CDC Says Up to One Fifth of Asthma Deaths Are Work-related, Potentially Preventable

A 39-year-old man hired by an auto parts manufacturer had been diagnosed with asthma six years earlier but never experienced any symptoms. Although he was a smoker and obese, his health check-up revealed nothing else of concern. His work involved die design, machining, grinding, injection process simulation, and inspection. Six years after hire, a cough and difficulty breathing became a nuisance. A year later, breathing difficulties sent him to the emergency department. A year later, he died at age 47. The cause of death was work-exacerbated asthma due to exposure to styrene, a chemical which was used in the injection process.¹

In another case, this one reported by the National Institute for Occupational Safety and Health (NIOSH), a man in his 20s went to work for a resin manufacturer. One of his job functions was to insert fuel into a reaction vessel. The fuel contained pulverized phthalic anhydride and anhydrous maleic anhydride, two substances that have been documented as linked to asthma.^2,3 This young man, in good health at the start, developed asthma two years into his job. It was occupational asthma directly associated with the work environment.⁴

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Workplace exposures and the cost of occupational asthma

The chemicals mentioned in these two cases are among more than 300 substances used in the workplace that are known or suspected to cause asthma in healthy employees or exacerbate asthma in employees who have received an asthma diagnosis.⁵ Other occupational exposures that potentially cause or worsen asthma include:

• Animals and animal by-products
• Diacetyl
• Formaldehyde
• Isocyanates
• Plant-based fibers
• Latex
• Nuts
• A range of other chemicals

In addition to the ones listed, other work aspects cited in reports of occupational asthma include smoke and fumes, physical conditions such as poor ventilation, vapors and gases, and other unidentified substances.⁶

The results are alarming. The American Thoracic Society (ATS) says the economic cost of asthma nationwide is $80 billion a year in medical expenses, missed work and school days, and deaths. ATS research concludes 8.7 million work days are lost each year due to occupational asthma.⁷

Occupational exposures are believed to be responsible for as many as 21 percent of deaths due to asthma in the United States.⁸ Among all cases of adult-onset asthma, almost one in five (17 percent) is work-related; depending on the time period in question, the prevalence of work-related asthma among all asthma cases may run as high as 58 percent.⁹

Occupational asthma represents a call to action across a wide range of industries that employ a labor force of 160 million people.¹⁰ Industries most likely to have asthma-linked exposures are:  metals, automobiles, food production and processing, construction, dairy, dentistry, electronics, educational/research facilities and laboratories, agriculture, health care, mining, painting, pharmaceuticals, foam, rubber, textiles, tobacco, animal handling and veterinary medicine, water treatment, welding, woodworking, and X-ray processing.¹¹

Protected by the Americans with Disabilities Act

Asthma and allergies are considered disabilities under the Americans with Disabilities Act (ADA) because of limits these conditions may impose on one or more major life activities. As such, the ADA says employees with allergies and asthma are entitled to reasonable accommodations, i.e., accommodations that will not create an undue burden for an employer or create a fundamental alteration to an organization.¹²

Positive measures to address occupational asthma

NIOSH recommends steps employers can take to address work-related asthma exposures, as shown below:¹³

• Adapt the hierarchy of controls, which recommends eliminating the exposure as the most effective control. If that’s not possible, substitute use of another substance not linked to asthma, install engineering controls such as better ventilation, and implement administrative controls in company policies and practices. Also, use effective respiratory personal protective equipment; by itself, this is not an adequate solution so it should be used with other measures.
• Establish a no-smoking policy. Tobacco smoke is a common asthma trigger.
• Provide flu vaccinations every year. People with asthma are at risk for developing serious flu complications.¹⁴
• Implement educational and training programs to promote good health overall. Comorbidities – including chronic sinusitis, gastroesophageal reflux, sleep apnea, cardiac disease and psychiatric disease – frequently occur when individuals have asthma. Comorbidities can make asthma more severe and increase the cost of treatment.¹⁵

Why you need medical expertise for occupational asthma

When asthma is untreated or not well-controlled, costs are higher, primarily due to increased emergency department visits and hospitalizations. Researchers compared medical expenditures for people with uncontrolled asthma to people without asthma. They found that people with uncontrolled asthma have a 4.6-fold greater frequency of hospitalizations and as much as a 1.8-fold higher use of emergency department visits. Productivity was also lower. Notably, the hospitalization rate for people with controlled asthma was no different than the rate for healthy individuals.¹⁶

Three factors that complicate an employer’s difficulty in mitigating occupational asthma and allergies are listed below. These factors support your need for an occupational health partner in addressing occupational asthma and allergies.

1. Lack of standards for potential allergens
2. Disagreement over suitable levels of controls
3. Effects of climate change and allergy sensitization

Lack of standards for potential allergens is a critical gap. Allergens are substances that are typically harmless to most people but provoke an allergic response (difficulty breathing, red, watery eyes, sneezing, and/or skin reactions) in others. Being exposed to allergens, secondhand tobacco smoke, air pollution, and viral lung infections have all been linked to developing asthma. While some employees may already have asthma, perhaps due to a genetic disposition, for many employees being exposed to allergens at work may cause asthma they would have otherwise avoided.¹⁷ The challenge for employers is that, for the most part, there is little data on human exposure to allergens/immunotoxicants, as reported in the Cornell University Employment and Disability Institute report, “Accommodating the Allergic Employee in the Workplace.”¹⁸

