systems. The flow rate of the required air to
reduction methods, reduction of its intensity and ventilate the mine is calculated on the basis of the
removal of dust by natural or artificial ventilation. calculations of the intensity of the dust in the par-
Dry dust removal or "wet drilling" is applied during ticular operating environment. It is not allowed to
drilling. If diggers are used - dewatering is applied. alternately ventilate the stopes with the same ven-
Covering the auto roads in the open cast mines with tilation jet.
durable flooring - concrete or reinforced concrete The air supplied by the ventilation system in the
slabs, wetting the roads with water (not less than 1 mine should be clean, which requires special atten-
time per hour) also reduces the intensity of dusting. tion to the complete dustless of the area around the
Cabins for mining machinery and motor vehicles shaft.
must be reliably secured by the dust (hermetic) and Much of the accidents and diseases in the mines
have air-purifying ventilation equipment. The opti- are due to the non-use of personal protective equip-
mal option is air conditioning. ment. They protect workers from discomforting
To reduce dust in underground mines, a com- microclimate, from dust, from noise, from electrical
plex of anti-dusting methods and means is used current, from moving parts of machines, from falling

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rock scale/ore, etc. Personal protective equipment the process progresses, the composition of the aero-
includes special work clothing and boots, gloves sol changes: in the crushing compartments it is pre-
and helmet, as well as safety devices - brackets to dominantly dusty and the fine powder and quartz
protect the hands when cutting support materials, content in it most often exceeds the MAC several
safety belts, glasses, dust masks, antiphonics, etc. times. In the reagent and flotation compartments
Medical-prophylactic measures. Due to the dif- the vapors of xentogenat, hydrogen sulphide, sulfu-
ficult conditions for working in the mining industry, ric acid, etc., predominate, and their concentration in
those who want to work in this sector are subject to the working environment depends on the efficien-
increased requirements. The contraindications for cy of the sanitary and technical facilities. Noise and
getting into work must be strictly adhered to and general vibrations are most characteristic of crush-
the results of periodic medical examinations analyz- ing compartments. Near the crushers and vibration
ed. screens, the noise exceeds the allowable level by 2
Special sanatoriums for recreation and restora- to 8 dB/A on average, and the low and medium fre-
tion of health have been created for mining workers. quencies prevail in its spectrum. General vibrations
Profilactic professional nutrition are provided. also exceed the permissible norm.
Employees serving flotation factories have a
17.2.2. ORE PROCESSING AND DRESSING different occupational risk. Those serving crushing
compartments and conveyor belts do not have a
Typically, a mine (open or underground) is also fixed work places. Walking on the various machines,
being built a flotation factory, where the initial pro- they are exposed to all the above-mentioned unfa-
cessing of the ore starts. The technology includes vorable factors. In the reagent and flotation com-
the operations: ore grinding, screening, fine milling partments the operator type of work is predomi-
and dressing (flotation). nant and the exposure is predominantly of the toxic
The ore is delivered to the bunker at the flotation chemical reagents.
factory with heavy-duty trucks. For crushing use jaw The morbidity of the workers from the flotation
and cone crushers, for sieving - vibration screens. factories has no specific features - cases of pneumo-
The transmission of the shredded product is carry by coniosis, chronic bronchitis, subtrophic and atrophic
conveyor belts. Prior to the enrichment, the crushed rhinitis and pharyngitis, diseases of the locomotory
ore was finely grind in drum mills in an aqueous me- system and others.
dium. The resulting mixture is transported for flota- The healing measures in the flotation factories
tion. Flotation is performed by chemical reagents in should be aimed at: sealing and controlling aspira-
flotation machines (open-area chambers). In the en- tion of the dust sources, especially in the so-called
richment of polymetal ores, "collective" (separation "purings" (for site transfer, material puring), reduc-
of all useful minerals from the "deserted" ore) and tion heigh of puring, wetting of the ore, humid clean-
"selective" (separation of different minerals from ing of the premises, mechanization of the processes
each other) flotation is applied. for unloading of the reagents and preparation of the
The concentrates obtained at the dressing are solutions, use of less toxic reagents, cladding of the
sent to the metallurgical plants for the extraction of machines and the walls of equipment with sound
pure metals. absorbing materials, vibro-insulating platforms, use
When dressing ores in floation factories workers of personal protective equipment, etc.
are exposed to an aerosol with complex composi-
tion, noise, vibration, discomfort microclimate. As

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REFERENCES

1. Аlteanbekov B.E. et. al. Hygiene of labour in mining, in "Manual of labour hygiene", ed. Izmerov N.F.,
1987, Moscow, Med. V. II, 8-37. (in russ.)
2. Bakardzhieva T. et. al. Labour hygiene at underground extraction of minerals - in "Hygiene in basic
industries", ed. Lukanov M., Sofia, Med. and phys., 1977, 1344. (in bul.)
3. Burilkov T. et al. - Mineral powders in the working environment, Sofia, Med. and phys., 1983, 103-124.
(in bul.)
4. Goranova L. et al. - The noise factor in manufacturing branches - in "Infrasound, ultrasound, noise and
vibrations", ed. Tsvetkov D. and Angelova M., Sofia, Med. and phys., 2007, 94-102. (in bul.)
5. Goranova L. et al. - The vibration factor in production - in "Infrasound, ultrasound, noise and vibrations,
ed. Tsvetkov D. and Angelova M., Sofia, Med. and phys., 2007, 173-183. (in bul.)
6. Hartman, H.L. (ed.) - SME Mining Engineering Handbook, 2nd edition. Baltimore, ND: Society for Min-
ing, Metalurgy, and Exploration, 1992.
7. Hock, E., P.K. Kaiser, and W.F. Bawden - Design of Suppoert for Underground Hard Rock Mines. Rot-
terdam: AA Balkema, 1995.
8. Karastanev Iv., N. Mitrev, Kr. Yazov - Vibrational Disease, Plovdiv, Hr. G. Danov, 1979, 14-35. (in bul.)
9. Mckenzie - Wood P., J. Strang - Fire gases and their interpretation. Mining Engineer 149 [345]: 470-
478, 1990.
10. Mitrev N. - The Noise in the Mining Industry - in "Noise as a Factor of the Living Environment", Plovdiv,
Hr. G. Danov, 1976, 35-38. (in bul.)
11. Morrow, G.S. and CD Litton - In-mine Evaluation of Smoke Detectors. Information circular 93-11,
Washington, DC: Bureau of Mines, 1992.
12. Petrova E. - Silicosis and Silicotuberculosis, Sofia, Med. and phys., 1993, 10-28. (in bul.)
13. Stamova N. - Hygienic characterization of the working environment and its impact on the body of
the workers from IOC "Assarel" - report on scientific topic, 1993. (in bul.)
14. United Nations (UN) Department of Technical Cooperation for Development and the German Foun-
dation for International Development - The Mining and the Environment: The Berlin Guidelines. London:
Mining Journal Books, 1992.
15. United Nations Environment Program (UNEP) - Environmental Aspects of Selected Non Ferrous Met-
als (Cu, Ni, Pb, Zn, Au) in Ore Mining, Paris: UNEP, 1991.
16. Voroncova E.I. - Hygiene of labour in mining in "Manual of labour hygiene" ed. P.K.Kotsianov, Mos-
cow, Medgiz, 1961, V. III, 60-93. (in russ.)

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Z.Ivanov, M.Lyapin, Em. Vodenicharov

17.3 FEROUS AND NON-FEROUS

METALLURGY
17.3.1. FEROUS METALLURGY ic component. The colds, as well as those of the pe-
ripheral nervous system and the locomotory system,
Metallurgy includes the following main indus- have increased.
tries: agglomeration, blast-furnace, steel foundry, In the blasting industry, reductive melting of
rolled-mil and ferro-alloy. agglomerates, iron ores, fluxes and coke is achieved
Agglomeration production provides the neces- in order to produce cast iron. The process is contin-
sary high quality raw material for the metallurgical uous and is carried out in blast furnaces at a melting
cycle. The technological process goes through: stock point of up to 1800°C. The addition of fluxes (usu-
preparation (crushing and primary mixing), second- ally limestone) helps to melt, and the bonding of
ary mixing and caking with the end product - pieces lime with iron oxides leads to the formation of large
of agglomerate and agglomeration to obtain a puri- amounts of slag. It swims over the cast flow and runs
fied agglomerate. through the chutes - the slagflow, at the top of the
The workers in the agglomeration production are furnace. From below, through a cast flow, pour cast
exposed to a complex of dangers among which dust iron into cast truck and transport to remake to steel
is first. Pollution varies widely between 20 and 200 or foundry pig iron.
mg/m3. Most significant is the grinding of the stock, The leading professional noxa is the extremely
the concentrate, the coke, the limestone; in mixing unfavorable microclimate. Conditions for overheat-
drums; in the premises of the return cycle; in the ing due to intense infrared radiation in the short
places where the raw materials are processed from wavelength of the spectrum, especially when the
one equipment to another; in vibrating screens; slag and cast iron are flowing (3500 to 7000 W/m2)
when loading the agglomerate, etc. The main com- are created. In summer, the ambient air temperature
ponents of the powder are iron compounds (up to reaches 35 ° C and in some cases up to 45 ° C. On
65%), calcium (up to 20%), silicon dioxide (up to 12% the other hand, strong air currents (with air velocity
- including free silica to 1-2%). For polymetallic ores above 5 m/s) and cold temperatures in winter (up
the powder may contain other heavy metals - lead, to 1-2 ° C above the ambient air temperature) cause
manganese and others. 85 to 88% of the powder overcooling of workers with all health consequenc-
particles have dimensions up to 2 and 99% up to 5 es.
μm. Most of the workers (excluding those in the
The microclimate is adversely affected by inten- open-air ore yard) are exposed to excessive dust
sive separation of infrared radiation (with values up concentrations (similar in composition and disper-
to 2550 W/m2) and convection heat, on many areas sion to agglomeration production). A major danger
in production premises with heat sources. During is the release of blast furnace gas (mainly due to the
the cold period of the year the production microcli- increased CO content). Particularly endangered are
mate is overcooled with predominantly sub-normal workers at the colliery platforme, the hydroinsula-
temperatures and in places with strong air currents tors and the openings of the gas pipelines, the joints
(up to 1.5 m/s). of the dust collectors with the raw gas collector and
Noise exceeds sanitary-hygienic norms (broad- others. Toxic-chemical damages also have to be
band with an intensity of up to 96 dB) only in places mentioned the pollution with sulfur dioxide, lead
at agglo machines. aerosols and others. The harmful impact of these
The working position is most often right - up to noxae is enhanced by the synergistic action of the
35% of the shift time, sometimes a significant load, overheating microclimate.
and the energy consumption is usually within the The noise near blast furnaces is usually medium
limits of heavy work. and high frequency with an intensity of 86-90 dB/A
As the leading professional nose is the produc- (although in some places it reaches too high values
tion dust, the most common disease is bronchitis. up to - 110 dB).
It is characterized by a low run, is not accompanied Many of the work operations are done manually
by pronounced functional disturbances of external and are associated with high energy consumption
breathing, and is rarely complicated by an asthmat- (at cast iron flowers and bucketmakers reaching

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 LABOUR MEDICINE
over 21 kJ/min). The labour of the flowers and gas- within the range of 21 kJ/min.
workers, where the energy consumption is below 20 The health consequences for workers are: the risk
kJ/min, is lighter. But at them, the job is associated of overheating and overcooling; Increase of: cold
with a certain high responsibility and control, and to morbidity, diseases of bone, peripheral nervous, di-
the gas workers high qualification is necessary. gestive (ulcers, gastritis, colitis) and cardiovascular
The most frequent health effects for workers (hypertension, atherosclerosis) systems; high level
include: danger of overheating or overcooling, in- of traumatism; severe burns; acute and chronic in-
creased colds, peripheral nervous system and loco- toxications and others.
motor system disease, trauma, severe burns, acute In the rolled-roll production a plastic deforma-
and chronic intoxications, bronchitis, etc. tion of metal products is made in order to obtain dif-
Steel is produced by melting iron, mixed with ferent rails, sheets, pipes and the like. Rolling is hot
iron waste or pure iron ores. This is done in three and much less cold (without heating the metal). In
technological variants, defining the three types of hot rolling, huge amounts of heat are released. Infra-
workshops: marten, bessemer and thomas and elec- red radiation is most often in the range of 2100-3500
tric steel foundry. Generally, in all three cases, too to 5600 W/m2, Significantly above the MAV. The air
much infrared radiation and high air temperature temperature in the summer is 30-40ºС (sometimes
are present. Sources of infrared radiation are the fur- up to 50ºС). In winter, however, only a few meters
naces, the casting-shuttles, and the high tempera- away from the furnaces and hot metal treatment,
ture of the air contributes to the hot gases coming the temperature slightly differs from the outside.
through the working openings in the furnaces. The The speed of air movement is relatively high - up to
technological cycle passes through three phases: 0.6 m/s and in some places even higher.
preparing stock materials and filling the furnace, The noise is broadband, with low frequency prev-
flushing and dropping the steel, spilling the steel. alence, and is usually above the MAV - reaching 102
In the stock compartments, the main disadvan- dB.
tage is the high dustiness of the air. The temperature The powder consisting mainly of iron oxides is
regime is completely dependent on the weather, as finely dispersed and its values are usually about 20
these compartments are not heated and there are mg/m3 (fluctuations are 0.2 to 70 mg/m3). The tox-
no heat sources. The speed of air movement varies, icochemical factors - CO, sulfur gases, oil aerosols
but the most characteristic are its high values - above (although usually their concentrations exceed 3-4
2 m/s. Workers here have a energy consumption of times MAC) are of hygienic importance. In today's
more than 21 kJ/min. Significantly loading the lo- rolling production, the physical load is reduced, but
comotorial apparatus from physical effort as well it is still high (over 21 kJ/min) in a number of work-
as from unfavorable working positions. The health places.
effects are: bronchitis, increased colds and those of The unfavorable combination of injuries leads
the locomotory system and the peripheral nervous to: danger of overheating, heat stroke, overload of
system, and so on. cardiovascular and respiratory systems, increase of
Mixer compartment workers are exposed to in- cold morbidity, traumatism, burns, diseases of the
frared radiation to a greater extent than those in locomotory system and of the peripheral nervous
blast shops, and summer air temperatures exceed 5 system, etc.
to 13°C outside air. During the winter season, how- Ferro-alloy production provides necessary for
ever, subnormal and even negative temperatures steels casting iron alloys with manganese, silicon,
are very common. chromium and others. The raw materials are ores,
Toxicochemicals are: dusts at concentrations up concentrates, converter slag, iron chips, coke, fluxes
to 70 mg/m3 (with iron oxides but also free silica up (limestone and dolomite). The technological cycle is
to 10%), condensation metal aerosols (manganese, continuous. It goes through pouring of the starting
lead, etc.) with very high dispersion and concentra- materials into the bunkers, filling the furnaces with
tions above the MAC; blast furnace gas, CO2, sulfur electrode masses and stocks, melting, casting (usu-
dioxide and others. (In the bessemer and thomas ally three times in 8 hours). The main occupational
workshops, noxious gases in the air of the rooms may hazards in the areas without heat release are: the
be released only when the convertors are blown). unfavorable microclimate, entirely dependent on
Workers here are almost always upright, with a the weather conditions of the season and the high
high intershift load of up to 80%, with more than dustiness. The microclimate has high infrared radia-
half of this time performing manual labour with a tion (400 to 2800 W/m2) at workplaces near to ther-
energy output of over 21 kJ/min. Only in case of mix- mal production sources. In the rest of the shop the
ers in the converter the energy consumption can be microclimate is almost entirely under the influence

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of atmospheric air. Dustiness exceeds MAC several the respective production: copper, lead, nickel, zinc,
times, and toxic gases, vapors and aerosols are usu- cadmium, etc. This leads most often to acute and/or
ally at the limits of the MAC, although at times they chronic intoxications characteristic of the particular
may exceed 2 to 5 times. The work of conveyor driv- non-ferrous metal yield.
ers, dosers, operators of various control instruments Copper production. The raw material from
has an energy consumption of 10.46 kJ/min, the dos- which copper is produced is an enriched copper
ers are within the average workload and the other concentrate, which contains impurities such as sul-
workers are characterized by considerable physical fur (containing up to 40%), silicon, iron, zinc, alumi-
load (especially in some technological operations). num, nickel, lead and the like.
The health effects are: the danger of overheating The main stages of the process are: preparation
with infrared radiation - to heat stroke, increased of stock (dosing and mixing of components); frying
colds, traumatism, diseases of the peripheral nerve the stock until it gets scum; melting and obtaining
and bone-muscular systems. of copper matte; converter obtaining black copper;
The main hygienic measures in the iron metal- raffinate to obtain anode copper.
lurgy are: proper organization of aeration by special The stock frying is carried out at 800-850 ° C in
roof structures - Pond type and openings for natural different types of frying ovens, with a "boiling lay-
ventilation (usually in the upper parts of the walls); air er" furnace are advantage in technical and hygienic
showers on workplaces with intensive heat dissipa- terms. Sulfur dioxide-containing gases separated
tion; water curtains - especially in front of the open- there are discharged to form sulfuric acid.
ings of the furnaces; reducing airflows with moving The scum concentrate obtained after frying, con-
curtains - especially at the entrance/exit openings of sists of copper oxides, FeO and copper sulphide. The
the premises; sealing and encapsulation of intensive next operation is to melt the scum in an electric fur-
dust excretion facilities and processes; implement- nace at ~ 1500 ° C. When melting, two liquid phases
ing automation and remote control wherever possi- are formed: copper matte - (an alloy of sulphides in
ble; regular wetting of the stock, including through which copper and other valuable components are
special irrigation systems; provision of efficient gen- concentrated) and slag (an alloy of oxides and sili-
eral and local ventilation facilities; regular cleaning cates that does not contain copper in usable quan-
of the planted dust, and of windows and artificial tities).
light sources with special solutions according to The extraction of raw copper from melted cop-
a suitable formulation; introducing scientifical- per matte is done in converters. Air or oxygen is sup-
ly-based work and rest regimes with the provision plied through the special openings of the converter,
of air-conditioned recreation rooms; mandatory use where the impurities burn or pass into the slag. The
of carefully selected personal protective equipment resulting black copper has a purity of 98-99%. Impu-
(especially for dust, toxic aerosols and noise); pro- rities are removed in subsequent technological op-
viding appropriate workwear, underwear and shoes; erations - firing or electrolytic refining. The refining
provision of professional protective meals - Type A of black copper is carried out in a flame-reflecting
diet (with products rich in essential amino acids, vi- furnace. The electrolytic refining of copper is carried
tamins C, B, A, milk, liquid foods and beverages, in- out in the electrolysis workshop in special matrix
cluding low salt content mineral water); mandatory baths with a high acid solution. Electrolytic refining
and regular conduct of preliminary and periodical of copper as a by-product produces copper sulphate
medical examinations; dispensary of diseaseds and - the most important technical salt of copper.
rehabilitation when needed, etc. One of the leading disadvantages of the working
environment of the predominant number of work
17.3.2. NON-FERROUS METALLURGY places the microclimate. A number of technological
processes (frying, melting, converting black copper)
After extraction of the ore containing non-fer- are accompanied by the release of large amounts of
rous metals (copper, lead, zinc, cadmium, etc.), it is heat, a significant part of which is released as infra-
enriched in special flotation plants to a concentrate red radiation. Powerful sources of thermal radiation
from which the respective non-ferrous metals are are heated furnaces, open flame, molten metal, cop-
extracted. per matte and slag. The highest in the copper pro-
In non-ferrous metallurgy, the main production duction is the temperatures of the workplaces when
processes and deficiencies are similar to those in pouring the copper matte and slag. Heat radiation
the iron and steel industry. A significant difference, (mainly as infrared radiation) when handling molten
which also affects the health consequences, is the metals is of considerable intensity - reaches 4900-
additional presence of specific hazards typical of 8400 W/m2. At the same time, the air temperature

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is significantly lower in working places, standing at sulfur dioxide, the highest concentrations being
5-10 m from the intensive heat sources, especially found in the roasting of copper matte and the slag
during the cold period of the year (temperatures and in the blowing of the converter (Table 1). Of-
below + 5 ° C are measured). Thus, the microclimate ten the feedstocks contain other impurities besides
can be defined as mosaic. Typical for shops with in- copper, so compounds of arsenic, zinc and lead are
tensive thermal power is the high airflow rate up to found in the air in the working environment.
2-2.5 m/s. Adverse health effects for workers. The most
Some processes (eg. stocking of ore materials) common are upper respiratory tract diseases (and as
are carried out in open halls and the microclimate a result of irritating action of sulfur gases), peripher-
in them is directly dependent on the macroclimate. al nervous system, digestive and cardiovascular sys-
An exception to these microclimate features are tem. There is a risk of overheating and heat stroke, as
the electrolytic refining workshops - they are con- well as grave burns.
stant and tend to overheat during both seasons of Production of lead. The raw materials for lead
the year. are sulphide lead ores containing the mineral galen-
Noise exceeds hygienic norms of about 1/3 of it - PbS. Enriched lead concentrates, containing 40-
workplaces (for furnaces, converters, compressors, 70% lead are used.
etc.) and its intensity reaches 100 dB. The first technological operation is agglomerat-
Copper mines are concerned with "dusty" pro- ing roasting, where at 700-900 ° C the lead sulphides
duction. In the initial stages of the process the dust are converted to oxides to produce a burned, ag-
is separated by crushing the starting materials and glomerated material. Melting of the agglomerate is
when the crushed material of the conveyor belts is carried out in a stock furnace in a mixture with coke
poured. Most of the dust in the copper production at a temperature of up to 1500 ° C, where lead oxides
is with the roasting and the electric casting. Smelt- are reduced to metal. The stock casting produces:
ing, conversion, roasting of slag and copper matte black lead containing copper, gold, silver and other
creates highly dispersed condensation aerosols impurities, copper matte (alloy of metal sulphides)
(90-98% of the particulate is less than 1 μm). Dust and slag (a non-metal oxide alloy often containing
formed in different technological stages contains a lot of zinc).
mainly iron (15-27%), copper (10-13%), silica (36- The purification of black lead is usually carried
53%), zinc (3-7%) - Table. 1. out by the so-called fire refining. Refining aims at re-
The presence of stream air in the working envi- moving impurities (copper, arsenic, zinc, silver, etc.)
ronment causes dust to enter into naturally sedi- and increasing the lead content to levels that meet
mentary dust, which increases dustiness and keeps the technical standards. Refinery plants are housed
it high also in technological operations where no in a separate building. The cleaning is carried out in
intense dust separation is characteristic. Due to the refinery boilers at a temperature of 500-600 ° C. The
high sulfur content of the raw materials, the main high-quality refined lead spills into molds using spe-
toxicochemical factor in the copper production is cial machines at a temperature of 450-500 ° C.

Tab. 1. Major technological processes, raw materials and pollutants in copper production *

Technological process Raw materials Аir pollutants Industrial waste

Receipt of copper Copper ore, water, chemical Sulphur dioxide, dust Flotation wastewater, waste
concentrate reagents, sealants containing arsenic, antimony, containing limestone and
cadmium, lead, mercury and quartz
zinc

Extracting honey Copper concentrate, sulfuric Heaps of concentrated acid

acid solution
Melting Copper concentrate, flux A slurry containing the iron
sulfide and silicon
Sulphur dioxide, dust A slurry containing the iron
Convert Matte flux containing arsenic, antimony, sulfide and silicon
cadmium, lead, mercury
and zinc A slurry containing impurities
Electrolytic refining Copper, sulfuric acid such as gold, silver, arsenic,
antimony, cadmium, lead,
mercury, nickel and others.

* In P. Roto, 1998

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 OCCUPATIONAL MEDICINE
And in the production of lead the microclimate the upper respiratory tract. Severe forms of lead-
is one of the leading adverse factors of the work en- like intoxication have recently been relatively rare,
vironment. The characteristic of microclimatic factor and light forms have been shown to be character-
as a whole is similar to that of the copper produc- istic of biochemical abnormalities without clinical
tion. The working places in the agglomeration fur- symptoms. The main reasons for chronic profes-
naces have measured air temperatures of 34-36 ° C sional intoxications are the various disturbances of
at a relative humidity of 75-88%; The thermal radia- the technological processes and deficiencies of the
tion of these workplaces is intense - 1700-2300 W/ ventilation equipment. Also, the toxic action of lead
m2. Similar are the thermal conditions of the melt of is enhanced by the impact of overheating microcli-
the agglomerate, and the intensity of thermal radia- mate and heavy physical work.
tion in the refining plants is generally lowered. Zinc production. The zinc content in the polym-
The noise characteristic is similar to that of cop- etal ores is 2-12%, which is why they are enriched
per. by the selective flotation method. The obtained zinc
Most dust of lead production are released in the concentrate contains 40-70% zinc, as well as impuri-
agglomeration (loading, roasting, stocking) and ties - sulfur (containing up to 30-37%), lead, copper,
melting workshops. The dust dispersion is high - iron, cadmium etc.
90% of the dust particles are up to 5μm in size. High Zinc concentrates can be obtained by pyrome-
levels of lead and silica in dust require a strict system tallurgical or hydrometallurgical method. In the
of prophylactic measures. pyrometallurgical process, the zinc is obtained by
The main toxico-chemical hazards that deter- reduction with charcoal and retorts of pre-oxidized
mine the risk of occupational poisoning are lead or roasted ore. In the hydrometallurgical method,
aerosols. Their concentrations increase rapidly in the the zinc is recovered from its sulphate solutions by
processes of pouring matte and slag. When refining electrolysis. In the world, both methods are almost
from the exposed surfaces of the molten metal in the equally applied.
air of the working environment, besides lead aero- In both methods, the processing of the concen-
sols, lead and nitrogen oxides, aerosols of zinc and trate starts with roasting. The process is carried out
other metals are released; overall concentrations of by blowing air through a layer of concentrates at a
toxic substances in these plants are lower. In some temperature of 1200-1300 ° C. When roasting, gas-
cases, due to the fact that the outside air is also pol- es containing 4-6% sulfur dioxide are formed. In the
luted with lead aerosols (in the case of a failure of pyrometallurgical process, the next process is the
the ventilation system filters), the air exhausted by it distillation of zinc at a temperature of the mixture
may be a source of aerosols for contamination of the of the roasting concentrate and the coke 1250-1350
working environment. ° C. Zinc is reduced and evaporated; its vapors in a
Sulfur dioxide is one of the main pollutants in the mixture with carbon monoxide are passed to a con-
air and in lead production - mainly in agglomeration denser in which molten zinc forms at a temperature
roasting and in batch kilns, but concentrations are of 450-500 ° C. The zinc obtained by the distillation
significantly lower than copper production (Table 2). process contains 1 to 3% impurities (lead, iron, cad-
Adverse health effects for workers. Diseases of mium, copper, arsenic, etc.) and is therefore refined,
the digestive system are frequent (for the increased and is 99.995% pure.
incidence of this pathology the role of lead expo- In the hydrometallurgical production of zinc,
sure is considered proven), the nervous system and roasted concentrates are treated with hot sulfuric

Tab. 2. Major technological processes, raw materials and pollutants in lead production *

Technological process Raw materials Air pollutants Industrial waste

Agglomeration Lead ore, iron, limestone flux, Sulfur dioxide, dust
roasting coke, soda, dust, pyrite, zinc containing cadmium and
lead

Melting Lead agglomerate, coke Sulfur dioxide, dust Slag containing impurities
containing lead and such as zinc, iron, silicon and
cadmium lime, industrial sewage

Electrolytic refining Black, “raw” lead

* In P. Roto, 1998

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 LABOUR MEDICINE
acid solutions. In addition to the zinc, other impuri- tion dust, sulfur compounds and acid vapors cause
ties pass through the solution, so the sulfate solution diseases of the nasopharynx (mucosal hyperaemia,
is purified by partial hydrolysis. The purified solution rhinitis, perforation of the nasal septum). At work-
is subjected to electrolysis and the zinc is deposited ers from electrolysis shops are more likely notice
on the cathode. The operating temperature is 30-36 chronic pharyngitis - a subatrophic form. Roasted
° C and, to maintain, the electrolyte is cooled. Leaves and electrolysis shops have notice signs of diffuse
of cathode zinc are removed manually and melted pneumosclerosis.
into induction furnaces, after which the metal spills Production of cadmium. The cadmium is de-
into molds. rived from secondary products in the processing of
In the frying of the zinc concentrate work plac- zinc, lead-zinc and copper-zinc ores: copper-cadmi-
es a warming microclimate is formed - during the um cake, dust of roasting and distilling furnaces, etc.
warm season of the year, the air temperature reach- The cadmium content in them is from 0.2-0.5% to
es 28-34 ° C at a relative humidity of 44-61% and an 6-7%.
air velocity of 0.4-1.7m/s. The heat radiation of these From these products the cadmium is extracted
work places is 800-1700 W/m2. At work places at in- (sometimes after oxidative roasting) by treatment
duction furnaces where cathode zinc is melted, the with dilute sulfuric acid. The resulting cadmium
air temperature is 28-34 ° C at a relative humidity of sponge like containing up to 80% cadmium, up to
42-57% and a thermal radiation up to 1400 W/m2. 20% zinc, as well as iron and copper, is subjected to
Electrolysis shops are characterized by the high rela- oxidation by staying in a warm and humid room for
tive humidity of the air - 80-98%. 2-3 weeks, then cadmium is extracted with dilute
Due to the fact that the processed stocks and the sulfuric acid. In some cases, the cadmium sponge
materials used in the technological process contain like is not oxidized but treated directly with 75%
many chemical elements, a number of pollutants are sulfuric acid. The cadmium precipitates from the
included in the air in the working environment- zinc, cadmium sulfate solutions by electrolysis of cadmi-
copper, lead, arsenic, cadmium, sulfur compounds um cathodes. The cathode electrolyte cadmium, af-
sulfuric acid, chlorine, etc. (Table 3). Large concen- ter drying, is melted in iron boilers under a layer of
trations of H2SO4, HCL, ZnSO4, ZnCl2, SO2, as well as molten sodium hydroxide at a temperature of 330-
arsenic, lead, chlorine, manganese are measured in 350 ° C and is cast in the form of rods or moulds.
the respiratory area of electrolysis shops. The peculiarities of the technological process of
Some of the manufacturing operations (especial- cadmium production determine the unfavorably
ly manual removal of leaves from cathode zinc) are acting toxico-chemical noxae. Highest concentra-
associated with a significant heavy labour. tions of cadmium in the air in the working environ-
Adverse health effects for workers. Inhala- ment were measured during melting and pouring
tion of zinc vapors in concentrations above 15 mg/ into the moulds. The most toxic are cadmium oxide
m3 may result in the so-called "founder fever". In and its inorganic compounds - nitrate, sulfite, chlo-
humans, chronic zinc intoxications have not been ride and others. Relatively less toxic are its insoluble
established. There is evidence of an increased inci- compounds - tellurium, sulfur and others. In case of
dence of chromosomal abnormalities in the leuko- cadmium production in the air of the working envi-
cytes of workers exposed to zinc. ronment, sulfur compounds also occur.
The incidence of respiratory, digestive (gastri- Adverse health effects for workers. Cadmium
tis and ulcer disease), cardiovascular and nervous and its compounds have a polytropic action. Toxic
system diseases is increased. The effects of produc- effects of cadmium can be subjectively manifested

Tab. 3. Basic technological processes, raw materials and pollutants in zinc production *

Technological process Raw materials Air pollutants Industrial waste

Roasting Zinc ore, coke Sulfur dioxide, dust Industrial wastewater
containing zinc and lead
Extraction of zinc Roasted concentrate, sulfuric Industrial wastewater
acid, limestone containing sulfuric acid
Purification Sulfuric solution, zinc dust Wastewater containing
sulfuric acid
Electrolysis Cleaned sulfuric solution,
colloidal additives

* In P. Roto, 1998

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by weakness, nasal bleeding, increased excitability Adverse health effects for workers. In the man-
and tiredness. Upon objective investigation, inflam- ufacture of non-ferrous alloys, the most common
matory changes of the upper respiratory tract and pathology is respiratory diseases (pharyngitis, na-
the bronchi, emphysema, hippo- to anosmia, hep- sopharyngitis and laryngitis, bronchitis, including
atitis, bone pain and deforming osteoarthritis, de- asthmatic). The diseases of the musculoskeletal sys-
creased calcium content in the urine, etc. tem (myofascites, radiculitis), of the digestive system
Cadmium accumulates in the body and remains (gastritis, gastroenteritis), of the skin and subcutane-
prolonged in the kidneys. Typical symptoms of pro- ous tissues, chronic intoxications are also frequent.
longed exposure to low cadmium concentrations The main hygienic and prophylactic measures
are bronchitis, emphysema and proteinuria due to in the non-ferrous metallurgy can be summarized
renal tubular damage. Additionally, anemia, hyper- in several main directions. Anti-dusting and toxic
tension, functional liver disorders and bone damage substances include effective sealing of crushing,
develop. grinding, transporting and packing of concentrates,
Manufacture of non-ferrous metal alloys. Cur- stocks, scums and agglomerates and of the mouth
rently, production is carried out in two ways - from of the shaft furnace; efficient local gas extraction
primary non-ferrous metals by melting or burning in the above-mentioned technological processes,
at high temperatures or from secondary metals by as well as in the openings for the slags, matte and
melting industrial waste. The technology of produc- metal discharge and for the outflow chutes and the
tion in the application of one or the other ways in buckets for carrying them; full technological use of
principle does not differ, which allows it to be treat- the released dust and gas waste products; the crea-
ed uniformly from a hygienic point of view. tion by mechanical ventilation of areas of clean air in
The production of non-ferrous alloys includes the the most polluted areas; efficient board ventilation
following basic technological processes: preparation of electrolytic baths and generalized ventilation of
of stock, melting in reflective or electric furnaces at electrolysis shops; sealing and pneumatic and me-
a temperature of 500-1800 ° C and spillage of the chanical removal of powdery materials from the
metal. Refining fluxes consisting of fluorine, chlo- black lead refining pots; regular periodic wet clean-
rine, carbon and other components are used in the ing of the floors and walls of the workshops and on
melting. The alloys obtained in the melting shops the territory of the enterprises, and with industrial
are introduced into the processing units in the form vacuums of the machines and equipment. In order
of balls, which melt in electro-induction furnaces to prevent the adverse impact of the production
and spill to produce certain details (foundry alloys) microclimate, it is necessary to effectively heat insu-
or undergo hot or cold mechanical machining. lation and shield all heat sources (coking machines,
Due to the presence of powerful heat sources, the furnaces, converters, etc.) and to provide a properly
microclimate and the production of non-ferrous al- organized aeration. Fighting noise includes silenc-
loys are generally characterized as overheating. ing of sources of intense noise (mills, screens, crush-
Sources of noise and general vibrations are ers, compressors, etc.) and in time compaction leak-
packet-presses, sorting conveyors, electro-induc- ages of compressed gases.
tion furnaces, spill machines. Workers wear appropriate special workwear,
A leading unfavourable factor in this type of gloves and shoes and personal protective equip-
production is the production dust containing sub- ment, to strictly adhere to personal hygiene require-
stances with fibrogenic, toxic and carcinogenic ef- ments. For workers in non-ferrous metallurgy, it is
fects. The main sources of dust are transport facili- necessary to provide professional food and drinking
ties, especially in the places where the raw materials regime with appropriate mineral water - ex. contact
are shipped from one equipment to another, dryers, with lead is provided with diet B and supplementa-
melting furnaces, floating machines. The physico- tion of chelators such as pectin, and for workers in
chemical properties of the powder are highly dis- contact with manganese, mercury, cadmium is pro-
persed (disintegration or condensation) - dust par- vided diet B. For workers in contact with sulfur gases
ticles up to 2 μm make up 65-70% of disintegrating it is necessary to set mouth rinsing stations with 1%
aerosols and more than 95% of condensation. As a sodium bicarbonate solution and alkali inhalations.
rule, dust particles contain oxides of the chemical el- Pay attention to the professional selection of work-
ements in the alloy (aluminum, copper, zinc, silicon). ers and periodic prophylactic examinations are car-
Often in the air of the working environment there ried out regularly.
are products of destruction of organic butyric sub-
stances (polycyclic aromatic hydrocarbons, acrolein,
carbon monoxide).

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REFERENCES

1. Boyadjiev Vl., Hygiene and Prof. Diseases, Sofia, Med. and phys., 1990. (in bul.)
2. Burgess W. A., Recognition of Health Hazards in Industry, 2 ed. New York, 1995
3. Domnin, S.G. Hygiene of labour in non ferrous metalurrgy. "Manual of labour hygiene." ed. N.F. Izmer-
ov, Moscow, Medicine, 1987, V. 2, pp. 103-187. (in russ.)
4. Environmental Protection Agency. Profile of the Nonferrous Metals Industry. EPA / 310-R-95-010. Wash-
ington, DC: ERA, 1995
5. Goldsmith A.H. A. Coll. Health hazards from oil, soot and metals at a hot forging operation. I Ind. Hyg.
Assos. J. 37: 217-226,1976
6. International Iron and Steel Institute, Steel for Sustainable Development. Brussels: IISI, 1997
7. Masaitis J. Iron and Steel Industry. Ed. J. M. Stellmann, Encyclopedia of Occ. Healt a. Safety, ILO, Gene-
wa, V. 4, 1998, 73,2-73,8.
8. Office of Population Censuses and Surveys. Occ. Healt: Decennial Supplement. Series AS N10 London.
Her Majesty's Stationery Office, 1995
9. Ontario Metal Finishing Industry Pollution Prevention Project. Metal Finishing Pollution Prevention
Guide Ottawa. Environment Canada, Water Technology International. Sheridan Environmental Technology
Institute, 1995
10. Ploshtakov P., G. Bobev, A. Dzhezdiev. Labour hygiene in non-ferrous metallurgy. In Hygiene of the
main branches of production, ed. M. Lukanov, Sofia, Med. and phys., 1987, pp. 88-100. (in bul.)
11. Roto P. Copper, Lead and Zinc Smelting and Refining, In. Encyclopaedia of Occupational Health and
Safety, 4th ed., Stellmann J.M. (Ed.), International Labour Office Geneva, 1998, 82.4-82.7.

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N. Gincheva

17.4 MECHANICAL ENGINEERING

The mechanical engineering is industry with a casting in permanent, reusable forms - metal cast
multiprofile activities. Includes heavy machine build- (iron, steel) - metal mould or by refractory materials
ing - production of machines for power engineering, - with a capacity of several hundred to tens of thou-
vehicles and equipment (automotive, shipbuilding, sands of castings. The most common casting meth-
etc.), production of agricultural machinery, produc- od is in single mold casting molds - more than 2/3 of
tion of electric trucks and engine-driven trucks, elec- cast castings.
tric hoists, metal cutting machines. The production of The main stages in the foundry production
electric motors, accumulators, instrumentation, the are: 1) Preparation of the molding soil and mak-
production of computing and organizational equip- ing shapes and hearts; 2) Burden preparation and
ment are also included in the mechanical engineer- melting of metal; 3) Pouring metal into shapes; 4)
ing industry. Due to the heterogeneous production, Demoulding, knocking and clearing (burnishing)
the technological processes in machine-building deformation of castings (Figure 1).
enterprises are diverse. For the greater part of the Working environment conditions.
heavy mechanical engineering, however, one-type The traditional method of casting in single-sided
production processes, machines and equipment are molds is the main source of unfavorable factors in
used that create similar labour-hygienic conditions. the working environment.
The main production stages carried out sequential- The main hazardous and harmful factors of
ly in the machine-building industry include: prepa- production are: high or low temperature and high
ration of semi-finished products and their primary speed of air movement, intense infrared radiation,
processing in foundry and forging-press industries; separation of the working area of silicoso-danger-
mechanical treatment, including the precision siz- ous dust and harmful chemical substances, pres-
ing of the product, mounting of the manufactured ence of intense noise and vibrations, a large num-
articles to obtain the machines and the equipment. ber of manual operations, danger of burning. All of
The final stages are painting and metallic coating of these factors can be in different combinations and
individual parts or whole products to prevent cor- degrees of application in the different stages of the
rosion and good commercial appearance of the fin- foundry production.
ished product. Microclimate. Foundry production is known as
"hot" production - with significant heat load (high
17.4.1. FOUNDRY PRODUCTION technological temperature and IR radiation). With
massive heat input, only separate stages of the pro-
Foundry production is a combination of techno- cess are connected, while others run at normal and
logical processes for the production of molten metal even low temperatures. The "hot" stages include
castings in specially prepared forms. The tradition- melting and casting of metal, demoulding of cast-
al foundry cast materials are iron, steel, non-ferrous ings, drying of mould and hearts, repair of a furnace.
metals and their alloys. The rest, related to the preparation of casting earth,
Initially, drawings of the future product are made, mold and heart shaping, the cleaning of castings re-
and patterns (mostly wooden) corresponding to the fer to cold operations. Half of the heat emitted by a
outer shape and internal configuration of the fin- furnace (external oven temperature - 200 ° C) is IR
ished product are made on the drawings of the con- radiated and the other is equal - by convection and
struction. Casting forms represent the outer wall of combustion gases. Intense heat (regardless of air
the article. They also contain an axial - core portion temperature) occurs during the filling of the mixer,
defining the dimensions of the inner cavities of the the pots, during transport, when the metal is poured
article. The way of casting is determined according into the molds, when the slag is removed. Less radia-
to the type of the molds and is carried out in two tion from castings. The air temperature in the found-
types: casting in single (disintegrating) forms - ries, in moderate climates, on hot days can reach the
mostly molding or melting molds (from wax, coat- founder work places to 35-38 ° C and the infrared
ed with refractory composition) - precision casting; radiation at the moment of the molten metal dis-

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Pattern section Core shop section Preparatory to
- Preparation of - Preparation of cores molding section
models for forms - Annealing of cores - Preparation of mold
- Preparation of - Drying of cores earth
models for cores - Placing of cores in - Preparation of core
the forms mixtures

Foundry division
- Preparation of molds
- Pouring of metal Regeneration
- Removing castings from molds of foundry earth
- Hammering - removal of cores

Division foundry furnaces Section cleaning castings

- Loading - Hammering
- Melting - Crushing-jet purification
- Discharging of slag - Hydro-jet purification
- Refining - Grinding
- Metal pouring - Cut roughnesses, growths
- Cleaning furnnaces, repair castings with electric welding

Fig. 1. Sequence of technological operations in a cast-iron workshop

charge - at 2 m distance - up to 6 kW/m2, at 5 m - 4.3- is in the case of grinders, medium frequency - for
3.3 kW/m2. At the "casting dislodge" workplace, the the molding machine, low frequency - for koller-
temperature is 30-35 ° C. In casting processes with gangs. When compressing the molding earth with
"in scattered casting", it is also possible that "cold" a molding machine, by vibration with dislodge grid
technological processes occur under overheating generate general vibrations with a norms excess for
conditions. At individual workplaces and at differ- frequencies above 8 Hz (8-63 Hz). With the impact
ent stages in foundry production, when located in a of local vibrations, are molding operations using
common hall, there are sharp differences in air tem- pneumatic rammering and the cleaning of piston
perature (especially during the cold season), which castings with hand grinder are used to measure an
leads to the occurrence of significant air currents over-integral vibration value for the 125-1000 Hz fre-
(dynamic microclimate). quency range.
Noise and vibration. In most of the processes in Dust. The specificity of the technological process
the foundry production, an intensive noise exceed- in the foundry industry determines high dust expo-
ing 85 dB/A is generated. Such features include the sure. All stages are related to the use (transport and
following: in the ground preparation - grinding, mix- processing) of powdery materials, and also by dust
ing and sifting of the molding earth and clay (coarse extraction operations: preparation and filling fur-
grain, ball mills, sieves); in molding - sealing of the naces with burden, preparation of molding mixture
molding earth in single casting molds using a vi- and making of foundry molds and hearts, casting
bro-stand, manual pneumatic rammer; when clean- and cleaning of castings, repair fireproof in furnaces.
ing - by purification the casting of shaking grille, by For obtaining 1 t of casting, between 60 and 130 t of
shot-stream or by hydro-cleaning in chambers, in molding earth is processed. Powder concentrations
rotating drums, by grinding of stationary grinder in the air vary depending on the mechanization of
aggregates or by manual pneumatic grinder. In all production processes and the effectiveness of an-
these operations noise levels of 90 to 110-120 dB/A ti-dusting equipment. Concentration of total dust
peak values were measured. However, the back- exceeds MAC in some productions up to 50 times.
ground noise at the foundry is about 80 dB/A, with Highest concentrations of dust - up to tens of mg /
the noise being broad-spectrum. High frequency m3 are observed in the earthworks - in sand dryers,

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soil mixers; in the foundry compartment - when the of a shot-stream or hydro-cleaner. Earth-preparator
castings are dislodged, when cleansed with artificial (delivery of forming ingredients) is a profession with
grinders disks. In most cases small particles with a moderate physical stress and strain. This process
size of 3-5 μm (over 90%) predominate in the dust. in the large foundries is mechanized and partially
The dust in the foundries is not homogeneous by automated while in the small ones it is carried out
chemical composition. Contains particles of sand, manually (with hand trucks) at a considerable dis-
clay, carbon, iron oxide (released from purification tance (200-300 m) and in a forced working posture.
casting of so-called scale) and many others compo- The labour process takes place under the conditions
nents of the molding mixture. The adverse effect of of a cooling microclimate during the winter and
the powder is mainly determined by its high disper- transition seasons, over-noise, general vibrations
sion and free crystalline SiO2 content ranging from 2 and considerable dustiness. The work of the form-
to 30-50%. When heating the molding earth during worker, manually preparing the forms, with partial
casting (1500°C), crystalline modifications of SiO2 mechanization of the processes, is characterized by
may also occur - crystobalite and tridemite, which severe physical (dynamic and static) loading and
are believed to be higher in fibrogenicity. In some moderate stress. The work is related to intermittent
operations, other powders are released - the talc effects of intense noise, local or general vibrations
used to easily separate the model from the casting (when sealing the form of a vibrator), often with a
mold enters the working environment both when cooling microclimate. Chemical exposure is also
applying the model and releasing the model. Pure possible if the drying of the molds is not done in fur-
metal aerosols - iron, manganese, chromium, etc. naces but by drying the earth with methanol. Most
are formed during the cleaning of the castings with of the operations are carried out in a forced working
oxygen or electric welding, with a size of less than posture, blowing low to the floor. The co-remaker
1 μm, also separating SiO2. Wood dust is produced performs similar as form-worker operations, but
when making wooden models with hand-held me- all are executed manually. A large part of the op-
chanical or electro-tools. erations are in a forced posture. It works under the
Chemical compounds. The use of chemical sub- conditions of a dynamic cooling microclimate and
stances and polymer materials in the preparation significant chemical exposure by the supporters. La-
and processing of foundry molds, as well as the ad- bour is determined by moderate physical stress and
dition of various fluxes and alloys in the furnaces, tension. The burdener transports the burden (cast
the use of solid, liquid and gaseous fuels leads to the iron, foundry waste, old iron or rolled metal, blocks,
introduction of various chemical compounds into steel, coke, lime, etc.) to a furnace, by hand, by hand-
the air. These are: polycondensation metal aerosols or electric truck - for small foundries, and trucks,
(lead, manganese, copper, zinc, chromium, beryl- wagons - for the big ones. Depending on the type of
lium) and gases (carbon monoxide, sulfur dioxide, foundry and the mechanization of labour, the pro-
carbon dioxide); In the preparation and drying of fession is characterized by moderate or severe phys-
foundry molds and hearts - phenol, formaldehyde, ical stress and moderate tension. It works most often
acrolein, ammonia, carbon monoxide, polycyclic in the conditions of a dynamic microclimate, during
aromatic hydrocarbons (benz (a) pyrene), furfuryl the cold period - cooling (part of the work shift goes
alcohol, diphenylmethyl diisocyanate, urea, sodium outdoors). The work is accompanied by the effects
silicate, carbon dioxide; during casting - products of of intense noise and dustiness. The founder (fur-
thermal and thermo- oxidation destruction of the nacer) performs two types of operations: the first is
supporters; in the destruction of oils - acrolein, car- related to the melting of the metal, the second one
bon monoxide, etc.; in the destruction of polymers - to the repair of the furnace. The work is moderate,
(self-hardening agents) - phenol, formaldehyde, for some operations - with heavy physical stress and
isocyanates, ammonia, nitrogen dioxide, carbon tension, in a forced posture. It works in a dynamic
monoxide, vapour of the resin catalysts - aromatic overheating microclimate environment, infrared
amines (based on pyridine). Of all the highest con- and ultraviolet radiation, intense noise, local vibra-
centrations, carbon monoxide is defined - from 2 to tions, dust with a crystal. SiO2, chemical contam-
4 times above the MAC. inants - CO, SO2, polycondensation aerosols, and
Working process of major professional with a continuing danger of traumatism and burn-
groups. ing. The founder is primarily concerned with cast-
The main activities in a foundry workshop are ing the metal from the mixer into molds. In the small
performed by the following professions: earth-pre- foundries the casting is done mainly by hand, and
parator, formworker, heartmaker, burduner, founder, in the big ones - mechanized, with a crane. Work is
cleaner (crusher, grinder, electric-welder), operator associated with heavy physical stress and significant

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tension. It runs under conditions of overheating mi- of occupational diseases with dust etiology - chron-
croclimate - dynamic, high intensity of infrared radi- ic pulmonary bronchitis (often accompanied by em-
ation, noise, chemical pollutants emitted by thermal physema) and slight forms of pneumofibrosis. They
and thermo-oxidation destruction, upon contact of are mainly registered in form-workers and cleaners
the molten metal with the form mixture - CO, CO2, - grinders. Electric and oxygen-workers often expe-
formaldehyde, acrolein, phenol, isocyanates, furfuril rience pneumoconiosis - siderosis, as well as mixed
alcohol, sodium silicate. There is an increased risk of pneumoconiosis. Less often in the foundry produc-
burning, traumatism. The workers - cleaners, in the tion there are people suffering from vibrational dis-
case of non-mechanized dislodge of the molding ease (vasospastic vibration syndrome), mainly in the
earth from the castings with a hammer, a chopper, case of workers with pneumatic tools (pneumot-
a lever, have a heavy physical load and considerable ampers, pistols, grinders). The cases of "acute smog"
tension in a forced labour position. They work un- (CO and SO2) in founders and craners are single.
der high dust conditions with fine dust dispersion. Prevention of work.
It is possible to inhalate chemical products from the The fight against dusting involves: isolating
thermal decomposition of the resins, the oils includ- high-dusting processes through rational planning
ed in the molding and core mixture. It works under of the building - separating the individual stages
the influence of pulse noise of considerable intensi- into separate rooms; sealing of dust sources; pro-
ty. In the case of cleaners-grinders, dust exposure viding very good compaction of the cleaning cham-
also includes metallic powder and grinder abrasive bers; maximum mechanization of dust-related pro-
powder (usually aluminosilicate). A major adverse cesses; construction of local exhaust ventilation at
factor is the impact of intense constant noise and all dust disposal sites; manual pneumatic tools to
local vibrations. There is also an increased risk of clean the castings no-frequently use or with built-
traumatism and burns. Workers cleaners serving in ventilation devices; weekly cleaning of the floor
the shaking grid have exposure to general vibra- of the premises by removing the mold- and burn-
tions and intense noise with a discontinuous nature. ing earth; use of wet methods for sand regenera-
Those serving the chamber for shot-stream and tion from the work off molding mixture; in castings
hydro-cleaner and rotating drums are mainly ex- cleansing operations use PPE - dust mask, dust-tight,
posed to intense, intermittent noise. Their work is working garment, closed to the neck (in the case of
moderate physical stress and tension. a shot-streaming outside the camera - inflatable
The electric-welders work is characterized by protective clothing); periodic medical examinations
moderate physical stress and tension, often in a with a focus on respiratory function research.
forced labour position. It works under the influence In order to reduce the noise and the vibratory
of ultraviolet and infrared radiation and exposure of impact in the foundry production, it is mainly the
chemical pollutants - weld metal aerosols with fine architectural and construction solution of the work-
dispersion - less than 1 μm (iron, manganese, chro- shop, with isolation of the noisy machines and pro-
mium) and gases (CO, CO2, ozone, nitrogen oxides, cesses and of the vibration generating machines
hydrogen fluoride, etc.). in separate rooms, in addition to specific opera-
General and occupational morbidity. tions, specific measures are applied. For example,
Workers in the foundry production have a very when cleaning castings with removable grinders in
high incidence of morbidity with temporary inca- non-stationary workplaces, movable screens with
pacity for work. High loss of work is primarily due sound-absorbing walls are installed; systemic con-
to traumatism (domestic and labour). The greatest trol of the technical condition of the hand tools
number of accidents at work were registered by the - pneumotampers, grinders; good warming of the
furnacers and the founders, followed by form-work- rooms in which it is working in contact with local
ers, cleaners and oxygen/electric-welders. The most vibrations. Application of PPE: against noise - anti-
common is eye trauma. Other high-intensity diseas- phoning; against vibratory impact - vibrating gloves
es include respiratory diseases (acute and chronic), and anti-vibration shoes. Appropriate work regimen
muscular-skeletal system, peripheral nervous sys- - 10-15 min intervals of staff in quiet rooms as well
tem, cardiovascular system. Of the occupational dis- as periodic change of work operations. The medical
eases with the highest relative share are the diseas- prophylaxis of noise and vibration effects is related
es of the musculoskeletal apparatus (epicondylites, to professional medical selection and periodic med-
myo-tendinosis, humero-scarapular periarthritis), ical examinations; prophylactic physiotherapeutic
PNC diseases (polyneuropathies), neuralgia of the procedures in vibrations - hydroprocesses, massage,
auditory nerve, allergic diseases of the skin (contact UV-irradiation; protective nutrition - diet A.
dermatitis, eczema ). There is a significant incidence Reduction of the air pollution in the foundries

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with harmful vapors and gases is accomplished metal billets is manually (with a metal lever, pincers)
by creating maximum sealing and effective artifi- or mechanized - with a wire rod, a crane, a thruster/
cial mechanical ventilation; replacing used chem- pusher, a roller conveyor, etc. Forging or pressing is
ical compounds and materials with less toxic and preceded by the cleaning of the anvil and the forg-
dangerous - e.g. replacement of organic supporters ing die of dust (cast iron-iron oxides) most often
with less toxic inorganic - water glass, phosphatic, with compressed air. The billet is placed manually or
ferro-phosphatic. Mixing, forming, metal discharg- mechanically. Pneumatic and mechanical hammers,
ing, dismoulding and cleaning to provide local as- hydraulic, friction and mechanical drive presses are
piration. Given the high risk of acute poisoning with used.
CO2, medical prophylaxis includes: provision of arti- Working environment conditions.
ficial respiration equipment as well as resuscitation Microclimate. Forging production refers to
equipment and training of operators for their ap- "warm" production, convection heat output of more
plication in case of emergency rescue work; work than 23 W/m3. During hot days and with ineffective
on dangerous areas only in pairs of workers. Com- ventilation, air temperatures in the working area are
pliance with medical contraindications for work on measured at 40-43 ° C but more often at 34-36 ° C.
releasing chemicals and periodic medical control. Important is the high intensity of infrared radiation.
To improve the microclimate in the foundries, For large forging units the intensity is 3.35-20.93
a number of measures are applied. Radical and kJ.cm-2.min-1, with an impact duration of 50-85% of
sanitary-technical include: sealing of convective the work shift. Relative humidity in these industries
heat sources; for protection against IR during cast- is low - 15-50%. The airflow rate varies depending on
ing, pouring and cooling of the castings, shielding, the size of the workshops, fluctuating in the summer
good thermal insulation of the heated aggregates from 0.4 to 1.0 m/s, and during the cold period (in
and transport lines, rapid removal of the heated pro- case of poor closing of doors) it can reach up to 6
duction outside the production premises, ensuring m/s.
efficient local and general exchanging ventilation, Noise and vibration. During work of heavy
remote control, etc. forging pneumatic hammers, mainly low-frequen-
More important hygienic and medical-prophy- cy noise and general vibrations are generated. The
lactic measures are: furnishing of rest rooms with a measured sound pressure values are between 95
normal microclimate; appropriate working and rest and 115 dB/A, reaching 125 dB/A. For different types
regime; providing a suitable drinking regime; or- of press, the noise is lower in intensity - between 83
ganizing protective nutrition - diet A; use of special and 104 dB/A. The noise of the forge-press equip-
overalls for heat protection; eye protection from IR ment is predominantly impacted, impulsive, with
rays - use of special filter glasses; preliminary profes- high peak values. Aerodynamic noise is generated
sional selection, observing the contraindications for when the compressed air discharge valves are oper-
accepting work in high temperature conditions and ated at hammers and presses. The general vibrations
IR radiation. generated during hammer/press work are above the
norms for frequencies above 8 Hz.
17.4.2. FORGE-PRESS PRODUCTION Dust. In the forging works, the incoming dust in
the working area is in small quantities (below the
In the forging workshops, coarse articles of metal MAC). This is a metal powder of "scale" (iron oxides).
castings coming from the foundry or rolling mill are The largest amounts are released when cleaning the
made. The technological process provides for plastic anvil (blowing with compressed air).
deformation of metal billets with or without forging Chemical compounds. In forge- press produc-
in hot or cold state, under the impact of hammer- tion, air in the working environment is polluted by
ing machines or with single impact (presses, rollers). chemical compounds from the combustion of var-
Hammering is performed only on hot metal, while ious types of fuel in flame heaters. Carbon monox-
pressing can also be applied to cold metal. Forge- ide, carbon dioxide, sulfur dioxide, possibly acrolein,
press operations can be fully mechanized, but often smoke, soot and other products of thermal and ther-
executed manually. The sequential course of the mo-oxidation destruction of the fuel are released.
process is: preparation of the metal billets (eg pre- Concentrations are usually below the MAC, at the
cut of a certain size), preheating, forging or pressing, MAC level or 1.5-2 times the MAC.
cleaning of the article and control. Work process of the main professional groups.
The heating of the metal billets is carried out in The main professions are a hammerman and a press
heating furnaces (flame - burners, electric furnaces, operator. The work of both professional groups is
MF-MW induction). The loading/unloading of the similar. In the low-level mechanization of press in-

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dustries, most operations are performed manually. here are: providing a room for rest with an optimal
The weight of the billets is from 1 kg to 50-100 kg. microclimate; rational nutrition and drink regime;
The hammerman is under the influence of general work and rest regime. Workers must be provided
vibrations transformed in local by adherence to tool, with means of personal protection. Adherence to
which is above the norms. The execution of the basic medical contraindications for work in conditions of
operations in low-level workshops is also associated overheating, intense noise and vibration, and peri-
with a high static load on the musculoskeletal sys- odic medical control.
tem. During service of heating furnaces, hammers,
presses, workers are subjected simultaneously to 17.4.3. MECHANICAL MACHINING
high air temperature and radiant heat. It is possible OF METALS
to increase the body temperature, and the amount
of the separated sweat during an 8-hour shift is be- Mechanical machining of all kinds of mechanical
tween 1.5 and 5 l. Depending on the mechanization machining of metal - turning, sharpening, milling,
and the type of forging-press production, the ener- drilling, threading, grinding. Machine tools are used,
gy consumption of the workers is between 12.56- which, depending on the operations performed, are
25.12 kJ/min. The physical load is ranked at the limit mainly divided into "cutting blades" (lathes, mills,
of moderate to severe. Nervous-mental stress is also drills) and "abrasive" (grinding machines, polishing
high due to continuous work with a high risk of me- machines, sharpening machines). Nowadays, mod-
chanical injuries and burns. ern methods of cold processing - electrochemical,
General and occupational morbidity. The inca- plasma technology, electro-erosion treatment are
pacity with temporary disability is very high. In its also used in mechanical engineering. The raw mate-
structure, with the highest proportion being colds rial (metal) used is metal preforms from foundry and
of the respiratory system, diseases of the skele- forging presses or cut metal (metal blocks of metal-
tal-muscular and peripheral nervous system, trau- lurgy). The abrasive disks used in this manufacture
matism (most often burns), diseases of the gastro- most often consist of corundum (Al2O3) or carborun-
intestinal tract (enteritis) and of the cardiovascular dum (SiC), with a ceramic binder (including quartz
system. Occupational diseases with high incidence sand) containing free crystalline SiO2 to 2-3.5%. When
are overload of diseases of skeletal-muscular system working on both types of equipment, due to high
and peripheral nervous system (vegetative polyneu- speeds and mechanical friction, heat is intensively
ropathy), occupational hearing disabilities. formed. This requires the use of lubricating coolant
Prevention of work. These include: a rational (LC) for cooling the cutting tool and the metal.
architectural and building solution of the produc- New processes of cold metal processing are ap-
tion buildings and the deployment of the equip- plied less frequently and only for special produc-
ment; choice of technological process, equipment tions. The chemico-mechanical method is based
and fuels with minimal detriment; mechanization on the use of a solution of acids, hydrogen peroxide
and automation of production processes; organiza- and triethanolamine (in chambers); the electro-
tion of effective ventilation; choice of suitable PPE. chemical method is based on the anodic dissolution
For example, one-storey buildings with large area in metal chambers of an electrolyte (sodium chlo-
and cubic capacity, with one-sided and one-way ride solution and sodium nitrite solution); the elec-
installation of the equipment (avoiding machine tro-erosion treatment is based on the occurrence
saturation), are built for the protection against over- of electrical discharges between the electrode and
heating microclimate in forge- presses production. the workpiece in a liquid dielectric medium (oil or
Aeration of production facilities is organized. Re- a mixture of kerosene oil), wherein at the discharge
place hot pressing with cold. To reduce heat gen- point the temperature is up to 5000-10,000°C.
eration, rational heat protection is built by thermal LCs are complex multi-component compositions
insulation of the walls and openings of the furnaces. consisting of various chemical compounds. They
Apply water cooling of the casing and the shelters usually contain a basic ingredient - 60-90% (oils,
of the furnaces and water curtains in front of them. polymers, surfactants, electrolytes) and additional
Local mechanical suction ventilation - umbrellas, additives (in low%) - emulsifiers, binders, anti-corro-
above the furnaces is built. Air showering is carried sion and antioxidants, antimicrobials, bacteriostats,
out by stationary and freely movable facilities. To im- Compositions (LC) are classified as: 1) oils; 2) emul-
prove the microclimate in the crane cabinets, ther- sifying; 3) synthetics; 4) semi-synthetics; 5) aqueous
moinsulation protection of the floor, walls, as well as solutions of electrolytes.
the placement of local air conditioners is provided. Additives include chemical compounds of var-
Of the hygienic-medical measures more important ious classes: sulfur, chlorine and phosphorus com-

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pounds, amines, alcohols, inorganic salts. ment regime and the LC regeneration, the micro-
With prolonged use of LCs in machines (often climate characteristics, the number of microor-
from 1-6 months), they are a good medium for the ganisms in the LC can reach significant levels - for
development of bacteria and fungi - oily aerosols example, in oil - 102-105 in ml, emulsion - 104-108 in
damaged 50-100%. ml, synthetic - 104-107 in ml, the number of patho-
Working environment conditions. genic microbes moving from 10 to 103 in ml. Without
The microclimate in the mechanical workshops inclusion in the composition of the LC of bactericid-
is most often within the limits of the norms and is al additives, the number of saprophytes increases
not a hygienic problem. Typically, it has lower airflow greatly. Trichosporon, Graphium, Fuzarium, Asper-
speeds - to static. In the large modern workshops gillus are defined as microscopic fungi.
equipped with automatic lines, with metal-cutting Labour process of the main professions. The
machines with a program-numeric device with dis- main professions in the mechanical workshops are
play, the rooms can be air-conditioned. turner, milling, grinding, hobel machines operators,
Processes of machining parts of different ma- operators of machines with program-numerical
chine tools are associated with noise generation. control and others. Their work is similar, they work
Usually the noise is medium and high frequency. under almost the same labour conditions. Manual
Some models of lathes with a digital programmer, machine servicing operations are light and medium
drills, dental machines, screwdriver machines gen- in physical loading but with significant psycho-sen-
erate noise under norms or an excess of 1-2 dB/A. sory stress. When servicing the machines, the work
High-frequency noise with an intensity of 95-98 is connected with lifting and transporting small
dB/A generates large grinding machines, up to 92 weights. Large parts and articles are placed on ma-
dB/A - dental machines with maximum sound pow- chines or mechanically carried - with cranes, hoists,
er in the 250-2000 Hz range. The noise in the me- manipulators, electric trucks. Modern metal cut-
chanical workshops is of continuous nature, with ting machines in the mass production of the same
constant, all-shift impact. type of parts are semi-automatic and automatic
No dust, but ships of different sizes are produced machines, aggregate machines with full or almost
for cutting machines. Airbrush-type machines have complete mechanization of operations, including
been measured for powder aerosols ranging from the machined part moving with automatic start and
several mg.m-3 to 45-50 mg.m-3. The powder is a fine- stopping of the machines. Operator functions are
ly dispersed aerosol with a mixed mineral-metallic limited to visual control on the display or on the con-
composition (20-40% - metal, 60 to 80% - mineral). trol panel. The commitment of the main professional
Contains in free quantities free crystalline SiO2 - groups for servicing the machine tools is significant
from 0.9% to 9.6%. The metallic component of the - from 60 to 82% of the working time. When servic-
powder depends on the type of metal to be treated, ing the universal hand held lathes, it is even great-
most commonly iron or iron oxide, aluminum, cop- er - 98%. The working posture is standing, very of-
per, etc. Some chromium, nickel, titanium, beryllium ten compulsion. Machine controls (buttons, levers,
are also released in the treatment of some alloyed pedals) are often non-ergonomics. The work done
steels with the metallic powder. requires constant high attention activity and good
Chemical substances enter the working envi- memory, the ability to concentrate. It is associated
ronment from finely dispersed LCs - steam-aerosol with a very heavy workload of the visual analyzer,
mixtures (95% of the aerosol is less than 5 μm). With especially in the case of hand-held machines. Very
prolonged use of LC, their starting composition may good coordination of the movements, high qualifi-
change due to metal particulate contamination (cat- cation and quick reactions are needed.
alytic action), products of thermal oxidation destruc- General and occupational morbidity. The per-
tion, evaporation of some components and partial sistence of the upper respiratory tract of the fine-
microbiological decomposition. High toxic and disperse vapor-gas-aerosol mixture of LC (mostly
dangerous products are formed, for example, In the irritant additives, bacterial aerosols and thermoox-
operation of electro- impulse and electro-erosion idative destruction products) disturbs the body's
machines. The released oily aerosols are in concen- protective barriers. This creates conditions for the
trations of 15 to 40 mg.m-3, soot - up to 22 mg.m-3, development of infectious processes in the respira-
CO - up to 30 mg.m-3, iron aerosol and iron oxides - tory system. In the structure of the morbidity with a
up to 6 mg.m -3, 3,4-BP - up to 17 mg.m-3 (the latter is high proportion of them, there are ACUAP, acute and
the result of heating the oil to thousands ˚С). chronic bronchitis, pneumonia. High frequency are
Depending on the chemical composition, the spastic bronchitis, allergic rhinitis and sinusitis. They
conditions of operation (storage), the metal treat- can also be directly associated with sensitization

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caused by the direct action of bacterial and chemical of the individual ingredients; sanitary- technical in-
allergens from the LC, as well as by the chromium, structions for the safe storage, transport and prepa-
nickel, and cobalt contained in the powder aerosol. ration of LC working solutions as well as instructions
Based on the resorption effect of certain com- for their use, cleaning and regeneration.
ponents of LC (saturated and unsaturated hydro- Personal hygiene and PPE: use of special work
carbons, amino-nitro compounds, etc.), vegeta- clothing, which prevents the penetration of the LC
tive-vascular type reactions (asthenic syndrome, into the skin; regular washing and processing of
angiospasms, hypertensive reactions) have been working clothes; bathing after work or after wetting;
reported in the workers. use of special detergents and protective creams;
However, the most commonly reported diseases safety glasses when working on non-insulated and
in workers are cutaneous - from the effects of LC non-screened machines; respirators and semi-masks
on the skin, especially mineral oils and emulsions. for abrasive machine operators. To reduce the
The chemical constituents of LC with local irritant noise impact: machine denoising; sound insulation;
action and contact allergens (chlorine-containing sound absorbing screens and barriers; technical
compounds, surfactants, ethanolamine, phenylen- maintenance; use of anti-phonics; work and rest re-
ediamines, benzylamines, aldehydes, chromium, gime. To reduce the weight and tension of labour:
nickel, etc.) further damage the skin and cause irri- machinery mechanization; ergonomic deployment
tative and allergic dermatitis. Also important for the of machinery controls and visual inspection; rooms
development of skin diseases is microtractility (from for short-term rest; natural, general and local artifi-
chips) at work. Bacterial allergens are referred to as cial lighting, according to norms.
a major link for the development of hyperkeratosis,
oil papillomas, chronic pigmentation of the skin. Mi- 17.4.4. ASSEMBLY PRODUCTION
croscopic funguses from the LC also play a role in
allergic reactions. The most commonly diagnosed In the assembly works, the main technological
skin diseases in workers are: oil folliculitis and "oil process is to collect, connect, assemble individual
acne"; allergic dermatitis; photodermatists; hyper- parts and details until a finished product (machine,
keratoses; papillomas (precanceroses); permanent aggregate, etc.) is obtained. Auxiliary (finishing) op-
pigmentation; dermatitis and onychomycosis. erations are: coating of metallic coatings, paints, var-
Production traumatism - mostly ocular - and nishes, lubricants for anti-corrosion protection and
hand wrists (finger injuries) from chips, cutting tools, good aesthetic appearance of the product. The last
etc. is also a great honor. step is a trial operation and a suitable packaging of
Potentially for workers there is a carcinogenic the product.
risk. This is predominantly in the case of skin con- Assembly in serial production is most often done
tact and inhalation of LC containing higher viscosity by part flow (conveyor) methods. The assembly of
oils; oils with more heavy aromatic hydrocarbons the individual units and the final assembly (fitting,
(3,4-BP); combined use of nitrites, nitrates, aliphatic joining, assembling) is done by hand tools - drills,
and aromatic amines in LC (formation of N-nitrosoa- screws, hydraulic presses for bending, welding ma-
mines); containing chromium, nickel, cobalt. chines, etc. For the transport of heavier and big-
Prevention of work. ger parts is used mechanized intra-shop transport
Sanitary- technical and technological means: - chain conveyors, transporters, telphers, bridge
complete isolation/shielding of the working part of cranes, electric trucks and others.
the equipment and provision of local aspiration for Specific technological processes in the assembly
removal of the separable vapor-gas-aerosol mixture production, which carry a higher professional risk are:
of LC. Securing a block (shutdown of the machine welding, metal coating and painting of the products.
and LC delivery) when lifting the hiding facilities; Welding. In the most frequently used thermal
Installation of chip refractories and chip-shifters, methods it is done by joining the metal parts by
fences, shields, screens. Mechanized collection and means of localized heating and melting. There are
removal of chips; Introducing electropark or elec- other more modern methods - the so-called "cold
tro-impulse sharpening of the cutting tool to avoid welding" (eg. ultrasonic welding). The thermal weld-
eye trauma; equipment of mechanical workshops ing methods include: arc, gas, electron beam, laser
with modern automatic assemblies. and plasma welding. Thermo-mechanical: electri-
Sanitary-hygiene: replacement of highly tox- cal contact (spot) welding, high-frequency welding
ic and dangerous LCs and additives with less toxic (contact and induction), vacuum diffusion welding,
and dangerous for health; hygienic standardization can also be referred to these methods. The most im-
of the LC based on the toxicological characteristics portant are arc, gas and contact welding.

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The electric arc welding uses the volt arc (6000 solvents (gasoline, trichlorethylene), alkaline solu-
°C). It works with special devices (manually, maybe tions, detergents.
robots) powered by direct or alternating current. In case of electrolysis, a breakdown of the process
Melting (steel) and non-melting (tungsten) elec- mode (increase in voltage, current strength, electro-
trodes are used. For the quality of the welds, coated lyte concentration and temperature) can cause a vi-
melting electrodes are used. It contains substances olent release of hydrogen (gas bubbles), entraining
necessary for the sustainable combustion of the arc part of the electrolyte solution and products formed
to create gas and slag protection of the metal from in result of chemical reactions in the bath. It is also
the air and also substances with alloying function to possible to remove hydrogen cyanide by mixing
improve the quality of the molten metal. The coating alkaline electrolyte with cyanide compounds and
composition includes: alloying agents - ferroalloys strong acids.
(ferro-manganese, ferrochromium, ferrosilicon, fer- Painting and varnishing. It is carried out in a
rotitanium); gaseous materials (marble, magnesite, certain sequence, including: surface preparation -
etc.); slag-forming materials (fluorine compounds, mechanical cleaning (from roughs, rust, oxides) with
carbonates); arc stabilizers (silicates, quartz, spat, hand or mechanized tools (metal brushes, grinder,
nefelin). In order to isolate the arc and molten metal crushing jet, etc.) and chemical cleaning (degreasing
from the air, gas protection is provided - supplying with alkaline solutions, organic solvents, detergents
inert gas (argon, nitrogen, helium, carbon dioxide) or staining with inorganic acid solutions); priming -
to the welding zone. casting of lead or zinc-containing primers dissolved
In contact point welding, the parts are joined in in organic solvents (hand-brushed, jet or pneumatic
separate points by pressing against the electrodes in chambers); filling - smoothing the surfaces (filling
(non-melting). Depending on the type of welded the roughness with nitrocellulose or oil kits); grind-
metals, the contact portion of the electrical current ing - mechanical or manual; painting/varnishing -
becomes plastic or melts and, as a result of the com- painting and varnishing, most often pneumatically
pression, the metals are joined together. by spraying with extruders (in 70%) or electrostati-
Oxygen or air and gaseous fuel (most common- cally; drying in hot air circulation chambers, induc-
ly acetylene, but also hydrogen, propane, a pro- tion or infrared dryers.
pane-butane mixture) are used for gas welding. Working environment conditions. In the
They are fed into the welding torch and mixed be- course of assembly, they are specific for each stage.
fore they are ignited in the nozzle. The high tem- When connecting, assembly of the parts, the lead-
perature (above 450 ° C) melts the metal surfaces at ing production factor is the noise-vibrating (using
the points where they are to be joined. When using manual instrumentation, intra-department trans-
a weld metal rod (a lower melting point metal), the portation). The impact is periodic. The noise is high
bonded metals only heat (do not melt). frequency with the highest intensity when working
Metal cover. The most commonly applied pro- with a nut-runner and drilling of parts (95-100 dB/A),
tective metal coatings are nickel, chromium, zinc, in manual grinding - (88 dB/A). When grinding, drill-
copper, cadmium. The following metal-coating ing is about 80 dB/A, and when moving conveyors
methods are used with great industrial application: - between 80-82 dB/A. In handheld instruments,
galvanoplasty, metallisation, dipping of metal prod- local vibrations exceed the norms in the range of
ucts in a molten metal bath, industrial tinning. The 32-250 Hz, with peak values at 32 and 63 Hz. The
electroplating method is most often used. On it, a working in welding, the metal coating and the paint
thin layer of a protective metal is deposited on the and varnish conditions are disadvantageous and
surface of the article, emitting an electrolyte solu- dangerous. In all three operations, labour-hygiene
tion under the influence of a constant electric cur- problems are mainly the result of airborne intake
rent. This process is carried out in special galvanic of metallic aerosols and gases and vapors of chem-
baths filled with aqueous solutions of acid salts ical compounds. In the arc welding, the weldable
(nickel sulphate, copper sulphate, zinc sulphate) or aerosol (condensed metal vapor) released is from
complex alcaline salts (cyanic compounds) of zinc, the electrode coatings and from the molten metal
copper, cadmium, aluminum, and silver. In advance of the welded surfaces. It is highly dispersed - up
the surface of the product is cleaned mechanically, to 98% of the particles have a diameter less than 1
chemically and chemico- mechanically. Crushing jet μm (0.01-0.6). Contains iron oxides and impurities
purification, grinding, polishing, ultrasonic scouring, - manganese compounds, hexavalent chromium,
etching using strong inorganic acids (hydrochloric, nickel, vanadium, molybdenum and others. The aer-
nitric, sulfuric) with subsequent neutralization are osol concentrations in the range of 5 to 12 mg.m-3
used. They are chemically degreased with organic have been measured in open-air welding, and in

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Tab. 1. Characterization of the chemical factor of the working environment in arc welding

Content of the compounds

Type
emission products concentration in mg.m -3
carbon dioxide 2000-6000
carbon monoxide 10-40
External * nitrous oxide 2.5-4.0
arc nitrogen dioxide 0.5-3.0
welding manganese aerosols 0.1-0.2
iron aerosols 1.2-2.2
lead aerosols 0.02-0.2
carbon dioxide 6000-8000
External **
carbon monoxide 3-5.0
welding
nitrous oxide 0.5-1.5
electrodes
nitrogen dioxide 0.3-0.5
"Vejen"
manganese aerosols 0.3-0.8
iron aerosols 3.0-12.0
carbon dioxide 46000-55000
carbon monoxide 120-180.0
Indoors ** nitrous oxide 12-16.0
welding nitrogen dioxide 3-6.0
in boiler manganese aerosols 0.6-0.7
iron aerosols 0.2-1.2
lead aerosols 0.05-0.06
* By D. Tsvetkov, 1990 - CT 72a of the Center for Hygiene
** By Tsvetkov D., 1990 - CT 143of the Center of Hygiene

closed and semi-closed spaces ranging from 100 to ious chemical compounds are introduced - mainly
250 mg.m-3. Extreme hazards and toxicities are the aerosols of hydrochloric, nitric, sulfuric, phosphoric
vapors and gases generated by thermal decomposi- acid, sodium, chromium, nickel, cyanide, etc. (Table
tion of materials (fluorine compounds) or as a result 2).
of the photochemical action of ultraviolet radiation In lacquer-painting work, the preparation of
on air gases (carbon monoxide, nitrous pentoxide, the metal surface - the mechanical cleaning, is as-
nitrogen dioxide, nitrogen oxide, ozone) . Concen- sociated with the removal of dust (roughly and
trations of these materials are by external welding fine-grained) and rust removal - iron oxides, and in
around the MAC or up to 1.5 times the MAC, where- case of dry grinding after priming and plating - lead
as in case of semiautomatic welding, the excess is compounds. Fine grinding also produces iron oxide,
repeated several times - up to ten times (Table 1). however, in insignificant concentrations - 0.25-0.7
In the welding works there is a combined effect of mg.m-3, while in crude grinding - the concentrations
chemical exposure and the effects of radiant ener- are high - 8.0-9.7 - 13.1 mg.m-3. Lead concentrations
gy - ultraviolet, infrared, as well as rays from the vis- - from 0.02 to 0.45 mg.m-3 are reported for pneumat-
ible area. The intensity of the infrared radiation var- ic application of lead-based primers. In the case of
ies according to different technical parameters and spray painting solutions in an aspiration chamber,
the mass of the heated metal and varies within the organic solvents were found in concentrations of
range of 100 to 2450 W.m2. For ultraviolet radiation around the MAC or slightly exceeded: amylacetate
a total spectral density is given at a distance of 1 m (190-215 mg.m-3), acetone (200-250 mg.m-3), turpen-
from the welding area - 0.4-162 W.m2. tine (180-300 mg.m-3), gasoline (75-150 mg.m-3), bu-
The working conditions of the gas welding are tanol (600 mg.m-3), toluene (83-275 mg.m-3), styrene
similar to those of the electric arc welding. Here, (12-15 mg.m-3). Larger concentrations are measured
however, there is less intensity of radiant energy, when drying dyed articles and ineffective ventila-
and the air pollution with carbon monoxide and ni- tion.
trogens is more pronounced. Due to the production Labour process in the main professions. The
of acetylene from carbide, which is sometimes con- main professions in the assembly workshops are:
taminated with phosphorus and arsenic, the high fitters, locksmiths, welders, spraying-painters, gal-
toxical gases phosphorus - and arsenic hydrogen vanotechnics. In the labour characteristic of all the
can form. groups mentioned, a large part has manual oper-
Depending on the stage of the metal-coating ations performed with different, most often pneu-
process in the air of the working environment, var- matic tools. Fitters collect, assemble, or fit individual

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Tab. 2 *. Characterization of the chemical factor of the working environment with metal coating

Content of compounds
Stage
released substances concentration in mg.m-3
chlorine 0.5-1.0
hydrochloric acid 0.3-0.5; 5-10.0
Preparation of metal sulfuric acid 3.0-3.8
surface chemical cleaning sulfur trioxide 4.0-7.0
sulfur dioxide 10.0-15.0
nitric acid 2.0-3.0
nitrogen oxides 2.0-3.0
Degreasing: gasoline 200.0-600.0
- Org. solvents hydrocarbons
- a mixture of sodium hydroxide, sodium hydroxide 22-32.0; 4-6.0
sodium carbonate phosphates traces – 0.25; 0.1-0.5; 1-1.5
and sodium phosphate sodium fluoride 0.7-3.0
Coating with gold cyanides 0.01-0.02
Chroming chromic anhydride 0.03-0.09; 0.07-0.15
Zink plating zink 10.0-15.0
* By К. Коchemidova, 1990

parts and details, make the necessary holes, screw, up to 25-50 kg (medium weight). Both technologies
rivet, reoiled, perform technical tests. All these op- require very good qualification and memory, high
erations are performed in a sitting or standing po- attention, moderate visual tension. Occupational
sition, but often also in a forced position. Occasion- risk is determined by the possibility of acute intoxi-
ally, weighing up to 50 and over 50 kg is required. cations - in accidents (eg. with cyanides), by remote
The physical load of the fitters is characterized as effects using electrolytes with an allergenic and car-
medium-heavy, the work is free-rhythm. However, cinogenic effect (chromium, nickel). Electrotraumas
conveyor assembly is another widely used meth- are also possible. The work of the extruder-painter
od, characterized by: rhythm, fragmentation and depends on the type of technology used, the degree
uniformity of operations, with repeated repetitions of mechanization and the automation of the pro-
leading to motor and psycho-sensory monotony. cess. In non-mechanized dyeing processes, manual
The work of the fitters requires high attention, good operations are in the course of the entire produc-
visual memory, spatial orientation, responsibility. tion cycle. The working posture is standing, in some
Occupational risk is related to the possibility of acci- cases forced, often with long static positions of the
dents at work. The work of electric welders is char- body. Production operations are associated with a
acterized by standing and very often with a forced significant load on small arm muscles (multiple re-
working position requiring a static position of the petitive monotonous movements with a small vol-
arms and shoulder girdle. Often these operations ume) and static shoulder girdle load. The work is re-
are for 40-80% of the shift. Work is also associated lated to the physical load in carrying materials and
with physical load - lifting/moving parts (character- details and is of medium weight. Nervous-sensory
ized as medium heavy). The visual tension is signifi- stress is moderate - constant attention is required,
cant. High attention, good memory, accuracy, high significant visual analyzer tension, accuracy, good
responsibility is required. It is associated with motor qualification. Respiratory and skin contact with or-
monotony with free rhythm of labour. Occupational ganic solvents determines the high professional risk
risk is also determined by the possibility of electro- of acute and chronic intoxications due to spraying of
trauma. Galvanotechnics in modern metal coating lacquer-painter solutions.
departments, with complete mechanization and General and occupational morbidity. High-fre-
automation lines, perform the function of operators quency at fitters are the diseases of overt6ension of
with predominantly nerve-sensing and nerve-men- the locomotory system, of the PNS, which dominate
tal load. In the old galvanic units the work is con- the structure of occupational morbidity. Less fre-
nected with many manual operations. The work is quent cases of vibrational disease with local vibra-
done in a standing position, in a free rhythm and tions are reported. In electrical welders, the struc-
is connected with continuous movement. When ture of occupational morbidity is mainly formed by
loading/unloading the parts, the work is also asso- chronic respiratory diseases (pneumoconiosis of
ciated with a physical load - manual carrying a load the type of siderosis or sidero-silicosis and chronic

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 LABOUR MEDICINE
bronchitis), from overtension of the locomotory sys- er; changing the belt speed according to the change
tem, PNS, cases of chronic manganese intoxication of capacity; providing ergonomic working furniture;
(manganoconiosis). Prolonged exposure to infra- work and rest regime, etc.
red and ultraviolet radiation may lead to cataract Arc welding: implementation of automatic
development. Typical acute occupational disease is welding processes (robots); standardization of weld-
photoophthalmia (ophthalmia electrica). UV-burns ing materials - reduced to the content of toxic com-
of unprotected skin have also been observed. The ponents in the coating of electrodes; welding under
acute professional diseases is also related to metal local aspiration protection with a capture efficien-
fever when welding articles containing copper, zinc, cy of not less than 90% for stationary devices and
and magnesium. In case of gas welding, acute and 75% for mobile; stationary work places be equipped
chronic poisoning with nitrogen oxides, phosphine with screens to protect against radiant energy; for
and arsine (in the preparation of acetylene) is pos- stationary welding of small and medium parts, with
sible. High frequency in galvano-technics includes the use of protective gases to provide aspiration
diseases of the irritant effect on mucous membranes cabins; to reduce the reflection of UV radiation, to
and the skin of excreted vapors from acids and bases: paint the walls of the rooms with zinc oxide include
upper respiratory catarrh (acute and chronic) - rhini- paint; use of PPE - protective masks with filters or
tis, pharyngitis, laryngitis, bronchitis; conjunctivitis, hose gas masks with air supply at welding in closed
tooth enamel destruction. Contact with chromium or semi-closed compartments; use of safety shields,
salts, especially chromium trioxide, also shows sig- helmets and glasses with protective light filter lens-
nificant damage to the UAP and especially to the es; provision of special workwear, gloves and shoes
nose mucosa (to necrosis of the nasal mucosa, ul- to avoid burns and electrotraumas; provision of on-
cers, perforation of the cartilage of the nasal septum board, inflow-suction, local ventilation for the re-
- currently the pathology is rarely found). Chronic moval of released chemicals and additional flow of
bronchitis, chronic pneumonia, asthmatic bronchitis general exchange ventilation for galvanic baths; use
are common here. Skin diseases (eczema, dermatitis) in galvanic bath compartments and chemical clean-
are also a major frequency of the action of chromi- ing of acid resistant floor coverings and wall linings;
um, nickel, dicyanoacetate and contact with organic replacement of organic solvents as degreasers with
solvents. By labour traumatism with high frequency synthetic detergents; Improvement of the technol-
is chemical burns with acids and bases. In case of ogy with exclusion and replacement of highly toxic
accidents and ineffective ventilation acute intoxica- metal salts in the composition of electrolytes with
tions with the used electrolytes and organic solvents less toxic; creation of automated flow lines with re-
are possible, and in galvanization - metal fever. mote control; providing special workwear - rubber
In spayer-painters the cases of high-frequency boots, aprons and gloves, glasses and filtering gas
there are diseases of over tension of the LS, of the masks. Using protective and greased skin creams.
PNS. Less commonly, acute and chronic intoxica- Lacquer-painting work: standardization of the
tions with lead (lead minium), diluents and organ- composition of varnishes and paints; exclusion of
ic solvents (inhalation and skin contact) occur. The toxic components (chlorinated hydrocarbons, ben-
contact with dust (metallic, polymeric) emitted by zene, methanol, etc.); replacing the tin lead with
mechanical cleaning, dry grinding, polishing is the iron; replacing organic solvents based on aromatic
cause of chronic bronchitis. In the structure of occu- hydrocarbons with less toxic and dangerous; re-
pational morbidity, the diseases of the skin (derma- placement of organic solvents as degreasers with
titis, eczema) are also a result of contact with dilu- synthetic detergents; performing pneumatic (spray)
ents and organic solvents. painting in pressurized chambers with powerful lo-
Prevention of work. The healing measures for cal suction and general inflow-suction ventilation;
the installation itself concern the use of pneumatic providing continuous mechanized and automated
tools and the conveyor working method. It is rec- flow lines for cleaning, degreasing, washing and
ommended to use: nut-drivers whose noise param- drying the details; use of modern methods of ap-
eters do not exceed the norms; technical control plying the painting solutions (electrostatic painting,
and regular technical support; using tools equipped airless painting method, etc.); in the case of pneu-
with vibration absorbing elements at the handle. matic painting, provision of effective insulating PPE,
In the conveyor assembly, to avoid monotony, it is with mechanical injection of fresh air, special work
required: to combined operations - to be able to clothes, gloves, a panoramic glass mask or hermetic
change and to manipulate several operations per glasses; protective and greasy skin creams.
day; considering the speed of movement of the con-
veyor belt with the capabilities of the average work-

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 OCCUPATIONAL MEDICINE
REFERENCES

1. Alexeyev S.V., B.R. Usenko - Hygiene of labour in Mechanical Engineering. In Hygiene of Labour, Med-
icine, Moscow, 1988, pp. 428-448. (in russ.)
2. CIS, 78-696 Measurement of hand-arm vibration levels, caused by chipping hammers of two designs.
Redwood R.A., K.P.Beale, A.S. Wiseman. In Annals of Occupational Hygiene (Oxford) Dec. 1977, 20/4, 369-
373.
3. CIS, 81-532 Health aspects of the foundry industry - Bibliography (Ind. Health Foundation, Inc. - 5231
Center av. Pitsburgh), 1980.
4. Gandev V., L. Vasileva-Todorova. - Labour hygiene in the machine building industry. In Hygiene of
main branches of production, ed. M. Lukanov, Med. and phys., Sofia, 1978, pp. 101-140. (in bul.)
5. Goldsmith A.H., K.W. Vorpahl, K.A. French, P.T. Jordan. Health hazards from oil, soot and metals at a
hot forging operation. I am. Ind. Hyg. Assos. J., 1976, 37, 217-226.
6. Gorban L.N., G.I. Eutushenko, B.M. Kireev, L.A. Naumova, L.A. Serebryany. - Labour hygiene in the
mechanical engineering. In Manual of Labour hygiene V. II, ed. N.F. Izmerov, Medicine, Moscow, 1987, pp.
187-214. (in russ.)
7. Johnson A.W., C.Y. Moira, L. Mac Lean, E.M. Atkins. Respiratory abnormalities amongst workers in
the iron and steel industry, in Brit. J. Ind. Med., 1985, 42, 94-100.
8. Kundyev Y.I., I.M. Trahtenberg, G.B. Porutzki, N.G. Ivanov, G.P. Rojkovska. In Hygiene and toxicol-
ogy of lubricating and cooling liquids, Health, Kiev1982, 120 p. (in russ.)
9. Mirer F.E., Metal Processing and Metal Working Industry. In Encyclopaedia of Occupational Health and
Safety, ed. J.M. Stellman, 1998, vol. III, 4th ed. ILO, Geneva, 82.13-82.41.
10. Taylor J.S. Dermatoses associated with metal at working fluids. In Proceedings. Second International
Conference, Chikago, Illinois. Institute of Technology Research, 1979, 239.
11. Welter E.S. Manufacturing exposure to coolant-lubricants. J. of Occup. Med., Aug. 1978, 20/8, 535538.

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N. Gincheva

17.5 CHEMICAL INDUSTRY

The production of chemical industry can be in- of filters, planned and emergency repair works, etc.
corporated into three major groups: products of The most commonly used equipment is: dis-
basic inorganic and organic synthesis; semi-fin- integrators, mills, crushers, screens, vibrators, sep-
ished products derived from basic chemical prod- arators, dryers, towers, reactors, furnaces, receivers,
ucts; finished chemical products obtained from the heat exchangers, baths, centrifuges, filters, crystal-
processing of semi-products. This production is ob- lizers, packing and filling aggregates; transport of
tained in the main and some other specific indus- powdered ingredients - augers, elevators and liquid
tries of the chemical industry (Table 1). ones - with pumps, compressors and others.
Despite the wide variety of chemical industries, Depending on the type of process, the required
technological processes have similar operations equipment can be installed in a closed building
(stages) performed with relatively uniform equip- (window, windowless) and can also be installed out-
ment. The main operations include: Preparatory doors on open ground (atmospheric installations)
- milling, sieving, separation, dosing, mixing and on the roof of one-story buildings. Large-clearance
transport of solid starting materials and pumping, appliances - columns, receivers, heat exchangers,
vacuum piping and filling of the reaction vessels reactors, etc., apparatuses operating at normal and
with liquid components; Flowing of basic chem- high pressure, under vacuum, high and low temper-
ical processes - oxidation, reduction, chlorina- atures, and more are usually installed outside the
tion, sulphurisation, nitration, amination, electro- buildings. Outdoor equipment is linked to a remote
chemical processes, etc.; Separation of chemical control and control system from the control room
compounds - distillation, filtration, centrifugation, (periodic monitoring of the separate apparatus by
extraction, crystallization, rectification, etc.; Final the servicing staff ). When highly toxic chemicals are
operations - drying, milling, prepacking and pack- used in the process, the hazardous steps are taken in
aging (in bags/sacks and filling of drums, tanks, etc.), separate isolated production facilities.
storage; Additional operations - making of techno- There are three main types of technological pro-
logical samples, replacement of catalysts, cleaning
Tab. 1. Chemical industry - production and products
PRODUCTION
PRODUCTION of other chemical industries
of basic chemical industries
1) Main products of inorganic synthesis - acids, bases,
1) Production of oil refining
salts, gases
2) Main products of organic synthesis - raw materials for the
2) Products of petroleum and coal - bitumen, asphalt,
preparation of plastics, synthetic resins, fibers, rubbers,
lubricants and additives, synthetic oils
alcohols, solvents and raw materials for detergents, dyes
and pigments

3) Fertilizers and pesticides 3) Car tires and other rubber technical goods, incl. shoes

4) Plastics, synthetic resins, synthetic rubber, cellulose

4) Products from plastic
and synthetic fibers
5) Chem. substances used as additives, emulsifiers, stabilizers,
antioxidants, flavorings, colorings, preservatives in food
5) Pharmaceutical
products, softeners and sterilizing agents for water

6) Chem. substances - corrosion inhibitors, for the treatment

6) Paints, lacquers, enamels of paper, wood, leather, fire-extinguishing agents and
the like.
7) Soaps, detergents, cosmetics, perfumes

8) Various chemical products - explosives, adhesives, inks,

photographic films and photopreparations

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 OCCUPATIONAL MEDICINE
cesses in chemical production: periodic; continuous; duction of acids and bases (inorganic synthesis); In
closed cycle production (waste-free technological organic synthesis - when cleaning the evaporator
process). In the periodic process there is no com- tubes of a reaction mixture (production of methyl-
plete mechanization and automation of production. mercaptopropionic aldehyde); in dismountling and
Many of the production operations are manual and cleaning of filters (manufacture of PAN-fibers).
labour-intensive - charging and emptying the appa- In most chemical processes, depending on the
ratus with liquid or powdered materials (raw materi- operations performed, even in the same room,
als, reaction mass, intermediate and end products), changes in concentrations are observed over time in
introducing catalysts, cleaning appliances. The the work shift. This type of impact also favors the ab-
frequent opening of the equipment creates an op- sence of permanent workplaces, the movement of
portunity for chemicals to enter the air, besides in- service personnel at different levels of equipment.
halation and skin contact of workers with chemical Different concentrations of chemical pollutants are
damages. With the periodicity of technological pro- also recorded in the different shifts in processes with
cesses characterize the production of pharmaceuti- mismatch of the shift cycle with the technological
cal preparations, of plastics products in low-produc- one - ex. emptying and cleaning of the reactors,
tion industries. cleaning of the filters takes place only in a fixed shift.
The continuous production process and the Relatively constant content of chemicals is observed
newer "closed-cycle-nowaste technology" are in the production processes with a stable techno-
beneficial in terms of their technological and hy- logical process, uniform equipment and permanent
gienic characteristics. They allow for mechanization work places - ex. plastics processing.
and automation of production, with remote control The chemical factor is multi-component and with
and control, which reduces residence in the work- a different aggregate state. Most commonly, in the
ing environment (only periodic control). In addition, air of the working environment, a vapor-gas-aero-
maintaining the persistence of the process parame- sol mixture, comprising starting, intermediate and
ters (temperature, pressure) preserves the hermetic end products, as well as substances formed by inter-
of the apparatus and reduces the risk of chemicals actions within the mixture or the result of thermal
being released. Continuous process and non-waste or thermooxidation destruction, is introduced. The
technologies are used to deal with highly toxic and chemical composition of the mixtures may remain
dangerous chemicals - ex. production of phospho- relatively constant and may change. In the air of the
rus compounds, isocyanates. Besides the mentioned working environment, besides chemical substances
types of technological processes of hygienic impor- with general-toxic action, substances with remote
tance are their characteristics at the level of the effects can also be introduced - mutagens, carcino-
maintained temperature (low and high tempera- gens, teratogens, etc. (e.g., paints for dyes, tar, soot,
ture), pressure (high, low pressure, in vacuum), PEH, chloroprene synth. rubber, etc.). Depending on
the inclusion of catalysts, etc. At high pressure, the density of the vapors and the specific weight of
there is a risk of chemical compounds being released the individual chemicals, they are unevenly distrib-
from leaks, accidents, explosions and fire. Catalytic uted in the space.
processes also carry an increased risk of manual pro- The air in the working environment is polluted
duction operations - opening of the chemical equip- with toxic dust. It is most often used in the initial and
ment for charging/removing the catalyst. Modern final stages of the technological process - preparato-
and hygienic conformation are chemical processes, ry and final operations (raw material processing and
running at low pressure or in vacuum, at low tem- drying, prepacking). Concentrations are determined
perature, automated (continuous) production. tens of times in excess of the MAC. Dust dispersion
Working environment conditions. is usually high - particles with dimensions less than
A leading unfavorable production factor is the 5 μm predominate. The possibility of adsorption of
chemical one. Air pollution is also in the production gases and vapours on the dust aerosols, which alters
premises and the open-air factory. The surface of the toxicity, is of hygienic importance.
the equipment, the vehicles, the ventilation equip- Physical factors, expressed and common to all
ment, the walls, the floor covering, the clothes and chemical industries, are the unfavorable weather
exposed parts of the workers' skin are also polluted. conditions and the noise-vibration factor. The mi-
The separation of chemicals depends on the leakage croclimate in high temperature process or exother-
of the equipment and communications - emergen- mic processes (lime, sulfuric acid, carbide, phospho-
cy or when performing certain manual operations rus, etc.) is characterized by air temperatures above
- eg. concentrations up to tens of times above the 30°C (reaching 35-36°C during the warm period).
MAC are recorded under planned repairs in the pro- Some manufacturing operations - filtering, centri-

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fuging, precipitation, flushing, etc., are associated the influence of low concentrations of compounds
with significant emission of water vapours and in- with non-specific symptoms. However, there is
creased room humidity. In open installations, the also a symptom that may be associated with dam-
thermal state is determined by the conditions typ- age to certain organs and systems (critical). Liver
ical of the geographical area. symptoms, for example, are detected by the use of
The noise-vibration factor is expressed in al- aliphatic halogenated hydrocarbons (mono- and
most all workplaces, and in the operating rooms. dichloromethane, carbon tetrachloride, vinyl chlo-
The main sources are the technological equipment ride, etc.), aromatic halogenated hydrocarbons
- mills, disintegrators, crushers, elevators, tumblers, (chlorinated naphthalenes), pesticides, and others.
vibrators, centrifuges, compressors, pumps. Gener- Symptoms from the kidneys occur with the effects
ated mechanical and shock noise has a high intensi- of cadmium, mercury, lead, arsenic, bismuth, carbon
ty of up to 100 dB/A norms. Fluid and aerodynamic tetrachloride, ethylene glycol, acetic acid; haemato-
noise, exceeding 4 to 10 dB/A, is generated in the logical abnormalities are observed when exposure
flow of liquids and gases in high-speed pipelines, to benzene and benzene derivatives, chlor-organic
operation of furnace burners and of coolers. pesticides, exposure to arsenic, arsine, lead, copper,
Labour process in the main professions. From aromatic amino and nitro compounds; neurasthenic
the technology staff, the main occupation is an ap- syndrome and psychotic syndromes occur when ali-
paratus-worker (operator) having controlling func- phatic and aromatic hydrocarbons and their deriva-
tions. The workplace is in control rooms, next to the tives (acetone, benzene, styrene, phenol, vinyl chlo-
control and operating panels. An assistant - opera- ride, etc.), carbon monoxide and the like are present.
tor, in addition to control functions of control meas- Several chemical noxiousnesses cause the devel-
uring instruments (MI), is involved about 60-80% of opment of certain reactions by the CVS - hypotonic
the time of active working time of the chemical ap- and hypertonic reactions, IHD. In the production and
paratuses. processing of certain plastics (polystyrene) and syn-
In the major process chemical industries with thetic fibers (polyamide - capron), female workers
continuous process, the main activity of the opera- found abnormalities in ovarian function and in the
tor is continuous monitoring of the CMI, which re- course of pregnancy and childbirth. At the highest
quires rapid visual perception, understanding and frequency these deviations are in the production of
processing of the information. The work is with a polystyrene and polyamide fibers - caprons articles.
slight physical load but with very high nervous-sen- The chemical industry with high professional risk is
sory and nervous-mental tension. In a stable techno- connected with chemical carcinogens - arsenic and
logical process and the operation of the equipment, compounds, benzene, benzidine, vinyl chloride,
their work is also markedly monotonous. High qual- chloromethyl, cyclic amines and others.
ification is required. The work of the assistant ap- Prevention of work. Concerning the leading un-
paratuses is more physical (medium weight work). favourable factor - chemical, prophylactic measures
The working posture is predominantly standing and include: choice of closed-cycle processes and use of
forced, less sitting. The work is also associated with waste-free technologies; use of low pressure or vac-
nervous-sensory tension with high responsibility. uum process processes; replacement of dry methods
Rapid reactions, good qualification and coordina- for the processing of solid or powdered starting ma-
tion of movements are required. They worked under terials with wet; excluding or limiting the content of
unfavorable weather conditions (outdoors, over- highly toxic harmful substances in the raw materials
heating), in environments with significant chemical and finished products; hygienic standardization (cer-
pollution and noise-vibration effects. tificate) of the raw materials and the final product;
General and occupational morbidity. Leading appropriate planning of the territory and produc-
groups in the structure of occupational morbidity tion facilities according to the technological process
in chemical industry workers are: diseases of the and maximum isolation of the dangerous processes;
musculoskeletal system by over tension; occupa- provision of artificial inflow-suction (general) me-
tional pulmonary diseases; allergic and skin-allergic chanical ventilation. Mounting of local aspirators.
diseases; hearing impairment. The relative part of Equipment lock when shutting down the aspiration.
diseases from chemical damages is low due to the Emergency ventilation device - general, with multi-
mechanization and automation of technological plicity of 8-10; instruction for performing repairs and
processes. Acute and chronic intoxications are rare emergency situations; Use of PPE to protect respira-
- acute intoxications occur mainly in emergency tory organs (helmets, respirators, insulating appara-
situations and in repairs. The most frequent are the tus, etc.), to protect eyes, exposed areas of the skin,
uncharacteristic forms of chronic intoxications in hand protection (eyeglasses, shields, gloves, boots

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 OCCUPATIONAL MEDICINE
and special workwear); provision of protective and examinations; organizing a gas-life-gard service for
professional nutrition depending on the chemical a first-aid and taking urgent measures.
substances used; preliminary and periodic medical

REFERENCES

1. Alexeyev S.V., V.P. Usenko. Hygiene of labour in chemical industry, in Hygiene of labour, Medicine,
Moscow, 1988, pp. 450-466. (in russ.)
2. Blagatin V.M., E.G. Dimova, U.L. Egorov, A.A. Kasparov. Hygiene of labour in chemical industry, in
Manual of Hygiene of labour, V. II, ed. N.F. Izmerov, Medicine, Moscow, 1987, pp. 234-270. (in russ.)
3. Ivanova St., Tz. Alexieva. Handbook on Occupational Diseases, Med. and phys., Sofia, 1986, 188 p. (in
bul.)
4. Kaloyanova F.P. Hygienic Toxicology - Special Part, Med. and phys., Sofia, 1983, pp. 7-236. (in bul.)
5. L. De Boer. Chemical Industry. In Encyclopaedia of Occupational Health and Safety, ed. J. M. Stellman,
1998, Vol. III, 4th Ed., ILO, Geneva, p. 77.2-79.11.
6. Lukanov M. Hygiene of basic branches of industry, Hygiene of labour in the chemical industry. Med.
and phys., Sofia, 1978, pp. 197-274. (in bul.)
7. Volkova Z.А. Hygiene of labour in production and processing of synthetic polymeric material. In Man-
ual of Hygiene of labour, V. II, ed. N.F. Izmerov, Medicine, Moscow, 1987, p. 310-342. (in russ.)
8. Volkova Z.A., N.P. Kokorev, E.N. Marchenko. In Hygiene of labour in chemical industry, Medicine,
Моscow, 1967, 403 p. (in russ.)
9. Zapryanov H. Distant effects of heavy metals. In Poisoning of heavy metals, ed. Vl. Boyadjiev and Tz.
Alexieva, Med. and phys., Sofia, 1990, pp. 97-99. (in bul.)

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N. Stamova

17.6 MANUFACTURE
TEXTILE INDUSTRY.
OF COTTON FABRICS

According to the type of processed raw materials The finished cloth is removed from the loom and
(cotton, wool, silk, flax, etc.) and the type of fabrics transferred to a special compartment for grading,
obtained, textile production has several branches. removing some defects, or scrapping defective sec-
Here, the issues of labour hygiene in one of the main tions and sizing. It is then sent for mechano-chemi-
proceedings - cotton textiles, due to its versatility, cal processing.
will be addressed, pointing out the differences typi- The mechano-chemical treatment of woven
cal of other branches. fabrics is a more complex and varied technology. It
The two main production stages in textile pro- takes place in the so-called finishing workshops -
duction have been adopted - spinning and weaving wet and dry. It consists of the following technologi-
are combined as "mechanical treatment of textile cal processes:
fibers". The other stages - bleaching, painting, fin- • sewing the finished fabrics to form a cloth
ishing and final processing of fabrics make up the tape with a length of 2000-4000 m;
"mechanic-chemical". • singeing the cloth tape in singeing machines
Technology of fiber machining (heavy metal surfaces are heated) to remove
The "spinning" stage consists of the following the fibers;
technological processes: • desizing (by soaking in bathtubs with water
• breaking and knocking of cotton in batter sec- and starch removal preparations applied to
tions, by sorting-batter aggregates; the substrate before weaving);
• dragging and scraping the cotton of the cot- • boiling of textile in hot sodium hydroxide
ton-combining machines machines and shap- solutions;
ing it in the form of a fluffy tape; • bleaching with chlorine preparations and
• drawing the fluffy tape into thinner strips by subsequent washing of the fabric with slightly
means of cross drifts; acidified water (boiling and bleaching can be
• extra retraction and initial tightening of the carried out as a continuous process in closed
cotton strip by flyer machines; aggregates);
• final pulling and tightening of the cotton strip • painting and stamping of fabrics; The painting
of spinning looms (rings). is carried out in different containers and ag-
The yarn produced is wound on spools which gregates (in hot or cold solutions) and stamp-
are referred to the next weaving stage of the same ing on special forming machines. Different
establishment or are dispatched to other weaving paints and pigments, as well as auxiliary rea-
industries. gents (acids, bases, salts, soaps, etc.) are used.
The "weaving" stage includes the technological After painting, the fabrics are flushed (hot and
processes: cold flushing) with water and dried in tumble
• rewinding the yarn by means of winding ma- dryers. After stamping, the fabrics are re-dried
chines; (according to their purpose and used paints
• warping, i.e. composition the base and wind- are used for "maturing" in special machines at
ing it onto a special shaft; high temperature, others go for washing and
• sizing the base in sizing baths with a solution flushing);
of starch, soaps, fats and antiseptics, drying in a • the final treatment of the fabrics consists of
drying drum and rewinding on a special drum; finishing, drying, smoothing, etc. Finishers are
• threading each thread from the base into the adhesive solutions of starch, dextrin, plasticiz-
corresponding remise hole and the corre- ers, etc., which give the necessary elasticity,
sponding reed plate; dampness, nice appearance, etc. of fabrics.
• preparation of weld by rewinding the yarn on Finished fabrics are sized, graded, rolled up and
special spools; stored.
• attaching the shaft to the base on the weav- Working environment conditions.
ing loom, loading the shuttle with a weld and In the mechanical machining of the fibers the
putting the loom into operation. combination of the technological requirements for
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performing quality spinning and weaving with the Level of noise in
Machine
technical characteristics of spinning machines and dB/А
weaving looms form specific working conditions. Devils 87
The microclimate in the spinning and weaving Cotton combining machines 84
Cotton strips 90
halls depends primarily on the requirements of the
Gross cuts 89
technology. As a result of the high friction between Ring machines 89
the moving parts of the machines, static electrici- Tighteners 92
ty arises, which charges the unprocessed fibers. In Spoolers 86
order to reduce it in the "spinning" in the rooms Warpers 85
should be maintained higher - the optimal from the Looms "Yantra" 100
technological point of view humidity 55-70%, and in Automatic looms "Covo" 101
Looms "Shyohner" 101
the "weaving" - 55 and 80%, according to the type
Looms "AT-101" 101
of fiber. Another characteristic peculiarity from the Looms „АT-125“ 99
technology and technical characteristics of the ma- Looms „Vinkenson“ 100
chinery and the production facilities are the forma- Looms „Stema“ 96
tion and release of a considerable amount of heat, Looms „Rosher“ 95
which leads to the formation of high air tempera- Looms „Pikanol 95
tures, especially during the hot seasons of the year. Jacquard looms 94
The low air velocities do not may play a significant Tab. 2. Noise characteristic of different textile machines
role in relieving the thermoregulation of workers (by S. Maximov)
under these conditions (Table 1).
The microclimate factor in spinning and weaving operation of the textile machines and are transmit-
halls is static. ted to the floor. Vertical vibrations are predominant,
Noise is one of the main disadvantages of me- their frequency is mostly low - 13-24 Hz, and the
chanical technology in textiles. The sound levels good fitting and foundation of the machines reduc-
measured at the workrooms of the various textile es them within hygienic norms.
factories depend on the number of machines in- Dust is also one of the main disadvantages in
stalled, their technical characteristics and condition, mechanical processing. In cotton and linen textile
the way of laying, etc., and almost always exceed plants, higher dust concentrations are produced,
the permissible hygienic norm. In a comparative as- whereas in wool and silk textiles they are lower.
pect, the noise in the weaving halls is higher than There have been observations that the use of syn-
the spinning noise. (Table 2). By nature, the noise is thetic materials in the textile industry also reduces
broadband - in spinning is more common medium the amount of dust aerosols.
and high frequency, and in weaving - mostly high The earlier the mechanical processing of the fi-
frequency. brous raw materials is found, the greater the dusti-
Silent looms generate lower sound levels - by ness is found in the work rooms - the highest dust
7-8 dB, but due to their large number in the rooms concentrations are found in the deviling, breaking,
(workshops), they can not make a significant im- dragging and scraping of the fibers (in batter and
provement in the overall noise background. cotton-combining sections), gradually decreasing in
The vibrations (general) are created during the spinning and weaving. The amount of dust gener-
Tab. 1. Measured mean values of microclimatic components in the spinning and weaving process
Room Cold seasons Warm seasons
Т Relative humidity V Т Relative humidity V
Stage "spinning"
°С % m/s °С % m/s
21,5- 0,07- 21,0- 0,02-
1.Bater sections 50-70 50-80
25,6 0,42 28,5 0,72
21,0- 0,04- 22,0- 0,02-
2.Carding sections 30-50 50-80
28,0 0,20 32,4 0,70
16,0- 20,0- 0,07-
3.Spining halls 30-75 0,04-0,32 55-80
29,3 32,8 0,46
Stage "weaving"
16,6- 0,01- 22,0- 0,03-
4.Warping sections 35-60 40-80
23,5 0,20 28,0 0,15
15,6- 0,03- 28,4- 0,12-
5.Sizing sections 32-88 49-70
23,6 0,20 32,0 0,30
20,0- 0,07- 20,0- 0,60-
6.Weaving halls 50-70 54-75
25,0 0,35 35,0 1,20

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ated also depends on the quality and the impurity rics. The desizing of the fabrics is associated with the
of the raw material, the nature of the treatment, the fermentation of the starch and the unpleasant tooth
technical characteristics of the machinery, the hu- odor (indole, skatole, mercaptans).
midity, the way of cleaning the machinery and the In bleaching pollution of the working environ-
premises, the availability and the efficiency of the ment with chlorine. Dyeing and stamping of fabrics
ventilation equipment. is associated with many and varied chemical sub-
The textile powder is polydisperse - with an av- stances.
erage particle size of 10-60 μm and falling into the The cotton textile is still used in the black aniline
rough dispersion powders. Textile powder particles painting Air pollution with aniline vapours can occur
less than 3 μm in length are not found, and particles during painting, drying and maturing Of the pro-
longer than 5000 μm are classified as textile fibers cessed fabrics (the black aniline dyeing has recently
(not in the "dust" category). been limited).
With the modern furnishings of textile enter- Sulfur dye painting has been spread, which is
prises with advanced textile machines, the dust related to the release of hydrogen sulphide in air
concentrations are within the permissible norms - during their preparation. Now days indigo- and ind-
deviations are only possible in the batter and cot- antren dyes find large application. They should also
ton-combining compartments due to the possible be reduced in advance to water-soluble leuko- com-
presence of silica. pounds, but this is done with sodium hydrosulfide,
There is also a significant bacterial and my- whereby it is possible to remove sulfur dioxide in a
cotic air pollution in textile factories linked to the minimal amount.
amount of dust. In sorting premises eg. 2000 colo- Very often used, so-called cold ("ice") dyeing with
nies/m3 of air were found, in the batter - 1.5 times diazo- dyes, a process associated with the release of
less, in spinning and weaving halls - 1300-4500 colo- nitrogen oxides, both in the preparation of the solu-
nies/m3; in most cases, it is about spore-forming and tion and in the treatment of the fabric. The release
Gram-negative rods, fungus - Penicillium, Aspergil- of nitrogen oxides, but in smaller quantities is also
lus, Mucor and others. The microbial insensitivity characteristic of the use of indigo- dyes. In the mech-
to flax processing is greater than that of cotton and anization and sealing of the painting apparatus and
wool processing. the presence of a suction ventilation installation, ni-
In mechanical and chemical processing (fin- trogen oxides are typically from 4 to 9 mg/m3.
ishing workshops), the microclimate is most of- Stamping the fabric is carried out most often
ten formed by unfavorable meteorological compo- with the same dyes mentioned above.
nents. At workplaces near the singeing machines, The use of acids in different types of painting is
hot dyeing, drying machines and drums, maturing accompanied by the release of their aerosols. The
machines, dressing and ironing of fabrics, etc., a lot most commonly used are acetic and sulfuric acids.
of heat is released in connection with the specific The use of finishers containing formaldehyde
technology. On the other hand, the use of many wet resins or other chemical compounds leads to the
processes (desizing, boiling, bleaching, painting, removal of formaldehyde, phenol and other toxic
continuous washing, flushing and drying of tissues) vapors and gases, both during dressing and in the
in open vessels and apparatus also creates high rela- subsequent technological operations - drying and
tive humidity resulting in overheating microclimate, ironing. This is especially true for the woollen textile.
especially during warm annual seasons. In cold sea- Labour process in the main professions.
sons, due to lower temperatures, up to 100% relative The spinning and weaving fabrication opera-
humidity and condensation of water vapor in the tions are highly mechanized and therefore the work
work rooms, and the formation of a cooling micro- of textile workers does not require any particular
climate can also occur. physical effort - energy expenditure averages up to
The noise of machinery and equipment in wet 10 kJ/min, but work is hight intensity during work
and finishing workshops is not as intense as com- shift. A typical feature of textile production is its
pared to noise in spinning and weaving halls. The feminization.
sound levels of the more noisy machines (drying The main and most prominent are the profes-
and washing machines, stamping machines, raised sional groups of carders, spinners and weavers
presses), are at 78-85 dB, and the exposure is shorter. engaged in the mechanical processing of fibers.
Toxic chemicals are most important to the work- Carders serve the cotton-combining machines
ing conditions of the mechano-chemical treatment. by placing and stopping the machines, monitoring
The carbon dioxide, carbon dioxide, and some alde- their work, controlling the proper collection and ar-
hydes are released during the singeing of the fab- rangement of the cardering belt in special contain-

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ers (pots). Their work takes place in the free standing most occupations, load and overload of upper limbs,
position of the body and in free rhythm. No heavy body and legs, high labour intensity, nervous sensory
weight is required, the load on the visual analyzer stress, shift mode, and more, determine occupational
is moderate and the work done does not place sig- risk both for the occurrence of occupational illnesses
nificant demands on the attention, the memory and and for high morbidity with temporary disability.
the qualifications of the workers. The long-time work in the case of intense high
The spinners carry out manipulations to: change noise has led to varying degrees of professional
the terminals and load the spinning looms; spinning; deafness in spinners and weavers.
timely and qualitative binding and spinning of the Exposure to high dust with textile dust is associat-
breaking threads; cleaning the rollers and the entire ed with the emergence of so-called byssinosis. There
machine from nap and others. One spinner usually are published data showing that 52% of workers in
serves several spinning looms. The working position the batter and cotton-combining premises after 10
of the body is free, standing or slightly bowed. Con- years of service experience signs of byssinosis, and
tinuous walking around the machines is necessary, 10% - advanced byssinosis with loss of working ca-
resulting in an average of 6-8 km for one shift. The op- pacity. In addition to chronic bronchitis, byssinosis is
eration of the spinners is also associated with a large accompanied by emphysema due to long-term inha-
number of hand movements (an average of 1000 lation and accumulation of textile dust, sometimes
movements per hour) with significant repeatabili- also asthma or asthmatic states - so-called hypersen-
ty (more than 300 times per shift) and accuracy and sitivity pneumonitis, hypersensitivity to cotton, and
speed is required. Working movements are usually other allergens in the textile powder aerosol.
performed in the maximum working area, accompa- The contact of the workers from the workshops
nied by static effort of the body. Continuous attention with the toxic substances can lead to the occurrence
and very good vision are required, resulting in signif- of acute and chronic intoxications, professional ec-
icant nervous-sensory intension. The mode of work zema and other allergic diseases, neoplasms and
has been shifted, including night shifts. others. The overload of the locomotor system is a
The working process of the weavers has the prerequisite for the occurrence of professional my-
same characteristics as the spinners. In this case, the ositis, tendomyositis, tendovaginitis, radiculitis, peri-
search for the breaking threads of the base is also ostitis and arthritis of the joints, with deformation of
associated with the bending of the body to a squat. the fingers, with formation of a flat foot, etc.
Serving several weaving looms requires high de- ITD among textile workers is characterized by
mands on coordinated activity of hand muscles and high intensity indicators. In its structure, colds, fe-
the visual analyzer. male genital organs and pregnancy complications,
The main professions in the finishing work- occupational accidents, gastrointestinal and cardio-
shops at the mechanical and chemical processing, vascular diseases, peripheral nervous system diseas-
are those of bleaches, painters, stampers, painting es, neuroses, and diseases of the locomotory system
workers, finishing workers, and others. The work of are the highest relative part.
these occupational groups is associated with mild During the different years (periods) there are
to moderate physical workload, standing posture, some minor shifts in the ranking of significance in
with the possibility of micro-pauses and unregulat- the above mentioned groups of diseases, but they
ed breaks and significantly less expressed intensity are obviously the problem pathology in the textile
compared to the workers involved in the machining. production and to a great extent their expression is
Sometimes it is necessary to carry loads, but using related to the specific working conditions, the na-
auxiliary equipment. In many cases, the work is car- ture of the labour process and the feminisation of
ried out with a large number of unvaried working professions.
movements of the upper limbs. Prevention of work.
The occupational activity of the above-men- Microclimate. Improvement in spinning and
tioned professions often requires constant atten- weaving workshops can be achieved by providing
tion, continuous participation in vision; it is also as- air conditioning (climatic instalation). The substan-
sociated with considerable responsibility for quality tial healing of the microclimate in the finishing
and implies good qualifications. All this results in an workshops can be accomplished by encapsulation
average nervous sensory strain. and thermal insulation of machines and aggregates
General and occupational morbidity. - heat sources; well-designed and maintained aera-
Unfavorable production microclimate, intensive tion of the working premises; air dusk of the worst
noise, dustiness, contact with dyes and other tox- work places and more. The limitation of released wa-
ic substances, standing position without seating in ter vapor and high relative humidity is achieved by

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closing all open vessels and apparatus; installation or low-grade raw material varieties, this should be
of ventilation equipment for continuous suction and done in insulated rooms with encapsulated ma-
discharge of water vapor. During the cold seasons chines provided with local aspiration. Certain raw
to avoid condensation and work places misting, it is materials also require pre-disinfection.
necessary to introduce heated air up to 40-45 ° C in The use of anti-dusty personal respirators is re-
the underfloor space. quired with high dusting and for a short time.
Provision and use of appropriate work clothes The removal or reduction of toxic substances
and drinking regime, and execution of hardening takes place in several directions: encapsulation of
procedures. the machines; mechanization of production opera-
Noise. Design of non-shuttle and micro-shuttle tions; pressurization and mechanization of the pro-
looms; replacement of mechanical spindles with cess of preparation of the solutions; use of dyeing
electric or pneumatic spindle-free spinning can re- aggregates with continuous action; installation of
duce the noise level by 8-10 to 20 dB. Isolation of efficient aspiration facilities; replacing chlorine as a
noisy machines by placing rubber pads, springs or bleaching agent with new preparations; use of less
other suitable materials between the machine and toxic dyes and finishes.
the place of its foundation is also important for re- Prevention of over-stress and fatigue requires a
ducing vibration. A modern method, which is wide- number of measures to ensure a more rational phys-
ly used, is the treatment of textile machines with iological organization of work, such as: for each oc-
sound-absorbing varnishes. cupation, a proper working and rest regime; to apply
Noise reduction is also achieved by sound acous- training (make easier in working) exercises to limbs;
tic treatment of the walls and ceilings of the prem- relaxing procedures during scheduled breaks and
ises or by sound absorbing screens - this can reduce more. Also: ergonomic machines, equipments and
the sound level by 8-10 dB. working furniture; natural and artificial lighting that
It is imperative to use internal antiphonies and meets the requirements of the respective professions.
establish a proper work and rest regime. Protecting the skin and eyes from toxic and ag-
Dust. There are modern closed aggregates, gressive chemicals requires the use of reliable per-
which ensure continuity of processes and pneumat- sonal protection with special workwear and shoes,
ic transmission of the raw material for defibering, safety gloves and eyeglasses. Wearing protective
carding and cardering. The periodic cleaning of the caps or headscarves is necessary to prevent hair
machines must be carried out pneumatically with from falling between rotating machine parts. The
industrial vacuum cleaners or with constructionally dynamic- standing posture requires working shoes
to machines separate suction and self-cleaning de- with orthopedic feet.
vices. Moisturizing and lubricating processed mate- Medical-prophylactic measures include: pre-
rials also reduces dust generation. liminary and periodic medical examinations with
The removal of dust in textile plants by ventila- contraindications to work; dispensaries; labour re-
tion equipment is hampered by the specificities of habilitation; climate and balneotherapy; protective
the textile powder aerosol. When processing waste professional nutrition and more.
REFERENCES
1. Blagodarnaja О.А. et. al. Hygiene of labour in textile and light industries. in Manual of Labour", ed. N.F. Izmerov,
Moscow, Medicine, 1987, V. II, 363-367. (in russ.)
2. Gandev V. - Labour Hygiene in the Textile Industry - in "Hygiene in basic industries", ed. M. Lukanov, Sofia, Med.
and phys., 1977, 146-178. (in bul.)
3. Goranova L. et al. - The noise factor in manufacturing industries - in "Infrasound, ultrasound, noise and vibra-
tions", ed. D. Tsvetkov and M. Angelova, Sofia, Med. and Fisc., 2007, 95-104. (in bul.)
4. Goranova L. et al. - The vibration factor in production - in "Infrasound, ultrasound, noise and vibrations, ed. D.
Tsvetkov and M. Angelova, Sofia, Med. and phys., 2007, 173-183. (in bul.)
5. Grund, N. - Environmental considerations for textile printing products. J. Soc. Dyers and Colourists, III [1/2]: 7-10,
1995.
6. Hussman, I. - Health Effects of indoor-air microorganisms, Scand J. Work Environ. Health, 22: 5-13, 1996.
7. Pasternak A.E., A.I. Pachomichev - Hygiene of labour in cotton fabrics, in Manual of labour", ed. L.K. Kotsianov,
Moscow, Medgiz, 1961, V. III, 502-543. (in russ.)
8. Perkins, H.H. Jr., S.A. Olenchock - Washing cotton by batch processes to control dust and endotoxin. Ann. Agric.
Environ. Med., 2:45, 1995.
9. Zuskin E., D. Ivancovic, E.N. Schachter, T.J. Witek-A, 10th follow-up study of cotton textile workers, Am. Rev.
Respir. Dis., 143: 301-305, 1991.

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N. Gincheva, M. Lyapina

17.7 CONSTRUCTION AND PRODUCTION

OF BUILDING MATERIALS

17.7.1. CONSTRUCTION In the case of monolithic construction, the con-

struction of the site includes the arrangement of
The technology of construction works can be bricks (clay, silicate) in horizontal rows, their connec-
grouped in three main stages: tion and attachment with building mortars made of
I. Works on a zero cycle (underground part of the cement, lime, sand, gravel and water. The monolithic
site) concrete and reinforced concrete structures (slabs,
II. Elevation of the overhead part of the site beams, columns) are made using cranes, concrete
III. Finishing operations. pumps, vibrating equipment for sealing concrete,
The first stage includes: a) earthworks - clear- and in small objects mainly hand tools - as electric-
ing of the site for construction, digging, consoli- and air tampers.
dation of soils (through cementation, silicification, The second stage includes carpentry, roofing,
bitumination, emulsification), drilling, blasting and anti-corrosion work, hydro-, heat- and sound insu-
caissonworks; b) construction of underground lation work.
communications facilities - water supply and sew- Carpentry works include: 1. installation of roof
erage systems (welding of steel, heating and gluing and floor wooden structures; 2. installation of join-
of PVC pipes, their laying in the prepared trenches), ery - frames, doors, windows; 3. installation of par-
heating installations (installation, welding of metal quet, paneling, railings. Timber building is delivered
pipes, anticorrosive and heat insulation works); elec- to sites pre-treated to protect wood with antiseptics,
trical installations (withdrawal of power cables and insecticides, fungicides, anti-pyrans. Also, various
their laying in the trench); c) drainage and building adhesives, such as tartal, casein, dextrin, nitrocellu-
of the foundations of the site - the foundations are lose or newer-, urea formaldehyde, melamine for-
made of concrete, which is pouring mechanically maldehyde, resorcinol formaldehyde resin, epoxy
or manually into pre-prepared formwork; reinforce- resin, natural latex, neoprene adhesives, polyam-
ment columns are planted in the foundations and ide, polyester, polyvinyl acetate, perchlorvinyl, cy-
concrete sealing is performed by vibrating with nee- anoacrylate. Finishing operations in carpentry are
dle vibrators. polishing, varnishing, staining and painting. The
Most of the I-stage activities are mechanized. wood is coated with liquid film-forming substances
Excavation and transport-technology machines are - non-pigmented (lacquers - polyester, polyurethane
used - excavators, bulldozers, scrapers, grooves and based on amino formaldehyde resins, polyvinyl
others. Sometimes (underground, high-altitude, chloride, perchlorvinyl etc.) and boiled oil - polymer
rocky soils, etc.) a part of earth-excavating, drilling of vegetable, dried oils - flaxed, hemped, tunged)
and blasting operations are carried out by hand- and pigment (paints, enamels). Dyes and enamels
held electric and pneumatic vibratory tools. contain inorganic pigments (compounds of zinc, ti-
The second stage depends on the type of the tanium, aluminum, iron, chromium, lead, cadmium,
site, the way of construction and the building ma- manganese) and fillers (chalk, bentonite, kaolin, kie-
terials. It is built mainly with ready-made items and selguhr, aerosil, barite, mica, talc, asbestos) in stable
bricks. suspension with organic solvents. In varnishes, lac-
In the modern industrial construction is done quers and paints, the most commonly used organic
the assembly of ready-made constructions and el- solvents and diluents are toluene, xylene, cyclohex-
ements (reinforced concrete, steel). They are fas- ane, methylethylketone, acetone, ethylbutyl-amyl
tened by welding and subsequent cement coating acetate, turpentine and the like. For painting, mostly
at the joint site. The assembly works can be carried non-mechanized hand tools, as well as electric and
out from the foundations up to tens and hundreds pneumatic tools, are used.
of meters high, using cranes, helicopters, welding Roofing includes various technological opera-
machines and hand-operated tools (electric perfo- tions and materials depending on the type of roof.
rators, welding pistols, pneumatic spanners, drills, For flat roofs the main operation is waterproofing.
etc.). It is made with rolled bituminous materials (tarpa-

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pers). These materials are bonded with cold (bitu- ing of the pipes with electrical, anticorrosive and
men, dissolved in gasoline) or with hot bitumen and thermoinsulation works, installation of radiators.
tar adhesives (coal tar). By another technology, the Basic operations during the installation of the elec-
gluing is done by direct heating of the roll materials trical installations are electric cables, installation of
with propane-butane burners on the prepared roof distribution boxes, switchboards, sockets, switches.
surface. Recently, non-rolled waterproofing materi- The technology of making floor coverings depends
als based on polystyrene and other polymers with on the type of flooring. On wooden flooring - see
organic solvents as solvent - naphtha and xylene carpentry; in mosaic, ceramic, terracotta coatings
have also been used. In this case priming with pol- - see anti-corrosion work; in the case of monolithic
ymer-cement and polymer-concrete compositions. polymer coatings (polymer-concrete, polymer solu-
The surface is first dried and then absorbed with or- tions, self-leveling coatings based on epoxy resins),
ganosilicate compositions, furan and vinyl polymer the priming and coating of the polymer coating in
compounds. When building sloped roofs, the op- basic and leveling layer, grinding and varnishing, are
erations include the installation of a wooden struc- prepared after preparation of the starting materials.
ture, piling of roof tiles and basalt tiles, installation In the interior and exterior painting works are car-
of gutters, etc. ried out after the preparation of surfaces - cleaning
Anticorrosion works include painting and lac- with electric brushes, coating and flattening, plas-
quering of metal structures and impregnation with tering, priming and painting.
polymer compositions and lining of reinforced con- The third stage, as well as the second, is less
crete surfaces. For metal facilities, rust cleaning is mechanized than the first. Some operations are per-
performed first, - manually, mechanically - by sand- formed with electric and pneumatic tools.
blasting, or thermally - with oxygen-acetylene burn- Working environment conditions
ers or gasoline lamps. Another method is to apply a The working conditions of construction workers
rust convertor (sulfuric or phosphoric acid). Then de- are difficult to characterize in general due to the het-
greasing with organic solvents and finally applying erogeneous technological processes and the impact
the anti-corrosion coating. It includes priming with of a number of specific factors such as:
oil, alkyd or nitrocellulose primers, painting (mini- - frequent change of work places - variability in
um, iron oxide coatings, etc.) or lacquering (epoxy, the working time of a given place from single days
polyvinyl chloride, polyacrylic lacquers). Ferro-con- to months, with frequent movements of workers
crete surfaces are cleaned, puttyed and grinded, within or outside the country; often - remoteness of
followed by priming and application of polymer sites from settlements;
coatings. In some cases, the anticorrosive treatment - differences in construction methods;
involves rocking (limestone, marble, granite, ceram- - non-permanent working conditions due to out-
ics, terracotta) that are prepared by cutting, and door or unfinished, non-isolated premises, in cabins
grinding. of transport or transport technology, often uninsu-
Thermo- and sound insulation is performed lated, insufficient or unheated; daily show influence
with: 1. Porous bulk grain materials (perlite, cer- sunshine intensity, wind direction and velocity, hu-
amsite, vermiculite, etc.) - mainly for thermo - and midity and rainfall, daytime and seasonal tempera-
sound insulation of floors; 2. fibrous materials (glass ture fluctuations, and in some cases-altitude;
and mineral wool) - for thermo-insulation of pipe- - working at different heights and having mech-
lines; 3. use of prefabricated monolithic structures anisms for moving heavy loads at different heights;
made of aerated concrete, foam concrete (for ther- - there is a risk of contact with hazardous materi-
mal insulation of roofs), foam plastics (foamed pol- als used in the past (crocidolite asbestos, lead-con-
ystyrene-styropor, polypropylene, polyurethane taining anticorrosive coatings, etc.) for collapsing
foam, foamed phenoplastics, etc.). and repairing buildings.
The third, final stage includes the following The main adverse factors in the construction are:
basic finishing operations: 1. installation of internal weather conditions, dust (from rock and materi-
water and sewerage systems, electrical installations, al, sand and soils, lime, cement, gypsum, concrete,
district heating; 2. production of floor coverings; 3. asbestos, ceramics, polymer materials), toxic gases
external and internal finishing-painting works. and vapors (welding gases and aerosols , explosive
The installation of internal water and sewerage gases, exhaust pipes, bitumen, tar, peaks, resins, ad-
systems is related to the drilling of holes in masonry hesives, varnishes and paints), noise and vibrations
and concrete, the preparation (cutting and bonding) (from transport and transport technology, construc-
of the pipes and their fixing in the walls, heating and tion hand-held machines - electrical and pneumat-
gluing of PVC pipes. In the district heating, the weld- ic).

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In the first stage, in the execution of the earth- on heating and bonding of PVC pipes - products of
works, the main workplace with a complex influence thermal and thermo- oxidation destruction of PVC -
of the production factors is the cabin of the exca- carbon monoxide, vinyl chloride, lead or cadmium
vation and transport-technological machines. The aerosols, aldehydes, etc., welding of pipes - welding
cabin air temperature in the summer reaches 37°C, gases, aerosols of metals and their compounds).
in the winter - 4-12°C (up to - 4°C). The humidity de- When constructing the foundations hygienically sig-
pends on the season, rainfall, region, altitude. The nificant occupational injuries are: the meteorologi-
concentration of dust depends mainly on the de- cal factor - depending on the cooling or overheating
gree of sealing of the cabins, but also the state of the season, with radiation cooling from the surrounding
site's area, the roads, the amount of rainfall. The dust surfaces; during installation of the fixture by weld-
usually consists of quartz particles and sand, the sili- ing - gas-aerosol mixture; when compacting the
cate and free silica content varies depending on the concrete mixture - generating intensive noise (90-
region. Fuel combustion gases (carbon monoxide, 115 dB) and impact of general and local vibrations
nitrogen oxides, aldehydes - acrolein and formalde- (amplitude 0.1-0.9 mm, frequency - 45-105 Hz); re-
hyde, hydrocarbons, soot, sulfur dioxide, oil-based moval of dust (concrete, cement, soil particles).
lubricants) are also found in the cabin air. The com- In the installation works, the hygienic impor-
position of the gases varies depending on the type tance of the meteorological factor depends on the
of engine, power and technical condition, operating climate of the region and the season, as well as on
conditions, fuel type, etc. When working on trans- the height at which it is being built. When using
port and transport technology machines, noise and the hand-held power tools generate noise and lo-
vibrations are generated, with noise being more in- cal vibrations; intense noise is also generated when
tense in low and medium frequencies. The vibrations working on bridge cranes, helicopters and loading
are general, with significant amplitude, with impact elevators. In the case of monolithic construction,
and by local at controls. In manual earthworks (such the meteorological factor is also leading, and ad-
as drilling, blasting), exposure to dust and unfavora- ditionally with great hygienic importance is the
ble microclimate is leading, depending on the sea- cooling from the long, direct contact with the cold
son. Hand-held power tools and pneumatic tools surfaces of the building materials and tools. In the
have noise-vibration effects (local vibrations). When air of the working environment dust of cement,
the soils are strengthened there is exposure to dust lime, gypsum, sand, etc., also containing free silica,
and vapors of chemical compounds: in cementa- is released. There is also the possibility of prolonged
tion - cement, lime, slag and chemical additives; for skin contact with highly alkaline building solutions
with sodium-silicate solution silicification and accel- (lime-cement).
erators - calcium and sodium chloride powder, alu- When carrying out the carpentry, the meteoro-
minum sulphate, sodium silicofluoride, phosphoric logical factor is again the most unfavorable factor.
and sulfuric acid vapours; in bituminization - poly- When using mechanized hand tools, intermittent
cyclic aromatic hydrocarbons, hydrogen chloride; noise and local vibrations are generated. In oper-
when resinized with carbide resins - formaldehyde, ations such as planing, grinding, circling in the air
phenol, furfuryl. There is also a skin contact with comes rough and fine wood dust (including exotic
these substances. In the case of caissonworks (tun- wood species), which also supports various chemi-
neling, construction in or under water basins, laying cal substances used in the treatment of wood (cre-
the foundations of bridge constructions), the lead- osote and anthracene oil vapours, compounds of
ing unfavorable factor is the increased atmospheric copper, zinc, mercury, chromium, chlorinated naph-
pressure. The air in the caissons can be contaminat- thalenes, chlorinated methane and ethane, nitro
ed with dust and a mixture of chemicals entering compounds). When assembling wooden parts using
by the compressed air as well as soil (methane, polymeric adhesives, vapours of organic solvents
hydrogen sulphide), explosives (carbon monoxide and outgoing monomers (toluene, butyl alcohol,
and dioxide, nitrogen oxides) and welding gases. A formaldehyde, epichlorhydrin, etc.) are released. In
number of technological operations (eg. pneumatic the polishing, varnishing and painting of wooden
tools) generate intensive medium and high frequen- surfaces the leading production factor is the chem-
cy noise. When building underground communica- ical - the vapors are released from organic solvents.
tions, working conditions are determined by the me- Hazardous are two-component varnishes, which
teorological factor (depending on season), dust (soil use high-toxicity substances such as isocyanates
particles, building materials), noise-vibration factor - from polyurethane varnishes, ethylenediamine -
(hand-held electric tools, construction machines), from epoxy varnishes (catalyst in epoxy resin). In the
chemical pollutants in some specific operations (eg. aforementioned carpentry there is a risk of fire and

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explosion due to the easy flammability of wood and eration of intense noise, local vibrations and dust
adhesives, paints and boiled oil. (wood, mineral with free silica content, cement).
In the waterproofing works, the most important When applying polymer flooring and painting, the
industrial noxiousnesses are dust and chemical con- leading factor is the chemical.
taminants. Powder is intensively removed during Labour process in the main professions
the preparation of the substrate - rough or fine de- In modern-day construction, much of the tech-
pending on the technology - concrete, cement, sand nological operations are carried out mechanically,
(containing free silica, chromium). Chemical con- but there are also many that are done manually. The
taminants are released during priming (depending relative share of manual work is high in small sites,
on the nature of the primer) and when applying wa- as well as in difficult accessible areas - in high moun-
terproofing materials. With the use of cement-sand tain areas, water basins and others.
primer, workers are in contact with alkaline building For most occupational groups, the work process
mortars, and when applying heated bituminous - is characterized by medium physical work - for ex-
polymerics and asphaltics primer emited polycyclic ample, the work of the drivers of the transport-tech-
aromatic hydrocarbons, initial monomers - furfuryl, nology building machines and the other means of
acetone, furfur-acetonic monomers, vinyl chloride, transport. The working posture is mainly seated, ex-
thermal products of destruction - formaldehyde and cluding maintenance-related for repair time, as well
other aldehydes, higher alcohols, chlorinated hydro- as for assembly and disassembly of machinery when
carbons etc., from the hardeners - vapours of sulfu- the posture is standing, forced, with a nonphysi-
ric and phosphoric acid. In the hot fixation of rolled ological position of the body. When driving ma-
bituminous materials with bitumen and tar adhe- chines due to the often non-ergonomical layout of
sives, the main pollutants are polycyclic aromatic the control levers and pedals, the sitting position is
hydrocarbons, carbon monoxide, sulfur and nitro- also characterized by a considerable static load and
gen oxides, and in the case of cold gluing - petrol forced position of the body. Driving is also associat-
hydrocarbons. Using nonrolled materials naphthane ed with constant observation and control, and work
hydrocarbons and xylene, emited. The unfavorable is characterized by nervous sensory and neuro-emo-
meteorological factor (depending on the season) tional intension because of the need to make imme-
is also important. The use of sandblasters, vibrators diate decisions in complex situations.
and others instruments is associated with exposure The work of other workers (engaged in insula-
to intense noise and local vibration. In the anti-cor- tion, anti-corrosion and carpentry) is characterized
rosion works for protection of reinforced concrete by alternating operations. There is a significant phys-
structures, the production deficiencies are analo- ical stress in lifting and carrying weights, with a wide
gous to those indicated in the waterproofing works. use of manual labour and a static load to maintain
Only in the preparation of dry-stone lining dust is the often forced posture, which for a time changes
released in higher concentrations and with a higher with standing, bending to the knees, with support
content of free crystalline silicon dioxide. In the case often on an inclined surface. The work of plasterers
of sandblasting of rust to protect metal structures, and painters is more monotonous, characterized by
dust containing iron oxide, particles of sand with a a great monotony of movements requiring physical
high content of free crystalline silica are released. In effort. The working posture is standing, very often -
the chemical cleaning and degreasing of the surfac- forced - a strong slope downwards with folding at
es, the vapors are released from the chemicals de- the waist, on the knees, or vice versa - lifting of the
scribed in the technology. Hydro- and noise insu- fingers, stretching up arms over the shoulders and
lating works are mainly associated with exposures stretching back and upward head, and pulling the
of foamed concrete dust, dust of glass and mineral neck, sometimes at high altitude . The inconvenient
wool, chrysotile asbestos and others. There is also a working posture is associated with a significant stat-
skin contact with fibrous materials and alkaline sol- ic load, most commonly in the neck and local, up-
vent mixtures containing chromium, nickel, cobalt. per limb, loads. The masonry work is considered the
The finishing operations are carried out in the most labour-intensive in building. Along with the in-
case of unfavorable, seasonal fluctuations in the convenient, forced working posture - a curved, lean-
meteorological factor and with the impact of specif- ing forward body, work mouvments is also a prob-
ic noxiousnesses depending on the type of opera- lem. They are monotonous, with a lot of monotony,
tion. When laying the WC installations, the leading repeated many times, with significant load on the
factor is the dust and the heating of PVC tubes and locomotory system and separate muscle groups on
welding and soldering of metal pipes - the chemical. the hands (mostly on the wrists). For one shift, about
The production of the flooring is related to the gen- 4000 uniform movements are performed with the

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right hand and a load is moved to 6 tonnes (bricks, sion of a drinking regime according to the operative
blocks, mortar, etc.), including on height. regulations.
General and occupational morbidity Removal of the harmful effects of dust and toxic
The incidence rate of temporary incapacity for substances can be accomplished by applying pro-
building workers is determined by the working con- gressive technological lines, sealing the equipment
ditions of the different occupational groups, their for dimensioning, dosing and preparing concrete,
age-sex composition, the sanitary-living conditions, mortars, adhesives, paints, and providing effec-
the organization of nutrition and often the remote- tive local ventilation. In order to reduce exposure
ness of the construction sites by healthcare servic- to asbestos dust, it is necessary to pre-spray water
es. Typical of this industry is seasonal dependence and to place warning signs and inscriptions for in-
- much higher morbidity during the cold and transi- creased asbestos concentration, when destroying
tion seasons of the year. asbestos-cement constructions. To reduce exposure
In the structure of the ITD, most intensive are to quartz dust, it is recommended to work with wet
diseases of the upper respiratory tract and the materials, spraying water in the work area, organiz-
lungs, diseases of the locomotory system (LS) and ing effective local ventilation with removable suc-
the peripheral nervous system (PNS) - radiculitis, tion devices, sand replacing in sand blasting with
polyneuritis, skin and subcutaneous tissue (contact slag or metal ball. Replacement of highly toxic by
dermatitis, eczema, photodermatitis), diseases of weakly toxic substances helps to reduce exposure
the gastrointestinal tract. A very high frequency and to harmful chemical compounds - ex. replacing the
weight in construction is traumatism. organic solvents with water emulsion, inactivation
Occupational diseases are the most common of the chromates contained in the cement and its
among construction workers, such as those of the solutions by addition of 0.1-0.2% iron sulphate and
LS and PNS, pulmonary aetiology (pneumoconiosis, the like.
bronchitis), occupational intoxications, vibrational To reduce heavy manual labour with physical
disease, occupational hearing impairment, caisson load, it is recommended to mechanize heavy and la-
disease (underwater). In some professions (concrete, bour-intensive operations, especially for lifting and
bricklayers, plasterers, painters, carpenters), allergic carrying loads. For workers with a high occupation-
diseases of the respiratory system and skin (contact al risk (exposure to silicozogenic and carcinogenic
with cement, wood dust from exotic trees, resins, dusts and chemical compounds) it is necessary to
oils, organic solvents, etc.) are high. Intoxications carry out prolonged prospective medical surveil-
with organic solvents (for painters, parquet work- lance in order to identify possible health effects af-
ers), lead (for anticorrosive coating workers), metal ter a latency period. Workers should be aware of the
aerosols and gases (for electric welders and fitters) immediate occupational risk by providing informa-
have been reported. Pneumoconioses suffer from tion leaflets, incl. and instructions for safe operation
isolationists (asbestosis), stoneworkers and sand- and basic information on first aid in traumas, acute
blasting (silicosis). Cases of vibrational disease have intoxications, etc.
been reported in concretors drivers of heavy-duty The most effective for building workers is person-
construction machines, crane drivers, grinders, and al protection with appropriate work clothes and
pneumatic machines. Hearing damage (reduction to personal protective equipment (PPE), especially
loss) occurs in carpenters, bombers, concreters, and for high-risk work. When exposed to silicone, asbes-
craneists. Risk factors for the occurrence of carcino- tos and others mineral powders, respiratory protec-
genic diseases are workers in contact with asbestos tion is recommended with dust masks, retaining
and derivatives, zeolite, chromate, nickel, coal, bitu- particles 2-5 μm and finer ingredients but with the
men, asphalts, peaks, as well as workers with ultravi- least resistance to inhalation; when working with
olet impact. sandblasters - insulated air-carrying helmets; When
Prevention of work exposed to lime dust - a protective mask combined
In order to prevent the impact of unfavorable with safety glasses. Protection of the body from dust
weather conditions, it is necessary during the cold is carried out with anti-dusting suits, made of dense
period to take short breaks for warming in special- cotton fabrics, the protection of the hands - with tar-
ly equipped rooms, offering hot drinks or stopping paulin gloves; in case of skin contact with cement
outdoor work at extremely low temperatures. When dust or lime, protective pastes and creams under the
working in high temperatures, a special working gloves are recommended, when exposed to glass
regime is required with longer interruptions in the fibers - whole body protective dress, hands, safety
hottest hours of the day and shift of workday earlier glasses or facial anti-dust helmets. To protect the
in the morning and later in the evening and provi- respiratory organs from gases, vapors and aerosols

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with exposure to paints and varnishes, half masks The leading unfavorable production factor in
with suitable filters are recommended, and for body cement production is the raw material dust and of
protection - suitable cotton cloths reinforced in front the finished product. Dust concentrations fluctu-
with a coated cloth. In the case of coal tar and peat, ate widely, up to tens of mg/m3, depending on the
we recommend workwear of impermeable material degree of mechanization and process automation,
covering the whole body; when welding in confined and on the effectiveness of ventilation. The mate-
spaces - gas masks with a suitable filter or insulating rial composition of the powder comprises from 20
breathing apparatus. The PPE and workwear must to 80% total silica, with an average of about 2-3%
always be fitted with crash helmets, seat belts, etc. being of free crystalline silica. The amount of crys-
talline SiO2 depends on the different types of start-
17.7.2. PRODUCTION OF BUILDING ing materials and additives used and the cement
MATERIALS brand. The powder composition also includes small
amounts of calcium oxide, magnesium oxide, bicar-
Building materials are several groups: 1) natural bonate and alumina, manganese and barium oxide.
a) compact materials (stones, rock fragments); (b) Also, hexavalent water-soluble chromium in concen-
bulk materials (sand, gravel); c) inorganic binders trations between 0.004 and 0.008 mg/m3. The dust is
(cement, lime, gypsum); 2) concrete and building mostly finely dispersed - 70-98% of the particles are
mortars; 3) ceramic materials and articles (bricks, less than 5 μm.
tiles, etc.); 4) thermal insulation and acoustic mate- The microclimate in the different stages of the
rials and products (mineral wool, perlite, glass fiber, technological process has different characteristics.
styrofoam); 5) organic binders and articles (fiber- The milling of the raw materials works at acceptable
glass, epoxy resin, linoleum, etc.); 6) roofing and levels (during the winter season with a cooling char-
waterproofing materials (ruberoid, asphalt concrete, acter), while during drying and baking of the raw
etc.); 7) metallic materials (fittings, iron structures); material to clinker, the temperatures are high and
8) wood materials (beams, parquet, woodwork, etc.); during the warm period can reach 40-42 ° C. For the
9) building materials of polymers (profiles, mill work, overheating microclimate, the impact of infrared ra-
cladding, PVC pipes and other polymers); 10) lac- diation (measured at 3780-5040 kJ.m-1.h-1) is meas-
quer-painting materials. ured by heated outdoor surfaces of kilns, drying
Cement production. It comes in two technolo- drums. It works outdoors during all seasons.
gies - dry and wet. Raw material for production are Noise and vibration. In the crushing, grinding,
limestone, marl, clay and corrective mineral addi- sifting and transport of raw materials and finished
tives (tras, zeolite, kieselguhr, gypsum, blast slag, ash product processes, the used technological equip-
from TEPP, etc.). Depending on inputs, cement with ment generates medium and high frequency noise
different qualities is produced. The raw materials with a significant intensity of 90-115 dB/A. When op-
are crushed, sieved, mixed, dried and baked. When erating the burners of rotating kilns, the measured
burning as fuel, fuel oil, gas or coal (powdered) is sound levels are between 110 and 120 dB/A. Two to
used. In the wet method, fine grinding (crushing) three times of the norms were exceeded by general
is done in water to form a charge in the kind of an vibrations when working on ball mills and pelletiz-
aqueous suspension - the so-called slime. In the ing trays.
dry process, the charge is in the form of a fine dry Chemical pollutants. When baking the raw ma-
powder. The next step for both methods is to bake terials to the clinker it is possible to produce CO, CO2,
the slime/charge at 1300-1400°C in vertical or rotat- SO2 hydrocarbons from the fuel and their entry into
ing inclined furnaces to form solid lumps - clinker. the working environment (around the furnaces).
After removing the furnace, the clinker is subjected Work process. From the technological staff, the
to rapid cooling. The clinker is maturing in a storage main professions in the cement industry are: a miller,
room, after which the mineral supplements are add- a furnacer and a cement filling machine. The number
ed, and they are grinded and sieved with them. The of auxiliary staff - fitters, locksmiths and maintaining
resulting cement is stored in large concrete silos. transport and sanitary facilities - is also significant.
The equipment used in the course of the process in- Technological staff works at a slight physical load,
cludes: crushers and mills (hammer, roller, jaw, cone, mostly in a standing position about three-quarters
rotating ball mills), crushers, shaft or rotating in- of the shift, with a free rhythm of labour. Work is pre-
clined furnaces, silos with compressor mixers, auto- dominantly of control and managerial nature, but it
matic filling machines. Contemporary cement plants is related to risk and responsibility. Manual opera-
are highly mechanized and automated production tions mainly involve periodic sampling. The work of
with remote control and management. cement fillers has a great physical load. Contempo-

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rary cement production with a high degree of au- cludes mainly clay processing operations (crushing,
tomation leads to high nervous sensory and nerv- sifting, battering, wetting, mixing and kneading).
ous-mental intension. The production of bricks is done in two basic ways:
Morbidity of workers. Occupational morbid- 1) plastic (wet) - crushing the clay with rollers; add-
ity is mainly associated with the impact of cement ing water to a blender; subsequent rolling of the mix-
dust. Cementary pneumoconiosis is benign and ture; passing the clay through a horizontal grinder
progresses very slowly. Single cases of silicosis in ce- to a homogeneous plastic molding table. The bricks
ment production were recorded in milling and belt are molded most often mechanically (also manual-
conveyance workers. A particular manifestation of ly with a template), making the clay tape (obtained
the effect of cement dust is the so-called "Cement in belt presses) with subsequent passage through
pneumonia" - fibrosing bronchitis, bronchiolitis and automatic or semi-automatic apparatus, cutting it
obturative emphysema. Chronic bronchitis with to undrying bricks. The bricks before burning are
dust etiology is common. Relatively high incidence dried in adjustable furnaces (tunnel dryers, etc.) or
is also bronchial asthma and allergic rhinitis that are outdoors. 2) semi-dry and dry - after the addition
associated with the effects of hexavalent chromium. of admixtures to clays, preparation of clay powder
Diseases of the respiratory system are also high in by drying and grinding, artificial humidification and
the structure of morbidity with temporary disability. rolling of semi-dry material, screening and feeding
There is also a high incidence of professional derma- of mechanical presses, in high-pressure steel molds.
toses - "cement eczema" (micro-impurities of chro- Bricks made by this method are baked without
mium, perhaps cobalt and nickel), and other skin pre-drying. Bricks are baked in ring and tunnel kilns
diseases - nail-around erosions and skin infections for 36-48 hours at 900-1000 ° C. The fuel used is sol-
(furuncles, abscesses, panartiums). Other occupa- id (coal) and gaseous. At present, electricity kilns is
tional diseases include eye diseases - conjunctivitis, used - band and multichannel.
occupational deafness and stomach and duodenal In the production of tiles, the plastic method is
ulcerative disease. mainly applied. The quality requirements for clay are
Prophylactic measures are aimed at: reducing high. Molding, drying and baking are analogous to
dust generation by encapsulating and sealing the the production of bricks. It is baked at a higher tem-
equipment and dust-free cleaning of production perature - 1000-1100 ° C.
facilities; reducing the intensity of radiant heat Working conditions. In the manufacture of con-
by installing heat screens, thermal insulation of the struction ceramic products the main adverse factors
equipment and control of production processes by of the working environment are meteorological and
insulated (closed) control panels; improvement dust. The chemical factor is also important for the
of microclimatic conditions by means of general "burning" process. In the extraction and preparation
mechanical ventilation; reducing the hard labour of the raw materials, the noise-vibrating factor can
through mechanization and automation of tech- be added to the leading unfavorable factors.
nological processes; medico-preventive measures The meteorological factor in raw material ex-
- preliminary and periodic medical examinations, traction is determined entirely by seasonal fluctua-
PPE, protective-professional diet and drinking re- tions - outdoor work. During drying and especially
gime (at overheating). during burning of articles in ring kilns, air tempera-
Manufacture of ceramic products (bricks, tures reach 30 and 50 ° C, combined with intensive
tiles). Ceramic products are a product of pure clay or infrared radiation (measured 5000 kJ.m-2.h-1) when
its mineral admixtures. The most common minerals loading or unloading bricks. Powder is released at
in clay are kaolinite and montmorillonite, which are high concentrations in the extraction and prepara-
contained in small amounts of mica, feldspar, calci- tion of the raw materials - measured from tens to
um carbonate and iron oxides. Mineral supplements hundreds of mg.m-3. At lower concentrations is the
include: quartz sands, diatomite; burning materials dust when removing the articles from the furnaces
- coal dust or sawdust; also feldspar, perlite, tuff, car- (2-25 mg.m-3). The free crystalline silica is between 1
bonates. and 20%. The dust particles have a high dispersion,
The main stages of production are: extraction which determines their high respirability. Chemical
of raw materials; preparation of the raw materials; compounds (CO, SO2, CO2) are released into the air in
Molding or pressing of bricks and roof tiles; drying; the dryer and mainly in furnaces as a result of incom-
burning; storage and expedition. plete combustion of fuels. Highest noise levels (over
The extraction of raw materials is most often in 100 dB/A) as well as general vibrations are gener-
open quarries and mechanized (excavators, bulldoz- ated when the raw material preparation equipment
ers, etc.). The preparation of the raw materials in- (crushers, ball mills) is used. The noise of the means

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of transport is of higher sound pressure in the low ers, sealants, antifreeze, etc. are widely used. In the
and medium range. The general vibrations here are specialized plants the production of concrete is fully
of considerable amplitude (thrusts). mechanized and partially automated. The techno-
Work process. The group of technological work- logical process takes place in the following stages: 1)
ers is formed by the following professions: metering, storage of the raw materials in a warehouse for pre-
milling, molding, cutting, furnace attendant and liminary preparation of inert materials (sieving, flush-
loading workers in furnaces (filling, extraction). The ing); 2) transport of raw materials in a concrete work-
working position of all is standing for 75-95% of the shop (in silos) and from there to the dispensers; 3)
working time. The work is of average physical load, dimensioning of materials of automatic or semi-au-
except for manual (non-mechanized) loading of dry- tomatic scales (dispensers); 4) loading - direct feed-
ers and furnaces of unfinished bricks and removal ing of the measured materials from the dispensers
of dried / baked products. The total load transferred into concrete mixers and mixing them with water; 5)
for one shift reaches 10 t. For most professions, work dosing, feeding and stirring the additives in the con-
has a free rhythm. For service belt presses, convey- crete mixture; 6)delivery of ready concrete by pumps
or lines the rhythm is imposed. For all professional in concrete trucks or special metal buckets.
groups the work is related to uniform operations Working conditions in concrete production are
and expressed monotony. characterized mainly by high dusting, cooling or
Illnesses of workers. At the highest incidence in overheating dynamic weather factors and intense
the structure of LS are the diseases of the ITD and noise. Dust is the leading harm in the working envi-
PNS (mainly of the upper limbs). They are associat- ronment. In the warehouse it is mainly released dur-
ed with both the overload of the skeletal-muscular ing unloading and preparation of building materi-
system and the significant physical load as well as als. The highest concentrations of unloaded cement
the unfavorable cooling or overheating microcli- from the wagons/cement plants, although in most
mate. Acute and chronic diseases of the respiratory cases pneumatic transport is used. Concentrations
organs, production and domestic traumatism are reach several hundred mg.m-3. Lower quantities of
also increased. Occupational diseases are character- dust are released when transporting inert materials
ized by the pneumoconiosis "kaolinose" (silicatosis). - when pre-wetted to 10-20 mg.m-3. When transport-
With a higher content of free crystalline SiO2 (in the ing dry materials with open belts, dust concentra-
sand fractions of the clay) develops mixed silicosis tions are very high (between 300 and 400 mg.m-3).
(not pure silicosis). There is an increased risk of occu- The powder has a very high dispersion (70-98% of
pational intoxication with carbon monoxide in the the particles have a size up to 5 μm).
furnace service. Noise - when moving conveyor belts - 75-86 dB/A;
Prophylactic measures include: using tech- when working on pumps, serving pneumotransport
nology with the plastic method instead of dry and and dosing devices - 90-110 dB/A; when paddle
semi-dry; complex mechanization of the entire tech- mixers and concrete mixers - 89-105 dB/A. Gener-
nological cycle; use of up-to-date equipment - tun- ated noise is constant, over-rated (over 85 dB/A),
nel dryers and furnaces, electric furnaces instead of mostly low and medium frequency. When working
ringing; covering (encapsulation) of crushers, con- on concrete mixers, general vibrations transmitted
veyor belts; humidification of input powders (espe- on the floor, exceeding the norms of 6-9 times, are
cially sand) and wet cleaning of production premis- generated. Weather conditions are especially unfa-
es; good thermal insulation on the surfaces of the vorable for workers in a warehouse - outdoor work.
driers and furnaces, shielding, air showering; work- Meteo- conditions in silos, dosing devices and con-
ing and rest regime in the conditions of overheating; crete mixers are similar, as air is free-flowing through
appropriate work clothes and PPE; under conditions the production area. Most often, the microclimate is
of overheating adequate drinking regime and pro- characterized as being cooling and dynamic.
tective professional nutrition; preliminary and peri- Work process. From the technology staff, the
odic medical examinations. main profession is the operator - on "dosing devic-
Production of concrete. Depending on the type es", "concrete mixers". The work of the operators in
of binder used, the concrete is: cement (most com- the majority of working hours is a low physical load,
mon), silicate (based on lime), gypsum, polymer con- whereas in the case of breakdowns, with manual
crete (based on synthetic resins - polyester, epoxy, work, there is a medium to heavy physical load (in
carbamide etc.). By using different types of cement the case of manual - non-industrial preparation and
and special chemical additives, concrete with dif- transport of concrete, labour is heavy and very heavy
ferent properties can be obtained. Plasticizers, ac- physical load). For the most part, the operator's work
celerators, retarders, air blowers, foam- and gasifi- is associated with nervous sensory and nerve-mental

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intension due to increased requirements for the at- Manufacture of reinforced concrete products.
tention activity for permanent control of panels and Ferro-concrete elements, panels (eg, facade, floor,
timely reactions. The operative position of the oper- bulk, for building), as well as beams, columns, pipes,
ator is mostly sitting, but also standing and forced etc. are made of reinforced concrete in specialized
depending on the manual operations performed. factories. Prepared elements are mounted directly
The job does not require high skill, accuracy, speed on the construction. The process involves: 1) prepar-
and processing of a large amount of information. In ing a concrete mixture; 2) preparation of reinforcing
the warehouse, the main profession is a craneist. The nets, metal profiles and structures and installation of
working posture is constantly sitting. Workers are ex- the fittings; 3) forming of the products; 4) heat-mois-
posed to adverse weather conditions, noise, general ture treatment of molds; 5) release of finished arti-
and local vibrations (from the control levers). When cles from shapes and finishing operations; 6) quality
working with dry aggregates and a poorly sealed control and expedition.
or enclosed cabin, dust exposure is also possible. Raw material for reinforcing meshs are rolled
The work is with a low physical load, but with nerv- concrete iron, which straightens, sizes, cuts, bends
ous-sensory, nervous-mental and nervous emotional profiles. The cut iron is welded to special molds by
intension due to continuous work at height and in spot or arc welding. Depending on the degree of
tightly closed space. Requires high attention, good mechanization and automation of production, we
visual-motor coordination, accuracy and speed. use: automatic metal cutting machines, automatic
Illnesses of workers. Workers have experienced and semi-automatic bending machines, spot weld-
the following occupational diseases: occupational ing machines with hand-held electrode, automatic
chronic bronchitis, bronchial asthma, allergic rhi- multi-spot welding machines, electrowelding, au-
nosinusitis, cement pneumoconiosis ("cementosis"), tomatic cutting machine and armature shears. The
skeletal and muscular system overload, peripheral forming process is carried out in metal moulds of
nervous system, occupational deafness, dermatoses different sizes. It consists of the following opera-
The structure of non-professional diseases high fre- tions: cleansing of concrete remnants (hand-blast-
quency are acute respiratory diseases, lumbosarral ing, levers, air blowing); daubing moulds with an-
radiculitis, domestic and industrial traumatism. tiadhesive (formwork) emulsions (hand brushes or
Prophylactic measures. They concern mainly spraying); closure of moulds; placing the reinforcing
dust, unfavorable weather conditions and noise-vi- net in them and filling the concrete mixture; sealing
bration impact. Dust protection measures include: the concrete in moulds by vibrating means (hand
wetting inert materials prior to transportation; en- vibrators, vibrotables, vibroplatforms) and non-vi-
capsulation of conveyor belts; good sealing and bratory methods (compression, centrifugation, vac-
hermetically of equipment, incl. soft connections to uum compaction). Heat-moisture treatment (for
and from dispensers; local exhaust ventilation de- accelerated concrete hardening and rapid release of
vice for dispensers, concrete mixers; good isolation the molds by: steaming (steam 70-85 ° C, 8-12 hours
of the cabins of the control panels; use of PPE - an- in the chambers, steam tubing with steam feed un-
ti-dust masks and half masks when leaving the cab- der the mold casing), in hot water pools autoclave
ins; provide adequate work clothing and PPE for eye treatment, electro heating; Releasing of hardened
protection as well as bathing conditions after work. reinforced concrete products from crane, telfers,
In order to avoid the adverse impact of the meteor- straightening on stands and finishing hand oper-
ological factor, it is recommended: to provide warm ations (cleaning, tapping, loosening of connecting
premises and hot drinks for the employees in the fitting, filling of slots and joints with cement mor-
warehouse; local heating of the crane and control tars, puttying, etc.) Quality control and storage.
panel cabins; appropriate warm work clothes; when The most important factors in the working envi-
working at high temperatures, providing ventilation ronment in the production of reinforced concrete
in the crane cabins as well as drinking (mineral) wa- products are noise, vibrations and unfavorable mi-
ter. To avoid the impact of general vibrations, it is ad- croclimate. Which is important in some stages is the
visable to: foundation the concrete mixers properly; separation of dust (cement, silicate, metal-iron ox-
providing crannets with shock-absorbing seats and ide) and chemical compounds (naphthenic aerosols
a comfortable semi-soft air-tight back; providing PPE and vapors, alkaline aerosols - sodium and potassi-
for hearing protection - antiphon, earbuds. In order um-bases, welding aerosols and gases). High noise
to avoid heavy physical load, it is recommended to levels are generated by: construction of the fitting
maximally mechanize the technological process. (cutting - 94 dB/A, single-spot welding - 91 dB/A,
Also, health control according to the Ordinance multispot welding on welding stand - 90-92 dB/A;
on preliminary and periodic medical examinations. forming (compressed air cassette cleaning - 88 dB/A,

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concrete sealing on vibro platforms - 115 dB/A, on (1.5-5 mg.m-3) are determined at higher concentra-
vibro tables up to 126 dB/A, manual vibrators - 67- tions. In molding, chemical substances are released
95 dB/A; of cranes - 82-85 dB/A. The noise is varia- during the treatment of heated forms with antiad-
ble, with sharply fluctuations in the sound pressure, hesive emulsions, especially at aerosol application
including impulse noise. Its frequency character- (injection forming) - petroleum aerosols, vapours
istic is predominantly low and medium frequency, of kerosene (300-450 mg.m-3) and alkaline aerosols
with vibro tables - it also includes high frequencies. (sodium or potassium base) - 1.5-2.5 mg.m-3. When
Vibrating means used for sealing concrete, are the used with additives in concrete - synthetic resins, va-
main intensive source of general and local vibra- pors are released from monomers, plasticizers and
tions. Of vibroplatforms and especially vibro-tables, hardeners, but usually in low concentrations below
there are several times exceeding the norms in me- the MAC.
dium and high frequency range (16-63 Hz). Hand Work process. The main professions in the in-
vibrators, depending on the model, generate: the dustry are steel fitters, arc welders, crane opera-
"internal" (so called "shaped") - medium frequen- tors, formworkers-concretors, steamers, patters.
cy vibrations (80 Hz) , "surfaced" - high - frequency The physical workload for these professions is aver-
local vibrations The exposure of workers to noise age, with the exception of crane operators, where
and vibrations when operating vibro tables and vi- it is mild. The working posture is imperative, often
brometers is about 26-30% of the working time and forced, for the crane operators - who are always seat-
48-54% when working with handheld vibrators. An- ed. The occupational activity of all professions in-
other source of general and local vibrations are the cludes many manual operations repeated over and
cranes - vibrations on the floor, seat and controls. At over for the shift. The rhythm of labour is free, does
all stages of the process the microclimate is unfa- not require great speed, accuracy, high qualification.
vorable. When making the fittings, the microclimate Occupational risk exists from industrial traumas, incl.
is most often dynamic and cooling. In the molding steam burning. Nervous-sensory and nerve-mental
of the reinforced concrete products, regardless of intension is only present in automatic lines opera-
the method of the heat treatment used, the relative tors in modern productions and crane operators.
humidity of the air is increased to 90-95%, and dur- Illnesses of workers. In the structure of the gen-
ing the warmer year period the air temperature is eral morbidity of workers, with very high frequency
up to 28-34 ° C. The greatest is the humidity and the and loss of work are acute respiratory diseases, dis-
heat intake when the reinforced concrete elements eases of the LS, PNS and traumatism. Occupational
are removed from the molds, in the steam chambers. morbidity is mainly caused by injuries caused by the
The production of dust is divided into 3 technolog- effects of noise and vibrations. In formworkers - con-
ical stages - production of fittings, molding and fin- cretors, the high-frequency professional deafness
ishing operations. A metallic powder (disintegration is registered. For vibratory tables workers, profes-
aerosol) is released during the production of fittings sional deafness is observed in the first 2-3 years of
in the unwinding, straightening and mechanical their work experience. Vibrational disease is found
cleaning of the ferrous iron rust - iron oxide. Much primarily in hand-held vibrators. In crane operators,
of the particulate matter has significant dimensions as a professional disease of general and local vibra-
(over 10 μm). The condensing aerosol (smoke) in the tions of higher frequency, vegetative polyneuropa-
electro-welding process (is also used in the prepara- thy occurs. In formworkers - concretors and workers
tion of the fittings) - metallic aerosols of iron, man- performing finishing work, incl. patters, professional
ganese, cadmium and zinc oxides, chromium, nickel dermatoses, cases with bronchial asthma, chronic
and fluorides, finely dispersed (less than 1 μm). At bronchitis, cement pneumoconiosis, diseases of the
forming, dust is released in a "mold cleaning" oper- LS and PNS, incl. vegetative polyneuropathy.
ation at the highest concentrations exceeding the Prophylactic measures. Hygienic activities are
MAC. The dust of the composition is mineral, mainly focused on mechanization and automation of the
cement. Contains also silicates and free crystalline technological process, protection against noise and
SiO2. The dust is rough or finely dispersed depend- vibrations, including technical means and PPE, isola-
ing on the cleaning method. Similar is dusting in fin- tion of vibro tables, prohibition of stepping on form-
ishing works - knocking, rough grinding. In case of work and work in vibration; use of vibration-free
patting, gypsum powder is also released. concrete consolidation agents; sealing of heat treat-
Harmful chemicals are released during the pro- ment equipment; ensuring efficient ventilation of
duction of reinforcing nets and constructions - in the production premises; medical-prophylactic events
case of arc welding and spot welding. In workload of - preliminary and periodical medical examinations;
welded mills, CO (20-35 mg.m-3) and nitrogen oxides appropriate work and rest regime, etc.

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REFERENCES

1. Alexeyev S.V., V.R. Usenko. Hygiene of labour in construction and production of building materials. J.
Hyg. of labour, Medicine, Moscow, 1988, p. 467-484. (in russ.)
2. Grangyn P. Aspects of Occupational Hygiene in Construction, WHO, European Regional Bureau, Co-
penhagen, 1986, ISSN 0250-8729. (in bul.)
3. Kisner, S.M., D.E. Fosbroke. Injury hazards in the construction industry. J. of Occup. Med., 1994, 36, p.
137-143.
4. Simeonov P.J. Environmentally safe application of building materials, Med. and phys., Sofia, 1993, 152,
p. (in bul.)
5. Weeks, J.L. Health and Safety Hazards in the Construction Industry. In the Encyclopaedia of Occupa-
tional Health and Safety. Ed. By J.M. Stellman, 1998, Vol. III, 4th., ed. ILO, Geneva, 93.2-93.52.
6. Zhilov Y. D., V.M. Retten - Hygiene of labour in the construction and in the production of building ma-
terials, in Manual of hygiene of labour, V. II, ed. N.F. Izmerov, Medicine, Moscow, 1987, pp. 350-360. (in russ.)

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B. Stefanov

17.8 LABOUR HYGIENE WHEN WORKING

WITH COMPUTER EQUIPMENT

The microcomputer is used by a variety of profes- ode cathode. However, the values of this factor are
sional groups. As a fast and intelligent tool, it is an also too small - the maximum is less than 1 W/m2
integral part of everyday life not only of profession- with a norm to 10 W/m2.
als (programmers, computing center operators, etc.), In order to accelerate the flow of electrons in the
but also of editors, journalists, accountants, bank video monitor's kinescope, an electrode with an ex-
and library staff, researchers, dispatchers, production tremely high potential is used. It becomes a source
processes, operators secretaries and many others. of electrostatic field. When the electron ray (beam)
Regardless of its main subject, a microcomputer enters the luminescence layer on the screen, elec-
worker performs work whose specificity is deter- trostatic charges are also created. Their presence can
mined by the specifics of the task being performed, be felt even when you touch the screen. A source of
the organization of the workplace and the factors of static electricity is not only the display, but also the
the working environment. Of particular importance electrified synthetic materials that abound the mod-
are the type of components of the computer config- ern working environment (carpets, plastic coatings,
uration used. including synthetic fabrics clothes).
Working environment conditions In a number of cases, the adverse effect of com-
Cathode ray tube displays emit electromagnetic puterized workplaces is noise. A source of steady
waves with a wide spectrum of X-ray, ultraviolet, vis- noise is the fan of the power supply unit and the
ible and infrared rays, and RF wave-fields (EMF). The processor. Along with this, noise also generates the
majority of the latter (over 70%) have a frequency working printer or plotter. Room noise also comes
below 300 kHz. from outside sources. The measured noise values
In the kinescope the electrons accelerate with of the printers are within 40-51 dB/A. According to
high voltage, which, depending on the model, is our hygiene regulations, the noise level for service
from 10 to 25 kV. This results in the appearance of of computer equipment should not exceed 55 dB/A.
mild x-ray radiation. Its intensity is too small and it Psychophysiological characteristics of labour
almost completely holds off the screen glass. Work with the use of a microcomputer is not uni-
The image on the video monitor screen is formed form. Depending on the task, it ranges from monot-
by an electron beam. Various magnetic and electro- onous performers (input of large arrays of data) to
static systems serve to focus and divert it. The beam intellectual creative work (programmers). In general,
is controlled by 15 to 22 kHz current, resulting in it is characterized by:
radio frequency electric and magnetic fields. The a) processing of significant volumes of informa-
latter also arise from the horizontal diversion system tion requiring intension and attention;
and its power generator. b) significant load on the psychosensory sphere,
The electromagnetic radiation from the displays primarily the visual analyzer;
is broadband - from 10 kHz to 26 GHz. At 10 cm from c) nervous emotional stress resulting from the re-
the screens, the intensity of EMF is within the hy- sponsibility of the work in proportion to the impor-
gienic norm (below 50 V/m), at 30 cm the radiation is tance of the information being processed;
below 6.5 V/m. However, maximum EMF values are d) a high degree of monotony with frequent,
measured at the back of the displays, which should accurate, uniform, short-term movements at high
be taken into account when disposing of them in a rates and repetitions (in some cases);
room. e) a fixed seating position with a load of mainly
There is evidence that the video monitor's kine- the small muscles of the upper limbs and a forced
scope also emits ultraviolet rays. Their intensity is position of the head, neck and upper limbs.
less than 1 W/m2, which is significantly below the The dialogue with the computer takes place
norm (maximum permissible value up to 10 W/m2). through a series of cycles, each of which involves
At work, the microcomputer also emits infrared three main activities: 1) entering commands or data,
radiation. Its main source is the heating of the cath- 2) monitoring the screen, and 3) reacting messages.

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Man Computer
Peripheral
Аnalysers devices

Аuditory Sound signal

Motorial
Keyboard Processor
Brain
Tactile

Visual Video monitor

Fig. 1. Scheme of human-computer interaction

In a more developed form, the human-computer Impact of display work on visual activity. Dis-
interaction is represented in the scheme of Fig. 1. eases.
The specificity of the microcomputer is largely One of the most characteristic effects on the
determined by the fact that there are consistently body when working with video monitors is visual
observed basic objects with different characteristics: fatigue. It is similar to the one on long-term TV
documentation, keyboard and screen of the video viewing.
monitor; in some cases even a printer, a scanner, and The most common symptoms in display moni-
more. toring are: burning eyes, nausea, tearing, redness,
Complaints with long-term computer work arise blurring, smearing and merging of letters, feeling of
not only from screen observation but also from the pressure in eyeballs. Eyelid complaints are usually
awkward working posture. Working with a micro- combined with headaches, most commonly in the
computer is characterized by a fixed sitting position head and forehead, to a lesser extent in the tempo-
with the head, neck, and upper limb being forced. ral area. Sometimes there is a feeling of nausea and
Prolonged work in such a posture is a prerequisite dizziness.
for limited motor activity (hypokinesia). Symptom of visual overload is also the decrease
The working movements of the computer, re- in the ability of the eyes to focus on the subject ob-
spectively with keyboard and "mouse", are mostly of served and to retain the fixation. Binocular vision
Class I and Class II - active fingers and hands. Most deteriorates with the appearance of a double image
busy are so-called big toes - index finger and middle (diplopia) and blurring of the image.
finger. Relatively rarely there are active movements Along with subjective complaints, longer work
of forearms and armpits (III and IV grade). Small mus- with video display worsens practically all visual
cle strength and a small amplitude of movement are functions: significantly reduces accommodation,
required. When entering large data sets, the high convergence, contrast and differentiation sensitivi-
speed of performing well-coordinated stereotypical ty, and the clear vision stability.
movements becomes necessary. A connection between the appearance of per-
Professional computer work is associated with sig- manent eye changes and display work is not found.
nificant neuro-psychical and intellectual effort due to Concerns about the occurrence of cataracts and
the high signal density (large number of signals/hour) myopia when working with a video monitor are not
that requires attention and memory intension. substantiated by sufficient facts.
Sometimes it is necessary to work under the con- In addition to general and visual fatigue, local
ditions of an acute time-pressure, which is a prereq- dynamic and static fatigue also develops in the op-
uisite, along with responsibility, for time-stress. It erator's body. The first is the work with the keyboard
too often leads to more pronounced changes in the and the second because of the fixed working pos-
body, particularly in the central nervous system than ture.
in physical work. Incorrect organization of the work process and

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the workplace is one of the prerequisites for the (natural or artificial) should always fall sideways, if
occurrence of possible occupational diseases. Pro- possible to the left of the workplace.
longed static intension combined with a fixed pos- Lighting should not dazzle the operator. Large
ture and rapid, often repetitive wrists and fingers reflective surfaces in the room should be kept to
can cause damage to the type of tendovaginitis. a minimum. Bright objects and surfaces are not
The need to carry out many frequent and rapid smooth, but matte. The same applies to the surface
stereotypical movements, e.g. when entering large of the display screen.
arrays of data, leads to dynamic intension on the fin- The ratio of screen brightness, keypad and work
gers. As a consequence, coordination neuroses, neu- surface of the table significantly influences work ef-
ralgia and polyneuropathy, microtraumopathy of ficiency. If it is irrational, visual fatigue occurs faster.
tendons, muscles and joints may occur, which may The recommended proportion in our country is 10:
subsequently cause chronic pain syndrome, that is 3: 1 or 5: 2: 1.
increased in activity. To limit the noise level, it is recommended that
Conditions resulting from physical overloading the printer have shutters and silencers. If there are
of muscles and joints during prolonged repetitive several printers, they should be placed in an adja-
movements are known under the name of Repeti- cent room if possible. This does not apply to low-
tive Strain Injury (RSI) or Carpal Tunnel Syndrome noise (jet and laser) printers.
(CTS). They are characterized primarily by discom- To reduce the static electric field, it is recom-
fort or pain in the muscles and/or joints. Local man- mended to increase the relative humidity of the
ifestations are pain, inflammation, edema, soreness, room, correct selection of floor coverings and cloth-
numbness, impaired coordination of movements. ing for workers with a minimum content of synthetic
There is also fatigue, muscle weakness, back pain, materials.
neck and shoulders. The work area for microcomputers typically in-
Long staying in a fixed working position with cludes several areas: keyboard and mouse, video
head and body inclination is associated with the monitor, input text or other information, scanner,
static load on the muscles of the neck area, shoulder printer, external modem, and more.
belt and waist area. In addition to a faster fatigue, Areas that are more closely monitored (keyboard,
the development of myofibrosis in these areas is screen, input text, etc.) should be approximately the
also possible. same distance from the eyes. This greatly reduces
Prevention of work the need for rapid accommodation adaptation and
Prevention includes various organizational, plan- may generally reduce visual fatigue.
ning, technical, technological, and oth. events. The The observed object is best viewed when it is
main ones are: within the optimum viewing angle. In a horizontal
• professional selection; plane, it is up to 40° left and right to the line of sight
• optimization of the environment parameters; for volume images and up to 60° for flat. In a hori-
• proper workplace organization and work po- zontal plane, this angle is: optimal - from 0° to the
sition; line of sight to the 30° downward, permissible - from
• compliance with the ergonomic requirements 30° up to 40° downwards.
for hardware and psychophysiological re- The height of the work surface (table, desk, pan-
quirements for the software; el) and seat height should provide an approximate-
• optimizing the visual activity ly horizontal position of the forearms. It is desirable
• introducing appropriate work and rest regime. that the height of the table can be adjusted from
The illumination of the workplace must be 680 to 760 mm. If it is unregulated, its recommend-
based on the nature of the work performed and the ed height is 720 mm (Figure 2).
type of screen. It is recommended to reduce the am- Work chairs must be adjustable. It is recom-
bient light when working with a darker screen. Un- mended that the height of the seat can be changed
der negative contrast (bright characters on a dark from 40 to 50 cm above the floor. The backrest
screen) it should be at least 300 lx, and with positive should provide support for the spine in the area of
contrast - 500 lx. the waist - resting in the area of the lumbar verte-
The window should not fall into the field of view brae around a palm above the seat. This is possible
of the operator. In some cases it is necessary to place at a height of its median to the seat of 17 to 25 cm.
windows with vertical lamellae, and on the comput- In some cases it is advisable to provide support
er - a sunshade. for the legs. The most ergonomic dimensions for
The luminaires should be located parallel to the such a stand are: 45 cm wide, 35 cm deep, 0 to 15 cm
windows and have a 30° protective angle. The light high, 0 to 30° slope.

