Waste management, namely, collection, transport, sorting and processing, and disposal, is an issue of social concern owing to its environmental impact and effects on public health. In fact, waste management activities are carried out according to procedures that can have various negative effects on the environment and, potentially, on human health. The aim of our study was to assess the potential effects on respiratory health of this exposure in workers in the waste management and disposal field, as compared with a group of workers with no occupational exposure to outdoor pollutants. The sample consisted of a total of 124 subjects, 63 waste collectors, and 61 office clerks. Informed consent was obtained from all subjects before inclusion in the study. The entire study population underwent pulmonary function assessments with spirometry and completed two validated questionnaires for the diagnosis of rhinitis and chronic bronchitis. Statistical analyses were performed using STATA 13. Spirometry showed a statistically significant reduction in the mean Tiffenau Index values in the exposed workers, as compared with the controls, after adjusting for the confounding factors of age, BMI, and smoking habit. Similarly, the mean FEV1 values were lower in the exposed workers than in the controls, this difference being again statistically significant. The FVC differences measured in the two groups were not found to be statistically significant. We ran a cross-sectional study to investigate the respiratory health of a group of workers in the solid waste collection and disposal field as compared with a group of office workers. In agreement with most of the data in the literature, our findings support the existence of a prevalence of respiratory deficits in waste disposal workers. Our data suggest the importance of adopting preventive measures, such as wearing specific individual protection devices, to protect this particular category of workers from adverse effects on respiratory health. Waste management, namely, collection, transport, sorting and processing, and disposal, is an issue of social concern owing to its environmental impact and effects on public health. In fact, waste management activities are carried out according to procedures that can have various negative effects on the environment and, potentially, on human health. They pose risks resulting from the emissions or release of hazardous chemical agents and biological agents, from the types of exposure to these agents, and from the susceptibility of the populations exposed to them.Epidemiological studies of the short- and long-term effects of exposure to waste on public health have been focused above all on identifying any associations between residence in the vicinity of a landfill and adverse effects on health ,2,3. MeaWaste sorting, collection, and recycling, procedures that have now been adopted by nearly all EU member states, have actually introduced new risk profiles for garbage collectors, largely attributable to the inhalation of bioaerosols generated by the decomposition of organic waste ,5. This In particular, endotoxins, the components of the cell wall of Gram-negative bacteria, are considered to be the most powerful proinflammatory component present in bioaerosols . ExposurExposure to bioaerosols, therefore, seems to induce an inflammatory response at the level of the airways mucosa, probably due to a complex interaction among microorganisms or cell wall components of these microorganisms and the host immune system .2, silicon oxide, talcum powder, asbestos, and other fibres [When assessing the respiratory health risk in solid waste disposal workers, it is also important to take into account the physical effort and muscle work that these activities entail, during lifting and manhandling of the various containers. This induces a ventilation response consisting of an increased flow volume and respiratory frequency ,16 that r fibres .The aim of our study was to assess the potential effects on respiratory health of this exposure in workers in the waste management and disposal field, as compared with a group of workers with no occupational exposure to outdoor pollutants.The research was carried out on a working population of 375 employees of two waste collection and disposal companies, 300 waste collectors (exposed), and 75 clerks (controls). Both exposed and control subjects were randomly selected to reduce the possibility of bias in self-selection. Upon inclusion in the study, a completed questionnaire as regards medical and working history, as well as various confounding factors, was collected from all workers in the presence of a physician.The response rate was higher for exposed (94%) than for controls (91%). All recruited subjects, both exposed and non-exposed, had a negative clinical history for previous respiratory diseases (inclusion criteria); only for non-exposed subjects did we adopt as exclusion criteria previous or current occupational exposure to outdoor pollutants. The final sample consisted of a total of 124 subjects, 63 exposed and 61 controls . The invAll the recruited subjects then completed two questionnaires validated for the diagnosis of rhinitis  and chroAll respiratory function tests were performed by the same operator, with the subject in a sitting position with his nose closed by a clip, following the American Thoracic Society (ATS) guidelines. The pulmonary function test was performed three times for each subject, and we chose the best one. The most important aspects of spirometry are the forced vital capacity (FVC), which is the volume delivered during an expiration made as forcefully and completely as possible starting from full inspiration, and the forced expiratory volume (FEV1) in one second, which is the volume delivered in the first second of an FVC manoeuvre. Spirometric airflow limitations were defined according to the Tiffenau Index as (FEV1/FVC) < 70% or an FEV1 < 80% of predicted values. A restrictive ventilatory pattern is characterised by a proportional reduction in FEV1 and FVC < 80% with a normal FEV1/FVC . StatistAll 124 study participants were male Caucasians (mean age 53 years for exposed workers and 51 for controls) and worked in the Apulia region in Southern Italy. As regards smoking habits, a confounding factor, 50.8% of exposed subjects were smokers or formerly smokers, while only 37.7% of controls had a history of smoking. Characteristics of both groups are shown in We ran a cross-sectional study to investigate the respiratory health of a group of workers in the solid waste collection and disposal field as compared with a group of office workers. The spirometric tests performed showed a significant reduction in the Tiffenau Index and FEV 1 values in the exposed workers, after adjusting for the confounding factors. Meanwhile, no statistically significant differences were found among the FVC values. These results suggest the prevalence of an obstructive pulmonary pattern and seem to be in agreement with the pathogenic hypothesis whereby cytokines, such as IL6, IL8, and TNF-alpha, which are produced as a result of contact with bacterial endotoxins of bioaerosols, may be the main mediators of the inflammatory response involved in the development of chronic obstructive lung diseases. This finding is in agreement with the results obtained by Athanasiou et al., who demonstrated a statistically significant reduction in FVC and FEV1 in a group of 104 municipal solid waste disposal workers in the city of Keratsini (Grecia) compared with a control group of 80 office workers . ComparaIn our study, the results of the allergological questionnaires did not reveal statistically significant differences between the two study populations, even if we found a higher prevalence of rhinitis symptoms in the controls, related to possible indoor air pollution. This evidence is not in agreement with Athanasiou et al. who showed that respiratory symptoms, investigated by means of a validated questionnaire, were also significantly more common in the exposed group than the control group. Moreover, in the exposed group studied by Ray et al. , there wIn a recent study made in 25 waste handlers at a landfill near Oslo, the spirometric FEV1 values were significantly lower at the end of the workweek than at the beginning of the week. In addition, cytological examination of sputum showed an increased percentage of neutrophils and IL-8, supporting the hypothesis that an etiopathogenic mechanism of an aspecific inflammatory nature, mediated by neutrophils, underlies the spirometric alterations [In a study by Gea de Meer, only a slight reduction in FEV1 was observed at the end of the workweek in a group of 16 organic waste loaders, only 6 of whom had a positive history for respiratory symptoms, which was determined by questionnaire. The bronchial challenge test subsequently performed with methacholine showed a significantly reduced FEV1 in the symptomatic subjects only. The authors concluded that the occupational exposure could be responsible for exacerbating airway inflammation only in those subjects with preexisting respiratory symptoms .In agreement with most of the data in the literature, our findings support the existence of a prevalence of respiratory deficits, as evidenced by spirometry, in waste disposal workers. Although this conclusion is not based on a correlation with the respiratory symptoms investigated in the questionnaires, it seems plausible to assume that the altered ventilatory function parameters obtained in our study may be considered as a preclinical indicator of respiratory diseases in subjects who have not yet shown the onset of clinical symptoms.It should be noted that our study, which was not conducted in a very large population, did not include environmental monitoring data on the concentrations of allergens, endotoxins, dust, and toxic substances in the areas surrounding the exposed group’s work zones. In particular, it would be useful to measure the concentration of endotoxins and β(1-3)-glucans that seem to play a key role, even via a synergic action, in inducing an inflammatory response of the upper airways. However, it is reasonable to suppose that there will be no significant differences in the concentrations values measured in other European nations with comparable waste management policies compared to those adopted in Italy . It mustOur data, which need to be confirmed with larger samples, suggest the importance of adopting preventive measures such as wearing specific individual protection devices, to protect this particular category of workers from adverse effects on respiratory health.Waste management is an issue of social concern owing to its environmental impact and effects on public health. In fact, waste management activities are carried out according to procedures that can have various negative effects on the environment and, potentially, on human health. On this basis, we ran a cross-sectional study to evaluate respiratory health effects in a group of workers in the solid waste collection and disposal field, compared with a group of administrative employees. Our study showed a significant reduction in the Tiffenau Index and FEV 1 values in the exposed workers as compared to the controls, after adjusting for confounding factors. These data suggest the importance of adopting preventive measures, such as wearing specific Personal Protection Equipments (PPEs), to protect this category of workers from adverse effects on respiratory health.


