Dignosis Of Occupational Lung Diseases : Importance of Occupational History

1. Dignosis Of OccupationalLungDiseases:Importance of OccupationalHistory Prof. Fatma Evyapan MD, PhD Pamukkale University School of Medicine Denizli, Turkey

2. Main Topics • Historical Perspective • Importance of occupational history • Key elements of occupational history • Occupational history in clinical practice

3. Historical Perspective • Early examples can be seen on Egyptean papyrus • Roman times it has been proposed that persons manifacturing hazardous powders should protect their face by loose bladder skin • XVth century occupational desases were mainly due to mining and termed “morbi metallici” • In 1473 Ellenberg wrote short pamphlet entitled “on the Poisinous and Wicked Fumes and Smokes” • Paracelsus (1493-1541) wrote the first monograph on occuparional diseases Asthma in the Workplace Edt Bernstein L 3d edt 2006

4. 1713 Bernardo Ramazzini (1633-1734) published his great classic landmark of occupational diseases “De morbis artificum diatriba” he indicated importance of occupational history: • “The Divine Hippocrates informs us that when a Physician visits a Patient, he ought to inquire many things, by putting questions to the patient and bystanders to which I Would presume to add one Interrogation more : namely, what Trade is he of’’ • 1832 Charles Turner Thackrah (1795- 1833) wrote effects of arts, trade and professional and civic status and habits of living on health and longevity Asthma in the Workplace Edt Bernstein L 3d edt 2006

5. Importance of Occupational Diseases • Crude estimated prevalence of occupational diseases in the USA range from 125.000 to 350.000 per year • 17 % of patients seen in primary care clinic thought their health problem were work related; • 75 % reported previous exposure to one or more recongnized toxic agents Newman LS ; New England J med 1995; 333 (17)

6. The Occupational History is the Key Diagnostic Element of Occupational Diseases

7. Occupational History • Workplaces and Exposures History • Medical History Lax MB Am Fam Phy 1998; 58 (4) Chang Yeung M Chest 1995; 108: 1084 Moscato G Eur Respir J 2003; 21:879

8. Occupational History • There is no standard questionniare for the occupational history • The quick survey • Detailed questionning based on the initial suspicion • Chronology of Jobs • Review of exposure • Examination of the link between work and the chief symptom Lerner P Occup Environ Med 1997; 39 (5): 401 Newman LS New England J Med 1995; 333 (17)

9. The Quick Survey • Chief symptoms and history of present illness • What kind of job do you do? • Do you think that your health problem are related to your work? • Are your symptoms are better or worse when you’re at home or at work? • Review of exposure • Are you now or have you been previously exposed to dusts, fumes, radiation or loud noise?

10. Detailed Questionning • Self administrated questionnaire for all patients • Chronology of Jobs • Exposure survey • Military service • Home environment • Hobbies • Hazardous expsures that may cause clinical diseases • Review of exposure with the questionnaire as a guide • More about the current job: description of a typical day • Review ofjob chronology and associated exposure • Examination fo the link between work and the chief symptom • Clinical clues • Exploration of the temporal link in detail • “Do the others at work have similar problems?”

11. Self Administrated Questionnaire Name surname : M.B. Date of birth: 1980 ID No:22657 List the jobs you’ve had since you first started working include the years worked at each job. Also include any military service and hobbies.

12. Major Type of Exposure Associated with Clinical Illness • Gases • Corrosive substances (acids, alkalis) • Dyes and stains • Dusts and powders • Asbestos and other fibers • Infectious agents • Insecticides and pesticides • Metal and metal fumes • Organic dusts (cotton, wood, biologic matter) • Plastics • Solvents • Petrochemicals (coal, tari asphalt, petroleum distillates) • Physical factors (noise, lifting, thermal stress, vibration, repetitive motion) • Emotional factors (stress) • Radiation (electrmagnetic fields, X-ray radiation,ultraviolet radiation)

13. Detailed Questioning • Self administrated questionnaire for all patients • Chronology of Jobs • Exposure survey • Review of exposure with the questionnaire as a guide • Health effect of suspetced agent • Assessment of Exposure level • Examination fo the link between work and the chief symptom • Clinical clues • Exploration of the temporal link in detail • “Do the others at work have similar problems?”

