Healthcare and Social Assistance

Participating core and specialty programs: Authoritative Recommendations, Engineering Controls, Emergency Preparedness and Response, Exposure Assessment, Health Hazard Evaluations, Personal Protective Technology, Surveillance, and Translation Research.

Employers, workers, professional organizations, medical educators, researchers, and policy-makers use NIOSH information to reduce work-related asthma among healthcare and social assistance workers.

NOTE: Goals in bold in the table below are priorities for extramural research.

  Health Outcome Research Focus Worker Population Research Type
A Work-related asthma Cleaning and disinfection agents, stress Healthcare workers Basic/etiologic

Intervention

B Work-related asthma Animal allergens (e.g., volatiles) Veterinary medicine/animal care workers Basic/etiologic

Intervention

C Work-related asthma Specialized exposures (i.e. Surgical smoke, aerosolized medication) Respiratory therapists, nurses, surgeons Intervention

Translation

D Work-related asthma Asthma-friendly workplaces All healthcare workers Intervention
E Work-related asthma Explore utilizing existing data sources to better understand exposures and asthma morbidity/mortality All healthcare workers Surveillance research

Activity Goal 5.4.1 (Basic/Etiologic Research): Conduct basic/etiologic research to better understand relationship between occupational exposures and work-related asthma among healthcare and veterinary medicine/animal care workers.

Activity Goal 5.4.2 (Intervention Research): Conduct studies to develop and assess the effectiveness of allergen and irritant exposure interventions to reduce work-related asthma among healthcare and veterinary medicine/animal care workers and foster asthma-friendly workplaces in healthcare.

Activity Goal 5.4.3 (Translation Research): Conduct translation research to understand barriers and aids to implementing effective engineering controls for surgical smoke to reduce work-related asthma in healthcare worksites.

Activity Goal 5.4.4 (Surveillance Research): Conduct surveillance research to explore utilizing existing data sources to better understand exposures and asthma morbidity/mortality among healthcare workers.

Burden

Work-related asthma encompasses occupational asthma (caused by work) and work-exacerbated asthma (existing asthma is made worse by work exposures). The healthcare and social assistance (HCSA) workforce in the U.S. is large with 19.4 million workers, and includes a disproportionate number with asthma at 10.7% [CDC 2016], for a total of about 2.1 million workers. Conservatively, about 15% of these have asthma caused by work [Torén and Blanc 2009], about 315,000 workers. In addition, about 21.5% have work-exacerbated asthma [Henneberger et al. 2011], about 452,000 workers. WRA occurs more frequently in HCSA workers as compared to other industries; the most common responsible work exposures reported in one study were cleaning products, latex, and poor air quality [Pechter et al. 2005].

Exposures in this industry that contribute to the risk of asthma include various chemicals, such as ammonia, bleaching agents, disinfectants, and certain aerosolized medications [CDC 2016]. The past 10 years have seen an increased emphasis on the contribution of cleaning and disinfecting to the onset and exacerbation of asthma. This topic was highlighted in a report published by the National Occupational Research Agenda (NORA) Cleaning and Disinfecting in Healthcare Working Group [Quinn et al. 2015]. Mixing of bleach with animal urine to create chlorine gas can be an issue in veterinary/animal care settings. In addition to these chemical exposures, high-molecular weight sensitizers such as animal allergens in veterinary settings and latex allergen are important exposures.

Need

There is a need for further studies of healthcare workers to identify which tasks, products, and constituent chemicals contribute to WRA in the healthcare industry, and to develop strategies for interventions that protect workers from asthma and patients from healthcare-acquired infections. While not as common as cleaning and disinfecting products, other specialized exposures such as surgical smoke and aerosolized medications provide risks for WRA, notably among respiratory therapists, nurses, and surgeons, and deserve more attention with respect to intervention and translational research.

Intervention research to develop asthma-friendly healthcare workplaces is needed to reduce asthma morbidity and impact on the quality of life of workers with asthma. Also, surveillance research is needed to investigate effective strategies for occupational health surveillance for secondary prevention of asthma in healthcare settings. In addition, population surveillance is needed that exploits existing sources of data to monitor exposures as well as asthma morbidity and mortality in healthcare.

A frequently overlooked aspect of the healthcare industry is the work done in veterinary medicine and animal care. Workers in these areas are exposed to a variety of animal allergens and chemicals associated with asthma onset and exacerbation, and both basic/etiologic research and intervention research are needed.

Employers, workers, professional organizations, medical educators, researchers, and policy-makers use NIOSH information to reduce interstitial and fibrotic lung disease among dental personnel.

