Prevalence of Ocular Trauma and Barriers to Use of Personal Protective Devices Among Welders in Hetauda, Nepal

Prevalence of Ocular Trauma and Barriers to Use of Personal Protective Devices Among Welders in Hetauda, Nepal | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Prevalence of Ocular Trauma and Barriers to Use of Personal Protective Devices Among Welders in Hetauda, Nepal View ORCID Profile Sunil Thakali , Mohini Shrestha , Aleena Gauchan , Dikshya Bista , Hom Bahadur Gurung doi: https://doi.org/10.1101/2025.08.09.25332577 Sunil Thakali 1 Hetauda Community Eye Hospital , Hetauda, Nepal Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Sunil Thakali For correspondence: sunilthakali{at}gmail.com Mohini Shrestha 2 Tilganga Institute of Ophthalmology , Kathmandu, Nepal Find this author on Google Scholar Find this author on PubMed Search for this author on this site Aleena Gauchan 2 Tilganga Institute of Ophthalmology , Kathmandu, Nepal Find this author on Google Scholar Find this author on PubMed Search for this author on this site Dikshya Bista 2 Tilganga Institute of Ophthalmology , Kathmandu, Nepal Find this author on Google Scholar Find this author on PubMed Search for this author on this site Hom Bahadur Gurung 2 Tilganga Institute of Ophthalmology , Kathmandu, Nepal Find this author on Google Scholar Find this author on PubMed Search for this author on this site Abstract Full Text Info/History Metrics Data/Code Preview PDF Abstract Welding poses significant ocular hazards in Nepal’s industrial settings; however, data on trauma prevalence and protective barriers remain limited. This cross-sectional study conducted in 2024 assessed the burden of ocular trauma, personal protective equipment (PPE) practices, and associated risk factors among 111 welders in Hetauda, Nepal. Comprehensive eye examinations and structured interviews revealed a high ocular trauma prevalence of 62.16%, primarily caused by metal chips (60.87%) and flames (37.84%). Although 78.39% of welders reported using PPE, 72.97% relied on non-certified sunglasses, and only 1.80% used certified protective goggles. Key barriers to appropriate PPE use included the absence of workplace mandates (62.50%) and a belief that protection was unnecessary (64.52%). Significant risk factors for trauma included male gender, lack of safety training (43.48%), and age between 46 and 60 years. Common ocular morbidities were corneal opacity (20.72%) and conjunctival congestion (10.36%), with only 8.11% of welders using prescription safety eyewear. Despite reported PPE usage, the continued high rate of ocular trauma highlights deficiencies in equipment quality and training. Mandating certified eye protection (e.g., shade-10 filters), enforcing workplace safety policies, and integrating occupational health education are critical steps for preventing eye injuries in Nepal’s industrial sector. Introduction Ocular trauma is a major yet preventable public health issue, ranking third among occupational injuries after hand and foot trauma. Globally, around 2.5 million cases occur annually, with 500,000 leading to permanent blindness. Work-related injuries and illnesses contribute significantly to human suffering and economic loss worldwide.[ 1 , 2 ] Welding, the predominant metal-joining method worldwide, is vital to metal fabrication but also a major cause of occupational injuries, especially in developing countries. Apprentices are exposed to toxic fumes, arc radiation, burns, and trauma, leading to both acute and chronic health issues. Welders face particularly high risks of eye injury due to mechanical, radiant, thermal, and chemical hazards.[ 3 , 4 , 5 ] While PPE use is standard in industrialized countries, poor safety practices in small-scale industries across developing nations lead to preventable and often severe ocular trauma.