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Burden, Need and Impact

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NIOSH strives to maximize its impact in occupational safety and health. The Immune, Infectious, and Dermal Disease Program identifies priorities to guide investments, and base those priorities on the evidence of burden, need and impact. Below are the priority areas for the Immune, Infectious, and Dermal Disease Program.

Immune Diseases

Burden

Millions of people suffer from allergic conditions characterized by exaggerated immune responses. Work related asthma comprises 15-23% of new onset asthma cases in adults.1,2  It can cause recurrent attacks of symptoms such as wheezing, chest tightness, shortness of breath, and coughing. An estimated 11 million American workers are potentially exposed to materials that can produce occupational asthma. There are over 200 documented agents which have been associated with the development of occupational asthma including: dusts, plant and animal proteins, latex, low molecular weight reactive chemicals, pharmaceuticals and non-sensitizing respiratory tract irritants.3 Workers in most occupational sectors have potential for exposure to some of these agents.

Need

Research is needed to develop, implement, and evaluate thoughtful interventions that increase adherence to safe handling of chemical and biologics and reduce worker exposure. In the healthcare setting, employer and healthcare worker adherence to safe handling guidelines is an ongoing challenge for many other hazardous drugs and chemicals. In many sectors, workers are in need of targeted prevention information to limit their exposures to chemicals such as cleaning agents or disinfection products. Many of these hazards are known but interventions have not been applied to these populations.

Impact

To prevent illness, workers need to be aware not only of the hazards associated with the chemicals in their environment but also the best ways to protect them from exposure and disease. Understanding the mechanisms of occupational diseases will allow for proper treatment and/or prevention. The identification of factors that can influence occupational exposure to chemicals will help to determine the most appropriate ways to prevent or minimize exposure. Ultimately hazard identification will lead to risk assessment which will ensure safe working environments. Guidance documents and other outreach to stakeholders could reduce risk for immunological diseases.

1 Dotson GS, Maier A, Siegel PD, Anderson SE, Green BJ, Stefaniak AB, Codispoti CD, Kimber I.(2015) Setting occupational exposure limits for chemical allergens—Understanding the challenges. J Occup Environ Hyg 12(sup1):S82-98.

2 Pralong JA, Cartier A, Vandenplas O, Labrecque M [2012]. Occupational asthma: new low-molecular-weight causal agents, 2000-2010 J Allergy 2012:597306.

3 Mapp CE [2001]. Agents, old and new, causing occupational asthma. Occup Environ Med 58(5):354-354.

Infectious Diseases

Burden

Another focus area of the IID program is to reduce the incidence and transmission infectious disease in the workplace. Infectious agents vary in their routes of transmission and can occur via contact with the skin, mucous membranes such as the eyes and nose, or inhalation. Not wearing appropriate personal protective equipment (PPE) such as respiratory protection, eye/face protection, gloves, and gowns can increase the risk of exposures. Infectious agents in the workplace include influenza, tuberculosis, human immunodeficiency virus (HIV), Hepatitis B and C, influenza, and methicillin-resistant Staphylococcus aureus (MRSA), and potential emerging or epidemic threats such as, but not limited to, Ebola. The burden of infectious disease exists across many occupational sectors, especially health care and social assistance, public safety, and agriculture.

Public safety and health care and social assistance workers are commonly exposed to airborne or blood borne infectious agents. In the U.S., the annual direct costs of influenza are estimated at $4.6 billion and up to 111 million workdays are lost because of influenza resulting in an estimated $7 billion/year in sick days and lost productivity.1 Additionally, agriculture workers are potentially exposed to zoonotic diseases along with vector borne infectious diseases.

Need

Research on surveillance, transmission, risk assessment, infectious disease networks, prevention, and control measures for U.S. workers is lacking and should be addressed. To reduce infectious disease transmission, basic research also needs to be conducted to better define the exposure pathways to airborne and vector-borne diseases among workers. In addition to Ebola, the potential threat of new and emerging infectious diseases are a concern including Middle Eastern Respiratory Syndrome (MERS), pandemic influenza, and multidrug-resistant pathogens. While in many cases, interventions exist to prevention transmission, much remains unknown regarding these emerging infectious diseases, particularly in the workplace.

Impact

Addressing infectious disease threats will require a multifaceted approach driven by evidence-based practices, thoughtful occupational health research and comprehensive surveillance. In addition to increasing worker health and safety, these efforts can also reduce costs. For example, vaccinating employees for influenza and reducing influenza-related absenteeism can save U.S. employers $2.58 for every dollar invested in a vaccination program.2

1Molinari NA, Ortega-Sanchez IR, Messonnier ML, Thompson WW, Wortley PM, Weintraub E, Bridges CB [2007]. The annual impact of seasonal influenza in the US: measuring disease burden and costs. Vaccine 25(27):5086–5096.