14. Health Effects of Exposed Agents • Employees and their physicians have right to review employers exposure records • Human health effects of most chemicals (80 %) have not been investigated properly • Information may be provided by • Employers • Producers • Product labels • Material Safety Data Sheets (MSDS) • From the web sites of occupational and environmental agencies. Bracker A Clin Chest Med 2002; 23:695

15. Material Safety Data Sheets • They are often incomplete • Only the acute effects are included • Chronical effects such as carcinogenity or effect on reporductive system are omitted

16. How to Read a Material Safety Data Sheets? • Section 1: Product Identification • The chemical or trade name of the product and the manufacterer’s name, adress and phone nbr • Section 2:Hazardous ingredients • The identities of the hazardouls chemical ingredients (if in a concentration >%1 for noncarcinogens; >%0,1 for carcinogens) • Section 3: Phyiscal and chemical characteristics • Section 4: Fire and explosion hazards data • Section 5: Health hazards • Section 6: Reactivity data • Section 7: Precautions for safe handling and use Bracker A Clin Chest Med 2002; 23:695

21. Assessment of Exposure Level • Exposure Level • Lenght of exposure • Concentration of suspected agent • Quantitative assessment of exposure • Acute peak doses of exposure • Use of protective measures • Cumulative exposure especially important for the diseases occuring after long latency period • Several job changes or time elapsed since first empolyment may affect the assessment of exposure level Brower P Am J Epidemiol1998; 148: 920-926

22. Detailed Questioning • Self administrated questionnaire for all patients • Chronology of Jobs • Exposure survey • Review of exposure with the questionnaire as a guide • Health effect of suspetced agent • Assessment of Exposure level • Examination fo the link between work and the chief symptom • Exploration of the temporal link in detail • “Do the others at work have similar problems?” • Clinical clues

23. Medical History • Temporal association between the occurence of symptoms and workplace exposures • Relationship between the use of a new product and symptoms • Presence of affected co-workers • Smoking • Atopy • Bronchial hyperreactivity • History of pulmonary diseases • Accidental peak exposures

24. Clues to Recognition of Occupational Diseases • Job title or type of industry • Description of the work tasks • Major employment opportunities in the region • The most common toxic exposures in local industries • Co-workers who are sick or case clusters • Past exposure to long latency agents • Pattern of aggravation of symptoms • Unusual combination of multiorgan symptoms and signs • Demographycally “wrong” patient • Susceptible organ systems • The “usual suspects” are innocents • Idiopatic diseases • Diseases that not respond to conventional medical therapy Newman LS New England J Med 1995; 333 (17)

25. Occupational History in Clinical Practice

26. Quality of Occupational History Assessments in Working Age Adults With Newely Diagnosed Asthma Shofer et al Chest 2006; 130 (2): 455- 462 • In only 75 % of Adults asthmatic there was occupational history assessment

27. Clinics and Provider Information for Patients With an Occupational History Other than Job

28. Approach to Diagnosis and Management of Occupational Asthma Amongst UK Respiratory PhysiciansBarber CM Respir Med 2007; 101 (3): 1903-1908

29. Concluding Remarks • Occupational history is the key step for diagnosis of occupational diseases • Detailed occupational history is time consuming and rough pathway • So it’s neglected by majority of practising clinicians • This problem is not unique to our country it is an important issue for many industrialized countries • The majority of the physicians agree that postgraduate courses may improve this negletcting approach • Active participation of patient by completing occupational history questionnaire; the use of web opportunities especially for the job duties and exposure assessment may shorten this process

30. Teşekkür Ederim • http://atsdr1.atsdr.cdc.gov • http://www.cdc.gov/niosh/homepage.html • http://www.osha-sic.gov • http://www.saglik.gov.tr • http://www.ssk.gov.tr • http://www.isgum.gov.tr • http://www.csgb.gov.tr • http://www.oasys.com • http://www.asmanet.com