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Fig. 2. Working furniture for use with a computer

When there are several computers in one room, it A basic condition for avoiding disruption and
is of no doubt what their mutual placement will be. damage to health is that all components of the com-
The ordering of workplaces one behind the other is puter configuration meet the ergonomic require-
not the most appropriate because maximum values ments.
of electromagnetic radiation (albeit substandard) For optimum visual performance, good video
are measured to the back of the displays. In order to quality is required: with minimal flicker, higher res-
reduce the potential occupational risk, it is advisable olution, higher separation rate, more raster lines and
to work respectively computers are in line with one lower-level of radiation(Non Glare, Non Interlaced,
another or symmetrical about one axis (Figure 3). Low Emission, Low Radiation).
Preferred is the positive contrast
of the screen - dark characters on a
light background, where glare and
reflections are smaller than negative
contrast, and the adaptation of the
eyes to different brightness is easier.
An important indicator of display
quality is the frequency of horizontal
beam deflection. To achieve a high-
er resolution (e.g., 1025 x 768 dots),
a non-interlaced, non-skipping lines
and associated image flicker is re-
quired. This requires a frequency of
about 50 Hz. If a higher resolution
graphics adapter is used, ergonomic
positions require a frequency great-
er than 75 Hz.
To customize the screen, it is de-
sirable to have a "sponge" stand that
allows the monitor to be adjusted
horizontally and vertically. Optimal
for vision is the front vertical (or
sloped back to 15°) screen position.
Fig. 3. Mutual deployment of multiple computers

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To avoid the intension of the muscles of the eyes, with closed lids. This has a favorable effect on the
neck and back, the horizontal line of sight should fall blood supply to the eyes and the eye pressure. To re-
at the top of the screen. The recommended eye dis- duce accommodation fatigue, it is desirable for the
tance for different authors is 400 to 700 mm. eye to move away for a short time to more distant
To prevent visual fatigue, it is necessary during objects - more than 2 m from the eyes.
the breaks to make a light massage of the eyeball

REFERENCES

1. Berthelette, D. Visual Display Units. In Encyclopaedia of Occupational Health and Safety, International
Labour Office, Geneva, 1998, 4th edition, vol. IV, 52.1 - 52.38.
2. Demirchoglyan, GG Computer and health, Moscow, Lucomorie, 1997, 254 p. (in russ.)
3. ISO 9241-3 - Ergonomic requirements for office work with visual display terminals (VDTs) - Part 3: Visual
display requirements. 1992.
4. Koicheva, V., V. Zlateva. Changes in the functional state of the visual system when operating on video
terminals. J Hyg. and publ. health, 1992, 4, 19-22. (in bul.)
5. Ordinance No. 8 on Hygiene Requirements for work places for Video Displays. SG. 29 of 5.04.1996 (in
bul.)
6. Ordinance No. 7 on the minimum requirements for ensuring healthy and safe working conditions for
work with video display. SG, 70 / 15.08.2005. (in bul.)
7. Stefanov, B. Bulgarian and European hygienic-ergonomic norms for computer work. Computer, 1996,
8, 49-54. (in bul.)
8. Stefanov, B., V. Birdanova. Hygienic-ergonomic evaluation of computer keyboard layouts. J Hyg. and
publ. health, 1997, 2, 3-6. (in bul.)
9. TCO-95 Certification. Requirements for environmental labeling of personal computers. Report 1, Third
Edition, Stockholm, 1996.

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E. Dincheva

17.9 ELECTRICITY PRODUCTION

In the modern world, electric power production gen gases are released. Their quantity varies widely
is in the base of economic life. In Bulgaria, this sector depending on the trouble free of the technological
is mainly represented by the production of electric- and purification facilities (feeders, electro filters,
ity in the thermal power plants (TPP), where about etc.) and can exceed the MACs several times. Work-
2/3 of the electricity is produced and by the nuclear ers from the "Chemical Cleaning" and "Reagent"
power plant (Nuclear Power Plant), which produc- departments are in contact with hydrogen chlo-
es 1/3 of the electricity. A small part, about 10%, is ride, sulfuric acid and hydrochloric acid, ammonia,
produced in hydropower plants (HPP). Unconven- benzene, hydrocarbons, etc., whose concentrations
tional ways of production electricity, such as wind, also, although rarely, can exceed the limit value. In
solar radiation or biomass, are little included for our the welding activities, the gas welders and other re-
country, and in other countries are also at the exper- pair staff are also exposed to various metal aerosols,
imental stage or with limited, local and partial pow- ultraviolet and infrared radiation.
er supply. Other widespread environment factors in power
generation and power distribution are the electric
17.9.1. THERMAL POWER PLANT and magnetic fields with industrial frequency (50-60
Hz). They are emitted in open distribution devices,
The TPPs operate with liquid, solid fuel or gas. from indoor distribution devices (IDD), and from
In our country the most common solid fuel is used, high-voltage power transmission lines themselves
such as coal from the Marish coal-mining basin, Bob- to intermediate transformer stations or to consum-
ov dol or imported. The TPP consists of the follow- ers. Intensity of the electric field is directly related
ing main sectors/facilities: 1. Coal/oil sector; 2. Boil- to the voltage (V), while the magnetic induction is
er-turbine sector (power equipments). higher at a higher current (A). The two electromag-
1. Working conditions. netic field components (electric and magnetic) are
а). Factors of the work environment. Exposure rapidly diminishing by moving away from the power
to coal dust can lead to pneumoconiosis and chron- lines, while in the ODD and the IDD their intensities
ic pulmonary bronchitis. In spent fuel (periodic depend on the location of the equipment.
cleaning of furnaces), due to the burning of carbon b). Factors of the labour process. The uninter-
and organic materials, silica in the dust increases rel- rupted process inevitably necessitates a shift op-
atively. erating regime for all operational and part of the
Noise is another unfavorable factor in the work- service staff. Working on two extended 12-hour
ing environment in the thermal power plant. Gener- shifts - day and night, the rotation takes 2 consecu-
ally, it can be characterized as constant "white" noise tive shifts and provides longer breaks and frequent
with considerable intensity. At most work places in breaks between shifts (24 or 36 hours). Such mode
"Boiler" and "Turbine" sectors, the noise exceeds 85 is preferred because it reduces transport time and
dB/A. Abnormal noise levels are also found in a num- the adverse effect of night work, which is only in two
ber of workplaces and in the transport and repair consecutive nights.
mechanics workshops. In most work places, labour can be characterized
A large percentage of workers work in an envi- as labour with moderate physical workload, and that
ronment of unfavorable microclimate. Many of the of the operating staff has marked nervous sensory
workers in the process of coal feeding and slag and mental intensions.
purification work all year round in the open, in the 2. Main professions.
conditions of overheating microclimate during the For operational staff, the main professions are
summer and mosaic or overcooling in winter. In the those of boiler operators, turbine operators, fuel
machine rooms of "Boiler" and "Turbine" and in the transport belt operators and switchboard operators.
slag removal, the air temperature is up to and above Their workplaces are mainly in the control rooms
40 ° C during the warm seasons. but they also carry out checks on the control devic-
In the process of combustion of coal in the work- es located in the machine rooms and on the course
ing environment, carbon monoxide, sulfur and nitro- of the equipment. Their work is characterized as a
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high-responsibility nervous-sensory. In normal op- exist with respect to ecosystem damage when wa-
eration, the information on the indicator devices is ter resources are diverted to artificial reservoirs and
rarely changed. The rare occurrence of relevant sig- canals.
nals leads to an information deficit that, along with In the HPP, unlike TPP, there are no such factors
the monotonic noise (around 65 dB / A) and reduced as dust and overheating microclimate. The main ad-
motor activity, creates a condition to develop un- verse factor of the working environment remains
pleasant mental conditions such as monotony and noise. In turbine halls, it exceeds the ALL-85 dB/A.
annoyance, and to reduce the human body's vigi- In the control room the noise level is within the hy-
lance and reliability in man-machine system. Oper- gienic norm - 65 db/A. Secondly, electromagnetic
ator fatigue occurs as a result of voluntary efforts to fields, whose intensity depends on the location of
maintain activity when all other factors lead to sup- the distributiv devices, transformers, etc.
pression of activation processes. In a hydropower plant where the turbine and
A large group of professions (fitters, welders, command room are underground, the artificial light
electricians, craneists, etc.) can be joined as repair problems are not only in terms of their physical and
and maintenance personnel. This group has been ergonomic characteristics but most often with the
exposed for a long time to the harmful factors of absence of changing illumination as a psychological
the work environment. Work is usually moderately equivalent in the dark and the light. The latter is im-
in terms of dynamic physical loads, but it involves portant for the activation processes of the operators.
considerable static effort. In the halls underground there may be an increase
3. Health Effect. in the natural background radiation, the intensity of
Occupational diseases can occur as a result of which varies depending on the geochemical com-
dust exposure (chronic bronchitis, anthracosis, position of the rock/earth masses.
mixed type pneumoconiosis). High noise levels may Major professions in HPP are those of turbine op-
be the cause of professional deafness development. erators, maintenance and repair staff.
Overheating microclimate and shifting work fa-
vor the development of gastritis and stomach ul- 17.9.3. NUCLEAR POWER PLANTS
cer. The extra-aural impact of noise, shift work and
a number of unfavorable work-related psychosocial Electricity from the NPP is cheaper than the TPP
factors increase the risk of cardiovascular disease at an average of 1.2 to 1.9 times (in Bulgaria it is
and dyslipidemia. cheaper 2.3 times). Logically, here are a number of
Prophylactic events should be addressed to pros and cons, such as: presence of local or imported
technical improvements (eg. reduction of noise by raw materials; environmental pollution; removal of
shielding, reduction of thermal radiation by shield- technological waste; operational safety; providing
ing), and other medical-prophylactic measures. The qualified personnel; sociopsychological feelings of
latter first require regular prophylactic examinations the population and others.
aimed at uncovering yet unmanifest clinicaly profes- Since their creation in the late 1950s, nuclear
sional pathology - early functional changes. Emer- power plants have not undergone any significant
gency workers need to be expelled in a time their change in terms of principle. Today, in the world,
unhealthy working conditions (eg. patients with ul- power plants are operated from the following main
cer disease at least during periods of exacerbation types of reactors: light water reactors with pres-
do not work at night shift). Another group of med- surized water; light water type "Boiler"; light-water
ically-prophylactic events is aimed at limiting the reactors with graphite neutron retarders; reactors
specific impact of adverse factors on the work en- with heavy water under pressure; heavy-water gas-
vironment, eg. a suitable nutrition and drink regime cooled reactors. Reactors from Kozloduy NPP are wa-
for those working in a overheating microclimate, the ter-water reactors - WWR-440 model B 230 and WWR
provision of antiphonics to workers exposed to ab- 1000 - model 320. They are light water with pressure
normal noise levels, dust masks for workers exposed water, working with slow (thermal) neutrons.
to dust. How does the reactor ("Boiler") work? In the NPP
turbines (as well as in thermal power plants), the ki-
17.9.2. HYDROELECTRIC POWER PLANTS netic energy of high-pressure hot steam rotates the
generator rotor, generating electrical energy. Work-
From the ecological and economic point of view, ing turbine steam pass into a condenser where it de-
HPPs are the preferred source of electricity. They livers its residual heat and liquefies (this also produc-
produce the cheapest electricity and do not pollute es secondary steam for technological purposes). The
the environment. An adverse ecological effect may liquefied steam (water) is pushed by pumps to the

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steam generator, which evaporates as a result of its of the generated 50 Hz electric current.
contact with pipes in which circulating heated wa- b) Factors of the labour process. NPP is compli-
ter up to 320 ° (the so-called "primary circuit") - this cated, requiring modern management energy com-
is taken away by the nuclear reaction in the reactor plex, which operates 24 hours a day.
Heat that flows through the walls of the pipes, in The most responsible place in the plant is the op-
so-called "second circuuit". It is important for radio- erating staff who controls the operation of the reac-
protection that in both circuits there is independent tors and the turbines, the engineers responsible for
water flow from each other. the entirety operation, the managers of the power
The nuclear reactor is a thick-walled metal cylin- units, the shifts, etc., Their work is classified as labour
der made of high-strength steel. In his bottom, in so- with very high neurosensory and neuro-emotional
called "Scoop" locates: 1. cassettes containing sev- intension, and the operational working time is over
eral dozens of fuel elements (zirconium alloy tubes) 95%, which shows an extremely intense workload.
with nuclear fuel (a mixture of 235U and 233U in an Reactor parameters are also monitored, and some
appropriate ratio). 2. control elements (rods similar (which constantly monitored and are most im-
to the fuel elements but made of boron steel) which portant) being call actively on the control system
are arranged in the form of a honeycomb; 3. neutron displays. The work requires a very frequent audio
retardants - light hydrogen is used in the form of connection (vertical and horizontal) with different
water. In WWR reactors, this water is used both as a groups and process managers. It imposes great de-
cooler and as a heat carrier. mands on the memory, the processes of attention,
The Kozloduy NPP has 4 power units with the thinking, requires the consideration of many facts.
WWR-440 reactor type (closed in 2007) and two The speed of technological processes often requires
WWR-1000. responsible decisions to be made in a time deficien-
1. Working conditions. cy. This, together with the extremely high responsi-
a). Factors of the work environment. Most atten- bility, determines the high stressful character of the
tion and control deserves the ionizing radiation fac- work.
tor. The operation of the Kozloduy NPP during the Another large group of workers are those from
whole operation period has not shown an impact on the repair and maintenance staff. Unlike similar pro-
the radiation parameters of the surrounding objects fessions from other industry branches, there is re-
and the environment. Relatively higher doses of ra- quired a lot of knowledge, precision and accuracy to
dioactive radiation are recorded there in non-ser- perform the job tasks.
vicing (with rarely human presence - only in repairs It works in 3 shifts of 8 hours, the total working
and exploitation abnormalities) premises, and in hours balance for the month being calculated based
others they are far below the allowable. The annu- on a 6-hour working day.
al dose limit (ADL) for irradiation of workers in the 2. Health effect.
environment of ionizing radiation (including NPP As a result of the radiation impact, stochastic and
personnel) is 50 mSv. According to the Kozloduy non-stochastic effects are possible. The stochas-
NPP dosimetric service data from 1986 until now tic effects are linearly dependent on the absorbed
the radiation above 50 mSv has received only 48 dose and are considered to be non-threshold - these
workers from a total of 2000 controlled, which dose are the damage to the somatic and genital calls ge-
is compensated for the next 5-10 years (according nome. The dose/effect relationship is expressed in
to radiation protection requirements). The average the statistical probability of increasing the preva-
annual individual dose there for the entire lifetime is lence of cancer in the population.
in the order of 9-10 mSv. The main, so-called "Dose In the case of non-stochastic effects, injuries (dis-
expense" was realized during the repairs of the first eases) are manifested when the dose is exceeded.
four blocks (WWR-440). Increased dose increases the severity of the disease.
Noise is a widespread unfavorable factor in the Non-stochastic effects are acute and chronic radia-
work environment. Generators of excessive noise tion illness, radiation skin burns, eye cataracts, em-
levels (over 85 dB/A (turbines, pumps, compressors, bryonic damage.
etc.) In the power control rooms, the noise is below High nervous-emotional intension, shift and
65 dB/A. night work increase the risk of cardiovascular dis-
The microclimate is overheating in the halls of ease, gastritis, stomach ulcer, and other psychoso-
the "Turbine" shop where during summer the air matic diseases.
temperature reaches 36-38 ° C, but there workplaces Personnel working in the strict regime zone (zone
are non-stationary. A) undergo special medical surveillance, periodic
Other factors are the electric and magnetic fields medical examinations are directed to the search for

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early stochastic and non-stochastic effects. These workers are subject to personal control by individu-
persons are dispensary and the medical information al dosimeters for external exposure. Strict control of
is stored (and compared in subsequent inspections) contamination of working surfaces, working clothes,
up to 30 years after leaving the job. Persons over age skin, air, and transport equipment is carried out.
of 18 are admitted to work; which have no haematic For workers in category B work, on controlling
disease, organic and systemic diseases of the central the dose rate of external radiation and the concen-
and peripheral nervous system, precancerous dis- tration of radionuclides in the air.
eases, chronic diseases of the gastrointestinal tract, In order to maintain a high level of work capacity
diseases of the liver and kidneys and other diseases and security at work, effective professional selection
attacking the critical organs. of staff, optimal working and rest regime, providing
The dosimetric control of the personnel is carried conditions for high motivation for work and con-
out by a special service of the power plant. Zone A stant qualification are required.

REFERENCES

1. Atanasov, G., N. Gouzin, T. Todorov, NPP - "yes" and "no". II ed., "Cydiprevantiva" - OOD, Sofia, 1997,
128. (in bul.)
2. Buchanan, J.C., S.O. Davis, M.D. Dunnette, Behavioural reliability program for the nuclear industry.
prepared for the U.S. Nuclear Regulatory Commission, 1986.
3. Crane M., N. McManus, A. W. Jackson, W. G. Morison, J. Fox. Power generation and distribution. In
the Encyclopedia of Occupational Health and Safety, 4 th edition, ed. Chief J.M.Stellman, 1998, Geneva, Int.
Labour office, 76.2-76.16.
4. Frank, F.D., L.S. Lindley, R.A. Cohen., Standards for the psychological assessment of the nuclear facil-
ity staff. Prepared for U.S. Nuclear Regulatory Commission, 1986.
5. Golikov, W.I., N.Y. Tarasenko, Working with sources of ionizing radiation. Work on nuclear power
plants, in Manual of labour hygiene, V. II, ed. N.F. Izmerov, Moscow, Medicine, 1987, 409-413. (in russ.)
6. Regulation for the safety of nuclear power plants. SG, No. 66 / 30.07.2004 (in bul.)
7. Vassilev G.,Ionizing radiation and the risk for the Bulgarian population. Doctoral thesis, 1984 (in bul.)

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Iv. Paunov

17.10 TRANSPORT

Transport hygiene is a complex prophylactic vessels - supporting and cleaning the depth and
medical discipline that combines the hygiene of rail, bottom of the canals, new construction, extraction
water, road and air transport, as well as the hygiene of inert materials, etc. - dredgers, suckers, floating
of labour in road construction. cranes, etc.
In the structure of stationary transport sites (fac- The main professional groups are: Group I - for
tories for new construction, repair plants, landfills, the ship-navigation and its direct service. It is sub-
garages, hangars, etc.) are usually included the cor- divided into a navigator command (involved in ship
responding departments of the machine-building navigation) - captains mates, captain's, pilots and
industry. The working conditions in them essential- helmsmans and deck command - radiotelegraphist,
ly are different from those in the machine-building boatswain and sailors; Group II - service engine
plants. room, electrical equipment, navigation and refrig-
The implementation of an uninterrupted 24-hour eration installations and other auxiliary mechanisms
organization to ensure safe movement is carried out and aggregates (machine command) - chief engi-
by several main categories of personnel: drivers neer, electrician-, refrigerator- and repair engineers
who directly manage the means of transport (rail- and technicians, machine boatswain, motorists, etc
way drivers, assistant railway drivers, captains, ship .; Group III - ship administration, household and oth-
pilots, car/bus/truck drivers, aviators, etc.); person- er service staff (housekeeping command): providing
nel providing remote control or route for the move- the nutrition of the ship - host, chef, baker, confec-
ment of transport means (motion managers, air traf- tioner, cameramen, loundresser; on passenger ships
fic controllers, railway-, airline-, naval dispatchers, - hotel and restaurant managers, waiters, barmans
radio operators, etc.); personnel servicing vehicles, buffet attachment, telephonist, librarian, doctor,
passengers and freight during the movement (rail- dentist, nurse and others.
way assistant drivers, conductors, chieftains, stew- In the water transport, besides the floating staff,
ardeses, stewards, cabin attendant, etc.) and during there are also coastal positions - coastal radio op-
their stay (control wagons, maneuvers, signalmans, erators, dispatchers, light-housekeeper, ship repair
flight mechanics, luggage and ticket cashiers, repair- workers, dockers, mechanics of the ports, etc.
ers of various modes of transport, etc.); staff who are Microclimate. The meteo factor of the ships is
currently supporting the means of transport (repair one of the most dynamic and varied in intensity of
workers in rail, road and water transport); staff for physical factor that constantly affects their crews. In
electrification in railway transport, new construction different areas of sailing it is different and is deter-
of railway tracks, sea and river canals, roads, tunnels, mined by climate and weather.
loading and unloading workers, etc. The microclimate of open decks wholly depends
on the macro climate, but they are not identical. Dif-
17.10.1. WATER TRANSPORT ferences exist especially during warmer periods and
intense solar radiation that heats ship's metal deck
Water transport by origin is the oldest mode of and superstructure. The latters give heat, whereby
transport. The main professional groups in it are the the air temperature on the deck rises by an average
crews of the ships. The latter, depending on their of 2 ° C. Thermal radiation also increases. In winter,
purpose, are: passenger - motor, underwater wings, conversely, cold metal structures create conditions
etc.; cargo - bulk (ore, coal, grain, etc.), liquid or gas- for negative radiation balance.
eous (tankers), container vessels, etc., and special Modern systems for heating, ventilation and air
vessels - ferries, thrusters, towboats, to maintain the conditioning of ships throughout the year create ac-
cleanliness of port and marine areas (oil-collector for ceptable levels of microclimate in the ship's operat-
seaport harbors and for the open-seas, solid waste ing and living spaces, of exceptionthe engine room,
collectors, motor and non-power feed tankers, bar- the kitchen unit, and some other rooms with heat
ragers, etc.), fishing and processing fish vessels sources where over-values are measured, reaching
(trawlers), construction and technical fleet's (CTF) 40-42°C. The creation of central control panels (CCPs)

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and the remote control of marine engines minimizes power tools - drills, electric flexes, riveting guns, and
the exposure of sailors to similar temperatures - only more.
for repair works in the engine-boiler section (EBS). In all ships, looking at their vibrational character-
A characteristic feature of the microclimate in istics, it is not possible to ignore the swinging of the
water transport is the ability of crews to change ships (vertically, laterally and longitudinally), result-
climate zones several times during one trip, which ing in irritation of the vestibular apparatus and the
brings increased requirements for thermo-regula- occurrence of marine sickness.
tion of the body. Lighting. The natural lighting in the ships is
Noise. Noise in ships is supported by a large num- made of illuminators (phyllins), side windows and
ber of sources, but the main engines, auxiliary mech- sky-lights.
anisms (diesel generators, compressors, pumps, etc.) In the EBS, CCPs, technical workshops and com-
in the EBS, the screw propellers, the heating, ventila- partments, holds, etc., located under the waterline
tion and air conditioning systems, some household all the day, are artificial lighting, which is fire- and
facilities, and in the specialized ships at the machin- explosion safety.
ery and equipment specific to the ship. Noise in Chemical Dangers. Originally they are external
ships, apart from airborne, also spreads indirectly as (the background concentrations of the harmful sub-
a structural noise. Another feature is that it has effect stances contained in the atmospheric air of the area
not only during the shift, but also during leisure, i.e. of residence of the ship) and internal ones. Also im-
around-the-clock, throughout the trip. portant here are the limited spaces of the working
Maximum values are measured in EBS - 101-102 and household spaces in the ships, allowing for a
dB/A (in thrust, towboats and trawlers); in ships sup- short time their saturation with relatively high con-
porting seawater purity - 96-104 dB/A; in ferries and centrations of toxic agents.
cargo ships - 107-108 dB/A; to 118-120 dB/A in un- Internal sources of chemical damages are:
derwater wingships. 1. From the energy sources and the lubricating
In other work and living areas, the noise level de- oils (aromatic hydrocarbons, sulfur compounds,
pends on the type, and size of the ship, the location etc.) and their waste products (exhaust gases) - CO,
of the superstructure over the EBS, the availability CO2, NO, SO2, H2S, soot, carcinogens, incl. 3-4 ben-
of its own sources of noise, and so on. - 84-86 dB/A zpyrene and the like. They are predominantly found
in the radio station cabins, 54-58 dB/A captain's in the EBS, but can not be ruled out in the adjacent
bridge, 43-56 dB/A crew saloons, 34-52 dB/A sleep- rooms. In 20% of the EBS samples, average petrol va-
ing rooms, and so on. por concentrations about 450.0 mg.m-3, unsaturated
Infrasound. In underwater wing ships, the infra- hydrocarbons - 220.0 mg.m-3, CO - 30.0 mg.m-3 are
sound rate is on average 93 dB. Opening the side measured. Average concentrations of petrol vapor
windows increases its level to 94-104 dB. In the 100-150 mg.m-3, unsaturated hydrocarbons - 50-70
engine compartments of this type of vessel, the in- mg.m-3 and CO - 7-12 mg.m-3 are recorded in the ad-
frasound is 86-96 dB (stopping ships) to 86-103 dB jacent premises.
(during movement). 2. Harmures emitted by different facilities, in-
In the EBS on sea vessels, the infrasound intensity stallations, utilities and people: polymeric materials
is from 64-88 dB (on the quay) to 82-114 dB (in mo- (various hydrocarbons, CO, phenol, formaldehyde,
tion). In the living premises of these ships, the infra- ammonia, styrene, polymethyl methacrylate, chlor-
sound level is 77-97 dB. When moving ships in a ruf- vinyl, etc.); paints, lacquers, enamels, etc., used in the
fle sea (Beaufort number 6), the level of infrasound construction, repair and maintenance of metal and
increases sharply in all rooms and reaches 124 dB. wood surfaces; refrigeration installations during re-
Vibration. Numerous external and internal pairs or accidents (ammonia, chloromethyl, freons,
sources generate vibrations of varying frequency etc.).
and amplitude - low frequencies with a long period 3. Hazards arising from the transported solid,
(swinging) from the impact of water masses, period- liquid or gaseous cargo - e.g. during loading and
ic - from screw propeller and basic - from the opera- unloading activities of tankers in pumping compart-
tion of engines and other aggregates of ships. ments, concentrations of hydrocarbons up to 3000
Measurement results show that for most ships mg.m-3 are recorded, and in enclosed spaces up to
the vibration velocity of general vibrations is over- 200-300 mg.m-3.
norms, with a peak usually at 8.0, 16.0 and 31.5 Hz Dust. The crews of bulk carriers (coal, ore, grain,
- 0.2 to 1.0 m.s-1.10-2. etc.) are exposed to dust during port loading opera-
Local vibrations, with over-norms values, are typ- tions and their deck commands additionally and in
ical of ship repair using hand-held pneumatic and transit - in hand-cleansing the holds and the deck.

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Maximum total powder concentrations reached hearing analyst.
300.0 mg.m-3. In the living quarters of these ships The work of sailors from the deck command is
concentrations of 1.0 to 62.0 mg.m-3 are measured also mostly physical and often occurs in forced la-
during loading operations. The powder is mostly bour postsure.
finely dispersed (less than 5 μm) with a free crystal- Work and rest regime. Continuity of the trans-
line silica content of up to 2%. port process, incl. and in the water transport requires
Sources of pollution can also be ship machines a change of mode of operation (including at night).
and equipment that emit powder dust - smoke, soot The working regime in water transport are charac-
and others. terized by: often long working hours, intermittent
The painters (when removing the rust and the night work and frequent transition from one shift to
old paint) and the electric welders are exposed by another. For example, in the navigational and ma-
the dust. chine commands of ships based on an 8-hour work-
Electromagnetic radiation. Sources of non-ion- ing day, the shift is divided into two parts (watches)
izing radiation - HF, VHF and UHF in water transport - daytime and nighttime of 4 hours with an 8-hour
are the means of radio station and radio navigation. break between them. The Captain, chief mechan-
One of the most powerful sources is ship radio sta- ic and the radiist are on an unnormalized working
tions. day. The remaining members of the crew are on an
For example, the intensity of the HF EMF on the 8-hour regular shift. There are no regulated week-
electric component is measured in river vessels at ends.
the work of SV and AM transmitters with average Factors aggravating the sailor's work and rest re-
power respectively: around the feeder tract of SV 50- gime are the length of the voyages reaching up to 6
2000 V.m-1, at AM - 150-2000 V.m-1; at the workplace months or more (in trawlers).
of the radiist - 20-300 and 50-600 V.m-1.
Ionizing radiation. The crews of nuclear-pow- 17.10.2. RAIL TRANSPORT
ered ships may be exposed to ionizing radiation.
Another X-ray radiation source can be used in Rail transport appeared at the end of the 19th
X-ray equipment. Ship crews may also be exposed century and was the second type of public transport.
to ionizing radiation and to the transport of radioac- The main professional groups in it are: drivers -
tive material. drivers and assistant drivers; staff providing remote
Biological factor. Ship crews, when sailing to control of trains - motion-heads and dispatchers
different continents, can become infected and carry (train, wagon, locomotive, energy dispatchers); staff
malaria, cholera, yellow fever, etc., and AIDS. At the handling the means of transport, passengers and
risk of contamination, crews of ships are also sub- freight while in motion - train master, conducers,
jected to the transport of animals or of their prod- stewards, etc.; staff servicing trains, passengers and
ucts - skins, bones, wool, etc., as well as fish process- freight at railway station - auditor wagons, descrip-
ing and fish meal production. tor wagons, shunters, signalman, ticket and bag-
Nature of work. The work of seafarers differs sig- gage cashiers, etc.; staff organizing and controlling
nificantly from that of other transport professions - driver graphics and health - depotmasters and per-
work and rest are carried out in the same place, in an sonal performing pre-railway medical examinations;
environment separated from the typical social and personnel assuring the technical condition of the
family contacts on land. locomotives and wagons before leaving the depots;
In sea captains, labour is typically mental, with maintenance workers on the contact network and
considerable nervous sensory and psycho-emotion- the railway; workers in electrical substations; tele-
al intensions with great moral and material respon- phone operators; teletypists; informants; workers in
sibility and high qualification. locomotive and wagon-equipment depots, in facto-
The work of the helmsman is executive, with a ries and others.
significant sensory load, a standing posture and no Microclimate. Many railway workers carry out
significant physical effort. their labour duties throughout the working shift in
The mechanics' work is mental, requires a long fo- the openair-auditor wagons, wagon-descriptors,
cus of attention, nervous sensory and psycho-emo- shunters, signalman, repair workers and new con-
tional intensions, but also a considerable and fre- struction of the contact network and the railway
quent physical effort. track.
In the case of engine mechanics, fireman, and Workers in the emergency maintenance of the
machine boatswain, labour is primarily physical, contact network, the railway track, the telephone
with a significant sensory load, especially on the connections, the facilities along the railway track

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and the railway station, etc. also work outdoors, but ms-1.10-2 (at 2.0 Hz) to 0.07-0.11 ms-1.10-2 (at 63 Hz),
only when needed. and for the diesel locomotives of 2,39-3.96 ms-1.10-2
Existing heating in locomotives, passenger and to 0.16-0.17 ms-1.10-2.
service wagons provides for acceptable values of As the locomotive's speed increases, the mean
microclimate parameters during the cold periods of values of both measured locations increase.
the year. During the hot seasons of the year, how- The vibration velocity of the electric locomotive
ever, due to lack of reliable thermal insulation and controller's for local vibration at 60 km.h-1 at 8 Hz is
ventilation in the cabs of diesel locomotives, tem- 1.50 m.s-1.10-2. With increasing frequency, the values
peratures of up to 40 ° C are measured, and in the decrease and at 1000 Hz reach to 0.009 m.s-1.10-2.
electric vehicles - 36-37 ° C. Similar values are also For diesel locomotives at the same speed, the
recorded in passenger wagons (in new locomotives values are 0.83 m.s-1.10-2 and 0.007 m.s-1.10-2 respec-
and air-conditioned wagons the microclimate is op- tively.
timal). Objective the vibration load of the train drivers
Workers at depots and railway repair workshops, in% to the admissible level of fatigue for 8-hour shift
especially those in the halls, during the cold periods (with three-component accelerometer according to
of the year often perform their labour duties at tem- ISO 2631) shows that the drivers of the motorways
peratures below acceptable levels. exceeded the norm by 48%, those of the highway
Noise. The noise in rail transport is generated by diesel locomotives by 6% and the drivers of the
locomotive engines, specialized self-propelled ma- shunting locomotives load only 1/3 of the allowable
chinery and equipment used in the construction, re- rate.
pair and maintenance of the track. A certain part in The vibratory characteristic of the specialized
the noise characteristic of the rolling composition is machines used in the construction, repair and main-
so-called. "Traffic noise". tenance of the track is even more complicated and
In the cabs of diesel locomotives noise levels difficult to estimate. The monotonous and steady
in the range of 64 to 119 dB/A are recorded, 66-90 state of the engine, the chain, the sieve and the con-
Db/A in shunting locomotives and 42-86 dB/A in veyor belt, and the greater the length of the ballast
electric vehicles. In coaches during a flat-plan mo- sieving machines, determine constant high values
tion, the noise level is 42 to 78 dB/A, and when driv- of the general vibration. In the case of transvers-
ing in a tunnel the noise level reaches 92 dB/A. Spe- ing machines, the general vibrations have a cyclical
cialized self-propelled machinery supporting the character, corresponding to the duration of the tie
track also generates high noise levels: ballast sieving tamping, and are defined vertically and transversal-
machines - 57-105 dB/A, transversing - 60-107 dB/A. ly. Longitudinals are considerably weaker, but their
Infrasound. For diesel locomotives, the main characteristic is compounded by low-frequency
source of infrasound at a stationary locomotive is its jump with low frequency and significant amplitude
engines, which generate infrasound with an inten- when moving the machine onto the next sleeper.
sity of 79-102 dB. The opening of the side windows The maximum exceedance of the permissible limits
increases its level by 4-10 dB. When the electric ve- (18 times) is at 31.5 Hz and the minimum (2.3 times)
hicle is stopped, the level of infrasound is 47-64 dB. at a frequency of 2.0 Hz.
The level of infrasound increases with increasing The general vibrations of the sieving and tie
speed - when moving with 130 km.h and an open tamping machines considerably exceed the permis-
one side window is measured 126 dB. sible norms - 2-18 times, and the local ones are with-
Vibration. The locomotive drivers, the staff han- in the limits. However, when working with manual
dling the trains while driving, and especially the tie tamping machines, their values exceed the toler-
drivers of the specialized machinery for the con- ances allowed several times.
struction, repair and maintenance of the track dur- Chemical dangers. By replacing steam loco-
ing work are subjected to combined general and motives with diesel, and subsequently with elec-
local vibrations. tric, chemical characteristics in locomotive booths
The vibration speed of the general vibrations on abruptly improved (especially with the replacement
the floor of the electric cabs is 2,64-5,13 m.s-1.10-2 (at of mercury rectifiers of electric locomotives with sil-
2.0 Hz) to 0.08-0.11 m.s-1.10-2 (at 63 Hz). For diesel lo- icon).
comotives due to their higher weight, these values At present, the main chemical hazards in railway
are lower - from 2.41-3.36 m.s-1.10-2 to 0.140.18 m.s- mobile composition are registered with diesel loco-
1
.10-2. motives and specialized machinery for the construc-
On the seat, the vibration velocity of the general tion and repair of the track. They are separated from
vibrations is: for the electric locomotives of 3,09-4.21 their engines.

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In the cabs of diesel locomotives, petrol con- The main mode of work and rest in the railway
centrations up to 600.0 mg.m-3, benzene - 0.17-1.50 transport is the extended 12-hour shift - a day (7-19
mg.m-3, toluene - 0.14-1.72 mg.m-3, xylene to 0.108 h) with a subsequent 24-hour rest, and a night (19-
mg.m-3, CO to 30.0 mg.m-3, SO2 to 2.0 mg.m -3, NO2, 7 h), followed by 48 hours of rest. That's work head
15-4.20 mg.m-3, CO2 - 1930-6300 mg.m-3 and oily aer- motion, dispatchers, depot masters, signalman,
osols - up to 11.0 mg.m-3. shunters, and others.
High concentrations of ammonia or freons from A specific working regime is performed by those
refrigeration installations are determined in refrig- working in the repair and maintenance of the rail-
erated trains - 76% of the measurements are above way tracks and tunnels. Here it works in a limited
MAC 1 to 25 times. time, the so-called "Technological windows" when
Dust. In the railway transport of dust impact are the movement of trains in the repair area is stopped.
exposed the loading and unloading workers, the Their duration is usually 4-5 hours.
workers in construction, repair and maintenance
of the railway track and the tunnels, the workers in 17.10.3. METRO
the repair of wagons transporting powdered loads
- cement, flour and others. The dust is of a different This transport is characterized by its higher traffic
nature, most commonly mixed - silica with metallic safety, greater passenger capacity and a higher op-
aerosols, iron oxide with lead minium, cereal pow- erating average speed compared to other modes of
der and the like. Its concentration depends on the public transport.
season and the humidity of the air. For example, a The main professional groups are similar to those
total dust concentration of 10.0 to 1250 mg.m-3 was in rail transport, but there are some peculiarities re-
measured during cement car repair. Over 80% is the garding working conditions.
fine fraction with content a free SiO2 of 0.8-1.8% and The fact that a large number of workers perform
fixed - 21-22%. their labouor duties in underground premises re-
Electromagnetic radiation. Railway-specific quires their equipment with powerful and effective
sources are traction substations that generate EMF ventilation not only in the working premises but
at work places up to 5.0 kV.m-1. also at the platforms of the metro stations and met-
Stationary dispatchers radio station screate EMF ro train wagons. Another key point is the realization
up to 10.0 V m-1 (on working tables) and up to 135 V of artificial lighting, which provides maximum com-
m-1 (for antenna cables). fort for work and travel.
In the electric locomotive booths of the 27.5 kV The microclimate is poorly influenced by the
mains, EMP values from 0.20 to 0.32 kV.m-1 are meas- macro climate and usually in the work rooms, and
ured. metro trains, is acceptable. low subterranean tem-
Nature of work. The dispatcher's work, heads peratures (below 10 ° C) and high air currents (7-8
motion, drivers and more is shift, under control to 10 m.s-1) are measured in the cold periods of the
(scheduled), with extended working shifts. The work platforms of the metro stations and in tunnels.
has neurosensoral and psycho-emotional tension. The driver's cab noise is 84 dB/A; the wagons are
High qualification and responsibility is required. 88-94 dB/A; and 73 dB/A (upon arrival of the met-
Higher requirements also exist for the hearing, and ro) and 86 dB/A (on departure) on the platform. The
for the drivers - and to the vestibular apparatus. movement of the metro train raises the background
In dispatchers and heads motion work is opera- noise in all working areas in the metro stations, and
tive, managerial, processing various and significant the continuous movement in the tunnel generates
information, quick switching of attention, making high levels of noise in the passenger carriages. This
important decisions, often in time deficiency. has high demands on their sound insulation.
Along with the operator's work in railway trans- The general vibrations in the metro train are
port, despite the mechanization and automation low-frequency with a peak at 2.0 Hz - 1.7 m.s-1 .10-2
introduced, there are still heavy-duty jobs - load- and sharply decrease with increasing frequency. The
ing and unloading workers, working on the manual rating for integral vibration velocity of the local vi-
maintenance and repair of the track and tunnels. brations of the metro trains control levers is 0.4 m.s-1
Work and rest regime. The duration of the work .10-2.
shift of locomotive and train staff is different and Toxic substances (CO2, CO, NO2, hydrocarbons,
depends on the category and type of train, while etc.) and dust can pollute airspace in metro stations
starting and ending hours are at any time of the day. and wagons through passenger flow, ventilation,
This makes harder to in working and build a dynam- after night tunnel cleaning, metro trains, etc. The
ic stereotype. electric brakes emit a dust with a concentration of

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 LABOUR MEDICINE
no more than 2.0 mg.m-3, and the mechanical ones Existing heating in passenger and commercial
up to 70.0 mg.m-3. The electro-thrust also produces vehicles ensures that the parameters of the micro-
insignificant amounts of ozone, which quickly pass- climate are set during the cold periods of the year.
es into oxygen. Insufficient maintenance of heating systems and
Biological factor. In the air in the working envi- seals in old cars is the reason for the low values (up
ronment in the metro stations and wagons can be to 8-10°C) in driver's cabs and passenger lounges.
isolated conditionally pathogenic and pathogenic Problems arise during hot periods of the year
microorganisms, helminth eggs, etc., and the crowd- when, due to insufficient thermal insulation, lack or
ing of many people in one place creates prerequi- insufficient mechanical ventilation in driver's cabs
sites for rapid and easy spreading of air droplets and and passenger lobbies, temperatures in the range
other infections. of 30-35°C are measured, and in heavy-duty vehi-
The nature of the work of the professional cles, especially those working in quarries and open
groups serving the metro is broadly similar to those mines, above 35°C. Conditions are created for over-
of rail transport, with an aggravating factor - work in heating, which is removed, to a certain extent, by
the case of artificial lighting. Apart from the latter, opening the windows, with all the disadvantages of
the working conditions of drivers are less favorable the emerging high air currents. In new cars with air
than those of locomotive drivers due to increased conditioning, this problem has been eliminated.
accelerations and very frequent starts and stops, The microclimate in the repair halls and auxiliary
while the full shift-motion in tunnels in the absence compartments during hot periods of the year is usu-
of a panoramic view results in a stroboscopic effect ally within the permissible limits - 20-25°C, relative
on train drivers in nearness to the walls of the tun- humidity - 55-75% and air speed - 0.2-0.5 m.s-1.
nel. All this determines the work of the metro train During the cold and transition periods in large
drivers as more strenuous, which to a certain extent halls and due to the lack of efficient heating in them,
is compensated by their different working regimen temperatures are considerably below the allowable.
and intervals of rest - eg. now in Sofia with a 12-hour Noise. The noise in road transport, which cre-
shift, the net driving time is 7-8 hours, and every 40 ates environmental problems, is mainly generated
minutes the drivers rest in the metro stations for 20 by motor vehicles, and in road construction and
minutes. repair - from used machinery and equipment. Parts
in vehicle noise are also characterized by "traffic
17.10.4. ROAD TRANSPORT noise", road condition, engine layout and technical
condition, driver's cab and passenger compartment
Road transport began its development in the seaing, etc.
early twentieth century. With the improvement of Noise levels in the range of 87 to 90 dB/A, 77-
internal combustion engines (gasoline and diesel) 87 dB/A and 76-86 dB/A in heavy-, medium- and
and the ability to make door to door deliveries, it light-duty vehicles are recorded in vehicle's cabs. On
quickly became the most used transport. buses, the noise level is 76 to 83 dB/A, in passenger
The main professional groups in the road trans- cars - up to 78 dB/A and 77-86 dB/A in international
port are: the drivers, which are divided into truck transport heavy duty vehicles.
drivers - light, medium, heavy, international, working Different types of repair work generate noise
in open mines and quarries, etc., drivers of passen- levels of 77 to 99 dB/A, and 80-99 dB/A in the road
ger cars - light (up to 8 people) and buses - urban, in- construction (excavators, scrapers, bulldozers, etc.).
terurban; personnel organizing and controlling the Infrasound. For the various trucks, at a speed of
movement of the vehicles - dispatchers; personnel 60-70 km/h and closed windows, the driver's infra-
conducting pre-hospital medical examinations for sound level has an average of 102 dB. Opening the
drivers; personnel servicing the passengers during side window increases its level to 109 dB.
the movement - conductors, stewards, etc.; staff ser- In the driving cabs of passenger buses at the
vicing passengers and freight terminals - ticket and same speed and closed windows, the infrasound
baggage cashiers; personnel ensuring the technical level is 98-112 dB (average 105 dB).
condition of the vehicles before leaving the garages; Vibration. Here, as in rail transport, drivers and
workers on current maintenance and repair of cars in staff handling buses while on the move are subject-
garages; construction and maintenance roads staff. ed to combined vertical, longitudinal and transverse
Microclimate. Throughout the open-air work, general and local vibrations.
staff are involved in the construction and mainte- Measured values of floor and seat general vi-
nance of roads, extraction, processing and prepara- brations are more favorable for buses compared to
tion of road building materials. freight cars. This is explained by their structural fea-

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tures (the trucks and dump trucks have a more rigid ing vehicles - cement, flour, etc., open-pit and quar-
suspension) and the conditions of operation (type, ries workers, including and their drivers and others.
relief and road condition). The unfavorable vibra- The powder is extremely inorganic, most commonly
tional characteristic is largely corrected by the an- mixed - silica with metallic aerosols, iron oxide with
ticipated shock absorber systems of the driver and lead minium, cereal powder and others. Its concen-
passenger seats. tration depends on the season, air humidity and
Increasing the speed of movement increases the condition of the road surface.
average vibration velocity of the general vibrations In the construction, repair and maintenance
of both measured locations. of roads the measured dust concentration is 3.12-
The objectivization of the all-shift vibrational 234.84 mg.m-3. The medium dispersion fraction was
load indicates (measured) that the drivers of trucks predominant, and the free SiO2 content was up to
in extra-urban traffic exceed the norm more than 3 16% in 50% of the samples.
times, and in urban traffic - by 55%. Drivers of buses Biological factor. High microbial contamination
and international road transport exceed the norm can be recorded in the bus lobbies. Biological pollut-
about 2 times. ants can also be registered for the transport of live
An integral vibration velocity assessment of the animals or their products - fur, wool, etc., as well as
local on steering wheel vibrations shows values for in the working environment of conductors, cashiers,
different vehicles from 0.4-0.7 ms-1.10-2 (for light- stewards and others.
weight) to 2.7-3.0-4.2 ms-1.10-2 (for heavy). When Nature of work. The work of the drivers is nerv-
working on open mines and quarries these values ous-sensory with great psycho-emotional intension.
were even higher - 4.5-5.5 m.s-1.10-2. They make important decisions, most often in deficit
Chemical dangers. Road transport is one of the of time, accept and process a large amount of infor-
main pollutants of both the environment and its mation. The visual, auditory and vestibular analyzers
own work and living premises. The main source of are very load.
toxic substances are the engines, their location, seal- Drivers of urban buses (with an straight engage-
ing, insulation and technical condition, used fuel-lu- ment of 82.0% on average) are the most burdened,
bricants, the type of vehicle, the condition and the followed by those traveling in interurban conditions
relief of the road, etc. (72.0%). For truck drivers, the hardest and most in-
With modern cars, the possibilities of getting tension is labour is at opening of mines.
exhaust fumes in cabs and passenger lounges are Main disadvantages in the work of service work-
minimized. The presence of chemical pollutants ers are the high percentage of forced labour posts,
(CO2, CO, hydrocarbons, SO2, NO, etc.) is detected in considerable static loading and physical effort in the
non-sealed engines located in the cabin, and their manual carrying of heavy details.
concentrations are usually below the MAC. In case Work and rest regime. The duration of the shift is
of aggravated engine operating conditions (climb- different and depends on the type of vehicle (freight
ing, forcing, driving on bad roads, open mines and or passenger), driving conditions (urban, interurban,
quarries, etc.), concentrations up to 600-900 mg.m-3 international, mixed).
are measured. Drivers' work and rest regime is norational with
CO2 concentrations in the range of 2160-5900 mounthly time accounting, extended working shifts,
mg.m-3, CO-5,0-60,0 mg.m-3 and sometimes traces often with unregulated breaks and a significant per-
of hydrocarbons are measured in the buses. The less centage of night work.
favorable values are measured for buses whose en- International drivers must comply with the ILO
gines are located in the cabs. Convention No. 153 of 1979, which regulates their
In trucks, particularly heavy duty, in mining and working and rest regime and limits the driving time
quarries, the hydrocarbon concentration in their to 9 hours daily (48 hours weekly) and after 4 hours
cabins reaches 100-150 mg.m-3, CO-15-60 mg.m-3. compulsory rest, and at least 10 hours rest in 24
Dust. Pollution is not a characteristic indicator hours.
for driving, but with certain loads (bulk, earth), cab- Service workers usually work on a regular 8-hour
in dust concentrations of 2.0 to 330.0 mg.m-3 are shift, in some services there are first and second day
found. Maximum values are measured for dumpers shifts, and night-shifts in those serving public trans-
working on mining and quarrying, when 70% of the port.
samples exceed the MAC.
In road transport are exposed to dust handling 17.10.5. AIR TRANSPORT
workers, construction, repair and maintenance of
roads and tunnels workers, repairers of dust-carry- Air transport is the newest mode of transport.

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The main professional groups in Civil Aviation Infrasound. For turbo-jet airplanes, the overall
(CA) are: flight and passengers servicing personnel - level of infrasound does not differ from acoustic
commander, pilot, radio operator, navigator, board- noise and ranges from 83 dB to 91 dB.
man and stewardess; personnel providing airplane In jet planes, the acoustic noise is below the pro-
remote controls - flight and air traffic controllers; peller at basically preserved infrasound intensity of
grounding staff - start-ups (starter, airmechanic, 68-100 dB.
aircraft technicians, drivers, fuel lubricant workers) - For helicopters - a total infrasound level of up to
serve landing and take-off aircraft and in the regula- 114 dB, and in the cockpits of AAs - up to 106 dB.
tion - aircraft mechanics and technicians performing Vibration. In air transport, general vibration
current and major repairs of the aircraft in the repair is not as important a factor as in other modes of
depots; staff servicing passengers and cargoes at transport. Flight staffs are subjected to high fre-
airports - ticket and baggage cashiers, informants, quency general vibrations (from aircraft engines) in
etc.; medical staff performing pre-flight medical ex- combination with aperiodic, low-frequency thrusts
aminations, etc. (airplane movement and turbulence in the atmos-
In agricultural aviation (AA), the main occupa- phere). Maximum values are recorded for taxiing on
tional groups are: on the worksite - pilots, aerome- the runway at take-off and landing. The less-favored
chanics and unskilled workers, loading the aircraft position is the AA and helicopter pilots.
with pesticides or fertilizers; in the repair facilities - Local vibrations, with overnorms values, are typ-
aircraft technicians and mechanics. ical of aircraft repairs using hand-held pneumatic
Microclimate. At open-air through all shift guns, drills, rifles, grinders, and others.
worked, workers on start at the CA and on AA load- Chemical Dangers. They have a leading role in
ing depots, without pilots. the AA, and at certain times during the repair and
The air conditioning systems and the good air- star-tup.
tightness of CA airplanes all year round create op- The average CO and CO2 concentrations of 25.0
timal microclimate values and barometric pressure mg.m-3 and 2600 mg.m-3 respectively are measured
up to 6300 m high. At higher flight altitudes (12,000 in the cockpits of cargo aircraft. In passenger planes
m) the atmospheric pressure in the airplanes is 0,57 these values are higher - CO - 75.0 mg.m-3 and CO2 -
atm, which is equal to the atmospheric pressure at a 3400 mg.m-3.
ground point at an altitude of 2300 m. An unfavora- On start-up, toxic substances are separated from
ble moment is the dry air in the airplanes -humidity the aircraft engines and the facilities used for their
around 25%. maintenance. Excessive hydrocarbons of gasoline
The microclimate in the CA and the AA hangars and petrol engines - 129.0 mg.m-3 average and of
and the auxiliary compartments to them during the kerosene - average 83.0 mg.m-3 are registered.
hot seasons of the year is usually within the per- The hydrocarbons content of the aeromechani-
missible norms. During cold and transitory periods, cal working environment has an average concentra-
temperatures are to a large degree below the allow- tion of 150.0 mg.m-3.
able temperature. At the start-up, the CO concentration is from 20.0
In non-sealed pilot cockpits of the AA, the micro- to 420.0 mg.m-3, nitrogen oxides - 4.0-11.0 mg.m-3
climate is determined by the macroclimate. and ozone and photooxidizers - 0.2-1.3 mg.m-3. Oily
A characteristic feature of the microclimate in aerosols are in concentrations of 2.50 to 44.0 mg.m-3.
air transport is the ability of flight crews to change In the various repair operations, benzene con-
the climate zones for a short time (2-3 hours), which centrations (average 31.0 mg.m-3), toluene (13.0
creates conditions for over-intension of the body's mg.m-3), xylene (9.0 mg.m-3), acetone ( 118.0 mg.m-
thermoregulatory systems. 3
), phenol (9.00 mg.m-3), and other.
Noise. Air traffic noise is a leading unfavorable The AAs have a less favorable sanitary and chemi-
factor affecting not only air transport workers but cal characteristics compared to those of CA as deter-
also the environment. mined by the additional toxic substances - PhOC, ni-
In the cockpits and passenger saloons of the tur- trogen fertilizers, etc. When repairing the AAs, PhOC
bo-propeller aircrafts the noise level ranges from 81 over-norms concentrations were also measured, al-
to 93 dB/A, in the reactive -67-87 dB/A, 87-103 dB/A though aircraft were washed before repairs.
in the helicopters, and 97-104 dB/A in AA aircrafts. At Electromagnetic radiation. A significant number
airplane startup, the noise levels are divided into 3 of powerful sources are found in air transport, both
zones: near to aircraft -112-122 dB/A, a background in aircraft (radar and radionavigation equipment), as
of the runway - 81-101 dB/A, and in the enclosed well as on ground-radars, radiostations, etc., and in
work premises - 68-88 dB/A. their repair in specialized laboratories. For example,

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up to the antenna of the portable radio stations is At the AA airplaces there are aggravated work-
measured the VHF EMF with an intensity of about 25 ing regimes with labour irregularities, extended and
V m-1, under the forepart of the aircraft at 2 m from fragmented working days - from 5 to 9 hours and
the radiating antenna - 25-40 V.m-1. from 16 to 19.30 hours with insufficient intershifts
Ionizing radiation. In some airplanes and heli- rests. The number of working days is directly related
copters there are radioactive anti-ice indicator de- to the flight hours, which are normalized depending
vices in which there are Sr90 and J90. They emit β and on the kind and type of the aircraft, the number of
γ rays at the exposure dose rate of 800 mR.h-1 at a dis- pilots in them, the type of aerochemical work, etc.
tance of 1 cm from the device, at 10 cm-150 mR.h-1 MORBIDITY AND TRAUMATIZATION
and at 1 m-0.3 mR.h-1. The total morbidity (the totality of the registered
In some devices, especially in older aircraft, ra- and the newly discovered cases) is the highest in rail
dioactive luminous dyes on scales containing Ra226 transport, followed by road, water and air. The high-
were used. They emit gamma rays with an exposure est indexes are those who are over 50 years of age.
dose of 2-17 mR.h-1. Prevalence of respiratory diseases (chronic bron-
A problem for the crews of the airplanes is also chitis, ACUAP, etc.), blood circulation (arterial hy-
the cosmic radiation. (FCA) has estimated that for pertension), digestive system (ulcers, gastritis, etc.),
960 flight hours (annual norme for flight hours) the nervous system and sensory organs, musculoskele-
crews receive a radiation dose of 0.24 to 8.9 mSv, tal system (intervertebral disc disease), that can be
which is below the recommended limit by the Inter- identified as problematic for transport workers.
national Commission on Radiation Protection (ICRP) Similar is the morbidity of temporary incapacity,
of 20 mSv per year. where the most common are ACUAP (about 1/5 of
Nature of work. The specificity of flight crew work all illnesses), followed by household accidents (10-
is determined by the nervous and psycho-emotion- 11%), osteochondrosis and hypertonic disease, etc.
al intensions of simultaneous observation of many Half of the registered cases of occupational dis-
time-varying parameters, acceptance and analysis eases are in the railway transport. Followed by those
of a large amount of visual and auditory informa- in the automobile (36%), the air (7%) and the water
tion, decision making, often in a complex environ- (6%). The most frequent are neurites of the auditory
ment and a deficit of time, great personal responsi- nerve (28%), followed by vibrational disease (21%),
bility and high risk. vegeto-vascular syndrome (12%), vegetative pol-
Work of flight controler and dispatcher's opera- yneuropathy of the upper extremities (9%), myo-
tions are extremely complex and diverse. There are tendinoses and myotendinitis (7%).
over 25, time-varying, objects with high concentra- Labour accidents are 2.2-3.0% of all cases of in-
tion and switching over attention, stress situations, capacity with temporary disability. The most serious
responsibility, time deficiency, heavy loading hear- and most frequent are the labour traumatism in wa-
ing and visual analyzers, imposed tempo, requiring ter transport, followed by the road, railway industry
urgent and precision. and transport constructions, and the lightest in air
The work of technical staff from start and repair transport.
is categorized as low to moderate physical, moder- HYGIENE MEASURES
ately intense. Hygienic measures applied in other sectors to
The work of AA pilots and mechanics, working on unfavorable working conditions can also be applied
airplaces is additionally aggravated by adverse fac- in the transport system. Transport-specific preven-
tors such as: open air, unevenness, nonrhythmicaly, tive measures can be summarized as:
frequent take-offs and landings, short flight times, 1. Development of specific hygiene standards
active flying at low altitudes, and at the same time related to the occurrence of fatigue in personnel
operate with spraying or fertilizing devices - worse (especially for workers in operation and related with
working conditions combined with excessive con- traffic safety) and providing comfortable conditions
centrations of PhOC and others. for travelers.
Work and rest regime. Flight activity over its dura- 2. Models and systems for optimizing work and
tion is governed by a daily, monthly and annual rate. rest modes.
A shift work with extended 48-hour rest periods 3. Effective medical and professional selection and
applies to the flight manager. expertise of the labour ability and suitability of the
For air mechanics and air technicians operating various occupational groups of transport workers.
at the start, two 12-hour shifts are - daily (7 to 19 4. Organization of systems for pre-road and peri-
hours), followed by 24-hour rest, and night (19-7 odic examinations, ensuring early detection of devi-
hours), followed by 48 hours of rest. ations in the functional state of the body related to

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traffic safety and occupational diseases. 6. Reduction of hypodynamics in the main trans-
5. Providing reliable bioprophylaxis for transport port professions - drivers, dispatchers, etc., by creat-
workers through rational food-drinking regime, ing appropriate recreational complexes.
hardening of the organism, etc.
REFERENCES

1. Association of American Railroads. Manual of Standards and Recommended, Specifications for TANK
Cars. Washington, 1982.
2. Automotive and Marine Service Station Code. NFPA 30A.Quincy, MA: NFPA, 1993.
3.Costa, G. A seven-point program to reduce stress in air traffic controllers in Italy. In Preventing Stress at
Work.Conditions of Work Digest, Geneva: ILO, 1992, Vol. 11
4. Goranova, L., Em.Ivanovic, Iv.Paunov. The noise factor in the manufacturing and transport sectors in
Bulgaria. In Infrasound, ultrasound, noise and vibration, ed. D. Tsvetkov and M. Angelova, S., Med. and phys.,
2007, 94 - 102. (in bul.)
5. Goranova, L., Em.Ivanovic, Iv.Paunov. The vibration factor in production and transport in Bulgaria.
In Infrasound, ultrasound, noise and vibrations, ed. D. Tsvetkov and M. Angelova, S., Med. and phys., 2007,
173 - 183. (in bul.)
6. Isakov, P.K., D.I. Ivanov, Y.G. Popov et al. Theory and practice of aviation medicine. M., "Medicine",
1975, 359. (in russ.)
7. Marine Safety Agency. Merchant Shipping Notice No.M.1607: The Merchant Shipping and Fishing Ves-
sel Regulations 1995.SI 1995, No 1802, Southampton, UK: Department of Transportation.
8. Marine Safety Manual. COMDTINST M 16465.6. Washington, DC: Department of Transportation, US
Coast Guard, 1996.
9. Nikolaeva, D., Iv. Paunov. Infrasound. In Infrasound, ultrasound, noise and vibrations, ed. D. Tsvetkov
and M. Angelova, S., Med. and phys., 2007, 11-46. (in bul.)
10. Paunov, I. Characteristics of infrasound in the means of transport and some aspects of its influence
on the body of the drivers. diss. 1990 (in bul.)
11. Prochorov, A.A., S.V. Surov, O.Gribarov. Manual of hygiene in rail transport. M., "Medicine", 1981,
381. (in russ.)
12. Sergeev, E.P. Manual of hygiene in water transport. M., "Medicine", 1974, 296. (in russ.)
13. Staimatsky, A.R.Labour hygiene in water transport. M., "Transport", 1984, 168. (in russ.)
14. Transport Industry and Warehousing. La Mont Byrd (chart. Ed.). In Encyclopaedia of Occupational
Health and Safety, Stellman, J.M. (Ed.). 4th ed. Geneva, International Labour Office, 1998, V.3, 102.2-102.44.
15. Weisman, A.I. Hygiene of labour for car drivers. M., "Medicine", 1988, 189. (in russ.)
16. Wu, Y.X., X.L. Liu, B.G. Wang, and X.Y. Wang. Aircraft noise-induced temporary threshold shift. Avi-
ation Spa & amp; Medicine, 1989, 60 (3), 268-270.

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M. Koleva

17.11 CHEMICAL-PHARMACEUTICAL
PRODUCTION. PHARMACIES

Chemical and pharmaceutical production is part workplace; - the conditions and requirements and
of the chemical industry and in many of the devel- the development and introduction of physiological
oped countries in the world is one of the most im- regimes for work and rest during work, taking into
portant and promising industries. It covers a large account the existence of work operations with sig-
number of state and private structures (companies nificant physical effort (mainly loading and unload-
and healthcare establishments) that carry out re- ing of raw materials and finished goods);
search and applied activities for setting up, pre-clin- - protection of workers against the risks associat-
ical and clinical tests, production and sale of phar- ed with exposure to noise;
maceuticals for the needs of human and veterinary - control of compliance with the permissible con-
medicine. centrations of harmful substances in the air of the
In Bulgaria there is a legal framework and an es- working environment;
tablished legal order for legalizing the production, - occupational safety rules in the chemical-phar-
import, export, use and trade of pharmaceuticals, maceutical, microbiological and perfumery-cosmet-
incl. the protection of copyright in the patenting of ic industries;
new medicines and trademarks, the reproduction of - the licensing rules for manufacturers and whole-
medicinal products and the right of company secret salers of medicines;
in production. - the documentation requirements for the regis-
The overall activity for providing the population tration of medicinal products;
with the necessary medicines is managed by the - the structure, procedures and organization of
Pharmacy Council at the Ministry of Health. pharmacies' operations and the nomenclature of
The production and sale of pharmaceuticals are medicinal products;
organized in compliance with the requirements of - water quality requirements for drinking and
the existing normative acts, which regulate: household purposes (since water is a raw material
- hygiene protection zones (HPZ). for the production of liquid pharmaceutical forms
They are: in the manufacture of synthetic medica- and its properties, especially in the manufacture
ments, antibiotics and preparations for agriculture - of ampoules and eye drops, very stringent require-
1000 m; production of glycerin, organopreparations ments are being put in place).
and phytochemicals - 100 m; production of phar- Compliance with the Company's secret law does
maceutical potassium salts, tabletting and arrang- not limit the control over the quality of working con-
ment of finished dosage medical forms; distillation ditions and mainly of the air in the working environ-
of ethereal oil products, cosmetic creams, shampoos ment provided by the Health and Safety at Work Act.
and toothpastes in enclosed installations - 50 m; These two aspects are directly related to the phar-
- an environmental impact assessment, which is macological and toxicological characteristics of the
an overriding step in the construction of new pro- manufactured medicinal products. Pharmacological
duction capacities; characteristics depend on their effectiveness as a
- methods for collecting, transporting, storing prophylactic or therapeutic agent. The toxicological
and disposing of hazardous waste, to which part of characteristics depend on the undesirable or side
the solid waste of pharmaceutical production be- effects (organ toxicity) that the drugs may have. On
longs; the other hand, the presence in the working envi-
- the ambient air quality requirements with which ronment of the active ingredients of the drugs as
the exhaust air purification devices must comply in well as of other chemicals in the form of raw mate-
production; rials, intermediate, final or waste products (chemical
- the order and the way: - to control the quality factor), combined with the accompanying produc-
of the working environment; - for work with video tion physical factors, forms specific working condi-
display; - the periodicity of carrying out a risk as- tions. Working conditions have a definite, significant
sessment in actual production conditions, which is impact on both the quality of production and the
a mandatory part of the overall assessment at the health of workers.

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The assessment of the compliance of the work- standards for production microclimate, noise, vibra-
ing conditions with the requirements of the Labour tions, dust, toxic substances, lighting and non-ion-
Code and the national standards and the risk for izing radiation in work premises and workplaces.
the health of the workers is part of the documen- Technological processes and activities with dust
tation for certification under ISO 9001 for quality of extraction, toxic and harmful substances, noise and
production. It is the duty of the employer to ensure vibrations above established norms, with overheat-
healthy and safe working conditions. ing microclimate, wet processes, etc. are organ-
ized in separate buildings or premises. Work rooms
17.11.1. PRODUCTION BUILDINGS and work equipment, incl. ventilation systems are
cleaned regularly.
According to the requirements of the Health and The workplace is shaped according to the ergo-
Safety at Work Act and Ordinance No 7 on Minimum nomic requirements and the anthropometric charac-
Requirements for Health and Safety at Work Work- teristics of the workers. Sufficient area, volume and
places and the Use of Work Equipment, the sites for free unoccupied work area are provided in the work-
the construction of enterprises, buildings, shall be place so as to ensure sufficient freedom of movement
determined according to the activity to be carried for workers to perform the work and fire safety for the
out in them, ensuring the norms and the require- activity concerned. The organization of work, dimen-
ments for protection of workers and the population. sions and layout of the workplace take into account
The above-mentioned normative documents con- the physiological and ergonomic requirements for
cern precisely these two aspects of health preven- ensuring the normal passing of the work process.
tion. When choosing a site must be the minimum The floors of work rooms must be rigid and
protection zones to the sites, taking into account the stable, ensure that workers are isolated from health
direction of prevailing winds, the peculiarities of the hazards, safe gradients, obstructions and openings.
terrain and climate. Minimum protection zones for The floors and walls of work rooms are made of
objects in the pharmaceutical industry range from materials that do not emit, leak and carry noxious
1000 m to 50 m. emissions and comply with fire safety requirements.
Buildings in which workplaces are located must They are made of materials and in a way that does
have design and operational safety as intended. not make it difficult for them to be cleaned regular-
The free areas of the plants are landscaped ly. Due to the specifics of chemical-pharmaceutical
with appropriate grass, tree and shrub vegetation. production and the risk of accidents (gassing, spill-
Protected areas are not allowed to build industrial ing of aggressive liquids, self-ignition or self-blast-
and residential buildings. The commissioning of en- ing), special requirements are made for the type,
terprises, sites and work equipment shall be carried number, dimensions, places and materials from
out with permission for use of the building, issued by which the doors and gates are made.
the competent authority in accordance with the Terri- The mechanized doors must have an easily vis-
torial and Urban Planning Act. The owner or the user ible and accessible opening mechanism. Doors on
of the enterprise, the site or the working equipment failure routes must be marked with the appropriate
compiles a file containing documents on the design characters, be opened from the inside out without
of health and safety at work and the documentation any obstacles at any time and without a key. In case
(protocols and acts) proving the conformity of the of an emergency in the power system, the mecha-
completed construction with the requirements of nized doors must be automatically opened and re-
the Health and Safety Work Conditions and all docu- main open. Doors and gates designated for passing
ments reflecting periodic and in-service checks. only vehicles shall be marked with signs prohibiting
The area of the enterprise (site) is enclosed and pedestrian traffic.
measures are taken to limit the access of outsiders. Windows and skylights should provide enough
With compositional decisions within the enterprise natural light, to be cleaned regularly.
ensure that all requirements related to safety and Electrical equioment and installations do not
health, zoning, marking hazardous areas, servicing create conditions for an increased risk of electrotrau-
roads and railways etc. The roads in the territory are mas. Road routs and hazardous areas are marked ac-
constructed and maintained with durable pave- cordingly. The places for loading and unloading of
ment and are marked with the necessary markings, raw materials and finished products are marked and
road signs and signaling. equipped with the necessary mechanization to re-
Work premises and workplaces must ensure duce physical effort at work. Approved and marked
safe working conditions and health protection for emergency routes and exits free to move workers at
workers. It is not allowed to exceed the established any time.

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For workers in the open, measures are to be tak- tions is possible, an automatically activated emer-
en to guard against falling objects, noise, gases, va- gency ventilation system shall be provided. Local
pors, dust, non-ionizing radiation, falling and slip- suction systems, serving high-toxic gas and dust ex-
ping, and to prevent the effects of adverse weather traction facilities and general-exchange ventilation
conditions. installations in work rooms shall be installed in such
a way that they are automatically switched on to-
17.11.2. WORKING ENVIRONMENT AND gether with the technological equipment and block
PRODUCTION PROCESS its inclusion in the case of a ventilation malfunction.
Quality control of the work environment is done
Hygiene requirements to the work environment by accredited control agencies. Periodicity for the
include measures to provide the necessary work- control is determined by the specific conditions,
place lighting and an optimal manufacturing mi- of the Occupational Health Service's instructions,
croclimate. It is necessary to provide for preventive which assesses the health risk and organizes the
measures to prevent the harmful effects on health preventive medical examinations. Ordinance No. 5
both in low-temperature and overheating rooms; in (1999) provides except for an initial risk assessment
the presence of a surface temperature of the process and another, to take place in the event of changes
equipment above 55°C; in manual handling with con- in technology, replacement of equipment or the in-
trol devices above 45°C. For activities hazardous to troduction of new production. The hazardous sub-
overheating workers, conditions should be provided stances used, incl. with carcinogenic potential, are
for rational cooling and a drinking regime to compen- necessarily filed. The chart contains data about their
sate for losses from liquids and mineral salts. characteristics, described in the so-called "Materi-
No concentrations of harmful substances al Safety Data Sheet", with the content of which is
in the air of the working environment are allowed known to people in contact with chemicals.
above the specified hygiene standards. The MACs If there are excessive noise levels in the work-
and the Tentative Safety Influence Levels (TSILs) of places depending on the technological possibilities,
the most commonly used organic solvents, other technical solutions of its limitation are applied by
chemicals, medicinal plants, certain antibiotics and means of screens, casings, covers, fences, sound ab-
finished pharmaceuticals are presented in Tables sorbing treatment of walls and ceilings, isolation, re-
1-4. mote control of machines and equipments, sound-
The production processes in chemical-phar- proofed booths for staff and more. When operating
maceutical production must be maximized mecha- under noise conditions above established norms
nized and automated. Since the handling of hazard- and when all the noise reduction requirements are
ous chemicals for high toxicity and pharmacological applied, workers use antiphons (external or internal
activity, the equipment must be maximally sealed. -ear muffs).
When handling powdery materials and materials, Machinery and equipment - sources of vibra-
apply dust collection measures. Powder materials tion, are installed on projects that guarantee the
are transferred indoors. In sifting for separation, mechanical reliability of the building structure of
thick casing with the possibility of connection to a the buildings and the facilities and their individual
aspiration device is mounted on screens. To reduce elements. To reduce the vibration level, machines
secondary dust pollution use vacuum cleaners for and equipment are mounted on separate founda-
workplace and work equipment, wet floor and sur- tions and/or technical solutions are used to reduce
face cleaning. In case of short-term contact with the vibration level.
harmful substances, which can not be prevented, The list of approved medicines for production
when handling powdered substances (weighing, and use in Bulgaria (presented in groups in Appen-
grinding, dry mixing, boiled layer drying, etc.) in the dix 1) includes a wide range of preparations for the
cleaning and repair of workplaces and equipment, prevention and treatment of a large number of dis-
which is often requires in the manufacture of med- eases and health injuries. This list contains the phar-
icines, that personal protective equipment (PPE) be macological groups which must be included in the
used. nomenclature of medicinal products of pharmacies,
In dusty, toxic and other harmful substances, according to Annex 1 to Art. 4 of Ordinance No. 8
forced ventilation is provided. The local aspiration on the structure, order and organization of medici-
occurs at the source of the release of harmful sub- nal products. The technologies for their production
stances. Where an emergency release of highly toxic are varied and characterized by a number of specific
substances or the creation of explosive and fire-haz- features. Bulgarian pharmaceutical companies pro-
ardous concentrations in the work rooms or loca- duce some of the famous medicines.

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Annex 1 (Ordinance No 8/2000) 6.5. Dialysis solutions
List of drugs in pharmacological groups 7. Drugs affecting the reproductive system
7.1. Gonadioactive agents
1. Drugs affecting the nervous system 7.2. Ureteral agents
1.1. Anesthetics 7.3. Aphrodisiacs and anti-aphrodisiacs
1.2. Analgesics and Non-Steroidal Anti-Inflamma- 8. Haematological medicinal products
tory Drugs 8.1. Antianaemic agents
1.3. Classical sedatives 8.2. Anticoagulants
1.4. Somnific preparations 8.3. Thrombolytics
1.5. Antiepileptic preparations 8.4. Platelet anti- aggregates
1.6. Antiparkinsonian preparations 8.5. Hemostatics
1.7. Psychotropic means 9. Infusion and dialysis solutions
1.8. Drugs used in alcoholism and tabacism 10. Endocrine and metabolomic drugs
1.9. Vegatotropic agents 10.1. Antidiabetic agents
1.10. Miorelaxants 10.2. Anti-hypoglycaemic agents
1.11. Revulsant and local anti-inflammatory drugs 10.3. Hypothalamic and pituitary hormones
1.12. Antiepileptics 10.4. Thioreactive agents
2. Autocoids 10.5. Antiparathyreoid agents
2.1. H1 - blockers 10.6. Corticosteroids
2.2. Serotoninergic receptor agonists and antag- 10.7. Anabolic steroids
onists, effective in migraine 10.8. Anti-gouty agents
3. Drugs affecting the cardiovascular system 10.9. Means affecting mineral homeostasis in
3.1. Anti-anginal (anti-stenocardie) agents bone tissue
3.2. Medicines to treat heart failure 11. Vitamins and trace elements
3.3. Antiarrhythmic agents 12. Antimicrobial drugs
3.4. Antihypertensive agents 12.1. Antibiotics
3.5. Anti-hypotensive agents 12.2. Anti-tuberculosis agents
3.6. Anti-atheromatous (hypolipidemic) agents 12.3. Sulfonamides
3.7. Peripheral vasodilators 12.4. Quinolones
3.8. Venotonic and capillary-tonic (vasculopro- 12.5. Antifurans
tective) agents 12.6. Oxyquinolines
4. Respiratory tract medication 12.7. Anti-lues agents
4.1. Anti-asthmatic agents 12.8. Antiviral agents for systemic use
4.2. Anti-cache 12.9. Antimycotics for systemic use
4.3. Expectorants and mucolytics 13. Anti-parasitic drugs
4.4. Pulmonary surfactants 13.1. Antiprotozoal agents
5. Drugs affecting the digestive system 13.2. Anti-helminthic agents
5.1. Antiulcer agents 14. Antiseptics and disinfectants
5.2. Appetite affectants 15. Immunoglobulins, serums, vaccines and
5.3. Antiemetics fortifiers
5.4. Means that affect the tone and motor of the 16. Biological response modifiers
gastrointestinal tract 16.1. Immunosuppressants
5.5. Antiflatulente agents 16.2. Immunostimulants
5.6. Laxatives 16.3. Immunoglobulins
5.7. Antidiararic agents 17. Antitumour drugs
5.8. Intestinal anti-inflammatory drugs 18. Dermatological drugs mainly for topical use
5.9. Means that affect the liver and bile secretion 19. Ophthalmic drugs mainly for topical use
5.10. Pancreatic enzyme preparations 20. Otorhinolaryngologic drugs mainly for
6. Medicinal products affecting the excretory topical use
system 21. Dental medicaments for topical use
6.1. Diuretics 22. Biobandages, biomaterials for transplant,
6.2. Means affecting bladder dysfunction tissue adhesives
6.3. Amino acid preparations for oral use in chron- 23. Diagnostic agents
ic renal failure 24. Antidotes
6.4. Uricolytic agents 25. Homeopathic medicines.

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 OCCUPATIONAL MEDICINE
Synthetic drugs production include a large num- form of vapors, aerosols and dust. This is most often
ber of chemicals, which are raw materials or end used as raw materials: reagents, initiators, catalysts,
products, and many other processes in the chemical fillers and organic solvents. In addition, the same
industry. Chemical agents in pharmaceutical manu- chemicals are also found in laboratories that control
facture can be divided into 2 large groups: industrial production quality and technological control. Work-
reagents and drug-related substances. Consequent- ers are in contact with chemicals and when they are
ly, a number of chemicals - industrial poisons - are by-or waste products and are subject to removal
found in the air in the working environment in the and disposal.

Tab. 1. Organic solvents used in the manufacture of medicaments

Physical MSMAC1 STMMAC2
Resolvent Participation Specific effects
state in mg/m3 in mg/m3
Amyl acetate OS;* F**; E*** vapor 270.0 540.0 -
Amyl alcohol OS; F; E vapor 100.0 – -
Ammonia (liquid / OS; F; E gas 14.0 36.0 -

Aniline OS vapor 2.0 – Allergen. Skin-resorptive effect.

Acetone OS; F; E vapor 600.0 1400.0 -
Carcinogenicity to humans (1 cat.).
Benzene OS vapor 3.25 – Skin-resorptive effect.
n-Butyl acetate OS; F vapor 710.0 950.0 Irritation
n- Butyl alcohol OS; F; E vapor 100.0 150.0 -
Allergen. Irritation.
DEA OS; E vapor 30.0 75.0
Skin-resorptive effect.
Dimethylamine OS vapor 3.8 9.4 -
Dimethylaniline OS vapor 2.0 – Allergen.
Dimethylformamide OS; F; E vapor 30.0 – Toxic for reproduction (2 cat)
1,4-Dioxane OS; E vapor 50.0 90.0 Skin-resorptive effect
1,2-dichlorobenzyl OS vapor 120.0 300.0 Skin-resorptive effect
1,4-dichlorobenzyl OS vapor 122.0 306.0 Skin-resorptive effect
1,2-Dichloroethane OS; E vapor 4.0 8.0 Carcinogen (Cat 2)
Ethyl acetate OS; F; E vapor 800.0 – -
Ethylene glycol OS; E aerosol 52.0 104.0 Skin-resorptive effect
Ethyl alcohol OS; F; E vapor 1000.0 – -
Isopropyl alcohol OS; F; E vapor 980.0 1225.0 -
o; m - ,; p-Xylene OS vapor 221.0 442.0 Skin-resorptive effect
Methylamine OS gas 12.0 – Allergen. Irritation
Methylen chloride OS; F; E vapor 100.0 517.0 -
Methylisobutylketone OS; F; E vapor 50.0 200.0 -
Skin-resorptive effect.
Methyl alcohol OS; F; E vapor 50.0 –
Irritation.
Pyridine OS vapor 15.0 – Irritation
Skin-resorptive effect.
Propyl alcohol OS vapor 300.0 500.0
Irritation.
Tetrahydrofuran OS vapor 150.0 300.0 Skin-resorptive effect
Toluene OS; F; E vapor 150.0 300.0 -
Triethylamine OS; F vapor 8.4 12.6 Skin-resorptive effect
Formaldehyde OS; F; E vapor 1.0 2.0 Allergen. Irritation.
Skin-resorptive effect.
Formamide OS vapor 15.0 30.0
Toxic for reproduction.
Irritation.
Furfural OS vapor 10.0
Skin-resorptive effect.
n-Hexane OS; F; E vapor 180.0 400.0 Skin-resorptive effect
vapor,
n-Heptane OS; F; E aerosol 1600.0 – -
Chlorobenzene OS vapor 47.0 94.0 -
cHloroForm OS; F; E vapor 10.0 – Skin-resorptive effect.
Cyclohexane OS vapor 500.0 – -
1
- Mean-shift MAC-MSMAC (Limit for 8 hours)
2
- Short time maximum MAC-STMMAC (Limit to 15 min.)
* OS - Organic Synthesis
** F - Fermentation (antibiotics production)
*** E - Extraction

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 LABOUR MEDICINE
Table 1 presents the MAC and specific character- in which the dynamic and static physical workload
istics of organic solvents and other substances used is minimized.
in the chemical-pharmaceutical industry. Along with organic solvents, as industrial poisons
Organic solvents used for extraction are practi- as an element of the chemical agent of the working
cally recovered as they are involved in closed pro- environment, there are also the active substances -
duction cycles. Few of them fall into waste water intermediates or end products in the manufacture
production depending on their water solubility of pharmaceuticals. Most often these are natural or
and the nature of the equipment. Precipitation is synthetic substances. Natural products are of plant
a method of separating medicinal products from and animal origin. Here, first of all, antibiotics, ster-
the liquid medium. Filtration and extraction from oid and peptide hormones, vitamins, enzymes, pros-
the composition of solid carriers (residues) are also taglandins and pheromones have to be mentioned
employed. For this purpose, copper or zinc is most here. Synthetic drugs may be products of both or-
commonly used. Ion exchange resins or absorbers ganic synthesis and biotechnology. For some of
(active coal) are also used to extract the active sub- them produced in Bulgaria, the MACs have been de-
stances. At certain stages of the technology, residual veloped and approved (Table 2).
organic solvents evaporate. The pharmaceutical industry uses biological
Regardless of the chemical processes and appa- agents (for example, bacteria and viruses) for use in
ratus common to the chemical industry, the phar- the production of vaccines, antibiotics, blood prod-
maceutical industry with a unique production with ucts and biotechnology.
characteristics. The high pharmacological activity In many countries (also in our country) in the
and the specific application of the end products - chemical-pharmaceutical industry is included the
the drugs - indicate that they even in small quanti- production of dressing materials, incl. gypsum
ties are hazardous to the health of workers. This pre- dressings. As a rule, in these compartments (work-
determines the leading hygiene requirement in the shops), one of the leading factors in the working en-
chemical-pharmaceutical industry: maximum seal- vironment is dust. On tabl. 3 presents the hygienic
ing of equipment and automation of production standards for dust found at these workplaces as well
processes. In modern high-tech and technically se- as for products involved in other phases of drug pro-
cured workplaces, the main profession in the man- duction. Phytochemistry and galenical production
ufacture of pharmaceuticals is an operator-devices are the places where natural drugs are produced by

Tab. 2. MACs in the air of the working environment of pharmaceuticals and other chemicals involved in production

Physical MSMAC STMMAC

Drug formulation Specific effects
state in mg/m3 in mg/m3
Amidofen aerosol 0.5 – Allergen
Ampicillin aerosol 0.1 0.3 Allergen
Analgin aerosol 0.5 1.0 Allergen
Acetyl salicylic acide
aerosol 0.5 1.0 Irritation; allergen
(Acetizal)
Gentamicin aerosol 0.1 0.6 Allergen
Diazepam aerosol 0.1 0.5 -
Caffeine aerosol 0.5 – -
Nivalin aerosol 0.05 – -
Oleandomycin` aerosol 0.4 0.8 Allergen
Penicillin aerosol 0.1 0.3 Allergen
Resorcin aerosol 45.0 – -
Streptomycin aerosol 0.1 – Allergen
Sulfosalicylic acid aerosol 3.0 – Allergen
Theobromine aerosol 1.0 – -
Theophylline aerosol 0.5 – -
Turpentine vapors 300.0 – Irritation.
Testosterone aerosol 0.005 – -
Urotropin aerosol 2.0 – Allergen
Phenacetin aerosol 0.5 – -
Skin resorptive effect
Halothane vapors 20.0 100.0
Toxic for reproduction.
Chlornitromycin aerosol 1.0 – -
Camphor aerosol 12.0 18.0 Irritation
Okisid zinc (as zinc) vapor 5.0 10.0 -

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 OCCUPATIONAL MEDICINE
extraction. The treatment of plants from which ac- In the past, raw materials for medicines have been
tive substances are extracted, with actions related to herbs, animal organs and tissues, minerals and salts
dusting. For control of the working environment in of nature. At present, despite the exceptional variety
phytochemical plants and some other departments of known pharmaceuticals, they are the product of
of pharmaceutical production, guidance values pro- three technologies based on: organic synthesis,
posed for provisional hygiene standards in 1992 can fermentation and extraction from plant and ani-
be used (Table 4). mal sources.
In the body of workers, chemical substances, incl.
the active ingredients of the drugs, can penetrate 17.11.3. FERMENTATION
through the lungs by the breathed air, when swal- (PRODUCTION OF ANTIBIOTICS)
lowed with contaminated food, beverages or smok-
ing in the workplace and through the skin. Fermentation is a biochemical process using se-
Many additives (binders, flavor enhancers, color- lected microorganisms and microbiological tech-
ants, emulators, consistency and volume substanc- nologies for the production of chemical products.
es, preservatives and antioxidants) are used in the The technology of production of microbiological
manufacture of medicaments which mix with the synthesis is characterized by periodicity of the pro-
active substances, conferring the necessary phys- cesses and consists of a number of successive steps:
ical properties and pharmaceutical characteristics • preparation of seed material and nutrient me-
in various types of dosage forms (tablets, dragees, dia;
capsules, solutions, suppositories, creams and oint- • cultivation of producer-strains (fermentation);
ments). Almost all additives do not have a therapeu- • filtration and separation of culture solutions;
tic effect or are minimal and their use is not associ- • drying;
ated with a health risk to workers. This is the reason • distributing and packaging of finished prod-
why some of them are not included in the lists of the ucts.
health-damaging chemicals whose presence in the The basic equipment consists of:
air of the working environment is limited by the Act • heat-isolated fermenters that allow steriliza-
for Health and Safety Work Conditions. tion of vessels by pressured steam;

Tab. 3. MAC of non-toxic dusts in the air of the working environment

MSMAC
Type of dust Specific effects
(limits) mg/m3
Gypsum containing less than 2% free crystalline silica in the respirable
6.0 Irritation
fraction. Inhalable fraction.
Wood dust: Soft wood inhalable fraction.
Solid wood and mixtures thereof with other wood species. 5.0 Carcinogenic (Càò.1)
Inhalable fraction.
Dust of vegetable origin (sugar, starch, flour).
10.0 Irritation
Inhalable fraction.
Dust from plant fibers (cotton, hemp, jute) and mixed with action Irritation
2.0
synthetic fibers. Inhalable fraction. Allergen
Talc (talkomagnezit, medical talc) containing less than 2%
free crystalline silica in the respirable fraction.
Fibrosogenic effect
Fibrous particles (fine).
6.0
Inhalable fraction. Respirable fraction
3.0
Fiber-respirable fraction; number of fibers/cm3 1.0

Tab. 4. Recommended values for some chemicals and natural products used in the pharmaceutical industry
Indicative Physical
Chemical, natural product Specific effects
value mg/m3 state
Yarrow, chamomile, valerian, mead, hollyhock, raspberry 3.0 aerosol -
Hawthorn, linden, devil's mouth, mint, comuniga, wild strawberry,
marigold, wounds leaf, St. John's wort, red podabniche, patch, 5.0 aerosol -
grass
Dikain 0.3 aerosol -
Iodoform 3.0 aerosol -
Potassium bromate 0.1 aerosol -
Novocaine 3.0 aerosol -
Salicylic acid 1.0 aerosol Mutagen, allergen

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 LABOUR MEDICINE
• separators, reactors for separation and purifi- or multiple interruptions during extraction and
cation of the preparation; purification. Since isolation and growth of microor-
• filter-presses with periodic action; ganisms are essential for fermentation, biosafety is
• drum vacuum filters; ensured by the use of non-pathogenic strains, main-
• dryers; tenance of equipment leakage and decontamina-
• packing machines. tion of the broths used prior to disposal.
Seed material from the microorganisms produc- Fermentation is safer than organic synthesis be-
ing the respective antibiotic is prepared in sterile cause fermentation is primarily based on "water"
boxes in advance. The fermentation process begins chemistry and technologically requires during the
with the cultivation of the seed material on a particu- seed preparation and fermentation process limiting
lar food (fermentation) medium in the preparatory processes to the usual hazards of pharmaceutical
fermentes. For crop and fermentation media, corn production. The fire and explosion hazards increase
extract, peptone, glucose, soy flour, various mineral during solvent extraction, although the flammabili-
salts, glycerin, etc. are most commonly used. Further ty of the solvents is reduced by diluting with water
fermentation is carried out in working fermenters by on filtration and recovery. The danger of thermal
continuous aeration of the culture fluid with sterile burning arises due to the high volumes of steam
air. under pressure and hot water used in fermentation
Upon completion of fermentation, the culture production.
fluid is released from micelles by means of filters. For
this purpose, the native solution is processed into 17.11.4. SYNTHESIS OF MEDICINES
continuously operating rotary drum filters or filter
presses. The extraction of the antibiotic from the na- In organic synthesis processes, organic and in-
tive solution and its chemical purification is carried organic chemicals are used to produce drug sub-
out in special installations by three basic methods: stances. Typical of this is that series of chemical re-
extraction with subsequent desorption (elution) us- actions take place in multi-purpose reactors and the
ing various synthetic ion-exchange resins and pre- products are separated by extraction, crystallization
cipitation in the form of insoluble salts with subse- and filtration. The final products are dry, milled and
quent crystallization. Some of the substances used mixed. In organic synthesis plants, basic and auxilia-
in these processes are regenerated partially or com- ry equipment is similar to the light chemical indus-
pletely and reused. They determine the spectrum of try.
chemicals found in the air in the working environ- Recently, the pharmaceutical industry has be-
ment and the exposure of workers. come a complex of multi-stage processes where sin-
After extraction from the chemical solution and gle-phase products become the starting materials
purification, the antibiotic is dried in a drying appa- for the next phase until the final phase of obtaining
ratus or lyophilized. The dried (lyophilized) antibi- the desired drug product is reached. The basic mass
otics are granulated and then the granular mixture of chemicals that are intermediate or end products
is dispensed for tabletting or encapsulation with can be exchanged between organic synthesis work-
subsequent packaging. The distribution of the anti- shops for a number of technical, financial and legal
biotics in vials is carried out using different batching considerations. The majority of intermediate and
devices. final products are produced in series through reac-
The risk of harming the health of workers in the tion groups (production processes run for a limited
production of antibiotics is created by: the moving period of time - before materials, basic and auxiliary
parts of the machines; the presence of high pressure equipment are changed to conduct new processes).
steam lines; contact with hot water and hot surfac- Many organic synthesis plants in the pharmaceuti-
es creating overheating microclimate at workplaces; cal industry are equipped in a way that ensures max-
the use of aggressive fluids with irritating and cor- imum flexibility (mobility). This has been achieved
rosive action on the skin and mucous membranes; through the construction of equipment and the in-
the heavy physical dynamic loading during manual troduction of process equipment, which are modi-
loading and loading of finished products; manual fied and supplemented for each new production.
handling of monotonic elements in manual packag- Multi-purpose reactors are the first process
ing; exposure to high-intensity noise. equipment in organic synthesis. These are stainless
Workers are exposed to increased concentrations steel vessels with pressure-reinforced walls coat-
of organic solvents in recovery and extraction oper- ed with a glass or metal mixture. The nature of the
ations. Exposure may be due to uncleaned filtration chemical reactions and the physical properties of
equipment or insufficiently sealed pumps, valves, the materials (eg reactivity, corrosivity, flammabili-

417
 OCCUPATIONAL MEDICINE
ty) determine the performance and construction of and nervous emotional intension, due to the high
the reactors. Multipurpose reactors have an outer requirements for concentration of attention, rapid
shell and internal coils that are filled with cold wa- processing of information in the control of techno-
ter, steam or chemicals with special heat transfer logical processes and responsibility for the quality
properties. The reactor shell is heated or cooled, de- of production . The dynamic physical load is negligi-
pending on the reaction conditions. Multipurpose ble, with continuous production cycles working on
reactors have agitators, barriers, and many internal shifts, but the mode of operation is free. However,
and external openings connecting them to other synthesis operations create many health hazards for
vessels, equipment, and stocks of the main chemical workers. These include the dangers of moving parts
mass. Temperature, pressure and humidity sensors of machines, equipment and pressure pipes, physi-
are installed to measure and control reactor pro- cal loads in the transport of materials or equipment,
cesses. Reactors can operate at high pressure and steam, hot liquids, surfaces and overheating micro-
vacuum, depending on technology, performance, climate at the workplace, limited space or hazardous
and requirements of chemical processes. The heat energy source (electricity) and over norm noise.
exchangers are connected to the reactors to heat or Acute and chronic health risks may be due to
cool the reactions or condensed vapours of solvents exposure to chemicals during synthesis. In case of
when their temperature exceeds the boiling tem- breakdown, the chemicals with acute action can
perature, causing reflux or recovery of condensed damage the eyes and skin, are corrosive or irritat-
vapours. Air pollution control devices (ie scrubbers ing, cause sensitization or allergic reaction, are as-
and traps) may be connected to the outlet ports of phyxiants causing suffocation or oxygen deficiency.
the vessels to measure and capture the reducing Chronic effects may cause cancer or damage to the
gases, vapours and dust emissions. Volatile solvents liver, kidney, lung, or to affect nervous, endocrine,
and toxic substances may be discharged into work- sexual systems and organs.
places or into the atmosphere, unless they are con- Occupational health and safety can be controlled
trolled during the reaction by heat exchangers or air by applying acceptable control measures (techno-
control equipment. Some solvents (see Table 1) or logical, technical, organizational, PPE). Reactions
reagents are not condensed, absorbed or trapped to organic synthesis can pose a serious risk of the
by air control equipment (for example: methylene presence of high toxical materials, fire, explosion,
chloride or chloroform) due to their chemical and or uncontrolled chemical reactions that affect the
physical properties. environment and the population. This requires that
The basic mass of chemical products are recov- safety measures be complex. They need to be direct-
ered or isolated by separation, purification or fil- ed in different directions: technological (preliminary
tration operations. As a rule, these products are tests of dynamics of chemical reactions, properties
contained in the "uterine" solutions dissolved or sus- of high toxical materials); technical (setting up, op-
pended in a mixture of solvents. "Uterine" solutions erating and maintaining the equipment); organiza-
can be transferred between reactors or equipment tional (training of the operational and engineering
through temporary or permanent pipes or hoses, in- staff, preparation for dealing with disaster situations
ert gas pumps, vacuum or gravity. Material transfer and responsibility of auxiliary means and local com-
is most often determined by the reaction rate, criti- munications). The technical instructions shall pro-
cal temperatures or pressures produced in the reac- vide an opportunity for analyzes of hazardous pro-
tor, equipment performance, and leakage potential cesses and activities to manage and reduce the risk
and chemical pouring potential. Special precautions of chemical synthesis operations.
to reduce static electricity are required when flam-
mable gases or liquids are used or generated in the 17.11.5. BIOLOGICAL (NATURAL)
production. Filling of flammable liquids through EXTRACTION
submerged water or ground pipes and maintaining
an inert gas atmosphere inside the equipments re- Large amounts of natural materials such as plants
duces the risk of fire or explosion. and animal tissues are raw materials for the extrac-
The workshops for organic synthesis of pharma- tion of pharmacologically active substances. At each
ceuticals are characterized by a high degree of au- step of these processes, the volumes of substances
tomation and mechanization, the main profession are reduced by series or group of processes to the
is an operator-device. The physiological character- final product, and this sometimes lasts for several
istic of the operator-device profession is dominat- weeks until the desired amount of finished product
ed by elements of nervous sensory, neuro-psychic

418
 LABOUR MEDICINE
is achieved. Solvents are used to extract water-insol- a metal matrix maintains the measured amount of
uble fats by means of the extraction of the final sub- drug mixture while compressing the tablet. Drugs
stance. The acidity (pH) of the extraction solution or that are not stable enough to wet granulation or can
waste water can be corrected by neutralization with not be compressed are injected. Injection, or dry
acids or bases. Metal compounds often serve as pre- granulation, mixes or presses relatively large tablets
cipitants, and phenolic compounds for disinfectants. which are coated and sized to the desired size and
Health and Safety at Work. Some workers de- then re-extruded to final tablets. Mixed and granu-
velop allergic reactions or irritation of the skin in lar materials may be encapsulated. The hard gelatin
contact with different plants. Animal products may capsules are dried, stacked, filled, and joined to en-
contain pathogenic micro-organisms (if no precau- capsulation machines.
tions are taken). Workers are exposed to solvents Liquid forms can be produced as sterile inject-
and corrosive liquids in the process of biological and able solutions or eye drops; liquids, suspensions
natural extraction. There is a risk of fire and explo- and syrups for oral ingestion; tinctures for dermal
sion when storing, processing and recovering flam- application. Conditions of production, equipment
mable liquids. The movement of mechanical parts, and raw materials are subject to strict control in the
hot steam, water, heated surfaces and workplaces manufacture of sterile solutions to prevent dust and
with overheating microclimate, high noise are risk microbial contamination. All used equipment and
factors. work surfaces are cleaned to minimize contamina-
Safety measures are determined by the magni- tion. High pressure and temperature water is used
tude and nature of the reduction in the large bulk to purify from bacteria and other contaminants of
of plant and animal materials and are related to the sterile water for injection solutions. Parenteral solu-
limitation of open solvent extraction activities. Fire tions prepared with fully demineralized and no-py-
and explosion, solvent exposures, irritants and cor- rogenic water are sterilized by dry or moist heat
rosive liquids are detected during extraction and re- under high pressure with bacterial filters. Solutions
covery depending on the specifics of the processes for oral or topical use do not require sterility, but eye
and the contamination of the equipment. solutions should be sterilized. Solutions for oral ad-
ministration are prepared by mixing the active drug
17.11.6. PRODUCTION OF READY-TO-USE substance with a solution or a preservative against
PHARMACEUTICAL FORMS molds and microbes. Liquid suspensions and emul-
sions are produced by colloidal mills and homog-
Medicinal products are formulated as dosage enizers. Creams and onyments are prepared by
forms prior to use. The active drug substances are attaching the active ingredients with vaseline, fats
mixed with the necessary pharmaceutical additives or softeners before placing them in metal or plastic
such as binders, fillers, flavors and added volume, tubes.
preservatives and antioxidants. These ingredients Major manufacturing operations
may be dried, milled, blended, compressed or gran- The weighing and distribution of solid and liq-
ulated to achieve the desired properties. Tablets and uid substances is a common operation in the phar-
capsules are the most commonly available ready- maceutical industry. Generally, workers distribute
to-use pharmaceutical formulations for oral use; and weigh the substances with precision electronic
other formulations are sterile injectable solutions scales, manually, using blades for solids and pour-
and eye drops. Typical operations for the manu- ing or pumping for liquid ingredients. The air in the
facture of finished dosage forms are: weighing of working environment is contaminated with dust,
active substances and excipients; mixing; granula- vapors or aerosols. Local exhaust ventilation is re-
tion; precompression; re-granulation; sieving; tab- quired. Work surfaces must be smooth to prevent
letting, which includes the manufacture of tablets, dust and dampness and allow thorough cleaning.
film-coated tablets or dragees and encapsulation. The loading and unloading of solutions and
The pharmaceutical compositions may be com- solids from containers or equipment is often a re-
pressed by wet granulation or direct compression to curring operation in the pharmaceutical industry. It
obtain the desired physical properties prior to final is usually done manually and this is associated with
shaping of the molds. In wet granulation, the active significant physical load, but other methods are
ingredients and additives are wetted with water or also implemented: gravity, mechanical or pneumat-
solvents to obtain granules of different sizes. These ic transport system. Special equipment, system for
granules are dry, mixed with lubricants (e.g., mag- transfer and control at loading and unloading, pro-
nesium stearate), anti-adheres or binders and then tect workers from exposure to highly toxic chemicals.
compressed as tablets. During direct compression, Loading by gravity from closed containers, vacuum

419
 OCCUPATIONAL MEDICINE
transfer, pressure or pumping reduces emissions of ing operations to produce solutions, suspensions,
volatile substances. When transferring solutions and syrups, flavors and pastes. It is recommended when
solids through open systems, conditions are created mixing toxic materials using special equipment
to contaminate the working environment with dust and transfer system. Buffering agents, detergents
(aerosols) and vapors, which requires control of their and antibacterial agents used to neutralize, clean
contents for concentrations above the MAC. and destroy biological agents can be dangerous for
Liquid mixtures are separated by methods workers. Washing showers and eyewash cleaners
based on their physico-chemical properties: relative reduce injuries if workers accidentally come into
weight, solubility and viscosity. This is also a com- contact with corrosive or irritant substances. Due to
mon and often performed operation in the manu- wet surfaces, workers must be protected from elec-
facture of medicaments. Toxic mixtures should be tric shock and electric trauma. Combustion hazards
transferred and separated into closed containers create steam and hot water used to mix or clean the
connected to pipelines to reduce worker exposure. equipment. Occupational accidents due to burning
Eyewash showers and baths in case of toxic and or slipping and falling are prevented by isolating
corrosive fluids on the skin, mucous membranes hot surfaces and maintaining the floors dry without
and eyes should be located in close proximity to spillage of liquids.
work places. It is necessary to provide for measures The dry and wet substances are granulated to
against spillage, fire and explosion when easily com- change their physical properties. The granulators are
bustible mixtures are separated. of different construction and with devices for auto-
Very often, in the pharmaceutical industry, it mated control of the mechanical danger and the air
is necessary to transport solutions from storage pollution with dust and aerosols. Closed granulators
vessels, containers or reactors. The best option is are ventilated by air control devices that reduce sol-
that equipment for this purpose minimizes the risk vent vapours or dust emissions in the environment
of spilling and exposure of workers. Solutions are and the work places. Exposure of workers increases
transferred through a system of pipelines that pass with manual manipulation with materials, requiring
through pumping stations. These stations are the greater physical effort when loading and unloading.
places where gassing and spillage are most often Mechanical equipment (lifting platforms, elevators
recorded. To reduce the risk, seals or seals of hoses and pallet jacks) is used to relieve physical stress.
and pipes are used. Closed-chamber drying or water Eyewash showers and baths are needed in contact
purification systems are also required. Well-sealed, with solvents or irritating powders.
closed vessels, containers and pipelines are par- The water- and solvent softened solids are dried
ticularly needed when large volumes of solutions by a variety of operations. Fluid dryers are often
are transferred. Special precautions are taken when used, but dryers may have different design and va-
using inert gas under pressure to transfer solutions por control devices. Flammable solvent vapors and
as the release of volatile organic substances or other explosive hazardous powders can form a flamma-
toxic pollutants into the air is increased. Recircula- ble and explosively hazardous environment. This
tion or condensation of waste gases and vapors re- attaches particular importance to ventilation to re-
duces atmospheric air pollution. duce the hazard. Dilution and maintenance of ac-
The solids in the solution are separated by filtra- ceptable concentrations also reduce the risk of fire
tion. The filters used have different designs, differ- and explosion. It is necessary to control exposure to
ent volume and possibilities for controlling liquids solvent vapours when wet briquettes are handling,
and vapors. When filtering toxic materials using and dust when dry products are discharged. When
open filters, workers are exposed to liquids, wetting loading and unloading the troughs, the bins or con-
agents, aerosols and vapors during loading and un- tainers of the driers, a significant dynamic physical
loading of the filters. Closed equipment should be load is observed. Mechanical equipment (drum-reel,
used in the filtration of extremely toxic and haz- elevator or work platform) reduces workload. In the
ardous materials. Filtration should be carried out in close proximity of the workplace there should be
places where spillage control and good ventilation eyewashes and showers in case of contact with sol-
are provided. The vapours of the liquid phase must vent and powders.
be discharged through ventilation system in closed The dry solids are milled to achieve a certain dis-
containers and controlling their discharge into the persion and free-flowing powders are obtained. The
air, through emission capture devices (condensers, mills have different designs and devices for mechan-
scrubbers or absorbers). ical protection and control of air pollution. Hammer
Solid and liquid substances are mixed (ho- mills are often used, which are very noisy and heavi-
mogenized) in mixers (mixer granulators) by bond- ly dust the working environment.

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It is necessary to check in advance the physical trauma and dust removal. Workers are also exposed
properties and toxicity of the grinding materials. to solvent aerosols when coating the tablets. Mod-
Explosion protection includes: the installation of ern machines have a high capacity of activity and
dust-proof electrical equipment, earthing devices, have control devices for excreting vapor and sol-
electrostatic discharge; the installation of providing vent aerosols. They are connected with ventilation
discharge valves in closed mills and the construction to remove volatile organic substances. It is possi-
of anti-detonation panels in the walls. These meas- ble to re-use the recovered solvents. Modern tablet
ures are due to the explosiveness of certain drug machines and capsule machines are also equipped
substances and excipients and high concentrations with noise-reducing panels, dust extraction during
of dust in the equipment. operation. Wearing PPE also reduces the risk of en-
The dry substances are mixed until a homoge- capsulation and tablet noise.
neous mass is obtained. Mixers (homogenizers) The production of sterile products in phar-
have a different construction and sensors to control maceutical practice requires modular equipment
the risk of mechanical trauma and air pollution with in clean workplaces and working surfaces, and
dust. Workers are exposed to dust, excipients and high-efficiency dust extraction ventilation. The prin-
mixtures when loading and unloading the mixers. ciples and practices for providing clean work plac-
During mixing by a flange with a return valve, the re- es are similar to those in microelectronics. Workers
leasable dust is reduced. The loading and unloading wear protective clothing to prevent contamination
of the mixers is associated with a dynamic physical of the products. Technologies for the production of
load which is limited and reduced by the use of work sterile products include lyophilization, use of liquid
platforms, winches and drums, pallet trucks, etc. or gaseous disinfectants, effective ventilation, isola-
The dry substances are compressed or charged tion of modules by maintaining differential pressure,
for compaction in order to change the state of dis- and loading and filling facilities.
persibility. Compression equipment is different in Chemical danger creates the use of liquid disin-
design and in various ways the risk of mechanical fectants (formaldehyde and glutaraldehyde) and
damage at work (mechanical trauma) and dust re- gases for sterilization (ethylene oxide). Where pos-
moval is controlled. These operations are accompa- sible, it is advisable to choose less toxic substances
nied by a high noise level. Encapsulation of the noise such as alcohols, ammonium compounds. Sterili-
source, reducing equipment vibrations, changing zation of raw materials and equipment can also be
workplaces and using headphones and earmuffs re- carried out under steam pressure. Sterilization of
duce the impact of noise. vessels should take place at a specific place (room)
Tablets and capsules are the most commonly with remote controls and a toxic substance control
produced oral dosage forms. Tablets are compressed system, without air recirculation (toxic emissions to
or formulated using modern tablet machines that be removed). Workers should be instructed on the
are equipped with computer control. The tablets rules of safe work and personal responsibility in an
contain mixtures of drug substances and excipients. accident. Gas sterilization rooms must be provid-
They are "no backed tablets" and coated with wa- ed with wacuum system and air must be cleaned
ter-soluble mixtures or solvents (film-tablets or dra- to reduce emissions to workplaces. Emissions from
gees). sterilization rooms should be through a ventilation
Pre-tablets are deodorized and fed to the dredg- system that includes carbon absorption or catalytic
er machines. Dyeing of tablets (dragees) is done in conversion to reduce environmental pollution. Se-
drums (dredgers), which are loaded with paint, hot curing safety is also provided for contact with steam
distilled water, talc and titanium dioxide. Acetone, and hot water, moving parts of machinery when
isopropanol, castor oil and glycerin are also used. washing, filling and packaging the finished prod-
Film coating (lacquering) is carried out with ace- ucts, high noise and monotone manual operations.
tophthalate cellulose, ethanol, ethyl phthalate, ethyl Packaging in pharmaceutical manufacture is
acetate, sugar, gum arabic, gelatin and titanium di- done by machines and manually. The finished ready
oxide, talc, demineralised water, coloring agent, pol- dosage forms can be packaged in different types of
yethylene glycol, glycerin. The gloss solution con- containers (plastic or glass bottles, foil blisters, bags
tains polyethylene glycol, isopropanol, acetone and or sachets, tubes or sterile ampoules). Mechanical
glycerin. equipment filled, encapsulated, labels, put in box-
Capsules that are produced may be soft or hard es and packs the finished products into shipping
gelatin shells. Tablet presses, encapsulating ma- containers. Employees serving packing machines
chines and coating drums are of different construc- must be protected from their moving parts. Machin-
tion and equipment for controlling mechanical ery must have signal lamps that are under voltage

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 OCCUPATIONAL MEDICINE
and emergency shutdown buttons. The closure and ological protection, shields (lids) are used to provide
isolation of equipment reduces noise and vibration airflow into the laboratory stove down and inward,
during packing. The use of PPE (headphones and preventing contamination of the work rooms with
earmuffs) reduces exposure to noise. The ergonomic microorganisms. Safety training and instruction,
design of the machines increases labour productiv- training on personal responsibility in case of fire and
ity, improves the comfort and safety of workers and spillage are important preventive measures. Do not
reduces the risk of injuries from forced labour pose, eat and drink at work places in the laboratories. Par-
physical loading and monotonous work. ticularly dangerous operations are carried out under
Unusual conditions are created when cleaning, the supervision of observers. The requirements for
repairing and maintaining the equipment and good laboratory practice include separate collec-
work places. Sometimes this is often done due to tion, treatment and storage of hazardous waste.
the change of the manufactured product, increas- Physical factors related to health risk such as ion-
ing the risk of performing non-standard tasks. Work- izing radiation and EMF are certified and the appa-
places and surfaces can be contaminated with toxic ratus generating these factors is operated according
substances or drug substances, which requires them to the specific rules.
to be thoroughly cleaned. The cleaning is done by
washing or wet wiping and drying or vacuuming the 17.11.7. PHARMACIES
powders. Dry suction and blowing with compressed
air is not recommended. When cleaning dangerous The hygienic requirements for the structure, or-
substances and high active pharmaceutical pow- der and organization of work in the pharmacies are
ders, vacuum cleaners with microporous filters are in line with the Health and Safety at Work Act and
required. Explosion-proof equipment and resistant are regulated by the current regulations and other
materials are required to vacuum explosive pow- by-laws of the Ministry of Health. All pharmacies
ders. Eyewashes, showers and PPE reduce the risk have medicinal products in the pharmacological
of damage by accidental contact with corrosive and groups according to Annex 1 (medicines licensed
irritant substances - detergents and cleaning solu- with color prescriptions require a license from the
tions. In the case of repairs or maintenance of equip- MH) and are divided into 2 main types. The first type
ment, workers sometimes have to carry out tasks re- of pharmacies provide medicines for the citizens
lated to the risk of mechanical, electrical, pneumatic and the second one - for the medical institutions
or thermal injuries. Careful monitoring and control with a stationary.
of these tasks is important preventive measures. This Pharmacies that provide medicines to citizens
prevents fire, explosion or other serious health risks. are 4 types:
Laboratory activities (operations) in the phar- • pharmacies that release pharmaceuticals ex-
maceutical industry are diverse and accompany the cept for extemporaneous dosage forms (only
various drug production technologies. They gener- work with ready-to-use formulations);
ate a biological, chemical or physical risk depending • that release pharmaceuticals pharmacies, in-
on the specific agents, operations, furnishings and cluding extemporaneous forms,non-ophthal-
work practices. There is a difference in the activity of mic formulations and solutions for parenteral
the laboratory staff performing research and devel- administration (do not prepare sterile formu-
opment activities and those who assess the quality lations);
of production and control the technological disci- • pharmacies that release medicinal products,
pline of production. Laboratory activities should be including extemporaneous formulations and
evaluated individually, although general require- the preparation of eye formulations;
ments for good laboratory practice are applied. • pharmacies that release herbs and herbal
Clearly defined responsibilities, training and infor- mixtures (herbal pharmacies), including ex-
mation, training to mastering safe working rules and temporaneous forms.
control measures as well as emergency situations In all pharmacies that release medicines to citi-
are effective means of managing safety, health and zens, the cosmetic and sanitary hygienic devices list-
environmental protection. ed in Annex 2 of Ordinance 8 / 23.06.2000 can be
For example, safety and reduction of health risks sold.
from flammable and toxic substances are achieved The pharmacies that meet the needs of health
by reducing their stay in laboratories and by keeping establishments with stationary are two types. De-
them in separate rooms. Laboratory tests and opera- pending on the activities performed, they supply:
tions related to the release of toxic air contamination • Medicinal products, including extemporane-
should be carried out in laboratory fireplaces. For bi- ous formulations without preparation of eye

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 LABOUR MEDICINE
formula and solutions for parenteral adminis- room of at least 15 m2 in one work place, a box of
tration; distilled water, and a sink for washing the dishes and
• Medicinal products including extemporane- instruments for preparing extemporaneous dosage
ous formulations and eye formulations and forms is required.
solutions for parenteral administration. The pharmacy to meet the needs of a medical
This approach to dividing pharmacies suppose a establishment, including extemporaneous forms
different technological process that determines the without eye drops and solutions for parenteral ad-
set of premises and specific hygiene requirements. ministration, should have a total area of 0.50 m2 per
Pharmacies for dispensing pharmaceuticals of cit- bed but not less than 50 m2. This area is distributed
izens who only work with ready-made forms and between a reception room, an assistant room, a san-
have only one work place are located on a total area itary unit with an entrance hall and a sink according
of at least 20 m2. On this area there is a reception to the requirements of the current norms for the de-
room and a storage room with a total area of not sign of hospitals of general type.
less than 15 m2 and a sanitary unit with insulated en- In the hospital pharmacy for medicinal products,
trance hall and sink. For each additional workplace, including extemporaneous formulations with the
a further 5 m2 is required. preparation of eye drops and solutions for parenter-
Pharmacies in which ready-to-use and extempo- al administration, the premises, areas and conditions
raneous formulations are realease, with one work for this type of activity and pharmacy are brought in
place, but do not prepare eye and parenteral formu- accordance with good practice in the manufacture
lations are disclosed on a total area of 30 m2 consist- of sterile dosage forms.
ing of a reception and storage area with a total area The premises of the pharmacies are completely
of at least 15 m2, one-work place assistant room, dis- isolated from premises for other activities. There must
tilled water box and wash basin for the dishes and be functional links between them. The reception
the equipment for preparation of extemporal for- room should be connected to the assistant with a di-
mulations with a total area of not less than 10 m2, rect connection and convenient access to the storage
sanitary unit with insulated entrance hall and sink. room. The assistant room has a convenient connec-
For each additional workplace, a further 5 m2 is re- tion to the dishwasher. It is allowed to use premises
quired. on other levels (basement or second level room), but
Pharmacies for ready-to-use and extemporane- their area is not included in the pharmacy area.
ous formulations with one workplace and eye for- The following building requirements are ap-
mulations, require premises with a total area of 40 plied to the pharmacy premises: the clear height of
m2 consisting of a reception and warehouse with a the premises must be not less than 2.50 m. The walls
total area of at least 15 m2, an assistant room with in the dishwasher, aseptic box, the apparatus room,
one working place, box for distilled water and a the dispenser box, and the sanitary unit are covered
washbasin for washing dishes and apparatus for the with a waterproof coating, allowing water cleaning
preparation of extemporaneous dosage forms with and distillers at a height of 2 m. Floor coverings at
a total area of not less than 10 m2, a work area for all pharmacy premises must be wateproof and easy
the preparation of eye solutions of a total area of not to clean. In the sector where pharmacists work, floor
less than 10 m2, box for aseptic preparation of eye coverings should be easy to clean and be warm.
formulations and sanitary unit with an insulating A mandatory requirement is the presence of
entrance hall and a sink. For each additional work- natural lighting in the reception and the assistant
place, a further 5 m2 is required. room. Combined lighting or artificial lighting only is
A herbal pharmacy with a workplace where herb- allowed in the storage room, the aseptic box, the ap-
al mixtures and teas are prepared and distributed paratus and the sanitary unit. The artificial lighting in
herbs must have a minimum area of 50 m2, which is the rooms shall be not less than 300 lx. Workplaces
distributed between a reception and a storage room in the production premises (reception and assistant)
with a total area of at least 30 m2, an assistant room are provided with local lighting. Aseptic room and
with one work place with an area of not less than 15 entrance hall to it, have bactericidal lamps.
m2 and a bathroom with a shower and an insulated A mandatory requirement is the presence of nat-
entrance with a sink. If a herbal pharmacy is released ural ventilation in the pharmacy's premises. Forced
and ready-made dosage forms have to be aditional, (artificial) ventilation is required in all indoor spaces
a separate work place with an area of at least 15 m2 to provide a maximum allowable dusting norm of 2
shall be established for the storage and sale of these mg/m3.
drugs. Where an extemporaneous dosage form is Heating, ventilation and air conditioning systems
prepared in the herbal pharmacy, an additional must ensure healthy and safe working conditions

423
 OCCUPATIONAL MEDICINE
and ensure compliance with the regulatory require- are destroyed. Impaired storage temperature and /
ments for a microclimate of the working environ- or high humidity in the premises can also affect the
ment. medication. Unfavorable microclimatic conditions
The water supply and sewerage of pharmacies are fatal when preserving bio-products (vaccines
must comply with the relevant building codes. Phar- and sera). They are stored in refrigerated chambers
macies should be provided with a sufficient amount or refrigerators at temperatures not higher than 8 °
of hot and cold water that meets the drinking water C. All others may store "in the dark, in a dry and cool
regulations. room" at temperatures of 8-20 ° C and a relative hu-
The pharmacies are furnished with suitable midity of up to 60%, unless otherwise specified in
working furniture: racks, tops, working tables, the current Pharmacopoeia.
chairs and height changing chairs, etc., which meet Herbs are kept separate from other drugs in
the ergonomic requirements and are made of mate- tightly closed cabinets. High humidity is also an
rials that allow wet cleaning and disinfection. Work- unfavorable factor in herbal pharmacies, because
places in the assistant room where extemporaneous in combination with high temperature it creates a
forms are being prepared must be equipped accord- danger of the development of fungi and molds on
ing to the minimum standard set out in Annex 5 to medicinal plants.
Art. 14 of Ordinance 8 / 23.06.2000. Extemporaneous dosage forms have an ad-
Distillation of water for the preparation of ex- verse effect on the already mentioned light, high
temporal forms is carried out in separate rooms. temperature and high humidity. The quality of the
Where there is no separate room, the water receiver extemporaneous forms is influenced by the pres-
is placed in a tightly closed glass box. In the same ence of gas and dust pollutants of air and microor-
room, it is forbidden to wash contaminated contain- ganisms. The gas pollutants (vapors of ammonia,
ers and store easily evaporable drugs. iodine, formalin, ether, chloroform in the air of the
Distilled water is stored in cool, clean and well- pharmacy, or penetrating from the outside of highly
sealed containers, pre-washed with distilled water. polluted air containing significant amounts of sulfur
The vessel is the date of receipt of the distilled water dioxide, nitrogen oxides, CO and dust) are adsorbed
and it is stored for not more than 48 hours. and enter chemical interactions with some ingredi-
Medicinal products, except for extemporane- ents of the formulations prepared by giving them
ous dosage forms, are stored on shelves or in tight- unpleasant odor and deteriorating quality. Powder
ly closed cabinets. Medicinal products in transport pollutants are also carriers of microorganisms. They
packs and sanitary and hygienic materials are stored fall into the air with coughing, sneezing and talking
on wooden grills. Strongly smelling, disinfecting, to the pharmacy's clients, along with the dust of
deratizing and cosmetic products, sold in pharma- their clothes and the outside air.
cies, are stored in separate, well-locked cabinets. For drug protection, they need to be packed in
Pharmacies licensed to dispense neuroleptics and hermetically sealed or tight-fitting containers with
psychotropics, containing narcotics, are stored in a the appropriate properties required by the pharma-
metal cabinet or safe box marked "Drugs containing copoeia and stored under appropriate conditions.
narcotic substances" and a list of medicinal products In the preparation of extemporal dosage forms it is
with the maximum doses indicated. In the same cab- necessary to respect the adequate technology and
inet, the utensils needed to work with these drugs the rules of personal hygiene. When preparing ster-
alone, are kept. Medicines that have expired, with ile antibiotic formulations, all sterility requirements
a primary or secondary packet disorder, are stored and good manufacturing practice rules are respect-
separately at a designated site (with a permanent in- ed.
dication that the medicines are blocked). The sanitary and hygienic regime in the phar-
Various factors influence the properties of the macies provides daily and immediately, upon con-
formulations. Among them are the light and the tamination, to perform wet cleaning and disin-
parameters of the microclimate. Light has a pro- fection of the floor, the surfaces of the furniture,
nounced photochemical effect due to the high en- the equipment, etc. according to Methodological
ergy ultraviolet spectrum. Under the influence of UV Guideline 0-20 for modern ways and means of disin-
rays, some photosensitive components of the drugs fection in healthcare facilities.

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REFERENCES

1. Alexeyev S.V., V.G. Artononova, V.P. Padalkin, et al. Hygine of labour in the production of microbio-
logical synthesis. in Guide of labour. ed. N. F. Izmerov, II vol. Medicine, Moscow, 1987, 295-309. (in russ.)
2. GD № 76 / 29.04.1991 for the adoption of Regulations of the HMC and Regulations of the Council of
Pharmacy with the Ministry of Health, SG, No. 37/1991. (in bul.)
3. Health and Safety at Work Act (HSWA). SG, No. 124/1997 (in bul.)
4. Hygiene of basic industries. ed. M. Lukanov, Med. and phys., Sofia, 1978. (in bul.)
5. Ordinance No. 7 / 25.05.1992 on the hygienic requirements for health protection of the urban environ-
ment. SG No. 46/1992 (in bul.)
6. Ordinance № 4 of 07.07.1998 on Environmental Impact Assessment. SG, No. 84/1998. (in bul.)
7. Ordinance № 7 of 3.05.1999 on the assessment and management of the ambient air quality. SG, No.
45/1999 (in bul.)
8. Ordinance № 7 of 23.09.1999 on the minimum requirements for health and safety at work and work
equipment. SG, No. 88/1999 (in bul.)
9. Ordinance No. 5 of 11.05.1999 on the order, manner and periodicity of conducting a risk assessment.
SG, No. 47/1999. (in bul.)
10. Ordinance No. 3 of 18.09.2002 on the minimum requirements for ensuring health and safety at work
with video display. SG, No. 95/2002 (in bul.)
11. Ordinance No. 5 of 11.05.1999 on the order, manner and periodicity of conducting a risk assessment.
SG, No. 47/1999. (in bul.)
12. Ordinance No. 15 of 31.05.1999 on the conditions, procedures and requirements for development
and introduction of physiological regimes for work and rest during work. SG, No. 54/1999 (in bul.)
13. Ordinance № 2 of 27.02.2003 for the protection of workers from risks related to exposure to noise at
work. SG, No. 32/2003 (in bul.)
14. Regulation for occupational safety in the chemical, microbiological and perfumery-cosmetics indus-
try (1982). (in bul.)
15. Ordinance No. 8 of 23.06.2000 on the structure, order and method of organization of operation of
pharmacies and nomenclature of medicinal products. SG, No. 54/2000 (in bul.)
16. Regulation No. 153 / 6.08.1993 on collection, transportation, storage and disposal of hazardous waste.
SG, No. 70/1993 (in bul.)
17. Regulation No. 13 of 30.12.2003 on protection of workers from risks related to the exposure of chem-
ical agents at work. SG, No. 8/2004. (in bul.)
18. Regulation for licensing of manufacturers and businessmen of pharmaceuticals. SG, No. 44/1994 (in
bul.)
19. Regulation No. 17 of 9 06 1995 on the requirements for the registration of medicinal products. SG, No.
56/1995 (in bul.)
20. Tait K., Pharmaceutical Industry. in Encyclopaedia of Occupational Health and Safery. ed J. M. Stel-
mann, v. III. Forth Edition, ILO, Geneva. 1998, 79.2-79.19.

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As. Petkov, An. Galev, Iv. Popivanov

17.12 ARMED FORCES

The State supports the armed forces to ensure 4200 kcal for driving armoured equipment, 4000
its territorial and political integrity. For the past 20 kcal for pilots) and for dehydration and loss of elec-
years, the main tasks of the Armed Forces have been trolytes. In order to correct the energy consumption,
added to operations other than war - humanitarian, it is necessary to include a number of nutritional
peace-imposing, peace-keeping, anti-terrorist, and supplements. In the event of crisis operations, logis-
others. In carrying out tasks related to these opera- tical provision of normal nutrition is difficult. This
tions, soldiers work on all types of terrain, in air and requires the maintenance and use of special individ-
under water, in different seasons and in various, of- ual food rations of different energy and low volume.
ten extreme, climatic conditions, handling specific The daily survival ration contains at least 150 grams
combat techniques against an armed enemy. of carbohydrates and is designed to survive in ex-
In order to effectively respond to crises and to treme emergency situations for up to six days. The
reduce combat losses, soldiers must possess basic daily emergency ration has an energy value of 1000
skills, such as the proficiency of various weapon sys- kcal and maintains the fitness for 24 hours. Individ-
tems, accurate shooting, high physical training and ual fighting rations have an energy value of 3200
aerobic endurance, discipline, ability to make quick kcal with a balanced ratio of the main nutrients and
decisions. Their maintenance is achieved through are used for no more than 30 consecutive days until
constant intensive training, which leads to the accu- normal military nutrition is restored. Humanitarian
mulation of physical fatigue. Incorrect or excessive daily rations contain no more than 2200 kcal, exclud-
training may result in serious injury. Maintaining a ing meat if they are used in areas with an ambient
high level of readiness leads to frequent violations temperature above 35 ° C but if the temperature is
of the work-rest regime and to limitations in social around or below 4 ° C their composition is mainly
contacts. Battle duties associated with prolonged meat - chicken or veal.
awaking, intense mental and sensory loading con- Temperature factor - militants often perform op-
tribute to the accumulation of physical and mental erations in extreme climatic conditions. The temper-
fatigue. Numerous other factors (noise, electromag- ature of the environment and the nature of the work
netic fields, long-distance transport) and increased can lead to heat or cold damages.
media attention lead to increased intension among Thermal effect - the increased heat output as-
military personnel and especially commanders. De- sociated with the significant physical loads in the
tachment for a long time from family and relatives fulfillment of the assigned tasks combined with
and the possibility of immediate opposing enemy's the elevated temperature of the environment is a
actions contribute to the increase in the effect of prerequisite for the development of thermal dam-
stress. The nature of the work of the militaries, and age. The use of ballistic protection means (armor,
especially in the land forces, poses a high risk of helmets) and WMD protection means further exac-
injuries from drafts, shrugs, explosive injuries, and erbates the release of heat from the organism and
varying degrees of thermal injury due to enemy ac- increases heat stress on the body. Means of protec-
tivity or impotent handling of combat equipment. tion from WMD create their own microclimate - the
In recent years, anti-infantries mines and improvised air enclosed between the body and the equipment
combat devices have been increasingly used, which is heated by body temperature and is saturated with
are difficult to detect, have a considerable striking moisture. In this way, the immediate surrounding
power, and are made from commercially available military environment becomes extremely hot and
materials. There is a high risk of damage from weap- saturated with moisture. For the overheating, the
ons of mass destruction (WMD) - nuclear, radiologi- microclimate also helps in combat machines and
cal, chemical and biological. ships, as the temperature in them often exceeds 15-
Energy consumption: Intensive mental and 20°C that of the environment.
physical efforts are associated with increased en- Cold effect - pronounced cold stress reduces
ergy consumption by the body (4200-4600 kcal for physical capacity, affects the moral qualities of the
field operations, 4200-6000 kcal for foot marches, individual, and can lead to the development of cold

426
 LABOUR MEDICINE
disabilities. It arises not only from extremely low diseases of the respiratory tract - rhinitis, tracheo-
temperatures, but also from the combined effects of bronchitis; and so-called "trenches diseases" - rheu-
moisture and low temperature and falling into cold matism, angina. A particular danger is the so-called
water. Cold weather contributes to increased res- "trench foot" - localized frostbite of the lower limbs,
piratory diseases and non-military injuries (frosts). which can lead to amputation of the affected limb in
On the other hand, the operational requirements severe cases.
for intense physical effort, waking and inadequate Closed facilities - army shelters, bunkers, com-
nutrition disrupt the body's effective physiological mand posts, artillery fire protection facilities - isolate
response to the cold. environmental militaries and create their own mi-
High factor - is characteristic of military oper- croclimate. They allow staff to reside for longer, to
ations in mountainous areas. Fast altitude climb at rest, and not to use personal means of protection
altitudes above 1500 m reduces the physical and against WMD. The parameters of the microclimate
recognizable abilities of militaries. Reduced atmos- in these facilities are generally outside the hygiene
pheric pressure and reduced oxygen partial pres- standards, due to the staff stay in them and the com-
sure increase susceptibility to mountain disease. bat operations they perform. The temperature in
Low temperatures predispose to generalized hy- them can rise up to 30-40 ° C and represent a prereq-
pothermia or local frostbite and combined with al- uisite for heat shocks, while the reinforced concrete
pine conditions are a prerequisite for more frequent constructions, which often build their structure, de-
traumas. The inability to provide adequate sanitary termine the possibility of overheating during the
measures increases the risk of developing infectious summer and cooling in the winter. The breathing of
diseases transmitted by water or food. even one military can lead to hygienic norms being
Infectious diseases - the nature of military ser- exceeded with condensation. On the other hand,
vice accommodation under field conditions limits breathing leads to an increase in CO2 concentration
development activities to deployment areas. There and a reduction in O2 partial pressure. In addition,
are difficulties in complying with the rules of indi- increased concentrations of gun powder and ex-
vidual and collective hygiene. The placement of a haust gases, vapours from heated oil, battery gases,
small area with a small amount of personal space for and more are found in the facilities. The duration of
each military is a prerequisite for a wide spread of residence of personnel in a medium saturated with
airborne infections. The difficulty of providing suf- gunpowder is determined by the CO content in 1
ficient water for drinking and domestic purposes liter of air. At a CO concentration of 0.25 mg/l the
leads to the development of waterborne epidemics. stay should not be longer than 25 minutes, at 0.50
Owing to contamination of food products, epidem- mg/l the stay should not be longer than 10 minutes
ic outbreaks of food toxico-infections and intestinal and at 0.75 mg/l the stay should not be longer than
infections are no-rare. The nature of military service 5 minutes. Accumulator gases and aerosols contain-
places them in direct contact with flying and crawl- ing H, O, P1, H2SO3 and those of the oils irritate the
ing arthropods, carriers of transmissible infections eyes, nose, trachea and bronchi.
and natural-focal diseases, as well as increases the Organized movement - "Marsh" is aimed at
likelihood of poisoning snakes, spiders, scorpions reaching a certain area within a given period of time,
and other dangerous representatives of flora and while maintaining a fighting. It can be carried out
fauna. on its own walk (classic foot march), on cars or oth-
Different types of armed forces have specific con- er combat equipment, by rail, sea or air transport or
ditions depending on the type and nature of the by combined means. In the classical walking march
tasks they perform. there is a heavy physical work (more than 4000 kcal is
Land Forces - One of the most important fea- spent for a 30 km transition), depending on the con-
tures of land troops is the use of various fortification ditions - the march is summer, winter, mountain and
systems for temporary and lasting protection of liv- night. It can also be normal (up to 30 km per day) and
ing force. forced (over 30 km per day). The main risk for summer
The open structures - trenches, ditches - are foot march is the occurrence of thermal injuries - sun
largely protected against the impact of convention- or heat stroke; the winter march is mainly the devel-
al weapons and weapons of mass destruction. How- opment of cold traumas and common cold; in the
ever, the military is exposed to adverse factors such mountain marshes problem is the increased energy
as extreme temperatures, humidity, snow and rain, consumption due to the nature of the terrain and the
wind, static intension, soil composition, groundwa- danger of the development of mountain sickness in
ter, asenization. The negative impact of these fac- areas with altitude above 1500 m. When using moto
tors is increased by extending their stay. There are machinery - motomarch - on the staff influence the

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 OCCUPATIONAL MEDICINE
constant static intension (deteriorates the work of the extreme overloading of aircraft and the possibility
lungs and develops stagnation of blood in the lower of hostile action. An important problem is the accu-
limbs), swinging, vibration, noise (in cars 80-90 dB/A, mulation of fatigue associated with long-term stay
and in armored equipment 100-120 dB/A), ambi- in forced pose, information overload and the need
ent temperature (in summer creating conditions for for quick decisions. As a result of the operation of
overheating, in winter colds), the speed of air, dust, the aircraft engines, vibrations occur which are more
exhaust gases from the machines contain CO, and in pronounced in taxiing, take-off and landing. Flight
war machines at shooting increases and the concen- turbulence causes aperiodic low-frequency thrusts.
tration of gun-powder gases and conditions are cre- The spatial disorientation that occurs in these cases
ated for intoxication, any combination of chemical, is also observed in flights at extremely low altitudes.
radiological and biological agents. For propelled transport aircraft, the major problem
Military equipment - optical quantum genera- is the intense engine noise. Exposure to cosmic radi-
tors (OQG) (laser rangefinders and systems for fire ation is a problem in high altitude flight.
control) have characteristics of weapons of elec- Helicopter pilots operate with relatively unstable
tronic warfare, but act within the legal geometric aircraft, which implies constant sensory, physical and
visibility, have a smaller range of action and are in- mental intension. The flights take place near the im-
fluenced by weather conditions. In current condi- mediate vicinity or overcome various natural or an-
tions, the use of the laser beam to target and target thropogenic obstacles. Spatial orientation can be lost
intelligent bombs and jets is increasing. Different in the absence of landmarks (flight over water basins,
application missiles (for airborne, anti-tank, etc.) are snow-covered surfaces). The use of night vision de-
also laser-directed. The OQGs are used for a laser lo- vices limits peripheral vision and makes orientation
cation, such as laser reconnaissence instalations, as difficult. At the same time, they are an easy target for
well as for laser simulators, imitation laser systems, attack by various weapon systems, including light
laser telecommunication systems, laser gyroscopes, arms. Problem of take-off and landing is the genera-
radar location stations suppressing devices (RLS). tion of swirling powder aerosols, which may contain
OQGs are also used in military medicine, mainly for biological agents. Cabin ventilation is provided by a
surgical purposes. As combat weapons, lasers have contrary airflow in the absence of sealing - there is a
characteristics similar to those of electronic weap- risk of crew intoxication when the fuel and lubricants
ons (REW), nuclear, biological and chemical warfare. are incompletely combusted. This specific risk is the
They mainly interfere with or disorganize the oper- highest in hovering mode when the cab is in the ex-
ation of receiving devices that operate in the light haust gases area. The level of vibration and noise is
or within the vicinity of the electromagnetic spec- much higher than that on airplanes, the noise often
trum. Combat laser weapons are primarily aimed at reaches 110-140 dB/A. The vibrations are low-fre-
destroying observation systems (periscopes, tele- quency, directed in the axial direction of the helicop-
scopes, night vision devices, etc.) When a laser beam ter and are most pronounced in landing and take-off.
falls directly on the exposed parts of the body and They contribute to decreased visual acuity, difficulty
the visible mucous membranes, local burns occur in speech communication, increased strain of para-
from the first to the fourth degree. In the eyes - to vertebral muscles with subsequent overwork. Chron-
irreversible disturbances of the functions of the eye. ic vibrational effects often result in the development
Air Force - Personnel are divided into two main of vibrational disease. A specific problem of chronic
groups - Flight and Ground. Pilots of combat air- vibrational effects on the vertebral and intervertebral
craft are subjected to the combined effects of grav- discs is the appearance of back pain, disc hernias, pro-
ity and acceleration during flight as well as altitude trusions, and radiculoneuritis.
hypoxia. Particularly high is the load on the pilots of The engineering and technical staff is subject
supersonic aviation, which are subject to high, rap- to the impact of on-board and aerodrome radars,
idly changing overloads. Very high linear, radial and radio, navigation and target systems, powerful EMF
angular accelerations (5-7 G with a duration of 10-40 army generators, sources of ionizing radiation, ad-
seconds) act on their body. Mechanical (anti-wear- verse climatic conditions, intensive noise and vibra-
ing suit, positive pressure breathing), physiological tions, dust, chemicals (kerosene, products from the
(muscle contractions, closed epiglottis expiration) decomposition of mineral oils, CO, CO2, nitrogen
and exercise (centrifugal training) methods are used oxides, acrolein, hydrocarbons, aldehydes, ketones,
to increase tolerance to these effects. Adaptation hydrogen sulphide). There is a high nervous-emo-
to hypoxia occurs with periodic residence in baro- tional intension, frequent disturbances of the work-
cameras. The risk of decompression in military avi- rest regime, monotony of work, limited contacts in
ation is much greater than the civilian, due to the the workplace.

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 LABOUR MEDICINE
Zenith-rocket troops and radio-equipment Deck and mast radar stations and radio stations affect
troops - the soldiers are exposed to electromagnet- all personnel. Meteorological conditions are dynam-
ic radiation around the antennas of radio stations ic and varied and mainly affect the deck command.
and radio transmitting centers, in the transmission Daytime heating and nighttime cooling on the ship's
rooms where are the generators, feeders, wave- deck make it difficult to maintain the microclimate
guides, antenna systems of radiotechnical devices, and load the body's thermoregulatory function. Dur-
magnetrons, klystrons, waveguides, also from the ing long voyages, crews often change several climatic
parasitic rays in the cabins and rooms, and in emer- zones, which puts the body's thermoregulatory adap-
gency situations it is necessary to work in the field tation. The temperature in the engine compartments
itself. Stationary personnel are exposed to mild often exceeds 45-50 ° C. Noise is intense and constant
X-rays, intense noise (over 95 dB/A), vibrations, CO, and prevents sufficient rest. Swinging of ships irri-
CO2, ozone, nitrogen dioxide, SML contacts, insuf- tates the vestibular apparatus and causes kinetosis.
ficient brightness, screen brightness, overheating Onboard submarines the main problem is maintain-
microclimate (to 45 ° C), forced posture, great nerv- ing air cleanliness and preventing its contamination.
ous intension combined with high responsibility, Personnel engaged in diving activities are at risk of
frequent disturbances of the work-rest regime. In ra- developing oxygen toxicity from inhaled air and de-
diolocation stations in scanning and rotation mode, compression (caisson) disease.
the antennas irradiate work areas and living areas Medical insurance - should focus on the preven-
in the grounds, with a large number of staff not di- tion of health risks. When introducing new arma-
rectly involved in their work. Those working on the ments and equipment, it is being studied to deter-
repairs and tuning of the radio waves generators are mine the possible health risks and how to control
working with a removed shield in overladen meas- them. Personnel are subject to primary and prophy-
uring rooms. The ZRTs personal is in direct contact lactic medical examinations. When deploying per-
with rocket fuels (solid and liquid, one and two com- sonnel in an unfamiliar area, they undergo a medical
ponents) and oxidants (nitric acid, liquid oxygen, ni- risk assessment to determine what medical prob-
trogen oxides, hydrogen peroxide). lems to expect and what action to take - vaccines,
Naval Forces - Personnel is exposed to the com- chemoprophylaxis, personal and collective protec-
bined impact of various factors of origin and nature. tive measures, health promotion measures. Medical
Confined space hinders staff movements and increas- professionals must be trained to identify early staff
es the incidence of injuries to the locomotor system. health threats.

REFERENCES

1. Annual report of the Scientific applied center for military epidemiology and hygiene at the Military
Medical Academy, 2011. (in bul.)
2. Baker-Fulco C.J., Patton B.D., Montain S.J., Lieberman H.R. Nutrition for health and performance.
Nutritional guidance for military operations in temperate and extreme environments. U.S. Army Research
Institute of Environmental Medicine, USA, 2001.
3. Bellamy R. F., Zajtchuk R. Conventional warfare: ballistic, blast, and burn injuries. Textbook of Military
Medicine Series, Borden Institute, Walter Reed Army Medical Center, Washington, D.C., USA, 1990.
4. Burr R. Environmental medicine: Heat, Cold, and Altitude. In: Military Preventive Medicine: Mobiliza-
tion and Deployment, Volume 1, Ed. Kelley P., Borden Institute, Walter Reed Army Medical Center, Washing-
ton, D.C., USA, 2003.
5. DeHart R.L., Jeffrey D.R. Fundamentals of Aerospace Medicine. 3rd edition. Lippincott Williams &
Wilkins, 2002.
6. Garcia N., Gartmann H. Aircraft Flight Operations. In: Jeanne M. Stellman, editor. Encyclopedia of
Occupational Health and Safety. 4th edition, vol. III, Chapter 102 - Transport Industry and Warehousing. ILO,
Geneva, 1998: 12-14.
7. Gaydos J.C., Thomas R.J., Sack D.M., Patterson R. Armed Forces. In: Encyclopedia of Occupational
Health and Safety, ed. Jeanne M. Stellman, 4 th edition, vol. III, Chapter 95 - Services 14-17. ILO, Geneva, 1998.
8. Petkov A., Popivanov I., Shalamanov D., Kanev K., Zhivkov I. Preventive medicine during the prepa-
ration of Bulgarian military contingents for participation in missions abroad. Balkan Military Medical Review,
Turkey-Ankara, 2008; Vol.11; 4: 173-176.
9. Popivanov I., Petkov A. Biological Protection. In: "Preventive Military Medicine - Textbook", Sofia, Mil-

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itary Medical Academy, 2010: 218-234. (in bul.)
10. STANAG 1269 (ed.2) NATO Handbook on Maritime Medicine AMedP-11 (A). NATO Agency for Stand-
ardization, Brussels, 2007.
11. STANAG 2550 (ed.1) Minimum standards for food safety and hygiene on operations. NATO Agency
for Standardization, Brussels, 2008.
12. STANAG 2937 (ed.3) Survival emergency and individual combat rations - nutritional values and pack-
aging. NATO Agency for Standardization, Brussels, 2001.
13. Stavrev P., Sheytanov M., Donev D. Military Hygiene. JFI, 1969. (in bul.)
14. Valkov A.I., Ivanov V., Hristov T. Problems of the hygienic provision of the troops involved in the
elimination of the consequences of natural disasters and catastrophes. Collection of materials from the sci-
entific conference "The Medicine of Catastrophes - analogue to the war medical trauma". Sofia, "St. George
the Victorious", 1995: 294-298. (in bul.)
15. Zhekova M. Specifics of the labour hygiene in the helicopter aviation crews. A Collection of aviation
medicine reports. Sofia, "St. George the Victorious", 1992: 514-516. (in bul.)

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 B. PROFESSIONAL
LABOUR MEDICINE
DISEASES

1
J. Hadjieva, L. Elenkova

OCCUPATIONAL DISEASES.
INTRODUCTION

1.1. OCCUPATIONAL DISEASES – details related to the nature of the work undertaken
BASIC CHARACTERISTICS implemented production processes by the person
and those close to his workplace. In addition, em-
Occupational disease is a disease that has oc- ployers provide a production record with informa-
curred exclusively or primarily under the influence tion including the qualification, the work route and
of the harmful factors of the working environment the working conditions of the person concerned
or the work process on the organism and is included (Decree No 133 of the Council of Ministers of
in the list of occupational diseases. 17.07.2000, Art.15, para.1).
Occupational illness also involves its complica- 2. Clinical assessment including a systematic
tion and its later consequences. clinical trial using routine clinical methods and rec-
Professional pathology studies etiology, patho- ognizing early symptoms of occupational impair-
genesis, clinical picture, treatment and disease pre- ment of different organs and systems.
vention, and work capacity expertise. 3. Paraclinic studies.
Occupational diseases and poisons are divid- 3.1. Clinical laboratory tests
ed into the following groups: - Toxico-chemical studies. They carry out the
Specific occupational diseases. Diseases in this determination of toxic substances and/or their me-
group have only the harmful factors of the working tabolites in biological media. These are specific lab-
environment and the labour process (silicosis, vibra- oratory tests (biomarkers) that are used to estimate
tion disease, production poisonings, etc.) for etio- the so-called "internal exposure" to a toxic substance
logical factor. and have a certain value to build the diagnosis and
Conditional occupational diseases. The profes- monitoring and evaluation of the applied therapy.
sional nature of the disease is accepted under cer- - Hematological studies. In most cases, haema-
tain conditions and requirements. The incidence tological parameters are not specific. Some of them
of these diseases is significantly higher in people contribute substantially to the diagnosis and to con-
with certain professions (professional infectious and duct adequate therapeutic management (methe-
parasitic diseases, professional myopia, diseases of moglobin, carboxyhemoglobin, basophil-stippling
the nervous and musculoskeletal system, allergies erythrocytes, reticulocytes, siderocytes, cells Heinz,
etc.). This category of diseases also includes those of etc.).
a general nature. - Clinical-chemical studies. A wide range of clin-
Paraprofessional diseases. These are work-re- ical and chemical laboratory parameters are used.
lated illnesses in which production activities are They are routinely used in practice and also have the
only a triggering or additional moment favorable to most non-specific nature in terms of professional
the development of the disease, not a main cause. pathology.
Their etiology is complex, also depends on other 3.2. Immuno-allergenic studies. Investigation
factors outside the working environment (arterial of IgE, IgG, variants of immunosuppressive tests, etc.
hypertension, ulcer disease, neurosis, etc.). (skin-allergy tests including epicutaneous, dermal
Basic criteria for assessing the occupational and intradermal tests, etc.).
nature of the disease. 3.3. Functional and instrumental tests
1. Etiological clarification of the disease in- - Breathing system (air obstruction of the nasal
cluding: cavities, the functions of the mucous membranes
- General and occupational history. Profes- of the upper respiratory tract, an x-ray of the lungs
sional history clarifies the type, amount of action - general x-raygraphy, fluorography, tomography,
of risk factors, the duration of the work and all the computed tomography, radiological and ultra-

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sound, pathomorphological invasive examination, serving the patient's working capacity and prevent-
bronchoscopy combined with biopsy, mediastinos- ing him from disabling. It determines the state of
copy and non-invasive examination of sputa, nasal professional working capacity by examining the
secretion, etc., microbiological study, functional ex- basic functions of the individual's body necessary
amination of external respiration - vital capacity, res- for the specific work. The tasks of the occupational
piratory volume, inspiratory and expiratory reserve disease expertise shall include:
volume, residual volume, forced expiratory volume, • diagnosis of the disease and expert evaluation
etc.; blood gas and acid-base status, etc.). of the state of professional working capacity;
- Cardiovascular studies (ECG, overburden test, • identifying the reasons for the disability;
etc.). • giving concrete job recommendations;
4. Assessment of length of service. When as- • systematic monitoring and control of the state
sessing the nature and extent of the disease, the of the working capacity;
length of the specialized work experience is essen- • determining the percentage of permanently
tial. With increasing work experience, the possibili- reduced or lost working capacity in percent-
ty of developing chronic occupational diseases is age relative to the healthy person;
increasing. This does not apply to acute poisoning, • carrying out measures for the prevention and
allergic diseases, etc. elimination of disability.
5. Sex and age. Adult and young individuals are Incapacity for work is temporary and lasting. Each
more likely to be affected by toxic factors. In women, one of them has its clinico-physiological characteris-
due to their anatomophobiological features, injuries tics, relevant regulation with certain normative acts
to toxic substances, over-exertion of the musculo- and social security.
skeletal system, etc. are more pronounced. Occupational disease is not always associated
6. Epidemiological test. There is an increased with impaired working capacity. The issue of work-
incidence of disease of persons with a similar clinical ing capacity is always decided on a case-by-case
picture, from the same workplace. basis and depends on the degree of expressiveness,
7. Elimination test. After termination of the con- the nature and the course of the disability, as well as
tact with the professional harmful factors, the total the contraindications for the exercise of the previ-
or partial disruption of the occupational disabilities ous profession.
(mostly in allergies) is established. When an occupational disease is detected, the
8. Exposure test. Repeated contact with the expert judgment may be:
harmful factors of the working environment is ob- • temporary release from work in the presence
served in the worsening of the disease. of acute or exacerbated chronic disease with
9. Assessment of general diseases (pre-exist- outpatient or stationary treatment;
ing or concomitant diseases); family heredidary • temporary transfer of another job without
burdened, individual peculiarities, harmful hab- contact with the harmful factors that caused
its, etc. the disease;
List of Occupational Diseases • providing the person with reduced working
A prerequisite for recognition of the occupation- conditions for the same job;
al nature of the disease is to be present in the list • translation for longer term of working without
of occupational diseases. With the promulgation contact with harmful factors (with a disability
of an Ordinance on the procedure for notification, group at disqualification);
registration, confirmation, appeal and reporting • full incapacity for a job (permanent retirement
of occupational diseases (State Gazette No 33 of and disqualification group definition).
04.04.2001), an illness not included in the list of Prophylaxis of occupational diseases.
occupational diseases may also be recognized For the prevention of occupational diseases, it is
when It is established that it was caused mainly essential to build a wide range of measures:
and directly by the usual work activity of the in- • technological, technical and sanitary-techni-
sured person and caused a permanent incapacity cal, architectural, urbanisation, conditions of
or death of the insured (Art. 2, Par. 2). life, etc.
The list of occupational diseases (Decree 175 of • labour-hygienic and healing-prophylactic;
the Council of Ministers/2008) is built on an etiologi- • labour legislation, which regulates special leg-
cal principle (Table 1). It contains 5 groups of diseas- islation on safety in harmful industries.
es divided into 20 subgroups. Occupational-hygienic and healing prophy-
Occupational disease expertise. lactic measures. Occupational-hygienic measures
The expertise on working capacity aims at pre- include occupational safety and hygiene - advance

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Tab. 1. List of Occupational Diseases (State Gazette, 66/2008 - extract)
1. Occupational diseases caused by chemical agents
1.1. Occupational diseases caused by inorganic chemical agents
Occupational
Clinical manifestations MKB- Grace Examples of typical risky
Code disease Conditions for recognition
caused by: (Diagnoses, syndromes) 10 period activities

1 2 3 4 5 6 7
1101 Lead and its Toxic cerebrasthenia F06.8 * 1. Proven impact - at least 1 Production and processing of lead
compounds Sideroahrestic anemia D64.2 1 year month, peripheral acid batteries, pipes, cables, balls,
Haemolytic anemia D59.4 1 year polyneuropathy and paint plastics, stabilizers, leaded
Abdominal colic R10.0 1 month encephalopathy - glass, metallurgy upon receipt of
Nephropathy (tubulopathy) N14.3 3 years at least 1 year. lead and lead alloys, soldering,
Motor type polyneuropathy G62.2 3 years 2. Paraclinical supported glazing and decorating ceramic
sindromokompleks (elevated products with lead compounds;
(mostly upper limbs)
values of Pb in biological fluids, tin coatings production and use of
Toxic encephalopathy G92 3 years
abnormal porphyrin lead oxides, salts and others.
metabolism).

1102 Cadmium Hypo-atrophic nasopharyngitis J31.1 6 months 1. Proven impact - at least 1 All activities of extraction and
and its anosmia R43.0 6 months year, neoplasms - a minimum processing of polymetallic ores
compounds Chronic obstructive pulmonary J44.8 5 years of 5 years, pulmopathy - containing cadmium, production
disease a minimum of 10 years, for bone and processing of cadmium-nickel
Diffuse pulmonary fibrosis J84.1 10 years lesions - at least 20 years. accumulators and batteries, cadmium
Nephropathy (tubulopathy) N14.3 3 years plating surface in electroplating,
producing fast melt alloys
Osteomalacia (spontaneous M83.8 12 years
2. Paraclinical supported production cadmium pigments
fractures)
sindromokompleks (elevated for paints, lacquers, glass, plastics,
Lung cancer C34.- 40 years
Cd in biological fluids). paper and pyrotechnics, cadmium
lamps, welding of cadmium-plated
parts and others.

1103 Manganese Toxic cerebrasthenia F06.8 * 1. Proven impact - at least 18 Extraction and processing of mangan
and its Parkinson's syndrome G21.2 10 years months for pulmonary fibrosis - containing ores , upon receipt
compounds Vegetosenzorial polyneuropathy G90.8 6 months a minimum of 10 years. of cast iron and stainless steel, in
Psychoses F31.- 1 year production and processing of
Pulmonary fibrosis J84.1 10 years 2. Paraclinical supported manganese alloy (duralumin,
complex syndrome (EMG - manganese bronze, etc.),
stretch reflex). production of ferro-manganese,
electric welding with high quality
manganese electrodes and others.

1104 Mercury and Gingivitis (edentulism) K05.1 1 month 1. Proven impact - at least six All activities of extraction,
its Stomatitis, mucosal ulcerations in K12.1 1 month months. processing and use of mercury
compounds the mouth J31.2 and its compounds and products
Pharyngitis F06.8 1 month 2. Paraclinical supported containing it. Production, use and
Cerebrastheniya G92 * complex syndrome (elevated repair of thermometers, barometers,
Encephalopathy (mercury erethism), G62.2 3 years Hg in biological fluids, manometers, pneumatic pumps,
positive CT). mercury lamps and other mercury
mercury intention tremor, N03.-
instruments. Leather processing,
psychoorganic syndrome) L23.0
production and use of pigments
Sensorimotor type polyneuropathy 3 years
and paints, extraction of mercury
from industrial waste and others.
Toxic nephropathy (nephrotic 1 year
syndrome and glomerulonephritis)
Allergic contact dermatitis 1 month

1.2. Occupational diseases caused by organic chemical agents

1225 Organic Conjunctivitis H10.4 * 1. Proven impact - at least 1 year. Production and use of mercury-
mercury Blepharitis H01.0 * organic compounds, such as
compounds Gingivitis K05.1 * fungicides and bactericidal agents
Stomatitis K12.1 * 2. Paraclinical supported for preserving plastics, textiles and
Pharyngitis J31.2 * complex syndrome (mercury wood and others.
Anemia D64.2 1 year in biological fluids).
Toxic cerebrasthenia F06.8 *
Toxic encephalopathy (psycho- G92 3 years
organic syndrome, psychosis)
Allergic contact dermatitis L23.- 1 month

* Do not allow discussion of professional character after termination harmful effects of professional factor.

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2. Occupational diseases caused by physical factors

2.1. Occupational diseases caused by noise

2101 Noise Neuritis of both H93.3 1 year 1. Proven impact - at least 5 years, All activities related to exposure to excessive sound loads,
(constant , auditory nerve (hearing in the case of particularly intense for example, work in workshops for boilers and cookers;
variable, loss above 35 dB) noise (over 100dB/A) - at least six hammering, bending and stamping metal; work with
hydrodynamic) Practical deafness H83.3 months. looms and shuttles; stamping on fabric; work with
(sensory neural hearing 1 year 2. Tone threshold audiometry in pneumatic hammer drill; in engine rooms of ships; with
loss 65-90 db); better hearing ear calculated at a rotary machines in the graphics industry; assembly line
Deafness (hearing loss frequency of 500, 1000, 2000 and filling (bottles, barrels, etc.) in the food industry; use or
above 91 dB) 4000 Hz; the average loss is the disposal of military munitions or explosives; construction
mean, calculated from the loss work done with noisy equipment (bulldozers, excavators,
observed at 500, 1000, 2000 and shovel and etc.). tuning, testing and use of
4000 Hz, as factor of engines, jet propulsion and reactors
calculation are respectively 2, 4, 3 (minimum exposure period - 30 days); discotheques and
and 1. others.

2.2. Occupational diseases caused by vibration

2201 Local vibration Distal arterial and microcirculatory disturbances in the I79.8 1 year 1. Proven impact - at least Working with mechanical
(vibration arm) upper extremities five years, taking into tools and machines
Raynaud's syndrome I73.0 3 years account the existence of generating vibrations
Vegetative disorders of the upper limbs G90.8 1 year a synergistic factors. (pneumatic hammers,
Polyneuropathy of upper limbs G62.8 1 year 2. Paraclinical supported saws, hammer-drills,
Compression neuropathy m.medianus wrist (carpal tunnel G56.0 2 years complex syndrome grinders, grinding
(capillaroscopy, distal machines, metalworking
syndrome)
Doppler diagnostic, and woodworking
Compression neuropathy n.ulnaris the level of the elbow G56.2 2 years
thermistor thermometers machinery, etc.).
(cubital syndrome channel) or the level of the wrist
cold test, palesteziometry,
(syndrome Guillon) EMG, X-ray, dynamometry,
Other compression neuropathy of the upper limbs G56.8 2 years etc.).
cubital osteoarthritis M19.2 3 years
Omartrozis M19.2 3 years
Osteonecrosis of the os lunatum M93.1 3 years
Osteonecrosis of the os scaphoideum M87.8 1 year
Shoulder injury M75.- 1 year
Medial epicondylitis M77.0 1 year
Lateral epicondylitis M77.1 1 year
Damage to the soft tissues of the upper limbs M70.- 1 year
2202 General vibration Damage to the intervertebral disc (lumbar and lumbar- M51.1 1 year 1. Proven impact - at Coal and ores mining,
(affecting the sacral segment) with radiculopathy least six years, taking into construction, transport,
entire human Cubital arthrosis M19.2 1 year account the existence of a agriculture and others.
body) Humeroscapulary periarthritis M75.0 1 year synergistic factors. (working with heavy
Medial (ulnar) epicondylitis M77.0 6 months 2. Paraclinical supported machinery and vehicles -
Lateral (radial) epicondylitis M77.1 6 months complex syndrome (distal bulldozers, tractors,
Doppler diagnostic, excavators, locomotives,
Stenotic tendinitis of the flexor of the fingers M65.3 3 months
palesteziometry, EMG, harvesters, dump trucks,
("click finger")
EEG, audiometry, loaders and digging
Stenotic tenosynovitis of the thumb (Disease de M65.4 3 months
otoneurological research, machines, etc.).
Quervain) image diagnostic, etc.).
Crackling chronic synovitis of hand and wrist M70.0 8 months
(tendovaginitis)
Other soft tissue injuries (myotendinosis the M70.8 6 months
forearms)
Chronic back pain M54.8 1 year
Lumbar or lumbar-sacral radiculopathy M54.1 1 year
nodiscogenic
Disorders of the autonomic nervous system G90.8 1 year
Polyneuropathy of the upper or lower limbs G62.8 1 year
Auditory- vestibular disorders H81.3 1 year
H81.4
H83.3
Hypothalamic syndrome G90.8 1 year

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2.3. Occupational diseases caused by atmospheric pressure

2301 Increased Myalgia M79.1 6 months 1. Proven impact - at least 1 year All activities carried out in
atmospheric Neuralgia M79.2 6 months osteonecrosis - at least 3 years. an environment with
pressure Osteonecrosis (most often in the M87.8 20 yeras 2. Paraclinical supported increased atmospheric
shoulder, hip or knee) complex syndrome(radiographs, pressure (working with
Platispondiliya (bone infarcts of the M48.5 6 months audiometry, otoneurological suits and underwater
lower thoracic vertebrae) studies, EEG, etc.). pneumatic chambers,
Vestibulopathy H81.8 6 months work of divers, etc.).
Subacute or chronic otitis media to H65.4 6 months
the point of irreversible hipacuzis
Encephalomyeloaeropathy G96.8 6 months

2302 Reduced Cerebroasthenic syndrome F45.3 6 months 1. Proven impact - at least 1 year. All activities carried out in an
atmospheric Cognitive impairment F06.7 6 months 2. Paraclinical supported environment with reduced
pressure Vestibulopathy H81.8 6 months complex syndrome (complete atmospheric pressure
Tachypnea, dyspnea R06.0 6 months blood count, ECG, EEG, (aviopersonal, working in
Tachycardy R00.0 6 months psychological testing, high sites - weather stations,
Cardiac arrhythmics R00.8 6 months otoneurological research etc.). cabins, rescue services, etc.).
Secondary polycythemia D75.1 6 months

2.6. Occupational diseases caused by ionizing radiation

2601 Ionizing radiation Radiation cataract H26.8 5 years 1. Proven occupational All activities related to sources of
(gamma rays, X rays, Anemia (hypo- or aplastic) D61.2 3 years exposure to ionizing radiation, including
ionizing particles) leukopenia D70.- 1 years manifestation radioactive substances of natural
Thrombocytopenia D69.5 1 years depending on the or synthetic origin (mining and
Hemorrhagic diathesis D69.8 1 years magnitude of the processing of radioactive ores,
Chronic radiation dermatitis L58.1 10 years effective dose to the manufacturing and handling of
Chronic mucous lesions L59.- 5 years target organ. radioactive material (isotopes),
Radiation bone necrosis M87.3 10 years 2. Paraclinical production and application of
Immunodeficiencies (D80-D89) 2 years supported radio pharmaceutical preparations,
Skin cancer C44.- 20 years complex syndrome nuclear medicine, experimental
Osteosarcoma (C40-C41) 20 years (blood count, image nuclear reactors, maintenance
Lung cancer (inhalation) C34.- 20 years diagnostic, and operation of equipment for
Malignant neoplasms of the target (C00-C97) 20 years biopsy, etc.). radiotherapy and diagnostic
organ gamma detection,
Leukosis (C91-C95) 10 years nuclear energy, etc.).

3. Occupational diseases caused by biological agents

3.1. Occupational diseases caused by bacteria

3101 Mycobacterium Tuberculosis (respiratory (А15- 6 months 1. Proven professional contact. Activities associated with contact
tuberculosis and organs, nervous system А19) 2. Clinical examinations (Mantoux test), with animals that carry the
Mycobacterium and other organs) X-ray, sputum for BT). bacillus tuberculosis;
bovis manipulation of organic products
and waste of animal origin
(animal consulting rooms,
slaughterhouses, processing
plants and preserving of meat
and meat products, incinerators,
etc.).
Activities related to the treatment
and care of tuberculosis patients
(bacteriological
laboratories, hospitals,
sanatoriums, etc.).

3102 Brucella Brucellosis (Bang's disease) А32.- 2 months 1. Proven professional contact. Activities in slaughterhouses,
(an acute 2. Paraclinical surveys (KAP with processing plants and preserving
form) brucellin, isolation of brucella from of meat and meat products;
biological fluids). dairies. Activities for raising goats,
1 year cattle, sheep and pigs and contact
(chronic with their excrement and
form) abortions products.

3103 Bacillus anthracis Anthrax (cutaneous, А22.- 1 month 1. Proven professional contact. All activities where there is
pulmonary form, 2. Clinical examinations (bacillus contact with infected animals.
gastrointestinal form) isolation from biological fluids). Activities in tanning.

3104 Clostridium tetani Tetanus А35 1 month Proven risk. Activities in construction,
agriculture, forestry and others.

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 OCCUPATIONAL MEDICINE
3105 Salmonella Salmonellosis А02.- 1 month 1. Proven professional contact. Activities under cultivation and
2. Clinical examinations (isolation of trade in livestock and poultry,
the causative organism from faeces). production and marketing of
feed protein flours. Activities
related to the treatment and
care of infected persons
(bacteriological laboratories,
hospitals, etc.). Repair and
maintenance of sanitation and
others.

3106 Pseudomonas Glanders А24 1 month 1. Proven professional contact. Activities for animal production,
mallei (an acute 2. Clinical examinations (microbiology veterinary practice,
form) and serology). slaughterhouses and others.
1 year
(chronic
form)

3107 Francisella Tularemia А21.- 1 month 1. Proven professional contact. Activities in livestock, hunting
tularensis 2. Paraclinical tests (serological and forestry, tanning and more.
samples with tularin KAP). Work in fumatoriums, pet shops
and more.

3108 Rickettsia (Coxiella Q fever А78 1 month 1. Proven professional contact. Activities in agriculture,
burnetti) (an acute 2. Clinical examinations (serological). laboratories (vaccine production)
form) veterinary practice and others.
1 year
(chronic
form)

3.2. Occupational diseases caused by viruses

3201 Hepatitis A virus Acute viral hepatitis A В15.- 2 months 1. Proven professional contact. Repair and maintenance of sanitation.
2. clinical examinations (ASAT, Work in large teams (barracks, schools,
ALAT, GGT, AF, direct and kindergartens) in the epidemiological
indirect bilirubin, transaminase situation.
activity). Jobs in health care and others.

3202 Hepatitis B virus Acute viral hepatitis B В16.- 6 months 1. Proven professional contact. All activities of collecting, handling
Chronic viral hepatitis B В18.- 2 years 2. clinical examinations ((ASAT, and use of human blood and its
Late effects of viral hepatitis B В94.2 15 years ALAT, GGT, AF, direct and derivatives.
indirect bilirubin, transaminase Work on supportive, washing and
activity early marker - Anti- sterilization of materials and equipment
HBc-IgM). that involve contact with the virus.

3203 Hepatitis C virus Acute viral hepatitis C В17.1 6 months 1. Proven professional contact.
Chronic viral hepatitis C B18.2 20 years 2. Clinical examinations
Late effects of viral hepatitis C B94.2 30 years (anti HCV, antibody).
(hepatocellular carcinoma)

3204 Rabies virus Rabies A82.- 6 years 1. Proven professional contact. Activities in agriculture, hunting and
forestry, veterinary practice.
Work in laboratories, pet shops, zoos,
vivariums and others.

and ongoing familiarization of workers with manu- Medical prophylaxis. Medical prophylaxis in-
facturing processes and safety measures in their im- cludes preliminary professional selection of admis-
plementation; implementing effective control over sions, periodic prophylactic medical examinations,
workers qualification and protective production dispensarisation and communication, registration
habits; organization of working and rest regime; and reporting of occupational diseases, preventive
ongoing control of concentrations of harmful sub- professional nutrition, physical prophylaxis, etc.
stances in the air of the working environment; use Prophylactic medical examinations (preliminary
of effective and functionally suitable personal pro- and periodic) are regulated by Ordinance № 3 of
tective equipment (suitably special work clothes, 28.01.1987, by the Ministry of Health and by Amend-
gloves, shoes, facial and respiratory protection); ments and suppl. from 1991 and 1994.
maintenance of the necessary personal hygiene and The pre-selection is carried out on the basis of
such in the working premises, etc. compulsory medical examinations on taking up em-

436
 LABOUR MEDICINE
ployment. Do not work in contact with harmful fac- 1408/71 / EEC. Col. Legal provisions of the Eu-
tors of the working environment, persons with disa- ropean Union in the field of social protection.
bilities of different organs and systems regulated in S. 1998.
Ordinance № 3. Special attention is paid to women Legislation in the country:
(pregnant women, nursing mothers and in fertile • Constitution of the Republic of Bulgaria. SG
age) as well as to the teenagers . no. 51/1991
The rhythmic and proper conduct of periodic • Code of Compulsory Public Insurance (CCPI).
prophylactic medical examinations provides early • Labour Code (LC)
diagnosis of the occupational disabilities of the body • Ordinance on the Procedure for Reporting,
and helps to reveal the risk factors that contributed Registration, Confirmation, Appealing and
to the development of these disabilities. The time Reporting of Occupational Diseases. SG no.
limits for conducting periodic prophylactic medical 33/2001, effective at 5.VII.2000
examinations are specified in Ordinance No. 3 and • Ordinance on the establishment, investiga-
vary according to the type of professions and pro- tion, registration and reporting of accidents at
cedures. The quality of these reviews requires strict work. SG no. 6/2000, amended and add No
adherence to the Ordinance. The formation of the 61/2000
medical teams conducting the examinations should Insurance relationship.
be done precisely with the participation of differ- The insurance relationship is governed by the
ent specialists and the use of specialized paraclini- legal relationship that arises in connection with the
cal studies. This is a sure prerequisite for an ex act material insurance of the citizens in cases of incapac-
and early diagnosis of the injuries of those working ity for work and other reasons regulated by the law,
in the harmful health conditions and resp. for their which prevent them from carrying out labour activ-
effective prophylaxis. ity, as a result of which they are deprived of income.
General Characteristics of the Insurance Rela-
1.2. OCCUPATIONAL DISEASE AND tionship:
OCCUPATIONAL ACCIDENTS. • Is property nature
SOCIAL RISKS PROVIDED. • continuous legal relationship
• complex legal relationship.
Occupational illness and occupational acci- The nature of the insurance relationship:
dents are provided occupational risks, related to • Compulsory social security is public.
labour in an working relationship. • Voluntary social security is private.
Legal regulation. Types of insurance legal relationships accord-
International regulation: ing to the subject of insurance:
• Universal Declaration of Human Rights. • In case of incapacity for general disease, occu-
• Convention No. 12 on Compensation for Acci- pational disease, labour accident, maternity,
dent at Work - 1921 SG no. 44/1997 old age and death.
• Convention No. 17 on Compensation for Acci- • In the case of health insurance
dent at Work - 1925 SG no. 253/1929 • Unemployment
• Convention 18 on Occupational Diseases - Occupational disease is a disease that has oc-
1925 SG no. 253/1929 curred exclusively or mainly under the influence of
• Convention No. 19 on Equal Treatment (Acci- the harmful factors of the working environment or
dents at Work) - 1925 SG no. 253/1929 the work process on the organism and is included
• Convention No 42 on Benefits for Occupation- in the List of Occupational Diseases issued by the
al Diseases (revised) 1934 Council of Ministers upon a proposal by the Minister
• Convention No 37 on Invalidity Insurance - of Healthcare.
1933 SG no. 45/1997 In the legal definition, the legislator has included
• Regulation 1408/71 / EEC on the application the two alternatives - exclusively or predominantly
of social security schemes to self-employed caused by the harmful factors of the working en-
persons, independently and to members of vironment or the working process, guided by the
their families, moving within the Community. medical classification of occupational diseases
European Union law on social protection. S. (Table 1).
1998 Similarly, European legislation in the CCPI is giv-
• Regulation No 574/72 / EEC laying down the en a legal opportunity to be recognized as an occu-
procedure for implementing Regulation No pational disease and illness not included in the List
of Occupational Diseases when it is established that

437
 OCCUPATIONAL MEDICINE
it was caused primarily and directly by the insured In the investigation of the accident at work, the
person's usual work and that it has caused perma- following are established:
nent disability or death of the insured. • the reasons and the circumstances that led to
Occupational illness also refers to its complica- the accident at work.
tions, both and its late consequences. • type of disability
The practitioners and dentists in case of suspi- • other information qualifying the accident as
cion of occupational disease also send a notice to labour
the territorial unit of the National Social Security The insurer declares every accident at work to the
Institute (NSSI), which carries out research, prepares Regional Office of the NSSI within 3 working days. In
documents and submits them to the medical expert 6 days, the injured person himself can do so if the
bodies. insurer does not declare the accident at work. The
The Ordinance on the notification, registration, procedure for establishing, investigating, registering
confirmation, appeal and reporting of occupational and reporting accidents at work is regulated in an
diseases (SG 33/2001) regulates the confirmation or Ordinance issued by the Council of Ministers.
rejection of the occupational nature of the disease In an accident investigation, the injured is entitled
by Territorial Expert Medical Committees (TEMC), to attend or indicate to be present:
determined by an Order of the Minister of Health • an employee of the same profession;
and National Expert Medical Commitee (NEMC), in- • a family member, or an ascending or descend-
cluding a specialist in occupational diseases and a ing relative;
specialist in occupational medicine. The meetings • a representative of a trade union in which he/
of the aforementioned committees are chaired by a she is a member;
specialist in occupational diseases or occupational • a representative of the employees of the
medicine. The Commission shall also decide on the Working Conditions Committee;
degree of reduced capacity in accordance with the • the heirs of the deceased from the accident at
order, principles and criteria regulated by the Ordi- work.
nance on the Expertise on the Capacity for Work (SG The statement of the investigation shall be valid
No. 61/2000). until proved otherwise and shall be sent to the ter-
TEMC makes a decision to confirm the occupa- ritorial unit of NSSI and shall be kept in the State Ar-
tional disease based on the clinical examination of chives. For each occupational accident and occupa-
the person, the data from the medical record and tional disease, the territorial unit of NSSI opens a file.
the additional evidence collected within 40 days The CCPI regulates the insurance funds, which are
of receiving the medical file. An expert judgment divided into:
on occupational disease is issued for a period of 3 • "Pension"fund;
years and a registration card for a recognized occu- • "Accident at Work and Occupational Disease"
pational disease is completed. The insured person, fund;
the insurer, the territorial unit of the National Social • "General Sickness and Maternity" fund.
Security Institute before NEMC have a legal interest The specific feature of the Accident and Occupa-
in appealing the expert decisions of TEMC within 14 tional Diseases Fund is that employers pay contribu-
days from the date of receiving the decision. Expert tions only to their employees and their size is deter-
decisions may be appealed to the court under the mined annually on the basis of the main activity of
procedure of the Administrative Proceedings Act. the enterprise, the frequency and severity of acci-
An accident at work is any sudden damage to dents at work and occupational diseases, the num-
health occurring during and in connection with or in ber and severity of violations in connection with the
occasion with the work performed, as well as any work implementation of investment programs and the
done in the interest of the enterprise when it caused in- organization of activities to ensure healthy and safe
capacity or death. working conditions, and depending on the degree
An accident at work is also recognized as an of professional risk. The other earnings in the fund
accident occurring when traveling and returning are raised from:
from the workplace to the main place of residence • State Budget Amounts;
or another additional residence with permanent • Revenue provided under other laws for occu-
character; a place where the insured person usually pational accidents and occupational diseases;
feeds on a business day; the place to receive remu- • Reimbursement of the insurance costs in-
neration. curred and the cases provided for in the nor-
There is no occupational accident when the in- mative acts;
jured has deliberately harmed his health. • Fines and penalty interest;

438
 LABOUR MEDICINE
• Fees determined by tariffs of the Council of or suffer from diseases referred to in Ordinance No.
Ministers; 5, in which list under item 5 an occupational disease
• Interest and dividends; is mentioned. For these persons, the employer is
• Donations and wills; obliged to request the opinion of TEMC and the La-
• Other sources. bour Inspectorate before the dismissal.
The means from this fund are spent for: Legal consequences of social security.
• Payment of cash benefits and pensions; Qualification of the disease as a professional in
• Updating, indexing and offsetting of cash due course gives rise to the injured and social and le-
benefits, pensions and financial aids; gal consequences:
• Measures to prevent accidents at work and • Right to compensation for temporary inca-
occupational diseases; pacity for work
• Supporting and technical means related to • Right to invalidity pension due to an accident
disability; at work and occupational disease - Art. 24,
• Other costs related to the insurance for acci- point 1. CCPI
dents at work and occupational disease. • Right to benefits - Art. 24, point 2 CCPI
The above-mentioned fund does not provide for • Updating, indexing and compensation of
the treatment, re-training, re-qualification and com- cash benefits, pensions and benefits - Art. 24,
pensation of the injured person for material and point 2. CCPI
non-material damages, which is a substantial dif- • Assistance related to disability - Art. 24, point
ference to the European legislation of the identical 4. CCPI
funds. Civil law consequences. An occupationally
Legal consequences under the Labour Code. qualified illness must be caused by guilty actions or
For the workers injured by the occupational dis- omissions that have led to the harmful result - oc-
ease, the legislator has established guard and priv- cupational disease. The legal basis for compensa-
ileged regimes under the Labour Code with a view tion for the person suffering from an occupational
to their proper rehabilitation and the fullest possible disease is settled in the institution at nopermitted
use of their residual capacity. According to the pro- damage (Article 45 et seq., from the LCL). Liability
vision of Art. 317 of the Labour Code, the employer for payment of damages - property and non-ma-
is obliged to move the employee to an appropriate terial to the injured person - is the legal obligation
job, as prescribed by the health authorities, within 7 not to harm others - "neminem lacdere". Everyone is
days of receipt. In case of non-fulfillment of the pre- obliged to repair the damage he has guiltily caused
scription of the health authorities by the employer, to someone else. Under the Obligations and Con-
he shall pay to the employee a compensation in the tracts Act, the prohibition is general and includes
amount of his gross remuneration from the day he any other culpable harm to others.
receives the prescription for re-employment until Compensation for civil action by the employ-
it is fulfilled (Article 217 paragraph 1 of the Labour er.
Code). The property damages in the case of a person
The fact that workplaces designated for employ- suffering from an occupational disease is expressed
ment by employed persons are exhausted is not a as the difference between the actual remuneration
reason for not complying with the above provisions. he receives as a healthy worker and the later indem-
The employer may terminate the employment nity for temporary incapacity for work, labour read-
contract if the employee is unable to perform the justment or disability pension. The property dam-
assigned job due to sickness resulting in permanent age suffered undergo on account of the disability,
disability or health contraindications, according to which temporarily or permanently deprived him of
the expert opinion of TEMC. When the employer has the income he had as healthy.
another job appropriate to the health of the worker Apart from a reduction in wages, the worker in-
and he wishes to take it, the employment relation- jured by an occupational disease can also suffer ma-
ship is not interrupted. If the employer fails to com- terial damage by terminating the receipt of certain
ply with this statutory requirement (Article 325 p.9 other permanent payments that he has had as health
of the Labour Code), his injunction to terminate the - overtime labour, subsistence, civil contracts, etc.
employment relationship will be unlawful and may In the case of claiming property damage, the in-
be challenged in court within 6 months of the date jured person may seek, in addition to all the perma-
of termination of the employment relationship. The nent claims, as well as the costs of the legal claim
Labour Code also provides for a special order for the and the claim for compensation for costs incurred
dismissal of employees who are labour-readjusted by him for medicines, for intensive food, special diet

439
 OCCUPATIONAL MEDICINE
and balneotherapy and any other costs are related Non-property damage can wanted all persons af-
to his/her health condition. fected by the occupational disease and which have
Judicial authorities are guided by the require- subject own non-property weefare-damaged person
ments of Art. 51 al. 1 of the LCL, i.e. the indemnity itself, but also the survivors of the deceased, may be
should correspond to the actual amount of the ma- sought for non-property damage. There is no text in
terial damage and loss of benefits in respect of the the LCL that explicitly indicates which persons are
occupational disease. entitled to seek non-property damages. The court
Persons having a legal interest in seeking determines them in each individual case, examining
property damage in the case of death from delict the presence of the components of the non-prop-
- occupational disease. These are the relatives of the erty damage. These facts are judged irrespective of
deceased who have suffered material damages from kinship, as it sometimes refuses to award non-pecu-
his death - children, spouse, parent, brothers, sisters niary damage to relatives who have been in a bad
and other relatives. Those listed must have been relationship with the deceased. The justice, which is
affiliated with the deceased or be entitled to main- stated in Art. 52 of the LCL as a measure for deter-
tenance by the deceased. Determining the circle of mining the non-prperty damage is not a source of
eligible persons is done by means of two criteria: right. It is only a measure to determine non-property
1. Persons who are entitled to maintenance by damage.
the deceased by law. When a person suffering from an occupational
2. Persons, who are incapacitated and have been disease suffers a deterioration in his health, a con-
supported by the deceased who, albeit by law, have sequence of the illness, the new complications or
no right to maintenance from the deceased. This in- the late effects of the disease, he is entitled to bring
cludes the child bring up but still unadopted. a new claim for compensation. However, in order
Non-property damage. Non-property damage to accept that there is a deterioration in the state
is, by its very nature, a violation of the non-material of health of the injured person, it is not sufficient
rights of the person - political rights, life, freedom, merely to ascertain such manifestations. New com-
honor, family rights, etc., resulting in pain, moral an- plications should have led to a new percentage rate
noyances, suffering and anxiety for the injured. They of disability as any condition necessary to establish
are defined as damages that are disproportionate to new material and moral damages under Art. 51,
money and therefore the benefit to them and the para. 1 and 3 of the LCL.
circle of persons entitled to them are determined by The period in which the claims for delict are ex-
the principle of fairness under Art. 52 of the LCL. The tinguished is 5 years in the sense of Art. 111, B. of
determination of the amount is related to court judg- the LCL. Where the claim is established by a court
ment of objectively specific circumstances, such as decision which has entered into force, the limitation
manner of disability, additional complications, med- period shall be 5 years, including the interest award-
ical prognosis of the course of the disease, pains and ed - Art. 117, para. 2 of the LCL. The taking of delict is
sufferings, etc. In case of death from an occupational due from the day of the opening of the perpetrator,
disease, the age of the deceased, his public status according to Art. 114, para. IV of the LCL.
and other qualities are of importance.

