1. Psycho-socio-economic impact of occupational asthma Olivier Vandenplas Department of Chest Medicine Mont-Godinne Hospital Catholic University of Louvain Yvoir - Belgium

2. Age, sex Work conditions Socio-economic status Emotional factors Co-morbidities, … IMPAIRMENT Physiological deficit Relative to “normal” values DISABILITY Impact on daily life Relative to prior patient’s status Focus on impairment & disability Airway obstruction Airway hyperresponsiveness Medication need Airway inflammation? Quality of life Work productivity

3. Evaluation of impairment in asthma ATS guidelines Score Airway obstruction Airway hyperresponsiveness Medication need FEV 1 (post-BD) % FEV 1 change post-BD PC 20 (mg/ml) 0 >lower limit of normal <10>8No medication 1 70% pred to lower limit of normal 10-198-0.5Occasional BD 260-6920-290.5-0.125 Daily BD or low dose ICS (<1000 µg beclomethasone) 350-59 ≥30 ≤0.125 High dose ICS (>1000 µg beclomethasoe) or occasional oral steroids 4<50 Daily high dose ICS and daily oral steroids From: ATS Guidelines Am Rev Respir Dis 1993;147:1056

4. Airway inflammation & evaluation of impairment Chan-Yeung M, Am J Respir Crit Care Med 1999;159:1434-8 50 patients with red cedar OA r = 0.52, p<0.001 Sputum eosinophils correlate with ATS class of impairment (Chan-Yeung M, Am J Respir Crit Care Med 1999;159:1434-8) Persistence of airway inflammation after removal from exposure:  sputum eosinophils in 20% of subjects  sputum neutrophils in 30% of subjects  eosinophils and/or neutrophils in 17% of subjects with normal FEV 1 and PC 20 (Yacoub MR, Eur Respir J 2007;29:889)  Increased risk of exacerbation?

5. Rating of impairment: requirements Stable asthma Asthma Control Questionnaire (ACQ): 7 items (www.qoltech.co.uk)  Score 1.50 = inadequately controlled Asthma control Test (ACT): 5 items (www.qualitymetric.com)  Score >19 = inadequately controlled GINA classification of severity/control (www.ginasthma.com) Optimal treatment Minimum medication required to maintain control Timing of assessment 2 to 5 yrs after removal from causal exposure (Malo JL, Am J Respir Crit Care Med 2004;169:1304)

6. Q 61 & 66. What is the impact of work-related asthma on Quality of Life (QoL) assessed using validated instruments in various populations? Q 61 & 62. What are the factors that determine QoL in subjects with OA: income loss, compensation, severity of asthma? Tarlo SM & Malo JL. An ATS/ERS report: 100 key questions and needs in occupational asthma. Eur Respir J 2006;27:607-14 Disability – Quality of life

7. Quality of life in occupational asthma Comparison with other types of asthma Non-occupational asthma  QoL is lower in subjects with OA (mean  AQLQ score: -0.6) than in those with non-OA matched for the severity of asthma (Malo JL, J Allergy Clin Immunol 1993) Work-exacerbated asthma  QoL is similar in OA and WEA (Lemière C, J Occup Environ Med 2006) Determinants of QoL  “Satisfaction with life” is associated with: - current employment - less severe asthma (use of medication, PEF variability) (Piirila P, J Occup Health 2005;47:112-18)

8. Q 65. Are psychological factors involved in the aetiology of work-related asthma and how psychological factors affect treatment and outcome of OA? Tarlo SM & Malo JL. An ATS/ERS report: 100 key questions and needs in occupational asthma. Eur Respir J 2006;27:607-14

9. Psychological factors in occupational asthma Significant level of psychological distress, including anxiety, and depression in ~50% of subjects with OA after cessation of exposure (Psychiatric Symptom Index,PSI) Anxiety disorders in 35% of subjects with OA (Millon Clinical Multiaxial Inventory, MCMI-III) (Yacoub MR, Eur Respir J 2007;29:889)  Prospective investigation of the influence of psychological factors on asthma control, QoL, and socioeconomic impact of OA by comparison with non-occupational asthma, and the effect of interventions (e.g. rehabilitation) on psychological disorders

