French Occupational Disease System: Examples of Diseases Caused by Hand–Arm Vibration †

: In France on 25 October 1919, a law was created so that workers suffering from occupational diseases because of their work could receive speciﬁc compensation. Built on the notion of “presumption of origin”, the occupational disease tables outline the conditions for recognition.


Introduction
Occupational diseases, which have constantly been on the rise for over more than 20 years now, can have an impact on both a person's professional life and private life. In France, employers are responsible for their prevention, but all occupational safety and health practitioners can play a role in identifying and preventing them to keep workers affected by these diseases in employment.

Definition
The French notion of an occupational disease is, above all, a medico-legal concept, conferring the right to specific compensation, which is identical to that of occupational accidents. This includes: a waiver of co-payments for all care relating to the disease including functional rehabilitation; a higher sick pay than that which is paid to people with a non-occupational-related sickness; the possible payment of benefits or annuities depending on the health effects according to the permanent impairment rating evaluated by Social Security's medical advisor. In France, costs are borne by employers through occupational accident/occupational disease contributions paid to the occupational hazard branch of Social Security by companies under the general social security scheme (RG) and to the agricultural mutual fund by companies under the agricultural social security scheme (RA). For civil servants, the system is managed by each individual administration.
Self-employed French workers are not covered for occupational hazards unless they have taken out voluntary insurance under the general social security scheme.

The Presumption of Origin
In the French system, a disease is occupational if it is the direct consequence of a worker's exposure to a physical, chemical, or biological hazard or resulted from the conditions under which they perform their professional activity. However, it can be difficult to establish a direct causal link between work and a given disease. This is why, since the introduction of a law on 25 October 1919, a disease has been recognized as occupational if it appears in one of the tables in the French Social Security Code or to the Rural Code. For civil servants, the disease tables under the general scheme also apply.
These tables all follow the same model (Table 1): • A title stating the hazard that is taken into account. This can be a chemical agent (for example "Occupational diseases following the inhalation of asbestos dust" RG 30 or RA 47), a biological agent (for example "Diseases due to tubercle bacilli and certain atypical mycobacteria" RG 40 or RA 16), a physical agent (for example "Diseases caused by ionizing radiation" RG 6 or RA 20), or a "work environment" (for example "Diseases caused by vibrations and shock transmitted by certain machine tools, tools and objects and repeatedly hammering objects with the palm heel" RG 69 or RA 29); • A left column enumerating the diseases or symptoms recognized as possibly being linked to the hazard mentioned in the title (for example, for

Restrictive List of Work Likely to Cause These Diseases and Disorders
-C -Hypothenar hammer syndrome (HHS) causing Raynaud's phenomenon or finger ischemia confirmed by arteriography, providing objective evidence of an aneurysm or thrombosis of the ulnar artery or the superficial palmar arch.
1 year (subject to an exposure period of 5 years) Work regularly involving exposure to repeat hammering of objects with the palm heel or involving exposure to shock transmitted to the hypothenar eminence by a percussive tool or a tool receiving impact.
The presumption of origin enables a worker, covered by a French social security body, meeting the conditions of an occupational disease table, to not have to prove the link between their disease and their work; rather, it is up to the employer in France or the French social security body to demonstrate that there is no link between the disease and the professional activity.
The French occupational disease tables are drafted based on social consensus according to scientific expertise, within advisory commissions under the Labor and Agriculture ministries. They then become the subjects of simple decrees, applicable after being published in the Journal Officiel de la République française (official journal of the French Republic). They are created and updated based on scientific and technical developments. As of February 2023, there were 118 tables for the general social security scheme and 61 for the agricultural scheme.

French Complementary Health Insurance
In certain instances, despite non-compliance with conditions mentioned in the tables, the employee's disease can still be recognized as having an occupational origin, either because the criteria in the center and right columns are not met if a direct link is established with the professional activity (paragraph 6 in Article L. 461-1 of the Social Security Code [2]), or because the disease does not currently appear in a table and has caused the death of the victim or an impairment rating of at least 25% and a direct and essential link is established between this disease and the work (paragraph 7 in Article L. 461-1 of the Social Security Code [2]). The establishment of these links falls within the jurisdiction of the regional occupational disease recognition committee.

Procedure
First, it is necessary to establish a precise diagnosis. To achieve this, in view of the symptoms suggestive of a disease, an occupational physician generally addresses the worker to a medical specialist who will conduct exams to confirm and specify the diagnosis.
In all cases (presumption of origin or complementary system), it is up to the victim or their beneficiaries to make the request for recognition with their French social security body or administration where civil servants are concerned. Examination of the request must follow the adversarial principle (employer/worker).

The Occupational Diseases Most Frequently Recognized in France
For more than 20 years now, from about 80% to 85% of occupational diseases recognized by social security bodies are those affecting the musculoskeletal system (musculoskeletal disorders (MSDs)) and corresponding to tables RG 57 or RA 39 "Peri-articular diseases caused by certain work movements and postures", RG 69 or RA 29 "Diseases caused by vibration and shocks transmitted by certain machine tools, tools and objects and by repeatedly hammering objects with the palm heel", RG 79 or RA 53 "Chronic injury of the meniscus", RG 97 or RA 57 "Chronic disorders of the lumbar spine caused by lowand medium-frequency vibration transmitted to the entire body", and RG 98 or RA 57bis "Chronic disorders of the lumbar spine caused by regular manual handling of heavy loads".
Between 2016 and 2021, there were an average 96 occupational diseases recognized per year under table RG 69. Osteonecrosis of the lunate (34%) and elbow arthritis (33%) are the most frequent disorders. Vascular disease represents 20% and angioedema roughly 10% of the disorders. Osteonecrosis of the scaphoid is anecdotal (slightly less than 3%). The sectors most frequently concerned are construction (structural work and finishings), civil engineering, and the automobile industry (manufacturing and repairs).
For diseases that do not appear in the tables, certain mental health effects (severe depression, generalized anxiety, and post-traumatic syndrome) resulting from psychosocial risks are at the top of the list, with several hundreds of cases recognized each year, which have been significantly more common in the past few years.
All of the tables, together with comments, can be consulted on www.inrs.fr/mp (accessed on 11 April 2023).