Occupational hazards of Brazilian solid waste workers: a systematic literature review/ Riscos ocupacionais em trabalhadores da limpeza urbana no Brasil: uma revisao sistematica da literatura.
Each year, about 1.3 billion tons of solid waste are generated worldwide. By 2025, this volume is expected to reach up to 2.2 billion tons annually, which is a cause of concern for governments and society (1).
Brazil is one of the nations that produces the largest amount of waste, following the increase of its population (currently 200.4million) each year (2). The country generates nearly 80 million tons of solid waste per year, being elected as the third largest waste producer in the planet (3). The situation is more concerning due to the fact that professionals involved with waste collection in the country do not receive the attention deserved by municipal authorities or attributable respect from the society (4).
In Brazil, the job of garbage professionals requires much effort to be accomplished, given the nature of the work, workplace conditions, besides predictable and unpredictable variables that follow their routine (5). It is contended that those professionals are exposed to a variety of occupational hazards (6), most of them not discussed within scientific literature in a context where such individuals face social stereotyping as an effect of cultural influences (7).
Thus, guided by the research question "What are the occupational hazards to which solid waste workers are exposed in Brazil?", a systematic review was conducted in order to identify occupational hazards that affect those professionals as well as factors associated with hazard minimization in this group.
STUDY DESIGN AND SEARCH STRATEGY
A systematic review of national and international literature was conducted which aimed to identify occupational hazards that affect Brazilian waste workers, as well as the factors that contribute to the minimization of hazards in the given population.
Data were collected from November to December of 2016 in two distinct, respective stages (S1 and S2). For S1, three authors performed an independent search on the electronic databases: Scientific Electronic Library Online (ScIELO), Latin American and Caribbean Literature in Health Sciences (LILACS), and PubMed. On the other end of the spectrum, for S2, the three researchers searched gray literature studies through Google Scholar, considering the small number of publications on the topic yielded from the electronic search.
For both stages and all databases, the following search strategy and terms were used:
1. Waste worker AND Occupational hazard OR Occupational risk;
2. Solid waste worker AND Occupational hazard OR Occupational risk;
3. Garbage worker AND Occupational hazard OR Occupational risk; and
4. Waste management AND Occupational health OR Occupational hazard OR Occupational risk.
Complete studies published between 2006 and 2016 in English, Portuguese, or Spanish were considered for analysis as long as they had the primary purpose of examining occupational hazards in Brazilian waste workers. The authors did not include literature reviews or studies whose subjects were not legally employed waste professionals (i.e. homeless persons or individuals from non-governmental organizations collecting garbage for personal or community purposes). Studies on individuals involved in recycling were also not considered.
STUDY SELECTION AND DATA EXTRACTION
For the selection of studies, instructions provided by Moher et al. in Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement (8) were followed. Once eligible literature was identified, they were exported to Mendeley, a reference manager, in order to organize titles by author and year of publication, excluding duplicates.
Eligible studies were read in full text and relevant data were extracted. Reference lists were also assessed. Finally, quantitative and qualitative data were segregated into categories for analysis. Microsoft Office Excel was utilized for further graphic representation.
REVIEW OF PAPERS
For this systematic review, the electronic and gray literature search yielded a total of 76 documents, which gave us an initial idea of the small number of publications on the topic. Only 57 studies remained after exclusion of duplicates. Then, the literature was screened for relevance after reading their titles and abstracts, and 18 publications remained. However, not all of the remaining publications met the inclusion criteria, leaving the final number of studies to 12, which then had their reference lists screened with no more studies included (Figure 1).
The few studies identified in the database search and in the gray literature are presented in chronological order and include information about author/year of publication, method, objective, and results. The selected papers were mostly cross-sectional studies (92%), with a quantitative approach (Chart 1).
In a chronological analysis, one study dealing with occupational hazards in urban waste collectors (9) was identified for the year of 2006. However, no studies on the topic published in 2007 were identified. In 2008, there was one publication (14) and for each of the two subsequent years there were two publications (10,15-17). It was possible to identify a single publication on the subject being published in 2011 (11) and two in the following year (18,19). In 2013, 2014, and 2015, there were no published studies on the topic. Nevertheless, for 2016, three studies were encountered (12,13,20). The fact points out a constancy in the number of published studies on occupational hazards in garbage workers.
