Performance of self-reported occupational exposure compared to a job-exposure matrix approach in asthma and chronic rhinitis

The combined effect of exposures to vapours, gases, dusts, fumes and tobacco smoke on current asthma

Smoking, exposure to environmental tobacco smoke (ETS) and occupational exposure to vapours, gases, dusts or fumes (VGDF) increase asthma symptoms. The impact of combined exposure is less well established. We aimed to evaluate the risk of combined exposure to smoking, ETS and VGDF on the prevalence of current asthma and asthma-related symptoms with a postal survey among a random population of 16,000 adults, aged 20-69 years (response rate 51.5%). The 836 responders with physician-diagnosed asthma were included in the analysis. Of them, 81.9% had current asthma defined as physician-diagnosed asthma with current asthma medication use or reported symptoms. There was a consistently increasing trend in the prevalence of current asthma by increased exposure. The highest prevalence of multiple symptoms was in smokers with VGDF exposure (92.1%) compared to the unexposed (73.9%, p = 0.001). In logistic regression analysis, combined exposure to several exposures increased the risk in all analysed symptoms (p = 0.002-0.007). In conclusion, smoking and exposure to ETS or VGDF increased the prevalence of current asthma and multiple symptoms. The combined exposure carried the highest risk. Preventive strategies are called for to mitigate exposure to tobacco smoke and VGDF.

Association of respiratory symptoms with body mass index and occupational exposure comparing sexes and subjects with and without asthma: follow-up of a Norwegian population study (the Telemark study)

BACKGROUND

Occupational exposure and increased body mass index (BMI) are associated with respiratory symptoms. This study investigated whether the association of a respiratory burden score with changes in BMI as well as changes in occupational exposure to vapours, gas, dust and fumes (VGDF) varied in subjects with and without asthma and in both sexes over a 5-year period.

METHODS

In a 5-year follow-up of a population-based study, 6350 subjects completed a postal questionnaire in 2013 and 2018. A respiratory burden score based on self-reported respiratory symptoms, BMI and frequency of occupational exposure to VGDF were calculated at both times. The association between change in respiratory burden score and change in BMI or VGDF exposure was assessed using stratified regression models.

RESULTS

Changes in respiratory burden score and BMI were associated with a β-coefficient of 0.05 (95% CI 0.04 to 0.07). This association did not vary significantly by sex, with 0.05 (0.03 to 0.07) for women and 0.06 (0.04 to 0.09) for men. The association was stronger among those with asthma (0.12; 0.06 to 0.18) compared with those without asthma (0.05; 0.03 to 0.06) (p=0.011). The association of change in respiratory burden score with change in VGDF exposure gave a β-coefficient of 0.15 (0.05 to 0.19). This association was somewhat greater for men versus women, with coefficients of 0.18 (0.12 to 0.24) and 0.13 (0.07 to 0.19), respectively (p=0.064). The estimate was similar among subjects with asthma (0.18; -0.02 to 0.38) and those without asthma (0.15; 0.11 to 0.19).

CONCLUSIONS

Increased BMI and exposure to VGDF were associated with increased respiratory burden scores. The change due to increased BMI was not affected by sex, but subjects with asthma had a significantly larger change than those without. Increased frequency of VGDF exposure was associated with increased respiratory burden score but without statistically significant differences with respect to sex or asthma status.

Inorganic Dust Exposure During Military Service as a Predictor of Rheumatoid Arthritis and Other Autoimmune Conditions

OBJECTIVE

Rheumatoid arthritis (RA) and other autoimmune (AI) conditions are associated with inorganic dust exposure. Many military activities are likely to entail inorganic dust exposures. We wished to identify associations between prior military dust exposure and RA and other AI conditions.

METHODS

We studied persons from a roster of Army, Navy, Air Force, or Marine Corps personnel who had served in Operation Enduring Freedom and Operations Iraqi Freedom and New Dawn. We linked military occupational codes to a job exposure matrix assigning dust exposure likelihood. We used the Veterans Affairs Health Care System (VAHCS) electronic health care records to identify cases of RA, systemic lupus erythematosus (SLE), systemic sclerosis (SSc), vasculitis, and inflammatory myositis. Generalized estimating equations modeled risk of RA and other AI conditions associated with dust exposure, taking into account military service branch, age at first VAHCS encounter, sex, race/ethnicity, smoking status, and years of military service.

