Dignosis Of Dignosis Of Occupational Lung Occupational Lung Diseases:ImportanDiseases:Importance of Occupational ce of Occupational

History History Prof. Fatma EvyapanProf. Fatma Evyapan

MD, PhDMD, PhDPamukkale University School of Pamukkale University School of

Medicine Denizli, TurkeyMedicine Denizli, Turkey

Main TopicsMain Topics

Historical PerspectiveHistorical Perspective Importance of occupational historyImportance of occupational history Key elements of occupational historyKey elements of occupational history Occupational history in clinical Occupational history in clinical

practicepractice

Historical PerspectiveHistorical Perspective Early examples can be seen on Early examples can be seen on

Egyptean papyrusEgyptean papyrus Roman times it has been proposed Roman times it has been proposed

that persons manifacturing that persons manifacturing hazardous powders should protect hazardous powders should protect their face by loose bladder skintheir face by loose bladder skin

XVth century occupational desases XVth century occupational desases were mainly due to mining and were mainly due to mining and termed termed “morbi metallici”“morbi metallici”

In 1473 Ellenberg wrote short In 1473 Ellenberg wrote short pamphlet entitled “on the pamphlet entitled “on the Poisinous and Wicked Fumes and Poisinous and Wicked Fumes and Smokes”Smokes”

Paracelsus (1493-1541) wrote the Paracelsus (1493-1541) wrote the first monograph on occuparional first monograph on occuparional diseasesdiseases

Asthma in the Workplace Edt Bernstein L 3d edt 2006

1713 Bernardo Ramazzini (1633-1713 Bernardo Ramazzini (1633-1734) published his great classic 1734) published his great classic landmark of occupational landmark of occupational diseases “diseases “De morbis artificum De morbis artificum diatriba”diatriba” he indicated importance he indicated importance of occupational history:of occupational history:

““The Divine Hippocrates informs The Divine Hippocrates informs us that when a Physician visits a us that when a Physician visits a Patient, he ought to inquire many Patient, he ought to inquire many things, by putting questions to things, by putting questions to the patient and bystanders to the patient and bystanders to which I Would presume to add which I Would presume to add one Interrogation more : namely, one Interrogation more : namely, what Trade is he ofwhat Trade is he of’’ ’’

1832 Charles Turner Thackrah 1832 Charles Turner Thackrah (1795- 1833) wrote effects of (1795- 1833) wrote effects of arts, trade and professional and arts, trade and professional and civic status and habits of living civic status and habits of living on health and longevityon health and longevity

Asthma in the Workplace Edt Bernstein L 3d edt 2006

Importance of Occupational Importance of Occupational DiseasesDiseases

Crude estimated prevalence of Crude estimated prevalence of occupational diseases in the USA range occupational diseases in the USA range from 125.000 to 350.000 per yearfrom 125.000 to 350.000 per year

17 % of patients seen in primary care 17 % of patients seen in primary care clinic thought their health problem clinic thought their health problem were work related;were work related;

75 % reported previous exposure to one 75 % reported previous exposure to one or more recongnized toxic agentsor more recongnized toxic agents

Newman LS ; New England J med 1995; 333 (17)

The Occupational The Occupational History is the Key History is the Key

Diagnostic Element Diagnostic Element of Occupational of Occupational

DiseasesDiseases

Occupational HistoryOccupational History

Workplaces and Exposures HistoryWorkplaces and Exposures History Medical HistoryMedical History

Lax MB Am Fam Phy 1998; 58 (4)

Chang Yeung M Chest 1995; 108: 1084

Moscato G Eur Respir J 2003; 21:879

Occupational HistoryOccupational History There is no standard There is no standard

questionniare for the questionniare for the occupational historyoccupational history

The quick surveyThe quick survey Detailed questionning based Detailed questionning based

on the initial suspicionon the initial suspicion Chronology of JobsChronology of Jobs Review of exposure Review of exposure Examination of the link Examination of the link

between work and the chief between work and the chief symptomsymptom

Lerner P Occup Environ Med 1997; 39 (5): 401

Newman LS New England J Med 1995; 333 (17)

Chief symptoms and Chief symptoms and history of present illnesshistory of present illness What kind of job do you What kind of job do you

do?do? Do you think that your Do you think that your

health problem are health problem are related to your work?related to your work?

Are your symptoms are Are your symptoms are better or worse when better or worse when you’re at home or at you’re at home or at work?work?

Review of exposureReview of exposure Are you now or have you Are you now or have you

been previously exposed been previously exposed to dusts, fumes, radiation to dusts, fumes, radiation or loud noise?or loud noise?

