Health and safety in waste collection: Towards evidence-based worker health surveillance.
ABSTRACT Waste collectors around the world are at risk for work-related disorders and injuries. The aim of this study was to assess work demands, acute physiologic responses, illnesses, and injuries as a starting point for worker health surveillance (WHS).
A systematic search was performed in PubMed and Embase on work demands, acute bodily responses, health, and injuries. A quality assessment and evidence synthesis was performed.
From a total of 379 retrieved studies, 50 studies fulfilled the inclusion criteria. Waste collecting varied from informal manual gathering to semi-automated systems. Most studies ("number of studies") on work demands and/or acute bodily responses addressed bioaerosols (14). Studies of health effects addressed respiratory complaints (8), and those on injuries addressed acute musculoskeletal disorders (3). Strong evidence is available that exposure to bioaerosols exceeds recommendations. Moderate evidence is available for an increased risk of respiratory complaints and musculoskeletal injuries, with significant odds ratios reported varying between 1.9-4.1 and 1.5-3.3, respectively. Limited evidence exists for gastrointestinal disorders and hearing loss.
WHS in waste collection is warranted for early detection of respiratory, gastrointestinal, and musculoskeletal disorders, and hearing loss.
- SourceAvailable from: Dick J J Heederik[show abstract] [hide abstract]
ABSTRACT: To compare respiratory symptoms and upper airway inflammation in domestic waste collectors and controls, and to find the association between measures of upper airway inflammation on the one hand and exposure concentrations of organic dust or respiratory symptoms on the other hand. Methods: In a cross sectional study among 47 waste collectors and 15 controls, questionnaire data on respiratory symptoms were collected. Nasal lavage (NAL), to assess upper airway inflammation, was performed before and after a work shift at the beginning and at the end of the working week. In NAL fluid, cells were counted and differentiated and concentrations of interleukin 6 (IL6), IL8, tumour necrosis factor-alpha (TNF alpha), and IL1 beta were measured. In collectors, inhalable dust samples were collected in which bacterial endotoxin and mould beta(1-->3)-glucan were assessed. Prevalence of respiratory symptoms was higher in waste collectors than in controls. Geometric mean exposure concentrations were 0.58 mg/m(3) for dust, 39 EU/m(3) for endotoxin, and 1.3 microg/m(3) for beta(1-->3)-glucan. At the end of the week collectors had higher concentrations of total cells and IL8 in NAL before and after a shift than controls (cells, before 1.9-fold p<0.10, after 3.3-fold p<0.01; IL8, before and after 1.8-fold p<0.05), and after/before work shift ratios of total cells were also higher (2.3-fold p=0.06) in collectors than in controls. Cells in NAL fluid consisted predominantly of neutrophils and epithelial cells, whereas eosinophils and mononuclear cells were rarely found. Exposure to dust and endotoxin was associated with concentrations of IL8 after the shift (p<0.05). Increased concentrations of IL8 (p<0.05) and total cells (p<0.10) after the shift were associated with respiratory symptoms. Concentrations of IL6, TNF alpha, and IL1 beta were not associated with waste collecting, symptoms, or exposure. Waste collectors show signs of increased upper airway inflammation and respiratory symptoms compared with controls. Exposure to organic dust probably underlies the inflammation mediated by neutrophils that result in respiratory symptoms.Occupational and Environmental Medicine 02/2002; 59(2):106-12. · 3.22 Impact Factor
- [show abstract] [hide abstract]
ABSTRACT: In order to secure a safer and healthy work situation, the heavy physical loads imposed on 23 refuse collectors (aged 26-54) working in the city of Haarlem, in The Netherlands, were studied in a series of three experiments between 1984 and 1987. The aims were respectively (1) to study the load for workers collecting dustbins or polythene bags; (2) to introduce changes to reduce the load to avoid exceeding the overload criteria by individual refuse collectors; and (3) to investigate the effects of interventions to improve the efficiency of refuse collecting. The maximal isometric lifting force (Fmax) and the maximal aerobic power (VO2max) of 23 refuse collectors were measured in the laboratory. Fmax was measured with an isometric dynamometer pulling with one arm from the floor; the mean value