Socioeconomic inequality in return to work after cancer treatment and rehabilitation have been documented, but less is known about its causes. This paper investigates the role played by breast cancer stage at diagnosis and comorbidity.We used the comprehensive Danish Cancer Registry to follow 7372 women aged 30-60, who were in the labour force when diagnosed with breast cancer in 2000-06 and survived at least three years. Controls were 213,276 women without breast cancer. Inequalities in employment outlook were estimated as interaction effects in linear regression between educational attainment and disease on employment.There is significant interaction between education and breast cancer, but it is only marginally affected by including stage and comorbidity in the regression models. Education, breast cancer stage, and comorbidity all have strong effects on later employment, and a considerable amount of the educational effect is mediated by comorbidity and pre-cancer labour market participation and income.The result of the study is negative in the sense that the stronger effect of breast cancer on employment among low-educated compared to highly educated individuals is not explained by cancer stage or comorbidity. The fact that comorbidity has little impact on inequality may be due to a different social patterning of most comorbidity compared to breast cancer. Social inequality in burden of disease is generated not only by inequality in incidence but also by inequality in the consequences of disease such as survival, disability, and labour market participation. For seveWe have focused on breast cancer since it leaves less severe functional limitations compared to most other cancer types following successful treatment and since there is no negative effect of educational attainment on incidence—in fact, the opposite is true. Breast cSeveral factors influence the probability of employment after diagnosis and treatment. Premorbid employment status, education, income, and extent of malignancy  as well as type of treatment have been shown to influence employment status in the years following diagnosis and treatment.,12 A DanBased on the findings of a clear educational gradient in employment consequences of cancer,  this papEstimate the extent to which educational differences in breast cancer stages at diagnosis explain educational differences in labour force participation and disability pension three years after diagnosis.Estimate the extent to which the effect of cancer stages is modified by educational differences in comorbidity.Social inequalities in consequences of disease are often studied among cases only. This approach provides a relevant but purely descriptive result. If, in contrast, we wish to estimate the effects of disease on employment and the extent to which the effect is modified by education, stage at diagnosis, etc., we must include healthy controls in the study and estimate interaction between disease, stage, and education. We have therefore designed a register-based prospective study. We identified all females in the Danish Cancer Registry who received a diagnosis of breast cancer (ICD10 code C50) in the period of 2000–2006 (base years). From all 28,367 registered cases of breast cancer in Denmark in 2000 to 2006, a total 7372 cases were included in the study, fulfilling the following criteria: they (1) were living in Denmark; (2) had no cancer registered prior to the breast cancer incident case; (3) were aged 30 to 60 in the year of diagnosis; (4) survived at least to the end of the third year following diagnosis; and (5) received no disability pension or so-called transitional benefits in the two years preceding the year of diagnosis . This means that all women who were part of the labour force, including those on temporary benefits due to sickness or unemployment, were included .Controls were collected from the population register covering all citizens of Denmark. For each of the base years 2000–2006, the controls consist of females living in Denmark, aged 30 to 60, who survived at least three years after the base year and who had no cancer diagnosis before or after the base year. For the analysis for each year, we selected a random sample of 4% of women meeting the aforementioned criteria with a total of 213,276 controls. The procedure for randomly selecting the control group ensures that no person is in the control group for two different base years.The Danish civil registration number (CPR), which is a ten digit PIN-code unique to every Danish citizen, makes it possible to link cancer registries with other official registry data on demographics, education, employment, occupation, income, municipality of residence, contacts to general practitioners, hospitalisations, and purchase of prescription drugs.localised stage (not yet entered the lymphatic system)  and another group of 3,603 women with regional lymphatic spreading or any other kind of metastasised cancer.Data on cancer was obtained from the Danish Cancer Registry, which is a population-based registry containing data on all incident cases of cancer throughout Denmark since 1943. The Cancer Registry contains information related to tumour characteristics, including tumour stage. For thisCompulsory , Vocational , and Further .SEP was defined by educational attainment. Information on education was obtained from registries for the baseline year. Education was classified into three categories, in accordance with the International Standard Classification of Education (ISCED) system (UNESCO 1997): Age was included in the analyses as a continuous variable covering the ages of 30 to 60. Information on family type was categorised into three groups: single with children, married with or without children, and cohabiting with or without children. Information on ethnicity was dichotomised as Danish born yes/no. Since prognosis on cancer could be affected by access to and quality of the regional health service system, we controlled for the five regions in Denmark (using four dummy variables) as well as size and degree of urbanisation of the municipality in which the study participants lived (using 11 dummy variables).Adjustments for a large number of covariates in the analyses were made with regression in a linear probability model. A linear model was applied as we find absolute effects more relevant for policy than relative effects. Covariates were chosen among factors that are known to be associated with both labour market outcomes and cancer. Age was Premorbid labour market status was carefully controlled for: Persons on disability pension and transitional benefits two years before diagnosis were excluded, but the very few homemakers and those on more temporary benefits such as sickness or unemployment benefits were included as they might return to work. Labour market status two years before diagnosis as well as change in unemployment, self-employment, occupation, industry, and part-time employment status from two to five years before diagnosis were, however, controlled for in detail. We furthermore measured individual income two years before diagnosis. Comorbidity was also measured and controlled for by several items: Number of contacts with GP, hospitalisations ; contacts with health services and factors influencing health status; and medicinal prescriptions . We decided not to use an established comorbidity index like the Charlson index because none of these are developed to predict employment consequences. We controlled for comorbidity variables measured at two to five years before the base year since health information measured in the base year or the year before may be affected by the cancer, especially if it is diagnosed at a late stage.left the labour force, including those on disability pension, sickness benefits, early retirement pension, social assistance, and supported by a spouse. We have also looked specifically at disability pension, which is given to people with medically certified permanently reduced working capacity and has important public health implications since it rules out return to work for the individual and results in long-term societal costs.The study’s endpoints are measured from registry-based information. To be registered with a certain employment status, this status must be the dominant status for the year. Labour market affiliation three years after diagnosis was categorised for those who permanently or temporarily We use a linear probability model to model the effect of cancer stage as a predictor of being out of the labour force or of receiving a disability pension. This involves running a regression of the two outcomes on a series of covariates, including dummy variables for cancer stage by ordinary least squares. As the outcomes are dichotomous variables, the estimates of the model are directly interpreted as the effect of the corresponding covariate on the probability that the outcome is equal to 1. The model has been estimated using the ‘Regress’ command from the statistical software package Stata 13.1. Furthermore, standard errors are corrected for in terms of the presence of unknown form heteroskedasticity, using the method suggested by Davidson and MacKinnon. We estimCancer). In Model 2, we further adjust for the stage of cancer as well as all interactions between stage and education. In Model 3, we further adjust for comorbidity defined by 18 indicators for hospitalisation for specific diagnoses, 20 indicators for consumption of prescribed drugs, number of GP contacts, and for premorbid labour market status and income.For each of the outcomes, we present the resulting estimates from three different models. Model 1 is adjusted for age, year of diagnosis, family type, ethnicity, region, and education. In this model, disease stage is not taken into account, i.e. the stage dummies are replaced by a single dummy variable for whether the individual has had cancer . The interaction terms for education and the two stages are not smaller in Model 2 than in Model 1, indicating that stage does not explain the inequality in employment prospects. The main effects of education are shown in the table. According to the estimates in Models 1 and 2, these indicate that, for women without cancer, the risk of leaving the labour force is 11% or 14% lower if they have a vocational or further education respectively compared to having only compulsory education.In Model 3, where we control for baseline labour market status, income, and co-morbidity, these ‘education effects’ are smaller. Interestingly, the effect of cancer stages and the interaction terms between education and cancer stages are slightly larger in Model 3 than in Model 2.The criteria for unequal employment consequences of breast cancer in this paper are calculated as the interaction (in terms of departure from additivity) between education and disease instead of a mere description of different employment prospects across patients with different levels of educational attainment. The significant negative interaction effect of educational attainment and breast cancer on the probability of being out of the labour force following treatment is consistent with social inequality found in other studies from Scandinavia, Korea, and Japan.