All of the selected publications sought to identify the occupational hazards to which waste workers are exposed in several Brazilian cities. Others also discussed a variety of diseases resulting from that career, while a few of them also addressed how to minimize or prevent occupational hazards. With that being said, the thematic analysis was based on the following themes: types of occupational hazards in urban waste workers and hazard prevention measures.
OCCUPATIONAL HAZARD IN WASTE WORKERS
In developing countries, waste management procedures are characterized by a dominance of manual labor tasks, which therefore exposes waste professionals to a number of occupational hazards of variable nature, occurring at every stage of the waste management process (21,22).
Considering the possible occupational hazards in the workplace, the Brazilian Ministry of Labor designed a standardized set of colors to indicate the main potential risks to which workers are exposed in the various worksites. The colors are as follows: green is used to represent physical hazards, red for chemicals, brown for any biological hazard, yellow for ergonomic (or "human" factors), and blue to represent hazards related to accidents (23). The psychosocial hazard, which was also evidenced in the literature (18), used to be associated with the ergonomic hazard; however, it has been considered a new category (24), without a standardized color representation, therefore why the authors attributed to it the gray color.
From the analysis of the publications, it was observed that waste management workers are exposed to five main occupational hazards, besides psychosocial hazards. Figure 2 shows the percentage of occupational hazards in those workers based on how much evidence was encountered, considering the number of times that hazards were cited in eligible studies.
Thus, the most evidenced hazards experienced by garbage workers were those of biological nature and accidents, respectively. The most common events happening to those professionals in the workplace are presented in Chart 2.
Biological hazard is the likelihood of exposure to microorganisms with potential to cause harm to the worker's health. Throughout the studies, it was identified that waste workers are exposed to contamination by viruses, bacteria (10,14,16-18), fungi (14,19), and parasites (9,12); all which can lead to acute or chronic infections, allergic reactions, and toxic reactions (23,25).
Garbage management workers are susceptible to several biological damages that lead to the acquisition of several infections (16-18). Sousa et al. (2015), attribute these infections not only to contact with waste, but to sewage and gallery contaminants that contain improperly discarded waste (26). Contamination with the hepatitis C virus and tetanus bacteria were also mentioned with gastroenteritis appearing more evident in those workers, therefore culminating an increase in diarrheal conditions (12,18).
In a study carried out in 2006, with a sample of 22 solid waste workers, it was identified the prevalence of 63.66% for parasites or commensals in those individuals, after a laboratorial analysis of feces. Of this percentage, 78.6% corresponded to protozoa while 21.4% to helminths (Entamoeba coli, Entamoeba hartmanni, Entamoeba histolytica, Endolimax nana, Ascaris lumbricoides, Trichuris trichiura, Strongyloides stercoralis) (9). For these studies, it is important to note the difference between such species. Helminths constitute any disease-causing organisms that live on a human or another animal and derive nourishment from their host (27), whereas a protozoa is defined as any parasitic single-celled organism that can divide only within a host organism (28).
Another study also performed similar analysis in 185 workers, identifying the presence of protozoan infection, with sweepers being the most affected (55.9%). In addition, the author identified the incidence of sinusitis in the last twelve months (between 14.7% and 37.8%) and pneumonia (between 8.8% and 22.2%), with waste truck drivers being the most affected. In the evaluation of the positivity for hepatitis B and leptospirosis, it was identified that the sweepers are the most affected (incidence between 20% and 25.7%, respectively) (10).
In a recent study, Santos (2016) identified the prevalence of soil transmitted helminthiasis above 35% in a sample of 163 workers in Piaui state, northeastern Brazil. The results were obtained from parasitological tests, with a prevalence of 25.15% for ascariasis, 7.36% for trichuriasis, and 9.82% for hookworm (12).
Another important aggravation reported in the literature was dermatitis, which can be from fungal origin as well as an immune reaction against antigens. Dermatitis was the complaint of 6% of the 16 individuals assessed in a study of 2008 (14). Yet, in a study with a larger sample of 97 individuals, Coelho (2012) identified a higher prevalence of dermatitis in waste workers (42%), occurring more commonly on the hands (19). Other diseases often found in those professionals are brucellosis, dengue fever, yellow fever, rabies, viral hepatitis (A, B, C, D, and E), leishmaniosis, and cysticercosis (29).