was 912 (+/- 127)N. VO2max was measured running on a treadmill; the mean value was 43.3 (+/- 0.8)ml O2 per kg body mass per min. The physical load on the oxygen transport system was measured through work analysis and by a continuous registration of the heart rate over three working days. Criteria for overload were set at a mean external load of 20% Fmax and a mean energy expenditure of 30% VO2max and an energy expenditure of 50% VO2max or more for a maximum of 60 min per day. Replacement of dustbins by polythene bags resulted in a 70% increase in the total amount of refuse collected, an increase in throwing frequency, but a lower mean load per throw, and no significant differences in the mean heart rate over the working day. When polythene bags were used the mean values did not exceed the overload criteria, but 39% of the individual collectors did have a workload that was too high with respect to one of the criteria. In the last experiment the collectors were advised to reduce their work load by (a) lifting no more than two bags at a time; (b) reducing their walking pace; and (c) taking more breaks. Although compliance with the recommendations was good, and the weight lifted and the walking speed decreased, the physiological load remained the same. This may have been caused by a 15% increase in the total amount of refuse that had to be collected at that time.Ergonomics 01/1991; 33(12):1471-86. · 1.67 Impact Factor
- [show abstract] [hide abstract]
ABSTRACT: A study was conducted among 151 municipal workers (72 solid-waste workers, and 79 workers not exposed to waste). Total antibodies against Hepatitis A virus (HAV) were measured, and socio-demographic information was collected using a self-administered questionnaire. Univariate analysis has shown that occupational exposure to waste, age, duration of employment and educational status were significantly associated with the prevalence of anti-HAV(+). Municipal Solid Waste Workers had a higher prevalence of anti-HAV(+) in comparison with municipal workers not exposed to waste. Duration of employment was significantly associated anti-HAV(+). Multivariate analysis revealed an independent association of anti-HAV(+) with occupational exposure to waste and ageing. Our results suggest a potential causal role of occupational exposure to waste, in the development of HAV infection.International Journal of Clinical Practice 12/2006; 60(11):1432-6. · 2.43 Impact Factor
AMERICAN JOURNAL OF INDUSTRIAL MEDICINE 53:1040–1064 (2010)
Health and Safety in Waste Collection:
Towards Evidence-Based Worker
P. Paul F.M. Kuijer, PhD,?Judith K. Sluiter, PhD, and Monique H.W. Frings-Dresen, PhD
injuries. The aim of this study was to assess work demands, acute physiologic responses,
illnesses, and injuries as a starting point for worker health surveillance (WHS).
Methods A systematic search was performed in PubMed and Embase on work demands,
acute bodily responses, health, and injuries. A quality assessment and evidence synthesis
Results From a total of 379 retrieved studies, 50 studies fulfilled the inclusion criteria.
studies (‘‘numberof studies’’) on work demands and/or acute bodily responses addressed
bioaerosols (14). Studies of health effects addressed respiratory complaints (8), and those
on injuries addressed acute musculoskeletal disorders (3). Strong evidence is available
an increased risk of respiratory complaints and musculoskeletal injuries, with significant
exists for gastrointestinal disorders and hearing loss.
Conclusions WHS in waste collection is warranted for early detection of respiratory,
gastrointestinal, and musculoskeletal disorders, and hearing loss. Am. J. Ind. Med.
53:1040–1064, 2010. ? 2010 Wiley-Liss, Inc.
KEY WORDS: occupational disease; injury; worker health surveillance; musculos-
keletal disorders; respiratory disease; bioaerosols
Worker health surveillance (WHS) is an important
component in the practice of occupational health [Koh and
Aw, 2003]. Surveillance refers to the periodic examination
of putatively exposed workers, and therefore requires a
longitudinal approach [Gochfeld, 1992]. WHS may be
performed for three purposes: (i) to prevent the onset,
recurrence, or worsening of work-related disease in individ-
uals; (ii) to watch and promote an individual’s health; and
(iii) to watch and promote an individual’s ability to perform
of self and/or others [International Labour Office, 1997;
Netherlands Society of Occupational Medicine, 2005]. The
International Labor Organization (ILO) has formulated
guidelines on how WHS should be organized [ILO, 1997].
