Immune, Infectious and Dermal Disease Prevention Program
Burden, Need and Impact
NIOSH strives to maximize its impact in occupational safety and health. The Immune, Infectious, and Dermal Disease Prevention (IID) 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 IID Program.
Occupational immune diseases are some of the most common illnesses that affect workers in the United States. One aim of the Program is to identify and characterize substances that can cause immune dysfunction including inflammation, allergy, suppression, or autoimmune responses following exposure in the work environment. The burden of occupational allergic disease is widespread and serious. An estimated 11 million U.S. workers are potentially exposed to agents, which can manifest as allergic diseases such as occupational asthma and allergic contact dermatitis. Hundreds of chemicals (e.g., metals, epoxy and acrylic resins, rubber additives, and chemical intermediates) and proteins (e.g., natural rubber latex, plant proteins, mold, animal dander) present in virtually every industry cause allergic disease and the incidence in the workplace is increasing1. Significantly, occupational exposures are responsible for between 9 and 25% of all adult onset asthma cases2,3 , and allergic contact dermatitis represents 20% of all work-related skin disorders4. These diseases can negatively affect an individual’s health, as well as their ability to perform at work and earn a living.6
In addition to allergic disease, occupational exposures can lead to autoimmune disease. Autoimmune diseases are ones in which the body mistakenly attacks itself. Normally, the immune system recognizes and does not respond to its own cells and tissues. Genetics, environment, and life style may exert pressure on immune tolerance and can result in breakdown of this safeguard leading to the manifestation of autoimmune disease. The National Institutes of Health estimates that there are more than 23 million people with an autoimmune disease in the United States alone (approximately 8% of the total population), and the incidence is increasing7. Individually, each autoimmune disease may appear rare, however, collectively, autoimmunity represents a significant burden, especially in women. Increasing evidence indicates that occupational exposures contribute to development of autoimmune diseases5.
Research is needed to develop, implement, and evaluate thoughtful interventions to increase use of safe handling practices and reduce worker exposure. In many industry sectors, workers need information to help them 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.
To reduce immune related disease in the workplace, research is required in several areas:
- Increased workplace hazard evaluations – Field studies are needed to identify and classify new hazards. Rapid and sensitive methods for early identification of hazards is also needed, along with increased surveillance for autoimmune diseases in the workplace.
- Mechanisms of Allergic Disease – Occupational allergic diseases are the result of complicated immunologic events. Researchers currently have limited knowledge about how workers become sensitized, and therefore how to prevent it from happening.
- Risk Assessment and Management – Numerous approaches that integrate risk assessment and risk management strategies have been developed to control workplace exposures and prevent the induction of allergic response8-9. However, additional research is needed in this area.
- Development and improvement of animal models of autoimmune disease – Animal models that closely mimic human autoimmune disease will greatly improve our ability to understand the mechanisms for disease and develop diagnostic tools.
- Biomarkers of disease – Biomarkers are measurable indicators of disease. They are important for disease surveillance and provide opportunities for early diagnosis and intervention.
To prevent immune-related dysfunction and disease, 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 immune diseases will allow for proper treatment and 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 and risk assessment which will help to ensure safe working environments.
- Anderson SE, Meade BJ (2014). Potential health effects associated with dermal exposure to occupational chemicals. Environmental Health Insights 8(2014):51-62.
- Dotson GS, Maier A, Siegel PD, et al (2015). Setting occupational exposure limits for chemical allergens–understanding the challenges. Journal of Occupational And Environmental Hygiene 12 Suppl 1:S82-98.
- Pralong JA, Cartier A, Vandenplas O, Labrecque M (2012). Occupational asthma: new low-molecular-weight causal agents, 2000-2010. Journal Of Allergy 2012:597306.
- Sasseville D (2008). Occupational contact dermatitis. Allergy, Asthma, and Clinical Immunology: Official Journal of the Canadian Society of Allergy and Clinical Immunology 4:59-65.
- Johnson VJ, Germolec DR, Luebke RW, Luster MI (2018). Immunotoxicity Studies. In Comprehensive Toxicology, 3rd, McQueen CA Editor, Elsevier, Oxford, UK. Chapter 9.17, pp. 255-270.
