Work-Related Asthma: An Employer

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Work-Related Asthma An Employers Guide for
Prevention, Identification and Control

• Susan Blonshine RRT, RPFT, FAARC, AE-C
• Debra Chester, MS
• Mary Jo Reilly, MS
• Kenneth Rosenman, MD

2
Test Your Knowledge of Work-Related Asthma (Yes
or No)

• 1. Can cigarette smoking cause asthma?
• 2. Can workers develop asthma from exposures lt
  MIOSHA permissible limits?
• 3. Will a baseline medical exam prevent people
  from being placed into jobs where they would
  develop work-related asthma?

3
Test Your Knowledge of Work-Related Asthma (Yes
or No)

• 4. Will transferring a worker with asthma to a
  different job in a company always take care of
  the problem?
• 5. Can you attribute new asthma in a long term
  worker to work, if he/she never had asthma
  before?
• 6. Can a worker with asthma symptoms that happen
  at night, not at work, attribute their asthma to
  work?

4
Michigan Worker Dies 2003

• Isocyanate cause of worker death
• www.oem.msu.edu\MiFace\03MI018.pdf

5
Michigan Worker Dies 2003
6
Objectives

• Asthma basics and diagnostic assessment.
• How is it related to your workplace?
• What is the cost of asthma to you?
• What can you do to identify, prevent, and control
  asthma in your workplace?
• Health and Safety Program
• Medical Surveillance Program
• Where can you go for more information?

7
What substances do you work with?
8
Asthma Basics

• Chronic inflammatory disorder of airways
• With recurrent episodes of
• wheezing
• breathlessness
• chest tightness
• and/or coughing
• particularly at night or in the early morning

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An Asthma Attack

• Irritation and swelling of airway
• Airways narrow, mucus produced
• Breathing gets more difficult
• Attacks vary, can develop immediately or later
  (4-8 hours) after the exposure
• Symptoms may include

• Coughing
• Breathing speeds up
• Wheezing

• Air hunger
• Depression of chest tissue
• Grayness of lips, fingertips
• Inability to talk or be active

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Airways
It all comes down to breathing through a smaller
tube!
11

• EVEN A PERSON WITH MILD ASTHMA CAN DIE FROM AN
  ASTHMA ATTACK!

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Diagnostic Assessment

• Skin testing and/or specific IgE assessment
• Pulmonary function tests
• Methacholine testing
• Peak flow monitoring
• Relate to work environment

13
Relate to Work Environment

• Some things cause asthma (sensitizers)
• Some things trigger asthma attacks (irritants)

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Causes of Asthma

• Out of workplace (cats, dust mites)
• Workplace (including acute overexposures to
  irritants)
• Viral infections
• Unknown

15
Substances Causing Work-Related Asthma (WRA)

• 1980 200 causes of WRA identified
• There are over 2,000 new substances developed
  each year most have not been tested whether they
  cause asthma
• 2006 405 natural and synthetic causes
  identified and the list is growing

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Identify Causes (Sensitizers)

• Use website to identify known causes
• www.asmanet.com/asmapro/asmawork.htm
• Handout
• List of 400 causes

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Causes of WRA

• Natural Products
• Flour
• Grain dusts
• Moldy compost or hay
• Animals
• Soybeans
• Natural glues

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Causes of WRA

• Synthetics
• Organics
• Inorganics
• Pharmaceuticals
• Miscellaneous

This brochure can be found at www.oem.msu.edu/Res
ources/Asthmabrochure.pdf
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Causes of WRA

• Organics
• Diisocyanates
• TDI, MDI, HDI
• Anhydrides
• Phthalic
• Amines
• Ethanolamine

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Causes of WRA

• Inorganics
• Platinum
• Nickel salts
• Chromium salts

• Pharmaceuticals
• Psyllium
• Penicillin
• Tetracycline
• Ampicillin

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Causes of WRA

• Miscellaneous
• Formaldehyde
• Organophosphorus insecticides
• Products of heated adhesives

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Patterns of Severity Asthma Symptoms by Duration
of Exposure
Severity of Symptoms
Duration of Exposure
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Patterns of Symptoms

• Co-workers may have similar symptoms
• Timing of symptoms
• Initial symptoms may occur after high-level
  exposure (e.g. spill or leak)
• Improvement during vacations or days off
• may take a week or more

