Cleaning agent usage in healthcare professionals and relationship to lung and skin symptoms.

BACKGROUND AND OBJECTIVES: Healthcare workers have an increased risk of respiratory symptoms and dermatitis, likely related to cleaning/disinfecting agents. The aim of this study was to identify work tasks and cleaning/disinfecting agents associated with respiratory symptoms and hand dermatitis among healthcare workers in a tertiary hospital. METHODS: Cleaning agent usage, respiratory symptoms and skin symptoms were recorded by participants using a questionnaire in a cross-sectional study. Age and sex adjusted odds ratios (OR) were used to examine associations between job tasks, exposures, respiratory, and skin outcomes. RESULTS: Two hundred and thirty healthcare workers who were exposed to cleaning agents were compared with 77 who had no, or minimal, exposure. Exposed workers had an increased risk of respiratory symptoms (adjusted OR = 2.17; 95% CI: 1.18-4.14) and skin symptoms (adjusted OR = 1.77; 95% CI: 1.00 - 3.17). Washing instruments manually, using aerosol products, cleaning operating rooms, cleaning sanitary rooms, preparing disinfectants, and filling devices with cleaning products were cleaning tasks associated with various respiratory symptoms. Bleach was the only cleaning agent associated with a respiratory symptom: tightness in the chest (unadjusted OR = 2.46; 95% CI: 1.01-6.89) but statistical significance did not persist after adjustment for age and sex. Hand dermatitis was associated with actual disinfecting tasks (adjusted OR = 2.19; 95% CI: 1.10-4.66). Bleach was the only cleaning agent significantly associated with hand dermatitis (adjusted OR = 2.54; 95% CI: 1.32-5.13). CONCLUSIONS: This study provides insight into possible work tasks that need interventions to reduce or prevent respiratory and skin symptoms in healthcare workers.

Risk factors for fatal and nonfatal reactions to immunotherapy (2008-2018): postinjection monitoring and severe asthma.

BACKGROUND: Subcutaneous allergen immunotherapy (SCIT) is highly effective but risks exist. OBJECTIVE: To identify practices that influence systemic allergic reactions (SRs) to SCIT and SCIT-associated infections. METHODS: Members of the American College of Allergy, Asthma and Immunology and the American Academy of Allergy, Asthma and Immunology completed an annual survey of SCIT-related SRs of varying severity (2008-2018). Injection-related infections were queried (2014-2018). Strategies to enforce postinjection waiting times and to reduce risks from asthma/severe asthma were queried (2016-2018). RESULTS: Data were gathered on 64.5 million injection visits. Ten confirmed fatalities occurred since 2008, including 3 new fatalities since 2017. One fatal reaction occurred per 7.2 million injection visits (2008-2018). No infections occurred. Practices that tracked the time after injections, and required checking out with office personnel, had significantly lower total (P < .001), grade 3 (severe) (P < .001), and grade 4 (very severe) SRs (P < .001). Having more individuals with asthma on SCIT was associated with more grade 3 SRs (P < .02). Not prescribing SCIT in individuals with uncontrolled asthma was associated with fewer grade 3 SRs (P = .02). Having individuals with more severe asthma on SCIT was associated with more total, grade 1, and grade 2 SRs (P < .001); 50% of grade 3 and 4 SRs occurred in individuals with severe asthma. CONCLUSION: SCIT-related fatalities have declined since 2008, with a slight increase in recent years. SCIT is not associated with an increased risk of infections. Tracking the time after injections and checking out with office staff confer significantly lower risks of severe SRs. Asthma, especially severe asthma, is a major risk factor for severe and fatal SRs. Strategies that reduce risks for individuals with asthma, such as not prescribing SCIT to patients with uncontrolled asthma, may lower the risks.

AAAAI/ACAAI Subcutaneous Immunotherapy Surveillance Study (2013-2017): Fatalities, Infections, Delayed Reactions, and Use of Epinephrine Autoinjectors.

