Asthma in the workplace

Transcription

1 Work-related asthma Session 2105 Definitions, public health surveillance, and workplace medical monitoring Edward Lee Petsonk, M.D. Professor of Medicine i Section of Pulmonary and Critical Care Medicine West Virginia University School of Medicine American Occupational Health Conference May 2, 2010 NOTHING TO DISCLOSE Asthma - Definition Asthma management guidelines: Asthma is a common chronic disorder of the airways that t involves a complex interaction ti of airflow obstruction, bronchial hyperresponsiveness and an underlying inflammation. This interaction can be highly variable among patients and within patients over time. * Individuals with asthma/rhinitis entering the workplace Onset unrelated to working conditions/exposures * Diagnosis and Management of Work-Related Asthma: Consensus Statement. CHEST Supplement Sept. 2008, vol. 134 *Vandenplas and Malo, Eur Resp J. 2003;21:706. No relation to working conditions/exposures Onset unrelated to working conditions/exposures WEA or WAA (work aggravated asthma) 1

2 Onset unrelated to working conditions/exposures No relation to working conditions/exposures Work-Related Asthma* Definitions OA - New-onset asthma that was initiated by an exposure during work. WEA - Pre-existing or concurrent asthma made worse by the work environment Worsening of symptoms Worsening of airway hyperresponsiveness Increased medication requirements Necessitates avoidance of activities or exposures that were previously tolerated * CHEST Supplement Sept. 2008, vol. 134 *WEA is from 1/3 to 2/3 of all Work Related Asthma. Henneberger, Curr Opin Allergy Clin Immunol No asthma Prior asthma Work exac.* Concurrent Occ. Asth. Defining work related asthma Issues and controversies Mechanisms Specific sensitizers IgE mediated,?other mediators Nonspecific increase in bronchial responsiveness Irritant induced asthma Reactive Airways Dysfunction Syndrome Low dose RADS Defining work related asthma Issues and controversies Data requirements quantity and quality Symptoms Immunologic sensitization Changes in airflow and/or NSBR Specific inhalation challenge Workplace exposures 2

3 Defining work related asthma Issues and controversies NIOSH Surveillance Classification: Work Related Asthma Data requirements Dependent on purpose Individual medical management Workplace health surveillance Public health reporting Compensation MMWR June 1999 public health surveillance What is it? How do we do it? What can we learn from it? medical screening/surveillance What is it? How do we do it? What can we learn from it? public health surveillance Track disease, distribution, and determinants medical screening/surveillance public health surveillance Case finding methods should be consistent almost always a compromise between sensitivity and specificity (effort and detail) Not necessarily comprehensive, representative Data sources: Individual medical records (?EMR) reports from clinics, offices, laboratories hospital discharge pharmacy death certificates Compensation or insurance records Physician reporting forms compulsory/voluntary 3

4 public health surveillance Reporting guidelines simple Case confirmation criteria more detailed NOT the same as OA diagnosis Can lead to confusion public health surveillance Reporting can be done at various levels National Finland, comprehensive health care SORDSA, South Africa SWORD, United Kingdom Regional SHIELD, Midlands UK SENSOR, State based USA SABRE, Australia Province Company or Clinic BASF, AOEC PROGRAM COUNTRY REPORTERS MOST COMMON OCCUPATIONS INCIDENCE NAME AGENT/S (1-3) AT HIGHEST RISK PER MILLION WORKERS SWORD United Occupational Isocyanates 1) Laboratory technicians; N/A Kingdom and Respiratory 2) Shoe workers; Physicians 3) Healthcare workers N/A SORDSA South Africa Pulmonologists, 1) Latex; 13.1 occupational 2) Isocyanates; medicine 3) Platinum salts doctors and occupational health nurses SHIELD Midlands of Physicians Isocyanates 1) Spray painters; England 2) Electroplaters; 3) Rubber and plastic workers; 4) Bakery workers; 5) Moulders FROD Finland Physicians 1) Animal epithelia, 1) Bakers; 174 hairs or secretions; 2) Painters and lacquerers 2) Flours, grains (including spray painters) and fodders N/A British Respiratory, Isocyanates, N/A 181 Columbia Occupational Western Red Cedar and generalist Physicians United States Sentinel Surveillance (formerly SENSOR) Physician reporting and other sources state-based Most common agents: diisocyanates for New Onset, dusts for Work Aggravated Asthma Misc. chemicals (cleaners, smoke) Indoor air:? mix of chemicals (e.g. cleaners), mites, and molds Workplaces - schools, hospitals, offices Table adapted from: OCCUPATIONAL ASTHMA DETECTION, SURVEILLANCE AND PREVENTION OF THE DISEASE BURDEN. FINAL REPORT, Sim, et al. Monash University, Management and Prevention public health surveillance medical screening/surveillance But Does medical screening work?? 4

5 Management and Prevention Management and Prevention But which parameters should be monitored? Which symptoms indicate exposure to sensitizers? medical screening/surveillance Nicholson et al. Evidenced based guidelines for OA. OEM 2005 medical screening/surveillance Data Skin prick and IgE testing are useful in detecting sensitization to many Symptoms HMW and some LMW occupational asthma agents. Immunologic sensitization Changes in airflow and/or NSBR Airflow changes detect some OA Workplace exposures not found by symptoms, especially with reticence to report symptoms. Valid measurements assist the interpretation of health findings. medical screening/surveillance Data Induced sputum? Exhaled NO? The role of these markers of inflammation in monitoring workers for OA remains to be clarified. Lemiere, Curr Opin Allergy Clin Immunol

6 medical screening/surveillance Data A comprehensive baseline evaluation is useful if symptoms develop later Symptoms Immunologic sensitization Changes in airflow and/or NSBR Workplace exposures medical screening/surveillance To maximize effectiveness, programs should be comprehensive Targeting Workers Process and Task Environmental Exposures Individual (age, concurrent morbidity) Screening Processes Methods/Procedures/Quality Participation /Confidentiality Interpretation and Reporting Medical Screening: Program Design Management of Individual Workers Referral Options Evaluation Protocols Hazard Control and Medical Follow Up Health Surveillance Sentinel Case Identification Data Management/Analysis Reporting Managers Worker Representatives Occupational Health Professionals Hygienists, Engineers Management of the Work Environment Control Technology Assessment Preventive Interventions Education/Information Dissemination Work-related asthma Session 2105 Definitions, public health surveillance, and workplace medical monitoring Thank You! Edward Lee Petsonk, M.D. Professor of Medicine Section of Pulmonary and Critical Care Medicine West Virginia Questions?? University School of Medicine American Occupational Health Conference May 2,