REFERENCES

1. Hygiene et securite. Lois et textes regulaires. 21 edition, Adase Editeur, Paris, 1994.
2. Occupational Disease - Record Systems and Surveillance. Chapt. Ed. St. B. Markovwitz in Encyclop. Of
Occup. Health and Safety, ed. J.M. Stellman, 4th ed. Vol. 1, 32.2-32.8, 1998.
3. Professional pathology - ed. Tsv. Aleksieva, Kr. Kiryakov, Sofia, Med. and phys., 1982, 262 p. (in bul.)
4. Work-Related Diseases and Occupational Disease: The ILO International List - M. Lesage: in Encyclop.
Of Occup. Health and Safety, ed. J.M. Stellman, 4th ed. Vol. 1 26.2-26.6, 1998.

440
 LABOUR MEDICINE

2
N. Tsacheva

EPIDEMIOLOGY OF
OCCUPATIONAL DISEASES

The epidemiology of occupational diseases in disease in Bulgaria and is a major document,

Bulgaria studied the distribution, structure and dy- which studies the epidemiology of occupa-
namics at national and regional level and contains tional diseases.
information about the number and frequency in Schematically, the process of epidemiology is
different economic sectors and occupations. It pro- shown in Fig. 1 and includes:
vides an important basis for monitoring and prior- І. Communicating occupational diseases
itizing preventive action to improve the hygiene and II. Study of occupational diseases
safety of workers. The Epidemiology of occupational ІІІ. Confirmation and registration of occupa-
diseases determines the leading factors in the work- tional diseases
ing environment and the labour process in the occu- ІV. Appealing occupational diseases
pational health and occupational risk labour medi- V. Reporting of occupational diseases
cal expertise. The Ordinance on occupational diseases of
In recent years, improvement of occupational 2008 continues the maintenance of the estab-
health legislation in the country and its harmoniza- lished register of occupationally ill patients.
tion with European legislation is created regulations In 2001, the MH, NCHMEN, NSI and NSSI estab-
that allow for modern epidemiology of occupational lished a EUROPEAN harmonized statistical sys-
diseases, evidence-based occupational medicine: tem for occupational diseases. On this basis, the
• Social Security Code - published in 1999 FIRST REGISTRY AND INFORMATION SYSTEM on
• Health and Safety at Work Act - since 2007 occupational morbidity is located in the Center of
• Ordinance on Occupational Diseases - since Hygiene. The system provides comprehensive and
2008 summarized information about the patients and
• Statistical System "Occupational Diseases" - their illnesses of MH, MLSP and NSSI. Requests for
since 2004 summary information may also be provided to the
• Ordinance on medical expertise of efficiency sponsor, GPs and other interested institutions and
- from 2005 organizations of employers and employees, subject
These documents regulate and ensure the inves- to the confidentiality of personal data.
tigation and registration of occupational diseases, The dynamics of occupational diseases in Bul-
shaping and storage of documentation and analysis garia in terms of the absolute number, the absolute
of frequency, structure and dynamics of occupation- growth and the rate of increase for the period 1975-
al diseases for certain periods. 2007 (Table 1) passes through several stages:
In the Official Bulletin 10/2001 of the Ministry of - 1975-1978 this stage is characterized by the re-
Health by the President of NSI published registra- duction of occupational diseases, a one-year period
tion forms necessary for the study of occupational of 2800 to 1800 cases.
diseases: - 1979-1990. In this greatest stage, occupation-
• quickly notice report card MH №PI - 58/2001; al diseases are growing - over 3,000 cases per year,
• production characteristic, report card MH which is also the result of the increased revelation in
No. Р601 / 2001; the preventive examinations of the employees and
• protocol for the Study of Occupational Dis- by directed activities of the Clinics of Occupational
ease. Issue No-20 of the NSSI (Article 5 of the Diseases in Sofia, Plovdiv, Varna, Pleven and Stara
TFTP of the NFIPRI); Zagora.
• expert solution - report card MH № 611а/2001; - 1991-1996. During this period the registration
• registration card, report card MH №304 / 2001. of the occupationally ill decreased due to various
It contains information on comprehensive and complex reasons, with a growth rate of -2.2 to
surveys, recording and reporting the health -39.1 (constant base 1975) and -5.0 to -3.5 on a chain
status of persons of recognized occupational basis.

441
 OCCUPATIONAL MEDICINE
Fig. 1. Stages of communication, investigation, confirmation, appeal and reporting
of occupational diseases - institutions and health documentation

І. COMMUNICATION ALL DOCTORS AND DENTISTS IN BULGARIA

QUICK NOTE (QN)- a medical document

ІІ. STUDY TERRITORIAL DIVISION OF THE NATIONAL SOCIAL SECURITY INSTITUTE (NSSI'S)
of residence of the worker

RESEARCH PROTOCOLS OF
OCCUPATIONAL DISEASE (RPOD) - document

ІІІ. REGISTRATION
CONFIRMATION
FILING MEDICAL RECORDS EXPERT
of residence of the worker FILE

medical records - includes QN, RPOD,

Manufacturing specifications and other medical documents

TERRITORIAL EXPERT MEDICAL COMMISSION

OF SPECIALISTS IN OCCUPATIONAL MEDICINE AND OCCUPATIONAL DISEASES

IV. APPEAL

EXPERT DECISION AND REGISTRATION CARD

PROVIDED

INSURER
V. REPORTING
TP RCZ-KMED
NSSI

NATIONAL EXPERT MEDICAL COMMISSION NSSI

WITH SPECIALISTS IN OCCUPATIONAL
MEDICINE AND OCCUPATIONAL DISEASES

EXPERT DECISION AND REGISTRATION CARD MH< RIPCPH

MLSP, IA”GIT”
JUDGMENT EVROSTAT

- 1997-2000. This stage is characterized by ex- - 2000-2007. There is a positive trend towards
tremely low levels of occupational diseases - about an increase in the absolute number of occupational
350 to 700 cases per year, as a result of a large share diseases and a chain growth rate of 35.6 in 2007. This
of "hidden" occupational morbidity, while the nega- result is also a consequence of the efforts made for
tive impact of different factors in the working envi- better regulation in the field of occupational medi-
ronment and the labour process. cal expertise .

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 LABOUR MEDICINE
Tab. 1. Dynamics of Occupational Diseases for1975 -2007

Number of Absolute growth Rate of growth

Year registered
occupational Chain base Permanent basis Chain base Permanent basis
diseases
1975 2791
1976 2755 -36 -36 -1.3 -1.3
1977 2189 -566 -602 -20.5 -21.6
1978 1819 -370 -972 -16.9 -34.8
1979 3084 +1265 +293 +69.5 +10.5
1980 2859 -225 +68 -7.3 +2.4
1981 3150 +291 +359 +10.5 +12.9
1982 3789 -639 +998 +20.3 +35.8
1983 3705 -84 +914 -2.2 +32.7
1984 3542 -163 +751 -4.4 +26.9
1985 3402 -140 +610 -3.9 +21.9
1986 3556 +154 +765 +4.5 +27.4
1987 3381 -175 +590 -4.9 +21.1
1988 3304 -77 +513 -2.3 +18.4
1989 2945 -359 +154 -10.9 +5.5
1990 3157 +212 +366 +7.2 +13.1
1991 2729 -428 -62 -13.5 -2.2
1992 2382 -347 -409 -12.7 -14.6
1993 2091 -291 -700 -12.2 -25.1
1994 1806 -285 -985 -13.6 -35.3
1995 1790 -16 -1001 -0.9 -35.9
1996 1700 -90 -1091 -5.0 -39.1
1997 590 -1110 -2201 -65.3 -78.9
1998 700 + 110 - 2091 +18,6 - 74,9
1999 357 - 343 -2917 -49.0 -87.2
2000 429 +72 -2363 -20.2 -84.6
2001 660 +231 -2131 +53.9 -76.4
2002 895 +235 -1896 +35.6 -67.9
2003 950 + 55 -1841 +6.1 -66.0
2004 1168 +218 -1623 +22.9 -58.2
2005 1010 - 158 -1781 -13.5 -63.8
2006 805 -205 -1986 -20.3 -71.2
2007 1125 +320 -1666 39.8 -59.7

All registered cases of professional patients in protective equipment, inefficient collective

Bulgaria as of 31.12.2007 are about 32100 (Table 2). protective equipment, low health culture and
The most common occupational illnesses have health behaviour.
been shown, and have been reported as the most • Powder of different composition (crystalline
common occupational diseases that have not silica, asbestos fibers, heavy metal aerosols,
changed substantially as a nosological profile (struc- organic substances).
ture) over the last 20 years. • Toxicochemical noxae as raw materials, inter-
The most widespread occupational risk factors mediate and end products from the techno-
for workers in recent years are: logical process, often combined with other
• Manual labour, heavy physical labour, monot- occupational hazards - unfavorable microcli-
ony, conveyor line work, and non-compliance mate, heavy physical labour, noise and vibra-
with physiological working and rest periods tions.
during work, overtime, night work and more, In 2002, at control by labour inspection 27,081
related to the functioning and rational organ- enterprises with 1,091,920 employees, who did not
ization of work systems. meet the hygienic limit values were
​​ 20% (or 220,483
• Noise factor and vibration impact individu- persons in very poor conditions). Their distribution
ally or with combined exposure. Most often by the individual factors is: in the case of an unfa-
they are accompanied by non-use of personal vorable microclimate - 41%; noise - 33%; physical

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Tab. 2. Probable number of registered persons with cases of occupational diseases
- total and groups of regions as of 31.12.2007

TOTAL NUMBER OF OCCUPATIONAL DISEASES

REGIONS
AND NOSOLOGICAL GROUPS *
(IN GROUPS)
1 2 3 4 5 6 7 TOTAL
Sofia, Pernik, Blagoevgrad, Kyustendil,
1589 1320 1069 761 511 309 120 5679
Botevgrad
Plovdiv, Kardzhali, Smolyan, Madan 1638 1160 1193 1053 524 237 73 5878
Varna, Dobrich, Shumen, Targovishte 1131 1193 530 571 353 239 49 4066
Ruse, Silistra, Razgrad 1122 930 441 316 280 151 29 3269
Pleven, Lovech, Veliko Tarnovo 975 969 509 429 368 153 41 3444
Vratsa, Vidin, Montana 1170 1129 673 611 383 199 46 4211
St. Zagora, Burgas, Sliven, Yambol,
1340 1099 1129 1191 512 210 72 5553
Haskovo
TOTAL 8965 7800 5544 4932 2931 1498 430 32100
* Nosological groups of occupational diseases: 4. Neuritis of the auditory nerves;
1. of the Locomotor system (LS); 5. Professional lung diseases;
2. the Peripheral Nervous System (PNS); 6. Occupational poisoning.
3. Vibrational disease; 7. Other

load - 32%; dust and toxic substances - 17%; lighting with high levels of occupational diseases, a high
- 11%; vibrations - 6%; ionizing radiation - 1%. The level of MTDW as well as for some groups of social-
highest number of occupational diseases registered ly significant diseases is characteristic. In Sofia-city
in the Plovdiv region, incl. Kardzhali, Smolyan and (the center for the most widespread economic ac-
Madan with developed mines from coal production tivities, or the variety of professional injuries), make
and ore mining. The region of Stara Zagora follows impression that the summary MTDW and the pri-
with Burgas, Sliven, Yambol and Haskovo. Third is ority socially significant diseases, such as respira-
the region of Sofia, Pernik, Blagoevgrad, Kyustendil tory and cardiovascular diseases, have high and
and Botevgrad. very high indicators (Table 3). This applies both to
Total morbidity with temporary disability to work health-insured working men and to a much higher
(MTDW) is also related to occupational diseases. For degree for insured women. The frequency of cases,
individual economic activities and basic professions the frequency of the days and the average duration
Tab. 3. Morbidity with temporary disability to work of labour people in Sofia for 1996-2000 (total and by sex)
1. TOTAL MTDW
INDICATORS FREQUENCY OF CASES FREQUENCY OF DAYS The average duration of 1 case
WORKING TOTAL Male Female TOTAL Male Female TOTAL Male Female
Sofia -city 1996 119,7 117,6 121,7 1320,9 1244,2 1388,6 11,0 10,0 11,4
1997 86,6 72,3 100,4 976,3 802,8 1142,4 11,3 11,1 11,4
1998 93,5 81,7 105,1 1200,1 1005,9 1390,2 12,8 12,3 13,2
1999 93,9 82,6 106,2 1210,8 1015,6 1388,2 12,9 12,3 13,1
2000 96,1 83,4 110,2 1210,8 1017,9 1401,2 12,6 12,2 12,7

2. MTDV RESPIRATORY SYSTEM

INDICATORS FREQUENCY OF CASES FREQUENCY OF DAYS The average duration of 1 case
WORKING TOTAL Male Female TOTAL Male Female TOTAL Male Female
Sofia -city 1996 31,2 31,1 30,1 160,8 158,0 163,3 5,1 5,1 5,4
1997 23,9 19,5 28,1 119,1 95,6 141,6 5,0 4,9 5,0
1998 22,1 18,8 25,4 119,7 102,5 136,7 5,4 5,4 5,4
1999 22,8 18,9 25,9 119,9 102,9 136,1 5,2 5,4 5,2
2000 30,1 19,6 26,2 122,6 103,6 142,5 4,1 5,3 5,4

3. MTDV OF CARDIOVASCULAR SYSTEM INCLUDING HYPERTENSION

INDICATORS FREQUENCY OF CASES FREQUENCY OF DAYS The average duration of 1 case
WORKING TOTAL Male Female TOTAL Male Female TOTAL Male Female
Sofia -city 1996 9,1 9,6 8,5 100,2 128,4 75,3 11,0 13,4 8,9
1997 5,9 5,8 5,9 71,8 85,6 58,6 12,2 14,8 9,9
1998 7,0 7,2 6,7 88,4 104,7 72,3 12,6 14,5 10,8
1999 7,1 7,3 6,7 85,4 104,9 73,2 12,0 14,4 10,9
2000 6,8 6,9 6,3 85,1 101,8 71,1 12,5 14,7 11,3

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Tab. 4. Claims for recognition of occupational diseases of 100,000 insured persons
Population
Country 1990 2000 Trend
thousands
Germany 192 211 80570 ↑
Austria 151 103 7796 ↓
Belgium 431 277 9979 ↓
Denmark 549 545 5124 →
Finland 320 238 4998 ↓
France 63 237 56634 ↑
Ireland 4.4 7.5 3526 →
Italy 354 160 59104 ↓
Luxembourg 113 82 365 ↓
Sweden 1524 309 8587 ↓
Switzerland 202 136 6876 ↓

Tab. 5. New cases of recognized occupational diseases per 100 000 insured persons

Population
1990 2000 Trend
thousands
Germany 35 49 80570 ↑
Austria 78 42 7796 ↓
Belgium 186 112 9979 ↓
Denmark 90 124 5124 ↑
Spain 42 160 39434 ↑
Finland 160 64 4998 ↓
France 44 177 56634 ↑
Ireland 2.3 3.3 3526 →
Italy 93 33 59104 ↓
Luxembourg 8 14 365 →
Sweden 1242 138 8587 ↓
Switzerland 162 109 6876 ↓

of one case for the example five-year period, are in- 2000s in the 12 European countries are presented in
creasing. The claims for recognition and recognized Tables 4 and 5.
(registered) occupational diseases in the 1990s and

REFERENCES

1. Eurostat Working Papers, "European classification of occupational diseases" (European occupational

diseases statistics – EODS), Population and social conditions 1/2006/E/No.19, Luxembourg
2. Ordinance on the procedure for notification, registration, confirmation, complaint and reporting of
Occupational Diseases - SG, No. 65/2008 (in bul.)
3. Ordinance on the medical expertise of the working capacity - SG, 47/2005 (amended, SG No. 23/2007).
(in bul.)
4. Official Bulletin of the Ministry of Health No. 10/2001 (in bul.)
5. Statistical System "Occupational Diseases" - SG, No. 5/2004 (in bul.)
6. The Health and Safety at Work Act - SG, No. 124 / 23.12.1997 (amended and supplemented, SG No.
108/2008). (in bul.)
7. Tsacheva N., "Health of the manpower - labour-medical problems", MMA, S, 2007, 154. (in bul.)
8. Tsacheva N. Practical methodology for assessment and analysis of the health status of insured work-
ers, S., NCHMEN, 2001, 65. (in bul.)

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OCCUPATIONAL POISONING *

3.1 METALS

3.1.1 ANTIMONY - J. HADJIEVA

Antimony is a silver-white metal insoluble in water. phenomena of toxic hepatitis and toxic nephropa-
It is oxidized from concentrated nitric acid to antimony thy, heart failure, collapse and death can be added.
acid. Lighted in the air, antimony can burn to form an- Chronic antimony poisoning occurs with
timony trioxide and antimony dioxide. chronic irritative changes in the lining of the nose
Usage. Antimony and its compounds are widely with subsequent necrosis and ulceration of the un-
used in metallurgy (such as antimony alloys), in the derlying tissue. Perforation of the cartilage of the
rubber, chemical, polygraphic and pharmaceutical in- nasal septum is observed. Ocular abnormalities, dry
dustries, insect pests, rodents, etc. throat and chronic bronchitis have been reported.
Biotransformations. The antimony enters the It is possible to develop toxic pneumoconiosis from
body mainly via the respiratory tract and, more often antimony or mixed powders (silico-antimonyconio-
than not, through the gastrointestinal tract. In the sis).
blood antimony (III) is bound to erythrocyte, and anti- Cardiovascular disorders are most often charac-
mony (V) - predominantly in plasma. From the blood, terized by conduction disorders, changes in repolar-
the antimony quickly passes into tissues and spreads to isation, myocardial diseases, and the like. Common
the lungs, the liver, the kidneys, the skin and the bones. skin lesions are dermatitis. Changes are placed on
Metabolism is mediated by methylation processes. It is the limbs, thorax and genitals. Allergic manifesta-
eliminated in urine - mainly antimony (V) and faeces - tions are also possible - eczema.
mainly antimony (III). Ovarian-menstrual disorders and spontaneous
Pathogenesis. Antimony disrupts protein and car- abortions are not uncommon. A carcinogenic effect
bohydrate metabolism. It binds to sulfhydryl groups of the antimony on the lungs and bladder has also
and inhibits SH dependent enzymes from the oxidation been reported.
of alpha-keto acids. Antimony is a hemolytic poison. It Clinical-laboratory tests. As an exposition test,
is believed to break the ionic composition of the cells, the determination of antimony in urine (normal val-
with a potassium deficiency observed. The antimony ues ​​of 0.2-1.3 μg/l) is used.
has a strong irritant effect on the skin and mucous Hematological parameters - reduced number of
membranes. Its carcinogenic effect is not excluded (Ta- erythrocytes and leukocytes, eosinophilia, haemoly-
ble 1). sis and hemoglobinuria.
Clinical picture. Differential diagnosis. Antimony poisoning
Acute poisoning is characterized by marked irri- and its compounds should be differentiate from
tant changes in the upper respiratory tract and eye unprofessional diseases of the respiratory, digestive
lining. Inhalation of antimony aerosols may cause and cardiovascular systems, skin diseases, and mu-
"metal fever", acute emphysema of the lungs and cous membranes, poisoning with arsenic, cadmium,
pulmonary edema. Gastrointestinal is characterized chrome and manganese.
by nausea, vomiting, abdominal pain, diarrhea, de- Treatment. In case of acute antimony poisoning,
hydration and subsequent disturbance in the wa- antidote therapy (dimercaprole or D - penicillamine)
ter-electrolyte balance. In severe cases of poisoning, is administered. In hemolysis cases, transfusion is
recommended. Treatment of chronic poisoning in-
* Acute poisoning - co-authored by N. Mirchev volves general and other symptomatic therapy (in

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Tab. 1. Toxicokinetics and toxicodynamics of metals

Roads
Element Landfills Pathogenesis Elimination
penetration
Antimony respiratory lungs connect the SH groups of enzymes urine
Sb oral liver, kidney violates protein and carbohydrate metabolism faeces
skin highly irritative effect
bones carcinogenic effect?
Arsenic oral liver, kidney connect with SH gr of enzymes, breaking cell metabolism urine
As respiratory muscles, bones
dermal hair, nails, skin
Beryllium respiratory bones irritant and allergenic effect carcinogenic effect? urine – 80%
Be oral liver berylliosis is a systemic disease - granulomas in various tissues
dermal spleen and organs

Vanadium respiratory bones impairs the metabolism of vitamins (vit C), biogenic urine - 60%
Va oral parenchymal organs amines, lipids and carbohydrates faeces - 10%
hair, nails
Mercury respiratory parenchymal organs potent inhibitor of enzymes having an affinity for free radicals urine
Hg oral muscles and predominantly sulfhydryl; faeces
dermal decreases cont. of cytochrome P-450 and OMF saliva, sweat, hair,
nails
Cadmium respiratory kidneys violates the metabolism of Ca and P; reduces the activity of Urine> 85%
Cd oral liver α- antitrypsin in lung mucosa, associated SH gr. of cellular enzymes Bile and feces -
bones and proteins, direct irritating effect on mucous membranes 10%
carcinogenic effect

Tin respiratory lungs, general toxic effect faeces

Sn oral kidney, liver carcinogenic effect urine
dermal spleen, bone
Cobalt respiratory liver essential trace elements, activating certain enzymes regulating urine
Co oral lungs internal respiration and hemapoesis.
thyroid disturbs tissue respiration (inhibits cytochromoxidase etc.)
adrenal glands allergenic effect
kidneys

Manganese respiratory brain direct damage to extrapyramidal structures (n. caudatus, gl.palidus, via bile and feces
Mn oral liver, kidney corpus striatum) urine
pancreas by enzymatic inhibition violates metabolism of dopamine
muscles
Copper respiratory liver essential trace element; plays an essential role in hematopoiesis, by bile
Cu oral kidneys in the activity of several enzyme systems, in the functions of urine
dermal pancreas the endocrine glands. sweat, hair, nails
it has expressed irritative and hemolytic effect.
Nickel respiratory liver local irritation action faeces (80%)
Ni oral spleen suppresses the activity of glutationreductase urine
kidneys stimulates the synthesis of cholesterol bile
allergenic effect sweat, hair
carcinogenic effect

Lead respiratory bones block. SH gr of enzyme urine - 80%

Pb oral liver porphyrin metabolism disorders feces - 15%
kidneys direct damages hepatocytes sweat, saliva, milk -
1-5%
Selenium inhaled kidney, liver essential trace element; garlic breath!
Se oral muscles block SH gr. of enzymes urine
dermal brain faeces
hair, sweat
Thallium oral parenchymal tissues binds SH gr. and block enzymatic systems, disturbing faeces
Tl dermal cellular respiration and protein sinthesis. Bonding with urine
respiratory riboflavin explain it’s neurotoxicity.
Tellurium inhaled bones inhibit cholesterol biosynthesis urine
Te oral liver bile and feces
dermal
Phosphorus oral liver binds to proteins and upset the function of enzyme systems urine
P respiratory kidneys regulating the oxidation processes in the cells, impairs the
dermal bones metabolism of carbohydrates blocking phosphorylation

Zinc respiratory parenchymal organs essential trace element; participates in many enzyme systems bile and feces
zn oral bones violates the electronic transport in the mitochondrial respiratory urine - 20%
muscles chain inhibits cytochromoxidase, violates the secretory function sweat, hair, nails
brain of the pancreas

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 OCCUPATIONAL MEDICINE
pulmonary edema - glucocorticoids, calcium prepa- also indicated as a possible mechanism of toxic action.
rations, diuretics, oxygen therapy) (Tabl. 2) Clinical picture.
Examination of working capacity. Acute anti- Acute poisoning. Acute poisoning occurs more
mony poisoning is most often associated with tem- often when the arsenic enters the mouth. They oc-
porary loss of working capacity. Chronic poisoning cur with the clinical picture of a local and absorptive
results in a temporary or permanent limitation of toxic effect - acute gastroenterocolitis with cholera
working capacity for specific working conditions. similar as symptomatology, toxic cardiopathy, hepa-
Prevention. Sanitary-technical prophylaxis. torenal syndrome, disturbed consciousness, epilep-
Compliance with safety requirements (ensuring ef- tiform convulsions, coma. Inhalation of higher con-
fective ventilation, mandatory use of individual pro- centrations of inorganic arsenic compounds leads
tective equipment, current control of antimony con- to acute upper respiratory and lung manifestations
centrations in the air in the working environment, - acute rhinitis, pharyngitis, laryngitis.
etc.). Poisoning with arsine. It develops after a latency
Medical prophylaxis. Do not come into contact period of 3 to 6 hours and occurs with a picture of
with antimony and its compounds, persons with res- haemolytic anemia, hepatorenal syndrome (acute
piratory, cardiovascular and digestive disorders, skin renal failure).
and mucosal diseases. Periodic medical examina- Chronic poisoning. Under production condi-
tions are performed once every 12 months with the tions, arsenic affects skin, respiratory organs, liver,
attendance of a therapist and by indications-derma- kidneys, haematopoietic organs and the nervous
tologist. system in prolonged exposure to low concentra-
tions. Initial changes in the upper respiratory tract
3.1.2. ARSENIC - V. PETKOVA, S. PAVLOVA - chronic rhinitis, pharyngitis, laryngitis, gastrointes-
tinal tract - chronic gastritis and gastroduodenitis as
Arsenic is a metalloid widespread in nature in the an expression of the irritant action of arsenic. Char-
form of compounds with metals and sulfur. Of more acteristic of the initial stages of poisoning are neuro-
toxicological importance are its compounds: (arsenic sensory manifestations as well as abortive forms of
(III) oxide, arsenites and arsenates). Arsenic trioxide is toxic sensory polyneuritis - pain and decreased sen-
a starting product for the synthesis of a number of ar- sation in polyneuritic type, acroparesthesias - pre-
senic compounds for the processing of leathers, semi- dominantly in the lower limbs. At this stage, the he-
conductors, plant protection products. It is used as an mostimulating effect of arsenic is also noted - with
initiator in the polymerization, a reducing agent in the polyglobulin and hemoglobin elevations.
production of glass. Arsenic salts (arsenates and arsen- In the next stages of chronic poisoning, typi-
ites) are used as pesticides and antiseptics for preserv- cal poisoning syndromes - toxic polyneuropathy
ing wood. - ascending, vegeto-sensory with marked pain syn-
Routes of intake, biotransformation and dis- drome are being developed. Signs of toxic hepatitis
tribution in the body. Arsenic compounds enter the and initial toxic nephropathy appear. The abnormal
body through the airways, the skin and the gastroin- changes in the respiratory organs are greatly en-
testinal tract. Absorb in the upper respiratory tract, but hanced. Perforation of the nasal septum may occur.
also through the lungs. In the body oxidation of the Severe forms of chronic poisoning resemble
trivalent arsenic is achieved in a five-valent and vice acute poisoning - pronounced hepatorenal syn-
versa - reduction of the five-valent to trivalent, which drome, sensory motor polyneuritis, myelopolyneuri-
is significantly more toxic. It accumulates in nails, hair tis with characteristic severe ataxia, so-called arsenic
and skin, which, according to some, is due to its chem- "pseudotabes", toxic anemia, toxic arsenic cardiomy-
ical keratin association. It is excreted through the kid- opathy with rhythmic and conductive disorders.
neys, with maximum urine output during the first 6 Skin changes are characteristic of arsenic expo-
hours of exposure. The excretion of arsenic with faeces sure. Palmar and plantar hyperkeratoses, arsenic
is insignificant and is of greater importance in its or- melanomas, contact dermatitis, ulcerations, trophic
ganic compounds. disorders, alopecia may accompany chronic poison-
Toxic effect. The arsenic compounds are toxic. The ing and are a sure sign of arsenic exposure.
toxic effect depends on the valency of the arsenic and Carcinogenic risk. Arsenic and its compounds
the solubility of the compound. Arsenic, as a classical are part of a group 1 of carcinogens for humans in
thiol poison, binds to the sulfhydryl groups of vital en- the IARC classification. The most common is lung
zymes, e.g. succinate dehydrogenase, glutathione and and skin cancer.
the like, disrupting cellular metabolism. The arsenic Laboratory diagnostics. Urine excretion in-
antagonism of selenium, iodine and phosphorus is creased in excess of 1.47 μmol/l, which is considered

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Tab. 2. Clinic, exposure tests and treatment of metals poisoning

Acute poisoning Chronic poisoning Exposure tests Treatment

Sb irritative manifestations in rhinitis, nasal septum perforation, impaired Sby> 1,3 μg/l Dimercaprol (BAL) 5% 5 ml
the eye and UAP sense of smell reduction of Er and Symptomatic
metal fever chronic bronchitis leuco, eosinophilia,
pulmonary edema toxic pneumosclerosis hemolysis,
gastrointestinal syndrome myocardiopathy hemoglobinuria
toxic hepatitis dermatitis and eczema
nephropathy lung cancer and bladder
As gastroenteritis rhinopharyngitis, perforation of the nasal Asurine> 1,47 μmol/l Acute poisoning:
hepatorenal syndrome septum, gastroduodenitis, Askhair> 3-5 mg/g dry Dimercaprol (BAL) 5% 5 ml
intravascular hemolysis distal sensory-motor neuropathy in the lower mass i.m. -3 mg/kg body weight
cardiomyopathy, extremities + autonomous violations Asnails> 5-10 mg/g dry in 12 h-24 h
epileptiform convulsions, cardiomyopathy with rhythmic and mass Chronic poisoning:
coma conduction disorders Dimercaprol (BAL) 5% 5 ml
anemia i.m or Unithiol -5% 5 ml of
tox. hepatitis and nephropathy i.m.; course-5 days
hyperkeratosis and hyperpigmentation Succimer (Chemet) -
lung and the skin cancer capsules -0,350 mg - day
dose 2,1 g - 5 days
CaNa2 EDTA 10% 10ml i.v.
(if lacking of these antidotes)-
1 g in 3 consecutive days.
Be irritative manifestations in granulomatosis lung Bey> 0,02 mg/l alkaline inhalations, oxygen
the eye and UAP dermatitis - ulcerative and granulomatous SH group-s. In serum; FID; therapy, diuretics, antibiotics,
beryllium fever skin allergic testing broncholytics, corticosteroids
bronhobronhiolitis Rö graphy biopsy of lung CaNa2 EDTA 10% 10ml i.v.
toxic pneumonia biopsy of skin granulomas (Twice daily 1 g in
3 consecutive days.)

Va Irritation of the eyes and UAP bronchitis, pneumonia Decreases in serum CaNa2 EDTA 10% 10ml i.v.
bronchial asthma cholesterol Vit.С
diffuse pneumosclerosis (> 10 yr.exp) Increase in Vbl
dermatitis, eczema
Hg cough, shortness of breath, gingivitis, stomatitis, pharyngitis Hgbl > 0,02 mg/l Acute poisoning:
cyanosis, toxopulmonitis, dental erosions Hgu > 10 μg/l Dimercaptol - amp.
pulmonary edema, tremor, erethism SH gr. in serum 100 mg/ml, Unithiol amp.
gastrointestinal syndrome, autonomic dysfunction psychological tests 25 mg/ml 1 mg per 10 kg
proteinuria, oliguria, ARF (hypersalivation, sweating, tachycardia, tremorografia weight i.m.
changes in dermography, polyuria) Chronic poisoning:
distal sensory polyneuropathy in the lower Unithiol -5% 5 ml i.m.
limbs + autonomous violations 1 ampoule per day;
psychiatric disorders Course 5 - 10 days
anemia Succimer - capsules
-proteinuriya, nephropathy, RF 0,350g- 2,1 g daily; course -
chronic dermatitis and eczema 5-7 days
Na thiosulfuricum 10-20%
10 ml (applied in the absence
of the above antidotes),
course five days
vitaminoterapy - B1,B6,vit.C
tranquilizers
neurotonics, vasodilators
Cd metal fever anosmia, rhinopharyngitis Cdbl > 5 μg/l CaNa2 EDTA 10% 10 ml i.v.-
cathars of UAP emphysema, bronchitis, pneumosclerosis Cdu > 2 μg/l for 3 or 6 days
dyspnea, pneumonia, anemia β2mikroglobulin > 34μg Cuprenil tablets 0,250 g -
pulmonary edema tubulopathy with proteinuria /mmol creatinine daily 2 g - course 5 or 10 days
gastrointestinal disorders Fanconi syndrome Vit. D forte- ampoule 600 000
hepatorenal syndrome osteomalacia, spontaneous fractures E i.m. once a month
kidney failure lung and prostate cancer calcium supplements

Sn irritative symptoms of eyes bronchitis, emphysema Snu > 0,11 μg/l symptomatically
and UAP pneumoconiosis
metal fever lung carcinoma
p.o. - gastroenterocolitis,
hepatitis

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 OCCUPATIONAL MEDICINE
Co irritative symptoms of eyes rhinopharyngitis polycythemia-increasing CaNa2 EDTA 10% 10ml i.v.
and UAP bronchitis, pneumonia, all. alveolitis, asthma HB, Er, Ret, Eo Dimercaprol (BAL) 5%
cough, shortness of breath myocardiopathy dyslipidemia 5 ml i.m
nausea, vomiting gastritis, peptic ulcer disease Cobl.> 0,5 μg/l symptomatically
convulsions hyperkeratosis, ulcers, allergic dermatitis
Mn metal fever cerebrasteniya psychological tests CaNa2 EDTA 10% 10ml i.v.-
CUAP Parkinson's syndrome EMG 3 last days
pneumonia Psychoorganic syndrome Mn bl. Mn u. are raised, anti-Parkinsonian drugs
encephalopathy but did not correlate with vit. E - high doses
toxicity vit. C and B com.
Mn bl. > 3,4 μmol/l;
Mn u. > 0,9 μmol/l
Cu copper fever rhinopharyngitis, gastritis increased cont. of Hb, symptomatic treatment
allergic dermatitis copper colic and ER
rhinopharyngitis, greenish-yellow or greenish-black CuSerum > 24 μmol/l
gastritis, copper colic discoloration of the skin
acute hemolysis, hemoglo- locally-ulceration of the cornea of the eyes,
binuria, jaundice, ARF skin, nasal septum
Ni inh- CUAP metal fever allergic dermatitis and eczema Niu. > 2,5 μg/l CaNa2 EDTA 10% 10ml i.v
p.o.- gastrointestinal metal fever Dimercaprol (BAL) амп 5%
syndrome sinusitis, anosmia, perforated the nose. 5 ml i.m.
sk-dermatitis, eczema septum
bronchial asthma
cancer of the nose, larynx and lung
Pb haemolytic anemia lead facies, gingival Pb strip Pbk >2,88 μmol/l (60 CaNa2 EDTA 10% 10ml
abdominal colic abdominal colic μg/dl) i.v.- 3 consecutive days, as
tox. hepatitis sideroachreocythemia (anemia) Pbу>0,53 μmol/l necessary twice a repetition
ARF toxic hepatitis 5-DALA>10 000nmol/4 h. of the course at intervals
encephalopathy uric acid nephropathy SE >15‰; RЕ>0,5‰; of three days.
asthenia, arthralgia, myalgia FPP>100 mg/dl CEMET capsules 0,350 g-
cerebrastenia 2,1 g daily -5 days
motor polyneuropathy (nn. radiales) Cuprenil tablets 0,250 g -
psychoorganic syndrome, encephalopathy 2 g daily - seven days

Se inh - irritative events conjunctivitis, rhinopharyngitis, bronchitis Sebl.>0,4 mg/l Respiratory resuscitation
eyes and UAP; pneumonia, reddish coloration of the skin Seu.>0,1 mg/l glucocorticoids, aqueous
pulmonary edema gastrointestinal complaints salt solutions
skin burns neuropathies When skin burns -
par. dermatitis, dispigmentation unguents with a 10% solution
paronychia, alopecia of Natrium thyosulfuricum
Vitaminotherapy
Tl alopecia alopecia hypokalaemia Acute poisoning:
gastrointestinal disorders fatigue, weakness tubular proteinuria Antidotum metallorum 100
ascending paralysis, distal sensory-motor polyneuropathy in EMG ml in stomach tube, then
coma the lower limbs, - axonal type Tlu. > 10 μg/l rinse with water and abs.,
sometimes lesion II, III and IV CN saline cathartic; drop infusion
with an aqueous salt solution
In chronic poisoning:
Natrium
thyosulfuricum-20% 10-50 ml
CaNa2 EDTA 10% 10ml
Dimercaprol (BAL) Amp 5%
5ml i.m.
Vitaminoterapy -B, C

Te irritative events in UAP metallic taste in mouth, nausea, vomiting Teu.> 0,05 mg/l CaNa2 EDTA 10% 10ml i.v.
gastrointestinal syndrome
haematuria
P p.o. - Gastroenteritis, rinofaringolaryngitis, pneumonia increase the activity of p.o.-gastric lavage with water
hepatorenal syndrome, chronic bronchitis, COPD liver enzymes, and potassium permanganate;
hemorrhagic diathesis, chronic gastroenteritis hyperbilirubinemia saline laxatives; 15 ml of a 1%
jaundice, convulsions, anemia subikter leukopenia, hematuria, solution of CuSO4, intravenous i
delirium, coma. toxic hepatitis proteinuria infusions, AB, hepatoprotective
inh.-cough, dyspnea, toxic nephritis treatment 10% 10 ml of
pneumonia, pulmonary necrosis of the jaw calcium gluconate; locally-3%
edema, cardiac arrhythmia. spontaneous fractures of long bones solution of CuSO4 - neutralize
ataxia, paraesthesia, tremor, P on skin.
diplopia, convulsions, in vitaminoterapy
contact - heavy burns

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 LABOUR MEDICINE
Cr tracheobronchitis, pneumonia conjunctivitis, keratitis reduced court. HM, ER, symptomatic
pulmonary edema atrophic rinofaringolaringiti anisocytosis, poikilocytosis vitaminoterapiya - B1;
gastroenteritis Nasal septal perforation were, cells Heinz in Er.; B6; B12 in allergic dermatiti-
hepatorenal syndrome bronchitis, emphysema, bronchial asthma leukocytosis with corticosteroid ointments
uraemia toxic pneumosclerosis neutrophilia and
contact - allergic dermatitis, Are bronchi (after 15-30g exp.) eosinophilia
ulcers type "bird's eye" gastritis, ulcer perforation methemoglobinemia>
2%
toxic hepatitis and nephritis (rare)
CrЕr >1 μg/l
anemia
Crу >5 μg/l

z n metal fever nasal sepum perforation reducing HB, Er, CaNa2 EDTA 10% 10ml i.v.
gastroenteritis bronchitis, pneumonia, pneumosclerosis leukocytosis symptomatically
uraemia gastroenteritis hyperglycaemia
Local ZnCl2 - skin and early atherosclerosis, arrhythmias glucosuria
eye burns hypochronic anemia Znserum >24μmol/l
neurasthenic syndrome
allergic dermatitis

to be the most reliable indicator of occupational risk. Diet D from the preventive diet is recommended.
The determination of arsenic in blood, urine, hair
and nails is used as a biological marker for arsenic 3.1.3. BERYLLIUM – Т. КUNEVA
exposure. In the blood, in the initial stages - elevat-
ed Hb and erythrocytes, in more advanced cases of - tracheobronchitis, pneumonitis
poisoning - normochromatic anemia, thrombocyto- - granulomatosis of the lung
penia, granulocytopenia. - dermatitis (ulcerous and granulomatous)
According to the latest data, arsenic disturbs - irritative manifestations in the eyes, nose, mouth
heme synthesis by altering the activity of copropor- Beryllium in nature is not found in pure form but
phyrin oxidase, hemsyntetase and hemoxygenase. contains some minerals, of which the most common is
As a result, elevated levels of uroporphyrin, copro- beryl Be3A12/SiO3/6 and chrysoberyl BeAl2O2.
porphyrin and bilirubin in the urine were observed. Pure beryllium is a silver-gray metal with a high
Differential diagnosis. In the differential diag- melting temperature (1280 °). It does not interact with
nosis plan, alcoholic and diabetic coma, thallium water, dissolves in dilute acids and bases. At high tem-
intoxication, acrylamide polyneuropathy, poly- perature forms compounds with oxygen, sulfur, nitro-
cythaemia vera, Addison's anemia, dimethylsulfate, gen, halogens.
antimony, chlorine, chromium, etc. intoxications Use - due to its valuable properties - high strength,
should be considered. hardness, heat resistance and delayed oxidation, be-
Treatment. Treatment is etiopathogenetic. ryllium is widely used in industry: in the machinery and
Chelation therapy with Ca Na2 EDTA - 10% - 10 cc i.v. the building industry, in the production of corrosion re-
Healing course - 9 g in three three-day courses with sistant alloys, electronic equipment, X-ray tubes, radio
a 3-day rest between them. Symptomatic treatment. fluorescent and neon lamps, ceramic paints.
Organoprotectors. Antioxidants - selenium as cofac- Occupational exposure - long-term exposure to
tor of glutathione peroxidase is thought to reduce dust and smoke exposed workers involved in the grind-
arsenic toxicity. ing and roasting of beryllium-containing ores and in
Prognosis and labour-medical expertise. Per- the production of beryllium alloys. Significantly lower
manently labour readjustment is required in residu- is the risk for persons in contact with beryllium com-
al manifestations following acute or chronic arsenic pounds used in aircraft and electronics industry.
poisoning such as, for example, polyneuritis, perfo- Absorption, metabolism, excretion. Beryllium
ration of the nasal septum, toxic hepatitis or precan- compounds have low absorption after inhalation, in-
cer hyperkeratosis and arsenic melanosis. gestion, or skin contact. Beryllium may last longer in
Prevention. Preliminary medical examinations the lungs or be deposited in the bones, liver and spleen.
aiming at non-admission to work with arsenic com- Renal excretion is weak and variable and confirms ex-
pounds of persons with chronic skin diseases, often posure because it is not detected in exposed individu-
recurrent diseases of the respiratory organs, liver als.
and bile ducts. Periodic medical examinations are Pathogenesis. Beryl and its compounds have lo-
performed once a year with the participation of in- cal irritant, general toxic, allergenic and carcinogenic
ternist, neurologist, ORL specialist and dermatolo- effects. Their toxicity is determined by their solubility
gist. and dispersion - soluble and more strongly dispersed
Exposure control is performed by surveying the are more toxic. Soluble compounds most often cause
content of arsenic in urine, hair and nails. acute poisoning, and insoluble - chronic intoxications.

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In chronic intoxication no dose-effect dependence was nal and articular syndrome, bone damage with thick
observed. ribbed and long tubular bones periosteum and skin
Clinical picture. Berylliosis is a systemic disease, granulomas. The interstitial form of chronic beryllio-
which is confirmed by the concurrent presence of sis is clinically benign and is usually limited to stage
granulomas in some tissues and organs - lungs, liver, I. Typical are "standstill radiiograms" with finely-re-
skin, lymph nodes. ticulate design. Possible degenerative lesions of the
Acute intoxications may occur in the form of: liver and kidneys.
Cataraural inflammation of the mucous mem- The most common skin lesions associated with
branes of the UAP: rhinitis, pharyngitis, tracheitis. beryllium are contact and allergic dermatitis, ecze-
They run out relatively mildly and quickly - a few ma, ulcers and granulomas. Typically, the exposed
days or weeks. parts of the face, hands and neck are affected. The
Beryllium fever - a few hours after inhalation of beryllium granulomas are slow running with fistu-
a vapour occurs a prodromal period, manifested by lae, forming for months. Beryllium is often found in
general weakness, headache, nausea, vomiting, dry a biopsy.
cough, shortness of breath. After 4-5 hours the real Beryl and beryllium compounds are proven car-
fever period begins - the temperature rises sharp- cinogens for humans and it is necessary to avoid di-
ly to 39-40°C, after 5-8 hours it falls with abundant rect contact with them.
sweating. Blood is found in leukocytosis and rapid Laboratory diagnostics. In the case of acute
transient hyperglycemia. pneumonitis, arterial hypoxemia is detected. Chron-
Severe form of acute berylliosis - broncho- ic berylliosis has hypergammaglobulinaemia, ane-
bronchiolitis and toxic pneumonia. Characteristic mia, elevated liver enzyme activity, and hyperu-
is the stormy start. It is possible to develop interstitial ricemia. Unlike sarcoidosis, angiotensin converting
myocarditis, hepatitis, nephropathy. Radiographical- enzyme serum levels are normal.
ly, emphysematous changes and a number of small The diagnosis of beryllium poisoning is based
but intense homogeneous shadows are seen that on proven contact, clinical syndromes, the presence
are not clearly delineated and do not merge with of beryllium in urine over 0,02 mg/l, a positive skin
each other. Bronchiolitis and pneumonia sometimes test with its soluble salts. Skin tests prove sensiti-
occur with high temperature and fever, recurrences zation to beryllium compounds. Lymphocyte blast
are possible. Danger of acute pulmonary edema. transformation is an alternative to an effective indi-
Chronic berylliosis occurs as a result of acute vidual assessment of reactivity to beryllium.
intoxication or as a primary chronic disease. Often Differential diagnosis of acute berylliosis is
it develops with minor acute exposure to berylli- made with colds, and chronic - with hemosidero-
um or many years after termination of the contact. sis, carcinomatosis, sarcoidosis, Hamman-Pich syn-
The latency period ranges from several weeks to 15 drome, miliarl tuberculosis. Diagnostic puncture
years. There have been cases of chronic berylliosis in biopsy of the lung is used in the most difficult diag-
people living near beryllium production. The onset nosis.
of the disease may be gradual, unnoticed, with mi- Treatment. In case of acute nasopharyngitis and
nor complaints or violent with pronounced clinical tracheitis against the irritant phenomenon of UAP,
symptoms. For the fast-progressing form of chronic alkaline inhalations are employed. A 2% solution of
berylliosis, it is characterized by an acute onset of ephedrine is dripped into the nose. Anti-tussive and
high temperature, fever, shortness of breath, parox- antihistamine agents are used.
ysmal cough, chest pain, abrupt weight loss (10-12 In case of beryllium fever, intravenous adminis-
kg). Dyspnoea is a leading and most symptomatic tration of 40% glucose with ascorbic acid, intake of
symptom. Compensatory erythrocytosis (arterial large quantities of sweet tea is recommended, as in-
hypoxemia), dysproteinemia, an increase in γ-glob- dicated - alkaline inhalations.
ulins were observed in the blood. Acute bronchoconstriction and pneumonia re-
Depending on the nature of radiological changes quire intensive and complex therapy for the elimi-
in the lungs, two forms differ: granulomatous and in- nation of acute respiratory failure and pulmonary
terstitial, and depending on their expressions - three edema - oxygen therapy, diuretics, antibiotics, bron-
stages. cholitics, corticosteroids. In case of skin and eye con-
The granulomatous form is heavier with the pres- tact, thorough washing with water is required. In the
ence of focal shadows (granulomas), with the exten- presence of beryllium ulcers and granulomas, sur-
sion of the lung roots due to lymph node hyperpla- gical wound processing and topical treatment with
sia and early development of the pulmonary heart. corticosteroid ointments is necessary.
Granulomatous berylliosis often involves hepato-re- The most commonly used antidote for acute poi-

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 LABOUR MEDICINE
soning is CaNa2 EDTA twice a day for 1 gram in a 5% phones, resulting in a rapid increase in their use (55%
glucose solution of 250 cm3, intravenously, three of all cadmium used in the industrial countries in 1994
days in a row. was for batteries).
For the treatment of chronic berylliosis, antibi- Cadmium compounds (30% of the use in developed
otics, oxygen therapy, corticosteroids are adminis- countries) are used as pigments and stabilizers in the
tered. In patients in stage III corticosteroid therapy is manufacture of plastics as well as for alloys (3%).
continuously administered with depot preparations, Cadmium compounds are also used as paint pig-
the dose depending on the clinical symptoms. ments in the porcelain and glass industry (cadmium
Prognosis. In mild acute poisoning - complete sulphide); as fungicides (cadmium chloride); semicon-
recovery with normalization of the X-ray picture; in ductor production (cadmium oxide).
severe forms of acute berylliosis (bronchiolitis and Occupational exposure - cadmium vapors and
pneumonia) - development of interstitial pneumo- dust are found in workers involved in the melting and
cosclerosis and chronic disease. At high concentra- refining of lead, copper and zinc ores. The following
tions of vapors and powder from beryllium com- professions, classified by weight: casters at cadmium
pounds a lethal outcome is possible due to severe production, operators of electrolysis apparatus, press
pulmonary edema. operators of cadmium-nickel accumulators, operators
Labour expertise. Temporary labour readjust- and fitters in maintenance, galvanic technicians, are
mentwithout contact with beryllium is recommend- also threatened.
ed for isolated ocular involvement (conjunctivitis, Absorption, metabolism, excretion. In occupa-
blepharitis), catarrh inflammation of the UAP, fever. tional exposure, the main pathway to cadmium in the
Termination of contact is required after severe acute body is respiratory - by inhalation of cadmium dust or
intoxication and in patients with chronic berylliosis. cadmium oxide vapors. Absorption in the lungs is be-
Manifest beryllium intoxication requires long-term tween 20% and 30% (smokers up to 50%) and depends
treatment of patients who are at least with perma- on the size and chemical composition of the particles.
nently labour readjustment. Gastrointestinal absorption of cadmium is between 2
Prevention. Prophylaxis of beryllium poisoning and 6%. In people with low iron stores (low serum ferri-
involves local and general ventilation, equipment tin concentrations), higher cadmium absorption (over
sealing, remote control. It is obligatory for the work- 20%) may occur. Gastrointestinal absorption also in-
ers to wash with a hot shower after work. Personal creases in calcium, zinc and protein-poor foods.
protective equipment is subject to daily cleaning. Skin absorption is negligible.
Preliminary and periodic medical examinations After absorption through the lungs or the gastroin-
are mandatory. Contraindications for getting into testinal tract, the cadmium is transported to the liver,
work with beryllium are chronic diseases of the where it is linked to a low molecular protein rich in sulf-
respiratory and cardiovascular system, liver, gastro- hydryl groups - metallothionein (MT). About 80% - 90%
intestinal tract, organic CNS diseases, allergic, en- of the total cadmium in the body is bound to metal-
docrine, blood and skin diseases. Periodic medical lothionein. Small amounts of metallothionein-bound
examinations are conducted once every 6 months cadmium constantly leave the liver and are transport-
with the participation of a therapist and an otorhi- ed to the kidneys. The kidneys and the liver are the
nolaryngologist. Laboratory tests: blood count, FID, main cadmium depots in the body (containing about
X-ray of the lungs. 50% of the body load). Kidney concentrations in the
renal cortex exceed about 15 times the liver concentra-
3.1.4. KADMIUM - T. KUNEVA tions prior to kidney damage.
Elimination of cadmium is very slow - it accumu-
Cadmium has similar physical and chemical prop- lates in the body. The biological half-life of cadmium in
erties as zinc and occurs naturally with it. In minerals humans varies from 7 to 30 years.
and ores cadmium and zinc are usually in the ratio of Clinical picture. Acute poisoning occurs rela-
1:100 to 1:1000. tively rarely. Two clinical forms are known: inhala-
Cadmium gives high corrosion resistance to steel, tion and digestive-resorption. The inhalation form
iron and a number of other metals, which also deter- is most often the result of inhalation of dust or va-
mines its primary use for galvanic coatings of metal pours from cadmium oxide. Common symptoms
parts in the airplane-, ship-, machine-, and car engi- occur after a latency period of several hours (1 to
neering, electronics and electrical engineering. Today, 8), most commonly flu-like and resembling met-
however, only 8% of the processed cadmium is used for al fever - pain throat, nausea, metallic taste in the
alloys and coatings. Cadmium-containing batteries mouth, headache, myalgias. When the disease pro-
are small, portable, easy-to-use and are used in mobile gresses, chemical pneumonia develops - coughing,

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tightness in the chest, shortness of breath, fever. In Treatment. For acute poisoning, use of BAL (Di-
the most severe cases, pulmonary edema and res- mercaprol) 100 mg every 6 hours intramuscularly or
piratory failure death occur. In severe forms of acute CaNa2EDTA of 0.5 g in 500 ml isotonic solution twice
poisoning, pulmocardial (cardiovascular decompen- daily is recommended. With continuous control of
sation) and hepatic syndrome (toxic hepatitis) may renal function.
develop. Acute exposure may be a cause of chronic The inhaled form includes broncholytic and de-
pulmonary fibrosis. hydration agents, intravenous glucose infusions
In the conditions of prolonged cadmium expo- with vitamin C, antibiotics against pneumonia.
sure, the critical organ is the kidney and the most The treatment of the digestive-resorption form is
characteristic symptom is proteinuria. The nephro- carried out by gastric lavage with sodium sulphate
toxic effect of cadmium is manifested by: tubular solution and medical charcoal, infusion resuscita-
dysfunction - increased excretion of low molecular tion with water-salt and glucose solutions, hepato-
weight proteins (β2-microglobulin, lysozyme, ribo- protective therapy with glucocorticoids, B and C vi-
nuclease) and glomerular dysfunction - increased tamins, in severe forms - early dialysis.
excretion of high protein molecules (albumin, trans- In chronic poisoning: antidote therapy involves
ferrin, orosomucoid, immunoglobulin, urea, low cre- administration of CaNa2EDTA 10% 10 ml intravenous
atinine clearance). Prolonged exposure is associated ampoules in 5% glucose or physiological saline solu-
with Fanconi syndrome - aminoaciduria, glucosuria, tion. The antidote is given once a day for 3 or 6 days.
hypercalciuria, phosphaturia. Renal impairment is Symptomatic treatment - depending on the type
irreversible and progresses after discontinuation of and extent of organ damage.
exposure. Renal tubular dysfunction may be a cause Once a month, it is desirable to take vitamin
of nephrolithiasis and osteomalacia. D forte - ampoule - 600,000 ME intramuscularly.
With prolonged contact with cadmium - over 20 Prophylactically against bone damage is appropri-
years, bone is damaged. Pain in the bones does not ate for calcium preparations.
have a strict localization, often occurs when mov- Prognosis - favourable in timely diagnosis and
ing or changing the position of the body. ("Itai-Itai discontinuation of exposure prior to glomerular dys-
disease", a severely painful type of osteomalacia function and bone fractures.
with multiple fractures and renal dysfunction due Expertise of working capacity - balneother-
to water and rice in environmentally contaminated apy, vitaminotherapy (B, C, D) in high doses is rec-
cadmium areas, has been observed in Japan). Other ommended for cadmium carriers. Manifest chronic
clinical manifestations of chronic cadmium intoxi- cadmium intoxication requires long-term treatment
cation include anosmia, chronic rhinopharyngitis, and long-term rehabilitation (% reduced ability to
pulmonary emphysema, pneumocosclerosis, mild work without contact with toxic substances).
hypochromic anemia, chronic gastritis, light yellow Prevention is aimed at lowering the level of con-
to golden brown dental pigmentation. Prolonged tamination, using personal protective equipment
exposure (over 20 years) of cadmium in the air in the and regular prophylactic examinations of the ex-
work environment certainly leads to the develop- posed ones.
ment of pulmonary emphysema. Cadmium is a car- Contraindications for work in contact with cad-
cinogen. In several large epidemiological studies, a mium are atrophic rhinitis, chronic diseases of the
dose-response relationship has been demonstrated lungs, kidneys, liver, organic neurological diseases.
between the growing lethality of lung cancer in cad- Periodic medical examinations are carried out
mium-exposed workers. Interpretation is complicat- once a year, with the participation of a therapist and
ed by the competitive exposure of other metals that dentist, as evidenced by an otorhinolaryngologist.
are known to be suspected carcinogens. The early cadmium effect screening test is the de-
Laboratory researches. Blood cadmium - nor- termination of protein in the urine, along with the
mally in non-professional contacts is less than 5 μg/l. mandatory determination of cadmium in biological
Early toxic effects - at values a​​ bove 10 μg/l; cadmium fluids. It is recommended that diet B be taken from
in urine - less than 2 μg/l. Renal impairment can be protective professional nutrition.
expected at concentrations above 0.01 mg/g creati-
nine. Trace excretion of β2-microglobulin, lysozyme, 3.1.5. CHROMIUM - J. HADJIEVA
albumin and total protein. β2-microglobulin in urine
should not exceed 34 μg/mmol creatinine. The chromium is a hard metal with a grayish-white
Differential diagnosis - endemic nephropathy, color. It dissolves easily in hydrochloric and sulfuric
other toxic nephropathies (beryllium, zinc, chromi- acid and is insoluble in water. Chromium exists in three
um, manganese, antimony). valent forms (elemental chromium, trivalent chromi-

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 LABOUR MEDICINE
um (III) and hexavalent chromium (VI). and lead chromates and chrome semiproducts. Pos-
Trivalent chromium is an essential microelement, sible carcinogens are also the bichromates of lithi-
unlike hexavalent chromium, which is highly toxic. um, potassium, rubidium and others.
Usage. Chromium and its compounds are used in Changes by other organs and systems: gastroin-
metallurgy and machine building, in the chemical, tex- testinal tract - manifestations of dyskinesias, often
tile, ceramic, pharmaceutical and electronics industries exacerbating gastritis and ulcers with perceptions
Biotransformation. Chromium and its com- of perforation; liver and kidneys - slight functional
pounds fall into the body via the respiratory tract, impairment may develop to cirrhosis of the liver,
the skin and the gastrointestinal tract The chromium nephrosonephritis; mucous membranes and skin -
absorption depends on its valency and is its electrical surface ulceration of the nose mucosa, perforation
charge. Hexavalent chromium (VI) is absorbed faster of the initial part of the nasal septum. Changes in
than trivalent chromium (III). Chromium accumulates the skin are manifested by hand sores localized be-
primarily in the lungs, liver, spleen, pancreas, and bone tween the fingers and nails, sometimes penetrating
marrow. A significant portion of the body's chromium to the bone - type "bird eyes", allergic contact der-
(VI) is reduced to chromium (III). Elimination of chro- matitis and eczema.
mium occurs mainly in the urine. Clinical-laboratory tests. Haematological syn-
Pathogenesis. The pathogenetic mechanism of drome-low hemoglobin, decreased red blood cell,
action of chromium is relatively well studied. It has a anisocytosis, poikilocytosis, polychromasia; Heinz
general toxic effect - on the liver, kidneys, hematopoie- cells in erythrocytes, leukocytosis with neutro-
sis, cardiovascular system and others. The stimulating philia and eosinophilia, increased methaemoglo-
effect of chromium on cholesterol synthesis is known bin content in the blood, sometimes establishing
to cause the development of early atherosclerosis. Its chromosomal aberrations in leukocytes. Renal
role as a glucose tolerance factor is undeniable. syndrome-proteinuria, haematuria, anuria and in-
Chromium has a locally irritating and sensitizing creased content of residual-nitrogen fractions in
effect on the skin and mucous membranes. Its aller- blood serum.
gic effect on the skin is mainly due to the reduction of Determination of chromium in erythrocytes
chromium (VI) to chromium (III) and the formation of (standard values up ​​ to 1.0 μg/l) and urine (standard
protein complexes with antigenic properties provoking values up​​ to 4-5 μg/l) is used as an exposure test.
the appearance of antibodies to chromium. Differential diagnosis. Acute poisoning with
His carcinogenic effect is well known. chromium is distinguished from other acute poison-
Clinical picture. The severity of the clinical ings caused by mercury, cadmium, zinc, beryllium,
course of poisoning is mainly determined by the manganese, acids, bases, nitrous gases and others.
intensity of exposure and the manner in which the Chronic poisoning requires a differential diagnosis
toxic substance is present in the body. with unprofessional diseases of the respiratory and
Acute inhalation poisoning involves symptoms urinary systems, liver, skin and mucosal diseases.
of tracheobronchitis, bronchopneumoniae -pains Treatment. In acute poisoning, procedures are
behind the sternum, shortness of breath, cough, and performed to stop poisoning in the body (skin and
in severe cases - development of pulmonary edema. mucous membranes with aqueous sodium bicarbo-
Acute oral poisoning - leading to symptoms nate, gastric lavage with water and medicinal char-
of the gastrointestinal tract - persistent vomiting, coal). Corticosteroids, dialysis procedures and the
severe colic pain, profuse diarrhea and subsequent like are administered as indicated. A good effect is
dehydration, hypovolaemia and acute heart failure. seen when using CaNa2EDTA and D-penicillamine.
Later symptoms of toxic nephropathy and acute re- The treatment of chronic poisoning includes mu-
nal failure were observed. It is also possible to diag- cosal protectors, vitamin therapy, general strength-
nose heterologus rate of hepatorenal syndrome. ening and other symptomatic remedies.
Chronic poisoning. Chronic chromium poison- Labour expertise. Acute poisoning with chromi-
ing is characterized by irritative changes in the upper um is most often associated with temporary loss of
respiratory tract and the lung, atrophic rhinitis, phar- working capacity. In severe poisoning, the progno-
yngitis, tracheitis, chronic bronchitis, pulmonary sis is a serious-possible lethal outcome. Chronic poi-
emphysema, bronchial asthma, pneumocosclerosis. soning can cause temporary disability, and irrevers-
The carcinogenic effect of chromium is predomi- ible damage to the respiratory system, liver, kidneys
nantly directed towards the lungs, nasal cavity and - permanent impairment of working capacity.
sinuses. The shortest exposure to lung carcinoma is Prevention. Sanitary and technical prophylaxis
over 8 years and the incidence increases in 20 years. - sealing, effective ventilation (general and local -
Proven carcinogenicity has zinc chromate, calcium above metal and leather chrome plated baths), use

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of individual protective equipment (special working nia, allergic obstructive syndrome. Recently, cases
clothes, gloves, etc.). similar to the clinical picture of exogenous allergic
Medical prophylaxis - Preliminary medical exam- alveolitis have been described. The cardiotoxic ef-
inations upon entry into employment. Do not work fect of cobalt is well known - the so-called "cobalt
in contact with chrome, people with respiratory, myocardiopathy" with development of dystrophic
digestive and urinary system diseases, with liver, (metabolic and ischemic) processes in myocardium
skin and mucous membranes diseases. Mandatory and hypotension. Gastrointestinal syndrome is man-
periodic medical examinations are conducted once ifested by lack of appetite, development of chronic
every 12 months with the participation of a thera- gastritis, ulcerative stomach disease, etc. Disorders
pist, an otorhinolaryngologist, and as evidenced- of the endocrine system are most often thyroid-re-
dermatologist, ophthalmologist and dentist. lated. Its structure and function is impaired as a re-
sult of troubled oxidation processes and thyroxin
3.1.6. COBALT - J. HADJIEVA synthesis. Skin manifestations include hyperkerato-
sis, skin ulceration mainly in the exposed parts of the
The cobalt is hard, hardly melting gray-white metal. body, allergic dermatitis and eczema. It is believed
Dissolves in dilute sulfuric and nitric acids. that the development of the so-called "cement ec-
Usage. Cobalt and its compounds are widely used zema" is mainly due to the mutual action of cobalt
in the ceramic and glass industry. They are used as cat- and chromium. The carcinogenic effect of cobalt is
alysts in some chemical processes (ammonia oxida- debatable. His immune embryotoxicity was studied
tion, nitric acid production, etc.), in the pharmaceutical primarily under experimental conditions.
industry and metallurgy in the production of special Clinical-laboratory tests. Hematological pa-
alloys. Cobalt alloys are used in the production of fer- rameters - polycythemia (increased red blood cell,
romagnets, in jet engines and others. reticulocytes, eosinophilia, basophilia), increased
Biotransformation. Cobalt falls into the body by hemoglobin and low serum iron, prothrombin time
the respiratory and digestive tract. It comes in all soft prolonged. Clinico-chemical indicators - total lipid,
tissues. Higher levels are found in the liver, lung, thy- beta-lipoprotein, cholesterol and triglycerides as
roid, adrenal glands and kidneys. Relatively lower is well as total protein and a1 and a2 - globulin frac-
its content in skeletal muscles, heart, spleen, pancre- tions are increased. Toxic-chemical indicator - deter-
as, brain. Inorganic cobalt is eliminated primarily (up mination of cobalt in whole blood (standard values​​
to 80%) with the faeces unresorbed. Resorbed metal is up to 0.5 μg/l).
excreted in the urine, less with bile, sweat and in hair. Differential diagnosis. Chronic poisoning with
Pathogenesis. As an essential oligoelement, co- cobalt imposes a differential diagnosis with unpro-
balt activates a number of enzymes regulating tissue fessional diseases of the respiratory, cardiovascular,
respiration and hematopoietic system. In elevated ex- digestive and endocrine systems, with skin diseases,
posure, it exhibits toxic effects: etc.
• disturbs tissue breathing (inhibits the activity of Treatment. Acute poisoning that occurs as a
oxidative-reducing enzymes - cytochrome oxi- result of entry through the gastrointestinal tract
dase, succine dehydrogenase, catalase, etc.); requires immediate washing of the stomach with
• allergies (allergic dermatitis, eczema, bronchial water and medical charcoal, The shock condition
asthma, etc.); requires the inclusion of antidote (dimercaprole,
• cardiotoxic, immune and embryotoxic effects. CaNa2EDTA, unitiol), anti-collapses, etc. In case of
Clinical picture. Acute intoxications - occur chronic poisoning, general supportive symptomatic
very rarely. Cobalt's inhalation in the body causes therapy is used.
a tingling cough, tightness and chest pain, short- Labour expertise. Acute intoxications are most
ness of breath, convulsions, hyperthermia, collapse. often associated with temporary loss of ability to
When the site of entry is the gastrointestinal tract, work. Chronic poisoning with marked symptoms by
nausea, vomiting, epigastric pain, etc. are observed. the respiratory and cardiovascular systems necessi-
In severe cases of poisoning, lethal outcome is not tates permanent rehabilitation without contact with
excluded. toxic substances and, in some cases, identification of
Chronic poisoning. Under production condi- a disability group.
tions only chronic poisoning occurs. On the back- Prevention. Sanitary-technical prophylaxis - au-
ground of the general toxic effect of the cobalt, tomation and sealing of production processes, use
there are disorders of the respiratory system - de- of personal protective equipment, personal hy-
velopment of chronic rhinitis, laryngitis, pharyngi- giene, etc.
tis, chronic bronchitis, chronic interstitial pneumo- Medical prophylaxis-mandatory medical exami-

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nation of incoming persons. Do not work in contact normal biosynthesis of porphyrins by altering the bi-
with cobalt and its compounds, persons with diseas- oactivity of enzymes, which carry out the synthesis of
es of the respiratory, cardiovascular, digestive and delta-aminolevulinic acid (DALA) from succinic CoA
endocrine systems and diseases of the skin. Periodic and glycine, and significantly more those participat-
medical examinations are performed once every 12 ing in the synthesis of the porphobillinogen. This leads
months with the participation of a therapist and an to increased accumulation in the blood and secretion
indication of a dermatologist. Protective profession- of DALA, uroporphyrinogen III, coproporphyrin III and
al nutrition - diet "D" is recommended. protoporphyrinogen IX. The other vulnerable level is
disturbed heterologous synthesis of protoporphyrin IX
3.1.7. LEAD and the blockade of the co-dehydrazes I and II involved
D. CHARAKCHIEV, ST. ANDONOVA in the inclusion of iron in the porphyrin ring and the
formation of hemoglobin. As a result of these disor-
Professional exposure to lead and its compounds ders, anemia with the development of compensatory
poses a significant risk to the health of workers from reticulocytosis (lead found to have not only a blocking
non-ferrous metallurgy, production of tetraethyl-lead, effect on the enzymes involved in porphyrin synthesis,
industrial and artistic ceramics, battery production, but at some stages induce them - with less exposure).
the production of lead minium and lead glass, polyg- Lead has a direct toxic effect on red blood cells.
raphy, plastics production, etc. It is also one of the most - Disturbance by nerve structures - an expression
important contemporary environmental pollutants. of direct damage to the vegetative and central brain
Biotransformation. Occupational exposure oc- sections, and the increased amount of porphyrins
curs mainly by the airway and less amount of digestive and their potential vasoconstriction. Surexcitation of
tract. Organic compounds of lead enter the skin. Re- the vegetative nerve structures determines lead colic,
absorbed lead is associated with hemoglobin and low atonic manifestations of the digestive system, vasos-
molecular weight erythrocyte proteins, less with plas- pasm of the vessels and elevation of blood pressure.
ma albumin and gammaglobulin, or circulating as free - Liver disorders - lead directly damages hepato-
ions. About 90% of lead accumulates in bones such as cytes, resulting in changes in the detoxic, protein, en-
tribasic lead phosphate, and the remaining amounts zyme, pigmentary and carbohydrate functions of the
are deposited in the liver, kidneys, brain structures, liver.
muscles, skin, hair, teeth, etc. Lead passes blood-brain Diffuse degenerative changes are observed in nerve
and placental barriers as its concentration in the blood cells of the central brain structures, anterior horns of
of the fetus is close to that of the mother. It is inactive the spinal cord and peripheral nerve stems, hepato-
in the bone depots, but in various conditions that alter cytes, etc.
the alkaline-acid balance such as infections, alcochol Clinical picture: Acute poisoning due to occu-
excesses, the reception of certain drugs (barbiturates, pational exposure is rare. It can have a way of living
sulfonamides) and foods lead to its release and clinical character. It is characterized by the appearance of
manifestation of intoxication. hypersalivation, epigastric pain, enterocolitis, or the
Elimination of lead from the body to 80% occurs development of typical "lead colic". Simultaneously
in the urine, up to 15% through bile and faeces, and with this symptom, anemia with hemolysis, signs of
the remaining amount with sweat, saliva, mammary toxic hepatitis, nephropathy, neurological manifes-
glands, dropping corneous layers, hair, nails, etc. tations, polyneuritis is rapidly developing. Arterial
The half-life of lead from the whole body at inter- pressure is increased. In the first hours there is anx-
ruption of exposure is about 5 years, and bones and iety, headaches that can pass into somnolentia and
teeth more than 20 years. As safe levels of lead in blood, coma with severe cardiovascular failure. After acute
so-called plumbemia in professionaly exposed recom- acute intoxications with lead, residual albuminuria,
mended to 400 μg/l, (for unexposed adults - about 150 astenovegetative events and encephalopathy may
μg/l and for children - around 100 μg/l, and for certain occur.
industries and environmentally polluted areas these Chronic lead intoxication. The following syn-
levels are specifically assessed). dromes are identified:
Pathogenesis. Lead in its toxicological character- Lead facies, which is observed in heavy lead in-
istics refers to the so-called thiolic poisons due to its toxications and characterized by a grayish-pale,
ability to block sulfhydryl groups and other free radi- earth-like colour of the face that disappears with
cals predominantly of enzyme structures, leading to improvement of the condition. Symptoms of profes-
disruption of metabolic processes and functions at dif- sional plumbism in the oral cavity are lead spots or
ferent levels: strips of grayish brown on the front gingiva rib, and
- Porphyrin metabolism disorders - lead blocks a more often sweet-metal taste, anemia of the lips

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and gingiva, violet tinge of cheeks and tongue, and lead poisoning, preclinical conditions of "lead car-
slowly progressing dystrophic paradontopathy. rier" have been introduced in Bulgaria - low-grade
Neurological syndrome - asthenovegetative plumbemia, plumburia, elevated urinary DALA val-
manifestations as an early sign of lead intoxication: ues ​​with possible lead stripes or spots and no com-
vegetative polyneuropathy and encephalopolineur- plaints from the exposed persons.
ial syndrome as an expression of severe lead intoxi- Clinical-laboratory tests: Contemporary early
cation. diagnosis and prophylaxis of poisoning is based on
Gastrointestinal syndrome - with a number of the determination of the amount of lead in biolog-
disorders in the gastrointestinal tract, the most com- ical substrates - blood, urine, saliva, hair, etc. Lead
mon is lead-colic - colic pain in the abdomen, around in blood at values ​​above 400 μg/l or above 2,889
the navel of varying intensity and duration and of- mmol/l for professionally exposed individuals are
ten occurs with persistent constipation. It is accom- significant for treatment (as well as the amount of
panied by increased blood pressure and bradycardia lead in the urine above 0.531 mmol/l).
(it is necessary to differentiate from "sharp surgical Other important laboratory findings are urinary
abdomen" here abdomen is soft). DALA elevations, urinary uro- and coproporphyrin
Anemic syndrome - characterized by a decrease increased, increased free erythrocyte porphyrins,
in hemoglobin and a reduction in erythrocyte decreased hemoglobin and erythrocyte count, retic-
counts, reticulocytosis and a sporadic increase in sti- ulocytosis of more than 15 ‰ and stipling erythro-
pling erythrocytes in peripheral blood. cytes of more than 0.5 ‰ in peripheral blood. Only
Hepatic syndrome - with laboratory abnormali- the single analysis is not informative enough. It is
ties in liver function in mild intoxications (elevation also necessary to conduct the so-called provocative
of serum transaminases, LDH, decrease in ChEA), test with CaNa2EDTA, after which the amount of lead
blockage of hepatic glycogen synthesis with in- in the urine reflects its mobilization from the depot.
creased glycogenokinase, disorders of bile pigment Differential diagnosis. Chronic intoxications
metabolism, damage to protein synthesis with man- with other heavy metals, anemic syndromes, hep-
ifestations of hypoproteinaemia, hyperglobulinemia atitis, various types of hereditary and symptomatic
and others. Subjective evidence of impaired appe- porphyria, porphyrinuria, etc.
tite, weight in the right hypochondrium, constipa- Treatment. The effect of treatment with
tion. In the more severe forms of intoxication, toxic CaNa2EDTA is best - amp. 10% 10 cm3. Apply intra-
hepatitis is observed. Subacute icterus or jaundice venously in glucose-salt solutions one ampoule for
and significant abnormal liver function may occur. three consecutive days, followed by three days of
Kidney damage is possible, but is less common. rest, a total of 9-10 ampoules per treatment course
Changes are observed by the visual analyzer, the (other regimens are also applicable).
cardiovascular system, the endocrine organs. For oral treatment, Penicillamine (Couprenil) can
Chronic lead poisoning has been observed: Lead be used, tabl. 250 and 150mg, 0.5 to 1g daily for 7-10
poisoning to a slight degree with asthenous-vege- days.
tative manifestations, gastrointestinal with hypo- Pectin and pectin products have a good prophy-
and anaciditis, hypotonia. Mild disturbances in liver lactic and healing effect at doses of 5-10% pectin
detoxification. Clinically and laboratorically there 100 g for 15-20 days. Balneotherapy with waters
is evidence of pronounced plumbaemia, increased containing hydrogen sulphide is recommended.
amounts of DALA in blood and urine, reticulocytosis, Lead carriers need to conduct a provocative test
mild anemia. At this stage, an increased incidence of with CaNa2EDTA or Penicillamine, and follow the
spontaneous abortions, reduced female reproduc- plumb-aemia and plumburia.
tive capacity and impaired spermatogenesis in men Occupational-medical expertise: In case of
may occur. mild toxicity, after normalization of all laboratory
Moderate severe stage - with lead colic, anemia, parameters, subjective and objective changes, af-
toxic hepatitis and vegetative polyneuropathy. Lab- ter balneotherapy usually the working capacity is
oratory characteristics typical of lead poisoning are restored. It is necessary, after medium-heavy intox-
significant. ications or recurrent minor, to work towards profes-
Severe stage - with serious neurological symp- sions without toxic effects.
toms such as toxic polyneuritis, encephalopathy, Prevention. Contraindications to work with lead
lead meningitis, toxic epilepsy, spinal hemiparesis, are liver, kidney, anemic, hypertonic, ulcer, nervous
etc. With good modern industrial technologies and system, and other diseases. The current prophylactic
prophylaxis, this stage is not observed. With regard review is important at 3, 6 and 12 months, depend-
to the early diagnosis and prophylaxis of industrial ing on the nature of the production and the occu-

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pational risk. Women of fertile age are not allowed ganese on hematopoiesis. Diagnosis of manganism
to work. at this stage is difficult because neurological symp-
toms are extremely unspecific and usually go under
3.1.8. MANGANESE - V. PETKOVA the mask of neurosis, hypodepressive states, etc.
Second stage. At this stage, these symptoms be-
Manganese belongs to the heavy metal group. Hy- come more demonstrative and lasting. Drowsiness,
giene significance has its oxides, manganese sulphate emotional lability, gait uncertainty, speech disorders
and some organic metal compounds (dithiocarba- and muscle tone - precursors to parkinsonism. At the
mates) that are used as pesticides. same time, clinical and EMG data for vegetosensorial
Possibilities of manganese poisoning exist in the manganese polyneuropathy can be established.
production and processing of manganese-containing Third stage. Against the background of the
ores (pyrolysite, manganite, housmanite, etc.) in met- preceding symptoms, the typical manganism symp-
allurgy, using pyrolysis to produce hydroquinones, po- toms of parkinsonism and amnestic-intellectual dis-
tassium permanganate and colored glass. High man- orders are outlined.
ganese exposure to ferro-alloys for high quality steel. Laboratory diagnostics. The determination of
Poisoning was also observed in arc welders using man- manganese in blood and urine is not particularly
ganese electrodes. Risk exists also in the production of relevant to diagnosis - these indicators are used as
dry alkaline batteries. The replacement of lead tetrae- biological exposure indicators. For the early diag-
thyl with methylcyclopentadienyl-manganese-tricar- nosis of chronic manganese poisoning, psycholog-
bonyl (MMT) in unleaded petrol creates prerequisites ical tests, as well as a relatively specific electromy-
for exposure to the population as well. ographic study, which establishes lower bioelectric
Routes of intake, biotransformation and dis- activity for the lower limbs, a positive strain of reflex
tribution in the body. Manganese resp. the oxides of that demonstrates increased muscle tone in earlier
it enter the airways, the gastrointestinal tract and its stages before Parkinson's syndrome develops.
organic compounds through the skin. In a short time, Differential diagnosis. Diagnostic considera-
it circulates in the blood associated with ß1 globulin, tions include cerebrasthenia and depression of an-
spreading and depositing into the brain, liver, kidneys, other nature, Wilson's disease, Parkinson's disease.
intestines, muscles, pancreas. The access of manga- Especially responsible is the motivation of manga-
nese to the brain except through the haematoence- nese parkinsonian syndrome. It should take into
phalic barrier occurs directly through the olfactory account young age, proven occupational exposure
pathways. The main route to eliminating manganese and exclusion from cranio-cerebral trauma and en-
is through bile and intestines with faeces. Separation cephalitis. In Parkinson's disease the tremor is more
through the kidneys is negligible. rough and almost constant. In acute poisoning a
Toxic effect. The toxicity of manganese is partly differential diagnosis with bronchopneumonia and
related to its involvement in metalprotein complexes poisoning with beryllium, antimony, chromium,
of some enzymes controlling the oxidation processes cadmium.
in mitochondriases, and its property also in enzyme Treatment. With curative but also for diagnostic
inhibition pathways to disturb dopamine metabolism. purposes chelation therapy with Ca2Na2EDTA - 10% -
Classical is the affinity of manganese to basal ganglia 10 cm3 - 1 amp. daily in three consecutive days, with
- n. caudatus, gl. pallidus, corpus striatum, which de- a two-fold repetition of the course at three-day in-
termines its neurotoxicity. tervals. In cases of severe manganism, antidote ther-
Clinical picture. apy has no effect and therapy is extremely sympto-
Acute poisoning. Acute intoxications are rare, matic. Symptomatically is treatment of neurasthenic
incidental and occur with conjunctivitis and upper conditions and parkinsonian syndrome. Modern
respiratory tract irritation, and in more severe cases manganese therapy also includes high doses of vi-
with manganese pneumonia - fever, cough, dyspnea tamin E.
to acute respiratory failure with tachypnea and cya- Prognosis and labour-medical expertise. In
nosis. the early stages of treatment and timely cessation
Chronic poisoning. They develop in three stag- of professional contact with manganese, regression
es. of clinical symptoms can be achieved. Diagnosis of
Initial stage. It runs with neurozosomal symp- chronic manganese intoxication, irrespective of its
tomatology, with predominantly hypotensive forms stage, is indicative of discontinuation of noxa contact
- headaches, easy fatigue, apathy, mood swings, and permanent rehabilitation or disability grouping.
and vasovagal dysfunction of the vagotonic type. Clinical symptoms of parkinsonism may also occur
It is possible to have the stimulating effect of man- after discontinuation of manganese exposure as an

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expression of the late evolution of poisoning. intoxications.
The long-term professional impact of manga- Upon orall ingestion of mercury compounds,
nese also leads to a decrease in the body's natural syndromes are:
immune-biologic resistance and to frequent inflam- - gastrointestinal syndrome that is manifested
matory-infectious diseases of the respiratory organs for a short period of ingestion with abundant saliva-
(pneumonia and bronchitis). tion, epigastric pain, abundant vomiting, profuse di-
Prevention. Medical prophylaxis includes pre- arrhea. Ulcer-haemorrhagic stomatitis and gingivitis
liminary medical examinations aimed at preventing appear in the oral cavity. Severe acute intoxications
contact with manganese in persons with organic result in marked dehydration of the body with hypo-
and pronounced functional CNS diseases, chronic volaemia, collapse and shock.
hepatitis, chronic respiratory diseases, anemia. In - kidney syndrome - diuresis decreases from a
periodic reviews, besides mandatory manganese few hours to two days, albuminuria occurs and acute
determination in biological media, a neurologist is renal failure outset for a short time.
required. Acute poisoning can also occur through the skin
Healing- prophylactic nutrition recommended: when applying mercury-containing ointments or in
Diet B - acidic and pectin-enriched foods and bev- contact with organic-mercury compounds. Allergic
erages that have a mild antidote effect. Vitamino- reactions may also occur.
prophylaxis. Chronic intoxication with mercury is character-
ized by:
3.1.9. MERCURY - ST. ANDONOVA - ​​neurological syndrome with astenovegetative
symptoms, tremor, abnormal handwriting, tachycar-
Mercury is the only liquid metal and evaporates dia, hypertension, angina pectoris, etc.
at 0 ° C, with its vapors seven times heavier than air. - Symptoms from the digestive system such as
Mercury exists in an elemental state and then the risk metallic taste in the mouth, abundant salivation,
of intoxication is its vapor. Toxic are its compounds in teasing of the teeth, mercury strip, loss of appetite,
which it is found in first and second valence (mercuro- diarrhea alternating with constipation.
compounds and mercury-compounds) such as cinna- - kidney syndrome. Inorganic mercury com-
bar, (mercury sulfide), mercury oxide (yellow and red), pounds primarily cause tubular lesions with the
mercuric chloride (sublimate), mercury cyanide, etc. development of mild functional disorders to severe
Mercury forms with other metals such as gold, silver, toxic nephropathies. Organic compounds lead to fo-
zinc, lead, tin alloys, so-called amalgams. There are cal extra- or intracapillary glomerulonephritis with
also organic compounds of mercury. It is used in the moderate tubular damage.
pharmaceutical industry, non-ferrous metallurgy, in- In case of severe chronic poisoning, anemia is ob-
strumentation, dentistry, paper industry, electronics, served. In contact with mercury compounds, chron-
military industry and others. ic dermatitis and eczema are observed.
Biotransformation. The pathways of penetration The diagnosis is based on the history of inha-
are respiratory, digestive and skin. Mercury is a potent lation of mercury vapors or the intake of mercury
inhibitor of enzymes with affinity for free radicals and, compounds, the level of mercury in the blood and
most importantly, sulfhydryl groups. It leads to morpho- urine. Differential diagnosis of poisoning with beryl-
logical changes of the endoplasmic reticulum in hepat- lium, arsenic, cadmium, manganese, ethylene gly-
ocyte, reduces the cytochrome P-450 and OMF levels col and somatic diseases, occurring with the above
and inactivates a number of enzymes in the proximal re- mentioned syndromes.
nal channels. Elimination is mainly through the kidneys. Antidote treatment with Dimercaptol (amp; 100
Clinical picture. Acute poisoning occurs when mg/ml), Unithiol (amp. 25 mg/ml), 1 mg per 10 kg
inhalation of mercury vapor or oral intake of its salts strictly intramuscularly! For acute poisoning, the
(mercuric chloride and cyanide mercury are most dose is administered one to two days, 4-6 hours,
toxic). Breathing in the airway is caused by: depending on the severity of the intoxication, with
- pulmonary syndrome characterized by cough, decreasing doses over the next few days. Vit C and
chest pain, shortness of breath, sometimes toxopul- group B vitamins are applied. Adequate water-salt
monite and less frequent pulmonary edema and fe- resuscitation. Gastrointestinal depuration. Organo-
ver. Complications - pneumothorax, subcutaneous protective therapy. In renal failure - dialysis methods.
emphysema, progressive pneumofibrosis, bronchi- In chronic intoxications, the antidote is administered
ectasis; once for 7 days in controlling the level of mercury in
- neurological syndrome with headache, par- the blood and urine.
aesthesia, tremor, and polyneuritis at more severe

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3.1.10. NICKEL - J. HADJIEVA Nervous system disorders are predominantly athe-
no-vegetative (headache, easy fatigue, vertigo, ar-
Nickel is a silver-white metal with a characteristic terial hypertension). In some cases, organic nervous
luster, malleable and plastic. It is easily melted, dis- system, at hearing and visual analyzers are also ob-
solved in dilute nitric acid. It reacts easily with halo- served. Kidney damage due to high exposure to its
gens, sulfur, phosphorus, arsenic, antimony and others. dissolved compounds.
Usage. Nickel is mainly used to produce alloys with Nickel and its compounds, especially nickel car-
other metals having high mechanical, anticorrosive, bonyl, nickel oxide and sulfide, have a carcinogenic
magnetic, electrical and thermoelectric properties. It is effect especially on the respiratory system (carcino-
used in the production of alkaline batteries, for chemi- ma of the lungs, nose and paranasal cavities).
cal apparatus, catalysts, in the reactive technique and Clinical-laboratory tests. Haematological indi-
construction of nuclear reactors, etc. cators - moderate leucocytosis with lympho- and
Biotransformation. Nickel and its compounds fall monocytosis, rarely leucopenia and rapid transient
into the body mainly via the respiratory tract and nick- reticulocytosis. Clinical and chemical indicators -
el carbonyl through the skin. Nickel is found in the liver, mostly hyperenzymemy of ASAT, ALAT, GGTP and
spleen, kidneys, and nickel carbonyl - and in the lungs, others. Increased carboxyhemoglobin due to partial
the brain, the heart, and the cortices of the adrenal decay of nickel carbonyl with CO release.
glands. It is possible to pass it through the placenta. The content of nickel in the urine is used as an
It is eliminated by the kidneys and intestines. Nick- exposure test (standard values ​​0.1 - 2.5 μg/l).
el carbonyl is also excreted with the exhaled air. Differential diagnosis. In acute poisoning a
Pathogenesis. The pathogenetic mechanism of differential diagnosis with acute poisoning of car-
the toxic action of nickel has not been fully studied. It bon monoxide, nitrogen oxides, with "metal fever"
is also a supposed essential microelement. The toxic- caused by zinc, copper, manganese and others. In
ity of the compounds varies considerably depending the case of chronic poisoning, professional lesions
on their solubility. Nickel has a local irritant effect on of the lungs, liver, skin.
the skin and mucous membranes. It has the qualities Treatment. In acute poisoning a complex of
of an allergen and an enzyme effector-suppressing the therapeutic procedures (respiratory resuscitation,
enzyme activity (arginase, carboxylase, etc.). His car- glucocorticoids, calcium preparations, diuretics) are
cinogenic effect is unresolved. His teratogenic effect is administered. In indications - infusions of glucose
discussed. and water-salt solutions. Dimercaprole is used as
Clinical picture. Poisoning with nickel is acute an antidote. The treatment of chronic poisoning is a
and chronic. Under production conditions, acute symptomatic and general strengthening organism.
poisoning is predominantly with nickel carbonyl. Labour expertise. Acute poisoning usually caus-
Slightly acute poisoning - resembles that of es temporary disability, and chronic - permanent
foundry fume fever. Exfoliation, dry cough, chest de- limitation of working capacity to work in contact
pression, chills, increased body temperature to 38- with toxic substances.
40 ° C, flushing, hyperemic mucus, full sweating, fol- Prevention. Sanitary-technical prophylaxis and
lowed by a fall in temperature appear several hours medical surveillance of exposed persons. Do not
after exposure (1 to 5 hours). It is possible that the work in contact with nickel persons with respiratory
fever syndrome will recur after 1-3 or more days. and nervous system diseases, liver, kidney and skin
Severe acute poisoning - resembles the clinical diseases.
picture of carbon monoxide poisoning and occurs Periodic medical examinations are performed
with adynamics, headache, apathy, disorientation, once every 12 months with the participation of a
loss of consciousness, clonic-tonic convulsions, de- therapist, an otorhinolaryngologist, and at indica-
lirium, hyperthermia, Cheyne-Stokes` breathing, tions-dermatologist.
coma. Injuries from other organs and systems most
often result in the development of pneumonia, pul- 3.1.11. PHOSPHORUS - T. KUNEVA
monary edema, varying liver changes, and the like.
Chronic poisoning. Characterized by chronic ir- - Jaw necrosis
ritative changes in the upper respiratory tract. Sub- - UAP irritation
atrophic and atrophic rhinitis, pharyngitis, sinusitis, - Skin burns
nasal bleeding and perforation of the nasal septum - Liver and kidney damage
are observed. Nickel and its compounds have a sen- Phosphorus is an essential microelement for the
sitizing effect on the skin and mucous membranes human body. Phosphorus does not occur naturally in
(allergic dermatitis, eczema, bronchial asthma). the free state, but only in the form of compounds, the

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largest amount being contained in the mineral apatite. ing, strong thirst, dry cough, tingling in the chest,
There are two allotropic forms: white (yellow) and red shortness of breath. Neurological symptoms include
phosphorus. ataxia, paraesthesias, tremor, diplopia. Death can
White phosphorus is highly toxic and chemically become by cardiovascular collapse or respiratory
very active. It is used for the production of red phos- failure.
phorus and phosphorus compounds, in explosives, In contact with phosphorus compounds on the
fireworks, smoke bombs, for making semiconductors, skin, severe burns occur, most often II and III degree,
is alloyed. Phosphoric acid is used in the production of with ulcerative defects healing very slowly and hard.
superphosphate fertilizers. Red phosphorus is many Chronic poisoning. For initial symptoms of
sub- toxic because of its water insolubility. It is used for chronic poisoning, dyspeptic disorders in the form
matchmaking, metallurgy and agriculture. of gastroenteritis are accepted. Typical are the
Prolonged professional exposure to phosphorus bleeding with the smell of garlic, nausea, vomiting,
compounds exposed workers in the production of ex- abdominal pain, sometimes diarrhea. Gradually,
plosives, matches, phosphorous fertilizers, phosphorus anemia, subicterus, mucosal hemorrhage, toxic hep-
compounds, semiconductors. Unprofessional poison- atitis and nephritis develop.
ing can occur with accidental or deliberate absorption In long-term exposure, changes in the bone sys-
of phosphorus compounds. tem are most characteristic. Typical are the necroses
Absorption, metabolism, excretion. Phosphorus in the upper and lower jaw. Carious teeth facilitate
compounds penetrate the body mainly through the the action of phosphorus on the jaws - complaints of
digestive tract, less frequently through the respirato- toothache, followed by inflammation of the gingiva,
ry system, skin and mucous membranes. In the body, early shaking and falling of the teeth, periostitis, ne-
most of them metabolize and are eliminated in a sig- crosis of the bone with stinging. There is a gray-yel-
nificant amount through the kidneys as salts of phos- low or brown stripe on the front teeth. Spontaneous
phoric acid. fractures of long bones due to decalcification are
In the liver, phosphorus binds to proteins and dis- rare.
rupts the functions of a number of enzyme systems Long-term exposure to phosphorus dust caus-
that regulate oxidation processes in cells of the central es chronic rhinitis, laryngitis, bronchitis, sometimes
nervous system, liver, kidneys, damages metabolism - pneumonia, and obstructive pulmonary disease.
especially carbohydrates by blocking phosphorylation. Laboratory researches. Acute poisoning has
Chronic exposure to phosphorus causes sub-epiphy- been reported to increase liver enzyme activity,
seal bone formation with vascular disorders leading to hyperbilirubinaemia, leucopenia, haematuria, pro-
bone necrosis. teinuria. After acute intoxication, arterial hypoxemia
Clinical picture. may develop.
Acute poisoning. One to two hours after inges- In a functional breathing study, obstruction or
tion of phosphorus compounds, the first symptoms mixed type ventilator failure occurs. X-ray shows
of the digestive tract appear - nausea, vomiting, stom- pneumonia, pulmonary edema, jaw necrosis.
ach ache, diarrhea. Phosphorescence of the vomited Differential diagnosis is made with acute poi-
matters and stools is characteristic. Hepato-renal soning with phalloides fungi, in chronic poisoning
disorders - hepatomegaly, jaundice, oliguria, uremia, - with tetrachloromethane and arsenic preparations.
haemorrhagic diathesis develop several days later. Treatment. There is no specific antidote. Upon
Hypocalcaemia may develop, leading to tingling of oral ingestion - gastric lavage with water and potas-
the extremities, paresis, tetany, trizmus, in the most sium permanganate, it may be with a 2% solution
severe cases - cardiac arrhythmia and coma. of copper sulphate. Following lavage, saline purifi-
Over acute forms of intoxication are known, end- cation (magnesium or sodium sulphate); 100 ml liq-
ing lethally for several hours and showing a severe uid paraffin; 15 ml of 1% copper sulphate solution
jaundice, convulsions, delirium, coma. is applied sequentially; several times a day sodium
Inhalation of dust from phosphorus compounds bicarbonate. Depending on the haemodynamic pa-
can cause bronchospasm with cough, tightness in rameters, intravenous drip infusion of glucose and
the chest, shortness of breath, dry wheezing. Local water-salt solutions is included: vitamin B1 and C.
tissue necrosis is the cause of haemoptoea. In some Hepatoprotective treatment is performed with 10%
cases, there is a chemical pneumonia with respira- 500 ml of levulosis. Antibiotics are included to pre-
tory failure undergoing at pulmonary edema and vent bacterial infection. Upon developing hypocal-
cardiac arrhythmia. caemia, 10% 10 ml of calcium gluconate is adminis-
Inhalation of phosphine causes headaches, diz- tered intravenously. In the case of skin and eye burns
ziness, tinnitus, fatigue, weakness, nausea, vomit- - thoroughly washing with water. In case of severe

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burns, the skin is smeared with a 3% solution of cop- ceramics, glass, rubber, and plastics. In agriculture, us-
per sulfate to neutralize the action of phosphorus. ing sodium selenite (Na2SeO3) as a pesticide.
Prognosis. In severe acute poisonings, the mor- Pathogenesis. Selenium is an essential microele-
tality rate is high. In all cases of acute intoxication, ment. Its toxic effect is related to its ability to block sulf-
treatment is prolonged. Organic injuries following hydryl groups of many enzymes and sulfur-containing
chronic poisoning (hepatitis, nephritis, bronchitis, amino acids and is expressed in a disorder of the func-
bone damage) require discontinuation of contact tional state of the CNS, the liver, etc.
with toxic substances and may cause a disability Absorption, metabolism, excretion. Selenium
group. enters the body via the respiratory tract, the gastroin-
Medical prophylaxis. Contraindications to work testinal tract and the skin. In blood, selenium is mainly
with phosphorus compounds include tooth and jaw found in the plasma associated with α2 and β1 - glob-
diseases, chronic diseases of bone, UAP, lungs, liver, ulin fractions and the free amino acids - cysteine, me-
organic CNS diseases, blood and metabolism diseas- thionine and leucine. Selenium penetrates into eryth-
es. rocytes, with about three times as high in serum. The
Workers engaged in the production of white biotransformation of selenium is accomplished by the
and red phosphorus are subject to periodic med- reduction, methylation and binding processes or direct
ical examinations every 6 months, and those from incorporation into proteins. The tissue distribution of
all other industries using phosphorus, phospho- Se shows maximum kidney and liver levels, followed by
rus compounds, superphosphate fertilizers - once those in the retina, spleen, lungs, myocardium, skeletal
a year. Prophylactic examinations are performed muscles, brain and hair. Selenium is mainly emitted in
by an internist and a dentist, also by a neurologist, the urine (30-50%), sweat, faeces, hair and exhaled air.
an otorhinolaryngologist and an ophthalmologist. Clinical picture.
Paraclinic studies include: complete blood count, Acute poisoning is rare. Inhalation of selenium
general urine and calcium urine test; at indications vapors, SeO2, H2Se, selenium hexafluoride and sele-
to the radiographs of the bones. It is recommended noxyl chloride causes irritation of the upper respira-
that diet D of the professional protective nutrition. tory tract and eye lining, dry cough, chest pain and
pressure, general weakness, headache, dizziness,
3.1.12 SELENIUM - S. PAVLOVA unpleasant taste in the mouth, Nausea, vomiting,
smell of garlic in the exhaled air, and sometimes con-
Acute poisoning vulsions. In some cases, there is pulmonary edema,
• irritation of upper respiratory tract mucosa enlargement and soreness of the liver and spleen. In
and inflammation of the skin contact with skin selenium compounds cause slow
• burning of the skin healing burns, as well as dermatitis.
Chronic poisoning Chronic poisoning. Respiratory organs are af-
• fatigue, lassitude fected - dry cough, rhino-pharyngitis, bronchitis, is
• gastrointestinal complaints observed. Exhaled air and sweat are smell of garlic,
• smell of garlic of exhaled air and sweat and pale pinkish-yellow spots appear on the mu-
• dermatitis, paronychia, alopecia cous membranes of the gums and the palate. Typical
• conjunctivitis are injuries of skin and skin - adjuncts - nail disorder,
Selenium (Se, atomic weight - 78, 96) occurs dental enamel changes, reddish skin coloring, hair
in several allotropic forms, most important of which discoloration and alopecia. Gastrointestinal disor-
are red amorphous and gray metallic selenium. Sel- ders (nausea, vomiting, metallic taste in the mouth),
en is less toxic than its compounds - selenium dioxide nervous disorders, as well as pulse delays and lower
(SeO2), selenium trioxide (SeO3), hydrogen sulfide H2Se) blood pressure without organic changes in the car-
and the salts of selenious, selenium-hydrogen and se- diovascular system have been observed. Chronic ef-
lenic acids. fects can also cause conjunctivitis - so-called "pink
Usage. Selenium and its compounds are used in eyes".
the glass, ceramic, pharmaceutical and rubber indus- Laboratory researches. Biological markers for
tries, in the production of high-quality alloy steel, plas- Se's exposure are used in blood, urine, hair and nails.
tics, pesticides, etc. It is assumed that the increased content of Se in
Professional exposure. Workers involved in the urine (Seu) is a reliable indicator of selenium absorp-
melting and purifying of copper are exposed to dust tion in the last 24 hours. Depending on the excretion
from Se and SeO2, as well as H2Se, formed by the in- of (Seu), selenium exposure is classified as follows:
teraction of acids with selenides (Se compounds with acceptable: at (Seu) <0.1 mg/l; significant: with
metals). The impact of Se is also found in electronics, a concentration of (Seu) to 0.5 mg/l and dangerous:

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 OCCUPATIONAL MEDICINE
at (Seu) above 0.5 mg/l. The amount of Se in blood two allotropic forms of Te-silver-white with a metal-
(Sebl) shows longer exposure. The level of (Sebl) to 0.4 lic luster of a hexagonal romboedron crystal and a
mg/l is not associated with signs of poisoning; with brown-black amorphous powder.
an increase of 0.4 to 0.6 mg/l, symptoms of intoxica- Usage. Tellurium is used for the production of tel-
tion are observed. lurium alloys as semiconductor materials. Tellurium
Haematological parameters - decrease in he- compounds - tellurides, are used in photography, in
moglobin and hematocrit, decreased erythrocyte the ceramic and glass industry, in vulcanization of rub-
count and relative lymphocytosis. Changes in the ber, in the process of petroleum processing, in lead and
indicators associated with oxidative-reduction pro- copper production, and in electronics.
cesses are also noted - a low level of reduced glu- Professional exposure. In the glass, ceramic and
tathione in the blood. Enhanced activity of the en- rubber industry, as well as those working in electronics
zymes characterizing liver function is established. and copper, silver, gold, lead and bismuth cleaning.
Differential diagnosis. In acute poisoning, a Absorption, metabolism, excretion. Tellurium
differential diagnosis with sulfur compounds and and its compounds enter the body through the gas-
nitro-gases intoxications, and in the case of chronic trointestinal tract and the lungs. Very rarely, skin pen-
poisoning with sulfur, arsenic and some heavy met- etration is observed. In the body, tellurium compounds
als (cadmium, manganese, chromium). Also with are metabolised to methyl telluride and elemental tel-
unprofessional diseases of the respiratory system, lurium, which is less toxic. Tellurium is deposited in the
gastrointestinal tract, skin, etc. bones (up to 90%) and in the liver. Excretion is by lung,
Treatment. In acute poisoning, respiratory resus- faeces and urine.
citation is administered and, in pulmonary edema, Clinical picture.
glucocorticoids, hypertonic glucose solution, cal- Acute intoxications: hydrogen telluride(H2Te),
cium solutions, etc. In the case of burns caused by irritates the mucous membranes, but because of its
SeO2, it is recommended to use a 10% sodium thio- rapid decomposition it is less poisonous than sele-
sulphate solution (or ointments). nium or arsenic (the lining of the upper respiratory
Chronic Poisoning - Symptomatic treatment of tract is colored in black and green). Other tellurium
respiratory, gastrointestinal, skin, and other diseas- compounds (tellurium dioxide, tellurium acid, tellu-
es. Vitaminotherapy. rium hexafluoride) cause headache, weakness, diz-
Occupational medical expertise. Loss of work- ziness, shortness of breath and pulse rate, nausea,
ing capacity in acute poisoning with Se is tempo- vomiting, kidney pain, haematuria, cystitis, cyanosis,
rary. Permanent or temporary work without contact comatose. Typical is the smell of garlic of exhaled air
with toxic substances is required in case of residual and sweat.
phenomena of acute poisoning and symptoms of Chronic poisoning: accompanied by nausea,
chronic intoxication. vomiting, metallic taste and dry mouth, depressed
Prevention. Sealing of production processes, state, drowsiness. The air exhaled by the mouth is
ensuring effective ventilation and use of personal a smell of garlic - from methyltelluride ((CH3)2Te),
protective equipment. Performing preliminary and which is easily volatile.
periodic medical examinations (once a year) of the Laboratory tests are non-specific. Haemolysis
workers. Particular attention should be paid to gas- may occur after exposure to hydrogen telluride. It
trointestinal and dermatological complaints, as well is necessary to test the urine content of Te, which
as to the detection of the smell of garlic in the ex- should not exceed 0.05 mg/l.
haled air, which implies high selenium absorption. Differential diagnosis. With poisoning caused
Protective professional nutrition - a diet rich in pro- by inorganic compounds of arsenic and selenium,
tein, high in cysteine ​​and methionine. also with sulfur, chromium, manganese.
Treatment. The treatment is symptomatic - pul-
3.1.13. TELLURIUM - S. PAVLOVA mopoprotection, respiratory resuscitation, vita-
minotherapy. At hemolysis - is transfused. Antidote
- Inflammation of the respiratory tract therapy is not administered.
- exhaled air with garlic odor Prevention. Sealing of technological equip-
- fatigue, drowsiness ment, ventilation of work rooms and control of con-
- dryness of the mouth and skin centrations of the toxic substance. Use of personal
- dehydration protective equipment. Conducting periodic medical
- skin coloration in blue-black color examinations (once a year). Pregnant women are
Tellurium (Te, atomic weight 127,60). It is en- not allowed to work in contact with tellurium com-
countered as an impurity in different ores. There are pounds.

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3.1.14. THALLIUM - V.PETKOVA tions complement the clinical picture of the severe
forms of chronic thallium poisoning.
Thallium (Tl) refers to the rare elements. It and its Laboratory diagnostics. In support of the di-
compounds are used in semiconductor engineering, agnosis, the characteristic EMG -typical for thallium
instrumentation, glass staining, ooptical glass produc- poisoning axonal "dying back" degeneration. Detec-
tion, precious stones and pyrotechnics, as a catalyst in tion of urinary thallium above 10 μg/l, in nails and
some chemical processes. Its salts are comprised of ul- especially in hairs, confirms the exposure.
traviolet luminophores. Thallium amalgam is used in Differential diagnosis. It is made with arsenic,
low temperature thermometers. lead, mercury, acrylamide poisoning, porphyria and
Routes of intake, biotransformation and distri- drug polyneuropathy.
bution in the body. In occupational exposure, thalli- Treatment. Symptomatic. Antidote treatment
um enters the body through the airways and through with chelators is not effective and even aggravates
the skin. It is possible accidentally taking the metal the condition.
through the mouth with contaminated drinking water Prognosis and labour-medical expertise. Res-
or food. After an even distribution between erythro- toration of thallic polyneurites is a slow process re-
cytes and plasma in the first hours of administration, quiring prolonged therapy and rehabilitation.
the metal is deposited primarily in the kidneys and the Prevention. In view of the easy penetration of
liver. It is excreted in the urine and faeces, but also in thallium through the respiratory tract and the skin,
the sweat glands and the bronchial secretion. the use of personal protective equipment is manda-
Toxic effect. The toxicity of TI is related to its chem- tory. Preliminary medical examinations aim to pre-
ical affinity, respectively inactivation of such biolog- vent individuals with chronic and often recurrent
ical antioxidant structures such as riboflavin (Vit. B2), upper respiratory tract diseases, diseases of the pe-
glutathione (sulfhydryl groups) and selenium, which ripheral nervous system, kidney and liver. Periodic
results in an increase in lipid peroxidation. It blocks the preventive examinations are performed once a year
SH groups of the mitochondrial enzymes - SCDH, MAO, with the participation of a neurologist and ORL spe-
etc., mainly damaging the nervous, digestive, cardio- cialist. Exposure control - determination of thallium
vascular and skin attachments. in urine, nails and hair. Vitaminoprophylaxis.
Clinical picture:
Acute poisoning. Acute poisoning may devel- 3.1.15. VANADIUM - T. KUNEVA
op with accidental ingestion of thallium and com-
pounds. It runs with acute gastroenteritis with a sim- - UAP irritation
ilar cholera clinical picture at severe poisoning and - bronchial asthma
rapid development of polyneuric, psycho-organic - green coloring of the tongue
pathology and hepatorenal syndrome. Hair dripping In nature, vanadium is found in a number of min-
is a characteristic feature of both acute and chron- erals, but the largest amount is contained in the crude
ic thallium poisoning. The cardiovascular system is oil. The main source of vanadium is vanadium ores
compromised - tachycardia, transient hypertension, and vanadium sulphide extracted in Peru and lead-
T-wave decline, acute heart failure occurring in se- zinc vanadite from South Africa. In other ores such as
vere cases. vanadinite, rosolite and carnotite, Va's content is low.
Chronic poisoning. Chronic poisoning resem- The ferovanadium slag is also the source of this metal.
bles those of lead and arsenic. The first symptoms of The largest amount is contained in the crude oil -
chronic thallium intoxication are increasing asthenia, vanadium oxide is released when burning liquid fuels.
anorexia and behavioural abnormalities - aggres- Vanadium belongs to the group of ultra-micro ele-
sion or depression. When the intoxication process ments. In small amounts, it is found in the adipose tis-
progresses, the full picture of the poisoning with sue and blood.
the typical sensemotirial polyneuropathy distal type Usage. The most important application of vanadi-
("dying back"). Exactly the lower limbs are affected. um is for the production of ferro-vanadium, cast iron
Distinctive symptom is the atypical pain ("burning and alloy steels, superconducting alloys for electrical
feet" - symptom). In the course of poisoning, crani- engineering, missile and nuclear engineering and aer-
al nerves may also be affected - visual, oculomotor. ospace industry. Vanadium is composed of inks and
The development of the neurological symptomatics typographic paints, alloys for magnets and catalysts.
is accompanied by complete hair removal, the skin Professional exposure. Workers are exposed in
is dry, appearance of white semilunar bands on the grinding and baking of ores, as well as melting and ob-
nail. Psychic disorders (speech disorders, maniacal taining vanadium alloys. A major source of air pollu-
or depressive states) and hepatorenal manifesta- tion with vanadium oxides is the combustion of black

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oil and diesel. Combustion of coal at the thermal pow- poisoning, with metal pneumoniae from beryllium,
er plant also releases harmful emissions that pollute cadmium, manganese, zinc, etc.
the air of the environment. The treatment of vanadium poisoning is symp-
Absorption, metabolism, excretion. Vanadium tomatic. Chronic bronchitis and pneumonia are
compounds penetrate the body through the airways treated with antibiotics, broncholitics, high doses
and the digestive tract. Absorption in the lungs is high- of vitamin C. In polyeneuritic events, high doses of
er for miners and persons working and living in close B vitamins are administered, and physiotherapeutic
proximity to liquid fuel deposits. The absorption of procedures.
vanadium from the gastrointestinal tract is negligible There are single messages to use Unithiol and Di-
(1-2%). It is excreted in urine and faeces. There is poor mercaprol as antidotes.
bone accumulation. The prognosis is good for discontinuing contact
Vanadium and its compounds inhibit oxidative and treatment.
phosphorylation in cells, have irritant activity, damage Labour expertise. In case of intoxication - tem-
the liver, kidneys, nervous system, lipid metabolism. porary removal from work. In the development of
Clinical picture toxic pneumosclerosis after acute poisoning and
Acute poisoning. At high concentrations of va- in chronic bronchitis without respiratory failure -
nadium pentoxide dusts and vapors (even at short termination of contact with toxic substances. With
exposure - 1 hour), there are severe tears and red- frequent recurrent bronchitis and bronchial asthma
ness of the conjunctiva, serous and haemorrhagic attacks, patients have permanently reduced work-
rhinitis, sore throat, cough, chest pain. Significant ing capacity.
exposure may result in bronchitis and pneumonia. Prevention. Basic sanitary-technical measures
Neurological manifestations - headache, dizziness, include mechanization, automation and sealing of
and renal impairment. Normally, in a timely treat- production processes combined with ventilation.
ment for 1-2 weeks, a full recovery is achieved. Preliminary and periodic medical examinations
Long-term exposure to vanadium oxide vapors - contraindications to work with vanadium include
and dusts is associated with respiratory disturbanc- atrophic rhinopharyngitis, bronchitis, bronchial
es: snuffle with epistaxis, laryngitis, chronic bronchi- asthma, pneumofibrosis, chronic liver, kidney, nerv-
tis with dry irritative, often spastic cough. The cough ous system, anterior eye, optic and retina diseases,
sometimes has profuse expectoration and haemop- chronic diseases of the skin.
toea. There is a greater incidence of pneumonia Periodic medical examinations are performed
passing as metal-fume fever (beryllium, cadmium, once a year by a therapist and a full blood count is
manganese). Workers with more than 10 years of ex- required.
posure to vanadium develop diffuse pneumosclero-
sis. Allergic reactions are observed - bronchospasm, 3.1.16. ZINK - J. HADJIEVA
seizures of bronchial asthma, dermatitis and ecze-
ma. Skin paleness, papular rash of face and hands, Zinc is a greyish-silver metal of medium hardness.
greenish-black tongue staining are detected. It is easily oxidized. It dissolves in mineral acids, strong
Gastrointestinal disorders include loss of appe- bases and ammonia.
tite, nausea, vomiting, constipation. It may develop Usage. Zinc is widely used in mechanical engi-
toxic nephropathy. neering (for electrolytic metal coating and corrosion
On the nervous system, headaches, dizziness, protection), metallurgy (for the production of alloys),
slight tremor of the fingers, mental disorders are ob- chemical, pharmaceutical and textile industries, etc.
served. Inflammatory changes in the optic nerve and Biotransformation. Zinc enters the body through
the retina, severe conjunctivitis are also described. the respiratory and digestive tract. Skin and mucous
Metabolic disorders include involve in cysteine​​ membranes are of secondary importance. The zinc in
and cholesterol biosynthesis, suppression and stim- the gastrointestinal tract is absorbed into the small in-
ulation of phospholipid synthesis. High concentra- testine and is slowly distributed throughout the body.
tions cause serotonin inhibition. About 35% of the inhaled zinc is permanently bound
Laboratory researches. At the beginning of to blood serum in the form of a metalloprotein, and
chronic vanadium exposure, an increase in eryth- the rest is labile to a globulin complex. Zinc is found
rocytes and hemoglobin was observed, and then in the pancreas, liver, kidneys, prostate, thyroid gland,
a rapid decrease. Plasma cholesterol is decreasing. bones, muscles, brain, and so on. It is eliminated with
Skin-allergy tests to prove sensitization to vanadium faeces, urine and, in lesser quantities, with sweat, hair
compounds. and nails.
Differential diagnosis with dimethyl sulfate Pathogenesis. The biological significance of zinc

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 LABOUR MEDICINE
is determined by its involvement in a number of en- caused by other metals (copper, arsenic, cadmium,
zyme systems. Its increased intake in the body causes a nickel, tin, manganese, etc.), acute respiratory dis-
decrease in serum sulfhydryl groups content, disturbs eases, corrosive and food poisoning. Chronic poi-
the electron transport in the mitochondrial respirato- soning should exclude unprofessional diseases of
ry chain, inhibits cytochrome oxidase activity, disrupts the upper respiratory tract, gastrointestinal tract,
secretory function of the pancreas. skin, etc.
The pathogenesis of zinc-induced "metal fever" is Treatment. Treatment of acute poisoning -
not fully elucidated. Its pyrogenic effect is associated inhaled form, includes antipyretics, antidotes
with the catalytic activity of the finely dispersed metal (CaNa2EDTA or dimercaprole), respiratory resuscita-
particles that denature cellular proteins. An immune tion and symptomatic remedies. In the gastrointes-
pathogenetic mechanism is also allowed. tinal form, cleansing, gastric lavage, physiological
Clinical picture. serum and polyelectrolyte solutions, anticollapse
Acute intoxications occur in two forms: agents, etc. Treatment of chronic poisoning is symp-
Inhaled form ("zinc fever") - characterized af- tomatic.
ter a latency period of 4-6 hours, mainly with pul- Labour expertise. In acute poisoning, loss of
monary syndrome (throat irritation, cough, chest working capacity is most often temporary. Repeated
depression), pyrexia syndrome (hard attack from zinc fever and symptoms of chronic intoxication re-
fever and hyperthermia to 40 ° C, which persists for quire temporary or permanent labour without con-
several hours, and then drastically lowering the tem- tact with toxic substances.
perature with abundant sweating) and general toxic Prevention. Sanitary and technical prophylax-
syndrome (malaise, fatigue, muscle aches, collapse, is (sealing of manufacturing processes, protection
etc.). Pulmonary edema may develop (less common- of the respiratory tract and skin through the use of
ly). individual protective devices, etc.). Medical prophy-
Gastrointestinal - Sweet metallic taste in the laxis - are not allowed to work in contact with zinc
mouth, nausea, vomiting, burning and sore throat and its compounds, persons with diseases of the res-
and epigastric pain, dyspeptic manifestations, col- piratory, digestive, nervous and cardiovascular sys-
lapsing and dehydration phenomena. Consequent- tems, diseases of the liver, kidneys and skin. Periodic
ly, renal syndrome (acute renal failure phenomena) medical examinations are performed once every
has developed. 12 months with the participation of a therapist, an
Chronic poisoning. The most common mani- otorhinolaryngologist, and with a dermatologist.
festations of chronic zinc poisoning are respirato-
ry symptoms (chronic upper respiratory catarrh, 3.1.17. TIN - J. HADJIEVA
chronic rhinitis, perforation of the nasal septum,
chronic bronchitis, pneumonia, and, in some cas- Tin is an supposed essential microelement. Low in-
es, pneumosclerosis), the digestive system (chronic activity is characterized by its inorganic compounds,
gastritis and colitis, ulcerative stomach and duode- while its organic compounds are highly toxic.
nal disease), cardiovascular system (development of Usage. Tin and its compounds are used in the tex-
early atherosclerosis, rhythm disorders), blood and tile industry, galvanoplasty, in glass and enamel pro-
blood-forming system (hypochromic anemia), nerv- duction, in the production of alloys, plastic stabilizers,
ous system (neurasthenia ), skin (toxic dermatitis, pesticides, etc. In pure form the tin is used for welding,
skin ulcerations in the form of "bird eyes"). The ef- tinning and the like.
fect of zinc on the immune-biologic reactivity of the Biotransformation. Organic compounds of tin
organism and the reproduction processes is known. come into the body via the respiratory, digestive and
Experimentally, its carcinogenic and mutagenic ef- skin pathways. The tin lasts for a short time in the
fects have been proven. blood. It is distributed quickly in the body, with the
Clinical-laboratory tests. Hematological param- highest levels found in the lungs, kidneys, liver, spleen,
eters - reduced hemoglobin and erythrocyte counts, bones. Some of the organic compounds of tin can be
aniso- and poikilocytosis, polychromasia, leukocyto- found in the brain and muscles.
sis, eosinophilia. It is possible to detect hyperglycae- The metabolism of tin organic compounds occurs
mia and glucosuria. mainly in the liver with mixed function oxidases and by
Zinc content in blood serum is used in the assess- processes of dealkylation and dearylation. Tin and its
ment of exposure of persons in occupational con- compounds are eliminated by urine and faeces.
tact with zinc - normal values ​​of 12.0-24.0 μmol/l. Pathogenesis. Organic tin compounds have a spe-
Differential diagnosis. Acute poisoning with cific and general-toxic effect. Depending on the chemi-
zinc requires a differential diagnosis of "metal fever" cal characteristics of the compound, the hepatobiliary,

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the excretory and the central nervous systems are pre- central nervous system diseases, liver, kidney and
dominantly affected. Inorganic tin compounds have a skin diseases. Periodic medical examinations are
damaging effect on the lungs, skin and mucous mem- performed once every 12 months with the partici-
branes. There is evidence of the carcinogenic effect of pation of a therapist, neurologist, otorhinolaryngol-
tin. ogist, and at indications - dermatologist.
Clinical picture.
Acute inhalation poisoning is characterized 3.1.18. COPPER - T. KUNEVA
primarily by irritant changes in the upper respira-
tory tract and the development of "metal fever". - Copper fever;
Oral ingestion of inorganic tin compounds causes - allergic dermatitis, green-yellow or green-black
the development of gastroenterocolitis. Its organic skin coloring;
compounds can provoke cerebral symptoms (head- - rhinitis, pharyngitis, gastritis, "copper colic";
aches, convulsions, photophobia, disturbed con- - local - corneal ulceration of the eyes, the skin,
sciousness, bulbar paralysis, cerebral and spinal cord the nasal septum.
edema, coma). It is possible to develop toxic hepati- Copper is an essential oligoelement - plays an im-
tis and toxic nephropathy. portant role in blood formation, in the activity of a
Chronic poisoning is mainly characterized by number of enzymes, in the function of some endocrine
pulmonary symptoms (cough, tightness in the glands.
chest, difficulty in breathing). Chronic bronchitis, It is widely used in metallurgy and machine-build-
early emphysema and moderate respiratory failure ing (extraction of copper and copper alloys - brass,
are observed. Prolonged exposure to tin can lead bronze); in electronics and radio engineering (wires,
to the development of pneumoconiosis (so-called details); in the chemical industry (vacuum cleaners,
stannosa). Lung carcinoma cases have been report- refrigerators, heat exchangers); in the manufacture of
ed. mineral paints, artificial silk, microfertilizers, as a cata-
Clinical-laboratory tests. As an exposition test, lyst in the tanning industry.
urine tin (normal values ​​of 0.2-11 μg/l) are used. Occupational exposures with copper aerosols are
Hematological and clinical-chemical studies con- exposed to workers involved in the processing of ores
tribute to the diagnosis. containing this metal as well as to the melting and pro-
Differential diagnosis. In acute inhalation poi- cessing of copper and its alloys. Parts of metallic cop-
soning, a differential diagnosis with poisoning per or copper alloys may fall into the eyes.
causing "metal fever" from other toxic substances. Relatively lower is the risk for agricultural workers
Chronic poisoning with tin is differentiated from dis- inhalating powders of copper sulphate and carbonate.
eases of the respiratory system and non-profession- Absorption, metabolism, excretion. The main
al genesis. ways of penetration of copper in the body are respira-
Treatment. It is imperative to discontinue the tory (vapours and dust) and gastrointestinal (when
contact with the toxic substance in a timely manner swallowed). It is resorbed through the intestinal mu-
and to eliminate it from the body (thorough cleans- cosa, circulates in the blood in the form of copper al-
ing of the skin, release of the digestive tract from the bumins, is mainly deposited in the liver and, to a lesser
poison, etc.). Cerebrovascular (hypertensive glucose extent, in the kidneys and pancreas. It is mainly elim-
solution - 20-40%, pyramem, B and C vitamins, glu- inated in urine. Accidental single ingestion of soluble
cocorticoids, mannitol, etc.), hepatoprotective, ne- copper salts is generally considered to be harmless to
phroprotective agents and appropriate symptomat- its resorption, as they cause severe vomiting.
ic therapy are used. Clinical picture.
Labour expertise. In acute poisoning, workabili- Acute poisoning. Inhalation of powders and aer-
ty is temporarily lost. Low chronic poisoning requires osols of copper salts may cause nasal blockage, mu-
temporary rehabilitation without contact with toxic cosal ulceration, and perforation of the nasal sep-
substances. Cases of pronounced, persistent pulmo- tum. A few hours of working with molten metal can
nary and cerebral pathology require rehabilitation. cause "copper fever". Prodromal phenomena include
Prevention. Sanitary and technical prophylaxis burning and dry throat, sweet taste in the mouth,
- sealing of production processes, use of individual general weakness and headache. Often, the first
protective devices in order to protect the respiratory symptoms are dry paroxysmal cough, sore throat
tract and the skin. pain, shortness of breath, conjunctival flushing. Four
Medical prophylaxis. Carry out a preliminary to five hours later a febricity occurred with a sharp
medical examination - do not work in contact with rise in temperature to 39°- 40°C, pains throughout
tin and its compounds, persons with respiratory and the musculature, most pronounced in the lower

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 LABOUR MEDICINE
limbs. The fever lasted for 1-2 hours, followed by a eyes - they can cause corneal, skin, nose septum ul-
lytic drop in temperature with abundant sweating. cerations, abscess development, loss of vision. Very
Blood is found in neutrophilic leukocytosis, followed common cases of allergic dermatitis occur in contact
by lymphocytosis, transient hyperglycemia; in urine with copper compounds.
- leukocytes and cylinders. In the next few days, the Laboratory researches. Increased hemoglobin,
patients complain of general weakness and fatigue. erythrocytes and copper in the blood and bone are
Sometimes copper fever attacks recur in a few days. detected.
Relatively rarely during an attack the functions of Differential diagnosis of acute poisoning is
the gastrointestinal tract and the liver are impaired. made with zinc and other metal fevers and colds
In severe cases, catarrh of the upper respiratory tract of the UAP, and in chronic poisoning with gastroin-
may progress into spastic bronchitis or focal pneu- testinal tract and UAP diseases by non-professional
monia. In acute oral intoxications, a gastrointestinal factors.
syndrome occurs with nausea, multiple vomiting of The prognosis is favorable - there are no lasting
greenish-colored stomach contents, abundant sal- consequences.
ivation, colic-like abdominal pain, diarrheal stools. Treatment. Antidote - in acute oral toxicity with
Hematologic (acute intravascular haemolysis, hemo- copper compounds (copper sulfate) as follows:
globinuria, jaundice, secondary anemia) and hepa- 1. CaNa2 EDTA - 10% 10 ml/1 g/day intravenous
to-renal syndromes are present in severe poisoning. ampoules with 500 ml phys. saline or glucose for
Chronic poisoning. three consecutive days with control of urine excre-
The question of chronic copper poisoning is de- tion.
batable. Chronical toxic effects of copper have been 2. D-Penicillamine (Cuprenil) 0.250 g tablets; a
demonstrated only in people with abnormal auto- daily dose of 2 g, a maximum daily dose of 3 g. Treat-
somal recessive genes inducing the development ment course - 5 days.
of hepato-lenticular degeneration (Wilson disease - 3. Dimercaprol (BAL) ampoules 5% 5 ml intra-
dysfunction and structural changes in the liver, CNS, muscularly once a day. Combined with gastric lav-
kidney, bone and eye). The primary disorder here is age with activated charcoal, infusion resuscitation
the reduced amount with ceruloplasmin - the cop- with glucose and saline solutions, vit. C in large dos-
per binding protein serum. After ingestion in the es, glucocorticoids (against hemolysis).
intestine, copper becomes unstable with serum al- In copper fever - physical and mental rest, infu-
bumin instead permanent of ceruloplasmin, and sions of glucose solutions 20% and 40% with ascor-
this bond quickly breaks down and copper is depos- bic acid; antipyretics, alkaline inhalations.
ited in a number of organs. Miners can also increase Perforation of the nasal septum - termination
body absorption when 1-2% of copper ore dust is of the contact for several months. Local cleaning
present in the air in the work environment. However, with subsequent treatment with antibiotic or corti-
convincing evidence of primary chronic copper poi- costeroid ointments.
soning (observed in patients with Wilson's disease) In the eyes - abundant flushing with water, ap-
has not been found in occupational exposure. plying a local anesthetic and dropping EDTA collyi-
A higher percentage of rhinitis, pharyngitis, gas- um at 5 minutes in the first few hours.
tritis has been found in people in contact with cop- In skin ulcerations - mechanical treatment and
per powder. Gastrointestinal disorders include loss compress with sodium thiosulphate 5%; corticoster-
of appetite, nausea, stomach pain ("copper colic"). oid ointments.
The liver and kidney functions are relatively rarely Labour expertise. In acute poisoning - tempo-
affected. Radiologically, copper pulp miners have rary disability. In case of residual symptoms after
been found to have a strong lung markings, thick- acute poisoning and pronounced phenomena of
ening of the lung roots, basal emphysema. Workers chronic injuries - termination of contact with toxic
spraying annually vines of copper sulphate can ex- substances.
perience pulmonary damage, known as the "lungs Medical prophylaxis. Contraindications to
of sprayers of the vineyards". working with copper compounds are chronic dis-
Frequent functional disorders of the nervous eases of the heart and lungs, the liver, the anterior
system occurring occasionally with vasomotor dis- ocular segment and the skin. Periodic medical ex-
orders. aminations are performed once a year by a therapist;
The skin areas in contact with copper prepara- At indications-dermatologist and otoneurologist are
tions are colored greenish-yellow or greenish-black, involved. Laboratory tests include a full blood count.
and a greenish band appears on the gums. Copper
and its salts have an irritating effect on the skin and

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 OCCUPATIONAL MEDICINE
3.1.19. ALUMINUM - S. PAVLOVA ments, tremor, gradual loss of memory, abnormal
thinking and depression. Common skin lesions are
Aluminum (Al) is a light, silver-white metal insolu- dermatoses, telangiectasia and eczema. Conjuncti-
ble in water. It dissolves in basic and in most acids. Alu- vitis and irritation of mucous membranes of the up-
minum powder in a mixture with air is explosive. per respiratory tract have also been reported.
Usage. Aluminum is used in the production of var- Clinical-laboratory tests. As a better biomarker
ious metal products; for the production of alloys used of exposure, the determination of Al in urine (bio-
in aircraft and automotive industry; for pyrotechnic logical limit value - 200 μmol/l) is used.
aluminum powders and paints. The compounds of Al Haematological parameters: Reduced levels of
(oxides, chlorides, formiates) are used in the ceramic, hemoglobin, lymphocytosis and eosinophilia are
perfume and paper industry. observed. In persons with insufficient renal function,
Biotransformation. Aluminum enters the body aluminum may cause microcytosis and hypochro-
mainly via the respiratory tract and through the gastro- mic anemia.
intestinal tract (with food, beverages, water). Simulta- Differential diagnosis. Poisoning with Al and its
neous administration of citric acid can significantly in- compounds should be distinguished from unpro-
crease its absorption. From blood Al quickly passes into fessional diseases of the respiratory, cardiovascular,
the tissues and is distributed in all organs but in larger digestive, skin and mucosal diseases.
amounts in the lungs, bones and muscles. Al concen- Differential diagnosis, as well as Alzheimer's dis-
trations in the brain have been found to increase with ease, suggests that the accumulation of Al in brain
age. Elimination is mainly done with urine and faeces. tissue is one of the causes of the disease, as well as
Patients with chronic renal insufficiency represent a by persons with chronic renal failure, undergoing
risk group due to reduced Al excretion, which results prolonged hemodialysis, at them observed hyper-
in its accumulation in the tissues. An additional way of aluminaemia and accumulation of Al in tissues.
excretion can be sweating. Treatment. In acute poisonings immediate lead
Pathogenesis. The mechanism of Al's toxic action away of the worker is required, respiratory resusci-
is not sufficiently clear. It is assumed that CNS and tation, and at severe pulmonary edema - glucocor-
bones are primarily affected by increased exposure. ticoids, calcium preparations, hypertonic glucose
Aluminum can form complexes with amino acids, nu- solution, etc.
cleotides, organic acids, phosphates, and its toxicoki- Chronic poisoning requires special treatment of
netics depend on the nature of these complexes. respiratory, gastrointestinal, skin, and other disor-
Clinical picture. ders. Antidote therapy with CaNa2 + EDTA is not rec-
Acute poisoning is characterized by pronounced ommended due to lack of effect.
increasing dyspnea, severely restricted respiratory Labour expertise. Acute poisoning with alu-
movements, cyanosis, tachycardia, decreased blood minum is often associated with temporary loss of
pressure, electrocardiographic changes and tran- working capacity. Chronic intoxications impose
sient atrial fibrillation. Heavier cases of poisoning temporary or permanent labour readjustment un-
occur with rapid development of diffuse lung fibro- der specific work conditions.
sis, abruptly pronounced peripheral emphysema, Prevention. Sanitary-technical prophylaxis.
spontaneous pneumothorax formation, often with Strict adherence to the requirements for safe oper-
mortal outcome. ation (ensuring effective ventilation, mandatory use
Chronic poisoning causes pneumoconiosis of personal protective equipment - clothing, glass-
(so-called "aluminosis"). There is severe tiredness, es, protective creams, ongoing control of aluminum
shortness of breath, cough, weight loss, dry and wet concentrations and its compounds in the air in the
lung's crepitations. Occasionally, anorexia, nausea, working environment, etc.) is required.
stomach's, and muscles pains of the whole body. Medical prophylaxis. Performing preliminary and
Secondarily, some cardiovascular disorders may oc- periodic medical examinations (once a year). Par-
cur as a result of pulmonary fibrosis and impaired ticular attention should be paid to the condition of
pulmonary function. Possible development of se- the lungs, skin and eyes.
vere encephalopathy with uncoordinated move-

REFERENCES

General studies
1. Clinical toxicology, ed. A. Monov, Med. and phys., 1981. (in bul.)
2. Mihaylov P. Professional skin diseases. Med. and phys., Sofia, 1984. (in bul.)

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3. Popov T. et al. Atlas of Toxicokinetics. Med. and phys., Sofia, 1984. (in bul.)
4. Hygienic Toxicology - special part, ed. F. Kaloyanova. Med. and phys., Sofia, 1983. (in bul.)
5. Professional diseases, ed. A. Lettavet. Medicine, Moscow, 1973. (in russ.)
6. Harmful substances in industries, ed. V.V. Lazarev and E. N. Levina, Volume I and Volume II. Chemistry
Publishers, Leningrad, 1976. (in russ.)
7. Petkova V., T. Kuneva, V. Kostova - Practical approaches in the treatment of chronic occupational
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Ltd., 1995, 90-110 (in bul.)
8. Manual of professional diseases, ed. Izmerov, N.F., Моscow, Medicine, 1983, p. 315 (in russ.)
9. Official Bulletin of the Ministry of Health, 1987, No. 4-5, Ordinance No 3 on compulsory preliminary and
periodical medical examinations. (in bul.)
10. Handbook on Toxicity of Compounds. ed. Hans G. Seiler. New York and Basel, 1988
11. Health Aspects of Chemical Accident. Organization for Economic Cooperation and Development. Par-
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12. Manual of Toxicological Emergencies. ed. Eric Noji. Year Book, Medical Publishers, Chicago, London,
1998
13. Medical Toxicology. Second Edition. ed. M.J. Ellenhorm, William and Wilkins Company. Baltimore,
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14. Occupational medicine, ed. J. La Dou, Apleton & Lange, Norwolk, Connecticut, San Mateo, California,
1990.
15. Comprehensive toxicology, ed. J. G. Sipes, Mc Qeen Ch., A. G. Galdolfi, Pergamon, 1997, Vol. 11.
16. Lewis R.J., Hasardous Chemical Desk Reference, 3rd ed. New York, Van Nostrand Reinhold, 1993, p. 25
17. Early detection of occupational diseases. WHO, Geneva, 1986.
METALS
General studies
18. Zapryanov H. Toxicology of metals and non-metals in: "Poisoning with heavy metals" ed. Vl. Boyad-
jiev and Tz. Alexieva, Sofia, Med. and phys.,1990, 59-99 (in bul.)
19. Biological monitoring of metals, WHO, Geneva, 1994, p. 78
20. Lewis R. - Metals in: Occupational Medicine ed. J. La Dou, Appleton & Lange, Norwolk, Connecticut,
1990, 300-322.
21. Norbderg G. - Metals: Chemical Properties and Toxicity in: Encyclopedia of Occupational Health and
Safety, ed. J. M. Stellman - Vol. IV Geneva, International Labour Office, 1998, vol. III, 63. 14; 63. 44; 63. 9
Aluminum
22. Biological Monitoring of Toxic Metals. ed. Th. Clarkson, L. Friberg, G. Nordberg and P. Sager, Ple-
num Press, 1988, USA, 323-336.
23. Ellenhorn's, Medical Toxicology. Williams & Wilkins, USA, 1997, 1532-1537.
24. Toxicological profile for Aluminum, Public Health Service, 1999, Atlanta, Georgia, USA, 393.
25. WHO, Biological Monitoring of Chemical Exposure in the Workplace, 1, WHO, Geneva, 1996, 294.
26. Toxicological Profile for Antimony and Compounds. Public Health Service, Agency for Toxic Substanc-
es and Disease Registry, Atlanta, Georgia, USA, 1992, p. 160
27. Toxicological Profile for Arsenic. Public Health Service, Agency for Toxic Substances and Disease Reg-
istry, Atlanta, Georgia, USA, 2000, p. 468.
28. Kuneva T. - Beryllium poisoning in: "Poisoning with heavy metals" ed. Vl. Boyadjiev and Tz. Alexie-
va, Sofia, Med. and phys., 1990, 204-209 (in bul.)
29. Toxicological Profile for Beryllium. Public Health Service, Agency for Toxic Substances and Disease
Registry, Atlanta, Georgia, USA, 2002, p. 290.
30. Kuneva. T. - Cadmium poisoning in: "Poisoning with heavy metals" ed. Vl. Boyadjiev and Tz. Alexie-
va, Sofia, Med. and phys., 1990, 166-180 (in bul.)
31. Zapryanov Z., T. Popov - Cadmium in "Hygienic Toxicology - Special Part" ed. F. Kaloyanova, Sofia,
Med. and phys., 1983, 18-22 (in bul.)
32. Toxicological Profile for Cadmium. Public Health Service, Agency for Toxic Substances and Disease
Registry, Atlanta, Georgia, USA, 1999, p. 439.
33. Toxicological Profile for Chromium. Public Health Service, Agency for Toxic Substances and Disease
Registry, Atlanta, Georgia, USA, 2000, p. 461.
34. Toxicological Profile for Cobalt. Public Health Service, Agency for Toxic Substances and Disease Regis-

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try, Atlanta, Georgia, USA, 2001, p. 39.
35. Toxicological Profile for Copper. Public Health Service. Agency for Toxic Substances and Disease Reg-
istry, Atlanta, Georgia, USA, 2002, p. 295.
36. Toxicological Profile for Lead. Public Health Service, Agency for Toxic Substances and Disease Registry,
Atlanta, Georgia, USA, 1999, p. 640.
37. Bauer S., Tsvetanov V., Pastecka - Kuch S. Intoxication of manganese - new looks and dilemmas.
Maced. Med. Pregled, 1999, 53 (suppl. 34), 36-42. (in maced.)
38. Toxicological Profile for Manganese. Public Health Service, Agency for Toxic Substances and Disease
Registry, Atlanta, Georgia, USA, 2000, p. 504.
39. Petkova V. Chronic manganese intoxication clinical picture, diagnostics and expertise. Maced. Med.
Pregled, 1999, 53 (suppl 34), 9-12
40. Toxicological Profile for Mercury, Public Health Service, Agency for Toxic Substances and Disease Reg-
istry, Atlanta, Georgia, USA, 1999, p. 676
41. Elemental Mercury and Inorganic Mercury Compaunds. IPCS, The conciences International chemical
assessment document No 50, WHO, Geneva, 2003, p. 61.
42. Toxicological Profile for Nickel. Public Health Service, Agency for Toxic Substances and Disease Regis-
try, Atlanta, Georgia, USA, 1997, p. 296
43. Phosphorus and its compounds in "Harmful substances in industry", ed. Lazarev N.V., Vol. II, Len.
Chem., 1971, 194-200 (in russ.)
44. Toxicological Profile for White phosphorus. Public Health Service, Agency for Toxic Substances and
Disease Registry, Atlanta, Georgia, USA, 1997, p. 248.
Selenium
45. Ellenhorn S., Medical Toxicology: Diagnosis and Treatment of Human Poisoning, Second Edition, Ed.
M. J. Ellenhorn, Williams & Wilkins, 1997, USA, 1607-1608.
46. Occupational Medicine, ed. J. LaDou, Appleton & Lange, California, USA, 1990, 316-317.
47. Selenium, Environmental Health Criteria 58, WHO, Geneva, 1987, p. 306.
48. Toxicological Profile for Selenium, Agency for Toxic Substances and Disease Registry, Atlanta, Georgia,
USA, 1994, p. 253
49. Zalev. D., Z. Zaprianov, Atomic Absorption Spectrometry in Health Practice, vol. II, 1983, 182-187.
50. Toxicological Profile for Thallium. Agency for Toxic Substances and Disease Registry, U.S. Public Health
Service, Atlanta, Georgia, USA, 1992, p. 114.
Telurium
51. Encyclopaedia of Occupational Health and Safety, ed., ed. J. M. Stellman, Int. Lab. Office, Geneva,
1998, p. 63. 39-63. 40.
52. Industrial Toxicology, III Edition, ed. A. Hamilton and H. Hardy, Publishing Sciences Group Inc., USA,
1974, p. 173-174.
53. Occupational Medicine, Ed. J. LaDou, Appleton & Lange, California, USA, 1990, p. 317-318.
54. Toxicological Profile for Tin and Compounds. Public Health Service, Agency for Toxic Substances and
Disease Registry, Atlanta, Georgia, USA, 2003, p. 382.
55. Toxicological Profile for Vanadium and compounds. Public Health Service, Agency for Toxic Substanc-
es and Disease Registry, Atlanta, Georgia, USA, 1992, p. 130.
56. Vanadium Pentoxide and other Inorganic Vanadium Compounds. IPCS, The Concise International
Chemical Assessment Document No. 29, WHO, Geneva, 2001, p. 53.
57. Toxicological Profile for Zinc. Public Health Service, Agency for Toxic Substances and Disease Registry,
Atlanta, Georgia, USA, 1994, p. 259.

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3.2 ORGANIC SOLVENTS

Solvents - water-soluble (water-based) or organ- The solubility of lipids (lipid solvents) is one of
ic (hydrocarbon-based) used in manufacturing are the most important characteristics determining
predominantly organic substances. In the largest both their effectiveness as production solvents and
quantities, they are used as intermediates in organic their health effects. The strength of the narcotic's ef-
synthesis in the chemical industry, but the greater fect as well as the degreasing agent is proportional
the number of workers using them as a means of to the degree of their lipid solubility (different for
cleaning, degreasing, extraction, dissolution. the individual organic substances and compounds).
Hundreds of organic substances are used to Their penetration through the skin is also relat-
make over 30,000 different types of solvent. These ed to lipid solubility but also to water solubility - e.g.
organic substances have their physical, chemical it is higher for dimethylformamide or glycol esters
and toxicological characteristics and peculiarity that which are lipid solvents but are also water soluble.
determine their behaviour, health risk, and make it The degree of penetration is also related to their vol-
possible to classify them into separate subgroups, atility (evaporation at lower temperatures) - Tabl. 3.
but their classification is mainly their chemical for-
mulation.
Tab. 3. Brief description of organic solvents
Chemical Representatives Toxic effects Acute poisoning Chronic poisoning Exposure tests
group
Aliphatic Alkenes (Paraffin) narcotic rhinopharyngitis dermatitis, dry and EEG - diffuse
hydrocarbons methane, ethane, neurotoxic nausea, vomiting erythematous skin slow waves
propane, butane, headache, dizziness headache, psych. tests
hexane) drowsiness, fatigue emotional lability EMG - slow
Olefins (ethylene, impaired balance impaired concentration speed of
propylene, amylene, disorientation and memory conduction in
butylene) depression cortical atrophy peripheral
Naphthenes impaired consciousness peripheral neuropathy nerves
(cycloparaffins) anemia Er  RE
(cyclopropane,
cyclohexane)
Aromatic benzene (benzol) irritative rhinopharyngitis dermatitis Le  Thr Er 
hydrocarbons toluene neurotoxic neurasthenic manifestations distal neuropathy Hb 
xylene myelotoxic vasomotor excitement behavioral and cognitive Phenol in urine
ethylbenzene convulsions disorders EEG - diffuse
styrene coma cortical atrophy slow waves
hypotension dementia psychological
cardiac arrhythmia encephalopathy tests
CT
Petroleum gasoline narcotic rhinopharyngitis conjunctivitis EEG - diffuse
distillates neurotoxic neurological disorders dermatitis slow waves
in aspiration - Pneumonia neurasthenic syndrome Psycho. tests
anemia Er RE Le Ly

Amino ethylenimine irritants conjunctivitis allergic contact dermatitis FID

derivatives of ethylenediamine allergens corneal edema spastic bronchitis AST
fatty cyclohexylamine rhinopharyngitis asthma
hydrocarbons
Chlorinated trichloroethylene narcotic rhinopharyngitis dermatitis ЕЕG
hydrocarbons perchlorethylene neurotoxic neurobehavioral disorders: impaired of concentration psychological
methylenchloride hepatotoxic headache, dizziness and short-term memory tests
chloroform drowsiness, fatigue lesion in cerebral nerve CT
impaired balance cortical atrophy
disorientation, depression,
impaired consciousness
jaundice, hepatitis
nephropathy

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 OCCUPATIONAL MEDICINE
Nitro derivati- nitrobenzene irritative
cyanosis, shortness of conjunctivitis anoxia
ves of aromatic nitrotoluene narcotic breath, arrhythmia, dermatitis metHb 
hydrocarbons trinitrotoluen methemoglo-
insomnia, agitation, ataxia cerebrasthenia Hb  Er, cells
nitrophenol bin formers
seizures hepatitis Heinz
trinitrophenol disorientation impaired nephropathy urine: albumin 
(picric acid) consciousness hyperthyroidism Er
visual disturbances nitrophenol>
anemia, jaundice anemia 0,06 mmol/l
hepatitis cataract aminophenol>
skin rashes hepatitis 0,09 mmol/l
cataract
Amino derivati- aniline methemoglo- conjunctivitis conjunctivitis Hb Er ,
ves of aromatic diphenylamine bin formers acrocyanosis, asthenia anemia celles
hydrocarbons p-phenylenediamine allergenic headache hepatitis Heinz, and
(Ursol) carcinogenic dizziness vestibulopathy poikilo- and
α- and β- tottering step ataxia anirzocytosis-
naphthylamine convulsions haemorrhagic cystitis MetHb 
coma bladder cancer urina- alb.,
hepatitis hyperkeratosis, eczema Er, urobilinogen
acne vulgaris 
bronchial asthma
Alcohols ethyl neurotoxic rhinopharyngitis pharyngitis EEG
methyl hepatotoxic cyanosis, shortness of dermatitis psychological
isopropyl breath, headache, Neuropathia n. optici testing
inebriation, tremors, Parkinson's syndrome
neuropathies hypothalamic syndrome
Glycols ethylenglycol narcotic Headache, dizziness, conjunctivitis proteinuria
diethylene glycol nephropathy nausea, vomiting pharyngitis
propylene glycol asthenia nephropathy
coordination disorders dermatitis
depression

Phenols phenol irritative rhinopharyngitis contact dermatitis HB Er ,

cresol vasodilatatory hypothermia gastrointestinal disorders poikilo- and
catechol necrotic myocardial ischemia (ptializam, diarrhea, anizocytosis
pyrogallol (liver, hepatitis anorexia) hemolysis
hydroquinone kidney nephropathy cerebrasthenic syndrome ASAT ALAT 
skin) skin burns vestibulopathy AP LDH
neurotoxic neurasthenic distal neuropathy proteinuria
manifestations behavioral and cognitive Phenol in urine,
disorders EEG
cortical atrophy, dementia EMG
psych. tests
Organic oxides ethylene oxide and neurotoxic, headache, dizziness, ataxic tremor Tremorogram
propylene oxide irritant step, polyneuropathy EMG
Organic izopropylbenzol corrosive speech disorder acrocyanosis
peroxides hydroperoxide acrocyanosis burning corneas
dermatitis, eczema

Esters methyl acetate irritative redness, burns to conjunctivitis EEG

ethyl acetate allergenic blindness rhynopharyngolaringitis psychological
propyl acetate neurotoxic neuropathy n. optici dermatitis tests
butyl acetate rhinopharyngitis
headache, dizziness,
drowsiness
palpitations
asthma
Ethers ethyl-, diethyl-, irritative rhinopharyngitis dermatitis Er
methyl-dimethyl-, narcotic irritability, drowsiness headache, pancytopeny
vinyl ether neurotoxic loss of consciousness dizziness
dioxane corrosive hepatitis
glycol ethers exp-in/in nephropathy
reproduction anemia, hemolysis
encephalopathy

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corrosive conjunctivitis dermatitis, eczema
Organic acids Formic acetic
irritants rhynopharyngolaringitis locally-burns
Aldehydes formaldehyde narcotic conjunctivitis, dermatitis
acetaldehyde irritative rhinopharyngitis asthma
glutaraldehyde allergenic excitation, tremors,
dimethylformamide visual disturbances
paralysis of
facial nerve
nystagmus
ataxia
Ketones acetone narcotic conjunctivitis, cathars of UAP Hb
methyl ethyl ketone irritative rhinopharyngitis anemia
cyclohexanone salivation, dizziness, dermatitis
headache,
flushing
impaired consciousness
Chlorfluoro- Chlorfluoro- narcotic rhinopharyngitis dermatitis EKG
karbonates carbonates (i.e. neurotoxic headache, dizziness ЕЕG
brand freons - CFCs) cardiotoxic drowsiness, fatigue
trichlorofluoro- impaired balance
methane (F- 11) disorientation, depression,
dichlorodifluoro- impaired consciousness
methane (F- 12) cardiopathies-rhythm and
trichlortrifluormetan conduction disorders
(F- 113)
3.2.1. BENZOL - J. HADJIEVA - a fast-acting form - there is a rapid loss of con-
sciousness followed by a lethal outcome as a result
Pure benzene is a colorless liquid with a pleasant of paralysis of the respiratory and vasomotor center.
smell, well soluble in organic solvents. Its vapors form After acute poisoning with benzene, residual
with air explosive mixtures at certain volumetric ratios. phenomena such as headache, vertigo, nystagmus,
Usage. Benzene is widely used as a solvent for fats, spastic paresis, epileptiform seizures can be identi-
varnishes, paints and more. It is a starting product for fied. It affects the cardiovascular system - tachycar-
the production of a large number of compounds in the dia, extrasystolic arrhythmia, arterial hypotension.
chemical industry for the production of styrene, phe- Irritative lesions of the mucous membranes - con-
nol, explosives, detergents, medicines. junctivitis, can epistaxis, catarrh of the respiratory
Biotransformation. Benzol penetrates the body tract to pulmonary edema.
through the respiratory and digestive tract. It is also Chronic poisoning. Observed with prolonged
possible to get it through the skin. In single exposure, it exposure usually from 3 to 5 years. The main dele-
is mainly deposited in the CNS, the adrenal gland, liver terious effects are related to the myelotoxic effect
and blood, and in prolonged exposure to bones, lungs, of benzene. The leukopoetic, megakaryocytic and
kidneys, pancreas and adipose tissue. It is metabolised erythroblastic functions of the bone marrow are
mainly in the liver with the involvement of the liver mi- suppressed. The immunotoxic, neurotoxic and, in
crosomal enzyme system. Metabolites of the benzene some cases, carcinogenic effects of benzene occur.
are phenol, pyrocatechin, muconic acid, and hydroqui- Three degrees of chronic benzol poisoning are dis-
none. Elimination is by exhaled air and urine. tinguished:
Pathogenesis. The single effect of high concentra- - mild degree - vascular symptoms, moderate
tions of benzene causes damage to nerve structures leucopenia, anemia, initial manifestations of haem-
with pronounced narcotic effects. Long-term exposure orrhagic diathesis are observed. Changes are usually
to low concentrations is dominated by the myelotoxic reversible with a timely discontinuation of exposure.
effect of benzene. In isolated cases, bone marrow changes are pro-
Clinical picture. gressing. Spontaneous remissions may also occur
Acute poisoning is rare, mainly in emergency with persistent exposure.
situations. Three degrees of acute poisoning are dis- - moderate degree - more pronounced leuco-
tinguished: penia, sometimes thrombocytopenia, deepening
- mildly - characterized by transient headaches, of hypochromic anemia and haemorrhagic diathe-
vertigo, euphoria, ataxia that resolve after a few sis, intensification of vegetative-vascular manifesta-
hours. tions.
- severe degree - psychomotor agitation, som- - severely - deepening of bone marrow hypo-
nolence, coma.

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 OCCUPATIONAL MEDICINE
plasia to pancytopenia. There is a tendency to infec- toxic substance. It is imperative to strictly observe all
tions and septic conditions. rules for safe operation, to conduct ongoing moni-
Under conditions of chronic benzole exposure, toring of the benzene content in the air of the work-
acute and chronic leukosis, erythroblastosis, can be ing environment and to comply with the MACs.
diagnosed. They may also develop after the expo- Medical prophylaxis. Do not work in contact
sure of the toxic substance. with benzene, people with diseases of the nervous
Skin damage occurs in the form of contact der- system, blood and haematopoietic apparatus, skin
matitis and eczema. diseases, etc. Periodic medical examinations are per-
Clinical-laboratory tests. Leading laboratory formed once every six months with the participation
tests are the haematological deviations. These are of a therapist, a neurologist, and at indications of a
related to leukopoetic, megakaryocytic, and erythro- dermatologist and obstetric gynecologist.
blastic bone marrow lesions. Reduced hemoglobin, Protective professional nutrition - diet "D" is rec-
decreased red blood cell counts, aniso- and poikil- ommended.
ocytosis, increased number of basophil stippling
erythrocytes, reticulocytosis, thrombocytopenia, 3.2.2. ALCOHOLS - R. STEFANOVA
leukocytosis and changes in leukocyte formulations
(myelocytes, metameliocytes) or leucopenia, chang- The group of alcohols includes a large number of
es in leukocyte quality, chromosomal aberrations in compounds. They are monoatomic and multiatomic,
bone marrow and peripheral blood cells. primary, secondary and tertiary, saturated and un-
The contents of the vit. "C" in urine is reduced. saturated. Alcohols are widely used as organic solvents
Immunological parameters (Ig A and Ig G) show a and are also used in organic synthesis - the production
decrease and the IgM content slightly increased. De- of plastics, artificial rubber, paints, varnishes, cleaning
termination of urinary muconic acid and phenol is agents, cosmetics, alcocholic drinks, etc.
used as exposure tests. Methyl alcohol. Methyl alcohol (methanol) is a
Differential diagnosis. Acute intoxications re- colorless, easy-moving liquid with a specific odor. It is
quire a differential diagnosis with alcohol poisoning, dissolved in water, ethanol, benzene, acetone and oth-
benzine poisoning, etc., and chronic - with hemor- er organic solvents. Its vapors form explosive mixtures
rhagic fever, systemic blood disorders, septic condi- with air. Oxidation forms formaldehyde, formic acid
tions, etc. and carbon dioxide.
Treatment. In the case of acute poisoning, it is Application. Methanol is used for the production
imperative to immediately break the contact with of formaldehyde, in painting, as an additive in liquid
the toxic substance (removal from the gassed envi- fuels (to increase the octane number), antifreeze and
ronment, when benzene enters the gastrointestinal the like.
tract - washing the stomach with water and medic- Occupational risk exists for workers, in unhermetic
inal charcoal, eye flushing). Antihypoxic and antiar- work processes and in contact with opened surfaces
rhythmic preparations, analeptics, nootropic drugs, of the substance. Persons consuming poor alcohol-
breathing stimulants, oxygen therapy, and at apnea ic drinks with a high methanol content are at risk of
- intubation and command breathing are used. non-professional poisoning.
The treatment of chronic benzene poisoning is Biotransformation. Methanol penetrates the
symptomatic. Data on impairment of bone marrow body mainly in the inhalation route. It is also possi-
function is a discontinuation of exposure. There are ble its absorption through the skin. It is distributed in:
tranquilizers, vitamin therapy (vitamin C and group liver, kidney, gastrointestinal tract, heart, muscle, adi-
B vitamins), corticosteroids, anabolic preparations, pose tissue and brain. A significant portion is oxidized
and others. to form formaldehyde and formic acid which lead to
Labour expertise. In acute poisoning, workabili- severe metabolic acidosis, damage to the nervous sys-
ty is most often temporarily lost. Chronic poisoning, tem and the optic nerve. At the cellular level, enzymes
depending on the severity of the disability, requires are blocked, such as hexokinase and the like. Methyl
temporary re-employment of 3 to 6 months (with a alcohol is eliminated in urine as formic acid and as
slight degree of poisoning) and long-term rehabili- non-metabolised methanol. Minor amounts are re-
tation (medium and severe). In many cases, it is nec- leased as beta-glucuronide.
essary to identify a disability group. Methanol has a narcotic effect and has a cumu-
Prevention. The high professional risk of pro- lative effect. The mechanism of its toxic action is as-
longed exposure to benzene (carcinogen - group sociated with its oxidation products (formic acid and
A1) requires that it be placed under special control formaldehyde). The eye analyzer is damaged due to
and, if possible, replacing benzene with another less disturbance in the retinal oxidative phosphorylation.