10. Q 62. What is the cost of OA in different countries? Q 62. What should be done to reduce socio-economic losses due to work-related asthma? Tarlo SM & Malo JL. An ATS/ERS report: 100 key questions and needs in occupational asthma. Eur Respir J 2006;27:607-14 Disability – Work productivity

11. Cost of occupational asthma Direct costs  Healthcare expenses Indirect cost  Impaired work productivity: Job changes/Unemployment Absenteeism Reduced work effectiveness  Compensation, rehabilitation Intangible costs  QoL

12. Socio-economic consequences of OA CountryReference No. of subjects Follow-up (yr) Work disruption (%) Loss of income (% of workers) UKGannon, 1993112Median: 1.435% Exposed: 44% Unexposed: 74% Canada, BCMarabini, 1993128Mean: 4.841%NA Canada, QcDewitte, 1994134Range: 2-525%NA UKCannon, 199587539%55% FranceAmeille, 1997209Mean: 3.134%46% USAGassert, 199855Mean: 2.669%NA UKRoss, 19987701.5-5.537%NA BelgiumLarbanois, 200286Median: 3.338%62% NorwayLeira, 20054962-649%51% FinlandPiirila, 2005213Mean: 1014%NA Updated from: Vandenplas O, Toren K & Blanc PD, Eur Respir J 2003;22:689

13. Findings in WEA compared with: Socio-economic outcome Asthma unrelated to work Occupational AsthmaReference Work productivity: UnemploymentSimilar (31% v 32%) NA Similar (43% v 38%)* Similar (31% v 39%) Similar (48% v 38%) NA Cannon J, 1995 Larbanois A, 2002 Breton CV, 2006 Job/employer changesMore common NA Similar Less common (54% v 72%) Less common (23% v 47%)¥ Similar (100% v 94%) Cannon J, 1995 Larbanois A, 2002 Goe SK, 2004 Lemière C, 2006 Lost workdays Similar More common (19% v 12%) Similar* NA Tarlo SM, 2000 Henneberger PK, 2002 Breton CV, 2006 Work ability (self-reported) Slightly decreasedNABalder B, 1998 Loss of income:More common (65% v 38%) NA Similar (65% v 62%) Similar (59% v 62%) Cannon J, 1995 Larbanois A, 2002 * Work-related asthma; ¥ New-onset occupational asthma Socio-economic consequences of WEA Adapted from: Vandenplas O & Henneberger PK, Curr Opin Allergy Clin Immunol 2007

14. Determinants of adverse economic outcomes (1) CountryReference Prevalence of income loss (%) % reduction of income Prevalence of income loss (%) % reduction of income Persistence of exposureAvoidance of exposure UKGannon, 199344Median: 54%74Median: 35% BelgiumLarbanois, 200227NA78NA ItalyMoscato, 199917-$268/yr69-$4,203/yr Same employer Other employer or unemployed FranceAmeille, 19971919 ± 10%8450 ± 28%

15. Avoidance of exposure to the causal agent Change of employer  15-21% of workers with OA are relocated within the same company vs. 31% in Quebec Age, low education level, small-size company Absence of retraining program?  Information on rehabilitation unavailable for most countries (<5% in Belgium)  Rehabilitation: 31% in Quebec and 34% in Finland Severity of asthma  Minimal effect in available studies  Exception of Finland: Unemployment is associated with nocturnal symptoms, PEF variability, and use of SABA (Piirila P, J Occup Health 2005;47:112-18)  Compensation should aim at reducing non-medical factors that determine work-disability Determinants of adverse economic outcomes (2)

16. Q 63. What are the consequences of initiating a claim for work-related asthma? Q 64. What weight should be given to impairment and disability in compensating subjects with OA? Tarlo SM & Malo JL. An ATS/ERS report: 100 key questions and needs in occupational asthma. Eur Respir J 2006;27:607-14

17. Compensation of OA Initiating a claim for compensation? Higher rate of unemployment (Ameille J, Eur Respir J 1997): cause or consequence? Loss of income offset by compensation 22% of compensated workers (Larbanois A, Eur Respir J 2003) ~30% of affected workers remain exposed to causal agent  Compensation of OA based on physiological impairment is highly inefficient, at least in countries where work-disability remains the major determinant of the impact on socio-economic status and QoL