NOTE: Goals in bold in the table below are priorities for extramural research.

  Health Outcome Research Focus Worker Population Research Type
A Interstitial/fibrotic lung disease Relationship between airborne occupational exposures and the risk for developing interstitial/fibrotic lung disease Dental personnel Basic/etiologic

Intervention

B Interstitial/fibrotic lung disease Identify interstitial/fibrotic disease risks and their magnitude Dental personnel Surveillance research

 

Activity Goal 5.12.1 (Basic/etiologic Research): Conduct basic/etiologic research to better understand the relationships between occupational exposures and risk for interstitial and fibrotic lung disease among dental personnel.

Activity Goal 5.12.2 (Intervention Research): Conduct studies to develop and assess the effectiveness of interventions to reduce the risk for interstitial and fibrotic lung disease among dental personnel.

Activity Goal 5.12.3 (Surveillance Research): Conduct surveillance research to develop new tools and methods to identify interstitial and fibrotic lung disease risks and understand the magnitude of those risks among dental personnel.

Burden

During 2016, approximately 674,000 dental personnel were estimated to be working in the United States, including over 122,000 dentists [BLS 2017]. Dental personnel are exposed to infectious agents, chemicals, heavy metals, airborne particulates, ionizing radiation, non-ionizing radiation, and other potential hazards [Leggat 2007]. Inhalational exposures experienced by dental personnel likely increase their risk for certain work-related respiratory diseases. Case reports of work-related lung diseases experienced by dental personnel have included silicosis, asbestosis, occupational asthma, and pulmonary granulomatosis [Chung et al. 2015; Kahraman et al. 2014; Jungmann et al. 2013; Sichletidis et al. 2009; De Vuyst et al. 2007; CDC 2004; Piirila at al. 2002; Selden et al. 1995; Reid et al. 1991; Loewen et al. 1988]. During 1996–September 2017, physicians at a tertiary care center specializing in treatment of idiopathic pulmonary fibrosis (IPF) identified 11 cases of IPF among dental personnel out of 899 patients undergoing treatment for IPF [CDC 2018; Nett et al. 2018]. Ten of the 11 identified cases occurred among dentists. The number of dentists identified in this patient population was 29-times higher than expected in the United States, as there is approximately one practicing dentist per 1,600 persons [Munson and Vujicic 2014]. An analysis of IPF mortality in the United States identified that 188 cases of IPF had occurred in 1999 among persons in the health services industry [Pinheiro et al. 2008]. A query of the National Occupational Respiratory Mortality System (NORMS) over four separate years (1999, 2003, 2004, and 2007) for the underlying or contributing cause of death as ‘other interstitial pulmonary diseases with fibrosis’, revealed 35 decedents categorized as having worked in the ‘office of dentists’ and 19 decedents categorized as having the occupation ‘dentist’, which results in proportionate mortality ratios (PMR) = 1.52 (95% confidence interval [CI] = 1.05–2.11) and PMR = 1.67 (95% CI = 1.01–2.61), respectively [CDC 2018].

Need

The burden estimates summarized above indicate that surveillance research is required to better define the burden of work-related interstitial and fibrotic lung diseases among all dental personnel. Likewise, additional research is needed currently to better understand the scope of inhalational exposures across a range of dental practice settings, including the activities and conditions that create those exposures. From this research, contributions these exposures have in the development of work-related interstitial and fibrotic lung diseases can be determined. Even in the absence of a complete understanding of these exposure-disease relationships, an improved characterization of inhalational exposures and how they are generated can help in identifying practical measures to control exposures across the broader hierarchy of available controls. Intervention studies, which might optimally take place in different workplace settings where exposures are occurring, can help to assess the effectiveness of such control measures. Both basic/etiologic research and intervention research will be critical in (1) improving our understanding of the relationship between inhalational exposures experienced by dental personnel and the risk for interstitial and fibrotic lung disease among dental personnel; and (2) informing evidence-based recommendations for appropriate controls, which might include a range of engineering and administrative controls, and the use of personal protective equipment.

 

BLS [2017]. May 2016 national occupational employment and wage estimates—United States. Washington, DC: U.S. Department of Labor, Bureau of Labor Statistics, https://www.bls.gov/oes/current/oes_nat.htm#29-0000

CDC [2018]. Dental personnel treated for idiopathic pulmonary fibrosis at a tertiary care center — Virginia, 2000–2015. MMWR Morb Mortal Wkly Rep 67(9):270-273.

