Physician reports of work-related asthma in California, 1993-1996

Occupational COVID-19 Exposures and Illnesses among Workers in California-Analysis of a New Occupational COVID-19 Surveillance System

Little is known about occupational SARS-CoV-2 exposures and COVID-19 outcomes. We established a Doctor's First Reports of Occupational Injury or Illness (DFR)-based surveillance system to study cases of work-related COVID-19 exposures and disease. The surveillance data included demographics, occupation, industry, exposure, and illness, details including hospitalization and lost work. We classified workers into 'healthcare', non-healthcare 'public-facing', or 'other' worker groups, and rural-urban commuting areas (RUCAs). We describe worker exposures and outcomes overall by worker group and RUCA. We analyzed 2848 COVID-19 DFRs representing workers in 22 detailed occupation groups and 19 industry groups. Most DFRs were for workers in metropolitan RUCAs (89%) and those in healthcare (42%) and public-facing (24%) worker groups. While DFRs were from 382 unique worksites, 52% were from four hospitals and one prison. Among 1063 DFRs with a suspected exposure, 73% suspected exposure to a patient or client. Few DFRs indicated hospitalization (3.9%); however, the proportion hospitalized was higher among nonmetropolitan (7.4%) and public-facing (6.7%) workers. While 56% of DFRs indicated some lost work time, the proportion was highest among public-facing (80%) workers. Healthcare and prison workers were the majority of reported occupational COVID-19 exposures and illnesses. The risk of COVID-19 hospitalization and lost work may be highest among nonmetropolitan and public-facing workers.

Challenges in the classification of chemical respiratory allergens based on human data: Case studies of 2-hydroxyethylmethacrylate (HEMA) and 2-hydroxypropylmethacrylate (HPMA)

Occupational asthma resulting from workplace exposure to chemical respiratory allergens is an important disease. No widely accepted or formally validated tests for the identification of chemical respiratory sensitizers. Consequently, there is a heavy reliance on human data from clinical examinations. Unfortunately, however, although such investigations are critical for the diagnosis of occupational asthma, and in guiding remedial actions, they do not reliably identify specific chemicals within the workplace that are the causative agents. There are several reasons for this, including the fact that specific inhalation tests conducted as part of clinical investigations are frequently performed with complex mixtures rather than single substances, that sometimes inhalation challenges are conducted at concentrations above the OEL and STEL, where effects may be confounded by irritation, and that involvement of immune mechanisms cannot be assumed from the observation of late asthmatic reactions. Further, caution should be taken when implicating substances on lists of "recognised" asthmagens unless they have undergone a formal weight of evidence assessment. Here the limitations of clinical investigations as currently performed for the purposes of regulatory classification and decision making are explored by reference to previously published case studies that implicate 2-hydroxyethylmethacrylate (HEMA) and/or 2-hydroxypropylmethacrylate (HPMA) as respiratory allergens.

Classification of chemicals as respiratory allergens based on human data: Requirements and practical considerations

Occupational asthma is an important health problem that can include exacerbation of existing asthma, or induce new asthma either through allergic sensitisation, or non-immunological mechanisms. While allergic sensitisation of the respiratory tract can be acquired to proteins, or to low molecular weight chemicals (chemical respiratory allergens) this article is on the latter exclusively. Chemical respiratory allergy resulting in occupational asthma is associated with high levels of morbidity and there is a need, therefore, that chemicals which can cause sensitisation of the respiratory tract are identified accurately. However, there are available no validated, or even widely accepted, predictive test methods (in vivo, in vitro or in silico) that have achieved regulatory acceptance for identifying respiratory sensitising hazards. For this reason there is an important reliance on human data for the identification of chemical respiratory allergens, and for distinguishing these from chemicals that cause occupational asthma through non-immunological mechanisms. In this article the reasons why it is important that care is taken in designating chemicals as respiratory allergens are reviewed. The value and limitations of human data that can aid the accurate identification of chemical respiratory allergens are explored, including exposure conditions, response characteristics in specific inhalation challenge tests, and immunological investigations.

How to assess respiratory sensitization of low molecular weight chemicals?

There are no validated and regulatory accepted (animal) models to test for respiratory sensitization of low molecular weight (LMW) chemicals. Since several decades such chemicals are classified as respiratory sensitizers almost exclusively based on observations in workers. However, both respiratory allergens (in which process the immune system is involved) as well as asthmagens (no involvement of the immune system) may induce the same type of respiratory symptoms. Correct classification is very important from a health's perspective point of view. On the other hand, over-classification is not preferable in view of high costs to overdue workplace engineering controls or the chemical ultimately being banned due to Authorities' decisions. It would therefore be very beneficial if respiratory sensitizers can be correctly identified and distinguished from skin sensitizers and non-sensitizers/respiratory irritants. The purpose of this paper is to consider whether LMW chemicals can be correctly identified based on the currently available screening methods in workers, and/or via in silico, in vitro and/or in vivo testing. Collectively, based on the available information further effort is still needed to be able to correctly identify respiratory sensitizers and to distinguish these from skin sensitizers and irritants, not at least because of the far-reaching consequences once a chemical is classified as a respiratory sensitizer.

Do we know how best to disinfect child care sites in the United States? A review of available disinfectant efficacy data and health risks of the major disinfectant classes

BACKGROUND

Children in child care settings have a high infectious burden. They are frequently exposed to sanitizing and disinfecting agents, whose toxicities have not been studied in these settings. Current guidance on the preferred disinfection agents for child care is vague.

METHODS

This article combines 2 different sources of information: the Environmental Protection Agency registration data on the efficacy of hospital-grade disinfectants and a review of the research on the toxicities of the most common of these disinfectants to summarize information that could be used for more evidence-based early care and education disinfection regulations and guidelines.

RESULTS

Coverage of these organisms varied both between disinfectant classes (defined by active ingredient), as well as within classes. The 3 most common active ingredients in the database-quaternary ammonias, bleaches, and hydrogen peroxides-had 251, 63, and 31 products, respectively. Quaternary ammonias and bleaches are both known asthmagens, with the potential for toxic gas release when mixed. Quaternary ammonias may also cause reproductive toxicity. Disinfectant-grade peroxides have relatively low inhalational toxicity.

CONCLUSIONS

A clear rationale is needed to establish policies for determining preferable disinfection products for use in child care settings, based on efficacy against relevant pathogens, toxicity, ease of use, and cost. When other factors are equal, the use of peroxide-based disinfectant products is recommended to minimize inhalational toxicity.

