Psycho-socio-economic

impact of

occupational asthma

Olivier Vandenplas

Department of Chest MedicineMont-Godinne Hospital

Catholic University of LouvainYvoir - Belgium

Age, sex Work conditions Socio-economic status Emotional factors Co-morbidities, …

IMPAIRMENT

Physiological deficitRelative to “normal” values

DISABILITY

Impact on daily life

Relative to prior patient’s status

Focus on impairment & disability

Airway obstructionAirway hyperresponsivenessMedication needAirway inflammation?

Quality of lifeWork productivity

Evaluation of impairment in asthmaATS guidelines

Score

Airway obstruction

Airway hyperresponsiveness

Medication need

FEV1

(post-BD)

% FEV1

change post-BD

PC20 (mg/ml)

0>lower limit of normal

<10 >8 No medication

170% pred to lower limit of normal

10-19 8-0.5 Occasional BD

2 60-69 20-29 0.5-0.125Daily BD or low dose ICS (<1000 µg beclomethasone)

3 50-59 ≥30 ≤0.125High dose ICS (>1000 µg beclomethasoe) or occasional oral steroids

4 <50Daily high dose ICS and daily oral steroids

From: ATS Guidelines Am Rev Respir Dis 1993;147:1056

Airway inflammation & evaluation of impairment

Chan-Yeung M, Am J Respir Crit Care Med 1999;159:1434-8

50 patients with red cedar OA

r = 0.52, p<0.001Sputum eosinophils correlate with

ATS class of impairment

(Chan-Yeung M, Am J Respir Crit Care Med

1999;159:1434-8)

Persistence of airway inflammation after

removal from exposure:

sputum eosinophils in 20% of

subjects

sputum neutrophils in 30% of

subjects

eosinophils and/or neutrophils in 17%

of subjects with normal FEV1 and PC20

(Yacoub MR, Eur Respir J 2007;29:889)

Increased risk of exacerbation?

Rating of impairment: requirements

Stable asthma

Asthma Control Questionnaire (ACQ): 7 items (www.qoltech.co.uk)

Score <0.75 = well controlled; score >1.50 = inadequately controlled

Asthma control Test (ACT): 5 items (www.qualitymetric.com)

Score >19 = inadequately controlled

GINA classification of severity/control (www.ginasthma.com)

Optimal treatment

Minimum medication

required to maintain control

Timing of assessment

2 to 5 yrs after removal

from causal exposure

(Malo JL, Am J Respir Crit

Care Med 2004;169:1304)

Q 61 & 66. What is the impact of work-related asthma on

Quality of Life (QoL) assessed using validated instruments in

various populations?

Q 61 & 62. What are the factors that determine QoL in

subjects with OA: income loss, compensation, severity of

asthma?

Tarlo SM & Malo JL. An ATS/ERS report: 100 key

questions and needs in occupational asthma.

Eur Respir J 2006;27:607-14

Disability – Quality of life

Quality of life in occupational asthma

Comparison with other types of asthma

Non-occupational asthma

QoL is lower in subjects with OA (mean AQLQ score: -0.6)

than in those with non-OA matched for the severity of asthma

(Malo JL, J Allergy Clin Immunol 1993)

Work-exacerbated asthma

QoL is similar in OA and WEA

(Lemière C, J Occup Environ Med 2006)

Determinants of QoL

“Satisfaction with life” is associated with:

- current employment

- less severe asthma (use of medication, PEF variability)

(Piirila P, J Occup Health 2005;47:112-18)

Q 65. Are psychological factors involved in the aetiology of

work-related asthma and how psychological factors affect

treatment and outcome of OA?

Tarlo SM & Malo JL. An ATS/ERS report: 100 key

questions and needs in occupational asthma.

Eur Respir J 2006;27:607-14

Psychological factors in occupational asthma

Significant level of psychological distress, including anxiety, and

depression in ~50% of subjects with OA after cessation of

exposure (Psychiatric Symptom Index,PSI)

Anxiety disorders in 35% of subjects with OA (Millon Clinical

Multiaxial Inventory, MCMI-III)

(Yacoub MR, Eur Respir J 2007;29:889)

Prospective investigation of the influence of psychological factors on

asthma control, QoL, and socioeconomic impact of OA by

comparison with non-occupational asthma, and the effect of

interventions (e.g. rehabilitation) on psychological disorders

Q 62. What is the cost of OA in different countries?

Q 62. What should be done to reduce socio-economic losses

due to work-related asthma?

