Occupational Sentinel Health Events SHE(O)

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An Occupational Sentinel Health Event (SHE[O]) is a disease, disability, or untimely death, which is occupationally related and whose occurrence may:

  1. provide the impetus for epidemiologic or industrial hygiene studies; or
  2. serve as a warning signal that materials substitution, engineering control, personal protection, or medical care may be required. (Ref. 1)

The genesis of the SHEO arises from a table of disease events that was developed by David D. Rutstein based on the concept of the Sentinel Health Event (SHE). According to Rutstein, an SHE is a preventable disease, disability, or untimely death whose occurrence serves as a warning signal that the quality of preventive and/or therapeutic medical care may need to be improved. (Ref. 2) Thus, these events serve as negative indices of the quality of medical care. For example, a case of polio is an SHE. The occurrence of this disease signals a breakdown in the immunization aspect of health care.

This approach of identifying and counting the number of preventable tragedies in the health care field was also used in the 1930s in New York State in preventing maternal mortality and in the 1960s for preventing infant deaths in the State of Massachusetts.

Based on the experience with maternal and infant mortality, Rutstein collaborated with NIOSH and successfully applied the SHE concept to the field of occupational disease. Thus the SHEO concept evolved with appropriate modification of the SHE table.

Following survey of the scientific literature, a list of 50 disease conditions linked to the workplace was published in 1983; these were codable within the framework of WHO’s International Classification of Diseases system (ICD-9). (Ref. 1 )

An updated list of 64 disease conditions was published in 1991. (Ref. 3) Criteria used for inclusion in the original list presented in 1983 were: documentation of associated agent(s), of involved industries, and of involved occupations. For the 1991 update, the following additional criteria were considered:

  1. Sound epidemiologic study with appropriate controls, endpoint, and specifics concerning occupation, industry, and agent;
  2. For case reports or case series reports, more than one case or case series identifying similar industry and occupation characteristics;
  3. In the case of lung cancer, the study must have been controlled for smoking history; and
  4. For death certificate studies, there must have been confirmatory studies using more rigorous methodologies.

Studies that were equivocal were not included in the updated list. Reports that needed confirmation by more supportive studies were also not included in the updated list. These included the following:

  1. studies in which results were only suggestive or preliminary;
  2. a single death certificate study;
  3. a single case report or a single report of cases in one workplace (i.e., a case series report);
  4. a questionnaire study; or
  5. studies using collapsed ICD codes for disease conditions.

In the updated list, two broad categories of SHE(O) were represented. The first group included those diseases or conditions that, by their inherent nature, are occupationally related, e.g., the pneumoconioses. It is unlikely that these diseases would occur in the absence of the inciting agent. The second set of conditions included diseases such as lung cancer, leukemia, peripheral neuropathy, and ornithosis, which may or may not be occupationally related; further information on the industry and occupation is required to establish a possible link between disease condition and occupation.


  1. Rutstein DD, Mullan RJ, Frazier TM, Halperin WE, et al: Sentinel Health Events (Occupational): A Basis for Physician Recognition and Public Health Surveillance.
  2. Am J Public Health 73/9:1954-1062, 1983 (Abstract–bibliographic information only).
  3. Rutstein DD, Berenberg W, Chalmers TC, Child CG, et al: Measuring the Quality of Medical Care (Second revision of Tables, May 1980) — A Clinical Method. New Engl J Med 294:582-588, 1976 (Abstract–bibliographic information only).
  4. Mullan RJ, Murthy LI: Occupational Sentinel Health Events: An Updated List for Physician Recognition and Public Health Surveillance. Am J Ind Med 19:775-799, 1991 (Abstract–bibliographic information only).