Processes of Care for Individuals with Work Related Asthma: Treatment Characteristics and Impact of Asthma on Work

The prevalence of asthma among working adults continues to rise each year. The California Department of Health Services conducts surveillance of work related asthma (WRA) to classify each work related exposure using Doctor's First Reports of Occupational Illness and Injury (DFRs). Using a cross-sectional, descriptive, comparative design, additional interviews were conducted and medical records were reviewed to explore workers' and providers' perceptions of follow up care. Two cohorts were compared: workers with WRA who belonged to a large, single HMO (n = 79) and workers with WRA who underwent follow up outside this HMO (n = 76). The interview asked about providers seen, tests ordered, and the impact of asthma on work. The HMO clients were significantly more likely than the non-HMO clients to see occupational medicine specialists (p = .004) and have pulmonary function testing (p = .049) during initial treatment. Twenty-four percent of clients currently working reported missed workdays caused by asthma in the past 6 months. The findings indicate management of WRA varies by health care system in California.

Azodicarbonamide (ADCA): A reconsideration of classification as a respiratory sensitiser

Azodicarbonamide (ADCA) is widely used by industry in the manufacture of a variety of products. ADCA has been classified as a respiratory allergen, and the purpose of this article was to consider whether this classification is appropriate based upon the available data. Here both clinical experience and relevant experimental data have been reviewed. Although there have been reports of an association between workplace exposure to ADCA and symptoms of respiratory allergy and occupational asthma, the evidence is less than persuasive, with in many instances a lack of properly controlled and executed diagnostic procedures. In addition, ADCA fails to elicit positive responses in mouse and guinea pig predictive tests for skin sensitisation; a lack of activity that is regarded as being inconsistent with respect to respiratory sensitising potential. Collectively, the data reviewed here do not provide an adequate basis for the classification of ADCA as a respiratory allergen.

Fragrances and work-related asthma-California surveillance data, 1993-2012

OBJECTIVE

Fragrance chemicals are used in a large array of products. Workers may be exposed to these chemicals in the workplace directly when used as air fresheners, or indirectly in personal care products used by coworkers or others. This study characterizes work-related asthma (WRA) cases associated with fragrance exposures in California workplaces from 1993 through 2012.

METHODS

We used the California Work-Related Asthma Prevention Program's surveillance database to identify individuals with physician-diagnosed WRA associated with the use of air fresheners and scented personal care products (perfumes, colognes, etc.). Cases were classified using previously published, standardized surveillance methods.

RESULTS

Perfume was the ninth most common exposure identified from 1993 through 2012. A total of 270 WRA cases associated with fragrance exposure were reported during this period, representing 3.8% of all confirmed cases. These 270 cases included 242 associated with perfume or cologne, 32 associated with air freshener, and 4 associated with both. Similar to non-fragrance cases, nearly a quarter of fragrance-associated cases were classified as new-onset asthma. Fragrance-associated cases were significantly more likely to be in office, health, and education jobs than non-fragrance-associated cases. When compared to non-fragrance cases, fragrance cases were significantly more likely to be female (94% vs 62%) and be classified as having work-aggravated asthma (38% vs 20%), yet had similar outcomes compared with cases associated with other exposures.

CONCLUSIONS

Our surveillance data show that fragrance use in the workplace is associated with WRA. Prevention methods include employee education, enforced fragrance-free policies, well-designed ventilation systems, and good building maintenance.

Interventions to increase the reporting of occupational diseases by physicians

BACKGROUND

Under-reporting of occupational diseases is an important issue worldwide. The collection of reliable data is essential for public health officials to plan intervention programmes to prevent occupational diseases. Little is known about the effects of interventions for increasing the reporting of occupational diseases.

OBJECTIVES

To evaluate the effects of interventions aimed at increasing the reporting of occupational diseases by physicians.

SEARCH METHODS

We searched the Cochrane Occupational Safety and Health Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (PubMed), EMBASE, OSH UPDATE, Database of Abstracts of Reviews of Effects (DARE), OpenSIGLE, and Health Evidence until January 2015.We also checked reference lists of relevant articles and contacted study authors to identify additional published, unpublished, and ongoing studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster-RCTs (cRCTs), controlled before-after (CBA) studies, and interrupted time series (ITS) of the effects of increasing the reporting of occupational diseases by physicians. The primary outcome was the reporting of occupational diseases measured as the number of physicians reporting or as the rate of reporting occupational diseases.

DATA COLLECTION AND ANALYSIS

Pairs of authors independently assessed study eligibility and risk of bias and extracted data. We expressed intervention effects as risk ratios or rate ratios. We combined the results of similar studies in a meta-analysis. We assessed the overall quality of evidence for each combination of intervention and outcome using the GRADE approach.

MAIN RESULTS

We included seven RCTs and five CBA studies. Six studies evaluated the effectiveness of educational materials alone, one study evaluated educational meetings, four studies evaluated a combination of the two, and one study evaluated a multifaceted educational campaign for increasing the reporting of occupational diseases by physicians. We judged all the included studies to have a high risk of bias.We did not find any studies evaluating the effectiveness of Internet-based interventions or interventions on procedures or techniques of reporting, or the use of financial incentives. Moreover, we did not find any studies evaluating large-scale interventions like the introduction of new laws, existing or new specific disease registries, newly established occupational health services, or surveillance systems. Educational materialsWe found moderate-quality evidence that the use of educational materials did not considerably increase the number of physicians reporting occupational diseases compared to no intervention (risk ratio of 1.11, 95% confidence interval (CI) 0.74 to 1.67). We also found moderate-quality evidence showing that sending a reminder message of a legal obligation to report increased the number of physicians reporting occupational diseases (risk ratio of 1.32, 95% CI 1.05 to 1.66) when compared to a reminder message about the benefits of reporting.We found low-quality evidence that the use of educational materials did not considerably increase the rate of reporting when compared to no intervention. Educational materials plus meetingsWe found moderate-quality evidence that the use of educational materials combined with meetings did not considerably increase the number of physicians reporting when compared to no intervention (risk ratio of 1.22, 95% CI 0.83 to 1.81).We found low-quality evidence that educational materials plus meetings did not considerably increase the rate of reporting when compared to no intervention (rate ratio of 0.77, 95% CI 0.42 to 1.41). Educational meetingsWe found very low-quality evidence showing that educational meetings increased the number of physicians reporting occupational diseases (risk ratio at baseline: 0.82, 95% CI 0.47 to 1.41 and at follow-up: 1.74, 95% CI 1.11 to 2.74) when compared to no intervention.We found very low-quality evidence that educational meetings did not considerably increase the rate of reporting occupational diseases when compared to no intervention (rate ratio at baseline: 1.57, 95% CI 1.22 to 2.02 and at follow-up: 1.92, 95% CI 1.48 to 2.47). Educational campaignWe found very low-quality evidence showing that the use of an educational campaign increased the number of physicians reporting occupational diseases when compared to no intervention (risk ratio at baseline: 0.53, 95% CI 0.19 to 1.50 and at follow-up: 11.59, 95% CI 5.97 to 22.49).

