Deemed diseases in Australia Tim Driscoll School of Public Health University of Sydney
Outline › Background to Deemed Diseases › Key aspects › Overview of methods and list structure › Consideration of some important issues › Overview of list content › Questions / comments 2
What is a Deemed Diseases List? › A list of disorders (and their exposures) that are deemed to be work- related. › The system aims to simplify relevant claims. 3
How does the list work? › If the worker has a listed disorder, AND › They have had the relevant exposure at work, THEN › The disorder is assumed to have developed BECAUSE of the exposure › UNLESS there is strong evidence to the contrary. 4
Normal workers’ compensation approach › Worker develops a disorder › Worker thinks it might be related to work › Worker makes a claim › WORKER MUST ESTABLISH that there is a causal connection between a particular work exposure and the disease › Worker must establish that they were exposed. 5
Deemed disease approach › Worker develops a disorder › Worker thinks it might be related to work › Worker makes a claim › IT IS ACCEPTED that there is a causal connection between a particular work exposure and the disease › Worker must establish that they were exposed. 6
Comparison of approaches › Normal approach: › - WORKER MUST ESTABLISH that there is a causal connection between a particular work exposure and the disease. › Deemed diseases approach: › - IT IS ACCEPTED that there is a causal connection between a particular work exposure and the disease. › That is, the onus of proof is reversed. › BUT, the worker still has to prove they were exposed. 7
Some key aspects › The onus of proof is reversed. - But evidence of exposure is still required. › Disorders that are not included on the List can still be the subject of a normal workers’ compensation claim. 8
What’s wrong with the current lists? › Out of date › - most are based on ILO Convention 42 (1934) › - minimal updates to most lists since! › - missing many conditions / exposures with clear evidence of relation to work. › Not structured usefully › - focus on exposure without specifying the relevant disorder › - required level of evidence sometimes not high. 9
The Deemed Diseases Project › The principal of Deemed Diseases has been part of workers' compensation for most jurisdictions for a long time (decades). › › The current lists are very rarely used. › The current lists are not conducive to being used in the way intended. › › This project was designed to develop a revised list, which jurisdictions can choose to adopt (or adapt) as they wish. 10
Project objective › Develop an up-to-date Australian List of Deemed Diseases › Base this work on the most recent scientific evidence on the causal link between diseases and occupational exposure. 11
Methods Decisions on inclusion and exclusion were required to be evidence-based. › Three criteria › - Strong evidence of causal link between the disease and occupational exposure; › - clear criteria for diagnosis; › - work responsible for a considerable proportion of cases of the disorder in the general community or in a subset of the community (for example, a particular occupation group). 12
Causal link › Evidence needs to be strong to allow presumption of a connection › A single study would be insufficient › Relied on systematic reviews of evidence › Sometimes used multiple good quality studies. › Based on strength of evidence, NOT the size of the effect. 13
Diagnostic criteria › Need to be able to confidently establish the diagnosis › Occupational asthma › Musculoskeletal disorders › Skin disorders 14
Proportion of cases › Not appropriate to include most disorders rarely related to work - e.g. TB would not commonly be related to work…… but TB in a health care worker WOULD commonly be related to work › Not appropriate to only include disorders where work is the major cause e.g. This would mean lung cancer from asbestos would be excluded. 15
Methods cont. › Each group of disorders was considered separately › Key disorders within a group were considered separately › For each disorder, the available evidence was appraised regarding its connection to work and the proportion of work-related cases 16
Methods cont. › Focussed review of the scientific literature › Discussions with relevant jurisdictional representatives › No new primary investigations › No new systematic reviews of literature 17
Project management › Overseen by a Temporary Advisory Group (TAG) › TAG reported to Strategic Issues Group – workers’ compensation. › Work performed by outside “expert” with advice from the TAG and support from Safe Work staff. › Consultation. › Peer review. › Response to comment and peer review. › Draft report completed. › Final report accepted. › Report released (August 2015): http://www.safeworkaustralia.gov.au/sites/swa/workers- compensation/deemed-diseases/pages/deemed-diseases 18
The List structure › The list is essentially a table. › Structured around the disorder. › Each disorder paired with one or more explicit exposures. › Accompanying guidance material: - provides some contextual information - not formally part of the list; - intended to be for the use of claims officers and potential claimants. 19
Balancing the choices › To what extent should the system: › - only encourage people to apply if the claim will almost certainly succeed, OR 20
Balancing the choices › To what extent should the system: - only encourage people to apply if the claim will almost certainly succeed, OR - encourage people to apply if they have a particular disorder and been occupationally-exposed to a relevant exposure? 21
Challenges › Amount of exposure - no specific requirement for a specified minimum exposure amount › Latency - no specific requirement for a specified minimum latency 22
Challenges › Amount of exposure - no specific requirement for a specified minimum exposure amount › Latency - no specific requirement for a specified minimum latency › Non-occupational exposures - no explicit requirement to consider non-occupational exposures - BUT this may occur as part of the claim review process e.g. lung cancer in person exposed to chromium at work and who smokes › Content and format of the guidance material. 23
Challenges › Disorders that clearly can be related to occupational exposures but for which there are many other relevant exposures or exposures are hard to identify or measure: - e.g cancer, asthma, COPD, dermatitis, some musculoskeletal disorders. › Noise 24
The old list (ILO list format) › Focuses on exposure › Often doesn’t have an explicit link to a specific disorder e.g. “Diseases of a type generally accepted by the medical profession as caused by chrome or its toxic compounds.”. 25
The old list (ILO list format) › Focuses on exposure › Often doesn’t have an explicit link to a specific disorder e.g. “Diseases of a type generally accepted by the medical profession as caused by chrome or its toxic compounds.”. › Unfortunately, chromium can cause lung cancer, dermatitis, skin ulcers, perforation of the nasal septum, respiratory tract irritation, and chronic renal failure….. But the list doesn’t specify the disease……. So, there is still argument about whether the disease is related to the exposure or not. 26
The new list › Links a specific disease to a specific exposure e.g. “Dermatitis associated with occupational exposure to chromium VI”, “Lung cancer associated with occupational exposure to chromium VI”. 27
28
Some examples from the list 29
Cancer › IN: Cancer-carcinogen pairs which IARC classify as having “sufficient” evidence i.e. IARC Group 1 agents and relevant cancers e.g. Layrngeal cancer and acid mist › NOT IN: › All other cancer-agent pairs 30
Infectious disease › IN: Leptospirosis TB in relevant occupations (health worker, clinical laboratory worker, funeral parlour staff, farmer, veterinarian) › NOT IN: Legionellosis TB in other occupations 31
Diseases of the nervous system › IN: NIHL - noise greater than 85dB(a) › NOT IN: Chronic solvent-induced toxic encephalopathy 32
Vascular diseases › IN: (Raynaud’s disease - vibration) › NOT IN: Ischaemic heart disease 33
Respiratory diseases › IN: Occupational asthma - sensitising agents or irritants › NOT IN: COPD 34
Liver diseases › IN: Non-infectious hepatitis – organic solvents › NOT IN: 35
Skin diseases › IN: Contact dermatitis - sensitising agents or irritants › NOT IN: 36
Musculoskeletal diseases › IN: Bursitis at knee or elbow - prolonged external friction or pressure or repetitive motion Raynaud’s disease - vibration › NOT IN: Rotator cuff syndrome Carpal tunnel syndrome › …………… 37
Acute poisoning › IN: Acute poisoning/toxicity – many specified agents › NOT IN: 38
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