Download Work-related infectious disease reported to the

Occupational Medicine 2005;55:275–281
doi:10.1093/occmed/kqi109
Work-related infectious disease reported to the
Occupational Disease Intelligence Network and
The Health and Occupation Reporting network
in the UK (2000–2003)
S. Turner, S. Lines, Y. Chen, L. Hussey and R. Agius
............................................................................................................................................................
Background Infectious diseases remain an important cause of self-reported work-related illness, with socioeconomic consequences, including sickness absence. Reporting of infectious disease by occupational
and specialist physicians is an important tool in the investigation of occupationally related infections
and is relevant in their management.
............................................................................................................................................................
Aims
To examine the reporting of cases of infectious disease by occupational and specialist physicians to
schemes collecting data on occupational ill-health.
............................................................................................................................................................
Methods
Cases of infectious disease reported by occupational and specialist physicians to the UK based
schemes, Occupational Disease Intelligence Network (ODIN) and The Health and Occupation
Reporting network (THOR), from 2000 to 2003 were analysed by reporting patterns, diagnosis, single
case or outbreak reporting and industry.
............................................................................................................................................................
Results
The total number of estimated cases of infectious disease reported to ODIN and THOR from 2000
to 2003 was 5606; 74.9% cases were diarrhoeal disease, and 11.1% scabies. The majority (81.4%)
of cases were reported in SIDAW, where the participation rate for reporters was 55%. Reporting
rates were much higher in OPRA, SWORD and EPIDERM (ranging from 86 to 96%). The most
frequently reported industrial sectors were social care (39.5%) and health (29.4%); while the
manufacture of chemical products contributed 4.3% overall, but 33.8% to estimated cases in
OPRA.
............................................................................................................................................................
Conclusions Despite limitations related to under reporting, the occupational and specialist physician schemes in
ODIN and THOR provide data that may be used to look at patterns of case reporting for occupational
ill-health, including infectious disease. The reporting schemes also provide an important means of
alerting peers about potential novel causes, precipitating factors, or industrial sectors associated with
occupational disease.
............................................................................................................................................................
Key words
Epidemiology; incidence; infection; occupational disease; respiratory; skin disease; surveillance; work.
............................................................................................................................................................
Introduction
In a recent survey of self-reported work-related illness an
estimated 32.9 million days were lost in 2001 – 2002 in
Great Britain through illness caused or made worse by
work, involving an estimated 2 328 000 people [1].
The most commonly reported reasons were musculoskeletal disorders and psychological ill-health (estimated
at 1 126 000 and 563 000 people ever employed,
Centre for Occupational and Environmental Health, University of Manchester,
Manchester, UK.
Correspondence to: S. Turner, University of Manchester, Centre for
Occupational and Environmental Health, 4th Floor, C Block, Humanities
Building, Devas Street, Oxford Road, Manchester M13 9PL, UK.
e-mail: [email protected]
respectively), while a prevalence estimate for infectious
diseases was 33 000.
In addition to these data based on self-reporting, there
are surveillance schemes operating in the UK involving
specialist physicians. Occupationally related infectious
disease is reported by specialists to the following
schemes; occupational physicians to OPRA, consultants
in communicable disease control (CCDCs) and public
health medicine to SIDAW, dermatologists to EPIDERM
and respiratory physicians to SWORD. There are a
further three surveillance schemes for rheumatologists
(MOSS), psychiatrists (SOSMI) and consultants in
audiological medicine (OSSA), but these are involved
in reporting of non-infective work-related cases. These
q The Author 2005. Published by Oxford University Press on behalf of the Society of Occupational Medicine.
All rights reserved. For Permissions, please email: [email protected]
276 OCCUPATIONAL MEDICINE
seven reporting schemes made up the Occupational
Disease Intelligence Network (ODIN) that operated
until 2002 when ODIN was succeeded by The Health
and Occupation Reporting network (THOR).
Recent data (from 2003) show that more than 2000
physicians throughout the UK are reporters to THOR.
The reporting schemes provide estimates of the incidence
of occupational disease or disorders and information to
further the understanding of causation (or aggravation)
of conditions by work.
