Occupational and Environmental Lung Diseases E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 917

Veröffentlichungsjahr: 2011

Beschreibung

Documents both environmental and work-related causes of lung disease Unlike other books on the subject, this new volume approaches occupational and environmental lung disease from the starting point of the patient who comes to the physician with respiratory symptoms. The authors recognize that potentially harmful exposures occur not only in the work environment, but also as a result of hobbies or other leisure activities, or from outdoor air pollution, and it is up the physician to identify whether a particular job or hobby is the cause of the patient's respiratory symptoms. To help you arrive at a differential diagnosis, chapters in the book are arranged by job or exposure, and are divided into 5 sections: * Personal environment * Home environment * Other indoor environments * Work environment * General environment Each is written by an expert in the specific topic and provides pragmatic information for the practicing physician. This practical book is an invaluable resource that belongs close at hand for all physicians dealing with patients experiencing respiratory symptoms.

Leseprobe

Contents

Contributors

Preface

Introduction

Asthma

Hypersensitivity pneumonitis (extrinsic allergic alveolitis)

COPD

Bronchiolitis

Pneumoconiosis

Lung cancer and mesothelioma

Attribution

Part I: The personal environment

1: Cosmetics and personal care products in lung diseases

1.1 Introduction: historical context of cosmetics and respiratory illness

1.2 Epidemiological context

1.3 Description of exposures

1.4 Respiratory diseases associated with exposure to cosmetics and personal care products

1.5 Diagnosis and management of occupational asthma in hairdressers

2: Passive smoking

2.1 Introduction

2.2 Exposure to second-hand smoke

2.3 Health effects of passive smoking in children

2.4 Health effects of passive smoking in adults

2.5 Diagnostic and management issues related to passive smoking

2.6 Prevention of SHS-related diseases

3: Emissions related to cooking and heating

3.1 Introduction

3.2 Description of exposures

3.3 Pollutants produced when using gas appliances in the home

3.4 Diseases associated with exposures

4: Cleaning and other household products

4.1 Introduction

4.2 Description of exposures

4.3 Diseases associated with exposures

4.4 Diagnosis and management issues

4.5 Summary and conclusions

5: Building materials and furnishing

5.1 Introduction to building materials and furnishing as sources of indoor air pollution

5.2 Emission of formaldehyde from building and interior surface materials

5.3 Emissions of volatile organic compounds

5.4 Emission of phthalates from PVC building and interior surface materials

5.5 Damp buildings and emissions of biological particles

5.6 Specific diseases associated with exposures from building materials and furnishing

5.7 Diagnosis and management issues

6: Mites, pets, fungi and rare allergens

6.1 Introduction

6.2 Mites

6.3 Cat and dog allergens

6.4 Rodents and other pets

6.5 Cockroaches

6.6 Fungi (molds)

6.7 Rare allergens

6.8 Diagnosis and management issues

7: Hobby pursuits

7.1 Definitions and general approach

7.2 Arts, crafts, and related activities in the plastic arts

7.3 Hobbies and pastimes involving pets and other animals

7.4 Sports and the performing arts

7.5 Miscellaneous hobbies, pastimes and avocations

7.6 Specific diseases associated with hobby activities

7.7 Diagnosis and management

Part II: Other indoor environments

8: Day-care and schools

8.1 Introduction

8.2 Description of exposures

8.3 Diseases associated with exposures in the school environment

8.4 Viral infections

8.5 Ventilation

8.6 Room temperature

8.7 Diagnosis and management issues

8.8 Summary

8.9 Recommendations

9: Secondhand smoke exposure and the health of hospitality workers

9.1 Introduction

9.2 Exposure of hospitality workers to SHS

9.3 Diseases and health conditions associated with exposures

9.4 Diagnosis and management issues

9.5 Conclusions

10: Health effects of environmental exposures while in automobiles

10.1 Environmental exposures in automobiles

10.2 Air pollution exposure while driving in cars

10.3 Smoking exposure

10.4 Other exposures in cars

10.5 Diseases associated with exposures

10.6 Diagnosis and management issues

10.7 Helpful websites

11: Indoor sports

11.1 Introduction

11.2 Ice sports and arenas

11.3 Ice arena air pollution: exposures and practical hints when taking a history

11.4 Indoor ice arena toxicant syndromes

11.5 Standards, guidelines and public health considerations

11.6 Cold air-exacerbated asthma and dyspnea

11.7 Water sports

11.8 Exposures

11.9 Diseases and health effects

11.10 Extrinsic allergic alveolitis (hypersensitivity pneumonitis)

11.11 Infections

11.12 Swimming-induced pulmonary edema

11.13 Trauma

11.14 Equestrian arenas and horseback riding

11.15 Gymnastics, weightlifting, athletics (track and field) and rock wall climbing

Part III: The work environment

12: Agricultural environments and the food industry

12.1 Introduction

12.2 Agriculture and agribusiness

12.3 Case 1

12.4 Case 2

12.5 Symptoms not related to allergen exposure

12.6 Other agrobusiness

12.7 Seafood and meat processing

12.8 Case 3

12.9 Bakeries

12.10 Other food industry

12.11 International perspective

13: Mining

13.1 Introduction

13.2 Population at risk

13.3 The mine environment

13.4 Pneumoconiosis

13.5 Obstructive pulmonary disease

13.6 Tuberculosis and nontuberculous mycobacterial diseases

13.7 Malignant disease

13.8 Pleural disease

13.9 Connective tissue and renal diseases

13.10 Mining and tobacco smoking

13.11 Acute lung and airway inhalational injury

13.12 Trauma

13.13 Conclusion

14: Metal industry and related jobs (including welding)