- Basketter DA, Kruszewski FH, Mathieu S, et al (2015). Managing the risk of occupational allergy in the enzyme detergent industry. Journal Of Occupational And Environmental Hygiene 12:431-437.
- National Institutes of Health (2005). Progress in autoimmune disease research: Report to Congress. https://www.niaid.nih.gov/sites/default/files/adccfinal.pdfpdf iconexternal icon
- NIOSH (2009). Qualitative risk characterization and management of occupational hazards: Control banding. DHHS (NIOSH) Publication No. 2009–152. http://www.cdc.gov/niosh/docs/2009-152/pdfs/2009-152.pdfpdf icon.
- AIHA (2011). The Occupational Environment: Its evaluation, control, and management. Falls Church, VA: American Industrial Hygiene Association.
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 or mucous membranes such as the eyes and nose, or through inhalation. Not wearing appropriate personal protective equipment (PPE), such as respiratory protection, eye and face protection, gloves, and gowns can increase the risk of exposures. Influenza is a major concern, causing U.S. employees to miss approximately 17 million workdays, at an estimated $7 billion a year in sick days and lost productivity1. Additional diseases now recognized to have an occupational risk of transmission include Norovirus2, Methicillin resistant Staphylococcus aureus3-4, Helicobacter pylori5, and Legionella6, among others. Still other emerging infectious diseases, such as Ebola or Middle East Respiratory Syndrome (MERS), in addition to antibiotic resistant strains of common bacteria, may pose a risk of occupational transmission.
The burden of infectious disease exists across many occupational sectors, especially healthcare and social assistance, public safety, and agriculture. Individuals working in the healthcare sector are at an increased risk for exposure to influenza and other pathogens. Among eight different reports of influenza outbreaks in healthcare settings, the infection rate of staff members ranged from 8-63%7, with the additional economic burden of a single outbreak at a hospital estimated to cost $34,1798. In addition to healthcare, workers in the public safety sector (e.g. emergency medical service workers, firefighters, police, prison guards) are exposed to a variety of infectious diseases. Livestock workers, veterinarians, and others working with animals are also at risk for infectious disease3-4,9-10.
Research on surveillance, transmission, risk assessment, infectious disease networks, prevention, and control measures for U.S. workers is needed. To reduce infectious disease transmission, research also needs to be conducted to better define the exposure pathways 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. In many cases interventions exist to prevention transmission, yet much remains unknown regarding these emerging infectious diseases, particularly in the workplace.
To reduce the incidence and improve the understanding of infectious disease in the workplace, research is needed in the following areas:
- Assessment of Exposure Pathways – Depending on the specific pathogen and workplace environment, disease can spread through one or more routes, including direct contact with patients or animals, contaminated surfaces, or airborne bioaerosols. Methods are needed to assess the exposure pathways and their relative importance to improve our understanding of infection risks.
- Quantitative Models – Quantitative microbial risk assessment (QMRA) models have been widely used in the estimation of infectious risks from food and water11,12, but few exist for the occupational scenarios13.
- Surveillance – To minimize the work-related risks of influenza infections and transmission of other infectious diseases, research is needed on development of clinical and environmental surveillance methods to identify transmission patterns and effective prevention strategies in the occupational setting.
- Intervention and preparedness – Many interventions exist to prevent transmission of infectious diseases including vaccination programs, barrier protection, and droplet reduction, however few have been evaluated for use beyond healthcare settings.
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 will also help to reduce associated costs.
- NIOSH (2018). Influenza (flu) in the workplace. https://www.cdc.gov/niosh/topics/flu/activities.html
- Wu HM, Fornek M, Schwab KJ, Chapin AR, Gibson K, Schwab E, Spencer C, Henning K (2005). A norovirus outbreak at a long-term-care facility: the role of environmental surface contamination. Infection Control and Hospital Epidemiology 26(10):802-10.
- Sun J, Yang M, Sreevatsan S, Bender JB, Singer RS, Knutson TP, Marthaler DG, Davies PR (2017). Longitudinal study of Staphylococcus aureus colonization and infection in a cohort of swine veterinarians in the United States. BMC Infectious Disease 17(1):690. doi: 10.1186/s12879-017-2802-1.
