Chronic Obstructive Pulmonary Disease and Work: The Continuing Narrative.

It has long been recognized that harmful inhaled workplace exposures can contribute to the development of chronic obstructive pulmonary disease (COPD). This article, intended for the clinician, summarizes some of this evidence and some areas of controversy. Current estimates based on pooled epidemiological analyses of population-based studies identify that approximately 14% of the burden of COPD (and 13% of the burden of chronic bronchitis) is attributable to such exposures. In addition to these approaches, various studies implicate specific exposures as contributing. Certain of these relating to cadmium, coal, and respirable crystalline silica are discussed in more detail. Despite this amassed evidence to date supporting associations between COPD and workplace exposures, there have been surprisingly few studies that have attempted to assess the attribution by experts of an occupational cause in cases of COPD. One study, using hypothetical cases of COPD, noted that while expert physicians were willing to make such an occupational link, this was only likely in cases with light smoking histories and a priori defined heavy occupational exposures. Relatively recent data relating to computed tomography (CT) scan appearances may give the clinician a further guide. Several studies from populations have now linked potentially harmful occupational exposures specifically with the presence of emphysema on CT scanning. It will be of interest to see if this finding, along with other clinical attributes of cases such as smoking and family histories, exclusion of asthma, genetic data, and the nature of workplace exposures, will increase the future diagnosis by clinicians of occupational COPD. In the interim, while better diagnostic approaches are developed, we suggest that consideration of an occupational cause is an important part of the clinical investigation of cases of COPD. Finally, we suggest that evidence-based workplace preventive strategies for occupational COPD should be informed by knowledge of which exposures are most important to reduce, and whether and when intervention to reduce exposure at an individual worker level is warranted.

Healthcare access for asylum seekers and refugees in England: a mixed methods study exploring service users' and health care professionals' awareness.

BACKGROUND: With the aim of decreasing immigration, the British government extended charging for healthcare in England for certain migrants in 2017. There is concern these policies amplify the barriers to healthcare already faced by asylum seekers and refugees (ASRs). Awareness has been shown to be fundamental to access. This article jointly explores (i) health care professionals' (HCPs) awareness of migrants' eligibility for healthcare, and (ii) ASRs' awareness of health services. METHODS: Mixed methods were used. Quantitative survey data explored HCPs' awareness of migrants' eligibility to healthcare after the extension of charging regulations. Qualitative data from semi-structured interviews with ASRs were analyzed thematically using Saurman's domains of awareness as a framework. RESULTS: In total 514 HCPs responded to the survey. Significant gaps in HCPs' awareness of definitions, entitlements and charging regulations were identified. 80% of HCP respondents were not confident defining the immigration categories upon which eligibility for care rests. Only a small minority (6%) reported both awareness and understanding of the charging regulations. In parallel, the 18 ASRs interviewed had poor awareness of their eligibility for free National Health Service care and suitability for particular services. This was compounded by language difficulties, social isolation, frequent asylum dispersal accommodation moves, and poverty. CONCLUSION: This study identifies significant confusion amongst both HCP and ASR concerning eligibility and healthcare access. The consequent negative impact on health is concerning given the contemporary political climate, where eligibility for healthcare depends on immigration status.

Determinants of health-related quality of life among residents with and without COPD in a historically industrialised area.