Tarlo SM & Malo JL. An ATS/ERS report: 100 key

questions and needs in occupational asthma.

Eur Respir J 2006;27:607-14

Disability – Work productivity

Cost of occupational asthma

Direct costs

Healthcare expenses

Indirect cost

Impaired work productivity:

Job changes/Unemployment

Absenteeism

Reduced work effectiveness

Compensation, rehabilitation

Intangible costs

QoL

Socio-economic consequences of OA

Country ReferenceNo. of

subjects

Follow-up

(yr)

Work

disruption

(%)

Loss of income (% of workers)

UK Gannon, 1993 112 Median: 1.4 35%Exposed: 44%

Unexposed: 74%

Canada, BC Marabini, 1993 128 Mean: 4.8 41% NA

Canada, Qc Dewitte, 1994 134 Range: 2-5 25% NA

UK Cannon, 1995 87 5 39% 55%

France Ameille, 1997 209 Mean: 3.1 34% 46%

USA Gassert, 1998 55 Mean: 2.6 69% NA

UK Ross, 1998 770 1.5-5.5 37% NA

Belgium Larbanois, 2002 86 Median: 3.3 38% 62%

Norway Leira, 2005 496 2-6 49% 51%

Finland Piirila, 2005 213 Mean: 10 14% NA

Updated from: Vandenplas O, Toren K & Blanc PD, Eur Respir J 2003;22:689

Findings in WEA compared with:

Socio-economic outcome

Asthma unrelated

to workOccupational Asthma Reference

Work productivity:

Unemployment Similar (31% v 32%)

NA

Similar (43% v 38%)*

Similar (31% v 39%)

Similar (48% v 38%)

NA

Cannon J, 1995

Larbanois A, 2002

Breton CV, 2006

Job/employer changes More common

NA

NA

NA

Similar

Less common (54% v 72%)

Less common (23% v 47%)¥

Similar (100% v 94%)

Cannon J, 1995

Larbanois A, 2002

Goe SK, 2004

Lemière C, 2006

Lost workdays Similar

More common (19% v 12%)

Similar*

NA

NA

NA

Tarlo SM, 2000

Henneberger PK, 2002

Breton CV, 2006

Work ability (self-reported) Slightly decreased NA Balder B, 1998

Loss of income: More common (65% v 38%)

NA

Similar (65% v 62%)

Similar (59% v 62%)

Cannon J, 1995

Larbanois A, 2002

* Work-related asthma; ¥ New-onset occupational asthma

Socio-economic consequences of WEA

Adapted from: Vandenplas O & Henneberger PK,Curr Opin Allergy Clin Immunol 2007

Determinants of adverse economic outcomes (1)

Country Reference

Prevalence of income loss (%)

% reduction of income

Prevalence of income loss (%)

% reduction of income

Persistence of exposure Avoidance of exposure

UK Gannon, 1993 44 Median: 54% 74 Median: 35%

Belgium Larbanois, 2002 27 NA 78 NA

Italy Moscato, 1999 17 -$268/yr 69 -$4,203/yr

Same employerOther employer or

unemployed

France Ameille, 1997 19 19 ± 10% 84 50 ± 28%

Avoidance of exposure to the causal agent

Change of employer

15-21% of workers with OA are relocated within the

same company vs. 31% in Quebec

Age, low education level, small-size company

Absence of retraining program?

Information on rehabilitation unavailable for most countries (<5% in Belgium)

Rehabilitation: 31% in Quebec and 34% in Finland

Severity of asthma

Minimal effect in available studies

Exception of Finland: Unemployment is associated with nocturnal

symptoms, PEF variability, and use of SABA

(Piirila P, J Occup Health 2005;47:112-18)

Compensation should aim at reducing non-medical factors that

determine work-disability

Determinants of adverse economic outcomes (2)

Q 63. What are the consequences of initiating a claim for

work-related asthma?

Q 64. What weight should be given to impairment and

disability in compensating subjects with OA?

Tarlo SM & Malo JL. An ATS/ERS report: 100 key

questions and needs in occupational asthma.

Eur Respir J 2006;27:607-14

Compensation of OA

Initiating a claim for compensation?

Higher rate of unemployment (Ameille J, Eur Respir J 1997):

cause or consequence?

Loss of income offset by compensation

22% of compensated workers (Larbanois A, Eur Respir J 2003)

~30% of affected workers remain exposed to causal agent

Compensation of OA based on physiological impairment is

highly inefficient, at least in countries where work-disability

remains the major determinant of the impact on socio-economic

status and QoL