BACKGROUND: Subcutaneous allergen immunotherapy (SCIT) is highly effective but safety risks exist. OBJECTIVE: The aims of this study were to: (1) identify clinical practices that could influence fatal and nonfatal systemic allergic reactions (SRs) to SCIT, and (2) identify SCIT-associated infections. METHODS: From 2008 to 2016, 27% to 51% of American Academy of Allergy, Asthma, and Immunology/American College of Allergy, Asthma, and Immunology members completed an annual survey of SCIT-related SRs of varying severity. Injection-related local cutaneous and systemic infections were queried for 2014-2016. For 2014-2016, respondents were queried about timing of onset of SRs, postinjection waiting times, and prescription/use of epinephrine autoinjectors. RESULTS: Data were gathered on 54.4 million injection visits (2008-2016). Two confirmed fatalities from SCIT occurred between 2008 and 2014. An additional 5 confirmed fatalities occurred between 2015 and 2017. No infections occurred in 17.3 million injection visits (2014-2016). Among practices monitoring patients for at least 30 minutes, 15% of SRs occurred after 30 minutes. Practices prescribing an epinephrine autoinjector >90% of the time (29% of practices) did not experience lower rates of delayed grade 3/4 SRs. Of patients experiencing grade 3/4 delayed SRs, 26% and 8% used prescribed self-injectable epinephrine devices during 2014-2015 and 2015-2016, respectively. CONCLUSIONS: There is an unexplained slight increase in SCIT-related fatalities for 2015-2017, although mean annual reported events over 9 years (0.8 fatal reactions per year) have declined. SCIT-related infections were not identified during 2 years of surveillance. The 15% incidence of delayed-onset SRs (>30 minutes) is similar to a prior annual survey. Prescribing epinephrine autoinjectors for SCIT does not appear to improve outcomes, possibly due to low rates of self-administration.

Comparison of Psychological, Quality of Life, Work-Limitation, and Socioeconomic Status Between Patients With Occupational Asthma and Work-Exacerbated Asthma.

OBJECTIVE: The aim of this study was to compare psychological status, quality of life (QoL), work limitation, and socioeconomic status between patients with occupational asthma (OA) and work-exacerbated asthma (WEA). METHODS: The following questionnaires were administered to participants: Beck anxiety and depression (II) inventories, Marks' Asthma Quality of Life Questionnaire, and Work Limitations Questionnaire. Cross-sectional analyses between OA and WEA subgroups were completed. RESULTS: There were 77 participants. WEA subjects had a trend to higher anxiety scores (OA = 9.2 ±â€Š8.0, WEA = 12.8 ±â€Š8.3, P = 0.07, Cohen d = 0.4). Depression scores trended higher for those with WEA (OA = 9.6 ±â€Š10.3, WEA = 13.4 ±â€Š13.5, P = 0.2, Cohen d = 0.3). QoL was comparable between groups. WEA subjects had fewer work limitations (N = 50, OA = 25.1 ±â€Š27.3, WEA = 20.6 ±â€Š24.4, P = 0.56, Cohen d = 0.3) and OA subjects were more likely to have reduced income. CONCLUSION: In a tertiary clinic, there were some modest differences for specific variables between OA and WEA subjects that may help inform management.

Evaluation of the efficacy of a web-based work-related asthma educational tool.

BACKGROUND: Work-related asthma (WRA) has been estimated to account for 15-20% of adult asthma cases. Studies have indicated that a substantial number of asthma patients have inadequate knowledge of work-related effects on their disease, which may contribute to suboptimal asthma control. A Canadian web-based educational tool on WRA was developed to address this knowledge gap in the population. OBJECTIVE: To evaluate the effectiveness of this web-based tool. METHODS: Participants were recruited prior to a routine visit at a tertiary care asthma clinic in Toronto. A brief WRA knowledge questionnaire was developed and administered immediately before and after using of the web-based educational tool, and one year later. RESULTS: The study sample (N = 34) was mostly female (68%) with a mean age of 50.7 (SD, 17.2). Participants demonstrated significant improvement in questionnaire scores following interaction with the tool. The mean score increased from 76% (SEM = 2.1) to 84% (SEM = 1.7) (p = 0.001). On average, scores improved on 12 of the 13 questionnaire items. A 1-year follow-up of a sample of 19 participants demonstrated a slight reduction in mean scores, from 86% (SEM = 1.9) to 84% (SEM = 1.9), but still demonstrated a trend towards a higher score than the baseline (78%; SEM = 2.9; p = 0.08). CONCLUSIONS: Our findings suggest that the educational tool has a positive effect on WRA knowledge, and that knowledge may be retained long-term. Future studies are needed in non-tertiary care clinic populations which may possess less baseline knowledge of WRA.

Risk factors for fatal and nonfatal reactions to subcutaneous immunotherapy: National surveillance study on allergen immunotherapy (2008-2013).