AUTHORS' CONCLUSIONS

We found 12 studies to include in this review. They provide evidence ranging from very low to moderate quality showing that educational materials, educational meetings, or a combination of the two do not considerably increase the reporting of occupational diseases. The use of a reminder message on the legal obligation to report might provide some positive results. We need high-quality RCTs to corroborate these findings.Future studies should investigate the effects of large-scale interventions like legislation, existing or new disease-specific registries, newly established occupational health services, or surveillance systems. When randomisation or the identification of a control group is impractical, these large-scale interventions should be evaluated using an interrupted time-series design.We also need studies assessing online reporting and interventions aimed at simplifying procedures or techniques of reporting and the use of financial incentives.

Acute symptoms associated with chemical exposures and safe work practices among hospital and campus cleaning workers: a pilot study

BACKGROUND

Cleaning workers are regularly exposed to cleaning products containing hazardous chemicals. This study investigated acute symptoms associated with chemical exposures among cleaning workers and their safe work practices.

METHODS

This cross-sectional study included 183 cleaning workers employed in an academic medical center and affiliated health sciences campuses in Northern California. Data on respiratory, eye, skin, neurological, and gastrointestinal symptoms and occupational factors were collected by in-person interviews or self-administered questionnaires.

RESULTS

Chemical-related symptoms (several times monthly or more often) were more common among workers who performed patient area cleaning (44%) than hospital custodians (36%) or campus custodians (28%). After controlling for age, sex, and job title, symptoms were associated with exposure to carpet cleaners (OR = 2.98, 95% CI 1.28-6.92), spray products (OR = 2.82, 95% CI 1.16-6.82), solvents (OR = 2.71, 95% CI 1.20-6.15), and multi-purpose cleaners (OR = 2.58, 935% CI 1.13-6.92). Except for gloves, regular use of personal protective equipment was infrequent.

CONCLUSIONS

Study findings suggest a need for additional interventions such as use of less toxic products to reduce health risks among cleaning workers.

When to suspect occupational asthma

Occupational asthma (OA) is a difficult diagnosis to make. The present review describes the work environments in which workers are at risk for developing OA, the characteristics of the individuals in whom OA should be suspected and the investigation that can be performed to diagnose the condition. Accurately diagnosing OA is crucial because of the major social and economic consequences of this diagnosis on the patient.

Airborne exposures to monoethanolamine, glycol ethers, and benzyl alcohol during professional cleaning: a pilot study

A growing body of epidemiologic evidence suggests an association between exposure to cleaning products and respiratory dysfunction. Due to the lack of quantitative assessments of respiratory exposures to airborne irritants and sensitizers among professional cleaners, the culpable substances have yet to be identified.

PURPOSE

Focusing on previously identified irritants, our aims were to determine (i) airborne concentrations of monoethanolamine (MEA), glycol ethers, and benzyl alcohol (BA) during different cleaning tasks performed by professional cleaning workers and assess their determinants; and (ii) air concentrations of formaldehyde, a known indoor air contaminant.

METHODS

Personal air samples were collected in 12 cleaning companies, and analyzed by conventional methods.

RESULTS

Nearly all air concentrations [MEA (n = 68), glycol ethers (n = 79), BA (n = 15), and formaldehyde (n = 45)] were far below (<1/10) of the corresponding Swiss occupational exposure limits (OEL), except for ethylene glycol mono-n-butyl ether (EGBE). For butoxypropanol and BA, no OELs exist. Although only detected once, EGBE air concentrations (n = 4) were high (49.48-58.72mg m(-3)), and close to the Swiss OEL (49mg m(-3)). When substances were not noted as present in safety data sheets of cleaning products used but were measured, air concentrations showed no presence of MEA, while the glycol ethers were often present, and formaldehyde was universally detected. Exposure to MEA was affected by its amount used (P = 0.036), and spraying (P = 0.000) and exposure to butoxypropanol was affected by spraying (P = 0.007) and cross-ventilation (P = 0.000).

CONCLUSIONS

Professional cleaners were found to be exposed to multiple airborne irritants at low concentrations, thus these substances should be considered in investigations of respiratory dysfunctions in the cleaning industry; especially in specialized cleaning tasks such as intensive floor cleaning.

Asthma and exposure to cleaning products - a European Academy of Allergy and Clinical Immunology task force consensus statement

Professional and domestic cleaning is associated with work-related asthma (WRA). This position paper reviews the literature linking exposure to cleaning products and the risk of asthma and focuses on prevention. Increased risk of asthma has been shown in many epidemiological and surveillance studies, and several case reports describe the relationship between exposure to one or more cleaning agents and WRA. Cleaning sprays, bleach, ammonia, disinfectants, mixing products, and specific job tasks have been identified as specific causes and/or triggers of asthma. Because research conclusions and policy suggestions have remained unheeded by manufactures, vendors, and commercial cleaning companies, it is time for a multifaceted intervention. Possible preventive measures encompass the following: substitution of cleaning sprays, bleach, and ammonia; minimizing the use of disinfectants; avoidance of mixing products; use of respiratory protective devices; and worker education. Moreover, we suggest the education of unions, consumer, and public interest groups to encourage safer products. In addition, information activities for the general population with the purpose of improving the knowledge of professional and domestic cleaners regarding risks and available preventive measures and to promote strict collaboration between scientific communities and safety and health agencies are urgently needed.

Irritant-induced airway disorders

Thousands of persons experience accidental high-level irritant exposures each year but most recover and few die. Irritants function differently than allergens because their actions proceed nonspecifically and by nonimmunologic mechanisms. For some individuals, the consequence of a single massive exposure to an irritant, gas, vapor or fume is persistent airway hyperresponsiveness and the clinical picture of asthma, referred to as reactive airways dysfunction syndrome (RADS). Repeated irritant exposures may lead to chronic cough and continual airway hyperresponsiveness. Cases of asthma attributed to repeated irritant-exposures may be the result of genetic and/or host factors.

Work-related asthma in Washington State

OBJECTIVE

Asthma is a common and costly public health problem. Occupational exposures contribute to the burden of asthma. Identifying workplace exposures and industries and occupations at risk can lead to more effective prevention measures.

METHODS

Data from Washington State's work-related asthma (WRA) surveillance program from October 2001 to December 2008 were analyzed. Workers' compensation records, physician reports, and telephone interviews were used to describe the occurrence of WRA during this time, in order to identify contributing exposure sources and industries and occupations that are associated with WRA in Washington.

