Consultant Occupational Physician University Hospital Birmingham Birmingham [email protected] Dr Alastair Robertson Occupational Lung Disease Unit Birmingham Chest Clinic Great Charles Street Birmingham RESPIRATORY SURVEILLANCE
Consultant Occupational Physician
University Hospital Birmingham
Birmingham
Dr Alastair Robertson
Occupational Lung Disease Unit
Birmingham Chest Clinic
Great Charles Street
Birmingham
RESPIRATORY
SURVEILLANCE
When should we be doing respiratory surveillance?
COSHH Risk
Assessment
Respiratory Surveillance
Identify Cases
Improve Control
Measures
Case of Occupational Lung
Disease
2744
2011
775
1135
781
152
379
105 14469 63
438
0
500
1000
1500
2000
2500
3000
Surveillance of Work-Related and Occupational Respiratory
Disease(SWORD) - Average Estimated Annual Cases (2013-2017)
Prof Raymond AgiusOccupational and Environmental Health Research GroupThe University of Manchester
Health Surveillance For Occupational Asthma
High Level Surveillance – When?Exposed to;
• Isocyanates
• Flour dust
• Grain dust
• Glutaraldehyde
• Wood dust
• Latex
• Rosin
• Lab animals
• Glues and resins
• Or substances where occupational asthma is a known problem
• Have a confirmed case of Occupational Asthma.
• Working with substances labelled R42
• Or
• H334 May cause allergy or asthma symptoms or breathing difficulties if inhaled.
• H335 May cause respiratory irritation.
• Risk assess the exposures
G402 Health Surveillance for Occupational
Asthma HSE
Health surveillance for occupational
asthma in the UK
D. Fishwick et al
Occupational Medicine, 2016, 66,365
Questionnaire
Item
Bakers (Total 153)
(%)
Woodworkers
(Total 149)(%)
Motor Vehicle
Repairers (Total
155) (%)
Reported occupational asthma risks in the workplace?
Yes 95/153 (62) 78/149 (52) 42/155 (27)
No 56/153 (37) 65/149 (44) 107/155 (69)
Missing 2/153 (1) 6/149 (4) 6/155 (4)
Health Surveillance in organisations reporting occupational asthma risk
23/95 (24) 11/78 (14) 7/42 (17)
Health Surveillance For Occupational Asthma
High Level Surveillance
• Early detection of work-related disease
• To prevent further harm
• Feedback on risk assessments
• Encourage reporting of symptoms
between tests
G402 Health Surveillance for Occupational
Asthma HSE
Health Surveillance For Occupational Asthma
High Level Surveillance
1) Pre-placement enquiry about respiratory health as a baseline.
• Ask about allergy and occupational asthma
• Consider lung function
• Respiratory Questionnaire
2) Yearly testing• Lung function
• Questionnaire
3) The health professional must explain the results to the individual and tell the employer if they are fit to work
Occupational Asthma Health Surveillance
Screening Questionnaire (1)
This screening questionnaire is designed for screening workers exposed to sensitising agents.
Any positive answers should lead to a full history from the responsible occupational physician.
Since your last medical have you;
1) had any episode of wheeze or chest tightness?
2) taken any treatment for your chest?
3) woken at night with cough or chest tightness?
4) had any episode of breathlessness?
Occupational Asthma Health Surveillance
Screening Questionnaire (2)
Since your last medical have you;
5) had any time off work?
(refer only those with respiratory cause for absence)
6) developed chest tightness or breathlessness after
exercise?
7) developed difficulty with breathing?
8) had irritation or watering of the eyes?
9) had a stuffy nose?
10) had soreness of the nose, lips or mouth?
11) had itching or irritation of the skin?
Health Surveillance For Occupational Asthma
Low level Surveillance
Appropriate where;
There is only occasional or potential exposure to a
respiratory sensitiser
Control is adequate
You decide to move to a lower level surveillance in
consultation with your health professional
G402 Health Surveillance for Occupational
Asthma HSE
Employee details plus,
Details of health surveillance check should include:• Date they were carried out and by whom
• Outcome of the test/check;
the decision on fitness for task and any restrictions required.
