Severe occupational accidents reported at a sentinel unit from 2008 to 2018

Introduction Occupational accidents are a major public health problem. In addition to damages to workers’ health, they are also associated with economic and social losses. Since 2004, this type of accident has become of mandatory reporting through the Notifiable Diseases Information System. However, underreporting still reaches high levels. Objectives To identify and describe data on severe occupational accidents reported at an Occupational Health Unit. Methods This is a retrospective observational study based on data from the Notifiable Diseases Information System. Occupational accidents that occurred from 2008 to 2018 in the state of Paraná, Brazil, and reported by the Occupational Health Unit, located in Hospital do Trabalhador in Curitiba. Results Overall, 7,396 occupational accidents were reported, and most workers evolved with temporary disability (86%). The most frequently affected occupations were related to the area of construction industry (3.4%); however, it is worth highlighting the significant absence of this information in the reports (16.4%). Upper limbs were the most affected body region (42.5%). Conclusions The report of occupational accidents has significantly improved in the last years, but underreporting remains a significant issue and there is a gap in data about the accident circumstances. Therefore, this study aimed to generate data to assist in the development of policies for the promotion and care of workers’ health, in addition to being used for comparison in future statistics.

intrOductiOn Occupational accidents are defined as accidents that occur during the performance of work activities. They represent an important public health problem in Brazil and worldwide and have a significant impact on population morbidity and mortality. Furthermore, they may result in economic and social losses and lead to chronic and delayed sequelae related to workers' health. 1 The International Labor Organization (ILO) estimates that more than 300 million of work-related accidents occur worldwide per year, with the death of more than 2 million workers. 2 In Brazil, severe occupational accidents have been of mandatory reporting through the Notifiable Diseases Information System (Sistema de Informação de Agravos de Notificação, Sinan) since 2004. 3 It is mandatory to notify occupational accidents from unnatural causes that occur in the work environment or while performing work duties and that result in body injuries or functional disorders liable to cause loss or reduction of work capacity or death. 1,3,4 However, despite the increased number of notifications of these accidents in the last years, underreporting and lack of information on accident conditions remain as an important problem. [5][6][7][8][9] Data on occupational accidents are known to be an important tool to establish the causal relationship with the work environment, because these data allow to raise hypotheses on the risk conditions present in the environment and to formulate measures to correct them. 7 Among work-related injuries, accidents should receive special attention, due to their high severity and frequency and great associated economic damage. 10 The ILO estimates that 4% of gross domestic product is spent on occupational diseases and injuries, with variations depending on the degree of development of different countries. 10,11 This damage becomes even more evident when one analyzes the age of the individuals most affected by these accidents, which ranges from 20 to 49 years, i.e., when these individuals are in the most productive period of their working life. 9,12 In Brazil, sequelae from occupational accidents are the leading cause of leave of absence from work. 13 It is estimated that occupational accidents account for approximately 25% of injuries from external causes treated at emergency services and for nearly 70% of accident benefits granted by Social Security. 