Philippine National Program on Elimination of Asbestos-related Diseases : A Framework for Medical Surveillance

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1 Asian Asbestos Initiative 5 th International Seminar Philippine National Program on Elimination of Asbestos-related Diseases : A Framework for Medical Surveillance Dina V. Diaz, M.D., MOH,FPCP, FPCCP, FCCP Lung Center of the Philippines

2 Topics Introduction Definitions Rationale Surveillance Program Objectives Main purpose Components Evaluation Benefits and Challenges The Future of Asbestos

3 Methods for Identifying Occupational Diseases and Hazards Environmental assessment Biological monitoring Medical surveillance Epidemiological approach

4 Surveillance Continuous analysis, interpretation, and feedback of systematically collected data, generally using methods distinguished by their practicality, uniformity, and rapidity, rather than by accuracy or completeness. By observing trends in time, place, and persons, changes can be observed or anticipated and appropriate action, including investigative or control measures, can be taken. Eylenbosch WJ, Surveillance in health and disease, 1988

5 Surveillance in Occupational Health The continuous analysis, interpretation, and feedback of data regarding the workplace and workers health. involves the periodic collection, analysis and reporting of information relevant to health for the purposes of disease prevention. Halperin, W, The role of surveillance in prevention, Am J Ind Med, 1996;29:

6 Exposure and Health Exposure surveillance or hazard surveillance: Focuses on exposure; allows prevention activities to be implemented before illness occurs Health surveillance or medical surveillance (health effects, health events, health outcomes) Focuses on health ; illness, injury, disability, death, quality of work life or satisfaction with occupational health care services Maizlish, NA, Workplace health surveillance, 2000

7 Philippine National Program on the Elimination of Asbestos-related Diseases (NPEAD) Activities 1. Development of the institutional framework for the Program 2. Development of a National Asbestos Profile 3. Review/development of relevant legislation, regulations, guidelines 4. Medical surveillance

8 Rationale for Medical Surveillance for Asbestos-related Diseases (ARDs) Adverse health effects of asbestos are well recognized. Currently 125 M people are exposed to asbestos at the workplace Global estimates : 90,000 people die each year from ARDs WHO, Elimination of Asbestos-related diseases, 2006

9 LCP Asbestos Screening Program, Results Total no. screened 1,542 Mean Age (Range) in years (43 to 84) Positive smoking history (current) % (48.89%) Mean duration of employment (Range) in years (21 to 30) Completed tests / total no. screened 796/1,542 (+) Chest x-ray or HRCT scan / Evaluable cases Pulmonary function test pattern: Restrictive Combined restrictive and obstructive Reduced DL CO 302 /587 (51.44%) 143/ 587 (24.36%) 321/587 (54.68%) 363/587 (61.84%) Diaz, D. Asbestos-related diseases in the Philippines: The Lung Center of the Philippines Asbestos Screening Program, Acta Medica Philippina, 2009, 43 (3): 64-69

10 Year Lung Center of the Philippines Malignant Mesothelioma Discharge Diagnoses : CY 2000 to 2012 Demographics Smoking History Asbestos exposure 2000 O.M., 65 yr old Male driver No ± 2004 E.B., 67 yr old Male seaman Yes P.D., 74 yr old Male electrician Yes M. V., 56 yr old Female ex-cannery worker No E.P., 71 yr old Male pipefitter (Subic) Yes G.L., 49 yr old Male auto denter Yes D.S., 52 yr old Male warehouse worker Yes ± 2009 G.V., 54 yr old Male gov. employee -mining Yes G.V., 53 yr old Male police investigator Yes ± 2010 R.P. 55 yr old Male NA Yes ± 2012 A.R, 62 yr old Male gas pump technician Yes LCP Medical Records ± LCP Medical Records

11 Rationale for Medical Surveillance for Asbestos-related Diseases (ARDs) Continued use in developing countries, like the Philippines, is made more alarming because of : Limitations in regulatory conditions Absence of optimal surveillance Lack of access to compensation for those affected

12 Steps in Planning and Implementing a Surveillance Program 1. Define the goals and scope 2. Gain management support and that of all participants 3. Assemble a multidisciplinary team 4. Make case definitions, reporting guidelines, and define the minimum data set 5. Make an inventory of information and analyze the flow of information 6. Establish mechanisms for case reporting and its promotion Maizlish, NA, Workplace health surveillance, 2000

13 Steps in Planning and Implementing a Surveillance Program 7. Select, recruit, and train reporters 8. Establish protocols to prioritize cases for follow-up 9. Activate case reporting, collect and code data into a database, follow-up, and manage individual cases 10. Analyze and interpret data, identify groups at high risk, possible interventions, cost-benefit, and prepare standardized reports 11. Provide feedback to participants and disseminate the results 12. Evaluate the surveillance system Maizlish, NA, Workplace health surveillance, 2000

14 NPEAD Surveillance Program Objectives To identify workplaces where preventive activity might be useful To develop better estimates of the incidence of Asbestos-related diseases

15 NPEAD Medical Surveillance Main Purpose To collect information for the following purposes: 1) Baseline evaluations 2) Respiratory Health status evaluations 3) Epidemiological : develop estimates of incidence of ARDs 4) As an indicator of the adequacy of asbestos dust control : identify workplaces where preventive measures are needed

16 Proposed Program Schedule Finalization and formal approval of the Program Organization of a Surveillance Team to implement Program Identification of Target Population who will undergo Surveillance and other data sources of information Preparation of materials, equipment prior to implementation and orientation/training of Program participants/reporters Networking activities for workplace monitoring Actual Implementation : Conduct of examinations Data collection, encoding, analysis, reporting Feedback/Communication to workers and appropriate recommendations to employers