• Only relate to the employee's functional ability and fitness
for specific work, with any advised restrictions.
• The record can be linked with other information (eg, with any
workplace exposure measurements).
• Occupational health record, separate, medical and confidential
Management record under COSHH
• Lung function testing should be included as part of the NHS Health Check for those over 40
• (FEV1 is a stronger predictor of all cause mortality than diastolic blood pressure or serum cholesterol)
• Certify the competence of all healthcare professionals undertaking and interpreting quality assured diagnostic spirometry
All Party Parliamentary Group on Respiratory Health 2014
“Diagnostic spirometry is provided in a variety
of settings; GP practices and community
services as well as secondary care and for
workplace surveillance. Whatever the
particular service model, the professionals
delivering the service should be appropriately
certified as competent and follow the
recommendations set out in this document.”
Key to this framework is the establishment
of a National Register of certified
healthcare professionals and operators.
“Regular workplace spirometry is also used
to screen for occupational respiratory
disease”
• “Health surveillance providers
should be suitably qualified, e.g.
with an Association for
Respiratory Technology and
Physiology (ARTP) diploma.”
Certification in Spirometry
• Through the ARTP
• Certificate valid for 3 years, then need to re-certificate
• NHS England and HSE recommend performers and/or
interpreters are certificated.
Training
• No need to undertake a course if you don’t want to.
• If you do want a course, any provider can be used.
• ARTP provide a blended learning style of e-learning with a
half day workshop.
• Other providers may offer face to face 1 or 2 day
workshops
• Foundation level = performance only
• Full level = Performing and interpreting
Using Predicted Equations
.
Benefits• Better age range
• More accurate normal values• Age dependant lower limits of normal• Corrects under diagnosis of airways
obstruction <50 yrs and over diagnosis >50 yrs
175-cm 17.9 yrs male FVC 4.2L 97% predicted
18 yrs FVC 4.2L 83% predicted
3
3
3
3
2
2
2
3
2
1
3
3
3
3
4
4
3
4
4
4
4
3
460
440
420
400
380
360
340
320
300
280
260
240
220
200
180
160
Pe
ak E
xp
ira
tory
Flo
w (
PE
F)
Litre
s /
Min
ute
20%
50%
D.V
.
By Whole Record Mean
Date
Readings
Work Hours
Additional
M
04
05
October, 1999
9
9
W
T
05
06
9
9
W
06
07
9
9
T
07
08
9
9
F
08
09
8
5
S
09
10
5
S
10
11
5
M
11
12
7
9
T
12
13
9
9
W
13
14
9
9
T
14
15
9
9
F
15
16
8
5
S
16
17
6
S
17
18
6
M
18
19
10
9
T
19
20
11
9
W
20
21
9
9
T
21
22
9
9
F
22
23
9
4
S
23
24
5
S
24
25
6
M
25
26
10
9
T
26
27
11
9
W
27
28
10
9
T
28
29
10
9
F
29
30
10
5
S
30
31
8
S
31
01
7
W
M
01
13
November
0
w
M
13
14
August, 2001
5
9
T
14
15
6
9
W
15
16
5
9
T
16
17
6
9
F
17
18
5
5
S
18
19
6
S
19
20
3
M
20
21
6
11
T
21
22
6
9
W
22
23
5
5
T
23
24
4
F
24
25
4
S
25
26
3
S
26
27
4
M
27
28
5
11
T
28
29
6
9
W
29
30
5
11
T
30
31
7
9
F
31
01
5
11
S
01
02
September
5
5
S
02
03
3
M
03
04
5
9
T
04
05
6
11
W
05
06
6
9
T
06
07
6
11
F
07
08
5
5
S
08
09
4
S
09
10
3
M
10
11
6
11
T
11
12
5
10
W
12
13
6
11
T
13
14
6
11
F
14
15
6
7
W
S
15
16
4
5
W
S
16
17
4
W
M
17
09
0
w
M
09
10
December, 2002
5
8
T
10
11
4
10
W
11
12
5
10
T
12
13
4
10
F
13
14
3
5
S
14
15
3
S
15
16
3
M
16
17
4
9
T
17
18
4
10
W
18
19
5
9
T
19
20
4
9
F
20
21
4
5
S
21
22
3
S
22
23
3
M
23
24
3
T
24
25
3
W
25
26
3
T
26
27
3
F
27
28
3
S
28
29
5
S
29
30
3
M
30
31
3
T
31
01
3
W
01
02
January, 2003
4
T
02
03
4
9
F
03
04
5
9
S
04
05
3
S
05
06
4
M
06
07
5
10
T
07
08
5
8
W
08
09
6
9
T
09
10
5
9
F
10
11
5
8
S
11
12
4
S
12
13
4
M
13
14
6
9
T
14
15
5
10
W
15
16
5
9
T
16
17
5
W
F
17
18
0
5
c
e
w
W
Daily Max
Daily Mean
Daily Min
Oasys 2b score for period
Infection?
