Occupational health regulation Regulations on occupational diseases and the current situation in Germany

Definition and current list of occupational diseases In Germany, only diseases due to hazardous influences on groups occupationally exposed to a much greater extent than the general population can be included in the list of occupational diseases, which fall under 551, section 1, of the National Insurance Code (Reichsversicherungsordnung, RVO) decreed by the Federal Government with the assent of the upper house of Parliament (table 1). In addition, 551, section 2, of The National Insurance Code offers the possibility to recognize and compensate a disease not yet listed if it is consistent with new medical knowledge and the aforementioned conditions are fulfilled (1). Today, 64 compensable occupational diseases (or groups of diseases) are listed in the Occupational Diseases Ordinance (Berufskrankheitenverordnung, BeKV) (2). Occupational diseases Before an insured activity can be recognized as an occupational disease, it must have had a hazardous effect and have caused illness (table 1). The insured persons carry the burden of proof. They are, however, able to appeal to the welfare tribunal if the claim for compensation is refused. Some diseases require special insurance-related conditions in addition to the causal connection and the individual medical characteristics. Thus the following diseases must also have induced the cessation of all activities which were or could be the cause of aggravation or recurrence of the disease: tendon sheath affection (occupational disease no 2101), circulatory disturbance in the hands due to exposure to vibration (no 2104), diseases of the intravertebral discs of the lumbar portion of the spine (no 2108--2110), obstructive airway diseases (no 4301 and 4302), and skin diseases (no 5101). Furthermore, skin affections require the attribute "severe disease or repetitive recurrence" (2). Statutory accident insurance institutions in industry and trade (Berufsgenossensdaft) recognize and compensate only those occupational diseases which have been attributed to particular tasks by the legislative body. Social safeguards against other diseases are principally covered by the health insurance system, and those against the restriction or loss of work ability due to other reasons are a part of the legal pension scheme. The Ministry of Labour and Social Affairs (Bundesministerium fur Arbeit und Sozialordnung, BMA) keeps statistics on both the claims made to all insurance carriers and the compensations that then are paid. In addition to statutory accident insurance institutions in industry and trade, insurance carriers exist in the public and agricultural sectors. Occupational diseases of the latter primarily refer to infectious diseases (no 3101 and 3102), diseases due to organic dusts (no 4202), obstructive airway diseases (no 4301), and skin diseases (no 5101) (3). Available data on the other insurance carriers, namely, those in the public sector and the statutory agricultural insurance institution, are shown in figure 1 A (4). Claims for the compensation of suspected cases of occupational disease In cases of substantiated suspicion, all physicians and dentists are obliged to report occupational diseases. Employers are subject to this obligation, too. Insured persons, health insurance companies, and other bodies can also report occupational diseases. The increase in the number of reports in recent years can be traced directly to three phenomena (figure 1 A and B). Until 1985, statutory accident insurance institutions in industry and the trades did not register claims that had been earlier identified as not fulfilling statutory requirements for occupational diseases. However, since 1986, each claim has been registered as "report of suspected occupational diseases." This measure has resulted in a rapid increase of suspected cases in the statistics since 1986. In 1988, the list of occupational diseases was broadened to include additional occupational diseases (no 1314, 4109, 4110 and 4203). Finally, since 1991, data from the German Democratic Republic (GDR) have been included in the statistics. The GDR applied a similar system for occupational diseases. Compensations according to former GDR law were granted temporarily. Since 1992, 551 of the National Insurance Code has also been valid for the new federal states ( Bundeslander ). Although the former GDR law on occupational diseases is no longer valid, full-scale benefits are granted for diseases not included in the list if their onset dated before 1 January 1992. In addition, there have been some more indirect influences on the increase in the number of reported cases of occupational disease. For example, public relations work in the media has sensitized the population to health risks in workplaces. Besides, the introduction of occupational medicine to university studies has elevated the attention of the medical profession. The increase in systematic occupational medical examinations to more than four million in 1994 is also a causal factor. The great increase in the number of cases in 1993 was mainly a result of the inclusion of discogenic diseases of the cervical and lumbar vertebral column due to the long-term lifting and carrying of heavy loads, activities in extreme postures or exposure to whole-body vibration requiring the cessation of activities (no 2108--2110). These new occupational diseases have to be recognized retrospectively on demand if the event occurred after 31 March 1988. Reports on, for instance, discogenic disease of the cervical and lumbar vertebral column due to the lifting or carrying of heavy loads or due to long-term activities in extreme positions (no 2108) decreased in 1994 by more than 5000 cases because the surplus of the previous year was reduced. The cases reported according to former GDR regulations dropped by about 50%. This development is due to the fact that diseases consistent with GDR law only had to be reported if they occurred before 1 January 1992. With a maximum of 31%, compensation claims for diseases due to mechanic impact (25 722 cases) dominated, followed by skin diseases with 18 786 cases (22%) and impaired hearing due to noise with 12 616 cases (15%). Claims for airway diseases due to inorganic dusts amounted to 9141 cases (11%), and there were 6912 cases (8%) of obstructive airway disease. Recognized occupational diseases Statutory accident insurance institutions in industry and trade recognized 19 419 new cases of occupational disease in 1994. The increase amounted to 1586 cases, or 9%, more than in 1993 (table 2). Other cases with confirmation of a work-related cause Among the recognized cases, another group of patients has to be considered. The suspected occupational cause of their disease has been confirmed, but the special insurance-related conditions required for some occupational diseases, for example, cessation of the hazardous activity, have not been met. In 1994 this group consisted of 8095 patients. Most of them suffered from skin diseases that have a particular degree of severity and also demand the cessation of exposure because of the possibility of relapses. In such cases, statutory accident insurance institutions in industry and the trades take partial measures under the jurisdiction of 3 of the Occupational Disease Ordinance to prevent the occurrence of an occupational disease. Mortality due to occupational diseases Mortality as a consequence of an occupational disease is assumed if the occupational disease was the only or at least the legally substantial cause of death. Especially among elderly persons, other affections are frequently jointly responsible. This aspect has to be considered with regard to mortality. Moreover, occupational diseases such as silicosis (no 4101), silicotuberculosis (no 4102 ), asbestosis (no 4103), and asbestosis with lung cancer (no 4104) are legally regarded as having a causal relation to death for patients with who have impaired job performance of at least 50% during their lifetime. Evidence of this fact has to be provided by the health insurance carrier. This group also includes persons who were not granted a lifetime or a postmortem pension. In addition to acute poisoning leading to death (eg, due to carbon monoxide) occupational diseases of patients who undergo rehabilitative treatment between the event and death and were thus not entitled to a pension according to 580 of the National Insurance Code (eg, silicotuberculosis) are included. In 1994 the mortality rate rose by 10%. Two-thirds of these cases were induced by inorganic dusts. Mortalities due to ionizing radiation mainly resulting in lung cancer due to activities in uranium mining in the former GDR also increased distinctly. Expenses related to occupational Approximately one-third of all reports of suspected occupational disease leads to benefits being paid by statutory accident insurance institutions in industry and the trades. Benefits are based on the confirmation of a suspected occupational disease. However, benefits are also due if the disease has not yet occurred but the risk exists. In such cases the decree on occupational diseases, especially 3, forms the legal basis for preventive actions such as hygienic measures at work or even a change of occupation and retraining. The spectrum of benefits provided by statutory accident insurance institutions in industry and the trades is comprised of medical rehabilitation, occupational rehabilitation, cash payments to injured persons, and temporary payments and benefits according to 3 of the Occupational Disease Ordinance. The total payment for compensation in 1994 amounted to DEM 13.4 billion. More than DEM 8.9 billion had to be spent on pensions and benefits to diseased persons, while the costs of cures added up to DEM 4 billion, corresponding to 66% or 30%, respectively. DEM 523 million was paid for occupational reintegration.

