Trattasi della “Responsabilità Civile prestatori d’Opera”, riguardante: la rivalsa dell’I.N.A.I.L. ex artt. 10 e 11 del DPR /65; – le pretese del. of DPR /65 and ex art. 13 DL 38/; The industrial diseases. Liability of Directors and Officers (D & O). The single persons of the management . /65 e s.m.i. Al Servizio PreSAL ASL Alla DTL Denuncia/ Segnalazione di malattia professionale ai sensi degli artt. DPR / e 10 del D.
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In Italy a complete ban of asbestos use is in force since national law No. Asbestos-related diseases, either non-oncologic or oncologic, usually have a long latency time that accounts for a health surveillance of subjects with previous occupational exposure to asbestos.
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In Italy, where a Beveridge welfare state provides health care to all citizens within its public health service, several health surveillance initiatives for former asbestos workers have been carried out by public occupational health services OHSs in some areas, especially where hundreds of workers employed in firms using asbestos in their industrial activity in the past were registered 5 – 7.
The procedures used by the local OHSs were inhomogeneous and without coordination in areas characterized by the same health administration. Similar experiences were also described in other countries 8 – In the Italian Ministry of Heath organized the second Italian Asbestos Conference 12 and at the same time it funded several projects regarding prevention and mitigation of asbestos risk, including a project aiming to define and test a specific protocol for health surveillance of former asbestos workers to be later implemented in whole Italy.
Eighteen Regions and Provinces joined in the project. A consensus document was draft 13 and it is now under evaluation by the Italian Minister of Health. In Tuscany, an Italian region in Central Italy, after having experienced initiatives similar to those abovementioned, an in-depth examination of several aspects organizational, economical, etc.
The Regional Council then decided to put it in practice assigning specific regional funds, and ratified its decision Deliberation of the Tuscan Regional Council n. Aim of this paper is to describe the main clinical and organisational features of the regional programme of post occupational health surveillance for former asbestos workers. In defining a protocol for health surveillance for former asbestos workers the first need to be addressed is the inclusion of evidence-based procedures and financial sustainability.
The literature on previous experiences on this issue and, in particular, the revision and following recommendations reported in the updated Helsinki Criteria document 15 were useful d.pr.1124 define the Italian protocol. 665 pays particular attention to diagnosis and care for non-malignant asbestos diseases in subjects with a reliable work history of exposure to asbestos. The Italian protocol includes two possible sequential phases of health evaluation: During the first phase the occupational health physician OHP defines the past occupational exposure to asbestos and the presence of all enrolment criteria for the examined subject.
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Then, for those entitled, the OHP:. The protocol does not include a low-dose computed tomography LDCTsuggested to be useful for the diagnosis of lung cancer in heavy smokers As in any health surveillance programme, a follow-up is foreseen.
It was defined ending 30 years after the last occupational asbestos exposure. Its periodicity depends on the level of exposure intensity: Patients diagnosed with a malignant asbestos related disease are promptly taken in charge by public health care programmes for cancer patients. Particular attention is paid to those with documented lung fibrosis who are also invited to undergo influenza and pneumococcus vaccination, and to current smokers who are invited to quit in order to reduce the possible risks of lung disease, deterioration of their lung function and progression of radiographic fibrotic processes, if applicable.
The above-mentioned health surveillance programme does not allow a primary prevention because the exposure took place in the past and at the same time it does not allow any secondary prevention in its strict term because it is not a real screening programme. The aims of a health surveillance programme for former asbestos workers, for its ethical and social characteristics, are summarized as following: I to correctly identify past occupational asbestos exposures; II to correctly identify non-malignant asbestos-related diseases; III to inform the former exposed workers about the risk related to their previous and current exposures, including other occupational exposures and smoking habit, that could enhance fibrotic processes; IV to certificate, if applicable, work-related diseases to claim compensation.
The promotion of further epidemiological study on health impact of asbestos at regional level can be added as an indirect aim of the programme. After the definition at national level of an health surveillance programme for former asbestos workers in terms of evidence-based procedures, efficacy and social utility, the public regional health administration asked a group of experts to evaluate in-depth those aspects not considered in the national consensus document, focusing in particular on the standardization of past asbestos exposures, the communication issues and the economical sustainability On Aprilthe programme started after a deliberation of the regional council that supplied specific funds for it.
In order to guarantee a homogeneous health surveillance in the whole region, the Tuscan programme includes:. Only subjects resident in Tuscany, aged less than 80 years, retired or still working in a plant different from that where the exposition took place in the past and whose exposure is certified by a public OHP, are included in the free of charge programme.