In 1996 –1997, 1037 (80.1%) of the 1294 cases of
occupationally acquired infectious disease were reported
to SIDAW (rather than to OPRA, EPIDERM, or
SWORD) [2]. The majority of cases and information
collected by OPRA, EPIDERM and SWORD [3 –5]
involved non-infectious diseases, for example workrelated musculoskeletal disorders, contact dermatitis
and occupational lung diseases for each of these schemes,
respectively. However, the potential impact of transmitted infective diseases on an individual worker (for
example, hepatitis and HIV) and the workforce or general
public [for example, influenza and methicillin-resistant
Staphylococcus aureus (MRSA)] cannot be overestimated.
This paper provides information on work-related
infectious diseases reported to SIDAW, OPRA, EPIDERM and SWORD from 2000 to 2003, including
reporting of outbreaks as well as single cases of disease.
Methods
Reporters to OPRA, EPIDERM, SWORD and SIDAW
are asked to report new cases of occupationally acquired
disease, and the methodology has been described in detail
previously [2 – 5]. In all four reporting schemes the
physician is asked to return information on age, gender,
geographical location (‘first half ’ of postcode, i.e. area
and district or town), occupation, workplace and agent
(for example, TB). For the purpose of this study
infectious disease cases including infestation (commonly
scabies) that were returned to the reporting schemes have
been analysed.
Participating consultants are asked to report diseases
based on their clinical judgement that have either been
caused or aggravated by work. Precise criteria and
definitions are not imposed. In addition, reporters are
not requested to carry out investigations beyond those
necessary on clinical grounds (for example, in order to
confirm a diagnosis).
When SIDAW was set up (in 1996) the reporting
group was largely made up of CCDCs in public health
medicine. Data from March 2004 gave the breakdown of
reporters in SIDAW as CCDCs (72%), consultants in
health protection (15%), public health consultants (8%)
and a miscellaneous category making up the remaining
5%. In SIDAW reporters allocate cases into eight
specified disease categories (plus 1 for ‘other’ diseases
that the reporter is asked to specify). The disease
categories are: brucellosis, hepatitis, legionellosis, leptospirosis, ornithosis, pulmonary TB, Q fever and diarrhoeal disease. Further information on single sporadic
cases or outbreaks (of two or more associated cases) is
also requested. Reporters are asked to return a reporting
card each month, including blank returns.
In EPIDERM and SWORD, participating physicians
are asked to report on a full range of occupational skin
and respiratory diseases respectively, with infective causes
making up one of the major sub groups on the reporting
card. In OPRA, occupational physicians are asked to
return case details for all causes of occupational ill-health
including: respiratory, skin, musculoskeletal, hearing
loss, stress/mental illness and ‘other’ diseases (infection
is included in this category). Information on diagnoses is
coded using the International Classification of Disease,
10th Revision (ICD-10) [6], to allow comparison of data
between specialist reporting schemes.
In SIDAW, all participating physicians are requested
to return a reporting card every month, while in
OPRA, EPIDERM and SWORD there are two groups
of reporters; ‘core’ reporters who return a reporting
card every month and ‘sample’ reporters who return a
reporting card for one randomly selected month per
calendar year. In SIDAW, as all participating physicians
are ‘core’ reporters the actual number of cases reported
is used to produce an annual rate. In OPRA,
EPIDERM and SWORD an estimated number of
cases reported in a calendar year is calculated by
multiplying the number of cases returned by ‘sample’
reporters by 12, and adding this subtotal to the number
of cases returned by ‘core’ reporters to produce an
estimated total.
Information on occupation is coded using the Standard Occupational Classification [7 – 8], and that on
workplace or industry using the Standard Industrial
Classification [9]. Postcode data is used to group
information according to the geographical classification
used by the Labour Force Survey (LFS) [10].
Prior to 2003, duplicate reports were identified and
excluded by searching the ODIN and THOR databases.
This checking process was discontinued in 2003, as the
information that allowed duplicates to be detected (such
as date of birth) could no longer be recorded according to
the ethical approval given to THOR. However, based on
the assessment of reported cases 1999 – 2002 in ODIN
and THOR, the proportion of duplicate reporting within
groups of specialists was 2.4% for ‘core’ reporting and
0.4% for ‘sample’ reporting.
Summaries of information collected from all the
schemes are produced every 3 months and the results
are circulated to reporting physicians. In addition, these
S. TURNER ET AL.: WORK-RELATED INFECTIOUS DISEASE 277
quarterly reports provide updates on reporting scheme
developments and commentaries on cases or topics of
interest.