- Nadimpalli M, Stewart JR, Pierce E, Pisanic N, Love DC, Hall D, Larsen J, Carroll KC, Tekle T, Perl TM, Heaney CD (2016). Livestock-associated, antibiotic-resistant staphylococcus aureus nasal carriage and recent skin and soft tissue infection among industrial hog operation workers. PLoS One 11(11):e0165713. doi: 10.1371/journal.pone.0165713.
- Kheyre H, Morais S, Ferro A, Costa AR, Norton P, Lunet N, Peleteiro B (2018). The occupational risk of Helicobacter pylori infection: a systematic review. International Archives of Occupational and Environmental Health;91(6):657-674. doi: 10.1007/s00420-018-1315-6.
- Principe L, Tomao P, Visca P (2017). Legionellosis in the occupational setting. Environmental Research 152:485-495. doi: 10.1016/j.envres.2016.09.018.
- Voirin N, Barret B, Metzger MH, Vanhems P (2009). Hospital-acquired influenza: a synthesis using the Outbreak Reports and Intervention Studies of Nosocomial Infection (ORION) statement. Journal of Hospital Infection 71(1):1-14. doi: 10.1016/j.jhin.2008.08.013.
- Sartor C, Zandotti C, Romain F, Jacomo V, Simon S, Atlan-Gepner C, Sambuc R, Vialettes B, Drancourt M (2002). Disruption of services in an internal medicine unit due to a nosocomial influenza outbreak. Infection Control and Hospital Epidemiology 23(10):615-9.
- Su CP, Stover DT, Buss BF, Carlson AV, Luckhaupt S (2017). E. Occupational Animal Exposure Among Persons with Campylobacteriosis and Cryptosporidiosis – Nebraska, 2005-2015. MMWR Morbidity and Mortality Weekly Report66(36):955-958. doi: 10.15585/mmwr.mm6636a4.
- Garland-Lewis G, Whittier C, Murray S, Trufan S, Rabinowitz PM (2017). Occupational risks and exposures among wildlife health professionals. Ecohealth 14(1):20-28. doi: 10.1007/s10393-017-1208-2.
- Brouwer AF, Masters NB, Eisenberg JNS (2018). Quantitative microbial risk assessment and infectious disease transmission modeling of waterborne enteric pathogens. Current Environmental Health Reports5(2):293-304. doi: 10.1007/s40572-018-0196-x.
- Membré JM, Boué G (2018). Quantitative microbiological risk assessment in food industry: Theory and practical application. Food Research International 106:1132-1139. doi: 10.1016/j.foodres.2017.11.025.
- Carducci A, Donzelli G, Cioni L, Verani M. (2016). Quantitative microbial risk assessment in occupational settings applied to the airborne human adenovirus infection. International Journal of Environmental Research and Public Health. 13(7). pii: E733. doi: 10.3390/ijerph13070733.
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. The skin is a portal for entry of toxic substances into the body, and therefore skin exposures may contribute to systemic toxicity. Systemic absorption represents a broadly recognized but difficult to quantify burden1. NIOSH 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 skin9. Approximately 82,000 chemicals are in industrial use with an estimated additional 700 new chemicals being introduced annually resulting in a high potential for skin exposures to chemicals 10. While hundreds of chemicals present in virtually every industry have been identified to cause direct and immune mediated effects such as contact dermatitis, less is known about the number and types of chemicals contributing to systemic effects.
Systemic effects resulting from skin exposure to chemicals have resulted in acute poisonings2, neurotoxicity3; lung, liver and kidney toxicity4; reproductive toxicity5; carcinogenicity6 and death7. Solvents and other chemicals may also enhance the penetration of other chemicals by disrupting the protective lipid layer of the skin8. Studies have suggested that exposure to complex mixtures, excessive hand washing, use of hand sanitizers, high frequency of wet work, and environmental or other factors may enhance penetration and stimulate other biological responses altering the outcomes of dermal chemical exposure 9. Therefore, it is critical to understand how skin exposures contribute to systemic toxicity.
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.
To improve our understanding of skin exposures and the corresponding potential for impact on occupational health, research is required in several areas:
- Quantification of chemical loading on the skin surface – Without an appropriate understanding of the loading of a chemical on the skin surface, an accurate characterization of dermal uptake or absorption is not possible. Information on transfer of chemicals to and from the skin surface is also needed, including, but not limited to, the transfer efficiencies from surfaces to skin, clothing to skin, personal protective equipment to skin, and skin-to-skin.