Yet, in the context of biological hazards, although not mentioned in the studies found, prions also constitute infectious agents of relevance in waste management. Those protein-composed agents are found to be the cause of occupational diseases in some studies (30).
The risk of accidents--understood as any probability of exposure to a factor that places the worker in a vulnerable situation, affecting their physical integrity and well-being seems to be a cause of great concern in such professionals (23). An accident is defined as a sudden and unexpected event that can cause damage not only to the worker, but also to the property or work environment (31).
In solid waste workers, accident hazards originate from a variety of causes. The literature points out that those workers are exposed to injuries from sharp objects such as glasses, syringes, nails, spikes, and thorns (11,14). Some authors (15,18,20) also evidence the risk of slips and falls.
Authors also concluded that waste collectors are exposed to the risk of being run over, which according to Pedrosa (2010) is mentioned by 16% of the 96 individuals interviewed in in his survey (16). Other hazards include animal attacks, especially dog attack (15), press, and amputations through equipment used at work (20).
CHEMICAL, ERGONOMIC, AND PSYCHOSOCIAL HAZARDS
Professionals involved in waste management are also susceptible to chemical hazards, when there is a likelihood of contact with chemical agents, including substances, compounds, or products capable of penetrating the body through the respiratory tract, skin contact, or ingestion (32). In this regard, workers are exposed to manure, smoke, and other toxic substances that are erroneously discarded in the trash, such as pesticides, oils, and batteries (11,20,26).
Ergonomic hazard is another occupational health risk affecting solid waste workers, which consists in the probability of a treat to the musculoskeletal system due to different factors, such as inadequate posture, excessive weight, excessive or repetitive physical exertion, among others (23,33). The literature has shown that those individuals have suffered from postural, spinal, and muscle strain problems as a result of the weight they have to carry, as well as the repetitiveness and effort required to perform the functions at work throughout a long shift (13,18).
In relation to the physical hazard, being the possibility of damage due to exposure to the different forms of energy, it was verified that waste management professionals suffer strong exposure to solar radiation, with intense heat or cold alongside exposure to climatic changes. In addition, they are subject to noise and intense vibrations caused by work equipment, therefore leading to hearing loss (14,18,26).
Finally, one of the least explored hazards in occupational health (24), psychosocial hazard has been evidenced in recently published literature (26). From the literature analyzed, the authors were able to identify that waste workers continue to suffer from a historical discrimination, with the devaluation of their work by society, government, and employees, along with precarious working conditions, and an overall lack of training (18,26).
PREVENTION OF OCCUPATIONAL HAZARDS IN SOLID WASTE WORKERS
In a context where there are several occupational hazards affecting solid waste professionals with different etiologies, the use of Personal Protective Equipment (PPE) has been the most effective in contributing to the minimization or elimination of exposure. However, it is a fact of negligence on the part of workers or even employers towards the use and mandatory compliance of PPE, respectively (15,17,18). In addition, it is of the utmost importance that there be ongoing guidance programs for workers on the correct use of PPE and handling of urban waste (20).
Orientation to the population towards the proper disposal of domestic waste seems to be another factor contributing to minimization of occupational hazards in garbage workers (11). In this way, by combining these actions, the occupational risks can be reduced (26).
LIMITATIONS OF THE STUDY
This study has some limitations derived from the fact that there are few national or international publications on occupational hazards affecting Brazilian solid waste workers available on electronic databases. For this reason, the authors included gray literature studies (undergraduate or master's degree paper), none of which negatively affect the quality of this review, based on validation by at least two individuals holding a Master's degree.
Another limitation refers to the generality of the results, which may be compromised since they represent only Brazilian data and are certainly consequences of policy and culture specific to the country. Nevertheless, considering the fact that most developing countries use the same procedures for waste management, mostly involving manual labor, the conclusions obtained through this study can be similar to the ones from future studies conducted in other developing countries.