RESULTS

Of 438 086 veterans (68% ever-smokers), 44% were classified with likely or somewhat likely dust exposure. Cases included 1139 cases with RA, 467 cases with SLE, and 180 cases with other AI diseases (SSc, vasculitis, or inflammatory myositis). Military dust exposure was associated with increased odds of RA (odds ratio [OR] = 1.10; 95% confidence interval [CI] = 1.003-1.20) and increased odds of SSc, vasculitis, or inflammatory myositis (OR = 1.23; 95% CI = 1.14-1.34) but was protective for SLE (OR = 0.81; 95% CI = 0.76-0.88).

CONCLUSION

Dust exposure during past military service comprises an occupational and environmental risk factor for RA and other AI diseases. This is potentially relevant for prevention activities.

Identification and Remediation of Environmental Exposures in Patients With Interstitial Lung Disease: Evidence Review and Practical Considerations

A relationship between inhalational exposure to materials in the environment and development of interstitial lung disease (ILD) is long recognized. Hypersensitivity pneumonitis is an environmentally -induced diffuse parenchymal lung disease. In addition to hypersensitivity pneumonitis, domestic and occupational exposures have been shown to influence onset and progression of other ILDs, including idiopathic interstitial pneumonias such as idiopathic pulmonary fibrosis. A key component of the clinical evaluation of patients presenting with ILD includes elucidation of a complete exposure history, which may influence diagnostic classification of the ILD as well as its management. Currently, there is no standardized approach to environmental evaluation or remediation of potentially harmful exposures in home or workplace environments for patients with ILD. This review discusses evidence for environmental contributions to ILD pathogenesis and draws on asthma and occupational medicine literature to frame the potential utility of a professional evaluation for environmental factors contributing to the development and progression of ILD. Although several reports suggest benefits of environmental assessment for those with asthma or certain occupational exposures, lack of information about benefits in broader populations may limit application. Determining the feasibility, long-term outcomes, and cost-effectiveness of environmental evaluation and remediation in acute and chronic ILDs should be a focus of future research.

Chronic obstructive pulmonary disease caused by inhalation of dust: A meta-analysis

BACKGROUND

A meta-analysis was performed to evaluate the relationship between chronic obstructive pulmonary disease (COPD) and occupational dust exposure, and to provide a scientific basis for the prevention and treatment of COPD caused by occupational factors.

METHODS

PubMed and Embase databases were used to search for original epidemiological literature related to theme. Both random and fixed effects models were used to calculate pooled odds ratios and their corresponding 95% confidence intervals. Review Manager was used to perform data analysis.

RESULTS

Nine studies were included in the meta-analysis in accordance with the inclusion criteria. There was a significantly obvious correlation between occupational dust exposure and COPD of the population-based studies assessed in this article. The risk of developing COPD for workers exposed to dust was 1.51 times higher than for controls (I = 40%, 95% confidence interval: 1.27-1.79). The presence of publication bias was not found.

CONCLUSION

The study provided evidence supporting the association between occupational dust exposure and the risk of developing COPD.

Possible risk factors for poor asthma control assessed in a cross-sectional population-based study from Telemark, Norway

