The frequency of workplace exacerbation among health maintenance organisation members with asthma

Hotel building design, occupants' health and performance in response to COVID 19

In the COVID-19 pandemic, the employee realized the importance of a healthy workplace. A healthy workplace provides natural protection against respiratory disease and reduces exposure to viruses. Therefore, the current COVID-19 pandemic should be a wake-up call to understand the importance of building design and a dress rehearsal for future challenges because building-based prevention and control measures have become one of the most significant ways of fighting against the epidemic. This study investigates the role of hotel building design in employee health and performance during the COVID-19 pandemic. The study covered the LEED-certified hotel building in India. The formulated Hypothesis was tested empirically by the structural equation modeling (SEM) for determining the potential of the hotel building design. It was obtained from the study that during the COVID-19 pandemic, the hotel building design of the hospitality industry had a more significant influence on employee performance, followed by employee health.

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.

Development of an Asthma-Specific Job Exposure Matrix for Use in the United States

INTRODUCTION

Existing asthma-specific job-exposure matrices (JEMs) do not necessarily reflect current working conditions in the USA and do not directly function with occupational coding systems commonly used in the USA. We initiated a project to modify an existing JEM to address these limitations, and to apply the new JEM to the entire US employed population to estimate quantitatively the extent of probable work-related asthma exposures nationwide.

METHODS

We started with an asthma-specific JEM that was developed for northern Europe (the N-JEM) and modified it to function with the 2010 US Standard Occupational Classification (SOC-2010) codes and to reflect working conditions in the USA during the post-2000 period. This involved cross walking from the 1988 International Standard Classification of Occupations (ISCO-88) codes used in the N-JEM to the SOC-2010 codes, transferring the N-JEM exposure assignments to the SOC-2010 codes, and modifying those assignments to reflect working conditions in the USA. The new US asthma JEM (USA-JEM) assigns exposures to 19 agents organized into five categories. The USA-JEM and N-JEM were applied to the same sample of working adults with asthma to compare how they performed, and the USA-JEM was also applied to the entire 2015 US working population to estimate the extent of occupational asthma exposures nationally.

RESULTS

The USA-JEM assigns at least one asthma-related probable exposure to 47.5% and at least one possible exposure to 14.9% of the 840 SOC-2010 detailed occupations, and 9.0% of the occupations have both probable exposure to at least one agent and possible exposure to at least one other agent. The USA-JEM has greater sensitivity for cleaning products, highly reactive disinfectants and sterilants, and irritant peak exposures than the N-JEM. When applied to the entire 2015 US working population, the USA-JEM determined that 42.6% of workers had probable exposure to at least one type of occupational asthma agent.

DISCUSSION

A new asthma-specific JEM for application in the USA was developed. Additional work is needed to compare its performance to similar JEMs and, if possible, to exposure assessments generated on a case-by-case basis.

Work-related asthma in a sample of subjects with established asthma

OBJECTIVE

To assess the impact of occupational exposure to irritants or sensitizers on the occurrence, recrudescence and worsening of asthma and to identify unrecognized cases of work related asthma (WRA) including Work-Exacerbated Asthma (WEA) and Occupational Asthma (OA), in a general asthma clinic population sample.

SETTING, DESIGN AND PARTICIPANTS

The study was a population-based cross sectional survey. 1289 asthmatic subjects (from 15 to 46 yrs old) living in a vast district of Tuscany (Italy) were identified from the Medical Reimbursement Register of the National Health System. 893 subjects agreed to take part in the study. Subjects who were currently working or had worked in past were classified in different categories of occupational risk exposure (No, Low or High) according to the italian standard classification for industries and job titles, associated with the judgment of occupational hygiene experts.

RESULTS

41% of subjects worked in industries and in job titles at risk for exposure to airway irritants and/or sensitizers, 48.6% reported an occupational exposure to gases, dust and fumes, more males than females. Prevalence of WEA and OA was higher in subjects who worked at higher risk exposure; these subjects reported a higher prevalence of markers of asthma severity (asthma control, level of treatment, FEV1) than subjects without WRA. Risk of WEA was significantly associated to female gender, older age, and self-reported exposure, while risk of OA was associated to job title with higher exposure risk to occupational asthmogens.