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Triggers
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Triggers of Asthma Attacks

• Chemicals/Dusts
• Cleaning agents
• Paint
• Animals/Insects/Molds
• Secondhand smoke
• Exercise (90 of asthmatics)
• Weather (cold, hot, wind)
• Stress (laugh, cry, fear)
• Medication (aspirin, blood pressure medications)
• Respiratory infections
• Scented products

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Fatal Asthma Attack Triggered by Secondhand Smoke
in Michigan
Cigarettes can aggravate, not cause, asthma.
A report of this WRA fatality can be found
at www.oem.msu.edu/MiFace/04MI223.pdf
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Fatal Asthma Attack Triggered by Secondhand Smoke
in Michigan

• 19-year-old female waitress worked in a bar

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Fatal Asthma Attack Triggered by Secondhand Smoke
in Michigan
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What is Work-Related Asthma?

• Asthma caused by exposure to an agent encountered
  in the work environment
• Most common occupational respiratory disorder in
  industrialized countries
• History of allergies and/or tobacco smoking may
  increase the risk of sensitization in some
  workers in specific occupations, e.g. snow
• crab processing
• Global Initiative for Asthma,
  National Institutes of Health, 2002.

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How Do We Find Out About WRA in Michigan?

• MI Occupational Disease Reporting Law 1978
• Known/suspected occupational diseases must be
  reported to the MDLEG within 10 days of diagnosis
• Special follow-up of respiratory problems -
  MIOSHA in collaboration with MSU since 1988
• Visit worksites to better understand the
  magnitude of and exposures associated with asthma
  from work
• www.oem.msu.edu/asthma/05Asthma_all.pdf

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Highlights of the OD Reporting Law

• Reporting by
• Physicians
• Hospitals and Clinics
• Employers
• Any work-related health condition must be
  reported
• Reports submitted
• By fax
• By mail
• By email
• Electronically _at_
• www.oem.msu.edu

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What Have We Learned

• Manufacturing 68
• Services 18
• Trade 4
• Construction Mining 3
• Miscellaneous 6

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Top 10 Exposures of MI WRA Cases

• Isocyanates 16
• Metal Working Fluids 12
• Manufacturing Agents 8
• Cleaning Agents 7
• Office Exposures 7
• Exhaust/Fumes 6
• Welding Fume 5
• Solvents 3
• Latex 3
• Epoxy 2

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What Have We Learned

• Out of every 5 workers
• One worker will experience daily or weekly
  shortness of breath, wheezing or chest tightness
  

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Lessons Learned Over a 14 Year Period of
Investigations

• Management commitment is key to solving health
  and safety issues
• Sensitization occurs
• despite exposure to low levels of an allergen
• from leaks, spills, and acute exposures
• Preventive Maintenance activities - ventilation,
  equipment, high pressurized lines, etc - is
  critical

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Cost to the Workplace

• What does it cost the employer?

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Asthma in Workers is Costly to Employers

• Annual per capita costs for employers of a worker
  with asthma estimated at 5385
• Disability from asthma costs 3x other
  disabilities
• Annual costs of WRA in U.S. estimated at 1.1
  2.1 Billion

Birnbaum et al 02, Leigh et al 02
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Consider That

• More individuals with asthma are entering the
  workplace1 out of every 10 workers will have
  asthma
• Range 4-58 WRA within specific industries
• ADA
• Am J Resp Crit Care Med 2003167787-791

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Direct Costs are the Tip of the Iceberg!

• Indirect costs can be 5-50 times the direct cost!

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Missed Work/School in the Past Year Due to Asthma
49
32
25
Base All respondents (unweighted N2509).
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Look at the Numbers for Medical Follow-up Since
WRA Diagnosed

• 58 had an ER visit
• Average visits to ER 6/person
• 35 had a Hospitalization
• Average hospitalizations 4/person

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Work-Related Asthma

• What can we do?

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Your Role
Safety and Health Program
Workplace Assessment
Workplace Control
Medical Surveillance
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What Can We Do?

