3/4/2020 The Occupational Burden of Respiratory Disease March 6, 2020 - PDF document

3/4/2020 The Occupational Burden of Respiratory Disease March 6, 2020 Carrie Redlich, MD, MPH Professor of Medicine, Pulmonary and OEM Director, Yale Occupational and Environmental Medicine Program Yale School of Medicine S L I D E 0 Disclosures I have nothing to disclose. S L I D E 1 Occupational Burden of Respiratory Disease 1) “Classic” Pneumoconioses ‐ 100% occupational 2) Airways Diseases • Asthma COPD / Bronchitis • 3) Interstitial lung Diseases • Idiopathic pulmonary fibrosis • Sarcoidosis, hypersensitivity pneumonitis 4) Pulmonary Infections Pneumonia • 5) Conclusions and Questions S L I D E 2 1

3/4/2020 Asbestos • 125 million people currently exposed at work • >50 countries have banned asbestos – not USA, CA – Continued disease risk due to long latency Thermal resistance, strength, flexibility Uses: Insulation, brakes, textiles, cement Cullinan et al. Lancet Respir Med. 2017; asbestos nation.org S L I D E 3 Non ‐ malignant Asbestos ‐ Related Respiratory Diseases Pleural disease Pleural effusions Plaques Diffuse pleural thickening Asbestosis (pulmonary fibrosis) S L I D E 4 Asbestosis • Typically chronic exposure (10+ years) • Long latency (20 ‐ 30 years) • Dyspnea, cough, slow progression • PFT’s: Restriction; reduced DLCO, mild obstruction • CT scan – subpleural fibrosis, traction bronchiectasis – similar to UIP (IPF) S L I D E 5 2

3/4/2020 Diagnosis Asbestosis: ATS Statement 2004 • Evidence of structural change by – Imaging OR Histology • Evidence of plausible causation by – History OR Markers of exposure (plaques) OR asbestos bodies • Evidence of functional impairment by – Signs and symptoms OR – PFT’s (restriction or reduced DLCO) OR – Inflammation (BAL) OR – Exercise testing • Exclusion of alternative diagnoses S L I D E 6 Trends in Respiratory Mortality Rates S L I D E 7 Silica • Respirable crystalline silicon dioxide (SiO 2 ) – Quartz = 10% of earth’s crust • Rock, concrete, masonry, silica sand • Drilling, cutting, sandblasting, demolition, mining NIOSH No. 1996 ‐ 112. S L I D E 8 3

3/4/2020 Silica ‐ Related Respiratory Diseases • Silicosis – Chronic = after 10+ years, lower concentrations – Accelerated = after 5 ‐ 10 years, higher concentrations – Acute = after weeks to years, highest concentrations • Increased risk TB • Lung cancer Akgun et al. Chest . 2015. S L I D E 9 New industrial processes re ‐ create an old exposure • Denim sandblasting in Turkey • Artificial stone countertops worldwide • Hydraulic fracturing for oil & gas S L I D E 10 OSHA new Silica rule (implemented June, 2018) 1) Construction and 2) General Industry & Maritime Standards Silica PEL ‐ 50 ug/m 3 Silica Action level ‐ 25 ug/m 3 Medical surveillance required if >PEL for >30 days (> Action level 6/2020) Baseline and every 3 years Exam, questionnaire Chest x ‐ ray with B ‐ read TB screening (baseline only) Spirometry Medical follow ‐ up with occ med or pulmonary physician S L I D E 11 4

3/4/2020 Coal: World Consumption 2010 ‐ 2040 Quadrillion (10 15 ) Btu U.S. Energy Information Administration. S L I D E 12 Coal ‐ Related Respiratory Diseases • Coal workers’ pneumoconiosis (CWP) – Simple – Complicated (progressive massive fibrosis [PMF]) • COPD S L I D E 13 CWP in US – Prevalence and Severity Increasing Am J Public Health. 2018;108:1220–1222. Ann Am Thorac Soc. 2018 December ; 15(12): 1420–1426. doi:10.2105/AJPH.2018.304517 doi:10.1513/AnnalsATS.201804 ‐ 261OC. S L I D E 14 5

3/4/2020 Change in Mortality Rates from 1980 ‐ 2014 Asbestosis CWP All Pneumoconioses JAMA. 2017;318(12):1136 ‐ 1149. doi:10.1001/jama.2017.11747 S L I D E 15 Summary Classic Occupational Pneumoconioses • Remain an important and preventable problem in the US and worldwide • Current preventive strategies are not sufficient In addition occupational exposures also contribute to the major “non ‐ occupational” lung diseases S L I D E 16 Occupational Burden of Respiratory Disease 1) “Classic” Pneumoconioses ‐ 100% occupational 2) Airways Diseases • Asthma COPD / Bronchitis • 3) Interstitial lung Diseases • Idiopathic pulmonary fibrosis • Sarcoidosis, hypersensitivity pneumonitis 4) Pulmonary Infections Pneumonia • 5) Conclusions and Questions S L I D E 17 6