From the analysis of the literature, it was possible to identify that solid waste workers are exposed to the five main occupational hazards. According to theis nature, they are classified as follows: biological, accidental, chemical, ergonomical, and psychosocial hazards. In order to contribute to the minimization and/or elimination of many of these risks, it is necessary to identify the importance of the combination of the guided use of PPE, training to the worker, and orientation to the population on the proper disposal of trash.
There are still few studies on occupational hazard in solid waste workers, which probably reflects the historical and social stereotyping faced by those professionals. Thus, the authors should emphasize the need for more evidence-based research that could serve as a subsidy for the development and implementation of public policies that are favorable to the reduction of occupational risks in the group studied.
Financial source: none
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Corresponding author: Miguel Henrique Pereira-de-Paiva--Avenida Rio Poti, n. 2.381, Bairro de Fatima--ZIP CODE: 64999-999--Teresina (PI), Brazil E-mail: email@example.com
Miguel Henrique Pereira-de-Paiva [1,3], Maria da Conceicao Calassa-Albuquerque , Emily Elizabeth Latham , Cleanto Furtado-Bezerra , Anderson da-Silva-Sousa , Liege Cunha-e-Silva-de-Araujo , Mayara Rafaela dos-Reis , Rogerio Ferreira-Luz 
Project performed at Faculdade Integral Diferencial (FACID)--Teresina (PI), Brazil.
 Nursing Department, Faculdade Integral Diferencial (FACID)--Teresina (PI), Brazil,
 Nursing Department, Faculdade de Ciencias Humanas, Saude, Exatas e Juridicas de Teresina--Teresina (PI), Brazil,
 Nursing Department, Walsh University--North Canton (OH), United States,
 Nursing Department, Faculdade de Saude, Ciencias Humanas e Tecnologicas do Piaui--Teresina (PI), Brazil,
 Nursing Department, Universidade Estadual do Piaui (UNESPI)--Teresina (PI), Brazil,
Figure 1. Flowchart for the review of papers. Inclusion Records identified through Duplicates excluded electronic and gray (n = 79) literature search (n = 76) Eligibility Titles and abstracts Records excluded Screened (n = 38) (n = 57) Screening Full text articles Records excluded with assessed for reasons (n = 7): eligibility (n = 19) * Literature review (n = 2) * Primary purpose not being occupational hazards (n = 2) * Subjects not being legally employed solid waste workers (n = 3) Identification Studies included (n = 12) Source: adapted from Moher et al., 20098. Figure 2. Literature evidence for studies on occupational hazards in waste workers. Biological hazard 36% Accident hazard 27% Chemical hazard 14% Ergonomic hazard 9% Physical hazard 9% Psychosocial hazard 5% Note: Table made from pie chart. Chart 1. Results from electronic database and gray literature search displayed in chronological order. Author/Year Method Objective of publication Database studies Nunes et al., Cross-sectional study Investigation of 2006 (9) prevalence of enteroparasitosis among waste collectors in Patrocinio, MG Graudenz, Cross-sectional study Comparison of health 2009 (10) aggravation due to contact with solid waste among waste professionals in Sao Paulo, SP. Lazzari and Reis, Cross-sectional study Identification of 2011 (11) biological hazards affecting urban, in Dourados, MS. solid waste professionals Santos, Cross-sectional study Estimation of 2016 (12) prevalence, infection degree, and factors associated with helminth infections in urban garbage workers in Parnaiba, PI. Galdino and Malysz, Cross-sectional study Identification of 2016 (13) occupational hazards in waste workers in the municipality of Mambore, PR. Gray literature studies Oliveira and Santos, Discussion paper Evaluation of 2008 (14) occupational health problems affecting solid management professionals in Hidrolandia, GO. Silva et al., Cross-sectional study Analysis of work 2009 (15) conditions in waste collectors of Muzambinho, MG. Pedrosa et al., Cross-sectional study Identification of the 2010 (16) main occupational hazards to which solid waste collectors are exposed in Boa Vista, RR. Pinho and Neves, Cross-sectional study Identification of 2010 (17) possible risk factors related to the occurrence of occupational accidents in urban waste collectors in Rio de Janeiro, RJ. Oliveira et al., Cross-sectional study Identification and 2015 (18) evaluation of occupational hazards in garbage workers in