The Occupational Respiratory Disease Experience of a State Wide Occupational Health Clinic Network - PowerPoint PPT Presentation

Loading...

PPT – The Occupational Respiratory Disease Experience of a State Wide Occupational Health Clinic Network PowerPoint presentation | free to download - id: 579ed-OGVhY



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

The Occupational Respiratory Disease Experience of a State Wide Occupational Health Clinic Network

Description:

secretaries-2.4% Results: Occupation. 20% of patients were operators or laborers ... Nylon flock lung disease ... HRCT in workers at 5 nylon flock facilities. ... – PowerPoint PPT presentation

Number of Views:944
Avg rating:3.0/5.0
Slides: 71
Provided by: aliciaf
Learn more at: http://www.macny.org
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: The Occupational Respiratory Disease Experience of a State Wide Occupational Health Clinic Network


1
The Occupational Respiratory Disease Experience
of a State Wide Occupational Health Clinic
Network
  • Greg Siwinski MS CIH
  • CNY Occupational Health Clinical Center
  • Dept. of Family Medicine
  • Syracuse, NY

2
New York State Occupational Health Clinic Network
Syracuse
Buffalo
Albany
New York City (Mt. Sinai)
Cooperstown
Rochester
Long Island
New York City (Bellevue)
3
Contributing Authors
  • Jaime Szeinuk, MD
  • Mount Sinai-Irving J. Selikoff Center for
    Occupational and Environmental Medicine
  • Alicia Fletcher, MPH
  • NYS Department of Health
  • Kitty H. Gelberg, PhD, MPH
  • NYS Department of Health
  • William S. Beckett M.D., M.P.H.
  • University of Rochester
  • Rochester, New York USA

4
OHCC Function
Medical -History symptoms work -Physical
Exam -Testing Diagnosis Treatment Referral
Exposure -Determinants material / amount /
duration/ how exposed ? / controls? -Toxicology
Work Relatedness -literature review -strength of
association -expert judgment
Prevention Worksite visit Disease
Reporting Education Intervention
Patient Care Treatment Financial Social Support
5
Occupational lung disease
6
Occupational Lung DiseasePopulation at risk
(in millions)
  • Occupational lung disease No.
  • Asthma 9.1
  • Acute toxic inhalation 5.8
  • Hypersensitivity pneumonitis 2.9
  • Silicosis 2.3
  • Asbestosis 1.9
  • Berylliosis 0.8
  • Cancer 0.2
  • (Markowitz Israel J Med Sci, 1992)

7
Occupational lung disease Overview
  • The reactions of the lung are quite limited, so
    many agents may produce the same reaction.
    Conversely, one agent may produce different
    reactions.

8
Occupational lung disease Concepts
  • Latency the gap in time between onset of
    exposure and development of disease
  • (acute versus chronic
  • Dose-response relationship
  • Interaction among causes cigarette smoke, air
    pollution
  • Inter-individual variation

9
Some common irritant gases and fumes
10
Some common irritant gases and fumes
11
Occupational lung disease pneumoconiosis
  • Deposition of dust in the lung and the lungs
    reaction to the dust
  • Two major categories simple and complicated
  • Examples Coal-workers pneumoconiosis,
    silicosis, asbestos-related, beryllium, talc,
    hard-metal (tungsten carbide with cobalt)

12
Occupational lung disease Cancer
  • Incidence 5 to 36 of all lung cancers are due
    to occupational agents
  • Definitely associated with asbestos, radiation,
    radon, arsenic, hexavalent chromium (welding),
    cadmium, nickel, mustard gas, aluminum,
    chloromethyl ether, silica, soots-tars-mineral
    oils.
  • Questionable talc, coal, fiberglass
  • Potentiated by cigarette smoking
  • Mesothelioma 60-90 occupational etiology

13
Occupational asthma
  • Asthma due to causes and conditions attributable
    to a particular occupational environment and not
    to stimuli encountered outside the workplace.

14
(No Transcript)
15
(No Transcript)
16
Asthma
  • What is it inflammatory condition of the lungs
    airways caused by allergens, irritants, and
    infections.

17
THE RIDDLE OF ALLERGIES 2002
  • ALLERGIES ARE INCREASING!
  • Up to 50 of children has or have had symptoms of
    allergic disease!
  • IN SWEDEN more in the north!
  • IN EUROPE more in the west!?
  • IN USA more among the poor!
  • MOST in countries that speak ENGLISH (UK, New
    Zeeland, Australia)
  • Also high in Peru...