CONCLUSIONS

Our study shows a high prevalence of WRA (especially WEA) associated with employment in industries and job titles at risk for airways sensitizers and/or irritants; data also support a role for occupational exposure in determining a poor asthma control and a higher level of asthma severity.

Occupational exposures associated with severe exacerbation of asthma

BACKGROUND

The exacerbation of asthma by workplace conditions is common, but little is known about which agents pose a risk.

OBJECTIVE

We used data from an existing survey of adults with asthma to identify occupational exposures associated with severe exacerbation of asthma.

DESIGN

Questionnaires were completed by 557 working adults with asthma. Severe exacerbation of asthma in the past 12 months was defined as asthma-related hospitalization, or reports of both unplanned asthma care and treatment with a short course of oral corticosteroids. Occupational exposures for the same time period were assessed using an asthma-specific job exposure matrix. We modeled severe exacerbation to yield prevalence ratios (PRs) for exposures while controlling for potential confounders.

RESULTS

A total of 164 participants (29%) were positive for severe exacerbation, and 227 (40.8%) were assessed as being exposed to asthma agents at work. Elevated PRs were observed for several specific agents, notably the irritant subcategories of environmental tobacco smoke (PR 1.84, 95%CI 1.34-2.51) among all participants, inorganic dusts (PR 2.53, 95%CI 1.37-4.67) among men, and the low molecular weight subcategory of other highly reactive agents (PR 1.97, 95%CI 1.08-3.60) among women.

CONCLUSION

Among working adults with asthma, severe exacerbation was associated with several occupational agents.

Clinical aspects of work-related asthma: past achievements, persistent challenges, and emerging triggers

OBJECTIVE

The aim of this article was to address common clinical questions pertaining to work-related asthma (WRA).

METHODS

This review is based on a presentation on WRA at the American College of Chest Physicians Course on Clinical Aspects of Occupational and Environmental Lung Disease, held in Toronto in 2013, and supplemented by a PubMed search of publications to 2013.

RESULTS

Seven clinical questions are addressed in relation to definitions, causes, diagnosis, management and emerging triggers, and challenges of WRA.

CONCLUSIONS

Although knowledge is expanding in this area, there remain challenges and uncertainties, particularly in the prevention of WRA.

Gender differences in work-related asthma: surveillance data from California, Massachusetts, Michigan, and New Jersey, 1993-2008

OBJECTIVE

To characterize work-related asthma by gender.

METHODS

We analyzed state-based sentinel surveillance data on confirmed work-related asthma cases collected from California, Massachusetts, Michigan, and New Jersey during 1993-2008. We used Chi-square and Fisher's Exact Test statistics to compare select characteristics between females and males.

RESULTS

Of the 8239 confirmed work-related asthma cases, 60% were female. When compared to males with work-related asthma, females with work-related asthma were more likely to be identified through workers' compensation (14.8% versus 10.6%) and less likely to be identified through hospital data (14.2% versus 16.9%). Moreover, when compared to males, females were more likely to have work-aggravated asthma (24.4% versus 13.5%) and less likely to have new-onset asthma (48.0% versus 56.5%). Females were also more likely than males with work-related asthma to work in healthcare and social assistance (28.7% versus 5.2%), educational services (11.8% versus 4.2%), and retail trade (5.0% versus 3.9%) industries and in office and administrative support (20.0% versus 4.0%), healthcare practitioners and technical (13.4% versus 1.6%), and education training and library (6.2% versus 1.3%) occupations. Agent groups most frequently associated with work-related asthma were miscellaneous chemicals (20.3%), cleaning materials (15.3%), and indoor air pollutants (14.9%) in females and miscellaneous chemicals (15.7%), mineral and inorganic dusts (13.2%), and pyrolysis products (12.7%) in males.

CONCLUSIONS

Among adults with work-related asthma, males and females differ in terms of workplace exposures, occupations, and industries. Physicians should consider these gender differences when diagnosing and treating asthma in working adults.