14.1 Introduction

14.2 Metals defined

14.3 Workplace hazards from metals

14.4 Metal industry processes

14.5 Pulmonary responses to metals

14.6 Beryllium: lung and systemic effects

14.7 Cobalt disease (hard metal pulmonary disease)

14.8 Welding-related lung disease

15: Automobile maintenance, repair and refinishing

15.1 Introduction - the industry

15.2 Exposures from automobile maintenance and repair

15.3 Exposures in auto body workshops

15.4 Respiratory diseases in auto mechanics and repair workers

15.5 Work-related asthma

15.6 Other lung diseases in auto mechanics and repair workers

15.7 Other nonpulmonary occupational diseases among auto repair workers

16: Automotive industry

16.1 Introduction

16.2 Respiratory hazards and disease

16.3 Vehicle parts manufacturing

17: Wood and textile industries

17.1 Wood industry

17.2 The pulp and paper industry

17.3 The textile industry

17.4 Prevention

18: Chemical, coatings and plastics industries

18.1 Introduction and definitions

18.2 Overview of the chemical, coatings and plastics industry

18.3 Major types of paints, coatings and plastics

18.4 Major respiratory disorders in chemical, coatings and plastics workers

18.5 Diagnosis and management

19: Work with electronics

19.1 Introduction

19.2 The history of soldering

19.3 Diseases in those exposed to soft soldering flux fumes

19.4 Epidemiological context

19.5 Definition of scope (and limitations)

19.6 Exposures and processes in the electronics industry

19.7 Practical hints (and pitfalls) when taking a history from patient

19.8 How to document exposure, including biomonitoring

19.9 Diseases associated with colophony and isocyanate exposure in the electronics industry

19.10 Diagnosis and management issues

19.11 Management and prevention

19.12 Medicolegal considerations and compensation

19.13 Public health issues

19.14 The spectrum of occupational diseases in electronics workers

20: The services industry

20.1 Introduction

20.2 Health diagnosing and treating occupations

20.3 Personal care and service – cosmetology professionals

20.4 Protective services

20.5 Food preparation and serving-related occupations

20.6 Building and grounds cleaning and maintenance occupations - janitors/cleaners

20.7 Conclusions

21: The construction industry

21.1 Introduction

21.2 Inhalation hazards in the construction industry

21.3 Diseases associated with exposures in construction work

21.4 Asthma and selected immunologic conditions

21.5 Occupational cancers

21.6 Other conditions

22: Police, firefighters and the military

22.1 Introduction

22.2 First responders: potential exposures common to police, firefighters and the military

22.3 Police

22.4 Firefighters

22.5 Military

22.6 Compensation

23: Office workers and teachers*

23.1 Introduction

23.2 Exposures in office buildings and schools

23.3 Diseases associated with exposures

23.4 Diagnosis and management issues

24: Research workers

24.1 Introduction

24.2 Respiratory hazards and diseases

24.3 Respiratory sensitization: asthma and rhinitis

24.4 Making a diagnosis of respiratory sensitization

24.5 Management of respiratory sensitization in the research setting

24.6 Respiratory disease arising from exposures to irritant substances

24.7 Immediate effects of acute exposures to respiratory irritants at relatively high intensity