–21 The aIt might be surprising that the effect of breast cancer on disability pension is not stronger than on being out of work in general. It illustrates the fact that tiredness and other symptoms following breast cancer might not qualify a person for a disability pension but might still force many patients out of work.Lower education increases the probability of being out of paid work in general, but the effect is stronger among women with breast cancer and stronger for those diagnosed with more advanced stages of the disease. This is potentially indicative of an unfair inequity. Returning to the two other proposed mechanisms, people with low levels of education often have to return to more physically demanding jobs following illness. As a result, the higher risk of disability pension might be well motivated by lower working ability in relation to one’s previous job. However,We excluded women who had permanently left the labour force prior to diagnosis but included those who were temporarily out of work and adjusted the analysis for these types of labour market status before diagnosis. A ‘cleaner’ estimation of the risk of leaving the labour force could have been achieved by excluding these factors.,22 The cThe strength of this paper is its high statistical power and minimal selection bias due to use of registry data covering the whole population. The inclusion of a large healthy control sample and causal analysis of effects and interactions that this makes possible is an improvement compared to most earlier studies, which have mainly described rates of exclusion in various educational strata.Since stage and comorbidity did not drive the inequalities, future searches for mechanisms should include a better understanding of how patients from different social strata succeed in getting a coordinated rehabilitation, including the various sectors of the Danish healthcare system involved, and of the Danish labour market’s flexibility in accepting citizens who combine disabilities with limited educational attainment. The choice of educational attainment as a measure of SEP might have affected the results. Especially in a Scandinavian country with rather high social mobility, occupational social position might better indicate the job, workplace, and labour market-related inequalities. In this case, one would expect even larger disparities in employment consequences.Based on our results, the lower employment rates among low-educated compared to highly educated female breast cancer survivors is not explained by cancer stage or comorbidity. The fact that comorbidity has little impact on the inequality may be due to a different social patterning of most comorbidity compared to breast cancer.


It is well established that unmarried people have higher mortality from circulatory diseases and higher all-cause mortality than the married, and these marital status differences seem to be increasing. However, much remains to be known about the underlying mechanisms. Our objective was to examine marital status differences in the purchase of medication for circulatory diseases, and risk factors for them, which may indicate underuse of such medication by some marital status groups.Using data from registers covering the entire Norwegian population, we analysed marital status differences in the purchase of medicine for eight circulatory disorders by people aged 50-79 in 2004-2008. These differences were compared with those in circulatory disease mortality during 2004-2007, considered as indicating probable differences in disease burden.The unmarried had 1.4-2.8 times higher mortality from the four types of circulatory diseases considered. However, the never-married in particular purchased less medicine for these diseases, or precursor risk factors of these diseases, primarily because of a low chance of making a first purchase. The picture was more mixed for the divorced and widowed. Both groups purchased less of some of these medicines than the married, but, especially in the case of the widowed, relatively more of other types of medicine. In contrast to the never-married, divorced and widowed people were as least as likely as the married to make a first purchase, but adherence rates thereafter, indicated by continuing purchases, were lower.The most plausible interpretation of the findings is that compared with married people, especially the never-married more often have circulatory disorders that are undiagnosed or for which they for other reasons underuse medication. Inadequate use of these potentially very efficient medicines in such a large population group is a serious public health challenge which needs further investigation. It is possible that marital status differences in use of medicines for circulatory disorders combined with an increasing importance of these medicines have contributed to the widening marital status gap in mortality observed in several countries. This also requires further investigation. Numerous studies from many different countries have shown that married people have lower all-cause mortality than the unmarried and lower mortality from several specific causes and cause groups, including circulatory diseases –3. HealtOur aim in this paper is to see whether there are differences by marital status in the purchase (encashment) of prescribed drugs for eight types of circulatory disorders. We also consider incident and continuing purchase of these medicines. These marital status differences in medication purchase (assumed to be indicative of medication use) are compared with marital status differences in mortality from four specific circulatory causes, used as an indicator of probable differences in disease burden. We use data from registers that cover the entire Norwegian population, and in particular the Norwegian Prescription Database, which includes all purchases of prescription medicine since 2004. The analysis covers the years 2004-2008.Circulatory diseases are the most common group of causes of death in high income countries, so such an analysis of marital status differentials in the use of medicines for these diseases and their risk factors is potentially very important from a public health perspective. This is particularly the case in the context of improvements in the efficacy of therapeutic treatments for circulatory diseases. Advances in drug-based and surgical treatments have been found to matter greatly at the population level , 12 and Previous research on marital status differentials in medication use is sparse and inconclusive. Delayed diagnosis or treatment for cardiovascular problems among unmarried groups has been reported in some studies , 21, whiThe study is based on analysis of two data files, constructed (in 2009-2012) from various Norwegian population registers. Both include, for everyone who has lived in Norway since 1960, year of death, immigration and emigration (if any) and marital status and educational level at the beginning of each year . These variables were taken from the Central Population Register and the Educational Database (operated by Statistics Norway). Additionally, one of the files includes information from the Cause-of-death Register (up to 2007), while the other includes information from the Norwegian Prescription Database (NorPD) for 2004-2008. NorPD covers all purchases of prescription medicine  classification) since 2004 by Norwegian residents, except individuals living in institutions . BecauseSeparate analyses were undertaken for women and men, as several studies have suggested that some of the health benefits of partnership may be sex-specific, especially in older age groups , 35. In The use of register data for this research purpose has been approved by the Regional Committees for Medical and Health Research Ethics and the Norwegian Data Protection Authority.th birthday or the year after immigration, respectively. Observations were excluded if the person lived temporarily abroad at the beginning of the year. Logistic models were estimated from all remaining observations. In total, there were 35,174 deaths within 2,602,246 person-years of observation among men and 23,970 deaths within 2,693,670 person-years of observation among women. Table Discrete time hazard models for all-cause and cause-specific mortality were estimated for the period 2004-2007, following standard procedures . A serieThe specific causes of death considered are ischemic heart diseases (ICD-10 codes I00-I25), other heart diseases (I26-I52), cerebrovascular diseases (I60-I69) and all other circulatory diseases (other I00-I99).In the analysis of drug purchases we considered eight groups of drugs, defined by Kuo et al.  as indicIn the second step, discrete-time hazard models for the chance of starting to purchase the specific type of drug (i.e. incidence) were estimated for those who did not use it in 2004. More specifically, one-year observations from 2005 were created conditioned on the individual being of age 50-79 that year, being alive both at the start and the end of the year and not yet having started to purchase the medicine by the beginning of the year. The outcome variable was whether the drug was purchased at least once during the year.Similarly, in the third step, discrete-time hazard models for discontinuing the purchase of the medicine were estimated. One-year observations from 2005 were created conditioned on the individual being of age 50-79 that year, being alive both at the start and the end of the year, having purchased the medicine at least once during the preceding year, but having had no earlier discontinuation of the purchase of that medicine . The outcome variable was whether the drug was purchased at least once during the year. For simplicity, the signs of the effects are reversed in the tables and can thus be interpreted as effects on continuation rather than discontinuation.Mortality from circulatory disease was more than twice as high among the never-married as among the married for both men and women. For all circulatory diseases combined the odds ratio for men was 2.11 (95% CI 1.99-2.23) and that for women 2.37 (2.15-2.61). Odds ratios for men and women varied between 1.94 and 2.84 across the four main sub-categories of circulatory diseases considered , hyperlipidemia, heart failure (among men), and ischemic heart disease. On the other hand, three types of medicine were purchased to a larger extent by the divorced than the married, for one or both sexes: medicine for coronary and peripheral vascular diseases (antiplatelet as well as anticoagulant treatment), arrhythmic diseases and angina. However, with two exceptions (1.20 and 1.24), the positive estimates were not above 1.10.The widowed were, on the whole, more likely than the married to purchase medicine for circulatory disorders. There was only one negative