Work-related exacerbation of asthma among adults treated by pulmonary specialists

The most common chronic occupational lung disease is occupational asthma. This study aimed to assess the prevalence of work-related respiratory symptoms (WRS) in asthmatic adults at pulmonary clinics. A cross-sectional study was performed. Current employed subjects were subdivided into 2 groups by WRS status according to questionnaire mainly based on one developed by the National Institute for Occupational Safety and Health (NIOSH). Subjects' occupation and workplace exposures were evaluated by asthma-specific job exposure matrix (JEM). Thirty-nine of 179 current employed asthmatics had WRS. Subjects with WRS were more likely to have self-reported allergy and exposure to low-molecular-weight antigens (prevalence ratio [PR]: 2.7). The 2 most frequent occupational classes for asthmatics with WRS were trades, transport and equipment operators, and processing and manufacturing. Self-reported allergy, high-risk exposures, and occupations unique to processing, manufacturing, and utilities were estimated to be risk factors of WRS.

Work aggravated asthma; a review of the recent evidence

BACKGROUND

The link between asthma and inhaled workplace exposures has been long appreciated, and yet aggravation of asthma symptoms by work conditions, known as work-aggravated asthma (WAA), remains relatively common.

SOURCES OF DATA

A review of the literature published over the last 3 years was carried out, and additional key articles were included from outside this timeframe.

AGREEMENT

WAA is commonly reported by workers with asthma. One published assessment of 12 studies identified a median prevalence of 21.5% among workers with asthma. Commonly reported causes included a variety of inhaled dusts, smoke, vapours, fumes, gases and mists, common and workplace-specific aeroallergens, physical environmental factors including temperature and humidity and physical activity at work.

CONTROVERSY

Remains in relation to definition, and how to distinguish WAA from occupational asthma in which there is sensitization to an agent in the workplace. Both these areas, and the development of workplace interventions to reduce WAA, are timely topics for future research.

Middle-aged men with asthma since youth: the impact of work on asthma

OBJECTIVES

To evaluate current occupational exposure and its associations with asthma control, exacerbations, and severity in middle-aged men with asthma from youth.

METHODS

We used the Finnish Defence Force registers, 1986 to 1990, to select conscripts with asthma to represent mild or moderate asthmatic group (asthma group 1; N = 505), men who were exempted from military service to represent relatively severe asthmatic group (asthma group 2; N = 393), and a control group without asthma (N = 1500). A questionnaire was sent out in 2009.

RESULTS

The current self-reported or expert-evaluated exposure to asthma-aggravating factors differed only slightly between the asthmatic groups and the controls. In asthma group 2, being a manual worker or self-employed (odds ratio, 4.5; 95% confidence interval, 1.2 to 16.3) significantly associated with asthma exacerbations.

CONCLUSIONS

Current work may associate with the asthma outcome of middle-aged men with relatively severe asthma in their youth.

A comparison of work-exacerbated asthma cases from clinical and epidemiological settings

BACKGROUND

Clinical and epidemiological studies commonly use different case definitions in different settings when investigating work-exacerbated asthma (WEA). These differences are likely to impact characteristics of the resulting WEA cases.

OBJECTIVES

To investigate this issue by comparing two groups of WEA cases, one identified using an intensive clinical evaluation and another that fulfilled epidemiological criteria.

METHODS

A total of 53 clinical WEA cases had been referred for suspected work-related asthma to two tertiary clinics in Canada, where patients completed tests that confirmed asthma and ruled out asthma caused by work. Forty-seven epidemiological WEA cases were employed asthma patients treated at a health maintenance organization in the United States who completed a questionnaire and spirometry, and fulfilled criteria for WEA based on self-reported, work-related worsening of asthma and relevant workplace exposures as judged by an expert panel.

RESULTS

Using different case criteria in different settings resulted in case groups that had a mix of similarities and differences. The clinical WEA cases were more likely to have visited a doctor's office ≥3 times for asthma in the past year (75% versus 11%; P<0.0001), but did not seek more asthma-related emergency or in-patient care, or have lower spirometry values. The two groups differed substantially according to the industries and occupations where the cases worked.