[ 6 ] The International Labour Organization (ILO) promotes a preventive safety and health culture in the workplace to address the global burden of work-related accidents and illnesses, which cause severe human suffering and economic loss[ 2 ].However, in Nepal’s industrial hub Hetauda, systematic reporting of such incidents remains scarce. Data from Hetauda Community Eye Hospital reveal that welding and metalwork account for 17.7% (379 cases) of all eye injuries, the highest among occupational causes. [ 7 ] These findings highlight welding as a disproportionately high-risk occupation for eye injuries in Nepal’s industrial sector. While the dangers of welding are well-documented globally, critical gaps persist in Nepal’s context, particularly in industrial areas like Hetauda. There is limited data on welders’ awareness of occupational hazards, their adherence to personal protective equipment (PPE) use, and the barriers to implementing safety practices. This study aims to (1) assess welders’ knowledge of workplace hazards, (2) identify obstacles to PPE utilization, and (3) evaluate existing safety measures. By addressing these gaps, the findings will inform targeted interventions to reduce preventable injuries and improve occupational health outcomes for Nepal’s welding workforce. Material and Method Ethical Clearance Ethical approval was obtained from the Institutional Review Committee (IRC) of Tilganga Institute of Ophthalmology (Ref. No. 07/2024) on April 22, 2024. The study adhered to the principles of the Declaration of Helsinki. All participants were recruited only after receiving IRC approval and providing written informed consent. Informed consent was also obtained separately for the use of any identifiable photographs. Participant privacy and confidentiality were strictly maintained throughout the processes of data collection, cleaning, and analysis. Study Design This was a prospective cross-sectional observational study conducted among welders in Hetauda Municipality, Nepal, in 2024. Only registered welders from welding workshops within the city, as recommended by the Grill and Steel Fabrication Association of Makwanpur, were included. A list of these workshops was obtained from the association, and all identified welders were made to invite for participation-effectively attempting a census of the welding population in Hetauda. Participant recruitment and data collection were conducted over a three-month period, from May 1 to July 31, 2024. Written informed consent was obtained from all participants prior to their inclusion in the study. Despite these efforts, only 111 welders consented and participated. Thus, the final sample represents a convenience sample of welders who were available and willing to participate during the study period. The data collection reflects real-world outreach and participation. Fig 1 shows the diagrammatic flowchart illustrating the recruitment process of study participants. Download figure Open in new tab Fig 1. Diagrammatic flowchart demonstrating recruitment of participants. Eligible welding workshops were identified in Hetauda Sub-Metropolitan City with the help of the Grill and Steel Fabrication Association of Makwanpur. All registered welders were invited to participate. A total of 111 welders provided informed consent and were included in the final analysis. Data Analysis Each participant underwent a complete eye examination and was interviewed using a structured questionnaire at Hetauda Community Eye Hospital. The questionnaire was adapted from a previous study conducted in Accra, Ghana, with minor modifications. Ocular trauma occurrence was based on self-reporting by participants. Data were cleaned and de-identified using Microsoft Excel (version 16.0). Statistical analysis was conducted using R version 2025.05.1 (R Core Team, Vienna, Austria). Categorical variables were presented as frequencies and percentages. Continuous variables were summarized as means with standard deviations(SD). Logistic regression was used to assess the association between various factors and ocular trauma. A p-value < 0.05 was considered statistically significant Results Participant Characteristics A total of 111 welders participated in the study. The majority were male (n = 103, 92.79%), with a mean age of 32.12 ± 12.21 years (range: 17–67) and a median age of 29 years. Education levels varied: 9.01% had no formal education, 25.23% completed primary education, 43.24% secondary education, and 22.52% higher secondary ( Table 1 ). View this table: View inline View popup Download powerpoint Table 1. Demography of welder’s study (N=111) Personal Protective Equipment (PPE) Ownership and Use Of the 111 welders, 80 (72.07%) reported owning PPE, and 87 (78.39%) reported using it during work. Among PPE users, the majority used protective glasses (72.97%), while a small number used goggles (1.80%) or eye shields (3.60%). Among the 31 who did not own PPE, the most common reason was perceiving it as unnecessary (64.52%), followed by expense (22.58%) and lack of access (12.90%). For the 24 who did not use PPE despite owning it, the most cited reasons were: lack of mandate (62.50%), perceived low risk (16.67%), and discomfort (8.33%) as shown in Table 2 . An illustration of the sunglasses commonly used by welders in Nepal is depicted in Fig 2 . View this table: View inline View popup Download powerpoint Table 2. Personal Protective Equipment (PPE) ownership and use among welders (N=111) Download figure Open in new tab Fig 2. Illustration of metal foreign bodies embedded in the cornea, a common form of ocular trauma among welders. Prevalence and Causes of Ocular Trauma The prevalence of ocular trauma among the welders was 62.16% (n = 69, 95% CI: 52.90% to 70.60%). The leading cause of ocular trauma was flying metal chips (60.87%), followed by exposure to flames (37.84%) and other causes (1.45%). This represents the most frequently encountered occupational eye injury in the study population. Characteristics of Welders with Ocular Trauma The mean age of welders with ocular trauma was 30.81 ± 12.30 years. Nearly all were male (97.10%). Of these, 72.46% owned PPE and 79.71% reported using it. A majority (91.30%) had received training in PPE use, yet 43.48% had never undergone formal safety training. Notably, 81.16% were wearing protective eyewear at the time of injury ( Table 3 ). View this table: View inline View popup Table 3. Characteristics of Ocular trauma patients among the welders (N=69) Workplace Safety and Training Among all participants, 92.79% were trained in PPE use. An eye PPE policy was reported to be present in 57.66% of workplaces. Regarding safety training at work: 33.33% received it frequently, 32.43% sometimes, and 34.23% never received any formal safety training ( Table 4 ). View this table: View inline View popup Download powerpoint Table 4. Workplace factors affecting ocular trauma among welder (N=111) Ocular Disorders and Visual Acuity Refractive errors were found in 9.91% of participants (myopia: 7.21%, hypermetropia: 1.80%, astigmatism: 0.90%). Presbyopia was present in 25.23%. On examination of 222 eyes, the most common findings were corneal opacity (20.72%), conjunctival congestion (10.36%), pinguecula (9.01%), and pterygium (3.60%). Cataract was found in 0.90% of eyes, and pseudophakia in 0.45%. Best-corrected visual acuity (BCVA) was 6/6 in 91% of right eyes and 92% of left eyes. One participant had perception of light only in one eye ( Table 5 ). View this table: View inline View popup Download powerpoint Table 5. Ocular disorders among welders (N=111) Spectacle Use A total of 17 welders (15.32%) used spectacles for distance vision, while only 9 (8.11%) used them while welding. Logistic Regression Analysis Multivariate logistic regression revealed that male gender and lack of formal safety training were significantly associated with an increased risk of ocular trauma (p < 0.05) ( Fig 4 ). In a separate model analyzing categorized age and welding hours per year, participants aged 46–60 years had significantly higher odds of reporting ocular trauma (p < 0.05) (Fig 5). Download figure Open in new tab Fig 3. Logistic regression analysis showing factors associated with ocular injury. Download figure Open in new tab Fig 4. Forest plot showing adjusted odds ratios (with 95% confidence intervals) for the association of age and welding duration with ocular trauma. Male gender and lack of safety training were significantly associated with higher odds of ocular injury among welders ( p < 0.05). The red dashed line indicates the null value (OR = 1.0). Only the 46–60 age group demonstrated a statistically significant association with ocular trauma. Discussion This study provides critical insights into the prevalence and risk factors for ocular trauma among welders in Hetauda, Nepal. The findings demonstrate a significantly high prevalence of ocular trauma (62.16%) among welders, highlighting the urgent need for occupational health interventions in Nepal’s growing industrial sectors. Prevalence and Patterns of Ocular Trauma The reported ocular trauma prevalence in this study aligns with findings from similar settings. In previous studies done in Nepal, reveal a high incidence of work and welding-related ocular injuries, mirroring trends observed in other industrializing developing nations.