BACKGROUND: In 2008, an annual surveillance study of systemic reactions (SRs) from subcutaneous immunotherapy (SCIT) injections was initiated in North America. OBJECTIVE: To define the incidence of SRs to SCIT. METHODS: From 2008 to 2013, 27% to 51% of American Academy of Allergy, Asthma, and Immunology and American College of Asthma, Allergy, and Immunology members completed an annual survey of SCIT-related SRs of varying severity. From 2012 to 2013, data were collected regarding SRs with off-label sublingual immunotherapy (SLIT), selection of patients with asthma for SCIT, and strategies for dose adjustment during pollen seasons. RESULTS: From 2008 to 2013, data were gathered on 28.9 million injection visits, including 344,480 patients for 2012 to 2013. Since 2008, a total of 2 confirmed fatalities were directly reported that occurred under the care of allergists. Two additional fatalities occurred under the care of nonallergists. The rate of SRs from SCIT remained stable, occurring in 1.9% of patients, with 0.08% and 0.02% experiencing grade 3 and 4 SRs. SRs occurred in 1.4% of patients receiving off-label SLIT, including 0.03% with grade 3 SRs. There were no SLIT-related grade 4 SRs or fatalities. Practices that never administered SCIT in patients with uncontrolled asthma (Asthma Control Test score <20) had significantly fewer grade 3 and 4 SRs (odds ratio, 0.7; 95% confidence interval, 0.5-1.0, and odds ratio, 0.3; 95% confidence interval, 0.1-0.8, respectively). Lowering doses during pollen seasons for patients with highly positive skin tests reduced SRs of all severity grades (P < .05). CONCLUSIONS: SCIT-related fatality rates may be decreasing, but continued vigilance regarding modifiable risk factors, including careful patient selection, is needed. Dose adjustment during pollen seasons for highly sensitive patients may reduce risks. Potential risk for SRs from off-label SLIT exists.

Diisocyanate and non-diisocyanate sensitizer-induced occupational asthma frequency during 2003 to 2007 in Ontario, Canada.

OBJECTIVE: To investigate proportions and outcomes of isocyanate and other causes of occupational asthma (OA) claims in Ontario, Canada, 2003 to 2007. METHODS: New accepted workers' compensation claims for OA compensated by the Ontario Workplace Safety and Insurance Board were retrospectively reviewed. RESULTS: There were 112 allowed claims for OA-30 (26.8%) from diisocyanates (ISO) and 82 (73.2%) from other causes (non-diisocyanates [N-ISO]). The most common occupations for ISO OA were production workers (50%). The most common agents in the N-ISO group were flour (13%) and metal dusts/fumes (10%). At a median time of 8 months postdiagnosis, 55% of ISO and 56.4% of N-ISO workers, respectively, were unemployed. CONCLUSIONS: Diisocyanates OA compensation claims in Ontario are recognized at a lower absolute number and proportion of all OA claims than those in earlier periods. More than half from all causes were unemployed at a median of 8 months postdiagnosis.

AAAAI/ACAAI surveillance study of subcutaneous immunotherapy, years 2008-2012: an update on fatal and nonfatal systemic allergic reactions.

BACKGROUND: Before 2002, there were an estimated 3.4 fatal reactions per year to subcutaneous allergen immunotherapy (SCIT). Recent incidences of SCIT-related systemic allergic reactions (SR) and fatal reactions are not well defined. OBJECTIVE: To define the incidence of and clinical practices associated with SRs to SCIT and skin testing. METHODS: From 2008 to 2012, 27% to 49% of the American College of Allergy, Asthma, and Immunology and American Academy of Allergy, Asthma, and Immunology members completed an annual survey of SCIT-related fatal and nonfatal SRs of varying severity. A shortened version of the World Allergy Organization (WAO) classification system for SRs was adopted in 2011 (grade 1, mild; grade 2, moderate; grade 3, severe; grade 4, very severe). From 2011 to 2012, data were collected regarding nonfatal SRs to skin testing and strategies to lower the risk of SRs from SCIT. RESULTS: Between 2008 and 2012, data were gathered on 23.3 million injection visits. One confirmed fatality occurred in 2009. Overall SR rates remained stable at 0.1%. The rate of very severe, WAO grade 4, SRs was similar to previously reported rates of near-fatal reactions (1 in 1 million injections). Although almost one-third of practices experienced at least 1 SR from skin testing, no WAO grade 3 or 4 SRs from skin testing were reported. A lower target dose during cluster buildup before transitioning to maintenance may be associated with a lower risk of WAO grade 3 SRs (P = .07). Dose adjustment during pollen seasons was associated with fewer WAO grade 3 or 4 SRs (P < .001). CONCLUSIONS: Although SR rates have remained stable and fatalities appear to be declining, continued vigilance regarding SCIT safety is recommended. Additional surveillance and study regarding methods to decrease the risk of severe SRs is warranted.

