Estimating population burdens of occupational disease
Sheila Pantry OBE
Knowing the public health impact of occupational hazards is important for prioritisation of preventive and mitigating measures and in monitoring how well they succeed. Information is needed on attributable morbidity and mortality, both globally and by national/regional jurisdiction. The best method of estimating population burdens will vary according to the nature of the hazard.
One important consideration is whether health effects can be ascribed to work with confidence in the individual. Such attribution is straightforward where a disease occurs only as a consequence of occupational exposure (e.g. coal workers’ pneumoconiosis, byssinosis). Alternatively, a link to occupation can sometimes be established through clinical investigation. For example, allergic contact dermatitis may confidently be attributed to work where it is associated with demonstrable sensitization to an agent encountered only in the workplace; and the role of work in an acute injury or poisoning may be clear from its circumstances and timing. Even where a disorder is not occupational in origin, it may be made worse by exposures in the workplace to an extent that can be determined in the individual case. For example, exacerbation of pre-existing asthma by occupational inhalation of irritants may be apparent from serial measurements of lung function when an employee is at, and away from, work.
In such circumstances, public health burden can be estimated by aggregating data on individual cases, either across the population as a whole, or in a representative subsample. Possible sources of information include routine surveillance schemes such as the Health and Occupation Research (THOR) Network, data on claims for industrial injuries compensation (provided they are sufficiently accurate and complete), and ad hoc surveys in representative samples of the population. Where a disease has material fatality (e.g. silicosis), counts of deaths may provide a good measure of attributable mortality.
More commonly, occupational disorders are not specific to work, and there is no reliable way of determining occupational contribution in the individual case. The hazard may increase the probability and/or the average severity of a disease. For example, asbestos makes development of lung cancer more likely, while coal mine dust causes chronic obstructive pulmonary disease (COPD) through incremental loss of lung function. Either way, the need is to determine how much morbidity or mortality would be eliminated across the population, if the relevant occupational exposure were removed. To this end, epidemiological data comparing health outcomes in people according to their exposure must be combined with information on the prevalence and distribution of exposure in the population for which an estimate is sought. This is the approach underpinning the WHO/ILO analysis that is reported in Pega et al’s paper. Estimates of relative risk for paired combinations of occupational risk factor and disease were collated with data on the population prevalence of exposure to calculate population attributable fractions (PAF), which then were multiplied by estimates of the total population impact of the disease (in terms of deaths and disability-adjusted life-years) to derive burdens attributable to occupation.
The analysis was necessarily restricted to combinations of risk factor and disease for which there was judged to be adequate evidence, but it also has other important limitations, not all of which are acknowledged and discussed. Some of the assumed hazards are questionable. For example, occupational exposure to formaldehyde is estimated to account for some 350–400 deaths per year from leukemia.
Full paper: “Estimating population burdens of occupational disease” by D. Coggon, Scandinavian Journal of Work Environmental Health, 2022, 48(2): 83-85. https://doi.org/10.5271/sjweh.4007
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