3/4/2020 The Occupational Burden of Respiratory Disease Aim: Estimate the occupational contribution to the burden of asthma, COPD / bronchitis, IPF, HP, sarcoidosis, respiratory infections S L I D E 18 Methodology to Estimate Occupational Burden • Asthma, COPD, Bronchitis, ILD, CAP The occupational attributable fraction (PAF) was estimated using population ‐ based or case control studies (ILD) PAF = [(P 0 +  P i (RR i )) – 1] / [P 0 +  P i (RR i )] P 0 is the proportion in the population not exposed P i is the proportion exposed, RR i is the RR exposed. PAF = p c (OR ‐ 1)/OR P c = proportion of cases exposed • PAP, HP, Sarcoidosis Occupational Proportion estimated from cases series where occ info available • Calculated pooled estimates using Stata. If high heterogeneity used random effects models. S L I D E 19 Work ‐ Related Asthma Asthma Asthma caused by work (OA) exacerbated by work (WEA) • 15% of adult asthma caused by work, cross ‐ sectional studies • ≈ 20 ‐ 40% asthmatics who work report symptoms worse at work • Numerous causative exposures: allergens, irritants • Most commonly reported occupational lung disease in industrialized countries S L I D E 20 7

3/4/2020 Occupational Contribution to Incident Asthma Pooled PAF asthma was 16% (95% CI 10 ‐ 22%) ‐ further supports prior cross ‐ sectional data S L I D E 21 Work ‐ related Asthma in California 8.4% adults in CA current asthma (2.3 M) 40.3% asthmatics in CA report WRA (> 0.9 M) • 24.6% caused by work • 35.0% aggravated by work Asthma Surveillance in CA 2017 Report. CA Health Interview Survey (CHIS) Work ‐ Related Asthma in CA 2012. Asthma Call ‐ Back Survey (ACBS) S L I D E 22 # WRA Cases in CA from case ‐ based surveillance About 600 cases WRA / year < 200 physician diagnosis vs If 2.3 M adults in CA have asthma then 350,000 – 900,000 WRA S L I D E 23 8

3/4/2020 Case 1 – Hospital cleaner with asthma 36 year old environmental services technician at your hospital is referred for evaluation work ‐ related symptoms. She reports onset asthmatic symptoms about 3 years ago. Better on vacation, worse at work, especially when ‘terminal room cleaning’ after patient discharge. Progressively worse with greater use inhalers. Asthma diagnosed about 3 yrs ago. Her pulmonologist has been treating her with inhaled steroids + LABA, montelukast, occasional prednisone. Also recently restricted her from ‘terminal cleaning’. S L I D E 24 Case 1 – Further Work ‐ up Very mild childhood asthma – resolved No asthma meds until past 3 years. Can’t remember an inciting event or infection No pets, home issues One child with asthma Mild seasonal allergies, obesity Former smoker, 1 ppd for 10 years. Exam – unremarkable S L I D E 25 Work ‐ related Asthma: Diagnosis ACCP, ATS / ERS, ACOEM Statements similar WRA should be considered in all adults with new onset or worsening asthma To make the diagnosis: 1) Confirm diagnosis of asthma 2) Identify /confirm exposure(s) in workplace can cause asthma 3) Determine association between asthma and work S L I D E 26 9

3/4/2020 Case 1 – Further Work ‐ up Spirometry with BD Minimal airflow obstruction, BD negative. No prior testing done. You request information on hospital cleaning products Given a long list of surface cleaners, sanitizers, SDS. You provide employee with a peak flow meter. 1 mo follow ‐ up: she has been away from terminal cleaning. Some improvement symptoms. Peak flows hard interpret. 6 mo follow ‐ up: Let go. Employer can no longer make accommodations. Applied for workers comp to help with medical expenses. Denied. S L I D E 27 Case 1 – Diagnosis You were asked to assess whether she has WRA. To make the diagnosis WRA: 1) Confirm diagnosis of asthma Neg BD (but on inhaled steroids) 2) Identify /confirm exposure(s) in workplace that can cause asthma Don’t know specific product, agent. 3) Determine association between asthma and work History, no peak flows, no immunologist test Yes or No work ‐ related? If yes – what type WRA ? S L I D E 28 WRA in CA – Causative agents and high risk jobs S L I D E 29 10

3/4/2020 Work ‐ related asthma: Conclusion • WRA remains common and under ‐ diagnosed for multiple reasons, despite Guideline documents, alerts, surveillance. • Current protective measures are not adequate. S L I D E 30 The Occupational Burden of Respiratory Disease Aim: Estimate the occupational contribution to the burden of asthma, COPD / bronchitis, IPF, HP, sarcoidosis, respiratory infections S L I D E 31 COPD – Mortality rate and trends from 1980 ‐ 2014 JAMA. 2017;318(12):1136 ‐ 1149. doi:10.1001/jama.2017.11747 S L I D E 32 11