[ 7 ] In a study done previously by Gurung et al, the prevalence of ocular trauma was 32.83%, while other studies showed lower incidences of 1.8% in Bhaktapur Eye Study.[ 7 , 8 ] In other studies, it ranged from 1.74% to 2.4% in Western Nepal and Nepal blindness survey respectively.[ 9 , 10 ] Our rate (62.16%) is comparable to that found in studies conducted in Ghana and Nigeria[ 1 , 6 ], underscoring the occupational vulnerability of welders in low- and middle-income countries. Flying metal chips and flame exposure were the most common causes of trauma, consistent with other studies such as Lombardi et al. [ 5 ], which also emphasized the high-risk nature of weldingrelated mechanical and thermal injuries. Interestingly, a large proportion of affected welders (79.71%) reported wearing some form of protective eyewear at the time of injury. This raises concerns about the adequacy and effectiveness of the PPE used. Many welders may rely on non-standard or uncertified eyewear, which may not provide sufficient protection against the hazards they face. These findings are in line with studies in India and Nigeria [ 2 , 4 , 11 ], which reported that although PPE ownership was relatively high, the protective value was often compromised by poor design or incorrect usage. PPE Use and Barriers Despite 72.07% of participants owning PPE and 78.39% reporting PPE usage during work, a significant portion still experienced trauma. In a cross-sectional interview based prospective study, Ben et al reported 38.30% of the workers experienced some form of ocular injury and 68.3% never wore safety gear at work.[ 12 ]Some other stories also support this where low rates of PPE use can be documented.[ 13 , 14 ] Contradicting this, 78.39% in our study were wearing safety gear which may be because of the high risk job. Barriers such as perceived low risk, discomfort, and lack of regulatory enforcement were commonly cited, echoing findings from other occupational studies. Notably, more than 60% of non-users cited the absence of a workplace mandate as a reason for not using eye protection. These gaps suggest that merely providing PPE is insufficient without accompanying behavioral reinforcement and systemic enforcement. The implementation of a well-communicated eye safety policy, combined with regular vision screenings and spot checks, plays a critical role in behavioral enforcement of workplace safety.[ 5 ]PPE use reinforce by employer can increase its use in the work place and decreases the risk of injuries. [ 14 ]Studies of Nils bull have shown that there is drastic reduction of incidence of ocular injury among metal workers after eye protection became mandatory.[ 15 ] The presence of workplace safety regulations was found to significantly enhance workers’ awareness of occupational hazards. [ 3 ]In our study, 56.52% had eye PPE policy at workplace but 43.48%never had any safety training at work which shows a huge gap of improvement proper law enforcement. Most of them used sunglasses as PPE (72.97%) followed by eye shield and protective goggles. Similar to our case, in a study by Budhathoki et al, sunglasses were the most used form of PPE, (74.3%). Though sunglasses are cheap and easily available, it is not among the recommended PPE.[ 16 ] The welding goggle with filter shade number 10 is recommended for eye protection, particularly in industry settings for heavy-duty welding work[ 17 ] In a study by Yetunde et al, Sabitu et al and Isahand Okojie, the most common PPE worn in other studies was welding goggles.[ 11 , 18 , 19 ]Welding goggles/face-shield use was seen in18% welders study by Budhathoki et al.