職業性皮膚病監控系統建立之初探

Developing the Surveillance Program for Occupational Skin Diseases in Taiwan Area

隨著對職業安全衛生的重視，使得了解各種職業的疾病率成為政府當局及工業衛生界刻不容緩的事。但國內目前除鉛中毒之通報系統較為完善外，其餘之職業病仍缺乏完善之通報系統，使得職業病真正罹率之相關資料付之闕如。職業性皮膚病在較工業化的國家中，為一種普遍的職業病。其中以以接觸性皮膚炎最為常見。要降低職業性皮膚病的盛行率，預防乃為最有效的方法：其中監控又是預防疾病最重要的方法之一。然而在國內，職業性皮慮疾病由於較無致命性，故往往受到忽略。至今，國內尚無有關職業皮膚病的統計資料以及控方法，因此本研究希望能研發職業性皮膚病的監控方法。我們參考了各國的職業疾病與職業性皮膚病的研究調查以及醫療監控方法，而歸納出在國內可以使用三種方式來得到最佳的職業性皮慮疾病的盛行率資料：1.即工作場所之調查研究；2.專科醫師之通報方式；3.參與勞工工作環境安全衛生狀況調查。我們將此三種方法同時進行了測試。工作場所之調查研究最容易得到完整的健康資料，且其研究對象之暴露資料亦較能取得。其研究對象，比其他兩種方法較能代表同業的全體勞工。因此其所得到的皮膚病盛行率，較能代表全體同業之皮膚病盛行率。然而，進行工作場所之調查研究所需的人力物力皆十分龐大，而不易針對所有行職業進行完整的調查。若取一個折衷的辦法，則針對已知較高危險性的行業進行調查，而得到較危險性行業之暴露與盛行率資料，亦為一種可行的方式。皮膚病專科醫師所通報的資料，其可靠性頗高，若能得到較多願意參與職業性皮膚病通報的專科醫師之參與，則可行性會增加。然而以本國的醫療國情，醫師對通報疾病的意願並不高。對於職業性皮膚病，除其通報意願不高之外，會以高度注意力去診斷職業皮膚病的醫師更少。這方面的改善必須從醫學教育、再教育著手。此外，如何去創造醫師們願意通報的動機，更是此系統要有所成的必要條件。若再教育已有成效，即醫師較能偵測出職業疾病，則利用保險給付的統計資料來通報職業病以至職業皮膚疾病，亦為可行的方針。若我們希望在最短的時間內得知我國跨各行職業之職業性皮膚病的盛行率與其相對危險性，則最可行的辦法，應是參與勞工工作環境安全衛生狀況調查，而針對職業皮膚疾病提出相關問題。並隨之邀請在回答問卷中，疑似職業性皮膚病的患者至就近教學醫院的皮膚病門診就診。在全國可以找到幾個鞏心，進行對斿似職業皮膚病的患者作進一步之檢查與診斷，遇到確定為職業性皮膚病的患者，則彙報到勞工安全衛生研究所的監控中心，此中心則可決定對那些發生職業性皮膚病較多的行職業進行危險因子的調查，或建議相關單位進行改善的工作。

The need for understanding the occurrence of occupational diseases is becoming very important in industrialized countries. Many developed countries have approached this need by utilizing the medical surveillance. In Taiwan, no medical surveillance program has been active at the present time except for the surveillance program for lead-exposed workers. Skin diseases are very common occupational diseases in most industrialized countries. Increasing use of new chemicals keep inducing new occupational skin diseases by irritation, sensitization, or other mechanisms. However, occupational skin diseases have been overlooked in the past due to the low probability of fatality. One of the important steps in the prevention of occupational skin diseases is to develop an effective medical surveillance program. We reviewed the methods of medical surveillance in several developed countries in order to establish the best methodology of surveillance for occupational skin diseases. Three approaches are most suitable for this purpose: 1.Survey of the industries with known high occurrences of occupational skin diseases; 2.Physician's reporting of occupational skin diseases; and 3.Nationwide questionnaire survey of a representative sample of the working population. Survey of the industries will provide the most complete data on occupational exposure and health effects at the same time, but costs significant efforts and manpower. Surveying a few selected industries with highest probabilities of skin problems may give most relevant information. Dermatologists' reporting of occupational cases gives relatively reliable information on work-relatedness of the skin diseases. However, few dermatologists are interested in reporting the occupational cases. Diagnosing occupational skin diseases requires a high index of suspicion and knowledge in occupational health. It is therefore important to include knowledge on occupational dermatoses in physicians continuing education. A nationwide survey of a representative sample of the working population will provide us information on the general prevalence of skin diseases in the population. Those with reported skin diseases will then be interviewed and examined by qualified dermatologists for the confirmation of occupational skin diseases. This approach will give us best information on the nationwide rate of occupational dermatoses and the work processes causing problems, therefore will give the public health workers directions for more detailed survey for risk factors, and suggestions for work practice improvements.