A prerequisite is that WHS should be based on a thorough
investigation of all work-related factors which may affect
Coronel Institute of Occupational Health, Academic Medical Center, University of
*Correspondence to: P. Paul F.M. Kuijer, Coronel Institute of Occupational Health,
Academic Medical Center, University ofAmsterdam, P.O. Box 22700,1100 DE Amsterdam,
is limited. For instance, in the Netherlands different WHS
evidence for these protocols is mostly lacking [Sluiter and
of evidence exists for the content of WHS, evidence for
the need of WHS lies in the preventive effect of WHS on
(work-related) disease. Unfortunately, this latter evidence is
One job that has contributed greatly to human health by
reducing the risk of several diseases like typhoid fever or
cholera is waste collecting. Waste collection in the present
study is defined as removing waste materials from house-
holds, typically in urban and suburban areas, to either the
point of recycling or final disposal. However, several studies
have pointed out the presence of work-related health and
safety risks for the waste collectors themselves. In 1998,
the United States Bureau of Labor Statistics reported that
U.S. waste collectors experienced 49 fatalities per 100,000
workers in 1996, and that waste collecting was the seventh
most risky occupation in the U.S. [An et al., 1999]. For non-
was at least 95 per 1,000 employees per year among Danish
waste collectors and 17 per 1,000 in the total workforce,
according to the Danish Registry of Occupational Accidents
and Diseases [Poulsen et al., 1995]. Both Poulsen et al.
important. For instance, collecting of sorted organic waste
might result in an increased risk of upper airway inflamma-
tion [Heldal et al., 2003a,b]. Pushing and pulling two-
As human population and consumption and packaging
increases, theworldwide amount of solid wastewill increase
related to an increase in waste. The more affluent a society
becomes, the more waste per capita it generates. As the less
wealthy nations develop, they too are creating more wealth
and thus adding to the world’s waste output as well as to its
population. Research and Markets  estimate that the
amount of municipal solid waste generated worldwide in
2006 was 2 billion tons. The forecast is that this amount will
increase by 37% between 2007 and 2011 [Research and
influence on volume.
This context means that worldwide waste collection
is becoming more important and better insight into the
work-related health and safety risks of the increasing
number of waste collecting employees is vital for occupa-
tional professionals. The aim of the present study was to
systematically describe the present knowledge on job-
specific work demands, acute bodily responses, and the
health and safety of waste collectors as a starting point for
the creation of a job-specific WHS to prevent work-related
disease and disability.
MATERIALS AND METHODS
Search Strategy and Inclusion Criteria
A systematic review of the literature was performed
using PubMed (through February 16, 2009) and Embase
(from 1980 through February 16, 2009). A sensitive search
was performed. Only search terms for waste collectors were
used in PubMed and in Embase, and they were combined
with the conjunction ‘‘OR’’ (Table I).
After checking for duplicates, the following inclusion
criteria were applied to the title and abstract by the primary
* The population of interest is household waste collectors.
* Work demands, acute bodily responses, health, or injuries
are described during their daily work.
* The paper is a primary study.
* The paper should be written in English, Dutch, German,
French, or Italian.
to decide whether the inclusion criteria were met, the full
paper was checked. Next, the inclusion criteria were applied
fulfilled the inclusion criteria, the other two researchers (JS
and MFD)were consultedand a decision was madebased on
consensus. For the included papers derived from PubMed,
the option ‘‘Related links’’ was used to check whether
thisresultedinotherpossibly relevant studies.Moreover,the
potentially relevant papers.
Data were extracted by the first author using a
standardized form. First, the main outcome of the study
Health and Safety in Waste Collection1041
was noted: work demands or acute bodily responses, health,
and/or injuries. The following definitions were used: work
are the short-term reactions of the body to the (work)
demands, health is the long-term reaction of the body to the
(work) demands, and injuries are the harmful consequences
byanaccident. Thestudies onworkdemands oracutebodily
responses were further categorized into biological, biome-
chanical, energetic, physical, chemical, and psychological
factors. The studies on health were categorized according
to the type of disease: respiratory, gastrointestinal, muscu-
loskeletal, (other) infectious, hearing, and ‘‘other health
effects.’’ The studies on injuries were classified according
to the type of injury or accident. Next, the following
information was extracted: primary author, year of publica-
tion, country, study design (cross-sectional, case–control,
or cohort (retro- or prospective)), characteristics of the
population at risk (i.e., number of waste collectors, method
of the control population (i.e., number of participants, ages,
and years of employment), type of work demand or acute
bodily response/health outcome/injury and, finally, the main
result of the study.