relationship: the use of medicine for hyperlipidemia. Relationships with respect to several other disorders were positive: hypertension, arrhythmic diseases, heart failure and ischemic heart disease for both sexes and coronary and peripheral vascular diseases and angina for women. Again, the positive relationships were not large; all effects were smaller than 1.12.The lower chance of purchasing medicine among the never-married reflects a lower chance of making a first purchase Table , Panel Bhigh. This was seen for several types of medicine for both men and women, and no effect runs in the other direction. On the other hand, they had a relatively low probability of continuing to purchase several types of the medicines considered, and there was only one example of the opposite.For the divorced, who generally purchased about as much medicine for circulatory disorders as the married, there is an almost opposite pattern. Their chance of starting to purchase medicine was quite The pattern for the widowed was similar to that for the divorced: there were several positive associations with the chance of starting to purchase medicine and one negative (as opposed to none for the divorced), and there was no positive association with the chance of continuing the purchases (as opposed to one for the divorced) and several negative ones. However, there were fewer of the latter associations , so on the whole, the widowed appear to be less different from the married than are the divorced.These results show, consistent with other studies, large marital status variations in mortality from circulatory diseases with the highest risks, relative to married people, for the never-married followed by the divorced and then the widowed. Overall, in the age group considered here (50-79), the unmarried had rates of mortality from circulatory diseases 1.4-2.8 times higher than those of the married. However, never-married people in particular purchased less of the medicines that are typically used after such a circulatory disease has been diagnosed or risk factors for it identified. This was primarily because of a significantly lower chance of first purchase of most of these medicines The picture is more mixed for the divorced and widowed, who purchased less of some of these medicines but more of others, though the difference in the latter direction, which was seen especially among the widowed, was quite small . In contrast to the never-married, the chances of starting to purchase these medicines were as least as high among the divorced and widowed as among married people, but adherence rates thereafter, indicated by continuing medication purchases, were lower .We assume that purchases of medication are good measures of actual use of medication, and therefore refer to use in the remaining discussion. To the extent that there is a difference between purchase and use, it would seem likely, if anything, that the unmarried might be less inclined than the married to use the purchased medication, because of the lack of social support and control by a spouse that is further discussed below. If so, marital status differences in actual use may be more pronounced than suggested by our analysis of purchases.need less of these medicines, despite their much higher mortality from all circulatory disease groups . Let us assume that they to a larger extent than the married suffer from the most severe types of each of these disorders, but have a lower prevalence of the less severe types for which medication is nevertheless recommended. Then, even if they take medicine in accordance with recommendations or needs (i.e. no underuse), they could end up using less medicine than the married and have higher mortality. In other words, low usage coupled with high mortality does not necessarily mean underuse.To draw conclusions about underuse of medicine one should ideally compare actual use with need or recommended use. Unfortunately, we lack information on the actual prevalence and severity of the various circulatory disorders (and associated risk factors), which would be good indications of the need, and must instead compare differences in medication purchase, reflecting medication use, with those in mortality. As mentioned, one of our key findings is that the never-married use less medicine than the married for all disorders considered except a few. In theory, it is possible that they also However, this situation seems improbable especially as there are common risk factors for many less and more serious conditions and evidence from numerous studies points to a higher, rather than lower, prevalence of circulatory diseases and associated risk factors among the unmarried than the married. More specifically, it has been shown that the unmarried have higher cholesterol levels than the married , higher other types of treatment, such as angioplasty or bypass surgery. However, a study by Bearden et al. [Theoretically, the never-married could also have a lower prevalence of both the more and the less severe types of any disorder - thus taking less medicine even without any underuse - and still have a strong mortality disadvantage because of less adequate use of n et al.  that addIf the unmarried are particularly inclined to use less medicine than recommended or needed for their circulatory disorders, the implications for mortality depend on whether this underuse is most pronounced with respect to the less severe or the more severe types of the disorder. The use of statins (for hyperlipidemia) may serve as a particularly relevant example. This drug is used both as primary prevention  and secondary prevention (i.e. when a circulatory disease is diagnosed and presumably treated). The efficacy of this primary prevention has been highly disputed, though a recent Cochrane review pointed towards a mortality reduction , which wFinally, it should be noted that, if the unmarried to a larger extent than the married take too little medicine compared to their needs, they may of course still use somewhat more medicine per person. For example, we have found that some groups of unmarried use more medicine for arrhythmic diseases than the married, and no group less, which may reflect that there is a particularly large difference between the married and the unmarried in the actual prevalence of that disorder. The fact that mortality from “cardiovascular diseases other than ischemic heart diseases” varies particularly much according to marital status lends some support to this idea. Similarly, the unmarried use more diuretics for heart failure (a subgroup of medicines for that disease and not shown in the tables), alone or in combination with other medicine, and this may indicate a relatively high prevalence of right-sided heart failure, which may be linked to chronic obstructive pulmonary disease and thus smoking – the latter being more common among the unmarried according to some studies as already noted , 43, 49.As mentioned above, studies of marital status differences in health and mortality consistently refer to economic benefits of marriage and the important role played by spouses in providing social support and exerting social control –7. Such The evidence on such causal pathways is not large, but some studies of cardiovascular diseases suggest that spouses may encourage attendance at screening, prompt consultation after onset of symptoms or otherwise increase the chance of an early diagnosis , 21. Condiscontinue the use of medicines.In the absence of a spouse, children may play a similar role in supporting consultation and treatment adherence, and as fewer of the never-married than the widowed or divorced have children, this might account for some of the differences we found between groups of the unmarried when it comes to the chance of using and starting to use the medicines for circulatory disorders. However there is little evidence from previous studies on this issue. Another possible reason for these differences between the never-married and formerly married is that the latter may persist with habits of health care seeking developed during their married life, though it is harder to understand why they are more inclined to The study has some limitations, the most important being the lack of information on actual disorders as discussed above. Furthermore, formal marital status does not tell us the full story about actual living arrangements. Some of the unmarried live in cohabiting unions , and ifAdditionally, NorPD does not include drug purchases for individuals in health care institutions. Since the unmarried are more likely to be institutionalized, the actual use of medicine in this group may not be quite as modest compared to the married as indicated by our estimates. However, this bias must be small, as the analysis only includes persons younger than 80, and at age 75-79 only 5% live in institutions .An important strength of the study is availability of data that covers the whole population in which the measure of drug use was based on recorded purchase, assumed to be a good indicator of use, rather than self-report of use.Our results suggest that there is an underuse of medicine for circulatory disorders among the unmarried, and especially the never-married. The low usage of medication by the never-married particularly reflects low initial purchase of medication whereas for the divorced and widowed failure to continue with medication seemed more important. Inadequate use of these potentially very efficient medicines in such a large population group is, of course, a serious public health problem. Furthermore, underuse of medication for circulatory disorders among the unmarried in relatively recent years, combined with an increasing importance of such medicines, suggest a growing disadvantage for the unmarried when it comes to this type of medication . This increasing disadvantage may have contributed to their falling behind with respect to mortality from circulatory diseases, and thus the widening marital status gap in all-cause mortality – which has been seen in a number of countries. In Norway, the excess mortality has increased particularly much for the group of unmarried also showing the clearest indications of underuse of medication for circulatory disorders, the never-married. Stated differently, the unmarried – and particularly the never-married- may not have benefited from recent life-saving improvements in medical treatment for circulatory disorders to the same extent as the married.Further investigation of this issue is clearly warranted. A central element of such investigations should be to collect data that make it possible to better measure the potential underuse of medication. For that purpose, one would need information about the actual prevalence of the disorders as well as all types of treatment that are used. Obviously, it would also be an advantage if the data could shed light on the underlying mechanisms such as, for example, the role of spouses and children in prompting seeking of and adherence to treatment.