CONCLUSIONS

Findings from both types of studies should be considered when measuring the contribution of work to asthma exacerbations, identifying putative agents, and selecting industries and occupations in which to implement screening and surveillance programs.

Diagnosis and frequency of work-exacerbated asthma among bakers

BACKGROUND

Work-exacerbated asthma (WEA) is asthma worsened by workplace exposures, although the asthma is not caused by sensitizers in the work environment.

OBJECTIVES

To evaluate the frequency of WEA in bakers reporting work-related respiratory symptoms and the usefulness of diagnostic tests in differentiating WEA from occupational asthma (OA).

METHODS

The study group included 393 bakers reporting respiratory symptoms at the workplace. In all patients, questionnaire, spirometry, skin prick tests (SPTs), and evaluation of serum total and specific IgE levels were performed. Recognition of OA was based on a specific inhalation challenge test.

RESULTS

Occupational asthma was found in 44.5% of patients, whereas WEA was recognized in 16%. The latency period was 11.2 ± 8.2 years in patients with OA vs 13.3 ± 9.7 years in those with WEA. Sixty percent of patients with OA and 50.8% of those with WEA had positive SPT reactions to common allergens; occupational SPT results were positive in 74.9% and 34.9%, respectively. Specific IgE to flours were found in 61.7% of patients with OA and 28.6% of those with WEA. In addition, OA frequently coexisted with occupational rhinitis (53.7% of patients), whereas WEA and rhinitis were found in 31.7% of patients.

CONCLUSION

Work-exacerbated asthma was diagnosed in 16% of bakers who reported allergic respiratory symptoms. The specific challenge test for occupational allergens should be performed in bakers with suspected work-related asthma, because an assessment of sensitization (SPT to occupational allergens, evaluation of specific IgE) is not specific enough to differentiate OA from WEA.

Work-exacerbated asthma

A task force of the American Thoracic Society has defined work-exacerbated asthma (WEA) as the worsening of asthma caused by conditions at work. Occupational asthma (OA) is asthma that is initiated by occupational exposures in people without prior asthma. In contrast, WEA is asthma (already present or coincident [new onset]) that is worsened because of conditions at work. This difference is critical because asthma is a common disease (present in approximately 7% of working adults). Among working adults with asthma, approximately 20% may have WEA. WEA has potential implications regarding asthma morbidity, health care use, and the economy.

Respiratory symptoms and respiratory-related absence from work among health care workers in Sweden

OBJECTIVE

To investigate respiratory symptoms and respiratory-related absence from work among Swedish health care workers (HCWs).

METHODS

From a postal questionnaire study among a general Swedish working population (n = 12,186), we identified 2156 HCW (555 assistant nurses, 377 nurses, 109 physicians, and 1115 others), including 429 with mainly cleaning tasks (HCW-cleaning). The remaining respondents were classified as non-HCW. Multiple logistic regressions with 95% confidence intervals (CIs) were used to compare respiratory symptoms and respiratory-related absence from work between HCW and non-HCW, adjusting for potential confounders.

RESULTS

The prevalence of adult onset asthma was 4.3% in HCW and 3.0% in non-HCW (p = .003). Asthmatic symptoms during the past year were reported mainly by HCW-cleaning, 14.7%, in comparison to 8.3% among non-HCW (p < .0001). HCW had an increased odds ratio (OR) for asthmatic symptoms during the past year (OR 1.3, 95% CI (1.1-1.5)) and more prominent among assistant nurses (OR 1.5, 95% CI (1.1-2.0)) and HCW-cleaning (OR 1.9, 95% CI (1.4-2.5)). Respiratory-related absence from work in the past year was reported by 1.4% of non-HCW, 3.0% of HCW-cleaning, 2.9% of nurses, and 1.6% of assistant nurses. Taking smoking and age into account, there was still significantly increased respiratory-related absence from work in nurses (OR 2.0, 95% CI (1.1-3.8)) and in HCW-cleaning (OR 2.1, 95% CI (1.2-3.7)).

