Establishing the Work-Relatedness of Diseases

Establishing Work-Relatedness of a Disease

Marissa G. Lomuntad-San Jose, MD, MOH

Objectives

At the end of this session, participants will be able to:

 Discuss the factors that

 Discuss the evidence-based approach

in establishing work-connection of diseases

Department of Labor and Employment

OCCUPATIONAL SAFETY AND HEALTH CENTER

Why Establishing Work-Connection

of Disease is Difficult?

1.

Cause-effect relationship between

disease and an agent or conditions in

the workplace may not be clear

2.

Occupational disease may be slow to

develop



Why Establishing Work-Connection


3. symptoms of disease may be confused with changes that are due to

the aging process, or with the effects

of smoking or alcohol abuse

4. Information on past work exposures often unavailable, inadequate, or

incomplete



Why Establishing Work-Relatedness


5.

not all individuals react in the same way to similar exposures to disease-

producing agents

6.

off-the-job exposures may contribute

or be a primary cause of illnesses and

accidents



Decision-Making

 decision must be based on an evaluation of the available information

 an equitable decision is likely to result when:

 appropriate evidence is presented in a logical and orderly sequence  major issues are identified, and

 the basis for any presumption is defined



Six Basic Steps

1.

consideration of evidence of disease,

2.

consideration of epidemiologic data,

3.

consideration of evidence of

exposure,



Six Basic Steps

4.

consideration of validity of testimony,

5.

consideration of other relevant factors, and

6.

evaluation and conclusion.



1. Evidence of Disease

 The first consideration:

 that a disease condition does, in fact, exist, and

 that the particular manifestations of the disease appear to be the result of

exposure to a specific harmful agent.




 Generally, a medical evaluation should

include:

 An analysis of the employee's medical, personal, family, and occupational

histories;

 a thorough physical examination and

clinical evaluation (analysis of signs and

symptoms); and



Occupational History



Factors Affecting Validity of Occupational History

 Occupational history may be insufficient

 Lack of specificity about the identity of hazards

 Inadequate information about exposure level

 Recall biases

 Other biases -e.g. fear of job loss




 Generally, a medical evaluation should

include: (cont)

 a laboratory evaluation (analysis of the results of specific tests).




 Other work-related medical information

 timing of symptoms

 existence of symptoms in co-workers




Inquiry on timing of symptoms:

1.

Change in the symptoms during the work

day

2.

Change in symptoms over the work week

3.

Change in symptoms on weekends and on

vacation

4.

Onset of symptoms away from work

5.

Other work-related experiences



Example:

Occupational

Asthma

Initiated or provoked by agents found in the work environment

causing asthmatic signs and symptoms

either due to excessive concentrations of these agents

or because of exaggerated response by the individual worker



Considetations

• Presence of asthma-causing agent in the workplace

• No previous history of asthma prior to exposure

• Improvement in symptoms with cessation of exposure



Considetations

• Recurrence of symptoms upon returning to work

• Worsening symptoms toward end of week or start of week



2. Evidence of Exposure

 The best evidence to confirm the

exposure of a worker to an agent is

measurements (such as air samples, noise levels or radiation

measurements) obtained at the

worker's actual job stations, past and

present.



2. Evidence of Exposure

 Identification of agents/ factors that a person has been exposed to  Information from industrial hygiene studies

 Data on work exposure evaluation  Work environment condition



3. Epidemiology

 The study of distribution and determinants of health-related events

in specified populations.

 Concerned not only with illnesses, injuries and death, but with means to

improve health



3. Epidemiology

 Point to high PROBABILITY or

ASSOCIATIONS of agents/ factors with

certain diseases  Studies

 Demonstration of effects after (prolonged) exposure  Descriptive accounts of observed effects



EPIDEMIOLOGICAL APPROACH TO DISEASE CAUSATION



Disease Causation

 CAUSE (of disease) – event, condition, characteristic or combination of these

factors which plays an important role in producing health outcome

 SUFFICIENT cause - produces or initiates

an outcome

 NECESSARY cause – must be present for

an outcome to occur



Disease Causation

 Ex. foodborne disease outbreak

(Salmonella diarrhea)

 Sufficient causes:

 chicken salad and cream desert

 Necessary cause:

 Salmonella spp.



Causes of Tuberculosis

Sufficient Causes

malnutrition

genetic factors

SUSCEPTIBLE

HOST

crowded

poverty

Necessary Cause

Mycobacterium tuberculosis

TISSUE

INVASION

EXPOSURE TO

BACTERIA

INFECTION

TUBERCULOSIS

MECHANISMS FOR TUBERCULOSIS

housing

RISK FACTORS FOR TUBERCULOSIS

Causal Inference

A. Bradford Hill

(1897-1991)

“Process of

determining whether

observed

associations are

likely to be causal”

 Commonly used approach on causal

inference using a set

of “considerations

for causation”

is

Hill’s criteria



Considerations for Causation

1.

STRENGTH

What is the strength of association between the cause and

effect?

2.

CONSISTENCY

Have similar results been shown in other studies ?

3.

SPECIFICITY

Is the effect only from one cause?

4.

TEMPORAL

Does the cause precede the effect ?

RELATION

5.

DOSE-RESPONSE

Is increased exposure to the possible cause associated with

increased effect ?

6.

PLAUSIBILITY

Is association consistent with other knowledge? (evidence from

animal studies)

7.

COHERENCE

Is association coherent (do not conflict) with other knowledge?



Strength

(What is the strength of association between the cause and effect?)