Development of a web-based, work-related asthma educational tool for patients with asthma.

BACKGROUND: Asthma is a common chronic condition. Work-related asthma (WRA) has a large socioeconomic impact and is increasing in prevalence but remains under-recognized. Although international guidelines recommend patient education, no widely available educational tool exists. OBJECTIVE: To develop a WRA educational website for adults with asthma. METHODS: An evidence-based database for website content was developed, which applied evidence-based website design principles to create a website prototype. This was subsequently tested and serially revised according to patient feedback in three moderated phases (one focus group and two interview phases), followed by face validation by asthma educators. RESULTS: Patients (n=10) were 20 to 28 years of age; seven (70%) were female, three (30%) were in university, two (20%) were in college and five (50%) were currently employed. Key format preferences included: well-spaced, bulleted text; movies (as opposed to animations); photos (as opposed to cartoons); an explicit listing of website aims on the home page; and an exploding tab structure. Participants disliked integrated games and knowledge quizzes. Desired informational content included a list of triggers, prevention/control methods, currently available tools and resources, a self-test for WRA, real-life scenario presentations, compensation information, information for colleagues on how to react during an asthma attack and a WRA discussion forum. CONCLUSIONS: The website met the perceived needs of young asthmatic patients. This resource could be disseminated widely and should be tested for its effects on patient behaviour, including job choice, workplace irritant/allergen avoidance and/or protective equipment, asthma medication use and physician prompting for management of WRA symptoms.

Impact of a cleaners' strike on compensation claims for asthma among teachers in Ontario.

BACKGROUND: A review of Workplace Safety and Insurance Board (WSIB) claims in Ontario from 1998 to 2002 showed an unusual spike in the number of claims accepted for work-exacerbated asthma (WEA) in April 2001. OBJECTIVE: To identify the cause for the spike in the number of WSIB claims for WEA in April 2001. METHODS: File reviews were performed to identify the occupations of workers with claims accepted for WEA in April 2001 compared with claims during March and May 2001, and during the same months in 2000 and 2002. RESULTS: In April 2001, there were 61 accepted WEA claims; the most common occupation was 'teacher'. In contrast, among educational workers, there was only one WEA claim in the previous month and one in the following month. From March to May in the preceding and following years, there were only four and two claims, respectively. The most frequently implicated causative agents were dust and dirt exposure, which were responsible for 98% of claims; the mean (± SD) number of lost workdays was 6.5±10. The only identified environmental change associated with this spike was a cleaners' strike at all elementary and high schools in the Toronto District School Board in Ontario, which started on March 31, 2001 and ended on May 1, 2001. CONCLUSION: [corrected] The spike in accepted WEA claims in Ontario in April 2001 was temporally associated with a strike by Toronto District School Board cleaners, suggesting acute symptomatic effects of poor workplace (school) maintenance on asthmatic employees. The WSIB database was sufficiently sensitive to capture this phenomenon.

Flock worker's lung disease: natural history of cases and exposed workers in Kingston, Ontario.

BACKGROUND: The natural history of flock worker's lung (FWL) and longitudinal lung function changes in nylon flock-exposed workers have not been well characterized. METHODS: Symptoms, pulmonary function testing, and chest radiographs from five index cases, subsequent case referrals, and screened employees of a flocking plant in Kingston, Ontario, Canada, were compared and analyzed for changes over time (variable follow-up intervals between 1991 and 2011). RESULTS: Nine cases and 30 flock-exposed workers without FWL were identified. Four cases had persistent interstitial lung disease despite three having left the workplace. Two developed hypoxemic respiratory failure and secondary pulmonary hypertension and died of complications 18 and 20 years after diagnosis, respectively. Five cases resolved after leaving the workplace. Compared with resolved cases, persistent cases had lower diffusing capacity of the lung for carbon monoxide at presentation (P < .05) and follow-up (P < .05). Among exposed workers employed for 14.5 ± 4.7 years, five had abnormal chest radiographs vs none at baseline (P = .001) over 14.8 ± 4.6 years of follow-up. The prevalence of wheeze increased (P = .001), and FEV1/FVC decreased (P < .001). FEV1% predicted was significantly lower at follow-up (P = .05). Average FEV1 decline was 46 mL/year (range, -27 to 151 mL/y). Seventy-seven percent of exposed workers were current or former smokers. CONCLUSIONS: The natural history of FWL includes the following patterns: complete resolution of symptoms; radiographic and pulmonary function abnormalities; permanent, but stable symptoms and restrictive pulmonary function deficits; and progressive decline in pulmonary function, causing death from respiratory failure and secondary pulmonary hypertension. A low baseline diffusing capacity of the lung for carbon monoxide is associated with the persistence and progression of FWL.