(Jan Sundell 2006)
18
Occupational asthma definitions
  • New Onset Occupational Asthma
  • Reactive Airway Dysfunction Syndrome (RADS)
    persisting asthma with a new onset within hours
    following a single exposure to inhaled irritants
    at very high concentrations.
  • Work aggravated asthma pre-existing asthma that
    is made worse by conditions at the workplace.

19
Occupational asthma magnitude of the problem
  • In the US, asthma has been estimated to affect
    14-15 million persons. Asthma affects 5-10 of
    people worldwide.
  • 2 to 18 of all asthma cases are occupational
    (ATS, Am J Resp Crit Care, 2005 172 280)
  • 21-33 of adult-onset asthma cases in a large HMO
    populations (Milton, Am J Ind Med, 1998 33 1
    Vollmer, JOEM, 2005 47 1292)
  • 33 of adult-onset asthma cases in a Canadian
    study (Johnson, Am J Respir Crit Care Med, 2000
    162 2058)
  • Numbers vary by study, country, author

20
Workplace exposures associated with occupational
asthma
  • More than 250 agents
  • - Chang-Yeung M, et al. Eur Respir J, 1994 7
    346-71
  • - Malo JL, et al. Appendix B in Harber P, ed
    Occupational and Environmental Respiratory
    Disease. Mosby eds, pp. 1006-1022
  • -Van Kampen, et al. Occupational airway
    sensitizers. Am J Ind Med, 2000 38 164-218
  • Classes of agents sensitizing, irritant, non
    immunologic or pharmacologic (organophosphate
    insecticides)

21
Common agents that cause occupational asthma
22
Common agents that cause occupational asthma
23
Common agents that cause occupational asthma
24
Characteristics of Work-related Asthma Patients
Seen by the New York State Occupational Health
Clinic Network
  • Alicia Fletcher, MPH
  • NYS Department of Health
  • (JOEM vol48, Nov. 2006)

25
BackgroundWork-related Asthma
  • Most frequently diagnosed occupational
    respiratory disease in the U.S.
  • An estimated 2-26 of adult asthma is work
    related
  • Can present as new onset condition or it can be
    work-aggravated

26
BackgroundWork-related Asthma
  • Over 250 irritants or sensitizers have been
    documented as triggers
  • Little is known about the distribution of this
    disease and its risk factors in New York State

27
Objectives
  • To characterize the work-related asthma
    population seen by the New York State
    Occupational Health Clinic Network
  • To determine what proportion of cases conform
    with the NIOSH case definition of work-related
    asthma

28
Methodology
  • The clinic database was analyzed to identify
    those patients with a definite diagnosis of
    work-related asthma, ICD9 codes 493-493.9, who
    were seen at the clinics between 1988 and
    February 2000
  • Medical charts were abstracted for 454 patients
    meeting this definition

29
ResultsClinical History of Patients
  • The most commonly reported symptoms include
    shortness of breath, wheezing and coughing
  • Sixty-five percent of patients were taking some
    type of asthma medication at the time of their
    first visit

30
ResultsClinical History of Patients
  • Over 50 of patients had a normal spirometry
    result (fev1gt80 predicted)
  • The majority of patients had no previous history
    of asthma

31
ResultsIndustry
  • 38.8 of patients were employed in the services
    industry
  • health services- 12.3
  • educational services-14.1
  • 23.1 of patients were employed in the
    manufacturing industry
  • industrial and commercial machinery and computer
    equipment-5.5
  • printing, publishing and allied industries-2.6

32
ResultsOccupation
  • 23.1 of patients were managers and professionals
  • teachers-7.3
  • executives-5.5
  • 22.9 of patients were in technical, sales and
    administrative jobs
  • health technicians-4.4
  • secretaries-2.4

33
ResultsOccupation
  • 20 of patients were operators or laborers
  • assorted machine operators-3.7
  • fabricators, assemblers and hand working
    occupations-3.7

34
ResultsOccupation
35
Results Etiologic Agents
  • The most frequently reported exposure agents were
    dust, indoor air, mold, solvents, cleaning
    products and paints

36
ResultsNIOSH case classification of
work-related asthma
  • NIOSH defines work-related asthma as
  • A health-care professionals diagnosis consistent
    with asthma
  • An association between symptoms of asthma and
    work
  • 421 cases (92.7) met the NIOSH case
    classification

37
NIOSH case classification of work-related asthma
  • Of the 421 cases meeting the NIOSH case
    classification of work-related asthma
  • 63 cases (15.0) were work-aggravated asthma
  • 358 cases (85.0) were new-onset work-related
    asthma