The relevance and effectiveness of the WHO Global Code of Practice on the International Recruitment of Personnel will be reviewed by the World Health Assembly in 2015. The origins of the Code of Practice and the global health diplomacy process before and after its adoption are analyzed herein.Case studies from the European and eastern and southern African regions describe in detail successes and failures of the policy implementation of the Code. In Europe, the Code is effective and even more relevant than before, but might require some tweaking. In Eastern and Southern Africa, the code is relevant but far from efficient in mitigating the negative effects of health workforce migration.Solutions to strengthen the Code include clarification of some of its definitions and articles, inclusion of a governance structure and asustainable and binding financing system to reimburse countries for health workforce losses due to migration, and featuring of health worker migration on global policy agendas across a range of institutional policy domains. Ultimately, the crisis in human resources is a shared problem requiring shared responsibility for cooperative action” [Working Together for Health [The recruitment of health workers from abroad is part of an expansive pattern of skilled workforce migration that has existed since the rapid welfare state expansion of many countries in the 1950s and 1960s. Already in 1972, 6 % of the world’s physicians were located outside their country of origin . Other vIn an interconnected world, globalization and scarcity are closely linked. The fiscal realities that frame available public financing for health systems and health workforce salaries are shaped by such issues as untaxed wealth, capital flight, wealth inequalities, etc. This fiscal crisis  has contributed to external migration, which, in turn, has caused significant savings in training costs to importing countries .deep legal and institutional framework” and may “promote deeper commitments” than legally binding instruments [In nine African source countries, the estimated government-subsidized cost of a doctor’s education ranges from US$ 21,000 in Uganda to US$ 58,700 in South Africa. The overall estimated loss of return on investment for all doctors currently working abroad is US$ 2.17 billion, ranging from US$ 2.16 million for Malawi to US$ 1.41 billion for South Africa. The benefit to destination countries of recruiting trained doctors was largest for the United Kingdom (US$ 2.7 billion) and the United States (US$ 846 million) . As a cotruments . A week truments . The CodWHO recommended that the Code be incorporated into national policies and laws so that it can become legally binding. However, some states suggested that a more formal system for monitoring and implementing the Code was necessary for it to become a meaningful response to global HRH recruitment. The adoption of the Code, unfortunately, marked the end of a few ‘good years for HRH’ in global health policy. The economic crises in the United States and Europe led to a reduction of funds for GHWA and WHO to effectively work on Code implementation and monitoring. Austerity in Europe and the United States put a strain on health systems, including the health workforce . Despitemissing and thus not in action” – and this shortfall is predicted to rise further to at least 12.9 million in the coming decade [The health workforce crisis should not be dealt with within its own thematic ‘silo’ , but should rather be looked at in a systemic way. The global health workforce gap has increased rather than decreased since the release of the World Health Report in 2006. Given current population growth rates in different regions in the world, an ageing workforce, and an epidemiological transition to chronic disease worldwide, there is a desperate need for more skilled health workers. In 2013, approximately 7.2 million more midwives, nurses, and physicians were “Against this backdrop, the relevance and effectiveness of the Code has been assessed in a number of European countries and in Eastern and Southern Africa (ESA). These regions were selected for the present review given that the authors, active in academia and civil society, have been closely involved in Code follow-up and policy dialogue over the last few years. In this analysis, the authors provide their experiences with and insights into the uptake of the Code and its potential for future directions.The period of implementation of the Code in the European region has coincided with the financial and economic crisis. The latter impacts directly on the relationship between investment in health workforce development and health workforce mobility, which is at the heart of the Code: the resulting new intra-European Union (EU) wage imbalances and the persisting shortages of health workers confer to the Code a renewed relevance in the region.Staff Working Document on an Action Plan for the EU Health Workforce, a potential shortfall of around 1 million healthcare workers by 2020, if no further measures were taken to meet existing challenges [Although countries in Europe have responded to the economic crisis in various ways, most have adopted large-scale cuts and public sector reforms: in the context of the austerity packages implemented in 2009–2011, public spending on health fell in many countries . As healallenges .Action Plan for the EU Health Workforce as a highly labour-intensive sector [The response coming from EU institutions adopts a perspective that stems from considerations on the employment potential of the health sector.e sector . As suche sector .Using this frame, public health considerations thus tend to take second place to market development approaches. The evidence shows, however, that the free movement of health workers leads to some seeking better opportunities abroad, creating a conflict in which personal and professional ethics sometimes collide  at the eThe Code can be a key tool to solve this incoherence, as it brings back a much needed public health perspective into the debate on the mobility of health workers by looking at the impact, in terms of brain drain, on health systems of origin. While the value of the Code as a policy framework to manage health workforce mobility is formally acknowledged in several EU level policy documents , its volIn the above context, non-governmental actors, including health professionals’ organizations, trade unions, non-governmental organisations, and universities, are autonomously taking steps to implement the public health approach to health workforce mobility promoted by the Code. Civil society organisations in eight European countriesIn the Netherlands, Wemos observed that hiring cheap personnel from other European countries or even from other continents is becoming an attractive option, both for home care provided via municipalities and for private (24-h) home-based care. Different civil society organisations and trade unions are seeking collaboration between recruitment agencies, Dutch inspectorates, the Ministry of Health, the Ministry of Social Affairs and Employment, municipalities, and other trade unions in order to ensure fair recruitment and the rights of international health workers .As the labour market becomes more globalized, rising demand is driving migration and mobility amongst health personnel.In the United Kingdom, Health Poverty Action showed the engagement of the United Kingdom Royal College of Nursing in overcoming data limitations through the production of a Labour Market Review, which provides an annual picture of the United Kingdom nursing labour market, including the number of internationally recruited nurses and the wider global implications .Redemptoris Missio documented how the National Chamber of Nurses and Midwives in Poland attempted to determine the actual scale of migration using direct requests to the appropriate authorities  in other European Member States .Planning, forecasting, and providing for domestic health workforces without resorting to international recruitment are key to the development of sustainable health workforces globally and a fundamental step towards reducing brain drain. This also requires reliable data about inflow and outflow of health personnel.In Germany, Terre des Hommes analysed the nurses’ struggle for decent work at the Charité University Clinics in Berlin – a renewed trend to recruit non-European candidates was observed, unfortunately occurring at the expense of improving conditions for the nurses already in the system. Thus, the recruitment of Asian or African nurses is the result of decreasing working conditions and may act as another ‘push’ for further cuts in wages and labour rights in the German nursing sector .Terre des Hommes further analysed the German–Philippine bilateral agreement for the recruitment of nurses, finding that the inclusion of social partners in both origin and destination countries at the right time, including in the monitoring of the agreement, allowed to shape a comprehensive agreement and avert detrimental consequences .Another case study documented how increased collaboration between the European Federation of Public Service Unions, Verdi, and the Spanish Trade Unions for Health Workers (FES-CCOO and FSP-UGT) raised awareness that exploitative working conditions experienced by a group of Spanish nurses in Germany are unacceptable and that collective agreements must be respected .In the Italian province of Florence, Amref documented how IPASVI, the professional federation of nurses, put in place the first Contact Point for international health workers: it supports and helps international colleagues find their way, addressing their concerns and concrete problems such as the recognition of professional qualifications, contract, and working conditions, as well as other general living and employment issues .The Code extensively covers the promotion of (and respect for) fair labour practices as well as the provision of equal rights to all health personnel. Several case studies show that there are barriers, but also identify solutions.In Belgium, the civil society-led