• Promote Safety and Health Culture
• Develop Health Safety (HS) Program
• General Industry
• www.michigan.gov/documents/CIS_WSH_sp02_778
  90_7.doc
• Construction
• www.michigan.gov/documents/CIS_WSH_CET_SP1_
  64019_7.doc
• Assess the Workplace
• Develop Corrective/Control Strategies
• Educate Employees
• Institute a Medical Surveillance Program
• Re-evaluate

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Promote a Positive HS Culture
Management actions are the driving force

• Dont talk the talk if you wont walk the
  walk

Resource Fostering Employee Participation in
Health and Safety -Kate Bertrand www.nsc.org/basic
s/participation.htm
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HS Program Development

• Step 1 Develop a plan of action that includes
  both Management Employee Involvement
• Step 2 Designate a person to be responsible
  for the HS program
• Step 3 Determine HS requirements
• Step 4 Conduct a Hazard Assessment
• Step 5 Correct/Control identified hazards
• Step 6 Train Employees
• Step 7 Schedule periodic evaluations
• Step 8 Re-Evaluate program Up-to-date,
  effective?

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Step 1Develop a Plan of Action

• Write a H S Policy Statement www.nsc.org/public/
  code_ethics.pdf
• H S philosophy
• H S program objectives
• Employee (and others) responsibilities
• Resource UKs Health and Safety Executive Tips
  for Worker Involvement www.hse.gov.uk/involvement
  /
• Establish Health and Safety Committee
  www.nsc.org/basics/safetyteam.doc

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Not a Job for the HS Committee
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Step 2Designate a Person for S H

• MUST HAVE
• Authority to do the job
• Respect of both Mgt and Employees
• Knowledge of the facility and its processes
• Time and Resources to develop and implement
  program

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Step 3Determine HS Requirements

• Benefits
• Develop hazard assessment strategy
• Pinpoint areas and procedures that historically
  have caused significant injury or illness, and
  identify potential causes
• Provide background for correction and control
  strategy planning

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Where to Find HS Information

• MIOSHA Laws, Regulations and Standards
  www.michigan.gov/mioshastandards
• Product Literature
• Equipment manuals, User Guides
• Industry Publications
• Chemical Inventory
• MSDS, Right to Know
• Employee Information
• Accident Injury/Illness History
• MIOSHA 300 log, Compensation claims, Exposure
  records, Worsening symptoms at work, Missed work
  days
• Existing Safety Health Materials

52
MSDS Where to Find Health Information

• Section II Composition/Data
• Section III Hazards Identification
• Section VIII Exposure Controls and Personal
  Protection
• Section XI Toxicological Information
• Section XV Regulations
• Section V Firefighting Measures
• Section VI Accidental Release Measures
• Section X Stability and Reactivity

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Its Not That Easy!

• Breathing problems
• Allergic reaction
• Respiratory irritant
• Irritation of trachea
• Cough, wheeze, shortness of breath
• Sensitizer

MOST LIKELY THE MSDS WILL NOT SAY CAUSES OR
TRIGGERS ASTHMA
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Step 4Conduct Hazard Assessment

• -Identify Evaluate
• Hazards that may affect worker health
• Activities likely to expose workers to hazards
• Housekeeping, Maintenance, Equipment repair,
  Hazards likely to occur, Emergency situations
• Employee routes of and exposure levels to the
  hazard
• Use of personal protective equipment
• Control systems to eliminate or reduce exposure
• Employee training needs
• Staff and Temp workers

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Conducting a Hazard Assessment

• Strategies
• Floor Plans, Checklists, Process Flow
• Job Hazard Analysis (MIOSHA) www.michigan.gov/docu
  ments/cis_wsh_cetsp32_137664_7.doc
• H S Committee could conduct survey
• Note areas where additional investigation and
  expert consultation may be necessary
• Take Time To Be Thorough!