38
NIOSH case classification of work-related asthma
  • Of the 358 new-onset asthma cases
  • 144 cases (40.2) were classified as reactive
    airways dysfunction syndrome (RADS)
  • 214 cases (59.8) were classified as occupational
    asthma

39
Discussion
  • Dust and indoor air represent the most frequent
    putative causes of work-related asthma in this
    population
  • Workers affected by dust include agriculture
    workers and teachers, while workers affected by
    poor indoor air include health technicians and
    teachers

40
Discussion
  • These findings represent the need to
  • Provide educational materials to these at-risk
    workers
  • Investigate indoor air quality in public
    buildings, especially hospitals and schools

41
Discussion
  • Since many patients are referred to the clinics
    from an outside source (39.4 from physicians),
    they may be in a more advanced stage of disease
    when first seen at the clinics
  • The fact that 65 of patients were taking asthma
    medication at the time of their first visit may
    indicate a progression of the disease
  • Earlier detection of work-related asthma should
    therefore be encouraged

42
Discussion
  • To enable earlier detection, high-risk industries
    should be targeted for surveillance programs to
    heighten worker awareness of work-related asthma
  • Surveillance data can then be used to develop and
    implement work-related asthma prevention programs

43
Occupational asthma typical patient
  • Older age at onset (43 v 21 years)
  • No seasonal variation in symptoms
  • Symptoms improve while away from work
  • Greater likelihood of becoming unemployed
  • (Jama, 1996 275 1831)

44
Settings in which to suspect an occupational
factor in asthma
  • All cases of adult-onset asthma
  • Cases in which a worker suggests a link between
    workplace and symptoms
  • Asthma that began or worsened after a job change
  • Asthma that follows a one-time high-level
    irritant exposure (RADS)
  • Occupations with airborne exposures that can be
    easily seen or smelled
  • Occupations in which the worker is advised to use
    a personal respirator

45
Occupational asthma therapeutic challenge
  • Treatment for occupational asthma same as for
    other forms of asthma, importance of inhaled
    steroids!
  • Reducing exposure (improving ventilation or
    respirator) more for irritant-induced asthma or
    for work-aggravated asthma, however worsening of
    symptoms immediate removal from exposure
  • Occupational asthma due to sensitizers (latency)
    removal from exposure

46
Occupational asthma prognosis
  • Occupational asthma causes permanent disability,
    even after cessation of exposure. No documented
    cure of OA cases.
  • Improvement continues on the long range. Faster
    during the first 2-years after cessation of
    exposure.
  • Longer duration of exposure (severity of immune
    and inflammatory load), lower PC20 at the time of
    diagnosis, exposure to high-molecular-weight
    agents, eosinophilia/neutrophilia in sputum, less
    time since removal from exposure all associated
    with poor prognosis.
  • (Maghni. Am J Respir Crit Care Med, 2004 169
    367)

47
Consequences of occupational asthma
48
Consequences of occupational asthma (Cannon.
BMJ, 1995 311 502)
49
(No Transcript)
50
(No Transcript)
51
Newer Occupational Lung Diseases
52
Whats new in occupational lung disease? Selected
Mineral Lung Diseases
  • Mineral
  • Mica (mixed with other minerals)
  • Kaolin
  • Talc (mixed with silica, asbestos)
  • Fullers earth (fibrous silicate clays)
  • Mapel and Coultas Occupational
  • Disorders of the Lung. (In press)
  • Example Exposure
  • Rubber manufacturing
  • Clay Processing
  • Mold release
  • Sepiolite work

53
Whats new in occupational lung disease?
Selected Metal Lung Disease
  • Metal
  • Aluminum powder
  • Beryllium
  • Tungsten carbide with cobalt
  • Iron Oxide
  • Cadmium
  • Example Exposure
  • Explosives
  • Nuclear industry
  • Tool grinding
  • Arc welding
  • Chemical industry
  • Mapel and Coultas Occupational Disorders of the
    Lung. (In press)

54
Whats new in occupational lung disease?
  • Nylon flock lung disease
  • Cough, SOB, restrictive impairment, low DL,
    interstitial markings on CXR or HRCT in workers
    at 5 nylon flock facilities. Cause cut or
    pulverized fiber that produces a velvet-like
    coating when applied to adhesive-coated fabric
    (flock). Pathology lymphocytic bronchiolitis
    with lymphoid interstitial pneumonitis. 6/20
    cases improved while out of work.
  • (Lougheed. Eschenbacher, Am J Respir Crit
    Care Med, 1999 59 2003)

55
Whats new in occupational lung disease?
Hypersensitivity Pneumonitis (Extrinsic allergic
alveolitis)
  • A spectrum of granulomatous, interstitial,
    bronchiolar, and alveolar lung diseases resulting
    from repeated inhalation and sensitization to a
    wide variety of organic dusts and low molecular
    weight chemical antigens.
  • Rose Hypersensitivity Pneumonitis in
    Environmental and Occupational Respiratory
    Diseases, 1996.