In Germany, only diseases due to hazardous influences on groups occupationally exposed to a much greater extent than the general population can be included in the list of occupational diseases, which fall under $ 551, section 1, of the National Insurance Code (Reichsversicherungsordnung, RVO) decreed by the Federal Government with the assent of the upper house of Parliament (table 1). In addition, $ 551, section 2, of The National Insurance Code offers the possibility to recognize and compensate a disease not yet listed if it is consistent with new medical knowledge and the aforementioned conditions are fulfilled (1). Today, 64 compensable occupational diseases (or groups of diseases) are listed in the Occupational Diseases Ordinance (Berufskrankheitenverordnung, BeKV) (2).

Occupational diseases
Before an insured activity can be recognized as an occupational disease, it must have had a hazardous effect and have caused illness (table 1). The insured persons carry the burden of proof. They are, however, able to appeal to the welfare tribunal if the claim for compensation is refused. Some diseases require special insurance-related conditions in addition to the causal connection and the individual medical characteristics. Thus the following diseases must also have induced the cessation of all activities which were or could be the cause of aggravation or recurrence of the disease: tendon sheath affection (occupational disease no 2101), circulatory disturbance in the hands due to vibration (no 2104), diseases of the intravertebral discs of the lumbar portion of the spine (no 2108-21 lo), obstructive airway diseases (no 4301 and no 4302), and skin diseases (no 5101). Furthermore, skin affections require the attribute "severe disease or repetitive recurrence" (2).
Statutory injury insurance institutions in industry and trade (Berufsgenossensdaft) recognize and compensate only those occupational diseases which have been attributed to particular tasks by the legislative body. Social safeguards against other diseases are principally covered by the health insurance system, and those against the restriction or loss of work ability due to other reasons are a part of the legal pension scheme.
The Ministry of Labour and Social Affairs (Bundesministerium fiir Arbeit und Sozialordnung, BMA) keeps statistics on both the claims made to all insurance carriers and the compensations that then are paid. In addition to statutory injury insurance institutions in industry and trade, insurance carriers exist in the public and agricultural sectors. Occupational diseases of the latter primarily refer to infectious diseases (no 3101 and no 3102), diseases due to organic dusts (no 4202), obstructive airway diseases (no 4301), and skin diseases (no 5101) (3).
Available data on the other insurance carriers, namely, those in the public sector and the statutory agricultural insurance institution, are shown in figure 1 A (4,s).