PURPOSE: Chronic obstructive pulmonary disease (COPD) is associated with substantial morbidity, including impaired health-related quality of life (HRQoL). Despite the prominent role of occupational factors in the aetiology of COPD, the relationship between these exposures and HRQoL has not been well elucidated. METHODS: A subpopulation from an epidemiological study, designed to assess the workplace contribution to COPD, was administered the EQ5D HRQoL tool. Demographics, an index of economic deprivation, health endpoints including the presence of COPD and lung function were also recorded. Workplace exposures were categorised using both self-reported exposures and also by the use of an established job exposure matrix (JEM). RESULTS: A total of 623 individuals participated (mean age 67.1 years). One hundred and forty-eight (24%) reported having received a physician diagnosis of COPD, 355 (57%) were male, and 386 (62%) were ever smokers. As anticipated, the presence of COPD was associated with a poorer HRQoL. Additionally, however, HRQoL was significantly lower in the presence of both self-reported vapours, gases, dusts and fumes exposure and JEM-based exposure irrespective of the presence of COPD. Regression analysis, adjusting for a variety of covariates including the presence of COPD, confirmed a persisting higher likelihood of occupational exposure categorised by JEM being associated with poorer HRQoL scores (ß estimate: -0.069; p < 0.05). CONCLUSIONS: Our findings suggest that work may have an important link to HRQoL and that this effect can persist even among those who have retired. In those with COPD, HRQoL is worse than among those without this condition, but the work-associated decrement appears to be similar across both groups.

Development of a quantitative North and Central European job exposure matrix for wood dust.

Wood dust is an established carcinogen also linked to several non malignant respiratory disorders. A major limitation in research on wood dust and its health effects is the lack of (historical) quantitative estimates of occupational exposure for use in general population-based case-control or cohort studies. The present study aimed to develop a multinational quantitative Job Exposure Matrix (JEM) for wood dust exposure using exposure data from several Northern and Central European countries. For this, an occupational exposure database containing 12653 personal wood dust measurements collected between 1978 and 2007 in Denmark, Finland, France, The Netherlands, Norway, and the United Kingdom (UK) was established. Measurement data were adjusted for differences in inhalable dust sampling efficiency resulting from the use of different dust samplers and analysed using linear mixed effect regression with job codes (ISCO-88) and country treated as random effects. Fixed effects were the year of measurement, the expert assessment of exposure intensity (no, low, and high exposure) for every ISCO-88 job code from an existing wood dust JEM and sampling duration. The results of the models suggest that wood dust exposure has declined annually by approximately 8%. Substantial differences in exposure levels between countries were observed with the highest levels in the United Kingdom and the lowest in Denmark and Norway, albeit with similar job rankings across countries. The jobs with the highest predicted exposure are floor layers and tile setters, wood-products machine operators, and building construction labourers with geometric mean levels for the year 1997 between 1.7 and 1.9 mg/m3. The predicted exposure estimates by the model are compared with the results of wood dust measurement data reported in the literature. The model predicted estimates for full-shift exposures were used to develop a time-dependent quantitative JEM for exposure to wood dust that can be used to estimate exposure for participants of general population studies in Northern European countries on the health effects from occupational exposure to wood dust.

Identifying causation in hypersensitivity pneumonitis: a British perspective.

Background: Establishing whether patients are exposed to a 'known cause' is a key element in both the diagnostic assessment and the subsequent management of hypersensitivity pneumonitis (HP). Objective: This study surveyed British interstitial lung disease (ILD) specialists to document current practice and opinion in relation to establishing causation in HP. Methods: British ILD consultants (pulmonologists) were invited by email to take part in a structured questionnaire survey, to provide estimates of demographic data relating to their service and to rate their level of agreement with a series of statements. A priori 'consensus agreement' was defined as at least 70% of participants replying that they 'Strongly agree' or 'Tend to agree'. Results: 54 consultants took part in the survey from 27 ILD multidisciplinary teams. Participants estimated that 20% of the patients in their ILD service have HP, and of these, a cause is identifiable in 32% of cases. For patients with confirmed HP, an estimated 40% have had a bronchoalveolar lavage for differential cell counts, and 10% a surgical biopsy. Consensus agreement was reached for 25 of 33 statements relating to causation and either the assessment of unexplained ILD or management of confirmed HP. Conclusions: This survey has demonstrated that although there is a degree of variation in the diagnostic approach for patients with suspected HP in Britain, there is consensus opinion for some key areas of practice. There are several factors in clinical practice that currently act as potential barriers to identifying the cause for British HP patients.