Patient rested
Patient worked a day shift
Patient worked an afternoon shift
Patient worked a night shift
Patient worked
Patient recorded no data
Day excluded
There are comments for day
Day is marked for exclusion
Missing waking reading(s)
Waking reading(s) Created
Normal Exposure
Opinions And Comments
Probable occupational asthma
Close to a 4 (definite OA). immediate reaction
Definite occupational asthma
getting progressively worse
50 Percent chance of occupational asthma
13/08/2001 - 16/09/2001 - Too few readings on some days off.
Definite occupational asthma
09/12/2002 - 17/01/2003 - Check what doing on 28th Dec
Occupational asthma in a foundry worker
Lower Limit Normal
Meas Pred %FEV1 1.75 3.3 52
NIOSH – SPIROmetry Longitudinal Analysis
(SPIROLA)
Occupational asthma in a foundry worker
Results of respiratory surveillance
“advised to stop smoking, repeat 6/12”
Started work
Occupational asthma in a foundry worker
“using 2 inhalers”
Occupational asthma in a foundry worker
“management informed not fit”
Copyright ©2006 BMJ Publishing Group Ltd.
Anees, W et al. Thorax 2006;61:751-755
Model of change in FEV1 over time in response to exposure and removal from exposure.
-101mls/yr 12mls/yr -27mls/yr
Characteristics of work related asthma: results from a
population based survey
• In the past 12 months, compared to individuals with non-
work related asthma individuals with work related current
asthma were;
• 4.8 times as likely to report having an asthma attack
• 4.8 times as likely to visit the emergency room at least
once
• 2.5 times as likely to visit the doctor at least once for
worsening asthma
C V Breton et al Occupational and Environmental Medicine 2006;63:411-415
Respiratory surveillance for Occupational Asthma Causing Agents Pre-employment screening
•Ask about allergy
•Ask about known occupational asthma
Questionnaire
• Baseline prior to exposure
• Annually (short questionnaire)
Referral Criteria
•Assess any change in symptoms
•Any “yes” to be referred for
clinical assessment
• Risk assessment of exposure to possible
asthma causing agents.
• Identify workers requiring surveillance
Spirometry
•Baseline prior to exposure
•Annually
Record results and plot to assess decline
Referral criteria
• Reduction in FEV1/FVC ratio <70%* - or
• Reduction in FEV1 +/- FVC <80%* - or
• FEV1 decline in 1 year or 5 years > 400mls
Interim action point
FEV1 fall 1 year 200mls or 2 consecutive years
200mls – early repeat lung function test
(3mths)
* or GLI Lower Limit of Normal
(whichever is the higher)
Referral to experienced
Occupational Physician
Referral to Occupational
Lung Disease Unit
Occupational asthma
Airways obstruction not
work-relatedNormal
Effective health surveillance for
occupational asthma in motor vehicle repair
Category 3 (possible occupational asthma)
Consulted GP - not
referred 15%
Referred to specialist
- did not attend
13%
Did not attend
GP 13% No reply from GP
37%
Referred to specialist
– occupational
asthma diagnosed
10%
Referred to specialist
– endogenous
asthma 12%
Mackie J, Occupational Medicine, Volume 58, Issue 8, December 2008, Pages 551–555
Managing occupational asthma
Making the diagnosis
❑ Make the diagnosis early and confirm by objective means
❑ Referral to local specialist unit for occupational lung disease
❑ List of units on GORDS web-page on Health and Safety Laboratory website.