[ 16 ] Training, Workplace Policy, and Risk Factors Our study found that while 92.79% of welders reported being trained in PPE use, 34.23% had never received formal safety training at work. Logistic regression analysis confirmed that lack of formal safety training was significantly associated with ocular trauma. This reinforces the importance of not only PPE distribution but also structured and recurring safety education. Moreover, welders aged 46–60 years were found to be at higher risk for ocular trauma. This may reflect cumulative exposure or decreased compliance with protective practices over time. In our study, higher proportion of male were prone to have ocular injury which is similar to other studies.[ 20 , 21 , 22 , 23 , 24 , 25 ]The maximum numbers of workers were from working age group as in other similar studies. [ 5 , 12 , 20 , 26 ] Among those who sustained ocular trauma, 91.30% had received training on the use of personal protective equipment (PPE), yet only 79.71% reported actual usage. This pattern aligns with findings from a study in Nigeria, where 98% of welders were aware of the risk of eye injury during welding, but only 15.3% were using protective eyewear at the time of injury.[ 6 ] Similarly, Budhathoki et al. reported that 90% of welders were aware of PPE; however, only about half of them consistently used it.[ 16 ] In contrast, our study demonstrates a comparatively higher rate of PPE use among those aware and trained, though gaps between knowledge and practice still remain evident. Ocular Morbidity and Spectacle Use Apart from trauma, the prevalence of ocular disorders such as corneal opacity (20.72%) and conjunctival congestion (10.36%) suggests chronic exposure to harmful radiation and particulate matter. While 15.32% of welders used spectacles for distance vision, only 8.11% used them during welding. This disparity points to another critical barrier—lack of awareness or access to prescription safety eyewear that meets both refractive and protective needs. Policy Implications These findings highlight the gap between policy and practice. While Nepal’s Labour Act mandates the use of safety devices in hazardous jobs, implementation in informal or small-scale workshops appears insufficient. Many welders use locally available, non-standard protective gear. There is a need for quality assurance, subsidies for certified PPE, and active enforcement of safety policies. Additionally, incorporating basic occupational eye health education into technical training curricula for welders could create lasting behavioral change. Conclusion This study reveals a critically high burden of preventable ocular trauma among welders in Hetauda, Nepal, despite relatively high reported awareness and use of personal protective equipment (PPE). The findings underscore a significant gap between perceived and actual protection-largely due to the use of non-certified or substandard equipment and the absence of consistent workplace safety training. Bridging this gap through targeted interventions, stricter enforcement of occupational safety regulations, and improved access to certified, quality-assured PPE could substantially reduce the risk of occupational eye injuries in Nepal’s expanding industrial sectors. Limitations This study is subject to certain limitations. As a cross-sectional design, it cannot establish causal relationships. The reliance on self-reported data may have introduced recall bias, especially in reporting past ocular injuries and PPE use. Additionally, the use of a convenience sample limits the generalizability of the findings beyond the study population. Data Availability All relevant data are within the manuscript and its Supporting Information files. Conflict of Interest The authors declare no competing interests. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Financial Disclosure A proposed research budget of NPR 200,000 was submitted to the Institutional Review Committee for approval. This study was supported by a research grant from Everest Parenterals, Nepal. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Authors’ contributions Conceptualization: Sunil Thakali, Hom Bahadur Gurung Formal analysis: Sunil Thakali, Hom Bahadur Gurung Investigation: Hom Bahadur Gurung, Dikshya Bista Supervision: Hom Bahadur Gurung, Dikshya Bista Writing – original draft: Sunil Thakali Writing – review & editing: Mohini Shrestha, Aleena Gauchan Acknowledgements The authors would extend their deepest appreciation to all the study participants for their time and cooperation. 