RESULTS

There were 1343 identified WRA cases in Washington State during this time. Of these, 1285 were workers' compensation claims, with a total medical cost for State Fund claims of approximately $3 million dollars. The top three sources identified were miscellaneous chemicals and materials, mineral and inorganic dusts, and plant material. Plant material claims proved to be widespread throughout various industries, were largely classified as new-onset asthma cases, and had higher median medical cost and higher median time loss days than cases associated with other exposure sources.

CONCLUSIONS

Washington State has an abundance of plant-material-related WRA cases among US states conducting WRA surveillance. Washington State's industry mix might explain the higher prevalence of cases, particularly its logging and wood processing industries and as a world leader in hops production. In Washington, further WRA prevention efforts should emphasize workplaces working with plant materials.

Non-sensitising air pollution at workplaces and adult-onset asthma in the beginning of this millennium

PURPOSE

This case-control study was undertaken to elucidate the controversy concerning whether low-level, long-term exposure to non-sensitising air pollution at workplaces may cause asthma.

METHODS

A case-control study of 192 adult-onset asthma cases aged 20-65 years and 323 controls was conducted in the southeast of Sweden. Cases were identified from computerised registers from the region, diagnosed 2000-2004 and diagnoses were confirmed via medical files. Referents were randomised from the population register of the region. Exposure was monitored by a 16-page questionnaire. Special attention was devoted to identifying and in the final analyses excluding subjects exposed to sensitising agents.

RESULTS

Three years or more of occupational exposure to air pollution from dust, smoke, fumes or vapours before the year of diagnosis by analyses adjusting for age yielded an increased risk for asthma (OR = 2.3, 95% CI 1.2-4.2) in men, while in women, no risk was seen. In a multiple logistic regression analysis in men without allergy in childhood, a significant risk was seen (OR = 2.8, 95% CI 1.07-7.4), when subjects exposed to identified allergens were excluded. In women, no excess risk was observed from occupational air pollution.

CONCLUSION

The results of this study support an association between occupational exposure to low level non-sensitising air pollution and adult-onset asthma in men.

Occupational asthma in professional cleaning work: a clinical study

BACKGROUND

Several epidemiological studies have reported an increased risk of asthma among professional cleaners. To date, however, no analysis of large patient series from clinic of occupational medicine has been published.

AIMS

To describe the cases of occupational asthma (OA) diagnosed at the Finnish Institute of Occupational Health (FIOH) during the period 1994-2004 in workers employed in professional cleaning work.

METHODS

OA was diagnosed according to patient history, lung function examinations and specific challenge tests with measurements of the forced expiratory volume in 1 second and peak expiratory flow values.

RESULTS

Our series comprised 20 patients, all female, with a mean age of 48.8 years (range 27-60 years). The mean duration of cleaning work before the onset of the respiratory symptoms was 14.3 years (range 1-36 years), and the mean duration of cleaning work before the FIOH examinations was 18.6 years (range 3-38 years). OA was triggered by chemicals in 9 cases (45%) and by moulds in 11 cases (55%). The chemicals were cleaning chemicals (wax-removing substances containing ethanolamines in five cases and a cleaning agent containing chloramine-T in one case) and chemicals used in the industrial processes at workplaces (three cases). Of the moulds, the most frequently associated with OA was Aspergillus fumigatus (nine cases).

CONCLUSIONS

OA was attributed not only to cleaning chemicals but also to other chemicals used in work environments. Moulds are presented as a new cause of OA in cleaners.

Relationships between asthma and work exposures among non-domestic cleaners in Ontario

BACKGROUND

Cleaners have been reported to have increased risk for work-related asthma symptoms but few studies have studied non-domestic cleaners. In this study, we compared work-related asthma symptoms among cleaners and other building workers and determined associations with tasks.

METHODS

School and racetrack workers in Ontario, Canada, completed a questionnaire to identify the prevalence of cleaning tasks, physician-diagnosed asthma, new-onset asthma, respiratory symptoms, and work-related asthma symptoms.

RESULTS

Cleaners and controls had a similar prevalence of most asthma outcomes although female cleaners reported significantly more respiratory symptoms; odds ratio (OR), 2.59 confidence intervals (CI) 1.6-4.3, and work-related asthma symptoms, OR 3.90 (CI 2.1-7.4) compared with female controls with adjustment for age and smoking history. Male cleaners showed a non-significant trend to more physician-diagnosed asthma, adjusted OR 2.10 (CI 0.9-4.8) and work-related asthma symptoms, adjusted OR 1.53 (CI 0.8-3.0). The work-related asthma symptoms among men were significantly associated with waxing floors, OR 2.19 (CI 1.0-4.4); wax-stripping floors, OR 2.54 (1.2-5.2); spot-cleaning carpets, OR 2.20 (1.3-3.8); and cleaning tiles, OR 4.46 (1.0-19.3) and grout, OR 2.12 (1.1-4.0).

CONCLUSIONS

Female cleaners have more asthma symptoms worse at work than controls. Work-related asthma symptoms among male cleaners were associated with a number of specific cleaning tasks. Findings suggest the need for school cleaners to have reduced exposure to cleaning chemicals and need for protective strategies during performance of tasks expected to exacerbate asthma, such as wax stripping.

Reducing hazardous cleaning product use: a collaborative effort

Workplace hazards affecting vulnerable populations of low-wage and immigrant workers present a special challenge to the practice of occupational health. Unions, Coalition for Occupational Safety and Health (COSH) groups, and other organizations have developed worker-led approaches to promoting safety. Public health practitioners can provide support for these efforts. This article describes a successful multiyear project led by immigrant cleaning workers with their union, the Service Employees International Union (SEIU) Local 615, and with support from the Massachusetts COSH (MassCOSH) to address exposure to hazardous chemicals. After the union had identified key issues and built a strategy, the union and MassCOSH invited staff from the Massachusetts Department of Public Health's Occupational Health Surveillance Program (OHSP) to provide technical information about health effects and preventive measures. Results included eliminating the most hazardous chemicals, reducing the number of products used, banning mixing products, and improving safety training. OHSP's history of public health practice regarding cleaning products enabled staff to respond promptly. MassCOSH's staff expertise and commitment to immigrant workers allowed it to play a vital role.

Quality of life of adults with workplace exacerbation of asthma

OBJECTIVE

A cross-sectional study collecting demographic, work history, disease, and quality-of-life (QOL) data from adults with asthma was explored for a relationship between workplace exacerbation of asthma (WEA) and QOL.

STUDY DESIGN AND SETTING

The study population of adults with asthma was drawn from adults affiliated with Fallon Community Health Plan, a health maintenance organization serving Massachusetts.