This cross-sectional study of the general population of Telemark County, Norway, aimed to identify risk factors associated with poor asthma control as defined by the Asthma Control Test (ACT), and to determine the proportions of patients with poorly controlled asthma who had undergone spirometry, used asthma medication, or been examined by a pulmonary physician. In 2014–2015, the study recruited 326 subjects aged 16–50 years who had self-reported physician-diagnosed asthma and presence of respiratory symptoms during the previous 12 months. The clinical outcome measures were body mass index (BMI), forced vital capacity (FVC) and forced expiratory volume in one second (FEV₁), fractional exhaled nitric oxide (FeNO), immunoglobulin E (IgE) in serum and serum C-reactive protein (CRP). An ACT score ≤ 19 was defined as poorly controlled asthma. Overall, 113 subjects (35%) reported poor asthma control. The odds ratios (ORs) and 95% confidence intervals (CIs) for factors associated with poorly controlled asthma were: self-reported occupational exposure to vapor, gas, dust, or fumes during the previous 12 months (OR 2.0; 95% CI 1.1–3.6), body mass index ≥ 30 kg/m² (OR 2.2; 95% CI 1.2–4.1), female sex (OR 2.6; 95% CI 1.5–4.7), current smoking (OR 2.8; 95% CI 1.5–5.3), and past smoking (OR 2.3; 95% CI 1.3–4.0). Poor asthma control was also associated with reduced FEV₁ after bronchodilation (β –3.6; 95% CI –7.0 to –0.2). Moreover, 13% of the participants with poor asthma control reported no use of asthma medication, 51% had not been assessed by a pulmonary physician, and 20% had never undergone spirometry. Because these data are cross-sectional, further studies assessing possible risk factors in general and objectively measured occupational exposure in particular are needed. However, our results suggest that there is room for improvement with regards to use of spirometry and pulmonary physician referrals when a patient’s asthma is inadequately controlled.

Job titles classified into socioeconomic and occupational groups identify subjects with increased risk for respiratory symptoms independent of occupational exposure to vapour, gas, dust, or fumes

Objectives: To evaluate the ability of three different job title classification systems to identify subjects at risk for respiratory symptoms and asthma by also taking the effect of exposure to vapours, gas, dust, and fumes (VGDF) into account. Background: Respiratory symptoms and asthma may be caused by occupational factors. There are different ways to classify occupational exposure. In this study, self-reported occupational exposure to vapours, gas, dust and fumes was used as well as job titles classifed into occupational and socioeconomic Groups according to three different systems. Design: This was a large population-based study of adults aged 30-69 years in Northern Sweden (n = 9,992, 50% women). Information on job titles, VGDF-exposure, smoking habits, asthma and respiratory symptoms was collected by a postal survey. Job titles were used for classification into socioeconomic and occupational groups based on three classification systems; Socioeconomic classification (SEI), the Nordic Occupations Classification 1983 (NYK), and the Swedish Standard Classification of Occupations 2012 (SSYK). Associations were analysed by multivariable logistic regression. Results: Occupational exposure to VGDF was a risk factor for all respiratory symptoms and asthma (odds ratios (ORs) 1.3-2.4). Productive cough was associated with the socioeconomic groups of manual workers (ORs 1.5-2.1) and non-manual employees (ORs 1.6-1.9). These groups include occupations such as construction and transportation workers, service workers, nurses, teachers and administration clerks which by the SSYK classification were associated with productive cough (ORs 2.4-3.7). Recurrent wheeze was significantly associated with the SEI group manual workers (ORs 1.5-1.7). After adjustment for also VGDF, productive cough remained significantly associated with the SEI groups manual workers in service and non-manual employees, and the SSYK-occupational groups administration, service, and elementary occupations. Conclusions: In this cross-sectional study, two of the three different classification systems, SSYK and SEI gave similar results and identified groups with increased risk for respiratory symptoms while NYK did not give conclusive results. Furthermore, several associations were independent of exposure to VGDF indicating that also other job-related factors than VGDF are of importance.

Occupational Exposures and Subclinical Interstitial Lung Disease. The MESA (Multi-Ethnic Study of Atherosclerosis) Air and Lung Studies

RATIONALE

The impact of a broad range of occupational exposures on subclinical interstitial lung disease (ILD) has not been studied.

OBJECTIVES

To determine whether occupational exposures to vapors, gas, dust, and fumes (VGDF) are associated with high-attenuation areas (HAA) and interstitial lung abnormalities (ILA), which are quantitative and qualitative computed tomography (CT)-based measurements of subclinical ILD, respectively.

METHODS

We performed analyses of participants enrolled in MESA (Multi-Ethnic Study of Atherosclerosis), a population-based cohort aged 45-84 years at recruitment. HAA was measured at baseline and on serial cardiac CT scans in 5,702 participants. ILA was ascertained in a subset of 2,312 participants who underwent full-lung CT scanning at 10-year follow-up. Occupational exposures were assessed by self-reported VGDF exposure and by job-exposure matrix (JEM). Linear mixed models and logistic regression were used to determine whether occupational exposures were associated with log-transformed HAA and ILA. Models were adjusted for age, sex, race/ethnicity, education, employment status, tobacco use, and scanner technology.