24.8 Management of the acute effects of high-dose irritant exposure

24.9 Longer-term effects of acute exposures at relatively high intensity

24.10 Nonasthmatic diseases

24.11 Asthma

24.12 Management of irritant-induced asthma

24.13 Other respiratory diseases in research workers

24.14 Other occupational diseases among research workers

25: Work in hyperbaric environments

25.1 Introduction

25.2 Respiratory hazards, diseases and their management

25.3 Further information

26: Effects of travel or work at high altitudes or low pressures

26.1 Introduction

26.2 Physics of the high-altitude environment

26.3 Physiology of flight

26.4 Altitude illness

Part IV: The general environment

27: Natural sources - wildland fires and volcanoes

27.1 Introduction

27.2 Biomass burning

27.3 Volcanoes

27.4 Management/prevention

28: Traditional urban pollution

28.1 Introduction

28.2 Particulate matter

28.3 Sulfur oxides

28.4 Nitrogen oxides

28.5 Ozone

28.6 Air toxics

29: Traffic-related urban air pollution

29.1 Introduction

29.2 History of traffic-related air pollution

29.3 Engines and emissions

29.4 Traffic-related air pollutants

29.5 Health effects of traffic-related air pollution

29.6 Conclusions

30: Outdoor sports

30.1 Introduction

30.2 Epidemiological context

30.3 Definition of exposures related to asthma and respiratory disorders in athletes - pathogenetic mechanisms

30.4 Diseases related to physical activity, training and competition in sports

30.5 Diagnostic considerations and medicolegal issues

30.6 Treatment of asthma and exercise-induced bronchoconstriction in athletes

30.7 International regulations for use of asthma drugs in sports

30.8 Controller treatment of EIA

30.9 Reliever treatment of EIA

30.10 Recommendations for the treatment of exercise induced asthma in athletes

Index

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Library of Congress Cataloging-in-Publication Data

Occupational and environmental lung diseases: diseases from work, home, outdoor and other exposures/[edited by] Susan M. Tarlo, Paul Cullinan, Benoit Nemery.

p. cm.

Includes index.

Summary: “Documents both environmental and work-related causes of lung disease. Unlike other books on the subject, this new volume approaches occupational and environmental lung disease from the starting point of the patient who comes to the physician with respiratory symptoms. The authors recognize that potentially harmful exposures occur not only in the work environment, but also as a result of hobbies or other leisure activities, or from outdoor air pollution, and it is up the physician to identify whether a particular job or hobby is the cause of the patient’s respiratory symptoms. To help you arrive at a differential diagnosis, chapters in the book are arranged by job or exposure, and are divided into 5 sections: Personal environment. Home environment. Other indoor environments. Work environment. General environment. Each is written by an expert in the specific topic and provides pragmatic information for the practicing physician. This practical book is an invaluable resource that belongs close at hand for all physicians dealing with patients experiencing respiratory symptoms” - Provided by publisher.

ISBN 978-0-470-51594-5 (hardback)

1. Lungs-Diseases-Environmental aspects. 2. Occupational diseases. I. Tarlo, Susan M. II. Cullinan, Paul. III. Nemery, Benoit.