476
 LABOUR MEDICINE
Clinical picture. Ethyl alcohol
Acute intoxications may occur when inhalation It is a colorless volatile liquid with a characteris-
of high concentrations of methanol or ingestion (of tic odor. Ethyl alcohol (ethanol) is slightly toxic, with
life). The lethal dose is 10 to 60 cm3, depending on marked lipotropicity, predominantly damaging the
the age and individual characteristics of the body. central nervous system and the liver, blocking the
It occurs with headache, fatigue, dizziness, reduced functions of a number of enzymes in cellular orga-
hearing and tinnitus, abdominal pain and vomiting. nelles. It destructed from alcohol dehydrogenase
In severe cases, seizures and coma are observed. Oc- to carbon dioxide and water. Exposure to ethanol
ular nerve damage is characteristic. Initially, the pu- vapor or swallowing (acute poisoning) is mainly
pils are enlarged and reduces the pupil's reflex. Later due to CNS changes: initially there are euphoria, hy-
there was blindness, followed by cyanosis, Cheyne- perthymias, psychomotor agitation. In the case of
Stokes breathing (due to bulbar paralysis), apnoe more severe intoxications, the narcotic effect of eth-
and lethal outcome (in over 20% of cases). anol-ataxia, somnolence, sopor, coma, hyporeflexia
Chronic poisoning - headaches, tiredness, diz- is manifested. Breathing and haemodynamic inhibi-
ziness, disturbed sleep rhythm, visual disturbances, tion may occur.
vegeto-vascular disorders - changes in Ashner-Dan- Prolonged exposure to ethanol vapour(chronic
nini reflex and in orthoclinostatic reflex, eyelid and poisoning) at concentrations above 5,000 ppm (10
hand tremor, increased tendon reflexes, etc. times the normal) causes mucosal irritation (eyes,
Laboratory researches. Strong reduction in nose), headache, infirmity, fatigue, dizziness, drows-
blood alkaline reserves (BE), presence of methanol, iness. Fallen on the skin causes dermatitis. Epidemi-
blood condensed, increased red blood cell count ological data of carcinogenic effect - an increased
and elevated hemoglobin. Urine contains albumin, incidence of laryngeal cancer, when exposed to syn-
hyaline cylinders, methanol and acetone. thetically produced ethanol, is associated primarily
Differential diagnosis is made with poisoning with its impurities - diethylsulphate and the like.
from ethyl alcohol, botulism, atropine, ethylene gly- Laboratory studies show increased alcohol con-
col, TEL, toluene, nickel carbonyl. tent in the blood, a positive urine ethanol sample.
Treatment. Antidote is ethanol (reduces metha- In the third and fourth degrees of acute alcohol poi-
nol degradation) - in acute poisoning 10g ethanol/h, soning, the excess of blood-bases (BE) is reduced -
5% p-p, drop, intravenous. the presence of metabolic acidosis, the urinary ace-
Stomach wash with 2% sodium bicarbonate, 30 tone bodies increase.
g magnesium sulphate in a glass of warm water, in- Differential diagnosis. Intoxications with gaso-
fusion therapy with glucose and alkaline water-elec- line, benzene, toluene, acetone, carbon monoxide,
trolyte solutions, up to 3 liters per day. If the patient other types of coma with non-professional etiology.
is conscious, alkaline agents can also be taken oral- Treatment. Cerebroprotective agents are used:
ly for 2-3 days (correction of metabolic acidosis). if needed, sedative (phenothiazine neuroleptics), or
The hemodynamic parameters are controlled and analeptics, respiratory and cardiocircular resuscita-
caffeine, cardiazole, etc. are administered to main- tion.
tain the cardiovascular system; Vitamins - C, B1, B12, Prevention. Effective ventilation of work rooms.
against toxic damage to the optic nerve. Later, bal- Sealing of production processes and storage vessels.
neotherapy and physiotherapy were used. Preliminary and periodic medical examinations.
Labour expertise. In the case of mild acute poi-
soning, the ability to work is temporarily lost, and in 3.2.3. ETHYLENE GLYCOL - D. APOSTOLOVA
the case of severe poisoning, optic nerve damage,
the patient is permanently disabled and is defined Ethylene glycol is a bivalent alcohol with high toxic-
as a disability group. In case of chronic poisoning - ity of its metabolites. It is a colorless liquid, water-solu-
labour recruitment without contact with toxic sub- ble and highly chemically active.
stances. Usage. Comes into antifreeze (up to 95%), brake
Prevention. Sealing during transportation and fluid, polyester fibers, plastics, resins, varnishes and
storage of methyl alcohol. Control of methanol con- paints. It is used as a solvent and raw material in many
centrations in air. Use of filtering gas mask. Contrain- industries - pharmaceuticals, tobacco, leather, textiles,
dicated for work with methanol are people with liver, paints and varnishes.
kidney, eye, and nervous system diseases. Periodic Toxic action. Occupational poisonings with eth-
preventive examinations are performed once a year, ylene glycol - inhalation of vapors or aerosols, less
with the participation of a therapist, neurologist and frequently through the skin, are relatively rare. The
ophthalmologist. toxicity of ethylene glycol itself is low, in the body is me-

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tabolized to formic acid, glycine or oxalic acid, which ing B1 and B6.
cause damage to the central nervous system, kidneys - cardiocirculatory reanimation.
and extreme acidosis. For chronic poisoning:
Acute poisoning. Usually, when swallowed after - inclusion of a salt-free diet with a protein restric-
a latency period of 30 minutes to 12 hours, vertigo, tion of up to 1-2 g/kg bodyweight for 24 hours.
headache, somnolence, ataxia, nausea, followed - drip and intravenous infusions - 1-2 l per day of
by severe sopor and coma intoxication, often myo- water-electrolytic, 10-20% glucose-levulose and al-
clonic seizures, occur. Nystagmus and ophthalmo- kaline solutions.
plegia (with no damage to the optic nerve), tachyp- - intravenously 10% Calcium gluconicum 10-20
noea, tachycardia, sometimes cardiovascular failure ml daily and at 5ml. 25% solution of magnesium sul-
may occur. During the second day, acute renal fail- phate.
ure is developing with oliguria anuria and azotemia. - vitaminotherapy - vit. B6, Vit. C.
The liver damage is infrequent and weaker. - hepatoprotective and cerebroprotective agents.
Chronic poisoning. They occur with functional Prognosis and labour-medical expertise.
changes in the nervous system, such as headaches, Acute poisoning is serious, and a mortal outcome of-
dizziness, ataxia, short-term syncope, nystagmus, ten occurs. Chronic intoxications can lead to marked
somnolence, vegetative dystonia with a tendency to disability.
hypotension. Ethylene glycol has a locally irritant ef- Medical prophylaxis. Do not work with ethylene
fect on mucous membranes, cornea, conjunctivitis. glycol with CNS diseases, chronic liver and kidney
In advanced cases, chronic dermatitis, toxic pneu- disease, blood disorders and secondary malnutri-
mofibrosis, hepatorenal syndrome with dominant tion. Annual prophylactic examinations with ther-
tubulopathy, hepatopathy are noted. Anemia with apist and neurologist and otorhinolaryngologist,
granulocytopenia is rare. with full blood count, urine and ASAT, ALAT, biliru-
Laboratory diagnostics. Metabolic acidosis, bin, differential blood count, oxalic acid in the urine.
characterized by a reduction of standard bicarbo- Prophylactic nutrition - diet B (with alkaline pre-
nate (SB) below 20 mmol/l and a decrease in excess dominance), yogurt half a liter daily, vitamins (vita-
of bases (BE); hypocalcaemia (Ca below 2 mmol/l), min C 150 mg daily, vitamin B6 50 mg daily).
hyperchloremia (chlorine above 110 mmol/l); ane-
mia with macrocytosis (Hb below 140 g/l for men and 3.2.4. PHENOL - J. HADJIEVA
below 120 g/l for women, Ery. less than 4.5 million
for men and less than 4.2 million for women); seg- Phenol is a colorless crystalline substance with a
mented nuclear neutrophils (Sg) below 50%. characteristic odor. It dissolves in water, chloroform,
Exposure test not developed, ethylene glycol in ether and oils. It has weak acidic properties.
urine may be determined at high exposure. Oxalic Usage. Phenol is one of the most commonly used
acid in the urine is also recommended - norme 15-20 hydroxyl derivatives of benzene. Used as monomer of
mg/24h. phenol formaldehyde resin, in the manufacture of pic-
Differential diagnosis. Poisons with other or- ric acid, dyes, pesticides, adhesives, etc. Phenol is the
ganic solvents (methanol, ethanol, acetone, gaso- starting material for the synthesis of a number of ar-
line, toluene); diseases of general character affecting omatic compounds and pharmaceutical preparations.
the nervous system, kidneys, liver and hematopoie- Biotransformation. Phenol penetrates the body
sis. through respiratory, skin and gastrointestinal tract. Its
Treatment. respiratory absorption is high and represents 70-80%
In acute poisoning: of the inhaled amount of phenol.
- gastric lavage with medicinal charcoal and sa- The phenol resorbed in the body is distributed
line cleanser (for oral admission). quickly and unevenly in the tissues in the following or-
- hemodialysis, acidosis correction and cleansing der: kidneys, liver, heart, blood, muscles. In the body,
endotoxin products (nitrogenous bodies). the phenol undergoes two oxidation reactions - hy-
- infusion of sodium bicarbonate, alkaline and droxylation of the aromatic nucleus and oxidation of
other salt and glucose solutions to maintain abun- pyrocatechin and hydroquinone in the corresponding
dant diuresis - 3-5 liters per day. quinones. The major amount of phenol is excreted in
- antidote treatment - ethanol to prevent the the urine as free and bound phenols in the form of sul-
degradation of ethylene glycol by alcohol dehydro- phates and glucuronides. Small amounts are eliminat-
genase, calcium gluconate 4x1g daily (as oxalic acid ed as carbon dioxide. The ultimate release of the phe-
antidote). nol from the body occurs after 24 hours.
- cerebro- and hepatoprotective agents, includ- Pathogenesis. Phenol belongs to the so-called

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protoplasmic poisons, which have lipotropic activ- Chronic poisoning is differentiated from diseases of
ity and the ability to quickly denature the proteins. It the nervous, urinary, digestive, liver at non-profes-
suppresses the oxidative-regenerating processes and sional origin.
disrupts the activity of a number of enzyme systems. Treatment. In cases of acute poisoning immedi-
It damages the nervous system and the parenchymal ate contact with the toxic substance is carried out
organs. It has an irritant effect on the mucous mem- and procedures for its removal from the body are
branes and the skin. performed. Calcium gluconate, infusion therapy
Clinical picture. Acute poisoning is rare in pro- with glucose and water-salt preparations, respira-
fessional conditions. Inhalation of phenolic vapors tory resuscitation, anti-shock therapy, antibiotics,
causes acute upper respiratory catarrh, bronchitis, exchange blood transfusion are used. In chronic poi-
bronchopneumonia, and pulmonary edema. Cor- soning, treatment is symptomatic. Hepatoprotec-
rosion changes occur when the phenol enters the tors, nephroprotectors, vitamin therapy and others
body via the gastrointestinal tract. are used.
Nervous system disorders include headache, diz- Prevention. Sanitary-technical-sealing and au-
ziness, agitation, and in more severe cases - somno- tomation of technological processes, provision of
lence, convulsions, coma, and paralysis of the center effective general and local ventilation, use of special
of breath. There is a development of toxic nephrop- work clothes of impermeable tissue and other indi-
athy and toxic hepatopathy. When phenol enters vidual protective means. In emergency situations, it
the skin, burns, necrosis (phenolic gangrene) and, in is imperative to use a gas mask.
severe cases, the appearance of general resorptive Medical prophylaxis. Do not work in contact
symptoms. with phenol, people with diseases of nervous, res-
Chronic poisoning. The clinical picture of chron- piratory and urinary system, liver, skin and visual
ic poisoning is characterized by a wide variety of analyzer diseases. Periodic medical examinations
symptoms and syndromes from different organs are performed once every 12 months with the par-
and systems. ticipation of a therapist, otorhinolaryngologist, and
- vegeto-asthenic manifestations (irritability, in- at indications - neurologist, ophthalmologist and
creased fatigue, impaired sleep and memory, un- dermatologist. Protective professional nutrition -
pleasant sensations in the heart, etc.) diet "D".
- motor disorders (increased tendon reflexes,
tremor, coordination disorders); 3.2.5. KETONES -
- cranial-brain dysfunction (insufficient conver- D. CHARYKCHIEV, ST. ANDONOVA
gence, nasolabial fold asymmetry, exophthalm);
- gastrointestinal discomfort (anorexia, dyspha- Ketones are aliphatic hydrocarbons which are
gia, ptyalism, dyspepsia, nausea, vomiting, stomach chemically characterized by the presence of a carbonyl
abdominal pain, epigastric pain); group (-C = O). They are colorless, volatile liquids with
- biliary-liver disorders (manifold symptoms of a specific odor. Representative are the compounds: ac-
mild functional impairment to toxic hepatitis); etone, methyl acetone (methylethylketone), acetophe-
- renal impairment (most commonly transient al- none, acetylbromide, acetylchloride, cyclohexane and
buminuria); the like.
- skin changes (develop dermatitis or eczema). Acetone (dimethylketone, propanone) is used in
Clinical-laboratory tests. the manufacture of paints, varnishes, plastics, artificial
- Hematological parameters (decreased hemo- rubber, explosives, photography, microelectronics and
globin, decreased red blood cell count, aniso- and others.
poikilocytosis, haemolysis); Methylacetone (methylethylketone, butanone)
- Urine (red color to green urine, proteinuria, also has excellent solvent properties and is used as a
erythrocyturia, oliguria, sediment of the urine - ep- component in many organic solvents to denature eth-
ithelial, granular and erythrocyte cylinders, abun- anol and the like.
dant kidney epithelial cells); Biotransformation. Entrance hole - breathing
- Clinical and chemical indicators (increased con- path, digestive tract and skin. Breathing in the air rap-
tent of residual nitrogen and residual nitrogen frac- idly saturates the blood, but is slowly eliminated by the
tions in blood serum, increased serum activity of body. They have cumulative properties. Acetone accu-
ASAT, ALAT, LDH, AF, guanase). mulates mainly in the brain, liver, pancreas, kidneys,
Differential diagnosis. Poisoning with other lungs, muscles, heart. Metabolized by oxidation to car-
corrosive poisons (dimethylsulfate, chlorine, nitro- bon dioxide and partly to isopropanol. It is associated
gen oxides), carbondisulfide, toluene and others. with glycogen, fatty acids and amino acids. It is elim-

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 OCCUPATIONAL MEDICINE
inated in urine as unchanged (7-8%), and its metab- Violated protein and lipoprotein synthesis in the en-
olites; through the skin - 10% of the body's ingestion; doplasmic reticulum, energy processes (production of
as carbon dioxide and unchanged with exhaled air up adenosine triphosphate), followed by fatty degener-
to - 50% of the received. Ketones have the ability to in- ation and centrolobular necrosis in the liver, tubular
duce cytochrome 450. They affect urea and cholesterol necrosis in the kidneys, degenerative changes and nar-
metabolism. cotic effect in the CNS.
Clinical picture. In acute poisoning, symptoms Clinical picture. Vapor exposure after a laten-
of respiratory tract irritation, such as rhinorrhea, cy period of 2-24 hours results in rapid transient
cough, chest pain, burning, skin irritation, are ob- irritation of the respiratory mucosa (in very severe
served. In cases of severe intoxication, there are nau- intoxications and pulmonary edema). Headaches,
sea, vomiting, headache, dizziness, disturbance of dizziness, nausea, ataxia, confusion, somnolence,
consciousness to coma. Acidotic breathing occurs. visual disturbances followed by coma, depression
An alkaline acid disorder is impaired with severe of the breathing and circulation, cardiac dysrhyth-
metabolic, and later respiratory, acidosis. Acetone mia, eventually and clonic-tonic convulsions occur.
and methyl acetone have no axonolytic activity in Damages of parenchymal organs: enlarged, pain-
contrast to other ketones that form a gamma ketone ful liver, jaundice, elevated bilirubin (conjugated)
with an axonolytic action in metabolism and lead to in the blood and urinary incontinence, high values​​
ascending polyneurites. Some of the ketones have of ASAT, ALAT, LDH and ammonia in the blood, low
pronounced hepatotoxic and nephrotoxic effects. fibrinogen and prothrombin time, haemorrhagic
Acetone describes the occurrence of cataracts, for diathesis, renal failure with oligo-anuria, azotemia,
methyl acetone phototoxic effect. hyperkalaemia. Analogous injuries develop in oral,
Chronic effects are mainly characterized by skin (with mainly hepatic lesions) and percutaneous in-
changes - dermatitis. The skin is dry, reddened, itch- toxication. The latter also has contact dermatitis
ing appear. Affects mucous membranes - conjunc- with erythema, fissures and desquamation.
tivitis, rhinitis, pharyngitis. Also head gravity and Trichlorethylene
headache, vertigo, salivation, functional neurosis, Trichlorethylene is a colorless liquid with a sweet
decreased body mass. smell and marked volatility. Dissolve well in organic
The diagnosis is based on the professional his- solvents and slightly in water. Long-term storage of
tory or household risk, the presence of acetone, sunlight and contact with an open flame forms phos-
methyl acetone in blood and urine, the expressed gene.
acidosis. Acetone in urine can not be used as an ex- Usage. Trichlorethylene is used as a solvent for lac-
posure test. quers, waxes, rubber, sulfur, phosphorus and the like.
Differential diagnosis - poisoning with other or- It is used for dry cleaning of clothes, extraction of fat
ganic solvents. from metal parts, etc.
Treatment. Breathing resuscitation. Rapid cor- Biotransformation. Pathogenesis. Trichlorethyl-
rection of acidosis with sodium bicarbonate ad- ene penetrates the body inhaled. Inhaled vapors are
ministered intravenously. Symptomatic treatment. absorbed very rapidly and are distributed predomi-
Upon receipt per os - gastric lavage. nantly in organs and tissues rich in lipids, mainly in
Prevention. Sealing of production processes. Ef- the CNS. Absorption is also possible through the skin.
fective ventilation and PPE. People with diseases of Trichlorethylene passes through the placenta.
the nervous system, liver, anemia are not allowed to Approximately 10-20% of trichlorethylene ab-
work. Periodic medical examinations - once a year. sorbed is excreted unchanged and 70-90% is mainly
metabolised to trichlorethanol and trichloracetic acid.
3.2.6. CHLORINATED HYDROCARBONS - Trichlorethylene metabolites are excreted in the urine
D. APOSTOLOVA, J. HADJIEVA - for long-term exposure, the trichlorethanol / trichlo-
racetic acid ratio is 2:1.
They are excellent organic solvents with high tox- Trichlorethylene has a narcotic and neurotoxic ef-
icity. They are used in the manufacture of paints, lac- fect. It primarily affects the nervous system. There is a
quers, plastics, dry cleaning, fire extinguishers and re- habit of becoming addicted to it. It has a toxic effect
frigerators, household cleaning products, etc. on parenchymal organs and has a carcinogenic effect.
Tetrachloromethane (carbon tetrachloride) Clinical picture. Acute poisoning as a result of
Biotransformation. Pathogenesis. After entering inhalation of high concentrations of trichlorethylene
the body, trichloromethyl is produced and no-chlo- causes a state of narcosis and coma. Symptoms of
rine free radicals are formed under enzymatic action, toxic hepatitis, toxic nephropathy and pulmonary
to form complexes of proteins, mainly in hepatocytes. edema have been reported. Short-term inhalation

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of trichlorethylene vapours at lower concentrations They penetrate the body mainly by inhalation of va-
than narcotic, causes irritation of the upper respira- pors or dust (by condensation), and possible poisoning
tory tract and eye. Vasomotory and dyspeptic events, through the skin pathway.
headaches, vertigo, vomiting, sometimes tremor, in- Acute poisoning. Under production conditions,
creased tendon reflexes, olfactory disorders, mental because of the low volatility of CN, acute poisoning
abnormalities, etc. are observed. is unlikely. They are characterized by hepatic and
Chronic poisoning with trichlorethylene occurs cerebral syndromes. Nervous-psychical disorders
primarily with nervous system damage. manifest with suppression (vapidity, apathy, drowsi-
The mild and moderate degree of chronic ness) followed by excitation (trembling, motor anxi-
poisoning is characterized by astheno-vegetative ety, manic state), deepening to coma.
changes (disturbed sleep, headache, vertigo, in- Hepatic impairment is manifested by the picture
creased fatigue) and vegetovascular manifestations of toxic hepatitis that can pass into acute or suba-
(bradycardia, hypotension, extrasystoles). It is also cute yellow dystrophy of the liver, cirrhosis.
possible to have microorganic symptoms (neuritis Chronic poisoning. In mild cases, it is charac-
and polyneuritis of vegetative-sense type, CNS de- terized by common and transient disorders, weak-
feat). ness, headache, dizziness, nervousness, sometimes
Severe stage with toxic encephalopathy, men- accompanied by catarrhal phenomena (tearing,
tal disorders, epileptiform convulsions. The damage coughing, nasal catarrh).
to other organs and systems by trichlorethylene is Initial liver changes occurred with right hypochon-
linked to the endocrine system (menstrual-ovari- driac pain, hepatomegaly, subicteric sclera discolour-
an and male sexual dysfunction) and skin (trophic ation to skin icterus, bilirubinemia, faecal discoloura-
disturbances of distal phalanxes around the nails, tion, urobilinogen and bile pigments in the urine.
dermatitis, eczema, etc.). The carcinogenic effect of At a more advanced stage, it develops toxic
trichlorethylene has only been described in exper- hepatitis, chronic hepatocholescitis, cirrhosis. Gas-
imental conditions (there is no higher incidence of trointestinal tract disorders - gastritis, duodenitis,
malignancies in exposed individuals). stomach and duodenum ulcers often occur. Toxic
Clinical-laboratory tests. Deviations in haema- hepatitis is often accompanied by skin lesions - pho-
tological parameters (polycythemia, lymphocyto- todermatitis (erythematous and erythemo-vesicu-
sis and leucopenia) are observed. Deviations in the lar) with subsequent pigmentation and subjective
clinical and chemical parameters are found with sensations of itching and burning when working in
relevant organ damage (liver, kidney, etc.). Excre- the sun. It also affects the follicular apparatus with
tion tests use the content of trichloroacetic acid and the appearance of comedones, chlorine acne, and
trichloroethanol in urine. secondary infections.
Methylchloride, methylene chloride, chloro- Clinical-laboratory tests. Bilirubinemia up to
form, ethylchloride, dichloroethane, tetrachlo- two to three times the norm, elevation of serum
rethane, pentachloroethane, dichloroethylene, aminotransferases (ASAT and ALAT) and γGTP three
tetrachlorethylene, dichlorethane, dichlorpro- to four times the normal; bile pigments in the urine
pane, ethylenechloride, dichlorethylether, di- - bilirubinuria and hyperurobilinogenuria; cholester-
chlorohydrin, chloroprene, isopropylchloride, ol over 7 mmol/l, hypoglycaemia and hypoprotein-
propylene chloride, allyl chloride, propylene aemia, Hb elevation, gastric hypoacid hyperaciditis.
dichloride, cause carbon tetrachloride and trichlo- Urine naphthol metabolites can be examined as an
rethylene-like changes. exposure test.
Chlorinated naphthalenes (CN) Differential diagnosis of chlorinated hydro-
These include all derivatives of mono- to octachlor carbons - exclusion of diseases of the nervous and
naphthalene. They are solids with a light yellow, green- secretory systems, the liver and skin with non-pro-
ish or brownish color. Generally, mixtures of chlorinat- fessional etiology. Also intoxications with benzene,
ed naphthalenes are used in industry. toluene, acetone, gasoline and others.
Usage. Used as a substitute for wax, resin and rub- Treatment. Acute poisoning requires immediate
ber; in the cable production, production of capacitors discontinuation of the poison and its removal (gas-
and transformers; tissue impregnation; in the ethyl al- tric lavage, cleansing agents, skin wash, etc.). When
cohol composition for the etylation of petrol. indicated, analgesics, respiratory resuscitation, drip
Toxic action. CN toxicity increases with increasing vein infusion of water-soluble and glucose solutions,
chlorine atoms in their molecule, primarily damag- hepatoprotective agents, The treatment of chronic
ing the liver and other parenchymal organs - kidney, poisoning is symptomatic. It also uses vitamin ther-
pancreas, heart. Individual sensitivity is observed. apy, general strengthening agents, balneotherapy

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and others. dizziness, nausea, vomiting, tachycardia, moderate
Labour expertise. Acute intoxications are most dyspnoea. Cyanosis is getting stronger. Methaemo-
often associated with temporary loss of working ca- globinaemia fluctuates from 30-40%, Heinz's body is
pacity. In case of residual phenomena due to acute found in erythrocytes.
poisoning or in case of pronounced symptoms of Severe grade. The symptoms described intensi-
chronic poisoning (eg. chronic hepatitis) permanent fy, disorders of sensitivity, visual acuity, speech oc-
rehabilitation without contact with toxic substanc- cur. There may be convulsions and a coma may oc-
es) cur. Blood methaemoglobin content reaches 60%. It
Prevention. Sanitary-technical prophylaxis (seal- is possible to develop a hemolytic process (jaundice,
ing and automation of production processes) Cur- increase of indirect bilirubin, hemoglobinuria, hepa-
rent control of concentrations of chlorinated hydro- tomegaly). Acute kidney failure may also occur.
carbons Chronic poisoning. The clinical picture of chron-
Medical prophylaxis - do not work, people with ic poisoning depends on the chemical characteristic
diseases of the nervous, secretory, endocrine and of the toxic substance and the duration of exposure.
cardiovascular systems, of the liver and skin. Prophy- Neurasthenic syndrome (headache, fatigue, dizzi-
lactic medical examinations are performed once ness, feeling of fear, etc.) is most often manifested.
every six to twelve months with the participation of With prolonged exposure, it is possible to develop
a neurologist and therapist, and by indications - a degenerative processes in the gray matter of the
dermatologist and ophthalmologist. Protective pro- brain, defeat of some peripheral nerves, obscuration
fessional nutrition - D diet. of the lens of the eye, narrowing of the field of vi-
sion, central scotomas, etc.
3.2.7. AMINO- AND NITRO DERIVATIVES Hepatic damage fluctuates from mild functional
OF BENZENE. TRINITROTOLUENE - disorders to toxic hepatitis. Hepatorenal syndrome
J. HADJIEVA is often seen.
Skin disorders most commonly occur as kerato-
Amino- and nitro derivatives of benzene repre- sis, dermatitis, eczema, acne vulgaris, etc. Benign
sent a large and varied group of compounds. With less and malignant bladder neoplasms have been re-
volatility and high lipo-solubility. ported in individuals in contact with aniline, al-
Usage. They are widely used in the chemical indus- pha-beta-naphthylamine. The allergic action of dini-
try as a starting product in the manufacture of more trchlorobenzene, p-phenylenediamine (so-called
complex chemicals, paints, synthetic resins, explosives, ursolic occupational asthma) is well known.
in the glass, pharmaceutical, rubber industry and oth- Clinical-laboratory tests. A pathognomonic
ers. sign of poisoning with amino- and nitro compounds
Biotransformation. Nitro compounds of benzene of benzole is damage to the blood system - meth-
fall into the body through the airways, the skin and aemoglobinaemia, haemolytic anemia, Heinz body
the digestive tract, and its amino compounds - main- in erythrocytes, etc. Urinary tests show albuminuria,
ly inhaled and through the skin. A major reaction in erythrocytria, increased urobilinogen and porphy-
the biotransformation of aromatic nitro derivatives rin. Deviations in enzyme, detoxic and other liver
is the reduction with the participation of the enzyme functions are observed.
nitroreductase. A characteristic metabolic reaction of Differential diagnosis. With some acute drug
aromatic amines is acetylation. Using the enzyme aryl- poisoning (phenacetin, levomycetine, etc.), with ni-
aminoacetyltransferase, they are converted to aromat- trogen oxides, arsenic acid, and the like. Chronic poi-
ic amides. soning should be differentiated from diseases of the
Pathogenesis. The major pathogenetic mecha- nervous system, blood and hematopoietic system,
nisms of injuries caused by the amino and nitro deriva- damage to the liver, skin, etc. with non-professional
tives of benzene are related to their action as methae- etiology.
moglobin-generators, as well as to their allergenic and Treatment. Acute poisoning includes - gastric
carcinogenic effects. lavage, saline cleanser, skin dressing. Breathing
Clinical picture. There are three levels of acute resuscitation is performed by indication. Haemo-
poisoning: protective agents (haemotransfusion or exchange
Light Grade. Clinical features include headache, blood), glucocorticoids, infusion therapy are used.
general fatigue, disorientation, euphoria, or drowsi- Antidotic treatment with methyleneblue (1-2 mg/kg
ness. Cyanosis of the labia, nose, ears and fingers is body weight, 1% sol. venous for 5 min) - at meth-
observed. aemoglobin above 35-45%. Anti-shock therapy is
Middle grade. Typical are persistent headaches, used in acute circulatory disorders, and in cases of

482
 LABOUR MEDICINE
acute renal failure - dialysis methods. The treatment injury in its early stages (possibly in isolated cases,
of chronic poisoning is symptomatic. the established cataract is also the only criterion in-
Labour expertise. In light poisoning, working dicating retrospective intoxication with trinitrotolu-
efficiency is temporarily reduced. The presence of ene).
hemolytic and hepatic changes necessitates labour Hepatic impairment may persist from mild func-
rehabilitation without contact with toxic substanc- tional disorders to toxic hepatitis, cirrhosis and
es. In severe cases of poisoning (toxic hepatitis, pro- acute yellow atrophy. The observed anemia is of a
nounced anemia, bladder papilloma, etc.) a disabili- hypochromic type.
ty group is defined. Effects of other organs and systems include: as-
Prevention. Sanitary-technical prophylaxis (seal- theno vegetative symptoms, gastrointestinal symp-
ing, ventilation, use of individual protective equip- toms (dyspeptic phenomena, gastroenteritis), skin
ment, etc.). diseases (allergic contact dermatitis, eczema), hair
Medical prophylaxis - Do not work in contact coloration in red, yellowing of the palms and nails,
with benzene amine- and nitrocompounds, people acrocyanosis, menstrual disorders and others. A
with diseases of the nervous and urinary system, higher incidence of skin cancer has been reported
diseases of the blood and the hematopoeitic appa- among trinitrotoluene exposed.
ratus, the liver and the skin. Periodic medical exam- Clinical-laboratory tests. Hematological pa-
inations are performed once every 12 months with rameters - decreased hematocrit and hemoglobin,
therapist and by indications - a dermatologist. Pro- reticulocytosis, methaemoglobinaemia, leucopenia
tective professional nutrition - D diet. with eosinophilia, lymphocytosis, thrombocyto-
TRINITROTOLUENE (trotyl) has six isomers penia, macrocytosis, increased number of nuclear
(technical trinitrotoluene contains alpha-, beta-, gam- erythrocytes, Heinz body.
ma-, and delta-trinitrotoluene). It is a crystal yellow Clinical and chemical parameters - a heterogene-
mass. Dissolves in ethanol, benzene, toluene and ether, ous increase in the activity of serum enzymes - ASAT,
is difficult to dissolve in water. ALAT and LDH, increased cholesterol.
Usage. It is mainly used in the military industry (ex- Differential diagnosis - with unprofessional dis-
plosive material, alone or mixed with other substanc- eases of the blood, liver, visual analyzer, skin, etc.
es). Wide is applied in the production of various dyes. Treatment. The treatment of acute poisoning
Biotransformation. Trinitrotoluene penetrates with trinitrotoluene takes place in the same way
the body primarily through the respiratory tract and as nitrobenzene poisoning, supplemented with
through the skin. Metabolism occurs in the liver. It is hepatoprotective agents. In chronic poisoning,
subjected to reduction processes to form aminoni- treatment is symptomatic-anti-anemic agents, vita-
trotoluene. Part of the trinitrotoluene is oxidized to min therapy, (A, C, etc.), hepatoprotectors and oth-
trinitrobenzyl alcohol, which, after reduction, forms ers.
dinitraminobenzyl alcohol. The two alcohols bind to Medical prophylaxis. Do not work in contact
glucuronic acid and in the form of glucuronides is elim- with trinitrotoluene, people with diseases of blood
inated in the urine. and hematopoietic system, liver, visual analyzer,
Pathogenesis. Trinitrotoluene has a haemotoxic ac- skin, etc. Periodic medical examinations are per-
tion - it causes methaemoglobinaemia. There is also a formed once every 12 months with the participation
pronounced hepatotoxic effect - this effect is associated of therapist, ophthalmologist, and at indications -
with its ability to selectively disturb amino acid metabo- gynecologist. Protective professional nutrition - diet
lism. Trinitrotoluene is also known as a carcinogen. "D".
Clinical picture.
Light acute poisoning occurs with headache, 3.2.8. GASOLINE - R. STEFANOVA
dizziness, general weakness, dyspeptic symptoms,
nausea, vomiting. Benzine is a complex mixture of saturated and
Severe acute poisoning is characterized by unsaturated aromatic hydrocarbons and sulfur com-
brain manifestations, methemoglobinemia, acrocy- pound impurities. It is a colorless or slightly yellowish
anosis, dyspnoea, toxic hepatitis, sometimes aplas- liquid insoluble in water, well, it dissolves in organic
tic anemia. solvents. Its vapour is heavier than the air.
Chronic poisoning. Alcoholism, gastrointestinal Usage. It is used in a variety of industries such as
diseases, obesity, etc. are predisposing to them. solvent for rubber, lacquers, oils, degreasing of metal
A major characteristic of trinitrotoluene poison- parts, extraction of fat. Particularly important is its im-
ing is the triad: toxic hepatitis, toxic anemia and tox- portance as a motor fuel.
ic cataracts. Trinitrotoluene cataract is a sign of toxic People at risk of intoxication are workers in garag-

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 OCCUPATIONAL MEDICINE
es, gas stations, drivers, fitters, workers in the rubber pha waves, the occurrence of beta waves layered on
industry, and workers in yielding, processing, transpor- the theta waves, and also paradoxical reactions of
tation and storage. light stimuls. At the same time there may be mani-
Biotransformation. Gasoline enters the body festations of the nasopharynx - rhinitis, pharyngitis,
through respiratory, skin and digestive tract. Satura- laryngitis; by the eyes - conjunctivitis; gastrointesti-
tion of the blood and the nervous system with gasoline nal manifestations - dyspeptic disorders, toxic liver
is happening very fast. It is excreted through the lungs damage. The menstrual cycle is disturbed, pregnant
unchanged. women may experience spontaneous abortions and
Gasoline is a lipotropic factor and damages pre- stillborns. When it comes to skin, gasoline dissolves
dominantly lipid-rich organs - brain, liver. fat, skin is dry and cracked, and dermatitis and ecze-
Clinical picture. Acute poisoning occurs when ma may develop. In some cases, bronchial asthma is
large amounts of petrol vapors are inhaled in closed also observed.
spaces - cleaning cisterns and tanks, spilling gaso- Clinical-laboratory tests. Moderate decreases
line in closed workshops, passing gasoline with suc- in hemoglobin and erythrocyte count, as well as
tion (inhaled and oral entering). lymphocytic leukopaenia, are observed. Sometimes
Benzine has a narcotic effect and damages the anisocytosis and polychromasia and basophilically
functional state of the central nervous system, the stippled erythrocytes have been found. Impaired li-
extent of its toxicity depends on the percentage of pid metabolism - an increase in total cholesterol and
its constituents. Higher levels of octane in gasoline free fatty acids in the serum. The activity of the ACAT,
cause rapid deep narcosis, while heptane acts para- ALAT enzymes and beta-lipoprotein in the blood se-
lytically on the respiratory center. rum is increased.
The following forms of acute poisoning have Differential diagnosis. In acute gasoline poison-
been observed: ing, differential diagnosis is made with alcohol and
a) a fulminant form - rapid loss of consciousness, barbiturates poisoning, benzene, acetone, chlorin-
and if the injured does not come out of the environ- ated hydrocarbons, upper respiratory tract catarrh
ment, death occurs from respiratory paralysis. and pneumonia, and in chronic - for diseases of the
b) severe intoxication - headache, dizziness, psy- nervous system, liver and the haemal system with
cho motor woes, unmotivated laughter or crying, non-professional etiology.
hysteroidal seizures. Arterial pressure drops, the pu- Treatment. The injured is immediately brought
pils are in mydriasis, occurs hyporeflexia, seizures, into the fresh air. Oxygen therapy (carbogene),
and can lead to coma. agents which stimulates respiratory and cardiac
c) lighter acute poisoning occurs with a condition activity is used. At aspiration of gasoline - gastric
similar to alcoholic intoxication. Aspiration of petrol lavage with medical coal. Follow-up treatment with
vapor may develop toxic pneumonia, manifested by antibiotics, against the possible development of
dyspnoea, chest pain, cough with bloody sputum, pneumonia.
rapid breathing and tachycardia. At chronic poisoning uses tranquilizers, vita-
Gasoline pneumonia is accompanied by fever. minotherapy (vitamin B1, C), physiotherapeutic pro-
Radiography shows massive obscurations in the cedures, and more.
lungs. Occupational medical expertise. In light poi-
When gasoline is ingested, cataracts of the di- soning, working capacity is temporarily lost. In case
gestive system are observed, along with the typical of residual phenomena of acute intoxications and
nervous signs of benzine poisoning. in chronic ones, labour is required without contact
After acute poisoning, residual phenomena such with toxic substances.
as emotional instability, neurosis-like conditions, im- Prevention. Sealing the production process, ad-
paired vestibular function, and neuritis are observed. herence to all rules of safe operation and dynamic
Chronic intoxication is manifested by neuro- monitoring of gasoline concentrations in the air of
ses, disturbances in the dark, irritability, frustration, the working environment.
sometimes ataxia, vegetative polyneuritis, dizziness, Medical Prevention. Do not work in contact with
tinnitus, chest constriction, head gravity and persis- gasoline persons with liver, nervous, digestive and
tent headaches, vascular disorders, accomodative haemal system diseases. Periodic medical examina-
eye asthenopathy, disturbed memory, psychoses, tions are performed once every 12 months with the
etc. Objectively, vascular disorders, decreased sense participation of therapist, neurologist and dermatol-
of smell, red dermograms, tremor, hyperreflexia, ogist. Protective nutrition, with more proteins and
Ashner-Danny's changed reflex were detected. The vitamins - diet D.
electroencephalographic study shows reduced al-

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3.2.9. CARBONDISULFIDE - Chronic poisoning occurs with: neurological
ST. ANDONOVA, S. PAVLOVA syndrome characterized by an equilibrium disorder,
memory disorders, visual disturbances, retrobulbar
Acute poisoning toxic neuritis, polyneuritis, toxic encephalopathy and
- disorder, manic delirium, hallucinations, para- sometimes psychical abnormalities; cardiovascular
noia syndrome - increased arterial blood pressure, angi-
- upper respiratory tract inflammation na pectoris with conductive and rhythmic disorders,
Chronic poisoning "carbondisulfide atherosclerosis"; gastrointestinal
- coronary disease complaints - appetite disorders, stomach weight,
- neurobehavioural disorders nausea, vomiting, gastro-intestinal disorders and ul-
- retinal micro-aneurism cerative disease; endocrine disorders - disturbances
- peripheral neuropathy with ascending, sym- in the menstrual cycle and the course of pregnancy,
metrical paresthesia and weakness impotence, hypothyroidism, diabetes. Hepatotoxic,
Physical and chemical properties. Carbondisulfide nephrotoxic effects, anemic syndrome, dermatitis
(CS2) is a colorless, volatile liquid with unpleasant odor. (erythema, vesicles, chemical burn) can be detected.
Evaporates at ordinary temperature. Its vapour is 2.6 Clinical-laboratory tests.
times heavier than the air. It is easily flammable and The diagnosis is based on the professional histo-
explosive. Good solvent is for fat, wax, rubber, sulfur, ry, clinical manifestations, the amount of carbondi-
phosphorus, iodine, etc. sulfide in the exhaled air, the blood, the evidence
Usage. Carbondisulfide is used in the production of of urinary metabolites (thiourea, thiocarbamic ac-
artificial fibers (viscose), waterproof adhesives, as a sol- ids, sulphates), iod-azide test-biological markers for
vent for fat, waxes, in the rubber and chemical industry, acute and chronic exposure.
for the extraction of essential oils and floral perfumes, Differential diagnosis - poisoning with meth-
for the production of tetrachlormethane, rhodanides, anol, toluene, tetraethyl-lead, freons, damages of
optical glass, pesticides, at flotation of ores, as an in- cardiovascular, nerve and endocrine functions with
secticide and others. It is separated in coal coke and non-professional etiology.
in distillation of charcoal (it is obtained by interaction Treatment. In acute poisoning - inhalation of
with sulfur vapors). alkaline aerosol preparations, oxygen-therapy, res-
Biotransformation. In production conditions it piratory resuscitation, forced diuresis, combination
enters the body through the airway and through the of pyramem, vit. B6, B12, symptomatic drugs, depend-
skin as one part dissolves in body fluids, so-called free ing on the stage.
carbondisulfide, and the other part is bound to the In chronic poisoning, treatment is based on the
amino acids to form thiocarbamates. leading symptoms.
About 70% of the carbondisulfide cumulated. Me- Prevention. Sealing of production processes,
tabolized to 2-thiothiazolidine-4-carbonic acids. It ventilation, control of the working environment,
is eliminated by exhaled air (up to 30%), urine-un- personal protective equipment. Medical prophy-
changed (1%) and up to 90% as metabolites: thiourea, laxis. It is necessary to carry out a strict medical ex-
thiocarbamic acids, sulphates and others. amination at the beginning of the work. The review
Pathogenesis. Its toxic effect on nerve structures from an internist, neurologist and ophthalmologist
is determined by its lipotropicity, its ability to bind should include a detailed history of past illness. It is
sulfhydryl and amine groups, resulting in cellular me- desirable to do ECG and laboratory tests (cholester-
tabolism disorders. The genetal toxic effect of CS2 is ol, blood sugar, transaminases). As the primary cri-
related to the inhibition of mixed function oxidases, terion for professional selection, a disulfiram test is
which leads to increased levels of cholesterol, steroid used to demonstrate inborn or acquired deviation
hormones, prostaglandins, fatty acids with the devel- of mixed function oxidases. Contraindications for
opment of the corresponding pathology - endocrine, entry are: pronounced neurosis, organic diseases
cardiovascular and nervous system disorders. of the central and peripheral nervous system, car-
Clinical picture. Acute poisoning occurs in diovascular diseases, chronic diseases of the liver
emergency situations. They are expressed in three and kidneys, diabetes, ulcerative disease. Periodic
stages: mild-irritative effects on the mucous mem- prophylactic examinations are performed for 12
branes of the eyes and the airways, headache, fa- months by an internist, neurologist, ophthalmolo-
tigue, psychomotor agitation; moderate degree gist, obstetrician and gynecologist, and include an
- vomiting, vertigo, visual disturbances; severe de- iod-azide test, cholesterol, thiourea and urinary pro-
gree - comatose status. Acute psychoses with deliri- tein. Protective nutrition - diet "D", rich in lipotropic
um are observed in moderate and severe grades. factors, vitamins (C, B1, B6), copper, zinc.

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REFERENCES
General Studies
1. Baker, El. Jr., Smith, T.J. - The neurotoxicity of industrial solvents - Am. J. Ind. Med., 1985, 8, 207209.
2. Craft, BF Solvents and Related Compounds in: Environmental and Occupational, Med., Rom WN (Edi-
tor), Little Broun, 1983.
3. James, R.C. The toxic effects of organic solventsin: Industrial Toxicology. Williams, PL, Burson, JL (Edi-
tors), Van Nostrand Reinhold, 1985.
4. Riihimaaki, V., Ulfarson, U. (Editors): Safety and Health Aspects of Organic Solvents - Proceedings of
the International Course on Safety and Health Aspects Of Organic Solvents, Health in ESPO, Finland, 2226 IV
1985, Alan R. Liss, 1986.
5. Rosenberg J. Solvents in Occupational Medicine, Appleton & amp; Lange, California, 1999, 359-387.
Alcohols
6. Monov, A. - Alcohols - in: Internal diseases, ed. A. Maleev, Sofia, Med. And Phys., 1980, vol. III, 533-536.
(in bul.)
7. Spassovski, M. - Exposition tests - in: Laboratory diagnosis of occupational diseases, ed. D. Charak-
chiev, Sofia, Med. And Phys., 1979, 9091. (in bul.)
8. Spassovsky, M., I. Benchev, V. Hristeva - Hygienic-toxicological studies of methanol workers in poly-
ester fiber production S., Letopisi of HEI, 1978, 76-79. (in bul.)
9. Professional pathology - ed. Ts. Aleksieva and Kr. Kiriakov, Sofia, Med. And Phys., 1982, 85-88. (in bul.)
10. Pharmacology - P. Nikolov, D. Paskov, S., Med. And Phys., 1960, 121-129. (in bul.)
11. Hygienic toxicology - a special part ed. F. Kaloyanova, S., Med. And Phys., 1983, 8492. (in bul.)
12. Alcohols. In the Encyclopaedia of Occup. Health and Safety, ed. J. M. Stellman, vol. IV, Fourth Edition,
ILO, Geneva, 1998, 104.32-104.45.
13. Alcohols. In Solvents - J. Rosenberg. Occupational Medicine, ed. J. LaDou, Appleton and Lange, Nor-
walk, Connecticut, 1990. 375.
14. Methanol. Environmental Health Criteria 196. WHO, Geneva, 1997, p. 180.
15. Toxicological Profile for Acetone. Public Health Service, Agency for Toxic Substances and Disease Reg-
istry, Atlanta, Georgia, USA, 1994, p. 276.
16. Toxicological Profile for Benzene. Public Health Service, Agency for Toxic Substances and Disease Reg-
istry, Atlanta, Georgia, USA, 1997, p. 463.
17. Sulivan J. B, M. Van Ert - Alkylbenzene Solvents and Aromatic Compounds in: Hazardous Material
Toxicology, Williams & Wilkens, Baltimore, Tokyo, 1992, 10961100
Gasoline
18. Kiriakov, Kr. in Professional pathologyed. ed. Alexieva, Tz. and Kr. Kiriakov, Sofia, Med. And Phys.,
1982, 75-78. (in bul.)
19. Lazarev, V. H. - Harmful substances in production, Vol. I, Len., Chemistry, 1976, 93-107. (in russ.)
20. Sokolov, V.V. - Professional diseases in chemical industry ed. A. Letavet, Moscow, Med., 1965, 21-25.
(in russ.)
21. Trendafilova, R. - Gasoline - in: Laboratory Diagnosis of Occupational Diseases, ed. D. Charakchiev,
Sofia, Med. And Phys., 1979, 218219. (in bul.)
22. Draft. Technical report for ethylene glycol / propylene glycol. Prep. By: Clement International Corpora-
tion under Contract No 205-88-0608. Prep. For the Agency for Toxic Substances and Diseases, Registry of the
US Public Health Service, May, 1993.
23. Ethylene Glycol: Human Health Aspects. IPCS, The Concise International Chemical Assessment Docu-
ment No. 45, WHO, Geneva, 2002, p. 38.
24. Toxicological Profile for Phenol. Public Health Service, Agency for Toxic Substances and Disease Reg-
istry, Atlanta, Georgia, USA, 1998, p. 241.
25. Stellman J. M, D. Osinsky, P. Markkanen. Ketones. Encyclopaedia of Occup. Health and Safety, ed. J.
M. Stellman, ILO, Geneva, 4th edition, 1998, 104, 313, 104-324.
Carbondisulfide
26. Izmerov, N.S., Manual of professional diseases, Medicine, Moscow, 1983, p. 313 (in russ.)
27. Pavlova, S., Toxico-chemical and clinical-chemical criteria for evaluation of chronic intoxication of
carbondisulfide. Dissertation, Sofia, 1982. (in bul.)
28. Carbon-disulfide, United Nations Program on environment, Moscow, 1983, p. 27. (in russ.)

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29. Cox C., S. S. Hee and W. P. Tolos, Biological monitoring of workers exposed to carbon disulfide., An.
J. Ind. Med., 33, 1998, 1, 48-54.
30. Toxicological Profile for Carbon Disulfide, Agency for Toxic Substances and Disease Registry, Atlanta,
Georgia, USA, 1994, p. 197.
31. Carbon Disulfide. IPCS, The Concise International Chemical Assessment Document No 46, WHO, Ge-
neva, 2002, p. 42.
Chlorinated hydrocarbons
32. Urano S., Tokura Y. An erythema multiforme - like eruption caused by exposure to 1-chloromethyl-
naphthalene. J. Dermatol. 1998, Jan. 25 (1): 13-8.
33. Gupta P., Banerjee D.K., Bhargava S.K., Kaul R., Shanker V.R. Abnormal pattern of lung function in
rubber factory workers. J. Indian. Med. Assoc. 1994, Aug. 92 (8): 260-3.
34. Ward E. M., Ruder A. M., Suruda A., Smith A. B., Halperin W., Fessler C. A., Zahm S. H. Cancer mor-
tality patterns among female and male workers employed in a cable manufacturing plant during World War
II. J. Occup. Med. 1994, Aug. 36 (8): 860-6.
35. Popp W., Norpoth K., Vahrenholz C., Hamm S., Balfanz E., Theisen J. Polychlorinated naphthalene
exposures and liver function changes. I am. J. Ind. Med. 1997, Oct. 32 (4): 413-6.

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3.3 POLYMERS
POLYMERIZATION POLYMERS
Plastics Monomer Acute poisoning Chronic poisoning Exposure tests
Polyethylene ethylene headache cerebrasteny –
asthenia autonomic dysfunction
arrhythmia IHD
Polyvinylchloride vinyl chloride >10000 ppm Raynaud's phenomenon Le Тhr 
narcotic action osteoporosis, acroosteolysis tiodiglycolic acid
hepatitis hepatitis, cirrhosis, angiosarcoma in urine> 5ppm
scleroderma
anemia
pulmonary fibrosis, asthma
Polystyrene styrene conjunctivitis conjunctivitis, pharyngitis, Le Тhr 
pharyngolaryngitis bronchitis ASAT ALAT 
dermatitis anemia, jaundice, hepatitis mandelic acid
myocarditis > 200mg/l
headache, asthenia phenylglioxalic acid
uncritically behavior > 20mg/l in urine
discoordination EEG-diffuse slow
cognitive and behavioral changes waves
memory loss psychological tests
CT
Polyacrylonitrile acrylonitrile irritation UAP conjunctivitis, keratitis thiocyanates in urine>
fibers cyanosis atrophic rhinitis 2,5 mg/g creatinine
dizziness vocal cord paresis
disorientation autonomic dysfunction
convulsions vestibulopathy
coma IHD
anemia
dermatitis, necrosis
increased risk of Ca pulmo
polymethyl- Methyl- asthenia conjunctivitis, rhinopharyngitis formaldehyde blood>
methacrylate methacrylate gastrointestinal dermatitis 0.2 mmol/l
disorders arterial hypotension formaldehyde urine
headache hepatitis > 0,3mmol/l
loss of hypochromic anemia methanol in urine> 15 mg/l
consciousness, autonomic dysfunction formic acid in urine -
epileptiformic polyneuropathy 80mg/g creatinin
convulsions vestibulopathy
encephalopathy

POLYCONDENSATION POLYMERS
POLYCONDENSATION POLYMERS
Plastics Monomer Acute poisoning Chronic poisoning Exposure tests
polyisocyanates pneumonia, bronchitis, COPD
polyvalent alcochols pulmonary edema bronchial asthma
Polyurethanes –
tertiary amines burning of the cornea allergic dermatitis
and skin
phenol
in splashing of 1/4 to 1/2
pharyngitis, bronchitis
of the skin - death phenol in urine
gastritis
fever >0,16mmоl/l
Phenol- neuroses
breathing disorders
formaldehyde
resins formaldehyde mucous membrane and conjunctivitis, pharyngitis Formaldehyde blood
UAP bronchitis, asthma >0,2 mmоl/l
cough, dyspnea, coma contact dermatitis formaldehyde urine
rashes, dermatitis >0,3mmоl/l
epichlorohydrin contact dermatitis and allergic dermatitis and phenol in urine
Epoxy resin diphenylpropane eczema eczema
ethylenediamine autonomic dysfunction
gastritis

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SYNTHETIC RUBBERS
Kinds Monomers Acute poisoning Chronic poisoning
Butadiene 1,3-butadiene headache, dizziness, asthenia, neurasthenia, palpitation, hypotension, dyspepsia
(divinyl) tachycardia, hypotension, coma conjunctivitis, pharyngitis, leucopenia with lymphocytosis,
dermatitis, eczema.

Butadiene- butadiene – conjunctivitis autonomic dysfunction

styrolous styrene pharyngitis myocardiodystrophy
bronchitis toxic hepatitis, dyslipidaemia
hepatitis menstrual disorders
Isoprenous isoprene + asthenia neurasthenia syndrome
lithium salts dyspepsia autonomous distal polyneuropathy
mucous membrane and UAP increase of thyroid
irritations toxic hepatitis
allergic dermatitis
Butyl isobutylic conjunctivitis asthenia, abnormal function of the ANS and CNS
rubbers isoprene pharyngitis rhinopharyngitis
Chloro- chloroprene conjunctivitis, pharyngitis, neurasthenia syndrome
prenous tachycardia, collapse autonomous vasomotor disturbances
leukopenia myocardyodistrophy
hair loss toxic hepatitis, nephrosonephritis
dyspepsia
anemia, reticulocytosis
dermatitis and eczema

3.3.1. ACRYLAMIDE - V. PETKOVA eczema. Typically, these skin changes precede the
emergence of classical neurological syndromes in
Acrylamide is an acrylic acid compound and has a the clinical picture of chronic poisoning. Feeling
significance as chemical professional factor in the pro- numb, constant freezing of the fingers, difficulty in
duction and processing of polymers (polyacrylamide), fine movements (when writing, for example), mus-
when used as a flocculants. cle pain and weakness in the wrists and feet are the
Biotransformation. Acrylamide enters the body first symptoms of peripheral nervous system in-
through the airways and skin. Because of its good sol- volvement. Consequently, the symptoms cover the
ubility in water, its distribution to the body's tissues is whole limbs. On the background of toxic cerebras-
rapid, with the highest concentrations found in eryth- theny, the typical for moderate and severe stages of
rocytes. Biotransformation is via the glutathione sys- poisoning "dying back" neuropathy develops with
tem. When conjugated to the latter, nontoxic metab- distal hypesthesia and limb paresis and severe ataxia
olites are formed, which are released relatively quickly phenomena - so-called acrylamide pseudotabes.
and mainly in the urine. Acrylamide is assigned by IARC to a 2-B group of
Toxic effect. The toxicity of acrylamide is associat- chemicals - a probable carcinogen of lower proba-
ed with its ability to disrupt by binding to cellular DNA, bility.
the protein synthesis in the proprioceptors, neurons, Clinical-laboratory tests. Electromiographic
and axonal endpoints of motor fibers. Its effects on data for axonal lesion with reduced amplitude of
neuromediator functions have also been determined induced muscle or nerve potentials as well as de-
by reducing the concentration of noradrenaline, dopa- layed conduction in motor fibers in severe cases of
mine etc. in central nervous system. peripheral neuropathy. In skin manifestations - pos-
Clinical picture. itive skin-allergic tests to acrylamide. Exposure tests
Acute poisoning. They run through manifesting for acrylamide have not been developed.
disorders in the CNS - behavioural abnormalities, au- Differential diagnosis. Poisoning with acryloni-
ditory and visual hallucinations, seizures. In severe trile, styrene, vinyl chloride, benzene, methanol.
forms there is a loss of consciousness and respirato- Treatment. Treatment of acute and chronic poi-
ry distress syndrome. Several weeks after the acute soning is symptomatic. There is no antidote therapy.
accident are expected to develop late peripheral High doses of vitamin B6 are recommended for neu-
neuropathy. rotoxic effects.
Chronic poisoning. Specific symptoms in the Labour expertise. The onset of peripheral neu-
early stages of chronic poisoning are abundant ropathy is an indication of termination of contact
sweating, erythema and desquamation of the palms with the toxic noxa - full recovery is expected in
and feet, forming contact or allergic dermatitis and treatment. In pseudotabes forms, recovery is slow

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and sometimes impossible - a permanent loss of action of cyanide and thiocyanates and its mutagenic
working capacity is determined. effect to glycidonitrile (a reactive metabolite capable
Prevention. Process sealing, ventilation, obliga- of alkylating macromolecules).
tory wearing of personal protective equipment. Do Clinical picture. The most common symptoms
not work with acrylamide persons with neurologi- of acute poisoning are upper respiratory tract irri-
cal, skin and allergic diseases. Periodic examinations tation, respiratory distress, nausea, cyanosis, vertigo,
are performed once a year with the participation of disorientation, weakness in the extremities, collapse,
a neurologist and dermatologist. If possible, EMG convulsions, cardiac arrest.
monitoring of peripheral nerves is performed. Pre- Continuous inhalation of acrylonitrile vapors
ventive-professional nutrition - diet D, vitamino- produces atrophic rhinitis, sometimes a vocal cords
prophylaxis. paresis. The majority of workers exposed to AN have
complaints of easy fatigue, weakness, headache,
3.3.2. ACRYLONITRILE - T. KUNEVA dizziness, drowsiness, irritability, lack of appetite,
pain in the heart zone. It is often diagnosed ashe-
Acute poisoning no-vegetative or neurasthenic syndrom. There are
- nervousness, irritability of UAP, nausea, vertigo, electrocardiographic changes and, in some cases,
- convulsions, coma, death myocardial dystrophy. Disorders of the gastrointes-
Chronic poisoning tinal tract, liver function, vestibular disorders are
- nausea, headache, vertigo, easy fatigue noted. In contact on liquid acrylonitrile on the skin,
- increased risk of lung cancer chemical burn is developing. Especially serious are
Acrylonitrile (AN) is a volatile colourless liquid with the damage to the conjunctivae, sometimes with se-
characteristic smell that can be detected at 20 ppm. It vere corneal damage. Epidemiological studies have
has the property of polymerizing itself (polymerization shown that AN is associated with an increase in the
can be inhibited by the addition of alkaline substances risk of lung cancer and colon cancer with a latency
- used to store it). Dissolve well in organic solvents. period of 20 years and is considered a probable car-
AN's vapors are explosive and highly flammable in cinogen for humans - IARC, group A2.
the range of 3 to 17% - hydrogen cyanide may be re- Clinical-laboratory tests. Chromosomal assays
leased during combustion. at acrylonitrile exposed there are no increase in ab-
Usage. AN is the starting material for the synthesis errations. In acute intoxication, an increase in the
of polyacrylnitrile fibers. It is used in the production of serum level of cyanide or thiocyanates in the urine
synthetic rubber, acrylamide, acrylic acid, paints and may be found. Exposure test - thiocyanates below
medicines. Acrylonitrile-containing plastics, especially 2.5 mg/g creatinine.
acrylonitrile-butadiene-styrene rubber and tirenacry- Differential diagnosis. Poisoning with cyanide
lonitrile, are used in fitting tubes for automotive engine compounds, methanol, acrylamide, toluene, sty-
parts. Due to the resistance of nitrile elastomers to oils rene, carbon tetrachloride.
they are used in the petrochemical and automotive in- Treatment. Bleeding out and oxygen therapy.
dustries. Upon oral ingestion, a stomach wash with water,
Biotransformation. Metabolism. The primary medical charcoal and 1% sodium hyposulphate
route of penetration of AN is the respiratory. Liquid solution.
acrylonitrile penetrates well through healthy skin and Depending on the available complications, glu-
especially through damaged skin and mucous mem- cose solutions, calcium preparations, B and C vita-
branes. mins are administered in large doses. Antidote treat-
The mechanism of action of acrylonitrile has not ment (CN radicals-rhodanates) does not apply.
yet been elucidated. Based on the observed increased Expertise on ability to work. In the case of
cyanide content in the blood and urine, the presence non-curable skin injuries, it is necessary change of
of cyanemethaemoglobin, the clinical and pathohisto- work that there is no contact with allergens.
logical similarities with the cyanide poisoning, it is as- Prevention. Safe technologies, effective ventila-
sumed that acrylonitrile acts to release a cyanide that tion, PPE.
determines its toxicity. The hypothesis is that the main Medical prophylaxis. Persons with chronic CNS
action of AN is through its whole molecule: blocking disorders, mental, endocrine, pulmonary, allergic
the active centers and groups of vital enzymes; cya- and cardiovascular diseases are not allowed to work
nide release in response of AN and cytochromosadase; with acrylonitrile. Periodic medical examinations are
reversible suppression of the activity of the respiratory conducted once a year with a therapist and neurol-
ferments; total blockage of cell metabolism. ogist involved, and include full blood counts, a gen-
The acute toxicity of AN is believed to be due to the eral urine study, and urinalysis of acrylonitrile and

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thiocyanates. Skin-allergy testing with acrylonitrile ifestations are irritation of the mucosal epithelium
is desirable. (chronic pharyngitis and bronchitis), eye (chronic
It is recommended that diet D from the protec- conjunctivitis), intestinal tract (gastritis). Workers ex-
tive professional nutrition. posed to styrene at concentrations of less than 100
ppm experience complaints of weakness, headache,
3.3.3. STYRENE - T. KUNEVA dizziness, tiredness, memory weakness, delayed
reaction time. Prolonged exposure may indicate
Acute poisoning anxiety, emotional lability, increased excitability, ir-
- Irritative manifestations of the eyes, skin and ritability, depression. Objectively, there are changes
UAP in the electroencephalogram, delayed peripheral
Chronic poisoning nerve conduction, disturbances in the performance
- Headache, weakness, fatigue, dizziness of psychological tests.
- Uncritical behaviour, distorted coordination It is possible for toxic liver damage - hepatomeg-
- Cognitive and behavioural changes aly, increased activity of serum enzymes and serum
- Personality changes bile acids.
- Memory loss Dystrophic changes in the myocardium and low-
- Hepatic dysfunction - jaundice, hepatomegaly, ering of blood pressure have been described.
carcinogen Styrene is a mutagen and can cause chromosom-
Styrene is a colorless volatile liquid with a sweet al aberrations in humans. Studies on cancer mor-
smell. tality do not indicate an increased risk of exposure
Usage. The main application of styrene - about - according to the IARC classification, it is in the B2
90% of the total production - is to produce polystyrene group and the styrene oxide - group A2.
(3rd place in the total polymer production after poly- Clinical-laboratory tests. Moderate leukope-
ethylene and polyvinyl chloride). Styrene is also used as nia with relative lymphocytes, reticulocytosis, mild
a copolymer in the production of polyester resins and thrombocytopenia is found in the blood. Elevated
synthetic rubber, as well as paints and varnishes. total fat, cholesterol, triglycerides; total and direct
Possibility of poisoning with styrene exists in work- bilirubin; increases the activity of liver enzymes. Ex-
ers engaged in synthesis and polymerization in the posure tests are: mandelic and phenylglyoxal acids
manufacture of plastics, rubber, fiberglass, paints. in the urine - above 200 mg/l and above 20 mg/l, re-
Biotransformation. Pathogenesis. Styrene pen- spectively.
etrates into the human body mainly via the airway, Differential diagnosis is made by poisoning
less often through the skin. Its distribution in organs is with benzene, toluene, ethanol and other organic
relatively even, accumulation is only seen in fat tissue. solvents.
Styrene is metabolised in the liver to mandelic acid and Treatment. Quickly remove from the gassed en-
phenylglyoxalic acid excreted in the urine. vironment, oxygen therapy. Upon swallowing - gas-
The toxic action of styrene is similar to benzene. Sty- tric lavage with water and medicinal charcoal, liquid
rene has a more irritating effect on the skin and mu- paraffin is infused at the end of the lavage. If it gets
cous membranes, but has a lesser effect on hemato- on the skin - thoroughly wash with water. Local der-
poiesis and has a lower narcotic effect than benzene. matoses are used topically to corticosteroids. Cere-
Clinical picture. bro- and pulmoprotective agents.
Acute poisoning occurs relatively rarely, due to Chronic obstruction is recommended for hepato-
the highly irritating action of the styrene on the mu- protective agents and vitaminotherapy. Balneother-
cous membranes. apy.
Concentrations between 100 ppm and 200 ppm Labour expertise. Depending on the degree of
styrene elicit inflammatory changes in eyes and ad- intoxication, temporary or permanent rehabilita-
enocarcinoma. Prolonged contact may cause skin ir- tion without contact with toxic substances. For pro-
ritation and dermatitis and increase skin absorption. nounced forms of toxic hepatitis and encephalopa-
Inhalation of styrene vapors causes irritation in thy, retirement by determining the disability group.
the throat, eyes, nose, metallic taste in the mouth, Prevention. Because of the high risk of ignition,
nausea, vomiting, dizziness, headache, apathy, complete automation of production processes, ef-
drowsiness, and at high concentrations - distur- fective ventilation, PPE - with appropriate gloves,
bance in equilibrium, weakened concentration, re- shoes, aprons and safety glasses is recommended.
duction of reaction time. Parenchymal organs are Medical prophylaxis. Contraindications for get-
not damaged. ting into contact with styrene are chronic diseases
Chronic intoxications. The most common man- of the heart and lungs, gastrointestinal tract, liver

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and kidney, organic diseases of the nervous system. cially angiosarcoma of the liver, which can develop
Periodic medical examinations are conduct- after a prolonged latency period of 15 to 40 years.
ed once a year with therapist, dermatologist and Reproduction effects are also described - an in-
otorhinolaryngologist. Paraclinic studies include the creased incidence of spontaneous abortions and
determination of mandelic and phenylglyoxalic acid congenital abnormalities of the CNS. A higher in-
in urine. cidence of arterial hypertension, headache com-
It is recommended that diet D from the protec- plaints, and tiredness were also found in workers.
tive and professional nutrition. Clinical-laboratory tests. Leukopenia or throm-
bocytopenia is observed in peripheral blood. In ex-
3.3.4. VINYLCHLORIDE - V. PETKOVA haled air, VC can be defined as an exposure test. The
content of one of the final metabolites of VC-thiodi-
Vinyl chloride (CH2 = CHCL) is also known as chlo- glycolic acid in the urine is also an exposure test -
roethane, monochloroethylene, vinyl chloride mon- above 5 ppm. Elevated ASAT, ALAT, LDH, bound bili-
omer. Possibilities for poisoning with VC monomers rubin in the blood.
exist in the production and subsequent thermal treat- Differential diagnosis. Raynaud's disease, scle-
ment of polyvinyl chloride - plastic, which is extremely roderma, vibration sickness, poisonings with trichlo-
widespread for household and domestic purposes. The rethylene and ketones.
highest risk of poisoning is the cleaners of the reactors Treatment. Treatment is symptomatic of acute
in which the polymerization of VC is carried out. poisoning. At Raynaud syndrome and vascular dys-
Biotransformation. VC enters the body mainly tonia syndrome use vasodilators and pain allaying
through the respiratory organs. In the process of bio- drugs, vitaminotherapy. Physiotherapy.
transformation, metabolites - chloroacetaldehyde, vi- Prognosis and labour expertise. In the initial
nylchloridedepoxide, glycolaldehyde, which have sig- stages of poisoning, the clinical symptoms are re-
nificantly higher toxicity than VC, are formed. versible, but regardless of the stage, vinyl chloride
Part of the inhaled VC is unchanged with exhaled disease is a reason for permanent cessation of pro-
air - at high concentrations in the air - up to 90%, at low fessional contact with VC. Clinical symptoms may
- 12-15%. Absorbed VC is excreted in the urine, partially also progress after discontinuation of exposure.
unchanged, but mainly in the form of metabolites. Prevention. Sealing of production processes,
Pathogenesis. The toxic effect of VC is due to the efficient ventilation. Persons with pronounced ar-
direct action of its metabolites on cellular proteins terial hypertension, liver pathology, chronic lung
and DNA as well as on some redox systems - it reduc- disease and diabetes are not allowed to work with
es the amount of glutathione in the liver, link also with VC. Prophylactic examinations are performed once
cysteine. a year with the participation of a neurologist, intern-
Clinical picture. ist and ophthalmologist and examination of platelet
Acute poisoning. At high concentrations, VC has and leukocyte counts as well as the activity of ASAT
a pronounced narcotic effect. and ALAT. For monitoring of exposure - periodic de-
Chronic poisoning. Chronic vinyl chloride intox- termination of thiodiglycolic acid in the urine.
ication is demonstrated with peripheral angiodys-
tonia and relative typing manifestations of Rayno's 3.3.5. ETHYLENE - T. KUNEVA
disease-type angiospasm, against the background
of neurosis-like conditions. In the subsequent heav- Acute poisoning - Headache, asthenia, arrhyth-
ier stages, sclerodermic skin changes, osteoporosis mia, coma
and acrosteolysis, as well as bone deformations of Chronic poisoning - Toxic cerebrovascular syn-
distal phalanges of the fingers lung affect and thick- drome, autonomic dysfunction.
ening of the nails in the form of a clock glass are ob- Ethylene is a monomer used to make vinyl chloride,
served. The clinical picture is complemented by the polyethylene resin and plastics. It's used in surgeon-for-
development of toxic hepatitis or lung affect - toxic narcosis.
pneumofibrosis, obstructive conditions. Ethylene penetrates the body through the airway
The characteristic combination of syndromes in and eliminates unchanged by breathing air. It is a clas-
the unfolded clinical stage of poisoning has given sic drug, a potential carcinogen.
rise to a terminological differentiation of a disease Clinical picture.
unit - vinyl chloride disease. Acute poisoning occurs as a narcosis but lacks
Vinyl chloride is among the humanly proven car- the initial stage of excitement. At high concentra-
cinogens (IARC classification 1 group). Characteristic tions, headaches, asthenia, temporary loss of con-
of the carcinogenic effect of VC is lung cancer, espe- sciousness, arrhythmia, breathing disturbances,

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 LABOUR MEDICINE
coma are observed. odor.
Chronic poisoning occurs in the form of neuroso Usage. Methyl methacrylate is a major monomer
similar (toxical cerebrathenic) syndrome, angiodis- in the production of acrylics, also used in the produc-
tonic or angiospastic syndrome and other manifes- tion of organic glass (plexiglas), optical lenses, varnish-
tations of autonomic dysfunction with thermoregu- es and resins, displays ,for the production of light con-
latory, sudomotor and vasomotor disorders, in rare structions for inscriptions, windows, etc.
cases hypothalamic syndrome. Biotransformation. Pathogenesis. Enters the
Electrocardiographic findings have been report- body mainly through the respiratory tract and through
ed for ischemic heart disease. Cases of hepatic inju- the skin. Methyl methacrylate is completely hydrolyz-
ry as well as ovarian-menstrual disorders have been ed to methyl alcohol and methacrylic acid. In turn, the
observed. There is no proven carcinogenic effect of methyl alcohol is oxidized and form formaldehyde and
ethylene and polyethylene in humans and laborato- formic acid. It is eliminated relatively quickly, it has
ry animals. no cumulative effect. Methyl methacrylate and meth-
Clinical-laboratory tests. Ethylene metabolites acrylic acid have irritating and narcotic effects (lipo-
have not been identified and there is no specific lab- tropic substances), damaging parenchymal organs.
oratory finding. A mild anemic syndrome with leu- Clinical picture. The most common symptoms
copenia and cytopenia tendency has been reported, of acute poisoning are weakness, nausea, vomiting,
increased hepatic enzyme activity and changes in headache, tightness in the chest, arterial hypoten-
lipid exchange. sion, and in more severe cases - loss of conscious-
Differential diagnosis - Raynaud's syndrome, ness and epileptiform seizures. Usually there are no
autonomic poly-neuropathy in vinylchloride intoxi- residual phenomena after acute poisoning.
cations, endocrine diseases, methane, acetone, eth- Leading place in the clinical picture of chronic
anol, gasoline, etc. intoxications. poisoning with methyl methacrylate is the dam-
Treatment - symptomatic. In toxic hepatitis - age to the nervous system. In the initial stage (I), a
hepatoprotective agents, dietary nutrition. neurasthenic syndrome with predominance of au-
In polyneuropathy - peripheral vasodilators: tonomic disorders is characteristic. Exposed workers
non-steroid anti-inflammatory agents; analgesics; complain of fatigue, headache, vertigo, feel faint, ir-
sedatives and mild antidepressants, vitamin B and ritability, sweating. Polyneuropathies (II) have been
vitamin E. diagnosed with polymetacrylate workers over 10
Labour performance. Pregnant women are la- years, as well as functional changes in vision, smell
bour readjustment. In the development of auton- and hearing, vestibular abnormalities, dystrophic
omous polyneuropathy, temporary labour is also bone changes. Patients report memory disorders
required without contact with toxic substances and and character changes. A psycho-organic syndrome
heavy physical labour. may be formed. Possible development of toxic en-
Medical prophylaxis. Contraindications for con- cephalopathy (IIIst).
tact with ethylene are diseases of the nervous, en- Dystrophic changes in myocardium and liver
docrine, cardiovascular system, chronic liver disease, (toxic myocarditis and hepatitis) have been report-
anemia. ed. Women with disorders in the ovarian-menstrual
Periodic medical examinations are conducted cycle have been observed.
once a year by an internist and a neurologist, at indi- Methyl methacrylate has a pronounced local ac-
cation - gynecologist. Paraclinic studies include full tion on the skin and mucous membranes. Workers
blood count, liver enzymes, ECG and vegetological with work experience over 6 months have found
tests. subatrophic rhinitis, nasopharyngitis, laryngitis,
It is recommended that diet D of the professional conjunctivitis, dermatitis, allergic changes (contact
protective nutrition. dermatitis).
Clinical-laboratory tests. Hypochromic anemia
3.3.6. METHYL METHACRYLATE - T. KUNEVA with lymphocytosis and neutropenia, increased he-
patic enzyme activity, increased bilirubin are found
- Headache, fatigue, irritability in the blood. For the exposure test, determination
- arterial hypotension, autonomic dysfunction of formaldehyde in the blood - up to 0.2 mmol/l or
- rhinitis, bronchitis in the urine: formaldehyde - norm to 0.3 mmol/l; of
- polyneuropathies methane - up to 15 mg/l; of formic acid - up to 80
- toxic hepatitis mg/g creat.
Methyl methacrylate is methyl ester of methacrylic Differential diagnosis. Alcohol poisoning and
acid. It is a colorless, volatile liquid with an unpleasant other organic solvents.

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 OCCUPATIONAL MEDICINE
Treatment. Acute poisoning - Immediate remov- stances. In development of encephalopathy - defini-
al from the gassed environment, oxygen-therapy, tion of disability group.
cardiotonics, glucose infusions. In chronic poison- Medical prophylaxis. Contraindications for
ing - vitaminotherapy (B1, B6, B12, C); hepatoprotec- getting into contact with methyl methacrylate are
tive agents. Symptomatic treatment - balneal phys- chronic diseases of the heart and lungs, cardiovas-
iotherapy. Allergic dermatitis - local corticosteroid cular system, skin, and blood. Periodic medical ex-
ointments. aminations are performed once every 24 months by
Labour expertise. In acute and mild chron- a therapist, complete blood count, fluorography. At
ic poisoning - temporary disability, recovery after indications - examinations by neurologist, otolaryn-
treatment. In the diagnosis of polyneuropathies - la- gologist and a dermatologist.
bour-induced termination of contact with toxic sub-

REFERENCES

1. Acrylonitrile. IPCS, The Concise International Chemical Assessment Document No 39, WHO, Geneva,
2002, p. 26.
2. Case studies in: Environmental Medicine, N 2, Vinyl chloride Toxicity, June 1990, US Dep. Of Health
Hum. Services.
3. Lewis R: Plastics in: Occupational Medicine, ed. J. La Dou, Appleton & Lange, Norwolk, Connecticut,
1990, 387-397.
4.Methyl Methacrylate. IPCS, The Concise International Chemical Assessment Document No. 4, WHO, Ge-
neva, 1998, p. 40.
5. Spasovski M. Ethylene in: Hygiene Toxicology - special part, ed. F. Kaloyanova, S, MF, 1983, 110-112
(in bul.)
6. Spassovski M. et al. Health status of workers from the production of ethylene and ethylene oxide, Hyg.
Pub. Hlth.., 1980, 1, 41-47 (in bul.)
7. Spassovski M., N. Stamova, V. Hristeva - Labour hygiene in the production of polyacrylic fibers, J.
Hyg. Pub. Hlth., 1976, 2, 134-170 (in bul.)
8. Toxicological Profile for Styrene. Agency for Toxic Substances and Disease Registry, US. Public Health
Service, Atlanta, Georgia, USA, 1992, p. 166.
9. Toxicological Profile for Vinyl chloride. Public Health Service, Agency for Toxic Substances and Disease
Registry, Atlanta, Georgia, USA, 1997, p. 277.

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3.4 PESTICIDES

CHEMICAL CLASSIFICATION OF PESTICIDES Usage.

(by F. Kaloyanova, 1993) Phosphorus pesticides are mainly used in agricul-
I. * PHOSPHORRGANIC ture as insecticides, some as fungicides and rodenti-
II. CHLORORGANIC cides. Occupational risk of intoxication exists during
IIa. ** MERCURY ORGANIC production and use in agricultural activities, disinsec-
III. * CARBAMATES AND TIOCARBAMATES tion and deratization. Acute intoxications with POP are
IV. * DITIO-CARBAMATE commonly observed in lesions as household or suicid-
V. TRIASINES al.
VI. DICHLORPHENOXYACETIC ACID DERIVATIVES Biotransformation. They penetrate the respirato-
VII. CARBAMIDE DERIVATES ry and digestive tracts and through the skin. The ma-
VIII. DERIVATIVES OF ANILIDES AND AMIDES jor biotransformation of POP occurs in the liver by the
IX. DINITRO COMPOUNDS monooxidase system (MFO), oxidative desulphurisa-
X. * KUMARIN DERIVATIVES tion, oxidative dealcylation, oxidative dimethylation,
XI. * COPPER PREPARATIONS nitroreduction, hydrolysis, and other hepatocyte and
XII. SULFUR PREPARATIONS blood cell enzymes. They are mainly excreted through
XIII. BENZOYL-PHENYLUREIC the kidneys and the intestinal tract. They do not have
XIV. DIPYRIDIL DERIVATIVES material accumulation in the human body.
XV. PHTALIMIDES Pathogenesis. POP due to structural similarity
XVI. SULPHATES, SULPHONES AND SULPHONATES irreversibly displaces natural substrates in the cho-
XVII. BENZIMIDAZOLES linesterase enzyme, resulting in substantial amounts
XVIII. * SYNTHETIC PYRETROIDES of acetylcholine being deposited in the synapses of pe-
XIX. TRIAZOLES ripheral and central brain structures, effector organs,
XX. PHOSPHIDES and blood plasma.
XXI. METHYLBROMIDE The clinical picture of acute poisoning is char-
XXII. OTHER DERIVATES acterized by three major syndromes:
* Pesticides that use antidote therapy Muscarinic - when reactivating M-cholinoreac-
** For mercury pesticides see also mercury intoxications. tive receptors. It is characterized by myosis, brad-
ycardia, increased salivation, sweating, nausea,
3.4.1. CHOLINESTERASE-INHIBITING vomiting, bronchospasm, signs of toxic pulmonary
PESTICIDES - ST. ANDONOVA, R. STEFANOVA edema, etc.
Nicotine-like - upon reactivation of the
Phosphorus Pesticides N-cholinorenective structures. It occurs with or after
Chemical phosphorus pesticides are derivatives of muscarinic-like syndrome with muscle weakness,
phosphoric, thiophosphoric, dithiophosphoric and twitching of the eyelids and muscles to severe sei-
phosphonic acids, which are structurally different zures. Tachycardia, increased blood pressure, and
compounds with different physicochemical properties the like may occur.
and biotransformation. They are poorly resistant to the Comatose syndrome - occurs due to direct ef-
environment. Depending on the high temperatures, fects on the receptors of the central brain structures
humidity and sunlight, they can be transformed into and occurs with headache, nausea, vomiting and
more toxic substances. They have unpleasant odor and rapid loss of consciousness.
high toxicity to mammals and humans. There is a slight, moderate and severe degree of
Some of the authorized preparations for use in this acute poisoning with POP, depending on the dose,
group are: chlorpyrifosetyl 48%, LD50 135-163 (* Ar- the physicochemical properties of the compounds,
gyphos, Dursbane), fenitrothion 50% LD50 250-500 (* and the degree of blocking of cholinesterase (CE).
Agria-1050), phosalone 35% LD50 135 (* Agria 1060), The lethal outcome occurs as a result of respiratory
diacinone 60%, LD50 300-400 (* Agridine, Bazudine), failure, cardiovascular weakness and toxic encepha-
monocotphos 55, 2, LD50 8-23 (* Azodrine), pyrimi- lopathy. In the course of intoxication, liver damage,
phosmethyl 50,5, LD50, 2050 (*Actelic), dimetoat 39%, toxopulmonites, toxic nephropathy, myocardiopa-
LD50 320-380 (* Bi58) and many others. thy, etc. have been observed.

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Chronic poisoning. It is observed when the 0.50%, LD50 411 (* Kronstone), metomyl 90% 20% ,
rules for working with production and agricultural LD50 17-24 (* Lanat 20 EC, Lanat 90 NP, Nudrin 20 EC)
activities are no-observed. Neurological symptoms and the like, of thiocarbamic acid - cyclost 720 g, LD50
with asheno-vegetative symptoms, neurasthenia, 2710 (* Ronit), ethyl dipropylthiocarbamate 720 g, LD50
depression and heavier manifestations such as ex- 2550, (*Bradican 6E, Eradican-extra, Bitam EC), moli-
trapyramidal symptoms, polyneuritis, spastic paral- nate 720 g, LD50 369 (ORDAM 6E, Hydram, Yalan), and
ysis, as well as liver damage - from mild functional others, and dithiocarbamic acid-tiram 50.85%, LD50
disorders to chronic hepatitis have been reported. 865 (* TMTD, Wolffentiuram), 35% aluminum ethyl-
Changes in cardiovascular, digestive and hemato- ene-bis-dithiocarbamate, LD50 5200 (* AMBIS), zinc
poietic effects can be identified from some POP, ir- ethylenebis dithiocarbamate 75%, LD50 5200 (*Cineb,
ritant and allergic. perocin), mancoceb 80%, LD50 8000 (* Dithane M45,
Clinical-laboratory tests. Reduction of serum Pencoceb 80 BP), methyl thiofanate 40%, 70%, LD50
and erythrocyte CE activity, evidence of POP or their 600, (*Metyl-topsin ULV, Metyl topsin 70VP) thiodicarb
metabolites, such as diethylphosphates, dimeth- 37.5% , LD50 66 (* Larwin), and others. Most of them
ylphosphates and others in blood and urine. are highly toxic to insects and low and middle toxic to
There is not always a good correlation between humans. They have environmental sustainability and
the decrease in CE and the severity of acute poison- only some have material accumulation in the animal
ing. and human body.
Differential diagnosis. It is poisonings with tox- Occupational risk. Agricultural workers working
ic gases, chlorinated hydrocarbons, other pesticides with pesticides of this group in the production of car-
(carbamate, pyrethroids), medications, mushroom bamates, tranquilizers, hypnotics, etc.
intoxications, stroke. Biotransformation. The primary route of penetra-
Treatment. It starts with depurjration events tion is the airways, less skin, and household intoxica-
and detoxical agents to the front door. An agent of tions - the digestive tract. Biotransformation occurs in
choice in the treatment of acute poisoning is the ad- the liver directly from esterases or by oxidative metab-
ministration of Atropinum sulfurium (ampoules of 1 olism of the carbamate group with the phenol group
mg 1 ml). For severe and moderate poisoning, start release. Excretion from the body is through the urine.
with 1-3 mg intravenously and then 15 minutes or In some of them at the kidneys, mainly a-naphthol and
30 minutes until an atropine effect is obtained, then sulphates are excreted.
dose is reduced accordingly and the increase in CE Pathogenesis. Toxic action of carbamates is based
in the following days. After atropine is used primarily on the binding of enzyme systems based on cholinest-
in the first 24 hours of acute poisoning so-called CE erase. Unlike POP, it is a competitive reversible inhibi-
reactivators (Toxogonin 250 mg 1 ml of Obidoxim tion of CE by carbamic acid and inhibition of DFS from
500 mg 5 ml in a dose of 1 ampoule intravenously dithiocarbamates. The latter are degraded to ethylen-
over 2 hours in severe intoxications or 4x2 amps, 3x2 ethiourea.
amps intravenously in water-saline solutions Also The clinical picture of acute poisoning with
using early carbohemorperfusion, complex detoxi- carbamate pesticides is characterized by signs of
cal, resuscitational and organoprotective therapy muscarin-like and nicotine-like syndrome, as with
The prognosis is unfavorable for severe acute poisoning with POP. Cholinesterase activity is less
poisoning and chronic with organic damage pronounced and rapidly recovers after treatment. At
Prevention. Use of PPE No labour with POP for intoxications with thio- and dithio carbamic acid de-
persons with CNS, endocrine, liver and kidney dis- rivatives, headache, nausea, ataxia, irritation of the
eases, chronic skin injures Periodic medical exami- respiratory tract mucosa, and severe constipation
nations - once every 12 months with the participa- with severe intoxications are observed. In alcohol
tion of a therapist and neurologist, if necessary a use, an antabuse effect appears - carbamates reduce
dermatologist and ophthalmologist and mandatory tolerance to alcohol. Various clinical manifestations
control of CEA. of allergy have also been observed.
CARBAMATE PESTICIDES Chronic intoxications are rare and occur with
These are widely used plant protection agents such neurotoxic effects, thyroid dysfunction, hematopoi-
as fungicides, insecticides, herbicides, nematodes and etic and hepatic function disorders. Experimentally,
oth. They are derived from carbamic acid - carbaryl mutagenic, embryotoxic, teratogenic and possi-
85%, LD50 850 (* Sevin, Dicarbam NP 85), pyrimicarb bly carcinogenic effects of carbamates have been
50%, LD50 147 (pyrimor 50 BP), propamocarbhydro demonstrated - mainly due to ethylene thiourea.
chloride, LD50 8600 (*Previcur), benomyl 50%, LD50 Clinical-laboratory tests. Proving of carbamates,
9000 (* Benileat 50 NP, Fundazol 50 NP), Etiofencarb their metabolites - α-naphthol and sulphates, in

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blood and urine, anemia, thrombocytopenia, meth- Clinical picture.
aemoglobinaemia. Differential diagnosis is made Acute poisoning with COP has a higher signifi-
with POP poisoning, synthetic pyrethroid contact cance in case of household accidents and represents
dermatitis of other origins (drugs, toxic substances). a synthesized type of symptom of chronic poison-
Treatment. Carbamate compounds that block ing. Upon oral ingestion, poisoning may occur with
cholinesterase carry out with Atropinum sulfurium severe gastroenteritis and subsequent general re-
(1 mg, 1 ml) intravenously, intramuscularly or subcu- sorbtion action of the drug with severe neurological
taneously in CEA monitoring, symptomatic therapy, symptoms - seizures, ascending bulbar paralysis and
general detoxical and depourging means. No cho- coma.
linesterase activators are administered! The progno- Chronic poisoning. Chronic poisoning is often
sis is usually favorable. occupational, but it is also seen in the household
Prevention. Use of PPE. Medical prophylaxis - as (especially sensitive to the toxic effects of COPs are
with POP. children and adults).
COPs are classical polytropic poisons with marked
3.4.2. CHLORORGANIC PESTICIDES polymorphism of organ damage.
V. PETKOVA, ST. ANDONOVA In its initial mild stages, the poisoning is mani-
fested by functional disorders of the central nervous
Chlorinated pesticides (COPs) are chlorine deriv- system with vegetative dystonia - neurosis similar
atives of hydrocarbons - predominantly cycloparaf- conditions with headache, insomnia, vertigo, ady-
fins (hexachlorocyclohexane and its gamma isomer namia, irritability, emotional lability, functional liver
- lindane, hexachlorocyclopentane) and multi-nuclear disorders, mild haematological abnormalities - leu-
(dichlorodiphenyltrichloroethane - DDT, chlorandan, kocytosis or leucopenia, eosinopenia.
heptachlor, dieldrin, endrin). In the more advanced - medium and severe
These are a large group of plant protection agents forms of poisoning, there is a worsening of the
that are used as acaricides (celtane, tetranidide, pen- symptomatology with a clear outline of the organ
tak, milball), such as insecticides (thiodane, thionex) pathology - toxic hepatitis, toxic vegeto-sensory
and others. polyneuritis, toxic encephalopathy and encepha-
They have an adverse environmental effect because lo-polyradiculoneuropathy in severe cases. The lat-
they are persistent in the environment (more than 20 ter manifests the characteristic myelotoxic activity,
years) and also accumulate in the human body. These which is most commonly associated with diene COP
unfavorable properties warranted the use of very effec- - aldrin, dieldrin and others. With prolonged exposi-
tive and widely used preparations such as DDT, aldrin, tion or severe poisoning due to the high cumulativ-
lindane, heptachlor and others. Poisoning can be ex- ity of COP, hypo- and aplastic anemia, agranulocyto-
pected during production, packaging and use, as well sis and pancytopenia may occur.
as in constant contact with materials treated with COP. The clinical picture of poisoning is supplemented
Biotransformations: COPs enter the body through by respiratory tract damage: chronic rhinopharyngi-
the respiratory organs, the skin and the gastrointesti- tis, tracheobronchitis, pneumofibrosis. A character-
nal tract. Due to their affinity for lipids, chlor-organic istic feature is the frequent complication of asth-
compounds, respectively their metabolites accumu- matic conditions. There is also a kidney syndrome
late in organs and tissues rich in lipids - adipose tis- - oligo-anuria, acute renal failure. Allergic dermatitis
sue, hemato-poietic and nerve structures. They also and eczema are also characteristic of the chronic ef-
damage the liver and kidneys. Removed from the body fects of chlor-organic compounds.
unchanged (metabolized hard) and a little like metab- Clinical-laboratory tests. Blood leukopenia,
olites - with faeces and less commonly with urine, the thrombocytopenia and hypochromic anemia (re-
mammary glands. They pass through the hepato-en- spectively the degree of involvement of the hae-
cephalic and hepato-placental barriers. matopoietic apparatus) are detected in the blood.
Pathogenesis. Most of the COPs currently used are Essential is the COP gas chromatography exam and
moderately toxic. Their cumulative effect determines metabolites in blood and urine.
their chronic toxic action, as well as some remote bio- Differential diagnosis: It is done with other ae-
logical effects (DDT - carcinogenesis, embryotropic ac- tiology hemopathies, most often myelodysplastic
tion). Toxicity of COP is associated with a cellular me- syndrome, drug leukemia thrombocytopenia, alco-
tabolism disorder by inhibiting the activity of certain holic, diabetic or para-neoplastic polyneuropathies.
respiratory enzymes, as well as disturbances in the cell Also with poisoning with POP, chlorinated hydrocar-
membrane lipid structure. bons, toluene and others.
Treatment. There is no antidote therapy, but an-

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tioxidants may be recommended, e.g. Tocopherol their high neurotoxicity. They are found to circulate in
0.5% - 2 ml. i.m. Treatment course - 10-20 days. the body for some time, then metabolise and as me-
Per os poisoning - gastric lavage, saline cleans- tallic mercury are deposited in some organs (liver, kid-
ing, hemodialysis. ney, endocrine glands, etc.) and/or separated from the
Organoprotective therapy: glucose solutions, co- body.
carboxylase, nootropic (pyramem 2.4 g/d), central Pathogenesis. The toxicity of these compounds is
vasodilators (cavinton - 20 mg/d). Treatment course due to the combination of their particular toxokinetics,
- 30 days. In polyneuritis - pain-allayings, peripheral remembered that of organic solvents and the affinity
vasodilators. of mercury (thiol poison) for sulfhydryl groups of cell
In haematological disorders - haemostimulating. proteins and some enzymes.
Treatment course 15-20 days. Corticosteroids - by Clinical picture.
scheme, and haemotransfusion - in severe cases. Acute poisoning. Clinical symptoms of acute
Labour expertise. Initial and mild forms of poi- poisoning occur rapidly after a short latency period
soning are reversible after treatment and do not re- with manifestations of general resorption - toxic cer-
quire change of work. The prognosis is unfavorable ebrasthenia, and in severe forms - severe disseminat-
in aplastic states and in the presence of myelopoly- ed damage of the nervous system with cerebellum
neuropathies - they determine longer-term disabili- (ataxia), diencephal and extrapyramidal symptoms,
ty and long-term retirement or disability group. optic nerve atrophy. Oral administration - metallic
Prevention. Sealing, effective ventilation in the taste, hypersalivation, erosive gastritis, and in severe
production and preparation of solutions. PPE when cases - haemorrhagic gastroenteritis with collapse,
in use. shock and uremia.
Medical prophylaxis requires that persons with Chronic poisoning. It may occur after a rela-
allergic, chronic pulmonary and often recurrent up- tively short exposure of 3-4 months. In the early
per respiratory tract inflammation, chronic hepati- stages of poisoning neurosis-like symptoms with
tis, recurrent inflammatory diseases of the bile and marked vegeto-vascular dysfunction and marked
biliary tract, anemia, organic and pronounced func- disturbances in the emotional sphere are observed.
tional diseases of the central nervous system. Neurological pathology is usually accompanied by
Periodic medical examinations - once a year with changes in the oral cavity - gingivitis and hypersali-
the participation of internist, neurologist and ORL vation as with mercury poisoning. In advanced cas-
specialist and with tracking the content of COPs in es, neurological symptoms have been exacerbated
the blood of the working people. with generalized vegeto-vascular disorders of the
Prophylactic intake of vitamin C (0.5 - 1.0 g daily) diencephal type, vegetosensory polyneuritis, psy-
or vitamin C treat drinks is recommended, and pro- cho-organic symptomatology and psychoses. The
fessional protective nutrition-diet D. most commonly reported mass poisoning with mer-
cury compounds in the Minimata in 1950 to 1,000
3.4.3. MERCURY PESTICIDES japanese fishermen consuming fish with a high
V. PETKOVA methyl mercury content, and that in Iraq in 1972, af-
fected about 6,000 people (500 deaths) after eating
The organic compounds of mercury - alkyl-, aryl, bread, made from seeds treated with mercury pesti-
alkooxy- compounds are the active ingredient of a large cides. In both incidents, the poisoning has occurred
and varied group of fungicides (methylmercuryiodinide, with the above described disseminated nervous
ethylmercuric chloride, ethylmercuryamide, methoxym- system damage and severe motor and sensory pol-
ethylmercuric chloride, phenylmercuric chloride, etc.) yneuritis (ataxia, dysarthria, deafness, visual distur-
Due to the high risk of poisoning among the popu- bances) and hepatorenal syndrome.
lation and in the workers and the accumulation (and On contact with the skin, they develop allergic
the biological chain) of mercury and methylmercury in and contact dermatitis and eczema.
the environment, food and in organisms, their use as Differential diagnosis. Myelopolyneuritis with
fungicides for seed treatment is very limited. other etiology (infectious, poisoning with arsenic,
Biotransformation. Mercury compounds enter lead, tetraethyl lead), diencephal syndrome, other
into the body through the respiratory organs, the skin types of psychoses.
and the gastrointestinal tract. The availability of a hy- Treatment. Specific antidote therapy with Unith-
drocarbon radical in the molecule determines their li- iol 5% - 5 cm³. In case of acute poisoning on the 1st
potropicity and favors the penetration of poison into day, 1 amp. at 6 hours, and in the next few days at
various tissues of the organism, and the passage of the 1 amps. 12 hours to resolve the most acute symp-
haematoencephalic barrier, which is associated with toms. In case of chronic poisoning - 1 amp. daily in a

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 LABOUR MEDICINE
course of 5 -10 days. brosis). In case of oral intoxication, stomach lavage,
Symptomatic therapy - neuroleptics and tran- saline laxative, forced diuresis (3-6 l/daily glucose
quilizers, antidepressants with soothing effect. Total solutions), hemoperfusion.
strengthening and vitaminotherapy.
Prognosis and labour-expertise. The progno- 3.4.5. NITROPHENOLS (DINITRO
sis is unfavorable for severe forms of poisoning. Ex- COMPOUNDS) - V. PETKOVA
ceeding the contact with the noxa does not exclude
the progression of clinical symptoms. The compounds of this group - nitrophenols,
Profilaxis. Organic mercury compounds are not 2,4-dinitrophenol, 2,4,6-tri-nitrophenol (picric acid),
allowed for persons with chronic skin diseases, func- dinitroorthocresols, etc., are nitrooxy derivatives of ar-
tional and organic diseases of the nervous system, omatic hydrocarbons. They are used in the manufac-
kidney pathology. Periodic medical examinations ture of dyes, such as explosives (picric acid) but mainly
are conducted once a year and include internal and as insectfungicides in agriculture (dinitroortocresol,
neurological status and urinary mercury determina- dinitrophenol).
tion. Vitaminoprophylaxis. Protective prefessional Biotransformation. Nitrophenol pesticides are in-
nutrition - diet B. Prevention of high skin resorption troduced into the body through the airway and, to a
- use of personal protective equipment. great extent, through the skin. Metabolized in the liver
to aminophenol compounds and excreted through the
3.4.4. DIPYRIDYLS - ST. ANDONOVA kidneys. These processes are slow, which determines
the significant coefficient of cumulation of these com-
The main pesticides in this group are paraquat di- pounds. Daily toxic intake of small quantities in the
chloride 20%, LD50 150 (* Gramoxon 20) and diquat body of the worker for one week is reached toxic con-
20%, LD50 440 (* Reglone). They are used as herbicide centrations in the blood (about 40 μg / g for DNOC).
defoliants and disinfectants. They are easily degraded PATHOGENESIS. The high toxicity of nitrophenol
and do not represent environmental pollutants. They compounds is due to their ability to block oxidative
have a pronounced toxicity to animals and humans, phosphorylation in mitochondria, which prevents
and therefore the use of Gramoxon 20 is ​​prohibited for the use of highly energetic ATP compounds. There is
use in our country. They enter the body through the res- a sharp increase in aerobic glycolysis, hyperglycemia,
piratory tract, the skin and the digestive tract. They are glycogen depletion in the liver and muscles, heavily in-
metabolised in the liver and emitted through the lungs creased heat production.
and urine. They have a pronounced irritant effect on Clinical picture.
the mucous membranes and the skin, causing severe Acute intoxications occur with the clinical pic-
destructive changes especially in the lungs, also in the ture of heat stroke with hyperthermia up to 40 °,
liver, kidneys and myocardium. thirst, headache, skin hyperemia and conjunctivitis,
Clinic of acute poisoning. Inhalation occurs and in severe cases - hepatorenal and pulmonocar-
with bronchospasm, toxic pneumonitis, after la- dial syndrome and pronounced neurological symp-
tency - toxic pulmonary edema. These changes are toms - delirium, convulsions, coma.
followed by progressive pulmonary fibrosis, making Chronic poisoning occurs with progressive ady-
the prognosis extremely unfavorable. Accepted by namia, vertigo, headache, and anorexia, character-
digestive tract dipyridyls cause mucosal ulceration, istic for toxic cerebrovascular disease. Distinctive
hyperemia and sore throat and abdominal pain. In signs are manifestations of hyperthyroidism - weight
the coming days, toxic hepatitis and hepatorenal reduction, subfebrility, hyperhidrosis, rhythm disor-
syndrome develop. In cases of severe intoxications, ders. In severe forms of poisoning, toxic hepatitis
central brain structures were impaired. Poisoning and toxic nephropathy are observed. Particularly for
with Reglon can take place with the ileus picture the chronic effects of nitrophenol compounds is the
with severe collapse. The skin is hyperemic with yellow coloration of the skin, nails, hair and conjunc-
changes that resemble burns and blistering. tiva. Other skin changes are also known - contact
Chronic effects are not well studied. dermatitis with papulo-vesicular rash.
Differential diagnosis is done with acute ex- An isolated occurrence of chronic poisoning is
posure to POP, chlorine, nitrogen oxides, explosive the nitrophenol cataract.
gases, etc. Clinical-laboratory tests. Acute poisons in the
Treatment - there is no specific therapy, but re- blood reveal non-specific changes - decreased ac-
moval of dipyridyls should be done very quickly, as tivity of catalase and peroxidase, increased lactic
well as oxygen therapy, bronchodilators, glucocorti- acid content. Heinz and methaemoglobin bodies
costeroids, vitamins, cytostatics (against pneumofi- are found. In more severe forms, electrolyte disor-

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ders, hyperglycemia, albuminuria, acetonuria are Byterode), alphamethrin 10%, LD50 200-858 (* Vaztak
observed. 10EK), phenpropratrin 10%, LD50 164 (* Dannitol 10
Chronic intoxications - increased thyroid hor- EK) lambda-diholothrin 2.5% LD50 60 (* Karate 2.5 EK),
mone activity, hyperchromic anemia, Heinz body cypermethrin 40%, LD50 251 (* Ripcord 40 EK, Simbush
and methemoglobin, hyperglycemia. 25 EK) They degrade quickly in the environment. Slight-
The presence of nitrophenol compounds and ly volatile and almost insoluble in water.
their metabolites in the blood and less frequently Endangered professional groups are working in
in the urine (there is also functional accumulation greenhouses, processing of fruit orchards, vineyards,
where pronounced symptoms of poisoning can also production and storage of pyrethroids.
be observed with low NF content). Biotransformation. The entrance door is the res-
Differential diagnosis. Consider hyperthyroid- piratory tract, the digestive system and the skin.
ism, diencephalosis, viral hepatitis, neurasthenia They have acute oral medium toxicity and a mild
with pronounced vegetative disorders and sympa- stage acute percutaneous. They do not cumulate. Prac-
thicotonia. tically non-toxic for birds and very toxic for fish and bees.
Treatment. The first medical assistance in acute Toxicity is significantly affected by solvents. Biotransfor-
poisoning is like a heat stroke. To suppress patholog- mation in the body primarily destroys the ester bond,
ically enhanced catabolic processes, thiouracil (thy- as the acids are released as free or bound to glycine or
midazole) preparations are administered in small glucuronic acid for 2-4 days. Metabolites with a cyano
doses with concomitant cardiocircular and infusion group are released more slowly, to form thiocyanates.
resuscitation with glucose and saline solutions. Pathogenesis. It depends on the chemical structure
Organoprotective treatment - cardiotonics, pe- of the preparation. Direct neurotoxic effect, blocking of
ripheral vasotonics, hepatoprotectives. Barbiturates enzymes such as monoamine oxidase, mild demyeli-
and acetyzal are contraindicated. nation, activation of nerve mediators (M-cholinorec-
The treatment of chronic poisoning is sympto- tive effects) have been demonstrated.
matic when the noxe is discontinued. Clinic. Acute poisoning occurs with irritative
Labour expertise. Chronic poisoning with NF changes of the mucous membranes, such as tear-
compounds is reversible and does not require long- ing, sneezing, rhinorrhea, burning sensation of skin
term rehabilitation except in the case of toxic hepa- and mucose. Severe intoxications are characterized
titis and cataracts. In acute poisoning (severe cases) by psychomotor agitation, headaches, numbness
the prognosis is bad. of tongue and lips, ataxia, gastroenteritis. For those
Prevention. The use of PPE is mandatory (high with muscarinic-like action (Ripcord, Decis) there is
dermal absorption). increased salivation, myosis, shivering of the limbs,
People with skin diseases, chronic respiratory tonic and clonic seizures. In dermal contact - derma-
pathology, blood, liver, and thyroid diseases are not titis with erythema, vesicles, bulls, paresthesias. The
allowed to work. Periodic medical examinations are outcome of poisoning is usually favorable.
aimed at timely detection of toxic nitrophenol cat- Experimentally, a slight sensitizing effect of pyre-
aracts and toxic hepatitis. Exposure control is mon- throids has been documented.
itored (blood NF monitoring). Vitaminoprophylaxis Chronic toxicity is rarely seen with irritant ef-
- vit. C - 0.5-1 g daily. fects on the mucous membranes of the eyes and the
airways, damage to the peripheral nerves.
3.4.6. PYRETHROIDS - ST. ANDONOVA Clinical-laboratory tests. Chemical analysis for
the presence of pyrethroids and their metabolites in
Known for centuries as a healing herb, the cam- blood and urine at normal serum CE levels.
omile and its native species contain substances with Treatment. Clean the mucous membranes and
very good insecticidal action - pyrethrins I-VI (esters skin areas with plenty of water; If ingestion - is oral -
of chrysanthemum and pyrethric acid) and others. gastric lavage. Medication treatment is symptomat-
Although their biological activity is many times less ic. If necessary (hypersalivation) - moderate atropini-
than that of DDT, after the ban on the latter, pyrethrin zation. Detoxic therapy by conventional methods.
I became important as a strong natural insecticide. For paraesthesias - vit.E local.
Difficulties in the production of industrial quantities, Prevention. Use of PPE and workwear. Medical
its instability in light and access to oxygen have led prophylaxis. People with organic CNS diseases, en-
to the synthesis of new species with a stabilized mol- docrine diseases, chronic diseases of the liver and
ecule with strong insecticidal activity and low toxicity kidneys, chronic skin injuries are not allowed to
to mammals and humans. These are cyclopropan- work. Periodic examinations - once a year, attended
ecarbonic acid analogs: cyflotrin 2,5%, LD50 500 (* by a therapist, neurologist, dermatologist.

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REFERENCES

1. Atlas of Toxicokinetics - T. Popov, Z. Zapryanov, I. Benchev, G. Georgiev, Sofia, Med. and phys., 1984,
174-176 (in bul.)
2. Hygienic Toxicology - a special part ed. F. Kaloyanova, Sofia, Med. and phys., 1983, 75,82, 149-192 (in
bul.)
3. Hayes, WJ - Pesticides Studies in ManWilliams Co Wilkins, 1982.
4. Ivanova L. - Toxicological characterization of dithiocarbamates CINEB and MANEB, Sofia, dissertation,
1969 (in bul.)
5. Kaloyanova - Simeonova F. Pesticides - toxical action and prophylaxis. Bulgarian Academy of Scienc-
es, Sofia, 1977 p. 307 (in bul.)
6. Mononitrophenols. IPCS, The Concise International Chemical Assessment Document No 20, WHO, Ge-
neva, 2000, p. 39.
7. Morgan, DP - Recognition and Management of Pesticides Poisoning - 3rd Ed. USA Government Regu-
lation Office, 1982.
8. NIOSH: Criteria for a Recommended Standards for Occupational Exposure during Manifacture and For-
mulation of Pesticides, USA, Governement Printing Office, 1978.
9. Rosenberg J. Pesticides in Occupational Medicine, ed. J. La Dou, Appleton & amp; Lange, Connectict-
icut, 1990, 401-431.

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ТРУДОВА МЕДИЦИНА

3.5 TOXIC GASES

These are a group of different irritant gases and particles that have a local irritant effect and cause sys-
temic toxicity. They are distinguished in the following groups:

Group Chemical affiliation

chlorine, ammonia, formaldehyde, sulfur dioxide, ozone, phosgene, nitrogen dioxide, fluorine,
1. Irritating gases
hydrogen fluoride
acetylene, argon, ethane, helium, hydrogen, nitrogen, methane, butane, neon, carbon dioxide,
2. Simple asfiksanti
combustion gas, propane
carbon monoxide, hydrogen cyanide, hydrogen sulfide, inhalants, phosphorus organic gases, hydrogen
3. Systemic toxic
fluoride, fluorine
oxides of sulfur and nitrogen, chlorine, hydrogen chloride, phosgene, hydrogen cyanide, carbon
4. Smoke gases
monoxide, isocyanate and the like.

IRRITATING GASES - HALOGEN

Irritation Acute poisoning Late consequences Chronic poisoning
1-6 mg/m з laryngitis, tracheobronchitis conjunctivitis
Chlorine

pneumonia ulceration and perforation of the nasal septum,

bronchiolitis dermatitis, eczema, "chlorine acne"
pulmonary edema pulmonary fibrosis teeth destruction
30-40 mg/ perf. and ulcers of the nasal septum rhyno-pharyngolaryngitis
mз pharyngolaryngitis, bronchitis bronchitis, pneumosclerosis, asthma
bronchiolitis, pulmonary edema pulmonary fibrosis hypotension, heart rhythm and conduction
Fluorine

rhythm disorders disturbances

gastroenterocolitis hepatitis bone fluorosis-deposition of calcium
dermatitis, keratoconjunctivitis fluoride
dental fluorosis
5-23 mg/ conjunctivitis conjunctivitis, pharyngitis, bronchitis,
mз dermatitis dermatitis
Bromine

pneumonia autonomic dysfunction

pulmonary edema pulmonary fibrosis abnormal thyroid
gland function
over 1,5 conjunctivitis, dermatitis COPD
Iodine

mg/mз bronchopneumonia autonomic dysfunction

pulmonary edema pulmonary fibrosis anemia, methemoglobinemia

BLASTING GAS
Pathogenesis Irritation
effect Acute poisoning Late consequences Chronic poisoning
CoHb 100-150 mg/ headache (10 % CОHb) autonomic violation in vision, hearing,
m3 dispnea (20% CОHb) dysfunction balance
hypoxia visual disturbances (30% vestibulopathy autonomic dysfunction
Carbone oxide

СОHb) hemiparesis neuritis, polyneuritis,

collapse, convulsions (40 % epilepsy BVDs
CОHb) Parkinson's angina pectoris, arrhythmia
myocardiopathy (50 % syndrome myocardial infarction
CОHb) psychoses early atherosclerosis
coma psychoses
myocardial infarction hypohromic anemia
methemo- 100- 250 conjunctivitis rhinopharyngitis
Nitrogen

globinemia mg/m3 cough, dispnea chronic bronchitis, pulmonary

oxides

hypoxemia pulmonary edema pneumosclerosis emphysema

psychoses

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irritative 20-50 conjunctivitis rhinopharyngitis, epistaxis
effects mg/m3 pharyngitis ulcers in the septum
laryngeal edema bronchitis with asthma
epistaxis, dyspnea, cyanosis components

Sulphur oxides
pulmonary edema pneumosclerosis
coma pneumosclerosis autonomic dysfunction
brittleness of teeth, yellow colour,
striae on enamel
dermatitis, eczema
thyroid hypofunction

tissue over 6 conjunctivitis, pharyngitis paresis keratoconjunctivitis

hypoxia mg/m3 headache, vestibulopathy psychoses rhinopharyngitis,
Hydrogen sulfide

tachycardia, hypotension laryngotracheitis

pneumonia, pulmonary bronchitis
edema, ataxia, polyneuritis
convulsions, coma

3.5.1. CARBON MONOXIDE - tion, angina pectoris. In the blood, the carboxyhe-
ST. ANDONOVA, D. CHARAKCHIEV moglobin content is 20-30%. Complaints continue
for 5-6 days.
Carbon monoxide is released in a number of pro- - moderate-severity - when, in addition to the
duction processes that are associated with incomplete symptoms described above, there is a loss of con-
combustion of carbon-containing substances. These sciousness for about 3-4 hours, convulsions and de-
include heavy metallurgy, the chemical industry, blast- velopment of pneumonia. Disorders of health status
ing activities in the mining, construction, electrical are about 10-15 days. Saturation with HbCO is up to
wiring and others. Accumulates in poorly ventilated 40%.
rooms when working on engines (garages, truck cabs, - severe stage - coma for several days with
airplanes, cars, etc.) breathing disturbance, cardiac activity (tachycardia,
Biotransformation. Pathogenesis. The pathway extrasystoles), changes in blood pressure with a ten-
of penetration in the body is the respiratory system. dency to increase in the beginning and decrease in
Carbon monoxide is indifferent to the structures of the deterioration. ECG data on rhythm, conduction dis-
bronchopulmonary system. Passed through the alveo- turbances and hypoxia. HbCO in blood is 50-60%.
lar capillary membrane, carbon monoxide quickly and Toxical hepatosis, nephrosis, pancreatic lesions (hy-
easily binds to the iron of hemoglobin and forms car- perglycemia) are observed. Restoration is slow with
boxyhemoglobin: HbO2 + CO-HbCO + O2. The dissocia- residual encephalopathy.
tion of carboxyhemoglobin is slow, and with these tox- Chronic intoxication. Mild intoxications occur
ic effects the dissociation of oxyhemoglobin is delayed. with astheno vegetative manifestations such as fa-
Resorbed CO also binds to plasma non-hemoglobin tigue, dizziness, headache, increased blood pressure.
iron and affects other iron-containing structures: my- In moderate poisoning, astheno-vegetative man-
oglobin, peroxidases, catalases, cytochromosoxidase, ifestations are more pronounced with evidence of
cytochrome C, cytochrome P-450 and others. As a re- toxic encephalopathy and myocardiopathy with
sult, severe hypoxic changes occurring direct and indi- changes in EEG and ECG, after a different period of
rect to which nerve structures are most sensitive. At CO discontinuation of exposure pass over, whereas in
concentrations in the inhaled air of 4000 mg/m3 and severe cases the symptoms persist and even pro-
HbCO 60-80%, a sudden death occurs. The skin of the gress.
affected persons has a pink to light red color (the color Clinical-laboratory tests. Higher amount of car-
of HbCO). There are punctual haemorrhages, throm- boxyhemoglobin over (5%), compensatory increase
botic changes, dystrophic and necrotic changes in the in erythrocyte count, hemoglobin count, changes
brain, lung, myocardium, liver, and so on. in alkaline-acid balance, and blood-gas analysis pa-
Elimination of CO is primarily by the airways. rameters with a typical reduction in oxygen in arte-
Clinical picture. rial blood.
Acute symptoms occur in three stages: The differential diagnosis of acute poisoning
- mildly - with fatigue, headache, dizziness, noise in impaired consciousness is done with acute intox-
or deaf ears, nausea, drowsiness, rapid cardiac ac- ications of opiates, cyanide, alcohol, etc. In chronic

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intoxications - with lead, freons, chlorinated hydro- Different, so-called - lightning forms of acute poi-
carbons, porphyria, ischemic heart disease, etc. soning with massive inhalation of HCN with a fatal
Treatment - in case of acute poisoning, it is nec- outcome from momentary breathing paralysis. Dis-
essary to immediately remove from the gassed en- tinctive diagnostic features of acute hydrogen cyanide
vironment and start oxygen therapy (a mixture of poisoning and its compounds are bright rose skin col-
oxygen and carbon dioxide). If possible, hyperbar- oring, reddish venous blood with a specific smell of
ic oxygenation is performed. Pyramem amp. 20% bitter almonds, and severe metabolic acidosis.
5 cm3 i.v. are applied, Centrophenoxin amp. 250 Chronic poisoning. They are rarely observed.
mg i.v. In doses of 4x2 amps. for 24 hours or more Neuro so-similar conditions with pronounced vege-
depending on the severity of intoxication, group B to-vascular dystonia (a tendency to hypotension)
vitamins, vitamin C, blood transfusion, balneo-, and are a characteristic clinical manifestation of chronic
climato- treatments. poisoning. Distinctive symptoms include persistent
Prevention is mainly related to technical and headache, heart heaviness, insomnia, varying de-
sanitary-hygienic activities. grees of hypothyroidism with diffuse thyroid en-
Labour expertise. The ability to work is impaired largement. Toxic hepatitis and cognitive-intellectual
after severe acute and chronic CO poisoning and re- disorders at cortex atrophy mark a transition to a
current acute intoxications. heavier stage of chronic poisoning.
Characteristic of the chronic effects of HCN on
3.5.2. HYDROGEN CYANIDE AND CYANIDES - the skin are erythema, eczema, contact and allergic
V. PETKOVA dermatitis.
Clinical-laboratory tests. In the blood in acute
Hydrogen cyanide (HCN) may have its own applica- poisoning cyan and thiocyanates above 0.169
tion as a pesticide (rodenticide and insecticide - fumi- μmol/l can be detected. In severe cases - metabolic
gant), as well as a professional chemical agent as an acidosis. Thiocyanates in the urine are the appropri-
intermediate in the production of synthetic resins and ate test for occupational exposure, but smokers also
plastics (polyurethane, acrylonitrile) in coke chemis- expect an increased level of thiocyanates, which
tries, in the production and application of cyanate salts may lead to a false positive result.
in galvanotechnics and steel, in hardening of metals, Differential diagnosis. Carbonoxide, hydrogen
gold and silver extraction, etc. sulfide and freon poisoning, latent brain circulation
Biotransformation. The risk of cyanide com- deficiency, diencephal syndrome, neurosis, etc.
pounds is due to cyanide, which is released in almost Treatment. In acute poisoning - cardiocircular
all processes associated with their use. Hydrogen cy- and respiratory resuscitation. Hyperbaric oxygena-
anide enters the body through the airways and, more tion, Vit. C in large doses, alkalizing solutions with
rarely, through the skin. It is partly exhaled unchanged sodium bicarbonate. Antidote treatment: Inhala-
through the lungs. Biotransformation of hydrogen tion of amyl nitrate - 5-8 drops every three minutes;
cyanide by binding to SH - groups of glutathione and methylene blue 1% in 20-25% Sol. glucosae i.v. or
other proteins results in the formation of classical me- per os; sodium nitrite 1-3% resp. 30-10 cm³ slow i.v.
tabolites of HCN - thiocyanates (rhodanides). They are (forms a methemoglobin that binds and disposes
excreted in urine and faeces. cyanide), with subsequent application in the same
Patogenesis. The high toxicity of cyanide resp. its needle of sodium hyposulphate - 10% - 10-50 cm³.
compounds are due to inhibition of cellular cytochro- CaNa2 EDTA - 2 x 300 mg in Sol. glucosae - 10% i.v.
mosadase due to their affinity for the trivalent iron of can also be used.
the enzyme. The toxic effect can also be manifested by In chronic poisoning, treatment is symptomatic.
the specific thiocyanate inhibitory action on the thy- Labour expertise. The prognosis for mild forms
roid gland. of acute poisoning is favorable. Severe poisoning
Clinical picture. can lead to irreversible and disability disorders such
Acute poisoning. In mild cases, the irritant effect as encephalopathy, conduction and rhythm dis-
of cyanide on the conjunctiva and upper respiratory turbances. With marked manifestations of chronic
tract, with signs of muscle weakness, vertigo, head- poisoning such as hypothyroidism, persistent hypo-
ache, nausea, vomiting, is observed. In severe poi- tension, as well as toxic dermatitis and eczema, the
soning, clinical symptoms expand with dyspnoea patients are recruited.
and neurological symptoms - seizures and coma Prevention. Mandatory use of PPE and sani-
resulting from severe respiratory distress and as- tary-technical measures to limit exposure. HCN is
phyxia. Also myocardial damage with heart failure, controlled in the air in the working environment and
decompensated metabolic acidosis. in thiocyanates in the blood and urine.

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Medical prophylaxis. Do not allow to work HCN is and PPE. Medical prophylaxis. Non-admission to
people with skin, respiratory, blood, and expressive work of persons with chronic diseases of the respira-
vegetative disorders. Periodic medical examinations tory, digestive and central nervous systems, chronic
are performed once a year with the participation of diseases of the skin and the anterior ocular segment.
an otorhinolaryngologist, dermatologist and neu- Reviews once a year, attended by a therapist, oph-
rologist. thalmologist, neurologist.

3.5.3. HYDROGEN SULPHIDE - 3.5.4. ARSINE (HYDROGEN ARSENIDE) -

ST. ANDONOVA T. KUNEVA

Hydrogen sulphide is a colorless gas with the smell Arsine is a colorless gas, odorless, heavier than air,
of rotten eggs, soluble in water and heavier than air. It poorly soluble in water. At room temperature it slow-
is a common toxic factor in the working environment ly decomposes (oxidized) to garlic-smelling products
in the production of artificial silk, plastics, petroleum that characterize its presence.
and petroleum production. It is found in sewers, pits, Arsine gas is released into the air in the working en-
caves, where rotting organic matter. vironment in all cases of metal arsenides interaction
Biotransformation. The primary route of pene- with water, humid air or acids. It is engaged in non-fer-
tration is respiratory and less skin. It is rapidly oxidized rous metallurgy (enrichment, melting, electrolysis),
to sulfuric acid. It is absorbed in the blood. Inhibits galvanizing, microelectronics and others.
cytochrome C-oxidase and other enzyme structures. Domestic intoxications occur in damp rooms paint-
Compensatory anaerobic metabolism is enhanced - ed with arsenic-containing paints.
lactic acid accumulates, metabolic acidosis develops. Biotransformation. Pathogenesis. Arsine gas
Metabolized by oxidation to thiosulphates and sul- enters the body through the airway, dissolves in plas-
phates. There is local and general toxic action. A small ma and is fixed in erythrocytes. It causes hemolysis of
portion is eliminated through the lungs, and the rest is erythrocytes and forms methaemoglobin. At erythro-
metabolites by the urine. cytes destrsction arsenic acid formation occurs, after
Clinic of acute poisoning. Mild intoxications chronic poisoning. Two forms are present in the body
are characterized by the irritating effect of the - colloidal arsenic and arsenic acid. Arsenic is found in
formed sulfuric acid on the mucous membranes of the kidneys, lungs and liver, in prolonged contact - and
the eyes, the upper and middle airways with the on- in hair and nails. It is separated into urine.
set of tears, rhinorrhoea, dry cough, burning. Neuro- Clinical picture. In case of acute poisoning with
toxic effects such as headache, vomiting, ataxia, pol- arsine, the most characteristic is the development
yneuritis are added to the moderate ones. Rhythm of hemolytic syndrome, methemoglobinemia and
and conduction myocardial lesions, tightness in the extrahepatic jaundice. Some hours after inhalation
cardiac area, hypotension, tachycardia are observed. of high concentrations of arsine gas, unwell, fever,
Severe stage-occurring with severe damage to abdominal pain, nausea and eruction of garlic, he-
lung structures such as pulmonary edema, toxopul- matemesis, cyanosis on the face and extremities
monite, pneumonia. Neurotoxic manifestations are appear; the skin and skleras turn yellow, later turn
loss of consciousness, coma with convulsions. Also red. Hemoglobinemia (the blood turns dark-brown
described is a fulminant form in which death occurs to black) and hemoglobinuria (urine is a wine-red)
for a few minutes from respiratory center paralysis. is observed. Hepatosplenomegaly and acute renal
Chronic intoxications are caused by the symp- failure (oligo-to anuria and uremia) develop.
toms described in sulfur dioxide poisoning - chronic In modern working conditions, the most com-
toxic bronchitis, chronic gastritis, skin lesions, etc. mon forms of acute poisoning with arsine are the
Clinical laboratory tests - presence of thiosul- mild forms, with headaches, general weakness, joint
fates in the urine and sulfhemoglobin in the blood. and muscle pain, sub-icterus, mild anemia and hae-
Differential diagnosis - Intoxication with chlo- maturia.
rine, nitrous gases, carbon monoxide, hydrogen cy- Chronic arsine poisoning occurs with head-
anide. ache, vertigo, nausea, eruction with garlic odor, dry
Treatment. Respiratory and cardiovascular resus- mouth, thirst, sometimes vomiting, diarrhea, sore
citation in severe cases. Antidote treatment - sodium throat, hoarse voice, cough, shortness of breath,
nitrite 1-3%, 30 or 10 cm3, slowly, intravenously. For edema of the face and eyes, tingling fingers of the
neurotoxic effects - Pyramem, Centrophenoxin, B vi- toes.
tamins. Symptomatic treatment. Disorders of the nervous system of arsine are
Prevention. Sanitary and technical prophylax- similar to those of chronic arsenic poisoning - pol-

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yneuropathy develops. Initially, decreased fingers- Diet D is recommended from a preventive profes-
sensitivity and weakening of tendon reflexes were sional nutrition.
observed; in the case of progression-paresis and pa-
ralysis with atrophy of musculature. Relatively rare 3.5.5. CHLORINE - ST. ANDONOVA
occurrence of taste and smell disturbances, bulbar
neuritis; in single cases, acrocynosis and obliterating Chlorine is a yellow-green gas with a specific sharp
endarteritis are described. irritating odor. It is heavier than air, easily water-solu-
With chronic effects of arsine, hepatitis, melano- ble, with pronounced chemical activity.
dermia and hyperkeratosis are more common. Usage. It is widely used in various branches of in-
Clinical-laboratory tests. In the blood there is a dustry such as plastics, pesticides, petroleum refining,
decrease in hemoglobin and erythrocytes, there is hydrochloric acid, paper-pulp industry, household
methemoglobin, in urine - albumin. Exposure test chemistry, water chlorination, etc.
uses urinary arsenic determination - norm to 0.13 Biotransformation. The entrance door has
μmol/l. breathing paths and damage to the skin in the produc-
Differential diagnosis is made by poisoning tion and digestive tract as of life toxications. With wa-
with hydrogen cyanide, hydrogen phosphorus, ni- ter and biological fluids, it quickly forms hydrochloric
trogen oxydes, nitro- and amino derivatives of ben- acid and hypochlorite, at resulting in the dissociation
zene. of them latter to give of nascent oxygen (O). Disorders,
Treatment. In acute poisoning to limit acute from irritant to necrotic action on mucous membranes
haemolysis, immediate administration of Urbason 2 (ocular, respiratory and alveoli) and skin are in most
ampoules of 80 mg intravenous is required. In case cases severe and determine the clinic.
of haemolysis, a partial transfusion with fresh (24 Clinical picture.
hour) blood is shown. At the onset of intoxication, Acute poisoning - mildness. It is characterized
preserved diuresis, with very good effect, the infu- by burning in the eyes, tearing, nasal and throat ir-
sions of hydro-electrolyte solutions, 20% glucose ritation with rhinorrhea, dry cough, mild bronchos-
and 20% levulous solutions - 1000 ml/day are well pasm. Objectively, conjunctival hyperaemia, nasal
known. In respiratory failure - respiratory and car- mucosa and throat, larynx, separate dry whistling
diocirculatory resuscitation; in anuria - haemo- and wheezes are detected.
peritoneal dialysis. Moderate-severity - Pain and burning of dam-
For chronic intoxications, antidote treatment aged mucous membranes are more pronounced,
with BAL (selective agent) or Unithiol - 5% ampoules coughing is painful with severe dyspnoea. Extremely
5 ml, 1 ampoule daily intramuscularly, 5-10 days. dry whistling wheezes. Very quickly, bronchopneu-
Succimer (CHEMET) - capsules 0.350 g - 3x2 daily; monia and cardiac weakness may develop. Mucosal
course of treatment 5-7 days. CaNa2 EDTA - 10% 10 hyperaemia is very pronounced.
ml (because of the weak antidote effect only applies Severe stage - which can be characterized by
in the absence of the above mentioned prepara- acute asphyxia and death, or severe toxic bronchitis,
tions); one ampoule daily, intravenously with glu- bronchiolitis, pulmonary edema with subsequent
cose or saline - three days. inflammatory changes.
Symptomatic treatment. Diagnosis is based on data on industrial accident
Vitaminotherapy - vit B1, B6 and B12, vit C, vit. A and leakage of chlorine or household use of chlo-
Labour expertise. In acute poisoning the course rine-containing preparations, clinical picture, ABB
is severe, with high lethality. Chronic toxic hepatitis data for acidosis, hyper lung markings, lung con-
or polyneuritis requires continued treatment and gestion, and inflammatory changes in X-ray exami-
discontinuation of contact with toxic substances. nation. After acute poisoning of moderate or sever
Depending on the lost working capacity, a disability stage, chronic rhinitis, pharyngitis, tracheobronchi-
group is defined. tis, bronchiectasis, pulmofibrosis, pulmonary em-
Prevention. Sanitary-technical prophylaxis. Con- physema may occur.
traindications to work are chronic diseases of the Differential diagnosis. Poisoning with paraquat,
lungs, liver, kidneys, blood, nervous system, optic dimethylsulfate, ammonia, hydrogen fluoride
nerve. Chronic poisoning. Cough, fatigue, burning in
Periodic medical examinations are performed the eyes, nose, throat, clinical data on chronic bron-
once a year by a therapist, an otorhinolaryngologist, chitis and pulmonary fibrosis, chest tightness are
a dermatologist; at indications - neurologist. Para- characterized. There are chronic dermatitis and ec-
clinic studies include full blood counts and urinary zema, sometimes chlorine acne. On the side of the
arsenic determination. oral cavity, the teeth and the cavity - hyperemia,

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cariousness, periodontal disease, anemic states are degree of fluorine and hydrogen fluoride intoxica-
described. tion, depending on the entrance door, occurs with
Treatment. In case of acute poisoning, ensure coughing, chest pain, mild breathlessness. Per os-
airway passage, oxygen therapy and, if necessary, nausea, vomiting, burning in the stomach, moder-
mechanical ventilation. Medication with broncho- ate diarrhea occur. The affected skin areas and mu-
dilators, broncholitics, cough soothing remedies. cous membranes are red and painful.
In inflammation - chemotherapeutics, antibiotics. Moderate grade - Clinical finding of the lung -
Wash eyes thoroughly with water or physiological pronounced bronchospasm, dyspnoea that occur
solution (consultation with an ophthalmologist). In after a latency period. From the digestive system -
the case of skin burns, the clothes are removed, the abundant vomiting and profuse diarrhea, leading
patient bathes with plenty of water, treatment of to risky dehydration, hyponatremia, hypokalaemia,
damaged skin and TAP insertion. hypocalcaemia. Muscle pains and cramps occur.
Treatment for chronic poisoning is dependent on From heart-tachycardia, extrasystolia. Skin lesions
organ damage and its severity. Depending on the are heavier.
severity of the injuries, the working capacity may be Severe degree - From the lung - data on bron-
distorted to varying degrees. chiolitis, pulmonary edema, acute respiratory fail-
Prevention. Sanitary-technical prophylaxis. ure. Deepening the clinical manifestations of the di-
Medical prophylaxis - persons with chronic diseases gestive system. Expressed cardiac rhythm disorders,
of the respiratory, cardiovascular and central nerv- camera fibrillation, shock. By inhalation of large
ous systems, the skin and the anterior ocular seg- amounts, the death from fluorine and hydrogen flu-
ment are not allowed to work. Periodical medical oride intoxication occurs for a short period of time
examinations once a year with the participation of with clonic seizures, respiratory and cardiovascular
a therapist, dentist, ophthalmologist and ORL spe- failure. Skin lesions are presented with severe ne-
cialist. crosis. In cases of severe and moderate intoxications
persons, marked pulmonofibrosis, renal and hepatic
3.5.6. FLUORINE, HYDROGEN FLUORIDE - impairment were observed.
ST. ANDONOVA Clinical-laboratory tests. Electrolyte imbalance
with elevated hypocalcaemia, toxo-chemical analy-
Fluorine is a pale yellowish gas with strong odor, a sis for the presence of fluorine and metabolites.
chemically very active metalloid, a strong oxidant. Differential diagnosis. Acute poisoning with
Usage. Hydrogen fluoride (HF), hydrofluoric acid heavy metals, chlorine, phaloid fungal intoxication
and its compounds (fluorides), fluoroacetic acid and its and others.
compounds (fluoroacetates), sodium fluoride for the Treatment. Depending on the entrance door
treatment of dental caries, fluorocarbon (freon) in the with depurging and non-specific detoxic combina-
refrigeration industry as solvent, production of plastics. tions, calcium preparations, symptomatic treatment,
Fluorine is also used as a rocket fuel oxidant, atomic in- specific dermatological and ophthalmic treatment.
dustry, uranium production, pesticides, plastics, derati- Chronic poisoning with hydrofluoric acid com-
zation specimens, dental practice, electro-welding, etc. pounds occurs with a prolonged use of water con-
Biotransformation. The main routes of pene- taining fluoride salts and in industrial exposure.
tration of the body are respiratory and digestive and, Chronic intoxication. It runs with significant
more rarely, through the skin. The damage effect is due osteoporosis due to calcium binding. It is more pro-
to the formation of hydrogen fluoride. In the stomach, nounced on the bones of the limbs, but can also be
hydrofluoric acid salts form with hydrochloric acid also generalized. Yellow-brown teeth coloring, brittle-
fluorine, which has a rapid resorption. It binds large ness and shaking of the teeth are observed. From
amounts of calcium and blocks many enzymes (glu- the respiratory system - chronic rhinopharingitis,
cose 6-phosphatase, cholinesterase, maltase, etc.), sup- tracheitis, tracheobronchitis.
presses the release of phosphoric acid, thereby increas- From the digestive system - stomach and abdom-
ing the amount of dextrose diphosphate, pyruvate and inal pain, nausea and less frequent vomiting.
lactic acid. Impaired metabolism of fluoroacetic acid Symptoms of the central nervous system (head-
leads to the accumulation of fluorcitric acid. These me- ache, vertigo, etc.) and cardiovascular system-hypo-
tabolites have a pronounced damaging effect on the tension, conduction and rhythm disturbances can
central brain structures, the digestive system, the lung, be detected. Liver damage is also described.
the heart. Fallen on the skin and mucous membranes Diagnosis is based on the occupational history,
can cause mild irritation to severe necrotic changes. the presence of fluorine in the toxo-chemical anal-
Clinical picture. Acute intoxication - the mild ysis of blood, radiographs for the presence of pro-

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nounced osteoporosis, dental examination, and (MAC - 18 mg/m3), which greatly reduces the risk of
data on hypocalcaemia. Treatment as with acute noxious poisoning in the production.
poisoning with dosage adjustment.
Prevention. Sanitary-technical. Medical prophy- 3.5.8. SULFUR GASES - ST. ANDONOVA
laxis - persons with chronic diseases of the CNS, cardio-
vascular and respiratory systems, skin, liver, oral cavity Due to the high chemical activity of sulfur, its
and bones, the anterior ocular segment, chronic gas- compounds are widely distributed, as sulfur dioxide,
tritis and ulcerative disease are not allowed to work. trioxide and hydrogen sulphide are most commonly
Medical examinations - 6-12 months with the partic- found in the production environment.
ipation of therapist, otorhinolaryngologist, a dentist SULFUR DIOXIDE
and radiologist. Control of Hb and urinary calcium. It is a colorless gas with a sharp, suffocating odor,
easily soluble in water. Manufactures where workers
3.5.7. AMMONIA - ST. ANDONOVA most often exposed to sulfur dioxide are non-ferrous
and ferrous metallurgy, gas production, machine
Ammonia is a colorless gas with a strong specific building, refining of oil, pulp and rubber products, sul-
odor and strong alkaline taste. Boils at 33-35 ° C. Easily furic acid production, etc.
dissolves in ether, water, alcohol, fat. Biotransformation. In industrial contact, the pri-
Usage. Ammonia is obtained synthetically and is a mary route of penetration is the airways, less skin and
major source in the production of explosives and syn- the digestive tract. With biological fluids it forms rapidly
thetic fibers, soda, nitric acid and nitrogen fertilizers. sulphurous and later sulfuric acids, therefore irritating
Used in refrigeration, oil refining, the sugar industry, effects on the mucous membranes of the eyes, airways
the textile industry, in the production of mirrors (silver manifest themselves early, and at high concentrations,
amalgam). It accumulates in septic tanks, meeting in toxopulmonites rapidly develop. Quantities of them
the air of chemical laboratories. Major industrial acci- passing in blood determines cumulative changes,
dents can also be affected the population close to the metabolic acidosis. Biotransformed into sulfates, part
industrial site. Along with other industrial gases, toxic of which forms S-cysteine, S-sulfo-glutathione and
pollutants cause a serious ecotoxicological problem. S-sulfonates, mercapturic acids and their derivatives.
Biotransformation. Ammonia is a typical toxic ir- Elimination of sulfur dioxide is via the lungs and me-
ritant. It penetrates the body primarily through the res- tabolites of urine.
piratory system. Depending on the concentration and Clinical picture of acute poisoning. Inhalation
exposure, it determines injuries of varying distribution of small amounts results in tearing, rhinorrhoea, dry
and depth. cough, pain in throat and sternum. In severe poison-
Clinical picture. ing, spasms of laryngeal edema, bronchospasm, tox-
Mild acute poisoning manifests acute irritative opulmonite development and pulmonary edema
lesions in the upper respiratory tract, laryngitis. are observed. Running is unfavorable. Liquid sulfur
Moderate forms occur with the clinical picture dioxide fallen on the skin has an irritant to a necrotic
of toxic tracheobronchitis, toxic pneumonia or pul- effect. Inhalation of large quantities leads to a rapid
monary edema. lethal outcome.
High concentrations cause laryngeal spasm, re- Chronic intoxication. It is characterized by burn-
flexive breathing stoppage, acute hypoxia, convul- ing, pain, secretion from the eyes, upper respiratory
sions, death. tract and esophagus. Astheno-vegetative manifes-
When an ammonia is applied in high concentra- tation is observed. In more pronounced forms, there
tions on the eyes for 5-10 minutes, burning, corneal are chronic toxic bronchitis, often with asthmatic
breakage, blinding can occur. When liquid ammo- expression. The development of toxic pneumoco-
nia falls on the skin, second degree burns develop. sclerosis in parallel with bronchitis or alone. Chronic
Combined lesions are heavier. oesophagitis, gastritis is detected. From the oral cav-
Chronic exposure to ammonia is characterized ity - increased cariousness, yellowish tooth coloring,
by reduced respiratory mucosal resistance, mani- stomatitis. On the skin side - dermatitis, eczema.
fested by frequent bacterial infections, chronic bron- Clinical and laboratory investigations. Pres-
chitis, pneumonia - in a significantly higher percent- ence of sulphates and other metabolites in the urine,
age than those in unexposed. Chronic conjunctivitis, ABB, functional breathing study, X-ray examination
keratitis and dermatitis are also more common. of the lungs.
Differential diagnosis, treatment and prophy- Differential diagnosis. Poisoning with paraquat,
laxis - as with chlorine poisoning. The smell of am- dimethylsulfate, ammonia, hydrogen fluoride.
monia is equal to or lower than its hygienic norm Treatment. In acute poisoning - oxygen therapy

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to mechanical ventilation in severe bronchospastic cardiogenic shock-reduced to 100 mm Hg.
conditions and lung edema. Symptomatic treat- - a period of reversal. After severe pulmonary
ment. In the presence of toxic pneumonia the inclu- edema, pneumosclerosis may develop as a residual
sion of antibiotics. phenomenon.
Prevention. Sanitary-technical prophylaxis. Chronic poisoning. Occupational contact work-
Medical prophylaxis. Do not allow persons with ers often experience inflammatory changes in the
chronic diseases of the respiratory and cardiovascu- mucosal membranes of UAP, chronic bronchitis, ear-
lar systems, of the skin, of the gastrointestinal tract, ly lung-emphysema. Dyspeptic disorders, metabolic
of the liver, of the anterior ocular segment. Period- disorders, muscle and heart weakness, hypotension
ic reviews of 24 months (dentist at 6 months) with are less common. Single cases of "toxic psychoses"
the participation of therapist, dermatologist, otorhi- with depressions and hallucinations have been de-
nolaryngologist, ophthalmologist. A "B" diet of pro- scribed. At high concentrations, yellow coloration of
tective professional nutrition is recommended. the hair, nose and fingers, greenish accretions with
metallic tint of the teeth, partial tooth decay can be
3.5.9. NITROGEN OXIDES - T. KUNEVA observed.
Clinical-laboratory tests. There is a slight in-
- In acute poisoning - conjunctivitis, cough, short- crease in hemoglobin, erythrocyte and reticulocyte
ness of breath, pulmonary edema counts, leukopenia with relative lymphocytosis,
- In chronic poisoning - bronchitis, emphysema, methemoglobinemia.
toxic pneumosclerosis. Differential diagnosis. Intoxication with other
Nitrogen oxides are: NO, NO2, N2O, N2O3, N2O4 and irritating gases. In chronic poisoning - with viral and
N2O5. The most common in manufacturing and with bacterial inflammation of the lungs.
the greatest medical significance is NO2. Treatment. In case of acute poisoning, oxygen
Usage. NO and NO2 are involved as intermediates through a nasal tube or mask to normal arterial ox-
in the preparation of nitric acid; NO2 finds application ygen partial pressure, in restless patients sedative
as a nitrating agent; N2O is used for narcosis ("laughing agents; diuretics; secretory agents; corticosteroids,
gas"). antibiotics (to prevent pneumonia); symptomatic
Nitric gases are released during the synthesis of ni- means.
tric acid and nitrites as well as in all processes in the In chronic poisoning, treatment is symptomatic;
chemical industry where nitric acid, nitrites and nitrates vitaminotherapy.
are used. Nitrogen oxides are formed in the blasting of Expertise on employment. After acute and
explosives, in electrical and acetylene welds, in the cel- chronic poisoning, people are temporarily incapac-
luloid burning, in the production of artificial fertilizers, itated. Suspended of contact with toxic substances,
in the ensilage and storage of cereals, in the operation dust and unfavorable microclimate are workers after
of internal combustion engines. acute contact with pulmonary edema or pneumonia
Pathogenesis. Nitric gases penetrate the body and in recurrent chronic bronchitis, pulmonary em-
through the respiratory tract. They have a pronounced physema or pneumosclerosis lesions.
local irritant effect on the mucous membranes of the Prevention. Sanitary-technical prophylaxis.
UAP, vasodilator and narcotic action. They fall into the Medical prophylaxis. Contraindications for exposure
group of methaemoglobin-forming poisons. to nitrogen oxides include atrophic rhinopharyngi-
Clinical picture. Acute poisoning is character- tis, chronic lung diseases, the cardiovascular system,
ized by several periods: the gastrointestinal tract, the liver, the skin and the
- period of initial events - a few minutes after con- anterior ocular segment disorders. Periodic medical
tact with high concentrations occurs irritation of the examinations - once every two years, with the par-
mucous membranes of the eyes and the upper res- ticipation of a therapist, an otorhinolaryngologist
piratory tract, head-pain and fatigue. Symptoms are and a dentist (6 months) - on indications dermatolo-
usually mildly and rapidly transient. gist, ophthalmologist and a blood sample is investi-
- a latency period of several hours to one day. gated. It is recommended that diet B be taken from
- period of development of bronchial edema - the preventive professional nutrition.
irritable cough and wheezing, shortness of breath.
In case of worsening, a high level of dyspnea with
cyanosis and coughing of foamy sputum, eventually
haemoptoea, occurs. Ausculatory in the lung areas is
heard from small to large wet wheezes. Sinus tach-
ycardia, systolic blood pressure is often elevated, at

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REFERENCES

1. Mihaylova A. et al. - "Exposure - effect" and "exposure-response" dependences at action of ethylene

oxides. in labour medicine and industrial ecology, 1993, 9-10, 40-41(in russ.)
2. Monov A. Poisoning with arsine in. Clinical Toxicology, S, MF, 1981, 195-200 (in bul.)
3. Stellman J. M., D. Osinsky and P. Markkannen - Cyano compounds in: Encyclopedia of occupational
health and safety, ed. J. M. Stellman, vol. IV, Geneva, International Labour Office, 1998, vol. IV, 104. 133-135.
4.Toxicological Profile for Ethylene oxide. Agency for Toxic Substances and Diseases Registry, US Public
Health Service, Atlanta, Georgia, USA, 1990, p. 122.
5. Toxicological Profile for Sulfur dioxide. Public Health Service, Agency for Toxic Substances and Diseases
Registry, Atlanta, Georgia, USA, 1998, p. 223.
6. Toxicological Profile for Sulfur Trioxide and Sulfuric Acid. Public Health Service, Agency for Toxic Sub-
stances and Diseases Registry, Atlanta, Georgia, USA, 1998, p.224.

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3.6 OTHER CHEMICAL

COMPOUNDS
3.6.1. ACIDS - S. PAVLOVA Organic acids
Formic acid (H.COOH) - mainly used in textiles
Acute poisoning (for wool, silk, cotton) and in the leather industry; in the
• Irritative dermatitis, burning of the skin; production of perfumes, soaps, varnishes, etc. H.COOH
• Upper respiratory tract inflammation, lung has the most pronounced toxic action of organic acids.
edema. Acetic acid (CH3COOH) - used in the textile indus-
Chronic poisoning try; painting; in the manufacture of medicines, paints;
• With hydrofluoric acid-osteosclerosis; in many organic syntheses and more.
• with nitric acid (nitric oxides) - fibrous oblite- Aliphatic dicarboxylic acids - maleic, fumaric
rating bronchiolitis; and adipic are used in the production of synthetic res-
• for chromic acid - nasal ulceration, perfora- ins, paints, inks, etc.
tion, skin ulceration. Glycolic acid (CH2(OH)COOH) and lactic acid
Usage. (CH3(OH)COOH) are widely used in the textile, leather,
Inorganic acids plastic and food industries.
Sulfuric acid (H2SO4) - used in the production of Pathogenesis. In contact with tissues, acids cause
fertilizers (superphosphate, ammonium sulphate, etc.); coagulation necrosis due to their "drying" effect on
Of soap; In metallurgy of non-ferrous and rare metals; proteins. Hydrofluoric acid alone induces liquable ne-
In the manufacture of dyestuffs; in the leather industry crosis by binding to calcium and magnesium.
(leather tanning); in the metalworking industry (met- Clinical picture. Acute poisoning in vapor ex-
al grinding); for charging batteries; in the production posure develops irritative to corrosive lesions of
of a large number of organic substances (acetic acid the conjunctiva and the mucous membrane of the
and tartaric acid, phenols, ethyl ether, various types of respiratory tract and chemical pneumonitis. These
esters, etc.); in the production of nitrocellulose, nitro- are manifested by keratoconjunctivitis, sometimes
glycerine, nitrobenzene; for the purification of various laryngeal edema, tracheobronchitis, bronchopneu-
petroleum fractions and others. monia, pulmonary edema. When on the skin, acids
Nitric acid (HNO3) - used in the production of ni- cause chemical burns of varying degrees (I-III), with
trogen fertilizers, explosives, nitrocellulose lacquers, the development of erythema, vesicles, bulls, ulcer-
cinema films, in the manufacture of synthetic silk and ations that reach even the bones when damaged by
celluloid, aromatic nitro compounds and a large num- hydrofluoric acid. All injuries are accompanied by se-
ber of synthetic dyes; in galvanoplasty (gold plating vere pain, eventual shock.
copper and brass); for engraving of metals; in the pol- Chronic poisoning
ygraphic industry. HNO3 easily forms nitrogen oxides. Inorganic acidic
Its vapours have a similar effect but are more toxic Sulfuric acid. Chronic poisoning is usually com-
than pure nitrogen dioxide. bined with the action of sulfur dioxide, hydrochlo-
Hydrochloric acid (HCl) - used in the production ric acid and nitrogen oxides. Diseases of mucous
of fertilizer; in galvanoplasty; for the production of membranes of the mouth, tooth decay, atrophic
sugar, organic dyes; in the refining of fats and oils; by changes of upper respiratory tract mucosa, bronchi-
tanning of fur and their dyeing; In the textile industry; tis, pneumocystis, in some cases bronchial asthma,
in photography and more. gastritis, ulcerative disease, etc. are observed. Also
Phosphoric acid (H3PO4) - finds application in the skin diseases - dermatitis, paronychia, etc., function-
production of phosphorous fertilizers; in the food in- al changes of the CNS and of the cardiovascular sys-
dustry; in the production of cinema films and photore- tem are also observed.
agents; to obtain tissues with fireproof impregnation Nitric acid. In contact with skin, concentrated
and the like. HNO3 causes severe burns, colored in a character-
Hydrofluoric acid (HF) - the main use is in the istic yellow color (xantoprotein reaction). Diluted
manufacture of creolet, for the production of alumi- solutions can cause eczema. Inhalation of vapours-
num; in the production of beryllium, manganese, ura- chronic bronchitis and relatively mild bronchiolitis
nium; when welding with electrodes containing fluo- with headache, dizziness, tinnitus, drowsiness.
rine compounds; in the manufacture of matches, etc. Hydrochloric acid. Chronic exposure causes der-
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matitis (to a lesser extent than those in the action of dentist (6 months) - as indicated by a dermatologist
sulfuric and nitric acids); airway catarrhs; tooth de- and ophthalmologist and includes the following
cay, which begins with the appearance of brownish paraclinical studies: blood alkaline-acid state, hemo-
spots on their surface; corrosive lesions of the lining globin, urine - total study, ammonia determination,
of the nose (it is possible to pierce the nasal septum); titration acidity and vitamin C in the urine.
gastrointestinal disorders. It is recommended diet C of the protective pro-
Phosphoric acid. In contact with skin - derma- fessional nutrition.
titis. The vapours cause atrophic processes of the
nasal mucous membranes, which can also lead to a 3.6.2. BASES - T. KUNEVA
break in the nasal septum. Typical haemorrhages of
the nose, nasal and swallow dryness, shaking of the • Acute effects - eye and skin burns, irritant
teeth. changes in the UAP;
Hydrofluoric acid. It acts highly corrosively on • chronic effects - ocular blindness.
the skin, with dermatitis formation II-III degree (even The most common inorganic bases are ammoni-
weak solution of HF - 0.03%, acts destructively on um, sodium and potassium. Many oxides and salts dis-
the epithelium). solved in water cause toxic lesions similar to inorganic
Organic acids bases-calcium, strontium and barium oxide, ammoni-
Formic acid - most strongly acting from organ- um and potassium carbonate (potash), sodium silicate
ic acids. Bleeding, nasal cold, sneezing, sore throat, (water glass).
cough, pain and tightness in the chest, dry mouth The bases are solid - amorphous or crystalline sub-
and throat, hyperacid gastritis are observed. stances or liquids with strong corrosive action. It is
Acetic acid - the action of her vapours irritates stronger than concentrated acids. By removing water
mucous membranes. Chronic exposure causes dis- from the tissues, the bases cause denaturation of the
eases of the nose, the nasopharynx, the larynx, as proteins and cause deep liquable necrosis.
well as conjunctivites and bronchitis. Usage.
Clinical-laboratory tests. Non-specific changes Sodium hydroxide (NaOH - caustic soda). In
in some haematological parameters (hemoglobin, production of caustic soda, chlorine, soap, cellulose
erythrocytes) have been observed. Chronic expo- and synthetic fibers, explosives, disinfectants, plastics,
sure to HNO3 increases the level of methaemoglobin black pitch distillation products (phenol, naphthalene,
in the blood. As a biological marker for the effects etc.). The most common use of NaOH is to neutralize
of HF, determination of F in urine (mean reference strong acids and dissolve water-insoluble chemicals.
values ​​- 0.5 mg/l) is used. X-ray exploration for inter- Calcined soda (Na2CO3.10H2O). Used in the
stitial or alveolar edema; blood-gas analysis hypoxia manufacture of glass, paper, laundry powders, soap,
is detected. ultramarine, bicarbonate and other sodium salts, dis-
Differential diagnosis. Intoxications with di- infectants, for bleaching tissues, for the purification of
methyl sulphate, ammonia, chlorine, bromine, sul- naphtha, it is composed of cooling alkaline solutions
fur dioxide, ozone, powders, bases, etc. Dermatites for cutting metals as well and in the form of mixtures
degrade from those due to bases, halohydrogens, for the cleaning of deposit from boilers.
salts of halohydrogen acids, chromium, arsenic and Potassium base (KOH). It is used for the produc-
others. tion of potassium compounds, bases, soap, in labora-
Treatment. Respiratory and cardiocirculatory re- tory practice.
suscitation; pulmoprotective treatment; analgesics Potassium carbonate (K2CO3.2H2O - potash). It
and alkali (alkaline bicarbonate) in acidosis; eye and is used in glassware, faience and pharmaceuticals, for
skin wash with physiological serum and ointment, saponing, wool dyeing, etc.
surgical treatment. Calcium oxide (CaO - quick lime). It is used in con-
Prevention. Sanitary-technical prophylaxis. Per- struction, agriculture, metallurgy, leather and textiles,
sonal protective equipment. Medical prophylaxis. in the production of synthetic paints, soda and others.
Contraindications for admission include: chronic Pathogenesis. Bases penetrate most often through
bronchitis, pulmonary emphysema, bronchial asth- the skin, less frequently through the respiratory tracts
ma, pronounced atrophic rhinopharyngitis, laryngi- and through the digestive tract (when used by mis-
tis, chronic diseases of the anterior ocular segment, take).
skin, liver, caries, disposition, chronic gastritis, ul- In production conditions, skin lesions are most of-
cerative stomach and duodenum, diseases of the ten observed. Oral sodium (even minor) administration
cardiovascular system. Periodic examinations of 24 may result in fatal burns, perforation of the esophagus
months by a therapist, an otorhinolaryngologist, a and stomach.

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Clinical picture the case of severe corrosive lesions with partial or
Acute poisoning develops upon oral adminis- complete obstruction of the esophagus, continuous
tration of the base. Symptoms are severe, similar to treatment is required and the persons have a re-
those seen with acid poisoning. Immediately after duced working capacity for a long time. In rare cases
ingestion of the base, the lips swell, there is burning (corneal blindness), a disability group is defined.
in the mouth and the gulp, accompanied by plenty Prevention. Sanitary-technical prophylaxis and
of salivation, followed by severe pain, disintegration personal protective equipment. Medical prophy-
in swallowing to inability to swallow. A profuse and laxis. Contra-indications for contact with bases are
continuous vomiting begins. Severe bleeding may atrophic rhinopharyngitis and laryngitis, chronic
occur as a result of deep necrosis of affected tissues. lung diseases (bronchitis, emphysema, asthma, fi-
Urine volume decreases. There are also general tox- brosis, bronchiectasis), chronic liver, heart, skin,
ical symptoms - somnolence, adynamia, dehydra- antero-ocular segment diseases. Periodic medical
tion, hypovolaemia with disorders of the water-elec- examinations are performed once a year, with the
trolyte and alkaline-acid balance (alkalosis). Shock participation of therapist and otorhinolaryngologist,
conditions and complications are similar to those at indications - ophthalmologist and dermatologist.
with acid poisoning, but they occur more frequently
and occur much more severely. Early complications 3.6.3. CHLOROMETHYL ETHERS -
are perforation of the esophagus with acute medi- R. STEFANOVA
astenitis, stomach with acute peritonitis. Late com-
plications include scarring and obstruction of the Halogenated ethers (monochloromethyl ether
esophagus and pylorus, cachexia, hypoproteinemia - CH3-O-CH2Cl and dichloromethyl ether ClCH2-O-
and hypovitaminosis. CH2Cl) are colorless liquids, easily volatile at room tem-
When inhalation of alkali, laryngeal edema is ob- perature, with suffocating odor. They are easy to mix
served, tracheobronchitis, bronchiolitis, sometimes with all organic solvents. They are alkylating agents. In
pneumonia develop. water they decompose with separation of formic alde-
If there is a direct contact with the skin on a con- hyde, hydrogen chloride and alcohol.
centrated basis, there are signs of severe chemical Usage. They are used for chloromethylation, such
burns. Secondary infection is often overlapped. Af- as nitrocellulose paint solvents, for the production of
ter cure of ulcers, scars are often. antioxidants, plasticizers and stabilizers in the tex-
Chronic skin lesions are often. In contact with tile industry, organic synthesis and the production of
unconcentrated bases, the skin is irritated and de- ion-exchange resins. The thermostable emulsion of
greased, becomes stiff, dry, gruff, cracks. Dermatitis polymers containing methyl acrylamide as a bind-
and eczema develop. Nails darken, break easily and er, can release formaldehyde which, in the presence
separate from the nail-bed. of chloride, forms chloromethylethers, endangering
Base-to-eye fall causes ulcerative corneal dam- workers in the production of certain resins and plastics.
age, sometimes lesion the iris, vitreous, and retina. Clinical picture.
Possible occurrence of the blindness. Acute poisoning. Chloromethyl ether vapors ir-
The prognosis is always serious. ritate the eyes, upper respiratory tract and skin. Even
Clinical-laboratory tests. No specific laborato- low concentrations can cause pulmonary edema
ry-diagnostic tests for risk assessment have been and fatal outcome. It is believed that the probable
developed. cause is the formation of formaldehyde from chlo-
Differential diagnosis. Differentiation from oth- romethylethers.
er corrosive chemicals - acids, formalin, mercury and Chronic poisoning is characterized by head-
other compounds. ache, irritation of the eyes and upper respiratory
Treatment. Respiratory resuscitation and pulmo­ tract, shortness of breath and cough. Affected peo-
protective treatment; administration of analgesics, ple can develop chronic bronchitis and emphysema.
antibiotics and glucocorticoids (against scarring); There have been cases of mass hysteria, bronchial
eye and skin wash with physiological serum and asthma and vestibular disorders.
spread with corticosteroid and antibiotic creams In the chemical industry, where chloromethyl-
and ointments; surgical treatment, incl. necrectomy ethers are used, three times more frequent lung car-
and plasty. Parenteral nutrition with concentrated cinomas (latent period of 5-25 years) are reported in
glucose, plasma, plasma substitutes and mixed nu- exposed workers. Mortality is high over 10 years of
trition (liquid feed). service.
Labour expertise. Mostly sicks are temporarily Clinical-laboratory examinations. Specific ex-
incapacitated - from a few days to several weeks. In posure tests have not been established. Lung X-ray

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 OCCUPATIONAL MEDICINE
and cytological examination of the sputum (screen- atous skin reactions - eyelids, hands and neck. It is
ing method) are required to establish pulmonary possible to provoke allergic contact dermatitis and
carcinoma. asthma. Prolonged occupational exposure is associ-
Differential diagnosis. In acute poisoning, a ated with astheno vegetative syndrome, facial nerve
differential diagnosis is made with damage from neuritis, impaired vision, damage to the parenchy-
irritating gases (chlorformraldehyde, sulfur dioxide, mal organs and myocardium.
acetone, acids, etc.). In diagnosed lung carcinoma Clinical and laboratory studies. Exposure test is
a differential diagnosis is made with malignancies the concentration of formaldehyde in the blood - up
caused by asbestos, arsenic, chromium, uranium, to 0.6 mg% (0.198 mmol/l), urine - 10 mg/l.
etc. Indicators for functional status of the liver and
Treatment. Eye and skin wash with saline, antibi- kidneys increased activity of the serum enzymes
otic ointments; pulpoprotective treatment; respira- ASAT, ALAT, elevated creatine, etc.) are altered. Par-
tory resuscitation (if necessary). tial oxygen pressure in the blood is reduced and ac-
Labour expertise. In cases of acute poisoning, idosis is observed.
the incapacity is temporarily lost, and in chronic, Differential diagnosis. In acute poisoning - with
with the development of pulmonary damage, the intoxications of irritating gases, acids, phenol, chlo-
patient is subject to rehabilitation. romethylethers, ethylene oxide, methanol, and in
Prevention. Sealing of chemical processes, and chronic - with non-professional diseases of the skin,
effective ventilation. Regularly control the concen- nervous, respiratory and digestive system.
tration of substances in the work environment. Use Treatment. Therapy is symptomatic, aimed at
of personal protective equipment. bronchopulmonary and skin manifestations. Inha-
Medical prophylaxis. Opposites for work are dis- lation of alkaline solutions, oxygen therapy, respira-
eases of the skin, respiratory and nervous systems. tory and cardiovascular agents. Specialized ophthal-
The medical examinations should be performed mic treatment.
once a year with the participation of a therapist, Labour expertise. In acute poisoning, working
neurologist and dermatologist. A cytological study capacity is temporarily lost. In organic changes after
of sputum is desirable. acute poisoning and chronic intoxication, the ability
to work is permanently limited.
3.6.4. FORMALDEHYDE - R. STEFANOVA Prevention. Sealing of production processes,
effective ventilation and use of individual means
Formaldehyde is a gas with an intense suffocating of protection. Control of formaldehyde concentra-
odor. With air and oxygen it forms explosive mixtures. tions.
Polymerizes in paraformaldehyde. Formalin is a 35- Medical prophylaxis. Conducting medical exam-
40% aqueous solution of formaldehyde. inations, once a year, with the participation of an
Usage. Formaldehyde is used as a feedstock in the internist, ophthalmologist, neurologist and derma-
chemical industry for the production of phenol formal- tologist and, if necessary, an allergist. Do not allow
dehyde resins in the textile, paper, leather and furniture persons with disabilities of the respiratory system,
industries. It is an antiseptic and deodorizing agent. skin, nervous system, anterior eye segment, liver
Upon heating of the polymers, rapid depolymerization and kidneys to work.
occurs and gaseous formaldehyde is released (even at
room temperature). 3.6.5. SURFACTANTS. R. STEFANOVA
Biotransformation. Formaldehyde penetrates the
body through the airway and through the skin. Me- Surfactants are polar organic compounds with an
tabolized to methyl alcohol and formic acid, which are asymmetric molecule. The hydrophilic part may be
eliminated by the body with exhaled air and urine. a sulfate, a carboxyl, a sulfonate, a polyoxyethylene
Clinical picture chain, or a nitrogen-containing dipolar group. The
Acute poisoning. Formaldehyde causes a high- hydrophobic part is a branched or straight aliphatic
ly irritating effect on the eyes, the skin and the res- chain of 10-20 carbon atoms, a benzene or naphtha-
piratory tract. It occurs with tears, thickness, loss of lene ring with substituents.
voice, cough, pain and tightness in the chest, diffi- The aqueous solutions of surfactants are of differ-
culty in breathing. At concentrations of 20-50 ppm ent ionic nature: anionic (α-surfactants) which dis-
formaldehyde may cause pulmonary edema. As a re- sociate with the formation of a negatively charged
sidual phenomenon of acute toxicity, toxic neuropa- organic ion and a positive ion of a metallic nature;
thy and toxic optic neuritis may be observed. cationic c-surfactants) - compounds that are dissoci-
Chronic poisoning. They develop with eczem- ated by separation of a positively charged organic ion

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 LABOUR MEDICINE
and a negatively charged inorganic ion; amphoteric allergic dermatitis and eczema may occur in some
surfactants - with different functional groups (in acid cases.
environment they react as cationic and in alkaline - as Workers exposed to high concentrations of sur-
anionic), non-ionic surfactants - which do not dissoci- factants containing proteolytic and other enzymes,
ate to ions. under adverse working conditions, suffer from short-
Surfactants alter the surface tension of aqueous ness of breath, and some asthma attacks. Dyspnoea
solutions, some of them also in oil solutions. occurs a few hours after the end of the day or night.
Usage. They are used as detergents, emulsifiers, Accompanied by red rashes on the face, neck and
ionizers. They come in the form of lotions, shampoos, hands, also from burning in the eyes and throat,
toothpastes and others. Anionic and non-ionic sur- swelling on the eyelids, intolerance to strong light.
factants are mainly used as washable and soap pow- Allergic reactions of the respiratory system are of a
der (liquid) detergents. Amphoteric surfactants are fast type. Direct falling into the eyes of c-surfactants
used in cosmetics for emulsifiers, children's shampoos leads to severe inflammatory lesions.
and others. Cationic surfactants have utility as bac- Clinical-laboratory tests. Increased absolute
tericidal and insecticidal disinsectants and antistatic number of eosinophils in the blood, increase in
agents. Productive exposure is the workers involved in specific antibodies of the type of immunoglobulins
the production, mixing, packaging and storage of sur- (IgG, IgE, etc.) in the blood serum.
factants, as well as those using them in auto cosmet- In bronchospastic conditions, the external
ics. All who are using them in the household are also breathing values changes. Skin allergy samples are
at risk. positive for surfactant.
Biotransformation. They most often penetrate Differential diagnosis. In acute oral poisoning
the skin through long contact (especially cationic - with intoxications from medications, from other
surfactants) and, to a lesser extent, by the respiratory toxic substances, as well as with unprofessional gas-
tract. It is possible to penetrate, albeit rarely, through troenterocolitis.
the digestive tract. They accumulate mainly in the liver. In cases of bronchopulmonary apparatus, skin
They are degraded by beta-oxidation to simpler chem- and eyes - with non-professional diseases of these
ical compounds or non-toxic products, eliminated for organs.
48 to 72 hours, mainly urine and bile, and some of Treatment. Upon entry of surfactants in the di-
them with exhaled breath. They do not have cumula- gestive system, stomach washes and alkalizing bev-
tive properties. erages are given.
Pathogenesis. The toxic effects of surfactants are In the case of skin injuries - corticosteroid oint-
highly varied. They have a local and general resorption ments and others. Irritative and allergic mani-
effect. Their irritating and sensitizing effect on the skin festations of the respiratory system are treated
has been well studied. This effect is due to some of their symptomatically-bronchodilators, vit. C, calcium
ingredients, such as bleach, preservatives and antimi- preparations, expectorants, and in asthmatic attacks
crobials. Some surfactants also have a photo-sensi- novphilin, ephedrine, dehydrocortisone and aerosol
tizing action. Surfactants disrupt lipid balance in the preparations (Alupent, Ventolin, Isoprenaline, etc.)
skin, damaging cell membranes and enzyme systems are used. Non-specific desensibilization occurs.
in the epidermis. Anionic, non-ionic and amphoteric In case of eye damage - plenty of physiological
surfactants have a less deleterious effect on the skin. saline, ophthalmic treatment.
They have an irritant and allergenic effect on the Labour expertise. Injuries caused by surfactants
respiratory system as well. In experimental conditions, are most often related to temporary loss of employ-
their teratogenic and carcinogenic effect has been ment. In case of allergic reactions - interruption of
proven. contact with professional allergens.
Clinical picture. Prevention. Automation and sealing of produc-
In case of accidental swallowing of cationic or tion processes, effective ventilation, personal pro-
anionic surfactants, toxic inflammation of the gas- tective equipments, control of surfactant concentra-
trointestinal tract (nausea, vomiting, diarrhea, dull tions in the air. Medical prophylaxis includes medical
abdominal pain, etc.) is observed. examinations once a year, with the participation of
Irritative changes in the mucous membranes of therapist, dermatologist and, if necessary, ophthal-
the eyes and the upper respiratory tract of breath, mologist and allergist. Contra-indications for work
coughing and burning in the eyes may occur with with surfactants are chronic skin, ocular, allergic dis-
inhalation of finely divided powders. Skin contact eases, respiratory and digestive diseases.
with anionic or cationic surfactants leads to skin er-
ythema, swelling, burning and pain. In skin contact,

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3.6.6. ETHYLENE OXIDE - J. HADJIEVA for humans - IARC group I. Higher rates of stomach
cancer, peritoneal mesothelioma, brain tumors, leu-
Ethylene oxide is a gas which, at a low temperature, kemia in subjects exposed to ethylene oxide have
turns into a colorless liquid with the smell of ether and been found.
bitter taste. Dissolve well in water, ethanol and diethyl Clinical-laboratory tests. Hematological pa-
ether. It tends to polymerize and to interact with many rameters - reduced hemoglobin and lymphocytosis
organic and inorganic substances (alcohols, amines, are observed. Cases of chronic lympholeukosis and
inorganic chlorides, etc.). Upon heating with water, it chronic myeloleukosis are described.
forms ethylene glycol. Differential diagnosis. Poisoning with acids,
Usage. Ethylene oxide is used as an intermediate in chloromethyl ethers, formaldehyde.
the production of various chemical substances (ethyl- Treatment. There is no specific treatment. Ne-
ene glycol, diethylene glycol, triethylene glycol, ethan- phroprotectors, cerebro- and pulpoprotectors,
olamine, choline, choline chloride, etc.) as a fungicide, hepatoprotectors and other symptomatic therapy
in the medical and dental practice for sterilizing dress- are used. Eye and skin wash with physiological se-
ings materials, systems and oth. rum, ointment application.
Biotransformation. It penetrates the body through Prevention. Sanitary-technical prophylaxis. Ad-
the inhalation route and to a lesser degree through the herence to regulations for safe operation, control of
skin. It is deposited in the spleen, less in the liver, lungs ethylene oxide concentrations in the working envi-
and testicles. Its metabolism is accomplished by hy- ronment.
drolysis processes and by binding to glutathione. Medical prophylaxis. Do not work in contact with
Pathogenesis. Protoplasmic poison. It has a strong ethylene oxide, people with diseases of the nervous
narcotic effect and expressed general and specific tox- and cardiovascular systems, diseases of the liver and
icity. It has an allergic and irritant effect. It affects re- skin. Periodic medical examinations - 12 months,
production, has mutagenic and carcinogenic effects. with the participation of dermatologist and at indi-
Clinical picture. cations - ophthalmologist.
Acute poisoning is characterized by disorders Protective professional nutrition - diet "D" is rec-
in the nervous and mental sphere (asthenia, drows- ommended.
iness, vertigo, heavy pulsatile headache, bradyp-
sychia, delayed movements, hypomimia), irritative 3.6.7. TETRAETHYL-LEAD - J. HADJIEVA
manifestations of the upper respiratory tract and
lungs, severe dyspnoea and pulmonary edema. In Organic compound of lead. It is an oily liquid with a
some cases there is a brief loss of consciousness and specific odor and high volatility. Practically, tetraethyl
persistent dyspeptic manifestations. In case of con- lead is insoluble in water, dissolves well in fats and or-
tact with the skin - chemical burn with erythema, ganic solvents.
edema, bulls. Iritative lesions of the conjunctivae - Usage. It is mainly used as an anti-detonator for
burning in the eyes, ferythema. gasoline and a lubricant for internal combustion en-
Chronic poisoning. Observed in persons with gines. It is a constituent (up to 75%) of the ethyl liquid
work experience over 5 years. The lesions of the that is added to the gasoline.
central and peripheral nervous system are leading. Exposed to ethylated gasoline are persons em-
Symptoms develop gradually with initial neuras- ployed in the production, transport, storage and use of
thenic and vertigo-vascular manifestations. Inten- the gasoline (air mechanics, airplane engineers, motor
tional tremor, dysarthric speech, hypomimia. Chang- vehicle drivers, etc.).
es in surface sensitivity of the limbs by type "gloves Biotransformation. The main way of getting into
and socks" are characteristic. Possible development the body is breathing. It is relatively easy to penetrate
of encephalopathy and polyneuropathy. There have through the skin and the digestive tract. Tetraethyl-lead
been cases of hypertonic reactions, sometimes with circulates in the blood unchanged from 8 hours to 2-3
myocardial disorders and coronary insufficiency days, and in individual cases up to 3 months. After its
symptoms. Various functional abnormalities of the degradation, part of the lead is deposited in the CNS
liver have been reported. and the parenchymal organs.
Ethylene oxide has a highly irritating and sensi- Pathogenesis. Tetraethyl-lead is a neurotropic poi-
tizing effect on the skin. Severe dermatitis and skin son with a pronounced cumulative effect. It changes
burns are possible. Ethylene oxide damaged male the functional state of the hypothalamus by the re-
and female reproduction. There is an increased in- flector pathway by irritating the vasoreceptors. Tetrae-
cidence of spontaneous abortions with nurses us- thyl-lead is an enzyme effector. It increases the content
ing it for sterilization. Ethylene oxide is carcinogenic of pyruvic acid and acetylcholine in tissues and impacts

516
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oxidative phosphorylation. Deviations in other organs morphine and bromine is contraindicated.
and systems are predominantly secondary and are re- Labour expertise. In acute poisoning (mild de-
lated to disorders of their CNS-regulated functions. gree), loss of working capacity is temporary. In the
Clinical picture. case of an medium degree of poisoning, labour is
Acute intoxications are most commonly caused required without contact with toxic substances, and
by the inhalation of large amounts of vapor, by at severe grade defined a group of disability. Chron-
pouring of the skin or by sucking and swallowing ic poisoning requires temporary or permanent reha-
high doses of ethylated petrol. After a latency period bilitation.
of 10-12 hours to several days, the clinical picture of Prevention. Sanitary-technical prophylaxis. Re-
poisoning unfolds, forming three stages of leakage: spect for personal hygiene and use of personal pro-
- Mild. It is predominantly characterized by tective equipment.
vegeo-asthenic events - headache, fatigue, restless- Medical prophylaxis. Do not work in contact with
ness, chest tightness, sometimes euphoria. The triad tetraethyl-lead individuals with CNS, liver, kidney,
is established - bradycardia, hypotension and hypo- cardiovascular, digestive, endocrine, skin and visual
thermia. Parallel with this, other vegetative manifes- analyzers diseases. Periodic medical examinations -
tations are observed - hyperhidrosis, increased sali- once every 6 months in the production of tetraethyl-
vation and red dermograms. lead and ethyl liquid and once every 12 months with
- Medium (pre-cumulative). Characterized by the use of ethylated benzine, with the participation
hallucinations (hearing, olfactory, tactile), deperson- of therapist, neurologist and at indications - derma-
alisation, tonic and clonic seizures, dysarthria. Paral- tologist and psychiatrist.
ysis of the facial nerve, the ptosis of the eyelids, di- Protective professional nutrition - diet "B" is rec-
plopia and the appearance of pathological reflexes ommended.
are observed.
- Severe grade (cumulative). Rich psychotic 3.6.8. POLYCYCLIC AROMATIC
finding - complete disorientation, psychomotor agi- HYDROCARBONS - D. APOSTOLOVA
tation, hyperkinetic disorders, epileptiform seizures,
etc. Hypothermia and hypotension change with hy- Polycyclic aromatic hydrocarbons (PAHs) - with sig-
perthermia (up to 40 ° C) and hypertension. Sponta- nificant toxicity and carcinogenicity, are: naphthalene,
neous bleeding and loss of consciousness. The exit antracene, benz (e) pyrene, benz (a) anthracene, diben-
is often lethal. zanthracene, benz (a) pyrene, chrysene, dibenzcarba-
Chronic poisoning. Characterized with a slow zole and the like.
and unclear beginning. Major clinical manifestations Usage. Occupational risk. They are obtained by
are vegeto-asthenic syndrome (early sign of intoxi- the high-temperature processing of organic raw mate-
cation) and toxic encephalopathy. The triad (hypo- rials (petroleum, resins, oils, bitumen, coal, etc.) by dry
thermia, hypotension and bradycardia) is optional. distillation, cracking, coking, incomplete combustion.
In some cases there is a tendency for hypertension Contained in coal tar, asphalt, coke, car gases, smoke,
combined with bradycardia. Increased tendon and soot, petroleum products, asbestos ore and treated
superficial reflexes, sometimes asymmetric, pro- asbestos. Naphthalene is used as an insecticide, in the
nounced small tremor of the eyelids, tongue and production of chemicals, plastics, paints; anthracene -
hands, diffuse sensory disorders, asymmetry in fa- in the manufacture of anthraquinone and dyes. Work-
cial inertia, hypothermia, etc. There have been cases, ers from the mining, chemical, transport and electrical
though very rarely, of pronounced parkinsonic syn- industries are at risk.
drome. Biotransformation. Pathogenesis. The primary
Clinical-laboratory tests. There are no charac- route of penetration in the body is respiratory, with
teristic deviations in the haematological parame- slow absorption. It is also possible in the case of skin
ters. Increased numbers of basophilically stippled contact, and ingestion (food, water). They are depos-
erythrocytes and reticulocytes is a rare finding. The ited in fat-rich tissues. In non-cancerous effects, the
enzyme and protein function of the liver has been target organ is the respiratory system. Liver disorders,
compromised. Increased urinary excretion of 5-ALA myelosuppressive effects, and the pathogenesis of ath-
and coproporphyrin. Urine content of lead is used as erosclerosis are also observed.
an exposure test. The carcinogenic effect of PAHs was demonstrated
Treatment. Antidote therapy with CaNa2EDTA, indirectly after a study of occupational tumors in work-
hepatoprotectors, neuroprotectors, vitaminothera- ers (where there was a PAHs group effect) and experi-
py (vitamin C and vitamin B group), etc. Physiother- mentally on animals. PAHs with proven experimental
apeutic procedures have a good effect. The use of carcinogenic activity include over 480 substances. In

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animal experiments, their carcinogenic activity has rarely hepatic carcinoma are also observed. Mye-
been shown to depend on the 1,2-benzapyren content, losuppressive activity is manifested by leucopenia,
since among the inherent PAHs 1,2-benzapyrene has rarely thrombocytopenia and aplastic anemia.
the highest carcinogenic activity, IARC group 2a. Can- Clinical-laboratory tests. Increased gGTP (over
cer cases in humans as a result of direct contact with 30 U/l), leucopenia (less than 3 G/l), thrombocytope-
pure 1,2-benzapyrene have not been reported, but a nia (below 100 G/l), aplastic anemia (Hb below 100
marked correlation has been observed between the g/l and Er less 2.1012/l), decrease to lack of reticulo-
incidence of occupational tumors in contact with ther- cytes in peripheral blood.
mal fuel treatment products, the temperature regimen Specific biomarkers for exposure are not availa-
of their preparation and the content of 1,2-benzpyrene ble (noxe and its metabolites in urine - e-hydroxy-
in them. pyrene can be investigated). Biomarkers for the toxic
It is assumed that the toxic effect and the carcino- effect are suitable in vitro tests for effects on DNA
genic effect of benz/a/pyrene are associated with its with manifestations of induced chromosomal aber-
metabolism. Its metabolic products (reactive epoxides) rations and daughters chromatin exchanges.
are genotoxic agents that covalently bind to DNA and Differential diagnosis. In acute poisoning - with
lead to mutations and initiation of tumors. irritating gases, amino- and nitro derivatives of ben-
Carcinogenic PAHs cause skin cancer at the site of zene and toluene. In chronic - with impairment of
the contact, but tumors are not excluded in individual other carcinogens in the working environment.
organs. It is believed that carcinogenic PAHs affect the Treatment. In acute poisoning, cerebral and pul-
incidence of lung, stomach, liver cancer. moprotective agents are administered; treatment of
Increased risk for smokers, excessive exposure to available methaemoglobinaemia and haemolysis
UV radiation, malnutrition (vitamin C, iron, riboflavin in the usual ways; washing the skin with water and
loss), concomitant liver and skin diseases, women of soap and ointment. Photodermates are treated with
childbearing age. Passing through the placenta benz cortisone-containing preparations, protective or ex-
(a) pyrene increases embryo - fetolethality and leads to posure-reducing creams. The manifestations of the
premature birth and malformations. carcinomas are surgically treated with chemother-
Clinical picture. apy radiotherapy.
Acute poisoning. Inhalation irritative lesions of Prognosis and expertise of working capacity.
the respiratory tract lining develop with sneezing, In acute poisoning, the prognosis is good. When de-
harassing of throat and behind the sternum, cough, veloping a professional carcinoma, the prognosis is
also headaches, nausea and vomiting. Naphthalene pessimistic. Patients are permanently removed from
can cause methaemoglobinaemia and haemolysis. the work environment and directed to WEMC. In
In massive skin contact, erythema with itch or mod- case of skin precanceros, they are permanently re-
erate chemical burning is observed. moved from the work environment and have tem-
Chronic effects. Benign skin changes - folliculi- porary limited working capacity.
tis, comedones, arteficial dermatitis and hyperpig- Prevention. Sanitary-technical prophylaxis and
mentation, leukoplakia, precancerous degeneration personal protective equipment. Medical prophy-
(keratoses, papillomas, melanoses, oil acne, torpid laxis. Do not work people with skin diseases with
ulcerations) more on the head, neck, limbs and gen- increased photosensitivity and skin precancerous.
itals. After prolonged skin contact with benz/a/pyr- Workers in contact with surfactants are subject to a
ene (10-30 years), spinocellular carcinoma with slow 6-month prophylactic examination with the partici-
evolution developed. It is possible to develop lung pation of therapist and dermatologist with Hb, leu-
cancer and urinary bladder carcinoma. Liver lesions kocytes; on indications BSR, DBC, γGTP, cystoscopy.
with hepatomegaly and elevations of γGTP, stimu- It is recommended diet B of protective professional
lation of hepatic regeneration (proliferative effect), nutrition.

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REFERENCES

General Studies
1. Harrison R.J. - Chemicals in: Occupational Medicine, ed. J. La Dou, Appleton & Lange, Norwalk, Con-
necticut, 1990, 327-358

Acids and bases

2. Hinkamp D.J., Acids, Inorganics in: Encyclopedia of Occupational Health and Safety, IV ed., V. IV, ed. J.
M. Stellman, International Labour Office, Geneva, 1995, p. 104.5-104.12.
3. Monov A. Poisons with inorganic bases. In: Clinical Toxicology, S, MF, 1981, 195-200 (in bul.)

Surfactants
4. Barrer, J. Bilan de morbidite d'une usine de fabrication et conditionne de detergents. Arch. de Mal.
Profess., 39, 1978, 631-632.
5. Coate, W. B., W. M. Busey, W. H. Schoenfisch - Respiratory toxicology of enzyme detergents in dust-
Toxicol, Appl. Pharmacol., 45, 1978, 477-496.
6. Jordanova, J., Ст. Yaneva, A. Bainova - Synthetic detergents in households, Sofia, Profyzdate, 1984
(in bul.)
7. Lazarev, V.N. - Toxical substances in industry, Len, Chemistry, Vol. I, 1976, 863-866. (in russ.)
8. Mihaylov, P. - Occupational diseases of the skin, Sofia, Med. and phys., 1982, 182-185. (in bul.)

Polycyclic aromatic hydrocarbons

9. Toxicological Profile for Fuel oils. Public Health Service, Agency for Toxic Substances and Diseases Reg-
istry Atlanta, Georgia, USA, 1995, p. 231.
10. Toxicological Profile for Polycyclic Aromatic Hydrocarbons. Prep. By Clement International Corpora-
tion under Contract No. 205-880608. Prep. For the Agency for Toxic Substances and Diseases, Registry of the
Public Health Service of the United States, December, 1990.
11. Tolbert P. E. Oils and cancer. Cancer Causes. Control. 1997, May, 8 (3): 386-405.
12. Vineis P., Pirast R. Aromatic amines and cancer. Cancer Causes. Control.1997, May, 8 (3): 346-55.

Formaldehyde
13. Blair, A., et al .: Mortality among industrial workers. Exposed to formaldehyde, J. N. C. I., 1986, 76, 107.
14. Browning, E. - Toxicity a. Metabolism of Industrial Solvents, Amsterdam, Elsevier, Public. Co, 1965,
98-102.
15. Formaldehyde. IPCS, The Concise International Chemical Assessment Document No 40, WHO, Geneva,
2002, p. 75.
16. Horvath, E. P. Jr. Et al .: The Effect of Formaldehyde on the Mucous Membranes and the Lung: Study
of an Industrial Population, JAMA, 1988, 259-701.
17. Sterling, T.D. - Reanalysis of lung cancer ortality in a National Cancer Institute study on mortality
among industrial Workers exposed to formaldehyde - J. Occup. Med. 1988, 38, 895.
18. Toxicological Profile for Formaldehyde. Public Health Service, Agency for Toxic Substances and Dis-
ease Registry Atlanta, Georgia, USA, 1999, p. 468.

Chloromethyl ethers
19. Lazarev, V. N. Toxical substances in industry, volume I, 416-422, 1976. (in russ.)
20. Maher, KV, De Fonso, DR: Respiratory cancer among chlormethyl ether workers, JNI, 1987, 78, 739.
21. Travenius, SZ: Formation and occurrence of bis chloromethyl ether and its prevention in the chemi-
cal industry, Scand. J. Work Environ Health, 1982, 8 Suppl. 3, І.
22. Ward E., Smith A. B., W-4,4 Methylene-bis (2-chloraniline): An urinary carcinogen. I am. J. Ind. Med.,
1987, 12, 537.

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Al. Monov

MASS ACUTE POISONING -

3.7 TOXOCHEMICAL TRAUMATISM. MASS

POISONING FROM INDUSTRIAL POISONS

Mass acute poisonings, also called toxo-chemical has different physicochemical properties. Due to the
traumatism, are disastrous conditions in a particular massive nature of the injuries of the victims of mas-
area due to industrial, household, natural accidents, sive poisoning and their simultaneous occurrence,
where a large amount of poisonous substances are they are also defined as toxochemical traumatism
released or by the inclusion of toxic compounds in - the most aggressive form of mass traumatism. It
special conditions. Many people are affected by the grows annually and is presented in the following
action of mono- or poly toxical agents. The condi- forms (Al. Monov):
tions of accidental incidents and the mass nature of 1. Monotoxic forms.
aggression determine availability of certain features (a) gas-inhalation;
in the clinical characteristic and treatment, which (b) nutritional;
distinguish them from single toxic injuries of the 2. Polytoxical forms;
same type of noxae. 3. Coupled forms: toxic-mechanical-baro-thermal
Mass acute poisoning is, by its nature, one of the species.
most aggressive pathologies in modern conditions. Etiology. Mass poisoning is most commonly
This is due to the fact that: caused by two types of agents: poisonous gases
• At the same time, a large number of people penetrating the body mainly through the respirato-
are struck in a very short time (minutes and ry system and less frequently through the skin and
hours), in which way another damaging cause mucous membranes and other types of poisons
(such as earthquake, flood) can rarely occur; penetrating the digestive tract predominantly with
• The striking agent causes such injuries in the different types of food.
body of the injured that, in inadequate combat, In some cases, the damaging agent is monotoxic
the same causes great mortality and disability. - only one toxic substance, in other cases it is mono-
Group and mass acute poisonings can be clas- or poly toxic, combined with other striking agents:
sified in the following classification (Al. Monov) ac- dusts, glowing of the gas dust mixture, exposure to
cording to the type and conditions of occurrence the latter under pressure on the human body. These
(Figure 1). peculiarities of the etiological nature of mass poi-
The type of damage from acute intoxications in soning determine the much heavier and wider pos-
these groups is determined by the toxic noxa that sibilities of their aggression. The conditions in which

Fig.1.

Basic model of mass poisoning

Professional Household Medical

mass poisonings mass poisonings mass poisonings

Agri-
occurred under

Industrial
health mass
Other types
poisonings

poisonings

poisonings

poisonings

conditions
Household
Food mass

production
poisoning

poisoning
Medicinal
Hospital-

mass
of mass

special
Mass
mass

mass

mass
poisonings
poisonings

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 LABOUR MEDICINE
poisonous gases are formed are mostly technical ac- tions of the intoxication. The main mechanisms here
cidents, fires, explosions. Hence, smoke or explosive refer to:
gases, silage gases, etc. are formed as agents of mass • Hypoxia - affecting particularly the brain and
poisoning. In terms of their chemical nature, they myocardium cells;
are most often carbon monoxide, chlorine, fluorine, • A shock condition - due to blood circulation
nitrobenzene and phenol vapors, hydrogen cyanide disorders;
and others. The complex composition of toxic gas • Direct damage to enzyme systems.
agents contributes to the potentiation of their dam- In this way, severe damage to the parenchymal
aging effects on injured persons. Also: organs, blood, disorders of the main balances in the
• In the gas mixtures mentioned above, the for- body, such as acid-alkali with severe acidosis, hydro-
mation of new toxic substances (eg carbon electrolyte - with severe dehydration and hemocon-
monoxide and chlorine - phosgene is formed centration; protein, carbohydrate, lipid balance, and
at this temperature). so on.
• Simultaneous combination of single and com- Clinical characteristics of gas-inhalation mass
bined poisonous gases with the above-men- acute poisoning. The following major syndromes
tioned non-toxic damaging agents (thermal, are formed:
dust, etc.). • general toxic;
Chemical food poisoning is caused by poisons • pulmonotoxic;
that do not at most exhibit their specific odor quali- • ophthalmotoxic and rhinotoxic;
ties or are poisoned by food stuffs and food technol- • chemotoxic;
ogy. Mass poisoning caused by toxic polluted sourc- • hepato- nephrotoxic.
es of drinking water is also the cause of these lesions. The prognosis of these mass poisonings is too of-
Pathogenetic mechanisms of gas-induced ten unfavorable due to complications, irreversibility
acute poisoning. of severe forms, rapid lethal outcome in improper
In the case of mass poisoning by mono- or poly treatment.
toxic gas combined and uncombined poisons, local Mechanisms of impairment and clinical fea-
and general mechanisms of damage are developed. tures of mass food poisoning. They also have local
Local damages mainly affect the respiratory system and general disabilities. Local include varying de-
and are manifested by: grees of damage to the lining of the digestive tract
• ​​irritative or necrotic lesions of the lining and (most commonly hyperemia and increased secre-
the walls of the airways with edema and in- tion) and rapid disruption of bacterial equilibrium in
creased secretion; the intestinal tract with a strong increase in patho-
• blockage of different parts of the bronchial genic forms.
tree - as from the lining edema and the lining General disorders are manifested by a variety of
secretions, and under corresponding condi- pathogenetic mechanisms and include: severe de-
tions of mechanical particles; hydration; impaired acid-base equilibrium; acute cir-
• multiple atelectatic areas - in connection with culatory disorders; syndromes by CNS, liver, kidney,
obstruction and the occurrence of bronchos- blood, and oth. (depending on the chemical charac-
pasm; teristics of the poison).
• inflammatory processes in the changed lung Clinical picture. In the case of mass poisoning, it
areas; is manifested by:
• pulmonary edema and bleeding in pulmonary General gastrointestinal syndrome - vomiting, di-
parenchyma. arrhea, abdominal pain.
When a baro- factor is present, microrupturesare Other syndromes from different organs and sys-
formed in the wall of the bronchi and bronchioli and, tems depending on the type of intoxication. Forms
in the presence of a thermofactor, burns occur on the of this type of mass poisoning are aggravated by
surfaces of the respiratory tract. To a lesser extent, shock conditions, respiratory disturbances, severe
there are various types of toxic damage on contact metabolic acidosis, etc., which determines severe
areas of the skin and ocular mucous membranes. prognosis and inappropriate treatment - lethal out-
These damage to the respiratory system results in come.
the formation of a broncho-alveolar capillary block - General healing tactics for massive acute poi-
disturbing the absorption of oxygen, which results soning
in severe general damages. Preparatory section. The uniform preparatory
The general lesions are varied depending on the program includes the following groups of events:
chemical characteristics of the poison and the condi- • Preliminary information from the various re-

521
 OCCUPATIONAL MEDICINE
gions of possible toxic noxae in industrial en- 3. Pulmoprotective agents - include aerosol and
terprises, farms, households, etc., which may parenteral forms of various drugs (glucocorticoids,
cause mass poisoning, under favorable condi- beta-stimulants, novphilin, acetylcysteine, etc.) to
tions. overcome the broncho-alveolar capillary block.
• Determination and estimation of medical and 4. Antidotal agents.
other means of transport. 5. Anti-hypoxants (Pyramem, etc.).
• Determination of the bed fund in the hospi- 6. Protective drugs and combinations to the af-
tals. fected organs and systems.
• Identification and preparation of the medical 7. Detoxic cleansing methods of blood - exchange
staff who will serve the incoming contingent. Transfusion and Dialysis.
• Designation of reserve buildings and spaces 8. Antibiotics and immunoprotective agents.
for further set up of hospitals at an extremely 9. Symptomatic remedies.
massive nature of poisoning. Basic Methods of treatment of mass food poi-
Therapeutic section. It identifies two types of soning.
data: criteria for assessing the type of intoxication 1. Detoxic cleansing of the gastrointestinal tract -
and the extent of its damage to poisoning; the applied at the onset of intoxication in the absence of
amount of medical assistance in the three stages of contraindications.
service to the victims - at the place of the accident, in 2. Drip infusion of hydroelectrolyte, monosaccha-
the transport vehicle and in the hospital. ride, amino acid solutions and protein preparations,
Basic actions in the treatment of mass poisoning plasma substitutes with corrective and replacement
of the gas-inhalation type. target of the three service stages.
1. Removing the victims from the gassed environ- 3. Resuscitation - in extremely severe and severe
ment. forms of blood circulation and breathing damages in
2. Reanimation methods - apply to the severe and the three stages of service.
extreme severe stadium of injuries to the victims in 4. Antidotal agents.
the three stages of their care. These are: respiratory 5. Organoprotective remedies at the hospitals.
and cardiovascular resuscitation and correctional-re- 6. Antibiotics and symptomatic agents.
placement therapy. An important meaning for the damages of mass
Breathing resuscitation. It is performed with port- poisoning is the fact that a number of non-toxic sub-
able or stationary respiratory equipment (if neces- stances, under certain conditions become a source
sary with portable and stationary barocameras); of poisons causing severe poly-toxic mass poison-
- cardiovascular resuscitation and correctional-re- ing. Such substances are plastics - at high temper-
placement therapy. It is performed with drip infu- atures (fires) the different synthetic materials form
sion therapy intravenously - with hydroelectrolyte, highly toxic gases and vapors: carbon monoxide,
monosaccharide and plasma-substitution solutions nitrogen oxides, sulfur oxides, phenol, nitrobenzene,
combined at shock with glucocorticoids and vaso- aminobenzene, phosgene, formaldehyde, toluene
pressor agents; cardiotonic drugs (such as strophan- and others.
tine, cardiac glycosides, etc.) are added.

Fig.2.

Mass poisoning of poisons in industrial environments

Polly toxic
Mono toxic mass poisonings
mass poisonings
poisoning of

poisoning of

poisonings
Pulmonary

organ toxic
pulmonary

plastic gas

Combined
toxic type

explosive
damage
cerebral

Cerebral

Multiple
cerebral

psycho

gases
Renal

mass
Toxic
type

type

type

Mass

Mass

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 LABOUR MEDICINE
Too often toxic factors in mass poisoning are 5. Special conditions: terrorist actions, military
combined with other factors: thermal agent - high conflicts, riot stuggle, etc.
temperature in fires; baro- factor - high pressure of In the case of mass poisoning by industrial poi-
the toxic mass, most often in an explosion. This com- sons the most common causes are gas poisons. The
bined etiological factor in mass intoxications causes following types of industrial mass poisoning occur
much more severe and varied lesions on the affect- (Figure 2):
ed contingent, and it is most common in industrial 1. Monotoxic mass poisoning - caused by only
mass intoxication damage. one type of toxic agent.
Mass poisoning of industrial poisons 2. Polytoxic mass poisoning - caused by a mixture
They occur in emergency situations in industrial of more than one toxic agent.
plants and large laboratories with the most frequent 3. Combined mass poisoning - caused by the
reasons: combination of a mono- polytoxic agent combined
1. Incident in technical equipment: gas pipe with other factors (thermo- baro factors, etc.).
cracking, tank breakage or explosion. The most common mass poisoning is with
2. Incident in the technology of the production leading pulmo-toxic lesions, mass intoxications with
process: in case of deviations in the temperature re- leading pulmocerebral lesions, leading renal-cerebral
gime and the pressure of the gas components. and cerebro-psychical injuries and mass poisoning
3. Fires in production and storage premises. with polyorganic damages to the injured.
4. Explosion of waterhousing pressurized poison-
ous substances.

REFERENCES

1. Medical aspects of chemical and biological terrorism. Biological terrorism and traumatism, ed. Monov,
Al. and Hr. Dishovski, ed. USB, 2004, 234 p. (in bul.)
2. Medical aspects of chemical and biological terrorism. Chemical terrorism and traumatism, ed. Monov,
Al. and Hr. Dishovski, ed. USB, 2004, 354 p. (in bul.)
3. Medical treatment of chemical and biological lesions, ed. St. Tonev and K. Kanev, MMA-IRITA, 2009,
360 pp. (in bul.)
4. Monov, Al. Clinical Toxicology, Vol. I, ed. Venel, S., 1995. (in bul.)
5. Monov, Al. Clinical toxicology, vol. II, ed. Venel, S., 1997. (in bul.)
6. Monov, Al. Scientific strategy against mass contemporary toxic damages, In: Ecology of spirituality, ed.
USB, 2001. (in bul.)
7. Monov, Al. Medical strategy against mass damages, ed. CIM, Medical University, Sofia, 2001. (in bul.)
8. Monov, Al. Early diagnosis and treatment of acute poisonings, ed. CIM, Medical University, Sofia, 2001.
(in bul.)

