Occupational asthma incidence: findings from the behavioral risk factor surveillance system asthma call-back survey--United States, 2006-2009

Prevalence and Burden of Asthma among US Working Adults by industry and Occupation-United States, 2020-2021

OBJECTIVES

Assess prevalence of current asthma, asthma attacks/episodes, and asthma-related emergency room (ER) visits by industry and occupation and estimate the proportion of current asthma cases associated with employment during 2020-2021.

METHODS

The 2020-2021 National Health Interview Survey data for persons aged ≥18 years who were employed at any time during the 12 months prior to the interview were analyzed.

RESULTS

An estimated 12.7 million US working adults had current asthma. Of those, 40% had an asthma attack/episode and 8.6% had an asthma-related ER visit. Prevalence varied by sociodemographic characteristics, industry, and occupation. Highest asthma prevalence was among workers in the administrative, support, waste management, and remediation industry and the community and social services occupation. Nearly half of workers with current asthma in the arts, entertainment, and recreation industry and arts, design, entertainment, sports, and media occupations reported having an asthma attack/episode. Workers in the accommodations and food services industry and food preparation and serving related occupation had the highest asthma-related ER visits. The proportion of current asthma cases attributable to employment was estimated to be 9.2% by industry and 12.2% by occupation.

CONCLUSION

An estimated 1.2-1.5 million asthma cases among workers might be attributable to employment by industry and occupation. Disparities in asthma prevalence, asthma attacks/episodes and asthma-related ER visits among workers exits. These findings underscore the importance of early identification of asthma cases in relation to work and implementation of targeted interventions (including, training and education, personal protective equipment use, health surveillance, workplace policies), especially among workers employed in industries and occupations with elevated asthma prevalence.

Work-related asthma prevalence among US employed adults

BACKGROUND

Work-related asthma (WRA), a preventable occupational disease, can result in adverse health outcomes and employment disability, including decreased productivity, lost workdays, and job loss. Early identification of WRA cases and avoidance of further exposures is crucial for optimal management.

OBJECTIVE

We estimate WRA prevalence among US workers by selected sociodemographic characteristics, industry, and occupation groups and assess the differences in adverse health outcomes, preventive care, and lost workdays between persons with WRA and those with non-WRA.

METHODS

The 2020 National Health Interview Survey (NHIS) data for working adults aged ≥18 years employed in the 12 months before the survey were analyzed. Prevalence, and adjusted prevalence ratios with 95% confidence intervals were estimated using multivariate logistic regression.

RESULTS

Of the estimated 170 million US adults working in the past year, 13.0 million (7.6%) had asthma. Among workers with asthma, an estimated 896,000 (6.9%) had WRA. WRA prevalence was highest among males, workers aged ≥55 years, those with no health insurance, those living in the Midwest, and those employed in the accommodation, food, and other services industry, and in production, installation, transportation, and material moving occupations. Workers with WRA were significantly more likely to use preventive medication and rescue inhalers, and to experience adverse health outcomes and lost workdays than workers with non-WRA.

CONCLUSION

Early identification of WRA cases, assessment of workplace exposures, and implementation of targeted interventions that consider the hierarchy of controls are critical to preventing future WRA cases and associated adverse health consequences.

Work-related asthma in adults with severe asthma from the Korean Severe Asthma Registry (KoSAR)

Background

Exposure to allergens or irritants in the workplace may affect asthma control and the quality of life (QoL) of patients with asthma.

Objective

To examine the prevalence and characteristics of work-related asthma (WRA) in adult patients with severe asthma.

Methods

We analyzed data from the Korean Severe Asthma Registry (KoSAR), which is a nationwide multicenter observational study on severe asthma in Korea. Severe asthma was defined according to the American Thoracic Society (ATS) and the European Respiratory Society (ERS) guidelines. WRA was identified on the basis of asthma symptom aggravation at the workplace, as indicated by responses to a structured questionnaire. We compared the demographic and clinical characteristics and QoL between adult patients with severe asthma and WRA and those without WRA.

Results

Among 364 patients with severe asthma who were employed at the time of enrollment, 65 (17.9%) had WRA. There were no significant differences in age, sex, obesity, or smoking history between the WRA and non-WRA groups. However, individuals with WRA exhibited a higher prevalence of anxiety (7.7% vs 2.4%, P = 0.046) and depression (12.3% vs 3.7%, P = 0.010) than those without. The levels of asthma control, lung function, and frequency of asthma exacerbations were similar between the two groups, but patients with WRA reported lower QoL, as determined by the Quality of Life Questionnaire for Adult Korean Asthmatics (56.6 ± 14.6 vs. 63.5 ± 13.9, P < 0.001).

Conclusion

Patients with severe asthma and WRA are more likely to experience anxiety and depression and have lower QoL than those without WRA.

Clinical Importance of Work-Exacerbated Asthma: Findings From a Prospective Asthma Cohort in a Highly Industrialized City in Korea

PURPOSE

Work-related asthma (WRA) occupies about 10%-30% of all asthma cases. Among 2 subtypes of WRA (occupational asthma [OA] and work-exacerbated asthma [WEA]), the rate of WEA has been reported to increase recently. WRA is described as having worse characteristics than non-WRA (NWRA), while WEA is known to show similar severity to OA in terms of symptoms and exacerbations. However, these data were mainly based on indirect surveys. Ulsan is a highly industrialized city in Korea; therefore, it is estimated to have a high incidence of WRA. This study aimed to identify the characteristics of WRA in the city.

METHODS

This was a prospective asthma cohort study of individuals diagnosed with asthma and treated at Ulsan University Hospital between Jan 2015 and Dec 2016. Baseline characteristics and work-related inquiry (9 questionnaires) were investigated at enrollment. Various severity indices and job change were then investigated for the longitudinal analysis at 12 months after enrollment.

RESULTS

In total, 217 asthma patients completed the study. WRA accounted for 17% (36/217), with an equal number of WEA and OA (18 patients each). Before the work-related survey, only 33% (n = 12) of WRA patients (22% [4/18] of WEA and 44% [8/18] of OA) were diagnosed with WRA by the attending physicians. Compared to the NWRA group and the OA subgroup, the WEA subgroup had more outpatient visits, more oral corticosteroids prescriptions, and trends of low asthma control test scores and severe asthma. The rate of job change was markedly lower in the WEA subgroup than in the OA subgroup (20% vs. 5%).

CONCLUSIONS

The overall prevalence of WRA (17%) was similar to those of previous studies, but the share of WEA was high (50% of WRA). WEA was more severe than OA or NWRA. The possible reason for this severity is ongoing workplace exposure.

Insights from Twitter About Public Perceptions of Asthma, COPD, and Exposures

OBJECTIVE

The aim of this study was to analyze tweets concerning asthma and chronic obstructive pulmonary disease (COPD).

METHODS

Approximately 40,000 tweets containing asthma or COPD were analyzed. Lexical analysis ranked terms and domains of interest, compared COPD with asthma tweets, evaluated co-occurrence of terms within tweets, and assessed differences by source (personal, institutional, or retweet). The frequency of indicator terms relevant to occupational health was determined.

RESULTS

Many tweets address community pollution and effects on children, but there is much less interest in work-related factors and occupational regulatory agencies. Environment is considered much more relevant for asthma than COPD.

CONCLUSION

Although epidemiologic studies demonstrate a major burden of occupational factors upon both diseases, significantly improved outreach is needed to overcome inadequate public interest. Social media represent a valuable resource for assessing perceptions about work-related disease and potentially discovering new associations.

Work-related asthma: A position paper from the Thoracic Society of Australia and New Zealand and the National Asthma Council Australia

Work-related asthma (WRA) is one of the most common occupational respiratory conditions, and includes asthma specifically caused by occupational exposures (OA) and asthma that is worsened by conditions at work (WEA). WRA should be considered in all adults with asthma, but especially those with new-onset or difficult to control asthma. Improvement in asthma symptoms when away from work is suggestive of WRA. Clinical history alone is insufficient to diagnose WRA; therefore, objective investigations are required to confirm the presence of asthma and the association of asthma with work activities. Management of WRA requires pharmacotherapy similar to that of non-WRA, however, also needs to take into account control of the causative workplace exposure. Ongoing exposure will likely lead to decline in lung function and worsening asthma control. WRA is a preventable condition but this does rely on increased awareness of WRA and thorough identification and control of all potential occupational respiratory hazards.

Work-related asthma in the USA: nationally representative estimates with extended follow-up

OBJECTIVE

We studied the associations of working in occupations with high asthma trigger exposures with the prevalence and incidence of asthma, and with ever reporting an asthma diagnosis throughout working life.

METHODS

We used the nationally representative Panel Study of Income Dynamics (1968-2015; n=13 957; 205 498 person-years), with annual reports of occupation and asthma diagnoses across 48 years. We compared asthma outcomes in occupations likely to have asthma trigger exposures with those in occupations with limited trigger exposures. We estimated the prevalence ratios and the incidence risk ratios using log-binomial regression adjusted for age, sex, race/ethnicity, education, and current and past atopy and smoking, and accounting for the survey design and sampling weights. We calculated the attributable risk fractions and population attributable risks, and used multinomial logistic Markov models and microsimulation to estimate the percentage of people ever diagnosed with asthma during working life.

RESULTS

The adjusted prevalence ratio comparing high-risk occupations with low-risk was 4.1 (95% CI 3.5 to 4.8); the adjusted risk ratio was 2.6 (CI 1.8 to 3.9). The attributable risk was 16.7% (CI 8.5 to 23.6); the population attributable risk was 11.3% (CI 5.0 to 17.2). In microsimulations, 14.9% (CI 13.4 to 16.3) with low trigger exposure risk reported asthma at least once, ages 18-65, compared with 23.9% (CI 22.3 to 26.0) with high exposure risk.

CONCLUSION

Adults were more than twice as likely to report a new asthma diagnosis if their occupation involved asthma triggers. Work exposures to asthma triggers may cause or aggravate about 11% of all adult asthma and increase the risk of work-life asthma by 60%.

Use of population data for assessing trends in work-related asthma mortality

PURPOSE OF REVIEW

Work-related asthma has been associated with poorer asthma control and frequent unscheduled healthcare visits, and can be fatal. Case reports of work-related asthma deaths are rare, but can initiate efforts to prevent additional cases. We reviewed relevant literature and data sources to evaluate whether analyzing mortality data at the population level can help identify potential sources of exposures that contribute to work-related asthma.

RECENT FINDINGS

A limited number of population-based studies have addressed work-related asthma mortality. Data on asthma mortality are derived from death certificates using the International Classification of Diseases (ICD) as a standard for coding cause. However, no discrete code for work-related asthma is available. Analysis of asthma mortality relative to industries and occupations appears to identify high-risk jobs that were not identified by analyzing asthma morbidity data.

SUMMARY

Beyond recognized work-related asthma deaths, it is possible that occupational exposures have contributed to other asthma deaths that have gone unnoticed and could potentially be identified by the analysis of mortality data at the population level. Such analyses in the United States appear to assist in recognizing high-risk occupations and industries. Additional analyses would be possible if a work-related asthma ICD code were available.

Review of Diagnostic Challenges in Occupational Asthma

PURPOSE OF REVIEW

Occupational asthma (OA) is one of the most frequent occupational diseases and its diagnosis is often difficult. This review summarizes its current diagnostic challenges.

RECENT FINDINGS

OA is associated with significant health and socio-economic burden. It is underdiagnosed and physicians need to adopt a stepwise approach to confirm the diagnosis. Although early removal from exposure to the offending agent is associated with a better prognosis, physicians should try to confirm the diagnosis of work-related asthma before taking a worker off work. A proper occupational and medical history is very important but is not enough to make the diagnosis of OA. Objective evidence of work-related asthma is required and this represents a serious challenge to most physicians. Measurement of non-specific bronchial responsiveness (NSBR) and spirometry may confirm the diagnosis of asthma but do not confirm the diagnosis of OA. Serial monitoring of peak expiratory flows (PEF), NSBR, and airway inflammation at and off work may confirm the diagnosis of OA but are often difficult to perform. Confirming sensitization by skin prick tests or specific IgE may help to support the diagnosis of OA. Specific inhalation challenges (SIC) in the lab or at work are considered the reference standard but are of limited access. Medical surveillance programs along with primary prevention (reducing exposure) may help to reduce the burden of OA, but the ideal program has yet to be defined. The diagnostic workup of OA remains a challenge and needs a rigorous stepwise evaluation.

Setting Occupational Exposure Limits for Chemical Allergens--Understanding the Challenges

Chemical allergens represent a significant health burden in the workplace. Exposures to such chemicals can cause the onset of a diverse group of adverse health effects triggered by immune-mediated responses. Common responses associated with workplace exposures to low molecular weight (LMW) chemical allergens range from allergic contact dermatitis to life-threatening cases of asthma. Establishing occupational exposure limits (OELs) for chemical allergens presents numerous difficulties for occupational hygiene professionals. Few OELs have been developed for LMW allergens because of the unique biological mechanisms that govern the immune-mediated responses. The purpose of this article is to explore the primary challenges confronting the establishment of OELs for LMW allergens. Specific topics include: (1) understanding the biology of LMW chemical allergies as it applies to setting OELs; (2) selecting the appropriate immune-mediated response (i.e., sensitization versus elicitation); (3) characterizing the dose (concentration)-response relationship of immune-mediated responses; (4) determining the impact of temporal exposure patterns (i.e., cumulative versus acute exposures); and (5) understanding the role of individual susceptibility and exposure route. Additional information is presented on the importance of using alternative exposure recommendations and risk management practices, including medical surveillance, to aid in protecting workers from exposures to LMW allergens when OELs cannot be established.

Prevalence of Work-Related Asthma and its Impact in Primary Health Care

BACKGROUND AND OBJECTIVE

To determine the prevalence of occupational asthma (OA) and work-exacerbated asthma (WEA) among asthmatic patients diagnosed in Primary Health Care (PHC). To analyze the impact at PHC level caused by under-diagnosis and inappropriate referral of OA.

PATIENTS AND METHODS

A descriptive, cross-sectional multicenter study in patients aged between 16 and 64years diagnosed with asthma, according to their medical record; all were working or had worked, and were assigned to one of 16 PHC centers in a healthcare district. Based on the responses to the questionnaire completed at the study visit, which included a thorough review of the subject's entire working history, patients were classified into three categories by an expert in occupational asthma: OA, WEA or common asthma (CA).

RESULTS

Three hundred and sixty-eight patients completed the questionnaire. The prevalence of OA was 18.2% (25% in men and 14.6% in women, P=.046), and 54 patients (14.7%) were classified as WEA. The proportion of patients with work-related asthma (WRA) was therefore 32.9%. Asthmatic patients with WRA took more sick leave than CA patients (P<.001).

CONCLUSIONS

A high prevalence of WRA was found, mostly treated in PHC. Under-diagnosis of WRA is widespread in PHC.

Distribution of asthma by occupation: Washington State behavioral risk factor surveillance system data, 2006-2009

Objective

Objective: To estimate the prevalence of asthma in workers by occupation in Washington State. Methods: Data from the 2006–2009 Behavioral Risk Factor Surveillance System (BRFSS) and the BRFSS Asthma Call-Back Survey (ACBS) in Washington State (WA) were analyzed. Using state-added and coded Industry and Occupation questions, we calculated prevalence ratios (PRs) for 19 occupational groups. Results: Of the 41 935 respondents who were currently employed during 2006–2009, the prevalence of current asthma was 8.1% [95% confidence interval (CI) 7.8–8.5%] When compared with the reference group of executive, administration and managerial occupations, three occupational groups had significantly (p < 0.05) higher PRs of current asthma: “Teachers, all levels, and Counselors’ (PR 1.3, 95% CI 1.1–1. 6%); ‘Administrative Support, including Clerical” (PR 1. 5, 95% CI 1.2–1.9%); and “Other Health Services” (PR 1.5, 95% CI 1.2–1.9). Half of the 2511 ACBS respondent workers (55.1%) indicated that they believed exposure at work had caused or worsened their asthma, but only 10.7% had ever spoken with a health care professional about their asthma being work related. Conclusions: Some occupations have a higher prevalence of current asthma than other occupations. The systematic collection of industry and occupation data can help identify worker populations with a high burden of asthma and can be used to target disease prevention efforts as well as to aid clinician recognition and treatment. Workers indicated that work-related asthma exposures are not discussed with their health care provider and this communication gap has implications for asthma management.

Occupational asthma

Occupational asthma has been defined as asthma due to conditions attributable to work exposures, not to causes outside the workplace. This review focuses on current data on pathogenesis, evaluation, and management.