CONCLUSIONS

HCW in Sweden, especially those with cleaning tasks, reported more respiratory symptoms and respiratory-related absence from work than the general working population. There is a need for longitudinal studies with detailed information on both occupational exposures and socioeconomic factors to explore what influences respiratory-related absence from work among HCW.

RADS and its variants: asthma by another name

This article describes the different clinical variants of irritant-induced asthma, specifically focusing on high-dose irritant-induced asthma and irritant-induced work-exacerbated asthma, as well as reviews known causes, addresses the often adverse medical and socioeconomic outcomes of this complex condition, and considers issues of causation from an occupational and environmental medicine perspective.

Asthma symptoms among adults with work-related asthma

Objective. To examine the number of days with asthma symptoms among individuals with work-related asthma (WRA) and non-WRA. Methods. We calculated adjusted prevalence ratios and compared mean number of days with asthma symptoms using 2006-2009 Behavioral Risk Factor Surveillance System Asthma Call-back Survey data for ever-employed adults with current asthma from 38 states and District of Columbia. Results. Compared with persons with non-WRA, those with WRA had higher mean number of days with asthma symptoms. Regardless of WRA status, individuals with higher number of days with asthma symptoms were more likely to be unable to work or carry out their usual activities due to asthma. Associations between frequency of asthma symptoms and activity limitation due to asthma were weaker among currently employed adults and stronger among adults not currently employed than the observed associations for all ever-employed adults. Conclusions. These results suggest higher frequency of asthma symptoms among adults with WRA and underscore the need for optimal asthma management in individuals with WRA.

Socioeconomic impact of work-related asthma

Work-related asthma (WRA) accounts for 10-15% of adult asthma. This review will summarize the available information related to the socioeconomic outcomes inherent to WRA. A substantial proportion of subjects suffering from WRA experience prolonged work disruption and subsequent loss of income. Moreover, recent studies have established that WRA is associated with a higher use of healthcare resources and a lower quality of life than asthma unrelated to work. The negative socioeconomic consequences are mostly influenced by professional and demographic factors, including reduced possibilities for relocation to an unexposed job within the same company, lack of effective retraining programs and low level of education. These socioeconomic considerations should be regarded as a central component in the implementation of rational management and prevention policies.

The epidemiology of work-related asthma

Much has been learned from epidemiologic studies conducted in the past 4 decades that can be directly applied to the management of workers affected with occupational asthma. Studies have provided information about host factors, environmental exposure, and occupational agents posing the highest risks for development of severe irreversible airway obstruction and asthma disability. Investigators have developed methods for screening workers at risk and novel interventions that may prevent new cases among exposed worker populations. Less is known about the natural history and chronic morbidity associated with work-aggravated asthma and irritant-induced asthma syndromes; more studies are needed in at-risk worker populations.

Work-related asthma: a case-based approach to management

The management of work-related asthma has some differences from management of other asthma. Components of management include not only making as accurate a diagnosis as possible, identifying the causative agent or triggers at work, and managing the asthma with pharmacologic treatment as for other patients with asthma, but also advising on the appropriate work changes that may be needed, assisting the worker with appropriate compensation claims, and supporting protective measures for coworkers. This article discusses the approaches that may be taken for patients with different forms of work-related asthma.

An official american thoracic society statement: work-exacerbated asthma

RATIONALE

Occupational exposures can contribute to the exacerbation as well as the onset of asthma. However, work-exacerbated asthma (WEA) has received less attention than occupational asthma (OA) that is caused by work.

OBJECTIVES

The purpose of this Statement is to summarize current knowledge about the descriptive epidemiology, clinical characteristics, and management and treatment of WEA; propose a case definition for WEA; and discuss needs for prevention and research.

METHODS

Information about WEA was identified primarily by systematic searches of the medical literature. Statements about prevention and research needs were reached by consensus.