MEASUREMENTS AND MAIN RESULTS

Each JEM score increment in VGDF exposure was associated with 2.64% greater HAA (95% confidence interval [CI], 1.23-4.19%). Self-reported vapors/gas exposure was associated with an increased odds of ILA among those currently employed (1.76-fold; 95% CI, 1.09-2.84) and those less than 65 years old (1.97-fold; 95% CI, 1.16-3.35). There was no consistent evidence that occupational exposures were associated with progression of HAA over the follow-up period.

CONCLUSIONS

JEM-assigned and self-reported exposures to VGDF were associated with measurements of subclinical ILD in community-dwelling adults.

Occupational exposure to chemicals drives the increased risk of asthma and rhinitis observed for exposure to vapours, gas, dust and fumes: a cross-sectional population-based study

OBJECTIVES

Occupational exposure to the composite measure vapours, gases, dusts and fumes (VGDF), contribute to the burden of asthma and rhinitis. The objective was to evaluate occupational exposure to VGDF, which is further divided into the components chemicals, organic and inorganic dust in relation to asthma and rhinitis.

METHODS

Previously examined participants from three population-based cohorts in the Obstructive Lung disease In Northern Sweden (OLIN) studies were re-examined during 2002-2004. In total, 4036 participated in a structured interview and answered a questionnaire on occupational exposures.

RESULTS

Occupational exposure to VGDF increased the risk of asthma, and concomitant asthma and rhinitis. Exposure to chemicals, but not dust, showed a similar pattern. Exposure to chemicals increased the risks (OR, 95% CI) of rhinitis without asthma (1.29, 1.10 to 1.52), asthma without rhinitis (1.42, 1.15 to 1.77) and concomitant asthma and rhinitis (1.60, 1.31 to 1.96) when adjusted for confounders such as age, smoking habits, body mass index and sex. The association between exposure to chemicals and asthma and rhinitis remained independent of exposure to dust and was also so when excluding exposure to isocyanates and welding fumes. The results were similar for women and men, as well as for never-smokers and participants without a history of allergy.

CONCLUSIONS

In this cross-sectional population-based study, occupational exposure to chemicals contributed substantially to the increased risk of asthma and rhinitis observed for occupational exposure to VGDF.

Secondhand Tobacco Smoke and COPD Risk in Smokers: A COPDGene Study Cohort Subgroup Analysis

BACKGROUND

Exposure to secondhand tobacco smoke (SHS) can be a risk factor for chronic obstructive pulmonary disease (COPD), but its role among relatively heavy smokers with potential co-exposure to workplace vapors, gas, dust, and fumes (VGDF) has not been studied.

METHODS

To estimate the contribution of SHS exposure to COPD risk, taking into account smoking effects and work-related exposures to VGDF, we quantified SHS based on survey responses for 1400 ever-employed subjects enrolled in the COPDGene study, all current or former smokers with or without COPD. Occupational exposures to VGDF were quantified based on a job exposure matrix. The associations between SHS and COPD were tested in multivariate logistic regression analyses adjusted for age, sex, VGDF exposure, and cumulative smoking.

RESULTS AND DISCUSSION

Exposures to SHS at work and at home during adulthood were associated with increased COPD risk: odds ratio (OR) = 1.12 (95% confidence interval [CI]: 1.02-1.23; p = 0.01) and OR = 1.09 (95%CI: 1.00-1.18; p = 0.04) per 10 years of exposure adjusted for smoking and other covariates, respectively. In addition, subjects with employment histories likely to entail exposure to VGDF were more likely to have COPD: OR = 1.52 (95%CI: 1.16-1.98; p < 0.01) (adjusted for other covariates). While adult home SHS COPD risk was attenuated among the heaviest smokers within the cohort, workplace SHS and job VGDF risks persisted in that stratum.

CONCLUSION

Among smokers all with at least 10 pack-years, adult home and work SHS exposures and occupational VGDF exposure are all associated with COPD.