For those still working in the plant where they were exposed to asbestos, Italian law prescribes that the health surveillance is in charge of the private occupational physician of the firm. Based on the compliance obtained by the local previous experiences on 4, former asbestos workers, it was estimated that almost 5, former exposed asbestos workers fit with the criteria mentioned above and will be involved in the programme This estimation was based on the individual data regarding workers in Tuscan asbestos firms involved in an Italian multicentre cohort study 18 Currently, 1, are the former exposed asbestos workers taken in charge during the previous cited local initiatives and 3, are further identified subjects.
Specific clinical practices of public OHSs have been opened all over the region, differently scheduled in relation to the estimated amount of past asbestos workers in each area. Only three occupational health departments provide in-depth health evaluations, one in each area considering that only one-forth of subjects will need a clinical in-depth study and only half of them will need a 1-year follow-up Figure 1.
Subjects with a history of asbestos exposure at the workplace will be directly invited to the OHSs, but if a subject thinks to have undergone asbestos exposure at work can directly contact the local OHS for an examination in the same clinic.
All the information gathered during the clinical examination will be registered in a specific database for preventive regional activities. It is expected in time to reduce the number of former exposed workers included in the programme because of loss of enrolment criteria aged 80 years old and more, 30 years and more since the cessation of exposure but at the same time an increase of second phase examinations for subjects with lung diseases with a 1-year follow-up.
Considering only the asbestos production, 3, tons of raw asbestos were 665 in Italy, with a peak between and The health surveillance of formerly exposed asbestos workers is legitimated by the long latency of asbestos related diseases.
This is the reason why great attention and initiatives have been registered in many European countries, beside Italy. Two reviews on international and Italian experiences on health surveillance programmes for subjects with past occupational exposure to asbestos were published by Italian researchers, the first one covering the years — 5 and the second one on further experiences both international and national during last decade 7. In Italy a consensus document developed by experts was developed in 13 after several experiences carried out in the previous two decades 5726 – Anyhow, official specific recommendations of the Italian Health Minister are not available yet.
The Constitutional Reform in Italy gave regional Administrations exclusive authority in execution-level planning and dp.r.1124 of health care, besides guaranteeing the core benefit package LEA to every citizen that are determined at national level and must be equally provided by every Region.
Therefore, in Italy at regional level organizational decisions on this issue d.p.t.1124 going to be taken in order to give an answer to social and ethical requests: In Tuscany, an organization of public health services devoted to this surveillance was defined, based on the d.pp.r.1124 recommendations, characterized in terms of efficacy, suitability, social utility and economical sustainability.
All these characteristics allowed to offer the programme free of charge within the regional public health services with the involvement of preventive OHSs, antismoking services and care services unit of radiology and unit of lung diseases. Nevertheless, d.p.r.124 open questions need further discussion, study evaluation and management, such as a diffuse knowledge of the surveillance service for all those who could benefit from it, the correct stratification of subjects for the follow-up and its usefulness, the real homogeneous delivery of the surveillance in the whole region.
The ability to solve the first question rely on d.r.1124 aspects: I the knowledge on asbestos exposures of the health professionals, first of all the General Practitioners, who can inform the past asbestos workers; II the support of professional associations; III the support and communication activity of no-profit association of workers formerly exposed to asbestos and Unions the specific agreement signed at regional level might contribute to establish an active cooperation.
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It is in fact necessary to identify all subjects with a past occupational asbestos exposure and therefore to invite them directly to the clinics. Regarding the second question, the stratification of subjects in relation to the intensity of their past occupational exposure is still under discussion: Moreover, it must be pointed out that the intensity of exposure is mainly related to lung cancer risk.
The third question relies on the correct standardization of the procedures all over the region, based on a high quality and effective training of all the involved professionals who are expected to actively exchange their experience and problem-solving activities. The new regional health system organized in three areas North-Western, Centre, South-East could facilitate this standardization. The ability to perform an homogeneous surveillance system relies also on the monitoring and evaluation procedures that are going to be implemented within the programme and are continuously under discussion by the specific regional group of experts and all the stakeholders.
The continuous and exchanged training activity among involved professionals, previously mentioned, is expected to increase their ability to correctly identify the past occupational exposure and the diseases of interest.
In conclusion, the identification of a specific public health surveillance programme for former asbestos workers including training and monitoring activities and the cooperation of professional and social stakeholders might facilitate to overcome still open problems as the lack of a diffuse knowledge of the service with a broaden invitation to adhere to the programme, the correct stratification of subjects for the follow-up and the real homogeneous delivery of the health surveillance in the whole region.
This work was supported by Tuscan Regional Administration Del. Figure 1 Health surveillance programme for Tuscan workers with past asbestos exposure: Cite this article as: Health surveillance for former asbestos exposed worker: J Thorac Dis ;10 Suppl 2: