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LUNGS AT WORK. www.lungsatwork.org.uk. Asthma and employment Trent OH October 2010. Paul Cullinan Imperial College and Royal Brompton Hospital London [email protected] 020 7351 8341. PEGASUS: rationale. pre-employment/pre-placement screening for asthma happens: frequently - PowerPoint PPT Presentation
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Paul CullinanImperial College and Royal Brompton [email protected] 7351 8341
LUNGS AT WORK www.lungsatwork.org.uk
Asthma and employment
Trent OHOctober 2010
PEGASUS: rationale
• pre-employment/pre-placement screening for asthma happens:• frequently• uncertainly• inconsistently• for many different reasons
• available guidance is:• limited• often of uncertain logic• often ‘dated’
• there have been important changes in:• ‘asthma’• attitudes to discrimination• relevant legislation
‘asthma’
• I have asthma• my doctor thinks I have asthma• I had asthma• I sometimes have asthma• I take treatment that is (used) for asthma
‘asthma’
• asthma is variable• people with asthma are not
• most asthma is readily treatable
SOM/SOHN/AOHNPn=664 (30%)
survey: summary
concerns were:• variable• specific• largely predictable• alleviated by experience
logistics re. employing persons with asthma
• OH: screening; monitoring; risk assessment
• employer: fitness; cost
risk of OA exacerbate asthma
sudden attack
risk to others
sickness absence
early retirement
litigation
firefighter 1 3 3 5 2 1 2
police 1 2 4 5 2 2 1
MVRI 3 4 2 2 2 1 3
animal work 3 4 2 1 1–2 2 2
welder or solderer
4 3 2 2 1–3 2 3
diisocyanate work
4 4 4 2 2 2 3
animal work 3–4 4 2 2 2 1–2 3
work with flour 3 4 3 1 3 3 3
any respiratory sensitizer
5 4 2 1 2 1 2
dust, fumes or vapours
2 4 2 1 2 1 2–3
1 none2 mild3 moderate4 very5 extremely
survey: median ‘concern’ scores
evidence review
• does asthma increase the risk of hypersensitive OA?
• how common are workplace irritant responses in asthma?
• do persons with asthma have an increased rate of sickness absence?
• (in current asthma, what is the risk of a future serious event?)
• (in current asthma what is the risk of an unanticipated attack?)
• do people with asthma retire early because of asthma?
• do persons with asthma cost an employer more?
• what are the diagnostic & prognostic values of provocation testing?
• do people with asthma have difficulties wearing breathing apparatus?
evidence review: does asthma increase the risk of hypersensitive OA?
• we don’t know
• atopy does• most people with asthma are atopic• (so are lots of people without asthma)
• studies of asthma do not adjust for atopy
• Canadian animal work apprentices: BHR
evidence review: how common are workplace irritant responses in asthma?
reference setting n prevalent asthma
response rate
workplace aggravation
Saarinen 2003 general population of working persons (Fin)
939 79% 39%
Henneberger 2003
general population of working persons (USA)
64 NA 25%
Henneberger 2006
members of medical insurance plan (USA)
598 61% 41%
Caldeira 2006 birth cohort (Brazil) 227 93% 13%
Axon 1995 adult hospital clinic (UK)
30 97% 31%(≈ OA clinic)
Tarlo 2000 adult hospital clinic (C) 682 NA 7%
Palmer 1997 employees of 4 electronics firms (UK)
21 97% 29%
• common (30%-40%)• real in half• mostly mild (10% more Rx)
• little sector-specific information• related to likely exposure(s)
• no reference• beware ‘aggravation’
reference setting n asthma
response rate
average days sickness in past year
Horn 1989 general practice (UK) 312 58% 8
Jolicoeur 1994
students (US) 51 28% 1.8*
Sørensen 1997
pharmacy customers (DK)
115 NA ~1.5 (estimate)
Ungar 2000 pharmacy customers (C)
386 NA median 0mean 4.4
Sauni 2001 construction workers (Fin)
76 71% 6 (=non-asthma)
Godard 2002 hospital clinic (F) 234 NA 0.03 (mild intermittent)0.58 (mild)5.38 (moderate)8.59 (severe)
Taylor 2005 birth cohort (NZ) 176 NA 3.83
Accordini 2006
general population (I) 527 4.1
Lamb 2006 employees of 27 businesses (USA)
797 NA ~1 (estimate)(3.7 all respondents)
Jansson 2007 general population (S) 115 NA 1.70 (mild intermittent)3.66 (persistent)
evidence review: do persons with asthma have an increased rate of sickness absence?
• essentially, No
• few referenced• skewed
(‘productivity’ data similar)
evidence review: do people with asthma retire early because of asthma?
reference setting n prevalent asthma
response rate
findings
Siebert 2001 Construction workers (D) 757 at baseline
NA No increase in risk vs those without asthma(RR=0.93)
• very little evidence• available, No
• ‘grey’ literature
evidence review: do persons with asthma cost an employer more?
• very little evidence• US• incomplete costings
• Yes, but not for asthma
asthma group non-asthma group
reference asthma other respiratory
other other respiratory
other
Birnbaum 2002 $51 $93 $272 $18 $182
evidence review: what is the value of provocation testing?
‘non-specific’ (histamine/metacholine/mannitol)
• broadly distinguishes current asthma from non-asthma• broadly distinguishes ‘severe’ asthma from ‘not severe’ asthma
• unclear whether it correlates with responses to ‘dust and fumes’
‘more-specific’ (exercise/cold air)
• more difficult to standardise (especially outside hospital)• physical capacity vs asthma
evidence review: what is the value of provocation testing?
I had asthma my asthma went away30%
my asthma will come back30%
3 12 21
26
my asthma will come back85%
histamine test
+ (10%)
-
if it comes back:• it’s usually mild• and easy to manage
in current asthma, what is the risk of future serious events?can they be predicted?
THIN database: 5.5 million patients from 350 participating GP practices in the UK.
past medical history
registration date
1.07.1998 1.07.2000
left practice
“future” exacerbations
qualification window
qualifying date
• aged 16-40 between 1998 and 2000• ≥1 asthma prescription during the qualification window• 5 years pre and post follow up
definitions of exacerbations
‘hospital’ exacerbations• asthma events resulting in attendance at A&E or admission
GP exacerbations• asthma events during out-of-hours consultation or • asthma events suggestive of an emergency exacerbation
‘prednisolone ‘exacerbations• acute prednisolone prescription for asthma • (reliever prescribed within 30 days)
trajectories: findings 1
cumulative risk (%)
years to come: 1st 2nd 3rd 4th 5th
hospital/A&E 0.3 0.6 0.8 1.0 1.2
out-of-hours GP 2.4 3.8 5.1 6.5 8.1
prednisolone 8.3 11.8 14.7 17.3 19.9
trajectories: findings 2
sex age ics
in next 12m: m f 16-24 25-34 35-40 no yes
hospital/A&E 0.2 0.4 0.4 0.3 0.3 0.3 0.5
out-of-hours GP 2.1 2.6 2.4 2.5 2.1 1.7 3.9
prednisolone 7.1 9.2 6.8 8.6 9.9 5.8 14.3
trajectories: findings 2
# ics in past year # events past 5 years years since last exacerbation
in next 12m: 0 1 2 3+ 0 1 2 3+ <1 1-2 2-3 3+
hospital/A&E 0.2 0.3 0.5 1.0 0.3 3.3 17.5 18.8 11.8 8.8 6.5 1.9
out-of-hours GP 1.6 3.9 2.6 5.2 1.7 9.0 12.5 30.8 20.5 11.0 9.2 5.8
prednisolone 6.5 8.2 9.6 15.9 5.9 15.3 24.8 49.5 39.5 22.3 16.2 13.6
trajectories: findings 3
trajectories: findings 4
hospital
year 1
exacerbations (%)
year 2
year 3
year 4
year 5
0.33%
0.27%
0.23%
0.29%
0.25%
represents 0.01%
Results: Exacerbations in the first year post-qualification – summary
• the overall incidence of exacerbations is low
• the (relative) future risk can be related to past experience ...
• those with more asthma prescriptions in the last year
• those with previous exacerbations ...
• ... and those with recent exacerbations
• (women)
• ... but in absolute terms most exacerbations are not predictable