Occupational exposures are associated with worse morbidity in patients with chronic obstructive pulmonary disease

RATIONALE

Links between occupational exposures and morbidity in individuals with established chronic obstructive pulmonary disease (COPD) remain unclear.

OBJECTIVES

To determine the impact of occupational exposures on COPD morbidity.

METHODS

A job exposure matrix (JEM) determined occupational exposure likelihood based on longest job in current/former smokers (n = 1,075) recruited as part of the Subpopulations and Intermediate Outcomes in COPD Study, of whom 721 had established COPD. Bivariate and multivariate linear regression models estimated the association of occupational exposure with COPD, and among those with established disease, the occupational exposure associations with 6-minute-walk distance (6MWD), the Modified Medical Research Council Dyspnea Scale (mMRC), the COPD Assessment Test (CAT), St. George's Respiratory Questionnaire (SGRQ), 12-item Short-Form Physical Component (SF-12), and COPD exacerbations requiring health care utilization, adjusting for demographics, current smoking status, and cumulative pack-years.

MEASUREMENTS AND MAIN RESULTS

An intermediate/high risk of occupational exposure by JEM was found in 38% of participants. In multivariate analysis, those with job exposures had higher odds of COPD (odds ratio, 1.44; 95% confidence interval, 1.04-1.97). Among those with COPD, job exposures were associated with shorter 6MWDs (-26.0 m; P = 0.006); worse scores for mMRC (0.23; P = 0.004), CAT (1.8; P = 0.003), SGRQ (4.5; P = 0.003), and SF-12 Physical (-3.3; P < 0.0001); and greater odds of exacerbation requiring health care utilization (odds ratio, 1.55; P = 0.03).

CONCLUSIONS

Accounting for smoking, occupational exposure was associated with COPD risk and, for those with established disease, shorter walk distance, greater breathlessness, worse quality of life, and increased exacerbation risk. Clinicians should obtain occupational histories from patients with COPD because work-related exposures may influence disease burden.

Occupational risk factors for COPD phenotypes in the Multi-Ethnic Study of Atherosclerosis (MESA) Lung Study

INTRODUCTION

The contribution of occupational exposure to the risk of chronic obstructive pulmonary disease COPD in population-based studies is of interest. We compared the performance of self-reported exposure to a newly developed JEM in exposure-response evaluation.

METHODS

We used cross-sectional data from Multi-Ethnic Study of Atherosclerosis (MESA), a population-based sample of 45-84 year olds free of clinical cardiovascular disease at baseline. MESA ascertained the most recent job and employment, and the MESA Lung Study measured spirometry, and occupational exposures for 3686 participants. Associations between health outcomes (spirometry defined airflow limitation and Medical Research Council-defined chronic bronchitis) and occupational exposure [self-reported occupational exposure to vapor-gas, dust, or fumes (VGDF), severity of exposure, and a job-exposure matrix (JEM)-derived score] were evaluated using logistic regression models adjusted for non-occupational risk factors.

RESULTS

The prevalence of airflow limitation was associated with self-reported exposure to vapor-gas (OR 2.6, 95%CI 1.1-2.3), severity of VGDF exposure (P-trend < 0.01), and JEM dust exposure (OR 2.4, 95%CI 1.1-5.0), and with organic dust exposure in females; these associations were generally of greater magnitude among never smokers. The prevalence of chronic bronchitis and wheeze was associated with exposure to VGDF. The association between airflow limitation and the combined effect of smoking and VGDF exposure showed an increasing trend. Self-reported vapor-gas, dust, fumes, years and severity of exposure were associated with increased prevalence of chronic bronchitis and wheeze (P < 0.001).

CONCLUSIONS

Airflow limitation was associated with self-reported VGDF exposure, its severity, and JEM-ascertained dust exposure in smokers and never-smokers in this multiethnic study.

A comparison of exposure assessment approaches: lung cancer and occupational asbestos exposure in a population-based case-control study

OBJECTIVES

In attempts to overcome the limitations of self-reported data in occupational health research, job-exposure matrices, which assign exposure by occupation, have emerged as an objective approach for assessing occupational exposures. On the basis of a lung cancer case-control study conducted in the Greater Toronto Area, 1997-2002, assessment of occupational exposure to asbestos was compared using self-reports and a general population job-exposure matrix (DOM-JEM).