RC756.O227 2010

616.2’4071-dc22

2010025645

ISBN: 978-0470-51594-5

Contributors

Michael Bagshaw

Professor of Aviation Medicine King’s College London Visiting Professor Cranfield University WC2R 2LS, UK

William S. Beckett

Associate Professor of Medicine Harvard Medical School, Boston, MA

Attending Physician, Medicine Mount Auburn Hospital 330 Mount Auburn St Cambridge, MA 02138, USA

Paul D. Blanc

Professor of Medicine and Endowed Chair Occupational and Environmental Medicine University of California, San Francisco Box 0924 San Francisco, CA 94143-0924, USA

Frédéric de Blay

Division of Pulmonology Asthma and Allergology Chest Diseases Department 1SB401 Hôpitaux Universitaires de Strasbourg BP426, 67091 Strasbourg Cedex, France

Jakob Hjort Bønløkke

Department of Environmental and Occupational Health Institute of Public Health Aarhus University Denmark

Sherwood Burge

Consultant Physician Occupational Lung Disease Unit Birmingham Heartlands Hospital Birmingham B9 5SS, UK

Kai-Håkon Carlsen

Professor of Paediatric Respiratory Medicine and Allergology University of Oslo Professor of Sports Medicine Norwegian School of Sport Sciences Oslo University Hospital, Rikshospitalet Department of Paediatrics NO 0027 Oslo, Norway

Arch I. Carson

Southwest Center for Occupational and Environmental Health Division of Environmental and Occupational Health Sciences The University of Texas School of Public Health Houston, Texas, USA

Yvon Cormier

Pulmonologist Institut Universitaire de Cardiologie et de Pneumologie de Québec (IUCPQ) Professor of Medicine Department of Medicine Université Laval Québec, Canada

Robert L. Cowie

Professor of Medicine and of Community Health Sciences University of Calgary Director, Tuberculosis Services, Calgary Director, Calgary COPD and Asthma Program Respirologist, Alberta Health Services Health Research and Innovation Centre 3280 Hospital Drive NW Calgary, Alberta, T2N 4Z6, Canada

Jean M. Cox-Ganser

Division of Respiratory Disease Studies National Institute for Occupational Safety and Health Morgantown, West Virginia, USA

Paul Cullinan

Professor in Occupational and Environmental Respiratory Disease National Heart and Lung Institute (Imperial College), and Royal Brompton Hospital, London, UK

George L. Delclos

Professor Southwest Center for Occupational and Environmental Health The University of Texas School of Public Health Houston, Texas, USA

Madeline A. Dillon

Center for Environmental Medicine Asthma and Lung Biology University of North Carolina Chapel Hill North Carolina, USA

Mark D. Eisner

Associate Professor of Medicine University of California, San Francisco San Francisco, CA 94143, USA

Mark W. Frampton

Professor of Medicine and Environmental Medicine Pulmonary and Critical Care University of Rochester Medical Center 601 Elmwood Ave., Box 692 Rochester, NY, 14642-8692 585-275-4861, USA

Mark Glover

Medical Director Hyperbaric Medicine Unit St Richard’s Hospital Spitalfield Lane Chichester West Sussex PO19 6SE, UK

Jouni J.K. Jaakkola

Professor of Public Health Center for Environmental and Respiratory Health Research University of Oulu, Finland Professor of Environmental and Occupational Medicine Institute of Occupational and Environmental Medicine University of Birmingham UK

Maritta S. Jaakkola

Professor and Chief Physician of Respiratory Medicine Respiratory Medicine Unit Institute of Clinical Medicine University of Oulu and Oulu University Hospital P.O. Box 5000 90014 Oulu, Finland

Debbie Jarvis

Respiratory Epidemiology and Public Health Group Emmanuel Kaye Building Manresa Road National Heart and Lung Institute Imperial College London SW3 6LR, UK