Sinop, MT. Coelho, Cross-sectional study Identification of 2012 (19) socioeconomic profile and working conditions, and occupational health with an emphasis on the occurrence of dermatosis in waste professionals in Morrinhos, GO. Carvalho et al., Cross-sectional study Identification of the 2016 (20) perception of solid waste professionals of Jatai, GO towards occupational hazards exposed in the workplace to which they are Author/Year Results of publication Database studies Nunes et al., 22 individuals participated. Among the 14 2006 (9) cases of parasite or commensal infections, 78.6% were caused by protozoa, while 21.4% were caused by helminths. Graudenz, 185 subjects participated. Prevalence 2009 (10) protozoa infection was 55.9%, sinusitis 14.7-37.8%, pneumonia 8.8-22.2%, hepatitis B 20%, and leptospirosis 25.7%. Lazzari and Reis, 42 workers participated. Occupational hazards 2011 (11) identified were: cuts and perforations with glass, syringes, thorns; bite of dogs; and contact with noxious substances. Such risks diminish with orientation to the population about appropriate waste disposal. Santos, 163 participants. Overall prevalence of 2016 (12) helminth infection was 35.58% being the main: ascaridiasis (25.15%), trichuriasis (7.36%), and hookworm (9.82%). Galdino and Malysz, 7 individuals involved. Constant exposure to 2016 (13) biological agents and ergonomic issues reported. Personal Protective Equipment (PPE) showed to be effective in preventing occupational hazards. Gray literature studies Oliveira and Santos, 16 workers participated. Dermatitis 2008 (14) prevalence was 6%. Posture, spine, and arm problems were identified. Flu, diarrhea, and acute respiratory infections were also diagnosed. Cuts and perforations were present. Issue related to low adherence to PPE were found. Silva et al., Three out of six individuals interviewed do 2009 (15) not use PPE. Risks identified through reports were: run over, cuts, and perforations, dog attacks, muscle strains, falling off the truck. Pedrosa et al., 96 participants. Evidence of cutting, 2010 (16) slipping, falling, injury, run over, and contamination from infectious agents. Pinho and Neves, 36 workers participated. Prevalence of 2010 (17) trampling of 16%. Main lesions identified: cuts, skin injuries, falls, and constant exposure to biological agents. Contributing factors to increase accidents: non- lack of attention, and absence of PPE. compliance with safety norms and procedures, Oliveira et al., 53 individuals participated. Solid waste 2015 (18) workers exposed to physical, chemical, biological, ergonomic, psychosocial, and accident hazards. Non-compliance with safety standards, lack of attention, and absence of PPE are contributing factors to occupational hazards Coelho, 97 workers. 42% of the subjects reported 2012 (19) having been affected by occupational dermatosis, being the hand the most affected area. Carvalho et al., 17 participants. 82.4% suffered some type of 2016 (20) accident, among which: trampling; fall, fracture, and press in a truck; perforations and cuts; chemical accidents (batteries, oils, leachate, and other household waste); dog attacks. Noncompliance with the use of PPE was identified. Chart 2. Classification of the main occupational hazards to which waste workers are exposed according to their nature as evidenced in the literature. Physical hazard Chemical hazard Biological hazard Excessive noise, Dusts, gases, Viruses, bacteria, vibration, odor, vapors, substances, fungi, and parasites solar radiation, and compounds, and (9,10,12-14,16-20). rainfall (14,18). chemicals in general (11,18-20). Physical hazard Ergonomic hazard Accident hazard Excessive noise, Intense and Cuts and vibration, odor, repetitive physical perforation, slips, solar radiation, and exertion, inadequate falls, animal rainfall (14,18). posture, and long attacks, rundown, working hours press, and (13,14,18) amputation (11,14-18,20). Physical hazard Psychosocial hazard Excessive noise, Devaluation at work, vibration, odor, lack of training, solar radiation, and and disrespect of rainfall (14,18). society (18).
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|Title Annotation:||SYSTEMATIC REVIEWS AND META-ANALYSIS|
|Author:||Pereira-de-Paiva, Miguel Henrique; Calassa-Albuquerque, Maria da Conceicao; Latham, Emily Elizabeth;|
|Publication:||Revista Brasileira de Medicina do Trabalho|
|Date:||Dec 1, 2017|
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