Occupational Lung Disease: Airing on the Side of Caution

May 14, 2002
Preventive action and a quick response to complaints can help employers reduce the estimated $8.5 billion price tag of occupational lung disease.

The air, dust and fumes some employees breathe at work are making them sick, very sick in some cases, and it's creating an ailing bottom line for employers and burdening federal programs such as Medicare.

Cases of lung cancer, obstructive lung disease (such as asthma) and chronic obstructive pulmonary diseases (such as bronchitis and emphysema), while not always work-related, are taking their toll on workers and employers. The American Lung Association estimates that:

  • More than 17,000 lung cancer deaths per year are attributable to inhalation hazards in the workplace.
  • Some 6.7 million adults over the age of 18 suffered from an asthma attack during 1999, the most recent year statistics are available, and asthma - even cases that aren't work-related - results in 3 million lost workdays per year.
  • Chronic obstructive pulmonary disease (COPD), the fourth leading cause of death in the United States, claims the lives of 119,524 Americans annually.

The terms "lung disease" and "respiratory illness" cover a lot of ground. They range from the common cold to lung cancer, from asthma to allergies and from pneumoconioses to pneumonia.

J. Paul Leigh, Ph.D., a professor of health economics in the Department of Epidemiology and Preventative Medicine at the University of California-Davis School of Medicine, recently examined the direct and indirect costs of occupational lung disease. He discovered $6.6 billion was spent on obstructive lung disease in 1996, an amount that likely increased in recent years.

Leigh says if you take the increasing prevalence of COPD and asthma and add in additional costs to account for inflation, you'll find the cost in 2001 for occupational lung disease to be roughly $8.5 billion. "Clearly, this is a significant price tag that deserves attention," he notes.

What Can Employers Do?

If you are an employer or safety professional who has noticed a growing number of workers' compensation claims related to respiratory illnesses, don't take it lying down, suggests Dorsett Smith, M.D., FCCP, who has a private practice in Everett, Wash., that focuses on occupational lung disease.

First, according to Smith, many cases of lung disease are incorrectly attributed to the workplace. "There is such public awareness now of toxic substances. People assume that if they're sick, it must be work-related," says Smith, who is also a clinical professor of medicine at the University of Washington School of Medicine. "Our culture assumes that everybody must be healthy, and if they're not, then there's something wrong with the workplace."

Employers and safety professionals can do a little homework and save themselves and their employees some grief down the road, Smith says. For example, examine the locations in your facilities where claims are originating. Are they all related to one process or area of your facility? Smith suggests conducting industrial hygiene monitoring and taking quick corrective action if you find a problem.

Questioning employees is also useful, he says. "Certain industries 'sort' employees. Only healthy people can stay in the job. Maybe a new person comes in and can't take it. It's hard when you've just got one case of something; that's not really a red flag," he says. If you talk to other employees in that area and they admit they had a problem at first but "got used to it," that's your red flag, he adds.

Smith lists other red flags:

  • A cluster of workers' compensation cases. Take a hard look at those cases and determine if the problem is the work environment (new processes, the addition of new chemicals, etc.) or interpersonal (a universally disliked supervisor, for example).
  • Employees from one area taking a lot of sick days. Ask yourself: Has a process changed? Is there a flu virus going around? Is there an interpersonal problem that needs attention?
  • Employees asking for personal protective equipment (PPE). When employees ask for PPE, they're putting employers on notice, Smith says. They are troubled about their work environment. If an employer issues PPE, Smith warns, he or she needs to ensure employees receive training in the hazards and proper use and maintenance of PPE. Proper fit-testing of certain types of respirators is essential, he notes.

Susanna Von Essen, M.D., who practices pulmonary and critical care medicine at the University of Nebraska Medical Center, offers basic, but important, tips for safety directors and employers who are considering adding respirators to their arsenal of PPE:

  • If respirators are mandatory, make employees wear them. Don't just have a rule that says employees should wear them and then leave compliance up to the employees. Conduct audits and walk-throughs to ensure your respiratory protection program is being followed.
  • Make certain that employees receive proper fit-testing and are wearing the proper respirator for the job.
  • Try to buy the most comfortable respirators, even if they are more costly.

Von Essen also suggests that employers in industries where lung disease is a particular hazard - such as agriculture - or who have employees with jobs that are associated with lung disease - such as welders - start a spirometry program to test employees' baseline lung function and follow them over time. Such baseline information, she says, helps you figure out what's going on if you notice a number of workers' compensation cases or have employees complaining of breathing problems.

What Can Employees Do?

To truly get at the root cause of lung disease and respiratory illness, employees need to notify their employers if they are experiencing problems at work and should give their physicians all the information available to them, Von Essen says. Rather than tell the physician that a condition is work-related right off the bat, Smith suggests giving the doctor a list of the symptoms first.

"Say: 'I'm fine on weekends but I cough and wheeze at work. Then I'm fine when I go home,'" Smith says. He also suggests keeping a diary. "Write it down if you notice you feel particularly bad around a certain process or chemical. It will help your employer and your doctor make an association between lung disease and the workplace."

Von Essen says that it helps her to know a patient's occupation and to hear what they were doing when they first realized they were experiencing problems.

"A man who was admitted to the hospital complaining of tightness in his chest and shortness of breath was diagnosed by a physician with heart problems," recalls Von Essen, who asked the man what he did for a living. He told Von Essen he was a farmer and that he had stored some grain [dust hazard] earlier that day and had fertilized his fields the week before [chemical hazard]. "I thought, 'Ah ha!' You can wheeze from heart failure too, but this patient didn't have heart failure," she says.