AAAAI and ACAAI surveillance study of subcutaneous immunotherapy, Year 3: what practices modify the risk of systemic reactions?

OBJECTIVE: To define the incidence of and clinical practices associated with subcutaneous immunotherapy (SCIT)-related systemic reactions (SRs). METHODS: From 2008-2011, American Academy of Allergy, Asthma & Immunology and American College of Allergy, Asthma & Immunology members completed an annual survey of SCIT-related SRs of varying severity (with grade 1 indicating mild; grade 2, moderate; and grade 3, severe anaphylaxis). From 2010-2011 (year 3) data were collected regarding SCIT-related procedures, including screening of patients with asthma, dose adjustment during peak pollen seasons, build-up regimens (conventional, cluster, or rush), and premedication. RESULTS: No fatal reactions were directly or indirectly reported from 2008-2011. The SR rates were similar for all 3 years (0.1% of injection visits; 83% of practices), as were severity grades. On average, for all 3 years, there were 7.1 grade 1, 2.6 grade 2, and 0.4 grade 3 SRs per 10,000 injection visits. Screening for worsening asthma symptoms was highly prevalent (86% always screened). Practices that always reduced doses during peak pollen season were significantly less likely to report grade 2 or 3 SRs (44% vs 65%; P = .04). Cluster and rush build-up were associated with significantly more SRs (P < .001). Practices that premedicated were significantly more likely to report grade 2 and 3 SRs (P < .01). CONCLUSION: Fatal reactions to SCIT appear to be declining, possibly related to almost universal screening of asthmatic patients. Adjusting doses during the pollen season may be associated with decreased risk for severe SRs. Cluster and rush immunotherapy were associated with increased risk for SRs. Premedication by practices reporting SRs likely reflects past experience with SRs.

Feasibility of a provincial voluntary reporting system for work-related asthma in Ontario.

OBJECTIVE: The Ontario Work-Related Asthma Surveillance System: Physician Reporting (OWRAS) Network was established in 2007 to estimate the prevalence of work-related asthma (WRA) in Ontario, and to test the feasibility of collecting data for cases of WRA from physicians voluntarily. METHODS: More than 300 respirologists, occupational medicine physicians, allergists and primary care providers in Ontario were invited to participate in monthly reporting of WRA cases by telephone, postal service or e-mail. RESULTS: Since 2007, 49 physicians have registered with the OWRAS Network and, to date, have reported 34 cases of occupational asthma and 49 cases of work-exacerbated asthma. Highly reactive chemicals were the most frequently reported suspected causative agent of the 108 suspected exposures reported. CONCLUSION: Despite the challenge of enlisting a representative sample of physicians in Ontario willing to report, the OWRAS Network has shown that it is feasible to implement a voluntary reporting system for WRA; however, its long-term sustainability is currently unknown.

Immediate and delayed-onset systemic reactions after subcutaneous immunotherapy injections: ACAAI/AAAAI surveillance study of subcutaneous immunotherapy: year 2.