9,10,14 In an attempt to reduce these accidents, the Worker's Health National Policy (Política Nacional de Saúde do Trabalhador e da Trabalhadora, PNST) has been in effect since 2004. With the purpose of reducing accidents and work-related diseases, the PNST develops promotion, rehabilitation, and surveillance actions in the health field. One of its attributions is identifying relationships between environment, organization, work conditions, and their effects on workers' health. The PNST is composed of different centers that provide medical and outpatient services of medium and high complexity aimed at workers' health and that perform the diagnosis of work-related diseases, as well as their report through Sinan. 10,15 Considering the above-described scenario, the main objective of the current study was to identify and describe the characteristics of severe or fatal occupational accidents graves treated at an Occupational Health Unit (Unidade de Saúde do Trabalhador, UST) in the state of Paraná, Brazil, from 2008 to 2018. methOds This is a retrospective, observational, quantitative study that conducted a survey on data from Sinan. There was the inclusion of severe or fatal occupational accidents that occurred in the state of Paraná, Brazil, from 2008 to 2018 and were reported by the UST located in Hospital do Trabalhador in Curitiba, state of Paraná. The data analyzed were related to the following information: number of accidents per year, body region affected by the accident (eyes, health, neck, chest, abdomen, upper limbs, lower limbs, the entire body, other regions), case outcome (cure, temporary disability, permanent partial disability, permanent total disability, death, others), and worker's occupation.
Data analysis was conducted using simple descriptive statistics, with calculation of absolute and relative frequencies. With regard to ethical aspects, since the study used secondary data from a database, there was no need to submit it to the research ethics committee, which waived assessment according to the ethical standards of Resolution n. 466/2012 of National Health Council (Conselho Nacional de Saúde) and to international ethical guidelines. With regard to case outcome, 86.2% (n = 6,379) of workers evolved with temporary disability to work; 0.7% (n = 55), with partial permanent disability; 0.0162% (n = 12), with a total permanent disability to work; and 1.17% (n = 87) of individuals evolved to death. Furthermore, 7.53% (n = 557) of workers reached full recovery of the injuries caused by the occupational accident, and 4.12% (n = 305) of the cases did not have their outcome registered (Table 1, Figure 2).
Most accidents affected the upper limb (shoulder, arm, forearm, and hand), accounting for 42.49% (n = 3.143) of the total of reported accidents. Of these, 16.65% (n = 1,232) affected the shoulder, the arm, or the forearm. The hand was the region most frequently affected by the accidents, with 25.8% (n = 1,911) of the registered injuries. The lower limbs (pelvic girdle, thigh, leg, and foot) were the second most injured region, accounting for 28.96% (n = 2,142) of accidents. Of the lower limbs, the foot was the most frequently affected region, with 12.5% (n = 931) of injuries. Head injuries accounted for 6.81% (n = 504), and chest injuries, to 3.73% (n = 276). Injuries affecting the whole body accounted for 4.04% (n = 299).
A total of 990 different occupations were registered, according to report forms. Among the occupations with