Most common agents; SWORD
Prof Raymond AgiusOccupational & Environmental Health
Research GroupThe University of Manchester
Supermarket baker’s asthma: how accurate is routine
health surveillance? Brant A etc al Occup Environ Med 2005;62:395–399
Sensitivity Specificty
High Molecular
Weight
74% 71%
Low Molecular
Weight
28% 89%
Lux H, Lenz K, Budnik LT, et alPerformance of specific immunoglobulin E tests for diagnosing occupational asthma: a systematic review and meta-analysisOccupational and Environmental Medicine 2019;76:269-278.
Good for identifying sensitisation - heightened surveillance
Good for indicating overall control of exposures to sensitisers
Does not confirm or exclude a diagnosis of occupational asthma
Work-related symptoms - 41% positive IgE to flour or amylase
Cleaning Agents, Sensitizers or irritants?
• Amine compounds (eg, ethanolamine)
• Disinfectants (eg, aldehydes)
• Quaternary ammonium compounds (eg, benzalkonium chloride, didecyldimethylammonium chloride)
• Scents containing terpenes (eg, pinene, d-limonene)
• Isothiazolinones,
• Formaldehyde
• Enzymes
• Na Dichloroisocyanurate - Chlorine ( bleach with acid), Chloramines ( bleach with Nitrogen)
• Ammonia
• Hydrochloric acid
• Sodium hydroxide
4
4
4
4
720
700
680
660
640
620
600
580
560
540
520
500
480
Pe
ak E
xp
ira
tory
Flo
w (
PE
F)
Litre
s /
Min
ute
20%
50%
D.V
.
By Predicted
Date
Readings
Work Hours
Additional
M
08
09
January, 2018
8
10c
T
09
10
9
10c
W
10
11
8
10c
T
11
12
7
10c
F
12
13
9
5c
S
13
14
7
c
S
14
15
8
c
M
15
16
8
10c
T
16
17
8
13c
W
17
18
8
c
T
18
19
7
c
F
19
20
8
c
S
20
21
7
c
S
21
22
6
c
M
22
23
7
c
T
23
24
9
c
W
24
25
7
c
T
25
26
7
c
F
26
27
8
c
S
27
28
7
c
S
28
29
8
c
M
29
30
9
10c
T
30
31
9
10c
W
31
01
9
10c
T
01
02
February
8
10c
F
02
03
10
5c
S
03
04
7
c
S
04
05
8
W
c
e
w
W
Daily Max
Daily Mean
Daily Min
Oasys 2b score for period
Infection?
Patient rested
Patient worked a day shift
Patient worked an afternoon shift
Patient worked a night shift
Patient worked
Patient recorded no data
Day excluded
There are comments for day
Day is marked for exclusion
Missing waking reading(s)
Waking reading(s) Created
mild steel, powder coating and possibly 2 pack paint.
Opinions And Comments
Definite occupational asthma
exposed to 2 pack paints (? isocyanates) (bystander exposure), powder coats and welding fume.
wears an half-face when welding but not when others weld. 8th January to the 4th of February
off sick with bad back 17th to the 22nd of January
Referral from consultant
respiratory physician
2 years increasing
breathlessness and cough.
Better on days away from work.
Spends night sitting on end of
bed gasping for breath
Welds mild steel
Exposed to isocyanate
• OH nurse advised him he doesn’t have OA because his
spirometry is normal
• We advised better respiratory protection – company
declined
• We offered to visit – company declined
• RIDDOR reported
• HSE visited – told he is normal???