Multicentre Research Ethics Committee approval has
been given for the THOR project.
Results
Within THOR as a whole, the proportion of cases
reported via SIDAW is small (only 4.9% in 2003). In
comparison, occupational physicians reporting to OPRA
contributed the highest overall proportion of cases
(49.2% in THOR in 2003), with OPRA cases encompassing a wide range of occupational diseases, and
infectious disease making up only 0.3% of OPRA case
reports.
From 2000 to 2003, the total number of estimated
cases of infectious disease reported to the surveillance
schemes in ODIN and THOR was 5606. The majority
(81.4%) were reported in SIDAW, with 12.7% in OPRA,
2.4% in SWORD and 3.4% in EPIDERM. Overall,
diarrhoeal disease was the most frequently reported
disease category with 4197 estimated cases (74.9% of
the total estimated cases), followed by scabies with 623
(11.1%) estimated cases (Table 1).
Infectious diseases categorized as ‘other’ in the
reporting schemes
Diseases categorized as ‘other’ within SIDAW accounted
for 38 cases; 13 cases of malaria, 5 of meningitis, 3 of
varicella, 2 of paratyphoid and the rest were either single
cases (including one report of MRSA) or the agent was
unspecified.
In OPRA, all cases within the ‘other’ infective disease
category were reported by ‘sample’ reporters (23 reports,
276 estimated cases), with MRSA being most frequently
reported along with dermatophytoses (60 estimated cases
each), followed by varicella (24 estimated cases). Again
the remainder comprised single case reports of specific
diseases, or the reporter did not specify the infective
agent.
There were only five reports (38 estimated cases) from
SWORD physicians in the ‘other’ infection category; four
reports where the agent/diagnosis was unspecified and
one of atypical mycobacterial infection.
In EPIDERM, the 25 ‘other’ infective reports (168
estimated cases) were largely made up of warts (61
estimated cases) and tinea (32 estimated cases), with
staphylococcal infections contributing 25 estimated cases
(including one case of MRSA) and orf adding a further 13.
Reporting patterns
Participation by reporters, calculated from the mean
number of cards returned per year, was 55% within
SIDAW but much higher (ranging from 86 to 98%) for
OPRA, SWORD and EPIDERM. The proportion of
cards containing case reports was also lowest for SIDAW
(15%), and ranged from 26 to 83% for the other groups
of reporters (Table 2).
Within SIDAW, reporting patterns throughout two
calendar years (2002– 2003) were studied; 54.3% reporting cards were returned (80.5% nil returns, 19.5% with
cases). The total number of cases reported in this time
period was 2252, with an average of 188 cases each
month. The number of physicians participating in
SIDAW in 2002 – 2003 ranged from 87 to 100. The
percentage of reporting cards returned each month over
this period did not show any particular trend, while the
percentage of cards returned with no cases to report rose
marginally. The proportion of cases reported each month
Table 1. Infectious disease cases reported to SIDAW, OPRA, SWORD and EPIDERM by disease category (2000– 2003)
Disease category
SIDAW
OPRA
a
Actual
Estimated
Actual
Estimated
Actual
Estimated
26
7
12
1
1
8
1
2
2
4
12
7
83
268
84
12
12
12
19
1
24
2
48
144
84
710
0
0
0
0
6
1
3
12
0
5
0
0
27
0
0
0
0
17
1
3
78
0
38
0
0
137
0
3
0
0
0
0
0
0
0
0
25
0
28
0
25
0
0
0
0
0
0
0
0
168
0
193
Actual
Diarrhoeal disease
Scabies
Brucellosis
Hepatitis
Legionellosis
Leptospirosis
Ornithosis
Pulmonary TB
Q Fever
Other—respiratory
Other—skin
Other—unspecified
Total
a
3929
514
15
3
13
16
6
29
3
0
0
38
4566
SWORD
There are no ‘sample’ reporters in SIDAW, therefore no estimated cases in this reporting scheme.
EPIDERM
278 OCCUPATIONAL MEDICINE
Table 2. Participation by reporters in SIDAW, OPRA, SWORD and EPIDERM (2000 –2003)
SIDAW
OPRA sample
OPRA core
SWORD sample
SWORD core
EPIDERM sample
EPIDERM core
Mean number of
reporters/year
Mean number (%)
of cards
returned/year
Mean number (%) of
cards returned
with case reports
102
592
13
428
22
183
24
57 (55)
519 (88)
13 (86)
366 (86)
21 (96)
153 (86)
23 (98)
10 (15)
259 (50)
3 (26)
100 (27)
15 (71)
56 (37)
19 (83)
ranged from less than 1 to 26%, with a rise seen over the
winter period 2002 –2003 (Figure 1).