RESULTS

The sample consisted of 598 adults with asthma. Based on univariate analyses, study participants with WEA had a statistically significant higher Total QOL score, indicating a worse quality of life, than participants whose asthma was not work-related (2.43 vs. 1.74, P < or = 0.001), and also higher scores on the instrument's four subscales for Breathlessness, Mood Disturbance, Social Disruptions, and Health Concerns. After controlling for covariates using multiple linear regression, the relationship between WEA and the Total QOL score was statistically significant (P = 0.0004) with a coefficient of 0.54. The coefficient for WEA was also statistically significant based on regression models for all the subscales with the exception of the Breathlessness score (P = 0.08).

CONCLUSION

In summary, WEA was associated with a worse QOL. Ideally, employees and employers would work together to minimize the conditions at work that contribute to WEA, which should decrease the frequency of WEA and related degradation of QOL.

[Epidemiology and etiologic agents of occupational asthma]

INTRODUCTION

Occupational asthma is, by definition, a disease that can be prevented through appropriate protective strategies. Epidemiological information is required to guide these interventions, and we here examine epidemiological data on the burden, causes, and risk factors for this condition.

STATE OF THE ART

Population-based surveys indicate that approximately 15% of adult asthma is attributable to the workplace environment. The most common occupational agents implicated include flour, isocyanates, latex, and persulphate salts. The occupations in which occupational asthma has been most commonly reported are bakers, spray painters, health-care workers, hairdressers, and cleaners. The level of exposure to sensitizing agents seems to be the most relevant risk factor. Atopy is a significant risk factor only for the development of sensitization to high molecular weight agents. The role of other individual determinants, such as genetic factors, has been less consistently established. Occupational asthma is associated with a substantial adverse impact on the employment and financial status of affected workers.

PERSPECTIVES

Methodological improvements are required in order to distinguish more accurately between occupational and work-exacerbated asthma. Further investigations of the effectiveness of primary and secondary preventive interventions are also needed.

Rhinitis and asthma symptoms in non-domestic cleaners from the Sao Paulo metropolitan area, Brazil

BACKGROUND

Exposure to cleaning products has frequently been reported as a symptom trigger by workers with work-related asthma diagnosed in workers' health clinics in the city of São Paulo, Brazil.

OBJECTIVES

To estimate rhinitis and asthma symptoms prevalence and to analyse associated risk factors.

METHOD

A respiratory symptoms questionnaire (Medical Research Council 1976) and the International Study of Asthma and Allergies in Childhood questionnaire were applied to 341 cleaners working in the city of São Paulo, along with obtaining full occupational histories, skin prick tests and spirometry. Timing their symptoms onset in relation to occupational history allowed estimation of work-related asthma and/or rhinitis. Risk factors related to selected outcomes were analysed by logistic regression.

RESULTS

11% and 35% of the cleaners had asthma and rhinitis, respectively. The risk of work-related asthma/rhinitis increased with years of employment in non-domestic cleaning (OR 1.09, 95% CI 1.00 to 1.18, >0.92-3 years; OR 1.28, 95% CI 1.01 to 1.63, >3-6.5 years; OR 1.71, 95% CI 1.02 to 2.89, >6.5 years). Atopy was associated with asthma and rhinitis (OR 2.91, 95% CI 1.36 to 6.71; OR 2.06, 95% CI 1.28 to 3.35, respectively). There was a higher risk of rhinitis in women (OR 2.07, 95% CI 1.20 to 3.70).

CONCLUSIONS

Cleaning workers are at risk of contracting work-related asthma and/or rhinitis, and the risk increases with years of employment in non-domestic cleaning. Women present higher risk of rhinitis than men.

Occupational risk factors and asthma among health care professionals

RATIONALE

Recent U.S. data suggest an increased risk of work-related asthma among health care workers, yet only a few specific determinants have been elucidated.

OBJECTIVES

To evaluate associations of asthma prevalence with occupational exposures in a cross-sectional survey of health care professionals.

METHODS

A detailed questionnaire was mailed to a random sample (n=5,600) of all Texas physicians, nurses, respiratory therapists, and occupational therapists with active licenses in 2003. Information on asthma symptoms and nonoccupational asthma risk factors obtained from the questionnaire was linked to occupational exposures derived through an industry-specific job-exposure matrix.

MEASUREMENTS

There were two a priori defined outcomes: (1) physician-diagnosed asthma with onset after entry into health care ("reported asthma") and (2) "bronchial hyperresponsiveness-related symptoms," defined through an 8-item symptom-based predictor.

MAIN RESULTS

Overall response rate was 66%. The final study population consisted of 862 physicians, 941 nurses, 968 occupational therapists, and 879 respiratory therapists (n=3,650). Reported asthma was associated with medical instrument cleaning (odds ratio [OR], 2.22; 95% confidence interval [CI], 1.34-3.67), general cleaning (OR, 2.02; 95% CI, 1.20-3.40), use of powdered latex gloves between 1992 and 2000 (OR, 2.17; 95% CI, 1.27-3.73), and administration of aerosolized medications (OR, 1.72; 95% CI, 1.05-2.83). The risk associated with latex glove use was not apparent after 2000. Bronchial hyperresponsiveness-related symptoms were associated with general cleaning (OR, 1.63; 95% CI, 1.21-2.19), aerosolized medication administration (OR, 1.40; 95% CI, 1.06-1.84), use of adhesives on patients (OR, 1.65; 95% CI, 1.22-2.24), and exposure to a chemical spill (OR, 2.02; 95% CI, 1.28-3.21).

CONCLUSIONS

The contribution of occupational exposures to asthma in health care professionals is not trivial, meriting both implementation of appropriate controls and further study.

Professional cleaning and asthma

PURPOSE OF REVIEW

The purpose of this review is to summarize the recent evidence on the effect of cleaning jobs on asthma, based on case reports and series of occupational asthma among cleaners, and epidemiological studies on the relationship between different characteristics of cleaning and asthma risk, as well as to elaborate the evidence on potential occupational exposures responsible for the increased asthma risk observed in cleaners.

RECENT FINDINGS

Six recent epidemiologic studies strengthen the evidence that domestic and industrial cleaners are at higher risk of asthma compared with professional employees in Europe and the United States. These studies take into account individual confounders, such as age and cigarette smoking. This finding is supported by case reports and registry-based studies of occupational asthma. The studies and reports have identified some chemicals, such as bleach, as specific causes of asthma. Increased risk of asthma has also been related to some specific job tasks, such as cleaning windows and washing dishes.

SUMMARY

Recent studies strengthen the evidence of an increased asthma risk among cleaners or individuals in other jobs in which they are involved in cleaning. Further research should be directed to elaborate how much of asthma is related to specific sensitization to certain chemicals and how much to airway inflammation induced by exposure to a mixture of irritants.

Promoting personal safety of building service workers: issues and challenges

This exploratory, descriptive study conducted at a large western Canadian university solicited perceptions of personal safety among building service workers who perform night shift work alone. Ten semi-structured interviews were conducted at approximately 10:00 p.m. or 7:00 a.m with a convenience sample of night building service workers in private or semi-private locations on the university campus. Transcribed interview data were subjected to inductive content analysis using descriptive, interpretive, and pattern coding (Miles & Huberman, 1994). Results suggest that building service night shift workers are exposed to personal safety hazards in their physical and psychosocial work environments. In addition, culturally and linguistically appropriate delivery of safety training and education about policies and procedures is required for culturally diverse building service workers. Promotion of personal safety in this heterogeneous worker population requires due diligence, assessment, and advocacy.

The proportion of self-reported asthma associated with work in three States: California, Massachusetts, and Michigan, 2001

OBJECTIVES

To assess the proportion of adult asthma at the state level that may be related to work.

DESIGN

Work-related asthma questions were added to the 2001 Behavioral Risk Factor Surveillance System (BRFSS) questionnaire in California, Massachusetts, and Michigan.

RESULTS

Findings indicate 7.4-9.7% of those with current asthma reported that their asthma may be work related. These results estimate that approximately 137,000 adults in California, 39,000 in Massachusetts, and 63,000 in Michigan have asthma that may be work related.

CONCLUSIONS

These findings are unique in providing population-based estimates at the state level that illustrate that a substantial portion of adult asthma morbidity is due to exposures in the work environment.

[The epidemiology of occupational asthma in Belgium]

INTRODUCTION

A national surveillance programme of occupational asthma was set up to estimate the incidence and identify the causes of this disorder in Belgium.

MATERIALS AND METHODS

The programme was based on the voluntary notification of new cases of occupational asthma by chest specialists and occupational physicians during the period 2000-2002.

RESULTS

92% of the reported cases included occupational asthma of an immunological type and 8% bronchial irritability. According to the opinion of the reporting physicians the diagnosis was considered certain in 39%, probable in 29% and possible in 32% of cases. On the basis of these notifications the mean annual incidence of occupational asthma is estimated as 23.5 cases per million workers (95% confidence interval 19.2-28.8). The most frequently incriminated substances were isocyanates (16%), cereals (12%) and latex (10%). At the time of diagnosis 38% of patients had not applied for compensation.

CONCLUSION

The results of this programme of notification of occupational asthma agree with the data available from other countries and provide information complementary to the medico-legal statistics.

Work-related asthma in the spray-on truck bed lining industry

OBJECTIVE

The objective of this study was to identify work-related asthma (WRA) workers' compensation claims associated with methylene diphenyl diisocyanate (MDI) exposure in the spray-on truck bed lining industry and estimate the asthma incidence rate in this industry.

METHODS

The authors conducted a descriptive study of workers' compensation claims meeting an established surveillance case definition for WRA.

RESULTS

Eight WRA workers' compensation claims were identified in the truck bed lining industry in Washington State for a claims incidence rate of 200 per 10,000 full-time equivalent. The medical evaluation of the cases was inadequate because none of the truck bed lining cases had medical testing to objectively link their asthma to the workplace.

CONCLUSIONS

The rate of work-related asthma in the truck bed lining industry is excessive and suggests a need for significant intervention, including improvements in the clinical assessment provided to MDI-exposed workers.

Occupational obstructive airway diseases in Germany: Frequency and causes in an international comparison

BACKGROUND

Occupational inhalative exposures contribute to a significant proportion of obstructive airway diseases (OAD), namely chronic obstructive pulmonary disease (COPD) and asthma.

METHODS

The number of occupational OAD in the German industrial sector for the year 2003 are presented. Other analyses of surveillance data were retrieved from Medline.

RESULTS

Most confirmed reports of OAD are cases of sensitizer induced occupational asthma (625 confirmed cases) followed by COPD in coal miners (414 cases), irritant induced occupational asthma (156 cases), and isocyanate asthma (54 cases). Main causes of occupational asthma in Germany comprise flour/flour constituents (35.9%), food/feed dust (9.0%), and isocyanates (6.5%). Flour and grain dust is a frequent cause of occupational asthma in most European countries and South Africa. Isocyanates are still a problem worldwide.

CONCLUSIONS

Although wide differences in the estimated incidences between countries exist due to deficits in the coverage of occupational OAD, the high numbers necessitate improvement of preventive measures.

Occupational asthma

Substantial epidemiologic and clinical evidence indicates that agents inhaled at work can induce asthma. In industrialized countries, occupational factors have been implicated in 9 to 15% of all cases of adult asthma. Work-related asthma includes (1) immunologic occupational asthma (OA), characterized by a latency period before the onset of symptoms; (2) nonimmunologic OA, which occurs after single or multiple exposures to high concentrations of irritant materials; (3) work-aggravated asthma, which is preexisting or concurrent asthma exacerbated by workplace exposures; and (4) variant syndromes. Assessment of the work environment has improved, making it possible to measure concentrations of several high- and low-molecular-weight agents in the workplace. The identification of host factors, polymorphisms, and candidate genes associated with OA is in progress and may improve our understanding of mechanisms involved in OA. A reliable diagnosis of OA should be confirmed by objective testing early after its onset. Removal of the worker from exposure to the causal agent and treatment with inhaled glucocorticoids lead to a better outcome. Finally, strategies for preventing OA should be implemented and their cost-effectiveness examined.

A descriptive study of work aggravated asthma

BACKGROUND AND AIMS

Work related asthma (WRA) is one of the most frequently reported occupational lung diseases in a number of industrialised countries. A better understanding of work aggravated asthma (WAA), as well as work related new onset asthma (NOA), is needed to aid in prevention efforts.

METHODS

WAA and NOA in the United States were compared using cases reported to the National Institute for Occupational Safety and Health (NIOSH) from four state Sentinel Event Notification Systems for Occupational Risks (SENSOR) surveillance programmes for 1993-95.

RESULTS

A total of 210 WAA cases and 891 NOA cases were reported. WAA cases reported mineral and inorganic dusts as the most common exposure agent, as opposed to NOA cases, in which diisocyanates were reported most frequently. A similar percentage of WAA and NOA cases still experienced breathing problems at the time of the interview or had visited a hospital or emergency room for work related breathing problems. NOA cases were twice as likely to have applied for workers' compensation compared with WAA cases. However, among those who had applied for worker compensation, approximately three-fourths of both WAA and NOA cases had received awards. The services and manufacturing industrial categories together accounted for the majority of both WAA (62%) and NOA (75%) cases. The risk of WAA, measured by average annual rate, was clearly the highest in the public administration (14.2 cases/10(5)) industrial category, while the risk of NOA was increased in both the manufacturing (3.2 cases/10(5)) and public administration (2.9 cases/10(5)) categories.

CONCLUSIONS

WAA cases reported many of the same adverse consequences as NOA cases. Certain industries were identified as potential targets for prevention efforts based on either the number of cases or the risk of WAA and NOA.

Asthma symptoms in women employed in domestic cleaning: a community based study

BACKGROUND

Epidemiological studies have shown an association between cleaning work and asthma, but the risk factors are uncertain. The aim of this study was to assess the risk of asthma in women employed in domestic cleaning.

METHODS

A cross sectional study was conducted in 4521 women aged 30 to 65 years. Information on respiratory symptoms and cleaning work history was obtained using a postal questionnaire with telephone follow up. Asthma was defined as reported symptoms in the last year or current use of drugs to treat asthma. Odds ratios (OR) with 95% confidence intervals (CI) for asthma in different cleaning groups were estimated using adjusted unconditional logistic regression models.

RESULTS

593 women (13%) were currently employed in domestic cleaning work. Asthma was more prevalent in this group than in women who had never worked in cleaning (OR 1.46 (95% CI, 1.10 to 1.92)). Former domestic cleaning work was reported by 1170 women (26%), and was strongly associated with asthma (OR 2.09 (1.70 to 2.57)). Current and former non-domestic cleaning work was not significantly associated with asthma. Consistent results were obtained for other respiratory symptoms. Twenty five per cent of the asthma cases in the study population were attributable to domestic cleaning work.

CONCLUSIONS

Employment in domestic cleaning may induce or aggravate asthma. This study suggests that domestic cleaning work has an important public health impact, probably involving not only professional cleaners but also people undertaking cleaning tasks at home.

Occupational exposures associated with work-related asthma and work-related wheezing among U.S. workers

BACKGROUND

National estimates of occupational asthma (OA) in the United States are sparse.

METHODS

Using data from the Third National Health and Nutrition Examination Survey (NHANES III) 1988-1994, we analyzed associations between occupation and work-related asthma and work-related wheezing among U.S. workers.

RESULTS

This study identified several occupations that were at risk of developing work-related asthma and/or wheezing, with cleaners and equipment cleaners showing the highest risks. Other major occupations identified were farm and agriculture; entertainment; protective services; construction; mechanics and repairers; textile; fabricators and assemblers; other transportation and material moving occupations; freight, stock, and material movers; and motor vehicle operators. The population attributable risks for work-related asthma and work-related wheezing were 26% and 27%, respectively.

CONCLUSIONS

This study adds evidence to the literature that identifies work-related asthma as an important public health problem. Several occupations are targeted for additional evaluation and study. Of particular interest are cleaners, which are being increasingly reported as a risk group for asthma. Future intervention strategies need to be developed for effective control and prevention of asthma in the workplace.

Occupational asthma in the city of São Paulo, 1995-2000, with special reference to gender analysis

BACKGROUND

Occupational asthma (OA) is the leading occupational respiratory disease in the area of São Paulo Municipality. Understanding its characteristics can provide useful information for better interventions.

METHODS

From a joint registry of OA from five outpatient public clinics for occupational respiratory diseases, data on occupation, with job titles corrected by an expert evaluation, agents, exposure and symptom duration, and spirometry were analyzed by gender. Data on employment for São Paulo Municipality were used to calculate expected ratios for men/women in broad economical sectors.

RESULTS

Three hundred and ninety four OA cases were reported with a ratio of men/women of 1.5. Women had significantly shorter exposure duration (5.6 +/- 5.2 vs. 8.9 +/- 9.0 years, P = 0.0005), shorter symptoms duration (2.6 +/- 3.7 vs. 3.2 +/- 3.5 years, P = 0.1270), and higher prevalence of previous atopy (27.0 vs. 18.4%, P = 0.0485). The main occupations related to OA cases were cleaning activities, working in plastics manufacture and in chemical and pharmaceutical plants. Women reported significantly more exposures to cleaning products, biologic agents, and textile fibers, whereas men reported more exposures to isocyanates, metal dusts and fumes, oil mists, wood dusts and anhydrides. Women presented an increased risk of OA in the service sector (odds ratio (OR) = 1.77, confidence interval (CI) = 1.61-1.96).

CONCLUSIONS

Cleaning services was the main reported occupation and cleaning products the main reported agents. Women had significantly shorter exposure duration possibly due to difference in exposures, previous atopy, and behavior. There was an excess of cases of women in the service sector.

Workplace irritant exposures: do they produce true occupational asthma?

OBJECTIVE

To describe the features of irritant-induced asthma and discuss the diagnosis in relation to differing workplace irritant exposures and symptomatic responses.

DATA SOURCES

A review of MEDLINE articles on this topic from January 1, 1985, through December 31, 2001 was performed.

STUDY SELECTION

The author selected relevant articles for inclusion in the review.

RESULTS

Many reports indicate that unintentional high-level respiratory irritant exposures can induce the new onset of asthma. Cases that meet strict criteria for a syndrome of irritant-induced asthma, termed reactive airways dysfunction syndrome, can be diagnosed with relative certainty. Several reports of irritant-induced asthma, especially prevalence studies, have relied on historical data or have otherwise modified the reactive airways dysfunction syndrome criteria for diagnosis (eg, expanding the definition to include the symptom onset several days after exposure). Such modifications, or inclusion of cases with incomplete documentation, likely increase diagnostic sensitivity but may reduce the certainty of diagnosis for individual cases. Expanding exposure criteria to moderate or long-term low-level irritant exposures causes difficulty in excluding transient irritant exacerbation of underlying asthma or coincidental onset of asthma during working life. Although recent population studies suggest a greater relative risk of asthma in occupations with expected low-to-moderate respiratory irritant exposures, currently no objective laboratory tests exist to exclude coincidental asthma in such patients.

CONCLUSIONS

Irritant-induced asthma can be produced by high-level unintentional respiratory irritant exposures at work or outside the workplace. Lower levels of exposure to respiratory irritants at work are more common, and additional studies are needed to determine the airway effects of such exposures.

Work-related reactive airways dysfunction syndrome cases from surveillance in selected US states

The objective was to elaborate the descriptive epidemiology of work-related cases of reactive airways dysfunction syndrome (RADS). Cases of work-related asthma (WRA) were identified in four states in the United States during 1993-1995 as part of the Sentinel Event Notification Systems for Occupational Risks (SENSOR). Information gathered by follow-back interview was used to describe 123 work-related RADS cases and to compare them to 301 other WRA cases whose onset of disease was associated with a known asthma inducer. RADS represented 14% of all new-onset WRA cases identified by the state SENSOR surveillance systems. RADS cases had significant adverse medical and occupational outcomes identified by follow-back interview. In particular, 89% still had breathing problems, 78% had ever sought emergency care and 39% had ever been hospitalized for work-related breathing problems, 54% had applied for worker compensation benefits, and 41% had left the company where they experienced onset of asthma. These values equaled or exceeded the comparable figures for those WRA cases whose onset was attributed to a known inducer. Work-related RADS represents a minority of all WRA cases, but the adverse impact of this condition appears to equal that of other WRA cases.

