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