platform for international health “Be-cause Health” engaged key actors, including the Belgian Technical Cooperation, non-governmental organisations, academic institutions, and private companies, on the issue of recruitment of foreign medical personnel, with the aim to harmonize, increase efficiency, and render more equitable the practices of Belgian development cooperation actors in this field .Memisa’s hospital twinning program stimulates professional development and exchanges between hospitals in Belgium and those in selected African countries .Amref documented how a multi-stakeholder dialogue could effectively strengthen the role of the Italian National Professional Organization of Medical Doctors (FNOMCeO) in global health, based on principles of inclusiveness and solidarity .Wemos demonstrated the role that health providers can take, through their Corporate Social Responsibility policies, in translating a global and European code at the local level in the Netherlands; this also needs various actors such as civil society organisations, trade unions, health care institutions, and recruitment agencies to help collectively raise awareness on this issue .The Center for Health Politics and Services illustrated the case of Bulgarian specialist doctors being hired part-time in the neighbouring Călăraşi region of Romania, thus ‘topping up’ their Bulgarian salaries and in this way remaining in their region without having to migrate to another EU country .Contributions from Europe towards achieving a sustainable health workforce and strengthening health systems worldwide require cooperation amongst several actors and a more common understanding and awareness – from global to local.These case studies indicate that the public health approach to health workforce mobility promoted by the Code is already translated into practice in many local and national contexts, thanks to the efforts by a variety of non-governmental actors. They are also a confirmation that the multi-stakeholder approach promoted by the Code is key to its successful implementation. These efforts, however, are often fragmented – it is time for a more systemic approach.Call to Action: A Health Worker for Everyone, Everywhere [As a contribution towards this end, the civil society-led erywhere  was launA study in the ESA region, with 10 countries in the region represented, found that 3 years after the Code was adopted by the World Health Assembly, the main HRH concerns in the region were considered to be internal migration, maldistribution, and absolute shortages of health professionals, rather than external migration . RegardiThe Code has not realised its potential to galvanise action on HRH in the ESA region, and yet it is one of the regions most affected by the HRH crisis. For instance, the topics of policy focus alluded to in the Code include improving migration monitoring , managing migration flows , HRH policy and practice , strengthening health systems , and coordination, collaboration, and monitoring progress. Clearly, most of the strategies needed to combat the health workforce challenges in the region can be adequately addressed through implementation of the Code.It goes without saying that the Code is relevant in driving forward the HRH agenda, and yet there has not been much progress in implementing the Code in the ESA region since it was adopted in 2010; most progress in implementation took place in European/Organisation for Economic Co-operation and Development countries . ChallenThe Code is relevant and has the potential to spur action on virtually all aspects of the HRH challenges in the developing world. Nevertheless, action has been lacking on both the part of governments and CSOs.EU Joint Action Health Workforce Planning and Forecasting, a 36-month project funded by the European Commission with the objective to provide a platform for collaboration and exchange between Member States to support them to prepare the future of the health workforce, has concluded that “The principles of the Code are also relevant within the free movement zone of the EU” [The analyses of Code implementation in the European and ESA region indicate stark differences between these regions. In Europe, Code implementation and its underlying norms have been effectively addressed. Most countries are aware about the Code, and have a designated authority in place that monitors the different elements of the Code. In 2013, most of them also submitted timely reports to the World Health Assembly regarding the monitoring of Code implementation by its member states. The WHO Regional Office for Europe has offered consistent policy advice and leadership to keep the Code relevant and under attention of its member states . The EU  the EU” . They suIn addition, a vibrant coalition of civil society , academic institutions, professional associations, and labour unions ensures that the governance of HRH migration is addressed and remains on the policy agenda. The inter-sectoral approach with involvement of multiple actors as promoted in the Code is taking place in a number of European countries. Hence, the Code remains relevant for policy guidance within the EU. However, due to the financial crisis and related austerity measures, employment opportunities for the European health workforce have diminished. There has been less recruitment from outside the European region, and more mobility of health workers between European member states. Migration mostly takes place from eastern and southern European countries to those in North and Western Europe . This miThe ESA region offers a contrasting picture. The Code is still relevant in addressing health workforce migration, but its implementation has been far from effective. Research has indicated that the number of African physicians into the United States workforce continues to increase substantially despite the adoption of the Code . The absAdditionally, weak political leadership, limited institutional capacity, and a silenced civil society have all played a role in failing to take the principles of the Code forward. However, poor dissemination and scarcity of resources might also explain, to a certain extent, why uptake of the Code has been hampered. In contrast to the EU, where there are several inter-governmental, research, and civil society projects funded in the field of health workforce mobility, this is hardly the case in the ESA region. Additional resources could advance dissemination and advocacy amongst African policymakers to implement the Code’s articles.Perhaps there are simply more urgent issues to address than mitigating the migration of health workers. Further, in the short run, it might even be beneficial to have migrated health workers sending their remittances home so that their families can cover basic economic needs. The long term objective of building a national health system, often in settings where institutional governance arrangements are fragile, might not be the main priority for many ESA governments, hence the disinterest to implement, monitor, and report on the Code.There are other issues that impede the effectiveness of the Code. “Active recruitment” (article 5.1) is not further explained, allowing space to interpretation and thus confusion as to what is considered “ethical” and what is not . A seconthe establishment of a more extensive global, public health reserve workforce” [A policy proposal has been made to recommend a global fee-supported system similar to that employed by UNITAID. This Global Health Resource Fund would basically use a dynamic fee structure that would oblige high-income countries and private sector actors engaged in the recruitment of resource-poor country health workers to contribute with funds earmarked for health systems strengthening and employment in the public sector. This fund would build upon the existing efforts of a health systems funding platform by WHO, the World Bank, the Global Fund, and the Gavi alliance . This prrkforce” .migration of health professionals is at the junction of the right to mobility, right to health and the right to decent work. It is about finding an acceptable compromise between the rights and obligations of migrant workers, employers and governments based on sound research findings” [Finally, the governance of HRH migration has become more complex over the years, as it is now at the nexus of wider global policy initiatives and debates. The “indings” . A key cindings” .When it comes to the relevance and effectiveness of the Code in the European and ESA regions, the picture is ambiguous. In a number of European countries the Code is effectively implemented, partly due to a dynamic civil society engagement. The financial crisis, the related austerity agenda, and the internal European policy context have made the Code even more relevant within the EU in recent years. Conversely, in the ESA region, the Code remains very relevant due to the high attrition rate of health workers migrating abroad. The Code is, however, far from being effectively implemented, mainly because policymakers and civil society do not think the Code brings many benefits. Hence, it does not have a high priority for the governments and societies in the region. There are limited resources for dissemination, advocacy, and policy support to implement the Code. The non-binding character and lack of compensation have led to a somewhat similar fate for the global Code as the bilateral and regional Codes of practice that were created over a decade ago. Solutions to overcome this situation would be to further clarify certain definitions within the Code and to develop a governance structure and a sustainable, binding financing system to reimburse countries for health workforce losses due to migration. Likewise, there is a need to address the governance of HRH migration within the context of global international labour migration frameworks, the sustainable development agenda, and the development of global and regional free trade agreements. A human rights-based approach, focusing on universal access to health care and health equity, should underpin such a global governance regime.