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OCCUPATIONAL MEDICINE

OCCUPATIONAL DISEASES
BY PHYSICAL FACTORS
Zl. Stoineva

4.1 PROFESSIONAL CRYOPATHOLOGY

Subject of cryopathology is the person in condi- blood circulation in arteriovenous anastomoses, and
tions of cold impact with his changed life activity, in capillaries, venules and other vessels gradually ceas-
altered reactions of the organism as a whole and es. Pathogenesis is associated with tissue frost, hypoxia
of the individual functional systems, changes in the and the release of inflammatory mediators with exces-
morphology of cells, tissues and organs. sive production of thromboxane A2, which disrupts the
Risky professions are workers in refrigeration normal balance between prostacyclin (prostaglandin
chambers and repositories for food and other prod- I2) and thromboxane A2, followed by progressive ne-
ucts; meat and fish processing industry; fishermen crosis. Systemic hypothermia disturbs physiological
and sailors; storage and processing of dairy products; vital functions - blood circulation, tissue metabolism,
artificial ice production; fermentation rooms for sugar respiration. Oxygen consumption is reduced by about
and beer production; chemical and biochemical labo- 7% at 1 ° C. Myocardial repolarisation is delayed, heart
ratories operating at low temperatures; sellers of frozen defibrillation occurs.
fish and meat; launders with non-mechanized work; External factors that increase the risk of cryopathol-
retouchers of porcelain; workers in winter outdoors in ogy include: increased humidity and speed of air move-
construction, logging, agriculture and others. Artificial ment, vibrations, sharp temperature drops, narrow,
cold applied to more than 250 branches of industry, sci- moisture-tight and wet clothing and shoes, altitude,
ence, technology, food industry. geographical specificity. Endogenous factors contrib-
All living tissues react to the effects of cold, but the uting to cold pathology include: exhaustion, overwork,
most sensitive and injured are the nervous system and avataminosis, hunger, smoking, alcoholism, reconva-
the vascular system. Diseases of the peripheral nerv- lescence conditions after severe illness, physical disa-
ous system - neuralgia, neuritis, radiculitis occur 1.5 to bilities, mental disorders, reduced motor activity, im-
2 times more often among workers in general or local paired adaptation and acclimatization, pre-existing
cold conditions and occupy second place after cold air- cold traumas.
way diseases. Crush damage can be generalized or local; tem-
Under the influence of low temperatures, the pe- porary (transient) or permanent. Depending on
ripheral blood vessels of the skin and the subcutaneous the cooling rate and the duration of the cold effect,
tissues shrink, which improves the thermal insulation acute, subacute or progressive and chronic cold
of the tissues and reduces the heat transfer. Peripher- trauma are distinguished. Progressive cold-induced
al vascular spasm is due to the direct action of cold effects are characterized by a gradual decrease in
on peripheral neurovegetative structures and blood temperature in peripheral and central body tissues,
vessels, to the excitatory catecholamine mechanism expressed in pain, neuro-muscular insufficiency, loss
of stress response with stimulation of the sympa- of sensation and resp. cold-induced damage. Chron-
tho-adrenal system. Centrally, hypothalamic efferency ic effects affect peripheral nerves and vessels as well
is caused by hypothermia. Compensator stimulates as cardio-pulmonary functions.
metabolic heat production through arbitrary muscle Generalized hypothermia, as a concept, in-
contractions and "cold tremor". The cold conditioned volves the influence of cold on the whole organism
vasodilator response is more pronounced in acclimat- and is the result of ineffective thermogenesis. It oc-
ed patients. Tissue metabolism is disrupted, vascular curs not only at minus temperature but is also pos-
permeability is disturbed, blood viscosity is increased, sible at + 10 ° C to -12 ° C at exposure over 12 hours
stasis and microtrombosis are detected by shutting and additional endogenous predisposing factors.
off various parts of the vascular line while preserving

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The initial phase of total cooling is a common and Treatment includes heating the body with elec-
easily reversible when warming condition. Body tric pillows or blanket, warm bed, bath with a water
temperature remains above 35 ° C, but frostbites of temperature of 37 ° C and according to a many of
varying degrees may be present on the acral parts authors and up to 40 ° C, with constant control of
of the body. Initial symptoms are often unobserva- the victim's consciousness. In moderate and severe
ble without specific clinical features. There is fatigue, hypothermia and body temperature below 32 ° C,
adynamia, apathy, drowsiness, dizziness, memory constant monitoring of heart rate and rhythm is re-
disturbance. The thermoregulatory "cold tremor" quired to increase body temperature to 36 ° C (risk
disappears, the speech becomes blurry, obscure, the of cardiac fibrillation). Due to the spontaneous re-
coordination of movements is disturbed. Increased covery of heart rhythm with warming, antiarrhyth-
irritability, hallucinations. Disagreeable pupil reac- mic agents are usually not used. Infusions of gradual
tions, hypo- to anesthesia for pain, touch and tem- warmed to 40 ° C dextrose-salt solutions, low mo-
perature, hyporeflexia, attenuated or absent pulse, lecular dextran, humanalbumin are required. Avoid
reduced respiratory rate, arrhythmia, arterial hypo- potassium-containing solutions (until stabilization
tension, increased blood viscosity have been report- of serum potassium level). It is necessary to manu-
ed. The skin is pale, cold, the fingers pale or cyanotic. ally and lung motor inhale with oxygen, prior to the
In a mild degree of generalized hypothermia, a warming up. Follow the diuresis every hour and con-
rectal temperature of 25°C-33°C, adynamia, bradyp- stantly body temperature. Acidosis, hypoglycaemia,
sychia, bradylalia, apathy - movements are sluggish, hyperkalemia are corrected. Antibiotics are used for
slow, speech is descant, slow. There is indifference. infections. Data on brain and/or pulmonary edema
The pulse is slightly slow. Local frosts of I-II degree uses dehydration therapy. Pretreatment and healing
are possible. local frosts.
At moderate degree of generalized hypother- Generalized hypothermia is a severe condition re-
mia, body temperature falls to 32°C-29°C. Stupidity, quiring urgent treatment in an intensive and resus-
somnolence, pale cold skin, bradycardia, arterial hy- citative ward.
potension, reduced to 7-12 per minute respiratory The prognosis is good for patients with precede
rate, breathing is superficial. Nerve conduction is de- good health, without predisposing external and in-
layed. Possible complications with local frosts from I ternal risk factors and timely medical attention.
to IV degree. There are a number of clinical forms of local cold
The severe degree of generalized hypothermia is pathology, which are generally divided into two
characterized by loss of consciousness, constant, main groups: externally visible cold injuries and cold
usually flexionary muscle contracture. The body lesions without externally visible disturbances (with
temperature is below 28°C. The pulse is slower than the predominant involvement of deeper tissues).
32 beats per minute, poorly filled, does not palpated The first group refers to frosts (congelatio) and
into the periphery. Arterial pressure is low to absent. perniones. The tissue damage begins with the for-
The respiratory rate is reduced to 3-4 per minute with mation of ice crystals in the extracellular fluid, the
a faulty rhythm - the Cheyne-Stokes. Urinary incon- blood with platelet aggregation, and stopping cap-
tinence is observed. Edematous brain, lungs, severe illary blood flow. The damage is most pronounced
frostbite of the extremities and face is observed. This after warming.
condition can go into a severe coma with cardiac fi- Congelatio is a local cold defect due to freezing
brillation and cardiac arrest. of tissues from superficial to deep structures. There
Necessary studies: complete blood count, blood are three, four, five-degree congelatio classifications
sugar, urea, electrolytes, amylase, alcohol and drugs depending on the depth of tissue disturbance. Wide
levels of blood, bleeding and clotting time, pro- application and more convenient to choose an ade-
thrombin index, ABB, diuresis, urine analysis of albu- quate therapeutic approach is the four-stage classi-
min, sediment. Functional study of cardiac activity, fication:
thyroid gland, radiography of the lungs and heart is I grade - congelatio erythematosus. Affects only
needed. The ECG describes a pathological J-wave, the surface epithelium. It is common for short-term
between QRS and ST. effects. It is characterized by mild or stronger red-
Differential diagnosis refers to other diseases, ness with livid spots, slight swelling of the skin and
passed by disorders of conscioussness, such as en- pressure sensitivity. Observed 12 to 24 hours after
dogenous and exogenous intoxications, cerebrovas- warming. As a result of capillary dilation and asep-
cular disease, traumatic brain injuries, brain tumors, tic inflammation, the previous cold, pale and dry
hyper- or hypoglycemic, uremic, hepatic coma and skin becomes hot and red, superficial painful and
others. stretched. For a short time, hyperaesthesias, pares-

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 OCCUPATIONAL MEDICINE
thesias and lesser anesthesia persist. First degree struction of cellular and tissue structures. Warming
frost zones recover without scarring (even without does not lead to recirculation and recovery. A de-
treatment), but often remain hypersensitive to cold marcation groove and a necrosis emerging, which
and hypothermic. Sometimes they are blue-red, pale requires urgent amputation and symptomatic and
or abnormally pigmented. preventive antibacterial treatment. A very good
Grade II - congelatio bullosa. Affects skin to stra- prognostic value for determining the weight of frost
tum basale s. germinativum. After 24 to 48 hours of and the demarcation line, as well as the treatment
warming, local swelling (due to disturbed vascular effect, is the biphasic scan of the bones of the limbs
permeability) and blisters occurred. Bubbles be- with technetium 99 m.
tween corium and epidermis are initially filled with Often after frosting, there is a hypersensitivity to
serous fluid, and later with opalescence-purulent cold, tingling of the fingers, reduced sensation to
of leukocytes and bloody, red-black of the erythro- touch, increased vasospastic reactivity.
cytes. Bullets are formed only on the dorsal side of Perniones (chilblains) are blue-red itchy spots
the limbs, face, body. After second-degree frost, a with edema of the dermis and hypoderm located on
sudomotoric disorder with hyper- or hypo- to anhy- the exposed parts of the body (face, ears, wrists, toes,
drous zones is detected due to disordered innerva- legs) and accompanied by itching, burning, pain. It
tion and circulation. Direct damage to the thermore- is possible to form sub-epidermal bulls, ulcerative
ceptors leads to hypothermesthesia. Prophylactic hemorrhagic lesions, which are scarring with fibrotic
measures against bulets infection are necessary. An- or atrophic changes.
ti-tetanus serum is required. Cytaraxes remain only Cutis marmorate (marrow, skin networking - in
after a secondary infection. Fingers usually fall off. women with hormonal disturbances and vegetative
Atrophic skin processes with increased vulnerability dystonia), livedo reticularis a frigore (spoted skin
are observed. Frozen areas can remain cyanic or hy- with a livid or red color on the extensor parts of the
perpigmented. Paresthesias and spontaneous, local extremities and the side part of the body), eryth-
pains, as well as hypersensitivity to repeated cold ef- romelalgia (redness and pain usually on exposed
fects, often remain. parts of the body), acrocyanosis (livid staining of
Grade III - congelatio necroticans, gangrenosa seu distal parts limbs sometimes with hypersesthesia
excoreatica. All layers of epidermis and dermis are af- and edema) or erythrocyanosis (the same, but on
fected by passing through the previous two stages of the open parts of body) are cases, that are mani-
local frostbite. An intensive edema with aseptic infla- fested or enhanced by cold effects but are not pro
tion of the entire area is observed. Necrotic process- fessionaly determined. Differential diagnosis should
es can be restricted or cover deeper lying tissues. On also be considered, as well as contraindications to
the second and third day after warming, a fine, false work in a cooler microclimate.
line of demarcation is restricted, which could fall dis- The second group of local cold pathology (with-
tantly during the warming process. Subsequently, out externally visible lesions) refers to an immersion
the definitive deep demarcation groove is formed leg and hand, and cold-induced vegetative poly-
with protruding edges covered with granulations. neuropathy.
Necrotic areas become dark red, brown or gray to Immersed foot, submerged hand (immersion
blue-black (if no wet necrosis occurs). Mummifica- foot, trenchfoot, shelter leg, Flander's foot, immer-
tion of dead tissues develops. There are black crusts sion hand, main detranche, pied de tranche) after
that fall on their own, while tendons, ligaments, cap- two or three hours at + 8°C to -15°C with wet clothes,
sules and bones are not released operationally. The and shoes, there is a cold defect that occurs in three
warming of frozen tissues is associated with blood stages: pre-hyperemic (lasting for several days) -
reperfusion and simultaneous generation of free slight edema, numbness, burning and local hypo-
oxygen radicals. Healing is a long-lasting process: thermia are observed. The pulse is not felt; hyperemic
the skin is hypersensitive, dystrophically thin, often stage (lasting from six to ten weeks) - redness, rising
with slowly healing ulcers. The cicatrixes are crude cold edema, hypothermia, paraesthesia, severe palli-
and painful. The wounds are dressed with ointments ative pain is observed; post-hyperemic stage (lasting
enriched with vitamins and epithelizing substances a few weeks to several months) - characterized by
and with cortisone to suppress granulation. Preven- stiffness, paraesthesia, dysaesthesia, pain, muscular
tive measures against secondary infections and wet rigidity, pronounced cold edema, a net pattern on a
necrosis. Fascio-skin graft on wound areas after frost pale or sloppy skin background.
has a good effect. The most common in occupational pathology is
IV grade - congelatio necroticans. It is character- the neurovegetative and vascular microcirculative
ized by necrosis of all tissues due to mechanical de- pathology of the extremities due to chronic cold

526
 LABOUR MEDICINE
effects (with terminological diversity: cold angio- phy, syringomyelia and others.
trophneurosis, cold angioneurosis, cold endarteritis, Treatment is preceded by taking the patient out
cold vegetative polyneuritis, cold neurovasculitis, of the cold environment.
angioneurodystonia et angioneurodystrophia a frig- The pathogenetic approach is determined by the
ore). We have the term vegetative polyneuropathy prevailing clinical manifestations: nestheroidal an-
in cold weather. Clinical events unfold gradually. In ti-inflammatory agents such as Tenoxicam (Tilcotil),
the case of a slight degree (upper limbs most com- Ketoprofen (Profenid), Lornoxicam (Xefo, Safem),
monly affected) subjective evidence of transient Meloxican (Movalis), Bumadizonum Calcium (Eu-
numbness, palpitations of the fingers and palms, motol), Diclofenacum Natrium (Feloran, Voltaren)
paroxysmal change in skin coloration (reddening or , Piroxicamum (Piroxicam), and others. They can be
pale) usually occurs in cold weather. From the objec- combined with Analgin, Alcozin, Tempalgin, Neu-
tive clinical finding, a partial dissociation of sensa- ralgin and other combined analgesics. It is appro-
tion is established, with the influence of the extra- priate to include trophic improving vasoactive and
ceptive sensation for warm and cold and preserved vasodilating drugs - Naftidrofuril (Dusodril), Pen-
sensation for touch, pain, deep and complex sensa- toxyphylline (Trental, Aagapurin), Pyridylcarbinolum
tion with distantly increasing hypothermesthesia. (Radecol, Ronicol), Triphosadeninum (Atriphos,
Capillary polymorphism, at capillaryscopy, on a pale Phosphobion). Evidence of the role of thrombox-
pink background. In cold provocative and mediato- anes and prostaglandins would change the ther-
ry tests and in the study of neurovascular reactivi- apeutic approach by using antiprostaglandin and
ty, dystonic vegetative manifestations predominate other therapy.
with sympathicotony. Mean degree of cold-induced In the case of an exaggerated sensory sympto-
vegetative polyneuropathy is characterized by par- matic and according to the general state of the or-
esthesia-algic manifestations of tingling, burning, ganism, it is appropriate to include psycholeptics or
sprained pain in the depth of tissues, mostly at night psychoanaleptics: Opipramolum (Insidon), Diaze-
and morning, ischemic or erythema-cyanothic skin, pamum (Diazepam, Relanium), Chlordiazepoxidum
swollen fingers and initial dystrophic disorders of (Elenium), Alprazolamum (Xanax).
the skin and nails, rising hypoesthesia for temper- Diluted neurological symptomatic include med-
ature, touch and pain, distal rising hypothermia (to ications that improve nerve conduction such as
thermoamputation in the fingers), spastic capillar- Galanthaminum hydrobromide (Nivalin) or Ben-
ies with pronounced permeability disorders, pro- dazolum hydrochloride (Dibazolum). Vitamins be-
nounced hyperhidrosis. In severe grade disease, the longing to group B, A, C, E are also suitable. It is also
tendency towards irreversibility of clinical symptoms appropriate to combine natural balneal procedures
with pronounced vagotonic vascular manifestations with analgesic, improving tissue nutrition and a
and pronounced dystrophic skin disorders and skin strenght giving (tonic) effect.
appendages is highlighted - stiffened, broken fin- The occupational-medical expertise in cryopa-
gernails, smoothed dermatoglyphic outlines of the thology provides for temporary disability and tem-
fingers (apex phalanx weakening), deformation of porary re-employment without a specific length of
the interphalangeal joints, tendency to flexicone time. In heavy grades and advanced stages of illness,
contractures. Changes in sensitivity indicate impair- a disability group is defined.
ment of small and large diameter myelinized and Prevention. No work with collagenosis, Ray-
non-myelinated nerves. Histomorphological chang- naud's phenomenon, vegetative dystonia, periph-
es are expressed in severe proliferative-destructive eral, vegetative and vascular insufficiency, vasculitis,
changes in vascular walls, arterio-venous anastomo- pre-existing cold traumas, systemic diseases, cryo-
ses, glomic bodies, sweat glands, fibrotic cellular tis- globulinemia should be avoided in cold and micro-
sue elements. climate conditions. Half-hour and one-hour breaks
In the differential diagnosis, vegetative poly- are arranged under comfortable microclimate, hot
neuropathy with other genes (over working, mi- drinks and a balanced diet, suitable workwear and
crotraumatism, vibration), cervical and lumbosa- shoes, PPE. Periodic physio- and spa treatments. Pe-
cral radiculitis, plexitis, mono- and polyneuritis and riodic medical check-ups once a year for workers in
neuropathies, endarterites, vasculitis, neurovascular cold-weather conditions involving internist, neurol-
compression syndromes, reflex sympathetic dystro- ogist and capillaryscopy and cold test complete.

527
 OCCUPATIONAL MEDICINE

Zl. Stoineva

PROFESSIONAL
4.2 THERMOPATHOLOGY

The development of metallurgy, machine building, Death occurs due to cerebral, cardiovascular, hepat-
chemical and light industry has created conditions for ic and renal disorders. Laboratory findings indicate
work on a microclimate overheating for many work- leukocytosis due to dehydration, decreased serum
ers. The risky professions include those working in potassium, calcium, phosphorus, hemoconcentra-
metallurgy - in rolling mills, blast furnaces and martin tion, thrombocytopenia, increased bleeding and
furnaces; machine building - foundries, smiths, met- clotting time, fibrinolysis and coagulopathy. Urine
alworking workshops; textile industry - spinning and was concentrated by proteinuria, myoglobinuria.
weaving workshops, dyeing and drying machines; In Differential diagnosis is necessary with all endog-
ceramic production; In chemical plants; thermal pow- enous and exogenous causes of a disease disorder of
er plants; gas and boiler installations; bakers, bakeries, consciousness.
confectioners, chefs, miners, tractors, combine harvest- Treatment is aimed at rapidly reducing body tem-
ers and others. perature in a cool, airy room. The patient is swollen
External factors that increase the risk of heat dam- with cold water (15 ° C) or wrapped in wet sheets
age include increased humidity, low airflow speed, that change. Apply ice gastrolavage. Cooling contin-
heavy physical work, rapid temperature rise, geograph- ues until the body temperature gastrolavage to 39 °
ic specificity. C. Because of the risk of hypoxia and aspiration, in-
Internal factors that promote thermopathology tubation is recommended. Appropriate intravenous
include: sex, age, exhaustion, overwork, hunger, over- infusion of 25-50 mg Chlorpromazinum to suppress
eating, obesity, avitaminosis, smoking, alcoholism, tremor, infusions of water-salt solutions to correct
systemic disorders, impaired adaptation and acclima- electrolyte imbalance and dehydration. Symptomat-
tization, skin and endocrine disorders, cardiovascu- ic treatment of renal, hepatic or cardiac pathology,
lar diseases, use of medications that reduce sweating the coagulopathy.
secretion, skin circulation or lead to dehydration (at- Heat exhaustion is observed in workers with se-
ropine, phenothiazines, tricyclic antidepressants, diu- vere physical labour during prolonged exposure in
retics, laxatives, anticholinergics, antihistamines, vaso- conditions of overheating microclimate with insuf-
constrictive means, MAO inhibitors, β-blockers). ficient sodium chloride and water intake. It occurs
Professional thermal injuries include heat stroke, as a result of dehydration and depletion of sodium
heat exhaustion, heat cramps, heat syncope, and due to loss of isotonic fluids (sweating). The patients
local skin injuries. complain of a strong thirst, weakness, nausea, fa-
Heat stroke occurs rarely, mainly in emergency tigue, confusion, headaches. The body temperature
situations, in workers performing heavy physical is above 38 ° C, the pulse is increased. The skin is
work with inadequate work clothes and predispos- red and damp. Symptoms of heat syncope or heat
ing internal factors. It is a life-threatening and requir- cramps may occur. In some cases, hyperthermia
ing urgent medical emergency, that occurs as a result leads to hyperventilation and secondary respirato-
of inefficient thermoregulation with hyperthermia ry alkalosis. Heat exhaustion could be a heat stroke
exceeding 41.1 ° C. It is characterized by sickly al- when increasing hyperpyrexia and reducing sweat-
tered consciousness, dizziness, weakness, nausea, ing secretion and sweating evaporation. The treat-
vomiting, confusion, delirium, visual disturbances, ment consists in removing the patient from the con-
clonic and tonic convulsions. The skin is hot, initial- ditions of overheating microclimate in a cool room
ly covered with sweat, and consequently dry. Blood and rehydrating and supplying with sodium chloride
pressure at the start may be slightly increased, but - orally or parenterally intravenously with physiolog-
quickly dropped. The pulse is rapid, filiform. Breath- ical saline. The patient is temporarily incapacitated.
ing is rapid, superficial. Respiratory alkalosis and Heat cramps. In the literature, they also occur
compensatory metabolic acidosis are established. as heat seizures, spasmous disease of overheating.

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 LABOUR MEDICINE
They are due to disturbances in the water-mineral flammatory process resulting from heat-sweating
balance with severe hyponatremia due to the sub- with erythematous and macerated skin.
stitution of the profusion perspiration only by the in- In the case of electric welders, fireman, furnaces,
take of water. They are characterized by slow, highly etc., more often in the exposed parts of the body are
painful, tonic contractions of the muscles involved formed single or grouped teleangiectasiae.
in work process by 1 to 3 minute duration. The skin is Localized or generalized heat urticaria (urticaria
cold and damp. The muscle groups covered are sol- a calore), summer itching (pruritus aestivalis), ery-
id. Body temperature is normal or slightly elevated. them by fire (erythema ab igne).
Differential-diagnostic is needed to distinguish heat In the treatment of these diseases it is required to
cramps from those with another genesis - hypothy- reduce or discontinue the thermal exposure and re-
roidism, myotonia, radiculopathies, hypokalemia, duce the perspiration.
lateral amyotrophic sclerosis, neuropathies, hypo- Burning (combustio) is an accident at work. The
magnesaemia, myophosphorylase deficiency or severity and prognosis of burns depend on the af-
phosphofructokinase deficiency and others. Treat- fected area, the depth of the affected tissues, the lo-
ment involves placing the patient in a room with a cation on the human body, the age of the patient,
comfortable microclimate and physiological saline the accompanying diseases and traumas. Heavy
infusion or oral uptake of 1-2% salted water for 1 to burns are more than 15% area for adults, over 3% of
3 days. the face or haired part of the head and prognostical-
Heat syncope. It is much more common than the ly bad for total skin necrosis of over 20%. Depend-
heat stroke. It is characterized by sudden loss of con- ing on the depth of tissue burning, the following are
sciousness due to reduced blood volume in cerebral distinguished: I degree - erythematous and painful
blood vessels and cerebral hypotension. The skin edema; grade II - blooms are formed with clear se-
is cold and damp, the pulse is weak. Systolic blood rous fluid, which later becomes darker, resorted to
pressure is below 100 mm Hg. The treatment consists the formation of crusts; III degree - skin necrosis; IV
of resting on a favorable microclimate, cooling and degree - necrosis of the skin and underlying tissues.
hydration of the patient. Clinically severe burns undergo a phase of thermal
Chronic effects of overheating microclimate in- shock, toxic infection, restoration phase, injury ca-
crease the risk of gastrointestinal diseases (ulcer chexia and the consequences of hypertrophic scar-
disease, gastro-enterocolitis), cardiovascular dis- ring, keloids and carcinogenic degeneration. Treat-
eases (arterial hypotension, later arterial hyperten- ment of patients with thermal burns is undertaken
sion, early atherosclerosis), avitaminosis, neurotic by a team in an intensive care unit for emergency
conditions, anemic syndrome. care. It is continuous and gradual (depending on the
Solar shock is a form of overheating due to the degree and severity of burning).
direct action of the sun's rays on the unprotected Occupational medical expertise. In the begin-
head. It is characterized by headache, vertigo, faint- ning, the patient is temporarily incapacitated, and
ing, weakness, tinnitus, nausea, vomiting. The face is often temporary or permanent change of work, is
red and damp. Unlike the heat stroke, hyperthermia required to work without overheating microclimate
is not detected. In the heavier stages there is a loss (with persistent hypersensitivity to thermal effects).
of consciousness, agitation, epileptic seizures, hallu- In severe conditions, a disability group is defined.
cinations. Treatment is symptomatic. The prevention of thermal damage besides san-
Skin diseases due to thermal effects. Canal oc- itary-technical measures requires a rational drinking
clusion of sweat glands in workers in conditions of and diet with 0.5% salted water, fruit juices rich in
elevated temperature and humidity leads to sweaty mineral salts, vitamins and trace elements, pro-
retention with vesicle formation, erythema, des- tein-carbohydrate diet, diet "A" of the professional
quamation, macules and is called miliaria. They are protective nutrition. Regular work breaks are re-
milaria crystallina (very superficial), miliaria rubra quired in cool rooms. Do not work in heat-affected
(deeper in the derma) and miliaria profunda (the conditions patients with cardiovascular diseases,
deepest clogging). Secondary staphylococcal rashes kidney and endocrine-exchange disorders, ulcer-
form miliaria alba. ative disease, neuropsychiatric disorders. Periodic
In body folds and friction surfaces, an intertrigo medical examinations once a year with the participa-
(dermatitis intertriginosa) may be formed - an in- tion of an internist, ophthalmologist, dermatologist.

529
 OCCUPATIONAL MEDICINE
REFERENCES

1. Cohen, R. Injuries due to Physical Hazards. In: Occupational Medicine, ed. J. La Dou, Appleton & amp;
Lange, Norwalk, etc., 1990, 106-115.
2. Daanen, H.A., H.J. Ruiten. Cold-induced peripheral vasodilation at high altitudes - a field study. High
Alt. Med. Biol., 1, 2000, 4, 323-9.
3. Fritz, R., D. Perrin. Cold exposure injuries: prevention and treatment. Clin.Sports Med., 1989, 8, 11128.
4. Griglak, M.J. Thermal injury. Emerg. Med. Clin. North. Am., 10, 1992, 2, 369-83.
5. Hassi, J., T. M. Macinen. Frostbite: occurrence, risk factors and consequences. Int. J. Circumpolar
Health, 59, 2000, 2, 92-8.
6. Killian, H. Cold and Frost Injuries, Springer-Verlag, Berlin, etc., 1981
7. Manual of professional diseases, V. II, ed. N.F. Izmerov, Medicine, M., 1983, 236-250. (in russ.)
8. Ozyazgan I., Tercan M., Melli M., Bekerecioglu M., Ustun H., Gunay G.K. Eicosanoids and inflamma-
tory cells in frostbitten tissue: prostacyclin , Thromboxanes, polymorphonuclear leukocytes, and mast cells.
Plast Reconstr Surg 1998 Jun; 101 (7): 1881-6
9. Paton B.C. A history of frostbite treatment Int J Circumpolar Health 2000 Apr; 59 (2): 99-107
10. Professional pathology, ed. T. Aleksieva and K. Kiriakov, Med. and phys., S., 1982. (in bul.)
11. Sawada S, Araki S, Yokoyama K. Changes in cold-induced vasodilatation, pain and cold sensation in
fingers caused by repeated finger cooling in a cool environment. Ind Health 2000 Jan; 38 (1): 79-86
12. Stoyneva, Zl. Occupational neurovegetative damage from cold impact, dis., S., 1983. (in bul.)
13. Su C.W., Lohman R., Gottlieb L.J. Frostbite of the upper extremity. Hand Clin 2000 May;16(2):235-47
14. Thermal damage. ed. I. Chervenkov and B. Shidarski, Med. and phys., S., 1991. (in bul.)

530
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L. Nakova

4.3 RADIO-WAVE DISABILITIES

The modern electronics industry is characterized conditions caused by the acute intense or chronic
by the widespread use of electronic devices for gen- exposure of microwaves with sub-thermal intensity
erating high frequency currents that excite in space in the production environment.
electromagnetic fields (EMFs) with a certain physical The acute impact of radio frequency EMF on
characteristic. health is rarely seen - in the case of accidents to HF
EMF generators are widely used in modern life and generators or rough violation of the technical safety
work, in industry - radio electronics, instrumentation, rules. Intense irradiation provokes the thermal effect
agriculture, medicine, television and radio relay links, of EMF on the body. Workers complain of fainting,
science. palpitations, relapsing headaches, increased body
The biological action of EMF increases with the in- temperature, thirst, cramps of the skeletal muscles.
tensity of the field, depending on its frequency and the After removal the person from the work environ-
time of exposure. The efficacy of the responses depends ment and symptomatic treatment, complaints re-
on individual characteristics. solve for 24 hours to several days.
In intensive EMF irradiance exceeding 10,000 W/ In chronic influence, a leading place in the so-
cm , the absorbed energy is transformed into heat. It
2
called radio wave pathology occupy the functional
accelerates the metabolic processes and induces, on an changes in CNS activity and cardiovascular regula-
interceptive basis, dystrophic changes of some brain tion. Clinical manifestations can be represented by
structures and myocardium in mammals. The highest the following syndromes:
heat effect in humans is given by VHF fields, absorbed • Cerebroasthenic;
by less blood-flowing organs - eye lens, testicles, blad- • Angiodystonic (hypertensive or hypotensive
der. Under the conditions of modern labour and after type);
the introduction of preventive measures (shielding, • Hypothalamic (diencephal) syndrome.
special protective means) the intensity of irradiation is Cerebroasthenic syndrome occurs in the initial
below that of the thermal effect. In experimental and 3-5 years of EMF exposure with non-specific, neuro-
clinical medicine, the non-thermal specific action sis-similar symptoms: headache, irritability, insomnia,
of radio frequency EMFs is now leading. Functional emotional lability, decreased working capacity and
changes in the central nervous system (CNS), predom- mild memory impairment. Addition of cardiovascular
inantly in the autonomic nervous system (CNS), and changes: blood pressure fluctuations, rhythm disor-
in the cardiovascular system (SCD), have been shown ders - extrasystolesia, sinus bradycardia, AV block, etc.
to be essential. The biophysical nature of subtermal, Vegeto-vascular dysfunction of the hypotensive
chronic microwave irradiation suggests phenomena type has a more favorable pass - systolic pressure is
of molecular paramagnetic resonance, non-thermal decreased by 30-40 mmHg at a preserved diastolic
denaturation of proteins, and alterations in the micro- boundary. More persistent for treatment are people
structure of the living cell. In mammalian experiments, with hypertonic crises (RR to 180/120 mmHg). The de-
the most sensitive microwaves are the cortex, hypo- velopment of hypo- or hypertension during the course
thalamus and cardiovascular structures. of neurocirculation dystonia is also determined by the
The pathogenetic mechanism of radiofrequency baseline of the body, and possibly by the characteristics
response is thought to be indirectly mediated through of the electromagnetic factor and the specific working
the brain centers of cardiovascular regulation, after conditions (psycho-sensory intension).
which reflex-induced hemodynamic disorders occur. At an advanced stage of chronic radio wave ex-
Endocrine-humoral changes have also been observed - posure, hypothalamic insufficiency develops. It oc-
cortisol rhythm abnormalities and electrolyte balance; curs with the so-called diencephalic crises - anxiety,
disturbances in neuromuscular transmission activity; tremor of the limbs, profuse sweating, redness or
disorders of erythropoiesis and leukocyte formula. Im- paleness of the skin, subfebrility, changes in blood
munological studies have shown that VHF-EMF inhibits pressure, headaches, palpitations and transient
the formation of antibodies to exo-allergens in mam- pain, dysmenorrhoea in women, Paraclinic disorders
mals and causes autoimmune reactions. Suppress the of carbohydrate tolerance, electrolyte imbalance,
adaptive capacity of the body. changes in leukocyte formula and thromboelasto-
Occupational radiofrequencies are pathological gram, increased excretion of catecholamines are
531
 OCCUPATIONAL MEDICINE
detected. ECG shows depression of the ST segment sion of infectious, atherosclerotic or traumatic ori-
in precordial leads, ventricular extrasystoles, less fre- gin. It is necessary to specify other etiological factors
quently AV block. Functional studies show increased for development of diencephalic pathology: endo-
vascular tone or pronounced angiodystonic chang- crine disorders (diabetes, thyrotoxicosis), collagen-
es - capillary spasm in the peripheral vessels of the osis, traumatic brain disease, early atherosclerosis,
limbs and the retina. In ultrasound diagnosis (Dop- household intoxications, alcoholism, psychogenic
pler sonography), increased vascular resistance of moments, etc.
the digital arteries of upper limbs or vertebral ves- Treatment of radio wave injuries is symptomat-
sels is reported. ic. Serum therapy, neuroleptics and antidepressants
The EEG in human beings subjected to low inten- are administered in cerebrasthenic conditions and
sity radio waves shows at the beginning of the effect angioneurodystones. Migraine-like cephalalgies
the activation of bioelectric activity, synchronization are well-affected by the use of combined-type
of oscillations, at the end of the work shift - predomi- preparations (Paracetamol or Efferalgan - 3 x 0.500
nance of the slow wave activity, as an expression of a g daily, Acetofen - 3 x 1 tablet daily). Also included
progressive increase of the cortex retention process. are vegetative harmonizers (Atropa Belladona alca-
The changes are of a phase character. Degenerative loides - Bellergamin - 3 x 1 tablet daily; Opipramoli
changes of the lens of the eye (cataract) are also often chloridum - 2 x 0.050 g daily for a long time - 2 to
observed. 5 months). Pain allaying procedures, physiotherapy
The described syndromology in its sequence (cer- and balneotherapy are recommended in climate
ebrasthenic symptomatology, vegetative-vasal dys- zones with negative aeroionization (Bankya, Etro-
function and hypothalamic insufficiency) determines pole, Rhodope, etc.). Arterial hypertension is treated
the stage pass of radio wave pathology. For the time according to the classical principles of internal med-
being, it is not considered as an individual nosological icine. The diencephalic crises are treated with Car-
unit (radio wave disease) and is not regulated by la- bamazepin 0.200 - 0.400 g daily for 2 months with
bour law (except for microwave cataracts). vitamins B, Geritamin and vasoactive agents Natti-
The diagnostic process of radio wave effects on drofurilum (Dusodril) 3 x 1 tablet daily, Pentoxiphyl-
the human body is difficult due to the expressed pol- linum 0.200 - 0.400 g daily (Agapurin).
ymorphism and the non-specificity of the responses. Prevention. The unfavorable impact of the EMF re-
This implies an in-depth analysis of symptomatolo- quires strict adherence to the engineering - technical
gy in people who have been in contact with EMF for rules to prevent intensities up from hygienic norms.
more than 10 years, as well as a dynamic tracking of We recommend general wellness activities, a ra-
their condition. tional organization of work.
Differential diagnosis of the described disor- Do not work in environments with EMF persons
ders is made with systemic diseases, occurring with with chronic diseases of the cardiovascular and
triadic cerebrasthetic manifestations, vegeto-vascu- central nervous system, blood diseases, vegetative
lar dystonia and hypothalamic dysfunction. First of dysfunction and mental illness, cataracts, endocrine
all, hypertonic disease, ischemic heart disease and gland diseases. Periodic medical examinations - 12-
rhythm disorders of organic origin should be elimi- 24 months, with neurologist, cardiologist and oph-
nated. Hypothalamic syndrome involves the exclu- thalmologist.
REFERENCES
3. Gordon, Z.V. Questions of labour medicine and biological activities, of electromagnetic fields, L, Medicine, 1966,
162 p. (in russ.)
1. Dumyanski, Y.D., Serdyuk, A.M. Influence on radio frequency fields of the human, Kiev, Health, 1975, p. 55. (in
russ.)
6. Nonionizing and ionizing radiation. In. Professional pathology. ed. Ts. Alexieva and Kr. Kiryakov. S., Med. and
phys., 1982, 119-136. (in bul.)
4. Taygin, N.V. Clinical aspects of VHF irradiation, L., Medicine, 1971, p. 172. (in russ.)
5. Elder J.A., P.A. Cerski, A.Stuchly et al. Radiofrequency radiation. In: Nonionizing radiation protection. ed. M.
J.Suess, D.A. Benwell-Morison, 2 ed. WHO-Publication No. 25, 1989, 117-173.
6. Knave, B. Electric and magnetic fields and health outcomes. In: Encyclopedia of Occupational Health and Safety,
4th edition, ed. J. M. Stellman, Geneva, International Labour Office, 1998, pp. 49.2-49.31.
7. Nakova, L., M. Israel. Biological efficiency of low-frequency electromagnetic fields on workers, XXth General
Assembly of the International Union of Radio-Science, Lille, France, 28.08.-05.09.1996.
8. World Health Organization. Radiofrequences and microwaves. Environmental Health Criteria No 16. Geneva:
WHO, 1981.
9. World Health Organization. Electromagnetic fields 300 GHz. Environmental Health Criteria No 160. Geneva: WHO,
1993.
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Ves. Bliznakov, A. Milchev

4.4 RADIATION ILLNESS

All living organisms are constantly exposed to blood cells from lymphoid, myeloid, platelets and
ionizing radiation, which naturally exists in nature. erythrocyte lines (initially with suppression and then
According to UN data, the average annual effective with aplasia).
dose due to natural sources of radiation is 2.4 mSv Gastrointestinal tract irradiation: the mucosa of
per person (ranging from 1 mSv to 10 mSv, depend- the small intestine is the most vulnerable as the fastest
ing on the specifics of a region). dividing tissue in the intestinal tract. The clinical out-
With the widespread penetration of ionizing ra- come is: nausea, vomiting, diarrhea, haemorrhage,
diation in the different spheres of life - economics, perforation of the intestine, septicemia.
industry, agriculture and science, including biology Reproductive system irradiation: reduction of
and medicine, the number of persons professionally fertility or oligospermia, sterility or endocrine disrup-
associated with ionizing radiation is growing rapidly. tion in women.
Various activities involving the use of ionizing ra- Nervous system irradiation: usually does not lead
diation lead to additional exposure. to clinical manifestations, but at higher doses, neu-
The basis of the biological action of ionizing radia- ro-circulatory disorders, EEG changes, cerebral vascu-
tion is the damage to the genome of the cell, namely lar damage, and even comatose status may occur.
DNA, which is mainly the initial event, whereby radia- Whole body irradiation has combined effects from
tion causes long-term damage to organs and tissues of various organs and systems.
the body. Unrehabilitated DNA damage (which did not
There are three main types of DNA damage, re- cause cell death) leads to cell modification. This mod-
spectively chromosomes: nitrogen basis damage, sin- ification is transmitted to the daughter cells and could
gle-chain disruption, and double-chain break. In most lead to the development of neoplasms. If the modified
cases, these lesions are recovered spontaneously, and cell is reproductive, then the next generation may in-
non-recovered result in one of two possible outcomes: crease the incidence of hereditary diseases. These ef-
cell death or cell survival but with impaired metabo- fects of ionizing radiation (neoplasms and hereditary
lism. diseases) can not be predicted for one individual (they
The function of most organs and tissues of the body are predicted and evaluated at population level) and
does not affect even the loss of a significant number of because of their probability character they are called
cells, but if this loss passes a certain threshold there are stochastic effects.
harmful effects on the body. This type of effects that Stochastic effects can be caused by the damage of
occurs in all subjects receiving acute irradiation with a single cell. However, as the absorbed dose increases,
a dose above a certain threshold dose for the effect is the number of damaged cells increases and the likeli-
called deterministic effects. hood of the stochastic effect increases.
The main features of the deterministic effects are The main features of stochastic effects are: no
the following: the result is cell death; the effect always threshold dose; as the dose increases, the likelihood
occurs if the threshold dose for the effect is passed; of the effect increases; the severity of the effect does
the severity of occurrence of the effect increases with not depend on the increase in the dose; the dose pow-
increasing dose; the dose-effect curve is sigmoid; the er may not significantly affect the risk; the dose-effect
dose power significantly influences the appearance of curve is more or less linear (conservative approach for
the effect; the threshold dose is relatively high and the maximal radioprotection); the latency period is long
latency period relatively short. (years); the individual risk is low even after high doses,
Such deterministic effects are: acute radiation dis- but the population risk is significant.
ease, chronic radiation disease, local radiation damag-
es, radiation cataracts, pulmonary fibrosis, and the like. 4.4.1. ACUTE RADIATION ILLNESS
The early deterministic effects can be:
Skin irradiation: erythema, phlyctena, edema, ul- Acute radiation disease is a nosological form
ceration or tissue necrosis; that develops after an external X-ray, gamma and/
Hemopoietic tissue irradiation: Reduction of or neutron irradiation over a dose of 1 Gy obtained

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for a short time (up to 10 days) or after incorporation run, which is due to the successive defeat of the crit-
of radionuclides (creating an adequate absorbed ical systems of the body. This is best expressed in the
dose). This is the most significant deterministic effect bone-marrow form developing at radiation doses of
of ionizing radiation. 1 Gy - 10 Gy. In the other forms - intestinal (10-20 Gy
The irradiation may be generally uniform or frac- absorbed dose), toxic (20-80 Gy) and cerebral (over
tionated, relatively short-lived or prolonged external 80 Gy) - due to the severe course and rapid onset of
irradiation; combined - external and internal radia- death, the typical periods and phases of the radia-
tion; combined action of radiation and non-radia- tion illness no distinguished (Table 1).
tion factors. The most clinically important from a therapeu-
Pathogenesis: Acute radiation occurs as a result tic point of view is the bone-marrow form of acute
of the development of complex biological process- radiation disease, as the probability of survive it is
es caused by the interaction of the energy of ion- greatest.
izing radiation with the cells, tissues and the fluid Clinical picture: There are three periods in the
environment of the organism. The primary biolog- course of the bone marrow form of acute radiation:
ical activity of radiation is realized through physi- a period of disease formation (about 2 months), a re-
cal, physico-chemical and chemical processes with covery period (2-4 months to 3 years), and a disease
the formation of active free radicals (H +, OH, HO2), outbreak period (and of the consequences).
which have strong oxidation properties. In the pro- The period of acute radiation illness formation is
cess of radiation damage or immediately afterwards, divided into 4 phases: phase of primary reactions,
regeneration processes are formed with formation latent phase, disease development and primary (im-
of various peroxide compounds (H2O2, etc.) mediate) recovery. The total duration of this period is
Oxidative radicals and organic peroxides alter about 2 months (the duration of the period is shorter
enzyme activity and thus influence autolysis pro- at a higher dose of irradiation).
cesses in tissues. The activation of the ferments in- Symptoms in the primary reactions phase can
creases the permeability of the cell membranes. As be divided into 4 groups:
a result of the destruction of radio-sensitive tissues • dyspeptic - nausea, vomiting, diarrhea;
and pathological metabolism, the manifestations of • general clinical - sleep disturbances, weakness
toxaemia are formed. (tiredness), headache, changes in motor activ-
High is the radiosensitivity of rapidly regenerat- ity, temperature rise, tachycardia;
ing tissues: haematopoietic tissue, intestinal epithe- • haematological - lymphocytopenia, neutro-
lium and skin. The nervous system in the elderly is philic leukocytosis;
not a renewing cellular system but also has a high • local - changes in the skin and mucous mem-
sensitivity. branes in the areas with the highest irradia-
Depending on the type of irradiation, two major tion.
variants of the disease can be most commonly de- These prodromal responses can play an impor-
veloped: acute radiation with relatively uniform ra- tant role in assessing the severity of radiation dam-
diation and acute radiation with irregular irradiation. age and in predicting the clinical course. Particular
1. Acute radiation illness at relatively even ra- significance is attributable to symptoms such as
diation nausea, vomiting, diarrhea, erythema, increased
This is the typical variant of acute radiation illness. body temperature. What matters is the time of their
It is characterized by undulation or periodicity of occurrence, frequency and severity. Several quanti-
Tab. 1. Clinical forms, degrees of severity and prognosis of acute radiation illness in whole-body irradiation
Dose
Clinical form Levels of severity Prognosis Outcome
(Gy)
Good
1-2 Bone marrow Light (І) Absolutely favorable
0% lethality
2-4 Bone marrow Average(ІІ) Relatively favorable Lethal to 0-50% in 6-8 weeks

4-6 Bone marrow Severe (ІІІ) Questionable Lethal in 20 to 70% in 4-8 weeks
Extremely
6-10 Bone marrow Unfavorable Lethal in 50-100% in 1-2 weeks
severe (ІV)
10-20 Intestinal Lethal 8-10 day
20-80 Toxemic Lethal 4-7 day
>80 Cerebral Lethal 1-3 day

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 LABOUR MEDICINE
tative indicators, such as absolute lymphocytopenia creases, appetite recovers. Clear recovery of periph-
in the first (3) days, and leukocytosis over 12.109/l, eral blood parameters is observed. The bone marrow
also have an unfavorable prognostic significance. has processes of active regeneration. Hair begins to
Bone marrow decreases the mitotic index, decreases grow, the condition of the mucous membranes and
the number of young forms and increases the leu- the skin improves. For a long time, however, mani-
co-erythroblastic factor. Circulating lymphocytes festations of astheno-vegetative syndrome with
are highly radiosensitive and the magnitude of their reduced working capacity, diminished memory,
absolute count deminution in peripheral blood is a headache, muscle pain, impaired neuro-humoral
widely used laboratory test for the determination of mechanisms, vegetative-endocrine and vascular
the severity and prognosis of acute radiation illness. dysfunctions remain. The duration of the phase is
Widespread and reliable bio-dosimetry is also cy- 1-2 months.
togenetic analysis - the frequency of chromosomal Treatment. Contemporary treatment of the vic-
aberrations in cultured peripheral blood lympho- tims of multiple radiation emergencies has shown
cytes is reported. Screening for micronuclei in pe- that the 4 Gy ​​of the semi-lethal dose can be in-
ripheral blood lymphocytes can also be used. creased and patients can survive even at radiation
During the latent phase, prodromal reactions doses of 10 Gy. The treatment is directed to priming
are reduced, the general condition improves. There reactions, restoring the activity of the hematopoiet-
are only some discreetly manifested clinical symp- ic organs, fighting infectious complications and pre-
toms such as vegetative regulation lability, general venting and treating haemorrhages.
asthenia, pulse and arterial pressure lability. During the primary reactions phase, anti-emetic,
Most attention is paid to the dynamics of haema- blood-sweetening and detoxifying agents, prepara-
tological parameters and cytopenia (it progresses) tions for metabolic balance maintenance are used.
during the latent phase. In severe cases, anemia can Cardiotonic and vasoactive agents are used for col-
also occur. At doses above 3 Gy, epilation also occurs. lapse and marked cardiovascular weakness.
The duration of the latent phase is from 3 to 30 During the latent phase, therapy consists of ad-
days. ministering sedative and polyvitamin preparations,
The clinical transition from the latent phase to assessing the need for antibiotic therapy, and dis-
the disease development phase occurs abruptly. cussing the feasibility of bone marrow transplanta-
Decreased self-esteem, appetite decreases, general tion.
weakness is increased, fever appears. Tachycardia, At the development of the disease, a guiding
arterial hypotension, deafened heart tones, changes principle is to manage the complications arising
in the distal part of the cardiogram were found in the from bone marrow depression - infections and
clinical study. The clinical picture is dominated by haemorrhages. Treatment is targeted to combat in-
infectious-toxic complications in the nose, mouth, fections by administering a combination of broad
pharynx, respiratory tract, digestive tract. Severe spectrum bactericidal antibiotics at maximum ther-
ulcer-necrotic enteritis and enterocolitis can lead to apeutic doses, controlling hemorrhages by substitu-
peritonitis, bowel obstruction, sepsis. tion therapy and haemostatics, detoxifying agents,
Mandatory manifestations are skin and mucosal polyvitamin preparations.
hemorrhages. Currently, various hematopoietic growth factors
At the stage of the disease development, symp- are used to accelerate the repair of the bone marrow.
tomatology is caused by the depression of bone Bone marrow transplantation has a limited role
marrow bleeding. There is abrupt leukopenia, throm- and can only benefit those whose bone marrow is
bocytopenia, agranulocytosis. completely damaged. Bone marrow transplantation
Adverse prognostic features include head and should be considered only for subjects who receive
body epilation, short or missing latent phase, severe doses of the order of 8-12 Gy evenly distributed
bone marrow damage with primarily reticulous and throughout the body without serious skin and other
plasma cells, peripheral blood monocytes deficien- lesions.
cy, high BSR, high blood sugar, leukopenia under Nutritional protein hydrolysates and hydrolysates
0.5.109/l, neutrophil count less than lymphocyte of nucleic acids are administered to the patients.
count, delayed appearance of young cellular forms In the primary recovery phase, the treatment of
in peripheral blood. patients includes anabolic and vitamin preparations,
The duration of this phase is 2-3 weeks. central nervous system toning agents, protein-rich
The onset of the primary (partial) recovery foods.
phase begins at the outbreak of the agranulocytosis 2. Acute radiation disease at irregular radia-
patients. Temperature is decreasing, self-esteem in- tion

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The clinical picture of acute radiation illness in the clinical picture coincides with that of acute radi-
uneven body irradiation is most often combined ation, and in the other radionuclides it is dependent
with signs of local radiation damage: radial derma- on isotopic accumulation in the relevant critical or-
titis, pharyngitis, gastrointestinal tract damage. Ra- gan (bone marrow, lung, liver and others.).
diated dermatitis occurs after irradiation of the skin If signs of long-lasting half-life of radioisotopes
and mucous membranes, depending on the dose fall into the body, signs of chronic radiation can de-
and radiation in time skin changes may be early and velop with certain organ manifestations. In less fre-
late. quent cases, late effects may occur in the form of
Clinical evolution of local radiation injury passes various malignant neoplasms.
through three stages: To determine the type, concentration and activity
1. Inflammation: hyperremia and edema of the radioactive substances, the radiophysical (de-
2. Passive congestion: thrombosis and ischemia termination of whole-body activity) and radiochem-
3. Necrosis and fibrosis ical (radiotoxicological) methods of investigation are
Early radiodermatitis occurs after irradiation at a applied.
dose of at least 5 Gy. The development of acute radi- Radiotoxicological analysis is carried out by ex-
odermatitis is shown in Table 2. amining biological excreta (urine, faeces, washes,
Most often acute local radiation injuries are ob- vomiting, etc.) collected in the first hours after the
served today with defectoscopes (portable gam- accident.
ma-defectoscopes). The damage is mainly on the In the treatment of radiation damage caused by
wrists and rarely on other parts of the body. poisoning with radioactive substances, early and
Late radiodermites are observed after systemic complex measures are being implemented aimed at
irradiation, mostly in the exposed parts of the body the accelerated removal of isotopes from the body.
with X-rays or gamma rays. The first stage is dry skin In case of poisoning with well-soluble and readily re-
atrophy. The second stage is characterized by ulcera- movable isotopes (etc. 137Cs), it is advisable to drink
tion. These two stages are considered precancerous. plenty of fluids - forcing diuresis and boosting meta-
In the third stage, skin cancer occurs. bolic processes in the body.
The most common radiographic lesions of other In many cases complexe formative compounds
organs and systems are: haematological changes; (complexons, chelates) for their removal from the
eye changes - blepharitis, conjunctivitis, late cata- body - polyamines, polyaminocarbolic acid (EDTA),
racts; gonade changes. some organic acids (oxalic acid, citric acid), unithiol
Primary erythema is not treated as it goes spon- (in case of poisoning with cerium, zirconium, pluto-
taneously. The onset of secondary erythema (1-3 nium, etc.) are used.
weeks) is an indication for treatment. Analgesics, Through the surface of undamaged skin, the ra-
non-steroidal anti-inflammatory drugs, topical anti- dioisotopes of iodine, sodium, tritium, strontium, ra-
biotics, vasodilators, anti-aggregates, epitheloton- dium, plutonium can be absorbed. Fast and careful
ics, antiproteolytics are used. If necessary for surgical washing with lukewarm water and soap reduces by
treatment it is done under an antibiotic umbrella. 90% the radioactive contamination. Special deter-
3. Incorporation of radioactive substances gents, adsorbents and ion-exchange resins are also
The fall of radioactive substances into the body used. Do not apply alcohol and ether due to skin de-
can occur in several ways - respiratory, digestive, greasing, and enhancing resorption.
wounds and skin lesions and, exceptionally, percu- Emetic, laxatives, cleansing enemas, absorption
taneous. of many fluids, diuretics, and even (by circulating the
In the case of the incorporation of uniformly dis- isotope in the blood) hemodialysis are applied when
tributed radionuclides with a relatively short half-life, gastrointestinal isotopes are present. Thyrotropic
Tab. 2. Acute radiation dermatitis
Degree of Absorbed Duration of
Lesions Duration Consequences
radiodermitis dose Gy activity (days)
First - radio erythe- Erythema + pigmentation Temporary
matous dermatitis 5-6 10-20 itching, desquamation 1 week
hair removal
Second - bullous Definitive
radiodermit Intense erythema, followed
15-25 8-10 by phlyctenas and ulceration 1-2 months pigmentation
and hair removal
Third - ulcerative Intense erythema, edema,
radiodermit painful bulls, deep Months or Scarring, sclerosis
> 25 Some days
ulcerations years

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hormone is used to remove iodine 131 from the thy- - the nervous, endocrine, cardiovascular system, re-
roid gland. spond to chronic radiation with complex functional
4. Acute relatively even irradiation at doses up responses in delayed dystrophic changes.
to 1 Gy Chronic radiation illness has several stages of de-
In single exposure at doses up to 250 mSv there velopment.
are no subjective complaints and no pathological During the first stage there are functional viola-
abnormalities in the paraclinical parameters that can tions in the activity of individual organs and initial
be established with the current methods of investi- vascular changes. The main syndrome is neurocir-
gation. culation dystonia. Permanent changes in peripher-
At doses of 0.25-0.5 Gy, only some transient re- al blood (leukopenia with lymphocytosis) are ob-
actions by individual systems of the organism (nerv- served.
ous, hematopoietic system) are detected. The second stage is characterized by gradual in-
Dosages of the order of 0.5-1 Gy may cause so- tensification of the above phenomena, trophic skin
called preclinical form of acute radiation illness. It changes, memory weakness and eventually signs of
is characterized by transient manifestations of neu- organic damage to the central nervous system.
ro-visceral dysregulation (cardiovascular, endocrine At the third stage of the disease there are severe
system) and transient haematological changes (lym- complications in the activity of all organs and sys-
phopenia, leucopenia). In this preclinical form an tems. The restoration capacity of individual tissues is
ambulatory treatment is carried out with the use of completely lost. There is a severe adynamia accom-
symptomatic means, general strengthening means panied by haemorrhages from the mucous mem-
and compulsory labour outside of the environment branes and the internal organs and pronounced
of ionizing radiation. Compensation period (without nervous symptoms.
additional dose load) applyed on the injured person, In the clinical aspect, the 4 grades of CRD are dis-
the length of which depends on the amount of dose tinguished:
received. First (mild) grade: characterized by disorders of
neural visceral regulation (easy tiredness, general
4.4.2. CHRONIC RADIATION DISEASE weakness, loss of appetite, pulse lability and blood
pressure, sweating, functional gastrointestinal dis-
Chronic radiation disease (CRD) is a single no- turbances, changes in libido, manifestations of dys-
sological form of radiation damage that develops menorrhea in women, etc.). All these violations are
in chronic irradiation (externally, internally) of the reversible. Bone marrow is affected by normal bleed-
organism at doses exceeding the permissible levels. ing processes. In peripheral blood there is unstable
Today in our country there are no cases of chronic leukopenia, sometimes combined with thrombocy-
radiation disease due to the strict radiation-hygienic topenia.
control over the working conditions and the dynam- Second (moderate) degree: Deepening of regu-
ic medical surveillance of all persons working in the latory disorders to a state of functional failure of the
environment of ionizing radiation. CRD is character- nervous, cardiovascular, digestive and other systems
ized by damage to a number of organs and systems with added morphological lesions of the most radi-
and depends on the total radiation dose, its spatial osensitive peripheral blood elements - leukocytes
distribution, the intensity of the radiation and the and platelets. Some disorders of metabolic process-
physiological features of the organism. es in the body may also occur.
Chronic radiation illness develops at a radiation Third (severe) stage: Clinical symptoms are quite
intensity of 1-5 mGy/day at a total dose of 0.7-1 Gy. It diverse: on the nervous system - signs of distract-
can occur with 2 types of radiation: a long total rela- ed encephalomyelitis; in the cardiovascular system
tively uniform irradiation and a continuous total un- - myocardiodistrophic changes, endothelial dam-
equable irradiation (irradiation of body segments). It age of medium and small caliber vessels, presence
should be in mind that the biological action of total of circulatory disorders; development of atrophic
irradiation is always greater than that of the local ex- processes in the gastrointestinal tract. Changes in
posure at the same exposure dose. the bone marrow and peripheral blood are getting
For chronic radiation disease, the long-term wavy worse. An infectious-septic condition often occurs as
clinical course of development is characteristic, of- a consequence of disorders in the immune system.
ten with simultaneous rehabilitation reactions. Fourth (extremely severe) grade: character-
Active proliferating tissues (with intense cell divi- ized by infectious complications, pancytopenia and
sion processes) have long retained their morpholog- others. Changes in the nervous and cardiovascular
ical recovery capabilities, while stable in this regard system are deepened. The parallel development of

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 OCCUPATIONAL MEDICINE
reparative processes can lead to new forms of regu- • Departments (8) to combat silicosis (for for-
lation of a number of systems in the body. mer uranium miners);
The prognosis in stages I and II is still good, in • Military Medical Academy (for employees of
third stage patients it is doubtful or bad and in grade the Ministry of Defense).
4 -bad. Health monitoring is carried out on more than 20
For the diagnosis and treatment of CRD, it is also 000 persons - working in Kozloduy NPS - 5000; work-
necessary to: ers in other industries (medicine, industry, science)
• review after a detailed detachment of the his- - 11,000 and over 4,000 former uranium miners.
tory; The types of health monitoring are:
• detailed laboratory tests (including bone mar- • usual: preliminary medical examinations, peri-
row puncture if necessary); odic medical examinations and medical exam-
• cytogenetic examination of peripheral blood inations of former workers;
lymphocytes; • operational: before and after refueling of nu-
• consultation with an ophthalmologist (risk of clear reactors, before performing risky opera-
developing cataracts); tions and manipulations, in case of emergen-
• conducting radiometric examination of the cy exposure of the body;
thyroid gland, biological excreta, determina- • special: in emergency radiation of the body.
tion of whole body activity of the organism The volume of the preliminary medical examina-
(anthropogamametry), etc. tion includes:
The basic principles of treatment coincide with • Clinical examination by: therapist (radiobiol-
those of acute radiation illness. The main efforts are ogist), neurologist, ophthalmologist, surgeon,
directed towards the general strengthening of the dermatologist, gynecologist;
nervous system, the treatment of the manifestations • Peripheral blood study - hemoglobin, eryth-
of neuro-visceral dysregulation and the bone mar- rocytes, reticulocytes, hematocrit, differential
row insufficiency. Careful use of hemogenic stimu- count leukocytes, platelets, BSR;
lants, immunostimulants, antibiotics and anti-haem- • Urine analysis - relative weight, protein, sug-
orrhagic agents is necessary. To enhance the body's ar, ketobodies, bilirubin, urobilinogen, blood,
vitality and reactivity, preparations that stimulate sediment;
the function of the central nervous system and sana- • Electrocardiography, sphygmometry. For op-
torium-resort treatment are used. erational and repair personnel at the NPS -
Patients with chronic radiation illness are con- and review by an otorhinolaryngologist; For
stantly labour readjustment and carefully refining NPS operators - and psychophysiological and
the need for X-ray and radioisotope research in the psychological research.
future. The volume of periodic medical examination is as
Medical prophylaxis (health monitoring) of a preliminary medical examination, with additional
workers exposed to ionizing radiation research - biochemical, immunological, cytochemi-
The medical units that carry out health monitor- cal, cytogenetic, electrophysiological, biophysical,
ing of the professionally irradiated persons in Bul- radiochemical, etc. at indications.
garia are: The choice of diagnostic methods for the incor-
• National Center for Radiobiology and Radia- poration of radionuclides is determined by the na-
tion Protection - central diagnostic expert and ture and amount of the incorporated isotope, by its
medical-advisory unit on the issues of radia- toxicological characteristics and by the dose load
tion pathology; formation.
• RIPCPH (RIOCOZ, HEI) - Radiation hygiene de- Where there is a doubt about the occupational
partments, in Plovdiv, Varna, Burgas, Rousse disease from the radiation exposure - leukosis, can-
and Vratsa; cer, cataracts, etc., the worker is referred to LEMC
• Occupational Medicine Service at Kozloduy (TELC).
NPS;

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REFERENCES

1. Guszkova A.K., Bayosoglov DG - Radiation sickness in man, Med. Moscow, 1971. (in russ.)
2. Guidbook for the treatment of accidental internal radionuclide contamination of workers. eds. Gerber
G.B. and Thomas R.G. Radiation Protection Dosimetry Vol.41 No 1, 1992, Brussels-Luxembourg, 1992
3. ICRP Publication 28 - The Principles and General Procedures for Handling Emergency and Accidental
Exposures of Workers, Pergamon Press, Oxford, 1977
4. International Atomic Energy Agency, Assessment And IAEA TECDOC - 869, Vienna, 1996
5. International Radiation Injuries Agency, Radiation Injuries Series, Safety Reports Series 2, IAEA, Vienna,
1998
6. Mitrov G., I. Nikolov, Em. Andreev, Medico-biological problems of ionizing radiation, Med. and phys.,
S, 1976. (in bul.)
7. Organization of dispensary observation for persons who work with sources of ionizing radiation. ed.
A.K. Guskova, Atomedite, 1975 (in russ.)
8. Rayonnements ionisants. Radioactivite. In Precis de medicina du travail. Sous at the direction de H.
Desoille, J. Scherrer and R. Truhaut, Masson, Paris, G. ed., 1991, 586-623.
9. Report of the United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR) to the
General Assembly, United Nations, New York, 2000.
10. Sources and effects of ionizing radiation. UNSCEAR 1993 Report to the General Assembly with Scien-
tific Annexes, United Nations, New York, 1993

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V. Kostova

4.5 VIBRATIONAL DISEASE

Vibration disabilities continue to be of interest to and spinal lesions; frequencies 16-30/40 Hz lead to
professional pathology despite their long-standing bone-joint injuries in the hands and shoulders; effects
research in various fields. In 1883, the use of pneu- on peripheral blood vessels and neuro-muscular struc-
matic vibratory instruments in French mines was tures occur at frequencies between 30/40 and 1000 Hz.
introduced, but only in 1911 G. Loriga described for According to other researchers, the most pathogenic
the first time vasomotor disorders in the fingers after impact on the development of vibropathology has the
the use of pneumatic guns. This message was fol- frequencies of 16-250 Hz.
lowed by the classical studies of vascular syndrome Major pathogenetic mechanisms
by A. Hamilton (1918), T. Rothstein (1918) and J. There is no single theory about the mechanisms un-
Leake (1918). der which the VD develops. It is assumed that its patho-
In our country, vibrational lesions are described as genesis is multifactorial, with different pathogenetic
a nosological unit, which includes the following defi- mechanisms involved in the various stages of the dis-
nition: a specific occupational disease that develops ease. Several hypotheses find a major place in explain-
progressively, progresses phase, and is characterized ing vibration pathology.
by a polymorphic clinical picture with leading nerv- The greatest number of supporters has the theory
ous system manifestations (Methodological instruc- of direct mechanical damage to peripheral struc-
tion - MH) - 0-56/79). tures in the extremities of the vibrations, resulting in
The term vibrational disease (identified as a single the following changes:
nosological unit by E.C. Andreeva-Galanina - 1955) is - in the arterial wall: lamina interna disruption,
used in Japan, the former USSR and Eastern Europe endothelial desquamation with subsequent release,
and the Scandinavian countries. In the Anglo-Saxon adherence and platelet aggregation at the site of the
literature the synonyms of the disease are vibration damage; proliferation of smooth muscle cells; thick-
syndrome, traumatic vasospastic disease, Raynaud's ening of intimate small blood vessels; fibro-cellular
professional phenomenon or Raynaud's profession- thickening of arteriol and arterial walls; development
al disease, vibrational "dead" fingers, hand-arm vi- of focal cell proliferation; regenerative formation of
bration syndrome and others. collagen and elastin; increased collagenisation of the
In the structure of occupational morbidity in Bul- dermis, vascular walls and perivascular spaces.
garia vibration disease (VD) is third and shows a ten- - peripheral neural lesions - damage to vasomotor
dency to decrease its relative share in recent years nerve endings, axonal degeneration, demyelinization,
- from 21.2% in 1996 to 9.6% in 1998 (related to a and extensive collagenisation of perineurium and en-
number of factors, diminished disclosure of occupa- doneurium.
tional diseases, restructuring of industry, health care - direct damage to the mechanoceptors in the fin-
reform, etc.). Its gender and age distribution shows gers - mostly fast adapting units II, associated with
a higher incidence of male sex and the highest in- Pacini's bodies (and perhaps with Golgi-Mazoni's bod-
cidence in the 46-55 age group. The greatest share ies): sensitized for frequencies above 40-50 Hz and SA
of VD is over the duration of the specialized service I-type (slowly adapting units I), including Merkel's disks
over 10 years. and subsequent dysfunction and hypofunction of re-
Etiology of vibrational disease ceptor system.
The disease is caused by complex unfavorable fac- - influencing "local" or peripheral factors involved in
tors of production - local or general vibration, excessive arterial tone control - so-called vascular tone modula-
noise, unfavorable microclimate, dynamic load, static tors associated with the endothelium: thromboxane A2
and psycho-emotional overtension, and as leading (potential vasoconstrictor); prostacyclin (potential vas-
factor in etiology - vibrations. odilator); endothelin-1, von Willebrand-Factor antigen,
According to most authors, a major role in the ef- ACE and other endothelin-dependent substances, and
fect on the human organism and the clinical symptom causing vascular spasm and impaired circulation.
is the role of vibration frequencies. It is assumed that Vasoconstriction and increased vascular tone are
vibrations with frequencies between 6 and 16 Hz cause explained in addition to direct, local action and with
predominantly motor disorders, autonomic disorders a general effect of the induced dysfunction of the
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autonomic nervous system: suppression of its par- palms of the skin - cyan or pale spotting. According
asympathetic part and especially affection of sympa- to the process, there is a lace lines, imbibition or puff-
thetic nervous system - sympathetic hyperactivity with iness of the palms and fingers. There are also positive
activation of central sympathetic reflex mechanisms symptoms of white spot (Laignel - Lavastine), of Pall,
(limbic system and hypothalamus). of Bogolepov and others. In clinical symptomatolo-
It is also assumed that the complex of adverse fac- gy, angiospastic or angiodystonic manifestations in
tors (including vibrations) unlocks the response of the hands are of major importance. Observing the
chronic or intermittent stress with the activation so-called dead fingers - bleeding attacks (most often
of the hypothalamic-pituitary-adrenal cortex and on the II, III or IV fingers) occurring at local and gen-
sympathic-adrenal system and their subsequent dys- eral cooling or spontaneous. The duration of bleed-
function. As a result, there are neuro-humoral and en- ing attacks ranges from a few minutes to hours. Pe-
zymatic disorders and disorders of tissue metabolism ripheral autonomic and vascular disorders develop
and homeostasis of the whole organism. gradually and show a tendency towards progression.
The Classification of Vibrational Disease (MH The parameters of local vibrations (especially their
Methodological guideline - 0-56/79) defines: frequency), other unfavorable factors of production
• VD due to local vibrational effects (eg cold effects) as well as the general health status
• VD, due to general vibrational impact. of the individual are affecting. Concomitant diseases
Depending on the degree of disability, three - cardiovascular, endocrine and metabolic disorders,
stages of the disease are indicated: generalized musculoskeletal disorders or collageno-
• Stage I (initial); sis, neurosis and mental disorders, as well as harmful
• Stage II (moderate); habits - smoking, systemic alcohol use, etc., facilitate
• Stage III (expanded, expressed). the development of peripheral autonomic and vas-
Clinical and labour-expert practice also uses in- cular pathology.
termediate stages: Sensorial disorders are a common objective find-
• VD I-II stage (transient); ing and are in the direction of distantly increasing
• VD II-III stage (advanced, with chronic leakage). hypoesthesia for pain and touch and reduced dis-
criminative and vibratory sensation in the hands.
4.5.1. VIBRATORY DISEASE FROM LOCAL Some authors describe hypopalestezie as a pathog-
VIBRATIONS nomonic mark of vibrational disease, but it should
not be forgotten that the elevated threshold of vi-
Threatened occupations are: miners; woodwork- bration sensation is present in diseases damaging
ers; band sowers; polishers; grinders; rough grinders; the backs of the spinal cord, spinal roots, peripheral
riveters; sharpenters; mosaicists and others. nerves, and possibly the lateral columna. Hypopal-
The tingling of the fingers is one of the early signs esthesy is common, for example, in peripheral neu-
of the disease. Appears at night, after work started, ropathies of different etiology - diabetic, alcoholic, in
usually disappears. These complaints are accompa- various endocrine-metabolic diseases - acromegaly,
nied by morning stiffness of the fingers and diffuse hypothyroidism, etc., in carpal tunnel syndrome, ra-
swallow pain in the upper limbs. Characteristic are diculopathies, etc.
spontaneous fits of fingertips whitening. Typically, As the pathological process progress, develops
patients initially report whitening of the toes of one trophic nail disorders (striae, koilonychia, nails type
or two fingers, and only on cooling. Later, there is a "clock glass"), the skin of the palms and fingers
whitening that covers the end, middle or all phalan- (smoothing the skin of the fingers, skin thickening
ges of the II-V finger of the hands and has a different to the sclerodactylium, hyperkeratosis, xanthochro-
duration. Restoration of the bloodstream after such mia, rhagades on the palms) or bones (mostly carpal
an attack is usually accompanied by "throbbing" bones and phalanges - focal osteosclerosis, osteopo-
soreness or paresthesia, sweating and blueing of rosis, bone cysts). In some cases there is thickening
damaged fingers. Often complaints of functional and deformation of the end phalanges of the fingers
weakness in the hands and ringing in the ears and with formation of so-called clubbed fingers. In the
faill hearing. advanced stages of the disease, hypothrophies of
The objective study shows peripheral autonomic thenar, hypothenar, mm.interossei are also found.
disorders - sympathicotonia or autonomic dystonia. Hearing disorders are the result of the combined
There is distal hypothermia in the upper limbs (often effects of local vibrations and over-noise. It occurs in
22 ° C - 24 ° C to 17 ° C - 18 ° C on the fingers). Some tinnitus and hypacusia, and the reduction in hearing
patients experience spontaneous hyperhidrosis of acuity is usually bilateral, symmetrically initially in
the palms and fingers. Changing the color of the the high frequency areas - 4000 to 6000 Hz.

541
 OCCUPATIONAL MEDICINE
Additional clinical signs describe: Measurement of the skin temperature gives in-
• Primary lesion of the peripheral nerves of the formation about circulatory deviations and neu-
upper limbs: e.g. neuropathy of n.medianus ro-vascular reactivity. Thermistor thermometry,
in the carpal canal; of n.ulnaris in the cubi- liquid crystalline cholesterol thermometry, infrared
tal duct or cervical radicular syndromes with thermography are applied. Hypothermia (to ther-
combined genesis; moamputation) in the distal hand compartments
• Bone-joint disorders - e.g. deforming arthrosis and sometimes thermoassimetry (above 1.5 ° C) for
of the elbow joints; risarthrosis; cervical osteo- the left/right hand is established.
chondrosis and spondylosis; To identify sensory disturbances in the upper
• Musculo-tendon lesions: humerus-scapular limbs, the following are used:
periarthritis, radial and ulnar epicondylitis and • algesiometry - to determine the surface sen-
tendomyositis sation for pain, and thermoesthesiometry - to
For the development of musculoskeletal dam- determine the sensation of warm and cold.
age, static overload, significant dynamic load, over- There is an increased threshold for pain sensa-
cooling, and increased humidity are of particular tion and thermohypesthesia in the distal com-
importance. partments of the upper limbs - fingers, wrists.
Clinical-functional studies. The development of • esthesiometry - to determine the threshold of
a diagnosis - VD due to local vibrational effects re- deep sensitivity and two-point discriminatory
quires a number of studies to evaluate the functional sensation - reduced sensory function is estab-
status of the peripheral blood circulation, the nerv- lished.
ous system, the autonomic background and the au- • palestesiometry - to measure the threshold of
tonomic reactivity (including the neurovascular end- vibrational sensation at different frequencies.
point), as well as the differential diagnosis exclusion There is a reduced vibrational sensation.
of other diseases with similar symptoms. A number of provocation tests are used to assess
Wide application finds methods of peripheral autonomic reactivity. Particularly informative is the
blood exploration - in routine practice, capillarysco- cold provocation test carried out in various modi-
py and capillarygraphy arteries are used. The chang- fications. Prolonged recovery of baseline skin tem-
es in the basic color and background of the field of perature, as well as frequent enhancement of clinical
view, the number, shape and position of the capil- signs following cold provocation, are observed.
laries are observed. Depending on the stage of the Other methods used are:
disease, capillary polymorphism, spastic capillaries, - X-rays of the cervical spine, upper thoracic ap-
spastic-atonic complexes, or even paretic capillaries erture, the bone-clavicle space, the hooped joints
with pronounced atony, AV-aneurysms, changes in with the fingers, the elbows or the shoulder joints.
blood flow and permeability disorders. A modern There are dystrophic changes in the spine (cervical
non-invasive method for quantification of vasomo- osteochondrosis, spondylosis), aseptic necrosis of os
tor reflex activity and microcirculation disturbances lunatum or os scaphoideum, deforming arthrosis of
is laser Doppler flowmetry. Skin blood flow and mi- the elbow or shoulder joint;
crovascular reactivity of the hands were examined • Alternating Dynamometry - reduced muscle
by monitoring the perfusion, the concentration of strength in the distal compartments of upper
the formed blood elements and their speed in the limbs;
investigated volume of tissue in a resting state and • Electrophysiological methods, cardiovascular
at thermal heat (44 ° C) with subsequent relative tests, various biochemical parameters, tonal
cooling to 32 ° C; a post vein-arteriolar test and a re- audiometry and auditory evoked potentials.
active hyperemia test were also used. Electrophysiological methods show the in-
Other non-invasive methods for recording pe- volvement of peripheral nerve structures in
ripheral angiopathology (especially for larger blood the pathological process. Determination of
vessels) are oscillometry and oscillography, rheog- the peripheral nerve conduction velocity of
raphy, Doppler sonography and plethysmography. the upper limbs, most commonly n.medianus
Through these, angiodystonic or peripheral vasos- and n.ulnaris, shows slowing rate and pro-
pasm is defined in the upper limbs, the asymmetry longed distal latency time.
in the left / right hand indicators. A commonly used The main signs of the disease in stages are:
indicator of angiospastic assessment is the measure- Stage I - occasional night numbness and pale au-
ment of the fingers systolic pressure in the initial po- tonomic and vascular disorders in the hands. In the
sition and after a cold provocation - a sympathetic objective study, a slight degree of hypopalesthesy,
vasoconstrictor reaction is observed. dystonic capillaries, a tendency to prolong the time

542
 LABOUR MEDICINE
of recovery of the skin temperature in the cold prov- tion suffer. There are also autonomic disorders in
ocation test. the extremities (paleness, cyanosis, changes in skin
Stage II - pronounced night paresthesias and temperature, swelling, hyperhydrosis). In advanced
morning stiffness of the fingers that pass after forms of VD there are also various trophic disorders.
movement, insensibility, awkwardness and gripping The lower limbs are most often involved, but be-
weakness in the hands, whitening of the end pha- cause the exposure is of mixed vibrations - local and
langes of II-V finger provoked by cold impact; swol- general, the abnormalities are also found later in the
len fingers and palms with cyanotic and cold skin, upper limbs.
pronounced hyperhidrosis, hypersthesy for pain Mononueuritis syndrome. It is characterized by
of distal-type in upper limbs, moderate degree of involvement of one peripheral nerve, most com-
hypopalesthesy; frequent spontaneous seizures of monly of the upper extremities - nn.ulnaris, medi-
white in distant and middle phalanges of II-V finger anus et radialis. The damage is a result of constant
fingers; (22°C - 24°C to 17°C - 18°C), distally elevated nerve compression in the osteo-fibrosis canal, i.e.
vascular resistance, pronounced capillary spasm and tunnel neuropathy develops. In addition to vibra-
pericapillary edema, significantly prolonged skin tions, etiopathogenetic significance is also the stat-
repair time in the cold provocation test; moderate ic overtension and forced posture, determining the
hearing abnormalities - ear noise and hearing loss compression of the nerve. Clinically characterized
for high frequencies (4000-6000 Hz). by numbness, tingling and burning, limiting in the
Stage III - permanent and intense paresthesias area of ​​nerve propagation, pain and weakness in the
and diffuse pains, covering almost all hands to the hand. Objective signs are: impaction and thickening
shoulders that do not pass and after movement, of the peripheral nerve at palpation over the com-
pronounced gripping weakness and clumsiness; in- pression site; sensory disturbances by zone type and
crease and deepen the angiospastic crises by cover- positive specific symptoms at the squeeze site (eg,
ing all phalanges of II-V finger and longer duration the symptom of Tinel, Phalen, etc. is positive); weak-
of seizures (over 10-15 min). The objective finding ened tendon and superficial reflexes and motor dis-
shows autonomic and vascular disorders in the orders (hypotension, hypotrophy, decreased muscle
hands (but with significantly greater from stage II strength). Characteristic signs are autonomic and
intensity); trophic disorders of the skin of the palms vascular abnormalities - hyperhidrosis, distal hypo-
and fingers, nails, clubbed fingers; hypothrophies of thermia, change in the color of the skin of the palms
thenar, hypothenar; flexion contractions of fingers; and fingers.
various bone-joint dystrophic and muscle-tendon Radicular syndrome. Secondary (vertebrogenic)
changes; significant hearing loss with reduced hear- lumbosacral and cervical-radicular lesions are most
ing acuity in the area and in low frequencies; ten- frequently found. They are diagnosed based on the
dency to generalization of disturbances - in lower characteristic clinical signs of spinal root damage
extremities, vestibulopathy, endocrine-metabolic supported by electrophysiological and X-ray studies.
dislocation, etc. Bone-joint dystrophy syndrome. In the case of
general vibrational impact, the spine structures in
4.5.2. VIBRATIONAL DISEASE OF GENERAL the lumbar region are affected. Lumbar osteochon-
VIBRATIONS drosis and spondylosis develop with secondary
symptomatic radicular manifestations. Certain etio-
The endangered occupations are: tractors, pow- pathogenetic significance also has the accompany-
er shovels, bulldozers, heavy truck drivers, cran op- ing impulses and static overtension in the lumbar
erators, vibroconcretors, miners who work with tele- region (winding, twisting and prolonged sitting) as
scopes on vibrating platforms, etc. well as the adverse microclimate. Clinical symptoms
Symptoms of VD from general vibrations are rep- are characterized by gradual development, restraint
resented by several syndromes. of movements and blunt pain in the waist area, of-
Polyneurial syndrome mainly with sensory and ten irritating down the leg and numbness of his toes.
autonomic limb symptoms (so-called vegeto-senso- Objectively, there are positive stretch phenomena,
ry polyneuropathy). It occurs with finger numbness soreness in the Valleix paravertebral points accord-
mostly at night, diffuse pain at rest, especially in the ing to the level of affected spinal cord structures and
distal compartments, frequent sweating, bleeding root-type sensory defects in the dermatomas. Very
attacks and stiffness of the fingers. Objectively, there rarely, peripheral paresis (hypotension or hypotro-
are changes in general sensitivity in polyneuritis phy of damaged muscles according to the affected
type. Above all, the sensation of pain, vibrational spinal cord roots), as well as weakened Achilles or
sensation, temperature and discriminatory sensa- knee reflexes.

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Cervical osteochondrosis and symptomatic radic- Autonomic disorders - nausea, vomiting, paleness,
ulopathies, deforming arthrosis of the elbow joint, sweating, pulse and arterial pressure changes, cou-
omarthrosis or aseptic bone necrosis of hoop joints pled with vestibular disorders - usually increased
with corresponding clinical symptoms are also fre- vestibular reactivity in the caloric and rotation tests.
quently found. Often hearing loss is reported, and tonal audiome-
Musculo-tendon syndrome. The complex of ad- try shows a reduction in auditory acuity bilaterally
verse factors, especially the overtension and adverse and symmetrically for frequencies 4000-6000 Hz. In
microclimate in combination with vibrations, often these cases, it is a hearing-vestibular syndrome.
result in the occurrence of stenotic tendovaginitis, Hypothalamic syndrome. Such a syndrome,
insertiopathy (most commonly radial epicondylitis), caused only by a general vibrational impact, has
shoulder periarthritis, tendomyosis of the hand ex- rarely occurred in recent years. Separate hypotha-
tenders, etc. Their clinical symptoms are not differ- lamic signs and symptoms can be identified with
ent from those of professional musculotendinous combined effects of intense general vibrations, sig-
syndromes at all. nificant over-noise and toxic noxae. Neuro-circula-
Cerebral dysregulation syndrome. It is charac- tory abnormalities (hypertensive reactions, palpita-
terized by a non-permanent (transient) general brain tions, changes in heart rate) and thermoregulatory
symptomatic with functional character, lacking focal and sudomotor disorders of sympathetic nature are
neurological lesions. There is a diffuse headache (no most commonly observed. Often they have a re-
nausea and vomiting), unsteady stagger, dizziness, lapsing nature: sympathetic-adrenal crises or, more
instability, sleep disturbance, decreased concentra- rarely, of mixed type - sympathetic/parasympathetic
tion of attention and weakening of memory, morn- paroxysms. In other cases, isolated endocrine dis-
ing (somato-psychic) ​​asthenia. In some cases, there orders: sudden increase in body weight, appetite
are various autonomic (neuro-circulatory) disorders: disorders (bulimia, rarely anorexia), increased thirst,
pulse lability, fluctuations and instability of the ar- hyperglycaemic reactions, sexual disorders, ovarian
terial pressure (most often occurrence of elevated dysfunction and others. Very rare signs of trophic
values), orthostatic hypotension, palpitation (some- (vitiligo, alopecia, scleroderma, etc.) or neuropsychic
times single "functional" extrasystoles), vasomotoric (psychastheny, depressive reactions, emotional cri-
"play" (facial flushing and fainting, limb coldness), ses) have been reported. Hypothalamic syndrome
hyperhydrosis, etc. There are no deviations in bio- can only be diagnosed when the listed symptoms
chemical and haemorheological parameters, from occur at the same time - i.e. the combined symptom
neurosonographic and impedance techniques (ie complex shows the primary damage to the hypo-
no evidence of organic brain circulation deficien- thalamus.
cy). Occasionally, non-invasive methods for brain Clinical-functional studies. The main methods
haemodynamics - reoencephalography (including include doppler sonography of brain vessels, reoen-
speed REG), Doppler sonography of cerebrovascular cephalography, EEG, otoneurological examination
vessels, etc., occasionally result in increased vascu- (including evoked auditory potentials), lumbar/cer-
lar resistance, transient changes in blood flow, and vical spine radiographs, computed tomography (if
asymmetries in right/left, directed, for circulatory necessary), as the methods for examination local
dystonia. There may be slight variations in the study vibrations.
of orthostatic self-regulation of the cerebral blood The main clinical signs and constellations accord-
flow. EEG has no significant diagnostic significance. ing to the stage of VD are:
In some cases, however, alterations in the bioelec- Stage I - discrete, barely targeted subjective and
tric activity of the cerebral cortex and signs of dys- objective data of polyneuropathy with autonomic
function in deep brain structures may occur. In the and sensory limb symptoms, intermittent vestibular
presence of generalized autonomic dystonia, there disorders or separate general autonomic manifesta-
are abnormalities in the autonomic background and tions.
reactivity, usually in the direction of sympathicoto- Stage II - pronounced and persistent symptoms
nia and increased sympathetic reactivity, as well as a including the features of the underlying syndromes
deficiency in the autonomic regulation of functions. (listed above), with specific clinical features domi-
Central otoneurological syndrome (vestibulop- nated by the specific profession. For example, the
athy). Central vestibular disorders are headaches, clinical picture of VD in crane operators is the central
dizziness, stunning, indefinite staggering, and tran- dysregulation syndrome, usually in combination with
sient vestibular-autonomous crises. Horizontal nys- vestibular disorders, most often lacking signs of poly-
tagmus, instability in the Romberg test and agitat- neuropathy in the limbs. For truck drivers, bulldozers
ed vestibular manifestations may also be found. and tractors are lumbar osteochondrosis, spondylosis

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The main criteria for diagnosing a vibratory disease are:

VD from local vibrations VD general vibrations

Proof of sufficient daily average (min 4 h) and total Proof of sufficient daily average (min 6 h) and total (min
(min 5 years) exposure to local vibrations 10 years) exposure of the general vibrations
Constellation of peripheral autonomic, sensory, vascular Proof combination of minimum two syndromes typical
and trophic disorders of the upper limbs and hearing of the clinic VD vibrations
disorders
Exclusion of other diseases and conditions occurring with Accurate differential diagnosis - exclusion of diseases
symptoms similar to VD - ie accurate differential diagnosis occurring with similar VD syndromes

Course of disease (especially after cessation of exposure to Dynamics of disease (especially after termination contact
vibration and adequate therapeutic behavior - elimination with the unfavorable factors of work and correct
test) therapeutic behavior - elimination test)

and symptomatic lumbosacral radiculopathies, fol- Peripheral vasodilators - myotropic drugs with
lowed by similar cervical lesions and other bone-joint vasodilator effect, other peripheral vasodilators,
dystrophic abnormalities in the limbs. In all these pro- capillary tonics drugs and others. Most common-
fessions, other risk factors are also important. ly Pentoxifyllinum (Agaprin, Trental, Pentofyllin) is
Stage III - expressed symptoms of autonomic administered at a dose of 300 to 600 mg/day; Naft-
distal polyneuropathy in the lower and upper limbs idroflurilum (Dusodril, Drosunal) at 100-150 mg/day;
(with the addition of sensory and trophic disorders); Cinnarizinum (Cinnarizin, Stugeron) - 75-100 mg/
persistent and severe vestibular crises and signifi- day and others. Non-steroidal anti-inflammatory
cant hypacusia - binaural reduction in hearing acuity drugs (NSAIDs) - most commonly used: Indometac-
is moderate to severe, also in areas above and below inum (indometacin) - 75-100 mg/day; Piroxicamum
4000-6000 Hz; pronounced bone-joint dystrophic (Piroxicam, Feldene, Remoxicam) at 20 mg/day; Di-
lesions of the spine - severe lumbar or cervical os- clofenac sodium (Feloran, Voltaren, Infla Ban) at 75-
teochondrosis, spondylosis, discopathies with sec- 100 mg/24 hours.
ondary radiculopathy with motor disorders, tense Combination preparations with pronounced an-
course and frequent recurrences; hypotalamic man- algesic effect - are usually used in the initial stages or
ifestations - neuro-circulatory disorders, hypergly- at the start of treatment to obtain a curative effect of
caemic crises, sexual disorders, psychosomatic reac- NSAIDs. Most commonly, Alcozin, Tempalgin, Neu-
tions with depressive elements, etc. ralgin, Sedalgin Neo and Alnagon are administered
The differential diagnosis of VD is most com- at the usual dosage of 2-3 tablets/day.
monly caused by the following diseases: Sedative agents and soft antidepressants with
• Raynaud's disease; an effect on the autonomic nervous system (cause
• Secondary Raynaud's syndrome (collagenosis, vasodilation, improve peripheral blood circulation).
endocrine and metabolic diseases); Applications are found mostly: Bellergamin 2,3x1 dr.
• Compression syndromes in the upper thoracic daily; Tofisopamum (Grandaxin) - 50-100 mg/day;
triangle (thoracic outlet syndrome, hyperab- Deanxit 1 tabl. morning and afternoon, etc.
ductive or bone-clavicular syndrome, etc.); Vitamins - include B group of parenteral (mus-
• Syringomyelia; cle) or various combination drugs: Neurobex; Vit.B
• Lateral amyotrophic sclerosis (LAS); complex; Milgamma N 3x2 to 3x1 caps/day; Benfog-
• Deforming spondylosis with osteochondrosis amma 3x1 dr/day. Also apply Vit. E or Geritamin and
and symptomatic radiculopathies with non- others.
professional genesis; Physiotherapy. Apply thermal procedures,
• Neuroses (create diagnostic difficulties in short-wave diathermy, ultrasound, ionophoresis,
some cases due to the full autonomic symp- common juniper baths. Reflective massage is also
toms and neuro-mental changes); useful - hand or with instruments, and healing gym-
• Polyneuropathies of different genesis (insuf- nastics. Balneological sanatorium treatment is also
fiencly and dysmetabolic, toxic, collagenous, recommended.
etc.). Regime and diet. Includes whole nutrition - diet
Treatment. Etiological treatment - Removing the A of protective professional nutrition; adding pectin;
patient from the contact with vibrations by tempo- avoiding smoking.
rary or permanent rehabilitation of work without vi- Labour expertise. In VD I-II stage 20-30% loss
brational impact according to the stage of VD. of working capacity is determined, which imposes
Medication treatment includes: temporary labour-free work without vibrations, stat-

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ic overtension and unfavorable microclimate. VD II VD II-III and III stage receive a permanent decrease in
stage results in a 50% loss of working capacity - i.e. working capacity - more than 50% for a certain peri-
temporary incapacity for work. Usually, patients with od of time (usually 1 year).

REFERENCES

2. Andreeva-Galanina, Е.C. Vibration and it importance in labour hygiene. Len., Medgiz, 1956, 189. (in
russ.)
4. Bosnev, V. Vibrational disease. In: Infrasound, ultrasound, noise and vibrations. ed. D. Tsvetkov and M.
Angelova. S., Med. and phys., 2007, 252-271. (in bul.)
10. Karastanev, Iv., N. Mitrev, K. Yazov. Vibrational disease. Plovdiv, Hr.G.Danov, 1974, 92. (in bul.)
11. Kirkov, Vl. Vibrational disease. In. Professional Neurological Diseases. S., Med. and phys., 1990, 109-
125. (in bul.)
12. Kostova, V. Peripheral neuropathies. S., Inforum + P, 1996, 119-140. (in bul.)
15. Malinskaya, NN, G.A. Souvorov, L. Shkarinov. Noise, Vibration, Ultra- and infrasound In: Manual of
labour hygiene, ed. N.F. Izmerov, V. I, M., Medicine, 1987, 168-204. (in russ.)
19. Stoyneva, Zl. et. al. Peripheral circulatory disorders in vibration pathology. - Angiology and Vascular
Surgery, II, 1997, 1, 22. (in bul.)
1. Allen, J. et al. Objective testing for vasospasm in the hand-arm vibration syndrome. - Br. J. Ind. Med.,
49, 1992, 688-693.
3. Bleeker, M. (Ed.). Occupational Neurology and Clinical Neurotoxicology. Baltimore-PhiladelphiaHong
Kong-London-Munich-Sydney, Williams & amp; Wilkins, 1994, 253-264.
5. Bovenzi, M. Hand-transmitted Vibration. In: Encyclopaedia of Occupational Health and Safety, 4th
edition. ed. J. M. Stellman, Geneva, International Labour Office, 1998,50.7-50.10.
6. Clement, D., J. Shepherd (Eds.). Vascular Diseases in the Limbs. Mechanisms and Principles of Treat-
ment. St. Louis ... London ... Toronto, Mosby-Year Book, 1993, 71-89, 169-86.
7. Gemne, G. Where is the research frontier for hand-arm vibration? - Scand. J. Work. Environ. Health, 20,
1995, 90-99.
8. Honma H., T. Kobayashi, H. Kaji. A Color Atlas of Circulatory Disorders in Hand-arm Vibration Syn-
drome. Sapporo, Sando Printing Co., 2003,122.
9. Houma, H., et al. Occlusive arterial diseases of the upper and lower extremities found in workers occu-
pationally exposed to vibrating tools. Int. J. Occup. Med. Environ. Health, 13 (4), 2000, 275-86.
13. Laskar, M. S., N. Harada. Evaluation of autonomic nervous activity in hand-arm vibration syndrome
patients using time and frequency-domain analyzes of heart rate variation. - Int. Arch. Occup. Environ.
Health, 72, 1999, Oct; 462-8.
14. Lindblad, L.E., L. Ekenvall. Raynaud's Phenomenon of Occupational Origin: Hand-arm Vibration Syn-
drome. In: Vascular Diseases in the Limbs. Mechanisms and Principles of Treatment. ed. D. Clement, J. Shep-
herd, St.Louis ...- London ... Toronto, Mosby-Year Book, 1993, 187-98.
16. Pelmear, P. et al. Occupationally-Induced Scleroderma - J. Occup. Med., 35, 1992, 20-25.
17. Petersen, R. et al. Prognosis of vibration induced white finger: a follow up study. - Occup. Environ.
Med., 52, 1995, 110-115.
18. Seidel, H., M. Griffin. Whole-body Vibration. In: Encyclopaedia of Occupational Health and Safety,
4th edition. ed. J. M. StellmanGeneva, International Labour Office, 1998, 50.2-50.7.
20. Symptomatology and diagnostic methods in hand-arm vibration syndrome: Stockholm Workshop
1986. - Scand. J. Work. Environ. Health, 13, 1987, 271.
21. Taylor, W. The hand-arm vibration syndrome: an update. Br. J. Med. Med., 47, 1996, 577-579.
22. Tommasi, G.V. et al. Angioneurosis due to vibrating tools with special reference to plethysmographic
and Doppler vascular diagnosis. - G. Chir, 21, 2000, Jan-Feb; 68-71.
23. Wilder D.G., D.E.Wasserman, M.N.Pope, P.L.Pelmear, W.Taylor. Vibration. In: Physical and Biologi-
cal Hazards of the Workplace. ed. P. H. Wald, G. U. Stake. NY, Van Nostrand Reinhold, 1994, 64-83.

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A. Savov

4.6 PROFESSIONAL DEAFNESS

Occupational hearing loss can be caused by trau- impact. In them, the structures of the middle ear,
ma, toxic substances and noise impact. rather than the inner ear, are disturbed. Transversal
LOSS OF HEARING by trauma fractures are less common (20% of cases) as result
Ear trauma can be caused by a wide range of inju- from a strong occipital stroke. They are usually ac-
ries. The most common cause of traumatic hearing loss companied by severe intracranial injuries. Typical of
is a blunt stroke on the head that creates a squeezing them is that they pass through the inner ear and lead
wave in the skull. Damage to the cochlea after a dull to complete hearing loss of the neurosensory type
head trauma histologically and audiologically is simi- and destruction of the labyrinth. They are accompa-
lar to that of high frequency acoustic trauma. nied by strong vertigo, lasting weeks, even months.
Vehicle catastrophes are accompanied by blunt in- Temporal bone fractures are clinically recognized
juries and cause about 50% of temporal bone injuries. by the presence of blood and cerebrospinal fluid in
Relatively rare are penetrating temporal bone inju- the ear canal, or by the presence of blood in the mid-
ries - about 10% of cases. Other professional reasons dle ear behind the uninjured m. Tympani. An ear that
for these traumas include falls, explosions, burns with is freshly traumatized should not be moistened.
corrosive chemicals, open fire or welding slag that can OTTOXIC LOSS OF HEARING
penetrate the ear. Most ototoxins damage femoral cells directly or
Traumas that cause conductive hearing loss may by demolition of other cochlear homeostatic mecha-
be due to hematoma of the eardrum (provided it is nisms. In most cases, ototoxic hearing loss occurs with
free of fracture of the temporal bone). If this is the the use of drugs such as aminoglycoside antibiotics
only injury, hearing usually recovers in a few weeks. (eg. gentamicin), diuretics (furocemide), antineoplastic
Burns usually heal slowly and often get a chronic in- agents (cisplatin) and salicylates (aspirin). In the noisy
fection. A strong explosion with a level above 180 work environment, workers treated with ototoxic drugs
dB can cause a rupture of the membrane tympani. are at increased risk for greater hearing loss.
Ruptura are usually healing spontaneously if no sec- Heavy metals - arsenic, cobalt, lithium, lead, mercu-
ondary infection develops. ry and thorium, have proven ototoxic potential. Other
Conductive hearing loss lasting more than 3 chemicals with ototoxic action are cyanides, benzene,
months after the injury is usually due to residual aniline dyes, iodine, fluorophenone, dimethyl sulfoxide,
perforation of the membrane or destruction of the dinitrophenol, propylene glycol, methylmercury, po-
ossicular chain. These lesions are suitable for surgical tassium bromate, carbon disulfide, carbon monoxide,
intervention. carbon tetrachloride, styrene and toluene.
Injuries causing neurosensory hearing loss are HEARING LOSS IN NOISE EFFECTS
trauma to the inner ear. In a labyrinth concussion, Professional hearing loss due to noise effects is
transient vertigo, permanent hearing loss and tinni- a slow-running process over a long period of time
tus usually occur. Therapy is waiting, with vestibular (several years) as a result of constant or intermittent
suppressants, giving symptomatic relieve to vertigo. strong noise effects. Occupational acoustic trauma is
The trauma can also cause a rupture of the round or a sudden change in hearing as a result of one-time,
oval membranes, leading to fluid leakage from the loud, impulsive, blast-like noise.
inner ear in the middle ear. Most perilimphatic fistu- Under the conditions of contemporary produc-
las heal spontaneously. However, a persistent peril- tion, professional hearing disorders have become
imphatic current is difficult to diagnose and requires the leading occupational diseases in Bulgaria. They
surgical treatment (recurrent episodes with vertigo are the second most frequent cause of overtension
and hearing loss, often associated with increased diseases of the locomotory system and the periph-
physical activity). eral nervous system. Their relative share in the struc-
Temporal bone fractures usually occur along the ture of occupational diseases varies from 9 to 15%.
lines connecting the weak points at the base of the The greatest percentage of hearing impairment
skull. Longitudinal fractures occur more frequently occurs in the age groups 50-59 (64%) and 40-49 years
(80% of cases) and are most often the result of a side (25%). They are more common in men than women.

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There is an increase with an increase in length of ser- Clinic. Patients complain of gradual hearing loss.
vice. The most common complaint is a difficulty in per-
The highest is the relative share of hearing im- ceiving speech, especially in underlying background
pairments in the ferrous ore mining and steel indus- noise. Because patients with professional hearing
try, transport, textiles and knitwear, machine build- loss have mostly high frequency abnormalities,
ing and metalworking, chemical industry. they hear vowels better than consonants. This leads
Accordingly, professions such as: metallurgists, to distortion of speech sounds. Background noise,
miners, blacksmiths, boilers, firemans, riveters, turn- which is usually low-frequency, masks better the
ers, millingers, motorcycle testers, avionics techni- preserved part of the hearing spectrum and makes
cians, motorcyclists, weavers, agricultural mechan- it even more difficult to understand the speech. Loss
ics, compressors and many others are threatened by of hearing is often accompanied by tinnitus - most
the impact of noise. often patients describe it as a high-frequency tone
Pathogenesis. Hearing loss due to noise impacts (ringing), but sometimes it is lower, such as buzzing,
is the result of trauma to the sensor epithelium of the blowing, hissing, or even without sound (clicking or
cochlea, damaging the stereocilias of the ciliary cells. snaping). This feeling can be intermittent or perma-
In the acute acoustic trauma of the labyrinth, the nent and usually deepens. Due to the tinnitus, pa-
acoustic action of the powerful sound is coupled with tients complain about the inability to sleep or con-
that of the shock wave. Internal ear elements are shuf- centrate in a quiet room.
fled, haemorrhages, trophic disorders, and later degen- In the tuning fork study, the patient has an air
erative dystrophy of the Corti organ, ganglion cells and conductivity better than bone conduction - neuro-
nerve fibers appear. sensory hearing loss. When using serial tuning forks
In chronic acute trauma, the underlying pathoge- from 512 to 4096 Hz, there is often a noticeable re-
netic mechanism is limited to changes in the inner ear; duction in hearing at higher frequencies. Audiome-
endolimphatic hydropae in the context of neuroveg- try usually shows two-sided, mainly high-frequency
etative vascular dystonia, metabolic and structural neurosensory hearing loss with a maximum drop in
changes in the Corti organ, utriculus, sacculus and clear tone thresholds of about 4000 Hz. Since the
semi-circular canals. Various degenerative and atroph- most important thresholds for understanding hu-
ic processes in these formations were later observed. man speech are between 500 and 3000 Hz, there is
Sensory and mental abnormalities resulted in a sig- no significant reduction in understanding and per-
nificant increase in plasma cortisol levels, an increase ception of speech. The degree of speech discrimina-
in minute volume and heart rate, and an increase in tion is normal in the initial stages of hearing loss but
blood pressure. Noise helps increase the level of adren- may be aggravated by progressive hearing loss.
aline and noradrenaline in peripheral blood. Parallel to Permanent hearing changes occur most often
this, there is a spasm of the cochlea's blood vessels, es- between the 4th and 10th years of work experience.
pecially the spiral vessels of the basilar membrane and They are symmetrical or nearly symmetrical, but in
the stria vasculiaris. some cases small differences between the two ears
The effects of noise alter the serum-biochemical are possible if the working posture exposes one ear
equilibrium, the function of the glands with internal se- to a stronger exposure.
cretion and the immune-biological reactivity. The harmful influence of noise on the central
Under the influence of an over-threshold energy and autonomic nervous system and other organs
sound stimulus, and depending on the duration of the and systems is manifested at a noise intensity signif-
sound pressure, the level of glycogen in the sensory cell icantly lower than that causing persistent auditory
initially increases and then decreases. Similar biases changes. Functional CNS disturbances precede the
are also found in the activity of enzymes associated occurrence of persistent auditory changes and are
with biological oxidation. particularly common in younger (newcomers) work-
The risk of hearing disturbance is related to the du- ing in noisy environments. At the beginning of work
ration and intensity of exposure, but also to the genet- experience, complaints of tinnitus, headache, rest-
ic susceptibility to noise trauma. Prolonged exposure less sleep, nervousness, unsteady vertigo are com-
(over 8 hours a day) of sounds with an intensity above mon. They are light, reversible, with the character of
85 dB/A causes hearing damage. Permanent exposure hearing fatigue. More pronounced at the end of the
to noxious noise levels has the greatest effect in coch- shift and the working week. Subjective noise in the
lear zones that perceive high frequency tones. Hearing ears has the most frequent high frequency charac-
loss is prone and strong for frequencies around 4000 teristic. In the beginning he is interrupted, and then
Hz, with downward spanning to speech frequencies becomes permanent. Its intensity ranges from 5 to
(500-2500 Hz) occurring after longer intense exposure. 10 dB with a frequency of about 4000 Hz. In the lat-

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er stages the noise becomes strong (in the order of cesses. Functional neurodynamic studies indicate a
25-30 dB), disturbs the patient's sleep and generates significant prolongation of the latency time in the
neurasthenic complaints. visual-motor response. In the EEG study, a character-
In the course of the noise deafness a certain istic low-energy bioelectric activity with dominant
phase is observed. At the outset, the common com- slow waves and high inertness reaches full noreac-
plaints are: fatigue, headache, depression and tinni- tivity in light irritation.
tus (recruitment phase). It lasts most often from one All this leads to a new nosological unit - a noise
week to several weeks or months. This is the phase of disease (Andreeva-Galanina E. C., 1972), whose au-
the best tolerance. Its duration depends on the noise tonomy is still debatable. Clinical manifestations are
intensity. This phase can last for years and then fol- reduced to several syndromes:
low the crash phase (critical period). Later on, there • vegetative-vascular;
is a delay in the course of hearing impairment (fed • astheno-vegetative;
up phase). • hypothalamic and
There are three forms of occupational hearing im- • discirculatory encephalopathy syndrome.
pairment: Depending on the exposure and the nature of
• Isolated defeat of the inner ear that progresses the noise, the individual syndromes may be stronger
with work experience; or less pronounced, and in some cases some of them
• Combined damage to the inner and middle may be missing at all.
ear and The main characteristics of occupational hearing
• Chronic catarrh of the middle ear with symp- loss due to noise effects are summarized as follows:
toms of inner ear irritation and vertigo attacks • the sensory cells of the inner ear are always
of the type of Menier's disease. affected.
Three levels of professional auditory neuritis have • almost always the damage is bilateral. The au-
been adopted: diometric indicators are similar bilaterally.
1st degree - the reduction for 4000 Hz reaches • almost never damage does not cause pro-
35dB and for low frequencies - up to 10dB; found hearing loss. Normally, the low-fre-
2nd degree - respectively up to 45 dB and up to 15 quency range is about 40 dB and the high fre-
dB and quency is about 75 dB.
3rd degree - hearing loss for 4000 Hz is up to 50 dB • once the noise has interrupted, further pro-
and for low frequencies up to 20 dB. gress in hearing loss is negligible.
The otoscopic picture is usually normal. Vascular • previous damage due to noise effects does
hyperemia of the tympanic membrane is often ob- not cause greater sensitivity to future noise
served. Long-time workers are found to be darks and effects. If the threshold of hearing perception
swallowing the eardrum, and the incidence of chronic increases, the rate of further decrease in hear-
otitis and dry perforations of the eardrum is greater ing sensitivity decreases.
than that of those who do not work at the noise. • the earliest damage to the inner ear reflects
The non-specific (extra-aural) effect of noise on the hearing loss at 3000, 4000 and 6000 Hz (usu-
body is characterized by a variety of changes in oth- ally highest at 4000 Hz). Hearing impairment
er organs and systems. This applies especially to the beyond 3000-6000 Hz requires longer expo-
central and autonomic nervous system, the diges- sure times.
tive system, the internal secretory glands, the cardi- • in case of constant exposure to noise, hearing
ovascular system. loss at 3000, 4000 and 6000 Hz usually reaches
Noise increases pulse rate and breathing, chang- maximum after about 10-15 years.
es in blood pressure, increased intracranial pressure, • in workers from "noisy" productions and occu-
changes in gastric peristalsis and gastric secretion, pations, vestibulometric investigation shows
etc. spontaneous vestibular symptomatology (sta-
Objective studies indicate: most commonly trem- tokinetic abnormalities and nystagmus). Dam-
or of the hands and eyelids, decreased corneal, ten- ages of the peripheral vestibular apparatus
don and abdominal reflexes, nystagmoid, hypoes- predominate, due to vessel vasospasm in the
thesia, decreased vibrational sensation, reduced labyrinth vascular system and changes in the
expression and duration of demographic reactions receptors of hearing and vestibular analyzers.
and inversions, opthalmocardiac and orthoclinostat- Diagnosis. Of great importance is a detailed his-
ic reflexes. tory - a clarification of the professional factor (includ-
The effects of noise are associated with mood ing past professions); previous illnesses, pretreat-
transitions and some retention of intellectual pro- ment with ototoxic and vestibulartoxic medications,

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 OCCUPATIONAL MEDICINE
etc.; ototoxic, acumetric (tuning fork) and audiologic should be ruled out: old deafness (presbycusis); he-
data as well as vestibulometry. reditary neurosensory hearing loss; metabolic dis-
The magnitude and nature of occupational hear- orders - diabetes, impaired thyroid function, kidney
ing impairments and labour expertise are solved by disease, autoimmune disease; cochlear otosclerosis
means of di ffe rent met h o ds o f h ear ing re - (family burden); sudden neurosensory hearing loss;
s e arc h. Vascular disorders (sudden loss of hearing loss due
The usual methods are easy to apply, but to blood vessel blockage or migraine); diseases of
with little informality (hearing with tuning forks, of the central nervous system - small brain tumors and
whispering and conversational speech, etc.). pons Varolii; demyelinating diseases (e.g., multiple
The special methods of hearing investigation sclerosis); Meniere's disease and its variants;
are more reliable. Audiometry is the main methodol- Prognosis. The development of occupational
ogy for determining the degree, nature and level of hearing impairments depends on the intensity and
hearing impairment. frequency of noise, the nature of the toxic noxae, the
The methods of tonal (threshold and su- duration of the daily impact, the working conditions
pra-threshold) audiometry - subjective audiometry, and the individual characteristics of the organism.
objective and speech audiometry are used. Initially, the disabilities are functional and reversible,
At tonal a u dio met r y dif ferent ly model ed but later they become lasting and almost irreversi-
c l ea r tone s s uch as aco ust ic sign als (125 to ble.
8000 Hz) are used and the minimum threshold of Treatment. Treatment is causal and symptomat-
hearing about air and bone conduction for each ear. ic. Efforts are directed at regulating the excitating
Tona l ove r-t h resh o ld audio met r y has a processes in the cerebral cortex. Sedative and psy-
higher topo-diagnostic significance.The character choleptic agents (Diazepam, Dimenhydrinat, Eleni-
of the perceptual acoustic signals and especially the um, Lexotan, Deanxit, Nootropil, etc.) are used. To
deformations in the sound intensity, known as the inhibit the increased tone of the parasympathetic
"recruitment phenomenon" (accelerated increase of vegetative nervous system, 0.1% Atropine, cor-
loudness), are determined. The most common use is tex sedative (Scopolamine 0.5%) is administered.
made of the overthreshold samples (tests) of: Fowler Good effect is Galantamin (Nivalin)/0.25%, as well
- measurement of loudness alignment; Langengbeg as strengthening agents (iron, arsenic, calcium,
- measuring the effect of deafening; Karhard and Kitz etc.), stimulating nervous activity and metabolism,
- measuring adaptation and fatigue. Overthreshold vitamins (A, B, C, E), Atrifos, Cocarboxilase. They are
tests are important for early diagnosis because they combined with intravenous administration of glu-
are very positive early on. cose (40%, 40 cm3) and vitamin C (5 cm3), Mannitol,
Speech audiometr y is an important method etc., achieving a dehydrating effect and boosting ox-
of hearing research. Use a specially selected, phonet- idative processes. At the same time, physiotherapy
ically balanced speech material from words, num- procedures (Kalii jodati electrophoresis, Ephedrine,
bers, sentences. The method is an over-threshold massage collar, etc.), appropriate hygienic regime,
test of importance for the labour expertize, allow- gymnastics, tourism, etc. are recommended.
ing the combined assessment of the function of the The treatment of permanent damage is difficult.
cochlear departments of the hearing analyzer and of There are no specific means of therapeutic impact,
the cortex sections of speech and hearing. but only means that act protectively and sympto-
Obje c ti ve audio met r y is based on the reg- matically. Widely used vasodilators (Sadamin, Cav-
istration of various motor and vegetative reactions inton, Stugeron, Trental, Radecol, Dibazol, Divascan,
or bioelectric potentials arising in response to sound Euphyllin, etc.). Good results are obtained from the
irritation.Impedance methods provide information administration of Ac. Glutaminici, Nivalin, Strichnin,
about the prereceptor, receptor, and root - trunck Papaverin, Group B vitamins (B1, B6, B12, B15) and oth-
part of the auditory analyzer. ers.
Hearing-induced potentials (ERA) that occur at Labour expertise. An important condition for
different hearing levels are recorded in clinical prac- the accuracy of the expert's conclusion in profes-
tice by advanced computer electrophysiological and sional hearing neuritis is the precise determination
electroacoustic equipment. of hearing loss. Binaural hearing loss in percent is de-
To assess the overall noise impact, neurological termined by a special formula (Fletcher). Up to 10%
examination, EEG, rheogram, neuro-vegetic, and binar hearing loss for the 500, 1000, 2000, and 4000
some other specialized studies - gastric functions, Hz frequencies is defined as the initial stage of occu-
cardiovascular indicators are needed. pational auditory neuritis; from 10 to 20% loss - as a
Differential diagnosis. The following disorders mild degree; from 20 to 30% - moderate grade; over

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30% - severe. In case of severe hearing, practical deafness and
D. Dimov (1986) suggests that auditory loss is de- deafness, you should always send a quick notice. F.
fined as the mean value (in dB) of the hearing thresh- 58 to NII and the case to be discussed in the regional
old values ​​of the four main frequencies - 500, 1000, LAMC after a poll.
2000 and 4000 Hz (the field of social hearing). There Prevention. A major preventive task is the re-
are 4 degrees of hearing loss: moval or reduction of noise through sanitary-techni-
1st grade (up to 30 dB), the hearing is socially ade- cal prophylaxis - replacement of noisy machines with
quate. Workers are able to work for noisy production, less noise; technical maintenance of machines; noise
but subject to dynamic monitoring. Audiometry is protection screens and isolation with sound-absorb-
done once a year. Individual prophylaxis is required. ing materials, etc.
The professional nature of the disease is not accept- Personal preventive measures - internal and ex-
ed. ternal antiphones, helmophones are also important.
Grade II is a severe hearing (hearing loss is 30-60 Outdoor recreation helps restore hearing sensi-
dB for a better listening ear): tivity. Relaxation rooms are organized and people
a) At 30-45 dB hearing loss requires labour reha- with progressive hearing loss are brought to silent
bilitation without deterioration of the qualification, work. Proper medical-professional selection - chron-
dynamic monitoring and treatment by an otorhi- ic catarrhalis, adhesions and purulent diseases of the
nolaryngologist. The duration of the rehabilitation ears are contraindicated for working under noise
is individual, depending on the results of the treat- conditions. Contra-indications for work are also neu-
ment; roses, hypertonic disease and other cortico-visceral
b) At hearing loss 45-60 dB has difficult social con- diseases.
tact, limited working capacity for the profession in Periodic medical examinations are once a year,
excess noise or the 3rd group of disability is defined. with the participation of otorhinolaryngologist and
c) Practical deafness (loss of 60-90 dB). These neurologist, and conducting an audiometric study. It
workers are receiving hearing aid or given a third is recommended that diet A of the professional pre-
group of disability for life. At over 90 dB hearing loss ventive diet.
can be worked in noisy production because such Medicinal ototoxins should be prescribed in min-
workers practically have no hearing and do not need imal doses sufficient for therapeutic efficacy. The
prophylaxis. simultaneous administration of various ototoxic
V. E. Ostapkovich and N.I. Ponomarjova (1979) agents should be avoided when this is possible in
also offer similar assessment criteria for hearing order to avoid a synergistic effect.
function (Table 1).

Tab. 1. Criteria for assessing the condition of the hearing function (V.V. Ostapkovic and N.I. Ponomarjova)

Tone threshold audiometry Speech audiometry

Degree of hearing loss
Hearing loss in sound Hearing loss at 50% 100% Adopting
frequencies 500, 1,000 4000 Hz and intelligibility intelligibility whisper
and 2,000 Hz/ a range of possible threshold threshold in m
Rating hearing arithmetical mean in dB deviations in dB in dB in dB

1 2 3 4 5 6
I. Practically normal
1-5 50 + 20 30-35 40-45 6 +1
hearing
II. Initial signs of cochlear
6-10 50 + 20 30-40 45-50 5+1
neuritis
III. Cochlear neuritis with
mild hearing loss 11-12 60 + 20 35-45 50-60 4+1

IV. Cochlear neuritis with

moderate hearing loss 21-30 65 + 20 45-55 60-75 2+1

V. Cochlear neuritis with a

significant degree of 31-45 70 + 20 55-70 75-90 1 + 0.5
hearing loss

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 OCCUPATIONAL MEDICINE
REFERENCES

1. Apostolov Hr., Al. Begov. Occupational diseases of the hearing and vestibular analyzer, and of the up-
per respiratory tract. in. Occupational diseases in otorhinolaryngology, ed. Vl. Pavlov, Sofia, Med. and phys.,
1981, 25-88 and 114-120. (in bul.)
2. Kehayov At., Savov A. Damage to the hearing analyzer and the body from noise. In. Professional pa-
thology, ed. Aleksieva Ts., Kr. Kirijakov, Sofia, Med. and phys., 1982, 156-163. (in bul.)
3. Laurens D. Fechter, Combined Effects of Noise and Chemicals. In: Occupational hearing loss, Philadel-
phia, 1995 Vol. 10, 609-623
4. "Le depistage precoce des maladies professionalles" - Organization mondiale de la sante (Geneve),
1989, 285p.
5. Marsel-Andre Boillat, P. Jacobsen, P. L. Pelmear - The Ear, In: Encyclopaedia of Occupational Health
and Safety, ed. J. M. Stellman, ILO, Geneva, 1998, Vol. I, 11.2 - 11.8.
6. Occupational noiseinduced hearing loss. J. Occup. Med., 31, 1989, No. 12, 996.
7. Ostapkovich B.E., A. B. Brofman. Professional diseases ORL organs, M. Medicine, 1982, 287 p. (in russ.)
8. Rees T., L. Duckert. Hearing loss and other otic disorders. In Tehtbook of Clinical, Occupational and
Environmental Medicine, ed. C. Rosenstock. Philadelphia: WB Saunders, 1994.
9. Riback L.P. Hearing: The Effects of Chemicals, Otolaryngology - Head and Neck Surgery, 1992, 106:
677-686.
10. Savov A. Occupational disabilities (illnesses) of the hearing and vestibular noise analyzer - in. Infra-
sound, ultrasound, noise and vibrations, ed. Tsvetkov D., M. Angelova, Sofia, Med. and phys., 2007, 126-
137. (in bul.)
11. Shishkov A. Audiometry, Sofia, Med. and phys., 1980, 115 p. (in bul.)

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A. Savov

4.7 OCCUPATIONAL DISABILITY

OF THE VESTIBULAR ANALYZER
Occupational disability of the vestibular analyzer The vestibular analyzer is intimately linked to the
occurs when there is a harsh (sudden) or long over- autonomic nervous system (parasympathetic part),
norm impact of: production noise; vibrations; toxic and through the Dither spinal path, the posterior longi-
substances; speed; acceleration; atmospheric pres- tudinal bundle, the reticular formation and other con-
sure (oto-borotraumatism); ionizing, electro-mag- duction systems with the other cranial-brain nerves,
netic, opto-kinetic effects, weightlessness and oth- the anterior horns of the spinal cord, etc. At significant
ers. overthreshold irritants suppression of the muscles
Threatened professions. The main risky produc- (limbs, bulk), digestive system tone, changes in se-
tions and professions with more frequent diseases rum-biochemical equilibrium, enzyme activity, internal
of the vestibular apparatus are: the textile industry, secretion glands, cardiovascular activity, etc., occur.
construction, mining, machine building, logging and Vibration is an adequate irritant to the vestibular
the woodworking industry (work with compressors, analyzer. In production conditions, they are usually ac-
vibrators, electric motors, etc.), agriculture, transport companied by intense noise with a different spectrum,
(aviation workers, truck drivers), caisson workers, aq- of linear or angular accelerations (at general vibrations).
ua-lungers, athletes, toxic industries, work in space. Certain responses of ganglion cells and neuroep-
The vestibular analyzer is first formed in embry- ithelial of of vestibular apparatus, of degenerative -
ogenesis and, in its complexity, close links to the cen- atrophic character have been identified - hyperemia,
tral nervous system and functional properties, differs edema, pycnose, ganglion cell decentralisation of the
sharply from all the cranial brain nerves: it is one of the otolithic apparatus.
main systems that stabilize the position of the center of General vibrations transmit over the endolimph
gravity in the body and make a permanent Control of high-level, supra-threshold accelerations that, as a re-
the locomotor and oculomotor apparatus, which pro- sult of prolonged exposure, cause degenerative-atroph-
vides the complex equilibrium function. ic changes. The pathogenetic basis is the disruption of
The peripheral part of the vestibular analyzer is the vegetative-vascular reflexes at different integration
located in the pyramidal part of the temporal bone. levels in the central nervous system. General neuroveg-
Its receptors are represented by the three semi-circu- etative dystonia causes such transient phenomena as
lar channels located in three mutually perpendicular hypotension - hypertension, bradycardia - tachycar-
planes and the otolithic apparatus made of the sacule dia. At the same time, it also causes microcirculation
and the utricle. The entire system is performed by the disorders in a number of parenchymal organs, as well
endolymph, and in its motion in the result of angular as frequent transient disturbances of the labyrinthial
(recurrent) or rectilinear accelerations, potentials are circulation.
generated in the neurosensory cells of the cupulo-mac- With sudden fluctuations in atmospheric pres-
ular apparatus. sure, various changes occur in the inner ear. They are
Pathogenesis. In the event of adverse professional encountered in the case of caisson workers, underwa-
factors, the vestibular apparatus produces numerous ter sports, researchers at great sea depths, on the sea-
variations in all body functions (somatic and vegeta- shelf, working in aviation, in space. Detonation trauma
tive) due to extensive inter-central nervous connec- is associated with explosive work.
tions with the central nervous system. At caisson disease suffers the sacule. Compression
In t h e vestibula r depa r tment of the labyrinth, and decompression are adequate irritants of the sacule
more significant changes are recorded in the area of​​ receptor apparatus. Under these conditions, hydrops
the antechamber, especially in the sacule, and in the occur in the labyrinth, and decompression can produce
semi-circular canals - in the sagittal and horizontal a gas embolism from the releasing nitrogen.
channels. Clinic. The vestibular apparatus suffers low from
Ultrastructural changes in the receptor cells of the a noise compared to the hearing analyzer. With loud
vestibular analyzer were found - cytoplasmic vacuoli- noise and unadapted more workers, there are phe-
zation, mild changes in preganglionic myelin nerve fib- nomena of dizziness, disturbing balance, difficul-
ers, nuclear lesions. ty in orientation, especially towards the end of the

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working day. These complaints disappear after a rest predominate.
or after an adaptation of the vestibular apparatus. Detonation trauma occurs in rapid, sudden com-
However, with sustained and repetitive noise effects, pression (blast). Typical changes occur in semi-circu-
permanent damage may occur. lar canals and utricle (bleeding, atrophy and degen-
Clinical studies show the individual specificity of eration of the neurosensory epithelium). There are
the respective to nystagmatic responses. With long- three forms of vestibular disorders: peripheral, cen-
term impact, spontaneous nystagmus was observed tral and mixed.
in 20% of cases. The excitability of the vestibular The clinical characteristics are:
analyzer usually decreases, which is manifested by • lack of caloric and rotation stimulation reac-
depression of nystagmus reaction (experimental tions;
post-nystagmus and especially that of caloric stim- • dissociation between a rotation and a caloric
ulation). test (a sign of retrolabyrinthic injury);
More typical clinical manifestations are expressed • positional syndrome (commotio syndrome)
in reduced duration, frequency and speed of the • vegetative reactions;
slow phase of caloric and post rotation nystagmus; • vestibulo-vasomotor reactions - diencepha-
dropping the quick component; asymmetry; occur- lo-vegetative symptoms, decompensation of
rence of dissociated reactions; changes in vestibu- the vestibular-vasomotor mechanisms of the
lar-sensory and vestibulo-vegetative responses; dis- cerebrum.
harmony of reflexes. The vestibular analyzer is harmed in industri-
In vibrational illness, vertigo complains are in al intoxications with lead, arsenic, mercury, silver,
three symptom complexes: phosphorus, manganese, carbon monoxide, carbon
• with a sense of disturbed balance at a differ- dioxide, petrol vapour, benzene, aniline, paint, ace-
ent head position, without objective vestibu- tone, alcohol, nicotine. There are two mechanisms
lar symptoms; of impact. In acute poisoning, toxic substances act
• with instability of the body support; directly on the structures of the inner ear - cell de-
• with a typical labyrinthic dizziness. generation or at blood vessels - hyperaemia, haem-
Objective clinical signs are: orrhage, atherosclerotic changes, etc., which aggra-
• spontaneous nystagmus, positional nystag- vates the trophic of the specialized epithelium.
mus, hyporeflexia (chronic vibrational trau- Disorders are bilateral and at different levels (re-
ma); ceptor, ganglia, lateral-vestibular nucleus, cerebellar
• dissociation between caloric and rotation test vestibular structures, vestibular connections, reticu-
(a sign of high diencephalic damage to vestib- lar midbrain formation, etc.).
ular centers and paths); The clinical picture includes: dizziness, spontane-
• a phenomenon of floating eyeball movements ous nystagmus, bilateral hyporeflexion of the laby-
(after vestibular irritation, in the middle and rinth, or a complete loss of vestibular function (lead),
end of experimental nystagmus); looking paresis (mercury), stem and nuclear damag-
• disturbed nystagmus rhythm (central sign of es (carbon monoxide), damage to the otolithic appa-
vestibular disorder); ratus (aniline).
• falling of the rapid component of the nystag- In acute poisoning, the vestibular crisis appears
mus (a central sign of damage to the vestib- in the background of general intoxication, and in
ular pathways and centers) - an early sign of chronic it is slow, not very pronounced, with tran-
central nervous system damage. sient vertigo, instability, nystagmus.
When combined with noise and vibrations, Methods of research. After taking into account
central vestibular disorder syndrome develops. It the history of vestibular vertigo, disturbed balance,
runs parallel to the cerebral form of a vibratory dis- vestibulo-vegetative and vestibular-somatic re-
ease, and in some cases precedes it. Often, manifes- actions, a full otoneurological study is performed
tations of the otolithic system and combination of which includes:
symptoms of positional disorders are observed. • ORL review;
There are two clinical forms of barotrauma: acute • audiometric investigation - tone threshold,
and chronic. The acute barotrauma is manifested by over-threshold, speech audiometry, objective
a Meniere's-like syndrome (ear noise, reduced hear- audiometry, impedancemetry;
ing, dizziness, nystagmus, harmonic-like statokinetic • study of the most specific symptom - nystag-
deviations, nausea, vomiting, sweating, pallor, col- mus (spontaneous and provoked): with Bartels
lapse). In the chronic form, the hyperreflective re- and Francels glasses, and study of experimen-
sponses to the caloric provocation of the labyrinth, tal nystagmus after vestibular irritations: opto-

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kinetic (opto-kinetic stimulator), thermal (cold tomatology. Workers are able to work, but attention
and warm caloric test), Fitzgerald-Holpick test is needed in certain professions (crane drivers, exca-
rotating, (nystagmography), accelerating vator drivers, truck drivers, etc.).
(with accurate dose of positiveand negative In the subcompensation stage latent nystagmus,
angular accelerations and constant velocities) positional nystagmus, statokinetic and vegetative
tests; disorders are established. Workers are temporarily
• statokinetics (posturography) - Barany's in- incapacitated, to receive compensation.
dex test, Romberg's test, Babinski-Vale's blind A spontaneous nystagmus is found at the decom-
walk, Unterberger's test; pensation stage. Workers are temporarily incapaci-
• precise stabilizing methods. tated for any type of work. Appropriate therapy and
• cranio-corpography (according to Klausen); surveillance at the hospital are carried out.
• static and dynamic stability (static ataxia is With simultaneous impairment of hearing and
investigated with a special platform and sen- vestibular function, the expertise is made complex.
sors for 1 min - 30 s with open and 30 s with If these injuries develop in young workers and for
eyes closed, dynamic disturbances are inves- a relatively short period of time, concomitant occu-
tigated with Unterbergerograma - in angular pational diseases of the nervous system, cochlear
degrees); neuritis with a significant degree of hearing loss and
• study of perceptions of space, time and move- frequent vestibular crises, further work on noise ef-
ment (A. Kehayov); fects is contraindicated. There is a need for retraining
• study of olfactory and taste function. and rational employment (with or without a disabili-
Labour expertise. At the compensation stage ty group for occupational disease).
there is no spontaneous and latent vestibular symp-

REFERENCES

1. Baloh, R. W., V. Honrubia. Clinical Neurophysiology of the Vestibular System. Philadelphia: FA Davis,
1990
2. Beyts, J.P. Vestibular rehabilitation. In Adult Audiology, London, 1987
3. Head, P.W. Vertigo and barotrauma. In Vertigo, ed. M.R. Dix, J.D. Hood, Chichester: Wiley, 1984
4. Ivanov Iv., D. Dimov - Occupational diseases of the vestibular analyzer. in. Occupational diseases in
otorhinolaryngology, ed. Vl. Pavlov, Sofia, Med. and phys., 1981, 95-107. (in bul.)
5. Kehayov At. Vestibular analyzer. in. Otoneurology guide, ed. At. Kehayov, Sofia, Med. and phys., 1982,
90-153. (in bul.)
6. Yardley L. Equillbrium. In: Encyclopaedia of Occupational Health and Safety, ed. J. M. Stellman, ILO,
Geneva, 1998, 4 ed., Vol. I, 11.8-11.10

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OCCUPATIONAL MEDICINE

OCCUPATIONAL DUST DISEASES

OF THE RESPIRATORY SYSTEM
E. Petrova

5.1 PNEUMOCONIOSIS. SILICOSIS

5.1.1. PNEUMOCONIOSIS. GENERAL PART. eral and metallic powders, anthracosis). Pneumoco-
niosis from working in small and medium-sized pri-
The development of biology, molecular medicine, vate enterprises with old or modern technologies,
genetics, electronics and the introduction of new with new dust factors in the working environment
imaging techniques have boosted the pathogenetic is expected in the future. Become more frequent re-
mechanisms of pneumoconiosis. There has been a ports for unknown now variants of pneumoconiosis
growing number of studies aimed at elucidating epi- (pneumoconiosis in dental technicians, pulmonary
demiology, etiopathogenesis, immunology, diagno- dust damages from asbestos substitutes (glass wool,
sis and genetic predisposition for pneumoconiosis. ceramic fibers), pneumoconioses from synthetic
New diagnostic methods and drugs are continually abrasive materials (corundum, carborundum), pneu-
being tested. More important in the clinical aspect moconiosis and other injuries (broncho-obstructive
are the pneumoconiosis, manifested by the growth conditions, lung carcinoma), of metallic powders,
of fibrous tissue in the lungs. Along with the fibrou- pneumoconiosis from solid metals, tonic pneumo-
sogenic effect of the powders, their other effects - ir- coniosis, and others.
ritant, carcinogenic and immunoallergic - are being Pneumoconiosis classifications:
studied more and more widely. From a pathoanatomic point of view, pneumo-
Pneumoconiosis is the accumulation of dust in conioses are:
the lungs and the response of the lung tissue to it. Pneu- • Non-collagenous - accumulation of dust with-
moconiosis is caused by different dusts. out the expansion of collagen (fibrous) tissue
Pneumoconiosis is the most significant occupa- in the lungs (baritosis, stannosis, pure sidero-
tional pulmonary disease in the world and in Bulgar- sis);
ia. They lead to serious health, social and economic • Collagenous-growth of collagen tissue (silico-
consequences for patients, employers and the state. sis, silicatoses, coal pneumoconiosis, mixed
The total number of collagenous pneumoconiosis pneumoconiosis - from mineral and metallic
patients in Bulgaria in 1995 is about 5776, and about powders, etc.);
2000 at the year 2000. The risk of pneumoconiosis • Intermediate with respect to collagen formation
(controls) registered in the silicosis divisions in the in the lungs are pneumoconioses of respirable
country ranges from 11,200 to 23,000. Recently, aluminum powder, different variants of coal
there has been a significant share of hidden morbid- dust and others.
ity and morbidity from pneumoconioses in connec- According to the etiological principle, the
tion with regulatory, economic and organizational pneumoconioses are subdivided into (Table 1):
reasons or insufficient knowledge of this subject by • silicosis (free crystalline silica - quartz, micro-
general practitioners and specialists in the areas of and cryptocrystalline modifications of silica,
internal medicine. A large proportion of pneumoco- high temperature modifications of crystalline
niosis arise or progressive after termination of em- or amorphous silicon dioxide (crystobalite
ployment with powder. The deposited aggressive and tridymite),
dust in the lungs of former workers has long pre- • coal pneumoconiosis - anthracosis (from highly
served its fibrousogenic properties and is the basis carbonated coal with different free crystalline
for the so-called "late forms" of pneumoconiosis silicon dioxide content),
(silicosis, asbestosis, mixed pneumoconioses of min- • silicatoses (from different silicon dioxide linked

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variants, asbestosis - from asbestos fibers, kao- characters. The quantitative evaluation of the small
linosis - from kaoline, talcosis - from talc) irregular (stripped) and small oval (spotted) shad-
• pneumoconioses of mixed powders (mixed min- ows per unit area in the lungs is performed using a
eral powders - talcasbestosis, pneumoconiosis 12-point density scale (expanded, precision version)
in stove builders, pneumoconiosis in stove re- or a 3-degree density scale (brief version, expressed
pairers, etc.) by categories 1-3).
• pneumoconioses of metallic powders (siderosis Clinical roentgenomorphological classification
- pure, iron powder (rare), aluminosis- breath- of pneumoconiosis. It is co-authored by the Johan-
able aluminum powder, pneumoconiosis in nesburg classification of pneumoconiosis and was
electric welders - iron powder, low silicon and adopted at the First Congress of Pneumoconiosis in
irritant gases in welds, corundum pneumoconi- 1930. It was updated in 1956 and was adopted in Bul-
osis - from dust composed of about 95% Al2O3, garia. According to its criteria, nodosal pneumoconi-
connecting clay minerals, minimal amounts oses are subdivided into 3 stages, roughly taking into
of free silica; pneumoconioses of solid metals - account the way the disease progresses (rapidly, slow-
tungsten, cobalt, vanadium, nickel, titanium, ly), the mode of manifestation (acute, chronic, early,
tantalum, chromium and others and berylliosis late form) and the characteristic of the respiratory
- a type of hypersensitive pneumonitis); function (compensated, decompensated). Two pre-
• other pneumoconiosis (apatite, barite, volcanic clinical conditions (Controla "Z" and Controla "L"), tak-
minerals, glass, ceramic fibers, graphite pneu- en from the first version of the 1956 ILO Classification
moconiosis, tonic pneumoconiosis, pneumo- of Pneumoconioses, are also reported in our country.
coniosis in dental technicians). They are rarely
occured or insufficiently studied. 5.1.2. SILICOSIS
Rangening Classification of Pneumoconioses -
ILO Internatinal Classification of Radiographs of Pneu- Studies on ancient Egyptian mummies give rise
moconioses, Geneva-1980 (ILO'80). This classification to the assumption that silicosis has existed since an-
provides a qualitative and quantitative description tiquity. The first descriptions of the disease are from
of the X-ray signs of pneumoconiosis recorded in Agricola (1556), Paracelsus, Ramacini, Straton, Vis-
anterior-frontal conventional pulmonary X-ray, tech- conti, Lomonosov, Collins and others. The term "sil-
nically performed according to the requirements of icosis" was created by Visconti and is borrowed from
the ILO'80 guideline. The qualitative description of the Latin translation of the word silicon - "silex". An
X-ray findings were made with certain alphabetic important moment in the development of the medi-

Tab. 1. Etiological classification of pneumoconiosis

Non-collagenous
Collagen pneumoconiosis pneumoconiosis
Mineral Metal Mixed Other
pneumoconiosis pneumoconiosis pneumoconiosis pneumoconiosis

Silicosis - Aluminosis - Mineral powders: Anthracosis - from

of free crystalline respirable high carbonization
silica (quartz) particulate Talcasbestosis coal with different
aluminium quartz content Clean siderosis Baritosis -
Silicatoses or Al2O3 Silicotalcosis of pure iron pure
- from the linked Apatitosis - from respirable dust powder
silica (silicates) Berylliosis - from Pneumoconiosis apatite powder (relatively rare) barite
beryllium aerosols in stove ripairers (rarely diagnosed) (rare)
Asbestosis
and other Pneumoconiosis
Caolinosis in stove builders and oth.

Talcosis and others. Pneumoconiosis of metal-

containing dusts
(Pneumoconiosis in
electric welders)

Pneumoconiosis of corundum
Pneumoconiosis in dental
technicians and other

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cal field, studying the pneumoconiosis, was the Lyon An etiological factor for the emergence of silicosis
Congress in 1929 and the Johannesburg Conference is the free crystalline silica (quartz). There are three ba-
on Pneumoconiosis (1930), which adopted the first sic forms of free silica: 1. crystalline, 2. micro (crypto-)
clinico-radiomorphologic classification underlying crystalline and 3. amorphous. Quartz is a crystalline
pneumoconiosis diagnostics. form of silicon structured by tetrahedra. The chains of
Silicosis is a fibrous lung disease caused by inha- Si-O-Si are at the base of the crystal structure. Fibrogen-
lation and deposition of free crystalline silica (quartz). ic effects also have high temperature modifications of
Silicosis is one of the most common occupation- crystalline and amorphous silica produced by heating
al pulmonary diseases in the world, especially in the from 870 ° to 1470 ° C and above 1470 ° C (crystobalite
countries of Asia, Africa, Eastern Europe and South and tridimide). Practically important for the develop-
America. According to WHO data, the incidence of ment of pulmonary fibrosis are fine (respirable) silicon
tin mines in Bolivia in 1987 is 7.6%, the mines in Ko- particles with a diameter of 0.5 μm to 5 μm.
rea - 3.5%, the gold mines in Egypt - 43.3%, the lead Risk production processes for silicosis are:
mines in India - 30.4%, mines and metallurgy in Chi- • mining, uranium mining and coal mining in Bul-
na - 3.5% and 5.5%, the ceramic industry in Brazil - garia (extraction of anthracite and black coal);
3.7%, all risky industries in Japan - 17.4%, the stone • transport and hydro-construction and extrac-
and ceramics industries in Thailand - 21% and 9 , 3%, tion of non-ore minerals;
gold, copper and chrome mines in Zimbabwe - 20%. • use of natural abrasive, and grinding materials;
Silicosis is less important for Western Europe and the • sandblasting for various industrial purposes;
United States. Data from the silicosis divisions in Bul- • production and use of refractory materials in
garia for a five-year interval (1985-2000 period) show metallurgy (iron-melting, agglomeration, ore
that the total number of silicosis + silicotuberculosis preparation);
patients ranges from 4566 to 5472 and the endan- • ferro-alloy production, foundries;
gered ones from 11238 to 24011 (Table 2)1. • glass industry, manufacture of porcelain and
Gradually, the cases of silicosis from underground stoneware products and others.
work on dry or dry and water drilling in mines for ex- An important role in the pathogenesis of silicosis

Tab. 2. Total number of silicosis, silico tuberculosis and controls (endangered of silicosis) in Bulgaria - 1985 - 2000 year

Year Average for

Diseases
1985 1990 1995 2000 the period
Total silicosis 4447 4195 3904 3828 4159
Total silicotuberculosis 1025 946 858 738 921
Total silicosis + silicotuberculosis 5472 5141 4762 4566 5081
Total controls 11238 10650 24011 20000 18684

traction of ores, anthracite and black coal in Bulgaria play the following factors:
are exhausted. New cases of silicosis and silicotuber- • size, shape, specific surface of quartz particles,
culosis in the future are expected from underground tendency to agglomeration;
and overground extraction and processing of non- • duration of exposure to dust;
ore minerals, production and use of refractory, fac- • dust concentration in the air of the working en-
ing, grinding materials, mosaics, in glass, ceramic, vironment;
faience, metallurgy, machine building, use of sand • amount of powder and latency in the lungs;
streamers, production and processing of monu- • - individual anatomical features of the lower res-
ments and others. Depending on the specifics of the piratory tract of the exposed;
powder and quartz content, different forms of sili- • possibilities of lymphatic transport and ability of
cosis are expected. Increasingly, there will be cases the mucociliary escalator to self-purify;
of reticular and reticulo-micronodous silicosis from • spent and accompanying pulmonary inflamma-
underground mines developed after a long latency tory processes;
period and prolonged exposure to low concentra- • individual features of the immune system;
tions of free crystalline silica. • genetic predisposition.
Modern perceptions of the pathogenesis of silicosis
1
The undisputed hidden morbidity and illness of silicosis and emphasize the cellular and immune mechanisms of
silicotuberculosis in recent years is due to the incomplete reg-
istration of former workers leaving home, relocation by place of quartz action.
residence, financial, organizational and other reasons of subjec- Key points are:
tive and objective nature.

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• clustering of alveolar, interstitial macrophages, monary inflammatory processes leading to sec-
blood monocytes; ondary collagen formation, and facilitating the
• polymorphonuclear cells, lymphocytes, few eo- faster progression of the silicotic fibrosis process.
sinophils and basophils around the dust parti- Pathomorphology of silicosis. The basic morpho-
cles in the alveoli; logical substrate of silicosis is the silicone node with a
• elimination of a minimal part of them by ab- diameter of 0.3 to 1.5 mm, located initially in the inter-
sorption by macrophages and purification by stitial peribronchialy, paraseptale and sub-pleural.
means of the mucociliary escalator; The silicotic nodes gradually increase and show a
• eliminating part of the respiratory quartz along tendency for conglomeration. In the central zone of the
the lymphatic pathway and transporting to re- silicone node, collagen fibers are formed with a predom-
gional lymph nodes; inantly concentric disposition exhibiting a tendency to
• transporting the respirable quartz particles from the hyalinization. Rarely, collagen fibers are unevenly
the macrophages to the interstitial of the lungs positioned. At the periphery of the nodules are found
where the pathogenetic mechanism is realized macrophages and less - plasmocytes and lymphocytes
at the cellular level; located in close proximity to the central zone. The large
• phagocytosis of the dust particles absorbed by conglomerate nodes are composed of a hyaline-free
the macrophages, covering a portion of them collagen without a distinctly concentric disposition. The
with a protein coat in the first 2-6 hours; presence of centrally located focal necrosis is most com-
• subsequent toxic injury and death of phago- monly associated with granulomatous inflammation,
cytes; tuberculosis or atypical mycobacterial infection. In acute
• lysing the protein coat around the quartz parti- silicosis, the morphological substrate is silicoproteinosis
cles from the released cell enzymes at the death with the presence of macrophages in the lesion and hy-
of the macrophages and taking the particles of perplasia of adjacent pneumocytes of the second type.
new generations of macrophages; There is a variant of low-silica mixed pneumoconiosis
• removal of superoxide radicals (predominant- and a predominant expansion of interstitial fibrosis with
ly O2-, H2O2), interleukin-1 (IL-1), tumor necrosis single nodous elements, taken as mixed silicosis, dif-
factor alpha (TNF-α), leukotrienes from mac- fuse-sclerotic silicosis or mixed mineral pneumoconiosis.
rophages; There are three basic classifications of silicosis -
• activation of T-lymphocytes, unlocking a X-ray, clinical-radiomorphological and classification
cell-mediated immune process, and cytokine re- by passing.
lease of T-lymphocytes - interleukin-2 (IL-2) and Radiographic classification of silicosis - ILO
g-interferon; International Classification of Radiographs of Pneu-
• re-activation of macrophages by IL-2 moconioses, Geneva, 1980 (ILO'80).
• changes in humoral immunity: blocking T-sup- This classification is used for qualitative and quanti-
pressor function of lymphocytes, unlocking an tative description of X-ray findings in pneumoconiosis,
autoimmune process; including for silicosis. With ILO'80, three main groups of
• the supposed adjuvant effect of quartz leading x-ray findings are described:
to an autoimmune process; small irregular (strial) shadows of pulmonary pa-
• fibroblast proliferation and collagen formation; renchyma:
• possible decreased ratio of helper to suppressor • s - small irregular shadows up to 1.5 mm wide.
(Th/Ts) in peripheral blood and pulmonary tis- (Figure 1);
sue, resulting in decreased cell-mediated immu- • t - small irregular shadows with a width of 1.5
nity: increased B-lymphocyte activity, autoanti- to 3 mm;
bodies production; • u - small irregular shadows with a width of
• reduced activity of natural killer cells (NK): re- 3-10 mm;
duced response to mitogens, chronic immuno- • small oval (micronodous, nodous) shadows of
suppression, impaired regulatory mechanisms pulmonary parenchyma;
resulting in pneumoconiosis development; • p - small oval shadows with a diameter of up
• predicted genetic predisposition to silicosis - to 1.5 mm. (Figure 2);
genes close to HLA-B locus; • q - small oval shadows with a diameter of 1.5
• involvement of other genetic mechanisms and mm. To 3 mm. (Figure 3);
role of programmed cell death (apoptosis); • r - small oval shadows with a diameter of 3-10
• impact of frequent inflammatory lesions of ac- mm. (Figure 4).
companying or complicating silicosis chronic There are also intermediate finds for small oval
bronchitis or other non-specific or specific pul- and small uneven shadows (eg p/q, s/t, etc.) as well

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Fig. 4. r - small oval shadows of category 3/3 in all pulmonary

fields - silicosis II stage r type

Fig. 1. s - Small uneven shadows of category 3/3 (control "L") - as mixed finds (p/s, p/t, r/s, t/q).
reticular silicosis Progressive massive fibrosis:
• A-type progressive massive fibrosis (PMF) -
solitary or confluent small oval shadows, oc-
cupying an area of 1 ​​ cm to 5 cm in diameter
(Figure 5);
• B-type PMF, with a diameter of 5 cm to a diam-
eter equal to the upper 1/3 of the right pulmo-
nary field (Figure 6);
• C-type PMF with diameter larger than that of
B-type PMF (Figure 7).
Pleural thickenings (plaques) are labeled with PL
and pleural calcifies with PLc. Their spread is reflect-
ed by numbers (1 to 1/4 of the lateral contour of the
chest wall, 2 - 1/4 to 1/2 and 3 - over 1/2 to the chest
wall), and their thickness - by letters (a - up to 5 mm,
b - 5 mm to 10 mm, c - over 10 mm).
The X-ray density (number of small oval and une-
Fig. 2. p - small oval shadows of category 3/3 in medium pul- quable shadows per unit area) is described using a
monary fields - silicosis I stage three-step density scale, reflected in the categories

Fig. 3. q - small oval shadows of category 3/3 in all pulmonary Fig. 5. Progressive massive fibrosis (PMF) type A - silicosis III of
fields - silicosis II stage q type type A

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• ho - "honey-comb" lungs;
• ih - nosharp outline of the heart contour;
• kl - Kerley's keys;
• od - other pulmonary X-ray findings;
• pi - inter-lobar or mediastinal splicing;
• px - pneumothorax;
• rl - Kaplan's syndrome;
• tba - signs of active pulmonary tuberculosis
and
• tbn - inactive pulmonary tuberculosis and
others.
Clinical-radiomorphological classification.
According to this classification, the pneumoconi-
oses are divided into three manifest clinical stages:
• 1st stage silicosis (Figure 2) - mainly p-spad-
ows from Cat. 2, located bilaterally in middle
Fig. 6. Progressive massive fibrosis (PMF) of type B - silicosis III and partial in lower pulmonary fields to the
stage of type B parietal or unequable shadows with superex-
- category 1 (Cat 1), cat 2 (Cat 2) cat. 3 (CAT 3). There posed p-shadows Cat. 1/1 and enlarged hilus
is also a 12-degree density scale used for precision shadow;
studies (Cat 0 / -, Cat 0/0, Cat 0/1, Cat 1/0, Cat.1 / 1, • Phase II silicosis (Figure 3, Figure 4) - bilateral-
Cat.1 / 2, Cat 2/1, Cat 2/2, Cat 2/3, Cat 3/2, Cat 3/3 and ly scattered across all lung fields to circumfer-
Cat 3+). entially symmetrical small oval shadows pre-
Existing additional X-ray findings from pulmonary dominantly of q- and/ or r-type with medium
parenchyma and pleura are described with certain al- to more pronounced x-ray density category;
phanumeric characters. The most common are: • III silicosis stage (Figure 5, Figure 6, Figure 7)
• ax - clustering of small oval shadows; - presence of bilateral symmetrical shadows
• em - pulmonary emphysema; type "PMF" - A, B or C.
• bu - emphysema bulls; There are two preclinical states:
• ca - lung cancer; Control "Z" - powder exposing former or current
• cn - small shadows with calcium density in the workers without visible X-ray changes in pulmonary
pulmonary parenchyma; parenchyma and
• co - changes in the configuration of the cardi- Control "L" - dust exposed individuals with min-
ac shadow; imal uneven shadows in middle and lower pulmo-
• cp - pulmonary heart; nary fields and enlarged hilus shadows.
• cv - cavity shadow (cavern); Classification of silicosis by passing:
• es - increased hilus shadows with circumferen- Acute silicosis. It occurs in massive quartz ex-
tial or full calcifies-type "egg shells" (Figure 7); position (sandblasting, milling, manual preparation
• fr - fracture of a rib; and use of quartz for various purposes, guniting,
massive dust impact on dry drilling in underground
mines). It runs progressively and quickly.
Chronic silicosis. It occurs with prolonged dust
exposure to relatively low quartz powders or a short-
term massive quartz exposure in the past. This is the
most common form of silicosis in recent decades. It
is divided into:
• Reticulo-micronodose form of silicosis (silicosis I
stage in clinico-radiomorphological classifica-
tion);
• Nodose form (silicosis II stage - according to
clinico-radiomorphological classification);
• Silicosis type of progressive massive fibrosis (sil-
icosis III stage - clinicall-radiomorphological
Fig. 7. Progressive massive fibrosis (PMF) of C type - silicosis III classification);
stage C type • Diffusion-sclerotic forms of silicosis (diffuse

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growth of fibrous tissue in the lungs with- In uncomplicated conventional reticulo-microno-
out clear formation of nodes and tumorous dose, micronodose and nodous forms of silicosis, the
masses, with a vague distinction from the sur- symptoms are:
rounding parenchyma); • easy fatigue;
• Late forms of silicosis. Occur after 5 years or • periodic tightness in the chest;
more of dust-free period - from quenching • lack of air.
quartz exposure. They still prevail among the In complicated conventional chronic silicosis
newly discovered cases of silicosis but have (PMF) with/without accompanying chronic pulmo-
significantly decreased due to the depletion nary or heart disease:
of the reservoir of former underground min- • shortness of breath;
ers who have worked in dry or dry and water • easy fatigue;
drilling of blast holes; • breasts in the chest;
• Mixed mineral pneumoconioses of quartz-con- • coughing
taining powders are equivalent to the term "mixed • sputa
silicosis" of some Bulgarian authors. They are In late forms of chronic silicosis (occurring 5 years
caused by powders with a low quartz content and more after the discountinuation of dust exposure),
(up to 2%) and the addition of other minerals to the more pronounced subjective pulmonary symp-
the dust from the working environment; toms are due to longer smoking and long-term use
• Kaplan syndrome (a combination of silicosis, of alcohol:
predominantly anthracosylicosis with rheuma- • cough;
toid arthritis). In some cases, arthritis may be • sputa;
pre-existing. Radiologically, it is manifested • breasts in the chest;
with large node shadows (with a diameter of • easy fatigue;
more than 1 cm) scattered across all the lung • shortness of breath.
fields bilaterally. It resembles collagenosis. Haemopthoae is a rare symptom of pure silicosis. It
Progressing fast. is usually seen with silicosis complicated by bronchi-
Clinical picture of uncomplicated and compli- ectasis, silicotuberculosis, accompanying lung carci-
cated silicosis noma, thromboembolism.
Clinical subjective pulmonary symptoms and Silicotuberculosis. The subjective clinical symp-
physical pulmonary phenomena in silicosis are un- toms in late and conventional forms of silicotuber-
specific and are determined by: culosis resemble those of silicosis (but in an active
• type of disease (acute silicosis, chronic silicosis tuberculosis process, additional intoxication events are
and chronic late forms of silicosis) by the de- identified):
gree of pulmonary fibrosis; • weakness;
• from existing complications with specific and • anorexia;
non-specific chronic pulmonary inflammatory • weight loss;
diseases; • very easy fatigue;
• the age of the patients (more pronounced in • subfebrility;
late forms of silicosis); • intermittent elevation of temperature;
• the smoking and alcohol use factors; • sweating;
• the incidence of inflammatory lesions of the • flu-like symptoms;
accompanying silicosis of chronic bronchitis. • upper dyspeptic, less common - lower dys-
* More severe clinical symptoms, more pro- peptic syndrome and other symptoms typical
nounced physical pulmonary phenomena and func- of the tuberculosis process.
tional respiratory disturbances are detected in the Physical phenomena in chronic silicosis
so-called "diffuso-sclerotic" forms of silicosis. Uncomplexed conventional chronic silicosis at the
Acute silicosis initial stage lacks physical pulmonary abnormalities
Subjectively acute silicosis is manifested by pro- or they are scarce.
nounced dyspnea, cough, rapid progressive respira- Late forms of silicosis are usually accompanied
tory and heart failure. It has been lethal for two or by a number of complications or accompanying
three years. Clinical pulmonary symptoms predom- illnesses due to the older age of the patients (over
inate X-rays manifestation. Radiographically base 50 years). Physical pulmonary findings are richer and
located, X-ray shadows, passing briefly into cloud more diverse than conventional chronic silicosis.
infiltrates. Higher hilus shadows are found. There are:
Chronic Silicosis • emphysematously altered chest;

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• Sonorous percussion tone; cific and specific inflammatory processes.
• Weak vesicular breathing Late chronic silicosis shows more frequent mani-
• Exacerbate vesicular breathing with accompa- festations of respiratory failure at the time of disease
nying crepitations. detection.
• Dynamics of the silicotic process in chronic In case of conventional chronic silicosis, beginning
silicosis. In late forms of silicosis, the transi- at the time of dust exposure, there is a faster progres-
tion from silicosis to silicotuberculosis is short- sion of respiratory failure over time. This is due to
er and more pronounced. younger age at a more pronounced reactivity of the
Complications of chronic silicosis body and a higher quartz depot in the lungs.
• chronic bronchitis; Our studies of changes in blood pressure (PaO2,
• pulmonary emphysema; PaC02, O2Sat, BE) indicate that they are not particu-
• complication with tuberculosis (silicotubercu- larly informative for assessing respiratory function in
losis); uncomplicated silicosis.
• complications with atypical mycobacterial in- The study of the ventilation index for microno-
fections; dose, nodose silicosis and progressive massive fibro-
• complications with mycotic infections (most sis (silicosis III stage) showed statistically significant
commonly aspergillosis in immunocompro- changes in PEF and FEF 50% in reticular silicosis and
mised individuals); in the group of micronodose, nodous silicosis and
• restricted pulmonary fibrotic areas outside of progressive massive fibrosis (PMF) - more expressed
silicotic fibrosis; in the second group. There was a decrease in FEV1,
• secondary bronchiectasis; PEF and FEF50%, age-dependent and decrease in
• bullous emphysema; FEV1 as the duration of powder exposure increased.
• frequent pneumonic processes; Our studies of pulmonary perfusion changes
• pleural adhesions; in various forms of silicosis (performed with 99MTe)
• pleurisy (in active silicotuberculosis); showed an insignificant predominance of pulmo-
• rarely - partial pneumothorax due to existing nary perfusion disorders in cases of progressive mas-
pleural adhesions; sive fibrosis (100%) and significant perfusion distur-
• chronic respiratory failure; - chronic cor pul-
monale;
• right heart failure.
Most common combinations of chronic silicosis
with other pulmonary and extra-lung diseases:
• with lung carcinoma (predominantly the caus-
al relationship between quartz dust exposure
and silicosis, and lung carcinoma);
• with rheumatoid arthritis - Kaplan's syndrome;
• with scleroderma;
• with systemic lupus erythematosus and der-
matomyositis.
Functional characteristics of silicosis
Most authors consider silicosis to have minimal
functional deviations in its discovery. With the onset
of progressive massive fibrosis, progressive deepen- Fig. 8. HRCT of the lungs in the silicosis I stage, reticulum-mi-
cronodose form - small-spotted shadows (p-type) of category
ing of respiratory failure occurs in a long delay in the 2/2, located dorsally
occurrence of hypoxic manifestations and in the ab-
sence of hypercapnia (the occurrence of hypercap- bances in accompanying silicosis chronic bronchitis,
nia is recorded in terminal stages of the disease). pulmonary emphysema, pneumosclerosis, CPI-I de-
Chronic late forms of silicosis show a predominant- gree CPI-I-II dg. and CPI-II degree.
ly restrictive, mixed, and rarely - obstructive respira- It is considered that pulmonary high-resolution
tory deficiency at the time of detection, and conven- computer tomography (HRCT) to allow for a more
tional chronic silicosis is manifested by a restrictive objective assessment of pulmonary X-ray changes,
and obstructive ventilator defect. Ventilation chang- as well as better correlated with functional ventilator
es in late forms of silicosis are also associated with a changes than conventional pulmonary X-ray (Figure
number of additional factors such as age, smoking, 8).
passing or accompanying silicosis, chronic non-spe- Diagnostic methods for silicosis

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• Powder-hygienic assessment of air in the work- Echocardiography, thoracoscopy, thoracotomy,
ing environment (sufficiently long-term work fibrobronoscopy with BAL, trans-bronchial pulmo-
exposure to excess free crystalline silicon di- nary biopsy (TBPB), transthoracal aspiration biopsy
oxide). (TTAB), pleural biopsy (PB) and cytological, histolog-
• Subjective pulmonary symptoms, even mini- ical, mineralogical, bacteriological and, other studies
mal, and physical pulmonary phenomena in of materials from invasive techniques.
quartz exposed workers are a signal to search • Study of cardiovascular system for complica-
for silicosis. tions with cor pulmonale, as well as accompa-
Silicosis-suspective cases are directed to diagno- nying other cardiovascular diseases.
sis for specialized clinics. X-ray diagnostic criteria for silicosis:
• The X-ray method is essential in the diagnosis of • Control Z - powder exposed individuals with-
silicosis. Conventional pulmonary radiography out significant X-ray traces
with special technical requirements and read- • Control L - powder exposed persons with s-, t-,
ing according to the criteria of the ILO Interna- s/t - uneven shadows of Cat. 1/0 to Cat. 3/3 +,
tional Classification of Radiographs of Pneu- sometimes - small oval p-type shadows from
moconioses, 1980, is performed. The quality Cat. 0/1 and Cat. 1/0, often - enlarged hilus
of two-sided anterior-front tomograms (9, 11 shadows (hi).
cm) for the visualization of uneven, oval shad- 1. Silicosis I stage - reticulo-micronodose form - un-
ows or shadows of the "progressive massive even shades of s-, t-or s/t - type of Cat. 2/1 to Cat. 3/3
fibrosis" type. +, with superposed p-small oval shadows of Cat. 1/1
• Additional imaging methods are: and upwards, disposed symmetrically to partial in
1) computer tomography (CT) and medial, partial - lower or partial - sub - clavicles, en-
2) high resolution computer tomography (HRCT) larged, deformed, non - uniform hilus shadows (hi);
of the lungs. They are recommended for difficult di- 2. Silicosis I Stage micronodose form - small oval
agnosis cases. shadows of p-type Cat. 2/2 and upward in middle,
• Functional breath test system for silicosis: partial - lower or partial subclavicles areas, located
1) breath ventilation, capacity and flow ventila- on both sides, enlarged and deformed hilus shad-
tion-vital capacity (VC), forced vital capacity (FVC), ows (hi), peripheral emphysema, sometimes light
Tifno index (VC/FEV1), extreme expiratory debit basal or subcluvicle emphysema (em).
(PEF), debits (FEF25%, FEF50%, FEF75% of the FVC curve) 3. Silicosis II stage, nodose form - q-, r- or a com-
in order to specify the type and degree of ventilator bination of both sometimes - with the presence of
disturbances p-shadows scattered across all lung fields at the
2) diffusion capacity study (DLco) and its mem- usual X-ray oval shadow density - Cat. 2/1 and up-
brane component (Dm) to determine the amount of wards, presence of less pronounced irregularities
disturbed diffusion of gases through the alveolar- (s-, t- shadows), enlarged and deformed hilus (hi),
capillary membrane; periphocal emphysema, basal and sometimes su-
3) airway resistance study (Raw); and preme sub-clavicle emphysema (em) and/or bullous
4) blood gases and alkaline - acid samples in arteri- emphysema (bu).
al blood (Ph, PaO2, PaCO2, BE, O2 Sat). 4. Silicosis III Stage - type progressive massive fibro-
• Other paraclinical diagnostic methods are: sis (PMF) or tumorous silicosis - bilateral symmetrical
BSR; haematological; biochemical indicators; bacte- shadows of A, B, C - type, pulmonary emphysema
rial studies of sputum, broncho-alveolar lavage (BAL), (em), distorted and extracted mediastinal shadow
pus from a focal point taken by a transthoracic biopsy, and trachea (di), often adhesions in bone-diaphrag-
hemocultures (for aerobic / anaerobic bacterial flora, matic (PL), presence of bullous emphysema (bu),
Mycobacterium tuberculosae, atypical mycobacteria, transverse diaphragmatic domes, presence of other
some mycotic bacteria, etc.) - via direct bacteriosco- additional X-rays, depending on the working dust
py, seeding culture, by Bactec technique; skin test for exposure or other pulmonary lesions added, often
atypical mycobacteria; adenosine deaminase (ADA) for enlarged right heart contours (cp). In case of doubt
a silicotuberculosis susceptibility; immunological tests about the addition of another process, in case of differ-
(Manthoux 5 TE, ELISA - for testing of antibodies to tu- entiation with another pulmonary disease, in reticulo-
berculous mycobacteria in serum, BAL and others, blast mic ronodose silicosis, for early diagnosis of borderline
transformation test, PCR - test - testing of anti-DNA an- p 0/1, p1/0 forms of silicosis, the HRCT of the lungs is a
tibodies against tuberculosis mycobacteria, serological much more informative imaging than the convention-
tests for mycosis, HIV and other microorganisms ). al pulmonary X-ray.
• Additional instrumental techniques: Silicotuberculosis is characterized by the follow-

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ing basic X-ray traits: 3) round croup pneumonia;
1) unilateral (asymmetric) changes; 4) pulmonary gangrene;
2) added soft-foci infiltrative shadows; 5) round viral pneumonia;
3) binding of the infiltrative shadowing with the 6) tuberculosis;
upper pole of the hilus to the affected side; 7) silicotuberculome;
4) retraction of the affected thoratic half; 8) lung echinococcus;
5) cavity shadows located rearward; 9) gum-infiltrative (pulmonary form of syphilis III
6) the cavity shadow is often without drainage stage);
bronchus; 10) lung abscess (filled);
7) pleural adhesions with blocking of the dia- 11) pulmonary aspergilloma filling a residual pul-
phragm on the affected side; monary cavity;
8) tentative drawing of the diaphragm domes on 12) filled-in solitary pulmonary cyst;
the affected side; 13) rheumatoid lung and others.
9) metatuberculosis calcium outbreaks from a tu- Medication treatment for silicosis includes:
berculosis process; Protective treatment of silicosis to delay or prevent
10) interlace of X-ray signs in a mixed silicotuber- the onset of silicosis. Prophylaxis has been done
culous process (silicosis III stage with fibrous-cav- with:
ernosal and caseous tuberculosis with / without cav- 1) Aluminum citrate inhalation, performing
ity shadow). BAL in healthy dust exposed workers (to eliminate
Differential diagnosis of silicosis. Good infor- quartz, inflammatory cells and cytokines leading to
mation on dust production is required. collagenation).
Differential diagnosis of clinical disease is per- Primary etiopathogenesis (antifibrous) treatment
formed with all inflammatory and non-inflammatory (to stop the progression of the disease). The follow-
lung diseases. ing preparations were used:
Differential diagnosis in x-ray is roughly divided In Asia (mostly China), hundreds of herbal and
into: herbal preparations based on the alkaloid bis-ben-
Differential diagnosis with all diseases occurring zylisoquinoline (tetrandrin, cepharan, varbamine)
with small oval spots: have been tested, the effect of which is associat-
1. Other pneumoconiosis variants (coal pneumo- ed with stopping fibrosis progression but not fully
coniosis, kaolinose, talcose, mixed pneumoconiosis, proved.
pneumoconiosis of metallic and metallic powders According to experiments in Europe (1997), bis-
and other benzylisoquinoline has a cytotoxic and immuno-
2. hypersensitivity pneumonitis suppressive effect on macrophages, so its use is not
3. pPulmonitis recommended.
4. pulmonary tuberculosis In the early 1970s, anti-malarial preparations
5. subacute and chronic haematogenous dissem- based on quinol-piperazine and quinol-piperazine-
inated pulmonary tuberculosis hydro­xyphosphate showed inhibition of fibroblasts-
6. sarcoidosis treatment used in China and in our country. No data
7. disseminated septic pneumonia are currently available on the use of these prepara-
8. disseminated pulmonary Metastases tions for this purpose.
9. idiopathic pulmonary fibrosis - Hamman-Rich The most used in the world until recently was the
syndrome preparation polyvinyl-2-pyridine-nitrogen oxide (in
10. pulmonary proteinase parenteral and inhaled form - Kexipink). Its effect is
11. primary and secondary pulmonary haemosi- associated with blockage of superoxide groups on
derosis the surface of quartz particles. Less known are the
12. histocytosis Chinese preparation Xifukain and the Russian bacte-
13. all disseminated forms of lung mycosis etc. rial anti-inflammatory agent Terilidin.
Differential X-ray diagnosis in progressive mas- The antioxidants (Prednisolone, Glutathione,
sive Fibrosis (PMF from A, B and C-type): N-acetylcysteine, Vitamin E, combination of Predniso-
1) other pneumoconioses with PMF (PMF coal co- lone, Vitamin E, Heparin; Vitamin E and Zinc combi-
agulation, kaolinose, other mixed mineral pneumo- nation) have been tested in humans and in animals,
coniosis); and have shown neutralizing effects on elevated
2) peripheral lung carcinoma and other be- lipid peroxidation, characterized with the overpro-
nign pulmonary neoplasms (adenoma, neurinoma, duction of superoxide radicals, playing an important
hamartoma); role in the formation of collagen and the pulmonary

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fibrosis. Bulgarian zinc aspartate Oxyrich stops the 6) In cardiac decompensation - eventual adminis-
progression of pulmonary fibrosis in primary forms tration of cardiotonics and diuretics
of silicosis due to antioxidant and immunomodulat- 7) Of COPD and arterial hypertension, to exclude
ing effect. any use of β-blockers from the treatment regimen of
Recent research has focused on direct mecha- silicotic patients with bronchial obstruction.
nisms of pulmonary fibrosis formation by: The peculiarities of the silicotuberculosis process
1) substances directed against growth hormones; require precision with regard to the duration of
2) cytokines; and treatment (at least 8 months), the tuberculostatic
3) antioxidants. combinations (better - quadruple) and their mode of
Secondary pathogenetic treatment focuses on administration (daily). There is a real danger of the
already formed pathogenetic mechanisms of ad- presence of resistant tuberculous mycobacteria and
vanced silicosis and its complications. ineffective de-bacillation.
Scheme for the treatment of an inflammatory le- The non-medication treatment includes:
sion of accompanying silicosis chronic bronchitis: 1) general strengthening motional and diet reg-
1) Antibacterial treatment of the added bacterial imen
infection. 2) use of food rich in vitamins and antioxidants
2) Bronchodilator treatment, including xanthine 3) prevention of inflammatory impulses through
derivatives, beta-agonists, atropine derivatives, sanatorial- and climatotherapy
combined preparations. 4) physical therapy
3) Corticosteroid treatment - in case of impossi- 5) respiratory rehabilitation.
bility of disobstruction with bronchodilators. Prognosis. For the progression of the disease is
4) Mucolytics - N-Acetylcysteine, Ambroxol, inha- bad. Mortality is higher than that of the general pop-
lations (heat-wet with NaCl, NaHCO3). ulation.
5) General stranght givings and vitamins. Prophylaxis of silicosis includes:
Treatment at exacerbated chronic respiratory Primary sanitary-technical prophylaxis consisting
deficiency in silicosis-sheme: of: effective ventilation, wet boring, personal protec-
1) All previous stages of bronchitis treatment tive equipment, dustless technologies.
2) Oxygen therapy (PaO2 below 50 mm Hg) Medical prophylaxis includes:
3) Heparin prophylactically - 10,000 IU s.c. In the 1) Preliminary and periodic medical examinations
abdominal wall (for the protection of pulmonary of exposed workers at a certain interval.
thromboembolism) 2) Do not allow people with chronic pulmonary
4) Antiaggregants - Aspirin, Antistenocardin and cardiovascular diseases to work with dust. Diet B
5) In high hematocrit (over 60%) - blood letting is recommended - professional protective nutrition.
and saline substitution

REFERENCES

1. Burilkov T., Dobreva M., Dyubrilova S. Mineral powders in the working environment. S., Med. and
phys., 1983. (in bul.)
2. Burilkov T. Professional lung diseases. S., Med. and phys., 1990 (in bul.)
3. Control of Pneumoconiosis (Prevention, Early Diagnosis and Treatment). WHO (1990) OCH / 1.
4. Crystaline Silica. Quartz, IRCS, The Concise International Chemical Assessment Document No 24, WHO,
Geneva, 2000, p. 50.
5. Fraser S.R., Pare-Peter J.A., Fraser J.R., Pare P.D. Pleuropulmonary disease. 1994.
6. ILO International Radiological Classification of Radiographs of Pneumoconioses, Geneva Guidelines,
1980
7. Katznelsson B.A., Alexeyeva O.G., Privalova L.I., Polzik E.V. Pneumoconioses: pathogenesis and
biological prevention. Ekaterinburg, 140-159, 1995. (in russ.)
8. Lesage M. ILO International Classification of Radiographs of Pneumoconioses. In: Encyclopedia of Oc-
cupational Health and Safety, ed. J.M. Stellman, ILO, Geneva, 4 ed., Vol. I, Chapter 10, 10.33-10.38. 1998.
9. Masamitsu K., Tuhru T. Pulmonary fibrosis due to Inhaled Inorganic Dusts In: Basic and Clinical As-
pects of Pulmonary Fibrosis, Part II, Chapter 28, 389-403, CRC Press. USA. 1994
10. Oksa P., Suoranta H., Koskinen H., Zitting A., Nordman H. High resolution computed tomography
in the early detection of asbestosis. Int Arch Occup Environ Health 65 (5): 299-304, 1994

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11. Olivetti L., Grazioli L., Milanesio L. et al. Anatomic-radiological definition of minimal interstitial sil-
icosis is a contributory diagnosis of computed tomography with another risolution. Radiol Med 85 (5): 600-
605, 1993
12. Parker E.J., Wagner R.G. Silicosis. In: Encyclopedia of Occupational Health and Safety, ed. J.M. Stell-
man, ILO, 4 ed., Vol. I, Chapter 10, 10.43-10.46, 1998
13. Petrov A. (1981) Pneumoconiosis in: Chronic respiratory failure. ed. B. Pavlov and B. Tsanev. S. Med.
and phys., 179-183, 1981. (in bul.)
14. Petrova E., Silica and silicotuberculosis. Med. and phys., S., 1993 (in bul.)
15. Petrova E., Delchev G. Roentgenological, radiological and ultrasound methods. S: Guide of hygiene
and occupational diseases, ed. D. Tsvetkov, Med. and phys., 229-234, 1994 (in bul.)
16. Petrova E. (1999) Professional pulmonary diseases. in: Treatment of pulmonary diseases. ed. P. Do-
brev, Med. and phys., 319-326, 1999. (in bul.)
17. Petrova E., Petkov D., Choshkov D., Nachev Ch. On the Diagnostic Value of the Conventional X-ray
Study of the Lung with High Resolution Computed Tomography (HRCT), Isotope Perfusion Scintigraphy and
Disturbances in the Diffusion Capacity of Patients with Pneumoconioses. Int. J. of Occ. And Env. Health, 8 (3):
231-238, 1995
18. Zlatanov Zl. Diseases due to inhalation of powder factors in: Clinical Pneumology S., Med. and phys.,
315-325. 1987 (in bul.)

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T. Burilkov, Kr. Dinkova

5.2 SILICOTUBERCULOSIS

Tuberculosis is the most common complication cirrhotic constriction with mediastinum, trachea or
of silicosis. In 1970, over 20% of patients with pneu- diaphragm adduct.
moconiosis in Bulgaria were with silicotuberculosis An important role is played by the repeated study
and their lethality was 7.2% versus 1.8% for patients of sputum for tuberculosis bacteria. When finding
with pure silicosis and 0.8% for persons with other mycobacteria in sputum-without cavern, a lymfo-
occupational pulmonary diseases. By improving bronchial fistula is sought from reactivated old tu-
working conditions in the mines and controlling the berculosis outbreaks in the hilus lymph nodes.
tuberculosis epidemic, the incidence of silicotuber- The presence of accelerated BSR, moderate leu-
culosis is significantly reduced. Today, we observe it cocytosis, or monocyte and tuberculin hyperergasia
in inspected, tuberculin-positive individuals over 50 helps diagnose. The blast transformation of lympho-
years with advanced silicosis. Except for acute silico- cytes after provocation with tuberculin can be ben-
sis, this complication is more frequent in contact with eficial.
tuberculosis bacilli excreters, under the influence of Diagnosis. It builds complex on the above signs
adverse factors (alcoholism, diabetes, malnutrition). and includes cases where there is no possibility of
It is ethiopathologically proven that the silicotic differentiating the two components. Then we talk
tissue in the lung predisposes to the development about a mixed form of silicotuberculosis and refine
of tuberculosis. In a significant number of cases, sil- the phase of the tubercular component - degrada-
icotuberculosis begins as a mixed process or is ap- tion, infiltration or consolidation without signs of
plied to reactivated old tuberculosis outbreaks. The activity. When differentiated after diagnosis, we de-
two ingredients are difficult to distinguish not only scribe in brackets the ingredients, e.g. Silicotubercu-
from the dissecting table, but also histologically. losis (second stage silicosis, infiltrative-pneumonic
Clinical picture. The initial stage is usually un- tuberculosis 1 k/0 in decomposition phase, BK /+/).
characteristic, with scarce symptoms - complaints Differential diagnosis of silicosis and silicotu-
of easy fatigue, increased tiredness, subfebrile tem- berculosis is difficult. In advanced silicosis, emphy-
perature, productive cough, or bleeding, shortness sema bulls around and in the fibrous areas are often
of breath. These complaints are generally attributed accepted for caverns, despite their characteristic fea-
to the established silicosis. In the case of poor pro- tures - thin walls, plurality, lack of draining bronchus,
fessional history, the opposite is observed - the late wall infiltration, or fluid level.
forms of silicosis found in prophylactic X-ray exami- Treatment. With modern anti-tuberculosis
nations of former miners are being treated for tuber- agents it is promising but harder and longer than
culosis. Mixed forms of silicotuberculosis often pro- that of pure tuberculosis. Operative treatment of
duce characteristic clinical manifestations only after resistant cases requires assessment of respiratory
cavern formation. function not only now but also in the future in view
Paraclinical examinations. X-ray diagnosis is es- of the expected evolution of silicosis.
sential for the diagnosis because clinical manifesta- Labour expertise. In the period of long-term sta-
tions may be missing or covered with silicosis. Any tionary treatment and saturated chemotherapy in
violation of the symmetry, distribution, and uniform- the home, the patients are incapacitated. After stabi-
ity of the silicone nodes in both chest halves makes lization of the process, due to an increased tendency
it necessary to think of overstated tuberculosis. It is to relapse and limited recovery, the patients remain
characterized by apico- caudal development, where- under observation in a second dispensary group and
as silicosis begins symmetrically in the mid-lateral are recruited for 5 years. In determining the disabil-
lung fields. The unilateral fusion of blurred shadows ity group, the incidence and severity of tuberculous
in conglomerates with narrowly defined borders and silicotic changes, the effect of treatment and the
and their association with the hilus with a lymphatic degree of functional impairment are taken into ac-
pathway is highly questionable for silicotuberculosis. count.
Also associated with this disease are parietal pleural Prevention. It is done above all by observing
adhesions, poor bullous emphysema, presence of hygiene standards for air pollution, elimination of
cavity shadows with draining bronchus, tendency to people with inactive tuberculosis outbreaks in the

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professional selection and effective treatment of in- patients, especially in the presence of risk factors or
fectious forms of tuberculosis. An important role is a lowering of the standard of living.
played by chemoprophylaxis with HICK in silicosis

REFERENCES

1. Burilkov, T. Characteristic of the manifestation and development of the silicotuberculosis in Bulgaria.

Occupational diseases. Haskovo, 1973. (in bul.)
2. Burilkov T. Professional pulmonary diseases. S., 1990, Med. and phys., 69-71. (in bul.)
3. Griefahn B. Arbeitenmedizin, Stuttgart, 1992, 165.
4. Parker J.E., G.R. Wagner, Silicosis. In the Encyclopedia of Occupational Health and Safety ed. J.M.
Stellman Vol.1.10.44-10.46 Geneva, 4th ed. ILO, 1998

T. Burilkov, Kr. Dinkova

5.3 ASBESTOSIS

The term "asbestos" encompasses a large group • pleural plaques;

of hydrated needle-like silicates with a common • asbestos exudative pleurisy;
property to decompose into fine and relatively flex- • lung cancer in asbestosis or after exposure to
ible fibers. Industrial application finds the chrysotile asbestos;
serpentine (approximately 90%) and the crocidolite • mesothelioma of the serosal envelopes - pleu-
amphibians ("blue" asbestos), amosite and the pro- ra or peritoneum;
duced in our country anthophyllite and tremolite. • asbestos warts type "foreign body" of needles
The application of asbestos in the industry is deter- in the skin.
mined by the valuable combination of thermo-, noisy-
and electro-insulating properties. PULMONARY ASBESTOSE
The main exposed groups are workers from the Pathogenesis. The rate of precipitation of needle
asbestos-textile and asbestos-cement industry, insu- particles in air is proportional to the square of their
lators, shipbuilders, furnace repairers and individual diameter until their length is of no importance (nee-
workplaces in the plastics, chemical and automotive dles of 30 μm or more may reach the alveoli, whereas
industries. for isometric silica particles it is less than 5 μm). The
Currently, asbestos (carcinogen IARC group I) in needles hardly change their direction in the bronchi-
a number of products is replaced by less dangerous al airflow - they are deposited mainly in the pulmo-
synthetic glass and ceramic asbestos needles or oth- nary base, and less in the upper parts. Fibrosis is the
er materials. Since 1980, world asbestos production result of both mechanical irritation and phagocytic
has declined steadily, as well as its use in Europe and damage with subsequent enzymatic activation of
North America, but has been growing in Africa, Asia fibroblasts and the onset of autoimmune processes.
and South America (a cheap material for construction, Pathological anatomy. Pulmonary asbestosis
water and sewerage supply). The world's largest pro- begins as an alveolite characterized by the accu-
ducers of asbestos are Russia, Canada and South Africa mulation of macrophages, asbestos needles, and
(in 1976, world production of asbestos was 5.7 million so-called. "Asbestos bodies". These are elongated
tons, in 1986 - 4 million tons and continued to decline).* formations of central mineral fiber and a segment-
Asbestos minerals cause a variety specific patho- ed protein envelope with a positive color reaction
logical effects on humans: for iron. Asbestos bodies are not evidence of disease
• pulmonary asbestosis; but are pathognomonic for contact with asbestos.
Over time, the alveolite finds its way into diffuse fi-
* In Bulgaria and in several neighboring Balkan countries there
brosis with predominantly basal localization.
are asbestos fields of industrial importance, which determine Clinical picture. The earliest symptom is dysp-
the so-called endemic asbestosis in farm workers, manifested nea in physical effort. A typical physical finding is the
by the formation of hyaline and calcified pleural plaques. In the
eastern regions of Bulgaria and Belasitsa, over 1200 cases have crackling wheals in the lungs, combined with cyano-
been reported. sis and drum fingers. From this triad the most com-

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mon are the cracklings, referred to as "sclerophonia". disorder, unless combined with pulmonary fibrosis.
Clinical picture. In case of doubt about asbesto- In the endemic regions in Bulgaria, 123 cases of
sis, according to an accepted international standard, pleural asbestos plaque have been identified (Buri-
the X-ray examination includes an overview of the lkov, T. 1983).
thorax and a I-profile with an angle of 45° instead of
the usual 60°. Strial fibrosis is present mainly in the ASBESTOS TUMORS
bases, sometimes accompanied by pleural plaques. Asbestos causes two different groups of tumors
Testing of ventilator function displays discrete dis- with different pathogenesis. Asbestos lung cancer is
tortions of a restrictive type that are increasing over associated with pulmonary fibrosis. For this reason,
time. Unlike silicosis, functional respiratory distur- its localization is predominantly in the foundations,
bances in pulmonary asbestosis outstrip the appear- but and multiple outbreaks of malignant degenera-
ance of an X-ray finding. Exploration of the phlegm tion are not rare. Smoking stimulates tumor risk. The
gives a characteristic finding - "asbestos bodies" and disease occurs after a latency period of over 20 years
needles, also hemosiderin. Broncho- and the scin- from the onset of asbestos exposure. The clinical find-
tigraphic findings in the bases show bronchial or ing is not specific except the combination of pulmo-
vascular branching in the form of "broom" and thus nary asbestosis and tumor. The basis for prophylaxis
confirm the presence of basal fibrosis. of this tumor is the prevention of pulmonary asbes-
tosis by observing hygienic requirements. In the en-
ASBESTOS PLEURAL PLATES demic regions of Bulgaria in exposed individuals with
Pathogenesis. Asbestos needles penetrate the pleural plaques, but without or with minimal pulmo-
lung into the pleural cavity through the so-called nary fibrosis, there is no increase in pulmonary cancer.
retrograde lymphflow. From there, they are also Mesothelioma of pleura and peritoneum after
eliminated via the lymphatic pathway through the asbestos exposure. The spontaneous frequency of
parietal pleura. Prolonged retention of the needles mesothelioma is estimated at about one case per
there leads to hyaline growth, especially in the weak- million inhabitants per year. Around asbestos mines
ly vascularized areas. and businesses, especially when using crocidolite
Pathological anatomy. Asbestos-induced hy- ("blue" asbestos), have a credible increase in this rare
aline thickens of the pleural pleura are identified, tumor. Its pathogenesis is related to the presence of
where calcium is gradually deposited due to poorly needles with certain parameters - long, thin and able
blood supply. They are localized most often in the to stay in the tissues for decades without breaking
centrum tendineum of the diaphragm, the chest apart. Synthetic fibers with the same properties in-
wall and the pericardial pleura. troduced into the pleural cavity of experimental ani-
Pleural plaques are clinically established after a mals also lead to mesothelioma.
latency period of at least 15 years after exposure to Pathologically, we have mesothelial cell growth
asbestos. They are diagnosed radiographically (Fig- to a mass of rubber-like consistency that presses the
ure 1) or by ultrasound - the latter method has an lung. Metastases in remote organs are not common.
advantage over the period prior to calcium deposi- Characteristic is the long latency period, which may
tion. In most cases, the plaques do not cause signifi- exceed 30-40 years, especially in the case of low as-
cant complaints and cause mild restrictive ventilator bestos exposure. Clinically dominated by complaints
of increasing dyspnoea and cachexia, chest pain,
persistent blood pleural effusion.
Radiologically and in computed tomography
(Figures 2 and 3) there is a massive parietal over-

Fig. 1. Diaphragmatic, pericardial and chest wall asbestos Fig. 2. Initial asbestosis with pleural mesothelioma
plaques
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Fig. 3. Asbestos pleural mesothelioma

shadow that presses the lung. Peritoneal mesotheli-

oma shows abdominal painlessness swelling, weight
loss, drowsiness. Tumor mass is palpated. Diagnosis
of mesothelioma is based on asbestos-related data,
especially crocidolite or amosite, over a latent period
of over 20 years, and a characteristic puncture find-
ing.
Prevention. Due to the strong carcinogenic ef-
fect of crocidolite, its use in many countries, and in
Bulgaria is forbidden.
REFERENCES

1. Burilkov, T. Silicatoses, Asbestosis. in Professional pathology, ed. Tsv. Alexieva, Kr. Kiriakov, Sofia,
Med. and phys., 1982, 185-189. (in bul.)
2. Burilkkov T., Studies on the biological action of asbestos needles, dis., S, 1983. (in bul.)
3. Burilkkov T., Professional pulmonary diseases, S., Med. and phys., 1990. (in bul.)
4. Burilkkov T., M. Dobreva and St. Ivanova - Dzhubrilova, Mineral powders in the working environ-
ment, S., Med. and phys., 1983. (in bul.)
5. Albrecht G., O. Schwertfeger. Herausforderung Asbest. Universum Verlaganshalh Wiesbaden, 1998.
6. Becklake. M.R. Asbestos - Releated Diseases. In Encyclopaedia of Occup. Health and Safety ed. J.M.
Stellman, vol. 1, 10.50-10.63, 4th ed, ILO, Geneva, 1998.
7. Toxicological Profile for Asbestos. Public Health Service, Agency for Toxic Substances and Disease Reg-
istry, Atlanta, Georgia, USA, 2001, p. 441.