 Strength of association between

possible cause and effect is measured

by risk ratio

 Strong association (risk of >2) is More likely to be causal than weak association

 Ex. The lung cancer rate for smokers is about 10 times (RR = 10) higher than for

non-smokers



Consistency

(Have similar results been shown in other studies ?)

 Different studies showing similar

findings in different populations under

increase the credibility of causal finding

 Examples:

 Pesticide exposure and neurotoxicity

 Organic solvents and neurotoxicity

 Hypertension and noise



Specificity

(Is the effect from only one cause?)

 Showing that an outcome is best

predicted by one

factor adds

credibility to a

causal claim

 Ex. Silica and Silicosis



Temporal Relationship

(Does the cause precede the effect ?)

 The disease follows after exposure and with an appropriate time interval

 Ex. Person smoking for many years results to his being diagnosed with cancer



Dose-Effect Relationship

(Is increased exposure to the possible cause associated with increased effect?)

 The greater the level of exposure, the greater the prevalence of severity of

disease



Biological Plausibility

Is association consistent with other knowledge? (evidence from animal studies)

 An association is plausible/believable, and thus more likely to be causal, if

consistent with other knowledge

 Plausible

 Benzene and malignancies

 Asbestos and mesothelioma

 Anthrax and animal handlers

 Not plausible

 trauma and breast cancer



Coherence

Is association coherent/do not conflict with other knowledge?

 Clear association when it does not conflict with what is already known

 Smoking as cause of lung cancer is based on epidemiologic, laboratory

animal, pharmacokinetic, clinical and

other biological data. It shows that all

available facts stuck together as a coherent whole.



4. Validity of Testimony

 Non-professional persons cannot be

expected to collect and evaluate all of

the information needed.




 physicians will provide testimony on medical conditions and laboratory and

other medical tests

 industrial hygienists will testify concerning evidence of exposure




 epidemiologists give testimony on epidemiologic data  professionals must consider all pertinent points in their area of

expertise in order to present an

accurate and meaningful evaluation of

the available data




 The examiner, board, commissioner, or officer should verify:

 the professional qualifications of those testifying, and




 the basis of the testimony, that is, the importance attributed to various areas of

the information reviewed, and the

conclusions that were drawn.




 the basis of the testimony, that is, the importance attributed to various areas of

the information reviewed, and the

conclusions that were drawn.



5.

Other Relevant Factors

 special circumstances

 unusual events at work that reduced the effectiveness of protective equipment  if the employee is a woman, are there special risks to women from exposure to

the agent



6. Conclusion

 decision made would be based on evidences presented



6. Conclusion

1.

Has a disease condition been clearly established?

2.

Has it been shown that the disease can result from the suspected

agent(s)?

3.

Has exposure to the agent been

demonstrated? (by work history,

sampling data, expert opinion?)



6. Conclusion

4. Has exposure to the agent been shown to be of sufficient degree

and/or duration to result in the disease condition? (by scientific

literature, epidemiologic studies,

special sampling, replication of work

conditions?)



6. Conclusion

5. Has non-occupational exposure to the agent been ruled out as a

causative factor?



6. Conclusion

6. Have all special circumstances been weighed? Were there any -unusual

events at work that reduced the effectiveness of protective

equipment? Of ventilation? Of safe

work practices? If the employee is a

woman, are there special risks to

women from exposure to the agent? If so, this factor must be evaluated.



6. Conclusion

7. Has the burden of proof been met - did the evidence prove that the

disease resulted from, precipitated by,

or was not aggravated by, conditions

at work?



Summary of Determining Work- Relatedness of Disease

 Determination of accurate diagnosis  Occupational history/ Description of working conditions



Summary of Determining Work- Relatedness of Disease

 Literature review of materials/ substances used in work processes  Information on dose-response relationship



Remember!!!!

 Evaluation of diseases for work- relatedness must be based on sound

and logical medical and epidemiologic

evidences

 The likelihood that an illness/ disorder is from occupation depends on the

strength of supporting evidences



Remember!!!!

 The concept of disease aggravation from work exposure should be

considered in the medical assessment for work-relatedness



THANK YOU!



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Popular en Causality

1.	Cause-effect relationship between
	disease and an agent or conditions in
	the workplace may not be clear
2.	Occupational disease may be slow to

5.	not all individuals react in the same way to similar exposures to disease-
5.	producing agents
6.	off-the-job exposures may contribute

1.	consideration of evidence of disease,
2.	consideration of epidemiologic data,
3.	consideration of evidence of

4.	consideration of validity of testimony,
5.	consideration of other relevant factors, and
6.	evaluation and conclusion.

1.	Change in the symptoms during the work
1.	day
2.	Change in symptoms over the work week
3.	Change in symptoms on weekends and on
3.	vacation
4.	Onset of symptoms away from work
5.	Other work-related experiences

1.	STRENGTH	What is the strength of association between the cause and
		effect?
2.	CONSISTENCY	Have similar results been shown in other studies ?
3.	SPECIFICITY	Is the effect only from one cause?
4.	TEMPORAL	Does the cause precede the effect ?
4.	RELATION	Does the cause precede the effect ?
5.	DOSE-RESPONSE	Is increased exposure to the possible cause associated with
		increased effect ?
6.	PLAUSIBILITY	Is association consistent with other knowledge? (evidence from
		animal studies)
7.	COHERENCE	Is association coherent (do not conflict) with other knowledge?

1.	Has a disease condition been clearly established?
2.	Has it been shown that the disease can result from the suspected
2.	agent(s)?
3.	Has exposure to the agent been