We tested indicators for evaluatingoccupational tuberculosis prevention programs in six hospitals. The criterion todefine feasibility was the time spent to calculate the indicators.  time spent to evaluate the indicators ranged from 2h 52min to 15h11min 24sec. Theindicator for structure evaluation required less time; the longest time was spenton process indicators, including the observation of healthcare workers' practicesin relation to the use of N95 masks. There was an hindrance to test one of theindicators for tuberculosis outcomes in five situations, due to the lack of use oftuberculin skin test in these facilities. The time requires to calculateindicators in regarding to the outcomes for occupational tuberculosis largelydepends upon the level of organizational administrative structure for gatheringdata.  indicators to evaluate the structure for occupational tuberculosis prevention arehighly feasible. Nevertheless, the feasibility of indicators for process andoutcome is limited due to relevant variations in administrative issues athealthcare facilities. Tuberculosis continues to be a threat worldwide. Consequently, many healthcare workers(HCW) are at risk of being infected and acquiring this disease,Quality indicator technology has been increasingly used for evaluating health carepractices. They are quantitative measures of features or attributes of a given processor systemStructure indicators refer to the features required, such as humanresources, equipment, information systems, etc. Process indicatorsmeasure the dynamics of a given process, or how this particular process was performed.Outcome indicators measure the frequency in which event occurs, andassess final goals, such as mortality, morbidity or patient satisfaction,,In 2006, a group of researchers in Brazil constructed and validated a set of indicatorsdesigned to evaluate the quality of programs for healthcare-associated infection (HAI)prevention, including occupational tuberculosis. They can also be used to gauge theextent to which the control of HAI differs between different institutions,Due to great difficulty in finding patterns for feasibility assessment in theliterature, the best criteria for defining feasibility was previously discussed in afocus group with specialistsIn the present study we aimed to analyze the feasibility of these quality indicators forthe evaluation of programs for preventing occupational tuberculosis. This descriptive, cross-sectional study tested the feasibility of quality indicatorsaimed at evaluating elements of structure, process and outcome of occupationaltuberculosis prevention programs in different healthcare facilities. Time required forthe calculationof the indicators was assessed as a measure of feasibility.The quality indicators are described in Indicators were applied in six different institutions in the city of São Paulo, Brazil,which met the following requirements: a) acute care hospital, b) public or privatesetting, c) caring for patients with suspected or confirmed pulmonary or laryngealtuberculosis in the bacillary phase, and d) having a formal Healthcare-associatedInfection Control Committee (HICC).Selected variables were used to characterize the participant institutions and toidentify the components that may contribute to the variations in the time required tocalculate the indicators. These variables included the number of active beds; theaverage prevalence of daily (or monthly) inpatients with pulmonary orlaryngealtuberculosis bacillus and aerosol precautions indicated, number of employees in theinstitution, and nature of the institution (public / private / philanthropic).Data were collected using a standardized form, and the time was measured using achronometer. Secondary variables were collected in order to identify elements justifyingthe time spent to collect each indicator. Periods of interruption and time intervalswere deducted from the overall time span of the activity. Also, the time spent onhealthcare facility characterization, as well as the time required to access thehospital facilities  was not included in data collection.Indicators were tested by the same researcher in all healthcare facilities (T.R.S.).The variables of analysis were the time spent on: a) data collection, and b) dataconsolidation and analysis. We compared the time spent on testing of each indicator inthe different institutions.Data were collected from December 2010 to July 2012. This period was required tocomplete data collection in all six institutions, due to the small number of inpatientshaving pulmonary or laryngeal tuberculosis who were placed in aerosol precautions insome of the hospitals.The data analysis was descriptive.Among the six institutions in which the quality indicators were tested, four weregeneral hospitals, one was a hospital specializing in infectious disease, and one was ageneral hospital, although it served as a reference site for tuberculosis treatment. Among 2 All evaluated facilities had the same recommendation for the use of a N95 particulaterespirator: to put it on in the anteroom or in the hallway before entering the room of apatient with known or suspected pulmonary or laryngeal tuberculosis bacillus.The TORPS indicator resulted in minimal effort and time spent on its application in allinstitutions  RegardinThe TOI indicator was collected in five of the six institutions; there was only onehealthcare facility in which data were not organized in such a way that it could becollected. The time used to collect this indicator was not toolong, but depended on thelevel of data organization. . To note, public hospitals were more likelyto require less time to collect data than the private sector. In public hospitals thereare usually more patients admitted with tuberculosis, therefore it was possible toobserve two or more patients simultaneously, thus reaching 51 observations morerapidly.The TOPWC indicator required greater time for calculation. To noteMany quality indicators have been proposed in the literature, however few have beenevaluated regarding their feasibility for application, which creates a gap betweentheory and practice. Nevertheless, the recommendation for their use is quite frequent.To our knowledge, the present study is the first to evaluate the feasibility of qualityindicators, using as the criterion the time spent on administering /calculatingthem.,Information on quality of care depends upon data availability. Therefore, quality isdifficult to measure without correct and consistent information, which is oftenunavailableAlthough time spent on the application of quality indicators of an occupationaltuberculosis prevention program may vary in different healthcare facilities, some commonfeatures were noted from this study. For instance, the indicator that evaluated thestructure of the program (TORPS) proved to be highly feasible. This indicator hascharacteristics suggestive of being used for external audits and evaluations. On theother hand, the process indicator (TOPWC) requires greater dedication of professionaltime for its application. This indicator should be used preferentially by healthcarefacilities that have a higher number of in-patients requiring special precautions fortuberculosis, aiming to evaluate compliance with the use of the N95 mask by HCWs. As asuggestion, TOPWC could be applied biannually, or after major intervention and trainingprograms.---It is a matter for discussion as to why, despite recommendations, some healthcarefacilities in Brazil are not using the TST routinely, as we demonstrated in our sample.As an outcome to be measured, it was shown that the indicator for skin conversion(TOSCI) was not feasible due to this lack of compliance. The Centers for Disease Controlrecommends the use of the TST whenever there is the possibility of high exposure totuberculosisThe main outcome indicator (TOI), which measures the incidence of cases of tuberculosisamong HCW, is quite simple to obtain, provided the Occupational Medicine Service has astructured form to record such cases. Usually cases of occupational tuberculosis are notas frequent as to warrant a great deal of effort in recording them. Besides this, thenumber of exposed HCWs is, in general, quite steady and does not require a sophisticatedsystem to collect the information. Despite this, many healthcare facilities are notaware of monitoring the annual incidence of occupational cases of tuberculosis. The World Health Organization (WHO) shows that tuberculosis mortality in Brazil in 2013was 3.2/100.000 and the prevalence was 57/100.000A Chinese study showed that the health care workers' annual tuberculosis notificationrates were lower than the general population. Healthcare workers with tuberculosis werea mean of 35.5 years old, with females out numbering males (58.0%>42.0%). Theproportion of pulmonary tuberculosis was significantly higher among the women comparedwith men . This study suggested that the priority fortuberculosis prevention in healthcare institutions should be given to the young femaleHCWs, An Argentinean study that included 15,276 HCWs from 15 centers found a mean incidencerate of tuberculosis in 111.3/100,000 HCWsWith 1.5 million deaths in 2013 and 5.7 million new cases of tuberculosis disease, theWHO goal is to dramatically reduce the global burden of tuberculosis by 2015The results are limited by the small amount of participant institutions, which onlyenables a suggestion of possible relationships between indicators and the institutionalprofile. Further studies should include multiple institutions to enable theinvestigation of relationships between the nature of the institution and the feasibilityof applying the quality indicators. , There were not many objective criteria found inthe literature that allowed for the evaluation of the applicability of indicators, so itwas decided to use time as a marker. However, we understand that this is a specificperspective that limits the study.This study brings new insight to the applicability of previously validated qualityindicators, revealing that even a validated indicator may not have all the properties ofapplicability; this approach needs to be considered to suggest recommendations for theiruse.Moreover, strengths in the structure assessment, and weaknesses in the process andoutcomes assessments, have been identified. Areas to be improved include maintainingperiodic screening for latent tuberculosis using TST, monitoring the annual incidence ofoccupational cases of tuberculosis, and evaluating compliance with occupationalprevention.The indicators to evaluate the structure for occupational tuberculosis prevention arehighly feasible. The feasibility of applying indicators for process and outcome islimited, due to relevant differences in administrative issues at healthcare facilities,such as the system for data archiving and management.