Distribution of cases by industry
Overall, cases from the social care and health sectors
made up the majority of reports to ODIN and THOR
between 2000 and 2003 (39.5% in social care and 29.4%
in health). In SIDAW this pattern of the social care and
health sectors contributing the highest proportions of
cases was repeated, with 47.7 and 28.6% cases, respectively (Table 3). Health care was also the most frequently
reported industrial group in SWORD (55.5%) and
EPIDERM (19.7%) and second (32.1%) only to
manufacture of chemical products (33.8%) in OPRA.
However, in OPRA this high frequency in the manufacture of chemical products sector resulted from a single
reporter returning 95% cases; these cases of infectious
Cards returned *
120
Cards returned
without cases+
Cases reported^
100
Percentage
80
60
40
20
p
ov
N
Se
ar
n
ay
Ju
l
M
M
p
ov
Ja
N
l
Ju
Se
ar
ay
M
M
Ja
n
0
Figure 1. Reporting patterns within SIDAW in 2002 and 2003.
*Calculated by (cards returned/cards sent to reporters) £ 100.
þ
Calculated by (cards returned without cases/cards returned) £ 100.
^Calculated by (number of cases/number of cases per calendar
year) £ 100.
disease were not specifically related to the industry (the
diagnosis given was viral gastroenteritis). Within EPIDERM, the two other industrial groups that were
frequently reported were the manufacture of food
products and beverages (18.7%) and social care (12.4%).
Of note, the 400 cases in ‘financial intermediation’ in
SIDAW are explained by a single outbreak of diarrhoeal
disease attributed to a Small Round Structured Virus.
Outbreaks and single case reporting
Information relating to outbreaks and single cases of
infection is requested on the SIDAW reporting card, with
4566 cases reported (2000 –2003). The majority (3929,
86.0%) of SIDAW cases were diarrhoeal disease, with
scabies being the next most frequently reported disease
category (514 cases, 11.3%), and a miscellaneous group
comprising the 123 (2.7%) remaining cases.
In SIDAW the number of outbreaks reported was 430,
while the number of single cases was 356 (Table 4).
Outbreaks made up the vast majority of diarrhoeal
disease cases (3683/3929; 93.7%) and scabies cases
(490/514; 95.3%) reported to SIDAW, but only 30.1%
(37/123) of the miscellaneous case reports.
For diarrhoeal disease, reported outbreaks varied in
size from two to more than 100 cases, with 355 outbreaks
of diarrhoeal disease being reported in total (Table 5).
The majority (79.4%) of diarrhoeal outbreaks contained
between 2 and 10 cases. As expected, however, outbreaks
involving large numbers contributed substantially to the
total number of cases reported, with the two outbreaks
containing over 100 cases (144 and 400 cases) making up
11.9% of all cases reported to SIDAW (2000 – 2003).
The pattern of outbreaks for scabies cases (62 in total)
is also shown in Table 5, with 66.1% of outbreaks
containing between 2 and 10 cases. The two largest
outbreaks (of 30 and 42 cases) contributed 1.6% to the
total number of cases reported to SIDAW in the 4 year
period 2000 – 2003.