The Quick SurveyThe Quick Survey

Detailed QuestionningDetailed Questionning Self administrated questionnaire for all patientsSelf administrated questionnaire for all patients

Chronology of JobsChronology of Jobs Exposure surveyExposure survey Military serviceMilitary service Home environmentHome environment HobbiesHobbies Hazardous expsures that may cause clinical diseasesHazardous expsures that may cause clinical diseases

Review of exposure with the questionnaire as a guideReview of exposure with the questionnaire as a guide More about the current job: description of a typical dayMore about the current job: description of a typical day Review ofjob chronology and associated exposureReview ofjob chronology and associated exposure

Examination fo the link between work and the chief Examination fo the link between work and the chief symptomsymptom Clinical cluesClinical clues Exploration of the temporal link in detailExploration of the temporal link in detail ““Do the others at work have similar problems?”Do the others at work have similar problems?”

Self Administrated Self Administrated QuestionnaireQuestionnaire

Name surname : M.B.Name surname : M.B.

Date of birth: 1980Date of birth: 1980

ID No:22657ID No:22657

List the jobs you’ve had since you first started working include the years worked at each 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.job. Also include any military service and hobbies.

TarihTarih Emplyer Emplyer name:producname:product or service t or service providedprovided

Job tittle and Job tittle and specific specific dutiesduties

Major Major exposuresexposures

(such as (such as dusts, dusts, chemicals, chemicals, noise,repetitinoise,repetitive motion, ve motion, stress)stress)

Protective Protective equipmentequipment

(such as (such as respirator, respirator, earplugs earplugs gloves)gloves)

2005-….2005-…. Türkmetal:Türkmetal:

Metal slugs Metal slugs for for ballbearingsballbearings

Inspector: Inspector: Control of Control of finished finished metal slugsmetal slugs

Oil Oil mists,metal mists,metal fluids, fluids, solvent solvent vapors, metal vapors, metal dustdust

--

2000-20052000-2005 Yıldız Yıldız cleaining cleaining agencyagency

Cleaning Cleaning worker in the worker in the hospitalhospital

Hypochloric Hypochloric acid, acid, ammonia, ammonia, detergent, detergent, parfume, parfume, latex, latex, microorganismicroorganismsms

Latex glovesLatex gloves

Major Type of Exposure Major Type of Exposure Associated with Clinical Associated with Clinical

IllnessIllness GasesGases Corrosive substances (acids, alkalis)Corrosive substances (acids, alkalis) Dyes and stainsDyes and stains Dusts and powdersDusts and powders Asbestos and other fibersAsbestos and other fibers Infectious agentsInfectious agents Insecticides and pesticidesInsecticides and pesticides Metal and metal fumesMetal and metal fumes Organic dusts (cotton, wood, biologic matter)Organic dusts (cotton, wood, biologic matter) PlasticsPlastics SolventsSolvents Petrochemicals (coal, tari asphalt, petroleum distillates)Petrochemicals (coal, tari asphalt, petroleum distillates) Physical factors (noise, lifting, thermal stress, vibration, Physical factors (noise, lifting, thermal stress, vibration,

repetitive motion)repetitive motion) Emotional factors (stress)Emotional factors (stress) Radiation (electrmagnetic fields, X-ray radiation,ultraviolet Radiation (electrmagnetic fields, X-ray radiation,ultraviolet

radiation)radiation)

Detailed QuestioningDetailed Questioning Self administrated questionnaire for all patientsSelf administrated questionnaire for all patients

Chronology of JobsChronology of Jobs Exposure surveyExposure survey

Review of exposure with the questionnaire as a Review of exposure with the questionnaire as a guideguide Health effect of suspetced agentHealth effect of suspetced agent Assessment of Exposure levelAssessment of Exposure level

Examination fo the link between work and the Examination fo the link between work and the chief symptomchief symptom Clinical cluesClinical clues Exploration of the temporal link in detailExploration of the temporal link in detail ““Do the others at work have similar problems?”Do the others at work have similar problems?”

Health Effects of Exposed Health Effects of Exposed AgentsAgents Employees and their Employees and their

physicians have right to physicians have right to review employers exposure review employers exposure recordsrecords

Human health effects of most Human health effects of most chemicals (80 %) have not chemicals (80 %) have not been investigated properly been investigated properly

Information may be provided Information may be provided byby EmployersEmployers ProducersProducers Product labelsProduct labels Material Safety Data Sheets Material Safety Data Sheets

(MSDS)(MSDS) From the web sites of From the web sites of

occupational and environmental occupational and environmental agencies.agencies.