L. Dimitrova

5.4 SILICATOSES

The term silicatoses is a common term for occu- Orthoclase Al, K

pational pulmonary diseases caused by the inhala- Zeolite Na, Ca, Mg, Al
tion of silicates - compounds of one or more metal Chain silicates
ions with silica (Table 1). Valastonit Ca
Orthosilicates
Approximately one third of the mineral breeds that
Mulit Al
occupy a significant proportion of the earth's soil and
rock masses are silicates. The mineralogical varieties
of silicates are largely based on their crystalline struc-
Tab. 1. Classification and composition of silicate minerals ture, and the particle shape defines them as isomet-
with pathological action ric powders (close sizes in the three dimensions). This
MINERAL METAL CATIONS gives some authors the opportunity to differentiate
Layered silicates them into a group of non-asbestos silicates, unlike as-
Talc Mg bestos or anisometric powders, where in one dimen-
Mica (muscovite) K, Na, Al sion the size is significantly different from the others.
Vermiculite Al, Mg, Co, Fe The majority of non-asbestos silicates are foliar or
Kaolin Al
lamellar (Figure 1).
Diatomaceous earth
Montmorillonite Ca, Na, Mg, Fe
The specific identification of silicate minerals in
Sepiolite Mg pulmonary tissue can be accomplished by various
Attapulgite Mg, Al techniques. Light microscopy with special coloring
Skeletal silicates methods objectively reflects parenchymal changes oc-
Feldspars curring in response to swallowed particles and often
Albite Al, Na gives evidence of the nature of dust exposure. Silicate
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TALCOSIS. This is the name of pneumoconiosis
combining symptoms similar to silicosis and asbes-
tosis (depending on the composition of the powder)
and the specific clinical and morphological features
of lean talc lesions. Talc is hydrated magnesium sili-
cate (Mg3Si4O10 (OH)2) with scaled form, but technical
talc generally contains asbestos, mica, serpentines
and quartz impurities.
Workers are exposed to the paper, paint and phar-
maceutical industry, rubber and battery production, as
well as workers involved in the production and process-
ing of gypsum.
The pathogenetic mechanisms of action are differ-
ent for the individual components of the powder aer-
osol. Pure talc causes the formation of mild peribron-
chial fibrosis from focal to more diffuse in workers with
prolonged exposure to high concentrations of talc.
The deposition of talc in the parenchyma provokes
focal clumps of the type of "foreign body" granuloma.
A quartz impurity in the talc or the content of crysto-
balite in its calcination up to 1200 ° C causes the for-
mation of silicate granulomas and diffuse interstitial
fibrosis of nodular type. Morphological features such
Fig. 1. Silicate minerals: as interstitial fibrosis, "asbestos bodies", pleural swabs
C. Valstonit D. Talc E. Kaolin F. Bentonite
and plaques are characteristic of the action of asbestos
minerals in the tissue sections look like polygonal par- (tremolite, anthophyllite) impurities. Consequently, in
ticles, plates or needle-like structures, colorless or pale the pooled term talcosis, different palomorphological
yellow to brown, but always biconvex. Phase-contrast findings are combined but with similar clinical symp-
light microscopy identifies fibers with 0.2 μm in diam- toms.
eter. Scanning electron microscopy visualizes smaller The clinical picture is characterized by a slow
particles, and elemental components can be identified onset of shortness of breath after prolonged peri-
with X-ray dispersion analyzes. ods of work, coughing and mucus expectoration. In
Biological effects. A variety of biological effects advanced stages, particularly complicated by infec-
characterize silicates - from inert dust depots and tions, the clinical symptom of pulmonary emphyse-
harmless granulomas to diffuse fibrosis. While asbes- ma and pulmonary heart with respiratory and heart
tos and similar needle minerals are highly aggres- failure is manifested - constant dyspnea, cyanosis,
sive compounds causing diffuse pulmonary fibrosis, drum fingers.
non-needle silicates cause the formation of "foreign The physical finding is scarce, represented mainly
body" granules (kaolin, nefelin, olivine, mica, etc.) or by basal crevices. Significant ventilator disorders are
are practically inert compounds (bentonite, cement, absent in the initial stages, while diffuse interstitial
glass wool). However, silicates often contain quartz or fibrosis is accompanied by restrictive ventilator dis-
asbestos impurities, or their thermal treatment is asso- orders. The X-ray traits represent different forms of
ciated with the formation of high-temperature quartz, pulmonary damage corresponding to the talc com-
the action of which on the body is characterized by a position (Figure 2). The nodose form of fibrosis, with
mixed and varied pathology that has been expressed reticulo-nodal shadows in the middle fields and the
in terms of mixed pneumoconiosis, mixed silicosis, sili- tendency to progression and fusion is characteristic
co-silicatoses, etc. It is generally accepted that the pos- of quartz impurity in the gypsum. The presence of
sibility that the majority of non-asbestos silicates used diffuse interstitial fibrosis and pleural plaques is as-
in industry can cause disease is limited. It grows only sociated with an asbestos impurity. In the extraction
in response to high exposure levels, especially in the and processing of pure talc, or in professional con-
presence of quartz and needle-like silicates. Although tact with medicinal or cosmetic talc, talc granulomas
relatively rarely diagnosed, some of the pathological of the "foreign body" type have been observed in
reactions caused by these powders are specific and are the pulmonary interstitium, in the absence of sub-
not found in subjects exhibited only with quartz and jective complaints and ventilator disorders for a long
asbestos. time. Experimental and epidemiological studies sug-

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pressed fibrosis, with numerous inclusions of "for-
eign body" granulomas.
The clinical picture is poor in subjective symp-
toms, in the absence of early stages of functional
breathing disorders. More substantial ventilator dis-
turbances are possible in the formation of fibrous
clusters with peak position and concomitant bron-
chitis.
X-rays are observed in small-scale shadows, in
the context of reticular perialveolar and peribron-
chial fibrosis, with no progression, to diffuse fibrosis
with alveolar obliteration or "honeycomb" type, at
severe disease rates, when morphological findings
correlate with kaolin content in the lungs (Figure 3).
Significant quartz impurities in the powder pose
a high risk of pneumoconiosis, which occurs more
recently in the silico-silicatosis type. Thus, in the pro-
duction of fire-resisting materials, pneumoconiosis
from chamotte (containing 20% ​​or more SiO2) is par-
ticularly prevalent. The development of the disease
is preceded by prolonged work experience over 10
Fig. 2. X-ray of a worker exposed to cosmetic talc for 27 years
years and rarely exceeds the first stage of intersti-
gest that pure talc is considered to be less fibrous in tial-focal fibrosis. The histological finding is repre-
man - the disease occurs after 15-20 years of work sented by peribronchial macules and nodules and
and progresses slowly. shows significant kaolinic deposition in complicated
Treatment is symptomatic. pneumoconiosis. Only in individual cases, with mas-
Labour-expert assessment is based on func- sive dust exposure, heavier forms, similar to silicosis,
tional disorders in the respiratory and cardiovascular occurring with granuloma confluency and tumorous
activities. transition have been observed.
Prophylactic measures, in the case of quartz or Treatment is symptomatic. Systematic measures
asbestos impurities, are consistent with those for bi- for sanitary-technical prophylaxis are required, lim-
ologically active powders. iting dust emissions, including hydrocycling pro-
KAOLINOSIS. The impact of dry clay dust on its cesses. Medical prophylaxis is aimed at early diagno-
extraction, crushing, preparation of articles and their sis of dust diseases and timely rehabilitation.
treatment is attributed to the group of pneumoco-
niosis, but in the majority of cases it is about mod-
erate interstitial or small-pulmonary pneumofibrous
changes without progression.
The most common silicosis in this group is ka-
olinosis caused by inhalation of kaolin - a group of
clay materials, with a major representative - kaolinite
(AL2O3.2SiO2.2H2O).
Kaolin has a wide application in the ceramic and
porcelain-faience industry, paper, paints, rubber,
medicine and cosmetics. The largest developed field
in Bulgaria is in the region of Kaloinovo; other kao-
lin-related precipitates, white earth, bentonite, some
of which have a significant quartz impurity, are also
obtained.
Epidemiological studies on workers from the
production and processing of kaolin in our country
identify diseases of pneumoconiosis with a frequen-
cy of 1 to 9%, occurring after prolonged exposure to
dust. Fig. 3. Roentgenography of a kaolin worker with 34 years of
Technically pure kaolin produces poorly ex- professional exposure

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NEPHELINE PNEUMOCONIOSIS. The disease is magnesium and sodium silicates - muscovite, biotite
caused by nefelin - an aluminum silicate extracted in and phlogopite.
a ore deposit on the Kol'ski peninsula (Russia). Used Mica-induced coniosis is a mild form of interstitial
in the production of aluminum and phosphorous fibrosis with a benign course.
fertilizers (apatite). In prolonged exposure it causes In the clinical picture, the symptoms of atrophic
benign interstitial fibrosis of reticulated and spot- catarrh of the upper respiratory tract and the bron-
ty-striped shadows. The course of the illness is slow, chial physical findings, with a progressive dyspnoea,
rarely complicated. prevail.
APATITOSIS. Apatite is a powdered substance A characteristic finding in pulmonary parenchy-
derived from nepheline, which has significant X-ray ma is "micous corpuscles", similar to asbestos, with a
contrast. By chemical composition, it is phosphate positive reaction to iron. Pleural plaque findings re-
anhydride, with calcium, iron and fluorine impurities. lated to the non-isometric platelet type of the parti-
Primary forms of apatitis have been observed in cles or to an unrecognized asbestos impurity are also
our country in workers in apathetic port silos after a described.
labour experience of 8 to 10 years. The treatment is sanatorium-resort and the
There is no specific clinical symptomatology and working capacity is preserved.
significant ventilator disturbances. X-ray changes The role of sanitary-technical prophylaxis is
are represented by intense, fine-grained shadows leading.
included in a fine mesh pattern. A characteristic CEMENT PNEUMOCOMINOSIS. The cement in-
finding is the presence of single, well-defined round dustry, which uses powdered materials (clays and
shadows in the middle and lower lung fields of the limestone, with gypsum, trace, etc.), is associated
"pea-disease" type. In some cases, changes in the with intensive dusting.
bone structure of the pelvis and the ribs associated The main Portland cement materials also contain
with the fluorine content are described. SiO2 with high hardness in the structure of quartz
OLIVINE PNEUMONOMICOSIS. Olivine - ortho- sand, quartzites, etc., with the free SiO2 content in
silicate of magnesium and iron is used in the fire-re- the fine powder being up to and about 2%. Probably
sisting and ceramic industry, is present in the com- due to the relatively stable content of SiO2, portland
position of blasting slags and some alloys. cement does not cause pneumoconiosis, and the
Olivine pneumoconiosis occurs in the type of morphological substrate of the disease is predom-
small meshy fibrosis of interstitial type, with small inantly dust granulomas in the absence of fibrosis.
foci in the middle and lower pulmonary fields, often High dust concentrations cause pulmonary bron-
accompanied by pleural adhesions. Cellular-dust foci chitis, but epidemiological studies have a lower in-
contain, besides olivine and coal and iron pigments, cidence than expected, due to the good solubility of
giant cells, collagen fibers. The disease occurs as a cement in the biological media.
benign process, and regression of X-ray morpholog- Cases of bronchial allergies and contact cement
ical changes is observed. dermatitis of eczematous type are due to a chromi-
Olivinosis is relatively rare and not very relevant um impurity in the cement. More puzzolan and fast
in our country. bonding cements containing more quartz are more
MICA PNEUMOCONIOSIS. Having the proper- aggressive.
ties of heat- and thermo resistance, mica is widely Professional contact with asbestos cement pro-
used in electrical engineering, for windows of fur- vokes broncho-pulmonary and pleural pathology
naces and ovens, as insulating material and others. described in the asbestosis section.
Mica is a complex compound of flaky aluminum,

REFERENCES

1. Bellis D., Belluso E. at all. An etiological definition of a case of mixed pneumoconiosis due to silicates and
coal in the absence of anamnestic data. Medicina del Lavoro. 85 (2): 122-331 1994 Mar. Apr.
2. Burilkov Т. Silicatoses in. Professional pathology. ed. Aleksieva Tsv., Kr. Kiriakov, S. Med. and phys.,
1982, 185-192. (in bul.)
3. Burilkov Т. Professional pulmonary diseases. S., 1990. (in bul.)
4. Burilkov Т., G. Hadjidekov, P. Gerasimov. X-ray diagnosis of occupational diseases. S., 1975. (in bul.)
5. Burilkov T., M. Dobreva, S. Ivanova-Dzhubrilova. Mineral powders in the working environment. S.,
1983. (in bul.)
6. Churg A. Nonasbestos pulmonary mineral fibers in the general population. Envir. Res. 1983, 31: 189-200.

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 LABOUR MEDICINE
7. Churg A., Francis H., Y. Green. Pathology of Occupational Lung Disease. Baltimore, Meryland., 1998.
8. Dobrev P. Clinical pneumology. S., 1987. (in bul.)
9. Fitzgeral E.F., Stark A.D., Vianna N., Hwang S.A. Exposure to asbestos minerals and radiographic chest
annormalities in a talc minning region of upstate New York. Arch. Of Env. Health. 46 (3), 151-4. 1991, May - Jun.
10. Flora G.S., Sharma A.M., Sharma O.P., Talc granulomatosis: two unusual presentations. Sarcoidosis. 8
(2): 136-9, 1991, Sep.
11. Gevenois P.A. et all. Computed tomography of pneumoconioses. Annales de Radiol. 37 (3): 222-8, 1994.
12. Gibbs A.E. et all. Talc pneumoconiosis: a pathological and mineralogic study. Human Pathol. 23 (12):
1344-54, 1992 Dec.
13. Gibbs, A.R., Pooly, F.D. Fuller's earth pneumoconiosis. Occup. Environ. Med. 1994; 51: 644-646.
14. Harrison T.R. At all. Principles of Internal Medicine. USA, 254: 1429-37, 1998.
15. Heppleston A.G. Minerals, fibrosis and the lung. Env. Health Persp. 94: 149-68, 1991 Aug.
16. Ivanova St., Ts. Alexieva. Handbook on Occupational Diseases. S., 1986. (in bul.)
17. Izmerov H.F. Guide for professional diseases M., 1983. (in russ.)
19. Mihailova A., V. Kapurdov, N. Doncheva. J. Hygiene and occup. health. XXX II, 1989, No 4. (in bul.)
18. Leonard I.F., Tempelton P.A. Pulmonary imaging techniques in the diagnosis of occupational intersti-
tial lung disease, in Occup. Med., State of the Art Review, vol. 7, Philadelphia, 1992, 241-260.
20. Parkes, W. R., Occupational lung disorders., 2nd ed. Butterworths, London, 1982.
21. Petrova E. Silica and silicotuberculosis. S., 1993. (in bul.)
22. Rosenstock l., Cullen M.R. Textbook of Clinical Occupational and Envir. Med., USA, 10, 11: 287-96, 1994.
23. Wehner A. P. Biological effects of cosmetic talc. Food & Chemical Toxicol. 32 (12): 1173-84, 1994, Dec.

E. Petrova

5.5 ANTHRACOSIS

Coal pneumoconiosis (anthracosis, anthracosi- • opsonization and phagocytosis of the mac-

likosis) is specific to a disease caused by the inhala- rophage coal particles;
tion and retention of coal dust in the lungs and the • clustering in the localized particles of mac-
response of the lung tissue (this pneumoconiosis rophage, blood mononuclear cells, polymor-
must be distinguished from the lungs in coil miners phonuclear cells and others;
which includes chronic obstructive pulmonary dis- • activation of macrophages.
ease). It is believed that O, H2O2, NO, cytokines, proteas-
In the production of coal dust with different fibro- es and antiproteases play an important role in the
sogenicity, the response of the lung tissue is hetero- remodeling of the cells in the respiratory trakt.Su-
geneous. Three major variants of pulmonary events peroxide radicals (O, H2O2) may be of a cellular and
are distinguished: extracellular origin.
• Collagen coal pneumoconiosis (nodose form Participation in the formation of pulmonary fi-
and progressive massive fibrosis); brosis of cytokines, such as tumor necrosis factor-al-
• Non-collagen (chronic obstructive pulmonary pha (TNF-α), interleukin-8 (IL-8), produced by blood
disease) caused by coal dust; monocytes activating a cell-mediated immune re-
• Pure silicosis or anthracosylicosis - with a high sponse.
content of quartz in the coal mining powder. Studies in vitro and in vivo with coil powder show
The risk of the occurrence of coal pneumoconiosis is impaired leukocyte factors such as leukotriene B4
determined by the nature of coal: (LTB4), platelet derived growth factor (PDGF), mono-
• Coal with high carbonation (anthracite, bitumi- cyte chemotaxis protein-1 (MCP-1), tumor necrosis
nous, brown) is the most fibrousogenic effect. factor - alpha (TNF- A), neutrophil adhesion factor
• The percentage of free crystalline silica (quartz) and intracellular adhesion molecule (ICAM-1).
in the fines fraction of the powdered aerosol The coal particles may produce other factors with
plays an important role - most often about 5-6%. the possibility of modeling the lung cells and / or ex-
Pathogenesis of collagen coal pneumoconio- tracellular matrix: fibroblast chemoattractants such
sis. Major pathogenetic moments are: as transforming growth factor - beta (TGF - β), plate-

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 OCCUPATIONAL MEDICINE
let-derived growth factor (PDGF) and fibronectin, pletely resemble silicosis finds.
and several stimulate or inhibit fibroblast prolifera- Simple coal pneumoconiosis is manifested radi-
tion factors (tumor necrosis factor - alpha (TNF-α), ographically (ILO'80) with scattered oval (nodosal)
transforming growth factor - beta (TGF-β), plate- shadows of varying sizes (p - up to 1.5 mm, q - 1.5
let-derived growth factor (PDGF), insulin growth fac- mm to 3 mm, r - 3 mm to 10 mm) and often - perifo-
tor (ILGF) and prostaglandin - E2(PG-E2). cal emphysema.
Presumably participation in a utoimmune patho- Progressive massive fibrosis (ILO'80) is characterized
genetic mechanisms. by: "progressive massive fibrosis" ("PMF") shades of
It is suspected a role of HLA antigen expression in varying diameter (A-shadows - 1 to 5 cm, B-shadows
the formation of progressive massive fibrosis. - 5 cm, to the diameter of the upper 1/3 on the right
Pathomorphology. There are two major forms of pulmonary field, C-shadows - with a diameter larger
collagen anthracosis: 1) simple coal pneumoconiosis than that of the B-shadows).
and 2) progressive massive fibrosis. Functional ventilatory disorders. In simple coal
The initial lesions in coal-simple pneumoconiosis pneumoconiosis, functional deviations are:
are coal macules (black areas of 1 to 4 mm in size), • small airways disease with a reduction in
located bilaterally symmetrically in the lungs, most maximum expiratory flows (FEF25%, FEF50% and
intensely in the peak zone. They are surrounded FEF75%) from the forced vital capacity curve
by focal emphysema in a perimeter about 1-2 mm. (FVC);
Fine reticular fibers are found in the macules. Usu- • normal or slightly reduced diffusion capacity
ally there is no collagen. Elastinic fibers disappear in (DLCO, DM);
the emphysematous sections. Common are vascular • altered ratio between dead space and total
changes associated with coal macules and interlob- lung capacity (VD / VT).
ular pleural thickenings. Massive progressive fibrosis "PMF" type coal pneumoconiosis is characterized
is represented by massive lesions, often involving by:
more than one lobe. At the center of the lesions • ​​reduced vital capacity (VC);
there is a cavity filled with homogeneous black mat- • reduced diffusion capacity (DLCO, DM);
ter. The walls are smooth or with fibrous drags on the • reduced lung complaint (CL).
surrounding tissue. The vessels are destroyed. The Ventilatory defects in chronic pulmonary bronchi-
lesions detect protein of unknown origin, calcium tis are:
phosphate and coal dust. • decreased forced vital capacity (FVC);
Clinical picture. The subjective symptoms of coal • decreased forced expiratory volume for one
pneumoconiosis are not pathognomonic. second (FEV1).
Simple coal pneumoconiosis is manifested with The progression of simple coal pneumoconiosis
scarce symptoms: to "progressive massive fibrosis" is usually eight or
1) easy fatigue in physical effort; more years.
2) weight in the chest. The most common complications of coal pneu-
Progressive massive fibrosis is characterized by: moconiosis are a combination of rheumatoid arthri-
1) cough; tis - Kaplan's syndrome (two-sided scattered nodose
2) black slime sputum; shadows, underlying rheumatoid nodes, progressive
3) shortness of breath. course, poor prognosis).
Chronic dust bronchitis and emphysema caused Diagnosis and differential diagnosis of coal pneu-
by exposure to coal dust are characterized by: moconiosis is similar to silicosis.
1) permanent cough with expectoration Treatment is similar to silicosis. Chronic pulmo-
2) significant airway obstruction nary bronchitis is treated in the conventional way for
3) dyspnea; the treatment of bronchitis.
4) signs of respiratory failure. Prevention - as with silicosis.
X-ray changes in coal pneumoconiosis precede
respiratory disturbances (VC and FEV1). They com-

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Kr. Dinkova

5.6 METALCONIOSIS

This name combines injuries from inhalation of ed to the picture of mixed pneumoconiosis.
metals in the form of pure or mixed powders. Res- Siderosilicosis can be observed in ochre miners
piratory organ damage has its own pathomorpholo- and grinders and other earth paints - siena and um-
gy and clinical-radiographic characteristics. ber. In this case, mixed silicosis is due to the quartz
CONIOSIS OF THE IRON content of the clay. X-ray changes are in a gentle
The variety of observed injuries necessitates the spotted nature on the backdrop of a generally rein-
distinction of individual forms: forced meshed lung pattern.
1. Siderosis ALUMINIUM PNEUMOCONIOSIS
At the end of the 19th century, Zenker first de- (ALUMINOSIS)
scribed siderosis. A major risk group under modern The main forms here are:
conditions exists in electric welding or gas cutting 1. Bauxite pneumoconiosis (Shiver's disease -
where the iron evaporates and condensation aero- first described in 1947).
sols are formed. The risk group is silver polishers us- It is encountered by workers engaged in the ex-
ing iron oxides. traction and processing of ore.
Pathoanatomical in lung interstitium there are Pathogenesis. The intensity of lung processes
iron particles, which are predominantly concentrat- caused by fibrous powders depends on the chemical
ed in macrophages and lymphatic pathways. The composition, the crystal structure and the properties
iron content exceeds 15 times the norm in dry lung of the surface and the dust particles. This also deter-
tissue. Siderosis is a pneumoconiosis of the so-called mines the importance of the high temperature mod-
pulmonary thesaurosis and may develop back after ifications of quartz - crystobalite, present in bauxites.
discontinuation of exposure. Pathologically, the lungs are rigid, with a bluish
Diagnosis is based on its characteristic occupa- color. Pleural adhesions and bulls can also be found.
tional history, preserved respiratory function, and Clinical picture. The usual complaints are found
X-ray picture, which is characterized by spotted - shortness of breath, sometimes paroxysmal, easy
shades of p-type, sharply outlined and more intense. fatigue, non-systemic cough. Anamnestic evidence
Employability. It is preserved in uncomplicated of severe chest pain, sudden increase in breathless-
cases. Change of work is required for workers with ness and cyanosis, is pneumothorax.
X-ray morphological changes. Radiologically, diffuse fibrosis is detected.
2. Siderosilicosis 2. Aluminum lung
The hazardous professions of this disease are asso- The disease occurs in workers in contact with a
ciated with iron extraction, mostly in the form of he- finely dispersed aluminum powder - in the grinding
matite and in some processes in the industry, where of duraluminous panels and joinery, in the warfare
an iron aerosol containing a significant amount of (flammable bombs) and as a dye.
quartz (casting cleaners) is mechanically formed. Pathogenesis. Aluminum and its compounds
Patho-anatomical alterations are associated lead to primary bronchopathy with a latency peri-
with the biological action of quartz rather than with od of months, but can be up to years (15 years). It
the available iron compounds. Diffuse fibrosis pre- is characterized by diffuse interstitial fibrosis with
dominates. The lung has a reddish-red color. widespread wrinkles, emphysema development and
Clinical picture. There are complaints of easy fa- spontaneous pneumothorax tendency.
tigue, shortness of breath, coughing. The sputa emit Clinically, complaints include dyspnea, at first on
may be reddish in color. exercise, and then at rest, which is accompanied by
X-ray picture is characterized by interstitial fibro- coughing and expectoration.
sis. This determines the development of obstructive Radiological changes are of type "s" and "t",
or mixed ventilator disorders. The course of the illness pneumothorax, due to the bursting of emphysema-
is slow and occurs of over 10-15 years. tous bulls. There is a mixed type of ventilator mal-
The so-called "Labrador lung" (in the Labrador function. A late complication is the chronic pulmo-
iron mines) is due to the impurity of anthopholity as- nary heart. Typically, the listed findings can occur
bestos. In this case, hyalinic pleural plaques are add- quickly (after several months of practice).

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PNEUMOCONIOSIS OF SOLID MATERIALS creased IgA, beryllium test for blast transformation
The new studies consider the cobalt contained of lymphocytes, epicutaneos test with 1-2% solution
therein to be used in metal alloy steels. Of great in- of beryllium fluoride, sulphate or nitrate (positive for
terest is the large use of cobalt alloys in jet engines contact persons), slowly developing diffuse fibrosis.
and the production of ferromagnets. Pure metal is Differential diagnosis is made with sarcoidosis.
used for staining glass and glazes. Treatment. It is symptomatic and does not lead
Clinical picture. Complaints occur after expo- to permanent remission. Corticosteroid preparations
sure over 10 years. They are nonspecific - cough, ex- are used. Recently, "pulse therapy" - a short course
pectoration, dyspnoea. They resemble chronic bron- with high doses to avoid complications.
chitis accompanied by persistent conjunctivitis and STANNOSIS
paraclinical with hypergammaglobulinaemia. The disease develops in inhalation of the conden-
Radiologically, there are enlarged hilus shad- sation aerosols of tin - by melting the enriched ore
ows, reticulonodous shadows with pre-selection in and pouring the pure metal.
the middle and basal lung fields. The cardial contour The clinical picture and functional studies
may be flat. show no changes. They contrast with the rich X-ray
Functional examination of external breathing find - the lung are sharply delineated in thick, miliary
determines it from a restrictive type, and then from shadows with significant frequency.
an obstructive, accompanied by disturbances in gas MANGANESE PNEUMOCONIOSIS
exchange. As an etiological factor, manganese plays a role in
The presence of cobalt ions in the cooling fluid the extraction and processing of ores (meaning their
when milling the metal can lead to the picture of ex- composition) and in the production of ferro-manga-
ogenous allergic alveolitis. A positive epicutane- nese.
ous test with cobalt was established. The mechanism of pathological reactions is
BERILIOSE closely related to protein structure degradation, sul-
Industrial applications find beryllium fluoride, fur-containing amino acids, enzyme activity and me-
chloride, nitrate and sulphate - in the production of tabolism of biogenic amines, in particular neurotrans-
steels, fluorescent lamps, X-ray tubes. Its most exten- mitters due to destruction of dopaminergic neurons.
sive application is in nuclear energy. Clinically, a cough with moderate expectoration,
Pathogenesis. Today, it is associated with im- obstructive or mixed type ventilatory failure is ob-
mune mechanism unlocking. Antigens (easily sol- served.
uble protein-bound beryllium compounds) lead to Changes in functional indicators point to small
IV type-delayed type hypersensitivity reactions. This airways obstruction. In the case of underground
brings the chronic forms of berylliosis closer to the workers the concentration of trace elements in bio-
group of collagenoses. logical fluids is increased - manganese, lead, copper,
Clinical picture. The similarity of systemic dis- zinc and iron.
ease with chronic berylliosis determines its interpre- Radiological changes of type "s" and "t" were de-
tation with detailed occupational history, even after tected, and over 10 years of reticular shadow with
discontinuation of exposure. In connection with the micronodose inclusions "p 1". Changes by the res-
development of emphysema the leading symptom piratory organs are characterized as toxo-irritative
is dyspnea. Consequently, coughing, broken gas ex- bronchitis. They are due to early lymphatic trans-
change, overloading the small circle of blood circu- port of the aerosol to the bronchopulmonary lymph
lation leading to a pulmonary heart. nodes. Bronchitis and peribronchitis develop with
Radiological changes are not typical. Increased predominantly basal localization and peak emphy-
roots, enlarged pulmonary pattern are seen, gradu- sema.
ally blurred shadows thicken to form "honeycomb" Manganese pneumoconiosis is associated with
or diffuse, scarry fibrosis. neurological manifestations (including early parkin-
Diagnosis. It is based on proven professional sonism).
contact with beryllium, immunological data for in-
REFERENCES
1. Daniels R. P. Berylium - induced lung disease. In: Occupational Lung Disease ed. J. B. Gee, W. K. Morgan,
Raven Press, 1983, 156-169.
2. Kazemi H. Berylium Disease; Chiapino G. Hard Metal Disease; Short S.R., Petsonk E.L. Respiratory
System: The Variety of Pneumoconioses. In Encyclopaedia of Occup. Health and Safety, ed. J. M. Stellman,
4th Ed., Vol. I, ILO, Geneva, 1998, 10.27-10.32; 10.63-10.69.

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5.7
Kr. Dinkova

MIXED PNEUMOCONIOSIS

PNEUMOCOMOINOSIS IN FURNACE REPAIRS of dust and toxic agents increases the appearance of
The disease occurs in workers from the metallur- changes in the respiratory system.
gical furnace, glass and other industrial furnaces, the Clinic. Chronic exposure to PVC powder during
construction of new thermal insulations. Pneumo- resin production is associated with the development
tropic damages - high dustiness, toxo-irritative gases of pneumoconiosis at over 10 years. The subjective
and overheating microclimate - are the leading roles. and physical symptoms are scarce and often absent.
The inhaled powder aerosol contains free crystalline Examination of the external breathing function did
silicon dioxide, asbestos, chamotte, dinas. not show significant changes in pulmonary volumes.
Pathogenesis. Two strong fibrousogenic com- A decrease in FVC and FED1 was observed.
ponents - quartz and asbestos, play a role in the de- X-ray changes are characterized by the appear-
velopment of mixed pneumoconiosis. ance of gentle, predominantly stripped and rarely
Clinical complaints are limited to easy fatigue, micro-nodal shadows that do not undergo further
dry cough, and shortness of breath with physical ef- development. The X-ray picture corresponds to I or
fort. They occur after the impact of the harmful fac- I-II degree of pneumoconiosis.
tors over 15 years. Vinyl chloride as a monomer systematically injure
The X-ray finding is two types: when the basic the skin of the hands, as in scleroderma (Raynaud's
component of the inspired aerosol is asbestos, the syndrome, bone cysts) and the liver in which it initi-
basal stripped shadows predominate, and when ex- ates a rare tumor - angiosarcoma.
posed to refractory dust - nodose with a tendency There is also an association between exposure to
to confluence. With computer tomography, hyalinic, PVC and lung carcinoma.
but rather calcified, pleural plaques can be detected. THESAUROSIS
The evolution of this pneumoconiosis is slow. Typi- In the systemic use of a hair spray, the main ingre-
cal here is the appearance of early hypertension, which dient polyvinylpyrrolidone (PVP) describes this type
is associated with the overheating microclimate. Given of pneumoconiosis.
the slow evolution of the disease, the significance of A small percentage of consumers of different sprays
the cocarcinogenic action of asbestos for the develop- without PVP react with bronchoconstriction or a typical
ment of lung tumors has not been proven. asthmatic attack by inhalation of the carrier gas freon.
PNEUMOCONIOSIS IN ENERGY FOUNDRY PNEUMOCONIOSIS
REPAIRS In the foundries, the workers are in contact with
The risk group here is working with asbestos-con- a mixed powder aerosol containing iron, quartz
taining materials by spraying (injecting asbestos, and silicates, which are in varying proportions. At
cement and water glass as a pressurized mixture). the greatest risk here are the arc- welders and the
Heating increases the fibrous- of silica and quartz sil- gas-welders.
icates and lowers that of asbestos. Pathological anatomy. Reticulin and collagen
Clinical picture. It does not differ from that of fibers in the lung are radially arranged in a star for-
the furnace repair workers. mation. The development of fibrosis is associated
Radiological (changes are caused by the action with the quartz component.
of asbestos) - stripped shadows in the two lung bas- Clinic. A picture of mixed pneumoconiosis is
es, hyaline pleural plaques, unclear diaphragmatic added to that of chronic bronchitis. This is due to the
and cardiac contour. high dustiness, the overheating microclimate and
POLYVINYL CHLORIDE PNEUMOUCONIOSIS the toxo-irritative gases.
First polyvinylchloride pneumoconiosis (PVC) is PNEUMOCONIOSIS IN GRINDERS
described by Zsende et al. In 1970. A mixed aerosol that contains metal particles
In a production environment chronic exposure and abrasives (when grinding metals with synthet-
occurs in the production of PVC products - fibers, ic abrasives - electrocorundum, carborundum) can
electrically insulating materials, tubes, resins. The lead to the development of mixed pneumoconiosis.
peculiarities of the technological process of the dif- It is observed during an internship of 15-18 years.
ferent productions determine the difference in the Radiological changes are of the reticulum-mi-
harmfulness. It is assumed that the combined effect cronodose type.

579
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BARITOSIS ufacturing contact leads to the clearance of the pul-
Injury of barium sulphate powder with quartz ad- monary parenchyma.
mixture develops the picture of mixed pneumoconi- The treatment of all listed forms of metal and
osis. Barium is used in painting in the form of white mixed pneumoconiosis is symptomatic, depending
pigment - lithopone, in vulcanization, in the textile on the stage and severity of the disease.
and porcelain industries, in X-ray contrast studies. Particular attention is paid to the prevention of
The highest risk is the production of pure barium or respiratory failure, overdosage on respiratory tract
its milling to lithopone. infections and right heart rate overburden.
Radiologically there are strong contrasting
stripped shadows in the lungs. Termination of man-
REFERENCES
1. Benjamin, E., S. Leskovitz. Type IV hypersensitivity reactions. In: Immunology. ed. B. Petrunov, 1994,
277-279. (in bul.)
2. Bozakov, A. Pneumoconiosis among the energy rapairs of TPP Maritsa-Iztok. dis., S., 1987 (in bul.)
3. Burlikkov, T. Prof. Pulmonary Diseases, S., Med. and phys., 1990 (in bul.)
4. Burilkov, T., M. Dobreva and St., Ivanova - Dzhubrilova, Mineral powders in the working environ-
ment, S., Med. and phys., 1983. (in bul.)
5. Dinkova, K. Respiratory damage to miners from manganese field. Dis. S, 1987. (in bul.)
6. Ivanova St., Tsv. Alexieva. Handbook on Occupational Diseases, S., Med. and phys., 1986. (in bul.)
7. Griefahn B. Arbeitenmedizin, Stuttgart, 1992, 156.
8. Natskov, L. Pneumoconiosis of the Metallurgical furnace repairs. Dis., 1986. (in bul.)
9. Velichkovsky, B.T. Patogeny of professional lung illnesses of dust etiology. Med. Labour and Ind. Ecol-
ogy, 5-6, 1994. (in russ.)
10. Zlatanov, Zl. Professional lung injuries. In: Clinic of Internal Diseases, ed. Nachev Ch., St. Zagora, ed.
"Knowledge" Ltd, 1994, vol. II, 93-96. (in bul.)

D. Charakchiev*

5.8 ORGANIC POWDER

Organic powders are divided into: non-living - 2. Allergic bronchospasm, usually accompanied
irritating or toxic and allergenic, and live - powders by bronchial hypersensitivity, which may be of the
with bacteria and powders with fungi and spores. first type (IgE antibodies) of the third type (IgG an-
The effects of organic powders on the respira- tibodies) or of the fourth delayed type (sensitized
tory system may be irritation of the bronchial mu- lymphocytes), existing separately or in combination.
cosa, allergic and immune reactions of the "foreign 3. Pharmacological bronchospasm (with or with-
body" type with formation of granulomas or for out bronchial hypersensitivity) as a consequence of
fungal infections, respectively. Allergic reactions to direct (non-immunological) secretion of mediators
their metabolic products. In any case, an individual such as histamine, serotonin, kinins, etc.
assessment of the work-hygienic factors and chem- 4. Acute inflammatory bronchospasm caused by
ical-bacteriological analysis of the powder to solve bacteria and viruses contained in plant dust.
the relationship between the dust profession and Agricultural plant materials and products such as
the pulmonary disabilities is required. hay, straw, cereals, feed, etc. are good substrates for
The following types of pulmonary lesions are dis- development at the appropriate temperature and
tinguished in the respiration of plant dust depend- humidity of a number of molds (microscopic fungi).
ing on their mechanism of action: The most important for pulmonary pathology as al-
1. Reflex bronchospasm (with or without bron- lergens are molds: Alternaria, Aspergillus, Penicilli-
chial hypersensitivity) as a result of mechanical irri- um, Termoactinomyces, Cladosporium. In the lungs,
tation from the dusts. spores or parts of their mycelium can cause true my-
coses - proliferation of the mold in the lungs, with
* Professional pathology, ed. Alexieva Tz., Kiriakov S., Med. and
phys., 1982 subsequent sensitization of the organism; bronchial

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asthma or asthmatic bronchitis - direct sensitization Diagnosis criteria for exogenous allergic alveo-
to a mold without the development of mold in the litis are:
lungs; granulomatous lungs - formation of specific I. Compulsory criteria:
granulomas with sensitization of the organism to 1. Confirm the presence of exposure by proving
the natural mold. Here is the typical professional al- antigens.
lergic disease "farmer's lung", also called "threshers 2. Respiratory or general symptoms 4-12 hours
disease", "harvest fever" and others. after exposure.
The "FERMER LUNG" was also known to B. 3. Detection of antigen-specific humoral or cellu-
Ramazzini (1713). The spores of actinomycetes Mi- lar sensitization.
cropolispora Faeni and Termoactinomyces vulgaris II. Additional criteria:
are the cause. Most affected are breeders, folders, 1. Typical disorders of pulmonary function.
millers and others. The morphological substrate of 2. Characteristic radiological changes in the lungs.
the disease is interstitial or granulomatous inflam- 3. Positive inhalation provocative test with the
mation of the lungs. An exogenous alveolite devel- specific allergen.
ops, for which "farmer's lung" is a classic example. Diagnosis can be confirmed by histological or
Clinical picture. After a few hours of latency, bronchoalveolar secretion analysis.
shortness of breath, fatigue, cough with scarce Treatment requires removal of the patient from
mucus expectoration and increased temperature, the harmful environment and the specific desensi-
sometimes with fever and night sweats, appear. tization that prevents the occurrence of severe pul-
Discontinuation of contact with the harmful mate- monary sclerosis with its consequences.
rial leads to healing for several days or weeks. There BISINOSIS. It is caused by the inhalation of cot-
are also severe acute cases with fatal outcome. Pro- ton, linen or hemp powder. The workers are most at
longed contact leads to recurrent pneumonia with risk in the primary processing of the material, where
development of pulmonary fibrosis and respirato- the dustiness is high. Smaller is the risk in spinning
ry-heart failure. and weaving workshops.
In addition to the typical history, X-ray findings, The bisinosis pathogenesis has not yet been
serological tests, skin and respiratory tests, pulmo- elucidated. Cotton powder contains histamine liber-
nary biopsy are important for diagnosis. ators and serotonin. Histamine is released from the
The functional, acute phase of allergic exog- lungs without prior sensitization. Constiratory action
enous alveolitis (hypersensitive pneumonitis) is on the airways is associated with increasing hista-
manifested by a reduction in respiratory volume, mine release and can be prevented with a small dose
oxygen diffusion capacity, alveolar arterial block- of antihistamine. The histamine liberator hypothesis
ade, hypoxia. Our data in patients with exogenous explains the more acute breathing effect of the tex-
allergic alveolitis in the fibrous stage show marked tile powder, but not the slow progression of the bis-
hypoxia with a tendency to hypercapnia and a minor inosis to the chronic stage in some workers. Isolated
decrease in act. blood pH, due to the compensatory allergens from the fibers of the textile fibers them-
increase of the excess of bases (BE) and standard bi- selves, which are an E-enzyme resistant glycoprotein
carbonate (SB). fraction. It is believed that the underlying effect of
X-ray in acute forms, a fine-grained diffuse dis- the glycoprotein allergen is Maillard's reaction with
semination, more pronounced for the foundations, lysine-saccharides links formation. Antibodies in se-
is found in the case of sharp forms. Often, the picture rum against cotton have also been demonstrated,
is similar to confluent infiltrates. Chronic forms are with no significant relationship between them and
characterized by a rough, reinforced mesh-striped the symptoms of the bisinosis.
pattern, emphysema and pulmonary heart. Clinical picture. In the early stages, the bisinosis
Two types of antibodies are formed in the body. is characterized by chest tightness on the first work-
Circulating class IgG antibodies have a major patho- ing day after the rest (around the end of the work-
genic significance for the disease, so it is related to ing day or after leaving the workplace). If the disease
type III allergic reactions. Parallel to these antibodies, progresses, tightness is accompanied by difficulty
typical anaphylactic antibodies - IgE class reagins are breathing, which goes on during the other days.
also formed during the course of the disease. Occasionally, the worker may experience symptoms
In skin tests 4-5 hours after intradermal adminis- on each working day with constant acute intoler-
tration of the antigens, a reaction occurs histologi- ance to the dust, which is necessary to remove from
cally as an Arthus phenomenon. Respiratory tests the professional environment. In the final stages,
with allergens are of limited use, because after 5-6 the disease is not distinguished from chronic bron-
hours they provoke a "farmer's lung" attack. chitis and emphysema caused by non-professional

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factors (indicative in these cases are the data from sex disturbances - reduced libido, metrorrhagia,
the professional history of chest complaints in the abortion - so-called "hemp atrophy".
past, expressed more strongly at the beginning of Skin testing by flax and hemp skin allergy tests
the week). Radiologically, no changes specific to bis- show a positive reaction in about 50% and 51% of
inosis (a specific pathological finding in the lungs are those tested, while a cotton allergen responds pos-
also not detected - it is usually the same as for chron- itively to a smaller number of exposed individuals
ic bronchitis and emphysema). - about 20% (more important is the inhalation chal-
Bisinosis has an acute stage that can progress lenge test with acetylcholine and cottonseed extract,
to chronic irreversible disease. At the acute stage with changes in FEV1, eosinophils and blood gases).
along with the symptoms on the first working day Leading place in prophylaxis is the reduction
after the rest, there is usually a decrease in FEV1. This of dustiness. Prophylactic importance is the proper
can also be found in dust-exposed workers without medical selection of workers (with no evidence of
complaints, more on monday than on other days. chronic pulmonary disease and changes in respira-
FEV1 reduction during the workday is a characteristic tory function), prophylactic periodic examinations
phenomenon and initially is reversible. Epidemio- and studies for early detection of changes in the res-
logical data indicate that workers who regularly re- piratory system.
ceive acute bisinosis symptoms are at a higher risk PNEUMOCONIOSIS FROM CORN POWDER. It
of developing chronic disease than those who have is caused by prolonged inhalation of cereal powder.
never had such complaints. Affected agricultural workers, millers, sillage- and
There are three stages in the development of the port workers.
bisinosis: The impact of particulate matter leads to chronic
I stage - weight in the chest, shortness of breath, granulomatous pneumonia terminating with pul-
dry cough, rapid fatigue, mostly on the first working monary fibrosis. Pathologically anomalous forma-
day of the week. tions are present in the lungs, hilus sclerosis and
Stage II - these complaints increase in strength bifurcation lymph nodes, non-specific "foreign body
and duration, asthma-like crises are added. type reaction, and so-called "corn corpuscles", in
Stage III - chronic spastic bronchitis with recurrent which protein envelope contains iron. Some authors
exacerbations leading to expressed emphysema. treat them as a tissue reaction of the type of exoge-
In workers from the flax and hemp industry, be- nous hypersensitive alveolitis.
sides these symptoms, febrile states, fever, have also Clinically, the disease at the onset of dust ex-
been observed. In hemp processing, the tempera- posure often occurs with the so-called "corn fever"
ture may reach 40 ° C, accompanied by headaches, that lasts for 2-3 days and is characterized by fever,
chills, nasal bleeding, vomiting and diarrhea. These shaking, coughing, nausea. Later these ebullitions
phenomena can last from 2 to 5 days. Sometimes are repeated only with a significant dust load, and
there is also a general weakening, feeling dizzy and instead there is a permanent cough with expectora-
Tab. 1. Professional lung injuries from some organic powders

Name Etiology and pathogenesis Endangered professions Clinical presentation and diagnosis

Wood dust and production and processing hypersensitivity alveolitis, the

cork powder (moldy)
timber of cork presence of precipitins
Koniosporiosis "lung
fuller on the bark of
of maple barkers" spore as "farmer's lung"
maple
pronounced shortness of breath, serum
Sequoiosis mushroom sawdust processing of California tree
antibodies from isolated mushrooms
antigens of serum proteins,
as "farmer's lung", manifests itself
Disease of poltry- egg proteins, feathers and poultry-farmers, especially
usually six hours after inhalation
farmer droppings of birds, especially pigeons
of antigens
pigeons
Disease of spores and metabolic workers in artificial
as "farmer's lung"
mushroomers products of molds mushroom cellars
allergic hypersensitivity in the
Disease of workers from the
pulmonary alveoli - toxomycosis
pepper spliters production of peppers

usually delayed reaction type III,

Disease of cheese workers in dairies, cheese but at atopics - delayed reaction type
spores of Penicillium casei
producers washing I "asthma cheese producers"

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Fever, cough, shortness of breath,

Processing of waste from radiological shadows or planar
Bagasosis Thermophilic actinomycetes
sugar cane (bagasse) infiltrates in the lungs, proof of
relevant precipitins
Febrile condition, phenomenon of
Workers employed in the
Disease of silage fillers fungal allergies chr. bronchitis and emphysema, may
preparation of silage
pneumosclerosis
Such as acute bronchopneumonia,
Plant pulmonary cellulose of powder from seeds Workers in contact with
miliary dissemination
granulomatosis of peas, beans, lentils the seeds of legumes
radiographically in the lung fields

dust of grass sainfoin

Disabled from dust of production of ropes and Shortness of breath,
containing acetylcholine or
the grass sainfoin carpets bronchopneumonia
similar active substances

tion and an exacerbation for years dyspnea. Some- (FEV1, PEF, VC), according to some authors, are the
times pneumonia, dermatitis and increased allergic initial signs of the harmful effects of flour powder. An
reactivity can be detected. acetylcholine inhalation test (for the detection of la-
Radiologically there may be evidence of pulmo- tent obstructive functional disorders) is recommend-
nary fibrosis in cases of prolonged work experience. ed. Etiological significance includes skin-allergic and
Sanitary-technical equipment includes im- especially inhalation tests with the corresponding
provement of ventilation and mechanization of the allergen. The demonstration of specific reagins (IgE)
working process. in serum of patients by radio-allergosorbent test
DISABILITIES IN WORKERS FROM THE FLOUR (RAS) is a reliable method of etiological diagnosis in
MANUFACTURING. While the grainy powder can flour production workers.
lead to pneumoconiosis, the flour attaches to the Etiological treatment is specific desensitization.
bronchi and causes chronic inflammation of the lin- If necessary, patients are readjusted.
ing followed by atrophic changes. Evolution is slow There are also many organic powders causing oc-
and benign if bronchial spasm does not develop cupational respiratory trauma. It is known, for exam-
(gluten of flour or grain beetle may cause prima- ple, the sensitizing effect of some plant seeds - cot-
ry bronchial asthma). Allergic reactions can also be ton, linseed, soybean, castor.
caused by Penicillium, Aspergilius, Acarina and other A number of occupational groups of workers are
of contaminated flours. exposed to proteins of different origins - in the pro-
Initial damage to bakeries is the development of duction of enzymes, fodder, yeast, leaven, antibiot-
rhinitis and bronchitis (at 9-10 years of exposure), ics, insect farming.
then bronchial asthma and end of emphysema and Allergic diseases can also be caused by organic
pulmonary heart. X-ray examination usually reveals plant protection products. There are also diseases of
normal lung transparency and often increased pat- the respiratory system of tobacco and other organic
tern in the lung basis. Changes in external breathing dust (Table 1).

Sh. Kuzmov, M. Demirova, Kr. Dinkova

5.9 PROFESSIONAL CHRONIC BRONCHITIS

The definition of chronic bronchitis (CB) is based CB is characterized by constantly growing, high
primarily on clinical criteria including chronic cough- prevalence. Globally it affects 12-25% of the adult
ing with expectoration in different daytime for at population.
least 3 months in 2 consecutive years. This defini- Accurate determination of the incidence of occu-
tion also introduces new requirements for CB deter- pational CB is mainly hampered by its multifactorial
mination - is there chronic airway obstruction; with conditionality. It is therefore one of the most disput-
what localization and degree; excluding other dis- ed nosological units for inclusion in the Official list of
eases with chronic cough and an expectoration. In occupational diseases (Convention 121, published by
professional CB, it is essential that the factors in the the Committee of Experts at the ILO 1980). Recent ep-
work environment are crucial to its manifestation. idemiological studies by our and foreign authors have
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shown that CB is more credible among some labour ation, etc. Their self-importance in the professional
contingents. Studies in our country show that man- bronchitis etiology is not great.
ganese workers have a frequency of 6.5 times that of Pathogenesis. The bronchial tree's ability to re-
controls. The CB rate for iron and steel workers ranges spond to multiple professional factors is the same.
from 15-29% for men and 5-21% with women, with- The main pathogenetic mechanisms are:
out dust risk workers only at 6 to 13% (1990). 1. Disturbed local and cleansing protective function
Therefore, more and more authors have sub- due to destruction of the ciliary epithelium and block-
scribed to the view that, under strictly defined ing of immunological and phagocytic protection.
conditions and specific procedures, CB can be con- 2. Some powders and gases can model bronchi-
sidered as an occupational disease. CB is listed in oc- al hyperreactivity (BHR) by blocking β2-adrenergic
cupational disease lists (tables) except in our country bronchial receptors or reflexively by direct vagal re-
(2008) and in countries of the European Community ceptor irritation.
and the CIS. 3. Along with its irritant action, some powders,
Unprofessional etiological factors that enter especially organic and a number of chemicals, also
into complex relationships with professional factors have an immune-allergic or histamino-liberate
(when acting together) are: non-allergenic effect.
1. Exogenous factors: 4. Different etiological factors lead to tubular
• smoking - a leading exogenous factor for the gland hypertrophy and hyperplasia of the bronchial
development of CB; gland, followed by hyper secretion and dissecretion
• viral and bacterial infections; (increased volume and altered bronchial secretion)
• environmental pollution; and subsequent development of mucostasis and
• various exogenous allergens; bronchial obstruction.
• low social status. Pathology. The following major pathological
2. Endogenous factors: changes were observed:
• Immune deficiencies of Ig-A, a1-antitrypsin; 1. Proximal in larger bronchi - hypertrophy of the
• congenital abnormalities of bactericidal ac- tubular gland with Raid index increase from 0.26 to
tivity of macrophages and polynuclear leuko- over 0.59, hyperplasia of the acinar cells and numer-
cytes; ical increase of the cupular cells with metaplasia of
• AVN - non-selective; the multilayered cylindrical ciliary epithelium (re-
• syndrome of non-moving cilia; placing it with a multilayer flat epithelium).
• growing age. 2. Distal in small bronchus (less than 2 mm in di-
The main etiological factors for a professional ameter) - inflammatory infiltration of the bronchial
CB are: mucosa, submucosal swelling and thickening of
A) Powders - inorganic and/or organic together the basal membrane and later atrophy of glandular
with the added microbial flora. structures.
B) Toxic-chemical factors in the form of gases, va- Obstructive and later destructive changes in
pors or condensation aerosols, which can be system- the bronchial tree cause difficulty in passing the air
atized in 4 groups: through the bronchi. The subsequent alveolar hy-
• fast volatile organic compounds such as: acet- poventilation and disturbance of the physiological
aldehyde, acrolein, formaldehyde, paint solu- ratio of ventilation/perfusion leads to limiting gas
tions, phosgene etc.; diffusion with subsequent arterial hypoxemia. Later
• hardly volatile organic compounds such as: in the evolution of CB and combining it with destruc-
dimethylsulphate, epoxy resin hardening tive changes in the pulmonary parenchyma, condi-
agents, some isocyanates, naphthalene, par- tions for arterial hypercapnia and development of
affhenylenediamine, phthalic acid, solids respiratory failure (RF) are created.
paints, etc.; Classification. According to the etiological clas-
• easily volatile inorganic substances such as: sification of chronic professional bronchitis, it is:
ammonia, chlorine, ozone, hydrogen fluoride, 1. Powder
nitrous gases, sulfur dioxide, hydrogen sul- 2. Toxic-chemical
phide, acid and alkali vapors, etc.; 3. Meteotrope
• poorly volatile inorganic compounds such 4. With mixed etiology
as metal powders, nickel smoke, cobalt, zinc, Depending on the way of its occurrence it is:
platinum and their compounds. 1. Primary - formed after prolonged exposure of
C) Meteotropic factors when operating in over- the damaging factors of the working environment.
heating or overcooling microclimate, ionizing radi- 2. Secondary - when accompanying or compli-

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Tab. 1.
Symptoms Clinical signs Laboratory Values Other methods
Dry and / or wet thorax
Cough, BSR, hemogram, sputum for Radiographic studies of lung
wheezing, increased front-rear
expectoration, banal flora, BGA, SA tests (in and paranasal cavities, ECG
diameter, cyanosis,
shortness of breath, allergic forms) with oflife EhoCG, FEB, broncho-provoc.
tachycardia, hepatomegaly, edema
tiredness and proff. allergens tests, bronhological researches
of the lower extremities.

cating another occupational pulmonary disease (eg and unful expectoration.

pneumoconiosis, toxic pneumosclerosis) or as a con- • Toxic-chemical bronchitis occurs after a short-
sequence of acute occupational intoxications involv- er exposure period. They end up with a rich-
ing the respiratory tract. er clinic, often with functional complications,
Clinical picture. In the course of professional and more quickly lead to complications and
chronic bronchitis, there is nothing strictly specific disability. When it is caused by water-soluble
that distinguishes him from the unprofessional. gases, vapors and aerosols (chlorine, ammo-
The main clinical symptoms are: nia, acids, bases) primarily damage the mu-
1. Cough - early onset in patients with CB, man- cous membrane of the URT, trachea and large
ifested mainly in the morning and / or in contact bronchi. More difficult and insoluble (ozone,
with production damage. Depending on the disease sulfur, beryllium, manganese, nitrogen oxides,
phase (remission or exacerbation), the cough chang- gasoline, phosgene) affect the lower compart-
es its appearance, strength and character. ments, bronchiols and even the alveolar wall.
2. Expectoration in qualitative and quantitative • Meteotrophic bronchitis factors affect directly
terms also strongly depends on the stage of the dis- on the bronchial mucosa and indirectly by cre-
ease. ating conditions for frequent exacerbations.
3. Dyspnoea and easy tiredness are later manifes- • Mixed etiology CB are the most common
tations. The breath originally occurs at higher physi- forms, as in most occupations the risk factors
cal stresses, and consequently smaller, as in the end are combined.
of the disease it is also at rest. If there is an allergic The clinical diagnosis is based on a thorough
component, it may be of a leaping nature. history and objective study of some laboratory, X-ray
The physical examination may initially detect an and functional studies (Table 1).
increased anterior-back diameter of the chest with It is important to know that:
limited respiratory motility, wheezing - small moist 1. X-ray examination of the lung has little infor-
non-bubbling in non-destructive forms and dry with mation and serves mainly to exclude other diseases
different acoustic characteristics in the obstructive. masked or associated with CB.
In more advanced forms of occupational aetiology, 2. X-ray examination of the paranasal cavities,
chronic pulmonary heart (CHD) and central cyanosis serves to detect any inflammatory changes present
respiratory failure can be identified. in them.
The main clinical forms are chronic non-obstuc- 3. When diagnosis is made, both the etiological
tive bronchitis and chronic obstructive bronchitis. form and the clinical form of the CB (via FID), the
With chronic exposures and frequent exacerba- developmental phase (remission, exacerbation) and
tions, chronic deforming bronchitis followed by bron- any related complications (RF, CHD, bronchiectasis)
chiectasis is reached. must be determined.
Depending on the etiological factor - concentra- Differential diagnosis. It is done with pulmonary
tion, dispersion and duration of action, as well as indi- emphysema, bronchial asthma, bisinosis, localized or
vidual characteristics, certain nuances are observed in spread pulmonary fibrosis and granulomatous pro-
the course of chronic professional bronchitis: cesses, interstitial lung edema in left ventricular CF.
• Powdered bronchitis of inorganic powder Diagnostic criteria for determining the occu-
usually develops slowly, proceeding with a pational nature of CB.
poorer clinic (as dry bronchitis) and for a long The following basic criteria are used:
time the patients have compensated respira- • Labour-hygienic - to prove the etiological fac-
tory function and preserved working capacity. tor, its intensity and duration of impact;
• Powdered bronchitis from organic dust can • Exposure period - impact of at least 10 years;
occur both as a normal CB (with normal bron- • Positive collective (epidemiological) test
chial reactivity) and as asthma-like bronchitis demonstrating a credible increase in CB in a
with bronchial hyperreactivity, coughing and given occupational group;
whistling repetation of a paroxysmal nature • Absence of smoking - exceptionally, only cas-

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es with a duration of smoking below 3 years oids (beta- methazone, fluticasone). Therapy should
and an intensity of less than 10 cigarettes be controlled and optimized according to FEB re-
per 24 hours (smoking is demonstrated by sults.
quantification of the nicotine metabolite in Mucoscretory treatment is intended to lique-
urine-cotidine); fy the hyperviscosity of the bronchial secretion. It is
• Absence of chronic lung disease (in particular, achieved by adequate hydration (intake of increased
CB) before commencement of work experience; amounts of fluids), inhalation affect with aqueous
• Absence of inflammatory diseases of an infec- solutions of sodium bicarbonate and administration
tious nature affecting the UAP - the exception of mucolytics and secretagogues (bromhexin, muco-
is only where the profession predisposes to solvan, acetylcysteine, etc.). Different physiothera-
such (eg. low temperature at underground peutic procedures (vibratory and percussion chest
work and elevated humidity). massage, postural drainage, inhalatory administra-
If there is a suspected presence of an allergic tion of mucolytics) are also found in treatment. An
component accompanying CB, the following criteria essential element of the complex treatment is the
are added: climatotherapy in suitable sea and mountain resorts,
• positive skin allergy and serological (immuno- healing gymnastics with breathing gymnastics. Proof
logical) tests to professional allergens of complications - chronic pulmonary heart and/
• positive broncho-provocative test to media- or respiratory failure - requires the administration of
tors and allergens cardiac glycosides, vasodilators, diuretics and oxygen
• positive exposure and elimination test therapy (dosed and controlled according to BGA).
Treatment. In principle it does not differ from Labour expertise. In the absence of functional
that of the unprofessional CB. Significance is attribut- respiratory complications, persons are able to work,
ed to the so-called etiological treatment - adequate and in case of exacerbation of CB, they are temporar-
rehabilitation (in case of functional complication of ily incapacitated. In case of frequent exacerbations,
CB), in case of dequalification is determined the% temporary labour is recommended, and in case of
of the lost working capacity, and in the case of the functional breathing disorders (RF), with or without
younger persons - the possibility of re-qualification. cardiovascular disorders, the% of the disability is
Proven allergic pathogenesis of CB requires compul- determined. Cases of asthmatic bronchitis are per-
sory rehabilitation, with a specific hyposensitisation manently incapacitated for the profession without
with the professional allergen. regard to functional breathing values.
The pathogenetic treatment is aimed at combating Prevention. Sanitary-technical prophylaxis con-
infectious exacerbations, bronchoconstriction and al- sists of measures whereby production deficiencies
tered rheological properties of bronchial secretion. reach norms.
Bronchodilator treatment includes the use of var- The medical prophylaxis of professional CB re-
ious in structure and mechanism of acting drugs: quires strict adherence to the rules for prior medi-
xanthine derivatives (novfilin), inhalatory sympa- cal examinations in order to prevent people with
tho-mimetics (salbutamol, fenoterol, salmeterol, chronic respiratory diseases from being at risk work
etc.), inhalant cholinolytics (ipatropium bromidum), environment. Quality medical check-ups and timely
and in asthmatic bronchitis and inhaled corticoster- medical treatment with labour readjustment.
REFERENCES
1. Alexiev N. Chronic bronchitis. In the "Clinic of Internal Diseases" ed. Ch. Nachev, V. II, 51-59, ed. "Knowledge"
1997. (in bul.)
2. Burilkov, T. Professional lung diseases. Sofia, 1990, Med. and phys., 74-152. (in bul.)
3. Demirova M. Bronchoallergopathies of organic dust. Sofia, Med. and phys.,1980, 12-67. (in bul.)
4. Demirova M., Kuzmov Sh., Kotseva K., Raynovska St., Chronic bronchitis. in Practical approaches in the treat-
ment of occupational diseases". ed. M. Demierova. ed. "Knowledge", 1995, 38-43. (in bul.)
5. Dinkova, Kr. Damage to the respiratory system in miners from the manganese deposit. Dis., 1987. (in bul.)
6. Griefahn, B. Arbeitenmedizin, Stuttgard, 1992.
7. Kuzmov, Sh. Proffnatological aspects of chronic bronchitis. Dis., 1995. (in bul.)
8. Marek K., J.E. Zejda. Chronic Obstructive Pulmonary Disease. In the "Encyclopaedia of Occup. Health and Safety".
ed. J.M. Stellman, 1998, IVth ed., ILO, Geneva, Vol. I, 10.69-10.74
9. Peter P., Fraser R. Diseases of the Airways. Chronic bronchitis and emphysema. In "Synopsis of diseases of the
chest". W.B. Saunders Company, 1983, p.536-40.
10. Popovic, V. Chronic obstructive lung disease. In: Medicine of labour, V. II, ed. Al.Vidakovic, Beograd, 1997, 1019-
1025. (in serb.)
11. Stresov, Chronic bronchitis. in Professional pathology. ed. Alexieva, Tsv., Kr. Kiriakov. Sofia, Med. and
phys.,1982, pp. 197-199. (in bul.)
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D. Medjidieva

5.10 OCCUPATIONAL DISEASES OF URT

The upper respiratory tract (URT) acts as a condi- capillaries and haemorrhages are evident, there is
tioning device for the inhaled air, which heats, mois- no inflammatory process of the URT. Often in the
turizes, cleanses mechanically and chemically, and case of bleeding, first aid is required through a front
retains and disposes of many microbial agents. An nasal tamponade.
important role in performing these functions is the When the body cools in the nose, the cavernous
presence of chemo-, baro-, thermal and olfactory re- bodies expand, the conat becomes pale, and nasal
ceptors in the nasal mucosa, the structure of the na- frost, sinusitis, pharyngitis, tonsillitis, laryngitis often oc-
sal cavities, the cavernous formations, the rich inner- cur. Treatment is anti-inflammatory and symptomatic.
vation of the nose and the swallow (n. trigeminus, Diseases of URT in ionizing radiation. Radia-
n. olfactorius, n. vidianus, ganglion sphenopalati- tion disease is complex damage to the body, which
num), defensive reflex mechanisms for elimination - occurs acutely or chronically. On the part of the
sneezing, cough, increased secretion, spasms of the URT, bleeding from the nasal mucosa, gums, throad,
throat, etc., creation of reflexes through the center of which often lead to secondary infections in this area,
breathing and regulation of the quantity of passing is typical. The treatment includes local administra-
air and its physico-chemical properties. tion of Vit. C, A, B complex.
In case of damage to the protective mechanisms Diseases of URT from powder substances. In
of the nose, its filtration capacity is reduced sharp- the production environment there are various dust
ly. In atrophic processes, the mucous membranes factors that pass through and influence the URT:
thinnish, atrophy the glands and nerve endings, re- • inorganic: metal (lead, cadmium, manganese,
duce the number of cilia, suffer drainage, filtration copper, zinc, iron), mineral (cement, sand,
and phagocytic role of the nose, and conditions for lime, gypsum etc.);
the occurrence of occupational diseases from physi- • organic: plant (cotton, flax, hemp, tobacco,
cal, chemical and other injuries. flour), animal (wool, silk, leather);
The lymphoid throat ring is actively involved in • mixed.
immunogenesis by the production of lymphocytes For occupational diseases of solids a significant
in the tonsils. Its superficial layout ensures close con- role play the dust size.
tact with harmful factors and plays an important role Pathogenesis. Dust is the most common cause
in the defense mechanisms of the body. Chronic ton- of occupational diseases in the URT. The influence
sillitis as an infectious-allergic disease leads to allergy of dust on the URT depends mainly on the amount
to the whole organism - physiological sensitization, of powder aerosol, the size of the dusts, the degree
e.g. with regard to hemolytic streptococcus be- of dispersion, the chemical composition thereof
comes pathological and leads to frequent recurrenc- etc. The powder, depending on its nature (metallic,
es. URT occupational diseases are not always directly mineral, plant, animal, etc.), irritates the lining me-
related to the length of service. They may occur due chanically, chemically, via the infectious route or
to physical (meteorological, ionizing radiation), toxic combined and causes inflammatory, vasomotor and
chemical (metals and their compounds, acids, bases, secretory reactions. The mucus loses its protective
organic compounds, plastics, pesticides), biological properties, edema occurs, secretion increases, nasal
(pathological bacteria, fungi, viruses) and allergic cavities swell, worsening blood circulation, difficulty
factors of work environment. breathing. Changes that occur arise into chronic and
Diseases of URT by meteorological factors develop a productive, hyperplastic process. The con-
(high and low temperature, increased humidity or nective tissue grows most in the area of ​​nasal cavi-
dry air, increased or decreased atmospheric pres- ties, the mucous glands atrophy, reduce the vessels
sure, etc.) Threatened professions include workers in of the cavernous bodies, the cylindrical epithelium
metallurgy, machine building, mining, bakery, agri- passes flat and the atrophy rhinitis picture is formed.
culture, etc. Erosions and necrosis with subsequent septum per-
Pathogenesis and clinical picture. At elevated forations develop.
temperature, the body reacts with capillary dilation, Often the inflammation goes down and covers the
accelerated blood flow, increased sweating. On the mucous membrane of the throat. It is hyperemised,
part of the URT, nasal mucosal dryness, enlarged with enlarged blood vessels covered with a tough
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fluid, hypertrophic changes occurring, which may be dislocation, polyposis, pharyngitis, laryngitis,
diffuse or cover only the lateral parts - lateral pharyn- tonsillitis; periodic prophylactic examinations;
gitis, the back - granulous pharyngitis. In late stages, • personal protective equipment - anti-dust
the lining atrophies, becomes smooth and shiny. masks, respirators, etc.
Changes from the throttle go from lateral chang- Diseases of URT from gases and vapors. In the
es with dystrophy to complete atrophy. The mucous case of inhalation of gases and vapors, the ability to
and vocal cords connections are hyperemic, edema- dissolve in liquids (water) plays an essential role. Var-
tous and with pachydermic changes. In advanced ious external and internal factors (temperature, air
stages of longer work experience, the lining of the humidity, body condition - general and local: curved
throat is dry, often covered with scabs. nasal septum, chronic rhinitis, pharyngitis, tonsilli-
Clinical picture. It does not differ significantly tis, laryngitis) also play a role in the onset of injuries.
from that of non-professional aetiology. There are The general toxic and local disease effects depend
some differences depending on the length of ser- on the concentration of the vapor, the nature of the
vice, the type of powder, the age of the patient, etc. action, the time of exposure.
Events start with acute snuffle, often with subse- Mineral acids in the form of aerosols lead to
quent inflammation of the nose cavities - difficulty chemical irritation of the lining of URT, as hydro-
breathing, sneezing, dryness, mucus secretion. This chloric acid damages predominantly URT due to its
picture gradually subsides and passes into chronic marked hydrophilicity, nitrogen acid is less soluble
- developing productive hyperplastic rhinitis. Nasal and mainly damages the lungs, while the sulfur acid
obstruction often disappears, but it is repeated again. damages equally in all parts of the respiratory sys-
With the development of atrophic rhinitis, dryness tem. In acute lesions coagulation necrosis of the lin-
in the nose and throat increases, weakens the sense ing occurs, manifesting as inflammatory changes of
of smell. Occasionally there are changes in the nasal hemorrhagic nature in the nose, larynx and throat.
skeleton - perforations that only affect the cartilage Chronic catarrhalis, hypertrophic or atrophic chang-
and manifest with characteristic breathing. In the case es are more common. Sodium and potassium bases
of nasal cavities, rhinolitis is often observed - concrete have a predominantly local, chronic, irritating effect
inorganic elements in the middle nasal passage, re- on the lining of the URT, resulting in chronic inflam-
sembling a cast (impress of the paranasal relief). In- mation - catarrhal, hypertrophic, atrophic.
flammatory changes in the nose and nose-swallow Clinical picture. Acute disabilities are rare, of-
descent and cause pharyngitis and laryngitis. Workers ten due to industrial accidents, low qualification of
complain of dryness, burning, pain, feeling of a "for- workers. The mild forms are manifested by rapid pas-
eign body" in the throat, dry cough. saged burning, irritation in the nose and throat. Me-
When cadmium powders are affected, there are dium heavy are expressed in painful cough, painful
atrophic changes in the lining of the nose, the mouth swallowing, bleeding and difficulty in breathing. Se-
and the taste papilla, often erosions with calcium de- vere forms are characterized by burns of the mucosal
posits. The picture of hypertrophic processes under lining of the URT and are experiencing by difficulty
the influence of zinc dust with subsequent atrophy breathing due to edema of the throat. Tracheotomy
and perforations of the septum is also characteristic1. is often required.
The damage from plant dusts to URT is most of- Chronic injuries often occur in the form of dry-
ten characterized by the catarrhal forms of rhinitis, ness, burning in the nose and throat, nasal bleeding,
granulosa and lateral pharyngitis, chronic tonsillitis, irritable cough, hoarse voice, etc.
sometimes accompanied by allergic components. Treatment. It is carried out in outpatient con-
Treatment. Local therapy is the leading - na- ditions for light forms with inhalations and gargles
sal drops and ointments, iodine-glycerin solutions, with alkaline solutions, analgesic drugs and antibi-
inhalations with broncholytic and antihistamine otics for inflammatory complications.
preparations. Severe forms require rapid removal from the
Preventive measures include: harmful environment, cardiotonic and analgesic
• sanitary-hygienic - improvement of techno- medications, oxygen passing, and hospitalization in
logical processes, production ventilation, san- the resuscitation and intensive care units.
itary control; Prevention. Includes sanitary-hygienic controls,
• medical-healing - pre-medical selection, exclud- personal protective equipment, professional selec-
ing workers with chronic rhinitis, nose septum tion, dispensary treatment of workers with chronic
disabilities at the URT.
1
Some peculiarities are observed in the case of damage to mer-
cury (mercury vapors) from the URT, so-called Cusmaul phar- Diseases of URT from organic substances and
yngitis with copper red shine, accompanied by sinusitis and compounds. Occupational harm to the chemical in-
lymphadenitis.
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dustry includes gasoline, benzene, phenol, acryloni- ryngostroboscopy (an increase in the amplitude of
trile, ethylenediamine and others organic substanc- movement of the vocal cords was observed - a hy-
es, often combined with variable microclimate, dust, potonic state). In the more advanced forms, objec-
noise, vibrations. Threatened professions are mainly tive morphological changes of the vocal cords are
fitters, repair workers, apparatus workers, and others. established in the form of permanent paretic states,
Pathogenesis. Under current conditions, work in "singing nodes", fibromas and others.
environments with high concentrations of toxic sub- Permanent tissue changes primarily affect the
stances is rare (failures). The prolonged action of toxic edges of vocal cords by thickening their mucous
substances in low concentrations is essential. Morpho- membranes in certain places. The most recent neo-
logical changes are mainly localized in the lining of the plasms of this genus are the "noduli cantatorum".
lower nasal cavities and in the palate tonsils, initially af- Rarely, the fibroids affect the vascular system with
fecting the epithelium of URT, later reacting the vessels the appearance of submucosal haemorrhage, which
in the subepithelial layer with subsequent destruction. is resorbable and develops a rich vascular network
Clinical picture. Damage to the URT is non-spe- and a conjunctival stroma (teleangiectatic form).
cific. Complaints include dryness, burning, nose and Clinical picture. Initial changes in the timbre and
throat irritation, feeling of a "foreign body" in the the density of the voice occur. It becomes hoarse and
throat, hoarse voice. Often, inflammation of the URT adds noises. As the process progresses, the changes
is also developing - catarrhal and atrophic forms of become lasting and are objectified with the morpho-
chronic rhinitis, rarely pharyngitis and laryngitis. logical changes of the vocal cords. The voice loses its
The length of service determines the localization power, becomes dysphonic to a different extent to
of the pathological process. Short-time workers have aphonic. Breathing disturbances begin.
disabilities mostly on the nose, and with a prolonged The objective manifestations of the developing
period of service they are downward in defeats. hypotension are visualized in a laryngoscopic study.
Treatment is predominantly topical. Inhalations There is incomplete adduction of the vocal cords in
are administered in catarrhal forms with alkaline-salt the middle, followed by hypothrophytes of the vocal
solutions, corticosteroids, in hypertrophic are pre- muscles with thinning at theirs rim, increased blood
ferred with sodium bicarbonate, and in atrophic - supply, resulting in redness and droplets of mucus.
with iodine-glycerin solutions. The nodules develop usually on both sides, on a
Prevention. It includes medical-prophylactic meas- broad base, reaching in size to a bean, have an off-
ures: professional selection of workers (excluding atrophic white color and locate between the front and the
diseases of the URT, allergic diseases of the URT, curved rear two-thirds along the edge of the vocal cords.
nasal septum, etc.), periodic medical examinations. Fibroma develops unilaterally, on a foot or wide
Diseases of URT from overtension. Voice func- basis, reaches a pea, has a red color and a smooth
tion has a leading role in the way of communication surface and locates in the anterior half along the
and as a tool of labour. Professions where voice is used edge of the vocal cords.
as speech in unfavorable conditions of production (at Treatment. Initial stages of dysphonia require
elevated or reduced temperatures, dust, gases, exces- complete vocal rest for several days with subsequent
sive noise, etc.) are endangered. Professions where orthophonic exercises, medication treatment with
voice is the main tool of work (actors, teachers, etc.) group B vitamins, atriphos, nivalin, novocain block-
and professions that have undergone special vocal ade in the Zhaharin-Hed zones for larynx, etc.
training and used their singing voice are endangered. Nodules and fibromas are removed by microsur-
Pathogenesis. Strong load makes it difficult for gery, and then a strict regiment of voice-rest and or-
the vocal vibratory muscles, as fatigue occurs ex- thophonic exercise regime is required.
pressed, in the hypotonic state of the vocal muscles. Prevention. An important role in the professions
At first, changes are an expression of easy voice tired- of singers, teachers, lawyers, speakers and oth. is the
ness due to functional disturbances of central origin need for not voice overloading by intensity and du-
or peripheral at the level of the loud musculature of ration of use, which requires the creation of a load-
the throat and are of a transient nature. ing regime, the application of vocal technique, the
Changes were observed in laryngoscopy and la- use of amplifying equipment, etc.
REFERENCES
1. Lippmann M., U. Ulfvarson, L. David et al., In Respiratory System. In the Encyclopaedia of Occup. Health and
Safety, ed. J. M. Stelman, 4th Ed. Vol. I, ILO, Geneva, 1998, 10.2-10.18
2. Maksimov Iv. Voices of voice function. in. Professional pathology, ed. Aleksieva Tsv., Kr. Kriyaikov, Sofia, Med.
and phys., 1982, 251-255 (in bul.)
3. Pavlov Vl., Hr. Apostolov, At. Gyulev et al. Occupational diseases of the upper respiratory tract. in. Occupational
diseases in otorhinolaryngology, ed. Vl. Pavlov, Sofia, Med. and phys., 1981, 110-187 (in bul.)
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6
V. Bosnev, G. Oncheva, Zl. Stoyneva

OCCUPATIONAL
OVERTENSION DISEASES

6.1 DISEASES OF PERIPHERAL

NERVOUS SYSTEM OVERTENSION

Peripheral nervous system (PNS) may be affect- is found in persons no older than 40-42 years (this is
ed by a variety of pathological processes of differ- based on a number of studies proving that working
ent aetiology: infectious-allergic, toxic, metabolic, conditions - physical load, working posture, signifi-
traumatic, vascular-ischemic, genetic insuffiently, cantly affect the incidence of osteochondrosis).
blastomic, etc. More and more often in the patho- The cervical radiculitis with the symptoms of low-
genesis of these diseases are some professional fac- er cervical and 1th thoracic root (C5-T1), forming the
tors that may also have a leading role in the causal brachial plexus and upper limb nerves, are common
process - chronic systemic microtrauma, long-term in manual labour. Pain is a leading symptom in the
overtension of the same kinematic chains, cold im- clinical picture. They also appear at rest and move-
pact, forced working position, rhythm imposed, etc. ment, they have different widespreadness, strength
Very often, the occupational disabilities of the PNS and character. They are caused by paravertebral
go along with the damage to the musculoskeletal pressure in the supraclavicular fossa as well in the
system or are their effects. roots of the nerve stems. The symptoms of stretch-
Relatively more frequent occupational diseases ing are particularly remarkable this of Remack. There
of overtension, microtrauma and other factors are are also root-type sensory outcomes such as thumb
cervical radiculitis, brachial plexitis, neuritis of n. me- hypesthesia (C6 dermatom), to 4th and 5th fingers
dianus and n. ulnaris, lumbosacral radiculitis, poly- (C8 dermatom) or between them (C7 dermatom).
neuritis and polyneuropathies, including upper limb Heavier forms of cervical radiculitis also affect mus-
vegetative, primary form of shoulder-arm syndrome, cles. If the 5th and 6th cervix roats (Duchenne Erb
angioneuro-dystonia, and angio-neurodystrophies. type) are affected, weakness and hypotrophy occur
In cervical radiculitis (ICD-X-54.2), the most in the muscles of the shoulder and arm. When 7th
common etiological factor is osteochondrosis. Rela- cervix root is affected,
​​ the muscles innervated by
tively rarely, the cervical root is damaged by common n. radialis are damaged, and C8-T1-root (type Aran
infections (influenza, angina, etc.). A major pathoge- Duchenne) - predominantly muscles innervated from
netic role in osteochondrosis plays the mechanical the medial and ulnar nerve - mainly tenar, hypotenar
factor as well as the occurrence of vascular-ischemic and interoseous muscles. Periosteum and tendon re-
and allergic-inflammatory changes in the affected flexes become weaker. The course depends entirely
cervical roots. on the causes of the disease - i.e. vertebral patholo-
The clinical picture of professional cervical rad- gy associated with cervical radiculitis usually occurs
iculitis is not different from that of another aetiol- more tightly, lasts weeks, even months and often re-
ogy. Only the gradual development of the disease curves.
and its frequent combination with forearm myositis Brachial plexitis (ICD-X54.0) can be caused by
and shoulder periarthritis could be noted. The de- severe physical labour, causing stretching or com-
termination of the causal link with the profession is pression in the shoulder joint area. Endangered
justified by this peculiarity, as well as by the nature professions include - carriers, blacksmiths, persons
of the workload, the localization (pre-ilection) and working with low-frequency and strong backlash
the length of service. The presence of cervical osteo- pneumatic appliances (miners, vibroconcretors, con-
chondrosis does not contradict the relationship be- cretiers, stonecutters, woodcutters, etc.).
tween the diagnosed illness and the occupation if it Clinical picture. The main sign is the severe pain

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in the shoulder area and neck. It quickly develops interdiscal hernia. And there is also pain in the neck,
and fails sensory and motor symptoms throughout shoulder and scapular area, which often occurs with
the arm and shoulder belt - muscle weakness, pro- a sharp head movement and often spreads to the el-
nounced hypesthesia, pain in palpitation and pres- bow and wrist. Unlike radiculitis, there is no sensory
sion, vegetative symptoms (cyanosis or redness, disorder. The myalgia, which is most common in the
swelling, cooling, sweat, etc.). Stretch tests are high- cervix-shoulder zone, is runed in root symptoms. It
ly positive. Tendon and periosteum reflexes become usually occurs with muscle tension and cold. Myosi-
weaker or disappear. Rapid and muscular atrophy tis (the chronic form of myalgia) is characterized by
develops. Running here also depends on the main a recurrent course. The affected muscles are painful
etiopathogenetic factors and is sometimes quite de- under pressure, and they often find a variety of hard
lay - up to months. and painful nodes. In the differential diagnosis, pseu-
Labour expertise. If there is only cervico-brachi- dostenocardial syndrome should also be considered,
al split neuralgia, after 10-12 days of treatment, it can which is observed not only in the neck but also in the
be translated into lighter work for 1-2 months. After thoracic osteochondrosis. Clinically, it is manifested
that, work can be continued in the profession. Ra- with complaints that are very reminiscent of angina
tional labour readjustment is imposed only in cases pectoris - gradual or paroxysmal pains in the heart
of recurrence. It is also mandatory in the case of cer- area or behind the sternum of sympathetic nature
vical radiculitis and brachial plexitis. In such patients, that continue for hours, and in some cases even days,
re-employment must be preceded by long-term and are not affected by the administration of nitro-
treatment. On rare occasions, there is a permanent glycerin (Table 1). Difficulties sometimes create the
partial loss of working capacity. humerus-scapular periarthritis, which is also mani-
Differential diagnosis of cervical radiculitis and fested with pain in the shoulder area, and often oc-
plexitis is done with cervical pain syndrome or cer- curring all over the hand. Typical for him is the pain
vicalgia due to irritation of the endings of the sinu- caused by the pressure on the tubercles of the shoul-
vertebral nerve in the area of ​​the fibrosis ring in the der bone, proc. coracoideus and the upper extrem-

Tab. 1.

Indicator / symptom Shoulder-hand syndrome Myocardial infarction Cervical-thoracic radiculitis

Pain
Localization Shoulder, arm, shoulder, heart zone Chest, spine, shoulder
Irradiation neck, head, heart area Shoulder, arm In the course of the C3, C6 roots
Begining Gradually, very rarely sharply gradually and sharply Suddenly - after colds,
physical over-intension
Character Diffuse, protopatic acute, sharp Gradually - rarely
Constant with periodic
enhanced
Behavior of the patient Calm, antalgic Anxiety, fear, protective reflex Limited movement in
posture of the hand posture, hand over heart zone cervical-thoracic zone of spine

Pupils Normal Mydriasis left normal

Disease reflexes Absent Weakened upper abdominal At first lively, and later
reflex left, pseudobulbar reflexes weakened arm reflexes

Sensory Painful points above the Hyperalgesia in the area of Painful points in the area of the
upper shoulder and scapular Saccharin-Head for heart roots, hyper- or hypoesthesia
angle in the area of radiculitic pain

Arterial pressure Unchanged reduced unchanged

Pulse rhythmical arrhythmia rhythmical
Heartbeat Normal tones, without Deaf tones, sometimes faint Normal tones, without
noise sound of pericardial friction noise
EKG No change Typical of myocardial infarction No changes
changes
Blood No change Leukocytosis, changes in LDH, No changes, in infectious
CPK, GGTP radiculitis has leukocytosis

Urine No change Sometimes reflex urinary No changes

retention
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ity of the trapezius muscle (radiography is of great roof builders, vegetable growers).
importance for diagnosis). In case of persistent pain Differential diagnosis. First, a distinction has to
in the cervix, it is always necessary to think of cervi- be made with the lumbar disc hernia, in the clinical
cal vertebrae metastasis, primary spinal cord or root picture of which the root symptomatology occupies
tumor, tuberculous spondylitis, spinal arachnoiditis, a central position. It is characterized by an acute
etc. These diseases are usually preceded by a long onset after abrupt movement, vertebral syndrome,
period of progressive pain and paresthesia. Correct monoradicular symptomatic, reduction of pain after
diagnosis is facilitated by X-ray examination. Root in- physical rest and recurrent flow. Radiologically, total
juries also occur with traumatic lesions of the spine. or partial downsizing of the affected disc, local os-
Some congenital diseases of the spine in the neck teophytes, and sealing of the disc-limiting surfaces
area also have differential diagnostics (the diagnosis of the adjacent vertebrae is often detected. In the
of these diseases is also above all radiological). so-called lumbago, it is also clinically manifested by
Lumbosarral radiculitis (ICD-H54.1). Like cervix, pain syndrome arising after physical exercise (pro-
they are found in a large number of hard-working longed bending and straightening, weight lifting),
workers, but with a load in the lumbosacral region but unlike radiculitis, there is no root symptom. Neu-
and lower limbs. Except for an accident at work, the ritis of the femoral nerve, in which the sensory dis-
main etiological factor is the microtrauma, which orders have no root, but peripheral-trunk nature on
is two types: external-multiple weight lifting, small the anterior surface of the thigh and the inside of the
thrusts, stretching at a significant frequency, and in- lower leg. Neuralgia of the external skin-thigh nerve
ternal-long-term muscle contracture imposed by the is characterized by the presence of numbness and
forced posture. A vertebral pathology with radicu- hyperaesthesia with elements of hyperpathy in the
lar manifestations is obtained. According to modern upper two thirds of the fore-outer side of the thigh,
perception, the most common cause of lumbosacral which are enhanced by walking and prolonged
radiculitis is the disc hernia - 70%, most commonly be- standing. Ankylosing spondylitis (Bekhterev's dis-
tween L5-S1 vertebrae. Followed by discopathy, spon- ease) in its early stages is often with rooted pain
dylosis, spondylarthritis, and colds. In pathogenesis, and is difficult to recognize. The main clinical sign is
the anatomical peculiarity of the L5- root is particularly the constant pain in the waist, which paroxysmaly
important, it is the thickest of all roots, but it passes intensified. The X-ray image, which represents the
through a narrow, intervertebral opening. spine as a bamboo stick, is very characteristic. Dis-
Clinical picture. The main symptom is the acute tinction from coxitis and coxarthrosis is not difficult.
stiff pain, usually one-sided with irradiation to the Hip joint movements in them are very painful and
seat and legs. Failure proceedings of motor, sensi- limited, especially rotation and thigh removal. Coxi-
tivity and vegetative function subsequently occur tis may have elevated temperature and accelerated
in a slow run. They respond to the affected roots BSR. Radiography of the joint clarifies the diagnosis.
in the disc hernia often the L5-root. The stretching Sacroileitis is characterized by spontaneous pain lo-
symptoms are positive, the painful pressure at the calized in the lumbosacral joint, most strongly man-
points of the Vale is strong. In the disc hernia verte- ifested in the sitting position. Here too, radiography
bral syndrome with the symptom of the "button" is helps clarify the diagnosis. Certain diseases of the
pronounced. In lumbosacral radiculitis as well as in vertebrae (spondilites, cancer metastases, primary
the cervix, vertebral pathology does not always cor- tumors) have to be taken into account - and here
respond to the clinical picture- at severe discopathy, the x-ray is decisive. Congenital abnormalities (sa-
a clinical picture may be missed, and in contrast - to cralisation, lumbarization, spina bifida, scoliosis, etc.)
mild spondylarthrosis, the pain may be strong, and occur asymptomatically or occur with unspecified
along with failing neurological symptoms - as other back pain and relatively weak root syndromes (they
factors, colds, focal infections, allergic reactions, etc., are also extremely radiologically recognized). In the
that doubtful the professional origin of the disease. differential diagnosis, vascular diseases of the lower
The course of lumbosacral radiculitis usually lasts limbs (thrombophlebitis, endarteritis, varices, inter-
for several weeks. Only in severe forms of disc her- mittent atherosclerotic claudication, etc.) should be
nia leading to permanent waste sensory and motor considered. In them the pain has no root, but more
changes with n. paresis of peroneus, pelvis-uretic diffuse and often indefinable character. Reflected
disorders, etc., the disease lasts for months. In such pain in the waist area in some surgical, internal and
cases, a permanent partial loss of working capacity gynecological diseases (appendicitis, renal and ulcer
is required. There are also single cases of occupa- disease, prostate adenoma, adnexitis, parametritis,
tional neuropathy of n. peroneus when working in post-operative scarring in the pelvis, etc.) should
a squatting or kneeling position (parquet workers, also be considered. And in them neurological status

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is lacking in morbid deviations. ors, chronic mechanical damage from overtension
Compression mononeuritis in certain professions (pianists, tennis players, etc.),
The most common form of mononeuritis is n. after injections in m. brachioradialis, fracture of the
medianus neuropathy less frequently in n.ulnaris, ulna with dislocation of the head radial ahead. In a
and even more rarely in n.radialis. The professions in radial epicondylitis, a supinator syndrome may de-
which these diseases are observed are very diverse. velop.
All of them are characterized by rapid and intense The diagnosis can be supported electromio-
wrist movements, and often by pressure on the graphically. Due to the difficulty of localizing the
palms. pain, the supinator syndrome may be mistaken with
Carpal tunnel syndrome (ICD-X-56.0). Pressure a number of other pain syndromes in this area, even
of n.medianus in the carpal canal may be due to trau- sometimes with psychogenic pain complaints in the
ma, edema, fracture, rheumatoid arthritis, tendinitis, same area. Treatment is primarily operative.
etc. The clinically manifested manifestation is the Ulnar canal syndrome (ICD-X-56.2). N.ulnaris's
atrophy of the thenar. Anesthesia of n. medianus in- compression is much less common than n.medi-
nervated fingers is often observed, which is initially anus's compression. It is most commonly associated
intermittent in contrast to anesthesia in cubital canal with traumatic genesis or the presence of abnormal
syndrome. There are severe second and third finger structures such as ganglion or muscle abnormalities
pains, sometimes hyperaesthesia in the n.medianus that narrow the Guyion's canal.
area. In atypical cases there may be pains through- Clinically, sensory and motor disorders are ob-
out the wrist, which include the forearms, night par- served. Sensory disturbances can be expressed to
esthesias (pathognomonic signs characteristic of the varying degrees and cover the small toe and the
early morning hours) and hyperhidrosis of the palms. ulnar half of fourth finger. Motor disorders predom-
Usually the pain does not reach the shoulder joint. inantly include hypopothenaric muscles and are ex-
Pronator syndrome (ICD-X-56.1). N.medianus pressed as muscle weakness, sometimes as paralysis.
can sometimes be squeezed into the m.pronator Cubital canal syndrome (ICD-X-56.2). Different
teres area and as a result form the clinical picture of mechanisms can chronically damage n.ulnaris as
the pronator syndrome. His knowledge is important it passes through the cubital area by squeezing or
for the differential diagnosis of carpal tunnel syn- friction - anatomic hand features, direct or indirect
drome. The similarity between the two syndromes is trauma, periodic nerve shifts in hand movement,
due to common signs: anesthesia and paraesthesia swelling, muscle abnormalities. The pain in the clin-
in the fingers innervated by n. medianus, weakness, ical picture is dominated, which can cover the en-
and later tenar musculature hypothrophy, wrist and tire upper limb, both distal and proximal - there are
forearm pain, microcirculation discrete disturbances paresthesia and anesthesia of the fingers involved.
with sympatheticotonic overload. As a difference, it Unlike ulnar canal syndrome, anesthesia and sting
is noted that in the pronator syndrome the Phallen in fingers are progressive and continuous. Sensory
test and reversal test are negative, there may be a disturbances in cubital canal syndrome include, in
delayed neural conduction that does not affect the addition to the fingers, hypothenar and ulnar half of
wrist. The treatment here is very often operational. dorsum manus, as the latter symptom may be deci-
Supinator Syndrome (ICD-X-56.3). The motor sive for the rejection of ulnar canal syndrome in dif-
branch of the radial nerve-r.profundus n. radialis in- ferential diagnosis.
nervate the wrist and finger expanders except for m. Radial canal syndrome (ICD-X-56.3). The emer-
ext. carpi radialis and m. branchioroidis. His lesion (su- gence of the radial canal syndrome, unlike the other
pinator syndrome) leads to a partially hanging hand syndromes described above, can only be associated
or to a paralysis of n. radialis without a hanging arm. with some local anatomical abnormalities and alter-
The passage of r. profundus through m. supinator al- ations that compress n.radialis. As a trigger factor on
lows in rare cases to be considered as a site of injury, this basis, over-pressure in the working conditions
resulting in a purely motional paresis of n. radialis. and more precisely some chronic repetitive, stereo-
As a rule, progressive paralysis of the innervation of typical movements of the wrist and forearm, can im-
the hand and fingers, outstanding in the foreground portance. In the clinical picture, the most common
to the symptomatic (the paresis of n. radialis with- symptom is the pain that extends to the extensor
out a hanging arm). The paresis are accompanied elbow area and can be radiated to the wrist and dor-
by pain in the proximal third of the forearm, due sum manus. It has a troublesome, painful character
to overload/overtension, which can be emitted by and is exacerbated by certain movements - wrist
dorsum manus. Movement in the elbow increases flexion and ankle pronation.
the complaints. Etiological can be considered: tum- Shoulder-arm syndrome (ICD-X-M89.0).

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Threatened occupations: textiles, carpets, type- is a decrease in skin temperature and changes in the
writers, drivers, spinners, hard labour workers, color of the swollen tissues - sometimes to paleness,
bookbinders, printers with intensive loading of the and in other cases to the lividity. Atrophies are as-
kinematic chain arm-shoulder and chronic high fre- sociated with differently expressed retraction of the
quency traumatism. It is most common between subcutaneous tissue and the muscles of the hand
the ages of 35 and 45 (the most active period in the and fingers.
volume and intensity of the workload). A significant The recovery and rescue processes are protract-
proportion of women almost 1: 3 (male: female) sug- ed and can last from 3 to 12 months. Full functional
gests a possible role of hormone-endocrine factors hand restoration is sometimes seen in about 2 years.
(preclimax and climax). Differential diagnosis of shoulder-arm syn-
The clinical picture shows a different degree drome with professional genesis should be made
of disease alteration. Initial manifestations may be with medication-toxic clinical forms caused by acute
slightly pronounced - paraesthesias and a vague or chronic chemical intoxication in drug treatment,
feeling of discomfort in the shoulder. There is objec- e.g. tuberculosis, epilepsy, and the like (isoniazid,
tively palpated soreness in the area of ​​the shoulder phenobarbital). Cases of shoulder-arm syndrome in
and scapula, particularly the pressure of the incisu- acute vascular disease with hemiplegia have been
ra scapulae. Gradually overwhelmed pains and dys- reported.
function in the shoulder, as the pains are of a typical Treatment. In severe cases with pronounced
vegetative nature - diffuse, undefined localization, pains, admission may be required until they are tak-
protopathic, with broad irradiation in the direction en.
of the hand distally and to the scapular area, neck, Medicinal treatment - in the first stage with acute
head. Typical is their appearance in the second half or sub-chronic course of manifest sympathicotonic
of the night. There are paraesthesias, and sometimes phenomena, capillary spasm, rarely and differently
anesthesia, mostly on the fingers. Circulatory and expressed inflammatory effects, may have vasoac-
trophic disorders are expressed in swellings, skin tive and rheology-improving drugs: Radecol, Ronicol,
moistening, color changes such as paleness, flushing Dusodril, Pentoxyphillin, Complamin, Tiklid and others.
or lividity, sweaty palms. Later, muscle hypotrophy For the sake of sympatholytic action, vegeotropic
and contracture of the forearm flexors and conse- agents and vegetative harmonizers such as Beller-
quent long-term contractions of the fingers, reflect gamin, Bellergal, Vegezin, Ipronal in combination with
the severe nerve-vegetative disorders. Diazepam, Seduxen, Rudotel, Tranxene, Xanax, are
Characteristic of the course of the disease process most commonly used.
is its phasic nature. The first stage may have an acute Vitaminotherapy is widely used. The combination
onset with marked prevalence of pain or develop of vit. A with vit. E (in the Geritamin preparation), vi-
gradually for 2 to 6 months with painful dysfunction tamins B1, B2, B12 (as well as the newer preparations -
of the shoulder and widening swelling with stiffness Milgamma, MilgammaN, Thiogamma, Benfogamma).
of the hand and fingers. The next, second stage also The usual analgesics - Analgin, Aspirin, Paracetamol
lasts between three and six months and can be seen and combined preparations - Benalgin, Tempalgin,
as a backward development because the pain and Saridon, are included in the therapy. Due to the met-
dysfunction in the shoulder area is noticeably weak- abolic disturbances and the possibility of osteopo-
er, and the swelling of the hand is noticeably drop- rosis changes in chronic development, anabolic and
ping (but improvement is apparent). With the entry calcium preparations are applied.
into the third stage, the trophic disorders in the area In the treatment plan, anti-inflammatory drugs
of the
​​ arm stand out. Limited flexion and stiffness of can also be taken with the NSAIDs - Indomethacin,
the fingers persist, and in some patients there are Sulinac (Clinoril), DiclofenacNa (Voltaren, Feloran), Di-
muscle contractions of the flexors and consequent clofenacK (Cataflam, Aulin, Niflural, etc.) Neurological
long-term contractions of the fingers, which some- therapy - the use of Novocain, Novoplex, Lidocain in-
times resemble the Dupuytren's contracture. There tramuscularly, intradermally or in layering.

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VEGETATIVE POLYNEUROPATHY
6.2 FROM OVERINTENSION OR
MICROTRAUMATISM (ICD-X-90.0)
In general, polyneuropathy combines diseases of neuritic) type pain for upper limbs;
the peripheral nervous system of a dystrophic na- • trophic disorders of the nails and the skin of
ture caused by exogenous or endogenous factors the palms and fingers.
(infections, toxic, malignant, dysmetabolic, genet- Objectivity is done by capillaryscopy or resp. cap-
ics. Multiple damages to the peripheral nerves (pre- illarygraphy, skin thermometry, cold test with initial
dominantly to their distal parts), where there is no temperature recovery, dynamometry, white spot
evidence of an inflammatory process, are expected. test (Lanyell-Lawastin), distal doppler flowmetry,
However, their difficult differentiation from inflam- X-ray of wrist's joints and fingers, electromyography,
matory polyneuropathies has given some authors cold stress test, polarization current study, investiga-
reason to speak of vegetative polyneuritis. tion of intensity of pain and more.
The vegetative pathology of the upper extremi- Stages of the disease. The mild degree is char-
ties of overtension encompasses a group of diseas- acterized by mild paresthesia pain, morning swelling
es affecting the extreme vegetative periphery and, and stiffness of the fingers, humidity of the palms,
most importantly, the neurovascular network of the objective signs of angiospastic syndrome of a tran-
wrists. Depending on the preferential involvement sitory nature.
of the peripheral structures, they are divided into The middle stage is characterized by pronounced
neurovasal and neurotruncal. and persistent symptoms. Paresthesias and pains in-
Etiology. Neurovegetative lesions of overtension tensify, swelling and hyperhidrosis become visible,
are observed in professions mainly with a uniform the lace pattern is pronounced. They appear and at-
manual work requiring rapid and frequent movements tacks from "pale" fingers. Muscle strength is reduced,
at physical overtension. Professionally threatened are distally increasing hypoesthesia is convincing.
most often bookbinders, cardboard workers, milkers, Severe stage is characterized by worsened, per-
carpet-weavers, knitters, ironers, polishers, grinders, as manent subjective complaints. To the objective find-
well as stenographers, telegraphists, typists, pianists, ing, talking about predominantly anthony or even
violinists. For the development of the disease, the irra- vasoparesis, trophic disturbances are added. The at-
tional organization of labour, the inappropriate physi- tacks of "dead" fingers increase.
ological amplitude, the disturbed optimum of working In the differential diagnosis, the other manifes-
movements, the static and dynamic overtension and tations of vegetative disabilities in occupational dis-
especially the increased traumatisation of the periph- ease - vibration disease, cold polyneuropathies and
eral neurovegetative and vascular substrates play a professional toxic factors (lead, vinyl chloride, mer-
significant role. cury, organic compounds, etc.) must be taken into
Pathogenesis. Permanent mechanical microtrau- account at first. The consequences of a number of
ma lead to recurrent microreactions of neuro-vascular systemic disorders (collagenosis, dysmetabolic pol-
net - vasospasms or vasodilatation due to blood flow im- yneuropathies, endocrinopathies, atherosclerosis,
pulses on the vascular wall. Consequences of these are etc.) should be distinguished. It is known that the
abnormal vascular reactions, pathological axon reflex- vegetative nervous system can be damaged in all
es, chain-amplifying, permeability disorders, swelling, forms of collagenosis, but it is most often afflicted
tissue dystrophy. The ultimate result is the deformation with nodular periarteritis, lupus and dermatomyosi-
of the capillary wall, the changes in the capillary net, tis, and rarely with scleroderma, rheumatoid arthritis
well perceptible by capillaryscopy and capillarygraphy. and true rheumatism. Dysmetabolic polyneuropa-
Clinical picture. Subjective syndrome occurs thies that occur as a result of impaired metabolism
with paraesthesias (thirst, tingling), pain, sweating, in some somatic diseases: diabetes, renal and hepat-
coldness, swelling of the fingers and wrists. ic failure, endocrine disorders, etc., should also be
Objective finding: considered. Apart from the endogenous toxic factor
• vegetative and vascular changes, hyperhidro- in the pathogenesis of some dysmetabolic polyneu-
sis, change in skin color (lacy pattern, mar- ropathies (diabetes, liver), B1 vitamin deficiency is
bled), puffiness of palm and fingers; attributed, and in others (amyloid, porphyrin, etc.) -
• reduced sensation of touch and distal (poly- genetic factors with a clear or unspecified metabolic

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 OCCUPATIONAL MEDICINE
defect. Alcoholic polyneuropathy is of particular in- calcium, combined with vitamin C, peflavit is admin-
terest due to its marked increase in recent years due istered. In all phases, B vitamins are indicated. The
to the widespread prevalence of alcohol abuse. In Dibazole is used as a neuronal stimulant, especial-
pathogenesis, an important role plays the deficit of ly in the vasoparalytic phase. Novocaine drugs are
(vitamin B1, B6 and PP) as well as impaired absorption used as trophotropic drugs. Physiotherapy includes
of proteins and carbohydrates due to gastrointesti- kinesitherapy, electrotherapy (ionization and galva-
nal lesions. As polyneuropathies, the early stenosis nization, ionophoresis with iodine, calcium, novo-
processes of the vessels (atherosclerosis, obliterat- caine), ultraviolet irradiation, diathermy, hydrother-
ing endarteritis) can also be manifested. apy, massage, gymnastics, passive movements to
Epicondylosis, dystrophic changes in the spine activate peripheral circulation.
(spondylosis, spondylarthrosis and osteochondro- Employability.
sis) also give vegetative disorders in the upper limbs. Slight degree - the ability to work is preserved. If
Polyneuropathies may be confused with cases of necessary, temporary disability up to 20 days.
acrocyanosis and erythropelalgia. Middle degree - temporary disability up to 30
Treatment. In the early stages of spasticity, vas- days, followed by 6 months of retraining or requalifi-
odilators: vasolat, nicotinic acid, papaverine, and in cation (in individual cases - disability group).
some more persistent cases - dillinal or dusodryl are Severe degree - compulsory reemployment. Re-
used. In the dilation phase ephedrine, vasotone is tirement from work experience (disability group in
used. Against permeability disorders, routascorbine, the absence of such possibility).

DISEASES OF OVERTENSION
6.3 OF THE MUSCULOSKELETAL SYSTEM

In the group of occupational diseases of overten- spinners, hand knitters, grinders, hand-made polish-
sion, the nosological forms related to the defection ers, painters, cutters, loaders, digger, crane-opera-
of various parts of the musculoskeletal system (MSS) tors and others.
are significant. Spondylosis, osteochondrosis (ICD-X-M43.C
The prevalence of musculoskeletal pathology also - M47.8). Degeneration of intervertebral discs
is related to the degree of use of systematic manu- is a result of age-related changes and external over-
al labour in a number of manufacturing industries, loads. Nucl. Pulposus loses its elasticity, reduces its
characterized by high intensity, numerous, frequent volume, affects the intervertebral joints and narrows
and monotonous recurrent upper limb movements, the intervertebral spaces. Spondylosis develops as
conveyor-type rhythm, static overtension of the kin- a result of a local degenerative process of the out-
ematic chain hand-arm. er layers of the fibrosis ring. Spondylarthrosis is the
These overtension factors, however, are condi- most common in the cervical and lumbar segment.
tional nature, individual reactivity is important. Clinical picture. Degenerative changes in the
Numerous studies of researchers not only in our spine may persist asymptomatically or may be man-
country are dedicated to musculoskeletal disorders ifested clinically with various manifestations and
of overtension with a characteristic tendency of with periods of remission and exacerbation.
lack of specific nosological interpretation of most Lumbar osteochondrosis is common, chronic,
of these disorders, but instead are used generalized with lumbago, lumboischialgia, and ischioneural-
concepts such as RSI (repetitive strain injury), overuse gia. The lower spine is subjected to heavy loads and
syndrome, cummulative trauma disorder, occupation- volume of movements. Sharp movements, lifting
al cervicobrachial disorder, and others. weights favor the exacerbation of radiculopathy.
Workers in many professions and industries are People at risk such as hard labour workers such as
especially vulnerable to the development of such dockers, loaders, carriers, metallurgists, rollers, exca-
disabilities: washing machines, ironing machines, vators and exposed to general vibration. The effect
packers, labels, boxes, typists, bookbinders, press- of physical overload on structures rich in receptor
es, carpets, pianists, violins, production counters, terminations results in the occurrence of reflex syn-
hand weavers, stampers, telegraphs, keyboards, dromes. As a result, reflex muscular tension, reflex
draftsmen, hand-made cigarette packs, shoemakers, vasomotor or vegeotrophic disorders, persistent dif-
conveyor-makers, masonry makers, stoners, miners, fuse pain occurs. The clinical picture can also be seen

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in the image of a discal hernia with root syndrome Treatment and labour expertise. Treatment
depending on the level of damage most common at with non-steroidal anti-inflammatory drugs and
L4, L5 and L5 - S1, due to the narrower space of the physiotherapy is carried out, after which it is appro-
latter, the thicker roots emerging at corresponding priate to work without loading the affected joint.
holes and the increased load on this segment. Diag- Periararthitis. Humeroscapular periarthritis
nosis is placed radiographically with radiograms in (ICD-X-M75.0) is a collective concept of a number
profile, front and oblique projections, the paraclinic of diseases in the area of the​​ shoulder joint - includ-
shows deviations from the norm. ing capsular, insertion, tendon stenosis muscular
Professionally-determined degenerative changes lesions, lesions of periarticular bursae - deltoid bur-
in the spine have a gradual onset, occur with periods sitis, calcural bursitis, subacromial bursae. Each form
of remission, and exacerbations are associated with has its own topographical and pathological anatom-
overtension, and radiological signs are early - they ical features, but similar clinical picture and disorder
usually occur before the age of 40. They need to be of hand function.
distinguished from some other groups of degenera- Risk contingents are operating under condi-
tive diseases - congenital dysplastic malformations, tions of prolonged muscular tension on the shoul-
affecting the disc under the influence of other caus- der girdle and increased volume of movements in
es - hernia, Schmorly corpuscles, M.Baastrup, inflam- the shoulder joint area - endangered occupations
matory diseases of the spine, bone-tumors, metasta- include weavers, blacksmiths, fitters, turners, ship-
ses, M .Paget and others. builders. Clinically, it is manifested with a gradual on-
Treatment is primarily rest, thermal procedures, set, soreness in the shoulder, strengthening with ro-
careful massage, non-steroidal anti-inflammatory tation in the shoulder joint, lifting of the arm above
drugs and local Lidocaine therapy - neural therapy. the horizontal level, with irradiation of the pain to
Expertise - The patient has to break away from work the neck and the scapula. Some movements, espe-
for at least 2 weeks or 1 month during treatment, cially internal rotation and retroposition, are limited,
then it is appropriate to be labour-readjustment at while the pendulum movement back and onward
work with no overtension and forced posture for along the body is preserved. In advanced cases, the
several months. The lifestyle is related to the regular limitation of movement is greater to the extent of
healing physical drill (HPD), physiotherapy and mas- complete immobility in the joint, and this favors the
sage. development of hypothrophies in adjacent muscles,
Arthrosis and periarthritis (ICD-X-M16 and bone osteoporosis, trophic disorders.
M18). It is the most common chronic disease of Diagnosis is determined clinically and radio-
the musculoskeletal system. Normal degenerative graphically. Radiographic features are common in
changes in joints expressed in varying degrees in the these cases calcium deposits in the subacromial and
elderly. In some professions, however, their earlier subdeltoidal bursa and other periarticular tissues,
appearance and wear of joints are characteristic due destruction and sclerosis of the large humeral tuber
to chronic microtrauma and overtension. Risk con- (periarthritis, however, may be clinically manifested
tingents for this are dockers, loaders, miners, stone- and without radiological features).
masons, blacksmiths. Deadlines for wear of cartilage Treatment. Suitable HPD, physiotherapy and
and appear clinical signs of arthrosis vary widely non-steroidal anti-inflammatory drugs. Appropriate
depending on the degree of mechanical discrep- rehabilitation is due to the tendency of periarthritis
ancy - from several months to several years. This is to chronic course and exacerbation.
important in the differential diagnosis of profession- Tendomyositis (myo-tendinosis) (ICD-X-M
ally determined arthrosis of other types of arthrosis 60.8). The damage is in the muscle-tendon transi-
and age-related changes. Professional arthrosis usu- tion, in the middle third of the forearm, most often
ally affects the congested joint, for example, gonar- affects the hand extensors, among the occupational
throsis in parketters and mosaics; omarthrosis and disabilities of the MSS is the highest incidence - in
arthrosis of the elbow joints of concretors, turners, our country 58% of all diseases of the MSS for the
miners, interphalangeal arthrosis of knitters, milkers, period 1986-1988.
pressers, miners, etc. Age arthrosis usually occurs Risk contingent - hand knitters, fitters, seamstress-
after the age of 40 slowly, gradually with moderate es, typists, locksmiths, turners, bricklayers and others.
degenerative joint changes affecting more joints - Clinically, it is manifested with constant soreness
polyarthrosis. Distinction from inflammatory diseas- in the forearm, chronic pain syndrome, increased
es of the joints - arthritis. Differential diagnosis is also pain in active movements, or palpatory pressure in
made with some out-joints illnesses such as radiculi- the area of ​​the muscle-tendon connection, swelling,
tis, periarthritis, etc. increased muscular consistency, increased density

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and crepitations. Diagnosis is based on the clinical sor muscles of the forearm, caused by forced fore-
picture and EMG data for damage to affected mus- arm movements, mainly supination and pronation,
cles. Differential diagnosis - with conditions associat- as well as when the extensor muscles are placed in
ed with myalgia and muscle weakness, e.g. systemic a tense position. It is also often seen in tennis play-
diseases of collagen and connective tissue - most ers ("tennis elbow"). It is clinically manifested with
often polymyositis, rheumatoid polyarthritis, rheu- pain in the area of ​​the lateral epicondyle, radiating
matic polymylagia, menopausal arthritis, some neu- from the dorsal side of the forearm. Here are some
rological diseases - peripheral nerve lesions, com- functional tests to prove weakness in the extensor
pression syndromes (supinatorial and pronatorial), muscles of the forearm - a Thompson test, a chair lift
cervico-arthrosis with root irritation, Pancoast- Tobi- test, or a telephone (practiced by French authors),
as syndrome, Parsonage-Turner syndrome, muscu- where sudden pain occurs in the lateral epicondyle.
lar dystrophies, damage to certain drugs, and local The illness may resolve for 2 weeks in mild cases, but
muscular lesions associated with frequent healing sometimes the symptoms may last up to 2 years or
manipulations (intramuscular injections). more. Conservative treatment is with novocain local
Myositis (ICD-X-M60.8, M61.0). This group in- blockades, physiotherapy, massage of affected mus-
cludes inflammatory processes in the muscle inter- cles, immobilization in gypsum dressing for about 6
stitium and is manifested by exudation, cell prolifer- weeks.
ation and sclerotic alterations. They are associated Aseptic necrosis (ICD-X-M93.1). Among the
with unfavorable work and chronic microtrauma. professional osteonecrosis, the most common are
The most common changes are in the shoulder mus- those of some of the bones of the wrist - os lunatu-
cles, the flexors and the extensors of the wrist and mand os scaphoideum (naviculare).
fingers. With more marked changes, seals of varying Aseptic necrosis of os lunatum, M. Kienbök-Pre-
degrees and sizes, mostly with oval shape - so-called iser, lunatomalacia.
myogeloses, are formed (some authors separate Risk contingent - turners, miners, woodworkers,
them as a self-esteem disease - myositis ossifying). crane workers, working with vinyl chloride (tox-
Myositis also occurs in athletes. The clinical picture ic damage), i.e. at work primarily associated with a
of myositis is dominated by pain symptom. load in the os lunatum area of the​​ wrist resulting in
Tendovaginitis, insertionitis. Dystrophic and pathological changes. There is a breakdown in blood
inflammatory diseases and tendon processes, out- supply and bone nutrition and dystrophic chang-
side of the transition to the muscle or the insertion es therein. Clinically, it develops with moderate to
part, are manifested with extensive clinical symp- severe pain in the wrist joint, increasing in motion
toms. From the etiological point of view, particular and pressure in the area of ​​os lunatum. Often, active
attention is paid to the effects of traumas and micro- and passive volar and dorsal flexion are limited. Ra-
traumatism in working conditions. diologically, aseptic necrosis of the os lunatum is es-
The disease of de Quervain (MKB-X-M65.4, tablished - a focal point of enlightenment and bone
M70.9) was described in 1885 and means still sten- sealing. Later, deforming arthrosis may develop in
otic ligamentitis, styloiditis, chronic tendovaginitis. the carpal bone area.
Disease is etiologically associated with prolonged mi- Treatment. Prolonged immobilization - several
crotrauma, combined with overtension, and is often months in gypsum bandage to the elbow joint, cov-
seen in tailors, pianists and other occupations. Clini- ering all fingers, physiotherapy, vitaminotherapy.
cally characterized by slow, gradual onset, spontane- Change of work - work without load on the wrist.
ous pain in the distal part of the forearm and the area Aseptic necrosis of os naviculare. It is less com-
of p
​​ roc. styloideus radii emitted to the toe. The trigger mon than lunatomalacia, usually associated with
point is proc. styloideus radii, and the movements that hard work and frequent movements in the radial
cause pain disturbances are thumb abduction and ul- carpal-joint, vibration - grinders, polishers, builders.
nar abduction of the hand in the wrist. The grasping It occurs with piercing pains, often at night, which
ability of the hand with the thumb is disturbed. initially occur gradually, but after about 2-6 months
Treatment. In case of failure of conservative they become strong and permanent, with swelling
treatment and physiotherapy, surgery is usually per- in the joint, sometimes with deformity. X-rays are
formed with good effect. similar to lunatomalacia.
Epicondylitis (ICD-X-M77.1). The most common It is necessary to distinguish them from the pri-
diseases in the elbow joint region are the radial and mary traumatic fracture of os naviculare - the frac-
ulnar epicondylitis. ture does not cover all the bones, and there is a for-
Radial epicondylitis - the lesions are expressed mation of adjacent pseudarthrosis. Treatment and
in single or multiple tears at the locus of the exten- rehabilitation - as in lunatomalacia.

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6.4 COORDINATION DYSKINESIAS

Coordinator dyskinesias are diseases with basic awkwardness, weight in the hand when performing
syndrome motor disorders, selectively affecting only precise movements, change in handwriting - the
specific professional movements requiring precision letters become distorted and illegible. Writing be-
and control that become awkward or impossible. comes painful, with pain and peculiar posture on the
The etiology of coordinate dyskinesias is not fully fingers of the hand - crushing the pencil strongly in
understood as professionally determined diseases in a typical way. Occasionally, rising the tonic stress of
most cases are etiologically associated with overten- the muscles of the 1-3 fingers of the hand and the
sion of certain kinematic chains committed to per- perronator muscles of the wrist, sometimes to the
forming rapid, repetitive movements with great athetosis-like cramps of the fingers, which can not
precision and fine coordination, performing rapid be overcome voluntarily. Similar spastic forms of
and accurate manipulations of workers in the case focal dystonia with other localization have been ob-
of shortage and increased responsibility. Threatened served, though less frequently, in the occupational
occupations include handwriting employees, secre- overload of other muscles or kinematic chains - eg
taries, stenographers, keyboards, teletypists, teleg- laryngospasm with aphonia, spasm of m. orbicularis
raphers, musicians, singers, dancers, handheld coun- oculi in clockmakers, cramps of m. triceps surae in
ters, milkers and knitters, drivers and others. drivers and others.
The most common professional coordinated Despite the violations of the precise specific
dyskinesia is graphospasm, writer's cramp. "Clerk's movements that are characteristic of a profession-
cramp" are a type of focal dystonia and are included al activity, the other hand movements are retained.
in the group of focal dystonias along with blepharo- Disturbances, however, are observed in other types
spasm, oromandibular dystonia, torticollis and spas- of activity, eg. related households and self-care that
tic dysphonia. As a relative share they are more than are similar in character, accuracy and precision to
half of all forms of focal dystonia. Affect men and injured professional movements - holding a sewing
women equally often and develop between 30-40 needle and sewing, shaving with a razor, serving a
years of age. Combinations between some of them, spoon next to the mouth, knitting a knot, winding
e.g. torticollis with tremor or with clerk's spasm or a clock, etc.
graphospasm with tremor. Diagnosis is based on the clinical picture, the ab-
Pathophysiological mechanisms are unclear. sence of another organic neurological disease that
Although a known hereditary predisposition is sus- could be the cause of the disorder, the data from
pected, the current understanding of these condi- the occupational program for prolonged work ex-
tions is that they are a form of focal dystonia asso- perience, and the performance of work related to
ciated with task-specific dystonia. No organic brain systemic microtrauma and overtension of certain
damage is detected, but cortical neurodynamics is muscle groups. In an electromyographic study, the
impaired - there is a pathological afferentation and bioelectric activity driven by wrist flexors and exten-
efferentation from a modified motoric zone of the sors during writing shows a bursting of bursts at a
cerebral cortex that selectively engages the kine- frequency of about 5-8 Hz and alternation in the two
matic chain of the working hand, the dynamic ste- muscle groups. Similar results are susceptible to the
reotype is disturbed. Typical relapse of stress and extra-pyramidal nature of the injury.
improvement during silence and relaxation, also Differential diagnosis is made with other dis-
meaning have psychotrauma. Electrophysiological eases of the nervous system and muscles - diseases
studies show abnormally prolonged activity of the of the peripheral nervous system (polyneuritis, rad-
muscle fibers involved in writing, but also increased iculitis). In some other occupational diseases of the
activity of adjacent muscles not included directly in musculoskeletal system such as myalgias, myositis,
the task, as well as a change in the EEG amplitude of epicondylites, there is also stiffness and awkward-
the record of the motor cortex zone, corresponding ness in the fingers of the hands (but there is also
to the affected hand. swelling in the wrist joint, crevices, radiographic ev-
Clinical picture. The illness was first described idence of epicondilitis). Chronic mercury poisoning,
in 1831 for long-term clerk workers. At first there is in which there is a fine, small tremor of the fingers,

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can be misleading in its early stages, but the tremor medication, appropriate relaxing acupuncture and
also includes eyelids, tongue, lips, and the mercury physiotherapy, as well as various techniques of bio-
test in biological fluids is crucial. Differential diag- logical feedback by means of EMGmethodics. Diaz-
nosis should be made with organic lesions of the epam, clonazepam, anticholinergic agents are used
strio-pallidar system - torsion dystonia, hepatolenic- to treat spasms and pain. The prospective treatment
ular degeneration. Parkinsonism, essential tremor, with botulinum toxin A injected into the affected
cerebellar ataxia, etc., also with chronic mercury poi- muscles is about 12 weeks effect. Appropriate re-
soning (fine tremor). cruitment and in severe clinical cases determine the
Treatment and rehabilitation. The complex ap- degree of disability, as patients are fit for almost any
proach is the removal of the etiological factor and, other type of work.
at the same time, the use of analgesic and sedative

REFERENCES

1. Adams R. D., Victor - Tremor, Myoclonus, Spasms and Tics in: Principles of Neurology, 2nd ed., 1981,
USA, Ch. 5,69-80
2. Alexyev B., St. Kozarev, K. Pernov, Occupational diseases of overtension in Professional pathology,
ed. Tsv. Alexieva, Kr. Kiryakov, Med. and phys., Sofia, 1982, 218-250 (in bul.)
3. Arthamonova V.G., N.N. Shatalov - Professional diseases, Medicine, Moscow, 1988 (in russ.)
4. Baykushev St. - Clerk's cramp in: Clinical Electromyography, 1987, 115-116, MF, Sofia (in bul.)
5. Behari M. - Botulinum toxin in the tretment of writer, with cramp. - J Assoc. Physicians India, 1999, Jul.,
47 (7), 694-8
6. Bojinov S. B .: Differential Diagnosis of neurological diseases. ed. N. Antonov and S. Bojinov, Med. and
phys., Sofia, 1980 (in bul.)
7. Bojinov S. - Polyneuritis and polyneuropathies. Med. and phys., Sofia, 1984 (in bul.)
8. Bosnev V., I. Mattev, Diseases of the hand Med. and phys., Sofia, 1989, 255 (in bul.)
9. Cohn L., R.M. Lowry, S. Hart - Overuse Syndromes of the upper extremity in interpreters of the deaf.
Orthopaedics, 1990, 13/2, 207-209
10. Dimberg L., Olafsson A., Stefansson E., Aagaard H., Oden A., Andersson G.- The correlation be-
tween the working environment and the occurrence of cervicobrachial symptoms.JOM , May, 1989, Vol. 31,
447.
11. Holevich Y. Clinical orthopedics, Med. and phys., Sofia, 1988 (in bul.)
12. Johansson K., Sjolander P., Djupjbacka M. - Pathophysiological mechanisms behind work-related
muscle, pain syndromes. I am. J. of Industrial Medecine, 1999, Sep., Suppl. 1, 104-6.
13. Kaji. R. - Facts and fancies on writer's cramps (commentary) (editorial). Muscle-Nerve, 2000, Sep. 23
(9), 1313-5, 1335-43
14. Marsden C.D., Sheehy M.P. - Writer, with Cramp in: Trends Neuroscience, 1990, 13, 118-153
15. Mumenthaler M. - Der Schulter-Arm-Schmerz. Hans Huber Verlag, Bern, 1980
16. Murase N., Kaji R., Shamaz H., Katayama-Hirota M., Ikeda A. - Abnormal conversion of somatosen-
sory input into writer, with cramps. Brain, 2000, Sep., 123 (Pt9), 1813-29
17. Riihimaki H., E. Viikari-Yuntura. Musculoskeletal System. In Encyclopaedia of Occupational Health
and Safety, ed. J. M. Stellman 4th ed., Vol. 1 - ILO, Geneva, 1998, 6.2-6.29
18. Sheytanov Y. - Osteoporosis, Magenta, Sofia, 1994 (in bul.)
19. Shindo Ts. - Decreased sympathetic outflow to muscles in patients with cervical spondylosis. ActaN-
eurol. Scandinavica, 1997, 96 (4), 241-6
20. Toro C., Deuschl-G., Hallet M. - Movement-related electroencephalographic desynchronization in
patient with hand cramps: evidence for motor cortical involvement in focal dystonia. - Ann. Neurol., 2000,
Apr. 17 (1), 156-61
21. Zekin K. Professional neurological diseases of overtension. In: Professional neurological diseases. ed.
Kr. Kiryakov, Med. and phys., Sofia, 1990, 33-79 (in bul.)

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7
Iv. Dikov, V. Boeva

PROFESSIONAL INFECTIOUS
AND PARASITIC DISEASES
Iv. Dikov

7.1 BACTERIAL AND VIRAL

INFECTIOUS DISEASES

I. Bacterial Infectious Diseases Prevention: with a spore vaccine JTI applied to

risk contingents - veterinarians, zootechnics, etc.
ANTHRAX
Anthrax is an acute infectious disease occurring BRUCELLOSIS
most often as skin, more rarely as intestinal or pul- Acute infectious disease with polyorgan damage
monary forms. and tendency to protracted and chronic flow.
Etiology: Bacillus anthracis - spore-forming aer- Etiology: Human pathogenic Brucella bacteria:
obic bacteria. Brucella melitensis, Br. abortus suis, Br. abortus bovis.
Epidemiology: Typical zoonosis - source are sick Epidemiology: zoonosis - the human infection is
animals. One is infected with direct contact with in contact with sick animals or the consumption of
them, more rarely when consuming meat from dis- raw milk from them. Professionalism has the disease
eased animals or inhaling dust containing anthrax for agricultural workers, livestock farmers, meat in-
spores. This determines the occupational risk: farm dustry workers, veterinarians and technicians. Labo-
workers - livestock breeders, shepherds, veterinary ratory infections are also possible.
surgeons, zootechnics and processing wool, prod- Pathogenesis: after the initial phase of multipli-
ucts of animal origin (bones, horns, hooves, etc.). cation in the monocyte macrophage system, haema-
Pathogenesis: serous- haemorrhagic and ne- togenic dissemination develops with polyorganic
crotic inflammation develops at the site of penetra- damage mainly to the CNS, the locomotory system,
tion of the agent. Role is also the endotoxin. the lymph nodes and the heart.
Clinical picture: Incubation period 2 to 8-12 days. Clinical picture: Incubation period of 7 to 21
The most common is the skin form with the forma- days. Toxico-infectious syndrome with an ondula-
tion of a typical pustule with bluish-brown contents tion temperature curve, generalized lymphonodu-
and subsequent central necrosis. There may be gen- lopathy, hepatosplenomegaly, marked tendency to
eral toxo-infectious manifestations. The pulmonary protracted and chronic course. Common meningitis,
form develops like severe haemorrhagic pneumonia polyneuritis, arthritis, endomyocarditis and other or-
with acute respiratory failure and the intestine as a gan manifestations.
severe haemorrhagic destructive enterocolitis. The diagnosis is based on epidemiological and
Diagnosis is based on epidemiological data, oc- clinical data and is confirmed by serological meth-
cupation, clinical data, and is confirmed by the b. an- ods - the Wright and Huddlesson agglutination reac-
thracis isolation of pustule, sputum, feces and blood. tion. The isolation of the causative agent is possible
The skin form must be distinguished from staphylo- but more difficult.
derma (furunculus). The prognosis is serious, espe- Prognosis - serious, especially in chronic form.
cially in the intestinal and pulmonary forms. Treatment: hospitalization, bed rest. Etiological
Treatment: compulsory isolation in the infec- treatment with antibiotics - from I order: Doxycy-
tious ward. Etiological antibiotics of I order: penicillin cline - 2 x 100 mg. oral, or Tetracycline - 3 x 100 mg.
- at a dose of 4 to 12 IU/day for a period of 7-10 days. muscle or Tetraolean 3 x 100 mg/day for 10-12 days.
Alternative preparations: cephalosporins of II-III p. It is good to combine with aminoglycosides: Strep-
Heterologous anti-anthrax antibacterial serum - 50- tomycin, or Chloramphenicol.
100 cm3, by the Bezred method. Several such healing courses should be conducted.

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Prophylaxis: specific - with a live vaccine that has drome, pronounced myalgias, two-wave tempera-
not yet been administered to humans. ture curve, hepatic lesion with jaundice, renal - acute
renal failure, serous meningitis, hemorrhagic syn-
ERYSIPELOID drome, rare skin rashes.
An acute infectious disease with specific skin Diagnosis - based on epidemiological and clini-
changes. cal data, is confirmed by changes in the hemogram -
Etiology: Erysipelothrix rhusiopathiae suis. BSR-induced leukocytosis at the onset of the disease
Epidemiology: zoonosis with source of diseased and with serological response - lysis-agglutination
animals - pigs. One is infected with direct contact (after the eighth day). Rather, leptospira in urine and
with the diseased animal. Occupational risk is the blood (with direct bacterioscopy) can be proven.
pig-tenders, veterinarians and zootechnics. Contam- Forecast: Generally good, more serious in ictero-
inants and contact with fish are described, which hemorrhagic form.
may cause illness and work in fish processing plants. Treatment: hospitalization, etiological treatment
Pathogenesis: In the place of the front door - with antibiotics. From I order: Penicillin - from 4 to 12
usually the skin of the fingers develops a serous, IU/day for a period of 10 days. Alternative prepara-
rarely pungent inflammatory process. Hematogenic tions: tetracyclines or chloramphenicol. Pathogenet-
dissemination is rare. ic treatment of acute renal failure and hepatoprotec-
Clinical picture: Incubation period of 1-3-7 days. tive agents.
Acute onset with a common toxigenic syndrome, Prevention: no specific. Use of work clothing
edema and severe hyperaemia of a restricted skin when working in water or in underground condi-
spot, most commonly on the fingers. Pain expressed. tions.
The septic form is rare.
Diagnosis is based on epidemiological and clin- TETANUS
ical data. Acute infectious disease involving NS and typical
Differential diagnosis with erysipelas, staphylo- seizures.
coccus or streptoderma. Etiology: Clostridium tetani.
Prognosis - good. More serious - in septic form or Epidemiology: Wound infection from tetanus
rare complications such as endomyocarditis. spores in wounds with anaerobic conditions. Profes-
Treatment: can also be done at home. Etiological sional is the disease of agricultural workers, livestock
treatment with antibiotics - from I order: Penicillin - farmers, gardeners, construction workers, excava-
from 1 to 4 IU/day, for a period of 5-7 days. Alterna- tors and others.
tive preparations: erythromycin or tetracyclines or Pathogenesis: One of the ingredients of tetanus
chloramphenicol. Local treatment with compresses exotoxin - tetanospasmine has pronounced neuro-
with Vishnevski ointment or rivanol solution. tropic activity, suppressing the retention processes
Prevention: no specific. Personal hygiene and in neuromuscular synapses due to increased glycine
use of gloves when handling fish and meat. secretion.
Clinical picture: Incubation period of 1-4 days
LEPTOSPIROSES to several months. After prodromal signs from the
Acute infectious diseases with general intoxica- wound - the entrance door, muscle stiffness devel-
tion and polyorganic damage. ops with trizmus, risus sardonicus, abdominal rigid-
Etiology: Leptospirosis of fam. spirochetes. ity, high fever, fulsome sweating, and finally with te-
Epidemiology: zoonoses. Source are animals tanous seizures.
and the mouse rodents. One is infected with bath- Diagnosis - based on epidemiological and clini-
ing, wading in ponds contaminated with excreta of cal data.
animals and rodents. Rare infection can also occur Prognosis - very serious. High lethality, especial-
through conjunctivae. There are diseases among ly in adult patients and those with a short period of
farmers, livestock breeders, slaughterhouse workers, time from the onset of the disease to the onset of
excavators, miners and other underground workers, first seizures.
as well as veterinarians and zootechnics. Treatment: mandatory hospitalization in inten-
Pathogenesis: After insertion, leptospires dis- sive care unit, relaxing regimen, feeding tube nu-
seminate haematogenically and cause polyorganic trition. Etiological treatment: with antibiotics from
damage, primarily of the kidneys, the CNS and the I order - Penicillin - 4-8-12 IU/day for a period of
liver. 10 days. Alternative preparations: cephalosporins,
Clinical picture: Incubation period from 6 hours ampicillin. Second place as etiological treatment:
to 20 days. Acute onset with common toxigenic syn- hyperimmune human immunoglobulin at a dose

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of 6 to 8000 U muscular or antitoxic heterologous cially those from the pulmonary and septic forms.
anti-tetanic serum - 100-200,000 U, by the method Pathogenesis: Inflammatory process of the
of Bezredka. Pathogenetic treatment with oxygena- lymph nodes develops at the place of introduction
tion, sedative agents, neuroleptics, if necessary, and with the formation of pest "pimples". From drop in-
apparatus ventilation. fection - severe haemorrhagic-necrotic alveolitis.
Prophylaxis: with specific tetanus toxoid - in the There may also be primary or secondary haemat-
DTC vaccine in childhood and as monovaccine in ogenic dissemination.
adults over 60 years of age. Clinical picture: Incubation period ranging from
6 to 10 days. Acute onset with marked toxigenic syn-
TULAREMIA drome. Plague bubones are solid, painful, merging
Acute infectious disease with a polymorphic clin- with surrounding tissues, often maturate and ulcer-
ic, with predominantly lymph node involvement. ating. Pulmonary plague is a very severe haemor-
Etiology: Francisella tularensis. rhagic pneumonia with acute respiratory failure and
Epidemiology: zoonosis - humans get infected poor evolution.
by direct contact with sick wild animals, rarely while Diagnosis: based on epidemiological and clinical
domestic animals are manipulated with their skin. data. Confirmed by the isolation of the agent from
Rarely, contamination can also occur after a tick bite. the bubonic content, blood or sputum.
Occupational nature is the disease for hunters, for- Prognosis: very serious, especially in pulmonary
est workers, leatherworkers and animal by-products, and septic forms. Treatment: obligatory isolation,
rabbit-farmers, and veterinarians and zootechnics. strict bed rest, observing all measures for handling
Pathogenesis: Serous-purulent inflammation, particularly dangerous infectious disease: special
especially lymph nodes, develops at the site of the protective clothing, rubber boots and gloves, mask,
infections. Generalization with septic forms can also safety glasses. Etiological treatment with antibiotics
occur rarely. - in combination with Chloramphenicol up to 4 g/
Clinical picture: Incubation period of 1-7-14 day + Streptomycin - 2-3 g/day + Tetracycline - 4 g/
days. Acute onset of general toxigenic syndrome. day for 10-15 days. Pathogenetic treatment. Preven-
Most common is the bubonic form with the devel- tion: specific - with a live antipest vaccine. Apply to
opment of "botons" - painless, non-growing, non-ul- risk contingents and in an epidemic situation.
cerated lymph nodes. Eye-bubonic, skin, pulmonary,
septic forms are rare. TUBERCULOSIS *
Diagnosis: based on epidemiological and clinical Tuberculosis is an infectious disease that can be
data. Confirmed with serological tests - agglutina- professionally dependent under certain conditions.
tion reaction with specific antigen and ELISA immu- Etiology: Tuberculosis in humans is caused by
noassay. two major types of tuberculous bacteria: human (ty-
Prognosis: Good, more serious in septic form. pus humanus) and bovine (typus bovinus) type. As
Treatment: hospitalization, bed rest. Etiological an aerobic bacterium, it is best developed in the lung
treatment with antibiotics - from I order: Strepto- parenchyma, so the pulmonary form, both in the do-
mycin - 1 g/d, tetracyclines such as: Doxycycline - 2 mestic and in the professional aspect, is the most
x 100 mg daily oral or Tetracycline - 3 x 100 mg in- common. This does not exclude other, extrapulmo-
tramuscularly for 10 days. Alternative preparations: nary localizations of tuberculosis to be etiologically
aminoglycosides or chloramphenicol. related to the occupation of the ill.
Prophylaxis: specific for a vaccine. Precautions Epidemiology: two main sources of occupa-
for handling animals - use of gloves. tional contamination - tuberculosis patients; tuber-
culously diseased domestic animals (cattle, pigs,
PESTIS horses, goats, dogs, cats) from which sick cows have
An acute infectious disease belonging to the the greatest importance (especially for udder tuber-
group of particularly dangerous infections, which culosis). The most common route of infection is the
have a varied clinical picture. air - droplet (spray) and dust particles containing the
Etiology: Yersinia pestis. bacteria. Less frequent infections are through the
Epidemiology: The main way to infect humans digestive system and injured skin (eg in the case of
is by biting the fleas in contact with a sick person. slaughter of sick animals). Threatened contingents
In the pulmonary form of plague, the infection is by for professionally-mandated tuberculosis are: med-
air-droplet route. Professional is the disease of hunt- ical and other staff serving tuberculosis patients in
ers, forest workers who are in contact with wildlife,
* V. Nichev, M. Demirova
as well as of medical workers serving the sick, espe-

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specialized health care establishments; livestock ure. There may also be confused gas diffusion and
farmers, milkers, veterinarians, milk controllers, and evidence of hypoxemia and hypercapnia in severe
workers from slaughterhouses contacting tubercu- forms.
losis-infected animals. X-ray changes in pulmonary tuberculosis are
Pathogenesis. After infection, the tuberculous characterized by marked polymorphism. For exam-
bacteria fall and remain most commonly in the lungs. ple, the primary pulmonary complex revealed ho-
From there they spread through blood and lymphat- mogeneous shadowing associated with pulmonary
ic routes - the so-called initial bacteraemia. Two im- hilus, which was expanded with unclear outlines; in
munological phenomena arise - specific allergy and focal tuberculosis has medium and large shadows,
specific immunity. An expression of the specific al- and tuberculoma is presented with a well-rounded
lergy is skin hypersensitivity to tuberculin (demon- solid circular shadow; caseous pneumonia is like
strated by the Mantoux skin-allergic test with 5U massive lobar pneumonia, and miliary tuberculosis
PPD, which is reported at 48-72 hours). Specific im- is represented by uniformly scattered small-spotted
munity is natural when acquired after a tuberculosis shadows - "starry sky", etc.
infection and acquired when it occurs artificially 4-8 Bronchoscopy shows: endobronchial stenosis,
weeks after vaccination with an attenuated or aviru- fresh granulations, deformations and fistulas on the
lent strain (BCG vaccine). bronchi (fibrobronoscopy takes material for cytolog-
Clinical picture: Professional tuberculosis occurs ical, microbiological and histological examination).
as well as domestic, such as primary or secondary Clinical-laboratory tests: BSR is differently ac-
tuberculosis, with the most common pulmonary celerated; mild to moderate leukocytosis, mild to
localization (the extra-pulmonary forms of tubercu- moderate neutrophilia, lymphopenia with monocy-
losis - bone-joint, serous, urogenital, intestinal and tosis and sometimes eosinophilia; in chronic forms
hepatolienal, lymphatic, are rare forms). - anemic syndrome; in tuberculous meningitis, the
Clinical manifestations are very varied and de- liqueur is clear with an increased lymphocyte and
pend on form, stage, localization, age, immune albumin content and a reduced sugar and chloride
system of the organism. The illness may also occur content; in kidney tuberculosis the sediment is poor,
completely asymptomatically (to be detected acci- the albumin is slightly increased, there is microhe-
dentally by fluorographic or x-ray examination). It matury.
rarely develops as an acute infectious disease, and Microbiological study: sputum or other bio-
more often as chronic pulmopathy. logical secretions and milk from diseased animals
Subjective complaints distinguish between two with evidence of tuberculous bacteria in direct mi-
groups of symptoms: intoxication phenomena - croscopy after Zyel-Nilsen staining or 40-45 days
subfebrile temperature, adynamia, loss of weight, in Löwenstein-Jensen's solid culture medium talks
sweating, cardiovascular lability (tachycardia, hypo- about unveiling forms of the disease. Rapid cultures
tonia, etc.), gastrointestinal symptoms, etc.; by the are confirmed by the Bac-Tech-Dickenson method,
respiratory system - cough, expectoration, haemop- as well as express diagnostic by polymerase chain
tysis, chest pains and soreness, shortness of breath. reaction for rapid bac. tuberculosis proofing. In the
The physical finding is also very different. Tuber- absence of an exposition - fibrobronchoscopy with
culosis of the tracheobronchial lymph nodes, limited bronchoalveolar lavage.
focal changes, small and deeply situated infiltrates, Immunological and enzyme tests: the blast trans-
tuberculoma, and in the small cavernous forms did formation test (BTT) with tuberculin positivates at
not reveal deviations with the physical methods. over 2.9% blast transformation of the cells; adeno-
Scarce can be the changes even in a miliary tubercu- sine deaminase (ADA) in the blood in tuberculosis
losis. The percussion finding depends on the stage rises above 16-20U.
and expression of pulmonary fibrosis and pleural Diagnosis: Complex, based on epidemiological
changes, the size of the infiltrates and the caverns and clinical data. Bacteriological and radiological
- there are attenuations of varying intensity. Auscul- studies, supported by skin-allergy and immunolog-
tation can cause sharp or weak vesicular breathing, ical tests and biopsy material, are crucial.
and some areas may also experience a variety of wet Prognosis and acceptance of a professional
wheezing. Over the large peak caverns, the "kro- character: the prognosis is serious - chronic forms
ning" fields are narrowed by the tracheal adduction of the disease. The primary incubation period for
and the peak pleural adhesions. primary tuberculosis in adults is 6 to 8 weeks; in re-
The functional breathing study is mainly deviated activation (secondary tuberculosis) the changes de-
in the chronic fibrosis and fibrous-cavernosal forms velop for a different period - up to 6 months. During
- the type of restrictive-obstructive ventilatory fail- a longer latency period, the probability of causal

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relationship with the occupation decreases (in case against the disease, by scheme and, if necessary, in
of unrecognized recurrences, however, the latency combination with immunoglobulin.
period may be up to 12-18 months). In veterinary or
livestock breeding, it is important to isolate bovine VIRUS HEMORRHAGIC FEBRIS
tuberculous bacteria. FEBRIS HAEMORRHAGICA CRIMENSIS (FHC)
Treatment: always combined with several tuber- Acute infectious disease with major haemostasis
culostatic agents. Schedule most commonly used in involvement.
our country: 600 mg Rifampicin (Tubocin) + 300 mg Etiology: Congo - Crimean virus from the Bunya-
Isoniazide (Rimicide) + 1 g Streptomycin (after the viridae family.
second month is replaced by Ethambutol 25 mg/kg) Epidemiology: the source of the infection is do-
In the caseous-productive forms, and pyrazinamide mestic or wild animals, and a carrier on the human
2 g daily, for 3-6 months. The treatment is prolonged being - ticks, mainly of the Hyaloma species. One
- up to 9 months, and in the extra-lung forms - up gets infected after a tick bite as well as in contact with
to 12-18 months. For the first two months, the treat- the patient's blood. Occupational risk is the disease
ment was conducted in stationary state, and then for farm workers, livestock farmers, veterinarians and
continued outpatient - under the supervision of the zootechnics, as well as for all who are in contact with
pneumophysiatric dispensary. All healing regimens animal ticks (upon their removal). The occupational
combine with hepatoprotectors and vitamins - vit. A, risk is very high for health workers to have contact
B6, and so on. with the patients - FHC is a particularly dangerous
Prevention: specific - BCG vaccine, combating infection in this sense (even hospital-borne epidemy
nosocomial infections, personal protective equip- are described). Laboratory infections are also possi-
ment, hygienic lifestyle, healthy nutrition. ble.
Pathogenesis: The virus primarily damages hae-
II. Viral infectious diseases. mostasis by several mechanisms: direct vascular
LYSSA (RABIES) damage, indirectly through nervous trophics, and
An acute infectious disease with specific CNS in- the development of disseminated intravascular co-
volvement. agulopathy.
Etiology: Rhabdovirus. Clinical picture: Incubation period 2 to 14 days.
Epidemiology: source of domestic and wild an- Acute onset with marked toxigenic and craniop-
imals with rabies. One gets infected after a bite or haryngeal syndromes. After 2-3 days - severe hem-
contamination with secretions from sick animals, orrhagic syndrome.
most often dogs. Occupational risk is rabies for hunt- Diagnosis: Based on epidemiological and clinical
ers, people who have contacts with dogs, veterinari- data, it is confirmed by haemostasis disturbances -
ans, laboratory medical workers (cases of laboratory thrombopenia and virological studies: isolation of
infections have been described). the virus from the blood of sick newborn mice or by
Pathogenesis: The causative agent is markedly serological methods - CFT and ANT.
neurotrophic by inducing polyoencephalitis with a Prognosis: serious, especially in severe forms
characteristic localization in the CNS. and delayed treatment.
Clinical picture: Incubation period from several Treatment: Compulsory isolation and treatment
days to one year. Start with prodromal manifesta- regimen as particularly dangerous infections. Eti-
tions: hydrophobia, paresthesia in the wound, gen- ological treatment with hyperimmune human an-
eral restlessness, followed by an excitatory phase ti-haemorrhagic immunoglobulin - 12-24 cm3, in-
with psychomotor agitation and a third-paralytic tramuscular or intravenous. Pathogenetic treatment
form with manifestations of bulbar paralysis and le- - haemotransfusions, vascular sealing preparations.
thal outcome. Prophylaxis: specific - with a live vaccine admin-
Diagnosis: based on epidemiological and clinical istered to risk contingents. Animal decontamination.
data. Confirmed by the histological examination of
the brain in the deceased. HEMORRHAGIC FEBRIS WITH KIDNEY
Prediction: Absolutely bad. SYNDROME
Treatment: Symptomatic only. The administra- Acute infectious disease with predominantly kid-
tion of hyperimmune anti-rabbit immunoglobulin is ney and haemostasis involvement.
attempted, but until now no effect. Etiology: Hantaan virus from the Bunyaviridae
Prophylaxis: specific - with a vaccine used in risk family.
contingents. When biting or slobbering from a dis- Epidemiology: The reservoir of the virus is the
eased or suspect animal - administering a vaccine mousies rodent. One gets infected with food con-

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taminated by secretions and excretions of rodents. hepatitis B. In fulminant development, acute hepatic
Professional is the disease for forest workers, agricul- necrosis with hepatic coma.
tural workers, campers, brigaders, soldiers, construc- Diagnosis: based on epidemiological, clinical and
tion workers. laboratory data - elevated serum transaminases. It is
Pathogenesis: After primary viraemia, a process confirmed by the virological serological tests - proof
of disseminated coagulopathy with a major involve- of the antigens of the virus B: Hbs and Hbe, as well as
ment of the kidney glomeruli develops most often. their antibodies: anti-s, anti-e and anti-core IgM class.
Clinical picture: Incubation period of 4 to 12-23 Some patients also have co- or superinfection
days. Acute onset with toxic-infectious and cranio- with hepatitis virus D (delta antigen).
pharyngeal syndromes, moderate hemorrhagic syn- Prognosis: serious, especially in fulminant and
drome. After 3-5 days, acute renal failure develops hepatic coma.
with two phases - anuric and polyuric. Treatment: compulsory hospitalization, bed rest
Diagnosis: based on epidemiological and clinical and dietary regimen. Etiological treatment with in-
data. Confirmed by the serological test with CFT, re- terferons, but only in protracted and chronic forms,
cently also by ELISA. with insufficient effect. Pathogenetic treatment with
Prognosis: serious, especially in the absence of hepatoprotective agents.
adequate treatment. Prevention: specific - with a hepatitis vaccine
Treatment: compulsory hospitalization. There is (Engerix B, Hevax, Bevax, etc.). It is mandatory for all
no etiological treatment. Try ribavirin as an antiviral. newborns, risk contingents and all willing (it is man-
Pathogenetic treatment - hemodialysis at ARF. datory for medical workers).
Prevention: no specific. Deratization.
VIRUS HEPATITIS TYPE C
HEPATITES VIRALES ACUTAE Etiology: hepatitis C virus from Flavividae family.
Acute infectious diseases with predominant liver Epidemiology: For the time being, the mode of
involvement. Five types of viral hepatitis caused by infection by haemotransfusion and hemodialysis
hepatitis A, B, C, D, and E are now known. Hepatitis procedures has been proven. Occupational risk is
virus G is suspected. the disease for patients undergoing chronic hemo-
dialysis and especially for medical workers in the he-
VIRUS HEPATITIS TYPE B modialysis sectors and departments.
Ethiology: hepatitis virus type B from the Hepad- Pathogenesis: After initial viremia selectively
na viridae family. most likely a direct hepatocyte lesion with a marked
Epidemiology: Anthroponosis. Source are sick tendency to chronic process and development of
or healthy virus carriers. The infection is by blood or chronic hepatitis type C.
by sexual intercourse, and vertically - by the mother Clinical picture: Incubation period of 30 to 90
of the newborn. Occupational risk is the disease for days. The most common mild course with moderate
medical workers who are in contact with the blood pre-icterous and icterous stages, but with frequent
of the sick. Studies have shown that in the different protracted evolution, recurrence and chronication
countries of the world, 2 to 15% of the medical prac- after the sixth month.
titioners have had an infection (in our country some Diagnosis: based on epidemiological and clinical
research shows 5-7%). The occupational risk is par- data, confirmation of serological testing and detec-
ticularly high for lab workers, dentists, surgeons, ob- tion of anti-HCV antibodies (seroconversion occurs
stetricians and otorhinolaryngologists as well as for one to two months after the onset of the disease).
staff in infectious departments. The risk is particular- Prognosis: serious given the high risk of chroni-
ly high for nurses and laboratory technicians. cation.
Pathogenesis: After viremia initiation, the virus Treatment: Mandatory hospitalization, bed rest
selectively damages hepatocytes by indirect immu- and dietary regimen. Etiological treatment - interfer-
nogenetic mechanism and activation of T-hepatocy- ons, in protracted and chronic forms such as: Intron A,
totoxic cells. Roferon, Heberon et oth. preparations in a dose of 3
Clinical picture: Incubation period from 40 days or 6 IU, three times a week, for a period of 6-9 months.
to 6 months. After an initial pre-icteric stage with Prevention: no specific. Mandatory screening of
adynamic, dyspeptic and rare arthralgic syndromes, all donor blood banks for the presence of anti-HCV
there is icteric syndrome with hepato- and/or sple- antibodies.
nomegaly and a prolonged convalescence stage. RUBELLA (EPIDEMIC ROSEOLA)
Complications: At 5% of patients prolonged and An acute infectious disease with rash, lympho-
inveterated the process and developing chronic nodulopaty and often embryotoxic effects.

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Etiology: Anthroponosis. The infection is by between them:
air-droplet route. Contangion index is about 40%. • a primary clinical complex with a mononu-
Occupational disease has the sickness for worked in clear-like picture;
childcare facilities: children's homes, gardens, hospi- • asymptomatic phase, with or without indica-
tals, nurses, doctors. tor opportunistic infections;
Pathogenesis: After initial viraemia, lymphotro- • generalized lymphonodulopathy;
py, dermatropy, and frequent damage to the fetus • terminal phase of AIDS with general signs,
during pregnancy. opportunistic infections, bacterial infections
Clinical picture: Incubation period of 11 to 23 (mostly tuberculosis) and neoplasms.
days. Moderately pronounced catarrhal manifesta- Diagnosis: Based on epidemiological and clinical
tions, occipital and cervical, sometimes generalized data, the available immune deficiency - a reduction
lymphonodulopathy, macular rash. The inborn ru- in the absolute number of TCD4-lymphocyte cells
bella develops with polymorphic malformative syn- below 400 in mm3, is confirmed by virological stud-
drome, hepatosplenomegaly, haemorrhages. ies: HIV p24 antigen detection, anti-HIV antibodies
Diagnosis: based on epidemiological and clinical by ELISA, and confirmed by a Western blot immu-
data, confirmed by serological tests: CFT, ANT and RDF. noblotting test.
Prognosis: good. Prognosis: Bad for those entering the final phase
Treatment: There is no etiological. of AIDS.
Prophylaxis: specific with a live antiviral vaccine Treatment: antiviral therapy with azidotimidine
that is used in the trivaxin - morbilli + mumps + ru- (Retrovir, Zidovudine) at a dose of 600 mg daily, oral-
bella (obligatory in the immunization calendar for ly for a period of 6-9 months and more. In combina-
children). tion with other antivirals: dideoxycytidine or dideox-
yinosine, lamivudine, protease inhibitors. Treatment
SYNDROME OF ACQUIRED IMMUNITY of opportunistic and bacterial infections.
FAILURE - AIDS Prevention: no specific. Safe sex, mandatory
This is the terminal phase in the evolution of in- screening of all blood products. For the protection
fection caused by the human immunodeficiency vi- of medical personnel: work with gloves, carry out
rus - HIV, from the Retroviridae family. blood handling with vacuum tainers.
Epidemiology: Anthroponosis is the source of ill In HIV pricking or contamination with blood, the
and healthy virus carriers. Infection occurs by sexual WHO recommends immediate initiation of azidot-
intercourse, blood and blood products transfusions, imidine prevention at 1200 mg daily for at least four
in contaminated instruments, cosmetic and other weeks. It is even better with triotherapy: with AZT +
procedures, as well as vertically from the mother of lamivudine + one protease inhibitor.
the newborn.
Occupational risk is the illness for medical workers III. Rickettsia and Chlamydia infectious diseases.
- who are in contact with the blood or sex secretions ORNITHOSIS/PSITTACOSIS.
of the sick or infected. According to WHO data, the Acute infectious disease with predominantly res-
occupational risk for health workers is very low - by piratory system involvement.
1993, WHO registered 119 medical workers infected Etiology: Chlamydia psittaci.
professionally with AIDS. These are mainly lab techni- Epidemiology: source of domestic and wild birds.
cians, orderlies, surgeons and pathoanatomists, nurs- One is infected with direct contact with sick birds,
es. The most common of these infections were when most commonly on an aerosol route. There is a pro-
they were pricked with a contaminated needle. fessional disease for poultry and workers in poultry
According to the WHO, the risk of occupational farms, zoos, veterinary surgeons and zoo technicians.
infection by FHC, VC type B and AIDS is as follows Pathogenesis: the front door is the respiratory
100: 30: 1. system where an inflammatory process develops in
Pathogenesis: The virus selectively damages the alveoli. Rarely generalization is also possible.
the immune system, the T-helper cells carrying its Clinical picture: Incubation period of 3 to 30 days.
CD4-specific receptor, resulting in immune defi- Acute onset with common toxigenic syndrome, pneu-
ciency with subsequent opportunistic infections, monia and APD. There may also be some organ dam-
neoplasms and secondary bacterial infections. In age: hepatomegaly, serous meningitis, septic form.
one part of the infected virus it also exhibits primary Diagnosis: based on epidemiological and clinical
neurotrophy. data and confirmed by serological tests - CFT with
Clinical picture: HIV infection passes through group antigen. A dermal allergic ornithine test may
the following phases with a different time interval also be used.

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Prognosis: Good, more suspicious in septic form. Treatment: etiological treatment with antibiotics
Treatment: Etiological treatment with antibiotics - from I order tetracyclines (see ornithosis). Alterna-
- from I order - tetracyclines, such as Doxycycline - 2 tive preparations - chloramphenicol or ciprofloxacin
x 100 mg daily, oral or Tetracycline - 3 x 100 mg intra- - 2 x 400 mg/day.
muscularly for 10 days. Alternate preparations: eryth- Prophylaxis: Corpuscular vaccine-specific; vac-
romycin or chloramphenicol. cine application for risk contingent.
Prevention: no specific. Struggle the birds epizo-
onotic. MARSELIENSIS FEVER.
Acute infectious disease with a characteristic
Q - FEVER rash, a primary affection at the site of the induction
Acute infectious disease with polymorphic clin- of the causative agent.
ical picture but with predominantly respiratory in- Etiology: Rickettsia CONORI.
volvement. Epidemiology: the source is dogs, rarely, other
Etiology: Rickettsia BURNETI. domestic and wild animals. Carrier is tick - mainly Rh-
Epidemiology: source is domestic animals and ipicephalus sanguineus, but and other species. One
birds. Carrier is a tick, but there are several mecha- gets infected mainly after a tick bite, but and when
nisms of transmission of the infection: aerogenic, is crushed. Occupational risk is the disease for shep-
tick bite, almentary and others. Occupational risk is herds, goatherds, farm workers and forest workers.
the disease for agricultural workers, livestock breed- Pathogenesis: Endotoxin reaction - "black spot"
ers (especially cowman), working in slaughterhous- - "tache noire" is developing at the site of the depot.
es, meat-packing companies, haylofts and farms. Generalization followed by systemic vasculitis.
There are single laboratory infections. Clinical picture: Incubation period of 3 to 15-20
Pathogenesis: After an initial phase of devel- days. Acute onset with toxo-infectious and cranio-
opment in the monocyte macrophage system and pharyngeal syndromes, maculopapular rash on the
dissemination, there is a predominantly pulmonary, body, including palms and feet, hepatosplenomeg-
rare and other organ localization. aly and "black spot".
Clinical picture: Incubation period of 3 to 12 days. Diagnosis: based on epidemiological and clinical
Acute onset with toxo-infectious and craniopharyn- data, confirmed by serological tests with indirect im-
geal syndromes, followed by pneumonia, hepatosple- munofluorescence and CFT with specific antigen.
nomegaly, lymphonodalopathy. Endocarditis, serous Prognosis: good.
meningitis and others are no-rarely developing. Treatment: etiologically with antibiotics - from
Diagnosis: based on epidemiological and clinical I order - tetracyclines (see ornithosis). Alternative
data and confirmed by serological methods - CFT preparations: chloramphenicol or erythromycin.
and immunofluorescence. Prevention: no specific. Desacarisation of dogs
Prognosis: good. More serious in septic form and and animals.
endocarditis.

REFERENCES
4. Diseases common to animals and humans, ed. I. Chanchev, S. Bardarov, Sofia, Zemizdat, 1979. (in bul.)
1. Burilkov T., Occupational diseases from biological factors. in. "Professional pathology", ed. Alexieva Tsv. Kr. Kiriakov, Sofia,
Med. and phys., 1982, 203-209. (in bul.)
5. Drankin D.I., L.S. Malapheeva - Epidemiology and prophylaxis of infectious diseases in professional infection, Moscow, Med-
icine, 1972. (in russ.)
6. Epidemiology of infectious and non-communicable diseases, ed. B. Iliev, G. Mitov, Sofia, Med. and phys., 1994. (in bul.)
9. Infectious diseases. ed. M. Radev, Sofia, Med. and phys.,1993. (in bul.)
7. Handbook on treatment of infectious diseases, ed. M. Radev, Sofia, Med. and phys., 1988. (in bul.)
11. Nichev, V. Pathomorphosis of pulmonary tuberculosis in adults, dissertation, Sofia, 1987. (in bul.)
12. Nichev V., Z. Yankova. Anti-tuberculosis agents. In: Internal diseases, ed. Ch. Nachev, V. IV. - St. Zagora, "Znanie", 1994. (in
bul.)
8. Handbook of infectious and parasitic diseases, ed. S.Bardarov, Sofia, Med. and phys., 1985. (in bul.)
3. Directory of infectious diseases, ed. Kazansev V.S., AP. Matkovskij, Moscow, Medicine, 1985. (in russ.)
2. Cohen R. Occupational infections. In Occupational Medicine, ed. J. La Dou, Appleton & Lange, Norwalk, 1990, 170-182.
10. Kernbaum S. - Elements de Pathologie Infectieuse, Paris, Aimep / Specia, 1980.
13. Prevention and Control of Infectious Diseases and Nosocomial Infections, ed. R.P. Wenrel, Baltimor / London / Los Angeles
/ Sydney, 1990.
14. Principles and Practice of Infectious Diseases, ed. Mandell D., Bennett Ch., K. Livingstone, New York / Edinbourgh / London
/ Melbourne / , 2000.

608
 LABOUR MEDICINE

V. Boeva

7.2 PROFESSIONAL PARASITIC DISEASES

ECHINOCOCCOSIS domestic dog and very rarely the wolves, the jack-
Human echinococcosis is a chronic helminthic als and the wild dog Dingo. Intermediate hosts are
disease resulting from the development of the larval the man and many grazing animals (sheep, goats,
stage of canine tape worm (echinococcal cysts) in buffaloes, pigs, horses, camels, elephants, etc.). The
various organs and tissues of the organism. mechanism of human infection occurs most often in
Etiology: Echinococcus granulosus. direct contact with a dog or indirectly - consumption
Sexually mature form is a small tapeworm With of poorly washed fruits, vegetables, etc.; sheep milk-
a size of 2.7 to 5.4 mm and parasitized in the small ing, shearing and wave processing; in the collection
intestine of the final host the dog.It has a head with of dog and other animal skins; when drinking water
four suckers and twin corona of hooks, neck and 3-4 from open waters and others. This makes the echino-
members, the latter being mature and containing coccosis occupational disease for certain risk groups
400 to 800 eggs.The eggs have a spherical shape of the population - stock-breeders, farm workers,
containing six-hooked embryo (oncosphere), remain leather collectors, breeding and training dogs, etc.
viable in the environment for up to 10-12 months. Pathogenesis: Mechanotrauma and toxo-aller-
The larval stage develops in the intermediate genic effects. Echinococcal cyst rupture - severe an-
host, and is a cyst full of fluid, ranging in size from aphylactic shock and scolexes dissemination - multi-
bean to large ball and more. The wall of the cyst has ple echinococcosis.
two envelopes: external - chitin and inner (germ). Clinical picture: The incubation period is from
From the latter, proliferating capsules are formed several months to ten years or more. Symptoms of
in which the scolexes that float in the cyst fluid and the disease are dependent on organ localization.
form the so-called hydated sand develop. In addi- Most commonly, the cysts are localized in the liver
tion to fertile (containing scolelex), sterile (acephal- (50-60%), the lungs (35-38%), the brain (3-5%), and
ic) cysts without scolexes also appear (Figure 1). then spleen, kidney, peritoneum, bones, muscles,
Epidemiology: Echinococcosis is a synantrop- and others.
ic-endemic oral zooantroponosis with natural out- Regardless of the organ localization, the disease
breaks (endemic outbreaks occur in areas with has three stages: 1. Latent - until the first symptoms
pasture livestock). The main source for man is the appear. 2. Stage of subjective complaints - most
common weight and support in the right subcostal
eworms in the intestines o
Adu
lt tap f do
g or epigastric, headache, dizziness, itching, urticaria,
dry cough, blood spit (up to 30% of cases of pulmo-
nary echinococcus), easy tiredness. 3. Stage of objec-
g
of
do An
im tive changes - in case of localization in the right part
ces al
o
fa
e ea
te of the liver, the pain syndrome is as in cholecystitis,
rg by
he

an do

and in the left part - occurs with nausea, weight in

t

n
sw g
in

ith
gs

the epigastrium; in the cerebellum cyst - headaches,

Eg

cys
ts

paresis, paralysis, stagnant papillae, etc.

Laboratory parameters have long been normal
- sometimes minor eosinophilia, hyperproteine-
mia, dysproteinemia, interferon inhibition, etc. have
been observed. Functional liver tests change only
gs
res
of eg
e

with large liver cysts. Serological echinococcosis re-

h
osp
ion

onc

actions are positive, but in some cases they may also

gest
In

be negative (large old cysts with calcium deposits or

s
an

immunodeficiency). The prognosis is unfavorable in

rg

so
ou
ari
si n v relation to frequent recurrences (over 21%) and le-
c ys t
Hydatid thality of 1 to 15%.
Fig. 1. Biological cycle of Echinococcus granulosus

609
 OCCUPATIONAL MEDICINE
Diagnosis and differential diagnosis: Complex ANCYLOSTOMIDOSES
on the basis of epidemiological data, history and ANKILOSTOMIASIS & NEKATORIASIS
results of laboratory and apparatus research. Basic
methods in diagnostics are: parasitological (mor-
ces Ora
phological and immunological); clinical; biological; th
fae l la
rv
wi ae
paraclinic and apparatus (abdominal ultrasonogra- gs

in
g
de
e Pe

fes
phy, CT of the liver and other organs, lung radiogra- th rcu

ite

tat
in t

Em

ion
e

tes s
phy, etc.). The most accurate information is obtained

ll in rm

an
tin

eo
sma kwo

us
from CT, taking into account the density of the Echi-

inv
t ho

asio
nococcus cyst in Hunsfield units. For pulmonary

Adul

n
larvae
echinococcus, the symptom of Escudero-Nemanov А. duodenale
female - 10-15 mm/0.6 mm
(change in the shape of the cyst when breathing) is male - 8-11 mm/0.4 mm
characteristic of X-ray. IV. americanus
Early diagnosis - by mass prophylactic studies of female - 9-11 mm/0.4 mm
male - 7-9 mm/0.3 mm
??

??
risk groups of the population: fluorography, echog-

?
raphy and serology: RIHA, RIF, ELISA, etc. ? ????
Differential diagnosis - with hemangiomas, pol- ? ????

ycystic disease, dyssembryogenic or biliary cysts,

amoeba abscess, liver cirrhosis, tumors and other Temperature, moisture, aeration topsoil
focal changes.
Treatment: Radical treatment is surgical. Con- Fig. 2. Biological cycle of A. duodenale and N. americanus
servative chemotherapy is only applicable to pa- a rhabdiform larva, which after 7-10 days becomes
tients with serious contraindications for surgical infestive (filamentary). In contact with skin and
intervention (not always with good healing effect). mucous membranes they penetrate the body and
The preparations Vermox (Mebendazol), Zentel (Al- through the blood reach the lungs, migrate through
bendazol), Praziquantel (Biltricid) are used. the alveoli and fall into the digestive tract where
Operated patients are dispensary - up to 5 years. they develop to adult helminths (Figure 2).
Prevention: Personal prophylaxis requires that Epidemiology: Ankylostomidoses are natural
contact with dogs and strict adherence to person- endemic percutaneous and oral anthropogeohel-
al hygiene be avoided. Public prophylaxis includes mintoses. Epidemiological incubation is 35-40 days.
decontamination of dogs - with Dronsit (4-fold de- They are spread in the tropics and subtropics. In the
helminthisation during the year); burial of animal temperate zone they are rarely encountered - in
carcasses; veterinary-sanitary control of meat pro- mines, wet and warm places. The source of the inva-
duction and others. sion is the parasitic man - through the stools.
Pathogenesis: Mechanotrauma, sensitization,
ANCYLOSTOMIDOSES malabsorption syndrome, anemic syndrome - iron
Ankylostimidodes are helminthoses that are deficiency anemia.
chronic with allergic manifestations, dyspeptic and Clinical picture: Three stages are distinguished:
anemic syndrome. 1. Stage of percutaneous invasion - erythema,
Etiology: "Ankylostomidoses" involves two par- itching, swelling, papules, vesicles and pustules (7-
asitoses - Ankylotomiasis (Ancylostoma duodenale) 10 days).
and Necatoriasis (Necator americanus), which have 2. Stage of pulmonary migration - spastic cough,
a similar clinical picture. Causes are small nematodes shortness of breath, haemoptoea, headache, subfe-
ranging in size from 7 to 13 mm. Their body is cylin- brility, Lyofler syndrome *, eosinophilia, leukocytosis
drical, with a well-developed oral capsule with cut- (7-14 days).
ting chitin teeth and platelets. Female parasites emit 3. Stage of intestinal localization (acute and
an average of 9,000 to 30,000 eggs. Ankylostomas chronic period, mild, moderate and severe form) -
live up to 5 years, and neckators up to 15 years. They nausea, vomiting, epigastric pain, diarrhea, dehydra-
feed on blood and fragments of the intestinal mu- tion, easy fatigue, anemic syndrome, occult bleeding
cosa (daily one parasite absorbs 0.02-0.2 ml blood). in the faeces, hepatomegaly, limb edema, ascites,
Sexually mature helminths inhabit the duodenum cardiac decompensation with pulmonary edema.
and other parts of the small intestine. Eggs of the
parasite fall into the outside environment in an im-
mature form through the stools. At a temperature * Lyofler syndrome - fast-passing eosinophilic infiltrates in the
of 14-37°C, moisture and oxygen from them hatch lungs.

610
 LABOUR MEDICINE
Diagnosis and differential diagnosis: Diagnosis 1970 and sexual reproduction in the epithelial cells
is certainly assured by (faecal helminthoovoscopy); of the intestinal tract of a domestic cat and some
Berman** helmintholaroscopy and the cultivation wild cat species that emit oocysts with their feces
and differentiation of larvae on Harada and Mori***. (Figure 3).
Differential diagnosis is made with ascaridosis, Epidemiology: Toxoplasmosis is a cosmopoli-
strongyiloidosis, anemic syndrome with other aeti- tan, contact-home zooanthroponosis. The source
ology, avitaminosis, heart and kidney disease, etc. of infection is most often the animal - very rarely a
Treatment: For etiologic therapy, preparations: person. The infection is carried out in an alimentary -
Vermox, Laevamizol (Decaris), Zentel, Flubendazole through the consumption of meat products from an-
and Combantrin (Pyrantel, Pamoat) are used. imals containing cysts, fruit and vegetables contam-
Prevention: Personal prophylaxis - prevents skin inated with oocysts and contaminated hands. It is
contact with soil, grass and water in endemic areas. also possible transplacental infestation of the fetus.
Public - search and treatment of patients with subse- Pathogenesis: Mechanotrauma and toxo-aller-
quent dispensarysation; mass dehelminthization in genic effects. Not every infiltration of the parasite
endemic areas; protection of the environment from leads to disease (in nature pathogenic strains are
faecal contamination; hygienisation of working con- rare, but apathogenic toxoplasmic strains are always
ditions in underground sites. immunogenic).
Clinical picture: There are three options:
TOXOPLASMOSIS 1. Asymptomatic leakage - only positive serolog-
Toxoplasmosis is a protozoonosis that occurs ical reactions.
most often asymptomatically (rarely as a disease 2. Congenital toxoplasmosis - hydrocephalus, cal-
with a pronounced clinical picture). cifications in the brain, chorioretinitis, iridocyclitis,
Etiology: Toxoplasma gondii. It is a bonded intra- uveitis, micro-ophthalmia, optic nerve atrophy, de-
cellular parasite. It occurs in three forms: a vegeta- layed neuropsychological development.
tive (trophozoite) of 4-7 μm in size, actively penetrat- Acquired toxoplasmosis - lymphadenitis, chronic
ing the cells of the body (toxoplasmic cells are called subfebrility, ocular manifestations (chorioretinitis,
pseudocysts and are found in the acute stage of the uveitis, haemorrhage), brain disorders, myocarditis,
disease); form of cist - the so-called true cysts that interstitial pneumonia, exanthema, etc.
have their own envelope and are a conglomerate of Diagnosis and differential diagnosis: At clin-
thousands of toxoplasms; oocyst form - proved in ical data diagnosis can hardly be diagnosed. Study
material is taken - blood serum, lymph node biopsy,
TOXOPLASMOSIS albumin, impress of placenta, brain, umbilical cord,
amniotic fluid. The main methods of diagnosis are
serologic reactions - RIHA, RIF, ELISA, etc. It is impor-
tant to have a two-fold serological test in 2-3 weeks
de
nts - the dynamics of the titres. The presence of elevated
ro
IgM antibodies is an acute process. Morphological
g
tin
Ea

methods - 3 passages by inoculation of white mice

c ys ts

at
on
me

over 5 days and preparations from biological mate-

pti
f oo

ked
sum
coo

rials stained by Romanovski-Gimza. Differential di-

Con
no

der
tio

of un

agnosis is made with infectious mononucleosis, ma-

ra
pa

Se
l lignant neoplasms, cytomegalia, rubella, brucellosis
ita is
en mos and others.
I n g e s tio n

s
tox ong

a
Treatment: Etiological treatment is conducted
ts

l
op
C
cys
f oo

with: Rovamycin, Tindurin, Sulfalen, Biseptol (Trimes-

of o

Ingestion o

ol), Clindamycim, Calcium Foliante. Rovamicin is as-

oc y
st s

signed 2 tabs. 4 times a day for 10-14 days. Tindurin

st s
cy

o
fo
ti o
no is prescribed on 1 tablet 2 times a day for 5 days. Sul-
ges
In
falen is given 2 g daily in three doses for 5 days.
Prevention: Strict personal hygiene, avoiding
the consumption of insufficiently heat treated meat
Fig. 3. The biological cycle of Toxoplasma gondii and milk, washing fruits and vegetables, avoiding
** Berman - a method for isolating and microscoping larvae contact with cats. It is recommended that pregnant
from parasites. women be examined at the beginning of pregnancy
*** Harada and Mori - method of cultivation and differentiation
of larvae from gut parasites to determine their immune status to toxoplasmosis.

611
 OCCUPATIONAL MEDICINE
Tab. 1. PROFESSIONAL INFECTIONS (by Choen R., 1990)
Diseases Factor Target organ Professional source Risk professions Preventive measures

Bacterial Bacillus skin, powder (spores in weavers, livestock workers

Anthrax anthracis lung wool, goat hair, fur) veterinarians, farm immunization
systematica- workers
lly
Brucellosis Brucela systematica- blood, workers in personal hygiene,
abortus, lly urine slaughterhouses and serological
B.suis, vaginal canning plants, identification of
B.canis,B.meli - secretions manufacturers of infected animals
tensis secretions and tissues lifesaving products,
of cattle, veterinarians, hunters
pigs, sheep, deer
Erizipeloid Erysipelothrix skin fish, meat, molluscs,fishermen, veterinarians, personal hygiene,
rhusiopathiae poultry workers employed by gloves
(insidiosa) meat and poultry
processing
Leptospirosis Leptospira liver, brain, urine or tissue from agricultural workers, personal hygiene,
interrogans kidney domestic or wild farmers, workers in boots,
systematica- animals or excreta of slaughterhouses, gloves,
lly rodents, contaminated veterinarians, immunization of
water fishermen, miners animals
working on sewers identification of
contaminated waters,
prophylaxis with
doxycycline
Plague Yersinia lung, fleas from infected hunters immunization
pestis systematica- rats, wild dogs, trappers
lly martens
Tetanus Clostridium nervous soil construction workers, immunization
tetani system prick with dirty sharps gardeners
farmers
Tuberculosis Mycobacterium lung, infected subjects, medical workers, skin test, followed
tuberculosis systematica- primates technicians, caregivers by prophylaxis for
lly of primates Sero-positive

Tularemia Francisella ulcerated blood, tissue, hunters, loggers, personal hygiene,

tularensis papule, secretions or bite of an farmers, veterinarians gloves,
systematica- infected animal or immunization,
lly arthropod control insects
Fungal Candida skin frequent skin injuries washers containers, skin protection,
Candidiasis albicans in a moist environment working in poultry farms protection from
and canning factories moisture
Koksidioi- Coccidioides lung, soil (spores) in arid farmers control dust (where
mycosis immitis meninges areas archaeologists, builders possible)
Dermato- Microsporum skin animals, hot humid breeders, shepherds, personal hygiene,
phytosis Trichophyton environment athletes protection from
Epidermophy - moisture
ton
Histoplasmosis Histoplasma lung, soil contamination farmers dust control,
capsulatum systematica- with feces of birds workers in canning rehabilitation of the
lly plants environment, spraying
formaldehyde
contaminated surfaces

Helminth and Echinocous CNS, lung, feces of infected dogs, stock-breeders, personal hygiene
protozoan granulosus liver foxes and others from veterinarians, shepherds
Echinococcosis E.multilocularis this group

Ankilosto- Ancylostoma small larvae in human feces farmers walking barefoot, building latrines,
midoses duodenale, Ne - intestine passing through intact sanitation workers, parks the use of boots,
cator america - skin and gardens shoes and gloves
nus

612
 LABOUR MEDICINE
Toxoplasmosis Toxoplasma reticulo cat feces technicians, veterinarians, personal hygiene
gondii endothelial breeders of cats
system,
eyes
Rickettsial Chlamidia psit - lung disposal of secretions breeders, sellers in shops detection and
and chlamy- taci systematica- from infected poultry for pets, zoo officials treatment of infected
dial lly (parrots, pigeons, etc.). birds
Ornithosis

Q fever Coxiella burnetii systematica- placental tissue, bird technicians, workers in personal hygiene,
lly secretions, excretions slaughterhouses, farmers, immunization
liver, lung, from infected animals stockbreeders
brain (sheep, wild animals,
goats, etc.).

Viral Arbovirus CNS laboratory viral working in virology immunization,

Encephalitis cultures infected laboratories insecticides, using
arthropods organic secure
methods
Hepatitis B Hepatitis B virus liver accidental introduction maxillofacial surgeons, personal hygiene,
of infected human dentists, dialysis workers, immunization
blood or blood clinical laboratory
products technicians, nurses

Rabies Rabies virus CNS wild animals (foxes, technicians, veterinarians, immunisation in contact
bats, polecat), rarely hunters, people growing or immunisation of
domestic animals wild or unidentified some animal kinds
animals (dogs, cats)
Rubella Rubeolla virus fetus infected people health workers immunization
systemat.
AIDS НIV Immune bodily secretions of health workers prophylaxis by universal
system infected people preventive means for
skin and slimes

Seroepidemiological screening among toxoplas- erinarians, laboratory workers, meat - and slaughter-
mosis risk groups - stock-breeders, zootechnics, vet- houses workers, etc.