The studies were described using items from the
STROBE statement [Von Elm et al., 2007] and Cochrane
quality criteria for cross-sectional, case–control, and cohort
studies [Dutch Cochrane Center, 2008]. Depending on study
design, the first author assessed whether the study described
the study population (i.e., provided a rationale for selection,
a rationale for the group size, a clear description of the
collection method for household waste, a description of
the contrast between ‘‘exposed’’ and ‘‘non-exposed’’),
addressed selection bias (i.e., described eligibility criteria
for participants, sources and methods of selection of
participants, and the possible effect of selection bias on
outcome), described exposure (i.e., information on the
definition and the quality of the assessment method),
described the outcome (i.e., information on the definition
and the quality of the assessment method, whether the
outcome was blinded for exposure), and described possible
confounding factors (i.e., a description of confounders
related to exposure and outcome, the quality of the assess-
ment method for confounders, and whether the outcomewas
adjusted for confounding).
Strength of the Evidence
To evaluate the levels of evidence, we used criteria
2005] to rate studies regarding health, namely:
Strong evidence: Results in the same direction in two
for confounders and sufficient follow-up.
Moderate evidence: Results in the same direction in at
least two independent studies such as a cohort study
without the strengths of 1, or a retrospective cohort
study or a case–control study.
Limited evidence: Results in the same direction in at
least one study fulfilling the criteria as described in
number 2, or one or more studies not fulfilling the
criteria of 2.
For injuries the same levels of evidence were used.
However,because forinjuries no uncertaintyexistsabout the
temporal relation between cause and effect, the longitudinal
nature of a study is not a prerequisite.
For studies on work demands and acute bodily
responses, the following criteria were formulated:
Strong evidence: Results in the same direction in at
least three cross-sectional studies with enough power,
and a scientifically sound assessment method for
exposure and outcome.
Moderate evidence: Results in the same direction in at
least two cross-sectional studies with enough power,
and a scientifically sound assessment method for
exposure and outcome.
Limited evidence: Results in the same direction in at
least one study with enough power, and a scientifically
one or more studies not fulfilling the criteria regarding
enough power and a scientifically sound assessment
method for exposure and outcome.
Waste Collector ‘‘at Risk’’
The following decision rule was used to assess whether
waste collectors were at risk based on the results of the
included studies on work demands and acute bodily
responses, health, and injuries. First, this was the case when
the majority of studies on work demands and acute bodily
responses exceeded generally accepted recommendations.
These recommendations are based on peer-reviewed scien-
tific studies and are described in ergonomic and/or occupa-
tional hygiene handbooks. Secondly, this was the case when
the majority of studies on health and/or injuries reported a
statistically significantly increased risk.
The search strategy resulted in 285 hits in PubMed and
the inclusion criteria, 50 studies remained from 18 countries
1042 Kuijer et al.
all around the world (Appendices A–C). Fifteen of these
included studies were found in both databases. Most studies
(72%) were on waste collectors working in Europe.
Waste collecting varied from informal manually gather-
ing to semi-automated systems. For example, on one side of
waste collectors working in Santo Andre ´, Brazil. These
recyclers work either on an individual, informal, and
autonomous basis or in groups through organized recycling
cooperatives or associations. Their work consists of selec-
tively collecting recyclables from businesses, schools,
apartment buildings, or out of the garbage in the streets and
sometimes at landfills. The recyclables are transported for
the continuum, Lavoie and Dunkerley  described
waste collectors that work either under municipal jurisdic-
tion or in the private sector. They collect sorted and unsorted
waste manually or semi-automatically using different types
of containers and compactor trucks.