discussiOn
According to the ILO, Brazil has the fourth highest annual incidence of work-related accidents worldwide, after China, India, and Indonesia. 16 However, it is worth considering that official data suffer from significant underreporting. In Brazil, underreporting is estimated to be as high as over 70% for fatal accidents and 90% for non-fatal ones. [17][18][19] Among the causes for this underreporting, there are the difficulty of reporting imposed by employers, the fragility of work contracts, which put workers in a risky situation (e.g., in the cases of outsourced workforce), and the great number of workers excluded from the formal labor market. It is also known that some sources of information limit their data to restricted workers' populations. 6,7 The lack of integration between official organs also contributes to the difficulty in obtaining data on workers' morbidity and mortality. Therefore, the number of accidents is underestimated when analyzing only official data made available by government agencies. A study published in 2003 about the reasons for underreporting calls attention to the difficulties faced by auditors and occupational health surveillance professionals when evaluating work environments and accessing private company files. 7 Several authors highlight the importance of obtaining data on the circumstances of the reported occupational accidents, because these data could assist in the indirect characterization of accident severity and in the development and improvement of preventive actions. [5][6][7] Underreporting is also a problem in other parts of the world. In Canada, researchers estimate the total number of fatal occupational accidents is 10 to 13 times higher than the officially disclosed number. 20 In China, there is also a high rate of underreporting of occupational accidents in the system, especially in sectors with the higher number of hired personnel, such as agriculture and labor force working in the heavy industry. 21 It is worth highlighting that the national database also presents with inappropriately filled report forms. In the present study, a considerable number of items were registered with unknown or blank answers. Two possible difficulties for the appropriate filling of the report form are lack of health care professionals' training and unawareness of the importance of the appropriate filling of report forms. 22 With regard to the results found in the present study, there is a wide variation in the number of yearly reports registered over the 10-year study period, with a peak in 2016. This finding is consisted with other national and state studies, which point out to a gradual increase in the incidence of work-related accidents in this period. 10,23 The Epidemiological Bulletin on Worker's Health in the state of Paraná, which assessed the period from 2006 to 2016, also showed a similar growing trend, with a peak of reports in 2015 and 2016. Also, according to the Bulletin, between the years 2007 and 2016, the reports in the state of Paraná accounted for nearly 7.81% of national reports, making this state as the one with the third highest number of reports of work-related accidents. 24 The data found also follow the trend of national data published by the Social Security Statistical Yearbooks. 25 In relation to the outcomes of severe accidents, most accidents led to temporary disability to return to work, with the higher number of cases occurring from 2015 to 2017. Previous epidemiological studies also obtained similar data. 10,17,23 However, it is worth emphasizing that the percentage of each outcome presents significant variations among different studies. 10,23 In an epidemiological study conducted in the state of Bahia, Brazil, in 2000, around 80% of Social Security benefits granted to injured individuals were due to temporary disability, a value close to that found in the current study. 17 When considering the entire period of the present study, the overall rate of deaths remained closed to 1%. It is worth highlighting that the number of deaths presented minor variations throughout the years, with no significant reductions. A study conducted in the state of Paraná from 2007 to 2010 with data from the entire state, found rates of death from severe accident close to 10%. 23 This difference may be attributed to the fact that the present study analyzed data referring to only one UST of the state. With regard to the affect body regions, most accidents involved the upper limbs, highlighting the involvement of hands in approximately 25% of the reported accidents. Lower limbs were the second body region most frequently injured, with the feet accounting for 12% of the cases. This result follows the trend observed in the literature. 4,9,10,23 As for the most reported occupations, there was the predominance of professionals from the construction industry, followed by those working in the transportation and cleaning industries. Previous national and international studies show similar results. 5,9,10,26,27 In relation to fatal accidents, the most reported industries were civil construction, transportation, and communications, manufacturing, and mineral extraction. 19 Knowledge on the type of labor activity related to the occupational accident is of major importance, because it assists in the planning and development of preventive actions. 5 Nevertheless, it is worth highlighting the great scarcity of information on national databases. [5][6][7] Occupational accidents are still frequent, despite technological advances, changes to legislation, and adoption of preventive measures. Researchers mention negligence and low effectiveness of prevention policies and programs. 17 It is worth emphasizing that, in most cases, occupational accidents could be potentially avoided, and, because of their multicausal nature, a series of preventive measures should be implemented. Among other measures, one can mention workers' education for the different risks existing in the workplace, accurate use of personal protective equipment and its inspection, reduction of work hours. 28,29 Furthermore, a study conducted in the state of São Paulo, Brazil addresses the trend to blame workers as a way to omit risks and unsafe conditions in the work environment. 30 As contributions of the study, we can mention knowledge on the characteristics of occupational accidents and affected workers. Among limitations, it is worth highlighting the use of information from a database with secondary data, failures in report form filling, and underreporting.

cOnclusiOns
The present study emphasizes the need of accurate reporting of severe or fatal occupational accidents. Knowledge on information related to worker's occupation and to the circumstances of the accidents is useful for the implementation of preventive and health promotion measures in the occupational environment in order to improve inspection measures.
The analysis of collected data revealed a considerable number of inappropriately filled report forms, with missing information about certain items. Therefore, it is important to provide training to professionals who perform this task.

authOr cOntributiOns
Mayara RG, Maryna RG, and FYI were responsible for the study conceptualization, formal analysis, and writing -original draft, and review & editing. NNM participated in the study investigation, formal analysis, resources, and writing -review & editing. MMH and MRH participated in the study conceptualization, investigation, and writing -review & editing. PRZ participated in the study conceptualization, project administration, resources, supervision, validation, and writing -review & editing. ED was responsible for the study conceptualization, formal analysis, methodology, project administration, supervision, validation, and writing -review & editing. All authors approved the final version submitted and assume public responsibility for all aspects of the work.