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Epidemiology of ocular trauma cases presenting to a tertiary care hospital in a rural area in West Bengal, India over a period of 2 years . IOSR Journal of Dental and Medical Sciences (IOSR-JDMS) 2016 ; 15 ( 3 ). 25. ↵ Kamran Maqbool Hassan SANW , S.V. Swamiraj , Syed Asghar Hussain . Ocular injury pattern in the university hospital of South India . Indian Journal of Clinical and Experimental Ophthalmology . 2017 ; 3 ( 2 ): 234 – 8 . OpenUrl 26. ↵ Rajendra P. Maurya TS , Virendra Pratap Singh , C. P. Mishra , Abdullah Al-Mujaini . The epidemiology of ocular trauma in Northern India: A teaching hospital study . Oman Ophthalmic Society 2019 . View the discussion thread. Back to top Previous Next Posted August 12, 2025. Download PDF Data/Code Email Thank you for your interest in spreading the word about medRxiv. NOTE: Your email address is requested solely to identify you as the sender of this article. 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Share Prevalence of Ocular Trauma and Barriers to Use of Personal Protective Devices Among Welders in Hetauda, Nepal Sunil Thakali , Mohini Shrestha , Aleena Gauchan , Dikshya Bista , Hom Bahadur Gurung medRxiv 2025.08.09.25332577; doi: https://doi.org/10.1101/2025.08.09.25332577 Share This Article: Copy Citation Tools Prevalence of Ocular Trauma and Barriers to Use of Personal Protective Devices Among Welders in Hetauda, Nepal Sunil Thakali , Mohini Shrestha , Aleena Gauchan , Dikshya Bista , Hom Bahadur Gurung medRxiv 2025.08.09.25332577; doi: https://doi.org/10.1101/2025.08.09.25332577 Citation Manager Formats BibTeX Bookends EasyBib EndNote (tagged) EndNote 8 (xml) Medlars Mendeley Papers RefWorks Tagged Ref Manager RIS Zotero Tweet Widget Facebook Like Google Plus One Subject Area Occupational and Environmental Health Subject Areas All Articles Addiction Medicine (568) Allergy and Immunology (863) Anesthesia (300) Cardiovascular Medicine (4441) Dentistry and Oral Medicine (444) Dermatology (383) Emergency Medicine (608) Endocrinology (including Diabetes Mellitus and Metabolic Disease) (1510) Epidemiology (15229) Forensic Medicine (30) Gastroenterology (1126) Genetic and Genomic Medicine (6606) Geriatric Medicine (668) Health Economics (998) Health Informatics (4541) Health Policy (1369) Health Systems and Quality Improvement (1613) Hematology (543) HIV/AIDS (1265) Infectious Diseases (except HIV/AIDS) (15923) Intensive Care and Critical Care Medicine (1103) Medical Education (623) Medical Ethics (147) Nephrology (668) Neurology (6604) Nursing (346) Nutrition (998) Obstetrics and Gynecology (1145) Occupational and Environmental Health (957) Oncology (3334) Ophthalmology (974) Orthopedics (369) Otolaryngology (420) Pain Medicine (436) Palliative Medicine (130) Pathology (663) Pediatrics (1693) Pharmacology and Therapeutics (692) Primary Care Research (711) Psychiatry and Clinical Psychology (5448) Public and Global Health (9235) Radiology and Imaging (2200) Rehabilitation Medicine and Physical Therapy (1370) Respiratory Medicine (1196) Rheumatology (594) Sexual and Reproductive Health (713) Sports Medicine (530) Surgery (712) Toxicology (99) Transplantation (289) Urology (265) (function(){function c(){var b=a.contentDocument||a.contentWindow.document;if(b){var d=b.createElement('script');d.innerHTML="window.__CF$cv$params={r:'a017cebaf9d4593a',t:'MTc3OTc0NjM2OQ=='};var a=document.createElement('script');a.src='/cdn-cgi/challenge-platform/scripts/jsd/main.js';document.getElementsByTagName('head')[0].appendChild(a);";b.getElementsByTagName('head')[0].appendChild(d)}}if(document.body){var a=document.createElement('iframe');a.height=1;a.width=1;a.style.position='absolute';a.style.top=0;a.style.left=0;a.style.border='none';a.style.visibility='hidden';document.body.appendChild(a);if('loading'!==document.readyState)c();else if(window.addEventListener)document.addEventListener('DOMContentLoaded',c);else{var e=document.onreadystatechange||function(){};document.onreadystatechange=function(b){e(b);'loading'!==document.readyState&&(document.onreadystatechange=e,c())}}}})();