There were 13 miscellaneous outbreaks (cases that
were not diarrhoeal disease or scabies), all containing
fewer than 10 cases (Table 5). The largest outbreak was
S. TURNER ET AL.: WORK-RELATED INFECTIOUS DISEASE 279
Table 3. Distribution of infectious disease cases reported to four schemes within THOR by industry
Industry
SIDAW cases
(actual)
n (%)
OPRA cases
(estimated)
n (%)
Social care
Health
Financial intermediation
Hotels and restaurants
Manufacture of food products
and beverages
Education
Agriculture
Public administration and
defence
Retail
Manufacture of chemical
products
Other industries
Unspecified
Total
2176 (47.7)
1305 (28.6)
400 (8.8)
246 (5.4)
83 (1.8)
12
228
0
0
8
(1.7)
(32.1)
(0.0)
(0.0)
(1.1)
SWORD cases
(estimated)
n (%)
EPIDERM cases
(estimated)
n (%)
0 (0.0)
76 (55.5)
0 (0.0)
12 (8.8)
0 (0.0)
24
38
0
0
36
(12.4)
(19.7)
(0.0)
(0.0)
(18.7)
71 (1.6)
63 (1.4)
25 (0.5)
13 (1.8)
8 (1.1)
62 (8.7)
12 (8.8)
0 (0.0)
3 (2.2)
12 (6.2)
16 (8.3)
12 (6.2)
20 (0.4)
1 (0.0)
0 (0.0)
240 (33.8)
12 (8.8)
0 (0.0)
12 (6.2)
0 (0.0)
64 (1.4)
112 (2.5)
4566 (100)
139 (19.6)
0 (0.0)
710 (100)
21 (15.3)
1 (0.7)
137 (100)
31 (16.1)
12 (6.2)
193 (100)
of malaria in members of the armed forces, and involved
eight cases. A breakdown of diagnoses for these 13
miscellaneous outbreaks is shown in Table 6.
Discussion
Underestimation of disease using this methodology is
inevitable (for example, if ODIN and THOR data are
used to calculate incidence rates), as might be extrapolated from the proportion of cards enclosing case reports.
However, there is a very high return rate for cards (of
86% or more) for all groups of reporters in OPRA,
SWORD and EPIDERM. In addition, the continued
participation of specialists within the occupational disease surveillance schemes in the UK is encouraging,
especially as these four voluntary reporting schemes have
all run in excess of 8 years, and some for considerably
longer (SWORD originated in 1989) [5].
The lower return rate seen for SIDAW reporters
(55%) might be explained by there being other reporting
schemes in existence for infectious diseases, for example
the surveillance of significant exposure to bloodborne
viruses in health care workers [11] and the mandatory
MRSA surveillance system for patients [12]. Alternatively, in comparison to the other groups of reporters
(occupational physicians, respiratory physicians and
dermatologists) SIDAW reporters are most frequently
CCDCs (72% of SIDAW reporters in 2004), may have
less face-to-face contact with patients and therefore not
necessarily link illness with employment. This may be
important as the association between illness and occupational ill-health is fundamental to the reporting
schemes in ODIN and THOR, especially with respect
to an individual physician’s opinion about work attribution. CCDCs reporting to SIDAW may also be more
likely to see infections requiring a relatively high degree of
attention or intervention; this may be influenced by the
severity or duration of the infection, or its impact on an
individual’s employment [13].
The distribution of reported cases of infectious disease
by industry is influenced by hazards inherent to the work
or workplace (for example, scabies in health and social
care), but also by whether or not workers within
an industrial group have access to the physicians who
report to the schemes. The geographical areas covered
by clinical specialists within SIDAW, SWORD
Table 4. Reporting of outbreaks and single cases in SIDAW (2000– 2003)
Disease category
Number of cases
reported as
part of an outbreak
Number of
outbreaks
Mean number
of cases per
outbreak
Number of single
case reports
Diarrhoeal disease
Scabies
Miscellaneous
Total
3683
490
37
4210
355
62
13
430
10.4
7.9
2.8
9.8
246
24
86
356
280 OCCUPATIONAL MEDICINE
Table 5. Distribution of cases within outbreaks in SIDAW (2000– 2003)
Number of cases per outbreak
2– 5
6– 10
11– 20
21– 50
51– 100
.100
Total
Number of outbreaks
Diarrhoeal disease
n (%)
Scabies
n (%)
Miscellaneous diagnoses
n (%)
172
110
51
13
7
2
355
33 (53.2)
8 (12.9)
18 (29.0)
3 (4.8)
0 (0.0)
0 (0.0)
62 (100)
12 (92.3)
1 (7.7)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
13 (100)
(48.5)
(31.0)
(14.4)
(3.7)
(2.0)
(0.6)
(100)
and EPIDERM correspond on the whole to those in the
national LFS [10], but in comparison occupational
physicians reporting to OPRA only provide services for
subsections of the employed population. The proportion
of employees having access to an occupational physician
has been estimated at 12% for the general working
population; but is higher in some sectors (for example
health and social services 43%) than others (, 1% of
workers in agriculture, forestry and fishing) [14].