BACKGROUND: Incidences of subcutaneous immunotherapy (SCIT) related systemic reactions (SRs) and fatal reactions (FRs) are not well defined, nor are delayed-onset SRs and their treatment. OBJECTIVES: To estimate SCIT-related SRs/FRs, and the incidence and treatment of delayed-onset SRs. METHODS: In 2008 and 2009, American Academy of Allergy, Asthma & Immunology (AAAAI) and American College of Allergy Asthma & Immunology (ACAAI) members completed a survey about SCIT-related SR severity (grade 1 = mild; grade 2 = moderate; grade 3 = severe anaphylaxis). In 2009, members reported the time of onset and use of epinephrine (EPI), with early onset defined as beginning ≤30 minutes, and delayed onset beginning more than 30 minutes after injections. RESULTS: As in year 1, no FRs were reported during year 2 (630 total practices responded). Among 267 practices providing data on the timing of SRs, 1,816 early-onset SRs (86%) and 289 (14%) delayed-onset SRs were reported. Fifteen percent (226/1,519) of grade 1, 10% (54/538) of grade 2, and 12.5% (9/72) of grade 3 SRs were delayed-onset. Among early-onset SRs, EPI was given for 71% of grade 1, 93% of grade 2, and 94% of grade 3s. Among delayed-onset SRs, EPI was given for 56% of grade 1, 67% of grade 2, and 100% of grade 3s (P = .0008 for difference in EPI administration based on severity; P = .07 based on time of onset). CONCLUSIONS: Delayed-onset SRs are less frequent than previously reported. Epinephrine was given less frequently for grades 1 and 2 (but not grade 3) delayed-onset SRs compared with early-onset SRs. Further study of prescribing self-injectable EPI for SCIT patients in the event of delayed-onset SRs may be warranted.

Search for chronic beryllium disease among sarcoidosis patients in Ontario, Canada.

Chronic beryllium disease (CBD) is clinically similar to other granulomatous diseases such as sarcoidosis. It is often misdiagnosed if a thorough occupational history is not taken. When appropriate, a beryllium lymphocyte proliferation tests (BeLPT) need to be performed. We aimed to search for CBD among currently diagnosed pulmonary sarcoidosis patients and to identify the occupations and exposures in Ontario leading to CBD. Questionnaire items included work history and details of possible exposure to beryllium. Participants who provided a history of previous work with metals underwent BeLPTs and an ELISPOT on the basis of having a higher pretest probability of CBD. Among 121 sarcoid patients enrolled, 87 (72%) reported no known previous metal dust or fume exposure, while 34 (28%) had metal exposure, including 17 (14%) with beryllium exposure at work or home. However, none of these 34 who underwent testing had positive test results. Self-reported exposure to beryllium or metals was relatively common in these patients with clinical sarcoidosis, but CBD was not confirmed using blood assays in this population.

Reduction in diisocyanate and non-diisocyanate sensitizer-induced occupational asthma in Ontario.

OBJECTIVE: To investigate relative frequency and features of diisocyanate (ISO) and non-diisocyanate (N-ISO) allowed occupational asthma (OA) claims in Ontario, Canada, during a 5-year period (1998 to 2002). METHODS: Records were abstracted from the Ontario Workplace Safety and Insurance Board using methodology similar to our previous investigation that had identified 30 ISO and 30 N-ISO claims/yr during 1980 to 1993. RESULTS: There were 99 OA claims: 37 ISO (7.4 claims/yr) and 62 N-ISO (12.4 claims/yr). The ISO group had more males (86% vs 69%, p = 0.01), but there were no other significant differences. The commonest professions were spray painters (41%) and production workers (38%) in the ISO group and production workers (49%) and health care workers (8%) in the N-ISO group. CONCLUSIONS: ISO and N-ISO claims declined from the previous period, especially for ISO, perhaps because of effective surveillance programs.

Work-related asthma in health care in Ontario.

BACKGROUND: The health of workers in health care has been neglected in the past. There are few reports regarding occupational asthma (OA) in this group, and work-exacerbated asthma (WEA) has rarely been considered. METHODS: We examined the frequency of claims for OA and WEA allowed by the compensation board in Ontario, Canada for which industry was coded as "health care" between 1998 and 2002, to determine the frequency of OA and WEA, causative agents, and occupations. RESULTS: During this period, five claims were allowed for sensitizer OA, two for natural rubber latex (NRL), and three for glutaraldehyde/photographic chemicals. The two NRL cases occurred in nurses who had worked for >10 years prior to "date of accident." There were 115 allowed claims for WEA; health care was the most frequent industry for WEA. Compared to the rest of the province, claims in health care made up a significantly greater proportion of WEA claims (17.8%) than OA (5.1%) (odds ratio, 4.1, 95% CI 1.6-11.6; P = 0.002). The rate of WEA claims was 2.1 times greater than that in the rest of the workforce (P < 0.0001). WEA claims occurred in many jobs (e.g., clerk), other than "classic" health care jobs such as nurses, and were attributed to a variety of agents such as construction dust, secondhand smoke, and paint fumes. CONCLUSIONS: WEA occurs frequently in this industrial sector. Those affected and attributed agents include many not typically expected in health care. The incidence of OA claims in this sector in general was low; the continued low number of OA claims due to NRL is consistent with the successful interventions for prevention.