METHODS

Cases and frequency matched controls provided life-time job histories and self-reported exposures to potential lung carcinogens including asbestos through a detailed questionnaire. Exposure to asbestos was also assigned to each job by linking occupational histories with DOM-JEM. Agreement in classification of exposed and unexposed jobs according to self-reports and DOM-JEM was evaluated using Cohen's κ. Risks for lung cancer were estimated using unconditional logistic regression for each exposure assessment approach.

RESULTS

The prevalence of occupational asbestos exposure was greater when based on DOM-JEM than when based on self-reports. Agreement in classifying exposure to jobs between the two assessment approaches was poor. The risk of lung cancer was not elevated among workers who self-reported asbestos exposure, whereas workers considered exposed on the basis of DOM-JEM were almost twice as likely as unexposed workers to be diagnosed with lung cancer (OR 1.9, 95% CI 1.3 to 2.7).

CONCLUSIONS

It is generally assumed by epidemiologists that self-reported exposure assessments result in inflated risk estimates. In this study, self-reports found no association with a well-established risk factor, whereas a high-quality job-exposure matrix revealed relative risk estimates that are more consistent with previous findings.

The prevalence of selected potentially hazardous workplace exposures in the US: findings from the 2010 National Health Interview Survey

OBJECTIVE

Assess the national prevalence of current workplace exposure to potential skin hazards, secondhand smoke (SHS), and outdoor work among various industry and occupation groups. Also, assess the national prevalence of chronic workplace exposure to vapors, gas, dust, and fumes (VGDF) among these groups.

METHODS

Data were obtained from the 2010 National Health Interview Survey (NHIS). NHIS is a multistage probability sample survey of the civilian non-institutionalized population of the US. Prevalence rates and their variances were calculated using SUDAAN to account for the complex NHIS sample design.

RESULTS

The data for 2010 were available for 17,524 adults who worked in the 12 months that preceded interview. The highest prevalence rates of hazardous workplace exposures were typically in agriculture, mining, and construction. The prevalence rate of frequent handling of or skin contact with chemicals, and of non-smokers frequently exposed to SHS at work was highest in mining and construction. Outdoor work was most common in agriculture (85%), construction (73%), and mining (65%). Finally, frequent occupational exposure to VGDF was most common among mining (67%), agriculture (53%), and construction workers (51%).

CONCLUSION

We identified industries and occupations with the highest prevalence of potentially hazardous workplace exposures, and provided targets for investigation and intervention activities.

Mediators of the socioeconomic gradient in outcomes of adult asthma and rhinitis

OBJECTIVES

We estimated the extent to which socioeconomic status (SES) gradients in adult asthma and rhinitis outcomes can be explained by home and neighborhood environmental factors.

METHODS

Using survey data for 515 adults with either asthma or rhinitis, or both, we examined environmental mediators of SES associations with disease severity, using the Severity of Asthma Scale, and health-related quality of life (HRQL), using the Rhinasthma Scale. We defined SES on the basis of education and household income. Potential environmental mediators included home type and ownership, exposures to allergens and irritants, and a summary measure of perceived neighborhood problems. We modeled each outcome as a function of SES, and controlled for age, gender, and potential mediators.

RESULTS

Gradients in SES were apparent in disease severity and HRQL. Living in a rented house partially mediated the SES gradient for both severity and HRQL (P < .01). Higher perceived levels of neighborhood problems were associated with poorer HRQL and partially mediated the income-HRQL relationship (P < .01).

CONCLUSIONS

Differences in home and neighborhood environments partially explained associations of SES with adult asthma and rhinitis outcomes.

Association between occupational exposure and the clinical characteristics of COPD

Background

The contribution of occupational exposures to COPD and their interaction with cigarette smoking on clinical pattern of COPD remain underappreciated. The aim of this study was to explore the contribution of occupational exposures on clinical pattern of COPD.

Methods

Cross-sectional data from a multicenter tertiary care cohort of 591 smokers or ex-smokers with COPD (median FEV1 49%) were analyzed. Self-reported exposure to vapor, dust, gas or fumes (VDGF) at any time during the entire career was recorded.