MEASUREMENTS AND MAIN RESULTS

WEA is defined as the worsening of asthma due to conditions at work. WEA is common, with a median prevalence of 21.5% among adults with asthma. Different types of agents or conditions at work may exacerbate asthma. WEA cases with persistent work-related symptoms can have clinical characteristics (level of severity, medication needs) and adverse socioeconomic outcomes (unemployment, reduction in income) similar to those of OA cases. Compared with adults with asthma unrelated to work, WEA cases report more days with symptoms, seek more medical care, and have a lower quality of life. WEA should be considered in any patient with asthma that is getting worse or who has work-related symptoms. Management of WEA should focus on reducing work exposures and optimizing standard medical management, with a change in jobs only if these measures are not successful.

CONCLUSIONS

WEA is a common and underrecognized adverse outcome resulting from conditions at work. Additional research is needed to improve the understanding of the risk factors for, and mechanisms and outcomes of, WEA, and to inform and evaluate preventive interventions.

Occupational and work-exacerbated asthma: similarities and differences

Over the years, there have been tremendous efforts to improve the understanding of occupational asthma (OA), whereas work-exacerbated asthma (WEA) has been somewhat overlooked. The aim of this work is to review the literature, comparing the prevalence of OA and WEA, their clinical and inflammatory characteristics, as well as the work environment of those suffering from OA and WEA. We performed a PubMed search up to September 2006 using the keywords: work-related asthma, WEA, work-aggravated asthma and OA. Only studies in English were included for consideration. We found that OA and WEA are prevalent conditions. The characteristics of subjects with OA and WEA vary according to the type of studies undertaken to describe these conditions. Many sensitizing agents have been reported to cause OA, whereas exposures to irritant agents seem to be associated with the occurrence of WEA. The inflammatory profile may differ between these two conditions, but the data are too limited and sometimes too contradictory to allow a firm conclusion to be drawn. The socioeconomic outcome of these conditions seems similar. Therefore, further studies investigating the prevalence of WEA, as well as its clinical, functional and inflammatory characteristics, are needed to improve the management of the workers with WEA.

Prevalence of work-related asthma in Michigan, Minnesota, and Oregon

INTRODUCTION

Adults who have asthma that is caused or aggravated by triggers at work experience a reduced quality of life. In this study, the authors sought to estimate the proportion of asthma that is associated with work using a state-based survey of adults with asthma.

METHODS

In 2005, Michigan, Minnesota, and Oregon piloted the Behavioral Risk Factor Surveillance System Adult Asthma Call-Back Survey, with sample sizes of 867, 469, and 1072, respectively. Six questions addressing work-related asthma (WRA) were analyzed to generate estimates of the proportion of adult asthma that is work-related and compare those with and without WRA.

RESULTS

Over half of all adults with asthma (53%) reported that their asthma was caused or made worse by any job they ever had, and among these respondents reporting WRA, only 21.5% to 25.1% reported ever telling or being told by a health professional that their asthma was work-related. Additionally, adults with WRA consistently reported poorer asthma control and higher health care utilization than adults with non-WRA.

CONCLUSIONS

WRA is a common but frequently unrecognized health problem, and this lack of recognition might contribute to poorer asthma control among adults with WRA. Because early recognition, treatment, and management of WRA are crucial for improving long-term prognosis, clinicians need to include assessment of workplace triggers in both their diagnostic and treatment plans for adult patients with asthma.

Management of work-related asthma

The physician managing work-related asthma (WRA) assumes many roles. The first is to confirm an accurate diagnosis, recognizing that WRA has multiple phenotypes, including sensitizer-induced occupational asthma (OA) caused by high-molecular-weight (HMW) proteins or low-molecular-weight (LMW) chemicals; irritant-induced asthma; and work-exacerbated asthma. Pharmacotherapy for WRA is identical to nonwork-related asthma and should be guided by current asthma guidelines emphasizing control of both asthma impairment and risk domains. It is well established that the majority of workers diagnosed with OA caused by sensitizers experience persistent asthma after leaving the workplace. However, the long-term risk of persistent unremitting asthma can be prevented in a minority of cases, particularly with OA caused by LMW sensitizers, by establishing an early diagnosis of OA and reducing or eliminating exposure. The physician consultant may advise employers on workplace interventions needed to minimize effectively an affected employee's exposure to a causative agent or condition, and what measures are required to prevent new cases of WRA (ie, primary prevention). Although allergen immunotherapy has a putative role in treating and preventing WRA caused by HMW sensitizers, further study is needed.