Reporting to these four schemes may also be affected
by physicians seeing different levels of disease severity, or
else as a result of attrition on ascending the referral
pyramid. Thus occupational physicians are perhaps most
likely to see primary referrals, with respiratory physicians
seeing secondary (or tertiary) referrals and reporters to
SIDAW mainly receiving tertiary referrals. One obvious
gap in the reporting of work-related infectious disease is
the caseload seen by general practitioners (GPs) and a
new reporting scheme is currently being set up (THORGP) to gain information from this very important source.
THOR-GP will be a UK-wide scheme that aims to collect
information on the wide range of work-related disease
seen by GPs. It will involve electronic (rather than paperbased) collection methods, and should provide valuable
information that can be used to compare with data
obtained from the extant schemes, involving occupational and specialist physicians.
In addition to providing information that can be used
to look at patterns of reported cases of occupational illhealth, the surveillance schemes allow reporters to alert
their peers about potential novel causes, precipitating
factors, or industrial sectors relating to occupational
disease. This is achieved through the regular reports
posted by the THOR team and additionally through the
internet/web-based interface [15]. A recent example of
this was associated with free movement of workers within
the European Union from an area with a high incidence
of TB, to another where the incidence was considerably
lower that resulted in disease transmission to the local
workforce, and also affected planning and provision of
Table 6. Breakdown of ‘miscellaneous’ outbreaks within SIDAW
by disease
Disease
Number of
outbreaks
Number of cases
within outbreaks
Brucellosis
Conjunctivitis
Legionellosis
Malaria
Meningitis
Paratyphoid
Pulmonary TB
Unspecified viral illness
Varicella
Total
1
1
2
1
2
1
3
1
1
13
3
3
4
8
4
2
9
2
2
37
medical services [16– 18]. The early warning facility is
important for both the individual reporter, and, for the
workforce. The individual reporter has a means of
benchmarking his/her practice against that of others
that is becoming increasingly important for continual
professional development, audit and revalidation. At a
workforce level, highlighting potential new factors relating to occupational diseases could have a substantial
impact on their prevention, but some caution should be
applied in view of recent ‘epidemics’ of work-related illhealth following increased awareness of a condition or
possible causal factors, for example, that of work-related
upper limb disorder in Australia in the 1980s [19].
Despite the reservations outlined above about the data
within ODIN and THOR, the reporting schemes have
provided valuable information on occupationally related
ill-health that has been used when planning service
provision, and by national bodies such as the Health &
Safety Executive in target setting to improve health and
safety within the workplace [20]. Department of Work
and Pensions data and information from the Reporting of
Injuries, Diseases and Dangerous Occurrences also
provide sources of information about occupational
infections, although these give even lower annual
S. TURNER ET AL.: WORK-RELATED INFECTIOUS DISEASE 281
estimates than THOR [13]. For example, for infections
that are prescribed diseases [21], over recent years
the total annual number for these prescribed infections
has fallen to single or very low double figures, although
there is no evidence of strong temporal trends in these
data. The schemes can provide details about diseases or
conditions ranging from those that may be clinically mild
and self limiting (for example, diarrhoeal disease) to more
serious clinical entities (for example, TB), but diagnoses
at both ends of this spectrum may have substantial effects
within the workplace, especially for force planning. The
range of diseases reported to the occupational surveillance schemes is therefore one of its strengths.
For individual physicians, especially those practising
occupational health medicine, involvement in the reporting schemes is associated with activities that scored highly
as priority areas for continuing professional development
[22], and as such, with ongoing support from reporters,
should ensure the continued success of schemes such as
OPRA, SWORD, SIDAW and EPIDERM.
Acknowledgements
We are grateful to Professors Corbett McDonald and Nicola
Cherry for access to data collected in 2000 and 2001. Corbett
McDonald initiated both the SWORD and SIDAW reporting
schemes; Nicola Cherry established EPIDERM. They were codirectors of ODIN from 1996 to 2002. The THOR project is
funded by a grant (D5044) from the UK Health & Safety
Executive awarded to Professor Raymond Agius and coinvestigators. This paper expresses the views of the authors
and not necessarily of the funding body. We are grateful to all
physicians in the UK who participate in the reporting schemes,
for their invaluable contribution and co-operation. Physicians
who wish to join THOR and participate in reporting can find
further details at http://www.coeh.man.ac.uk/thor. Thanks are
also due to Susan Taylor, Catherine Roberts and Lisa Fulluck
for their research and administrative assistance.
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