Results

VDGF exposure was reported in 209 (35%) subjects aged 31 to 88 years. Several features were significantly associated with VDGF exposure: age (median 68 versus 64 years, p < 0.001), male gender (90% vs 76%; p < 0.0001), reported work-related respiratory disability (86% vs 7%, p < 0.001), current wheezing (71% vs 61%, p = 0.03) and hay fever (15.5% vs 8.5%, p < 0.01). In contrast, current and cumulative smoking was less (p = 0.01) despite similar severity of airflow obstruction.

Conclusion

In this patient series of COPD patients, subjects exposed to VDGF were older male patients who reported more work-related respiratory disability, more asthma-like symptoms and atopy, suggesting that, even in smokers or ex-smokers with COPD, occupational exposures are associated with distinct patients characteristics.

Occupational exposure to dusts, gases, and fumes and incidence of chronic obstructive pulmonary disease in the Swiss Cohort Study on Air Pollution and Lung and Heart Diseases in Adults

RATIONALE

There is limited evidence from population-based studies demonstrating incidence of spirometric-defined chronic obstructive pulmonary disease (COPD) in association with occupational exposures.

OBJECTIVES

We evaluated the association between occupational exposures and incidence of COPD in the Swiss Cohort Study on Air Pollution and Lung and Heart Diseases in Adults (SAPALDIA).

MEASUREMENTS AND MAIN RESULTS

Prebronchodilator ratio of forced expiratory volume in 1 second over forced vital capacity (FEV(1)/FVC) was measured in 4,267 nonasthmatic SAPALDIA participants ages 18-62 at baseline in 1991 and at follow-up in 2001-2003. COPD was defined by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criterion (FEV(1)/FVC < 0.70) and Quanjer reference equation (FEV(1)/FVC < lower limit of normal [LLN]), and categorized by severity (≥ 80% and <80% predicted FEV(1) for stage I and stage II+, respectively). Using a job-exposure matrix, self-reported occupations at baseline were assigned exposures to biological dusts, mineral dusts, gases/fumes, and vapors, gases, dusts, or fumes (VGDF) (high, low, or unexposed as reference). Adjusted incident rate ratios (IRRs) of stage I and stage II+ COPD were estimated in mixed Poisson regression models. Statistically significant (P < 0.05) IRRs of stage II+ GOLD and LLN-COPD, indicating risks between two- and fivefold, were observed for all occupational exposures at high levels. Occupational exposure-associated risk of stage II+ COPD was observed mainly in males and ages ≥ 40 years, and remained elevated when restricted to nonsmokers.

CONCLUSIONS

In a Swiss working adult population, occupational exposures to biological dusts, mineral dusts, gases/fumes, and VGDF were associated with incidence of COPD of at least moderate severity.

Negative impact of occupational exposure on surgical outcome in patients with rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is a frequent condition that is treated by functional endoscopic sinus surgery (FESS) when medical treatment fails. Endogenous as well as exogenous factors may be responsible for persisting symptoms after FESS. The role of occupational exposures on success of FESS has never been investigated.

METHODS

In this case-control study, we tested the hypothesis that the outcome of FESS procedures is related to exposures at work. Questionnaires were sent to 890 patients who had undergone one or more FESS procedures and to 182 controls. Three independent experts assessed blindly the reported work exposures to inhaled agents. The relationship between exposure and the number of FESS procedures was analyzed.

RESULTS

Relevant occupational exposure was reported by 25% of all responding patients undergoing FESS (n = 467) and 12% of controls (n = 69). The prevalence of occupational exposures increased linearly with the number of FESS procedures from 21% in those who had one FESS to 44% in those who had four or more FESS (χ(2)  = 12.74, P < 0.001). Logistic regression analysis with adjustments for potential confounders, including smoking, atopy, and asthma, confirmed that the odds ratio (OR) for reporting occupational exposures was significantly higher in those needing more than one FESS (OR = 1.64) or more than two FESS (OR = 1.97). These results were mainly driven by exposure to low molecular weight agents.

CONCLUSION

Exposure at work appears to be a risk factor for the occurrence of CRS and for its recurrence or persistence, as evidenced by the need for revision surgery.