2Campbell DS, Rumley MH [1997]. Cost-effectiveness of the influenza vaccine in a healthy, working-age population. J Occup Environ Med 39(5):408–414.

3Klumb C, Saunders S, Smith K. [2013] E. coli 0157:H7 surveillance in agricultural populations in Minnesota. J Agromed 19(2): 221, http://www.tandfonline.com/doi/full/10.1080/1059924X.2014.890555?scroll=top&needAccess=true

Dermal Diseases

Burden

The advancement of knowledge of occupational skin hazards and diseases in the workplace through field and laboratory research is a third focus of the IID program. CDC estimates that more than 13 million workers in the United States, spanning a variety of occupational industries and sectors, are potentially exposed to chemicals that can be absorbed through the skin. Approximately 82,000 chemicals are in industrial use with an estimated additional 700 new chemicals introduced annually, resulting in a high potential for dermal exposure to chemicals.1 Occupational skin exposures can result in numerous diseases which can adversely affect an individual’s health and capacity to perform at work. Associated costs are estimated to exceed $1 billion annually in the United States alone.2,3 In 2012, skin diseases alone accounted for 34,400 cases at a rate of 3.4 per 10,000 employees as reported by the Bureau of Labor Statistics, exceeding occupational respiratory illnesses (19,300 cases with a rate of 1.9 per 10,000 employees).4 Hundreds of chemicals present in virtually every industry (metals, epoxy and acrylic resins, rubber additives, chemical intermediates) have been identified to cause skin disorders

In additional to immune mediated and skin disorders, there is also the potential for systemic effects following dermal chemical exposure. This is a concern for industries including agriculture and oil and gas extraction.  Agricultural workers are exposed to pesticides during mixing, loading and application tasks and during reentry following application. Skin is the primary route of pesticide exposure, contributing between 81 to 97% of total systemic uptake from these operations.5 Acute pesticide exposure illnesses have been reported and can include abdominal pain, dizziness, headaches, nausea, vomiting as well as skin and eye complications. Death is rare but still a known outcome. Oil and gas extraction workers also encounter hazardous exposures including drilling fluids (i.e. muds), minerals, and formulation amendments used during drilling activities. While these is the potential for dermal exposures to these agents, investigations of the related health effects are lacking.

Need

To minimize the hazards of dermal occupational exposures, research is needed to understand the mechanisms driving the diseases related to exposure. Improved surveillance; exposure monitoring to identify, evaluate and prevent occupational chemical exposure; and proper implementation of protective measures are essential to ensure worker safety and health.

Data is also needed to improve dermal risk assessments of occupational chemical exposures. Basic research needs to be conducted to measure the dermal uptake rates of chemicals in concentrated and in-use commercial formulations at exposure levels that are typical of applications used in industries including agriculture and oil and gas extraction. Quantitative exposure assessments among workers will provide this additional data. Systemic absorption represents a broadly recognized but difficult to quantify burden. Well-reasoned assessments of exposure and risk following skin exposure are essential. Current assumptions and rationales underling the decision-making process may lead to conclusions that do not provide adequate protection to workers exposed to toxic chemicals through skin. Additionally research that addresses the accuracy of current risk assessment strategies for skin exposures is needed.

Impact

Workers should be aware not only of the hazards associated with the chemicals in their environment but also the best ways to protect them from exposure and disease. Understanding the mechanisms of occupational diseases will allow for proper treatment and/or prevention. The identification of factors that can influence occupational exposure to chemicals will help to determine the most appropriate ways to prevent or minimize exposure. Ultimately hazard identification will lead to risk assessment which will ensure safe working environments. Guidance documents and other outreach with stakeholder involvement could reduce risk factors for dermal diseases.

1GAO [2005]. Report to Congressional Requesters: chemical regulation options exist to improve EPA’s ability to assess health risks and manage its chemical review program. Washington, DC: U.S. Government Accountability Office, GAO-05-458, http://www.gao.gov/products/GAO-05-458

2Cashman MW, Reutemann PA, Ehrilich A [2012]. Contact dermatitis in the United States: epidemiology, economic impact, and workplace prevention. Dermatol Clin 30(1):87-98.

3Mancini AJ, Kaulback K, Chamlin SL [2008]. The socioeconomic impact of atopic dermatitis in the United States: a systematic review. Pediatr Dermatol 25(1):1-6.

4BLS [2012]. Updated BLS Occupational Injury and Illness Classification System. Monthly Labor Review. Washington, DC: U.S. Department of Labor, Bureau of Labor Statistics, https://www.bls.gov/opub/mlr/2012/08/art3full.pdf

5EFSA (European Food Safety Authority) [2013]. 2,4-D renewal assessment report-volume 3, annex B.6: toxicology and metabolism. Parma, Italy: European Food Safety Authority, http://dar.efsa.europa.eu/dar-web/provision

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