The quality of the description of the included studies on
injuries is depicted in Table II. Most studies provide a clear
rationale for the selection of the population at risk, gave a
description of the way the refuse is collected, defined the
exposure and outcome, and addressed confounders when
relevant. The rationale for the group size was almost never
mentioned (percentage of studies providing rationale varied
between 0% and 8%). This was also true for the sources and
methods of selection of participants (percentage of studies
bias on outcome (percentage of studies varied between 0%
and 33% with the exception of both case–control studies),
and whether the outcome was blinded for exposure
(percentage of studies varied between 0% and 4%).
Work Demands and Acute Bodily
In total 27 studies described one or more work demands
described biological factors (Appendix A). The next largest
described biomechanical factors, two physical factors, one a
chemical factor and another a psychological risk factor.
The biological factors mostly addressed so-called
bioaerosols such as dust, bacteria, fungi, and endotoxins.
The mean or median exposure for dust varied among studies
between 0.3mg/m3[Wouters et al., 2006] and 7.7mg/m3
The studies are categorized by the type of design (cross-sectional, cohort, and case^control), number of studies (n), population (i.e., rationale for selection, rationale for the group size, clear description of the collection method for
household waste, description of the contrast between‘‘exposed’’and ‘‘non-exposed’’), selection bias (i.e., eligibility criteria for participants, sources and methods of selection of participants, and possible effect of selection bias on
Health and Safety in Waste Collection 1043
[Krajewski et al., 2002]. For bacteria it varied between
5.6?103CFU (colony-forming unit)/m3[Lavoie et al.,
2006] and 60?103CFU/m3[Krajewski et al., 2002], for
fungi between 5.9?103CFU/m3[Lavoie et al., 2006] and
63?103CFU/m3[Krajewski et al., 2002], and for endotox-
ins between 0.1ng/m3[Thorn et al., 1998] and 36ng/m3
and 100EU/m3[Lavoie and Dunkerley, 2002].
maximum oxygen uptake (% _ _O2max), and noradrenaline
measured the same outcome, the mean %HRR during a
working day was 33% [Fontana et al., 1995; Anjos et al.,
2007] and the mean % _VO2max while working varied
However, in each of the three studies on %_ _O2max,
individual waste collectors exceeded the recommendation.
For instance, in the study by Frings-Dresen et al. [1995a]
(n¼47) and 59% handling bags (n¼51) exceeded the
Three out of the four biomechanical studies reported on
the compression forces on the lower back. Depending on the
method of collection, this force varied for two-wheeled
containers between 300N [Schibye et al., 2001] and 2,654N
4,991 and 5,810N [De Looze et al., 1995], and for bags
between 2,312N [Schibye et al., 2001] and 5,179N [De
Looze et al., 1995]. The two studies on noise level both
reported an 8-hr weighted minimum level exceeding 90dB
(A) [Kessler et al., 1987; Pfeiffer and Hoormann, 1988].
Strong evidence is available to show that biological
factors like dust, endotoxins, bacteria, and fungi exceeded
generally accepted recommendations in waste collecting
(Table III). Moderate evidence is available for the
Musculoskeletal complaints such as lower back and
The total number of studies are classified into three categories: whether the studies described an increased risk (yes), or not (no), or whether this is unclear (?) based on
1044Kuijer et al.
compression force on the lower back as a biomechanical
factor and the heart rate reserve and oxygen uptake as
energetic factors. Limited evidence is available that noise
levels exceeded generally accepted recommendations
during waste collecting. Based on our decision rule, the
presence of these risks confers possible eligibility for WHS
Nineteen studies reported one or more health effects.