Occupation and chronic obstructive pulmonary disease (COPD)

INTRODUCTION

There is growing interest in preventable, non-smoking causes of chronic obstructive pulmonary disease (COPD), among which are chronic exposures to respiratory irritants in the workplace.

SOURCES OF DATA

Reviews of occupational COPD in specific occupations and industries and in general populations; supplemented with other or more recently published material.

AREAS OF AGREEMENT

There is good evidence for an increased risk of COPD from certain specific exposures (coal mine dust, silica, welding fume, textile dust, agricultural dust, cadmium fume).

AREAS OF CONTROVERSY

Less clear is the causal role of non-specific dusts or fumes/gases in general populations where the available literature is notably uncritical.

GROWING POINTS

Other specific exposures, such as diesel fume; interactions between specific exposures and cigarette smoking; the development of safe working limits.

AREAS TIMELY FOR DEVELOPING RESEARCH

Occupations with large numbers of exposed employees, particularly in low-income countries.

Socioeconomic status, race and COPD health outcomes

BACKGROUND

Although chronic obstructive pulmonary disease (COPD) is a common cause of death and disability, little is known about the effects of socioeconomic status (SES) and race-ethnicity on health outcomes.

METHODS

The aim of this study is to determine the independent impacts of SES and race-ethnicity on COPD severity status, functional limitations and acute exacerbations of COPD among patients with access to healthcare. Data were used from the Function, Living, Outcomes and Work cohort study of 1202 Kaiser Permanente Northern California Medical Care Plan members with COPD.

RESULTS

Lower educational attainment and household income were consistently related to greater disease severity, poorer lung function and greater physical functional limitations in cross-sectional analysis. Black race was associated with greater COPD severity, but these differences were no longer apparent after controlling for SES variables and other covariates (comorbidities, smoking, body mass index and occupational exposures). Lower education and lower income were independently related to a greater prospective risk of acute COPD exacerbation (HR 1.5; 95% CI 1.01 to 2.1; and HR 2.1; 95% CI 1.4 to 3.4, respectively).

CONCLUSION

Low SES is a risk factor for a broad array of adverse COPD health outcomes. Clinicians and disease management programs should consider SES as a key patient-level marker of risk for poor outcomes.

"Patients don't lie"; a view on adherence in asthma

OBJECTIVE

The primary objective of this article is to examine the extent of self-reported non-adherence among patients participating in a controlled trial of an asthma compliance optimization intervention. The secondary objective is to introduce a two-question questionnaire that is, in wording and design, a neutral tool for disclosure of non-adherence behaviour.

METHOD

Data in this study was obtained as part of a controlled trial on an SMS monitoring and compliance intervention developed for Danish asthma patients. The trial was conducted from November 2007 to May 2008. A total of 244 patients participated in the study. Two new designed nonadherence questions were asked in immediate succession. This practice, along with the wording of the questions and use of the Web as medium, constitute a new approach to self-reported adherence assessment.

RESULTS

A total of 43.9% of the participants in the trial reported non-adherence to the medical dosage regime for which they had, only one question earlier, documented their awareness.

CONCLUSION

This illustrates that at least 43.9% of the participants in the trial dared to report nonadherence to asthma medication.

Further exploration of the links between occupational exposure and chronic obstructive pulmonary disease

OBJECTIVE

To examine occupational risk for Chronic Obstructive Pulmonary Disease (COPD).

METHODS

We randomly recruited 233 subjects aged 55 to 75 reporting a physician's diagnosis of COPD, emphysema, or chronic bronchitis. Interviews assessed cigarette smoking and longest held job, identifying exposure to vapors, gas, dust, or fumes (VGDF). Lung function was assessed in n = 138. Comparison data were derived from a sample of referents without COPD.

RESULTS

VGDF was reported in 123 (53%) of 233 cases versus 577 (34%) of 1709 referents. VGDF was associated with COPD (Odds Ratio [OR] 2.5; 95% CI = 1.9 to 3.4); the population attributable fraction was 32%. In the lung function subset, the FEV1/FVC was <70% in 79 (57%); 35 (44%) reported VGDF associated with an OR = 1.6 (95% CI = 0.99 to 2.6) and population attributable fraction 17%.

CONCLUSIONS

These data support an important role for occupational exposures in COPD.