REFERENCES

1. Andreeva N., V. Boeva, P. Petrov. Parasitology. ed. P. Petrov, Med. and phys., Sofia, 1993, 94. (in bul.)
2. Bahr et al. Chemotherapy of human Echinoccocosis. Surgeon., 1984, 55, 2, pp. 114-116.
3. Boeva-Bangjizova V., K.Vutova. Parasitology (Local and Tropical) "Arso", 2001, 184. (in bul.)
4. Geller I.J. Echinococcosis. Moscow, "Medicine", 1989, 207. (in russ.)
5. Genov G. Parasitic diseases in temperate and tropical climates. Med. and phys., Sofia, 1993, 246. (in
bul.)
6. Genov G. Practical parasitology. "Znanie", Sofia 1998, 311. (in bul.)
7. Leikina E.C. Important human helminthoses, M., Med. 1967, 250. (in russ.)
8. Markell. E. K., M. Vogel, D. T. John. Medical Parasitology. 7th ed. W.B. Saunders, Philadelphia, 1992,
463.
9. Nikiforov St., V.Boeva. Echinococcosis. Sofia, Med. and phys., 1983, p.234. (in bul.)
10. Peicheva Zl., D. Krastev. Toxoplasmic lymphadenitis, Med. and Fisc., Sofia, 1983, p. 85. (in bul.)
11. Vuchev D., Studies on the ankylostomiasis and conditions for local distribution in Bulgaria, Dis., Sofia,
1984 (in bul.)
12. Wildfuhr G. Dr. Toxoplasmose. Jena veb Gustav Verlag, 1954, p. 176.
13. Zasuhuna D.N. Toxoplasmosis problem. Moscow "Medicine", 1980, 308. (in russ.)

613
 8
OCCUPATIONAL MEDICINE

OCCUPATIONAL ALLERGIC
DISEASES
M. Demirova

8.1 INTRODUCTION. CLASSIFICATION

The sensitization of the organism to the numer- to 10 mg/m3. Their MAC. Is 5 times lower;
ous environmental factors, manifesting itself as la- Class III substances with an allergy threshold
tent and clinically manifest, is one of the complex above 10 mg/m3. In their case, MAC Is 3 times lower.
forms of interaction between man and nature. An Classification. Allergens are plant, animal and
average of 10% of the world's population is affected chemical factors, and in contact with the body are:
by allergic diseases - they occupy an important place inhaled, contact (undamaged skin), oral and pen-
in the general morbidity structure of industrially de- etrating through injured skin and mucous mem-
veloped countries. Accordingly, the number of pro- branes (Figure 1).
fessionally-determined allergic diseases, whose rel- Risk factors. The action of professional allergens
ative share in total allergic morbidity varies from 3 can be facilitated e.g. from a number of exogenous
to 10%, and in the case of registered occupational other work environment factors - physical, chemi-
diseases - from 10 to 30%. cal, biological, which can lead to a change in gen-
Professional allergies are associated with specific eral or local reactivity, or cause anatomophysiolog-
etiological factors from the work environment. Their ical changes that potentiate the action of allergens
number is constantly increasing and today there are - ex. mechanical and toxic irritants and mucosal in-
few jobs that do not pose a risk of allergies. fections of the respiratory system, eyes and skin. In
A professional allergen is a substance that is addition to exogenous, endogenous risk factors (so-
found in the human working environment and leads called "allergic diathesis") are important: age, gen-
directly or indirectly to sensitization. The sensitiza- der, family predisposition, endocrine and nervous
tion ability of allergens is different - strong allergens system conditions.
are thought to have high affinity for human proteins Occurrence of a professionally allergic disease is
and therefore lead to frequent and severe allergies a result of a complex, two-sided process between
to workers. Substances with weaker immunogenici- external and internal risk factors. In occupational
ty sensitize only individuals - so-called atopics1. pathology, great importance is attributed to exter-
It is believed that in atopics there could be no nal factors (occupational allergens and irritants), as
MAC for allergens, however, in most non-atopic pa- unintentional hereditary workers, who are subjected
tients there is a dose-response relationship. That is to prolonged periods of action by strong industrial
why MAC adopted for this substances to be deter- allergens, may develop mass allergic reactions, and
mined by their so-called "sensitizing threshold" - this backbred hereditary persons may remain healthy
concentration, which produces an allergic reaction under favorable working and living conditions.
in an experiment. In connection with this, they are Pathogenesis. Allergen, as a genetically foreign
divided into classes: biological irritant of the immune system, causes the
Class I - substances with an allergy threshold low- formation of specific allergic antibodies or sensitized
er than 1 mg/m3. Their MACs should be 10 times low- cells (lymphocytes) that are produced in the human
er than the threshold; immune system. All cells have a unified origin - from
Class II - substances with an allergy threshold of 1 the polypotential bone marrow strain cell. During
embryonic development, some of them under the
1
The atopy is characterized by the following main features: influence of the thymus differentiate into small lym-
enhanced synthesis of reactive antibodies due to a genetic de-
fect associated with decreased T-suppressor Ly; a positive skin phocytes - T-lymphocytes, which are the effectors of
reaction (papules and erythema) to the corresponding allergen; cellular immunity, i.e. of delayed hypersensitivity (IV
family predisposition for allergic manifestations. type). Its expression is eczema, eczema-like dermati-
614
 LABOUR MEDICINE

INHALATOR, CONTACT, ORAL, INJURED SKIN AND MUCOUS MEMBRANE

VEGETABLE ANIMAL CHEMICAL

POLLEN DANDRUFF Inorganic Оrganic

SEEDS HAIR
FIBERS EXCREMENT
LEAVES
ROOTS
CHROMIUM ACYCLIC CYCLIC
NICKEL
JUICES
MANGANESE
AND OTHERS.
COBALT CHLOROPRENE DINITROCHLOROBENZENE
MERCURY FORMALDEHYDE ASPIRIN
PLATINUM METHACRYLATE A-NAPHTHOQUINONE
SILVER OTHER ACRYLATES EPICHLORHYDRIN
GOLD TRIETHANOLAMINE PHENYLHYDRAZINE
ARSENIC ACETONITRILE DIPHENYLAMINE
AND OTHERS. THIRUM URSOL
CINEB ISOCYANATES
AND OTHERS. DDT
NEOSON D
NAPHTHALENES
AMINASINE
PYRIDOXINE - VIT. B6
CAPTAX
ANALGIN
PENICILLIN
AND OTHERS.

Fig. 1. Classification of professional allergens

tis, some forms of bronchial asthma, and the chron- by antibodies agglutinins and precipitins are: some
ic form of hypersensitive pneumonitis (HSP). Other forms of allergic rhinitis, bronchial asthma and acute
thymus cells, regardless of thymus, differentiate into form of hypersensitive pneumonitis. Because of its
B-cells in bone marrow, probably in lymphatic-in- complex antigenic mosaic, most professional aller-
testinal structures. Activated by allergens, they are gens can cause both a humoral and a cell-type sen-
transformed into plasmatic cells that synthesize hu- sitization.
man immunoglobulins A, D, E, G and M. Of these, E, Occupational allergic diseases can have various
G and M are important for humoral, antibody-medi- organ manifestations but most often engage the
ated immunity, i.e. for fast - type I, and immunocom- eyes, the skin and the respiratory system, which is
plex - III type, allergic reactions. The rapid (type I) al- related to the functions of these organs and their
lergic reaction is mediated by antibodies - reagins, anatomical and physiological features - the skin, for
with anaphylactic reactions, urticaria, Quinche al- example, Is the barrier of the human organism to the
lergic edema, allergic rhinitis, bronchial asthma, al- environment and in the workplace it is exposed to
lergic conjunctivitis and atopic eczema. Expression continuous irritants and allergens. The same type of
of the immunocomplex (III type) reaction, mediated effect applies to the respiratory system and eyes.

REFERENCES

1. Allergology. ed. B. Bozhkov. - Sofia, ARCO, 2000. (in bul.)

2. Demirova, M. Bronchoallergopathies of organic dust. - Sofia, Med. and phys., 1980. (in bul.)
3. Donald F. Clinical Immunology. In: Occupational Medicine ed. J. La Dou, Appleton Lange, Norwolk,
Counecticut/San Mateo, California, 1990. 140-154.
4. Grillat, J.P. Allergy and histamino-liberation, Sem, Hop., Paris, 1979.
5. Shepperd, D. Occupational Lung Diseases. In: Occupational Medicine ed J. La Dou, Appleton Lange,
Norwolk, Counecticut/San Mateo, California, 1990. 221-230.

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8.2 ALLERGIC DISEASES OF THE

RESPIRATORY SYSTEM

The type of respiratory allergy is often determined II group – irritants, which have only an irritant
by the place of deposition of allergens (nose, larynx, effect on the lining and its receptors: quartz, asbes-
trachea, bronchi and alveoli). The significance of the tos, carborundum powder, ammonia, acid vapors,
size of the inhaled particles and the intactness of the bases, etc.
lining is essential. For example, in the silk industry in III group of substances with complex action
the silk-worm, where the dust is more roughly dis- (allergic, irritant and histaminoliberal) on the respira-
persed and retained in the upper respiratory tract, tory mucosa: most organic powders, salts of heavy
allergic diseases of the upper respiratory tract pre- metals, organic solvents, some pesticides, paints,
dominate. In the production of silk itself, where the lacquers, piperazine, plastics and others. Along with
allergen is inhaled with steam deeply to bronchioli, the reflex (vagal) mechanism, some of them also
bronchial asthma is more common. The number of have a histaminoliberal mechanism - some organ-
substances that cause direct or indirect respiratory ic powders, ammonium persulfate, snake and bee
allergy in the professional environment is progres- poisons, some medications such as amphetamine,
sively growing. According to their mechanism of ac- D-tubocurarine, galamine, papaverine, morphine,
tion, they are divided into three groups: atropine, codeine, strychnine, ACTH, synacten, vita-
1 group – allergenic substances leading to sen- mins A, B, C, D, K, dextran, peptones and others. The
sitization in І, ІІІ, and possibly IV immune-allergic substances of III g represent the greatest risk of aller-
type: medicaments, bioproducts, enzymes, epialler- gies due to the mutual potentiation of the bronchos-
gens, pollens, molds, bacteria, etc. . pastic effects (allergic and non-allergic).

A. Savov, M. Stoynovska

8.2.1 ALLERGIC DISEASES OF THE

UPPER RESPIRATORY TRACT

Allergic diseases of the upper respiratory tract Allergic rhinitis occurs most often and occurs in
(URT) occupy a leading position in the structure of two forms - acute and chronic. A classic example of
allergic diseases, as the mucosal epithelium of URT is allergic rhinitis is pollenosis (allergen - tree, grass
one of the first barriers to allergen contact with the and flower pollen) that is related to the work envi-
body. ronment only for a limited number of professions
Etiopathogenesis. URTs occupational allergic (agronomists, herbalists, greenhouses workers). The
diseases are related to the individual's residence in immunological response to the pollenosis is of type
the work environment. Occupational allergens pen- I hypersensitivity. Symptoms include: itching in the
etrate the body by inhalation route in the form of nose, throat irritation, olfactory disorder, watery se-
simple or complex compounds such as formalde- cretion from the nose, running early or late (10-12
hyde, epichlorhydrin, furan, isocyanates, aromatic hours). Common signs of weakness, headache, dif-
nitrobenzene compounds, pyridazinone, chromium, ficulty breathing, and seasonal dependence are also
nickel, cobalt, platinum, beryllium, polymers, organ- observed. The rhinoscopic examination shows a pale
ic powders, medicaments, molds, bioproducts and or livid colored swollen mucosa. Serum IgE is elevat-
others. Their sensitizing effects may be due to a pre- ed. Eosinophils are increased in the blood and nasal
vious mechanical damage to the lining or to inflam- secretions.
matory changes. The illness occurs in different times In occupational allergic rhinitis, complaints are
from the start of work. related to the individual's residence in the work en-
URTs occupational allergic diseases include sev- vironment and resolve in the elimination of contact
eral nosological units - allergic rhinitis, rhinosinusitis, with allergens at work.
pharyngitis, laryngitis and tracheitis. The complaints of the patient are similar to
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those of pollenosis: episodes of sudden obstruction, pational allergic diseases of the UAP is the focused
sneezing, nasal secretion, olfactory changes, difficul- profphatological history with a study of the profes-
ty in breathing, headaches, which, however, are not sional route and the factors of the working environ-
seasonally dependent and do not take place acutely. ment. It is necessary to clarify the relationship of the
Rhenoscopy reveals: mucosal hyperplasia, narrow patient's complaints to his/her place of residence in
nasal passages, secondary infections and lesions, the work environment - exposure and elimination
pale mucous membrane. tests, and clinical, laboratory and other studies:
Allergic rhinosinusitis often occurs in allergic • detailed ORL review;
nasal disease but is not always registered because of • allergenic tests:
the prevalence of allergic rhinitis. When combined, s skin allergy testing;
the name "allergic rhinosinusopathy" is also seen, s determination of total Jg E in serum;
which is also observed in two forms - acute and s specifically Jg E in the serum;
chronic. Sometimes the mucosal polyposis devel- • endoscopic ORL examination;
ops. The polyps are pale and pink, with a soft con- • cytological examination of nose material;
sistency and influenced to appropriate therapy. They • bacteriological examination of the material of
further increase nasal obstruction, create conditions the nasopharynx;
for additional banal inflammation, and this is a seri- • X-ray examination of sinuses;
ous prerequisite for the occurrence of concomitant • examination of mucociliary function of the na-
bronchial asthma and other allergic diseases. The sal mucosa (nasal-mucociliary clearance, elec-
objective study establishes edema, hyperplasia and tron microscopy);
polyposal degeneration of the lining, mainly bilater- • status of the UAP function (nasal inspiratory
ally in the maxillary and ethmoidal sinuses. air flow, anterior and posterior rhinomanom-
Allergic pharyngitis occurs in two forms - acute and etry);
chronic. The pharyngeal mucosa is involved in the body's • olfactometry;
general reaction in contact with production allergens. • blood tests: BSR, differential count, Jg E, anti-
The focal process in the swallow (tonsils, tonsilar epithe- neutrophil cytoplasmic antibodies.
lial rest, lymphoid ring) plays an additional role for the Treatment. An obligatory condition for the treat-
sensitization and auto-sensitization of the organism. ment of occupational allergic rhinitis is the elimination
Acute edematous pharyngitis (swelling of Quinke) of the ill worker from the harmful working environ-
is characterized by acute leakage, diffuse edema of ment. Local treatment is by nasal spray - beclometh-
uvula, swallow, tongue and entry of the throat, oral asone preparations or cromoglycates. Oral therapy
cavity, affecting parts from the face. Breathing, itch- includes antihistamines, calcium preparations, Vit. C,
ing, general reaction of the body occur. specific desensitization with the causative agent - al-
Allergic laryngitis can develop alone or in com- lergen, immunotherapy. Synthetic cortisons are not
bination with allergic pharyngitis and rhinitis. It oc- recommended in everyday practice, except for ex-
curs in two forms: acute (diffuse or restricted aller- treme situations. Especially favorable for the outcome
gic laryngitis) and chronic (laryngopathy, catarrhal, of the disease is the use of physiotherapy and climatic
hyperplastic, pollenosic allergic laryngitis). This dis- treatment. In some cases, surgery is also involved.
ease often affects the following professions: textiles, Working capacity for UAPs occupational illness
millers, bakers, chemists. Additional factors such as depends on the localization of the process, the dura-
voice overtension, cold air, psycho-emotional ten- tion of the disease, the clinical signs, the nature of the
sions that are characteristic of vocalists and teach- work activity (permanent or periodic contact with
ers lead to illnesses that are neither inflammatory occupational allergens), the presence of combined
nor functional, and in their etiology, the presence of diseases (UAP and skin manifestations, UAP and pul-
dust from the scene, library dust, cosmetic materials. monary localization of allergic process, etc.). In case
Leading complaint is dysphonia, swallowing, and in of a tightening and absence of general allergic reac-
severe seizures - inspiratory dyspnoea. tions in dynamic follow-up (endonasal allergy test-
Allergic tracheitis rarely occurs as a single dis- ing), the worker continues to work in the profession
ease. It is most often combined with allergic laryngi- but is tested once a year and hyposensibilization
tis and pharyngitis in the form of allergic laryngotra- therapy is performed. In case of initial disease, it is
cheitis or pharyngolaryngotracheitis. The leading treated as a professional and temporary work is rec-
symptom is persistent paroxysmal coughing, which ommended for another job. In the case of a signifi-
is due to the presence of highly reflexogenic zones cant spread of the allergic process in the UAP, long-
in the trachea. term removal from the given profession (dynamic
Diagnosis. Of relevance to the diagnosis of occu- monitoring and therapy twice a year) is determined.

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In the cases of poly-allergy and marked clinical signs, are carried out. Combined with bronchospasm and
as well as during a long period of illness, rational allergic diseases of the skin and lungs, the issue of
labour and working capacity discussions in WEMC limited and permanent disability is discussed.
REFERENCES
1. Dessi P., Pech A., Allergie en ORL, Allergologie, ed. J. Charpin et al., Vervloet, Medecine et Sciences, Flammarion,
Paris, 1992, 432-447.
2 Hovarth P., K. Holmberg. Allergic rhinitis: an increasing clinical problem. - Allergy, 50, Suppl, 1995, 23, 4-5.
3. Intern. Consensus Report on the Diagnosis and Management of Rhinitis, Alergy, 49, 1994, Suppl. 19
4. Mileva G., G. Georgiev. National consensus on allergic rhinitis. Sofia, Schering Plow Central East AG, 1999, 30.
(in bul.)
5. Ostapkovich V.E., A.V. Brophman. Professional diseses ORLs organs. Moscow, Medicine, 1982, 280. (in russ.)
6. Popovic V., J. Comic. Oboljenja gornjih disajnih puteva. V. Medicine II, gl. ur. Al. Vidacovic, Beograd, 1997, 974-982.
(in serb.)

M. Demirova

8.2.2 PROFESSIONAL BRONCHIAL ASTHMA

B. Ramacini (1700) describes an increased inci- Substances such as lectins (concavalin A, phyto-
dence of bronchial asthma amongst flourman and hemagglutinins), bacterial polysaccharides, viruses,
millers - he is considered the first researcher of this trypsin, papain, silica and asbestos, activate non-im-
occupational disease. It is also known that in the munologically lymphocytes, macrophages, mast
nineteenth century frequent cases of asthma were cells, basophils and even the complement system.
reported among a number of professions: pharma- Concavalin A and phytohemagglutinins selective-
cists, furriers, bakeries, etc. ly stimulate T-lymphocytes, while polysaccharides
It is currently reported that in the US, 5% of the stimulate B-lymphocytes and macrophages. Non-im-
population suffers from bronchial asthma, and 2% is mune activation of effector cells and mechanisms can
professionally determined. In Germany, profession- also be induced by other agents. Fungal products,
al asthma accounted for 12% of all reported occu- for example, activate by non-immune way T-cells
pational illnesses, while in Bulgaria for 1991 - 17.3% and macrophages, leading to interstitial fibrosis.
(retrospective analysis for a 10-year period shows These agents stimulate lymphocytes to release lym-
its uneven increase). The main distinction of profes- phokines, and basophils and mast cells - mediators,
sional asthma from other forms of bronchial asthma as well as macrophages - interleukin 1. Silicon diox-
is that it is associated with a certain etiological factor ide and asbestos directly stimulate macrophages to
from the work environment. The number of these release interleukin 1, which in turn stimulates fibro-
factors has steadily grown - more than 300 causative blast growth, collagen synthesis, and T- and B- cells.
agents are registered in more than 100 risky occupa- • Histaminoliberated, via endogenous
tions that can cause bronchial asthma. non-immunological histamine release.
In occupational asthma, substances (powders, • Blockade of β-adrenergic bronchial recep-
vapors, and gases) provoke bronchospasm through tors and uptake of a-adrenergic receptors,
a variety of mechanisms: with subsequent tendency to bronchospasm.
• Allergic as a result of the reaction between Most substances in the working environment act
Ar and At, through complete antigens and so- on a complex pathogenic mechanism. For example,
called haptenes with subsequent release of isocyanates released in the manufacture of plastics,
mediator's substances responsible for clinical paints, lacquers and adhesives have in their chemi-
symptomatology. cal structure reactive NCO groups which, in contact
• Inflammatory, by inflammation of the lining, with the bronchial mucosa, can functionally block
which increases the sensitivity of bronchial b-adrenergic receptors with subsequent imbalance
receptors. It is known that inflammatory re- and the effect of α-adrenergic bronchial receptors. In
sponses can also be initiated by non-immu- addition, the isocyanate molecule has a high affinity
nological activation by cellular and humoral for reacting with the amino groups of the proteins,
effector mechanisms (Figure 1). whereby the isocyanate-hapten becomes a com-
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Fig. 1. Classification of occupational asthma
ETHIOLOGY PATHOGENESIS CLINICAL VARIANT

GROUP I Ar + At PRIMARY ALLERGIC PROF.

ALLERGENS ALLERGIC BRONCHIAL ASTHMA

I TYPE III TYPE

GROUP II IRRITATION SECONDARY ALLERGIC

ALLERGENS AND PROF. ASTHMA
IRRITANTS Chronic professional
bronchitis
Infectious Autoallergic

GROUP III REFLECTOR

NON-ALLERGIC (IRRITANT)
IRRITANTS MECHANISM
PROF. ASTMA
Histaminoliberation

plete antigen, i.e. non-specific activators, together Allergic form in professionally determined asth-
with specific antigens, play an important role in im- ma may occur suddenly in visible health, i.e., pri-
mune-allergic reactions. mary, or to form against a background of another
There is nothing specific about the clinical picture chronic occupational pulmonary disease with fre-
of professional asthma - specificity is related to its eti- quent infections (pneumoconiosis, chronic occupa-
ology and therefore, in most cases, paroxysmal dysp- tional bronchitis, etc.) as a complication thereof, i.e.
nea with noisy whistling breathing is exposingly de- secondary.
pendent on the work environment. They occur more The primary-allergic form occurs both in atopic
often at work, but are not uncommon when bronchial and non-atopic individuals. In the first, it occurs in
spasm occurs later and seizures can occur after leaving the rapid type of hypersensitivity with the formation
work and at night. Using functional and immunologi- of reagin antibodies and the formation of bronchoc-
cal methods, it has been shown that substances with onstriction at 15-30 minutes from contact with the
chemical and organic-powder nature can cause two allergen. In noatopic, it develops semi-delayed with
types of rapid reactions - those that are blocked by the addition of complement and agglutinin and
intal and others that are not blocked by it. Two forms precipitin antibodies, where bronchoconstriction
of late bronchospastic reactions have also been stud- occurs after 4-6 hours. Diagnostic skin and inhaled
ied - one begins after 1-2 hours and disappears in the provocative tests are positive at 30 min or 4-6 hours,
fourth to sixth hour, and the others are held for hours respectively.
or appear at night. Biphasic reactions have also been The secondary-allergic form is most often infec-
observed - a rapid, introducing, passing, followed by tive-dependent and rarely occurs with auto-allergic
a second, late reaction. Most professional factors, as mechanisms. Clinically, this form is severe with fre-
well as bacteria and fungi, can cause both rapid and quent attacks that are difficult to treat. Labour read-
delayed reactions, and sometimes biphasic. justment is ineffective, unlike primary-allergic asthma.
The main pathogenetic mechanisms for the oc- Non-allergic professional bronchial asthma
currence of bronchial asthma determine its different (called irritant in Anglo-Saxon literature, and in
forms: French-syndrome) is a common form of occupa-
• Immunological, Allergic asthma; tional asthma, especially in the chemical industry.
• Non-immunological, causing so-called Irrita- It does not happen with allergic symptoms, but the
tive (non-allergic, syndrome) asthma; bronchospastic crises are dependent on the working
• Combined, leading to the so-called Mixed environment and therefore the change of work has a
asthma. good healing effect.
A common sign of all forms of asthma is the in- Criteria for Diagnosis of professional bronchial
creased sensitivity of the bronchi to a number of asthma (Table 1).
non-specific or specific stimuli - i.e. bronchial hyper- The occupational hygienic criterion, through pro-
reactivity. fessional history, production characteristics of the

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Tab. 1.
Criteria for allergic professional asthma Criteria for non-allergic professional asthma
1. Labour-hygiene criterion. 1. Labour-hygiene criterion.
2. Epidemiological criterion. 2. Epidemiological criterion.
3. Exposure period. 3. Exposure period.
4. Nonspecific increased bronchial reactivity 4. Nonspecific increased bronchial reactivity.
5. Positive exposure test. 5. Positive exposure test.
6. Positive elimination test. 6. Positive elimination test.
7. Specifically increased bronchial reactivity to prof. al-
lergens.
8. Detection of specific antibodies to professional aller-
gens by skin-allergy tests or by more sophisticated
immunological methods.

enterprise and sanitary inquiry from the medical ma. This is especially true for chemically-induced
services, occupational safety or NII, proves the pres- bronchial asthma.
ence, type and amount of the professional risk. Treatment
With the epidemiological criterion and the so- The wide variety of etiological factors and com-
called collective test is looking for a possible in- plicated pathogenetic mechanisms in occupational
crease in bronchospastic manifestations in a group asthma require an individual approach when formu-
of workers in the profession. lating the healing plan (Figure 2).
In the so-called exposure period it is established It is particularly important to have targeted and
whether the disease does not precede work in the adequate etiological treatment. Labour readjust-
profession. ment here is equally effective for both primary-aller-
The first three criteria, the proving of non-specif- gic and non-allergic professional asthma.
ic increased bronchial reactivity through mediators, In the etiological aspect of allergic asthma, it is
β-blockers and others, pharmacodynamic substanc- also possible to rely on specific hyposensitization
es, as well as the exposition dependence of seizures with the professional allergen if it is organic-dust
through the so-called exposure and elimination etiology. Infectious-dependent secondary-allergic
tests, are equally valid for both primary forms of oc- bronchial asthma also includes treatment with poly-
cupational asthma. valent bacterial preparations such as respivax or
In so-called аllergic professional asthma out- bronchovaxom, ribomunil and others.
weighs the diagnostic value of skin allergy tests, The main task of pathogenetic treatment is to
bronchoconstriction tests with allergens and, in deal with bronchial obstruction. Included in the
some cases, immunological studies (RAST, immu- treatment plan are agents for suppressing the re-
noprecipitation, haemagglutination, etc.). The data lease of mediators from mast cells and their block-
from these tests are only relevant when they corre- ing, as well as those for controlling bronchospasm,
late one-way with the history and clinical course. On edema and discrimination - direct and indirect sym-
the other hand, negative skin-allergy tests can not pathicomimetics, parasympathicolytics, methylxan-
categorically reject the professional nature of asth- thines and corticosteroids.

TREATMENT

ETIOLOGICALLY PATHOGENIETIC SYMPTOMATICALLY

LABOR REDEVELOPMENT ANTIHISTAMINE ANTIBACTERIAL

SPECIFIC INTAL O2 THERAPY
HYPOSENSIBILIZATION ZADITEN CARDIOTONICS
SYMPATHOMIMETICS DIURETICS
XANTHINE DERIVATIVES ANTITUSSIVE
CORTICOSTEROIDS MUCOLYTICS
PARASYMPATHOLYTIC AGENTS

Fig. 2. Treatment of occupational asthma

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 LABOUR MEDICINE
Symptomatic treatment is used for complica- tients with mild and initial forms of asthma, after
tions such as insert infection, respiratory and cardiac which they have to be labour-readjustment with-
insufficiency. Treatment requires special attention in out harm, but with equal qualification. Where this is
the presence of concomitant diseases such as arteri- not possible or when the ability to work is not reim-
al hypertension, IHD, ulcerative disease, diabetes: in bursed for 12 months, permanent disability (invalid-
the case of cardiovascular diseases, the preparations ity) is determined and determines the percentage of
of Atriovent and Hamona are recommended for in- lost working capacity.
halation; in coronary disease cortisone preparations Prevention. Modern technical prophylaxis, by
are administered, mainly inhaled and only in vital technological and ventilation improvements (au-
signs - parenterally; diabetes also avoids cortisone tomation, sealing) reduces the risk of allergies. Pro-
treatment, but cortisone-dependent asthma regu- fessional recruitment is an essential tool of medical
larly monitors blood glucose with readiness to cor- prophylaxis. The importance of periodic medical ex-
rect anti-diabetic treatment. aminations of risk contingents is very important - to
Labour expertise. Temporarily disabled are pa- detect the initial forms of bronchial asthma.

REFERENCES

1. Allergic diseases treatment, ed. Vl. Tzvetanov., Skopje, MEDIS Informatika, 1998, 196 p. (in mac.)
2. Clark T.J.H., S. Godfrey T.H. Lee. Asthma. - London, Chapman Hall Medical, 1992.
3. Demirova M., B. Petrunov. Professional bronchial asthma. - Sofia, Med. and phys., 1988. (in bul.)
4. Demirova M. Professional allergic diseases. In: Allergology. - Sofia, ARCO, 2000. 326-336. (in bul.)
5. Demirova M., St. Raynovska. Professional bronchial asthma. in: Practical approaches in the treatment
of occupational diseases. "Knowledge" Ltd., 1995. 24-33. (in bul.)
6. Demirova M. Professional bronchial asthma. in: Problem of bronchial asthma. ed. J. Mileva. - Sofia,
Quintessence B.G. 1994. (in bul.)
7. Donald F.G. Clinical Immunology. In: Occupational Medicine, ed. J. La Dou, Apfelton Lange, Norwalk,
Conecticut / San Mateo, California, 1990. 140-154.
8. Fuchs E. Occupational asthma. Das Mediziniche prisma, 2, 1978.
9. Gervais P. et al. Guide pratique de l'Asthme professionnel Paris, Dudas and Co., 1979.
10. Internal Diseases - Volume IV. ed. Ch. Nachev. - St. Zagora, "Znanie" Ltd., 1994. (in bul.)
11. Kosturkov G., N. Aleksiev, P. Dobrev. Bronchial asthma. - Sofia, Med. and phys., 1990. (in bul.)
12. Pavlovic M.Z. Professional asthma. V & Occupational Medicine - II, ed. Al. Vidakovic, Beograd, 1997.
1028-1035. (in serb.)
13. Shepperd D. Occupational Lung Diseases. In: Occupational Medicine, ed. J. La Dou, Apfelton Lange,
Norwalk, Conecticut / San Mateo, California, 1990. 221-230.
14. Vermeil, A.E. Professional bronchial asthma. - Moscow, "Medicine", 1966. (in russ.)

M. Demirova, Y. Simeonov, M. Stoynovska, D. Baltadjieva

8.2.3 HYPERSENSITIVE PNEUMONITIS

Hypersensitive pneumonitis (HSP) is an allergic by some enzymes (e.g., proteolytic produced by Ba-
inflammation that engages the most peripheral air- cillus subtilis); antibiotics (for example, basitracin
way structures - the alveolar wall and the interstitial. in forage mixtures) and chemical compounds (e.g.,
Depending on the source and its causes, there are desmoduron used in plastic production). To date,
different names - J. Pepis groups the syndromes in more than 20 species of HSP have been known, with
the disease unit "exogenous allergic alveolitis"; in their number growing constantly (Table 1).
the United States his synonym is "hypersensitive Pathogenesis. It is currently assumed that the
pneumonitis". Organic powders and the thermo- main mechanism of development of hypersensitive
philic mushrooms contained therein are the major alveolitis is immune-allergic, which is also aided by
sources of the disease. Similar lesions are also caused non-immune activation. It is believed that in the

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Tab. 1. Etiological factors, sources of HSP
Etiological factors
Synonym of the HSP Sources
І. Bacteria
Farmer lung Mouldy hay Micropolispora faeni
Bagasosa Mouldy bagass (sugar cane) Termoactinomyces sacchari
Mushroom - grower’s lung Compost Thermophilic actinomycetes
Proteolytic enzymes
Disease of detergent workers Washing powder
of Bacillus subtilis
ІІ. Fungi
Pulmonary aspergillosis Spores on aspergillus Aspergilus fumigatus
Suberosis Cork powder Penicillinum frequentans
Sequoiasis Wood powder from sequoia Aureobasidium
Maple bark disease Maple bark powder Criptosoma corticale
Disease of the carpenters Wood dust Alternaria
Bookwarmer's disease Paper dust Alternaria
Cheese-maker’s disease Production of cheese Penicillinum casei
Aspergilus clavatus, niger,
Brewer's disease Malts
fumigatus, nidulans
Wine-maker’s disease Grapes Botritus cinerea
Weaver disease Textile powder Cephalosporium trochoderma
Disease of fur-dressers Leather powder
Disease of millers Flour powder
Newguinea disease Mouldy papua roofs Streptomyces olivaceus
ІІІ. Animal
Bird's lung Dust and excrement Bird proteins
Disease of breeders Fish meal Fish protein
Experimenters disease Urine from rats and experimental animals Animal proteins
ІV. Medications and chemical
substances
Aerosols and metal compounds - Al, Cr,
Lung of metals Metal - protein complex
Co, Ni, Zn etc.
Isocyanate lung Toluendiisocyanate Isocyanate haptene
Lung of pituitary powder Animal pituitary powder Proteins of cattle and pigs

acute forms of forehead is the third type of immu- granulomas devoid of caseous necrosis unlike tuber-
no-allergic reaction in which the specific precipitat- culomas.
ing antibodies bind to the antigen, forming immune Clinical symptoms are a combination of bron-
complexes with complement activation. For chronic chopulmonary cough with scarce expectoration,
pulmonary fibrosis, stage leading is the allergic re- inhaled or mixed type dyspnoea and flu-like syn-
action of type IV. Sensitized T-lymphocyte cells then drome - fever, sweating, headache, myalgias with ar-
bind to the antigen, releasing the lymphokines re- thralgias. An objective study is the so-called "silent"
sponsible for local tissue inflammation and necrosis. dyspnoea, i.e. breathless with cyanosis without noisy
The immune-allergic mechanism in hypersensitive whistling breathing. In auscultation, creaking or
pneumonitis is of paramount importance, but it is small wet wheezes are heard in the lungs. For diag-
also aided by an additional non-immune mecha- nosis is essential the radiography of the lungs. In the
nism. Disclosed in the cell wall of various bacteria acute stage there are infiltrative-pneumonic shad-
and fungi lipopolysaccharides directly activate an al- ows of different density and size, located bilaterally
ternative complementary pathway, resulting in the and symmetrically in the middle and lower pulmo-
release of anaphylatoxins - chemotaxis for phago- nary fields (Figures 1 and 2). In the chronic stage,
cytes. Lipopolysaccharides stimulate lymphocytes there are X-ray data for diffuse pulmonary fibrosis
to release lymphokines, and lymphocytotoxins and and emphysema (Figure 3). Functional breathing
macrophage activators (responsible for allergic in- patterns indicate pulmonary restriction and dis-
flammation). turbed gas diffusion - reduced diffusion capacity,
During biopsy, clusters of neutrophils, mono- and in heavier, and especially chronic, hypoxia in
cytes, lymphocytes, plasmocytes, histiocytes, mac- blood-gas analysis. In contrast to bronchial allergies,
rophages, and giant cells have been observed, with in hypersensitive pneumonitis no bronchial hyper-

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Fig. 3. Chronic Stage of HSP - diffuse pulmonary fibrosis in

detergent worker (Bacillus Subtilis)
Fig. 1. Acute stage of HSP - infiltrative-pneumonic
shadows in stock-breeder (Thermoactinomyces)
• Clinical: start of complaints 6 hours after pro-
fessional contact with organic powders, deter-
gents and other chemical substances;
• Functional: Restrictive or mixed type ventila-
tor failure, reduced diffusion capacity, hypox-
emia, normal bronchial reactivity;
• X-ray: data on infiltrative shadows in the mid-
dle pulmonary fields (acute stage) and diffuse
pulmonary fibrosis (at the chronic stage);
• Immuno-allergenic: positive skin tests for the
pro-allergen at 6 hours and evidence of specif-
ic immuno precipitin antibodies by Uchterloni
or electroimmunodiffusion.
Treatment. From the etiological point of view,
it is best to immediately remove the patient from
Fig. 2. The same case after 20 days of treatment the provoking environment. Only effective is the
with corticosteroids medication treatment of allergic inflammation with
corticosteroids at a dose of 40-60 mg daily. Dehy-
reactivity was found - the broncho-provocative test drocortisone with gradual dose reduction for a total
with methacholine was negative. duration of treatment of 3-4 weeks - for prophylactic
Laboratory values is uncharacteristic and incon- use, cortisone therapy should be combined with a
sistent, but may have leukocytosis with neutrophilia. broad spectrum antibiotic. Symptomatic therapy is
Important are the results of immune-allergenic conducted in the acute stage when there is respira-
tests with the suspected allergen: positive skin al- tory failure and in the chronic stage with definitive
lergy tests to the professional allergen at 6 hours, pulmonary fibrosis leading to respiratory and heart
positive immunoprecipitation tests (by Uchterloni, failure.
electroimmunodiffusion and other immunoprecipi- An antibacterial therapy is added to the inflamma-
tation tests). tory process in chronic forms in the treatment plan.
Also important for the diagnosis are bronchoal- Allergic alveolitis concomitant diseases require
veolar lavage (BAL) data for a significant increase in careful judgment - in hypertension and IBS, corti-
IgG and a real increase in lymphocytes (predomi- sone treatment is conducted under enhanced and
nantly T cells) and precipitating antibodies. controlled hypotensive and coronarodilatory thera-
Diagnostic criteria. For the timely and correct py; in ulcer artery disease, corticosteroids are admin-
diagnosis of HSP, two conditions are essential: istered by parenteral and inhalation routes only, with
• to have a professional medical history; daily Hb control, occult blood stools and abdominal
• use a clinical minimum of laboratory and in- status; in diabetes, oral treatment is combined with
strumental examinations (Table 2). aerosol cortisone treatment in blood glucose con-
The main diagnostic criteria are: trol.

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Tab. 2.
Symptoms Laboratory indices
I. Routines: ESR, PKK, KGA, CRA
II. Specific: HPP at 6h and 24h to professional
Shortness of breath, cough with scarce expectoration;
allergens; Immunological tests to demonstrate
Fever, sweating, headache, myalgia, arthralgia.
specific precipitates.

Clinical features:
Dyspnoea, predominantly of the inspiratory type with cyanosis,
no noisy breathing; You can hear creaking or small wet
wheezes in the lungs and the middle fields.
Instrumental methods: Ro-graphy and scintigraphy of the lungs, FID, diffusion test, bronchoconstriction tests,
exposure tests (in rare cases), BAL, fibrobronoscopy with biopsy
Labour expertise. Hypersensitivity pneumoni- immediate labour readjustment through WEMC. At
tis is a disease with serious consequences. In order dequalification determines a percentage of loss of
to avoid chronic, with definitive pulmonary fibrosis, working capacity.
stage of the disease, it is necessary to perform an
REFERENCES
1. Bozhkov B. Hypersensitive pneumonitis. in: Allergology (Principles and Practice). ed. Bozhkov. B., S., ARSO, 2000,
239-240. (in bul.)
2. Demirova M. Bronchoallergopathies of organic dust. S., Med. and phys., 1980. (in bul.)
3. Demirova M. Professional allergic diseases. in: Allergology (Principles and Practice). ed. Bozhkov. B., S., ARSO,
2000, 326-336. (in bul.)
4. Demirova M., R. Boeva, Y.Simeonov. Hypersensitive pneumonitis. in: Practical approaches in the treatment of
occupational diseases. ed. M. Demirova - S., "Knowledge" Ltd., 1995. 34-37. (in bul.)
5. Donald F.G. Clinical Immunology. In: Occupational Medicine, ed. J. La Dou, Apfelton Lange, Norwalk, Conecticut
/ San Mateo, California, 1990. 140-154; 221-230.
6. Homenko AT, St. Muller, V. Schilling. Exogenous allergologic alveolitis - M., "Medicine", 1987. (in russ.)
7. Patterson R. et al. Diagnostic problems in hypersensitivity lung disease. Allergy Proc., 1989, 10.
8. Pepys J. Hypersensitivity diseases of the lungs due to fungi and organic dusts. Basel - New Jork, Karger, 1969.
9. Richerson H.B. et al. Guidelines for the clinical evaluation of hypersensitivity pneumonitis. Report of the subcom-
mitte on Hypersensitivity Pneumonitis. J. Allergy Clin. J. Immunol., 1989, 84 (5 pt2); 839-844.
10. Salraggio J.E. Immune reaction in allergic alveolitis, Eur. Respir. J. Suppl. 1991; 16: 47-59.

V. Zlateva, R. Toncheva, M. Stoynovska

8.3 PROFESSIONAL ALLERGIC

CONJUNCTIVITIS
The eye has specific anatomical and physiological tive barrier to the pathway of exogenous antigens.
barriers that make it unique in its immune response The proximity of the conjunctiva to the eyelid skin
- the eye has the ability to perform all types of aller- and the connection of the lacrimal pathways to the
gic reactions. The conjunctiva is very often a place of nasal mucosa is a prerequisite for the emergence of
these reactions because it is easily contacted for var- combined dermato - and rhino-conjunctival forms.
ious exogenous allergens. The normal conjunctiva Occupational risk exists in many professions
is a natural barrier that prevents the penetration of (endangered occupations): workers in the chemical
exogenous substances. It has a huge number of cells industry, cement production, agriculture, pesticide
involved in inflammatory reaction-lymphocytes, production, pharmaceutical and cosmetic indus-
plasmocytes, neutrophils. Ig from all 5 classes were try, textile industry, food, shoe and leather industry,
found in the subepithelial tissues, and in the prelim- medical personnel, etc.
bic zone Ig - producing plasmocytes. The leak film Pathogenesis. In patients sensitive to one or
contains immunoglobulins - A and G, complement, more allergens, a local type I-type hypersensitivity
lactoferins, lysozyme and they form the first protec- reaction followed by a response to the ocular muco-

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sa. The immunological response begins with a spe- test; microbiological examination of conjunctival se-
cific binding of an antigen with an IgE antibody on cretion.
the membrane surface of the conjunctiva mast cells, Diagnostic expertise is associated with diffi-
defined as "tryptase-containing" and "tryptase + culties arising from the fact that there are no limit
chymase-containing". "Pre-formed" mediators (hista- concentrations or safe concentrations of allergens in
mine, chemotactic factor, cytokines) and "newly syn- the working environment. For workers with a genet-
thesized" mediators / prostaglandins - PgD2, leukot- ic predisposition to allergic diseases, contact with
rienes - LTC4, LTD4, LTE4 are released. The presence professional allergens in the work environment only
of mediators of inflammation results in acute con- unlocks the disease.
junctival symptoms, as well as secondary accumula- Criteria for etiological diagnosis are:
tion of neutrophils, Eo, Ba. These cells are prolonged • Occupational risk for allergy;
by the inflammatory processes ending with chronic • Collective epidemiological test;
inflammatory association of non-specific hyperreac- • SAT with professional allergens;
tivity. The release of biologically active substances • Elimination and exposure test.
leads to conjunctival hyperemia, increased vascular Treatment. The first determining factor in the
permeability, hypersecretion of the mucosal glands, treatment of allergic eye diseases is the establish-
edema of the eyelids and conjunctivitis. ment of an allergen and the discontinuation of con-
Clinical picture. Acute conjunctivitis is seen tact with it.
in a single encounter with the allergen. Subjective The means of immunopharmacology are specif-
complaints are: itching, burning, irritation, dryness ic and non-specific hyposensibilization, cytostatics,
or tearing in the eyes, photophobia. The objec- immunostimulators, steroids and non-steroidal an-
tive symptoms are: diffuse conjunctival hyperemia, ti-inflammatory agents, antihistamines.
bulbous and tarsal conjunctival haemorrhage, wa- Medicinal anti-allergic agents are for general and
tery-mucous lucid secretion, edema of eyelid skin, topical use. Anti-allergic preparations for topical use
eyelash rib hyperaemia, papillary hypertrophy, fol- are:
licular reaction, blepharoconjunctivitis, keratocon- Prophylaxis. Medical prophylaxis includes pre-
junctivitis. MEDICINAL DOSAGE MODE
Chronic form occurs as an IV type reaction. In this LIVOSTIN 2 DROPS MORNING
form there are less objective symptoms than subjec- BICROMAT 4 x 1 DROP
tive complaints. VISINE 2 x 1 DROP
Pathogenetically, T-cell mediated allergic reac- SPERSALLERG 3 x 1 DROP
tions occurring with inflammatory infiltrative chang- CUSICROM 3 x 1 DROP
EMADINE 2 DROPS MORNING
es in ocular tissues. These include: ALERGODIL 2 x 1 DROP
• Contact dermatitis and eyelid eczema ALERGOFTAL 2 x 1 DROP
• Blepharitis CELESTON “S” 3 x 1 DROP
• Contact allergic conjunctivitis and keratocon- MAXIDEx 3 x 1 DROP
junctivitis (concomitant contact dermatitis). ULTRACORTENOL 3 x 1 DROP
Diagnostic methods. Biomicroscopy; skin-aller-
gic tests (skin-prick test, intradermal test, epicutane- liminary and periodic medical examinations of work-
ous test); immunological diagnosis: determination ers. For some professions, a thorough allergic history
of IgE specific IgE immune-enzyme method "ELISA", and research is needed to "treat atopic individuals".
UniCAP-test system, determination of total Ig-E, de- Early diagnosis is necessary for timely rehabilitation
termination of inflammatory factors - eosinophilic of patients. Recently, so-called "lubricants", as a pre-
cationic protein; cytological study of curettage ma- ventive agent for conjuctiva contacting by environ-
terial from the tarsal and fornix conjunctiva for the mentally harmful agents.
presence of Eo, Ba, Ne, Pl; elimination and exposure
REFERENCES
1. Bozhkov B., Allergology - principles and practice, Sofia, ed. Arso, 2000.
2. Maichuk Y., Allergic eye diseases, Sofia, Med. and phys., 1988. (in bul.)
3. Marinova D., T. Zlatkov. Eye diseases, in: Clinical immunology, ed. B. Bozhkov and M. Ognianov,
"Knowledge", 1997, 327-335. (in bul.)
4. Alldnsmith M. U. The eye and immunology, Mosby, St. Louis, 1982.
5. Silverstein A. M., G. R. O., Conor. Immunology and immunopathology of the eye, Masson, New York,
1979.

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OCCUPATIONAL MEDICINE

PROFESSIONAL MALIGNANT
NEOPLASMS
D. Todorov

9.1 ONCOLOGICAL DISEASES -

BASIC SITUATIONS

Oncological diseases (malignant neoplasms) are five years and more than 60% in US (with a high per-
considered to be a composite term involving a large centage and radically cured patients), by early diag-
heterogeneous group of over 200 different nosologi- nosis and modern complex treatment and tracking,
cal units, previously called "localizations". Individual which is balanced and individualized for each pa-
oncological units have common characteristics, but tient. Progress here is also evident from the fact that
they differ significantly. Thus, breast, lung, prostate, the five-year survival in 1900 was only 5%, and since
testicular, melanoma, ovarian, and so on cancers, are then it has grown slowly but steadily.
considered as separate nosological units rather than Epidemiology. According to WHO statistics, the
localizations of a disease. Some of them, according world's cancer patients are currently over 15 million
to modern perceptions, are also formed by several in total. Most of them are in developing countries.
different nosological units - small cell and non-small Every year about 10 million new patients are found
cell lung cancer, seminomal and non-seminomal tes- and around 6 million per year die. According to lead-
ticular tumors, etc. (especially great is the heteroge- ing American biostatistics, over 20 million new can-
neity of the group of lymphomas, brain tumors and cer patients are expected to be found in the world by
other oncological units). They differ significantly in 2020, and 10 million of them will die.
their clinical picture, treatment options, prognosis, Oncological diseases in most developed coun-
traceability and rehabilitation, and probably in their tries is now second of socially significant diseases
specific etiology and pathogenesis at the molecular after cardiovascular diseases. However, scientifical-
level, hence the prophylactic approach. ly-based projections indicate that, around 2020, and
Oncological diseases is generally characterized by even earlier, oncological diseases will become the most
impaired control mechanisms of cell proliferation, dif- important disease in Europe. This fact is explained
ferentiation and apoptosis, heterogeneity of tumor cell both by the real positive results of the prolonged,
populations, early dissemination and micrometasta- well financed and organized at the highest state
ses, invasive growth, and others common characteris- level cardiovascular prophylaxis in the developed
tics. countries, as well as the successes of their modern
Diseases have recently been identified as cell sig- treatment. According to the latest data for the Unit-
naling pathways caused by activation of multiple ed States, there is probably now a social equalization
oncogenes or loss of tumor suppressor genes. between cardiovascular and oncological diseases.
One of the main functions of oncogenes is to en- Globally, taking into account developing countries,
code proteins, components of intracellular signaling about one-third of all cancers are now being prevented
pathways, activated by growth factors. Therefore, by oncoprophylaxis, 1/3 are radically cured, and 1/3 are
overexpression of certain oncogenes or their perma- kept palliative in good quality of life.
nent activation by mutation, leads to a continuous de- However, for individual oncological units in the
livery of growth signals to the cell. The combination of developed countries, overall mortality and morbidi-
a number of oncogene-activated signaling pathways ty still increase, albeit with different rates for individ-
may result in the transformation of the normal cell into ual nosological units, for different countries and re-
a cancer cell. On this most recent theoretical basis, new gions of the world. Worldwide, the highest incidence
approaches to the prevention, diagnosis and treat- of stomach cancer (although declining in developed
ment of cancer are now being sought. countries and also Bulgaria in recent years), followed
In the more advanced countries of the EU, more by lung cancer (although some decline in the Unit-
than 50% of all cancer patients survive for more than ed States, England and other developed European

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countries, but not and in our country) and colon can- all cells in the body) is transformed into a tumor cell
cer. There are also trends for a predominant increase by natural mutation or physical, chemical or biolog-
in prostate cancer in men and breast cancer and ical induction. As a result of the proliferation of this
uteri cervical cancer in women. Taking into account cell (becoming practically immortal, unlike normal
the clinically unidentified microcarcinomas, prostate cells), a new cell cluster is formed. It may result from:
cancer is probably the most common tumor in men, a malignant tumor and the clinical picture of on-
and perhaps the most common tumor in humans at cological disease; a capsular benign tumor may be
all (excluding skin cancer). These onco-epidemiology formed or the transformed tumor cells may remain
data serve as a solid scientific basis for the organiza- in a "sleeping" state for a long time - they may also
tion of prophylaxis in developed countries. later develop a tumor or at least lack clinical manifes-
Every year around 27 000 new cancer patients are tations throughout the human life. However, it is ex-
found in Bulgaria and about 17 000 die, with a total tremely rare that a clinically proven and histological-
number of cancer patients in the country already ex- ly proven tumor undergoes a "spontaneous" reversal
ceeding 200 000. There has been a constant increase of development, with "spontaneous" regression and
in the overall morbidity and mortality rate since the self-healing of the diseased, currently poorly under-
1950s. Particularly unfavorable is the relatively late stood mechanisms - for example, in melanoma pa-
detection, at an advanced stage, of a significant per- tients, in chorioncarcinoma, kidney cancer.
centage of cancer patients in our country. It leads The formation of a malignant tumor (oncogenesis,
to poor therapeutic results and a significant cost of carcinogenesis) is a complex, prolonged and multifac-
treatment, which does not correspond to the capa- torial process. Oncogenesis passes through three main
bilities of the developed countries of the European stages:
Union, US and Japan. The reasons for this are nu- • The initiation stage - lasts from minutes to
merous - especially the lack of a scientifically and hours and days;
financially-based modern cancer program in our • A promotion stage - lasts from a few weeks
country, involving the whole society (and not just to several years. It has accumulated genetic
doctors-oncologists) at the highest priority national changes in somatic cells, with activation of
level, such as programs that have long been success- protooncogens and / or inactivation or loss of
fully implemented in all developed countries. Unsys- antioncogenes;
temic and inadequate is the oncology training and • Progression stage - progressive changes are
qualification at all levels - the whole civil society, as likely to be reversible and, in principle, the
well as the medical oncological and non-oncological possibility of reversing the tumor cell is nor-
staff. mal. This view has an extraordinary theoretical
Bulgaria also finds the well-known "rejuvenation" and also practical relevance to oncology, but
of cancer mortality observed in developed countries it is not yet conclusively proven in humans.
(but still the major percentage of cancer patients are So far, such differentiation of tumor cells to
in the "third" age). Thus, in people between 20 and corresponding normal cells has been found
39 years of age, oncoletality has increased by about primarily in tumor cell lines "in vitro" and in
40% in the last 15-20 years. In women between 15 some leukaemias. It is the basis of vanguard
and 59 years of age, oncological diseases accounts therapy with differentiating agents, for example
for 1/3 of the causes of death, while another 1/3 of retinoids that are still of limited clinical use,
cardiovascular diseases and 1/3 of all other diseases, and other potential differentiating antitumour
traumas and road accidents. drugs are in different clinical trial stages.
Etiology and pathogenesis. As a genetic dis- The malignant tumor may have a long latency
ease of somatic cells, the cancer is characterized by period that is clinically asymptomatic. It then goes
impaired regulation of cell proliferation and differ- through several clinical stages - local, loco-regional,
entiation, unlimited invasive growth and metastasis, recurrent and/or distant metastases, and it is possible
possibly caused by disorders in gene regulation and to develop new tumors.
transmission of cellular signals between cells and/or Chemical, physical and biological carcinogens can
within the individual cell. Increasingly importance in play the role of initiators of carcinogenesis.
this respect has recently been given to the suppres- Polycyclic aromatic hydrocarbons, nitrosamines,
sion of programmed cell death (apoptosis) by vari- aromatic amines, amino azo derivatives, various afla-
ous molecular mechanisms. toxins, alcohol, alkylating agents, androgens, oestro-
It is assumed that the majority of malignant tu- gens, arsenic, asbestos, phenacetin, and so forth are
mors have clonal origin. One or more of the dividing already well studied in chemical carcinogens. The re-
each day about 350 billion normal cells (about 1/3 of sults of such studies have been regularly published

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for many years in the IARC Newsletters of the Lyon • protooncogens for cell signal transmitters
Agency for Research on Cancer (IARC). (transmitters);
Physical carcinogens may be ionizing or non-ion- • propionogens for transcription factors;
izing radiation of different wavelengths. Many of • protooncogens for regulators of apoptosis.
them are still only suspected but not proven and are In addition to the described molecular mechanism
undergoing intensive research. of carcinogenesis - the activation of protooncogens to
Biological carcinogens (oncogenic viruses) that active oncogenes, there is also a second major mech-
have been proven to be such are hepatitis B virus anism - suppression of the so-called tumor-suppressor
for liver cancer, multiple human papilloma viruses genes (antioncogens), most commonly by point mu-
such as type 16 and others. For uteri cervical can- tations. Between the tumor suppressor genes, p53
cer, HTLV-1 for endemic T-cell leukemia in adults, is the central site of the antioncogen. It is a nuclear
Epstein-Barr virus in Burkitt's lymphoma and many protein with a molecular weight of 53 kd, located on
others viruses - so far more suspected than proven. the short arm of chromosome 17. It is called a "guard-
Other substances can act as promoters that are not ian of the genome", which causes programmed cell
oncogenic in themselves, but can potentiate the ef- death or arrest of the cell cycle. In many cases of on-
fect of subcarcinogenic doses of true carcinogens. cological diseases, the p53 antioncogen has been
Promoters may be croton oil and phorbol esters found to have a mutation that has lost its function.
therein, saccharin, bile acids, fatty acids, diterpenic These p53 mutations were most commonly ob-
esters, phenobarbital, surfactants, and many others served in adult oncological patients and significant-
chemical agents. Certain carcinogens require man- ly less frequently in childhood tumors. It has been
datory metabolic activation in the body, most often found that some mutant forms of p53 may activate
in the liver (less frequently in other tissues) to exert cells to unrestricted divisions and cause immortali-
their carcinogenicity. Therefore, there may be large zation of the cells.
interindividual differences in their carcinogenic ef- Other recent anticogens have been found to be
fect, depending on the individual metabolic com- RET (tyrosine kinase receptor), WT (a transcription
petence of the body - many studies show that it is factor) that has been mutated in the Wilms tumor
predominantly genetically determined. in children, the p16 gene in melanomas, gliomas,
Molecular carcinogenesis, protooncogens, onco- bladder cancer and leukemias, NF1 and NF2 in neu-
genes and tumor suppressor genes. In normal cells, rofibromatosis, BRCA1 and BRCA2 in breast cancer of
there are so-called protooncogens or cell oncogenes women, and others -now "candidate antioncogens".
that are very conservative in evolution, and are likely More than 100 oncogenes and more than 40 an-
to play a role in regulating normal cell proliferation ti-oncogenes have been discovered - the description
and differentiation. So far more than 40 protoon- of new ones and the clarification of their functions
cogens have been identified in various retroviruses continues. The enormous difficulties in clarifying the
- RNA tumor viruses (many others are undergoing molecular mechanisms of oncogenesis, however,
intensive research and demonstration). Under the come from the fact that only 6-8 oncogenic diseases,
influence of the described carcinogenic factors, by and most of these rares, are caused by monogenic
mutation, chromosomal rearrangement or gene am- defects. The prevailing number of over 200 tumor dis-
plification, these inactive protooncogens can be con- eases is characterized by a polygene (multiple) nature
verted into active oncogenes. Oncogenes encode of the defects.
the synthesis of various protein products, including The research of oncogenes and anti-oncogenes,
growth factors from the epidermal, thrombocyte, the identification of changes in them and the mod-
insulin, fibroblast, hepatocyte, and other families ern molecular methods for their quantification re-
growth factors as well as growth factor receptors veal in principle new possibilities for real molecular
involved in the regulation of cell proliferation and prophylaxis, diagnosis and monitoring of oncological
differentiation, and hence in the growth of tumors. diseases, as well as a new approach to their complex
Much of the oncogenes act by encoding the synthesis treatment.
of membrane tyrosine-specific protein kinases - in this Biology of human tumors - general data. Us-
way they probably influence the molecular process- ing conventional clinical diagnostic methods, it is
es of cell signal transmission, which is now the sub- now possible to detect tumors with a diameter of
ject of particularly intensive experimental studies. at least 0.5-1 cm in which there are about 1 billion
The protooncogens are classified into five groups tumor cells then the tumor has already undergone
according to the functions of their protein products: 30 consecutive doubling. Numerous studies on tu-
• protooncogens for growth factors; mor biology have shown that distant hematogenic
• protooncogens for growth factor receptors; or lymphogenic micrometastases have already been

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diagnosed at 50-60% of the oncologists at this time cells recover faster than tumor cells. Conversely, in
of diagnosis. They can be detected with labeled slowly growing "solid" tumors, due to the same fea-
monoclonal antibodies and the highly sensitive and tures of tumor biology, an optimal therapeutic ef-
specific polymerase chain reaction. This basic fact of fect is achieved by longer courses of treatment with
tumor biology explains why, in such patients, radical greater intervals between them.
therapies with local action (surgical and radiothera- The greater the tumor mass, the smaller the
py) are doomed to failure due to the development "growth cell fraction", and the lower the sensitivity of
of recurrence and metastasis, most often with fatal the tumor to drug treatment and vice versa. There-
outcome. These data on the early micrometastasis fore, in large, advanced tumors, first, the tumor mass
and the so-called residual disease (a small number should be reduced to the minimum possible by sur-
of residual tumor cells after removal of the main gical or radiological treatment and then drug treat-
tumor mass) have become the theoretical basis for ment is used to destroy the remaining relatively few
the creation of modern therapeutic approaches for viable tumor cells. It is now well known that only one
adjuvant (complementary, prophylactic) therapy as or several viable tumor cells remaining after treat-
well as for neo-adjuvant therapy. Adjuvant therapy ment are sufficient to induce a relapse of disease.
is administered after radical surgery or radiotherapy The so-called adjuvant drug treatment (destroying a
(very rarely) and neo-adjuvant (primary) therapy be- relatively small number of residual but viable tumor
fore other radical treatments. cells) has been administered to the so-called residual
Biological characteristics of the individual disease following radical operative or lesser-radia-
tumor. The kinetics of tumor growth is essential for tion treatment. Tumor biology data and experimen-
the prognosis of oncological disease and the pre- tal therapy indicate, according to most researchers,
diction of its sensitivity to drug treatment. In tum- that immunotherapy (treatment with modulators of
ors with a small "growth fraction", a high "doubling biological response) administered alone can only be
time" and slow growth, such as some nodular forms effective in very few viable tumor cells (below 100,000
of non-Hodgkin's lymphomas, so-called aggressive cells or less than 0.1 cm diameter of the tumor),
drug treatment, is no-recommended, whereas in which is also theoretically expected to be effective
other patients with the same diagnosis, but of ag- in a residual disease. Conversely, in large, advanced
gressive clinical course is necessary and more ag- "solid" tumors or leukemias where the tumor mass is
gressive combined drug treatment. The "growth very high, immunotherapy is not only ineffective but
fraction" or "proliferative pool" of the tumor is can potentiate tumor growth, possibly due to the
formed by the active fission tumor cells, that are in formation of blocking antibodies, and other reasons
one of the cell cycle phases (G1-pre-syntetic, S-syn- that have not yet been clarified.
thetic, G2-postsynthetic and M-mitotic). Tumor and One of the mathematical models of the dynamics
normal cells that are out of the cell cycle, so-called of tumor growth is expressed by the Gompertz si-
"sleeping cells" or G0 phase cells are generally con- nusoidal curve. It is characterized by an early phase
sidered to be mildly sensitive to drug treatment and of slow proliferation, followed by a second phase
irradiation. For a variety of reasons, they may re-en- of rapid logarithmic growth and a third phase of a
ter a cycle and thus relapse the oncological disease, new delay in proliferation, until reaching a plateau
but they are usually re-sensitive to treatment (if they in growth close to the death of the patient. From the
have not developed resistance to it). High sensitivity cytokinetic point of view, in order to achieve com-
to antitumor drugs generally exhibits malignant tu- plete destruction of the tumor cells, it is necessary to
mors with a large "growth fraction" and rapid growth administer the antitumor drug repeatedly at certain
such as Burkitt's lymphoma, uterine chorionepithe- intervals. So far such cell kill has only been achieved
lioma, some leukemias, lymphosarcomas, and oth- in experimental conditions in rapidly growing as-
ers. Tumors with small "growth fraction" and slow cites transplanted tumors in mice, such as lymphoid
growth are usually more resistant to drug treatment leukosis L1210, a model of Skipper-Schabel-Wilcox.
- primary or acquired resistance (eg. stomach cancer, According to their hypothesis about the logarithmic
rectum and colon, pancreas, prostate, etc., so-called destruction of tumor cells, this is a first order pro-
"solid" tumors). Normal bone marrow cells have a cess in which a constant portion of the tumor cells
large "growth fraction" and are highly susceptible is destroyed at each subsequent application of the
to antitumor drugs. Therefore, myelosuppression is antitumor drug. Thus, in 2-log arithmical destruction
one of their most common and severe side effects. In of the cells, 99% of them are destroyed, in case of
fast-growing tumors, the optimal therapeutic effect 5-log. destruction, 99.999% of them are killed, and
is achieved by intensive intermittent drug treatment so on. An antitumor effect may occur theoretically
at short intervals, where damaged bone marrow in 2 to 5-log. tumor cell destruction by the antitu-

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mor drug (monotherapy) or a combination of drugs tumor cells occurs through the following steps:
- most commonly used in clinical oncology as multi- a) adherence to the endothelium - is accom-
ple protocols for combination drug therapy. Another plished by interacting the tumor cell with fibrin,
cytokinetic model that is closer to human "solid" tu- platelets and hemostatic factors, adhesion to recep-
mors is that of Norton-Simon. tors of the PGD type;
Heterogeneity of tumor cell populations. Al- b) endothelial retraction - involving platelets as
though tumors are likely to have a clonal origin be- well as tumor cell factors;
cause of the large genetic plasticity and instability c) adhesion to the basal membrane - receptors
of tumor cells, mutations often occur, some of which for laminin, thrombospondin and collagen type IV;
are inherited and thus several different cell clones d) dissolution of the basal membrane - metallo-
are developed in a malignant tumor. Thus, 2 to 4 cell proteinases, serine proteinases, heparinase, cathep-
clones are most commonly found in human breast sin;
tumors, and more than 20 different cell clones are e) movement - autocrine motility factors and
found in the multiple glioma of the brain, which can chemotaxis factors have been identified.
be explained by extremely complex brain histoge- 7. Formation of colonies at a secondary site - re-
netics. Some of these cell clones are sensitive to an- ceptors for local tissue growth factors; angiogenesis
titumor drugs and/or radiation therapy and are rap- factors; mutation or loss of metastatic suppressor
idly destroyed, but others are naturally resistant or genes.
acquired resistance, and therefore remain and prolif- 8. Avoidance of tumor cells from the protection of
erate. Cell clones are also different in their ability to the organism and the emergence of resistance to ther-
induce angiogenesis, invasion and metastasis. Het- apy - resistance to destruction by the macrophages
erogeneity of tumors also justifies some of the ben- of the organism; to natural killer cells and activated
efits of intensive and high-dose drug treatment, as T-cells; unsuccessful expression or blocking of tu-
well as multi-drug combinations with different mo- mor-specific antigens; amplification of drug resist-
lecular mechanisms of antitumor activity, to mono- ance genes.
therapy (treatment with only one anti-cancer drug Neovascularization is a prerequisite for the local
that is used relatively less frequently). Heterogeneity expansion of tumor colonies out of the area, limited
of tumor cell populations; drug resistance, especially by the diffusion of oxygen and nutrients.
multiple drug resistance to a large number of MDRs; Angiogenesis is needed at the beginning and
as well as early micrometastasis, are one of the main end of the metastatic cascade. Because of the dis-
reasons for the failure of drug treatment for cancer. ruptions in the basal membrane, the tumor vessels
Invasive growth. Metastasis. Angiogenesis. In- are permeable, the tumor cells easily pass through
vasion and metastasis are complex multistage process- their walls and enter the circulation in large numbers
es (so-called metastatic cascade) that sequentially in- - several million tumor cells per day. Studies have
volve the following relationships between the tumor found a positive correlation between the number of
and the oncopatient's organism: tumor microvessels in a biopsy material and the pa-
1. Tumor initiation: during the initiation the car- tient's fate in prostate cancer, melanoma, breast and
cinogenic effect occurs, activation or depression of ovarian cancer.
oncogenes and rearrangement of chromosomes. The individual stages of the metastatic cascade -
2. Promotion and progression: characterized by angiogenesis, adhesion, proteolysis, motility and
karyotype, genetic and epigenetic instability, gene proliferation, can serve as new guidelines for the
amplification of promotional and growth-associated prevention and treatment of oncological diseases.
genes, mutation or loss of suppressor gene products. Thus, the antiangiogenic effect of alpha-interferon -
3. Uncontrolled proliferation: includes autocrine suppresses gene expression for angiogenic growth
growth factors or their receptors as well as receptors factor, leads to regression of life-threatening he-
for most hormones, for example, for estrogens. mangiomas in children. Clinically, anti-angiogenic
4. Angiogenesis: Multiple factors of angiogenesis agents, such as the known teratogen thalidomide,
are activated, incl. known growth factors. also TNP-170, marimastat, angiostatin, and others,
5. Invasion of the local tissues, blood vessels are tested. Intensive experimental studies are also
and lymph vessels - with the participation of serum devoted to influencing the signaling pathways of
chemotractants; autocrine factors of motility; at- the metastatic process - calcium homeostasis, kinase
tachment receptors; degrading enzymes; loss of ex- activity, ras-oncogene activation, specific antisense
pression of proteinase inhibitors. nucleotides, selective cyclooxygenase-2 (COX-2) in-
6. Circulating tumor cell suppression and extrava- hibitors, etc.
sation - homotypic and heterotypic aggregation of Prevention. The origin and evolution of oncolog-

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ical diseases is determined by complex interactions prophylaxis, it is possible to halve the incidence of on-
between numerous environmental factors (carcin- cological diseses.
ogens, cocarcinhogens, anticancerogens, etc.) and Secondary prophylaxis of oncologi diseases in-
factors of the patient's own organism (immune sys- cludes their early diagnosis, emphasizing the par-
tem, hormonal status, cell populations, individual ticularly important role of detecting precancerous
metabolic competence, state of mechanisms recov- diseases. Screening programs have proven to be ef-
ering DNA, genetic predisposition, etc.). fective primarily in uterine cervical cancer, where
About 80-90% of the disease is caused by environ- Papanicolau vaginal smears screening has led to a
mental factors, most of which are well-known and re- reduction in mortality from the very prevalence of
late to the lifestyle of modern man. According to the oncological diseases in women by about 70% over
WHO data, the most important part is the nutrition the past 40 years. In another, so far limited part of
(diet) followed by smoking. They account for about the cancer, screening studies have a controversial lo-
60-70% of oncooletality together. Relative role is cation according to the value-effectiveness indicator
played by reproductive and sexual behaviour of and are recommended primarily for some relevant
people, alcoholism, occupational risk factors, envi- risk groups of the population.
ronmental pollution, excessive use of certain drugs Recently, the genetic predisposition has been in-
and other risk factors. About 5% of oncooletality is tensively investigated by the body's factors. Over
related to professional factors (the classic first de- 100 monogenic diseases have an increased risk of
scription in this area refers to the high incidence developing cancer. In some of the monogenic dis-
of scrotum cancer in chimney sweep, done in 1775 eases, the carcinogenic risk is increased by more
by Percivall Pott in England). For founders, miners, than 10,000 times, for example in familial retinoblas-
workers in the rubber and textile industry, and ship- toma, familial colon polyposis, and oth. Xeroderma
building, printing, leather, painting, asbestos work- pigmentosum describes a defect in DNA repair and
ers, and others occupations, a higher frequency of hence increased carcinogenic risk. In developed
individual onco-nosological units is registered. countries, special genetic counseling works on par-
Based on these onco-epidemiological data, ad- ticular oncological diseases, especially when pa-
vanced primary cancer prevention programs have tients are involved in clinical trials. However, their
been developed to reduce or eliminate carcinogen- widespread routine implementation in practice is,
ic factors. After more than 30 years of activity on a for the time being, considered insufficiently scientif-
well-organized and powerfully funded anti-smoking ically and prematurely. Thus, for breast cancer (the
program, involving the entire society and the Pres- most common tumor in women and the most com-
ident of the United States, there has already been a mon cause of death among women in the European
reduction in lung cancer (a similar reduction has been Union), it is now recommended that genetic coun-
seen in England and elsewhere developed EU coun- seling should not be done on a large-scale, but only
tries). within clinical trials.*
A relatively new direction in primary prophylax- At now known "copy" of human genome (50
is of oncological diseases is so-called pathogenetic terabytes of information), made by the US Govern-
prophylaxis. Hygiene prevention is primarily intend- ment's Human Genome International Project and in
ed to reduce the risk of contact with various types parallel and independently by the privately-owned
of carcinogenic agents and known risk factors. It American company Celera Genomics, as well as by
is expanded and supplemented by pathogenetic the latest methodological achievements of molecu-
prophylaxis, which aims to inhibit carcinogenesis lar biology for simultaneous measurement of the ex-
in all its stages, with the help of specific diets and pression of several tens of thousands of genes (DNA
chemical agents with anticancer activity. Pathoge- microarray technology), by so-called oncogenomics
netic prophylaxis is targeted at healthy people from and proteomics, expected a new break in molecular
the general population or at higher risk populations oncology and pharmacogenomics (targeted genera-
- e.g. precancer patients, smokers or patients under- tion of drugs directed to specific genes) is expected
going specific anti-tumor drug therapy (alkylating as a basis for future prophylaxis, diagnosis and treat-
cytostatics and some other antitumor drugs as well ment of oncological diseases.
as ionizing radiation are known to have a strong car- The latest WHO cancer priority ladder are: to-
cinogenic effect and are capable of inducing chemi- bacco control, infection control, cancer treatment
cally induced secondary tumors at 2- 10% of cancer program, effective pain control, early detection
patients - most often leukemias and lymphomas,
* Genetic research can pose a potential threat to women's per-
especially in long-term survivors). It is suggested sonal freedom and safety, which is why legislative changes are
that by priming prophylaxis and mainly pathogenetic needed to protect women from these dangers.

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strategy, national cancer registry, healthy nutrition the region, clinical research program, fundamental
program, updated permanently guidelines, nurs- research program, program for international assis-
ing training, national oncology specializing net- tance.
work, clinical trial units, technological renewal of

REFERENCES

1. American Cancer Society. Cancer facts and figures, 1995, Atlanta, Ga.
2. Balanski R. Pathogenetic prophylaxis of neoplastic diseases. in: Oncology 2001, ed. Iv. Chernozemski
and T. Shipkov, Sofia, Ciela, 2000, 39-61. (in bul.)
3. Bobeff D. Oncogenesis. Molecular basis of tumor diseases, ibid., 571-573. (in bul.)
4. Byers T., Dietary Trends in the United States. Relevance to cancer prevention. Cancer, 1993, 72, 1015-
1118.
5. DeVita V. et al. - eds. Biological therapy of cancer, Philadelphia, J. B. Lippincott, 1991.
6. Doll R., P. Peto. The causes of cancer. N.Y., Oxford University Press, 1981.
7. Druker B. et al. Oncogenes, growth factors and signal transduction. N. Engl. J. Med., 1989, 321, 1383-
1391.
8. El-Deiry W. S. Role of oncogenes in resistance and killing by cancer therapeutic agents. Current Opin-
ion in Oncology. 1997, 9, 79-87.
9. Erbar P. Oncology, Sofia, ed. "Sharov", 1996. (in bul.)
10. Harris C., M. Hollstein. Clinical implication of the p53 tumor suppressor gene. N. Engl. J. Med., 1993,
329, 1318-1327.
11. Holand J. et al. - eds. Cancer Medicine, IV ed., Baltimore, Williams and Willkins, 1997.
12. Holleb A. et al. - eds. Textbook of Clinical Oncology, Atlanta, American Cancer Society, 1996.
13. Huang P. S., D. C. Heimbrook. Oncogene products as therapeutic targets for cancer. Current Opinion
in Oncology, 1997, 9, 94-100.
14. Hulka B. Cancer Screening. Degrees of proof and practical application. Cancer, 1988, 62, 11761183.
15. Kaplan E., P. Meier. Nonparametric estimation from incomplete observations. J. Amer. State. Assoc.,
1958, 53, 457-481.
16. Koeffler H. et al. Molecular mechanisms of cancer. West J. Med., 1991, 155, 505-513.
17. Lippman, S., Benner, W. Hong. Chemoprevention. Strategies for the control of cancer. Cancer, 1993,
72, 984-990.
18. Nowell P. The clonal evolution of tumor cell populations. Science, 1976, 194, 23-28.
19. Powis G. Signaling pathways as targets for anticancer drug development. Pharmac. Ther., 1994, 62,
57-95.
20. Powis G., P. Workman. Signaling targets for the development of cancer drugs. Anti-Cancer Drug
Design, 1994, 9, 263-277.
21. Todorov D.K., A. Dudov. Basic principles of drug therapy of oncological diseases. Oncologos, 2000,
4, 3-19. (in bul.)
22. Todorov D.K. Research at the german oncology research center in Heidelberg. Oncol. Review, 1999,
6, 2, 3-11. (in bul.)
23. Todorov D.K. Scientific research as the basis of the anti-cancer struggle in Germany. Biomedicine,
1999, 35, 1, 3-10. (in bul.)
24. Tomatis L. et al. Avoided and avoidable risks of cancer. Cancerogenesis, 1997, 18, 1, 97-105.
25. Vogt P. Cancer genes. West J. Med., 1993, 158, 273-278.
26. Wood M., P. Bunn. Hematology/Oncology Secrets, St. Louis, Mosby, 1994.
27. Zeller W., H. zur Hausen - eds. Onkologie. Grundlagen, Diagnostiks, Therapie, Entwicklungen. Lands-
berg / Lech, Ecomed, 1995.

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9.2 MALIGNANT NEOPLASMS OF

THE RESPIRATORY SYSTEM
M. Demirova, Y. Simeonov, E. Stoynova

9.2.1 PULMONARY CANCER

The interest in the etiology of respiratory tumors Histology. Four major histological types of lung
has increased especially after a number of epidemi- carcinomas are:
ological studies that indicate that lung cancer is the • squamous cell (epidermoid);
most common cause of death from malignancies - • adenocarcinoma;
an average of 25% 35% for men and 15% for wom- • giant cell;
en), and among those with occupational hazards - • small cell (type of oat grain).
from 3% to 17%. Squamous carcinomas more often have a central lo-
In 1987, the IARC issued a list of chemical sub- calization associated with hyalous lymphadenopathy.
stances and industrial products for which there is Adenocarcinomas are usually presented as peripheral
evidence of carcinogenicity in humans. According nodules with involvement of the pleura and the chest
to him, carcinogens for lung tumors are: arsenic and wall. Giant cell carcinoma has a large peripheral local-
its compounds; asbestos, chloromethyl ethers, 6-va- ized formation with added pneumonitis. In small cell
lent compounds of chromium, asphalt, coal, nickel carcinoma, a central lesion with athelectasis is present,
and its compounds (oxides and sulphides), coke and hyalous and mediastinal lymphadenopathy is also
gases, radon and thorium, vinyl chloride. Addition- common. No histological type is pathological for pro-
al registers also discuss substances that are likely to fessional injury - i.e. there is no characteristically domi-
be lung carcinogens but with insufficient evidence nant histological type in occupational lung tumors.
of this: acrylonitrile, benzidine, beryllium and cad- There is nothing strictly specific about the clinical
mium with their compounds, hydrazine, chlorophe- picture of occupational lung tumors. Their clinical
nothane, dibromochloropropane, chloromethan, picture, as and unprofessional malignant tumors, are
epichlorhydrin, ethylene dibromide, dimethylani- defined by the following major syndromes: :
line, tetrachlordibenzodioxin, etc. • bronchial-pulmonary cough, haemoptysis,
The following are reported as risky professions and dyspnoea, pneumonia, etc.;
factors for the occurrence of malignant lung tumors: • intoxication: weight loss, anorexia, asthenia,
• aluminum production, coal mining and coke subfebrility, sweating, anemia;
gas, with probable carcinogens polycyclic aro- • from squeezing due to tumor growth and in-
matic hydrocarbons; vasion of adjacent structures or metastasis:
• production of iron and steel with probable tracheal obstruction, esophageal compres-
carcinogens polycyclic aromatic hydrocar- sion, "vena cava superior syndrome", paralysis
bons and metal aerosols; of n. recurrens, n. vagus with dysphonia, etc.;
• operations related to the refining of nickel, • paraneoplastic syndrome.
likely to cause nickel, nickel oxide and nickel In addition to the clinical symptoms of diagnosis,
sulphide; some additional research methods are also essential:
• rubber production with possible carcinogenic • X-ray methods provide the best opportuni-
aromatic amino compounds; ty for early diagnosis. The X-ray finding de-
• production of uranium (thoron), iron and pends on the histological type of the tumor;
non-ferrous metals with probable agents ra- of its location (central or peripheral); from the
don and thoron stage and the presence of metastasis in the re-
• production and production of asbestos and gioneal lymph nodes or in the lungs.
asbestos products. • Cytological examination of phlegm in 60% of
• using arsenic preparations in fruit growing cases helps diagnose.
and in the production of copper ore • Invasive methods allow the most accurate di-

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agnosis as well as the operability of the ma- • if both can cause the tumor, it must be recog-
lignant tumor. Approximately 65% of ​​ cases of nized as professional;
lung carcinoma are visualized with flexibel fi- • if only the sum of the two injuries can cause
brobronchoscopy, but an accurate diagnosis is the tumor, it is also considered to be profes-
made by biopsy (including brush) - 90% of the sional because the occupational risk is impli-
cases. In some cases the diagnosis is beneficial cated and without it the disease develops;
for the transthoracal aspiration biopsy under • if the impact of occupational carcinogens is of
the X-ray control. In difficult cases, an explora- minor importance, the adoption of an occupa-
tive thoracotomy can also be performed. tional disease is not justified.
• Conventional and computed tomography, as Types of professional pulmonary neoplasms.
well as a radioisotope assay, is made when the A. Pulmonary neoplasms of physical factors
patient is unsuitable for invasive screening. A and dust. In this group are tumors caused by ioniz-
radioisotope assay with 67Ga-citrate seeks se- ing radiation, mineral powders - mainly needles and
lective accumulation of the isotope in tumor isometric, and some organic powders.
tissue. Professional lung tumors of ionizing radia-
• Of the routine blood and biochemical exam- tion. Occupational risk exists in:
inations, the BSR, the red and white blood • miners from the extraction of rare metals. It is
counts, the cytological and biochemical ex- known that modern uranium mines are char-
amination after pleurocentesis. acterized by low dustiness (near to the MAC)
Diagnostic criteria for the professional nature under constant emission of α-particles;
of lung neoplasms. For a more accurate etiological • working on the shredding and further pro-
diagnosis, the following criteria are recommended cessing of uranium ore;
for this type of illness: • labtechnicians of radioisotope laboratories;
• Labour-hygiene, which has to address the is- • working in nuclear power plants;
sue of occupational risk, i.e. for the presence of • radiation risk, albeit less significant, in some
carcinogens in the working environment. mines with increased radioactive background:
• an exposure criterion that corresponds to the for non-ferrous metals (eg copper - Burgas
assumed exposure duration and the latency copper mines), iron, fluorite extraction, some
period (Table 1). tunnels, hiding places, quarries and opencast
mines (Zeolite).
Radiation risk is due to uranium and tho-
Average, minimum and
Organ Carcinogen
maximum latency period rium that emit the radioactive gases radon
Asbestos 18 (15-21)
and thoron. They act with α-particles that
penetrate to a depth of no more than 50 μm,
Chromates 15 (5-47)
Lung i.e. around the basal membrane of the bron-
Nickel 22 (6-30)
chi.
Ionizing rays 25 (7-50) The clinical picture does not differ from
Carbon vapors 16 (9-23) that of another aetiology of cancer. Signs
of radiation sickness (adynamia, asthenia,
At low exposure and particularly short latency anemia, leucopenia) can be observed, but may be
period, there is little probability of professional tu- absent. Radiation is thought to increase the relative
mor etiology. Usually, small exposure prolongs the share of undifferentiated small cell tumors and re-
latency period. duce the relative share of squamous tumors.
• Epidemiological test (collective test), which is In previous silicosis, sudden changes in the gen-
becoming increasingly important especially eral state, the accelerated BSR, rapid changes in the
in the discovery of new occupational carcino- X-ray image, lead to a diagnosis of lung carcinoma.
gens. The diagnosis is refined by cytomorphological ex-
• Localization should be consistent with the amination of the phlegm, bronchobiopsic methods
prospective experience and literary data. As- and computed tomography.
bestos carcinoma, for example, tends to mul- Professional pulmonary neoplasms of needles
tiple locations in the lungs basis, where is also dust. The carcinogenic effect of mineral needles
asbestos fibrosis. is mainly related not to their chemical but to their
Difficulties arise in the combination of profession- physical qualities. They have their own mechanism
al and non-professional carcinogens. For the same of tumor induction and their carcinogenic effect is
critical organ, the following could be observed: related to certain properties:

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• the needles should be long and thin - with a in bronchiols and cause usually pulmonary asbestosis
length of more than 5-10 μm and a diameter or lung cancer respectively). For the carcinogenic ef-
less than 0.5 μm, that is, the ratio of these two fect, only the dose is not critical and therefore there
metrics is 10: 1 - 15: 1; is no relationship between dose and biological re-
• needles should have a pronounced bio-resist- sponse - mesothelioma may develop even after short
ance, i.e. to be able to persist in the tissues of exposure, but over a long latency period. Unlike as-
the lungs for decades. bestos lung cancer in mesothelioma, smoking does
Asbestos. The carcinogenic effect of asbestos has not significantly affect its incidence.
been discovered and studied at the earliest. All types Mesothelioma develops from the mesothelial
of asbestos fibers are considered to be carcinogen- cells of the serous shells, most often from the pleu-
ic, but crocidolite (blue asbestos) is more dangerous ra to the asbestos plaques. It is a thick mass with a
than chrysotile (white asbestos). thickness of 0.5-1.0 cm and an ivory color that pro-
Asbestos neoplasms (bronchopulmonary cancer gresses along the pleural layers and interlobar slits. A
and pleural mesothelioma) are generally associated large mass is created with a rubbery consistency that
with pulmonary or pleural asbestosis (fibrosis). presses, "crushes" the lung and can grow to the per-
Epidemiological studies by Doll and Breslaw sci- icardium, chest wall, diaphragm, mediastinal lymph
entifically demonstrated the causal relationship be- nodes. Metastases in other organs are extremely
tween asbestosis and lung cancer. Also noteworthy rare. There are 4 types of histology: tubulo-papillary,
is the Selikoff study - tracked 17,800 asbestos work- sarcomatous, undifferentiated and polygonal, and
ers for the 1967-1976 season and found 486 deaths sometimes mixed and transient forms resembling
instead of the 105-106 predicted. sarcoma or carcinoma.
Pulmonary cancer is the most important asbes- Clinical picture - breathlessness that progressive-
tosis-related disease that causes 20% of all deaths in ly increases. Often there is weight and pain in one
asbestos-producing groups. Studies in Bulgaria show chest, which is initially of a grate character, but later
that in professional asbestos-exposed patients the in- becomes strong and constant. General signs of intox-
cidence of lung cancer is 3 times higher than that of ication - adynamia, weight reduction, night sweats,
the standardized by sex and age general population. as well as persistent and rapid gathering of pleural
The synergistic carcinogenic effect of smoking hematic fluid are also characteristic. The content of
with asbestos dust has been proven. Asbestos par- hyaluronic acid in fluid has increased. Although it is
ticles are believed to absorb benzopyrene from cig- not pathognomonic for mesothelioma (also occurs
arette smoke. Also, here are some additional carcin- in asbestos plaques and is associated with the accu-
ogens, such as natural mineral oils adsorbed by the mulation of hyaline in them), it is an indication of as-
anthophyllite and amosite asbestos, as well as chro- bestos origin of the tumor. Diagnostic value of X-ray
mium and nickel content in chrysotile and crocido- and computed tomography is great (Figure 1).
lite and iron in amosite and crocidolite. Treatment here is symptomatic only, as the tumor
Pulmonary asbestos cancer develops after a long is resistant to radiation and to cytostatics. The out-
latency period against the background of diffuse
pulmonary fibrosis - asbestosis. Lack of asbestosis re-
duces the likelihood of asbestos-induced lung can-
cer. The localization of the tumor is predominantly in
the lungs basis, where fibrosis is most pronounced.
Histologically, the tumor does not show differences
from unprofessional tumors. Diagnosis is support-
ed by biopsy material taken by fibrobronchoscopy.
Finding asbestos bodies in phlegm or biopsy materi-
al supports massive contact with asbestos.
Mesothelioma of the pleura is a relatively rare
tumor - its spontaneous frequency is 1 case per
million inhabitants per year (J. Stumphius). The rela-
Fig. 1. Mesothelioma of pleura
tionship between this tumor and asbestos has been
proven by J.Warner et al. in epidemiological observa- come is unfavorable - cachexia, severe respiratory
tions of workers from asbestos mines in South Africa. and heart failure, bacterial pneumonia.
All types of asbestos can cause mesothelioma, but At present, there is evidence that, besides asbestos
especially crocidolite, whose properties make it acces- and other needles and fibrous minerals, they have a
sible to the pleura (the more rough fibers are retained carcinogenic effect. Pulmonary neoplasms have been

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described in Turkey from needleloid zeolite materi- production of copper ore, as well as among viticul-
al, erionite. In the Bulgarian zeolite deposits it is not turists using arsenic sprays. In 163 deceased viticul-
found, but mainly clinoptilolite and the needle-like turists in the Reinach region, 66% of the autopsy
mordenite, which experimentally have less carcino- confirmed lung cancer.
genic activity. For needles mineral actololite, the car- Nickel (metal) and some of its salts - nickel sul-
cinogenicity was confirmed experimentally. phide (Ni2S3) and nickel oxide (NiO), were recognized
The carcinogenic risk of synthetic asbestos substi- in 1988 as professional carcinogens. The issue of nick-
tutes - mineral and glass wool - is also discussed. Most el carbonyl is controversial. It is currently assumed
authors, though with some caution, believe that there that the risk of lung carcinoma develops only in the
may be an increased risk of lung neoplasms. nickel refining (purification). Manganese in an exper-
Professional pulmonary neoplasms of isomet- iment also showed carcinogenic activity like nickel.
ric mineral powders. The carcinogenic action of Chromium and especially its 6-valent com-
mineral isometric powders has been the subject of pounds, have a pronounced carcinogenic effect.
many controversies (in the past prevailed the view Chromotic cancer predominates small cell tumors.
that there was no statistically significant increase in There are no specific, clinical or X-ray traits for the
pulmonary neoplasms in pneumoconiosis patients). professional nature of the tumors.
The most attention is paid to quartz, because Polycyclic aromatic hydrocarbons with the
epidemiological data on the increased risk of lung most well-known representative benzopyrene, are
cancer in exposed to crystalline silica: minerals from commonly accepted lung carcinogens. An increased
iron mines, iron workers, casting cleaners, sandblast- incidence of lung cancer has been reported in work-
ers, even ceramics workers, have been highlighted ers at gas generators, in coke chemistry plants, and
in recent years. The official statistics of Sweden and in iron production, in asphalt bases, with diesel en-
Canada showed increased lung cancer mortality gine testers. Workers on the electrolysis of aluminum
in silicosis patients. There is also experimental evi- can also be affected by the content of the coal tar in
dence that quartz may be a direct acting carcinogen the anode mass. The high tumor burden of rubber
or co-carcinogen. Three hypotheses are discussed: workers some authors associate with the use of soot.
• the direct carcinogenic action of quartz; Due to the greater aggressiveness of chemical
• silicosis as a basis for developing the so-called carcinogens, the lag period for lung cancer is shorter
"scars" carcinoma; - on average 15-17 years.
• quartz as an absorber of polycyclic aromatic Treatment. Resection is the most reliable meth-
hydrocarbons originating from the working od for the treatment of non-small cell carcinomas.
environment or from smoking. Small chemotherapy or irradiation is used in small
Other isometric materials such as hematite, le- cell carcinomas that are contraindicated for surgery.
monite, grunerite, sandstone, kaolin, dolomite, ver- Survival depends on the stage of the disease and
miculite, etc. are also the subject of this study. on the histological type of the tumor. The progno-
Professional pulmonary neoplasms of organic sis of squamous tumors is more favorable. Small cell
powders. There has been an increased incidence of carcinomas have the worst prognosis due to early
lung cancer and pleural mesothelioma in sugar cane and extensive metastases.
workers. It is shown here in the powder of biogenic Prevention. The main purpose of the technical
silicon fibers, which are considered a promoter, and prophylaxis is to eliminate the possibility of expo-
as the initiator of tumor growth - polyaromatic hy- sure to carcinogens by adequate ventilation, use
drocarbons. of respirators or other protective devices, as well as
The connection between the fine wood dust from by technological improvements for the inclusion of
tropical and subtropical trees with upper respiratory non-cancerous substitutes.
tract cancer has also been proven. For medical prophylaxis, the importance of early
B. Pulmonary neoplasms of chemical factors x-ray (fluorographic) diagnosis, cytological examina-
Chloromethyl ethers are one of the most impor- tion of phlegm in risk groups, and active legal and
tant chemical compounds with carcinogenic risk for health-enhancing work on smoking cessation is
pulmonary neoplasms. W. Weiss in 1982 described a great.
small epidemic of small cell tumors of the lungs and Labour expertise. Patients with occupational
larynx in young non-smokers. Experimental animals pulmonary neoplasms are 100% disabled and there-
inhaled with chloromethyl ethers showed metapla- fore retire from WEMC.
sia and bronchial epithelium atypia.
Arsenic is associated with convincing epidemio-
logical data with the increase of lung cancer in the

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REFERENCES
1. Apostolova D. Health status of former uranium mining workers in Southwestern Bulgaria - Dis. 2000 (in bul.)
2. Balmes, J.R., C.H. Scannel - Occupational Lung Diseases. In: Occupational and Environmental Medi-
cine (II ed.), ed. J. La Dou, Prentice-Hall Internetional Inc., 1996.
3. Boffetta P. et al. Current Perspectives on Occupational Cancer Risks. In Occupational and Environmen-
tal Health, 1995, 1 (4): 315-325.
4. Burilkov T., E. Stoinova. Criteria for the professional conditioned of the tumors. in: Methodological
materials on professional pathology, Sofia, Medical Academy, 1987. (in bul.)
5. Burilkov Т. Professional lung diseases., Sofia, Med. and phys., 1990 (in bul.)
6. Dimitrova M. Professional malignant neoplasms. in: Professional pathology, ed. Tsv. Alexieva, Kr. Kiri-
akov, Sofia, Med. and phys., 1982, 215-217; (in bul.)
7. Dinkova K., T. Burilkov. Recherches sur la frequence des tumeurs chez les silicotiques. Archives Balcan
Medical Union, 2000
8. Fischman M. et al. Occupational Medicine. Appleton Lange, Norwalk, Connecticut, San Mateo, Califor-
nia, 2002, 182-194
9. Griefahn B. Arbeitenmedizin., Stuttgart, 1992
10. Krstev S. Profesionalne maligne pain. In: Medicine of labour V.II, ed. Al.Vidacovic, Beograd, 1997,
889-991 (in serb.)
11. Steenland K. et al. Occupational causes of lung cancer. In: Occupational and Environmental Respira-
tory Disease, Mosby, 1996
12. Tcherneva-Jalova P. R. Lucanova, M.Demirova. Asbestos in Bulgaria. People and Work, Research
Reports. Finnish Institute of Occupational Health, 19, 1997, 33-38.

M. Melamed

9.2.2 LARYNX, NASAL AND LARYNGEAL

CAVITIES CANCER
I. Malignant neoplasms of nose and sinus cav- groups - spinocellular, glandular and undifferentiat-
ities represent 0.5-2% of all malignancies and 6% of ed (anaplastic).
malignant neoplasms of the upper respiratory tract. Extremely undifferentiated carcinomas show
Carcinomas are most common between the ages strongly marked atypia of epithelial cells (even
of 50-70 years. Sarcomas predominate at younger monstrous cell richness) and deletion of the nesting
age or in children. Men are more likely to suffer than structure. This in some cases makes it difficult to di-
women - a ratio of 2: 1. The most common malignant agnose them correctly and they are even defined as
tumors of the nose and sinus cavities are carcino- sarcomas.
mas. Sarcos are observed 10 times less frequently. In Flat cell carcinomas are characterized by strong
terms of histology, malignant tumors are distributed growth and bone involvement in about 1/3 of the
as follows: carcinoma - 86.5%, sarcoma - 12%, other patients.
malignant tumors/melanomas, plasmacytomas, etc.) Nasal neuroblastoma - esthesioneuroblastoma
- 1.5%. Of the sarcomas most often occur reticulosar- (which is relatively rare), originates from the neuro-
comas, less often fibrosarcomas, lymphosarcomas, leptic olfactory membrane. Its histological structure
angiosarcomas and sometimes chondrosarcomas, is characterized by a certain gestation. The cells are
Ewing's sarcoma, Paget's disease, etc. slightly larger than lymphocytes, with scarce cyto-
Etiology. Causes of nasal and cavity carcinomas plasm and oval or circular hyperchrome nuclei.
are known to have pre-existing illnesses - inflamma- From lymphoreticular tumors that can begin
tion, tuberculosis, syphilis, scars, and injuries. In the to develop in the lining of the sinuses, lymphosar-
sarcomas, there is sometimes a history of trauma long comas are the most common. However, in severely
before the neoplasm appears. Chronic inflammatory expressed lymphatic hyperplasia, differentiation of
processes cause metaplasia of the cylindrical epithe- these changes of lymphosarcoma is sometimes dif-
lium in the flat and create favorable terrain for the oc- ficult, and multiple studies are required.
currence of malignant tumors. Plasmacytoma is also a rare lymphoreticular tu-
Morphology. Depending on the histological mor in this area. Its differentiation from a chronic
structure of the carcinomas, there are three main inflammatory process with a wealth of plasma cells

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in the infiltration is difficult, and only the availability paired eye movement, persistent headache, olfac-
of other elements in the inflammatory process can tory disorders. Upon lateral growth, swelling of the
help correct diagnosis. outer face of the face occurs, and the lateral wall of
Sarcomas from other connective tissues tumors the swallow can also engage, after back speaded in-
are also rarely seen in the nose and sinus area. Most filtrate. When compressing or infiltration of n. Infraor-
often they have a histological structure of fibrosarco- bital, neuralgia and paraesthesia in the area of the ​​
ma, hydrosarcoma and mixosarcoma. Characterized nerve or upper back teeth pain due to tuber maxillar
by local destructive growth and recurrence. involvement. The initial forms of malignant tumors
Malignant melanoma, which also rarely develops of the ethmoid, frontal and sphenoid sinus develop
in the lining of the nose and nasal cavities, does not in the clinical picture of persistent sinusitis that does
cause any difficulty in diagnosing when it is pig- not respond to anti-inflammatory treatment. Typical
mented. In the absence of a pigment, its histological symptoms occur when the tumor passes the sinus
similarity to extremely undifferentiated carcinoma boundary - the breakthrough of the hard palate, the
or fibrosarcoma may make it difficult to accurately incidence of the orbit, the spread of the tumor to the
determine it. Malignant tumors of the nasal and la- septum, the tuber maxillar growth, and the facial
ryngeal cavities provide metastasis in the regional area are signs of an advanced malignant process.
lymph nodes, the submaxillary and the deep cervical Nutrition disorders, severe frequent bleeding,
nodes. Distant metastases are rare. breathing difficulties, malnutrition and cachexia are
Clinical picture. The development of symptoms also the consequences of an advanced neoplastic
in malignant tumors of the nose and sinus cavities is process.
related to the localization, spread and histological ap- Local metastases occur in the area below the low-
pearance of the tumor. By localization, some authors er jaw, along the neck, distant metastases are in the
distribute the malignant neoplasms of the nasal and lungs and the liver, and, moreover, the bones and
sinus cavities in the following way: the upper jaw and other organs.
the sinuses - 38%, the maxiloethmoid angle - 23%, the Diagnosis. It is difficult in the initial forms when
nose 22%, the ethomoid bone - 12%, the frontal and the tumor is small, hidden in the sinus and the symp-
the sphenoid cavity - 3%, in the nasal septum - 2%. toms are insignificant. From history, one-sided pro-
In order to properly record the topographic dis- gressive nose obstruction, sneezing-purulent and
tribution of malignant tumors, a number of schemes sometimes bloody exudate, decreased sense of
have been developed, the Sebileau scheme being smell, epistaxis, persist headache, sometimes eye
the most appropriate. According to her, the malig- manifestations.
nant tumors in the facial-cranial bones are distribut- In anterior rhinoscopy, the carcinomas are seen
ed in lower, middle and upper floors (infra-, meso-, as an uneven, grainy, easily bleeding formation. Un-
suprarstructural tumors). To the lower floor are the like carcinomas, sarcomas are tumors with a smooth
tumors in the alveolar growth, the hard palate and surface and equal edges. The posterior rhinoscopy
the lower part of the maxillary sinus. The middle provides a view of the nasopharynx and the choa-
floor includes the tumors in the walls, including the nae. X-ray examination plays an important role in
orbital and upper-jaw cavity. Upstairs are tumors in determining the exact distribution and destruction
the ethmoidal labyrinth, the frontal and sphenoidal of bone barriers.
sinuses. Limit localization examines the tumors that Biopsy is, in any case, mandatory. In tumors in the
are detected in the maxilo-ethmoidal area. In a sep- cavities a puncture biopsy or a possible trepanation
arate group are the primary tumors in the nasal cavi- is performed.
ties that secondary growth to the sinuses. Differential diagnosis. It occurs with acute and
The first and the earliest symptoms (both carci- chronic inflammatory processes, granulomas and
noma and sarcoma) are a unilateral disturbance in benign neoplasms, lues gum, osteomyelitis, polypo-
nasal breathing due to more extensive exudation sis, dental diseases, essential neurinomas and others.
and blood supply disorder. There are hyperemia and Treatment. For the treatment of malignant tu-
swelling of the lining of the nose, which cause inter- mors of the nose and the sinuses, surgical, radia-
ference with breathing, smell and headache. tion, chemotherapeutic methods and combinations
To the sneeze-purulent exudation is added an ad- thereof are used.
mixture of blood. In the sarcomas there are frequent Surgical treatment is a method of choice, but due
and heavy nasal bleeding. to small spatial possibilities, it is not always possible
Upon engagement of the upper-back inner seg- to provide for radical treatment - combined treat-
ment of the maxillary sinus, the tear duct is pressed, ment - radiotherapy and chemotherapy (in some
ophthalmic events are determined - exophthaly im- cases radiotherapy can be pre-operative).

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The endonasal surgical procedure is used in biop- of secondary cancer from all larynx cancer patients. A
sy and in small restricted tumors at the front of the certain role is played by changes in larynx - scarring,
septum and the lower extremity. lues, tuberculosis, and all mucosal processes that are
To remove carcinoma of the maxillary sinus, total accompanied by hyperplasia and epithelial prolifera-
or partial resection of the maxilla is performed. Full tion. Chronic laryngitis is not precancerous, but it is a
resection of Dieffenbad is required for middle-class predisposing cause. It is essential that larynx precan-
carcinoma. In tumors on the lower floor resection of ceroses - keratoses and papillomas - which can lead
alveolar growth, hard palate and part of the walls of to cancer (morphological studies show that 20.6%
the sinus are performed. At maxiloethmoidal local- of the carcinomas originate from papilloma and in
ization, the Maure or Zange paranasal access is ap- 22.6% of the patients the larynx cancer is combined
plied. The same method is used for tumors in the na- with papilloma).
sal cavities or only for the ethmoid bone. When the Morphology. At the beginning of the process,
carcinoma grows in the roof of the ethmoid bone or there are pronounced seals or plaques, later mas-
the back wall of the anterior sinus, Preising access is sive infiltrates, and in advanced development the
used. For operative treatment of fossa pterigopalati- carcinoma is presented in three well-defined forms
na, the Mozer method is used with resection of the - papillary, modular and ulcerative (the ulceration is
anterior, lateral and posterior wall of the maxillary si- in most cases secondary). Histologically largest is the
nus. When engaging the skull base, it is necessary to number of carcinomas with a structure of spinocel-
open a dura mater and an additional plate. lular carcinoma of varying degrees of differentiation
Prevention. The primary focus should be on - highly differentiated (highest percentage), moder-
removing carcinogenic noxiousness in aniline, tar, ately and poorly differentiated. Histologically they
chromium, nickel and oth. productions. Chron- are connected to the flat epithelium covering the
ic purulent inflammation, especially with mucosal true vocal cords or to a metaplastic cylindrical epi-
changes - hypertrophy, metaplasia, should be treat- thelium. In the spinocellular carcinoma group there
ed. Smoking has a role to play in the changes in the are two varieties - verrucous and fusiform-cell carci-
lining of the nose and the paranasal cavities, so it noma.
should be limited. Verrucose carcinoma, which is modular or papil-
II. Malignant neoplasms of the larynx lary, with a smooth or slightly rough surface, histo-
Of all malignant tumors in the larynx, 99% are of logically has a papillary device but proliferates the
epithelial origin. Connective tissue tumors - sarco- epithelium inwards. Grows relatively slowly and later
mas, endotheliomas, malignant lymphomas, etc. are metastasizes.
rare and are observed in 0.5-1% of patients. Fusiform carcinoma (with synonyms-carcinoma
It is reported that the incidence of cancer of the with sarcoma-like stroma, pleomorphic carcinoma,
larynx is 1-3% of all malignant neoplasms. The inci- carcinosarcoma, pseudosarcoma) is a relatively rare
dence of laryngeal cancer varies from different coun- tumor.
try: for countries in Europe, it ranges from 0.54 to 8 Glandular carcinomas are very rare. They are char-
per 100,000 population. In Bulgaria, the morbidity is acterized by infiltrative growth, mainly in the course
from 3.6 to 4.8 per 100 000 population. Men suffer of nerves.
about 25 times more often than women. The most Carcinomas of the larynx, mainly those with the
common age of involvement is 40 to 60 years, as in location of true vocal cords, remain for a long time
recent years there is a tendency to shift the morbid- localized at the site of their appearance.
ity to younger age. Laryngeal sarcomas are extremely rare - the num-
Etiology. There are a number of carcinogenic ber of fibrosarcomas is greatest, but angiosarcomas
factors, the prolonged effects of which can cause and chondrosarcomas are also seen.
cancer in the larynx - e.g. benzpyrenic components The lymphoreticular malignant blastomas are
from internal combustion engine fuels, production also very rare - they may be lymphosarcomas and
gases and powders. Over 65% of patients with larynx reticulosarcomas. Melanoma is localized extremely
cancer have occupations associated with inhalation rarely in the larynx and is more pronounced pleo-
disorders (asphalt, painters, miners, petrochemical, morphism than skin melanoma.
tobacco, etc.). Clinical picture. A division of the larynx of the su-
From NIO studies, 83.5% of patients with larynx per glottis, glottis and subglottis region is assumed.
cancer are smokers and only 16.5% are non-smokers. The two-thirds of the larynx are most often cov-
Physiological effects of laryngeal cancer also include ered by the malignant process, the posterior third
ionizing rays. Recently, the number of radiogenic of the larynx is extremely rarely affected. There are
cancer patients has risen significantly - from 4 to 9% several forms of growth of larynx cancer: monofocal

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- from a restricted mucosal site; wall-paper form - pri- supra-glottis, the process develops more quickly).
mary, on a wide basis; multifocal - simultaneously in The mature forms of cancer metastasize less fre-
several places (multiple outbreaks gradually merge quently and later than the immature. According to
and form a broad-based tumor). epidemiological studies, the superglottis cancer pro-
Laryngeal cancer, regardless of its location, de- duces lymphatic metastasis in 40-50%, glottis cancer
velops in two basic forms - infiltrative and exophytic. - 0.4%, the subglottis - from 15 to 45%.
The most common is the ulcer-infiltrative form, of- Diagnosis. It is based on medical history data,
ten exophytic-ulcer. The color of the tumor depends objective finding, X-ray and biopsy. An anamnesis
on the maturity of the epithelium - the horned ep- should also pay attention to the fewest complaints
ithelium is white, and in the case of the no-horned of the patients on the part of the phonation and
is dark-brown or greyish-red. The ulceration of the swallowing - throat irritation, feeling of a foreign
tumor indicates the development of the process and body, a slightly hoarse voice or a change in timbre
occurs more in the infiltrative forms. Regarding lo- lasting more than 20 days should give rise to doubt
calization and macroscopic appearance, our obser- about malignant tumor.
vations show that infiltrative-ulcer forms are more An extrinsic view at more advanced stages may
often found in supra-glottis, and exophytic forms - in reveal laryngeal enlargement or a broken neck con-
glottis (predominantly infiltrative forms are found in figuration. The palpation is done with a bent head,
the subglottis). In more advanced stages it is difficult systematically examining the waistline, the area of​​
to determine the patterns of development due to the Adam's apple, the cricoid cartilage, the anteri-
the inclusion of different parts of the larynx and the or and posterior edges of the sternocleidomastoid
occurrence of inflammatory changes. muscles and the supraclavicular fossae.
The early symptoms of malignant tumors of the The internal view gives the most rich objective data
larynx depend on the localization, size and distribu- on the larynx status. It is performed through indirect
tion of the primary tumor. The initial manifestations laryngoscopy, direct laryngoscopy and laryngoscopy
of malignant tumors of the supraglottide are due to through an optical laryngoscope and a microscope.
interference with the swallowing function, in glottis Biopsy is mandatory in all cases (sometimes a thy-
- disturbances in the phonation, and in the subglot- roidtomy with a subsequent biopsy). Cytological exam-
tis - breathing disturbances. With the progression of ination of sputum and larynx smears helps diagnose.
the disease and the passage of the tumor from one Differential diagnosis. It is caused by tubercu-
to the other anatomical area proceedings of the
​​ swal- lous lesions of the larynx, tertiary gummy infiltrates,
low, the phonation and the breathing are combined. laryngoceles in the area of ​​the ventricular folds, in-
In very initial forms the symptoms are hardly spotted - fectious granulomas, fibromas and polyps, chronic
mild discomfort in swallowing and feeding, stickness, laryngitis, keratoses (pachydermia and leukoplakia),
feeling of a foreign body, changes in the timbre of the Reinke edema, papilomas, foreign bodies in the lar-
voice, annoying cough and breathing disturbances. ynx.
Dysphonia is the first and earliest symptom of Treatment. The main treatment methods used
true vocal cords cancer. At first, dysphonia may be are surgical treatment, radiotherapy, chemotherapy,
transient but gradually becomes permanent. hormone therapy and their combination. Radical
Dysphagia is the first symptom of the cancer of healing methods are surgical, ray and their combi-
the supraglottis and can be expressed with mild irri- nation. Initially, the elective method of treatment of
tation, a sense of "foreign body" sticking, painfulness laryngeal carcinomas is operative.
when swallowed. In single limited variations, an operative treat-
Dyspnea is the rarest initial symptom (it is char- ment is made taking into account the age of the pa-
acteristic of exophocal tumors that develop in the tient. Up to 50 years of age, hordectomy is preferred
subglottis). due to the likelihood of a longer life expectancy. In
When the tumor progresses, tumor diffluence, older patients radiotherapy is preferred because of a
additional inflammatory process, exteriorization, low chance of secondary radiogenic cancer.
the occurrence of close and distant metastases, in- At supraglottis locations T1 - central and periph-
toxication of the body occur. Very common compli- eral epiglottis carcinoma, better results are achieved
cations such as bronchopneumonia, bleeding from with surgical treatment. In the glottisal T1 localiza-
the disintegrated tumor, inability to ingest, difficul- tion in the anterior third of the true vocal cord (ex-
ty breathing to asphyxia and severe carcinomatous ophytic differentiated spinocellular carcinoma), the
cachexia appear. In a way of growth, laryngeal can- same durable results (90%) are achieved both by
cer develops slowly - sometimes for 1-2 years (such chordectomy and radiotherapy.
growth has a glottic localization - in the case of the Primary-stage subglottis cancer is successfully treat-

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ed with hemylarringectomy or subtotal laryngectomy. methodology, (M. Melamed).
The operative treatment of T3 along with the 4. Operative methods for voice production - the
radical removal of the tumor is associated with new operation of Stafieri, Amatzu.
functional methods for the recovery of the voice and Prevention. Lung cancer prevention activities
the airway. In this direction, the following operation- should be aimed at ending and eliminating carcino-
al methods have been implemented: genic harm in the household, labour and the envi-
1. The operation of Serafini, which is a reconstruc- ronment and active treatment of precancerous dis-
tive methodology after the horizontal resection of eases.
the lower floors of the larynx. An important role in the overall prevention is the
2. Subtotal laryngectomy - with some modifica- fight against smoking and alcohol use. Also treat-
tion of the Ogura, Myodonski methods and real pos- ment of predisposing moments (chronic rhinitis,
sibilities for restoration of function. sinusitis, laryngitis, etc.) and active treatment with
3. Supracricoid functional laryngectomy - a new dispensary monitoring of precanceroses.

REFERENCES
1. Baradulina M.G. Clinic and treatment of regional metastases of cancer. Moscow, Medgiz, 1963 (in bul.)
2. Boykiykev Sv., R. Raichev. Tumors of upper airways. Sofia, Med. and phys., 1979 (in bul.)
3. James G., Richard. A. F. Wound repair in the context of extracellular matrix. Current Opinion in Cell
Biology, 1994, 6, 717-725
4. Jonesk, R. Ann. Oto-Laring. Paris 1978, 95, 6, 423-430
5. Leipziq B. et al. Ann. Otol. 1980, 89.3, 204-208
6. Melamed. M. Diagnostic and medical problems of larynx cancer. Dis. 1983 (in bul.)
7. Nemes A. Venak betogsegoi es kezelesuk Medicina Koninkiado. Budapest, 1896 (in hung.)
8. Pachez, A. I. Head and neck tumors, Moscow, Medicine, 1983 (in russ.)
9. Shabad L. M., G. Mitrov. Prevention of cancer, Sofia, Med. and phys., 1976 (in bul.)
10. Sulfaro S. Quetin F. et al., "Taging of the laryngopharyngeal Carcinoma Arch", Otolarynng. Head &
Neek surgery, 1999, 115-613

Hr. Damyanov

9.3 BLADDER CANCER

The disease is the second most frequent among the cause of cancer in 15% to 35% in men and 1% to
the tumors of the urogenital system. The ratio of 6% in women.
male/female bladder cancer patients is 3: 1, with Etiology. In 1895, the Swiss urologist Rehn
men being the fifth place among all tumors in men. first described a high incidence of bladder tumors
More than 700 newly discovered cases are regis- among aniline dyes. Subsequently, numerous epi-
tered annually in our country, accounting for 3.6% demiological and experimental studies confirm the
of all human tumors - also since 1970, the disease increased risk of developing bladder tumors in the
has been steadily rising and this trend has increased chemical industry.
since 1993. The highest incidence of newly discov- It has been found that urologic carcinogenesis
ered tumors are seen in the highly industrialized is caused by aromatic amines: 2-naphthylamine,
countries - the United States, England, Wales, Den- benzidine, 4-aminobiphenyl, dichlorobenzidine, or-
mark, etc., and the lowest in the Asian countries. An thodianisidine, orthotolidine.
exception is the epidemiological spread of bladder To the workers with the highest risk for tumor
tumors in Taiwan, which is attributable to the high development are 5 industrial areas: chemical and
content of arsenic in drinking water. dyeing, rubber, printing, petroleum processing and
Possible cause of the increased incidence in in- leather-dressing. Less risk is experienced by plastic,
dustrialized countries is the higher risk of exposure dyeing, hairdressers, working with organic chemi-
to industrial carcinogens. It is stated (Matanoski cals and those in laboratories.
G.M., and Ellciot E.A.) that occupational injuries are

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There is a certain correlation between the dura- is characterized as an anaplastic epithelium whose
tion of exposure to the occupational environment, apparent manifestations can often be mild edema,
the younger starting age of workers and the risk of elevation and redness of the bladder mucosa. The
developing a tumor disease. average period in which carcinoma "in situ" goes
Along with aromatic amines, phenacetine, chlor- into invasive carcinoma is 26-33 months.
naphazine and cyclophosphamide also come into Based on the degree of cellular atypia, nuclear
the group of carcinogenic factors. The increased in- abnormality and the number of mitoses, transient
cidence of bladder tumors in smokers (50% in the cellular tumors are graded ("grading"). There is a
male and 31% in the female) is attributable to the clear correlation between tumor grading and the
excretion of alpha- and beta- naphthylamine in the incidence of tumor invasion, progression and recur-
urine of smokers. Factors that determine the devel- rence. Tumors with a high degree of differentiation
opment of the tumor of the urothelium include in- (Grade I) are characterized by 10 years of survival
fections, various instrumental procedures and calcu- in 98% of cases, while survival in undifferentiated
lus, causing mechanical trauma. (Grade II-III) reaches only 35%.
Pathogenesis. Neoplastic changes in the urete- Clinical picture. In the clinical manifestation of
rium result from the so-called "multistep phenome- the disease, hematuria dominates - in 85-90% of cas-
non". The multiple nature of the transformation pro- es, most often painless and macroscopic. In a few
cess involves the activation of oncogenes as a result patients, it may be accompanied by manifestations
of the prolonged action of various carcinogenic fac- of dysuria.
tors and the activation or loss of cancer suppressor In advanced cases, the manifestations of the dis-
genes. Tumor suppressor genes regulate cell prolif- ease include: edema of the limbs in venous and lym-
eration and their loss or inactivation results in tumor phatic obstructions, bone pain in bone metastases
development and progression. Aromatic amines and abdominal pain in retroperitoneal metastases or
with a proven carcinogenic effect come into contact ureteral obstruction.
with the body through the skin, the gastrointestinal Urine testing in most cases (except for macro-
tract and the inhalation route. As a result of high kid- scopic haematuria) indicates the presence of eryth-
ney concentration, the urinary bladder is the body rocytes. Concomitant infection can also cause pyu-
exposed to longer duration of carcinogenicity. Sig- ria.
nificant in this regard is the increased percentage of In profusion and prolonged haematuria, blood
localization of tumors in the trigonum area. testing may indicate the presence of anemic syn-
A major barrier to the metabolism of aromatic drome. In cases of urethral obstruction, azotemia
amines in carcinogens is the liver where they either may be expected.
inactivate or become urothelial carcinogens. The in- Urine cytology is important both at the begin-
activation of aromatic amines is accomplished with ning of the diagnostic process and in the course of
the enzyme system of N-acetyltransferase. Conju- post-treatment follow-up. Flow cytometry is diag-
gated N-hydroxy metabolites can be deconjugat- nosed in 80% of cases. Investigation of blood group-
ed by beta-glucuronidase in urine at optimal pH ing agents (AHVs) in the presence of tumors demon-
and release active carcinogens interactioned with strates the lack of antigenicity that correlates with the
urothelialcell. In the presence of acid urine, N-hy- tumor stage, extent and frequency of progression.
droxylamines damage cellular DNA, which is a major Intravenous urography may indicate a defect in
prerequisite for the occurrence of carcinogenesis. filling and unilateral or bilateral ureteral obstruction.
Morphology. Bladder tumors in 98% of cases are There are similar abdominal ultrasound capabilities.
present in epithelial tumors, of which approximately Intracavitary ultrasound can provide useful informa-
90% are transient-cellular. Less common are adeno- tion about the depth of the process in the muscle
carcinomas (2% of cases), squamous cell carcinoma wall. Computed tomography (CT) and nuclear mag-
(6-8%), non-differentiated small cell carcinoma-like netic resonance imaging (MRI) inform about the
pulmonar carcinoma (less than 2%) and mixed tum- extent of muscle invasion and the presence of en-
ors or a combination of transient cellular, glandular larged lymph nodes in the pelvis.
squamous and undifferentiated carcinoma (in 4-6% Pulmonary and bone metastases are diagnosed
of cases). Rare non-epithelial tumors include: phae- respectively with lung Ro-graphy and bone scintig-
ochromocytoma, choriocarcinoma, lymphoma and raphy.
various mesenchymal tumors. The cystoscopy and biopsy confirm the final di-
Most commonly, transient cellular tumors are agnosis. Biopsy through transurethral resection en-
presented as papillary exophytic formations and, ables the extent of tumor bladder invasion to be de-
less often, as solid or ulcerative. Carcinoma "insitu" termined.

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Prognosis. The prognosis of superficial bladder cases with small invasive tumors with a possibility
tumors with the use of treatment and prophylaxis is of removal in a healthy tissues and non-metastatic
very good - with a 5-year survival in more than 90% process.
of cases. Radical cystectomy, with or without preoperative
The prognosis for invasive tumors is determined radiotherapy, gives serious chances for long-term
by the presence or absence of a metastatic disease. survival of patients without lymphatic metastases.
The five-year survival rate of invasive tumor patients Over the last decade, combining different cytostat-
is 40-50%. In the presence of lymphatic metastasis, ics lead to increased results in metastatic cases. The
the five-year survival after cystectomy is 15-20% (in use of M-VAC chemotherapeutic mixtures (Meth-
patients with micrometastases in lymph nodes - 35- otrexate, Vinblastine, Cisplatin), CIS CA (Cisplatin,
40%). In case of surrounding organs, the 5-year sur- Adriamycin and Cyclophosphamide) and CMV (Cis-
vival after cystectomy is below 10%. platinum, Methotrexate and Vinblastine) results in
A determining factor in the treatment of bladder an objective affect in 50-70% of the cases.
tumors is the stage of the disease. The usual treat- Prevention. The main thing in preventing profes-
ment of superficial tumors is transurethral resection sional bladder tumors is to take measures restricting
(TUR) with subsequent intravesical BCG vaccine or the exposure of workers to carcinogens. These meas-
cytostatics (Thiotepa, Mitomycin, Epirubicin) proph- ures include the use of highly developed industrial
ylaxis for relapses. technologies with maximum safety, the use of pro-
In situ carcinoma treatment includes transure- tective clothing and regular control of the working
thral resection and intravesical BCG vaccine. In more environment.
advanced cases and those not affected by BCG vac- Higher risk productions use screening for work-
cine therapy, it may be necessary to perform radical ers - control studies for urine cytology, flow cytome-
surgical treatment - cystectomy. try and blood grouping (AVG) can contribute to early
Partial resection can be performed in 6-8% of detection of the disease.

REFERENCES

1. Badalament R. A. et al: The relative value of cytometry and cytology in the management of bladder
cencer: The Memorial Sloan-Kattering Center experience, Semin. Urol. 1988, 6, 22.
2. Jordan A. M., J. Weingarten W. M. Murphi; Transitional cell neoplasms of the urinary bladder: can
biological potential be predicted from tumor grade. Cancer, 1987, 60, 2766.
3. Logothetis C. J., F. H. Dexeus, L. Finn, A. Sella, R. J. Amato, A. G. Ayala, R.G. Kilbourn: A prospective
randomized comparison of MVAC and CISCA chemotheraphy for patients with metastatic urothelial tumors,
J. Clin. Oncol, 1990, 8, 1050.
4. Matanoski G.M., E.A. Elliot: Bladder cancer epidemiology, Epidemiol. Rev., 1981, 3, 203.
5. Olum A.F. et al: Molecular of Human Bladder Cancer, Semin. Urol., 1990A, 4, 270.
6. Perry J. L., B. M. Hyman: Management of Dessiminated in the Patient with Bladder Cancer, Urol. Clin.
North America, 1994, 21, 4, 661.
7. Ruben H., W. Lutzeyr D. A. Wallace: The epidemiology and aetiology of bladder cancer, in: Bladder
Cancer, ed. Zingg, E.G., D.M.A. Wallace, Springer-Verlag, Berlin, Heidelberg, 1985, 1-21.
8. Skeet R. G .: Epidemiology of Urogenital Tumors, in: Scientific Foundations of Urology ed. Chisholm
G.D., Fair W.R., Heinmann Medical Books Oxford and Year Book Medical Publishers, Inc. Chicago, 2009, 427.
9. Sternberg G. N .: The treatment of advanced bladder cancer. Ann. Oncol., 1995, 6, 113.
10. Sweeney P., E. D. Kursh, M. I. Resnic, Partial cystectomy, Urol. Clin. North Am., 2003, 19, 701.
11. Thompson J. M., W. R. Fair: Occupational and Enviromental Factors in Bladder Cancer, in: Scientific
Fondation of Urology, ed. Chisholm, GD, Fair WR, Heinemann Medical Books Oxford and Yearbook Medical
Publshers, Inc., Chicago, 1990.
12. Torti FM et al .: Supraficial Bladder Cancer: The primacy of the grade in the development of invasive
disease, J. Clin . Oncol., 1987, 5, 125.

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T. Meshkov

9.4 MYELOPROLIFERATIVE DISEASES

Myeloproliferative diseases (MPD) are malignan- tagenic action is also found for a number of agricul-
cies that originate from malignantly transformed tural products - DDT, lindane, hexachlorocyclohex-
bone marrow stem cells. Due to the varying passing ane and others.
of malignant progression in the clinical develop- The complicated leukemogenic process is facili-
ment of the disease, there are differences. Two ma- tated by the involvement of internal factors, most
jor groups are identified - leukemias (originating commonly presented as chromosomal diseases:
from myeloid stem cells, i.e. myeloproliferative dis- Down's syndrome (trisomy 21), Klinefelter syndrome
eases (MPDs) with acute, subacute or chronic course and Fanconi syndrome. There is a higher incidence
- Table 1) and lymphomas (arising from malignant of MPD in patients with congenital immune defi-
transformation of lymphoid stem cells - bone mar- ciency (Louis-Barr syndrome - teleangiectasis ataxia,
row or peripheral lymphatic organs). Chediak-Higashi syndrome, Wiscott-Aldrich's IgM
Etiology. MPDs are one of the diseases in oncolo- deficiency syndrome).
gy with the clearest etiological noxae, pathogenesis Pathogenesis and classification. Although
and predisposing factors. In leukemogenesis external somewhat conditional, the emergence of MPD oc-
factors found in the environment have been proven: curs in three phases (with varying duration over the
radiation, chemical mutagens, drugs (alkylating cyto- years), with only the end (third) phase being clinical-
statics), mycotic factors in agricultural production. ly recognizable and conducting treatment.
Ionizing radiation is the earliest established leu- In the first phase (tumor initiation), molecular
kemogenic factor and the most common. The first changes in the genetic apparatus of target cells in
observations were on radiologists from 1930 to 1950. the bone marrow (stem myelopoietic cells - "CF2L-
Radiologists who work with sources for healing pur- GEMM" - polypotential) develop. Changes in certain
poses have 9 times more neoplasms. The emergence genes (oncogene activation), alteration in RNA tran-
of MPD is after about 5 years of professional expo- scription, suppression and mutation of regulatory
sure, with the peak being between the 5th and the genes (p53, p14, p15, INK gene RB, etc.) have been
9th year, but also described after 35-40 years. Among established (including in experimental lines), chang-
Japan's atomic bombing survivors, there is a slow es (mutations) in receptor configurations and activa-
increase in chronic MPDs and a dose and epicenter tion of enzymes (caspases) with apoptotic disorders
distance dependence. Workers in uranium mines and - e.g. acceleration in myelodysplasia or delay in my-
accidents in nuclear reactors as well as after radio- eloleukaemia of programmed cell death. A particular
therapy of bones (for example Bekhterev's disease) site for tumor cell development has disturbances in
have a definite increase in CMPD. At present, despite the synthesis of protein molecules from controling
improved radiation protection, there is a risk of MPDs check-point genes such as the CHN 2 gene.
for patients with other neoplasia who are receiving The discovery of changes in the first phase of leu-
radiation therapy, especially in conjunction with kemogenesis began in 1960, when the Nowell and
alkylating cytostatics. In all these cases genotoxicity Hungerford translocation between 9 and 22 chromo-
is due to free radicals. The higher risk should be not- somes. It has been established that two oncogenes
ed at lower doses, but given for a long time. - BCR and ABL - are fused, and a new RNA is created
Chemical agents are a large group of leukemo- from which at least three types of proteins with ty-
genic factors, the most dangerous of which is ben- rosinekinase enzyme activity are created. Enzymatic
zene and its derivatives. Long-term contact with stimulation of the granulocyte clone proliferation, it
them in the chemical, drug and manufacturing in- expands and myeloleucosis develops. Such mecha-
dustries leads to six times the incidence of MPDs, nisms operate in acute leukemias, myelodysplasias
and exposure for more than 5 years - the risk in- and other MPDs.
creases 21 times. Benzene is believed to block pro- In the second phase of leukemogenesis (pro-
liferative processes in the bone marrow (diagnosis moter) mutated cells form a colony (clone) and
of so-called benzene myelopathy) by colchicine-like overcome the immune barrier. Branch expansion is
action on the polymerization of tubular components stimulated by growth factors (cytokines), hormones,
in the tubular apparatus for the mitosis process. Mu- interleukins and lymphocyte blocking factors. An-

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Table 1. CLASSIFICATION OF MIEOPLIPERATIVE DISEASES *
Type MPD Symbol/s Frequency
I. Acute myeloblastic leukemias AML / AML
- Undifferentiated AML-Mo / AUL 5%
- AML without maturation AML M1 15%
- AML with maturation AML M2 30%
- Promyelocytic AML M3 / APL 10%
- Myelomonoblastic AML M4 / AMML 20%
- Monoblastic AML M5 / AMoL 15%
- Erythroleukemia AML M6 / AEL 3%
- Megakaryoblastic AML M7 / AmegL 2%
II. Subacute MPD / primary myelodysplasias SMPD; PMDs
- Refractory anemia increasing I type / RA / RA 20-30%
- RA with pathological sideroblasts (sideroblastic) II type / RA / RA 5%
- PA with myeloblast increasing III type / RAW / RAEB 30%
- Chronic myelomonocytic leukemia IV type / CMMML / CMML 30%
- RAM in transformation V type / RAWM / RAEB 25%
III. Chronic myeloproliferative diseases (CMPD)
- Chronic Myeloleukemia (leucosis) CML / CML
(chronic granulocytic leukemia) HLG / CGL
- Essential thrombocythemia ET / ET
(megakaryocytic leukemia) CmegL
- True polycythaemia IP / PV
- Di Guglielmo syndrome DiG
(chronic erythroleukemia) HEL
- Myelofibrosis (osteomyelofibrosis) MF / OMF / MF
* In addition to the FAB (French-American-English) classification, there is a newer version of the WHO since 1997.
Including cytogenetic and phenotypic data - very detailed and practically complicated.

titumor immunity (both cellular and blocking anti- • evaluation of the effectiveness of the treat-
bodies) is an essential precondition for the duration ment - resp. ineffectiveness due to drug resist-
of this phase, respectively for rare cases of "self-heal- ance (timely change of treatment scheme);
ing". Tumor clones in the promoter phase only in re- • establishing recovered hematopoiesis and
cent years can be identified by the so-called tumor minimal leukemia cell count, i.e. a state of re-
markers (molecules of tumor origin that can be iden- mission ("minimal residual disease"), which
tified and monitored in blood serum). This allows for should be maintained for years and is the ba-
very early screening prophylaxis of tumors. sis for cure;
During the third phase (tumor progression), • establishing timely recurrence of the disease
cell mass increases to a degree recognized by im- re-conducting intensive cytoreductive therapy;
aging and invasive methods. It is generally believed • in screening studies of endangered healthy
that this is possible in 108 tumor volume and quality subjects for early detection of dysplastic chang-
medical diagnostics. This may highlight the difficul- es and assessment of leukemogenic risk.
ty of unassigned increases in undifferentiated cells Epidemiology. In Bulgaria, in 1996, the incidence
in the bone marrow (at 108 cells in MDL in the my- of leukemia was 11.5 per 100,000 people - 14.1 for
elogram accounts for about 4% myeloblasts). How- men and 8.9 for women (the most incomplete infor-
ever, there is no difficulty in an advanced process mation on subacute MPD - myelodysplasia, but MDS
- 10⁹ cells are up to 10% myeloblasts, and at values​​ at least 8 times more than acute leukemias). There
above 20% the tumor volume is 109-1010 cells, i.e. are age, racial, geographic and professional charac-
the weight of the tumor mass is already above 10 g. teristics and deviations from the average data. De-
During this phase are also the non-random chromo- spite these deviations, statistics show a very stable
somal abnormalities in bone marrow and peripheral morbidity rate during the 1981-1996 period.
blood cells. For example, in AMLs there are t (8; 21) Clinical picture. The three types of MPD show
and t (15; 17) and many others, for MDS there are de- both general clinical manifestations and differenc-
letions usually 5; 7; 8; 11; 20; chromosomes, in HMPD es in acute, subacute or chronic course. The basis of
is the typical Philadelphia chromosome - t (9; 22). the symptoms is the rate of clonogenic malignant
Knowledge of the quantitative side (leakage cell proliferation with the whole cascade of humoral
phase) of leukemic processes is the mainstay of mod- effects, the reduction of normal hematopoiesis with
ern quantitative hematology and is a guideline for: consequences of decreased bone marrow popu-
• planning and conducting the initial (induc- lation function and associated complications, and
tive) antileukemic (cytoreductive) treatment the phenomena of suppressed immune responses.
by polychemotherapy and/or bone marrow Here are the so-called "Major symptoms," predom-
transplantation; inantly for acute leukemias and so-called " "Small

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symptoms" that occur in all MPD, especially at the mas, cardiac symptoms, respiratory failure; renal and
beginning, and are more common in subacute and endocrine complaints due to leukemic infiltrates;
chronic MPD. complaints of hyperleukocytosis - hyperviscosity
Pathogenesis interferes with and generates cer- syndrome of the CNS, eyes, heart. Often the initial
tain complaints of tumor populations that initiate manifestation is from hemorrhagic or inflammatory
narrowing of normal hematopoiesis and cytokine organ processes. Symptoms and frequencies of the
production, tumor necrosis factors, blocking factors, various MPD are summarized in Table 2.
and creating a humoral imbalance. Of these complex In the assessment of laboratory data, some fac-
intracellular relationships above a certain threshold tors, which are also the basis for standard diagnos-
(determined by tumor volume), the uncommon but tics adopted in the developed countries' practice
very important common symptoms of MPD include (Table 3), should be considered:
weakness, weakness and decreased physical activity, • they are mandatory both at the beginning of
loss of appetite, decreased body mass, night sweats, the diagnostic process and in the differential
bonealgies, abdominal pain of enlarged visceral or- diagnosis And the final decision must be op-
gans. Humoral imbalance and cytokine production timal in volume and include classical cytolog-
above the needs are most often manifested in the ical, cytochemical, immuno-phenotypic, cy-
so-called "Paraneoplastic syndrome - subfebrili- togenetic and molecular-biology tests;
tis, skin changes, adynamia, weakness. There is also • some of the indicators (quantitative) are very
a specific symptom - bone pain with periostal and variable and should be carried out frequently;
widespread character; skin infiltrations (leukemias) • interpretation requires specific haematologi-
throughout the body; skin and mucous bleeding cal preparation:
similar in time, buco-pharyngeal and gingival syn- • adequate treatment is associated with stand-
dromes of necrotic nature; spleen infarcts (such as ardized laboratory control of cytoreduction,
abdominal dramas); obstructive or haemolytic jaun- requiring further studies on the efficacy of
dice, initial anemic organ disorders - CNS, eye scoto- the therapy (cytology, oncogenes by PCR

Tab. Symptoms in acute, subacute and chronic MPD

Type of MPD / Syndrome Frequency Pathogenesis
I. ACUTE LEUKEMIAS
Astheno-adynamic 95 % Anemia + toxicose + cytokines
Anemic 92 % Induced erythropoiesis
Hemorrhagic 80 % Thrombocytopenia + hypocoagulation
Feverin 75 % Infections + paraneoplastic expression
Infections 45 % Granulocytopenia + Immunodepression
Neurological 25 % Leukemic infiltrates + anemia
Osteoalgic 10 % Periostal infiltrates
Splenomegaly 70 % Leukemic proliferation
Hepatomegaly 55 % Leuk. Infiltrates + toxicosis
II. MYELODYSPLASIAS
Anemic-asthenic 80-90 % Impaired erythropoiesis
Adynamia 70 % Analytic aggression
Infections 25-40 % Dysgranulocytopoesis, -penia
Hemorrhagic 20 % Distrombocytogenesis
Hepatosplenomegaly 5% Secondary MDP’s complications
III. CHRONIC MPD (myeloleucosis, polycythaemia, thrombocythemia, myelofibrosis or osteomyelofibrosis, Di Gullielmo
syndrome - chronic erythroleukemia)
Weight (abdominal pain) 95 % Organomegaly-splenomegaly
and heart attacks
Feveriness 60 % Paraneoplastic syndrome / infections
Anemic 48 % Pressed erythropoiesis
Night sweats 35 % Paraneoplastic syn. + TNF *
Consumative 30 % TNF + increased exchange
Osteoalgic 10 % Osteoporosis + infiltrates
Thrombosis 20 % Hyperthrombocytosis
Hypervsceral (CNS, heart) 20% Hyperleukocytosis
Splenomegaly 95 % Leukemic proliferation
Hepatomegaly 75 % Infiltration + hepatitis
Lymphadenomegaly 10 % Extramedular haemopoiesis
Skin leukemias 5% Leukemic infiltrates + necrosis
Priapism 3% Thrombosis + pens infiltrates
* TNF - tumor necrosis factor (cytokine)

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Tab. 3. DIFFERENTIAL DIAGNOSTIC CRITERIA FOR MPEs
Chronic MPDs * Benign leukemoid
Parameter CML PV ET MF DiG reaction
I. HEMOGRAM:
– Hemoglobin – +++ н – – –/+
– Leukocytes ++/+++ + + +/++ + +/++
– Platelets +/++ +/++ +++ –/+ – –/+/N
– DBP** leu. leu. leu./N N/leu. N leu.
– GAP*** – index zero/– + N/+ +++ N N/+
II.MYELOGRAPHY:
– Celluritisy ++/+++ +/++ + „Dry puncture“ ++ N/+
– Populations:
Granulocytes +++ + + –/+ N +
Erythroblasts – + + – + +
Megakaryocytes +/– N/+ ++/+++ +/– – N
III. ORGANIC EVENTS
– Splenomegaly +/++ N/+ N/+ ++/+++ N/+ N/+
– Hepatomegaly N/+ N/+ N N/++ N/+ N
– Lymphadenopathy – – – –/+ – –/+
– Haemorrhages + + +/++ –/+ + –
– Thrombosis –/+ –/+ + –/+ – –/+
Note: * the names of the chronic MMPs listed in table. 1; ** DBP - Differential Blood Pressure; *** GAP - granulocyte alkaline
phosphatase index; Quantities symbols: "-" - Missing / Reducing; "+, +++ +++" - moderate, intermediary, significant increase; "N" - norm.

methods, residual resting molecular molecule ing cells and resp. in organs with appropriate
probes Go through so-called FISH methods). protection from complications (infections and
A special place is under the control of the two haemorrhages);
main processes: tumor (leukemic) proliferation and • the repetition of the inductive courses at the
cytoreductive polychimotherapy. The control is beginning is maximally compressed i.e. inten-
based on quantitative cytological examinations of sive application of the adopted treatment
the bone marrow (every 14 days - the time to gen- protocol;
erate mature cells from normal stem precursors), pe- • combination of several cytostatics is man-
ripheral blood (reduction in the percentage of ma- datory and phase-dependent (mitogenic in-
lignant cells) and regenerative processes - quantity hibitors) and phase-independent (for inter-
and qualities of restoring normal populations (gran- phased cells in "calme" - G0 phase).
ulocyte, erythroblast, megakaryocyte and immuno- • substitution therapy and anti-infectious
competent cells - lymphocytes and plasmocytes) in drugs should be included early in the course
myelogram and hemogram. Retaining the malignant of treatment to protect patient from the often
population is the first sign of primary or emerging fatal complications;
resistance and is a motive for changing or intensify- • psychotherapy should prepare the patient
ing treatment. In the case of effective treatment and and his/her relatives for prolonged and diffi-
minimization of the malignant population ("remis- cult anti-tumor therapy.
sion"), there is a reason to determine the chance of In acute MPDs (acute myeloleukemias = M0-M7
cure, which includes and bone marrow transplanta- of Table 1), the major drugs are Cytosine-arabino-
tion (the possibilities and access of the patients for side (antimetabolite of pyrimidine) acting on the
this difficult and expensive treatment is not, how- synthesis mitotic phase, anthracycline preparations
ever, massive and that is why in all countries the (Daunorubicin or Zavedos) that intercalate into the
main treatment Is poly-chemotherapy). Polyhemic DNA and damage it and purine antimetabolite Thi-
therapy has achieved the so-called "minimal resid- ogwanin, Lanvis) acting on the S-phase of fission
ual disease" i.e. persistence of a minimal number of cells by suppressing the synthesis of purine and
leukemia cells and restored (regenerated) hemato- hence DNA and RNA synthesis. Promyelocytic leu-
poiesis with complete recovery of clinical health and kemia (M3) required specific treatment with retinoids
working capacity. In about 30-40% of patients, such (ATRA). Once a remission has been achieved, the so-
MPD remissions can be maintained for years. called maintenance treatment for 2 or 3 years with
Treatment. The principles of anti-leukemia ther- purine antimetabolites - mercaptopurine (purinetol)
apy are: and methotrexate (a competitor of folic acid in the
• aggressive initial ("inductive") therapy for synthesis of thymidine and purine).
maximal eradication of bone marrow clon- In myelodysplastic syndromes (subacute MPD),

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treatment is still ineffective to stop the transformation cortico-hormones) and symptomatic treatment of
to leukemia. It starts with substitution therapy (plate- splenomegaly (surgery or fractional radiotherapy).
let and erythrocyte concentrate against cytopenias) The prognosis of these malignancies is pessimis-
and stimulates therapy with growth factors that affect tic without treatment and with increasing optimism
granulocytopoiesis and thrombocytopoiesis (against in modern treatment, including bone marrow or
anemia - with erythropoietin), i.e. a cocktail of induc- stem cell transplantation (isolated from peripheral
ers to activate the stem cell compartment. In type I blood or umbilical cord and placenta of a newborn).
and II MDS, this therapy is basic - sometimes in the In acute MPDs without treatment, the disease
type II assisted and chelates (desferal) to release from occurs within 1-2 months. Summarized data show
hemosiderine cumulation. In III, IV, and V types, addi- that in polychimiotherapy, up to 2 years experience
tional effects are assessed with: anabolic hormones, in 60-80% of patients, but up to 5 years - 30-35%.
retinoids (Vesanoid), vit. D3 (Calcitriol), Vestatin, al- Young people have a significantly better prognosis
pha-interferons (Roferon A, Intron A). In IV and V type - over 80% get remission, while in patients over 70 -
with transformation, polychemotherapy is performed 30% they get remission. The average duration of the
as in acute leukemia (M1 or M5). Ineffective chemo- first remission is 12-25 months, and the follow-up is
therapy is the cause of bone marrow transplantation shortened. Significantly worse is the forecast for so-
- with good effect in 40-60% of patients. called secondary leukemias (occurring after antican-
Treatment of chronic MPDs is specific for each. cer treatment of other neoplasias). This happens af-
In chronic myelogenous leukemia, primary treat- ter a period of 5-8 years and often has primary drug
ment includes hydroxyurea, alpha-interferon and resistance.
cytosine-arabinoside, and bone marrow transplan- The prognosis of myelodysplasia differs in type I
tation (made in the chronic phase - early, giving 45% and type II - occurring for years with substitution ther-
cure for the first 5 years). Excellent results have been apy only, and III, IV and V type - within 12-24 months,
reported for Glivec, which blocks adenosine triphos- there is a transformation into acute leukemia.
phate receptors and successfully stops the prolifera- Chronic myeloproliferative diseases have been
tive leukemia process in over 75% of patients. ongoing for years.
Essential thrombocythaemia is treated with cy- Prevention. The main purpose of preventing
tostatics, hydroxyurea, melphalan and successfully damage from ionizing radiation is to minimize
with alpha-interferon. Combination with antiplate- the absorbed dose. Prophylactic events include a
let anti-aggregates (aspirin, antistenocardin), and wide range of measures: organizational, medical,
the latest - for example, Anagrelid. health-education, architectural and planning, etc.
Treatment of true polycythaemia aims at reduc- The aim is to ensure that they do not exceed the
ing blood viscosity and suppressing the hyperaphin- norms (annual dose limits, annual radionuclide in-
ity cell branch to erythropoietin. A combination of puts, and annual average allowable concentration)
systemic bleeding, hydroxyurea, bisulphonates and, when working with ionizing radiation.
in some cases, radioactive phosphorus (32P) is used. For exposure to chemical agents (benzene and
Antiaggregants are mandatory. its derivatives), prophylactic measures provide for
Chronic erythroleukemia (Di Gugliemo's syn- control to assess levels of toxic substances in the air
drome) is treated according to the rules of granulo- in the working environment and compliance with
cytic leukemia in the chronic phase. the MACs. If possible replace toxic substances with
Myelofibrosis (myeloosteosclerosis) is difficult to less toxic.
treat. The healing complex includes: replacement Conducting prophylactic medical examinations
therapy (erythrocyte concentrates); medicamental (preliminary and periodic) and protective profes-
treatment (hydroxyurea, alpha-interferon against sional nutrition - diets A, E, according to the active
megakaryocytic proliferation, gamma-interferon noxae.
against overproduction of collagen, testosterone,
REFERENCES
1. 5th Intern. Symp. On Myelodysplastic Syndromes, Prage - 1999, in Leukemia Res., Vol. 23, Suppl. 1, 2000
2. Golstein B. D., Kipen W. M., Hematological disorders in. Occupational Health: Recognizing and Preventing Work
- Released Diseases, ed. B. S. Levy, D. H. Wegman, II ed., 1994, 441-445.
3. Haematology, ed. Williams W.J. et al., McGraw-Hill Publ. Company, N. Y., 1998.
4. Harris N.L. and al. WHO classification of neoplastic diseases of the haemopoetic and lymphoid tissues. Histopa-
thology 3: 69-86, 2000.
5. Leone G. et al. The incidence of secondary leukemias Haematologica 84: 937-945, 1999.
6. Mecuci C. Cytogenetics of myelodysplastic syndrome Forum Genova, 33: 127-138, 1999

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7. Meshkov T., D. Avramova, G. Georgiev. Practical approaches to the diagnosis and treatment of leukemias and
lymphomas. Ed. "Knowledge" Ltd., 1995, 452. (in bul.)
8. Mufti G.J., D.A. Galton The Myelodysplastic Syndromes Churchill-Livingstone Publ., London, 1992.
9. Myelodisplastic Syndromes, ed., Yarbro J. W., Seminars in Oncology, vol. 19, 1: 106, 1992.
10. Tefferi A. Overwew of Chronic Myeloproliferative Disorders Sem. Haematology, 36, Suppl 2, p. 1 - 26, 1999.
11. Thompson R. B. Disorders of the Blood, in A Textbook of Clinical Haematology, Churchill - Livingstone, 1997.
12. Weatherall S.R. and al. Disorders of the blood, in Oxford Textbook of Medicine, vol. 2, 2005.

D. Todorov, K. Timcheva, D. Tsvetkova

9.5 MODERN APPROACHES TO

CHEMOTHERAPY OF ONCOLOGY
One of the major unresolved problems of clinical proliferating cells - normal and tumorous. The first
drug therapy for tumors (classical chemotherapy), practiced antitumor drug, the action of which is
which significantly limits successful treatment, along based on this approach, was discovered by accident.
with early micrometastasis, high heterogeneity and The use as a warfare poison mustard gas, used dur-
genetic instability is the drug resistance of tumors ing the First World War, causes suppression of the
(natural or acquired). Despite the significant recent nervous activity through its interaction with the my-
success of oncology, more than 90% of the oncology elin envelope of the nerve cell and myelotoxic effect.
mortality is associated with some form of resistance These effects initiate clinical trials as an anticancer
to treatment. This is largely due to the non-selective agent in patients with lymphomas.
genotoxic (common cytotoxic effect on all rapid- At the beginning of the 20th century, the effect
ly proliferating cells in the body) of the majority of of vitamins was identified as low molecular enzyme
existing anti-cancer drugs. With the accumulation cofactors, and in 1946, with the determination of
of enormous numbers of molecular biology and the folic acid structure, light was cast on their role
oncology data over recent decades and the discov- in many diseases. Clinical studies with the folic acid
ery of many new targets in the complex multi-stage analog aminopterin resulted in significant inhibition
regulation of cell proliferation and differentiation, it of acute leukemia in children.
has been possible to create a fundamentally new ap- The relationship between these two compounds
proach to the treatment of cancer - targeting drug with radically different chemical characteristics and
therapy that has a high degree of selectivity on tum- biological activity was also found in their ability to
ors without genotoxic and general cytotoxic action. damage DNA. For the antitumor agent, mustard gas
Oncodiseases is generally characterized by im- was found to chemically interact directly with DNA,
paired control mechanisms of cell proliferation, causing the so-called alkylation of the molecule
differentiation and apoptosis, heterogenity and while the antimetabolite aminopterin disturbs the
micrometastasis, enhanced angiogenesis, invasive DNA biosynthesis and destroys it by the so-called
growth, and the like common characteristics. antimetabolic action. The massive creation of new
Global trends are towards a gradual increase in cancer drugs that break the integrity of the genet-
morbidity from most oncological diseases, with a ic material of the cell begins and every two years at
slower increase in mortality and the possibility of least one new drug has entered the clinical practice.
turning oncodiseases into chronic, treatable diseas- Mitosis inhibitors. The colchicine - plant sub-
es in developed countries. stance, isolated from autumn crocus, is one of the
Contemporary treatment of malignant tumors is first to be tested on mouse tumor models. It has
complex - it includes the three basic healing meth- been found to retain the cells in the mitosis process
ods: surgical, radial and medicinal. and to demonstrate a new way of initiating destruc-
Drug treatment for malignant tumors is systemic tion of the genetic material - by disrupting its even
and includes cytostatic therapy (chemotherapy distribution in the daughter cells during mitosis. De-
in the narrow sense), hormone therapy, target spite its effectiveness, colchicine exhibits unaccept-
therapy and other types of biological treatment. ably high toxicity to be administered as an antitu-
CYTOSTATIC (CHEMO-) THERAPY mor drug. Therefore, interest was directed towards
Clinical chemotherapy of oncology disorders in so-called Vinca - alkaloids isolated from the plant
the 20th century is dominated by genotoxic drugs Vinca rosea. The two alkaloids vincristine and vin-
with non-specific cytotoxic action on all rapidly blastine, as well as their semi-synthetic derivatives

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vinorelbine, vindesine and others, and now play a gemcitabine, which is currently widely used in many
role in the treatment of a number of oncology disor- cancers.
ders. Studies on karyokinetic spindle inhibitors have The topology of DNA as a target for antitumor
led to the discovery of a new class of compounds agents. Detection of DNA-topoisomerases provides
isolated from the yew plant (Taxus baccata). Thus, an explanation for the molecular mechanism of
paclitaxel in its biological action is principally dis- the cytotoxic action of many natural products that
tinguished from vinca alkaloids by enhancing rather damage DNA but do not interact chemically with
than inhibiting the assembly of the microtubules of it. Thus, the antibiotic actinomycin D, isolated from
the karyokinetic spindle. Paclitaxel and docetaxel (its streptomycetes, now with limited use in rare onco-
semisynthetic derivative) have a significant place in logical diseases, binds to DNA by inserting polycy-
modern anti-tumor therapy, as one of the most pow- clinc chromophore between the base pairs of the
erful therapeutics. double spiral. Actinomycin D inhibits the synthesis
DNA-interacting drugs. Mustard gas derivatives of RNA, but this does not explain its antitumor activ-
have provided the basis for the synthesis of a large ity. The subsequent discovery of both anthracycline
number of clinically applicable derivatives, such as derivatives - daunorubicin and doxorubicin, which
melphalan, cyclophosphamide and dozens of oth- also bind to DNA by inserting their chromophores,
ers. They exhibit their antitumor activity by alkylat- however, shows reduced inhibition of RNA synthe-
ing the macromolecule of DNA. A great number of sis compared to actinomycin E. Clinical application
natural products such as bleomycin and others also of daunorubicin Is limited to haematological malig-
interact chemically with DNA. An important role in nancies, mainly due to unacceptable toxicity, unlike
the treatment of cancer among the DNA-interacting doxorubicin and its derivatives, which have a broad
compounds plays cisplatinum. Platinisation of DNA spectrum of action and main therapeutic applica-
has become a new way of disrupting its structure tion at present. The synthetic compound amsacrine,
and has led to the creation of new platinum deriv- which has limited use in acute leukemia, binds to
atives with reduced toxicity and broad antitumor DNA by insertion of its acridine chromophore but
spectrum. has a negligible effect on RNA synthesis. These
DNA replication inhibitors. After the clarifica- drugs act as inhibitors of the enzyme topoisomerase
tion of the structure of DNA, it was quite natural for 2, changing its normal function to one that leads to
the synthesis of analogs of the bases that make up DNA destruction.
this macromolecule. They were suggested to exhib- The so-called podophyllotoxin analogs derived
it antitumor properties by disrupting the replica- from root mandrake. Podophyllotoxin, similar to
tion process. Such analogs are the thymine analog colchicine, binds to tubulin, but some synthetic gly-
5-fluorouracil and the purine analogs 6-mercaptop- cosylated derivatives, called epipodophyllotoxins,
urine, 8-azaguanine and the like. The cytotoxic effect show a broader spectrum of antitumor activity at
of aminopterin and methotrexate is based on their reduced toxicity. Etoposide and related teniposide,
ability to inhibit the enzyme dihydrofolate reduc- useful in a large number of solid and haematological
tase, which converts deoxyuridine monophosphate oncological diseases, have reduced ability to bind
to thymidine monophosphate. The so-called "death tubulin, but enhance DNA destruction by modifying
in the absence of thymine," which occurs in bacteria the function of topoisomerase 2.
that have lost the ability to synthesize DNA in the ab- The non-DNA-bound plant product camptothe-
sence of this base, which also occurs in animal cells. cin specifically modifies the topoisomerase function
This fact has begun a new class of biologically active 1. The water soluble analogues of camptothecin to-
substances - antimetabolites, which have already potecan and irinotecan have greatly expanded their
been created on a rational rather than empirical ba- clinical application after topoisomerase 1 has be-
sis. Once all the individual enzymes involved in DNA come a new target for antitumor therapy.
replication have been identified, it has been found Increased selectivity of anti-tumor agents. The
that the successful normal operation of the replicase selectivity of cytotoxic therapy depends mainly on
complex requires a constant influx of triphosphate the characteristics of the tumor mass. The use of mi-
precursors. Breaking this influx leads to distortion crobiological models has shown that the action of
of DNA synthesis, and hence to antitumor action. acylating drugs is killing cells in exponential depend-
By disturbing DNA replication, the arabinose nucle- ence - a certain percentage of the cell population is
osides isolated from the Cryptothethya fungus also destroyed with each subsequent dose administered.
act. Further testing of chemical analogs of cytosine- On this basis, using animal models, the cytotoxici-
arabinoside has led to the discovery of many oth- ty of certain antitumor agents has been optimized,
er antitumor drugs with improved properties, e.g. depending on the moment of their application to

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the cell cycle, as well as by rational combination of A. Adjuvant (post-operative) chemotherapy - is
the patterns for their application. This approach has applied in cytostatically drugs sensitive tumors fol-
been successfully applied to haematological onco- lowing radical surgery to fully reverse the possible
logical diseases, which in most cases has a high level micrometastases . Adjuvant treatment is conducted
of cell division but does not form solid tumors. for a certain duration with cytostatics and combi-
Another approach to increasing selectivity focus- nations of these, which have proven to be most ef-
es on intra-cell transport mechanisms of enzymes fective in multi-center international clinical trials, in
and active substances that differ in tumor and nor- certain groups of patients, depending on complex
mal cells. Many antimetabolites exhibit their selec- factors derived from the pathomorphologic finding
tivity in this mechanism. Topoisomerases are an or after additional immunohistochemical and other
example of such selectivity in which high cellular studies so-called prognostic and predictive factors).
activity is associated with increased susceptibility to For example, in the classical known prognostic fac-
agents that bind to these enzymes. tors of mammary carcinoma (involvement of axillary
In recent years, increasing selectivity has been lymph nodes, hormonal sensitivity, tumor size, over-
achieved through the creation of the so-called pre- expression of HER2), lately, the success of genetics
cursors of cytotoxic agents, that do not have their has also been added - revealing the so-called "ge-
own cytotoxic activity until they are activated by an netic signature": 70- or 21- genetic profile character-
enzyme or other agent. Initially activators of these istic of patients who progress rapidly after adjuvant
precursors were normal enzymes in the cell, but ac- treatment is complete.
tivating enzymes have recently been investigated by B. Neoadjuvant chemotherapy - is performed
targeting antibodies or by gene therapy. before the main therapeutic procedures - surgical
The most important feature of cytostatic ther- treatment or radiotherapy with several main objec-
apy is that it primarily damages proliferating cells tives: reduction of tumor volume with a view to its
by various mechanisms and leads to cell death. The radical removal; treatment of micrometastases in
sensitivity of a malignant tumor to chemotherapy is distant organs; provides information on the sensi-
determined by the specificity of the cells that make tivity to the cytostatic combination used, to assess
it, namely: the type of postoperative treatment most appro-
• Cell cycle and doubling time; priately. Before starting treatment, it is necessary to
• Growth fraction; study tumor material and to determine the maxi-
• Volume of the tumor (proliferation fraction/ mum number of prognostic and predictive factors.
resting cell ratio); Neoadjuvant chemotherapy is only susceptible to
• Sensitivity to cytostatics; drug-induced tumors. In hormone-dependent tum-
• Heterogeneity of the tumor. ors (breast cancer), neoadjuvant hormone therapy
On the other hand, the effectiveness of a particu- could also be performed.
lar cytostatic depends on its concentration and time C. Palliative chemotherapy - performed in a
of exposure, as well as on the presence or otherwise metastatic disease. The results of this treatment
of resistance. depend on many factors: tumor sensitivity, general
Since malignant tumors are comprised of a heter- condition of the patient, type and size of the metas-
ogeneous population of cells of varying sensitivity to tasis, side effects of the combination administered.
the various cytostatics, the most effective cytostatic At the stage of metastasis, most tumors are incura-
combinations contain substances with a different ble, the primary goal of treatment is to control the
mechanism of action and with proven antitumour symptoms caused by tumor growth, improve quality
activity on self-administration. The ideal option is for of life, and increase survival.
the cytostatics of the combination to have a syner- WHO group malignant drug-sensitive tumors
gistic effect. At the same time, overlap of toxic effects into five categories:
should be avoided. Apart from a suitable combina- • Category 1 - tumors for which there is evidence
tion of cytostatics, the therapeutic efficacy of chemo- that the use of drugs alone or in combination
therapy can be increased by administering high dos- (with each other or with other treatments) will
es or by the so-called "compressing" the doses. result in a cure of normal duration of life or pro-
Currently, due to the discovery of new antitu- longing survival for the majority of patients.
mour substances with a different mechanism of ac- Here are some child hematological diseases,
tion, it is possible to treat about 20% of new cases trophoblastic tumors, germ cell tumors.
of malignant neoplasms only with systemic therapy. • Category 2 - tumors where median survival is
In practice, cytostatic treatment is generally divided prolonged after chemotherapy as an adjuvant
into three types, depending on the goals it pursues: after local surgical intervention or radiothera-

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py in early stages of the disease. These include administered: pulmonary toxicity is observed with
malignant breast tumors, ovarian carcinoma, Bleomycin, hepatic, with some enzymes, and so on.
tumors of the colon and the right gut. Hypersensitivity reactions are another
• Category 3 - tumors where there is evidence life-threatening side-effect phenomenon requiring
that the use of medication alone or in combi- rapid and adequate intervention. This is the case
nation causes a tumor volume reduction of with taxanes - preparation with an oral or parenter-
more than 20% in some patients with distant al corticosteroid is required from the day before the
metastases and almost certainly improves the infusion of cytostatics. Anaphylactic reactions have
quality of life in all patients treated. This group been observed with platinum salts, epipodophyllo-
refers to the metastasis stage indicated in toxins (etoposide), and others (for cytostatics in the
category 2, as well as malignant lung tumors, taxane group, as well as for platinum derivatives,
some lymphomas and oth. neurotoxicity, which is dose dependent and usually
• Category 4 - tumors where local disease con- reversible, is also characteristic).
trol can be improved with chemotherapy be- The most common toxicity that damages the skin
fore, during or after surgery or radiotherapy and its appendages is alopecia. There are currently
- such as malignant breast, ovarian, malignant no effective means of prevention. Usually, alopecia is
bladder tumors, and prostate carcinoma. reversible. Signs of skin sensitivity include hyperker-
• Category 5 - tumors where there are currently atosis, hyperpigmentation, photosensitivity. A kind
no effective drugs. Such are malignant tumors of skin toxicity is so-called palmar-plantar erythrod-
of the kidney, pancreas, primary liver carcino- ysaesthesia - painful erythema of the palms and feet,
ma and others. which can be complicated by desquamation, exsul-
Combination chemotherapy requires knowledge ceration and overlapping infection. This toxicity is
about the possible side effects of treatment. Because typical of Capecitabine antimetabolite (Xeloda) and
the metabolic processes in normal and tumor cells liposomal doxorubicin (Caelyx).
do not differ significantly, as well as due to the lack In addition to immediate (observed over time or
of selectivity of cytostatics, cytostatic treatment in- shortly after treatment with cytostatic drugs), appear
evitably impacts healthy tissues as well. The most and suspended to toxicity - delayed growth in child-
suffering mitotic activity cells-haematopoietic and hood, late cardiotoxicity (cardiomyopathy and con-
reproductive. Accurate dosing and tracking of the gestive heart failure), deferred renal and pulmonary
patient in the critical time for haematological toxic- toxicity, ototoxicity, endocrine and metabolic dys-
ity is key to avoiding life-threatening complications function (hypogonadism, hyperlipidemia, etc.), the
such as febrile neutropenia, thrombocytopenia. onset of secondary tumors. The higher incidence of
Almost all cytostatic combinations are accom- leukemias in patients treated with alkylating agents
panied by gastrointestinal toxicity, expressed to or topoisomerase II (anthracycline antitumor anti-
varying degrees: nausea and vomiting, diarrheal biotics) inhibitors, is known to occur. No other pre-
syndrome, mucositis and stomatitis. Adequate an- ventative measures to avoid late toxicity are known
ti-emetic therapy, the training of patients to adhere except for the qualitative and systematic follow-up of
to an appropriate hygiene regime and timely report- the patients treated.
ing of symptoms of toxicity have a key role in over- Systemic treatment of fundamental importance
coming gastrointestinal toxicity. in oncology is hormone therapy. Some malig-
Some of the cytostatics used are characterized nant tumors require hormonal stimulation for their
by so-called cumulative cardiotoxicity (anthracy- growth - e.g. malignant tumors of the mammary
cline antitumor antibiotics). This requires that their gland and prostate require corresponding action
application be preceded by a thorough examination with estrogens or androgens. Capture places of hor-
of the myocardial function as well as its monitoring mones in the cell are called hormonal receptors. In
during the course of treatment. Cardotoxic are also hormone sensitive tumors, blockage of receptors
some modern antitumor agents - the monoclonal may result in tumor growth arrest or apoptosis. Hor-
antibody Herceptin, some "small molecules" - Lapa- mone treatment is associated with much less pro-
tinvib and others. nounced adverse side effects than cytostatic treat-
A typical unwanted side effect following plati- ment, and the effects achieved with this therapy are
num salt administration is nephrotoxicity. This fact of longer duration. This treatment often brings addi-
also necessitates a thorough preliminary refinement tional benefits - eg. in the treatment of breast cancer
of the renal function and its follow-up during the with hormone therapy (anti-estrogens) reduces the
course of treatment. Other parenchymal organs risk of malignant tumor in the contralateral mamma-
could also be impaired when certain cytostatics are ry gland, increases bone mineral density, improves

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the lipid profile. enter the extracellular space, invasive tumor growth
TARGET THERAPY occurs. If tumor cells invade newly formed vessels in
Simultaneously with the development of the de- the extracellular space, there is a tumor spreading - a
scribed cytotoxic drugs, new alternative approaches process known as metastasis. Proteolytic changes of
have been developed to influence the signals that the extracellular matrix are determined by the activi-
control cell growth and differentiation. With the rap- ty of four classes of endopeptidases: serine, cysteine,
id development of molecular biology and oncology, aspartyl proteases and matrix metalloproteinases
dozens of potential targets have been identified for (MMPs). The latter are zinc-dependent endopepti-
pharmacological impact on the complex regulation dases capable of destroying almost all components
of cell growth and differentiation processes. Thus, in of the extracellular matrix. In some tumors, the ex-
1960-1970, in vitro cell cultures - normal and tumor pression of MMP is higher than in normal tissues.
cell studies have shown that different sets of poly- In particular, the expression of MMP-2, MMP-7 and
peptide growth factors as well as their receptors MMP-9 correlates with invasive tumor growth, the
are vital for these processes. Many of these are tis- metastatic potential of the tumor and the adverse
sue-specific. The basis of their action is the activity of outcome of the disease. Inhibition of MMP activity
these growth factors on the regulation of DNA repli- is achieved with a number of substances that have
cation and cell division. proven their effectiveness in preclinical studies, but
These targets are considered to meet the follow- due to underlined side effects, they have not yet
ing general requirements: to be found in a large pro- found a wide clinical application. The different phas-
portion of patients with a certain type of cancer, to es of clinical trials are Marimastat (I-III phase), Bati-
be causally related to the tumor genesis, to be essen- mastat (I-II phase), Neovastat (I-III phase), and others.
tial for the tumor cell, and for the normal cell To have 2. Angiogenic Inhibitors.
little meaning. For most of these targets, specific tar- Important discoveries have laid the groundwork
get-directed anti-tumor drugs of a new type that are for the rapid development of this field: endotheli-
non-genotoxic and have no cytotoxic effect on all al cell culture in vitro, the creation of methods for
fast-growing cells in the body have already been de- quantification of angiogenesis, the detection of an-
veloped or are being investigated. These new drugs giogenic stimulants (BFGF - basis fibroblast growt
usually bring tumor cells into a "sleeping" state with- factor; VEGF/VPF-Vascular Endothelial cel Grouth
out being divisive, but their destruction requires the Factor/Vascular Permeability Factor; ang-1-angio-
action of anti-cancer drugs from the classical cyto- poeitin), the detection of endogenous inhibitors
toxic type. (TSP-1-thrombospondin, INF alpha, angiostatin), the
Programmed cell death (apoptosis). One of the development of anti-angiogenic drugs on a rational
most impressive discoveries in the processes of di- basis, the role of oncogenes and tumor suppressor
viding normal and tumor cells was the presence of genes in tumor angiogenesis, the possible lack of
the so-called a biological clock, that program the cell drug resistence to angiogenesis inhibitors as well as
when it replicates DNA and when it enters a division the beneficial integration of angiogenesis inhibitors
cycle. A number of known antitumor drugs have with standard treatment methods (mainly with clas-
been shown to act by enhancing the processes of sical cytotoxic antitumour drugs).
apoptosis in the tumor along with other molecular Angiogenesis is needed at the beginning and end
mechanisms of action, but these processes will not of the metastatic cascade. Due to breaks in the basal
stop here. membrane, the tumor vessels are permeable, and
Potential molecules - "targets" are found inside the tumor cells easily pass through their walls and
cellular structures or on the surface of the cell. enter the circulation in large numbers - several mil-
Examples of extracellular targets are stromal factors lion tumor cells per day. A positive correlation was
(so-called matrix metalloproteinases) and blood found between the number of tumor microvessels
vessels. Targets on the inner or outer side of the cell in a biopsy material and the patient's fate in prostate
membrane are membrane cell receptors and intra- cancer, melanoma, breast cancer and ovarian cancer.
cellular signaling processes. Tumor angiogenesis is a multistage process stim-
I. Targets outside the tumor cell ulated by pro-angiogenic factors. VEGF secreted by
1. Matrix metalloproteinase inhibitors. tumor cells has been most extensively studied. It
It is known that proteolytic changes of the extra- has many isoforms. Since there is a correlation be-
cellular matrix surrounding tumor cells as well as the tween VEGF expression, increased angiogenic activi-
basal membrane have a key role in tumor growth ty, aggression of the malignant tumor, its metastatic
processes. potential, and the adverse outcome of the disease,
When tumor cells pass the basal membrane and inhibition of angiogenesis has been perceived as an

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important antitumor target for decades. After obtain- Fig. 1. Spatial Structure of Ang-2
ing the results of large-scale clinical trials, the mon- (Barton W. A., Tzvetkova D., Nikolov D. B., 2005)
oclonal anti-VEGF antibody Bevacizumab (Avastin) is An Ang-2 - RBD model showing the location of the side (ac-
tive) radicals involved in receptor recognition in oval and rod-
already being clinically proven. Its use in malignant shaped form. The exact location (spatial orientation) of each of
colon tumors leads to a higher percentage of clinical the side radicals in the P-domain (active site)
remissions, greater duration of effects achieved and
greater survival when adding to chemotherapy line
I at this location. This is the first angiogenic inhibitor
to achieve better survival in randomized clinical tri-
als.
Another way to inhibit VEGF-induced angiogen-
esis is blocking tyrosine kinase receptors. There fol-
lows an intracellular information cascade of signal-
ing processes leading to suppression of endothelial
cell proliferation. Numerous small molecule inhibi-
tors of VEGF receptors for tyrosine kinase activity are
found in different phases of clinical trials: PTK 787,
SU11248, ZD 6474, and so on.
The large number of angiogenic factors iden-
tified, the more important and better-understood
are fibroblastic growth factors (FGF family), vascular
endothelial growth factor (VEGF), the family of an-
giopoietins, etc., as well as their receptors, give pos-
sibility to discover many new targets for rationally
1. Side (active) radicals
targeted non-genotoxic therapy. Of great theoreti-
2. P-domain (active site)
cal and practical interest are the most advanced mo-
lecular studies on the structure of these receptors
and in particular on the identification of surfaces in- activity. Widespread clinical use in metastatic breast
volved in receptor recognition (Figure 1). cancer, as well as in adjuvant treatment, finds Tran-
II. Intracellular targets and targets on the cell stuzumab (Herceptin). Its use together with cyto-
surface static treatment or alone leads to an increase in the
During the 1980s, tyrosine kinase phosphoryla- percentage of clinical remissions as well as survival.
tion processes were established and their key role in Similar are the effects of Cetuximab (Erbitux) in met-
regulating important cellular processes: cell cycle, cell astatic colorectal cancer - alone or in combination
metabolism, cell growth, cell proliferation. The fami- with chemotherapy.
ly of the so-called epidermal growth factor receptor Small molecules - tyrosine kinase inhibitors of
(EGFR). It consists of four types of receptors: ErbB1, EGFR are also in advanced phases of clinical trials or
ErbB2 / HER2, ErbB3, ErbB4. They all have a common already with clinical use. Such medicinal product is
structure made up of an extracellular and intracellular Gefitinib (IRESSA) in non-small cell lung carcinoma
(cytoplasmic) part that contains a protein kinase and - alone or in combination with chemotherapy. In a
can be phosphorylated. Attachment of ATP to the cy- small percentage of the patients (about 10%) who
toplasmic site results in activation of the tyrosine ki- have a specific EGF receptor mutation, the effect is
nase followed by a cascade of cellular processes. remarkable-disappearance of the symptoms of the
It has been shown that in many epithelial human disease for a few days and reversal of the tumor.
tumors the expression of EGFR has been increased, Chronic myeloleucosis and gastrointestinal stro-
which correlates with tumor aggressiveness and mal tumors are two distinct diseases due to a single
adverse outcome of treatment. Inhibition of uncon- genetic defect - the presence of so-called Philadel-
trolled EGFR-tyrosine kinase activity is a target for a phia chromosome (t / 9,22) translocation and pres-
number of antitumor agents, some of which are al- ence of KIT - protooncogene, respectively. Imatinib
ready in clinical use. These include: monoclonal an- mesylate (Glivec) is a tyrosine kinase inhibitor that
tibodies Transtuzumab (Herceptin), Cetuximab (Er- has resulted in complete clinical remissions in these
bitux), reversible tyrosine kinase inhibitors Gefitinib two incurable diseases (Figure 2).
(IRESSA), Erlotinib, Imatinib (Glivec). For monoclonal The individual stages of the metastatic cascade
antibodies, the target is extracellular part of the - angiogenesis, adhesion, proteolysis, motility, and
EGFR has been shown to result in blocking receptor proliferation, serve as new targets for the prevention

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and treatment of oncology. Thus, the anti-angiogen- Fig. 2. Target blocking approaches
ic action of interferon that suppresses gene expres- (Noonberg S. B., Benz C. C-2000)
sion for angiogenic growth factor leads to regression
of hemangiomas in children.
Several antiangiogenic agents such as thalido-
mide, TNP170, and others that suppress endothe-
lial cell proliferation are clinically tested. Intensive
strategies for blocking vascular endothelial growth
P
factor, strategies for inhibition of integrin function, P P

TK inhibitors
P
strategies for blocking the degradation and remod- Anti-EGFR Anti-ligand Ligand Anty-body
eling of the extracellular matrix, etc. are being devel- blocking blocking toxin con- toxin
antibodies antibodies jugates conjugates
oped. Intense experimental studies are devoted to
influencing the signaling pathways of the metastatic
process - calcium homeostasis, kinase activity, ras 2. Antibodies against the ligand - at the stage of pre-
oncogene activation. clinical testing.
The introduction into clinical practice of target 3. Low-molecular substances that inhibit reversibly
molecular therapy has fundamentally altered the or irreversibly tyrosine kinase (TK) activity at intracellular
level - block all EGFR. Two such drugs are due to be reg-
way of thinking about the treatment of malignant
istered.
tumors. This type of treatment is getting closer to
4. Cytotoxin or cytotoxin ligand conjugates - kill the
the optimal option - applying a specific treatment cell after internalization as an add-on to inhibition of ty-
for each individual tumor and for each individual pa- rosine kinase. The ability of the monoclonal antibody to
tient. transport the cytotoxic agent to the target receptor on
Approaches to target EGFR dysregulation. the cancer cell is used - after internalizing the receptor,
1. Antibodies against EGFR - receptor antagonists in- the cytotoxic agent is released inside the cell.
terfere with ligand binding. They are widely used in prac-
tice - Mab Thera, Herceptin.
REFERENCES

1. Anticancer Drug Development. ed. Baguley B.C., Kerr D.J. Acad. Press, 2002, p. 397.
2 Barton W. A., Tzvetkova D., Nikolov D. B. Structure of the Angiopoietin-2 Fibrinogen Domain and Identification
of Surfaces, Structure, Vol. 13, 825-833, 2005.
3. Burnstein H., Parker L., et al. Phase II trial of the anti-VEGF antibody bevacizumab in combination with vinorel-
bine for refractory advanced breast cancer. Breast Cancer Res. Treat. 2002; 76 (Suppl 1): S115 (abstr 446).
4. Cancer management - a multidisciplinary approach. Pazdur R. et al., PRR Melville, NY, 2002, p. 37.
5. Demetri G., von Mehren M., Blanke C. et al. Efficacy and safety of imatinib mesylate in advanced gastrointestinal
stromal tumors. N. Engl. J. Med. 2002; 347: 472-80.
6. DeVita V.T., S. Hellman, S.A. Rosenberg. Cancer. Principles and practice of oncology, Lippincott Company, 2002.
7. Diagnosis, treatment and follow-up of patients with malignant neoplasms. ed. Iv. Chernozemski, Str. Karanov,
Z. Valerianova. Sofia, 2003. (in bul.)
8. Giaccone G., Herbst R., Manegold C., et al. Gefitinib in combination with paclitaxel and carboplatin in advanced
non-small cell lung cancer: a phase III trial - INTACT 2. J. Clin. Oncol., 2004; 22: 785-94.
9. Kai Xu, Z. Wu, N. Renier, A. Antipenko, D. Tzvetkova-Robev, Yan Xu, et al. Structures of netrin-1 bound to two
receptors provide insight into its axon guidance mechanism, Science, 2014.
10. Miller K., Gradishar W. et al. A randomized phase II pilot trial of marimastat adjuvant in patients with early stage
breast cancer. Ann, Oncol. 2002; 13: 1220-4.
11. Powis G. Signaling pathways as targets for anticancer drug development. Pharmaceuticals. Ther., 1994, 62, 57-95.
12. Seegat T. C., Tzvetkova - Robev D., Kolev M. V., Henderson S. C., Nikolov D. B., Barton W. A. ​​Tie 1 - Tie 2 inter-
actions mediate functional differences between angiopoietin ligands. Mol Cell, 2010, Mar 12; 37 (5): 634-55.
13. Sikora K. et al: Essential drugs for cancer therapy: a World Health Organization Consultation, Annals of Oncolo-
gy, 10: 385-390, 1999.
14. Timcheva K., I. Pageva, D. Todorov. Drug Resistance in Malignant Tumors - Fundamental and Clinical Aspects.
Studia Oncologica, 2000, 1, 10-27. (in bul.)
15. Todorov DK, A. Dudov. Basic Principles of Drug Therapy of Oncological diseases. Oncologos, 2000, 4, 3-19. (in bul.)
16. Vijver MJ, Yudong D., Laura J. van't Veer, et al. A gene-expression signature as a predictor of survival in breast
cancer. N. Engl. J. Med., 2002, 347, 25: 1999-09.
17. Vogel G.L., Coblein M.A., et al. Efficacy and safety of transstumab as a single agent in the first-line treatment of
HER2-overexpressing metastatic breast cancer. J. Clin. Oncol. 2002, 1; 20; 719-26.