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Step 5 Correct/Control Identified Hazards
Least Effective
Most Effective
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Competing Air Currents

• Diffusers man-cooling fans traffic operator
  body motions mechanical movement compressed
  air ejected particles

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PPE Resources

• www.chemrest.com/ (Best Glove)
• www.mapaglove.com (MAPA)
• www.northsafety.com (North)
• www.amazon.com
• MIOSHA PPE CET Publication SP-16
• www.kristerforsberg.com/cpc/

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Respiratory Protection Resources

• NIOSH Respirator Selection Logic, 2004 will help
  guide you to select the appropriate respirator
  www.cdc.gov/niosh/docs/2005-100/default.html
• MIOSHA Part 451, Respiratory Protection Standard
  will let you know the law www.michigan.gov/mioshas
  tandards
• MIOSHA Sample Respiratory Protection Program will
  aid in the development of your worksite-specific
  program www.michigan.gov/documents/cis_wsh_cet5730
  _90302_7.doc

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Step 6 Train Employees

• Orientation for new employees
• What is your employee base?
• Permanent?
• Temp workers?
• What kind of training have they received?
• What is your new-hire orientation?
• Benefits review?
• Insurance forms?
• Do you explain health and safety philosophy?

Are you walking the walk?
61
Train Employees

• General safety orientation for employees starting
  new jobs
• Specific training on hazards of their jobs and
  how to do their jobs safely
• Retraining
• Training records kept
• See MIOSHA Training Requirements for General
  Industry and Agriculture www.michigan.gov/document
  s/cis_wsh_cetsp04_107243_7.doc

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Step 7 Schedule Periodic Evaluations

• Is your HS Committee effective?
• Do you establish effective two-way communication?
• Do you develop written procedures for
• work performed infrequently?
• Do you observe manager/employee behavior
• Is training effective?
• Improvements need to be made?
• www.osha.gov/SLTC/etools/safetyhealth/

Look at Facility Procedures, Programs, Processes,
and People
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Workplace Evaluations Identify

• Equipment problems
• wear and tear or improper use
• Improper work practices
• Housekeeping issues
• New hazards from changes in workplace
• Inadequate corrective action(s)
• Good health and safety practices
• New employees/temporary workers who slip through
  the training

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Step 8Re-evaluate Program

• Determine
• How the program will be reviewed and revised
• When program will be reviewed
• Who will take what actions and keep what
  documents
• Conduct additional reviews whenever
• Changes in the workplace that may affect health
  or safety
• Discover new hazards
• Problems develop

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Need Help?

• MIOSHA Consultation, Education and Training (CET)
  Division
• Services provided throughout MI by in-house staff
  of professional occupational safety consultants,
  occupational safety specialists and industrial
  hygienists
• Non-enforcement personnel
• Safety and Health Consultants
• AIHA www.aiha.org/
• NSC www.nsc.org/
• Insurance-provided programs

66
CET Services

• CET web address www.michigan.gov/cis/ Click on
  MIOSHA, then Consultation, Education Training
  links in left box
• A complimentary copy of the Michigan OSHA
  Walkthrough for Industry CD can be found at
  www.oshawalkthrough.com

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MIOSHA CET Toolbox

• Modules with ideas and suggestions for promoting
  the following major areas
• Module 1 Management Leadership Commitment
• Module 2 Employee Involvement
• Module 3 Worksite Analysis, Hazard Prevention
  Control
• Module 4 Safety Health Training
• Module 5 Stand Down for Safety Health Day

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Effective HS Programs

• Reduce risk of injury or illness
• Reduce direct and indirect costs from injuries or
  illnesses
• Enhance teamwork skills
• Positively impact safety culture
• Improve communication between management and
  employees
• Provide a forum for safety, health and technical
  exchanges

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HS Programs and Medical Surveillance Go
Hand-in-Hand
Medical surveillance is systematically watching
out for early signs of work-related ill health in
workers exposed to certain health risks
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Medical Surveillance

• Where a risk of work-related asthma is
  identified, medical surveillance should be
  provided
• This can detect the disease at an early stage and
  the outcome is improved in workers who are
  included in the program

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Medical Surveillance

• Provides information which helps you protect
  employees from illness caused by being exposed to
  health risks at work
• Enables you to manage risks effectively by acting
  as a check on
• How your control measures are working
• Helping to pinpoint where you need to take
  further steps
• Provides a valuable opportunity for feedback from
  employees and a chance to reinforce your health
  and safety messages to them

72
Medical Surveillance

• Dont confuse medical surveillance with health
  promotion or general health checks
• Medical surveillance is NOT a substitute for
  controlling health risks or exposures at work

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Medical SurveillanceWorkers Exposed to
Occupational Allergens