Bracker A Clin Chest Med 2002; 23:695

Material Safety Data Material Safety Data SheetsSheets

They are often incompleteThey are often incomplete Only the acute effects are includedOnly the acute effects are included Chronical effects such as Chronical effects such as

carcinogenity or effect on carcinogenity or effect on reporductive system are omittedreporductive system are omitted

How to Read a Material How to Read a Material Safety Data Sheets?Safety Data Sheets?

Section 1: Product IdentificationSection 1: Product Identification The chemical or trade name of the product and the The chemical or trade name of the product and the

manufacterer’s name, adress and phone nbrmanufacterer’s name, adress and phone nbr Section 2:Hazardous ingredientsSection 2:Hazardous ingredients

The identities of the hazardouls chemical ingredients (if in a The identities of the hazardouls chemical ingredients (if in a concentration >%1 for noncarcinogens; >%0,1 for concentration >%1 for noncarcinogens; >%0,1 for carcinogens)carcinogens)

Section 3: Phyiscal and chemical characteristicsSection 3: Phyiscal and chemical characteristics Section 4: Fire and explosion hazards dataSection 4: Fire and explosion hazards data Section 5: Health hazardsSection 5: Health hazards Section 6: Reactivity dataSection 6: Reactivity data Section 7: Precautions for safe handling and use Section 7: Precautions for safe handling and use

Bracker A Clin Chest Med 2002; 23:695

Assessment of Exposure Assessment of Exposure LevelLevel

Exposure LevelExposure Level Lenght of exposureLenght of exposure Concentration of suspected Concentration of suspected

agentagent Quantitative assessment of Quantitative assessment of

exposure exposure Acute peak doses of exposureAcute peak doses of exposure Use of protective measuresUse of protective measures Cumulative exposure Cumulative exposure

especially important for the especially important for the diseases occuring after long diseases occuring after long latency period latency period

Several job changes or time Several job changes or time elapsed since first elapsed since first empolyment may affect the empolyment may affect the assessment of exposure levelassessment of exposure level

Brower P Am J Epidemiol1998; 148: 920-926

Detailed QuestioningDetailed Questioning Self administrated questionnaire for all Self administrated questionnaire for all

patientspatients Chronology of JobsChronology of Jobs Exposure surveyExposure survey

Review of exposure with the questionnaire as Review of exposure with the questionnaire as a guidea guide Health effect of suspetced agentHealth effect of suspetced agent Assessment of Exposure levelAssessment of Exposure level

Examination fo the link between work and Examination fo the link between work and the chief symptomthe chief symptom Exploration of the temporal link in detailExploration of the temporal link in detail ““Do the others at work have similar problems?”Do the others at work have similar problems?” Clinical cluesClinical clues

Medical HistoryMedical History Temporal association between the Temporal association between the

occurence of symptoms and workplace occurence of symptoms and workplace exposuresexposures

Relationship between the use of a new Relationship between the use of a new product and symptomsproduct and symptoms

Presence of affected co-workersPresence of affected co-workers SmokingSmoking AtopyAtopy Bronchial hyperreactivityBronchial hyperreactivity History of pulmonary diseasesHistory of pulmonary diseases Accidental peak exposuresAccidental peak exposures

Clues to Recognition of Clues to Recognition of Occupational DiseasesOccupational Diseases

Job title or type of industryJob title or type of industry Description of the work tasksDescription of the work tasks Major employment opportunities in the regionMajor employment opportunities in the region The most common toxic exposures in local industriesThe most common toxic exposures in local industries Co-workers who are sick or case clustersCo-workers who are sick or case clusters Past exposure to long latency agentsPast exposure to long latency agents Pattern of aggravation of symptomsPattern of aggravation of symptoms Unusual combination of multiorgan symptoms and signsUnusual combination of multiorgan symptoms and signs Demographycally “wrong” patientDemographycally “wrong” patient Susceptible organ systemsSusceptible organ systems The “usual suspects” are innocentsThe “usual suspects” are innocents Idiopatic diseasesIdiopatic diseases Diseases that not respond to conventional medical Diseases that not respond to conventional medical

therapytherapy

Newman LS New England J Med 1995; 333 (17)

Occupational Occupational History in History in

Clinical PracticeClinical Practice

Quality of Occupational History Quality of Occupational History Assessments in Working Age Adults Assessments in Working Age Adults

With Newely Diagnosed AsthmaWith Newely Diagnosed Asthma In only 75 % of Adults asthmatic In only 75 % of Adults asthmatic

there was occupational history there was occupational history assessmentassessment No %No %