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10
P. Mihaylov, D. Nyagolova

PROFESSIONAL
SKIN DISEASES

Skin is a biologically active organ that separates Acute irritant contact dermatitis occurs after
the human body from the surrounding environment. single or double contact with strong irritants, is not
In many professions it is exposed to harmful factors preceded by a latency period, and in most cases
such as chemicals, biological materials, mechanical occurs only at the site of contact with the stimulus.
and physical violence. Occupational diseases of the Phototoxic contact dermatitis is a more specific type
skin develop in the balance between its resistance of chemical burn in which the irritant agent acts only
and the strength of the factor of the environmental in combination with sunlight.
and the professional environment. The clinical picture is characterized by erythe-
There are different views on the classification ma, edema, sometimes with vesicles and bulls. Sub-
of occupational diseases of the skin. According to jectivally, it may be accompanied by pain (Table 1).
Sezary, professional dermatoses are divided into two Diagnosis: A history of contact, possibly a bi-
main groups: irritating (orthoergic) and allergic. opsy. Skin testing is not done due to the danger of
The primary disease is contact dermatitis: exacerbation and inadequate results. Differential
• irritative (orthoergic) contact dermatitis; diagnosis: arteficial dermatitis of another nature
• toxic contact dermatitis; (physical, thermal, etc.).
• allergic contact dermatitis, incl. contact urti- Treatment: Immediately wash the affected skin
caria; thoroughly with water. Topical treatment: wet dress-
• phototoxic contact dermatitis; ings with 10% Burov solution, potassium hyperman-
• photoelectric contact dermatitis; ganate solution etc. two to three times a day. These
• pigmentary skin disorders; compresses are followed by applications of topical
• chlorine acne; corticosteroids. If dermatitis is disseminated, system-
• professional dermatoses caused by plants; ic corticosteroids and antihistamines are required.
• professional dermatoses caused by biological In secondary bacterial infection, local antibacterial
factors; therapy. In necrotic changes - surgical treatment.
• professionally determined skin tumors. Prevention: removing contact with irritating
chemicals. Workplace survey for detecting harmful
10.1. IRRITANT CONTACT DERMATITIS stimuli. Use of protective clothing and gloves.
Prognosis: Favorable in lighter forms.
Irritant contact dermatitis is a non-immuno- Chronic irritant contact dermatitis is the most
logical acute local inflammatory response charac- common occupational skin disease that occurs with
terized by erythema, edema or corrosion after sin- multiple cumulative exposures to weak irritants:
gle or multiple exposure to chemical substances on soaps, detergents, water, lubricants. Affects most of
the skin. The clinical picture depends on the nature the hands. It is common among female hosts clean-
of the stimulus - organic solvents, machine oils, de- ers, who have day-to-day contact with these irritants.
tergents, etc. Dermatitis caused by acids is charac- Clinical picture: Disease changes are quite char-
terized by rapid skin damage, while that of alkali is acteristic - erythema, scaly plaques with vague bor-
significantly slower. It is expressed by skin redness, ders, fissures. Subjective complaints are itching and
drought, hyperkeratosis and rhagades. The disease often pain (mostly from the fissures available). Nails
is most often localized on the skin of the hands and are transverse. This particular picture gives reason to
forearms. Persons with endogenous eczema or other call it the "hostess' hand". People with a family his-
forms of atopic disease get easier dermatitis in con- tory of atopy are more likely to be affected. On this
tact with chemicals and paints: fitters, hairdressers, basis, subsequent individual sensitization to the
sanitary personnel, and others. same substances that have triggered earlier irritative
Irritating contact dermatitis has two main forms: changes or new allergens, is often developed. Some
acute and chronic. workers may also develop relative resistance to irri-

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Tab. 1. Types of contact dermatitis (by D. Birmingham)

Features Irritating contact Allergic contact

dermatitis dermatitis
Receipt mechanism Direct cytotoxic effect Late cellular immunity type
(Gell and Coombs type ІV)
Potential risk Everyone Minority
Begining Progressively, after repeated Fast, after 12-48 hours in
long exposure sensitive patients
Clinical changes Subacute to chronic eczema with Acute to chronic eczema with
erythema, desquamation and fissures erythema, edema, bulls and vesicles
Symptoms Pain and burning Itching
Concentration of High Low
the stimulus
Research History and research History and research,
Patch test

tants with which they have been in professional con- the accumulation of fluid between epidermal cells
tact (eg cement, lime, chromates, etc.). This phenom- (spongiosis). Localization: most often at the point
enon is called non-specific hardening. In these cases, of contact, but it also occurs in remote, more sen-
the worker may continue to work and do not require sitive areas. A generalized measles-like rash, called
re-employment. "auto-sensitizing dermatitis," or "ID" reaction, occurs
Differential diagnosis: it is done with allergic in a preserved disease process at the site of contact.
contact dermatitis (history and positive skin sam- Photo-allergenic response occurs when the site of
ples), atopic eczema, dyshidrotic eczema. contact is exposed to sunlight with a wavelength
Treatment: local corticosteroid ointments and of more than 320 nm. Sometimes the nature of the
creams, general treatment - antihistamines and oth- allergen determines the clinical picture - so contact
ers. with plants may lead to abruptly limited linear ery-
Prevention: Workers with a family history of ato- thems and bulls; some chemicals used in the rubber
py are at high risk of developing chronic irritative der- industry, e.g. phenyl-isopropyl-para-phenylenedi-
matitis, which should be considered when choosing amine may cause Purpura like eczema; the develop-
a profession. Use personal protective equipment to er of colored film strips causes a eruption resembling
avoid contact with irritants (clean working clothes, Lichen ruber planus and so on.
gloves, protective creams). Avoid highly irritating Diagnosis: History, skin tests, exposure and elim-
skin cleansing agents. ination test, histological examination.
Forecast: Safeguarding. In heavier cases, re-em- Differential diagnosis is difficult between
ployment is recommended. With good prophylaxis, chronic irritative contact dermatitis and allergic con-
the work process can last a long time. tact dermatitis (Table 3).
The most common causes of occupational aller-
10.2. ALLERGIC CONTACT DERMATITIS gic contact dermatitis are being investigated world-
wide through good professional history and data
Consists of 20% of workers with professional from the so-called testing with a standard series of
contact dermatitis. Appears after 48 hours to two allergens, specific to individual production. Testing
weeks after contact with a chemical (hapten). The with the standard series, which is a sort of screening,
latter binds to the skin protein to produce a com- does not replace individual research with other aller-
plex antigen and develops a cell-associated immune gens, but complements it.
response in the body. Upon further re-exposure to Treatment. For the successful treatment of pro-
the same antigen a lymphocyte-cell inflammatory fessional dermatitis (irritant and allergic) it is neces-
skin reaction (late-type allergic reaction) is obtained. sary to eliminate the risk factors of the professional
Changed working conditions and the intervention environment on the one hand and to increase the
of new industrial allergens also lead to changes in resistance of the skin to their impact.
the dynamics of the professional dermatoses with a Topical treatment is based on the stage of the dis-
tendency to increase the allergic contact skin dam- ease. During the acute phase, compresses (wet band-
age compared to the irritative and infectious ones ages) with potassium hypermanganate (1: 5000) or a
(Table 2). solution of oak bark, chamomile, etc. are made every
Clinical picture: Characterized by the onset of 1-2 hours, then aniline dyes (Solutio Fuchsini 1%,
erythema, edema, desquamation, and papule crusts. Solutio Pyoctanini 1%) and others are coated. After
Sometimes there are vesicles and bulls as a result of stopping wetting and passage in subacute stage,
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Tab. 2. The most common professional irritants in some important productions (J.B. Olishifski, 1988)

Chemicals Primary Sensitization Skin and other Production /

irritation changes Profession
Acids
Acetic х ? Dermatitis and Acetate silk and coloring,
ulcerations vinyl plastic
Phenol х Corrosion, local Production of phenol, disinfectants,
anesthetic effect paints, pharmaceutics, plastics

Chromic х х Ulcus, inflamation Production of organic chemistry,

and perforation of dyeing, silverware
septum nasi
Formic х Irritation with blisters Rubber, detergents, cellulose
and ulcerations and lubricants

Hydrochloric х Irritation, ulcerations Production of bleaching agents

in refineries, chemical industry

Lactic х Ulcerations at high Adhesives, plastics, textiles

concentrations
Nitric х Burning, ulcera Production of nitric acid, metal
cleaning agents, paints

Oxalic х Skin corrosion, Leather fur, indigo, oxalic acid

cyanosis, nail production
fragility
Picric х х Erythema, dermatitis, Production of explosives,
yellow skin and hair painting, mining
coloring
Sulphuric х Corrosion of the skin Chemical production, vinegar,
inflammation of the galvanization
mucous membranes
Alkalis
Calcium х Irritation and ulcerations Farm workers, production
cyanamide of nitrogen compounds

Calcium oxide х Dermatitis, burns or Working with lime, producing

ulcerations calcium salts, glass, fertilizing

Potassium х Skin corrosion, deep Production of KOH, paper,

hydroxide persistent ulcus, loss soaps, printing inks
of nails
Sodium х Skin corrosion, deep Manufacture of NaOH, soaps,
hydroxide persistent ulcus, loss paints, bleaching, oil refineries,
of nails plastics

Sodium х Skin corrosion, ulcera Cement, water treatment,

silicate on fingers detergents
Salts and elements
Antimon х ? Irritation and licheniform Extraction of antimony, glass,
skin eruptions aniline, fireworks, alloys

Arsen х х Spotty pigmentation, Leather, insecticides, glass,

perforation of septum nasi, agriculture, tanning, alloys, oils
carcinoma, hyperkeratosis
of the hands, dermatitis,
pustules
Bromine х Iritis, vesicles, ulcus, acne Extraction of bromine, bromine
salts, paints, medicaments,
photo materials
Chrome х х Punched ulcera, dermatitis, Chrome, paints, chrome
perforation of septum nasi manufacture, tanning

Nickel х х Folliculitis, dermatitis Nickel production

Zinc chloride х ? Skin ulcera and septum Manufacture of chemicals, paper,
nasi disinfectants, paints

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 LABOUR MEDICINE
Solvents
Acetone х Dry skin Celluloid industry, artificial silk and
leather, working with varnishes and
sprays, garage

Benzol х Dry skin Chemical and rubber Industry

Trichlorethylene х ? Dermatitis Chemical intermediate products

Turpentine х х Dermatitis Artists working with polishes
and varnishes
Oil and tar
Petrol х Dermatitis, folliculitis Engine-drivers, mechanics working
with oil
Resin and х Dermatitis, folliculitis Production of resin, asphalt
asphalt keratoses, skin
carcinoma
Tar х х Dermatitis, folliculitis, Production of tar, roof paper,
skin carcinoma, construction and repair of roads
keratitis
Paints
Paraphenylen- x Contact dermatitis Painters, cosmetics
Diamine (Ursol) (Erythema, edema, blisters)
Insecticides
Creosote х х Dermatitis, folliculitis, ke- Production of preservatives
ratoses, hyperpigmentation, for wood, railway rails, tar, resin
skin carcinoma
Fluorides х Dermatitis, burning Production of insecticides,
enamelling
Pyrethrum х х Dermatitis Production and application
of insecticides
Rottenon х Dermatitis Dentists, paper processing

Natural resins
Shellac х Dermatitis Cosmetics, cladding
Colophon х Dermatitis Dentists, paper processing

Explosives
Nitrates,
Nitroglycerine х х Iritation, dermatitis, Production of explosives
pigment changes
Others
Vinyl chloride х Dermatitis, acro- Polyvinyl resin, chemical
osteolysis markers
Formaldehyde х х Dermatitis Biologists, textile workers

weak corticosteroid creams (1% hydrocortisone, water insoluble and have a chemical instability to
etc.) are used. In the treatment of chronic forms, cor- the acids and substances such as turpentine, potas-
ticosteroid ointments, which can be combined with sium bichromate, formalin and the like. It is recom-
salicylic acid or tar, are recommended. When general mended washing with a soft, non-irritating soaps,
treatment is needed, antihistamines are used and for fuller's earth, followed by coating the skin with 2%
short period systemic corticosteroids with high dos- pined or normal vaseline (do not use abrasive deter-
ing at the start and gradual reduction. gents), PPE - working and protective clothing, gloves
Rehabilitation. High-mountain and sea climate and the like.
therapy, balneotherapy has a beneficial impact. It is Prognosis. If the disease process is not affected,
due to non-specific action and changes in reactivity, it is necessary to work readjustment or change the
immune mechanisms, neuro-vegetative system, etc. profession.
Prevention. Change in the technology by elim- Contact urticaria occurs with edema, erythemic,
inating or replacing the substances with high sen- itching fast transient papules or raised (angioedema)
sibilization index with other protective (hydrophilic lesions at the site of the contact. The latency period
or hydrophobic) protective creams, skin protection is from a few seconds to minutes after the contact,
from oils, solvents, petroleum products, hydrocar- and the duration of the rash is 1-4 hours.
bons, paints, varnishes and the like. Easy to wash af- Etiology. Changes may be due to a specific anti-
ter work. Hydrophobic pastes, liquids or aerosols are gen or result from a pharmacological reaction that

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 OCCUPATIONAL MEDICINE
Tab. 3. Differential diagnosis between irritant and allergic contact dermatitis (P. Mihaylov, J. R. Nethercott)

Acute irritative Chronic irritation Allergic contact

contact dermatitis contact dermatitis dermatitis
Begining Suddenly, at first contact, Slowly in weeks After a phase of
no incubation period sensitization and a
latency period
Number of Everyone who was in touch In most persons who were Only individuals
affected persons in contact
Dependence From the nature of the primary From the reactivity
stimulus and its concentration of the body
Clinical Erythema, edema, vesicles, Dryness, lichenification Erythema, edema,
picture bulls, chemical burns excoriations vesicles
Subjective Pain Pain, weak itching Itching
complaints
Histological Epidermolysis, epidermis necrosis, Spongeosis, vesiculation,
picture polymorphic nuclear and leukocyte infiltrate acanthosis, lymphocyte
infiltrate
Passing A short time Long, with periods A short time
of abatement
Mechanism Non-immunological Non-immunological Immunological
of appearance (cumulative)
Skin tests Negative Negative Positive
Causes Strong acids and Soaps, detergents, Nickel, Chromium,
alkalis, solvents water, oils Plastics, Paints, Plants,
Medicines, Cosmetics
Treatment Quickly Slowly, with a tendency Anti-allergic
to relapse
Prevention No redevelopment No redevelopment Often work readjustment
is required

occurs in the various occupations, and IgE response Treatment. Topical-cooling compresses, general
may induce contact urticaria. For this type of reac- treatment - antihistamines (Diphenhydramine 25-50
tivity, the release of histamine and other vasoactive mg 3 times a day, Hydroxyzine 10-50 mg daily, Ter-
substances from mast cells is characteristic. Howev- fenadine 60 mg daily, etc.). Corticosteroid therapy,
er, some substances (sodium benzoate, etc.) can lead local or systemic, is not recommended.
to direct release of histamine. There must be intense Prognosis - good.
initial exposure without a latency period. Prevention. Personal protective equipment.
Contact urticaria may also occur upon contact
with platinum salts, ammonia, formaldehyde and 10.3. PHOTOTOXIC CONTACT
others. Inhalation urticaria occurs in gas-related and DERMATITIS
volatile chemical compounds (hydrogen sulphide,
ursol, etc.). They can also be combined with the on- Most photoreactions of the skin are phototoxic.
set of respiratory allergy, rhinitis, bronchitis, asthma. Natural and artificial light sources alone or in com-
Contact urticaria occurs also in contact and in bination with different chemicals, plants or medica-
touch with proteins from various organs of animals, tions can cause a phototoxic or photosensitive re-
body fluids, blood, saliva, epithelium. sponse. The phototoxic reaction is mainly related to
Contact urticaria develops and in contact with the light-exposed parts, whereas the photosensitive
certain exotic trees and plants (chrysanthemum, response is more common in the exposed parts of
mahogany) in bakers and flour workers, hairdressers the body.
(contact ursol, ammonium persulfate), hosts (from Phototoxic contact dermatitis occurs in contact
latex gloves, etc.), drugs, cosmetics (acetone, ammo- with certain substances (by a non-immunological
nia, nail polish and hair, lipsticks, etc.). mechanism) that come into contact with ultraviolet
Urticaria par effort occurs in athletes, farm work- light. These substances cause reactions in all persons
ers. Cold urticaria occurs in swimmers and heat urti- at first contact, provided they have a sufficiently
caria - in metallurgists. high concentration and absorb enough ultraviolet
Diagnosis. It is not difficult - the appearance of energy.
rapid transient rash and its passage without leaving Clinical picture. It is characterized by the occur-
traces. rence of edema, in the more severe cases with vesi-
Differential diagnosis: urticaria and angioedema. cles and bulls resembling sunburn and localized on

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 LABOUR MEDICINE
the exposed parts of the body and the photodynam- ten hair. Best seen in the light of Wood.
ic substance. If the substance is volatile, the reaction Diagnosis. Pre-existing contact in history, post-
may spread beyond the limits of the directly exposed partum repigmentation, presence of similar manifes-
areas. Sometimes skin changes can be linear in plac- tations and other workers, histological examination.
es that have been in contact with the grass and flow- Differential diagnosis: idiopathic vitiligo, Pityri-
ers and the sunlit (i.e. Dermatitis pratensis, variant asis versicolor alba, post-inflammatory hypopig-
phytophotodermatitis). The phototoxic reaction re- mentation and others.
solves rapidly with residual hyperpigmentation. Treatment. Discontinuation of contact with de-
The most common professional phototoxic sub- pigmentation agents and exposure to ultraviolet
stances are: tar, resins, creosote, furocoumarines light results in repigmentation, reception of methox-
(psoralens), dyes (eosin, acridine), drugs (sulfona- ylene in combination with ultraviolet light at 320 nm
mides, barbiturates, griseofulvin, etc.). to accelerate repigmentation. Local corticosteroids
may also be used.
10.4. ALLERGIC CONTACT Prognosis. Repigmentation occurs in a few
PHOTODERMATITIS months, but in some cases it may not be complete.
Prevention. Avoid exposure to known depig-
It is encountered in a small number of persons menting agents.
sensitized to a given substance under the simul- Riehl Melanosis (Melanosis Riehl, Kriegsmela-
taneous effects of light. A certain latency period nose).
is required for the occurrence of the reaction. The Tab. 4. Reasons for Professional Vitiligo
photoallergic reaction develops in the same immu- (by J.R.Nethercott, 1990)
nological mechanism as the contact allergic reaction
Hydroquinone
of the late (late) type. Photoallergens show proper-
Hydroquinone monobenzyl ether
ties of a contact allergen only in the presence of light
Hydroquinone monomethyl ether
rays of a certain wavelength. p-Cresol
Clinical picture. It is expressed by erythema, p- tert – Amyl phenol
infiltration, papules, sometimes vesicles. They are p- tert – Butyl phenol
located in places that have been in contact with
o-Phenyl phenol
photosensitizing substances and are irradiated with
o- Benzyl –p- chlorophenol
sunlight (mostly the skin of the face, neck, chest,
4-tert-Butyl catechol
forearms). The most common photoallergens are:
medicines (phenothiazine derivatives, sulfonamides, Described in 1917 by Riehl among workers in the
antimicrobials, salicylic derivatives), eosin, dichloro- arms industry. Contact with untreated tar products,
phen, antimycotics and others. vaseline, etc., which also have photosensitizing ac-
Treatment. In light forms, local treatment with tion.
anti-inflammatory agents such as zinc oil, white Clinical picture. Erythema, later chocolate-gray-
mixture, cooling cream, corticosteroid creams, etc. ish-colored hyperpigmentations, which extend and
is recommended. The severe forms that occur with form a reticular mesh, are seen on the skin of the
vesicles, bulls and general symptoms (temperature, lateral face and temporal area, in front of the ear
fever, etc.) treatment are common - with antipyret- -conchs and lateral parts of the neck. The skin is dry,
ics, antihistamines, corticosteroids, and local. rough, with slight desquamation. It is accompanied
Prevention. Avoid sunlight. Use of photoprotec- by pruritus and mild burning.
tive creams with an adequate UV protection factor. Treatment: topical corticosteroid ointments and
hydroquinone preparations.
10.5. SKIN PIGMENTATION Prognosis: unfavorable.
Photochemical skin changes (Solar Elastosis,
Occupational Vitiligo, Leucoderma profes- "Farmer's Skin", "Sailor's skin").
sionale. Sun exposure leads to degeneration of elastin in
Appears with white spots on the skin at the site of the dermis and atrophy of the epidermis. It occurs
contact with depigmenting chemicals (Table 4) as a with the appearance of wrinkles, yellowish pigmen-
result of inhibition of melanin biosynthesis. In most tation with hair follicles passing and the formation
cases, disconnection leads to slow repigmentation. of comedones. The changes are localized on the
Clinical picture. Blurred depigmentation of the face, V-shaped on the neckline, nape, shoulders and
sites of the contact with the most frequent localiza- dorsal surface of the hands. Damage to the skin pig-
tion on the skin of the hands, folds and genitals, of- mentation of the skin leads to persistent hyperpig-

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 OCCUPATIONAL MEDICINE
mented spots on the exposed face of the sun and and, above all, the primine component is the most
the dorsal surface of the hands, which are called so- common cause of plant contact dermatitis. In contact
lar lentigo. Degeneration of elastin is histologically with primrose gardeners, pharmacists and oth. get
proven. erythema and edema on their fingers and eyelids. In
The presence of these changes is an indication of the preparation of fig-jam confectioners and hosts,
harmful sun exposure and the need to monitor for they get very characteristic dermatitis (Feigenbaum-
skin malignancies. dermatitis), localized to the fingers and wrists. There
is erythema, edema, and in more severe cases blisters
10.6. CHLORACNE and erosions, and after their resumption - hyperpig-
mented macular plaques. For the occurrence of plant
Chlor acne, also called "Perna disease" or "Perch- dermatitis, in many cases, besides plants, sun expo-
lornaphthalin" or "chlorine scab", was described by sure also plays a role. The combination of both factors
Herxheimer in 1899. The largest number of people results in the so-called phytophotodermatitis. Most of
affected were described during the Second World them are the result of touching the plants to moist,
War. Appears after contact with chlorinated hydro- sweaty or wet skin.
carbons (chlorinated naphthalenes, azobenzenes, Plant dermatitis is a professional disease for gar-
dibenzofurans, dioxin, polychlorinated biphenyls). deners, farmers, pharmacists, confectioners at work
The contact is always professional. with plants. In the summer, gardeners, land workers
Clinical picture. Affected adults develop come- and others the so-called Dermatitis pratensis appears
dones, straw-colored cysts, miliums and papules when the grass is in contact with damp and sweaty
with localized facial, neck, ear-conchs, shoulders, ab- skin and at the same time they are exposed to sun-
domen, genitals, legs. There is also blepharitis with light. A few hours later, red lines and strips of grass
granular changes along the edge of the eye. Hepa- and plants on which they lay appear on the skin. It is
totoxic changes, Porphyria cutanea tarda, peripheral accompanied by severe itching and burning, which is
neuropathy and hypertriglyceridemia are also ob- due to ethernal oils that have a photosensitizing ef-
served. fect.
Differential diagnosis - see Tab. 5.
Treatment. Removal of contact with polynaph- 10.8. OCCUPATIONAL SKIN INFECTIONS
thalene products. Local treatment with anticome-
donical preparations with evening application, abra- Bacteria, viruses, fungi, dermatophytes and para-
sive cleaning agents and procedures. sites can cause professionally related skin infections
Prognosis. Continuous backward development (Table 6):
after interruption of the contact. The treatment of occupational infections is as
usual in their development - general and local, ac-
10.7. PROFESSIONAL DERMATOSES cording to their type and stage.
FROM PLANTS (PHYTODERMATITIS) Prevention - protective measures against the
possibility of infection in the workplace.
Contact with many plants can cause contact der-
matitis irritating or allergic. Irritating action has leaves, 10.9. PROFESSIONALLY DETERMINED
stems, fruits and roots. Various substances are believed SKIN TUMORS
to play a role - alkaloids, essential oils, glycosides and
others. For example, Ragweed causes contact derma- In the last four decades there has been a general
titis due to the water-soluble oleoresin content. Other dramatic increase in skin carcinomas. This phenom-
plants that can cause allergic contact dermatitis are enon is also associated with changes in sunlight and
Chrysanthemum, Philodendron, Oleander, Tulipis, thinning of the ozone layer. Professional skin tumors
Narcissus and others. In Europe, Primula obconica are mainly three types: spinocellular and basal cell
Diagnosis Age Localization Clinical changes
Acne vulgaris 13-26 years Face, breast, back, waist Comedones, papules, pustules,
cysts, crusts
Folliculitis Every age The whole body in contact Black comedones, papules,
with oils pustules, melanosis
Chloracne Every age Face, neck, ear lobes, Weak stained cysts, comedones,
breasts, legs, genitals miliums, papules, some systemic
events.
Tab. 5. Differential Diagnosis of Chloracne (Adams)

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Tab. 6. Professional Skin Infections (J.R. Nethercott)
Causes Professional relationship
Bacteria
Bacillus anthracis Wool sorters, tanning
Brucella abortus Veterinarians, meat production
Erysipeloid Fishermen, meat production
Francisella tularensis Farmers, veterinarians, laboratory workers
Mycobacterium tuberculosis Pathologists, veterinarians, farmers, meat producers
Mycobacterium marinum Fishermen, fishery
Fungi
Candida albicans People working in the food industry, health professions
Trichophyton,Microsporum Health professions
Sporothrix schenki Farmers, gardeners, child caretakers
Blastomyces dermatitidis Farmers, laboratories
Coccidioides immitis Farmers
Actinomyces,Nocardia (Mycetoma) Agricultural workers
Viruses
Pox virus Shepherds, farmers, veterinarians
Paravaccina Virus (milker’s noduli) Milkers, farmers, veterinarians
Herpes simplex virus Medical staff
Medical staff, police

(associated with epidermal keratinocytes), and ma- Prevention: reduction of injuries and interruption
lignant melanoma - from pigment-forming cells. In of long-term contact with carcinogenic substanc-
many industries and professions, the incidence of es. Personal precautions include personal protective
skin cancer is higher than that of the general popu- clothing. Particular attention is paid to workers with
lation (Table 7). a history of atypical dermatitis, scarring, seborrhoea,
Basal cell carcinoma (Carcinoma basocellu- sun allergy. If necessary, change of work in time. Reg-
lare) ular prophylactic examinations and studies for the de-
Basal cell carcinoma is the most common tection of precancerous conditions.
non-melanocytic skin carcinoma. It is due to prolif- Malignant melanoma (Melanoma malignum)
eration of the basal layer of the epidermis. It can be A relatively rare pigment tumor that develops as
seen as a solitary nodus or eroded as ulcus (Ulcus ro- a slowly growing node in the solar lentigo or as a
dens). Sun-induced carcinomas are localized on the new rapidly developing black nodule (nodular mela-
head and neck. noma). Multiple development can also be observed
Professional arsenic exposure (gold mines) can for several years as superficial spreading melanoma.
cause multiple superficial basal carcinoma in unex- All pigment tumors of pigment cells develop in
posed locations as well. the exposed parts of the body on pre-existing actin-
Carcinoma spinocellulare (Squamous Cell Car- ic changes. Outdoor workers are at increased risk for
cinoma) melanoma.
After many years of recurrent sun exposure, skin Malignant melanoma has an aggressive develop-
keratinocyte abnormal proliferation is provoked so- ment, originated from pigment cells and always on a
called Actinic keratosis. Some of the actinic kera- pre-existing nevus. The tumor is usually from a few
toses develop as spinocellular carcinoma of the skin, millimeters to a few centimeters in thickness, brown
which can metastasize to the lymph nodes or the or black in color, can change color, bleed or ulcer-
hematogenous dissemination pathway. The associ- ate. Criteria for poor prognosis are: nodular subtype,
ation with the profession is one of the oldest listed tumor thickness, metastasis, ulceration, bleeding,
occupational diseases. tumor duration, localization (body or extremities),
Spinocellular carcinoma can also develop in the male gender.
non-exposed parts of the skin - under the influence Diagnosis is necessarily confirmed by histologi-
of petroleum distillates or tar, e.g. scrotal carcinoma cal examination.
in chimney sweepers. This type of carcinoma is also Treatment: surgery, chemotherapy, biological
described as a post-traumatic result of repeated me- therapy (Alfa Interferon, Interleukin-2) alone or com-
chanical trauma or burns. bined.
Diagnosis: Clinical changes responding to Prophylaxis: systemic dermatoscopic monitoring
non-melanocytic occupational skin cancers with of pigment lesions in patients in contact with chlo-
mandatory histological confirmation. rine, propane, synthetic adhesives, trichlorethylene,
Treatment: surgery, radiation, etc. etc., sun exposure, etc. Use of individual precautions.

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Tab. 7. Risky Professions (by D. J. Birmingham)
Carcinogenic materials Industry or risk Process or risk group
or agents
Resin, tar or products Aluminum covering Production of terracotta, pottery

Coal, gas, coke Coke ovens, tar distillation,

coal gas production, resin loaders

Open production of fuels Production of briquettes

Asphalt Road construction

Using creosote Running bricks and tiles,
Woodworking
Soot Chimney sweepers
Rubber production
Lubricants and Glass blowers
cooling oils Refining of shale oil
Cotton processing Pipe cleansing
Paraffin processing and Typesetters, turners working with
waxes automatic machines (cooling oils)
Technical activities
Oil refinery Distillers
Arsen Arsenic insecticides Production and use
Ionizing radiation Radiologists
Others working in the environment
Ultraviolet radiation Running outdoors Farmers, fishermen and others.
(256-320 nm) Industrial UV radiation welding, voltage arc, UV lamps,
cutting, printing

REFERENCES

1. Berova N., N. Tsankov. Medicinal dermatoses. Med. and phys., S., 1984. (in bul.)
2. Dourmishev A. Skin pigmentation disorders. Med. and phys., V., 1986. (in bul.)
3. Durlenski B. Occupational skin diseases among workers in livestock farming and animal product pro-
cessing. Dis., 1987. (in bul.)
4. Frosch P.Y. Aktuelle Kontaktallergene. Der Hautarzt., Suppl. 41, Jahrgang 1990, p.129-133.
5. Gassenmaier G., Berufsbedingte. Hauttumoren. Berufsdermatosen. Aktuelle Perspektiven. Grossver-
lag, Berlin, 1988.
6. Hyorth N., S. Fregert. Contact Dermatitis in: Textbook of Dermatology.1979, IIIed. Vol.1.
7. Kanerva L. Occupational Marks in: Handbook of Occupational Dermatology, Springer-Verlag, Berlin,
2000, 137-140.
8. Mihailov, P. Occupational diseases of the skin. Second edition. Med. and phys., S., 1984. (in bul.)
9. Michailov P., L.Stranski, A.Durmischev. Clinical and experimental studies on p.-ter. Butyl-phenol. Int.
Symp. Neubrandenburg, April, 1980.
10. Michailov P., N.Berova, Zl.Penev. Berufsdermatosen bei Herstellung von photographischen Filmen.
Dt.Dermm. 39, Heft 3 (1991), Hannover.
11. Nethercott J.R. Occupational Skin Disorders in Occupational Medicine, 1990, ed. J. La. Dou, Apple-
ton & Lange, USA, 209-220.
12. Olishifski J.B. The Skin in: Fundamentals of Industrial Hygiene, 1988, National Safety Council, Chica-
go, 47-58.
13. Penev Zl., N. Berova. Urticaria. Med. and phys., S., 1984. (in bul.)
14. Rycroft R.J.G., T. Mennel, P.Y. Frosch. Textbook of Contact Dermatitis., Second ed., Springer Verlag,
1994, 840 p.
15. Sasseville D. Occupational Contact Dermatitis in: Encyclopaedia of Occupational Health and Safety,
ed. J. M. Stellman. 4th ed., International Labour Office, Geneva, 12.9-12.13, Vol. I, 1998.
16. Stranski L. Exploring the role of some local etiological factors in the etiology of contact dermatitis.
Dis, Sofia, 1994. (in bul.)

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11 PROFESSIONAL DISEASES OF
THE VISUAL ANALYZER
V. Zlateva

11.1 PHYSICAL AND CHEMICAL

AGENTS AND LOAD

In spite of its many protective mechanisms, the electric furnaces, converters, apparatuses in quartz
vision is extremely sensitive to professional impact. radiation cabinets, etc.
In recent decades, the production and use of appli- Workers in the metallurgy are at risk - scumbers,
ances that are sources of different types of non-ion- foundries, converters; those working in the produc-
izing and ionizing radiation have increased for in- tion of radio lamps and mercury rectifiers, and in
dustrial, military, consumer, cultural and medical particular electric welders, as well as technicians and
purposes. At a given frequency, wavelength, power, medical practitioners working with mercury-quartz
and duration of exposure can cause different lesions lamps. Under intensive irradiation occur photoery-
in the human eye. themas, photodermatitis, general toxical symptoms
A large number of workers are in contact with by affecting the central nervous system - headache,
chemicals. The possibility of eye diseases as a result dizziness, hyperthermia, effects of agitation and
of acute intoxications is now reduced at the expense the like. Electro-ophthalmia develops in the eyes. In
of the chronic effects of low concentrations. the presence of photosensitising substances - the
The main groups of professional factors that af- distillation of coal (anthracite, anthraquinone) and
fect the eyes are: oil (resin, paraffin, fuel oil, etc.) may develop pho-
I. Physical factors of the working environment tosensitivity with frequent ophthalmia, combined
II. Occupational intoxications affecting the visual with chronic dermatitis, folliculitis, eczema, atrophic
organ changes etc.
III. Occupational work associated with increased One of the most common diseases of the eyes by
visual load. the impact of radiation energy is electro-ophthal-
I. Damage to the visual analyzer by physical mia. It occurs as a result of UV radiation during gas,
factors arc or plasma welding and cutting of metals. Threat-
The nature of the damage to the eye depends on ened occupations are welders, medical staff in phys-
the prevailing or isolated effect of one or other part iotherapy cabinets.
of the spectrum on the radiation energy stream and Pathogenesis. The cornea and the conjunctiva
on the duration of its action. In production condi- absorb the great part of the UV rays - the cell nuclei,
tions, the predominant effect of certain rays can also in particular the nucleoproteins, are predominantly
be observed. This explains the specificity of eye loss damaged. Photochemically active UV rays practical-
in persons with different occupations. ly do not cause serious changes in the retina with
Ultraviolet radiation in production conditions short-term effects.
Rays with a wavelength of 200 nm to 280 nm Clinical picture: Inflammatory effects of the cor-
(UV-C) have the strongest biological effect of dena- nea and conjunctiva occur usually after a latency
turation of cellular proteins and lipids; the rays with period of four to twelve hours. Symptoms include
a wavelength of 280 to 315 nm (UV-B) have a pro- light-headedness, pain, tear, blepharospasm, hy-
nounced anti-rachitis effect, and with a wavelength peremia, and conjunctival edema. When the effect
of 315 to 400 nm (UV-A) they are biologically weakly is short-lived or of lesser intensity and the corneal
active. Ultraviolet rays act on a photochemical mech- epithelium is not affected, the events resolve for 12
anism on the eye structures. Industry is dominated to 18 hours. When the epithelium is affected, biomi-
by sources of ultraviolet rays with a wavelength of croscopy reveals a swollen cornea, sometimes with
200 to 280 nm (UV-C) - oxygen- and electric welding, thin villi and a scarified surface layer. The vision is re-
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 OCCUPATIONAL MEDICINE
duced as long as the acute phase lasts. Only one eye for various types lens changes in individuals working
is extremely rarely affected. with heated bodies.
Repetitive UV irradiation, develop a chronic form Threatened professions are metallurgists in vari-
of elektroophtalmia, expressed in increased sensitiv- ous industries having contact with large surfaces of
ity to light and the effects of chronic blepharocon- heated metal - for metal rolling, production of slabs,
junctivitis. Chronic UV effects on the eyes may be of cast iron founders; workers in the glass industry;
damaged and the lens - most often at a wavelength Bakers, bakers, chefs and more.
greater than 290 nm - UV-C (below 290 nm UV-rays Pathogenesis: According to Focht, the cataract
are absorbed by the cornea and the front-camera develops as a result of the high temperature effect
fluid). Occupational cataract is a disorder of lens on the entire front part of the eyeball. The increased
transparency caused by prolonged exposure of temperature of the tissues, especially the ciliary
working environment factors. The lens of the eye is body, disturbs the feeding of the lens.
the only formation of the body that has no mecha- Clinical picture: The disease usually starts in one
nism to release it from normal, damaged or unviable eye. At the rear pole of the lens there is an opacity in
cells. Irradiated abnormal cells remain there, which the form of a wedge or pan, abruptly limited by the
is why it is sensitive to chronic irradiation. In specific strong lens. Opacity develops slowly for years, but
UVcataract mainly rear cortical layers centrally are early reduces vision because the cataract is centrally
shaded, as in the initial phases changes are more located. The magnitude of the opacity initially corre-
gentle and better constrained by the transparent sponds to the area not covered by the iris, i.e. of the
lens and at the evolution of the process feculences broad pupil. It is also characteristic for the deposi-
coarsened and distributed at periphery. This evolu- tion of the surface layers of the lens capsule which
tion is slow and is maturing for several years. When are curved forward and may also "swim" in the ante-
the changes are centrally located and are too dense, rior chamber. This condition persists for many years,
but progressive development may also be observed
with whitish non-homogeneous opacity in the front
of the lens. Subsequently, the second eye is also dis-
eased. This cataract occurs usually in older workers,
as the sclerosed lens absorbs to a greater extent IR
rays.
Cataract from the impact of ionizing radiation
It was first described in Halupetsky in 1897.
Threatened professions are gamma-defecto-
scopes of metals, the use of radioactive isotopes for
control of production processes, research, use for
production purposes of powerful high-voltage and
accelerator apparatus, nuclear reactors, in medicine
for diagnosis and treatment.
The lens is highly sensitive to penetrating ioniz-
ing radiation (especially to X-rays and gamma rays,
but also beta-rays, neutrons). Opacity of the lens
Pic. 1. UV cataract
develops after prolonged latency (2-12 years). The
visual acuity decreases early in a narrow pupil (nor- cataract-induced absorbed dose in 1-5% of exposed
mal conditions) Pic. 1. individuals is assumed to be 5 Gy.
Cataract from infrared radiation in production Pathogenesis: All types of ionizing radiation
conditions causing lens opacity cause similar lesions and there-
IR rays are the part of the EM spectrum with a fore these cataracts may be clinically and histolog-
wavelength of 760 nm to 1 mm. It has been assumed ically separate from the many other lens opacities.
that, because of their low energy levels, when ab- The primary effect of the rays is on the anterior
sorbed by the tissues, the IR photons lead to an in- epithelial cells having a high exchange and on the
crease in the kinetic energy of the system - the radi- young fibers that are formed by them. These new
ant energy becomes heat. fibers are located directly under the lens capsule, so
The defeat of the lens of IR radiation is the subject the earliest damage should be sought there.
of a detailed study of the early twentieth century for Clinical picture: Biomicroscopic study shows
many years, and the name "cataract of glassblower" that the first opacities occurs at the back of the lens
described by Wenzel in 1917 remains common name in the axial zone. In this place a polychromatic over-

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 LABOUR MEDICINE
flow appears on the background of which are visible Effects of laser radiation on the eyes
vacuoles and tender graininess. Later the opacity Laser is the source of radiation in the optical
becomes disk shaped in the posterior pole of the range of the EM spectrum - infrared (IR), visible, and
lens subcapsular. The disk of this opacity consists of UV-radiation.
several concentric layers. The complete cloudiness The eye is seen as a critical organ for laser radia-
of gamma-lagers resembles the opacity of asbestos. tion. The front eye segment is designed to concen-
Radiation cataract is characterized by clearly limited trate and direct the rays to the retina.
areas of cloudiness from the transparent areas. Later Threatened professions are in machine building
the specific picture is cloudy. - for cutting metals and hard materials, welding; in
Electrical cataracts geodesy; for environmental control - deformation of
Caused by high voltage electrical currents, atmos- the earth's crust, air pollution, water, etc.; in medi-
pheric electric discharge, electric shock. The name cine - in ophthalmology, surgery, physiotherapy; in
electrical cataract encompasses several pathogenet- science - for holographic records, super-surface con-
ic types that are not exactly distinct. In most cases it trol, optics, microelectronics; for military purposes
is about electrolysis due to the passage of an electric and others.
current through the eye or the heat that forms in it. Laser beams can get into the eyes of laser-pow-
Pathogenesis is sometimes unclear. ered devices with direct or diffuse and reflected laser
Clinical picture: The development of cataract radiation. In the laser application technology and in
and the corresponding decrease in vision develop the setting of laser devices using high power lasers,
after a latent period of 1 to 2 years. Opacity are locat- the damage to the eye tissues is most often caused
ed at the beginning subcapsular, sometimes in the by direct or mirrored reflected rays, - i.e. direct eye la-
front lens capsule. In form may be diffuse, punctu- ser trauma. A second group of eye injuries is caused
ate, striped, often take the form of a rosette. Some- by diffuse laser light - these lesions are defined as
times they remain unchanged for a long time, but indirect.
they often progress to full opacity and blindness. In recent years, using high-performance metal
Differential diagnosis of occupational cata- cutting lasers (Nd: UAG and CO2 lasers), workers are
racts is mainly due to pathological and complicat- exposed to reflected and scattered light not only in
ed cataracts, but with either a common disease or the act but also in the maintenance and service of
pre-existing or concomitant eye disease. Diagnosis the lasers. The effect on the eyes also depends on
is mandatory after an examination of patients with the material being handled. Nearly all types of lasers
a biomicroscope mydriasis, as well as information emitting in the visible or nearby IR spectrum (IR-A -
on work experience and contact with occupational between 400 and 1400 nm) are so bright that they
injuries. pose a danger to the eye. Exceptions make some
The treatment of professional cataracts is oper- very small low-power semiconductor lasers that
ative. The possibilities of modern eye surgery allow emit only a few microwatt power. As a result of fo-
the surgery to take place when the normal life and cusing light on the cornea with wavelength of the
work of the patient are disturbed. Since there are no visible and IR-A spectrum, its energetic density on
changes in eye bottoms, the surgical result is usual- the retina increases sharply.
ly good. After appropriate labour expertise, workers Occasional incidents occurring during laser work
may continue their employment under a regime are associated with reduced visual acuity as a con-
consistent with post-operative outcomes. sequence of burning the macula (Pic. 2). Especially
Prevention: In the case of electric welding, the sensitive is the pigment epithelium of the retina in
rays act harmful not only to the eyes but also to the whose cells the most intense absorption is, and the
exposed parts of the head - this is why not only safety heat released therein can lead to severe burns, and
goggles (in the case of gas welding) but also protec- loss of vision. With direct laser beams, the clinical
tion with a manual shield (screen). A shield attached picture is very characteristic. Besides oculorbital
to the head is also recommended when welding in pain at the moment of falling, followed by a feel-
hydrogen using argon or helium. IR rays separated ing of dazzle, there is often a feeling of heat in the
from the source of radiation can be absorbed or re- head and discomfort. Depending on the weight of
flected. The design of most safety glasses is based the burning of the macula, transient or permanent
on their absorption by incorporating one or sever- central scotomas may be obtained, including a com-
al chemical compounds (bivalent iron, chromium, plete drop in the possibility of fine visual activity.
nickel, etc.) into the glass (in the liquid glass mass). Angio-fluorographic studies contribute to both di-
For X-ray and gamma rays-lead are used to protect, agnosis, differential diagnosis, and prognosis of im-
in glasses and glass-screens. pairment.

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 OCCUPATIONAL MEDICINE
Not high energy densities cause reversible chang- haemorrhages and focuses (reminiscent of retinitis
es, but re-exposure can cause damage to the retina albuminurica) can be observed. Retrobulbar neuritis
and other eye tissues (various eye structures can be or papillitis is usually a consequence of vascular le-
sions due to spasm, sclerosis or obliterating endarte-
ritis. Paralysis of m.abducens, nystagmus and disap-
pearance of pupil light reactions may occur. Vascular
changes are often seen - atherosclerosis, endarteri-
tis, hyaline degeneration. It is believed that the dam-
age is due to primary degenerative changes in the
optic nerve and also to vascular changes. Probably
both factors work.
Ocular symptoms of mercury poisoning are
most often not the direct effects of mercury. They
are secondary to kidney damage. There are atrophic
foci in the retina, bleeding, edema in the course of
the vessels. In case of chronic poisoning inflamma-
tion of the tenon capsule, retrobulbar neuritis, en-
dogenous deposition of the metal in the Descemet's
membrane or corneal endothelium, in the conjuncti-
Pic. 2. Burning of the macula due to laser trauma va and more often in the anterior sub-capsular layers
damaged depending on which structure absorbs of the lens can be observed.
the largest radiation energy for volume tissue). Atkinson's Symptom - a peculiar color reflex
The treatment is dependent on the severity of from the front surface of the lens is found in people
the lesions. With large edema in the macula - dehy- who have been continually working with mercury
drating agents such as manitol, glucose and local and its compounds. Biomicroscopic picture shows
retrobulbar corticosteroids. that the front of the lens has a glare that changes its
Prophylaxis: A basic safety device is suitably de- color from brown to dark reddish brown. It is believed
signed spectacles and the non-direct alignment of that this mark is a permanent and early diagnosis in
the laser beam to the eyes. chronic mercury poisoning. Visual acuity is normal.
II. Damage to the visual analyzer by chemical In case of methyl alcohol poisoning, eye symp-
factors toms occur on the second-third day of acute poi-
Chemical factors in the working environment can soning when the patient is already out of the severe
affect either the eye structures or secondary damage general condition. They appear fog in front of the
due to general damage to the body. Eye symptom eyes, and after a few hours the visual acuity sharp-
is sometimes so characteristic that it contributes ly falls, often to complete blindness. The pupils are
significantly to the early diagnosis, prophylaxis and wide, with a faint reaction of light, a central scotom
therapy of occupational intoxications. appears. In the optic floor there is a hyperemia of
Occupational risk. The workers in the chemical, the papilla of the optic nerve, sometimes with large
pharmaceutical, cosmetic, perfumery, alcohol, leath- swelling and bleeding around the vessels and the
er, furniture, woodworking industries, in the extrac- vitreous. Later there is an atrophy of the optic nerve.
tion, processing and application of heavy metals, Visual improvement may also occur after 4-5 weeks
pesticides, synthetic fibers, organic solvents, etc., are with appropriate treatment and in less severe cases.
threatened by the damage to the visual organ. Chronic poisoning with methanol vapors, along
Eye symptoms of lead poisoning are not ob- with headaches and gastrointestinal disorders, can
served in isolation but are accompanied by other also lead to eye damage - retrobulbar pains, which
signs of saturnism. It is possible to lower vision to increase in eye movement and pressure on the eye-
complete blindness of both eyes. In case of lead en- ball; pupil extension; paralysis of the external eye
cephalopathy (currently not present), visual distur- muscles with diplopia; upper eyelid ptosis; absolute
bances are central - central hemianopsia or amauro- or relative central scotom. Ophthalmoscopy shows
sis with conserved pupillary responses. In the field of inflammation of the optic nerve with significant
view, there are also changes - homonimic haemian- swelling and enlargement of the retinal veins or rap-
opsia, central scotoma, concentric narrowing. id early-onset paleness of the papilla. Chronic cases
In chronic intoxication, lead is deposited sube- may also cause retrobulbar inflammation of the op-
pithelial in the cornea. Optic neuritis with papillary tic nerve leading to atrophy. There is individual sen-
edema and tightly narrowed vessels with retinal sitivity to methyl alcohol.

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 LABOUR MEDICINE
Aniline poisoning shows blue or yellowish brown Ocular symptoms of dimethyl sulphate intoxica-
conjunctival and corneal epithelial cleft colouration, tion are characterized by severe pain and light-head-
less corneal erosions, and parenchymal opacity. If an- edness. The conjunctiva is hyperemic, swollen. Lac-
iline is directly in the conjunctival sac, tissue necrosis rimation is abundant. Visual acuity is reduced due
can also be induced. Keratitis stay for many weeks, to edema of the corneal epithelium. Biomicroscopic
healing with solid leukomas. In the optic floor, bluish at the beginning are superficial point-like opacities,
optic papillary staining and dilation of the venous and in severe forms - epithelial sliver from the upper
vessels may appear. In severe poisoning complica- corneal parts. The pupils are narrowed. Acute inflam-
tions are haemorrhages and veno-thromboses, rare- matory events in conjunctiva resolve for 5-7 days,
ly neuritis of the optic nerve with narrowing of the but in the cornea there are opacities in the stroma
field of vision, central scotom and subsequent atro- that are difficult to spread.
phy. If aniline is in the conjunctival sac, a flush should When liquid dimethylsulfate falls into the eyes,
be made and then sub-conjunctivally injecting vita- severe burns with loss of tissue and deep corneal in-
min C. Antiseptic ointments (Vitaform, Nemybacin filtrates, often leading to blindness, occur.
eye ointment 2-3 x daily) are placed. Trinitrotoluene cataract is the most characteristic
In case of carbon monoxide poisoning, paralyt- manifestation of trinitrotoluene (TNT) on the optic
ic ptosis, paralysis of the external ocular muscles, analyzer.
nystagmus, conjunctival hyperemia, mydriasis or Trinitrotoluene cataract is often the only symp-
myosis may occur. In more severe cases, edema and tom on the basis of which retrospectively can be
haemorrhage in the retina, venous thrombosis, optic judged for past intoxication. It has four stages of de-
neuritis, homonymous hemianopsia, chromatopsias velopment. At first, at biomicroscopy in full mydria-
- seeing in yellow. In rare cases, carbon monoxide sis, scattered gray-whitish opacities are observed in
poisoning may result in almost complete vision loss, the corneal layer of the lens, which gradually group
with the maintenance of normal pupil responses, together to form an uncompleted ring. In the next
most likely due to damage to the visual center cells stages the ring thickens by forming triangles with
in the occipital brain part. The disorder may be tran- peaks to the center. A tender central ring also ap-
sient or lead to permanent blindness. Sometimes pears. At the last stage, the available opacities are
they are accompanied by visual hallucinations. increasing in size. The triangle tips are moved to the
Upon poisoning with hydrogen sulphide and at central ring (Pic. 3).
negligible concentrations in the air, eye pain occurs, The vision diminishes. Treatment is operational.
and at higher concentrations - photophobia, blepha- Eye damage due to poisoning with pesticides.
rospasm, tears - "hydrogen sulphide ophthalmia". As Pesticides may have either a direct irritant effect
a result of corneal edema, the patient sees colored on the eyes or, in the case of chronic effects, damage
circles around the light source. The corneal epitheli- the visual nerve and the retina secondary.
um is raised in the form of bubbles and easily slides.
Chronic hydrogen sulfide impact a chronic recurrent
keratoconjunctivitis occurs.
In carbon di sulphide poisoning, irritative and
inflammatory changes in conjunctivitis, fine epithe-
lial lesions in the intereyelid slit which occur with
lacrimation, blepharospasm, light-beating ("the eye
of the spinner") are observed. The cornea has spot-
ted gray infiltrates that fall apart after a few days. The
process occurs in the surface layers of the epitheli-
um, so there are no scars in the cornea. If secondary
infection occurs, ulcerations with hypopyon-irritis
and secondary glaucoma may occur. Weak corneal
and pupillary reflexes are observed in severe poison-
ing. Retrobulbar neurites, oculomotor palsy, oph-
thalmoplegia interna, and color vision may appear
in chronic intoxications - the injured person sees Pic. 3. TNT cataracts
in yellow or red. Retinal capillary micro-aneurysms,
rarely complicated with exudates and haemorrhag- Chloro-organic compounds, due to their fat-sol-
es - retinopathia sulfocarbonica of Japanese authors, uble properties, can affect the visual nerve, as toxic
are observed in the optic floor. neuropathy occurs with decreased vision, light- and

669
 OCCUPATIONAL MEDICINE
color perception. In severe cases, atrophy of n. Op- Prevention. Persons with chronic ocular disease
ticus with loss of vision. Chronic effects cause con- are not allowed to work. In the case of established
junctival irritation with tearing and photophobia. occupational eye diseases, post-treatment is ap-
Phosphoorganic pesticides such as cholinest- propriate temporary rehabilitation without contact
erase inhibitors in chronic intoxication may provide with toxic substances. In case of recurrences or more
autonomic optic neuropathies, resulting in bilateral severe complications, the possibility of re-qualifica-
decrease in visual acuity, concentric narrowing of the tion and determination of loss of working capacity
field of vision without or with central scotomas, red should be provided.
color vision. In more than 50% of cases, papillary hy- III. Increased visual acuity load
peremia and congestion are observed. Rarely ends Progressive short-sightedness
with papillary full atrophy. In acute intoxication, con- The great interest in short-sightedness is deter-
junctival hyperaemia, spasm of the eyelid muscle, mined by the fact that it is the most common cause
myosis, ciliary muscle spasm with focal disturbances of visual acuity fail, while, according to various au-
were observed. In severe cases transient amaurosis thors, between 10% and 25% of the adult popula-
may occur. tion of the world have myopia. Also, myopia most of-
Dinitrophenol pesticides, whose mechanism of ten disrupts man's ability to work from an early age,
action involves dissociation of oxidative phosphoryl- thus limiting the choice of a profession.
ation with subsequent energy balance disturbances, Progressive short-sightedness is a severe illness
selectively affect the ophthalmic lens in chronic in- that leads to a sharp reduction in vision (even after
toxication. The specific cataracts are two-sided and correction), and complications accompanying it lead
start as fine gray opacities with spotty character to disability and sometimes to blindness.
on the front lens capsule. Opacity develop rapidly Etiology and pathogenesis. Progressive short-
and sometimes lead to secondary glaucoma due to sightedness is thought to be the result of the patho-
swelling of the lens. In acute intoxication, dilation of logical extension of the sagittal axis of the eye due to
retinal vessels, as well as haemorrhages, is observed. prolonged nearby work and accommodation stress.
Methyl-mercurial pesticides - in addition to The hypothesis (Kuschel, Filatov, Radsycshovsky) is
pronounced oral hypoesthesia and polyneuropathy, plausible, according to which myopia develops as a
ataxia, speech disorders, a narrowing of the field of vi- result of weakening of the sclera as part of a gener-
sion with intact central vision is observed. Occasion- al weakness of connective tissue. This attenuation is
ally, eye changes progress to blindness, especially in associated with physicochemical changes occurring
the terminal phase of the disease. More often, small in it, caused by metabolic disturbances in the eye
scattered scotoms, disturbed vision, xanthopsia, etc. (calcium metabolism disturbances are reported). In-
are more common. Atrophy of the brain cortex in the fluence also exerts heredity.
area of ​​Sulcus calcarinus at postmortem study. Occupational risk. A major risk factor is work
Diagnosis. In addition to specific eye changes that requires continuous fixation of small objects
and increased incidence of unilateral eye pathology from a small distance. Workers from the printing and
among workgroups, the elimination and exposure textile industry, microscopists, designers, jewelers,
test and response to detoxification therapy are often watch makers and others are at risk.
used to prove the diagnosis. Important in differential Clinical picture. Long-range visual acuity is al-
diagnostics is the bilateral disability of eye injuries. ways reduced, and there is no strict correlation be-
Specific eye symptoms and evidence of chemical tween its reduction and the degree of myopia. How-
agents or their metabolites in biological media help ever, in the higher degrees of myopia, good visual
diagnose. acuity is not always achieved and after a proper cor-
Treatment. If the anterior eye segment (keratitis, rection.
etc.) is affected, it is necessary to cause mydriasis (Sol Visual acuity for near is usually good because,
Atropin - 1% collyr, Mydrumcollyr), drop antiseptic in comparison to emetropes, the same size objects
collars and ointments. (Ophthalmoseptonex collyr give larger images on the retina.
- 4 x 1-2 drops, Sulfacetamid 20% collyr, Chlornitro- Muscle asthenopia - is due to the excessive effort
mycin ung. opth.). Nonspecific anti-inflammatory of the internal straight muscles, realizing conver-
agents - calcium, butapirin, vitamins, possibly corti- gence, which is quite large in the proximal PP of the
costeroids and antibiotics are also used. In neuritis myopic eyes. It occurs in unpleasant sensations in
- dehydrating, detoxifying and anti-inflammatory the eyes and forehead after prolonged close work at
agents, group B vitamins; in the chronic stages - niv- medium and high degree of myopia.
alin, strychnine, dibazone, vasodilators, tissue thera- "Flying flies" are often seen, when looking away
py and others. on a well-lighten surface. Spasm of accommodation

670
 LABOUR MEDICINE
is very common, especially in the rapid increase of spot - the so-called spot of Fuchs. Sometimes there
myopia. are bleeding in the macula that is difficult to resorb.
Objective changes. The lens at high degrees of One of the most serious complications in myopia is
myopia can be luxated. In old age, it gets a brown- ablatio retinae.
ish hue in the kernel. The structure of the vitreous Prevention and treatment.
is split, with fibrils disintegrating. Opacities occurs, Prophylaxis of myopia involves the elimination of
which may be due either to bleeding or to the col- harmful externalities influencing its appearance and
lection of disintegrated fibrils. development, the timely detection and correction of
In the optic floor, a "myopic cone" may be ob- myopia, proper wearing of eyeglasses and contact
served - a semilunar white or yellowish area. Se- lenses, and the general strengthening of the body.
vere alterations may occur in the area of ​​the macu- There is no need to remove young people with
la - white spots appear as a result of atrophy of the short-sightedness from work. For workers with ad-
choroid, and pigment is gradually deposited around vanced myopia, appropriate working conditions
the atrophic areas. Pigmentation increases and an should be created - lighting, ergonomic workplace,
ophthalmoscopically visible oval or circular black correction of vision.

REFERENCES

1. Alieva Z.A., A.P. Nesterov, Z.M. Scriynichenko, Professional visual pathology, Moscow "Medicine",
1988. (in russ.)
2. Balocco L. Les lasers: evaluation et consequences pour l'homme et son environnement. Revistadi mec-
canica, 1982, N767,113-122.
3. Felixberer F., D. Szalkowski - Occupational laser eye disorders. Arlbeitsmed. sozialmed. preventivmed,
1982, 17, 14-17.
4. Grant W.M. Toxicology of the Eye, 3rd ed., Thomas, 1986.
5. Goodner E.K. Eye Injuries, in Occupational Medicine, ed. J. La Dou, Appleton & Lange, Norwalk, Con-
necticut, 1996, 80-94.
6. Markov Ts., V. Zlateva - Radiated eye injuries, Med. and phys., S., 1990. (in bul.)
7. Maychuk U., Allergic diseases of the eyes, Med. and phys., S., 1988. (in bul.)
8. Rey P., Y.Y. Meyer. Vision and Work. In the Encyclopaedia of Occup. Health and Safety, ed. J. M. Stell-
man, IV ed., ILO, Geneva, Vol. I, 11.10-11.21, 1998.
9. Sliney, D.H., M.L. Wolbarsht. Safety with lasers and other optical sources. New York, 1980.
10. Zlateva V. Professional visual a disabilities - evaluation approaches and experimental models. Diss.,
Sofia, 1991, 336 (in bul.)

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V. Zlateva, R. Toncheva

11.2 ACUTE OCCULAR TRAUMAS

Professional ocular traumatism is a current and tissues, their destructive action can last for hours if
serious problem for ophthalmology due to its high they are not washed away by the eye.
frequency, variety and often unfavorable function- In contrast, acids precipitate tissue proteins and
al outcome of vision. Includes bodies in eye contu- quickly create a barrier against deep penetration,
sions, penetrating and non-penetrating foreign bod- resulting in burning more often localized within the
ies in eyes, conjunctival and corneal erosions, eyelid contact area.
ruptures, retinal and optical nerve damages, chemi- The corneal endothelium, which is extremely im-
cal and thermal burns. portant for its normal structure and function, is very
Particular attention should be paid to eye trau- vulnerable to chemical agents. If anterior chamber
mas to the anamnesis. A good history can help both and drainage system is affected, secondary glauco-
the effective treatment and the precautions for oth- ma may occur. Obliteration of conjunctival and scle-
er workers in this production. ra blood vessels may lead to severe anterior ocular
Even in cases where only one eye is thought to be ischemia.
affected, it is imperative to carefully examine both It is almost impossible to predict the outcome of al-
eyes. If the accompanying trauma of the eyelid im- kaline burning immediately after the accident - the de-
pedes the eyesight of the eyeball, a single sterile lo- gree of damage to the eye tissues and the eventual out-
cal anesthetic may be used. come of burning can only be estimated within 5-6 days.
І Type of trauma II The severity of the trauma Type of injured agent IV Type of injury
Industrial Lightweight Chemical An injury
Unpunctured without or with a
Agricultural Mechanical
foreign body
Transport Moderately heavy Thermal
Sport Other physical factors Punctured without or with a foreign body
Others Heavy Destruction of the eyeball
V Trauma characterization
Depth of trauma, concomitant lesions, presence of blood in the anterior chamber and vitreous, prolapse
and loss of ocular tissues

I. Chemical injuries The classification and prognosis of chemical

Chemical burns are among the most urgent eye burns of the eye are related to the degree of incin-
injuries and are caused in the production environ- eration:
ment by bases and acids or by chemical compounds CLASSIFICATION OF CHEMICAL
of a basic or acidic nature. If they are not in high con- BURNS OF THE EYE
centrations and if the medical help is timely, the dis- Type (weight) Clinical findings
abilities are transient. However, there are also severe Lightweight Erosion of corneal epithelium, slight
production eye burns that lead to loss of vision. corneal edema is missing Ischemic
Etiology and pathogenesis: The most serious necrosis of the conjunctiva and sclera.
chemical burns are caused by: alkaline materials Average Corneal opacities engaging the stroma
- sodium, calcium, potassium bases, ammonia, ce- with increased corneal thickness,
ment; acidic substances - sulfuric, acetic, sulfurous minimal ischemic necrosis of the
acids, industrial solvents, pesticides and others. conjunctiva and sclera, superficial
Alkaline burns are heavier than those with ac- neovascularization.
ids due to their rapid penetrating effect through
Heavy Strong corneal edema, corneal opacities
the cornea and the anterior chamber (usually less to full opacity, severe ischemic necrosis,
than 1 min) due to the effect on the lipids of the cell and conjunctival and sclera whitening.
membranes. Because of their slow neutralization by

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 LABOUR MEDICINE
The treatment is conducted in three directions: Foreign bodies in the cornea. In many profes-
1. Emergency aid, aimed at removing the sub- sions such as turning, milling, carpenters, black-
stances in the eye. smiths, machine and auto mounters, etc., when
2. Prevent the development of infections or cor- working without safety glasses or screens, met-
nea breakthroughs. al shavings are often found in the eye. The worker
3. Achieve maximum recovery of visual functions. must be sent immediately to an optician's office.
Immediately flush with water at the workplace. Unlike burns where mutual assistance is urgent, it is
Health eye care should also be provided with phys- not necessary to take the foreign body by at hand
iological serum to ensure that the conjunctival sac means.
is clean (in the presence of small particles of the Puncture eye injuries. They are one of the worst
chemical they must be carefully removed with a wet traumas. Three main points characterize puncture
pad). Place an antiseptic ointment in the eye. The through eyeball injuries: the site of injury, the amount
patient must be referred to an ophthalmologist for of rupture, the presence or absence of an intraocular
continued washing with a physiological, isotonic or foreign body. They are most often accompanied by
neutralizing solution, including after reversing the the loss of intraocular tissue and the contents. Rare
eyelids. A single and sterile local anesthetic may be injuries only affect the cornea and the sclera. In most
used. cases they are accompanied by damage to underly-
Depending on the condition of the ophthalmic ing tissues. Immediately occurring complications are
tissues, appropriate therapeutic approaches, includ- most often haemophthalm, hyphema and traumatic
ing surgical, are applied. cataracts.
II. Thermal injuries To the obligatory questions of foreign bodies that
Thermal burns, unlike chemical ones, are in a mo- have pierced the eyeball is the type of material used:
ment. The effect of defeat depends on the temper- magnetic - iron or steel, non - magnetic - aluminum
ature of the substance. More often, the lyelid's skin or copper, organic - wood or plastic as this informa-
is affected by the blinking reflex protecting the eye- tion is of particular importance for determining the
ball. Often, splashes of molten metal are fall directly method of treatment and prognosis. Soluble metal
into the eye when casting into molds, as well as hot salts of iron and copper, contained in foreign bod-
metal particles (in forging workshops). Light metals ies can cause irreversible toxic damage to the retina
- e.g. zinc, zinc alloys, have a low melting tempera- if not removed in time. More inert materials such as
ture and fall into the eye they cool quickly and stop aluminum, plastics, glass have a better forecast. Or-
their thermal action. However, if it falls in the eye of ganic foreign bodies such as wood, parts of plants
molten cast iron or steel (over 1000 ° C) while it cools, can cause severe intraocular infection with unfa-
it continues to penetrate deep into the tissues and
TYPES OF FOREIGN CELLS
subsequently form deforming scars.
METAL NONMETAL
Treatment: For slight eyelid's skin burns, an anti-
Toxic Nontoxic
biotic ointment and a sterile dressing are provided.
Iron Gold Stone
With wider skin lesion damage, subsequent scars Copper Silver Glass
may lead to corneal desiccation due to insufficient (bronze, brass)
eye lid closure. In order to protect the bulb from me- Mercury Platinum Porcelain
chanical damage from rough scarring, trichiasis and Aluminum Tantalum Coal
the like a soft hydrophilic contact lens is placed on Nickel Some plastics
Zinc
the cornea, or early plastic surgery is performed on Lead
the eyelids.
III. Mechanical traumas vorable prognosis.
Eyeball contusions. In production conditions, Magnetic foreign bodies are removed by a mag-
they can be caused by powerful air waves, water jets, netic device. Immagnites are removed with a special
various solid objects, and more. Dull traumas range pinch for microsurgical subtraction.
from ecchymosis to severe intraocular damage: The technique by which foreign bodies are local-
hyphema, lens subluxation, iridodialysis, traumat- ized in various eye structures includes biomicrosco-
ic mydriasis, haemophthalmia, edema and retinal py, ophthalmoscopy, X-ray, ultrasound diagnostics,
haemorrhage, choroid rupture, retinal detachment scanner, and more.
can be observed. The inability to remove iron and copper foreign
The main goal of the treatment is to quickly re- bodies can cause severe visual impairment due to
store haemodynamics and eye hydrodynamics and their toxic effect on the eye tissues. Inert materials,
overcome local ischemia. such as glass or plastics, cause mechanical damage

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 OCCUPATIONAL MEDICINE
to the eye, but the absence of a local toxic reaction Ophthalmia sympathica is believed to be an au-
makes their long-term prognosis better (some of toimmune disease arising as a result of sensitization
them may not be taken depending on their position to the antigen of the outer membrane of photore-
in the eye). Foreign bodies can cause severe intraoc- ceptors. This rarely autoimmune inflammation of the
ular infection and lead to loss of eyeball. second eye can be prevented by rapid and adequate
As with most ocular incidents and also eyeball treatment of the puncture injury. Ocular traumatism
injuries, the worker should refer to an ophthalmol- leads to temporary or permanent, partial or total
ogist. It is imperative to place a sterile dressing, an- disability.
ti-tetanus prophylaxis, analgesic therapy, haemo- Prevention of industrial eye traumatism is limit-
stasis medication. Puncture eye injury is an urgent ed to a system of events relating to the organization
condition requiring surgical treatment. and rationalization of manufacturing processes, to
One of the most serious complications of eye trau- professional selection and qualification, personal
ma is "sympathetic ophthalmia", which occurs in the protection equipment, safety glasses, screening and
healthy eye, most often after a puncture injury involv- good health education.
ing the ciliary body. It occurs in 0.2 to 1% of the eye Knowing the damaging effect of chemical agents
trauma. If immediate treatment is not initiated, sym- and protecting against the risk factors that may
pathetic ophthalmia may result in complete vision loss come into the eyes during work, the availability of
of both eyes. Ophthalmia sympathica has been found washing and irrigation of the face and eyes at the
to develop in 50-60% of cases after 3-12 weeks of inju- workplace are important in the primary and second-
ry, in about 80-90% of cases during the first year after ary prevention of ocular traumatism.
the trauma, and only 10-20% at a later time.

REFERENCES

1. Baychev Hr. Urgent ophthalmology, Sofia, Med. and phys., 1980. (in bul.)
2. Bukov A., St. Banalieva. Eye trauma, Med. and phys., Sofia, 1986. (in bul.)
3. Dabov St., N. Konstantinov. Urgent ophthalmology, Sofia, Med. and phys., 1981. (in bul.)
4. Dentsch T. S., D. B. Feller. Paton and Goldberg's Management of Ocular Injuries, 2nd ed., Saunders,
1985.
5. Phillips C., C. Clark, Sh. Tsukahara. Ophthalmology (Trauma - 145-157), Bailliere Tindall, London,
1994, 454.

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Zl. Panova

12 OCCUPATIONAL DISABILITIES
OF FEMALE REPRODUCTION

Recent scientific data and analyzes indicate an mone (FSH), luteinising hormone (LH), estrogens
increase in disease abnormalities in the reproduc- and progesterone. For example, the intervention of
tive function of women. It was found that one of toxic factors can occur at the earliest stage with a
the 7 married couples had infertility, approximately mutagenic effect (organic solvents, ethylene oxide,
20% of pregnancies ended with miscarriage, 7% of arsenic, nickel) or during tubular transport of the
newborns were of lower weight and 7% were born ovum, influencing the endometrium and inhibiting
with defects. It has also been shown that the relative implantation accordingly.
share of loss of fertilized ova in both the pre- and the A critical period for fetotoxic and teratogenic
post-implantation periods is significant. chemicals is the first trimester of embryo and fetal
In working conditions in the working environ- development. Cell differentiation leading to the
ment there may be harmful chemicals, noise, vibra- formation of individual organs and systems can be
tions, high or low air temperature, electromagnetic disturbed and lead to malformations (spina bifida,
waves, etc., as well as the woman being in a state of palatum phisum), to abnormalities (skin growths,
inconvenient working position, lifting weights, to extra fingers) or functional deficits (delayed mental
endure nervous emotional intension, etc. All labour development). The second and third trimesters of
factors at a certain degree of intensity and duration pregnancy are characterized by toxic effects in the
may have an adverse effect on the reproductive fetus, such as intrauterine maturation, skin defects,
function of the woman. broad fontaneles. Functional disturbances in the
Characteristics of the female organism and endocrine, immune, urogenital and central nervous
reproductive physiology. The anatomical and systems, which continue to develop during the sec-
physiological features of the skin, whose resistance ond and third trimesters and are therefore easily vul-
to external effects changes during menstruation, nerable (lead, organic mercury compounds). In re-
pregnancy and climax, are important for the more cent years, the transplanted passage of carcinogenic
intense introduction of chemical substances into the factors, as well as damage to germinative cells in par-
body of the woman. The characteristic morphologi- ents in the pre-conceptual period (adenocarcinoma
cal composition of the blood, the functional charac- with diethylstilbestrol exposure), are not excluded.
teristics of the enzyme systems, its higher reactivity, The question of the passage of some toxic agents
and therefore, under the influence of the chemical into maternal breastmilk (perchlorethylene, halo-
production factors in women occur more often than genated hydrocarbons, dieldrin) is also not debata-
men's adaptation failure with the development of ble. Some physiological changes during pregnancy
anemic syndrome and other changes in health. The can get worse. For example, in some disposition the
different sensitivity of the female organism to the presence of organic solvents may lead to preeclamp-
factors of the labour and the environment are also sia in pregnant women.
due to some peculiarities in the intake, distribution In summary, the reproductive outcome associat-
and metabolism of toxic noxae and most of all - the ed with women's exposure to harmful production
presence of hormone-conditioned physiological factors is manifested as:
rhythms. During pregnancy, the woman's microso- • menstrual disturbances;
mal system, incl. and the placenta and the fetus, can • changed fertility;
metabolize xenobiotic substances differently, which • single gene defects;
in some cases is important for the newborn and for • chromosomal defects;
the adequate lactation. • spontaneous abortions;
The reproductive cycle in the woman is extreme- • congenital malformations;
ly complex and is regulated by the neuro-endocrine • intrauterine growth retardation;
system via the pituitary-ophthalmic axis (Figure 1). • late fetal death;
There is a balance between follicle stimulating hor- • changed gestational time

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 OCCUPATIONAL MEDICINE
Fig. 1. Reproductive cycle in a woman makes early diagnosis difficult as well as timely pre-
Embryonic development ventive measures. Attention
Oogenesis is usually directed to counter-
(Mitosis)
acting adverse late effects in
reproduction, which confirms
Fetal growth
Next Organic development occupational risk, but has long
generation time been realized with other,
no less significant, health con-
sequences. In addition to ob-
Birth stetric- gynecological, some of
the most important profpatho-
logical methods of diagnosis
Implantation are important for diagnosis:
Growth • In-depth professional profile
Development
with data on the parameters of
harmful working environment
factors.
Sexual • Epidemiological study for
maturity
outbreaks, seeking them from
Fertilization of meiosis II
more than one person in the
same team.
Tubolar Menstruation, separation of ovum • Dynamics of pathological
transport Meiosis I abnormalities using the base-
Start of Meiosis II
line for the profpathology ex-
posure and elimination test, ie.
• changed sex ratio; reversibility of the phenomenon after discon-
• perinatal mortality; nection, and vice versa.
• troubled development; • Finding into the biological media the toxic
• behavioural disorder; agent, metabolites or other biotransformation
• carcinoma; products.
• carcinoma in childhood; Other relatively specific criteria are limited to:
• female genital carcinoma; • The condition of the ovarian-menstrual func-
• weakened libido; tion - too early signal for the adverse impact
• premature menopause. of occupational hazards. Clinical and gyneco-
Potential biochemical mechanisms of exposure logical endocrinology methods, objectively
to harmful production factors are associated with: reflect this infertility pathology in women.
• mutations or chromosomal abnormalities; • The results of objective genital examination
• hormonal imbalance; (examination and palpation) most often cor-
• direct cytotoxic effects; respond to the type of hormonal cycle.
• causing cell death; • Dosage of ovarian and other hormones in bi-
• a defeat in cell interactions; ological fluids may support the results of oth-
• reduction of enzyme biosynthesis; er studies, eg. colpo-cytological. For the pur-
• obstruction of morphogenetic activity; pose of practice, cytodiagnosis, determining
• mechanical destruction of cells; the hormone receptivity in dynamics, is more
• interference through energy metabolism; prominent.
• depletion of energy; • Abnormal pregnancy: bleeding, spontaneous
• race in the location of the receptors. abortions, gestoses, premature birth, child-
When discussing the abnormal normogenesis of birth, malformations; Complications in the
the fetus, it is not necessary to absoluted the harmful labour act - labour activity, bleeding in the
factors of production, as other causes - genetically placental period, etc.; primary and secondary
determined, fetal hypoxia, rhesus conflicts, inade- functional infertility.
quate nutrition, previous infections and many oth- • Asphyxia in the newborn, which can not be
ers, have long been known. explained by the conditions in which the child
Criteria for diagnosis. The lack of specificity in was born or other factors. It is also important
occupational obstetric-gynecological pathology to take into account the lag in the physical and

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 LABOUR MEDICINE
mental health of the newborn, as well as in the These data, and especially those related to genetic
later development of the child. consequences, necessitate the periodic updating of
The mentioned criteria for diagnosis of the pro- radiation protection standards for workers with or
fessional obstetric- gynecological pathology do not near sources of ionizing radiation and the popula-
exhaust the diversity of the type and degree of the tion as a whole. Other factors that affect production
adverse events under the influence of the produc- conditions, often alongside of forced labour, muscle
tion factors and processes. In the complex diagnosis over-strain, increased mental-psychological load,
it is important to take into account both the gonad- overcooled or overheating microclimate, are vibra-
otropic - teratogenic, carcinogenic effect and the re- tions and noise. The faster development of "vibra-
mote consequences. tion-noise disease" in women has been established,
Epidemiological and clinical data on the im- with smaller parameters and with some kind of clini-
pact of productive factors on reproduction. The cal picture. Vibrations cause spontaneous abortions,
influence of environmental factors on the moth- gestations of pregnancy, abortive birth bleeding,
er-placenta-fruit biological system is varied. It has premature leakage of amniotic fluid. These patho-
been proven that 4-6% of the births have abnor- logical changes, incl. and changes in the menstrual
malities (severe and minor developmental defects, cycle, are still in the earliest stage of development of
metabolic disturbance), etiologically 10% are due to vibration-noise disease. Self-noise as a production
chromosome changes, about 20% to other genetic factor adversely affects the female organism much
abnormalities and approximately 70% - as a result earlier than on the male, especially during menstru-
of the impact of the environment or in combination ation and pregnancy. The suggestion of some au-
with genetic factors. thors to bring pregnant women out of workplaces
The effects of chemical substances are associat- with high air temperature and infrared radiation
ed with the greater incidence of functional sterility is warranted because hypotension, congestive phe-
in terms of production contact with petrol, benzene, nomena in the small pelvis, fast heartbeat are more
toluene, xylene, trichlorethylene, lead, mercury, prominent in pregnancy gestations, delayed labour
arsenic, etc. Pregnancy gestations are more pro- activity requiring frequent surgical birth, asphyxia
nounced and more frequent in women contacting of the newborn during labour and in early post-na-
gasoline, benzene and homologues, trichlorethyl- tal period. Arterial hypotension at birth, with all the
ene, carbon disulfide and hydrogen sulphide, dinil resulting complications, is common also in those
and caprolactam, and others. These chemicals can working under electromagnetic fields from the ra-
also cause spontaneous abortions, premature births dio frequency range. And since the biological effects
in the early outflow of amniotic fluid, partus precip- of RF EMF is reflected in the complex effects on the
itatus. Transplantation of lead, mercury, phospho- CNS, VNS, neurohumoral, hematopoietic and most
rus, gasoline and benzene, trinitrotoluene, carbon, to germinative, functions, complications in fertility
manganese, cadmium, carbon monoxide, pesticides is reduced to events representing contraindications
leads to a higher incidence of spontaneous abor- for work pregnant in an environment with EMF. Inter-
tions, deaths and those born with malformations. est is a study on the work of women of reproductive
The penetration of toxic substances into maternal age in windowless rooms with static microclimate
milk leads to increased incidence of children up to and lack of natural solar radiation. Except underlined
1 year of age, lagging behind in their physical devel- genital pathology, in 36 pregnancies 16 has been
opment, reduction of the immunobiological reac- pathologicaly, mainly threatening abortions com-
tivity of newborns. For some toxic substances, it is plicated was born in 9 cases, 3 children were born
not debatable whether circulating in the body of the preterm, 1 - full-term, but immature, 1 - with hydro-
mother both they and their metabolites are active, cephalus and spontaneous abortion has occurred
especially since they are contained in breast milk, In 4 pregnancies (the limited number of observed
blood, urine and fecal matter, placenta, amniotic flu- subjects only draws attention to possible risk). In the
id , In the ovum. case of lasers, there is still no conclusive evidence of
Clinical manifestations when working in an ioniz- impairment of reproductive function, and only in ex-
ing radiation environment are too early, before pos- periment there is evidence of induced hyperestrog-
itivation of blood changes, mostly functional, and in eny. Physical overload and lifting of overweight
some cases morphological with irreversible dam- have been shown to negatively affect pregnancy,
age to the follicles - sterility or spontaneous abor- and that is why they have first found a place as a ban
tions, infertility, malformations. Even small doses in labour law.
may cause menstrual disorders, mainly oligo-men- Prevention of damage to the genitals and re-
orrhea, amenorrhea, menorrhagia, metrorrhagia. productive function in manufacturing contact with

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 OCCUPATIONAL MEDICINE
chemical factors include organizational, technical inations is mandatory in contact with lead and its
and technological activities - rational design, con- compounds, mercury and its compounds, hydro-
struction and equipment utilization, organization gen sulphide, and at indications: manganese and its
and technology of manufacturing processes, co- compounds, arsenic and its compounds, unsaturat-
formable to the specificities of the female body and ed aliphatic hydrocarbons, aromatic hydrocarbons,
the need to preserve Its reproductive function. The amino- and nitroderivatives of aromatic hydrocar-
safe handling of toxic substances requires strict ad- bons, hormonal preparations and others.
herence to the rules of personal and public hygiene. Hygienic and technological issues related to
In medical prevention is an important professional- limiting production risk from adverse physical fac-
ism at selection of incoming, through strict adher- tors are also too complex. Special requirements are
ence to the contra indications - i.e. the women with provided for limiting the production risk from the
impaired ovarian-menstrual function are contrain- effects of noise, vibrations, EMF, lasers, etc. Periodic
dicated for use with lead, mercury, cadmium, and medical examinations require attendance of obste-
their compounds, organic solvents, carbon disulfide, tricians-gynecologists in work in local and general
styrene. In some productions with an increased risk vibrations, intense production noise, sources of ra-
for reproductive function there is a statutory pro- dio frequency electromagnetic fields, etc. Although
hibition to work for women of fertile age - up to 35 pregnancy is a physiological condition, it is a con-
years of age in the synthesis and polymerization of traindication for a number of industries, which pro-
vinyl chloride; up to 40 years of age - in contact with hibit work in a hostile work environment - noise and
selenium and its compounds with styrene, ethylene vibration, in conditions of EMF, ionizing radiation, la-
and ethylene oxide and others. In periodic inspec- sers, overheating and overcooling microclimate and
tion of the risk contingencies, gynecological exam- others.

REFERENCES

1. Barbanel C.S., Ducatman A.M., Garston M.J., Fuller T. Lazer hazards in research laboratories. J. Oc-
cup. Med. 1993; 369-374.
2. Brent R.L., Gordon W.E., Benett W.R., & Beckman D.A. Reproductive and teratological effects of elec-
tromagnetic fields. Reprod. Toxicol. Rev. 1993; 535-580.
3. Buscagla M., Peragallo M. Ambiente e gravidanza. Influenza dei fattori nocivi ambientali elavorativi
sulla funzione riproduttiva. Palermo, Cofese Edizioni, 1982, 37-44.
4. Hartikainen A., Sorri M., Anttonen H., Tuimala R., Laara, E. Effect of occupational noise on the
course and outcome of pregnancy. Scand. J. Work Environ. Health. 1994; 444-450.
5. Hemminki K., Niemi M.-L., Koskinen K., & Vainio H. Spontaneous abortions among women em-
ployed in the metal industry in Finland. Int. Arch. Occup. Environ. Health. 1980; 53-60.
6. Lindbohm M.L., & Hietanen M. Magnetic fields of video display terminals and pregnancy outcome. J.
Occup. Environ. Med. (1995) 37, 952-956.
7. Lindbohm M.L., Taskinen H., Kyyronen P., Sallmen M., Anttila & Hemminki K. Effects of parental
occupational exposure to solvents and lead to spontaneous abortion. Scandi. J. Work Environ. Health, (1992)
18 (Suppl 2), 37-39.
8. Lipscomb J.A., Fenster L., Wrensch M. Scusterman, D. & Swan S. Pregnancy outcomes in women po-
tentially exposed to occupational solvents and women working in the electronics industry. J. Occup. Med.,
(1991) 33, 597-604.
9. Mattison D.R., Cemasters G.K. Structure of the Female Reproductive System and Target Organ Vulner-
ability; Maternal Occupational Exposures and Adverse Pregnancy Outcomes, in the Encyclopaedia of Occup.
Health and Safety, ed. J. M. Stellman, 1998, 4th edition, vol. 1, ILO, Geneva, 9.8-9.17.
10. Nurminen T. Female noise exposure, shift work, and reproduction. J. Occup. Environ. Med., (1995) 37,
945-950.
11. Panova Zl. Professional obstetrics and gynecological pathology. Med and phys., Sofia, 1988. (in bul.)
12. Panova Zl. Problems of professional obstetric - gynecological pathology. Criteria for diagnosis and
expertise. Dis. Sofia, 1992. (in bul.)
13. Rudolph L., Forest C. S. Female Reproductive Toxicology in Occupational Medicine, ed. J. La Dou,
Appleton & Lange, Norwalk, 1996, 275-287.

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 LABOUR MEDICINE

Iv. Grozdev

13 OCCUPATIONAL IMPAIRMENT OF
THE ORAL CAVITY AND TEETH

Most of the occupational hazards penetrate the ranges from 2 to 70% depending on the duration
body through the mouth. Some of them are deposit- and intensity of the exposure. Erosion teeth remain
ed in the oral tissues and damage them directly. Oth- vital, but are susceptible to recurrent caries.
ers are absorbed through the lining or are excreted Direct contact of the oral mucosa with concen-
by the salivary secretion. Intoxications and other oc- trated acids and bases causes painful burns, followed
cupational illnesses are often manifested with char- by low sensation, taste dullness, hypersalivation and
acteristic dental symptoms of proven importance for stomatitis. Later, specific stained scarring is formed.
their diagnosis and causal therapy and prophylaxis. The chronic action of the caustic factors irritates the
People with toxins and aggressive chemicals are lining and leads to cheilitis, catarrh, pigmentation,
at risk and, to a lesser extent, individuals under the desquamation, and hyperkeratosis.
influence of certain physical, physicochemical and Unlike mineral, organic acids exert a cariogen-
biological factors. Direct engagement of the lips and ic effect on all teeth and contribute to mucosal
teeth in the work process poses a risk of their imme- and periodontal inflammations. Typical is so-called
diate harm. "sugar or confectionery" caries with circular, broad-
Etiology and pathogenesis. They are clearer leaved teeth neck injuries and frequent complica-
with the consequences of direct physical and chem- tions in food industry workers.
ical effects - demineralization, abrasion, usuration, 2. Heavy metals. Oral symptoms are among the
etc. of the teeth; pigmentation, cauterization, irrita- cardinal signs of increased deposition or intoxica-
tive inflammation, etc. mucosal lesions. tion from these noxae. Exceptionally, classic heavy
General occupational diseases and poisoning lesions in the mouth can be observed today.
affect the mouth after disruption of metabolism, Mercury is accompanied by metallic taste some-
trophic and reactivity of tissues. Local expression is times with hypersalivation, "cold" mucosal edema
vascular dystonia, staining and inflammation of the with mucous tongue and cheeks, tremor of the
lining, structural changes in jaw bone and joints, etc. tongue withdrawn, non-specific periodontiopathies,
Individual resistance or disposition to unfavorable very rarely, and a mercury strip on the gingiva.
exogenous influences plays an important role. The Saturnism is currently developing with an un-
effect of harmful professional factors is also aggra- pleasant "lead" breath and a sweet-metal taste, ane-
vated by bad oral hygiene and by the presence of mia of the lips and mucous membranes, an increased
other non-professional pathology (the latter is deep- incidence of dystrophic periodontitis (up to 63%).
ening under the influence of professional harm). Relatively rarely, discrete gray-brown pigmentation
I. DISEASES OF ORAL CAVITY OF TOXO-CHEM- of the mucosa occurs - depending on the extent
ICAL FACTORS. of lead exposure and impact in 10 to 16% of work-
1. Acids, irritants gases and bases are chemi- ers. By way of exception, the classical endogeneous
cal substances with markedly aggressive action on lead-sulfide garland on the gingival edge (Bourton's
chewing organs. Prolonged exposure to vapors and band) is now observed.
aerosols of inorganic acids and their anhydrides in- Cadmium intoxication occurs with metallic
creases the saliva's acidity and causes demineraliza- taste, dryness in the mouth and golden-yellow col-
tion of the frontal teeth with characteristic erosion oration of the teeth neck ("cadmium ring"). Osteopo-
of the enamel. Affected people complain of sour rosis of the jawbone rarely develops.
taste, hyperesthesia and dullness of teeth. Later the 3. Organic solvents. Oral changes in benzene
tooth enamel becomes cloudy, becomes rough and and gasoline intoxication are more characteristic.
yellow-brown. Toothed columns become brittle and From the developing fatty dystrophy and damage to
susceptible to abnormal abrasion (up to 55% of peo- the capillaries, the tenderness and tendency of the
ple working with acids). An open occlusion is formed lining to bleed increases. Inflammatory edema and
in the front. The incidence of acid-damaged teeth hyperemia of the gingival edge and the rest of the

679
 OCCUPATIONAL MEDICINE
mucosa appear and are followed by minor traumatic face, unpleasant popping and chest pain, temporari-
and spotting bleeding. The decreased periodontal ly or permanently impaired working capacity.
resistance increases to 80-90% the incidence of per- 2. Radiant energy. Ultraviolet rays damage the
iodontal disease, which is difficult to treat. There are lips after disturbing protein, mineral and water me-
no-rare, cumbersome, post-extraction haemorrhag- tabolism in tissues, especially in vitamin deficiency
es. and the help of photocatalysts. In open-air fisher-
The direct irritant effect of phenol, chlorinated men, sailors, farmers, cheilosis and cheilitis ("cheili-
hydrocarbons, nitro compounds of benzene, and tis solaris") are often developed. Ionizing radiation
oth. causing chronic catarrh, erosion and burns of causes mucosal dyskeratosis, dystrophic changes
mucous membrane with disordered taste and sali- in dental pulp and salivary glands with characteris-
vation. Intoxication with trichlorethylene affects the tic xerostomia, multiple rapid "ray caries", rarely os-
sensory fibers of n. trigeminus with paraesthesias, teo-radionecrosis of the jawbone.
glossalgia, shaking and falling teeth. Working with 3. The sharp temperature fluctuations (over-
tar, asphalt, resins, aniline paints and mineral oils in- heating, overcooling) of the work environment
creases the risk of developing cheilitis and mucosal are often the cause of n. facialis and n. trigeminus
hyperkeratosis as the basis for malignant degenera- neuralgia and transient rheumatoid arthritis of the
tion. maxillary joints with an effect on working capacity
4. Other toxic-chemical damages can be ex- at workers in furnaces, at overflow, refrigeration, etc.
pected in professional contact with: Combined heat and dust effects damage the lining
Arsenic and thallium. Their excretion through and facilitate the formation of tartar and plaque - a
the salivary glands causes metallic taste, garlic prerequisite for an increased incidence of gingivitis
breathing, xerostomia with dysphagia, stomatitis, and marginal parodonthopathies.
parodontosis, and a tendency to hyperkeratosis. 4. Barometric factors (abrupt decrease or in-
Phosphorus and fluorine: breath of garlic, hy- crease in atmospheric pressure - in aviators, divers,
persalivation, initially osteosclerosis, and later os- caisson workers) are reflected in the mouth with
teoporosis of the jaws. Under modern working sudden severe pain from carious or undercured
conditions, classical phosphorus jaw necrosis and teeth (aerodenthalgia), tendency to bleed, dryness
osteomyelitis are not developed. and inflammation of the lining and the teeth sup-
Pesticides: change taste and salivation, irritate port tissues.
the lining of pain, hyperemia, haemorrhage and III. DISEASES OF ORAL CAVITY OF BIOLOGICAL
keratinization, potentiate periodontal disease. FACTORS
Plastics (non-polymerized ingredients - mon- Professional zoonoses and phytoparasitic dis-
omers, plasticizers, etc.): irritate the mucous eases are currently significantly less frequent among
membrane and periodontal and cause non-specific, agricultural, veterinary, medical and other workers.
difficult to treat cheilitis, recurrent gingivitis, paro- Reflection in the mouth is caused by aphtae epizo-
dontosis and hyperkeratosis. otical, actinomycosis, aspergillosis, oral candidiasis,
Vegetable and animal powders: change the anthrax, tularemia and other infectious diseases.
taste and color of the teeth and mucous membranes, Diagnosis is based on evidence of a causal re-
trigger the development of allergic cheilitis and sto- lationship between the pathological process and
matitis especially in bad oral hygiene. adverse work environment factors: specific occupa-
II. DISEASES OF THE ORAL CAVITY OF PHYSI- tional stigma and increased incidence of one-size-
CAL FACTORS fits-affected disorder influenced by discontinuation
1. Mechanical traumas (from instruments, pow- or renewal of exposure; the effect of applied detoxi-
ders, vibrations) most often lead to the development fying therapy is monitored; the presence of chemical
of pathological dental abrasion, traumatic perio- damages and their metabolites in the biological en-
dontiopathies with frontal teeth luxations and ar- vironment is investigated.
thropathies. Chronic microtructures on the mucous Prevention and treatment. With the prelimi-
membrane cause pigmentation, erosion, and hyper- nary dental examinations of workers with agents
keratosis. A characteristic occupational disorder of intervening in the oral cavity, professional selection
wind instruments and glass-blowers is the so-called is made on dental indications. Periodic reviews aim
stomatodynia that occurs with taste disturbances, at early detection and early rehabilitation of occupa-
paraesthesias, spasms and lip pains in contact with tional and banal diseases. To enhance the resistance
the tool. Sometimes the air blowing blows over and of local tissues to intense professional effects, pro-
pervades the parenchyma of the parotid glands. A tective coatings and tooth fluoridation, system brush
pneumocellulitis develops with a distinctly changed and shower massage of the gums, maintaining per-

680
 LABOUR MEDICINE
fect oral hygiene, timely sanitation and removal of applied to the tissues, stimulating their trophic and
local irritants and injuries are applied. Healthy nutri- regeneration. General and local detoxification thera-
tion rich in vitamins, mineral salts and protein foods, py. Specific requirements for workers: in overheating
improvement of the labour process with possible microclimate - non-metallic fillings; with cariogenic
exclusion of the mouth from direct participation in substances - corona photopolymers instead of amal-
working manipulations - in case of impossibility - use gam fillings; of blowers (musicians and glass makers)
of suitable mouthpieces, safety splints, screens and - fixed prosthetic structures.
other means of local protection. Temporary discontinuation of exposure (or rede-
Treatment - Physical procedures, rinse with light velopment) has a beneficial effect on treatment.
disinfectants, dyeing, high doses of vitamins (B, C,
K, PP), novokain blocks, calcium preparations are REFERENCES

1. Balcheva E., B. Velikov. Pathological manifestations in the mouth with impact of professionally deter-
mined nodes. in: Oral Syndromes and Diseases, Med. and phys., S., 1979. (in bul.)
2. Desoille H. et al. (Sous at direction de). Precise medicine du travail - Affections buccal, dentaires et
maxillaires, Masson, Paris, 1991, 692-696.
3. Gobbato F. Mouth and Teeth. In: Encyclopedia of Occupational Health and Safety, ed. J. M. Stellman,
4th ed., Vol. I, ILO, Geneva, 1998, 4.3.-4.5.
4. Grozdev Iv. Oral disorders in heavy metals. in: Occupational diseases in dentistry, ed. E. Balcheva and
Tsv. Alexieva, Med. and phys., S., 1982, 33-48. (in bul.)
5. Grozdev Iv. Occupational impairment of the oral cavity and teeth. in: Occupational diseases in otorhi-
no-laryngology, ed. Vl. Pavlov, Med. and phys., S., 1981, 187-197. (in bul.)
6. Grozdev Iv. Oral disorders of chemical factors, in: Professional pathology, ed. Tsv. Alexieva and Kr.
Kiryakov, Med. and phys., S., 1982, 106-109. (in bul.)
7. Lammert K. Berufsschaeden im Zahn-, Mund- und Kieferbereich, Berlin, 1979.
8. Ovruckij GD, A. S. Japeev. Acid's teeth necrosis, ed. Medicine, М., 1994. (in russ.)
9. Peekker R. Y., Profesionale pores tkanei polostyrta, Medicine, M., 1987.
10. Velikov B. Injury in the oral cavity of inorganic acids. in: Occupational diseases in dentistry, ed. E.
Balcheva and Tsv. Alexieva, Med. and phys., S., 1982, 48-57. (in bul.)

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K. Kotseva

14 OCCUPATIONAL DISABILITIES OF
THE CARDIOVASCULAR SYSTEM

Cardiovascular diseases are the most common of cadmium intoxications, the catecholamines in the
cause of death in the developed world. In Bulgar- blood and urinary excretion are elevated. A positive
ia, this indicator has markedly unfavorable dynam- correlation was found between the level of cadmium
ics, and according to the WHO, it ranks first among in serum and systolic and diastolic blood pressure, as
the ten countries in the world where cardiovascular well as the severity of arterial hypertension.
disease mortality is steadily rising. It is known that Cobalt. The term "cobalt cardiomyopathy" was
the major risk factors for coronary artery disease introduced in 1965-66, when it was observed in peo-
(IHD), arterial hypertension, smoking, hypercholes- ple who consumed beer with a cobalt sulfate stabi-
terolemia and diabetes can only account for about lizer. The cobalt disturbs the oxygen consumption
50% of the disease. The rest depend on the so-called and the mechanisms of oxidative phosphorylation
secondary factors for which data are contradicto- in the myocardium. Cases of cardiomyopathy and
ry. Among them, a particular place is attributed to increased mortality from ischemic heart disease and
the negative impact of some chemical, physical and workers exposed to cobalt have been reported. In
manufacturing deficiencies. patients with cobalt cardiomyopathy, increased co-
The cardiotoxic effect factors and cardiovascular balt content was found in the myocardium.
lesions are shown in Table 1. Mercury. In subjects with mercury intoxication,
Chemical Factors there are relatively frequent electrocardiographic
Lead. The results of many experimental and changes - arrhythmias, Q-T interval prolongation,
clinical studies have shown that acute exposure to S-T segment depression and T-wave negative. It is
high concentrations of lead may cause rise in blood believed that mercury may play a role as a risk factor
pressure and cardiac rhythm disturbances. Chronic for arterial hypertension and atherosclerosis. Patho-
effects increase the risk of developing arterial hyper- genetic mechanisms discuss the nephrotoxic action
tension and increase mortality from ischemic heart of mercury, a direct toxic effect on the vessels and
disease and cerebrovascular disease. An increased the heart, and a lipid metabolism disorder.
incidence of non-specific electrocardiographic Arsen. Acute arsenic exposure may cause repo-
changes - rhythm, conduction and repolarisation larisation ECG abnormalities and severe ventricular
disorders, as well as cases of cardiomyopathy in pro- arrhythmias, most likely due to direct cardiotoxic
fessionally exposed workers. The following possible effects. Cardiomyopathy with heart failure was ob-
mechanisms of influence of lead on the cardiovas- served in more acute intoxication. An "exposure-re-
cular system are discussed: 1. Renal impairment; 2. sponse" relationship between arsenic trioxide expo-
Activation of the renin-angiotensin-aldosterone sure and mortality from ischemic heart disease has
system; 3. Disturbance in the exchange of catecho- been found, with relativistic risk increasing with in-
lamines; 4. Vasospastic effect and increase of periph- creasing duration of exposure.
eral vascular resistance; 5. Direct cardiotoxic effect; 6. Antimon. In case of acute impact of antimony,
Dislipoproteinemia with accelerated development various rhythmic and conduction disorders as well as
of atherosclerosis. A positive correlation between changes in repolarisation are recorded. There have
the level of lead in the blood and the blood pressure been reports of sudden death in workers exposed to
values ​​was found. antimony trisulphide. The cardiotoxic effect of anti-
Cadmium. Occupational exposure to cadmium mony has been demonstrated in experimental stud-
is discussed as a risk factor for the development of ies. Antimony production increases the incidence of
arterial hypertension. Experimental studies have electrocardiographic changes in the absence of car-
identified renal tubular lesions as well as sclerosis diomyopathy or ischemic heart disease.
and generalized thickening of the walls of arterioles Beryllium. A positive correlation was found be-
and small and middle arteries of the kidney. In case tween beryllium exposure and IHD (relatively few

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Tab. 1. Production factors with possible Impact on the cardiovascular system

Production Effects on the cardiovascular

factors system Mechanism
of impact
Acute Chronic
1 2 3 4
Lead Hypertension Hypertension Nephropathy? Activation of the renin-angiotensin-
Arrhythmias Arteriosclerosis? aldosterone system. Disturbance in the exchange
Increases mortality of catecholamines. Generalized angiospasm;
from IHD and BVD. Increased peripheral vascular resistance. Direct
Cardiomyopathy? cardiotoxic effect? Dyslipidemia?
ECG changed

Cadmium – Hypertension? Nephropathy? Activation of the renin-angiotensin-

aldosterone system. Disturbance in the exchange
of catecholamines? Increased sympatho-adrenal
system activity. Increased peripheral vascular
resistance. Increased sodium retention
in the body?
Cobalt – Dilatational Oxidative phosphorylation disorder.
cardiomyopathy Disturbance in the exchange of catecholamines?
Mercury ECG changed Hypertension? Nephropathy. Disturbance of oxidative
Atherosclerosis? phosphorylation. Dyslipidemia.
ECG changed
Arsen ECG changed Increases mortality Disturbance of oxidative phosphorylation.
from cardiovascular
disease?

Antimon ECG changed ECG changed Disturbance of oxidative phosphorylation.

- Arrhythmias
- Conductive
disturbances
- S-T changes
Yellow phosphorus Arrhythmias – Direct toxic effect on the myocardium
Acute CHD
Nitrates Angina pectoris – "Rebound" vasospasm when the exposure-is
Myocardial discontinue
infarction "Monday morning attacks".
Sudden death Disturbance in the exchange of catecholamines.
Carbon monoxide Angina pectoris Atherosclerosis Myocardial hypoxia due to formation of
Myocardial carboxyhemoglobin. Direct toxic effects on
infarction vessels and myocardium. Disturbance in lipid
Arrhythmias. metabolism. Increase of aggregation of the
Sudden death platelets.
Hydrocarbons ECG changed Arrhythmias Myocardial sensitization to catecholamines.
A. Chloroderivatives - Arrhythmias Cardiomyopathy Depressive effect on contractility and conductivity.
(methylene chloride, - Conductive Disturbance of oxidative phosphorylation.
chloroform, carbon disturbances Methylene chloride is metabolised to CO.
tetrachloride). Sudden death
1.1.1. Trichloroethane,
trichlorethylenes, etc.

B. Fluorinated Arrhythmias – Myocardial sensitization to catecholamines.

derivatives (Freon 11, Sudden death Direct toxic effect
12, 113, 114) on the myocardium.
Vinyl chloride – Raynaud's Disturbance of peripheral microcirculation.
Syndrome. Increases Direct toxic effects on vessels and myocardium.
mortality from IHD?
Hypertension?

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 OCCUPATIONAL MEDICINE
Carbon - Atherosclerosis Dyslipidemia, suppression of the function of
Increases mortality the thyroid gland, reduction of
from IBS. fibrinolytic activity. Direct vasotoxic effect.
Hypertension? Disturbance in the exchange of catecholamines.

Other solvents Arrhythmias Dilated Direct toxic effect on the myocardium.

(Ethanol, phenol, Myocardial cardiomyopathy Myocardial sensitization to catecholamines.
toluene, benzene) infarction Atherosclerosis Dyslipidemia
Pesticides
A. Chlororganic Arrhythmias Atherosclerosis? Dyslipidemia. Direct toxic effect on myocardium.
(DDT, lindane, aldrin, ECG changed Increased sensitivity of myocardium to
dieldrin, toxofen, Hypertension catecholamines.
epichlorhydrin Atherosclerosis?
and others.)

B. Phospho-organics ECG changed Atherosclerosis? Inhibition of cholinesterase by

(parathion, intrathyon, - arrhythmias Arrhythmias acetylcholine accumulation
chlorophos, zolone, Acute HVD Direct toxic effect on the
etc.) myocardium. Electrolyte disturbances

C. Mercury Organic Arrhythmias – Direct toxic effect on the myocardium.

D. Carbamates – Atherosclerosis? Dyslipidemia

E. Herbicides Acvute HVD Atherosclerosis Disturbance of oxidative phosphorylation.
(paraquat, TDDD, Dyslipidemia.
dioxin, etc.)
Noise (over 85 dB) Hypertension Hypertension The type of intermittent stress with activation of
Atherosclerosis? the hypothalamic-pituitary axis - adrenal cortex
and the sympathic-adrenal system with enhanced
release of catecholamines and glucocorticoids;
Increased peripheral vascular resistance.
Dyslipidemia.

Vibration – Hypertension Damage of nerve endings, perivascular

Atherosclerosis? connective tissue and microvasculature at the
periphery. Vegetative and vascular dysfunction.

High temperatures Angina pectoris, Atherosclerosis? Increase the oxygen needs of the myocardium.
myocardial Disturbance of water-electrolyte exchange.
infarction, sudden Increased blood viscosity.
death (with
coronary-
sclerosis).

Low temperatures Angina pectoris, – Increase the oxygen needs of the myocardium.
myocardial Peripheral vasoconstriction.
infarction, sudden Coronarospasm. Activate sympatic adrenal
death (with system.
coronary-
sclerosis).

Non-ionizing NCD, ECG NCD, hypertension? Differential dysfunction. Impaired neurovegetative

radiation (radio changed ECG changed regulation; vegetative and vascular dysfunction.
waves) Direct toxic effects on vessels and myocardium.

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 LABOUR MEDICINE
studies). In a retrospective cohort study of US work- Other hydrocarbons (organic solvents). Their in-
ers, an increased mortality from IHD was also found fluence on the cardiovascular system is primarily asso-
due to exposure to beryllium. ciated with the possibility of causing arrhythmia and
Yellow phosphorus. Acute yellow phosphorus sudden death in the presence of high concentrations.
intoxication causes disturbances in the repolarisa- The first messages are sudden deaths in people who
tion phase and rapid progression of heart failure due are breathing aerosols with a narcotic action ("sudden
to direct myocardial toxicity. There are no epidemi- sniffing death"). In young adults who inhaled adhe-
ological studies on professionally exposed workers. sives containing organic solvents, severe ventricular
Carbon monoxide. The acute impact of carbon arrhythmias have been observed. Sudden death and
monoxide can cause myocardial infarction and sud- ventricular arrhythmias are also observed in workers
den death as well as the onset or potentiation of exposed to 1.1.1 trichloroethane, trichlorethylene,
angina pectoris - especially in subjects with pre-ex- chloroform, carbon tetrachloride, fluorohydrocarbons,
isting coronary artery disease. In experimental stud- ethanol, toluene, benzene and the like. Chronic effects
ies, chronic exposure to carbon monoxide has been of toluene and trichlorethylene have reported cases of
shown to accelerate the development of athero- dilated cardiomyopathy. The pathogenesis of cardiac
sclerosis due to the combined effect of hypoxia, in- lesions indicates: 1. Sensitization of myocardium to cat-
creased cholesterol deposition in arterial walls, and echolamintitis, which causes arrhythmias and sudden
increased platelet aggregation. death; 2. Suppression of sinus node activity and atri-
It is known that smoking is a major risk factor for oventricular conduction, causing sinus bradycardia or
IBS and that the carbon monoxide contained in cig- arrest, and atrioventricular block; 3. Direct cardiotoxic
arette smoke is considered to be one of the major effect. Increased incidence of arterial hypertension and
etiological factors. In patients with chronic exposure increased morbidity and mortality from IHD have also
to high concentrations of carbon monoxide (with been reported. Epidemiological studies in workers ex-
carboxyhemoglobin above 30%), cardiomyopathy posed to low concentrations are insufficient.
with congestive heart failure has been observed. Pesticides. In case of acute intoxication with
The results of some epidemiological studies show some pesticides, there were manifestations of in-
an increased incidence of angina pectoris, myocardi- creased myocardial excitement - occurrence of var-
al infarction, ischemic changes, and ECG rhythm dis- ious rhythmic disorders.
turbances, as well as increased IHD mortality, which The mechanism of action of phosphoorganic
decreased after discontinuation of exposure. pesticides is associated with inhibition of acetyl-
Carbon disulfide. Chronic exposure to abnormal cholinesterase, with tachycardia and hypertension,
serum carbon disulfide concentrations is considered and bradycardia and hypotension later in the initial
as a risk factor for the development of atheroscle- phase of acute poisoning. Various rhythm and con-
rosis and IHD. The mechanism of action of serum duction disorders such as ventricular extrasystole,
is explained by a disorder of lipid metabolism and ventricular tachycardia, fibrillation and asystole, as
the development of dyslipoproteinemia. Other pos- well as non-specific changes in S-T segment and
sible causes for accelerating atherosclerosis include T-waves have been reported.
decreased serum fibrinolytic activity, direct toxic ef- Some organochlorine pesticides have a direct
fects on vessels, and the development of hypothy- toxic effect on the myocardium. Occupationally ex-
roidism and arterial hypertension. Studies in recent posed workers are more likely to experience ather-
years have shown that the increased risk of IHD is osclerosis of coronary and cerebral arteries - there is
reversible and reduces with decreasing exposure / evidence that chronic effects of chlororganic pesti-
discontinuation of exposure as well as strict control cides and carbamates may cause lipid metabolism
of other cardiovascular risk factors. disturbances.
Organic nitrates. Many cases of angina pecto- An "exposure-response" relationship has been
ris, myocardial infarction, arrhythmias and sudden found between the professional impact of phos-
death are reported in young workers exposed to pho-organic pesticides and the frequency of "is-
organic nitrates (nitroglycerin and ethyleneglycold- chemic" changes in the ECG.
initrate). Heart incidents are known as "monday Polycyclic aromatic hydrocarbons (PAH). Poly-
morning attacks" because they occur 48-72 hours cyclic aromatic hydrocarbons are thought to have
after discontinuation of exposure. Cardiac attacks not only a carcinogenic effect but also increase the
are thought to be due to "rebound" vasospasm (no risk of IHD - this is in line with the monoclonal theory
coronary atherosclerosis develops) caused by the (EP Benditt et al.) according to which atherosclerotic
temporary cessation of exposure at the end of the plaques can be formed by proliferation of one cell
working week. and seen as benign tumors.

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Workers exposed to PAH found an increased inci- as angina pectoris attacks, myocardial infarction,
dence and mortality from IHD and cerebrovascular or sudden death. Acute exposure to low tempera-
disease. tures may also cause peripheral vasoconstriction,
Physical Factors coronarospasm, and sympatho-adrenal system ac-
Noise. Production noise is seen as a risk factor for tivation. Working under high temperature condi-
the development of arterial hypertension. A positive tions also leads to a disruption of water electrolyte
correlation was found between the intensity and du- equilibrium and increased blood viscosity. It is con-
ration of the noise effect and the incidence of arteri- sidered that overheating microclimate in long-term
al hypertension, serum cholesterol levels, and adren- work can be considered as a risk factor for the devel-
aline and noradrenaline content in the blood and opment of atherosclerosis.
urine. The impact of noise is explained by the activa- Ionizing radiation. Experimental studies have
tion of the hypothalamic-pituitary-suprarenal gland shown that ionizing radiation has atherogenic activ-
and sympatho-adrenal system, generalized vaso- ity, as well as in patients undergoing radiotherapy,
constriction. Experimentally, atheromatous changes there is a premature development of atherosclero-
were observed in the aorta and middle-sized arteries sis. However, there are insufficient epidemiological
as well as morphological changes in the myocardi- studies on IHD incidence and mortality in profes-
um. sionally exposed workers.
Vibration. Production vibrations damage nerve Non-ionizing radiation. Long-term exposure to
endings, perivascular connective tissue and micro- electromagnetic waves may cause development of
vasculature at the extreme periphery, cause vege- neuro-circulatory dystonia (NCD) of hypo-or hyper-
tative and vascular dysfunction. Like the noise, their tensive type. Functional changes may progress to
effects as a chronic intermittent stressor with acti- sustained arterial hypertension.
vation of the hypothalamic-pituitary-adrenal cortex Knowing the harmful effects of chemical and
functional axis and the sympathic-adrenal system physical factors on the cardiovascular system is of
with enhanced catecholamine and glucocorticoid great importance for the prevention of cardiovascu-
release and increased peripheral vascular resistance lar diseases. Their frequency can be greatly reduced
are possible. An increased incidence of arterial hy- in strict compliance with the limit concentrations
pertension and IHD has been reported, as well as li- and rates of chemical and physical hazards, as well
pid disorders in professionally exposed workers. as limiting the entry of workers with an increased
High and low temperatures. In workers with cardiovascular risk - chronic cardiovascular diseases,
coronary sclerosis, the acute effects of high and diabetes mellitus, obesity, hereditary and oth. pro-
low temperatures (where myocardial oxygen needs ductions where there are factors damaging the car-
suddenly increase) can cause ischemic attacks, such diovascular system.

REFERENCES

9. Zlateva M., E. Ivanovich, G. Antov. Cardiovascular system and production factors, Med. and phys., S.,
1984, p. 219. (in bul.)
3. Kotzeva K., T. Popov. Chemical factors in the working environment and cardiovascular diseases Med.
and phys., S., 1990, p. 76. (in bul.)
7. Tsvetkov D., K. Kotseva, M. Boev. Occupational factors and risk assessment - cardiovascular diseases,
dyslipidemias and occupational risk assessment. Current lipidology, 2001, 1, 9-19. (in bul.)
1. Benowitz N. L. Cardiovascular toxicology. In: J. La Dou (ed.). Occupational medicine. Appleton &
Lange, Norwalk, Connecticut / San Mateo, California. 1990, 237-246.
4. Kotzeva K., Zl. Stoyneva, D. Tzvetkov, A. Kiriakov. Cardiovascular effects of occupational exposure
to noise and vibration, Scripta periodica, vol. III, 3, 2000, 530-536.
2. Kristensen T. S. Cardiovascular diseases and the work environment. In: P. N. Cheremisinoff (ed.). Ency-
clopedia of Environmental Control Technology. Gulf Publishing, Houston, vol. 7, 1994, 217-243.
5. Rosenman K. D. Environmental-related disorders of the cardiovascular system. Medical Clinics of
North America, Vol. 74, 1990, 2, 361-375.
6. Tomei F., T. Baccolo, B. Papaleo et al. Cardiovasculopatie professionali: Studio clinico-epidemiologico
delle malattie cardiovasculari nei luoghi di lavaro. Ricerca dei fattori profesionali precoci di rischio. Prevenzi-
one oggi, ISPESL, 1992, 2, 87-148.
9. Zanettini R., K. Kotzeva, O. Agostini, G. Cesana. Esposizione professionale ad agenti chimico-fisici e
malattie cardiovascolari. Archivio di Sciene del Lavoro, 5, 1989, 4, 347-358.

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Iv. Kirova, M. Neykova

15 PHYSIATRICS AND REHABILITA-

TION OF PREFESSIONAL DISEASES
AND INTOXICATIONS
15.1. OCCUPATIONAL INTOXICATIONS Kinesitherapy is a good result in patients with as-
thenovegetative and polyneurial syndrome.
15.1.1. REHABILITATION OF PROFESSIONAL Construction of kinesitherapeutic complex in pa-
METAL POISONINGS ** tients with polineurial syndrome in chronic metal
In professional metal poisonings sulfide mineral poisoning is dependent on the clinical picture that
waters are specifically detoxicating agent, since they is too diverse by the prevailing symptoms and the
associate the metal with their sulfide component effect on one or other peripheral nerves. In the prev-
and eliminate it from the organism. Drinking treat- alence of motor impairment, kinesitherapy was built
ment is with mineral waters with a sulphide content on manual muscle testing. Through the general ton-
of 10-15 mg/l and fluorine at a dose of up to 20 ml/ ing of the patient, the aim is to lower the threshold
kg per day divided into 3 - doses. Sulfid mineral wa- of excitability. It is necessary to choose optimal start-
ters also make inhalations, baths and enemas. The ing positions and to apply, depending on the dam-
baths have a water temperature of 36-37° C, duration age, the method of the proceptive neuro-muscular
of 10-15 minutes in a healing course 15 procedures facilitation with reflective influence of the injured
applied each other day or with 2 rest days weekly. structures, analytical exercises for the limbs togeth-
The sulphide mineral waters in Sapareva Banya are er with relaxing techniques - all based on breathing
particularly suitable. and fortifier exercises.
Both iodine and iodine-bromine natural and arti- A good effect is underwater gymnastics with a
ficial water are used. The methodology of their inter- water temperature of 36-37 ° C.
nal and external application is as for sulphide miner- In patients with astheno-vegetative syndrome
al waters. Iodine-bromine artificial water is prepared kinesitherapeutic complex includes exercises com-
as follows: for 100 batches 2.540 g of potassium bro- bined isotonic and isometric mode extremities, ab-
mide and 1.500 g of sodium iodide are dissolved in domen and gluteal muscles, free active with relaxing
10 l of water1. Place 100 cm3 of the prepared solution effect exercises with upper and lower extremities, ex-
in a bath of 200 liters of water, if necessary tempered. ercise for balance and coordination, to improve the
Contraindications for balneo therapy treatment: sensory, breathing and general roborant exercises.
acute infections; severe- and moderate - severe We train the patient in the ways of general relaxation.
chronic intoxications; sensitivity to sulfur, iodine, The duration of the procedure is 30 to 60 minutes.
bromine; cardiac decompensation; hypertension II The best results are the complex treatment,
degree; infarct; advanced atherosclerosis and the which, depending on the leading syndrome, is:
like. The release of metals from depots is also aided When prevalence of polyneuritic phenomena
by thermal procedures in the liver and kidney. It is occurs with paresis or paralysis of peripheral nerves,
achieved by exogenous heat with paraffin, curative nerve cell electrophoresis, electrostimulation, ki-
mud, infrared, sollux, as well as through endogenous nesitherapy, underwater gymnastics, massage are
heat with diathermy, VHF and microwave therapy. most often used.
With these agents, active hyperaemia is achieved, In astheno-vegetative syndrome is assigned bal-
metabolism increases and stimulates the detoxic neotherapy, galvanic collar with calcium and bro-
function of the liver and kidneys. mine, physical therapy, massage collar, hygienic-di-
Galvanic collar of Sterbach with calcium and bro- etary regime.
mine, electrophoresis with coffein and bromine, ju- In predominance of gastrointestinal syndrome:
niper baths and others are used to restore the func- hygienic - diet regime, drinking treatment, balneo-
tional fitness of the autonomic nervous system. therapy, thermal procedures.
Hepatic disorders recommended drinking miner-
* Iv. Kirova al water from Hisaria, Gorna Banya, Slivenski miner-
** M. Neykova alni bani, spa baths in the same resorts, heat treat-

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 OCCUPATIONAL MEDICINE
ments in the liver area and hygienic-dietetic regime. different starting positions (occipital, lateral leg in
When the prevalence of anemic syndrome, gen- semireclining and sitting position), begins and ends
eral UV irradiations 1/4 biodose daily - 20 days, drink- with abdominal - diaphragmatic breathing and ex-
ing administration of iron-containing mineral water ercises to strengthen the respiratory muscles. Or-
(Breznik) and hygienic-dietetic regime. thostatic and clinostatic responses, equilibrium and
coordination are trained. In sensory disturbances,
15.1.2. PHYSIOTHERAPY AND exercises are given for superficial and deep senses.
KINESITHERAPY IN ORGANIC In patients with chronic intoxications, a good ef-
SOLVENTS INTOXICATION fect on neurasthenic syndrome and vegetative dys-
functions is underwater gymnastics with a water
PHYSIOTHERAPY* temperature of about 36 ° C, as well as underwater
Physiotherapy is applied in chronic intoxications jet massage - 1.5 at (0.15 MPa). Analytical exercises for
and possible detoxification, general body strength- the limbs in isotonic and isometric mode are based on
ening and neurasthenia syndrome affecting, which breathing and tonic exercises. Field terrain treatment,
are differently manifested in individual intoxications. nearby tourism, sport discipline parts apply.
Drinking mineral water treatment at 38-40 ° C,
taken 3-4 times 200-250 ml, 45 min before meals for 15.1.3. PHYSIOTHERAPY AND
4-6 weeks, was shown. The following mineral waters, KINESITHERAPY IN POLYMERS
poorly mineralized (Gorna Banya, Bankya, Hissar, Kn- INTOXICATION
yajevo, Pancherevo etc.), hydro-carbonates (Mramor,
Ilientsi, Chepintsi, Birimirtsi, Kourilo), carbon-acid PHYSIOTHERAPY *
(St. Karadjovo, Mihalkovo), sulfide (Separeva banya, Physiotherapy is applied at the chronic stage
Kyustendil), salted (Mirkovo, Staro- and Novo Orya- and has the following tasks: possible detoxification,
hovo, Shkorpilovtsi, Ovcha mogila). Balneological increase of the general resistance of the organism,
treatment is applied in Velingrad, Bankya, Narechen, influence of the different syndromes (neurasthenic,
Varshets; Mountain climates (Pestera, Kurtovo, Yun- astheno-vegetative).
dola, Borovets, Pamporovo), sea treatment and Black Methods of physiotherapy are described in the
sea resorts. A good effect is treatment with medici- section "Physiotherapy for poisoning with organic
nal baths with juniper, tripinate, brobalyl, rosemary, solvents".
36-37 ° C, 10-15 min, 12-15 procedures. It is a good With vinyl chloride intoxication, besides the
response with: common iontophoresis with calcium above tasks, physiotherapy aims to also influence
and bromine in Vermel (10-20 mA, 15-20 min, 10-12 the available osteoporosis and Raynaud's syndrome.
procedures) or galvanic collar on Shcherbak calcium They are efficient:
and bromine (6-16 mA, 6-16 min, 10-12 procedures) Balneotherapy in Haskovo mineral bani, Momin
brush body massage (15-20 min, 10-12 procedures) prohod, Pavel banya, Kyustendil, Sapareva banya.
psychosensory relaxation of impact of speech, mu- Specific effects on arterial spasm, and osteoporosis
sic, colors and flavors (45-60 min, 8-12 sessions) and is the use of low-frequency magnetic field (12,800
acupressure in the following points: 3CM 14, 16, 19, A/m, 1 Hz, 0,2 s, 1-20 procedures).
20, CPM 6, St 36, DP6, MD4, 11, 3E5, P6, 1-2 min at a Chronic poisoning with ethylene available an-
point, 10-15 procedures. giodistoniya affected by carbon-acid, pearl, oxygen
In the advanced stage of chronic poisoning with bats or medicinal baths with juniper, brobalil, tripi-
carbon disulfide and the occurrence of lesions of the nat (36-37 ° C, 10-15 min, 12-15 procedures). The spa
type of vegetative-sensory polyneuritis, physiother- treatment with radon waters is effective in Momin
apy is applied for this kind of lesions. prohod, Strelcha, Pavel banya, Velingrad and others.
Similarly to the above, in the presence of chronic
bronchitis in chronic phenolic intoxications, physio- KINESITHERAPY **
therapy relevant for this condition is administered. The kinetisi therapeutic complex in chronic poly-
mer intoxications is dependent on the predominant
KINESITHERAPY ** syndrome.
Kinesetherapy is used as a prophylactic agent With Raynaud's syndrome with kinesitherapy, we
when working with organic solvents and for the aim to restore and maintain the blood supply in af-
treatment of chronic poisoning. The number of kine- fected areas. This is achieved with simple in coordi-
sitherapeutic procedures is unlimited. The patient is nation attitude gymnastic exercises for developing
trained in the methods of general relaxation and in type all parts of the body, carried freely and rhythmi-
the so-called autoselect method. It shall apply from cally full amplitude and slow to medium pace, relax-

688
 LABOUR MEDICINE
ing and breathing exercises. Games, swimming and POUNDS AND CARBAMATES *
nearby tourism in proper dosage also have a place in In acute poisoning, physiotherapy is pathogenic
the motoring program. Local therapeutic impact is by the application of cholinolytic agents - atropine
achieved through special exercises for the affected injections/prepared atropini sulfurici 0,0025 g and
limbs. These are active, rhythmic exercises of their aqua destilata 20,0 ml of which for one inhalation, 2
distal parts running freely or against moderate re- ml, 10 min, 10-12 procedures are taken.
sistance and rhythmic short, isometric exercises. The In chronic poisoning, physiotherapy aims to
best results in this respect are obtained by proper ro- detoxify and influence the presence of vegetative
tation of exercises against adequately and relaxation dystonia with predominance of parasympathetic,
techniques, such as active swinging and shaking toxic cerebrovascular and chronic bronchitis. Balne-
of the limbs, the withdrawal of the limb along the otherapy with iodromatic waters (Slanotrun, Shabla,
longitudinal axis - method Schaarschuch, surface Shkorpilovtsi, Staro and Novo Oryahovo), radon wa-
soothing massage, gently stroking, squeezing and ter (Narechen, Momin prohod, Strelcha, Pavel banya,
rocking). Underwater gymnastics with a water tem- Velingrad) is used. Effective is also bats with juniper,
perature of 36 ° C ± 0.5 ° and a submersible jet mas- tripinate, brobabyl, rosemary (36-37 ° C, 10-15 min,
sage of 1.5 (0.15 Mpa) also improve haemodynamics. 10-12 procedures), total brush massage (15-20 min,
In the presence of osteoporosis, the gravitation- 10-12 procedures), acupressure at points: St 36, MD4,
al burden and the tension of the affected bones are 11, P6, PM10, POM6, 3CM14, 20, 1-2 min at a point,
carefully measured. In osteoporosis of the spine is the 10-15 procedures.
most suitable is fixing corset of Hohmann, who has For treatment of existing bronchitis, see "Physio-
a metal frame supporting pelvic bones and armpits. therapy of Chronic dust Bronchitis".
Wearing warm woolen "belts" is more elemental and
widespread. For limbs use dynamic frames that stabi- PHYSIOTHERAPY IN CHLORORGANIC INSECTICIDES *
lize the bones and allow movements in the adjacent Physiotherapy is applied at the chronic stage for
joints. Keep in mind that orthoses weaken muscles the purpose of detoxification and increase of the
and are always applied with kinesitherapy. The most general resistance of the organism. Drinking mineral
suitable for this purpose are analytical exercises in iso- water (250 ml, 38-40 ° C, 3-4 times 45 minutes before
tonic mode of 7-8 s pause and contraction in a ratio meals) and baths with the following mineral waters:
of 1: 1. They are performed repeatedly during the day low mineralized (Bankya, Gorna banya, Knyazhe-
30-40 times for each muscle group. Analytical exercis- vo, Pancharevo, Hissar, Banya - Pazardjik), chlorides
es in isotonic mode are from relieved baseline. Under- (Mirovo, Ovcha mogila, Staro and Novo Oryahovo,
water gymnastics has a water temperature of 30 ° C. Shkorpilovtsi), fluors (Velingrad, Strelcha, Blagoev-
No thermal procedures are given. The basic kinesith- grad, Pavel banya). Water treatment with juniper,
erapeutic principles of gradual, systemic, distraction, salted, salimar, tripinate baths (36-37 ° C, 10-15 min,
etc. are respected. Occupational therapy (entertain- 12-15 procedures) is recommended. Effective is gen-
ing, functional, professional) is also applied. eral ionogalvanisation of calcium by Vermel (10-20
In case of sclerodermic skin changes and thyroid mA, 15-20 min, 10-12 procedures), total brush mas-
hypofunction, a sauna is administered 1-2 times a sage (15-20 min, 10-12 procedures), acupressure at
week in combination with hydrotherapeutic heat points: D4, 11, P6, 3E5 , 3CM14, 16,20, PCM6, St36,
(paraffin or mud application). It can be applied once DP6, 1-2 min at a point, 10-12 procedures.
a week and cryotherapy for both reflex action and
immediate action of cold factor on the tissue tro- KINESITHERAPY FOR PESTICIDES **
phy. Mandatory manual massage and kinesitherapy Chronic poisoning with pesticides has been suc-
including isothermal and isotonic analytical exercis- cessfully applied: autogenous training from various
es, breathing and general tonic exercises are man- starting positions, breathing gymnastics, including
datory. Underwater gymnastics and underwater jet exercises for general influence, breathing rate con-
massage have a water temperature of around 36 ° trol, improved mobility in the diaphragm strength-
C. The kinesitherapeutic program also includes field ening; means for training the orthostatic reactions;
treatment, nearby hiking, swimming. coordination exercises; means for regulating blood
pressure; isometric exercises for pelvic floor training,
15.1.4. PHYSIOTHERAPY AND as well as nearby tourism, occupational therapy, etc.
KINESITHERAPY IN PESTICIDES The basic principles of kinesitherapy are respect-
INTOXICATION ed and, after using the mentioned means, these are
applied without limitation of the procedures in the
PHYSIOTHERAPY IN PHOSPHORGANIC COM- treatment course.

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 OCCUPATIONAL MEDICINE
15.1.5. PHYSIOTHERAPY AND 1 Hz, 0,2 s, 15-20 min, 15-20 procedures). Ultrasound
KINESITHERAPY IN IRRITANT GASES is also effective applied paravertebral of the upper
INTOXICATION limbs at the C3-T4 level, and to the lower limbs at
the level L1-S2, 0.2-0.4 W / cm2, 4-5 minutes for each
PHYSIOTHERAPY* zone. Interference currents (constant frequency 100
In acute poisoning, physiotherapy aims to over- Hz, 15 min, 10-12 procedures), sympatholytic-acting
come the inflammatory process and added upper diadynamic currents applied in the areas described
respiratory tract infections. Heat-moisted inhala- above under ultrasound (100 Hz, 4-5 min, 10-15
tions with 2-3% sodium bicarbonate (2 ml, 10 min), mA, 10 Procedures). Microwaves (0.36 W / cm2, 10-
inhaled etheric oils, antibiotics, sulfonamides, expec- 12 min, 10-12 procedures), ultra-short waves (oli-
torants are made. Mineral water inhalations are ef- gothermal dosage, 10-15 min, 10-12 procedures)
fective: (Mihalkovo, St. Karadzhovo), alkaline (Hissar, are shown. Etiopathogenetically is the effect of ex-
Bankya, Knyazhevo, Velingrad), low mineralized ternally applied sulphide mineral waters (Sapareva
(Gorna Banya, Pancharevo, Banya - Panagyursko, banya, Kyustendil) as well as the sulphate-sodium
Banya-Karlovo), sulphide (Sapareva banya, Kyus- and fluorine waters of Haskovo mineralni bani. It also
tendil). Indicated are: breathing with oxygen, abduc- recomended the iodinebromine mineral waters (Sl-
tion means (chest synapses, suction cups). anotrun, Shabla, Novo and Staro Oryahovo, Shkorpi-
Chronic poisoning is recommended for mountain lovtsi). Efficient acidulae, oxygen, pearl baths, as well
climates in warm and dry weather (Pamporovo, Yun- as four-chamber bathtubs with tripinate, brobalil,
dola, Peshtera, Kurtovo) as well as balneotherapy in salimar (37-38 ° C, 10-15 min, 12-15 procedures).
Velingrad, Sandanski, Momin prohod. At the chronic stage, mild muddy applications
KINESITHERAPY ** (38-40 ° C, 20-30 min, 10-12 procedures) are carefully
In the case of those working in a harmful envi- applied in the stabilization of the condition, taking
ronment, it is necessary to build a kinesitherapeutic into account the individual tolerability.
program for the prevention of poisoning, including: KINESITHERAPY **
increasing the mental tone and the general training Kinesitherapeutic agents have a beneficial effect
with kinesitherapeutics (general tonic exercises, sport on the functions of the autonomic nervous system,
discipline items, puli therapy etc.) targeted respirato- contributing to the normalization of vascular and
ry gymnastics for rhythmic breathing , breathing with muscular tone, improving the metabolic and trophic
extended expiratory phase, for active movement of processes in the limbs. The kinesitherapeutic pro-
the diaphragm and strengthening of the respiratory gram for the prevention of cold diseases includes:
muscles; exercises to improve peripheral haemody- isotonic and isometric exercises for the limbs, relax-
namics; training in local and general relaxation. The ing exercises, breathing exercises, and exercises from
sports disciplines most suitable for the threatened different starting positions at different amplitudes at
professions are: hiking, swimming, skiing. the beginning of the workday (so-called inaugural
In case of pronounced chronic poisoning, we gymnastics). In the middle of the working day, ana-
strive to normalize the functions of the cardiovascu- lytical exercises are performed in isotonic mode at a
lar, respiratory, nervous systems. Depending on the ratio of 1: 1 with free, active, relaxing effect, breath-
clinical picture, methods of blocking the diaphragm, ing and general tonic exercises in baseline, different
the thoracal cage and the spine are used, using func- from the working posture. At the end of the day
tional respiratory reserves; exercises to improve pe- work massages (self-massage), underwater gymnas-
ripheral haemodynamics; autogenous training; field tics with elements of swim sport or swimming, un-
treatment and more. derwater massage, etc.
At angio-neuropathy is used exercises to support
15.2. OCCUPATIONAL DISEASES BY peripheral blood circulation, antiedematous exercis-
PHYSICAL FACTORS es and sensory exercises. Analytical exercise in iso-
tonic mode is up to 90 ° armpits and in a 1: 1 or 3:
15.2.1. PHYSIOTHERAPY AND 1 ratio with free active and relaxing effect exercises.
KINESITHERAPY IN COLD In more severe cases, there is a segmented-reflective
ANGIONEUROPATHY effect on vegetovasal disorders (the method is de-
PHYSIOTHERAPY * scribed in vegetative polyneuropathy). The patients
Physiotherapy aims at influencing the limb frost- are trained in autogeneous workout with the so-
bite, vascular spasm and obliterating thrombangitis. called "Autoselect method".
The most efficient and specific action is the low-sen-
sitivity magnetic field applied topically (12,800 A / m,

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15.2.2. PHYSIOTHERAPY AND tensive type, sea and mountain climatic treatment
KINESITHERAPY IN THERMAL SHOCK, is carried out in the above-described resorts during
THERMAL CRAMP, THERMAL EXHAUSTION the cold seasons. Also shown are carbonic wather
PHYSIOTHERAPY * In heat stroke, physiotherapy and oxygen baths (35-36 ° C, 10-5 min, 10-12 pro-
is applied as a first aid. Place cold compresses (ice) of cedures). Hypotensive effects are expressed by the
the head, pouring, shower or bath with cold water, four-chamber at Hauffe baths, especially combined
wrapping a sheet wetted with cold water, adopting with juniper, brobalyl, tripinate (37-42 ° C, 15-20 min,
a cold liquids, acupressure points PSM24, ZSM20, 10-12 procedures). It also uses a galvanic collar of
28, P9 methodology finger - needle 30 S to 1 min at Shcherback with calcium and bromine, brush body
point. massage, psychosensory relaxation with speech,
In case of chronic overheating it is necessary to music, color, aromas (45-60 min, 8-12 procedures),
provide bathrooms for cold water procedures (baths, acupressure in points: P6, 9, 3CM20, MS4, 11, 15,
showers, swimming pools). It is not only a cooling ef- DP6, 1-2 min at a point, 10-15 sessions.
fect but also a hardening effect. A good effect is the KINESITHERAPY **
sharp temperature changes of the water jet at the In radio wave injuries, kinesitherapy contributes
Scottish shower (hot jet 40-43 ° C, 20-30 s, followed to the increase of the body's general tone, normal-
by cold jet 15-20 ° C, 5-10 s, each repeat 5-10 times, ization of the basic nervous processes, ortostatic
15 -20 procedures. reactions, vascular tone with improvement of blood
KINESITHERAPY ** circulation and the psycho-emotional tone of the
For workers in industries with overheating mi- patient. Depending on the predominant syndrome,
croclimate is prepared kinesitherapeutic program a kinesitherapeutic program is being developed.
aimed at improving the adaptation capabilities of Teaching in autogenous training from different start-
the organism. The program includes exercises and ing positions with and without musical accompani-
techniques with a strong influence on the gener- ment is required. Respiratory gymnastics includes:
al and local blood flow - and lymphatic circulation. exercises to improve passability of airways; to reg-
used: rhythmical exercises in isotonic and isometric ulate airflow and breathing rhythm; exercises for
regimen from different starting points: breathing training and strengthening the respiratory muscles;
exercises (chest, diaphragmatic, yogic breathing). exercises to improve diaphragm mobility, etc. The
Rhythmic muscle contractions and movements of clino - and orthostatic reaction of the patient, the
the joints against adequate resistance from proximal balance and the coordination is trained. Good effect
to distal extremities act as muscle pump and sup- is swimming, cycling, skiing, tourism and more.
port the flow of venous blood to the heart. The pro- 15.2.4. PHYSIOTHERAPY AND
gram includes underwater gymnastics with a water KINESITHERAPY IN RADIATION DISEASE
temperature of 27 °, underwater jet massage with a PHYSIOTHERAPY *
water temperature of 35 ° C, cryotherapy, autogenic The decorporating (etiopathogenetic) effect on
training from different starting positions, swimming, the radionuclides of drinking (3-4 times 250 ml, 45
cycling, hiking, etc. min before meals, 38-40°C, 4-6 weeks) and bath ap-
15.2.3. PHYSIOTHERAPY AND plication of the following bulgarian mineral waters:
KINESITHERAPY IN RADIOWAVE DAMAGES hydrocarbonate-sulphate (Merichleri), low mineral-
PHYSIOTHERAPY * ized and gas waters (Birmirci, Kyustendil), weak min-
Asthenic syndrome and hypotensive type vege- eralized (Gorna banya, Pancharevo), fluors (Sandan-
tovasal dysfunctions, are influenced by physiothera- ski, Haskovo mineral bats, Sliven mineral baths)
peutic agents with a tonic and generalized support- At initial stage are used hardening procedures,
ive effect. The following are shown: sea treatment thalasstherapy in the Black Sea resorts, mountain cli-
in the Black Sea resorts, mountain climate in Pamp- mate treatments in Kurtovo, Pamporovo, Peshtera,
orovo, Borovets, Peshtera, Kurtovo, Yundola, bal- Yundola, Borovets, general brush massage (15-20
neotherapy in Bankya, Narechen, Varshets, Banya min, 12-15 procedures), cold showers, bathing, rub-
- Karlovo, Velingrad. Effective are: bats with brobalil, bing, sauna, etc.
tripinate and juniper (36-37°C, 10-15 min, 12-15 pro- KINESITHERAPY **
cedures), galvanic collar of Shcherback with calcium The use of the kinesitherapeutic program depends
and bromine (6-16 m A, 6-16 min, 10-12 procedures), on the nature of the damage and the stage of the
brush body massage (15 -20 min, 12-15 procedures), radiation illness. Kinesitherapy increases the body's
acupressure at points: DM20, PM10, MD4,11, St36, general tone, stimulates cortical processes, helps
DP6, P9,3E5, 1-2 min at a point, 10-12 procedures . normalize the functions of different organs and sys-
In vegetative-vascular dysfunctions of the hyper- tems, and improves the patient's psycho-emotional

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tone. Applied: music therapy, psychosensory relaxa- 15.2.6. PHYSIOTHERAPY AND
tion or autogenic training from different starting po- KINESITHERAPY IN MOUNTAIN SICKNESS
sitions; breathing gymnastics, including exercises to PHYSIOTHERAPY *
improve the strength of the respiratory muscles and Physiotherapy aims to increase the general psy-
the chest, to strengthen the diaphragm; exercises chophysical sustainability of organism through gen-
and techniques with beneficial effects on the cardio- eral fortify procedures.
vascular system and on the musculoskeletal system; Apply: climatic impact of the high mountain asso-
terrain treatment; underwater gymnastics with a wa- ciated with physical activity and sharp change of the
ter temperature of 34-35 ° C; occupational therapy mountain altitude, achieved with specially selected
(functional, professional) and in the first stage of the tourist routes. Shown are: balneotherapy with slight-
disease and mobile games and elements of sports ly mineralized waters (Bankya, Varshets, Knyazhevo,
disciplines. Gorna Banya, Stara Zagora mineral baths Banya -
15.2.5 PHYSIOTHERAPY AND Karlovo, etc.), sun - and sea-prophylaxis, hardening
KINESITHERAPY IN CAISSON DISEASE bath treatments (sauna, pouring and rubbing with
PHYSIOTHERAPY * cold water, brush massage the entire body (15-20
After exiting the recompression chamber physio- min, 10-12 procedures), acupressure points in: St36,
therapy helps to separate the nitrogen from the tis- DCH4, DP6, 3E5, 3SM20, 1 min at any point 10-12
sues by: general classical massage (30-40 min.), hot procedures.
dry air or water procedures (steam bath, hot tub - 39- KINESITHERAPY **
40 ° C, 8-10 min) or lighter (SOLUX) - 15-20 min. When operating in conditions of reduced atmos-
In chronic forms, physiotherapy appropriate to pheric pressure prepares a long-term kinesithera-
developed syndromes is employed: e.g. Meniere's peutic program for training and adapting the body
syndrome(See Physiotherapy for vestibular analyzer requirements of the working environment. The pro-
damage), which distorts arthrosis (see Physiothera- gram includes exercises and techniques with bene-
py of musculoskeletal system disorders). ficial effects on the cardiovascular system (improv-
KINESITHERAPY * ing venous and lymphatic flow, to regulate arterial
Kinesitherapy is dependent on the clinical form of pressure, supports heart, training orthostatic effects,
caisson disease. Muscular - articular forms are admin- etc.), breathing exercises with training in abdom-
istered: treatment by means of a situation in which the inal-diaphragmatic, thoracic and yogic breathing;
posture of the limb is changed and maintained in a exercises and methods for nervous system response
physiological situation, isometric training in different and special ones for the visual, auditory and tactile
modes (1: 3 or 1: 1 - contraction: pause); respiratory analyzers; Exercises to develop muscle strength and
gymnastics to improve ventilation and circulation in endurance, coordination and balance; exercises act-
the lungs, to regulate respiratory rhythm, airflow, and ing relaxing and mobilizing on certain segments of
to strengthen the respiratory muscles and diaphragm. the back muscles, etc.; sport disciplines (swimming,
Relaxing and drawing methods used in respiratory cycling, skiing, basketball, etc.).
gymnastics and autogenous training are used. After 15.2.7. PHYSIOTHERAPY AND
pain relief, the exercises are in isotonic mode in a 1: 1 KINESITHERAPY IN VIBRATION DISEASE
ratio - relaxing. They also apply to general tonic exer- PHYSIOTHERAPY*
cises from different starting positions. Physical therapy is administered throughout the
In case of pronounced hemiparesis or hemiparal- course of the disease, but the most effective is in
ysis with aphasia, ataxia, etc. the kinesitherapeutic stage I and II. Physical agents are applied segmen-
complex includes: treatment by position; the spe- tarily in the root zone of C3-T4. Shown are: ultra-
cialized methodologies of Kabat, Bobat, etc.; cryo- sound paravertebrally (0,2-0,4 W/cm2, 4-5 min, 10
therapy; massage (relaxing), and at aphasia and ex- procedures), electrophoresis with novocain, pyma-
ercises to restore speech functions. din, nivalin, potassium iodide, calcium chloride (10-
In case of Meniere's syndrome, autogenous train- 15mA, 10-20 min, 10 -12 procedures), Shcherback
ing is applied in the patient's preferred position; collar with calcium, bromine, magnesium (6-16 mA,
exercises for training the vestibular apparatus from 6-16 min, 10-12 procedures), diadynamic currents (1
relieved baseline at the beginning of the treatment min DF, 3 min KS, 3 min DC, 5-15 mA, 10 -12 proce-
course; coordination exercises; breathing and gener- dures), microwaves (0.36 W/cm2, 10-12 min, 10-12
al tonic exercises. procedures), ultraviolet erythemas in the form of a
In neuritis of the facial nerve after testing, the pa- sea collar (1-3 bio-doses, 5-6 procedures).
tient performs mimic gymnastics under the control Has expressed anti-pain and improving vascular
of the kinesitherapist. tone effect of low-frequency magnetic field (16,000

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 LABOUR MEDICINE
A/m, 0,3-0,4 s, 1 Hz, 15-20 min, 15 procedures), in the plex acupressurec acupressure combined with tech-
same acupuncture points; of laser puncture (6 mW, niques of classic massage - rub, caress the neck and
30 s to 1 min at point) and acupressure by 1 min at the area around the ear). Acupressure is applied at
point: points ZHM20, PM10,11, DCH4,10, 3E5, P6, the following points: PM10, DM2, 8, 12, 20, 19, 3E 5,
St36, TCH11, 10-12 procedures. 19, 20, 21, 23, 2 min at a point, 15-20 procedures.
In resort situation apply: four- camera baths, or
baths with juniper, brobalil, thymiane, sulfidium, 5.3. PROFESSIONAL DUST RESPIRATORY
sulfolil (36 ° C, 10-15 min, 12-15 procedures), sulfide DISEASES
baths (Separeva banya, Kyustendil), radon baths
(Momin prohod, Narechen, Pavel banya, Strelcha) PHYSIOTHERAPY IN SILICOSIS *
iodinebromine baths (New and Old Oriahovo, Sl- It is a long-term and aim delaying the course of
anotran, Shabla Shkorpilovtsi), sea treatment, mud the disease, fighting infections and complications.
treatment (38-40 ° C, 20-30 min, 10-12 procedures), In the initial stage particularly efficient methods
general brush massage (15-20 min, 10-12 proce- for suppressing silicotic fibrosis are: aerosolthera-
dures) or underwater massage with tangentor (36- py with polyvinylpyridine - N oxide (R 204) 2 ml, 10
37 ° C, 1 atm, 20-30 min 10-12 procedures). min, 15 procedures suberythemal UV irradiation of
KINESITHERAPY ** the thorax (10-15 procedures), ultra high currents
Kinesitherapeutic complexes in vibration disease (oligotermal dosage, 10-15 min, 10-12 procedures).
prepares on the basis of the syndrome leading to the For elimination of the powder, expectorating and
clinical picture and the stage of the disease. The ki- antiinflammatory apply: warm-damp, salty-alkaline
nesitherapy procedure begins and ends with a total and alkaline inhalations (2 ml, 10 min, 10-12 pro-
relaxation of 10 minutes. In patients with stage I, the cedures) aerosoltherapy with radon mineral waters
ratio between analytical exercise in isotonic mode (Momin prohod, Hissar, Krasnovo, Pchelin, Strelcha),
and free relaxation-active exercise is 1: 1. In II and II- hydro-carbonates (Velingrad, Birmirci, Knyazhevo,
III stage of disease at the position of general relaxa- Mramor, Gorna Banya), chloride (Mirovo, Varbitsa,
tion, forearms are resting on the pads and raised to Novo and Old Oryahovo, Ovcha mogila), iodine-bro-
40 °, with the ratio between the analytical and relax- mine (Shabla, Slanotrone and Shkorpilovtsi) and low
ation exercises is 3: 1. They are based on breathing mineralized waters (Hissar, Bankya, Pancharevo, Var-
and general low tonic exercises. shets, Banya - Karlovo). Inhalatory, bronchodilatory,
In the II-III stage of the disease, the method for mucolytic, antibacterial preparations are also used.
segmental-reflective action on vegetovasal disor- Climate and balneotherapy are very important, es-
ders (described in vegetative polyneuropathy) has a pecially in the I and II stages of the disease. Special-
very good effect. ized resorts are: Varna Black Sea Coast, Bankya, Kyus-
Underwater gymnastics in vibration disease is tendil, Dolna Banya, Levochevo, Smolyan, Velingrad,
conducted at a water temperature of 36 ° C ± 0.5 ° C, Shipka, Troyan. Significant role plays the primary
8 to 25 minutes, 15 procedures. Analytical exercises and secondary physioprophylaxis performed in the
for upper limbs in isotonic mode at different rates prophylactorium. The following are used: bronchial
and amplitudes have a shoulder belt in the aquatic inhalation "toilet" with low-mineralized and alkaline
environment. They are followed by breathing exer- waters, ultraviolet irradiation in solariums, water-
cises where the heart area is above the water. The sun- and aeroprocedures with hardening effect.
basic principles of kinesitherapy are followed by ex- PHYSIOTHERAPY IN DUST CHRONIC BRONCHITES *
ercising with the lower limbs and the corpse. After It is anti-inflammatory and has a bronchodilato-
3-4 procedures, elements of swimming and water ry effect. In the phase of exacerbation apply: aero-
polo games are also included. soltherapy with sulfonamides, mucolytics, broncho-
15.2.8. PHYSIOTHERAPY IN dilators (2 ml, 10 min, 10-12 procedures), or with
PROFESSIONAL DEAFNESS * mineral waters: alkaline (Bankya, Velingrad, Pavel
The disease is refractory, which is why physio- bani, Hissar Knyajevo) sulfide (Separeva banya, Ky-
therapy is early and multi stage. It aims to improve ustendil), radon (Momin prohod, Narechen, Kras-
blood circulation and conduction of the nerve. In the novo, Strelcha, Pchelin) iodine-bromine (Slanotran,
initial "acute" stage ionophoresis with nivalin, pyma- Shabla, Shkorpilovci), salty (Mirovo, Old and New
din novocain, potassium iodide, stugeron, 0.5-1.2 Oryahovo, Varbitsa, Ovcha mogila), carbon-acid (St.
mA, 10-15 min, 10-15 procedures is assigned. Karadzhovo, Mihalkovo Ilientsi, Mramor), low miner-
The chronic stage has beneficial effects with a alized (Varshets, Banya - Karlovo, Gorna Banya - So-
low-frequency magnetic field (12,400 A/m, 0,2 s, fia, Stara Zagora mineral baths). Also recommended
1 Hz, 15-20 min, 20 procedures). Efficient is a com- are: suberythemic thoracic radiation with ultraviolet

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 OCCUPATIONAL MEDICINE
rays (10-12 procedures), ultrashort wave (oligother- Respiratory gymnastics should be combined with
mic dosage, 10-15 min, 10-12 procedures), low-fre- oxygen therapy and aerosolotherapy.
quency magnetic field (16,000 A/m, and 1 Hz, 0, 2
s, 15-20 min, 10-15 procedures), chest massage with 15.4. OCCUPATIONAL OVER-TENSION
vibrating and percussion techniques, acupressure in
points: BD 1, 7, 9, MS4, PM13, 3CM14, MD11, 2 min at 15.4.1. PHYSIOTHERAPY AND
a point, 10-15 procedures, total Vermell calcium ion- KINESITHERAPY IN
tophoresis (10-20 mA, 15-20 min, 10-12 procedures). MUSCULOSKELETAL DISEASES
In the phase of remission are shown aeroiono- PHYSIOTHERAPY *
therapy (10-15 min, 10-12 procedures), aerosolo- Physiotherapy attempting to remove inflamma-
therapy with expectorant and anti-inflammatory tion, pain, improve circulation and trophic tissue,
drugs, sea treatment, mountainous climate treat- restoring the function of the hand. Physiotherapy
ment (Levochevo, Smolyan, Troyan), balneotherapy is applied in all three stages of the disease by hand
(Sandanski, Momin prohod, Velingrad). The healing overtension.
procedures are important: sunny - air baths, sea In the first stage are preferably administered an-
baths, bathtubs and showers with cold water, sauna tiinflammatory and anti pain means: diadynamic
and others. currants (local and segmentary - reflex zone of the
KINESITHERAPY IN PROFESSIONAL DUST C3-T4,1 min MF, 3 min KC, 3 min DS, 5-15 mA, 10-12
DISEASE OF RESPIRATORY SYSTEM ** procedures) interference currants (constant frequen-
Kinesitherapy is shown predominantly in I and II cy 100 Hz, 15 min, 10-12 procedures), ultraviolet ery-
(compensated and subcompensated) stage of the themas as a "cuff" over the pathological process and
disease. Tasks for general positive impact and im- in the form of a "mariner's collar", (1-3 bio-doses, 5-6
provement of the functions of the cardiovascular procedures), galvanic collar of Shcherback (6-16 mA,
system are solved with general - developed exercis- 6-16 min, 10-12 procedures). The anti-pain effect of
es and dosed training with walking, climbing and acupressure at the points: D4, 11, 15, TH3, 11, 3E5, 14,
descending on stairs, swimming, biking, etc. Special GM 20,21, PM 10, 11, 60, St 36,P 6, 1-2 min in point,
tasks on respiratory function are solved with pur- 12-15 procedures.
poseful breathing exercises in the form of systemic In a second stage in the phase of exacerbation be-
breathing gymnastics. sides the above-described physiotherapy agents are
The parts of the lung with sustained elasticity are also such to improve blood circulation and trophic:
moved by appropriate starting positions and various ultra high frequency currents (oligohermic dosage,
ways of assisting chest excursions and the unfolding 10-15 min, 10-12 procedures), microwaves (0,36 W/
of the pulmonary parenchyma. cm2, 10-12 min, 10-12 procedures), ultrasound or
Patients with pneumosclerosis and leading re- phonophoresis with ointments with voltaren, in-
strictive syndrome, respiratory failure with diaphrag- dometacin, hydrocortison (0,4-0,5 W/cm2, 5-6 min,
matic breathing, tachypnea and shallow breathing, 10-12 procedures), ionophoresis with novocain, li-
should not be reduced much respiratory rate, and docain, potassium iodide , nivalin, calcium and oth-
to find optimum frequency, depth and rhythm of ers. (10-15 mA, 15-20 min, 10-12 procedures). With
breathing under which consumes minimum energy expressed anti-pain and anti-inflammatory effects
to overcoming resistance. include: acupressure (described above), laser punc-
In case of gas diffusion disturbances, the use of ture at the same points (6 mW, 30 s - 1 min, 8-12
a characteristic breathing technique with pause in procedures), low-frequency magnetic field (14,400
maximum breathing is indicated. Patients with in- A/m, 1 Hz, 0, 5-0.6 s, 15-20 min, 10-12 procedures). In
terstitial fibrosis, accompanied by chronic bronchitis the phase of subsidence of acute phenomena apply
and emphysema, who have respiratory disturbances baths with sulphide waters (Separeva banya, Kyus-
at rest, are usually able to perform a significant vol- tendil), radon waters (Momin prohod, Narechen, Ve-
ume of muscular work. Physical effort can reduce lingrad, Pavel banya), iodine-bromine waters (Shabla
bronchospasm. Assisted ventilation is applied not Shkorpilovci), salted (Mirovo, Vurbitsa, Slanotran ),
only to normalize air distribution but also to re- paraffin procedures (30 min, 55 °, 10-15 procedures),
duce respiratory rate within certain limits, extend mud applications (40-42 ° C, 20-30 min, 10-12 pro-
the exhalation phase and reduce residual air, when cedures).
increased. Attention is paid to the relaxation and In the third stage, physiotherapy is predominant-
enhancement of respiratory muscles. In this way ly symptomatic - against pain, contracture, degener-
breathing is economized. In cases of increased se- ative changes, adhesions, reduced volume of move-
cretion, drainage situations and exercises are used. ment, etc. Apply: phonophoresis with aminosin,

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voltaren, indometacin, ionophoresis with potassium sive loading agonists. The exercises are without ap-
iodide, novocain, lidocain, low-frequency magnetic pliances, with appliances and appliances, against
field, UHF microwave, lye compresses (38-40 ° C, 20- adequate resistance. Gradually, isotonic movements
30 min, 12-15 procedures), mud, applications acu- acquire the character and approach the rhythm of
pressure, cryotherapy (with an ice bar, rounding for 1 the productive activity with the active involvement
minute, repeated 3-4 times, according to individual of the damaged structures.
tolerance, 8-10 procedures). 15.4.2. PHYSIOTHERAPY AND
KINESITHERAPY ** KINESITHERAPY IN PERIPHERAL NEURVOUS
The construction of individual complexes in kine- SYSTEM DISEASES
sitherapy is based on functional disorders in the limb PHYSIOTHERAPY IN LUMBOSACRAL AND CERVI-
and the localization of injuries. Depending on the CO-BRAHIAL RADICULITIS *
stage of the disease, a healing-sparing, healing-tonic Physiotherapy aims to combat pain, improve
or healing-training regime is applied. the inflammatory process, nervous conduction and
In the healing-sparing regime, damaged struc- waste motor and sensory manifestations. Anti-pain
tures influenced indirectly in the first days. The and anti-inflammatory apply diadynamic currents
patient is trained in the techniques of general re- (or diadynamophoresis with novocain, lidocain,
laxation, which is applied for 10 minutes at the be- 1 min DF, 3 min KC, 3 min DS, 5-15 mA, 10 proce-
ginning and end of the procedure. His attention is dures), novocain and potassium iodine ionophore-
directed to localized pain for the application of the sis (10-15 mA, 20 min, 10 procedures), interference
so-called auto select method. The analytical exercis- currents (constant frequency 100 Hz, 15 min, 10-12
es for the analogous muscle groups of the injured procedures), low frequency magnetic field (16,000
are aimed at their reflective repercussion. They are A/m, 0,2 s, 1 Hz, 15-20 min, 12-15 procedures) , ultra-
without and with damages, with manual resistance sound/phonophoresis with indometacin, voltaren,
at different rates and from different starting posi- hydrocortisone, 0.5-0.6 W/cm2, 5-6 min, 10-12 pro-
tions. For the damaged limb, the first days are given cedures), ultraviolet erythemas (1-3 biodoses, 3-4
only free active with relaxing effect exercises. Exer- fields, 6-8 procedures), microwaves (0.36 W/cm2,
cise from lighter position eliminates pain, relaxes 10-12 min, 10-12 procedures), ultra-short waves (ol-
muscles and improves haemodynamics. When the igothermal dosage, 10-15 min, 10-12 procedures). A
muscles of the forearms are damaged, the move- good application effect (at the same acupuncture
ments are performed initially in the shoulder joint. points) of acupressure and laserpuncture (6 mW, 1
Later, flexion and extension of the elbow joint was min per point) was found. The cervico-brachial radic-
provided, which involved the injured structures from ulite dots complex is: JM12, 20,21, PM10, 11,13,3CM
relieved baseline. Movements are combined with 14, 3E 5,14,15, TH3, 9-15, D4, 11, BD1, and for lumbo-
breathing exercises. General tonic exercises for the sarral radiculitis: 34, 36, 40, 60, 62, DM 30, 1 minute
carcase and lower extremities with high intensity are at a point, with the soothing acupressure method,
applied to the general principles of kinesitherapy 12-15 procedures.
and to the improvement of general blood and lym- For elimination of waste phenomena and im-
phocirculation. provement of nerve conduction: ionophoresis with
The healing-toning regime is progressing grad- pymadin, nivalin (10-15 mA, 10-20 min, 12-15 proce-
ually. Affected structures are involved in movement dures), stimulation with low-frequency currents (ac-
first as synergists and later as agonists. The action cording to individual parameters) or with sinusoid
of the muscles in the fingers is performed with the modulated Currents (also on an individual sheme).
synergistic activity of the muscles in the wrist and In discopathy are administered by manual ther-
vice versa. Isometric training is in different modes. At apy, extensive therapy, acupressure (as described
the beginning the contraction: pause is 1:3, and later above).
changes 1:1. Analytical exercise in isotonic mode is In the chronic stage, balneotherapy with sul-
1:1 ratio, with free, active relaxing exercises. Exercis- phide waters (Sapareva Banya, Kyustendil), radon
es for the contralateral limb are without appliances, water (Momin Prohod, Pavel Banya, Velingrad) is
with appliances and appliances against maximum performed.
resistance. The complex includes breathing, co-or- KINESITHERAPY **
dinating exercises and games that improve not only The aim of kinesitherapy here is by stimulating
the general blood- and lymphocirculation and the the regenerative processes to restore nerve conduc-
psycho-emotional tone of the patient. tion, preventing the formation of secondary defor-
The healing-training regime is applied after pain mations, and in case of irreversible defects, compen-
relief. Affected structures are included as progres- sation is formed.

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Kinesitherapy begins the first few days with exer- with juniper, trypinate, brobalil(36-37°C, 10-15 min,
cises for the healthy limb against manual resistance 10-12 min, 10-12 procedures), Scherback galvanic
and instruments to reflexively affect damaged struc- collar (6-12 mA , 6-16 min, 10-12 procedures), gen-
tures. For paretic muscles passive exercises are given eral brush massage (15-20 min, 10-12 procedures).
several times a day, for undamaged muscle groups They have anti-pain effect: ultraviolet erythemas (1-3
- active. It starts from the proximal to the distal parts biodoses, 6-8 procedures in the form of seaman's
of the limb. Passive and active exercises improve collar), diadynamic currents or diadynamophoresis
circulation, reduce venous- and, lymphatic stasis with novocain (1 min DF, 3 min KC, 3 min DS, 10-
and concomitant edema. Movement in the joints 15 mA, 10-12 procedures). Amplification of trophic
and pulling of the paretic muscle groups prevents and vascular changes with other physical factors:
adhesions and joint contractions. Treatment is also low-frequency magnetic field (16,000 A/m, 1 Hz, 0,2
applied by a position in which the joint is in a func- s, 15-20 min, 15 procedures); Acupressure in points:
tional position. DM20,21, PM10,11, 3CM14, MD4, 11, Th3,3-15, 3E5,
The kinesitherapy and massage procedure should St36, DP6, 1-2 min at a point, 12-15 procedures; laser
be light, non-traumatic, as the denerved muscle fib- puncture at the same points, 6 mW, 30 s - 1 min at
ers are sensitive to mechanical trauma, that acceler- a point, 10-12 procedures. In the second and third
ates atrophy and leads to degeneration. stages except the above procedures are shown: si-
With the onset of active movements, the follow- nusoidal-modulated currents (in alternating mode,
ing additional tasks are set: elimination of substitu- III gen, 80-100 Hz, depth of modulation 25%, series
tion and compensatory movements; improvement duration 1-2 s), interference currents (with constant
of exteroreceptive sensitivity and coordination; frequency 100 Hz, 15 min, 10-12 procedures), micro-
complete restoration of muscle function and muscle waves (0.36 W/cm2, 10-12 min, 10-12 procedures),
strength (note that during the restoration phases, ultra high frequency currents (oligothermal dosing,
all senses in the limb acquire a hyperpathic tinge). 10-15 min, 10-12 procedures), ultrasound 0.2-0.4 W/
A good effect is underwater gymnastics. Massage cm2, 5-6 min, 8-10 procedures), mud collar (38-40°C,
techniques paravertebrally on cervical and thoracic 20-30 min, 10-12 procedures), paraffin application
vertebrae have a reflective effect on injured struc- (55°C, 20-30 min, 10-12 procedures) - all described
tures. Kinesitherapeutic procedures and massage procedures applied segmentary-reflectory In the C3-
procedures should not cause pain as it leads to in- T4 zone. Common baths or bath tubs for hands are
creased muscle tone and contractions. Procedures also shown with: sulphide mineral waters (Sapareva
choose the optimum starting position. Active moves Banya, Kyustendil), radon mineral waters (Momin
are sought, maintained and developed. In the pres- Prohod, Velingrad, Strelcha, Pavel Banya). Climate
ence of willing contractions by isolated accurate treatment of the Black Sea resorts is recommended.
movements (analytical gymnastics with adequate KINESITHERAPY **
dosage), a given muscle is trained. Passive move- In patients with pronounced angiospastic syn-
ments to maintain the volume of movement are also drome, the ratio of analytical exercises to isoton-
applied. The method of proprioceptive neuromus- ic mode and free, active relaxing exercise is 1: 1. In
cular facilitation is also used, where the contractions those with spastic-atonic and atonic vessels, analyt-
of the paretic muscles are facilitated by those of the ical exercise in isotonic mode is up to 90 ° forearms
preserved muscle groups. During the procedure, and is in a 3: 1 ratio with relaxation exercises. Proce-
the paretic musculature is contracted and the an- dures begin and end with total relaxation.
tagonists are stretched. In definitive changes, when The best and quickest effect on vegetovasal dis-
nerve damage is not recovered, attention is directed orders in patients with moderate and severe disease
to training in substitution movements. is combined segmented-reflexology.
15.4.3. PHYSIOTHERAPY AND Segmentary-reflective effect is accomplished by:
KINESITHERAPY IN VEGETATIVE 1. General relaxation of occipital leg with thermal
POLINEUROPATHY AT THE UPPER LIMBS procedure performed by a cushion of wool cloth in
PHYSIOTHERAPY * the area of t​​ he cervical and upper thoracic vertebrae
It aims at increasing resistance and improving the - 10 min.
local pathological process - influencing vascular, veg- 2. A 15 minute procedure where the patient's
etative and trophic disorders; pain relief; improved head is outside the couch on the knee of the ki-
hand functions. It is recommended that the segmen- nesitherapist for free access to the neck area. Per-
tal-reflective application of the physical factors in formed: superficial and deep stroke; treatment of
the paravertebral zone of C3 - T4 is recommended. In reflective changes in the skin, connective tissue,
the first stage to improve the general condition, bats muscle and periosteum by appropriate toning or

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sedative techniques, acupressure paravertebral at and decongestant effect on the bronchi, restoring
the base of the skull and on C4-5; manual resistivity the function of the external breathing, rehabilitation
of head movements and on distal parts of forearms; of foci.
passively, flexion, extension, rotation and circles are During the attack, aerosol therapy with broncho-
performed, followed by low flexion of the head with dilators (astmopen, ventolin, salbutamol, berotec,
a manual extension. Again in the position of gener- inthal, etc., 2 ml, 5-10 min) is the most effective. Very
al relaxation patient performs isometric training the effective is the application of various physical factors
muscles of the upper limbs and shoulder girdle, ab- in acupuncture points (acupuncture, electroacu-
dominal-diaphragmatic breathing and relaxation. puncture, laserpuncture, acupressure). The follow-
Under-water gymnastics also have a good effect. ing points are used: BD1,2,7, B27, Ст9,10,13,36, PMM
15.4.4. PHYSIOTHERAPY AND 17,21,24, 3SM14, PM10, 43, GM20, 21, DC4,10, DP6.
KINESITHERAPY IN OCCUPATIONAL In case of attack, four chamber baths at Haufe (for
DYSKINESIAS redistribution of blood to the limbs and alleviation
PHYSIOTHERAPY * of the lungs) are also administered - 37-42 ° C, 15-20
Physiotherapy is prolonged, multi-stage and aim min.
to relieve congestive focus in the central nervous sys- Outside attack applies aerosolterapy with anti- al-
tem and eliminate pathological reflexes by strength- lergy (antihistamine) drugs such as: alergosan, sin-
ening and sedative procedures. There are: moun- open, dimedrol and oth., mucolytics (mucosolvin,
tain climates (Troyan, Ribaritsa, Yundola, Peshtera, bromhexin, sodium bicarbonate, etc.) 2 mln 10 min,
Pamporovo, Borovets) and sea treatment during the 15-20 procedures and with radon mineral water
cool seasons in the Black Sea resorts. Balneotherapy (Momin Prohod, Narechen, Velingrad), hydrocarbon
procedures are also displayed in Narechen, Varshets, sulphate (Sandanski). Effective are: air ionization (10-
Bankya, Velingrad, as well as medicinal baths with: 15 min, 12-15 procedures), low-frequency magnetic
juniper, tripinate, brobalil, rosemary (36-37 ° C, 10-15 field in the adrenal area and local (16,000 A/m, 1Hz,
min, 12-15 procedures). 0,2 s, 15-20 procedures), ultrasound (segmentaryre-
Effective are: ultralow wave (oligothermic dos- flexly) in three zones : two fields paravertebral T1-T12,
age, 10-15 min, 10-12 procedures), galvanic collar on 0.2 W/cm2, 2 min, VI and VII intercostal bilateral, 0.4
Shcherbak with calcium, bromine, magnesium (6-16 W/cm2, 2 min, subclavicular areas 0.2 W/cm2 for 1
mA, 6-16 min, 10-12 procedures), a general brush min, 10-15 procedures, UHF (oligothermic dosage,
massage (15-20 min, 10-12 procedures), psychosen- 10-15 min, 10-12 procedures), ultraviolet irradia-
sory relaxation with speech, music, colors, aromas tion of the thorax or in total in suberithemic dos-
(45-60 min, 8-12 procedures), acupressure at points: age 10-12 procedures classical massage chest with
St36, DP6, 3CM20, 11, P6, 2 min at a point, 12-1 5 pro- vibrating and percusion devices (10- 15 min, 10-15
cedures. procedures). The resort treatment is essential in the
KINESITHERAPY ** specialized resorts: Sandanski, Momin Prohod, Ve-
At coordination neuroses (dyskinesias) by means lingrad, Levochevo, Smolyan, Troyan, Dolna Banya,
of kinesitherapy improve strength, mobility and Kostenets, Black Sea resorts.
steadiness of the main nerve processes, suppress Physioprophylaxis includes: aero-, sun- and hydro
be pathological reflexes and recovers dynamic ste- procedures hardening; rehabilitation of the inflam-
reotypes of the working movement. Kinesitherapy matory processes of the upper respiratory tract with
includes: autogenous workout, soothing massage, physioprocedures (UHF, UAV, inhalations, etc.).
stretching of the limbs along their longitudinal axis KINESITHERAPY **
using the Schaarchuch method, free active relaxing Kinesitherapy in patients with bronchial asthma
exercises, proprioceptive neuromuscular facilitation, is applied in out-paroxysmal periods. It aims to: re-
exercises with antagonist replacement, underwa- duce the hypersensitivity of the body to allergies by
ter gymnastics, underwater jet massage, suspen- destroying the pathological dominant and patho-
sion therapy, field treatment, breathing gymnastics, logical reflexes; to normalize major nerve processes;
swimming, tourism and more. to strengthen the patient's psyche by training him in
proper, rhythmic breathing. Often, only relaxing of
15.5 OCCUPATIONAL ALLERGIC muscles improves breathing. Achieved by: psychic
DISEASES - BRONCHIAL ASTHMA response (verbal, music, abducting therapy); with
autogeneous side-bed, bed, seat, training etc.; with
PHYSIOTHERAPY * relaxing exercises for the upper limbs, the shoulder
Physiotherapy apply: non-specific desensitiza- belt and the chest; rhythmic massage with vibra-
tion of the organism, anti-spastic, anti-inflammatory tion of the chest with shaking; with relaxing-pulling

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poses and more. Respiratory gymnastics includes: the patient. Kinesitherapy during this period is also
breathing exercises for general impact; to improve of great importance for the prevention of post-op-
the passing of airways; exercises and means for reg- erative complications such as lung atelectasis, hy-
ulating airflow and breathing rhythm; exercises for postathic or aspirational type bronchopneumonia,
training and strengthening the respiratory muscles phlebotrombosis, embolism, etc.
and improving the mobility of the chest and dia- With rehabilitation in the late postoperative pe-
phragm; exercises to unblock the diaphragm, as riod and in the home environment, the respiratory
well as exercises to control the cough and to assist and cardiovascular systems and the general tone of
expectoration. Particular attention is paid to the ex- the organism are maintained in the possible good
halation, which should be slow, soft and prolonged, state. There is also psychological adaptation of the
without impulses and unnecessary strain. In the patient in the family and society.
presence of emphysema the patient is assisted in the Rehabilitation in patients with nasal and sinus
expiratory phase. For respiratory gymnastics appro- cancer
priate starting positions, poses and stands are used. The development of the kinesitherapeutic pro-
It is important for the patient to develop habits for gram depends on whether radiotherapy or surgical
reconciliation of breathing with general develop- treatment is performed. In radiation therapy the
ment and applied exercises (walking, climbing and patient is trained in autogenous workout, rhythmic
descending, body inclines and curves, etc.). breathing and mimic gymnastics. After surgery, with
subsequent prosthetics and speech disorder, kine-
15.6. PROFESSIONAL MALIGNANT sitherapy aims, in addition to restoring psychic equi-
NEOPLASMS ** librium and possible correction of speech disorder.
The patient is required to speak loud the vocals in
A complex rehabilitation program is needed in front of mirror and then make syllables and small
cancer patients. It is important to initiate early reha- words like "alo", "echo", "mum", "sea" etc. combined
bilitation, patient co-operation and relatives, gradu- with proper breathing. Autogenetic workout, mim-
al transition from hospital to ambulatory and home ic gymnastics, occupational therapies, which from
rehabilitation. amusement pass to functional and professional, are
Rehabilitation in patients with skin cancer applied.
Kinesitherapy in skin-operated aids skin healing Rehabilitation in patients with larynx cancer
and prevents the formation of large scars that limits Rehabilitation is aimed at a possible recovery of
the function. With scars already formed in addition to the psyche and of the voice function. The patient is
gymnastic exercises in isotonic and isometric mode, trained in autogenous training, rhythmic breathing
massages, phonophoresis with anti-scarsing creams, with extended expiratory phase, abdominal-dia-
ointments, gels (indomethacin, contratubex, made- phragm breathing and isometric training of abdom-
casol, etc.) are also used. inal muscles. Rehabilitation of speech is accom-
In radical lymph dissections usually leave heavy plished through: training; voice prostheses; plastic
and persistent lymph edemas that restrict limb func- surgical procedures. The so-called "esophagous
tion and lead to disability. With early targeted kine- voice" is best suited for this purpose, and training
sitherapy, where rhythmic exercise in isotonic and starts no later than 3-4 weeks after surgery (the air
isometric mode has a raised limb up to 45°C, lym- jet comes from the stomach and the esophagus and
phatic outflow is assisted and its functional fitness is sounds forms at the entrance of the esophagus). In
maintained. patients with larynx cancer, psychosensory relaxa-
Rehabilitation in patients with lung cancer tion, music therapy, occupational therapies (enter-
With targeted kinesitherapy in the preoperative taining, functional, professional), hardening proce-
period of lung cancer patients, it contributes to: re- dures are also applied.
duction of the purulent intoxication; improving the
condition of the cardiovascular system and of the 15.7. OCCUPATIONAL DISORDERS OF
external breathing; strengthening the physical po- THE VISUAL ANALYZER *
tency of the patient and increasing his neuro-mental
tone. The exercises for the early post-operative peri- Good effect of the following physiotherapeu-
od covering the first 15 days are also mastered. Res- tic complex: acupressure of specific points located
piratory gymnastics in a 1:1 ratio with mild, rhythmic around the orbit (PM1, 2, St1, 3E23, IM6 (yu-yao)
isotonic exercise and early stand up of the patient 2min at a point, ocular relaxation (puts gently the
(2-3 days after surgery), counteract pleural adhe- palms of the patient himself on closed eyes for 10-
sions and have a definite psychological impact on 15 minutes, on background of general relaxation),

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exercise of ocular muscles with special exercises pace from all starting positions. Exercises with light
(close-up, look away, look down, up, left, right, circu- devices (balls, clubs, hoops, dumbbells) and exercise
lar clockwise and counter clock 10 to 15 times each of appliances (gymnastic bench and wall) are includ-
exercise performed slowly, with breaks between ed in the main part of the procedure. A special place
them), 20-30 times, splash eyes closed with cold wa- in the kinesitherapeutic complex occupies static and
ter every morning and after eye fatigue dynamic breathing exercises, performed slowly and
rhythmically without breathing retention. Besides
15.8 OCCUPATIONAL CARDIOVASCULAR the positive effect on the respiratory function, they
DAMAGE affect the blood flow and act soothingly. Similar is
the effect of both passive and active relaxation with
PHYSIOTHERAPY IN HYPERTONIC DISEASE * elements of suggestion and self-stimulation. The ex-
The hypotensive effect of sea climatic treatment ercises with moderate dosage and isometric compo-
in the cold seasons (Kiten, Nessebar, Varna) as well nent have a stimulating effect on the blood supply
as the mountain climatic treatment associated with and trophic processes of the heart muscle. In hyper-
active kinesitherapy (Kurtovo, Peshtera, Borovets, tensive patients with proven therapeutic effect are
Pamporovo) have been proved. Balneotherapy is the equilibrium and coordination exercises, as well
applied in profiled resorts (Bankya, Narechen, Var- as the appropriate games and dances with appropri-
shets). A specific effect is the four-chamber Haufeu- ate musical accompaniment with adequate dosing
baths, particularly suitable for a hypertensive attack of their emotional impact. With a marked normal-
(37-42 ° C, 15-20 min), as blood is withdrawn from izing effect on the functions of the cardiovascular
the internal organs to the extremities. Manual baths system in patients with arterial hypertension, stage
with tripinate, juniper, brobalil (36-37 ° C, 10-12 pro- I is a dosing exercise for endurance with cyclic phys-
cedures) are shown. ical exercises: walking and running, cycling, swim-
A positive response with acupressure was found ming, walking and cross-country skiing, rowing, etc.
in the following points: St36, 9, DP6, P6, 7, MS4, 11, Physical exercises should be in the so-called "steady
15, 3CM15, 16, 20, 23, DM20, PM10, PM14, 15, 25, state" (the oxygen supply of the body fully satisfies
43, , CHD3, 1-2 min at a point, 12-15 procedures. its needs) - aerobic workout.
Very effective is the following, tested by us acupres- In hypertensive stage II, the motor regimen is
sure method, which lowers blood pressure by 2.67 / limited. Only components of sports disciplines are
4.00 kPa. The patient is seated and even better lying carefully used. They are made: massage collar and,
down. Place the two pointers from the patient him- if necessary, segmented massage or underwater jet
self inside the ear canals (close the ears) and hold for massage, along with free, active, relaxing exercises
1 min. Remove the fingers and inhale several times at comfort start position. Blood pressure, pulse rate
very slowly and deeply. The manipulation is repeat- and breathing values ​​are monitored.
ed three times. In hypertensive stage III, the use of kinesitherapy
Good effect: general brush massage (15-20 min, is limited (consistent with the degree of cardiovas-
12-15 procedures), underwater massage with tan- cular failure).
gentor - 1-1.5 at (0.1-0.15 MPa), 20 min, 36-37 ° C,
10-12 procedures; galvanic collar of Shcherback 15.9. OCCUPATIONAL DISABILITIES
with calcium, bromine, magnesium (6-16 mA, 6-16 OF THE VESTIBULAR ANALYZER
min, 10-12 procedures); general iongalvanisation of
Vermell with calcium and bromine (10-20 mA, 10-12 PHYSIOTHERAPY *
procedures); psychosensory relaxation with speech, Physiotherapy aims at improving the vestibular
music, colors, aromas (45-60 min, 8-12 sessions). analyzers blood circulation, influencing neuro-vege-
KINESITHERAPY IN HYPERTONIC DISEASE ** tative and functional nervous disorders, influencing
Kinesitherapy contributes to the normalization of the general resistance of the organism. A good effect
cortical processes and the elimination of stagnated has been found in the application of a complex of:
excitability in the vasomotor centers, normalizing acupressure, low-frequency magnetic field, juniper
the dynamics of the autonomic nervous system, the baths. Acupressure is applied at points: 3CM15, 20,
cortical-visceral connections and the endocrine-hu- PM10, DM20, 2, 8, 12, 3E1, 4,5, 19, 21, 23, TC8, 19,
moral regulation of the vascular tone. In the first CHD3, 1-2 min at a point, combined with rubbing
stage of hypertonic disease, the activities are group, and flattening around the ear, 12-15 procedures.
everyday. Mostly free gym exercises are used for The low-frequency magnetic field is applied in the
large muscle groups, performed without strain, fly, ear area with parameters: 16,000 A/m, 0,2 s, 1 Hz,
with maximum amplitude of movement and slow 10-20 min, 15-20 procedures. We also use juniper

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or brobalyl baths (36-37 ° C, 10-15min, 10-12 pro- es and determines the plane where the exercise is
cedures), general brush massage (15-20 min, 10-12 most difficult to perform. Followed the vegetative
procedures), Shcherback galvanic collar with calci- reactions (fainting or redness of the face, sweating,
um, magnesium, bromine 6-16 mA, 6-16 min, 10-12 increase or slowing of the pulse), blood pressure, the
procedures). presence of spontaneous or latent nystagmus, sta-
Confounded bleeding of the vestibular analyzer tokinetic stability is determined. The special exercis-
responds well (especially if due to cervical osteo- es revealing the particularities of the vestibular re-
arthritis) by: paravertebral ultrasound in the C3-C7 actions are elementary, they are applied carefully to
area (0.3-0.4 W/cm2, 3-4 minutes per field, 10 proce- avoid an attack, with slow pace and pauses. The ratio
dures), diadynamic currents (1 min DF, 3 min KS, 3 of special exercise to respiratory and general tone ex-
min DS, 5-10 mA, 10-12 proc.), ionphoresis with KJ at ercises is 1: 2. The initial period is 2-3 days (with more
neck (10-15 m A, 15-20 min, 10-12 procedures), par- pronounced vegetative reactions, the procedure is
affinic applications at neck (55 ° C, 20-30 min, 10-12 discontinued). Keep in mind that in middle ear disor-
procedures), mud application (38-40 ° C, 20-30 min, ders, movements in the frontal plane are difficult to
10-12 procedures). Very good effect is the psycho- handle; harassing of semi-circular channels-angular
sensory relaxation with speech, music, aromas and accelerations; in the case of the otolithic apparatus
color effect (45-60 min, 8-12 sessions). disorders - rectilinear acceleration.
KINESITHERAPY ** The baseline period is 3-4 weeks. The aim is to
The aim of kinesitherapy is to lower the thresh- restore the patient's statokinetic resistance. Special
old of excitability of the vestibular and vegetative exercises are in proportion to the 1: 1 to breathing
response by restoring the patient's stability and ori- and general tone exercises in the first half of the
entation in space and adapting it to physical stresses healing course. The tempo is slow at the beginning
in different body positions. and moderate at the end of treatment. In the first
In the case of significant vestibular disorders with days the procedure starts and ends with the meth-
violent vegetative disorders, the aim is to eliminate ods of general relaxation. The classes are individual.
the psychogenic violation, to influence the vegeta- In the second half of the course, groups of three pa-
tive nervous system, by the means of general relaxa- tients with similar disabilities and a close clinical pic-
tion in the patient's preferred position and breathing ture are formed. Games and elements from various
exercises. After the interruption of the attack in the sports disciplines are also used.
initial period, at continuous eye and verbal contact, In order to strengthen the established habits and
specifies the patient's tolerability to physical stress- prevent relapses, a home rehabilitation complex is
being built.

REFERENCES

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bul.)

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VOLUME II

OCCUPATIONAL MEDICINE
INDUSTRIAL HYGIENE
OCCUPATIONAL DISEASES
EDITED BY
Prof. Dr. Dimitar Tsvetkov, DSci

2019