• No legal requirement except for formaldehyde
• Recognize health changes in groups
• Identify hazardous working conditions
• Evaluate effectiveness of exposure controls
• Identify symptomatic individuals
• Detect possible onset of asthma
• Prevent future cases
• Decrease costs

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www.oem.msu.edu/Resources/AsthmaScrnProtocol_2003.
pdf
75
Medical Surveillance

• Baseline and Annually
• Medical questionnaire
• Physical exam
• Pulmonary function testing
• Suspected cases confirmed with further testing
• Confirmed cases transferred to areas without
  exposure whenever possible

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Medical Questionnaire

• Administer baseline questionnaire
• Have you seen a doctor for shortness of breath,
  sinus problems, eczema?
• Ever had asthma, allergies, hay fever, or eczema?
• Any blood relatives with allergies, hay fever,
  asthma or eczema?
• Do you smoke cigarettes? (TRIGGER not sensitizer)
• NeverSeldomMonthlyWeeklyDaily to a list of
  symptoms suggestive of allergic responses
• Annually thereafter
• Same questions since last visit
• Looking for any new symptoms

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Physical Exam

• Baseline exam components
• A baseline physical exam with particular
  attention to
• skin
• head
• eyes
• ears
• nose
• throat
• lungs
• Annually thereafter
• To note any changes from baseline

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Pulmonary Function Testing

• Baseline Breathing Tests
• Follow American Thoracic Society protocol
• Technologist complete accredited training course
• Results evaluated by a physician
• Annually thereafter
• Evaluate for excessive loss in lung function,
  gt25-35 ml per year

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Pulmonary Function Testing

• Consider
• Lung function can decrease even in the absence of
  symptomsyou cannot rely on a symptoms
  questionnaire or physical alone
• American College of Occupational and
  Environmental Medicine- Evaluating Pulmonary
  Function Change Over Time in the Occupational
  Setting
• http//www.acoem.org/position/statements.asp?CATA_
  ID59

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Further PFT Testing of Symptomatic Individuals

• Suspected cases confirmed with testing
• Pre-work
• Mid-shift
• After work
• Peak Flow Measurements every 2 hrs for 2 wks
• May need to be off work and do testing for up to
  2 weeks to allow for recovery

82
Individuals with Confirmed Work-Related Asthma

• Confirmed cases should be given the option to be
  transferred to areas of non-exposure when
  possible
• Sensitized individuals may react at extremely low
  levels of exposure

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Who is Responsible for Asthma Education?

• Physicians
• Occupational Asthma Specialists
• Certified Asthma Educators
• Resources
• www.getasthmahelp.com

84
Education Program Components

• Recognize Patterns of Symptoms
• Develop an Asthma Management Plan
• Conduct Peak Flow and/or Symptom Monitoring
• Understand Medication Delivery Devices

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Asthma Management Plan
Peak Flow Meter
Asthma Medicines
86
What is the result of NO Medical Surveillance?

• Once asthma develops, problems persist
• Of individuals no longer exposed
• 88 still have breathing problems
• 80 are still taking medications

87
Remember!

• Medical therapy to allow a worker to better
  tolerate the workplace exposure is not an
  acceptable means of controlling risk

88
What Can You Do Now to Support Your Employees
With Asthma?

• Identify use of sensitizers
• Evaluate and implement controls
• Perform medical surveillance
• Seek follow up medical care for employees
• Serve as a resource

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Test Your Knowledge of Work-Related Asthma (Yes
or No)

• 1. Can cigarette smoking cause asthma? NO
• 2. Can workers develop asthma from exposures lt
  MIOSHA permissible limits? YES
• 3. Will a baseline medical exam prevent people
  from being placed into jobs where they would
  develop work-related asthma? NO

92
Test Your Knowledge of Work-Related Asthma (Yes
or No)

• 4. Will transferring a worker with asthma to a
  different job in a company always take care of
  the problem? NO
• 5. Can you attribute new asthma in a long term
  worker to work, if he/she never had asthma
  before? YES
• 6. Can a worker with asthma symptoms that happen
  at night, not at work, attribute their asthma to
  work? YES

93
If you need additional information

• Michigan State University
• Department of Medicine
• Occupational Environmental Medicine
• 117 West Fee Hall
• East Lansing, MI 48824
• 517.353.1846
• www.oem.msu.edu