Occupational exposures and adult asthma

Occupational exposures can cause a new onset of asthma in a subset of susceptible workers on the basis of sensitization to a specific work agent or a high-level irritant exposure. Epidemiologic studies give insight into the natural history of occupational asthma, including host factors and environmental factors leading to the development of occupational asthma, the progression, and the potential role of preventive measures. Work-exacerbated asthma has been a focus of studies only recently but is recognized as common among asthmatic workers and is a potential cause of significant morbidity and socioeconomic impact.

Diagnosis and management of work-related asthma: American College Of Chest Physicians Consensus Statement

BACKGROUND

A previous American College of Chest Physicians Consensus Statement on asthma in the workplace was published in 1995. The current Consensus Statement updates the previous one based on additional research that has been published since then, including findings relevant to preventive measures and work-exacerbated asthma (WEA).

METHODS

A panel of experts, including allergists, pulmonologists, and occupational medicine physicians, was convened to develop this Consensus Document on the diagnosis and management of work-related asthma (WRA), based in part on a systematic review, that was performed by the University of Alberta/Capital Health Evidence-Based Practice and was supplemented by additional published studies to 2007.

RESULTS

The Consensus Document defined WRA to include occupational asthma (ie, asthma induced by sensitizer or irritant work exposures) and WEA (ie, preexisting or concurrent asthma worsened by work factors). The Consensus Document focuses on the diagnosis and management of WRA (including diagnostic tests, and work and compensation issues), as well as preventive measures. WRA should be considered in all individuals with new-onset or worsening asthma, and a careful occupational history should be obtained. Diagnostic tests such as serial peak flow recordings, methacholine challenge tests, immunologic tests, and specific inhalation challenge tests (if available), can increase diagnostic certainty. Since the prognosis is better with early diagnosis and appropriate intervention, effective preventive measures for other workers with exposure should be addressed.

CONCLUSIONS

The substantial prevalence of WRA supports consideration of the diagnosis in all who present with new-onset or worsening asthma, followed by appropriate investigations and intervention including consideration of other exposed workers.

Work-related asthma in the educational services industry: California, Massachusetts, Michigan, and New Jersey, 1993-2000

OBJECTIVES

To characterize work-related asthma (WRA) cases working in the educational services industry identified by state-based occupational disease surveillance systems.

METHODS

We examined 2,995 WRA cases reported from 1993 to 2000 to four states: California, Massachusetts, Michigan, and New Jersey.

RESULTS

A total of 265 (9%) WRA cases were employed in the educational services industry; 69% of cases were classified as new-onset asthma and 31% as work-aggravated asthma. New-onset asthma cases were further classified as occupational asthma (61%) or as reactive airways dysfunction syndrome (8%). The most frequently reported occupation was teachers and teachers' aides (54%). The most frequently reported agents were indoor air pollutants (28%), unspecified mold (16%), dusts (14%), and cleaning products (7%).

CONCLUSIONS

Asthma within the educational services industry is an occupational health problem. The health of school employees should also be considered when initiatives addressing asthma among schoolchildren are instituted. The identification, elimination, and/or control of respiratory hazards are important factors for the protection of staff and students alike.

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.

Socioeconomic outcomes in work-exacerbated asthma

PURPOSE OF REVIEW

Work-exacerbated asthma has received little attention until recent years, although it is likely that the condition has a considerable societal impact because of its high prevalence. The purpose of this review is to provide a critical analysis of recently published data pertaining to the socioeconomic outcomes of work-exacerbated asthma.