Reported incidence of occupational asthma in France, 1996-99: the ONAP programme

AIMS

To estimate the general and specific incidence of occupational asthma in France in 1996-99; and to describe the distribution of cases by age, sex, suspected causal agents, and occupation.

METHODS

New cases of occupational asthma were collected by a national surveillance programme, based on voluntary reporting, named Observatoire National des Asthmes Professionnels (ONAP), involving a network of occupational and chest physicians. For each case, the reporting form included information on age, sex, location of workplace, occupation, suspected causal agent, and methods of diagnosis. Estimates of the working population, used to calculate incidence rates by age, sex, region, and occupation, were obtained from the Institut National de la Statistique et des Etudes Economiques (INSEE) and from the French Securite Sociale statistics.

RESULTS

In 1996-99, 2178 cases of occupational asthma were reported to the ONAP, giving a mean annual rate of 24/million. Rates in men were higher than rates in women (27/million versus 19/million). The highest rate was observed in the 15-29 years age group (30/million). The most frequently incriminated agents were flour (20.3%), isocyanates (14.1%), latex (7.2%), aldehyde (5.9%), persulphate salts (5.8%), and wood dusts (3.7%). The highest risks of occupational asthma were found in bakers and pastry makers (683/million), car painters (326/million), hairdressers (308/million), and wood workers (218/million).

CONCLUSION

Despite likely underreporting, the number of cases of occupational asthma reported to the ONAP was approximately twice the number of compensated cases over the same period. The relevance of the programme is confirmed by the reproducibility of the results year after year, and its consistency with other surveillance programmes. The ONAP programme is useful for the identification of targets for primary prevention.

Occupational airways diseases from chronic low-level exposures to irritants

Short-term, high-level exposures to dusts, gases, mists, fumes, and smoke that are irritating to the respiratory tract are capable of inducing asthma, the so-called reactive airways dysfunction syndrome. Such exposures, however, do not occur frequently; chronic or recurrent exposures to lower levels of irritants are much more common. This article reviews the evidence that supports the concept that low-level exposures to respiratory tract irritants can contribute to the development of chronic obstructive pulmonary disease and asthma.

New developments in work-related asthma

Although work-related asthma is the most commonly recognized occupational lung disease, the condition remains underrecognized and underreported. New-onset occupational asthma and work aggravated asthma can have deleterious medical and socioeconomic consequences for the individual. Although interpretation and comparison between studies are hampered by the use of variable definitions of WRA and criteria for the diagnosis, as many as 20% of cases of new or aggravated adult asthma has important work-related factors. Thus, all asthmatic patients should be asked about their work, if their respiratory symptoms are worse when they work, or if a new job/exposure preceded the onset of symptoms. A series of longitudinal inception and apprentice cohort studies were undertaken to address significant weakness in the previous medical literature. These studies are just beginning to produce results, and provide strong evidence for asthma caused by exposure to specific occupational environments. They have begun to produce new understanding of the risk factors for developing OA, the natural history of OA and immune sensitization, and the existence of the healthy worker effect. New, non-invasive measures of airway inflammation have been developed with the potential for broad applications in the field of WRA. Although the measurement of exhaled NO and induced sputum analysis are primarily used as research tools, their place in clinical practice is likely to become clearer. These methods also have the potential to elucidate the various pathophysiologic mechanisms involved in WRA and may broaden our concept of occupational exposures that can initiate the onset of asthma.

Occupational injury and illness surveillance: conceptual filters explain underreporting

Occupational health surveillance data are key to effective intervention. However, the US Bureau of Labor Statistics survey significantly underestimates the incidence of work-related injuries and illnesses. Researchers supplement these statistics with data from other systems not designed for surveillance. The authors apply the filter model of Webb et al. to underreporting by the Bureau of Labor Statistics, workers' compensation wage-replacement documents, physician reporting systems, and medical records of treatment charged to workers' compensation. Mechanisms are described for the loss of cases at successive steps of documentation. Empirical findings indicate that workers repeatedly risk adverse consequences for attempting to complete these steps, while systems for ensuring their completion are weak or absent.

Chronic obstructive lung diseases and occupational exposure

The scope of this review is to highlight important and interesting articles in the field of the epidemiology of chronic obstructive pulmonary disease and occupational exposure. Relevant information from the literature published within the past year, either on general population samples or on workplaces, indicates that a substantial proportion of asthma and chronic obstructive pulmonary diseases are work related. Methods of investigation include self-reported or interview-obtained questionnaires, job title and job exposure matrix, as well as voluntary or mandatory notifications. Furthermore, data on lung function and immunological tests are available. Specific settings and agents are quoted that have been indicated or confirmed as being linked to chronic obstructive pulmonary disease. In conclusion, occupational exposure to dusts, chemicals and gases will be considered an established, or supported by good evidence, risk factor for chronic obstructive pulmonary disease. The implications of this substantial occupational contribution to asthma and chronic obstructive pulmonary disease must be considered in research planning, in public policy decision-making, and in clinical practice.

Occupational reactions to foods

The spectrum of occupational diseases most commonly seen in the food industry includes occupational asthma, rhinitis, conjunctivitis, dermatitis, and hypersensitivity pneumonitis. Occupational asthma represents between 3% and 20% of all asthma cases and is the most common form of occupational lung disease. Occupational skin diseases may represent between 10% and 15% of all occupational diseases, and they have significant economic impact. Hypersensitivity pneumonitis affects the food industry, with farmer's lung representing a common form of the disease. Each of these diseases may have serious and potentially irreversible effects on the health of a farmer, food processor, or food preparer, even after removal of the offending exposure.

Frequency of occupational health concerns in general clinics

Studies have suggested that occupational disease and injury are under-recognized by clinicians. To estimate the frequency of occupational factors in disease and injury, 108 patients in a general (not occupational) health care facility were interviewed about the frequency and types of workplace-health interactions. Thirty-nine percent reported possible causation by work, and 66% reported a possible increase in symptoms by work, even if not caused by work. Twenty-seven percent reported changing jobs and/or tasks because of work-health interactions. The majority of men and women reported that worksite changes could improve their functional ability at work. This study therefore indicates that (1) occupational health concerns are common in primary care clinics, even if not addressed by clinicians; (2) the definition of occupational health concerns should be broadened to include disease caused by work, disease symptoms worsened by work, and the need for occupational accommodation even if the disease itself is not caused by work; and (3) inquiring about patient concerns about workplace-health interactions can provide clinicians with significant opportunities for primary, secondary, and tertiary prevention.