Employment statusEmployment status

Documentation of patients Documentation of patients employed employed

Documentation of patients Documentation of patients unemployedunemployed

137 (75)137 (75)

122 (62)122 (62)

25 (13)25 (13)

Occupational DutiesOccupational Duties 9 (5)9 (5)

Exposure at workExposure at work 21 (11)21 (11)

Protective equipment used at Protective equipment used at workwork

5 (3)5 (3)

Prior occupational historyPrior occupational history 19 (10)19 (10)

Clinician diagnosis of Clinician diagnosis of occupational asthmaoccupational asthma

4 (2)4 (2)

Recomendation for change of Recomendation for change of jobjob

5 (3)5 (3)

No elements in medical recordsNo elements in medical records 49 (%25)49 (%25)

Shofer et al Chest 2006; 130 (2): 455- 462

Clinics and Provider Information Clinics and Provider Information for Patients With an Occupational for Patients With an Occupational

History Other than JobHistory Other than JobClinicClinic Tanımlanan hasta sayısı (%)Tanımlanan hasta sayısı (%)

General medicalGeneral medical 15 (29)15 (29)

PneumologyPneumology 19 (37)19 (37)

Environmental medicalEnvironmental medical 3 (6)3 (6)

DermatologyDermatology 2 (3)2 (3)

Urgent careUrgent care 6 (11)6 (11)

RheumatologyRheumatology 1 (2)1 (2)

PhysiotherapyPhysiotherapy 2 (3)2 (3)

NeurologyNeurology 1 (2)1 (2)

NeurosurgeryNeurosurgery 1 (2)1 (2)

OrthopedieOrthopedie 1 (2)1 (2)

AllergyAllergy 1 (2)1 (2)

Patient with inpatient stay during Patient with inpatient stay during survey prsurvey pr

7 (13)7 (13)

Author SourceAuthor Source

Staff (attending physicians)Staff (attending physicians) 30 (58)30 (58)

Physician in trainingPhysician in training 18 (35)18 (35)

Non-physician health care Non-physician health care providerprovider

4 (8)4 (8)

Approach to Diagnosis and Approach to Diagnosis and Management of Occupational Management of Occupational

Asthma Amongst UK Respiratory Asthma Amongst UK Respiratory PhysiciansPhysicians

Barber CM Respir Med 2007; 101 (3): 1903-1908Barber CM Respir Med 2007; 101 (3): 1903-1908

Clinical approach to diagnosisClinical approach to diagnosis (%)(%)

History takingHistory taking

Work relation improvement away Work relation improvement away from workfrom work

4646

Chest examinationChest examination 3939

ImagingImaging

CXRCXR

Consider CT scanConsider CT scan 100100

2121

Physiologic testsPhysiologic tests

SpirometrySpirometry 9898

TLC/ TLCOTLC/ TLCO 6262

NSBHNSBH 1010

Serial PEF (at least 4 times)Serial PEF (at least 4 times) 7272

OASYS yorumuOASYS yorumu 1414

Concluding RemarksConcluding Remarks Occupational history is the key step for diagnosis of Occupational history is the key step for diagnosis of

occupational diseasesoccupational diseases Detailed occupational history is time consuming and Detailed occupational history is time consuming and

rough pathwayrough pathway So it’s neglected by majority of practising cliniciansSo it’s neglected by majority of practising clinicians This problem is not unique to our country it is an This problem is not unique to our country it is an

important issue for many industrialized countriesimportant issue for many industrialized countries The majority of the physicians agree that The majority of the physicians agree that

postgraduate courses may improve this negletcting postgraduate courses may improve this negletcting approach approach

Active participation of patient by completing Active participation of patient by completing occupational history questionnaire; the use of web occupational history questionnaire; the use of web opportunities especially for the job duties and opportunities especially for the job duties and exposure assessment may shorten this processexposure assessment may shorten this process

Teşekkür EderimTeşekkür Ederim http://atsdr1.atsdr.cdc.govhttp://atsdr1.atsdr.cdc.gov http://www.cdc.gov/niosh/homepage.htmlhttp://www.cdc.gov/niosh/homepage.html http://www.osha-sic.govhttp://www.osha-sic.gov http://www.saglik.gov.trhttp://www.saglik.gov.tr http://www.ssk.gov.trhttp://www.ssk.gov.tr http://www.isgum.gov.trhttp://www.isgum.gov.tr http://www.csgb.gov.trhttp://www.csgb.gov.tr http://www.oasys.comhttp://www.oasys.com http://www.asmanet.comhttp://www.asmanet.com