RECENT FINDINGS

Recent data have confirmed that work-exacerbated asthma is associated with a similar impact on work productivity and earning capacity as immunologically mediated occupational asthma. The specific impact of work-exacerbated asthma on these outcomes should be further distinguished from the consequences of asthma unrelated to work. There is some suggestion that work-exacerbated asthma might be associated with higher rates of symptoms and exacerbations when compared with asthma unrelated to work. The impact of work-exacerbated asthma in terms of disease severity and healthcare utilization should therefore be further characterized.

SUMMARY

The socioeconomic impact of work-exacerbated asthma should be taken into account in the management of this common, although often underestimated, condition. In addition, evaluating the economic burden of work-exacerbated asthma and its various components is a key step in implementing cost-effective prevention policies.

Work-exacerbated asthma

PURPOSE OF REVIEW

To summarize recent findings on work-exacerbated asthma, based on medical literature published during 2005 and the first 10 months of 2006.

RECENT FINDINGS

Although prevalence estimates varied considerably among six recent epidemiologic studies, collectively they contribute to the conclusion that work-exacerbated asthma is common. Median work-exacerbated asthma prevalence estimates were 18% of adults with asthma, 25% of working adults with asthma and 45% of all work-related asthma cases. Work-exacerbated asthma can result from a variety of occupational triggers, including physical factors (e.g. extreme temperatures, exercise), behavioral states (e.g. strong emotions, stress), odors (e.g. perfume), general irritants and dust, and second-hand cigarette smoke. Work-exacerbated asthma cases have many of the same demographic and clinical traits as other adults with asthma and occupational asthma cases, although some differences have been reported. Recent review articles have offered some recommendations on the management of work-exacerbated asthma, but more comprehensive advice is anticipated from a professional medical society in the next few years.

SUMMARY

Epidemiologic studies indicate that work-exacerbated asthma is common. Researchers have started to pay attention to work-exacerbated asthma, but more studies are needed on all aspects of this condition in order to improve diagnosis, management and prevention.

New insights into occupational asthma

PURPOSE OF REVIEW

To examine recent publications on the types of agents involved in occupational asthma, the mechanisms by which they induce asthma, and how best to evaluate and treat workers suspected of this respiratory condition.

RECENT FINDINGS

High rates of occupational asthma and inhalation accidents were found in workers in crafts and related occupations in the manufacturing industries, and in plant and machine operatives; cleaners and construction workers may also be at risk. Further data support a role for CD4 T cells in low-molecular-weight agent-induced asthma, such as with isocyanates, and neurogenic mechanisms may also be involved. The use of noninvasive measures of airway inflammation in the diagnosis and management of occupational asthma such as sputum eosinophils monitoring is promising, although this is less obvious for exhaled nitric oxide. Finally, the persistence of troublesome asthma even after withdrawal from relevant exposure has been re-emphasized and surveillance programs have been proposed.

SUMMARY

Further data have been gathered on the prevalence of occupational asthma in various working populations, its mechanisms of development, the contribution of noninvasive measures of airway inflammation in the diagnosis and management of this condition, and its management and prevention.

The validation of work-related self-reported asthma exacerbation

OBJECTIVE

To determine the validity of work-related self-reported exacerbation of asthma using the findings from serial peak expiratory flow (PEF) measurements as the standard.

METHODS

Adults with asthma treated in a health maintenance organisation were asked to conduct serial spirometry testing at home and at work for 3 weeks. Self-reported respiratory symptoms and medication use were recorded in two ways: a daily log completed concurrently with the serial PEF testing and a telephone questionnaire administered after the PEF testing. Three researchers evaluated the serial PEF records and judged whether a work relationship was evident.

RESULTS

95 of 382 (25%) working adults with asthma provided adequate serial PEF data, and 13 of 95 (14%) were judged to have workplace exacerbation of asthma (WEA) based on these data. Self-reported concurrent medication use was the most valid single operational definition, with a sensitivity of 62% and a specificity of 65%.

CONCLUSIONS

A work-related pattern of self-reported asthma symptoms or medication use was usually not corroborated by serial PEF testing and failed to identify many people who had evidence of WEA based on the serial PEF measurements.