High and fair correlations  occurred between frequencies generated with the dominant leg and the nondominant leg during knee extension exercise and pedaling, respectively. Fair to high correlations  occurred between frequencies performed with each of the two legs in an activity, and the two-legged frequency performed in the same type of activity. In general, the correlations were higher for knee extension exercise than for pedaling. Correlations between knee extension and pedaling frequencies were of modest occurrence. The correlations between movement frequencies generated separately by each of the legs might be interpreted to support the following working hypothesis, which was based on existing literature. It is likely that involved central pattern generators (CPGs) of the two legs share a common frequency generator or that separate frequency generators of each leg are attuned via interneuronal connections. Further, activity type appeared to be relevant. Thus, the apparent common rhythmogenesis for the two legs appeared to be stronger for the relatively simple single-joint activity of knee extension exercise as compared to the more complex multi-joint activity of pedaling. Finally, it appeared that the shared aspect of knee extension in the related types of activities of knee extension exercise and pedaling was insufficient to cause obvious correlations between generated movement frequencies in the two types of activities.Understanding of behavior and control of human voluntary rhythmic stereotyped leg movements is useful in work to improve performance, function, and rehabilitation of exercising, healthy, and injured humans. The present study aimed at adding to the existing understanding within this field. To pursue the aim, correlations between freely chosen movement frequencies in relatively simple, single-joint, one- and two-legged knee extension exercise were investigated. The same was done for more complex, multiple-joint, one- and two-legged pedaling. These particular activities were chosen because they could be considered related to some extent, as they shared a key aspect of knee extension, and because they at the same time were different. The activities were performed at submaximal intensities, by healthy individuals ( Better understanding of behavior and control of common voluntary human rhythmic movements is useful in the work to improve performance, function, and rehabilitation of exercising, healthy, and injured humans. Examples of human voluntary stereotyped rhythmic leg movements such as walking  The degree of common frequency generation for the two legs  is similar in the activity of knee extension exercise and the activity of pedaling. (ii) The shared aspect of knee extension, in itself, in the related types of activities of knee extension exercise and pedaling is sufficient for the generated movement frequencies in the two types of activities to correlate at least moderately. Knee extension contributes to characterize the down stroke phase in pedaling where most of the external power is produced  volunteered to participate in the study. They were carefully informed about the procedures of the study and the overall aim (“to enlarge our knowledge on control of rhythmic movement”) but at the same time kept naive to the specific purpose. The latter served to avoid any particular conscious movement control during the applied activities. All participants occasionally performed cycling as personal transport or exercise, but none of them were competitive cyclists. Fourteen of the participants reported that the right leg was their dominant leg while two participants reported that the left leg was their dominant leg. Written informed consent was obtained from all participants. The present study was carried out in accordance with the recommendations of the regional committee of Southern Norway for research ethics and the study conformed to the standards set by the Declaration of Helsinki.Each participant was informed to abstain from alcohol and tobacco 24 h before the test session. In addition, the participant was informed not to perform any intensive exercise 48 h before the test session.Each participant reported to the laboratory for a single test session that lasted 1 h and consisted of the following. First, the participant was allowed to adjust the cycle ergometer with respect to seat and handlebar position. Second, warm up and familiarization to the knee extension activities were performed in form of 5 min of two-legged knee extension exercise followed by 3 min of rest and 5 min of one-legged knee extension exercise. After another 3 min of rest, six activities were performed in random order as 5 min-bouts interrupted by 3 min-rest periods. The six activities consisted of one- and two-legged knee extension exercise as well as one- and two-legged pedaling. The two-legged knee extension exercise was performed in a way that each of the legs was extended in an alternating way as in pedaling. Each participant was informed in “not thinking of anything special” and “letting the legs move by themselves” during the activities. Frequency was freely chosen in all activities. During the activities, the participant was blinded to the frequency and the time.For knee extension exercise, a custom build electromagnetically braked ergometer was applied  every 30th s during each bout and an average value was subsequently calculated across each bout. Rate of perceived exertion (RPE) was indicated by the participant immediately after the bout. For this, a 15-grade Borg RPE scale with scores from 6–20 and corresponding subjective ratings from “Very light”  to “Maximal exertion”  was applied Borg, .The specific outcome measures of the present study were pedaling and knee extension frequencies, power output, heart rate, and RPE.R-values) were applied for investigation of the correlation between movement frequencies. Linear regressions were performed for associations presented in Figure t-tests were applied for evaluations of potential differences in average values. The ratings based on the size of the R-values apply to both positive and negative correlations as follows: ≤0.25 is considered weak, 0.26–0.50 is moderate, 0.51–0.75 is fair, and ≥0.76 is high  that they were lower than the R-values from correlations between knee extension frequencies  with movement frequencies in all knee extension exercise activities  in a group of 27 recreationally active individuals. However, that at the same time, freely chosen pedaling frequency was not correlated with stride frequency in each of the locomotion types of walking and running (Sardroodian et al., The activity of pedaling is to a degree characterized by knee extension. Thus, knee extension contributes to characterize the down stroke phase in pedaling where most of the external power is produced. Based on that, it could be hypothesized that generated movement frequencies in pedaling and knee extension exercise might strongly correlate. However, the present study indicated that this did not appear to be the case. Rather, the type of task, or activity, appeared to be of relevance in the present study. Firstly, the common between-leg rhythmogenesis appeared to be strong for knee extension exercise, which may be characterized as relatively simple, single-joint, exercise. For comparison, the common between-leg rhythmogenesis appeared to be weaker for pedaling, which may be characterized as a more complex activity involving multiple joints. An interpretation of this might be that the two legs’ CPGs shared a common rhythmogenesis, however, that this characteristic became attenuated during leg movement that involved more segments, joints, and muscles, i.e., in pedaling. Reasons for that could involve differences in degrees of complexity, afferent feedback, and supraspinal input. Another reason that type of activity appeared to be of relevance is the following. There appeared to be only minor sharing of between-activity rhythmogenesis when comparing knee extension exercise and pedaling. For comparison, it has recently been reported that freely chosen stride frequencies in related activities of walking and running correlated (The frequency during one-legged pedaling with the nondominant leg showed fair correlation with frequencies during all three types of knee extension exercise. Interestingly, the same was not the case for one-legged pedaling with the dominant leg. This difference is difficult to explain. But, perhaps it indicates that rhythmogenesis during one legged pedaling with the nondominant leg, in particular, to a degree is “driven” by CPGs responsible for rhythmogenesis during the simpler knee extension exercise.The present type of investigation has some built-in interpretational challenges. For example, it is not possible to directly measure a gross frequency output from a human CPG with available techniques. Here, we suggest that the observed movement frequencies are net, or resultant, outputs from CPGs, i.e., accounting for influence from in particular afferent feedback and supraspinal input. Regarding the complexity of the applied types of activities, it should be noted that during pedaling activities, there is both a pushing phase in which the foot is pushed forward at the top dead center, a down stroke phase where most of the external power is produced, and an upstroke phase in which the leg is partly lifted (So et al., In conclusion, fair to high correlations occurred between freely chosen movement frequencies generated separately by each of the legs. This might be interpreted to support the working hypothesis that the involved CPGs of the two legs share a common frequency generator or that separate frequency generators of each of the legs are attuned via interneuronal connections. Further, the apparent common rhythmogenesis for the two legs appeared to be stronger for the relatively simple single-joint activity of knee extension exercise as compared to the more complex multi-joint activity of pedaling. Finally, it appeared that the shared aspect of knee extension in the related activity types of knee extension exercise and pedaling was insufficient to cause obvious correlations between generated movement frequencies in the two types of activities.EAH had the initial idea for the study. All authors contributed to the planning of the study design. JS, MH and HW performed the data collection. All authors contributed on the data analyses and the intepretation of the results. EAH completed the first draft of the article. All authors have participated in revising of draft to finalize the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The Review Editor Dr. Pedro Figueiredo declares that, despite being affiliated with the same institution as the Associate Editor Dr. Jae Kun Shim, the review process was handled objectively.