CDC [2016]. Asthma among employed adults, by industry and occupation — 21 states, 2013. MMWR 65(47): 1325-1331.

CDC [2004]. Silicosis in dental laboratory technicians—five states, 1994–2000. MMWR Morb Mortal Wkly Rep 53:195-197.

Chung SJ, Koo GW, Park DW, Kwak HJ, Yhi JY, Moon JY, Kim SH, Sohn JW, Yoon HJ, Shin DH, Park SS, Pyo JY, Oh YH, Kim TH [2015]. Pulmonary foreign body granulomatosis in dental technician. Tuberc Respir Dis (Seoul) 78:445-449.

De Vuyst P, Vande Weyer R, De Coster A, Marchandise FX, Dumortier P, Ketelbant P, Jedwab J, Yernault JC [1986]. Dental technician’s pneumoconiosis. A report of two cases. Am Rev Respir Dis 133:316-320.

Henneberger P K, Redlich CA, Callahan DB, Harber P, Lemier̀e C, Martin J, Tarlo SM, Vandenplas O, Toreń K [2011]. An official American Thoracic Society statement: Work-exacerbated asthma. Am J Respir Crit Care Med 184(3): 368-378.

Jungmann H, Godbert B, Wissler MP, Regent D, Vignaud JM, Bavelele Z, Martinet Y [2013]. Diffuse pulmonary ossification in a patient exposed to silica. Eur Respir Rev 22:189-190.

Kahraman H, Koksal N, Cinkara M, Ozkan F, Sucakli MH, Ekerbicer H [2014]. Pneumoconiosis in dental technicians: HRCT and pulmonary function findings. Occup Med (Lond) 64:442-447.

Leggat PA, Kedjarune U, Smith DR. Occupational health problems in modern dentistry: a review [2007]. Ind Health 45:611-621.

Loewen GM, Weiner D, McMahan J [1988]. Pneumoconiosis in an elderly dentist. Chest 93:1312-1313.

Munson B, Vujicic M [2014]. Supply of dentists in the United States is likely to grow. Chicago, IL: American Dental Association, http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_1014_1.pdfpdf iconexternal icon

Nett RJ, Cummings KJ, Cannon B, Cox-Ganser J, Nathan SD [2018]. Dental personnel treated for idiopathic pulmonary fibrosis at a specialty clinic. Am J Respir Crit Care Med 197:A3541.

Pechter E, Davis LK, Tumpowsky C, Flattery J, Harrison R, Reinisch F, Reilly MJ, Rosenman KD, Schill DP, Valiante D, Filios M [2005]. Work-related asthma among health care workers: Surveillance data from California, Massachusetts, Michigan, and New Jersey, 1993-1997. Am J Ind Med 47(3): 265-275.

Piirilä P, Hodgson U, Estlander T, Keskinen H, Saalo A, Voutilainen R, Kanerva L [2002]. Occupational respiratory hypersensitivity in dental personnel. Int Arch Occup Environ Health 75:209-216.

Pinheiro GA, Antao VC, Wood JM, Wassell JT [2008]. Occupational risks for idiopathic pulmonary fibrosis mortality in the United States. Int J Occup Environ Health 14:117-123.

Quinn MM, Henneberger PK, Braun B, Delclos GL, Fagan K, Huang V, Knaack JL, Kusek L, Lee SJ, Le Moual N, Maher KA, McCrone SH, Mitchell AH, Pechter E, Rosenman K, Sehulster L, Stephens AC, Wilburn S, Zock JP [2015]. Cleaning and disinfecting environmental surfaces in health care: Toward an integrated framework for infection and occupational illness prevention. Am J Infect Control 43(5): 424-434.

Reid AS, Causton BE, Jones JS, Ellis IO [1991]. Malignant mesothelioma after exposure to asbestos in dental practice. Lancet 338:696.

Selden AI, Persson B, Bornberger-Dankvardt SI, Winstrom LE, Bodin LS [1995]. Exposure to cobalt chromium dust and lung disorders in dental technicians. Thorax 50:769-772.

Sichletidis L, Spyratos D, Chloros D, Michailidis K, Fourkiotou I [2009]. Pleural plaques in dentists from occupational asbestos exposure: a report of three cases. Am J Ind Med 52:926-930.

Torén K, Blanc PD [2009]. Asthma caused by occupational exposures is common – A systematic analysis of estimates of the population-attributable fraction. BMC Pulm Med 9:7.

Note: Goal 5.12 was added in November 2018.

Page last reviewed: April 24, 2018