Studies described respiratory complaints (n¼8; Appendix
B), gastrointestinal complaints (n¼4), infectious diseases
Six out of the eight studies on respiratory complaints
used a control group as comparison. Fourof these six studies
collectors. For instance, Heldal et al. [2003b] found an
increased percentage of neutrophils in the nasal lavage
among 31 waste collectors from Monday (28%) to Thursday
(46%) that was correlated with an increase in eosinophilic
cationic protein (rs¼0.71, P<0.001) and myeloperoxidase
with nasal swelling (rs¼?0.55, P¼0.07). In a cross-
sectional study, Yang et al.  compared 533 waste
confidence interval) of self-reported cough 2.1 (1.4–3.3),
phlegm 2.2 (1.3–3.6), wheezing 1.9 (1.2–3.1), dyspnea 1.3
(0.8–2.4),andchronicbronchitis 2.4 (1.1–5.1).Isseveretal.
found a 4.1 (1.1–14.5) increased risk (OR, 95% confidence
interval) of bronchitis symptoms. An increased risk of
bronchitis for waste collectors (P<0.06) was not found in
the study by Bunger et al.  when comparing 72 waste
collectors with 77 compost workers. Allmers et al. 
described a case study of a waste collector with allergic
For gastrointestinal complaints, three out of the four
studies reported an increased risk of diarrhea and nausea
established a dose–response relationship between nausea
and exposure to endotoxins. High-exposed waste collectors
had a prevalence proportion ratio (PPR) of 1.6 (95% CI 0.9–
CI 1.0–2.1). For diarrhea and exposure to fungi, these
numbers were: PPR¼5.6 (95% CI 2.4–13.1) for high-
exposed, and PPR¼3.5 (95% CI 2.2–5.3) for medium-
Four studies reported on infectious diseases. These
diseases were Hantavirus, hepatitis A, B, and C, HIV, and
all except the Hantavirus [Chen et al., 1998]. At least two
studies reported an increased risk of hepatitis A and B
[Dounias and Rachiotis, 2006; Rozman et al., 2007;
Luksamijarulkul et al., 2008].
Klein et al.  and Yang et al.  both reported
an increased risk for MSDs, especially of the lower
back. Finally, two studies reported on hearing loss. No
comparison was madewith a control group: one study found
that the explained variance for hearing loss of up to 50%
could be attributed to the hours of waste collecting
(P<0.04), and the age (P¼0.001) of the waste collectors
[Visser et al., 1999]. The other study found that 12 out of the
16 waste collectors had clinically diagnosed hearing loss
[Kessler et al., 1987].
Moderate evidence is available that waste collecting
increases the risk of respiratory complaints (Table III).
musculoskeletal complaints of the lower back and upper
colon and rectal cancer, and allergic bronchopulmonary
aspergillosis. Based on our decision rule, these risks confer
evidence is available to support that waste collectors do not
have an increased risk for Hantavirus and acute irritation of
the eyes (Table III).
Seven studies reported on injuries (Appendix C). The
rates of injuries appear high and vary considerably
among studies. Only three studies made use of a reference
group. Ivens et al.  reported that 17% of waste
Baeder  reported that 38% of the employees hurt
that 41% of the waste collectors had one or more injuries
during 2001–2002. Englehardt et al.  calculated an
incidence of 80 injuries per 100 municipal solid waste
workers per year. Significant odds ratios varied between
studies from 1.5 to 3.3.
Ivens et al.  described the causes of these injuries
and concluded that 88% of the injuries occurred outside the
a higher elevation (19%), overloading of body or internal
organs (18%), stepping on or making contact with a sharp
object (13%), and falling from the same level (e.g.,
Moderate evidence is available to support the statement
that waste collecting increases the risk ofinjuries (Table III).
Based on our decision rule, these risks confer possible
whether these risks have been reduced to an acceptable
Health and Safety in Waste Collection 1045
Moderate evidence is available to support the statement
of respiratory complaints and injuries, with significant risk
ratios varying between studies from 1.9 to 4.1 and 1.5 to 3.3,
respectively. Limited evidence is available for an increased
risk of gastrointestinal complaints, musculoskeletal com-
plaints of the lower back and upper extremities, hearing loss,
hepatitis (A, B, or C), HIV, syphilis, colon and rectal cancer,
and allergic bronchopulmonary aspergillosis. The findings
regarding respiratory and gastrointestinal complaints are
supported by the available strong evidence that exposure to
bioaerosols exceeded generally accepted recommendations.
