respiratory surveillance - trent occupational...

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

mailto:[email protected]

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)


High Level Surveillance

• Early detection of work-related disease

• To prevent further harm

• Feedback on risk assessments

• Encourage reporting of symptoms

between tests


Asthma HSE


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?


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


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

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By Whole Record Mean

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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.


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)


Results of respiratory surveillance

“advised to stop smoking, repeat 6/12”

Started work


“using 2 inhalers”


“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%


– occupational

asthma diagnosed

10%


– 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

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D.V

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By Predicted

Date

Readings

Work Hours

Additional

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January, 2018

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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


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

respiratory surveillance - trent occupational...

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