Stefanos N. Kales

Medical Director Employee & Industrial Medicine Cambridge Health Alliance Assistant Professor Harvard Medical School Director Occupational & Environmental Medicine Residency Harvard School of Public Health 1493 Cambridge Street Cambridge, MA 02139, USA

Howard M. Kipen

Professor and Interim Chair Department of Environmental and Occupational Medicine Acting Associate Director Environmental and Occupational Health Sciences Institute UMDNJ-Robert Wood Johnson Medical School 170 Frelinghuysen Road Piscataway, NJ 08854, USA

Kathleen Kreiss

Division of Respiratory Disease Studies National Institute for Occupational Safety and Health Morgantown, West Virginia, USA

Ware G. Kuschner

Associate Professor of Medicine Stanford University School of Medicine Division of Pulmonary and Critical Care Medicine United States Department of Veterans Affairs Palo Alto Health Care System 3801 Miranda Avenue, 111P Palo Alto, CA 94304, USA

Steven M. Lee

Pulmonary and Critical Care Medicine Southern California Permanente Medical Group Kaiser Permanente Fontana Medical Center 9985 Sierra Avenue, Fontana, CA 92335, USA

Kenneth D. Linch

Division of Respiratory Disease Studies Surveillance Branch National Institute for Occupational Safety and Health Morgantown, West Virginia, USA

Gary M. Liss

Assistant Professor Gage Occupational and Environmental Health Unit Dalla Lana School of Public Health University of Toronto (and Ontario Ministry of Labour) Toronto, Ontario, Canada

Harman S. Paintal

Clinical Assistant Professor of Medicine Stanford University School of Medicine Division of Pulmonary and Critical Care Medicine United States Department of Veterans Affairs Palo Alto Health Care System 3801 Miranda Avenue, 111P Palo Alto, CA 94304, USA

Ju-Hyeong Park

Division of Respiratory Disease Studies National Institute for Occupational Safety and Health Morgantown, West Virginia, USA

Sam Parsia

Assistant Professor Division of Pulmonary, Critical Care, and Sleep Medicine Department of Medicine New York University School of Medicine New York, NY, USA

Amee Patrawalla

Assistant Professor Division of Pulmonary and Critical Care Medicine University of Medicine and Dentistry of New Jersey New Jersey School of Medicine Newark, NJ, USA

Gabrielle Pauli

Division of Asthma and Allergy Chest Diseases Department University Hospital Strasbourg BP 426, 67091 Strasbourg Université Strasbourg 4 rue Blaise Pascal 67000 Strasbourg, France

David B. Peden

Center for Environmental Medicine Asthma and Lung Biology University of North Carolina Chapel Hill North Carolina, USA

Edward L. Petsonk

Professor of Medicine Section of Pulmonary and Critical Care Medicine West Virginia University School of Medicine PO Box 9166 Morgantown, West Virginia 26506, USA

Magdalena Posa

Division of Asthma and Allergy Chest Diseases Department University Hospital Strasbourg BP 426, 67091 Strasbourg Université Strasbourg 4 rue Blaise Pascal 67000 Strasbourg, France

Ashok Purohit

Division of Asthma and Allergy Chest Diseases Department University Hospital Strasbourg BP 426, 67091 Strasbourg Université Strasbourg 4 rue Blaise Pascal 67000 Strasbourg, France

Reginald Quansah

Institute of Occupational and Environmental Medicine University of Birmingham Birmingham, UK

Carrie A. Redlich

Professor of Medicine Occupational and Environmental Medicine and Pulmonary & Critical Care Medicine Yale University School of Medicine New Haven, CT, USA

William N. Rom

Sol and Judith Bergstein Professor of Medicine and Environmental Medicine Director Division of Pulmonary, Critical Care and Sleep Medicine Department of Medicine New York University School of Medicine 550 First Avenue New York, NY 10016, USA

Eva Rönmark

Associate Professor Department of Public Health and Clinical Medicine Occupational and Environmental Medicine Umeå University SE-901 85 Umeå, Sweden