The same holds true, albeit with a lower level of evidence, to
musculoskeletal complaints, and high noise levels with
Pros and Cons of the Study
The strength of the present study is the systematic
retrieval of the literature using two databases and a sensitive
search strategyusing only the search term ‘‘waste collector’’
and its synonyms. In this way, it is probable that all relevant
studies with their unique findings are described. The
disadvantage of this approach is the presence of significant
heterogeneity in quality of the studies and the possibility of
publication bias. We tried to overcome this disadvantage by
describing the quality of the study and rating the evidence
using accepted criteria [CBO, 2005; Von Elm et al., 2007;
Dutch Cochrane Center, 2008]. An advantage of the latter
criterion is that for studies of lesser quality, publication bias
does not result in a higher level of evidence because,
independent of the number of studies, the quality rating
remains ‘‘limited.’’ A disadvantage of this criterion for the
report a positive association is attributed the same level of
gastrointestinal symptoms and syphilis (Table III). Both are
qualified as ‘‘limited.’’
As noted previously, the findings regarding the health
effects of respiratory, gastrointestinal, and musculoskeletal
complaints and hearing loss accord with the findings
from studies regarding work demands and acute bodily
responses; these two groups of studies concerned the
same working populations and used comparable collection
methods. These findings partly overcome the fact that
only 6 of the 50 included studies had a cohort design, and
in only 3 of these studies [1 study on health effects, Lund
et al., 2001; and 2 studies on injuries, An et al., 1999; Bena
et al., 2005].
Worker Health Surveillance
The present study was performed to systematically
describe the present knowledge on work-related health and
safety risks in the jobs of waste collectors as a starting point
for a job-specific WHS in order to prevent work-related
disease, injuries, and disability. What aspects should be
included in a job-specific WHS to prevent the onset,
recurrence, or exacerbation of work-related diseases and
injuries in individuals?
The includedstudies came from 18 countries around the
world. One has to bear in mind that the methods of waste
collection and associated terminology vary considerably
around the world and thereby the related health and safety
risks also vary. This caveat is probably especially true for
injuries and infectious diseases. The use of bins or two-
wheeled containers diminishes the risk of contact with sharp
objects or contained materials. Moreover, the increased risk
of infectious diseases might also coincide with national,
B is endemic in China and other parts of Asia [WHO, 2008].
In these regions, 8–10% of the adult population is chroni-
southern parts of Eastern and Central Europe. In contrast,
<1% of the population in Western and Northern Europe and
on the country and type of collection, it is necessary to
decide what health and safety outcomes are relevant as
depicted in Table III. For instance, in Brazil no distinction is
made between household and non-household waste while
collecting recyclables. Health effects that are probably
present in all countries and independent of the described
methods of collection are respiratory complaints, gastro-
intestinal complaints, hearing loss, and musculoskeletal
Primary prevention is the key before introducing a job-
and safety benefits of interventions regarding, for example,
bioaerosols [Lavoie and Dunkerley, 2002]; [Lavoie et al.,
2006], noise and safety [Kuijer and Frings-Dresen, 2004],
energetic and biomechanical factors [Frings-Dresen et al.,
[Kuijer et al., 2005]. As an example, in the Netherlands new
methods of waste collection have been developed such as
automated side collection of two-wheeled containers and
underground storage systems for household waste [Kuijer
to stringent nationwide regulations on the maximum amount
of waste that can be collected per day per worker per
collection method [Frings-Dresen et al., 1995b] and to the
active enforcement of these regulations by the Dutch labor
inspection. In this way, manual collection has been
automated. It appears to have reduced the old risks of the
aforementioned negative health effects and injuries to an
1046Kuijer et al.
acceptable level. Of course, the possibility of new emerging
risks should be evaluated whenever the work changes.
However, when waste is collected manually, regardless
of the method of collection, WHS of individual waste
risk for hearing loss and respiratory, gastrointestinal, and
musculoskeletal complaints. Whether a health risk is
included in WHS is also dependent on for instance the
clinimetric properties of the test involved. Tests for early
signs of these complaints should at least be reliable and
predictive of the disease. Moreover, tests should be propor-
tional to the expected health and work ability gain and (cost-
effective) preventive measures or treatment should be
available. Some of the studies presented in this review can
was outside the scope of the present review. The existing
evidenceforthe increasedrisk ofinjuriesissufficient tourge
management and employees to start a multifaceted safety
campaign. These initiativesare probably more effectivethan
WHS in reducing injuries [Lehtola et al., 2008].