SPIROMETRY:
Actual Predicted
%Predicted
FEV1 4.05 3.94 102.8
FVC 5.70 4.80 118.7
FEV1/FVC 71%
Occupational chronic obstructive
pulmonary disease; a standard of care• Workplace exposures contribute 10 – 15% COPD
Agents• Coal mine dust
• Silica
• Iron/steel and smelting
• Welding fumes
• Flour
• Endotoxin
• Cadmium
• Asbestos
• Refractory ceramic fibres
• Carbon black
• Agricultural dusts
• Rubber dust
• Cotton dust
• Wood dust
• Isocyanates and other chemicals
A3 *** SIGN 2++
Occupations• Coal miners and underground workers
• Gold miners
• Construction workers
• Cement factory workers
• Metal workers
• Welders
• Farmers
• Cotton workers
• Carpenters
• Painters
• Railroad workers
A4 *** SIGN 2++
Occupational chronic obstructive pulmonary disease: a standard of care
Fishwick D, Occupational Medicine, 2015; 65; 270–282
Foundry Worker
• 15 yrs Increasingly breathless
• 20 yds on flat
• Lost weight
• Life-long non-smoker
Occupational History
• 18 – 27 Foundry making
Zinc Cadmium alloyPuts two sticks of cadmium into
ladle of molten Zinc
( same job as father and brother)
Boiling point
Zinc 907oC
Cadmium 767oC
Sacrificial Anodes
Welder
Age 21 – 31 MIG and arc welding of tractor cabs
31 - 66 MIG fabrication welding (60 hrs/wk)
3 years increasing breathlessness < 100yds
Lifelong non-smoker
Actual Pred % Pred
FEV1 0.82 2.68 30.4
FVC 2.13 3.46 61.6
FEV1/FVC 38.3%
Alph-1-antitrypsin 1.47 g/l (0.90 – 2.00)
COPD
COPD/ Chronic Bronchitis/
Emphysema
Exposures
• Coal-mine dust - mining
• Silica – stone mason, construction
• Flour dust
• Grain
• Wood dust
• Metal fumes
• Irritating gases
• Nitrogen oxides
• Sulphur dioxide
• Textile work
• R34 causes burns
• R35 causes severe burns
• R37 irritating to the respiratory system
COPD G401Baseline
• Lung Function
• Questionnaire
• Regular testing - look for long-term trends
• ARTP diploma
• Report symptoms between tests to responsible person
• Workers should keep a copy of their results
• Monitor patterns of sickness absence
• Keep COSHH record
• D1 * SIGN 2−: Accelerated lung function decline is a feature of occupational COPD. This can be identified at work if regular measures of lung function are taken
• D2 ** SIGN 2++: Workers at risk of occupational COPD should be assessed through a health surveillance programme including lung function measured by spirometry
• Conclusion• Workplace exposures contribute significantly to the Population
attributable risk for COPD
• Reduce exposure to VGDF
• Early identification of those with declining lung function important.
• This can be achieved with accurate annual measures of lung function Occupational chronic obstructive pulmonary disease: a standard of care
Fishwick D, Occupational Medicine, 2015; 65; 270–282
Occupational chronic obstructive
pulmonary disease; a standard of care
New York Firemen and Emergency Medical Services 9/11
Asbestos Health Surveillance
• Licensed work –
appointed doctor
approved by HSE
• Non-licensed work –
fully registered medical
practitioner
Respiratory surveillance in Asbestos
exposed workers• 40 yrs delay to peak asbestosis
• 50 yrs delay to peak mesothelioma
• Aims
• provide workers with information about their current state of respiratory health;
• alert workers to any early indications of asbestos-related disease and advise them on whether they should continue working with asbestos;
• Warn workers of the increased risk of lung cancer from combined exposure to smoking and asbestos;
• alert employers or the worker’s GP (with consent) to any particular problems;
• Advise workers to use available control measures.