Kenneth D. Rosenman

Professor of Medicine Chief, Division of Occupational and Environmental Medicine College of Human Medicine Michigan State University 117 West Fee East Lansing MI 48824, USA

Torben Sigsgaard

Professor Department of Environmental and Occupational Health Institute of Public Health Aarhus University Denmark

Greta Smedje

Department of Public Health and Clinical Medicine Occupational and Environmental Medicine Umeå University SE-901 85 Umeå, Sweden

Meredith H. Stowe

Associate Research Scientist Department of Medicine Yale Occupational and Environmental Medicine Lecturer Epidemiology and Public Health Yale University School of Medicine New Haven, CT 06510, USA

Oyebode A. Taiwo

Associate Professor of Medicine Director, Fellowship Training Occupational and Environmental Medicine Program Yale University School of Medicine 135 College Street, 3rd Floor New Haven, CT 06510-2483, USA

Susan M. Tarlo

Department of Medicine and Dalla Lana School of Public Health University of Toronto Division of Respiratory Medicine University Health Network Toronto, Ontario, Canada

Aaron M. S. Thompson

Occupational & Environmental Medicine Clinic St. Michael’s Hospital 30 Bond Street Toronto, Ontario M5B 1W8, Canada

Kjell Torén

Professor/Senior Consultant of Clinical Allergology and Occupational Medicine Head Section of Occupational and Environmental Medicine University of Gothenburg Box 414, 405 30 Gothenburg, Sweden

Lea Ann Tullis

Southwest Center for Occupational and Environmental Health The University of Texas School of Public Health Houston, Texas, USA

Sverre Vedal

Professor of Environmental and Occupational Health Sciences University of Washington School of Public Health Adjunct Professor of Medicine University of Washington School of Medicine Seattle, WA, USA

Jan-Paul Zock

Associate Research Professor Centre for Research in Environmental Epidemiology (CREAL) and Municipal Institute of Medical Research (IMIM-Hospital del Mar) Barcelona Biomedical Research Park (PRBB) Doctor Aiguader 88 08003 Barcelona, Spain

Editors

Susan M. Tarlo, MB BS, MRCP(UK), FRCP(C)

Department of Medicine and Dalla Lana School of Public Health, University of Toronto, and Division of Respiratory Medicine, University Health Network, Toronto, Ontario, Canada

Paul Cullinan, MD, FRCP

Occupational and Environmental Respiratory Disease, National Heart and Lung Institute (Imperial College), London, UK

Benoit Nemery, MD, PhD

Toxicology and Occupational Medicine, Department of Public Health, Faculty of Medicine, Catholic University of Leuven, Leuven, Belgium

Preface

This book was initially the concept of Dr Ben Nemery, who identified that no current textbooks approach the topic of Occupational and Environmental Lung Diseases from the starting point of the patient who comes to a physician with respiratory symptoms. Early in the clinical history the patient should be identified as having a particular job or ‘environmental’ exposure(s). A natural question then should be ‘Is this job (or other exposure or even hobby) the cause of the respiratory symptoms in this patient, and if so, what could be the differential diagnosis?’

The chapters in this book are therefore arranged by job or exposure(s) rather than by specific causative agents. Each is written by an expert in the specific topic and aims to provide pragmatic information for the practicing physician. The format of various chapters varies in keeping with the emphases considered to be most useful by the invited authors. In keeping with the aims of the book we have asked authors to provide practical information and to keep specific references to a minimum, but to include some key review articles that the reader may access for more detailed references if wished. With this format, the information presented represents the views of the author of each chapter, and there may be small differences expressed in different chapters. We also recognize that there is some degree of repetition in the book, but we felt it most useful to include this if it pertains to different jobs or exposures in different chapters.

We recognize that potentially harmful exposures occur not only in work environments but also as part of hobbies or other leisure activities such as sports, and also from outdoor air pollutants; we have included sections on each of these. We have not included a chapter on the personal effects of tobacco products (since these effects are well recognized by all physicians), on the smoking of marijuana (for which there are far fewer published data) or on exposures to nanoparticles other than as outdoor ultrafine particulates (since the knowledge of their effects is currently very sparse). However we believe that most of the important exposures are addressed.