Finally, without the availability of effective interven-
tions or treatment at the group or individual level, one
should not start WHS [Barratt et al., 1999]. In consultation
with representatives of management and workers of waste
collectors companies, we believe that an evidence-based
job-specific WHS can be developed, implemented, and
evaluated. Only in this time consuming way can the
effectiveness of WHS—a core activity of occupational
health services—be established and subsequently evaluated.
Allmers H, Huber H, Baur X. 2000. Two year follow-up of a garbage
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ReferencesCountry Design PopulationatriskControls Riskfactor Mainresult
bins and containers, age¼?,
Dust concentration: 7.7mg/m3
2^18 household waste collectors
with seven types of collection
Studies describing work demands or bodily responses of
waste collectors categorized into biological, biomechanical,
energetic, physical, chemical, and psychological factors.
Studies are described in terms of author, year of publication,
country, study design, population at risk, control population,
type of risk factor, and main result of the study.
Health and Safety in Waste Collection1049
2^18 household waste collectors
with seven types of collection
(location,type ofwaste,type of
urban, mixed, manual; II: urban,
commercial, manual; III: urban,
recyclable, manual; IV: urban,
for the seventypes (location,
type of waste, type of truck,
type of loading) of collection
(colony forming units/m3),
and fungi (CFU/m3) for the
waste, type of truck, type of
loading) of collection during
I: 6,300^10,500; II: 6,750^
Bacteria (colony forming units/
? Exposure at the rear side of the
garbage truck to bioaerosols
(bacteria and fungi) between
and mixed) while emptying
German county Westfalen?
endotoxins) using a personal
References CountryDesignPopulationatrisk ControlsRiskfactorMainresult
1050 Kuijer et al.
endotoxins) using a personal
?Fungi concentration using vehi-
Serum Clara cell protein (CC16)
and serum surfactant protein
B (SPB) as markers of lung
epithelial injury, taken into
Appendix A (Continued)
References CountryDesignPopulationatrisk Controls Riskfactor Mainresult
Health and Safety in Waste Collection1051
Thorn SwedenCohort Householdwastecollectors
placed in well-ventilated metal
Relationship between seasonal
personal sampler equipment
(on Fridays) from September
Relationship whether exposure
to endotoxin measured using
personal sampling increases
5th^95th percentile): never
No significant relationship was
assessed using nasal lavage
IL-8, tumor necrosis factor-a
References CountryDesignPopulationatriskControls RiskfactorMainresult
1052 Kuijer et al.
Waste collectorshad more total
higher concentrations of IL-8
concentrations of IL-6,TNFa,
a measure ofacute effectsof
NAL inflammatory markers
did not differ between waste
concentrations after the shift
0.6 (3.2, <0.2^9.1); driver/
(2.0, 0.2^5.2); driver/loader:
driver/loaders of the municipal
four large Dutch cities, n¼78,
Appendix A (Continued)
References Country Design PopulationatriskControlsRiskfactor Mainresult
Health and Safety in Waste Collection 1053
(3.2, 16^257); driver/loader:
(3.6, 9^2,279); driver/loader:
6.0); loader: 1.6 (4.2, <0.3^
30.8); driver/loader: 1.1 (3.3,
Organic: driver: 0.9 (2.8, <0.3^
3.4); loader: 1.5 (3.5, <0.3^
12.2); driver/loader: 1.0 (4.2,
Mixed: driver: 1.4 (2.7, <0.3^
4.8); loader: 1.6 (3.3, <0.3^
14.9); driver/loader: 2.2 (4.5,
transportation of 2-wheeled
during a working day (SD):
Mean time (min) arm(s) >608
during a working day (SD):
Peak compression force (N):
Mean moment (Nm): push: 6;
9 refuse collectors of 2-wheeled
during pushing and pulling of
shoulder load while pushing
containers (amount of waste
(300^1,392) (tilting phase);
ReferencesCountry DesignPopulationatriskControls RiskfactorMainresult
1054Kuijer et al.