Notifiable Non-licensed Asbestos Work
Non-licensed asbestos work
Respiratory Surveillance
• Not more than 3 years apart
• Respiratory symptom
questionnaire
• Medical examination
• Expansion
• Clubbing
• Basal Crackles
• Measurement of lung function
FEV1 and FVC
• Issue a Certificate of Medical
Examination
Silicosis in Great Britain 2008- 2017
0
10
20
30
40
50
60
70
80
90
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
IIDB cases (Silicosis /Unspecified pneumoconiosis
THOR (SWORD) cases
Deaths
Maximum daily silica exposure
Complications of Silica Dust Exposures
• Silicosis• Sarcoidosis• Chronic Bronchitis and Airflow Obstruction (COPD)• Immune-Mediated Complications
• Scleroderma • Renal disease• Rheumatoid Arthritis
• Lung Cancer• Mycobacterial Infections ( Esp TB), Nocardia
Classical or Chronic Silicosis
Most common presentation
Patients usually remain asymptomatic until after an
interval of 10-20 years of continuous silica exposure.
Reid 2012
Progressive Massive Fibrosis or Conglomerate Silicosis
Destructive progressive scarring of lungs
Silicosis THOR 2006 - 2015
Stonemasons and bricklayers 26%
Other construction-related occupations 25%
Mining and quarrying 20%
Foundry-related occupations 13%
20062006 20082008
Case 1
Case 2
•25 assessed
•10 lung transplant
• Caesarstone
• 93% quartz
Health surveillance for silica
• COSHH risk assessment
• Exposed to Respirable Crystalline
Silica
• Reasonable likelihood of silicosis
• Do respiratory surveillance
• Exposure low – discuss and
consider not doing it.
Crystalline silica
Mineral
• Quartz
• Cristobalite
• Tridymite
Rocks
• Granite
• Flint
• Sandstone
Occupations• mining
• stone cutting/ masonry
• foundry
• quarrying
• road and building construction
• work with abrasives
• glass manufacturing
• sand blasting
• pottery workers
• refractory work
Health Surveillance for Silica
• Baseline assessment before or shortly after first exposure
to RCS will include:
• Respiratory questionnaire
• Lung function testing (spirometry)
• FEV1 and FVC
• Consideration of baseline chest x-ray for future comparison
• Annual health surveillance
• Respiratory Questionnaire
• Lung function testing
• After 15 years of exposure to RCS
• For employees who have had 15 years of exposure to
RCS while working for one or more employer(s), the
health surveillance for that year will include:
• respiratory questionnaire;
• lung function testing; and
• PA chest X-ray.
• Thereafter continue with annual questionnaire and lung
function testing
• Plus chest x-ray every 3 years
Health Surveillance for Silica
Referral criteria
• Any worker with the following should be referred to a health professional with appropriate expertise:
• FEV1/FVC < 0.7 (70%) ( or LLN)
or
• FEV1 < 80% predicted ( or LLN)
+/-
• FVC < 80% predicted ( or LLN)
or
• I year decline in FEV1 of 500 mls or more
• 5 year decline in FEV1 fall of 500 mls (an average of 100 mls per year each year).
• All previous lung function results should be included in the referral
• LLN = Lower Limit of Normal
Action points
• The following interim action points are suggested that will
require early repeat lung function testing– any worker
with:
• FEV1 fall over one year of 200 mls; or
• FEV1 fall over two consecutive years of 200 mls;
Outcomes From an X-ray Health Surveillance
Programme For Silica-Exposed Workers
• 1383 workers x-rayed
• 1139 pottery workers
• 120 foundry workers
• 100 refractory products workers
• 24 other industries
161 abnormal CXRs
135 referred to GP
??outcome
26 referred to GORDS
18 complete records
3 silicosis7 CT results
awaited, 4 probable, 3 possible silicosis
1 Pottery
2 Refractory
How R A, Hobson J Occupational Medicine, 2019;69, Issue 5
The Occupational Burden of Non-malignant Respiratory
Diseases. An Official ATS and ERS Statement
Blanc et al Am J Respir Crit Care Med, 2019
3029
26
19
16
1413
10
2.31
0
5
10
15
20
25
30
35
Occupational B
urd
en (
%)
Respiratory Surveillance – needs action
• Not doing surveillance when we should
• Not doing surveillance competently
• Not acting on results of surveillance
• Not managing cases well