- Characterization of dermal absorption or permeation – To properly characterize the effects of skin exposures in the workplace, the amount of permeation into the body following skin exposure must be understood.
- Efficacy of workplace controls for dermal exposures – The hierarchy of controls should be applied in response to dermal chemical Further research is needed to understand the effectiveness of skin exposure controls in the workplace, as well as the identification of most effective controls.
- Efficiency of skin and surface decontamination methods – Better information is needed to characterize the effectiveness of skin and surface decontamination techniques used in the workplace to control and prevent skin exposures to workers and reduce the potential for systemic toxicity from skin absorption.
- Advancements in skin permeation measurements and modeling – The importance of measuring the skin permeation of chemicals under conditions relevant to workplace exposures has recently been emphasized. Because of the large number of chemicals used in the workplace, the skin permeation rates can only be measured for a small fraction. Therefore, mathematical modeling of skin permeation is an important tool to predict systemic absorption of workplace chemicals in contact with skin.
- Refinement of skin exposure and risk assessment strategies – To protect workers, accurate assessments of exposure and risk following skin exposure are essential. Current assumptions and rationales underling these assessments may lead to conclusions that do not provide enough protection to workers exposed to toxic chemicals through skin.
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 diseases resulting from skin exposure. Understanding the mechanisms of occupational dermal exposures and related diseases will allow for proper treatment and prevention. The identification of factors that can influence occupational exposure of chemicals through the skin will help to determine the most appropriate ways to prevent or minimize exposure. Ultimately, hazard identification and risk assessment will lead to implementation of control to ensure safe working environments. Guidance documents identifying exposure hazards and safe exposure limits along with stakeholder outreach and involvement could reduce risk factors for dermal diseases.
- Nylander-French LA (2003). Occupational Dermal Exposure Assessment. Patty’s Industrial Hygiene. 69.
- Sahmel J, Boeniger M, Knutsen J, ten Berge W, Fehrenbacher MC (2009). Dermal exposure modeling. In Mathematical Models for Estimating Occupational Exposure to Chemicals, CB Keil, CE Simmons, TR Anthony, eds. Fairfax, American Industrial Hygiene Association, pp 105-132.
- Frasch HF, Dotson GS, Bunge AL, Chen C-P, Cherrie JW, Kasting GB, Kissel JC, Sahmel J, Semple S, Wilkinson S. (2014). Analysis of finite dose dermal absorption data: implications for dermal exposure assessment. Journal of Exposure Science and Environmental Epidemiology 24:67-73.
- Cohen Hubal EA, Nishioka MG, Ivancic W, Morra M, and Egeghy PP (2008). Comparing surface residue transfer efficiencies to hands using polar and nonpolar fluorescent tracers. Environmental Science and Technology 42:934–939.
- du Plessis J, Stefaniak A, Eloff F, John S, Agner T, Chou T-C, Nixon R, Steiner M, Franken A, Kudla I and Holness L. (2013). International guidelines for the in vivo assessment of skin properties in non-clinical settings: Part 2. transepidermal water loss and skin hydration. Skin Research and Technology 19: 265–278.
- Schneider T, Vermeulen R, Brouwer DH, Cherrie JW, Kromhout H, Fogh CL (1999). Conceptual model for assessment of dermal exposure. Occupational and Environmental Medicine 56:765–773.
- Gorman Ng M, Semple S, Cherrie JW et al. (2012). The relationship between inadvertent ingestion and dermal exposure pathways: a new integrated conceptual model and a database of dermal and oral transfer efficiencies. Annals of Occupational Hygiene 56:1000–12.
- American Conference of Governmental Industrial Hygienists (1991). Threshold limit values and biological exposure indices for 1991–1992. ACGIH Cincinnati OH.
- Anderson SE, Meade BJ (2014). Potential health effects associated with dermal exposure to occupational chemicals. Environmental Health Insights 8(2014):51-62.
- GAO (2005) Report to Congressional Requesters: CHEMICAL REGULATION Options Exist to Improve EPA’s Ability to Assess Health Risks and Manage Its Chemical Review Program. GAO-05-458. In: (Office. USGA, ed).