Von Essen says she makes it a point to visit as many workplaces in as many industries as possible. If local physicians are aware of the working conditions at a facility, then employers and safety managers can use them as resources to help prevent exposures, illness and injury, she adds. It can also help those physicians make a proper diagnosis as to the work-relatedness of the illness.

As much as 10 percent to 15 percent of the population has asthma, Smith says, and many physicians don't have the knowledge and tools to conduct an extensive examination to determine the cause of respiratory problems. They base their diagnosis of occupational lung disease on anecdotal information from workers, rather than scientific test data or information acquired by visiting the workplace, he adds, and employers end up paying the price.

Footing the Bill

Even if many cases of lung disease are incorrectly attributed to the workplace, Smith and Leigh agree that costs are skyrocketing for work-related claims.

In some cases, employees begin to exhibit symptoms of occupational lung diseases while they are still employed and are diagnosed with work-related conditions. Employers who pay into workers' compensation insurance foot the bill for these cases, paying for medical costs, lost wages, retraining and, in many cases, disability pay.

In some cases, occupational lung disease does not manifest in a worker until after he or she reaches retirement age. At that point, workers' compensation is no longer available, and Medicare and other healthcare providers pay the high price for previous occupational exposures.

"There is a great inequity here," complains Leigh. "Innocent third parties - the sick employees, their families, their health insurance - are paying for something they didn't create. Workers' compensation should pay for it."

Leigh has a rather radical solution to the problem of who should pay the price for occupational lung disease: a tax. "One way to reduce the pollution [that causes lung disease] might be to tax the industries that generate poor air and use those funds to pay Medicare directly. That approach provides an incentive for industry to clean up the air while lessening the financial burden on Medicare and, thus, the taxpaying public," he says.

While that is not likely to happen anytime soon, Leigh admits, he, Smith and Von Essen agree that the smartest course of action for employers is to prevent as many cases of occupational lung disease as possible by controlling exposures at work.

"COPD and asthma incidence can be reduced or prevented by cutting down on dust and particulate matter in workplace air," Leigh says. "Control exposure in the work environment, and you eliminate the problem."


Types of Respirators

A recent report issued by the National Institute for Occupational Safety and Health (NIOSH) found that approximately 3.3 million workers used a respirator in the past year.

Several types of respirators can be used to protect employees from respiratory hazards in the workplace. Each type of respirator is made for use in a specific environment.

There are two basic types of respirators: air-purifying and air-supplying. Air-purifying respirators remove harmful contaminants from the air and should not be used in an oxygen-deficient environment or in any other condition that is immediately dangerous to life and health (IDLH). Air-purifying respirators range from simple disposable masks to more sophisticated positive-pressure, blower-operated respirators.

Air-purifying filters and cartridges have a limited lifespan and must be changed frequently. Dust filters should be changed when breathing becomes difficult due to clogging of filter pores by dust particles. Chemical cartridges/canisters should be changed before the chemical absorbent is used up, and this should be done under the guidance of a qualified person, such as an industrial hygienist.

Air-supplied respirators provide air from a clean source outside the work area or from a compressed air cylinder. They are used in IDLH environments and for substances with poor warning properties. Examples of air-supplied respirators include airline units, self-contained breathing apparatus (SCBA) and complete air-supplied suits.

For more information about choosing respirators and their use, visit NIOSH's Web site at www.cdc.gov/niosh/respinfo.html. You will find a certified equipment list, which is a database of NIOSH-certified respirators and coal mine dust personal sampler units, as well as the publications "NIOSH Guide to Industrial Respirator Protection," "Medical Aspects of Wearing a Respirator" and "NIOSH Respirator User Notices."


Respiratory Protection Programs: What OSHA says

In 29 CFR Part 1910.134, OSHA states that:

"In any workplace where respirators are necessary to protect the health of the employee or whenever respirators are required by the employer, the employer shall establish and implement a written respiratory protection program with worksite-specific procedures. The program shall be updated as necessary to reflect those changes in workplace conditions that affect respirator use."

Requirements for respirator use require employers to include the following provisions in their respiratory protection program:

  • 1910.134(c)(1)(i) Procedures for selecting respirators for use in the workplace;
  • 1910.134(c)(1)(ii) Medical evaluations of employees required to use respirators;
  • 1910.134(c)(1)(iii) Fit-testing procedures for tight-fitting respirators;
  • 1910.134(c)(1)(iv) Procedures for proper use of respirators in routine and reasonably foreseeable emergency situations;
  • 1910.134(c)(1)(v) Procedures and schedules for cleaning, disinfecting, storing, inspecting, repairing, discarding and otherwise maintaining respirators;
  • 1910.134(c)(1)(vi) Procedures to ensure adequate air quality, quantity and flow of breathing air for atmosphere-supplying respirators;
  • 1910.134(c)(1)(vii) Training of employees in the respiratory hazards to which they are potentially exposed during routine and emergency situations;
  • 1910.134(c)(1)(viii) Training of employees in the proper use of respirators, including putting on and removing them, any limitations on their use and their maintenance; and
  • 1910.134(c)(1)(ix) Procedures for regularly evaluating the effectiveness of the program.

For more information about regulations concerning respiratory protection, visit OSHA's Web site at www.osha.gov, click on "Regulations," and type in keywords "respirators" or "respiratory protection."

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