Disagreement over suitable levels of control is a natural consequence of the gap in data highlighted by Cornell University. If standards for allergens are to be developed, data is needed on the level of control that will avoid adverse health effects and employee sensitization. Because allergic responses vary and can be either immediate or longer term and represent different doses, developing a permissible exposure limit or an action level, as is done for medical surveillance of chemical exposures, is problematic.^19,20

Effects of climate change and allergy sensitization are documented with increasing frequency. Employers interested in learning more about the link between climate change and the incidence and severity of allergic disorders are referred to a guidance statement published in the Journal of Occupational and Environmental Medicine. Ronda McCarthy, MD, MPH, national director of medical surveillance services for Concentra®, is a co-author. The American College of Occupational and Environmental Medicine (ACOEM) Task Force on Climate Change produced the extensive findings, which include documentation of more intense seasonal variations and extreme weather patterns contributing to more allergen exposure.²¹ Also, in October 2020, other research published in Europe showed that ragweed plants grown in elevated carbon dioxide conditions, the effect of climate change, produce a stronger allergic lung inflammation response than ragweed grown at pre-climate change carbon dioxide levels.²²

Why Concentra should be your partner in the occupational asthma battle

Employers who partner with Concentra are able to have the ACOEM guidelines implemented optimally to safeguard their employees because:

• Concentra has more than 40 years of experience as an occupational health leader.
• Concentra serves the needs of your workforce through an integrated network of nearly 520 medical centers, more than 150 employer-based onsite clinics, and telemedicine.
• Concentra provides all recommended screening for occupational asthma, including spirometry and pulmonary function testing, as well as physical exams and ongoing medical surveillance to identify and help mitigate the impact of exposures on employee health.

Concentra has provided occupational asthma and allergy diagnostic and medical surveillance services for many years. In 2020, to raise awareness and better serve employers, especially those with workforces in multiple states, Concentra standardized our occupational asthma and allergy services. Concentra can provide a uniform occupational health approach to identify, document, and monitor the impact on employee health of exposures including plant-based fiber, animals and animal by-products, chemical compounds used in flavoring foods, formaldehyde, isocyanates, latex, and nuts. This eliminates the need for employees to see multiple providers and helps ensure that you are optimally supported to address the growing challenge of occupational asthma and allergies.

Contact a Concentra expert today.

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NOTES

1 Lee JS, Kwak HS, Choi BS, Park SY. A Case of Occupational Asthma in a Plastic Injection Process Worker. Annals of Occupational and Environmental Medicine. 2013.   
2 Lee HS, Wang YT, Cheong TH, Tan KT, Narendran K. Occupational asthma due to maleic anhydride. 1991; 48(4): 283-5.
3 Hansen MR, Lander F, Skjold T, Kolstad HA, Jurgen H. Occupational asthma caused by maleic anhydride. Ugeskr Laeger. 2014;176(37).  
4 Lee HS, Wang YT, Cheong TH, Tan KT, Narendran K. Occupational asthma due to maleic anhydride. 1991; 48(4): 283-5.
5 Work-related Asthma. The National Institute for Occupational Safety and Health. Centers for Disease Control and Prevention. 
6 Work-related Asthma in Wisconsin. Occupational Health Surveillance Program, Bureau of Environmental and Occupational Health. 2009. 
7 Asthma costs the economy more than $80 billion per year. American Thoracic Society research. ScienceDaily. January 12, 2018.
8 Asthma Mortality Among Persons Aged 15-64 Years, by Industry and Occupation – United States, 1999-2016. Morbidity and Mortality Weekly Report. January 19, 2018. Centers for Disease Control and Prevention.
9 Work-related Asthma. Epidemiology. The National Institute for Occupational Safety and Health. Centers for Disease Control and Prevention. May 24, 2017.   
10 Employment status of civilian population by sex and age. Bureau of Labor Statistics. October 2020.  
11 Workplace Health and Safety. New Jersey Health.  
12 Are Asthma and Allergies Disabilities? Americans with Disabilities Act: How it affects you if you have asthma or allergies. Asthma and Allergy Foundation of America.  
13 Work-related Asthma. How are work-related asthma exposures identified and prevented? The National Institute for Occupational Safety and Health. Centers for Disease Control and Prevention.  
14 Flu and People with Asthma. Centers for Disease Control and Prevention.
15 Nunes C, Pereira AM, Morais-Almeida M. Asthma costs and social impact. Asthma Research and Practice. 2017; 3:1. 
16 Nunes C, Pereira AM, Morais-Almeida M. Asthma costs and social impact. Asthma Research and Practice. 2017; 3:1.
17 Learn How to Control Asthma. Centers for Disease Control and Prevention. September 6, 2019.    
18 Accommodating the Allergic Employee in the Workplace. Cornell University Employment and Disability Institute. Updated 2010.  
19 Accommodating the Allergic Employee in the Workplace. Cornell University Employment and Disability Institute. Updated 2010.   
20 “What is Medical Surveillance,” Concentra. January 6, 2020. 
21 Perkinson WB, Kearney GD, Saberia P, Guidotti T, McCarthy R, Cook-Shimaneck M, Pensa M, Nabeel I. ACOEM Task Force on Climate Change. Journal of Occupational and Environmental Medicine. February 2018; 60(2): e76-81.   
22 Rauer D, Gilles S, Wimmer M, Frank U, Mueller C, Musiol S, Vafadari B, Aglas L, Ferreira F, Schmitt-Kopplin P, et al. Ragweed plans grown under elevated CO2 levels produce pollen which elicit stronger allergic lung inflammation. European Journal of Allergy and Clinical Immunology. Wiley Online Library. October 2020.