Claims for the compensation of suspected cases of occupational disease
In cases of substantiated suspicion, all physicians and dentists are obliged to report occupational diseases. Employers are subject to this obligation, too. Insured persons, health insurance companies, and other bodies can also report occupational diseases.
The increase in the number of reports in recent years can be traced directly to three phenomena (figure 1 A and B). Until 1985, statutory injury insurance institutions in industry and trade did not register claims that had been earlier identified as not fulfilling statutory requirements for occupational diseases. However, since 1986, each claim has been registered as "report of sus-  (2) Mechanical impacts (21) Diseases of tendon sheats, peritendineum, muscular and tendinous insertions causing the cessation of all activities that were or might be responsible for the aggravation or recurrence of the disease (2101) Meniscus lesions following long-term or repetitive activities exerting stress on knee joints (2102) Diseases due to vibration while handling compressed air tools or equipment with the same effect (2103) Blood circulation disorders of the hands due to mechanical vibration causing the cessation of all activities responsible for the occurrence, aggravation or recurrence of the disease (2104) Chronic diseases of bursae due to constant pressure (2105) Neural paralysis due to pressure (2106) Fractures of the vertebral processes (2107) Diseases of the intravertebral discs of the lumbar portion of the spine due to lifting or carrying heavy objects over a number of years or working in extreme positions over a number of years causing the cessation of all activities that were or might be responsible for the aggravation or recurrence of the disease (2108) Diseases of the intravertebral discs of the cervical portion of the spine due to carrying heavy objects on the shoulder for a number of years causing the cessation of all activities that were or might be responsible for the aggravation or recurrence of the disease (2109) Diseases of the intravertebral discs of the lumbar portion of the spine due to the effects of vertical vibration over a number of years causing the cessation of all activities that were or might be responsible for the aggravation or recurrence of the disease ( In addition, there have been some more indirect influences on the increase in the number of reported cases of occupational diseases. For example, public relations work in the media has sensitized the population to health risks in workplaces. Besides, the introduction of occupational medicine to university studies has elevated the attention of the medical profession. The increase in systematic occupational medical examinations to more than four million in 1994 is also a causal factor.
The great increase in the number of cases in 1993 was mainly a result of the inclusion of discogenic diseases of the cervical and lumbar vertebral column due to the long-term lifting and carrying of heavy loads, activities in extreme postures or exposure to whole-body vibration requiring the cessation of activities (no 2108-

Mortalitv due to occuoational diseases
Mortality as a consequence of an occupational disease is assumed if the occupational disease was the only or at least the legally substantial cause of death. Especially among elderly persons, other affections are frequently jointly responsible. This aspect has to be considered with regard to mortality. Moreover, occupational diseases such as silicosis (no 4101), silicotuberculosis (no 4102 ), asbestosis (no 41 03), and asbestosis with lung cancer (no 4104) are legally regarded as having a causal relation to death for patients with impaired job performance of at least 50% during their lifetime. Evidence of this fact has to be provided by the health insurance carrier. This group also includes persons who were not granted a lifetime or a postmortem pension. In addition to acute poisoning leading to death (eg, due to carbon monoxide) occupational diseases of patients who undergo rehabilitative treatment between the event and death and were thus not entitled to a pension according to $ 580 of the National Insurance Code (eg, silicotuberculosis) are included.
In 1994 the mortality rate rose by 10%. Two-thirds of these cases were induced by inorganic dusts. Mortalities due to ionizing radiation mainly resulting in lung cancer due to activities in uranium mining in the former GDR also increased distinctly.

Expenses related to occupational diseases
Approximately one-third of all reports of suspected occupational disease leads to benefits being paid by statu-tory injury insurance institutions in industry and trade. Benefits are based on the confirmation of a suspected occupational disease. However, benefits are also due if the disease has not yet occurred but the risk exists. In such cases the decree on occupational diseases, especially § 3, forms the legal basis for preventive actions such as hygienic measures at work or even a change of occupation and retraining.
The spectrum of benefits provided by statutory injury insurance institutions in industry and trade is comprised of medical rehabilitation, occupational rehabilitation, cash payments to injured persons, and temporary payments and benefits according to # 3 of the Occupational Disease Ordinance.
The total payment for compensation in 1994 amounted to DEM 13.4 billion. More than DEM 8.9 billion had to be spent on pensions and benefits to diseased persons, while the costs of cures added up to DEM 4 billion, corresponding to 66% or 30%, respectively. DEM 523 million was paid for occupational reintegration.