We hope that this book will not be a reference guide on a bookshelf but will be a useful and much-used adjunct in the clinical setting, finding a place at your right hand.

The editors

Introduction

Paul Cullinan1 and Susan M. Tarlo2

1Imperial College and Royal Brompton Hospital, London, UK

2University of Toronto and University Health Network, Toronto, Ontario, Canada

In this Introduction we aim to set the stage by giving a brief overview of the lung diseases that are alluded to in this book. While their details and those of the investigations used in their diagnosis may be familiar to the specialist respiratory physician, they may be more useful to review for other readers. Conversely, the discussion of disease attribution at the end of this chapter, which is probably familiar to occupational physicians, may be more useful for the pulmonary and primary care physician. We again wish to emphasize the importance of taking a detailed occupational and environmental history. Important in all patients, it is particularly so in those with respiratory symptoms, as can be clearly seen in the chapters that follow.

There is a limited number of ways in which the lungs can respond to an environmental exposure, whether this is at work, home, outdoors or as part of a hobby. While the specific cause for the disease is important in diagnosis, and in allowing appropriate management to prevent further disease in the patient (and potentially in others), nevertheless, the pattern of disease can be similar from many different causes. The diagnosis of an occupational (and sometimes other environmental) disease may lead to disease-related compensation for the individual affected, but in particular should serve as a sentinal event, leading to appropriate consideration of co-workers who may also be at risk. Confirmation of an occupational disease, and where possible, identification of the cause can potentially lead to changes at work to protect others and reduce their risk of disease, and readers are encouraged to determine the appropriate steps locally to allow workplace interventions, e.g. by public health agencies or company physicians.

Asthma

Asthma is a common condition that can start at any age. It affects between 5 and 10% of adults and can be caused or exacerbated by work or other environmental exposures, or may start incidentally and be provoked without a clear environmental trigger. It has been estimated that 10-15% of adult asthma may be attributed to occupation, and cohort studies have shown that up to 20% or more of working asthmatics can have exacerbations of their asthma due to exposures or conditions at work.

Occupational asthma is defined as asthma that is caused by a specific exposure at work. It may be due to a demonstrated or presumed immunologic response to a work agent (sensitizer-induced occupational asthma), or can be due to a high-level irritantexposure (irritant-induced asthma, for which the most clear example is reactive airways dysfunction syndrome, RADS). Work-exacerbated asthma comprises unrelated asthma (preceding or with concurrent onset to work), which is worsened either on a sporadic or frequent basis by conditions at work. Both occupational and work-exacerbated asthma are included in the term ‘work-related asthma’.

The features from the history which should increase suspicion of sensitizer-induced occupational asthma are primarily: (a) asthma beginning during a work period; (b) asthma symptoms improving on days or holidays away from work and/or worsening on work days; and (c) a known or presumed sensitizer exposure at work. Investigations for suspected occupational asthma include: objective confirmation of asthma with pulmonary function tests showing a significant bronchodilator response or positive methacholine or equivalent test of airway responsiveness; serial peak flow monitoring, with recordings of peak flow rates in triplicate at least four times a day during days at work and periods off work over several weeks, concurrently recording asthma symptoms and medications; repeat of methacholine or equivalent tests near the end of a work week and after 10 days or more off work to assess changes in PC related to work exposures; skin prick or in-vitro tests to identify specific IgE antibodies to a work sensitizer (when feasible); induced sputum cytology to identify changes in eosinophil and neutrophil counts during work period and off-work periods; and specific inhalation challenges with the suspected work substance (if needed and if available). Published guidelines, standards of care and consensus statements are available to provide more detail for investigations and interpretation of results. The best prognosis for sensitizer-induced occupational asthma occurs with early diagnosis and complete removal from further exposure to the sensitizer.