56
Hypersensitivity Pneumonitis (Extrinsic Allergic
Alveolitis) Clinical Features
  • Acute Fever, chills, cough, dyspnea, with a few
    hours of exposure, self-limited CXR may show
    infiltrates
  • Subacute Increasing dyspnea over weeks to months
    without obvious acute episodes interstitial or
    ground glass pattern.
  • Physyical Exam crackles
  • Lab Elevated white blood cell count
  • Radiograph patchy infiltrates
  • Lung function restriction, gas diffusing
    abnormality

57
Hypersensitivity Pneumonitis (Extrinsic Allergic
Alveolitis) Selected Causes
  • Amoebae
  • Animal proteins
  • Fungi
  • Thermophilic bacteria
  • Contaminated metal working fluid
  • Toluene diisocyanate,
  • diphenylmethane diisocyanate
  • Trimellitic anhydride, phthalic anhydride

58
Whats new in occupational lung disease?
Inhalation Fever
  • Self-limiting fever after a single exposure, with
    peripheral leukocytosis but minimal lung
    inflammation, from
  • Microorganism-contaminated water spray from
    humidifier
  • Zinc oxide fume
  • Cotton dust
  • Polytetrafluoroethyelene (Teflon)

59
Whats new in occupational lung disease? Man Made
Mineral Fibers
  • Glass Fiber Acutely irritating to upper
    respiratory tract. Inadequate evidence of the
    carcinogenicity of glasswool in humans (IARC).
  • Mineral Wool
  • Refractory Ceramic Fiber pleural plaques with
    prolonged exposure
  • (No human data on carcinogenicity. IARC)

60
Whats new in occupational lung disease?
  • Popcorn workers lung
  • Cough, SOB and wheezing 5m-9yr after starting
    work at a microwave popcorn plant. Cause
    diacetyl (ketone with butter-flavor). Pathology
    constrictive bronchiolitis. 5/8 pts lung
    transplant.
  • (Kreiss, NEJM, 2002 347 330)

61
Whats new in occupational lung disease?
  • Nano-particles ???

62
Whats new in occup. lung disease?
63
World Trade Center Lung Disease
  • Syndrome of WTC cough
  • RADS, asthma
  • Interstitial disease acute eosinophilic
    pneumonia, granulomatous pneumonitis, BOOP and
    pulmonary fibrosis.
  • Role of GERD and RUDS
  • Role of psychiatric component (PTSD, depression,
    anxiety)

64
Prevention of Occupational Respiratory Disease
  • Regulatory Exposure Limits not current.
  • Asthmagens
  • OSHA few ?
  • NIOSH 15 substances
  • ACGIH TLVs 9 substances
  • Over 250 asthmagens thus far and counting.
  • Globalization and economic pressures.

65
Occupational lung disease prevention
  • Elimination of exposure
  • Banning the agent (industry pressure,
  • damage is already done)
  • Substituting one chemical for another
  • Engineering and administrative controls
  • Regulation of workplace toxins OSHA-PELs
  • Worker Education
  • Respiratory Protection

66
The Challenge
  • Small Medium size Employers (SMEs)
  • 6.3 million (98) of the US private employers
    employ fewer than 100 employees each.
  • (NYS 416,000 (86) workplaces lt 100 Ees)
  • SMEs have few health safety resources.
  • Lack of understanding OELs.
  • Many chemicals lack OELs.
  • SMEs want practical help.

67
Emerging Concepts in Controlling Hazards
  • Pollution Prevention (P2)
  • Precautionary Principle
  • Control Banding

68
Control Banding A Generic Risk Assessment
Approach
Work Task
EXPOSURE POTENTIAL
RISK ASSESSMENT
HEALTH HAZARD

CONTROL STRATEGY
69
Control Bands (omits Hazard band E all
special)
70
Control Banding
  • SUMMARY
  • Producing exposure limits is slow, expensive,
    difficult, necessary.
  • Exposure limits do not prevent ill health.
  • They are not well understood.
  • Alternative approaches necessary
  • Global development process.
  • Trade craft specific control banding
    opportunities.
About PowerShow.com