17 The NPEAD Surveillance Team 1) Overall Team Leader : Occupational health care professional as overall Program coordinator 2) Epidemiologist or Data analyst : to oversee data collection, analysis, reporting 3) Information systems technician 4) Office support staff 5) Multi-sectoral Consultant/Advisory Committee

18 NPEAD Program Components 1. Industry-based Surveillance A. Conduct of Medical surveillance on asbestosexposed workers B. Periodic Workplace environment monitoring 2. Sentinel health care provider-based surveillance Recruited into the surveillance network to report cases to the Surveillance Team

19 Program Components A. Industry-based surveillance Target population : At-risk workers (exposed or potentially exposed to asbestos) Data sources : Results of medical surveillance examinations Employer reports of workers illness Requires cooperation of the Company's upper management, health and safety committee members, plant supervisor, worker representatives, plant engineer in addition to consent from the target workers

20 Industries with Exposure to Asbestos 169 companies engaged in the importation, manufacture, distribution and use of asbestos and ACMs (as of 2007 and 2008) Firefighting gears Asbestos fiber, yarn Fabric Gasket sheet Packing paper Protective clothing Gloves Thread needle, needle kit Window and exhaust filter, table cloth, pillowcase Friction pad Cable accessories Brake linings Cement roofing and cement flat sheets

21 Industry-based Surveillance Medical Surveillance Examinations I. Preplacement Evaluation : Aims to develop baseline information on an individual s pulmonary status for use in assessing future pulmonary changes To be performed within 30 days of initial assignment to a work place in which asbestos/asbestoscontaining product is used

22 Industry-based Surveillance Medical Surveillance Examinations I. Preplacement Examinations: a) A comprehensive medical history emphasizing respiratory symptoms and conditions b) Physical examination emphasizing thoracic findings. c) Chest x-ray : PA, oblique views; films to be interpreted by a B reader d) Spirometry: with forced vital capacity (FVC) and forced expiratory volume at one second (FEV1) entered into the record.

23 Industry-based Surveillance Medical Surveillance Examinations II. Periodic Evaluation : For early detection of ARDs To identify jobs and operations that pose a hazard and require further control

24 Industry-based Surveillance Medical Surveillance Examinations II. Periodic Examinations : For workers < 40 years of age and who have a duration of potential exposure to asbestos of < 10 years: a) Annual: History (Questionnaire), physical exam b) Chest x-ray, PA view only every 3 years with notation of changes occurring over the threeyear interval c) Annual spirometry: With comparison of FVC and FEV 1 with the results of the previous tests

25 Industry-based Surveillance Medical Surveillance Examinations II. Periodic Examinations : For workers > 40 years old OR any employee of any age who has been exposed to asbestos for > 10 years. a) Annual: Questionnaire, physical exam b) Chest x-ray to include the following views at the frequency specified: PA only annually, and obliques every 3 years. c) Annual spirometry: Note changes in results from the previous year and establish trends in the decline of lung function with adjustment for the age of the employee

26 Industry-based Surveillance Medical Surveillance Examinations III. Termination Examinations : Performed within 30 days of termination of employment or exposure if a periodic examination has not been performed within the preceding year. Examinations are the same as those for preplacement: a) A comprehensive medical history emphasizing respiratory symptoms and conditions. b) Physical examination emphasizing thoracic findings c) Chest x-ray: PA, oblique views d) Spirometry

27 Industry-based Surveillance Medical Examinations : Abnormal Tests An abnormal chest x-ray: Bilateral parenchymal irregular opacities with profusion IL0 l/0 or higher; Pleural plaques or thickening; Presence of findings suspicious for bronchial cancer or mesothelioma An abnormal lung function parameter: Values below the lower limit of the 95% CI for worker s age, height, gender, or a drop in 15% from baseline spirometry data

28 Case Definition Asbestosis without pleural disease: A reported history of exposure to asbestos, or job title with a reasonable likelihood of asbestos exposure PLUS A B-reading of standard PA chest film demonstrating bilateral irregular parenchymal opacities (shape and size: s,t,u) with profusion score of 1/0 or greater Absence of a B-reader notation of findings of unilateral or bilateral pleural thickening consistent with asbestos-related pleural disease Lung function test results showing restrictive or combined restrictive and obstructive defect not likely attributable to another agent known to cause asbestos-related disease

29 Case Definition Asbestosis with pleural disease: A reported history of exposure to asbestos, or job title with a reasonable likelihood of asbestos exposure PLUS A B-reading of standard PA chest film demonstrating bilateral irregular parenchymal opacities (shape and size: s,t,u) with profusion score of 1/0 or greater A B-reader notation of findings of unilateral or bilateral pleural thickening consistent with asbestos-related pleural disease Presence or absence of lung function test results showing restrictive or combined restrictive and obstructive defect not likely attributable to another agent known to cause asbestosrelated disease

30 Case Definition Asbestos-related pleural disease: A reported history of exposure to asbestos, or job title with a reasonable likelihood of asbestos exposure PLUS A B-reader notation of findings of unilateral or bilateral pleural thickening consistent with asbestos-related pleural disease Absence of a B-reading of standard PA chest film demonstrating bilateral irregular parenchymal opacities (shape and size: s,t,u) with profusion score of 1/0 or greater

31 Case Definition Asbestos-related malignancy: A reported history of exposure to asbestos, or job title with a reasonable likelihood of asbestos exposure PLUS Presence or absence of a B-reading of standard PA chest film demonstrating bilateral irregular opacities (shape and size: s,t,u) with profusion score of 1/0 or greater or findings of unilateral or bilateral pleural thickening consistent with asbestos-related pleural disease Additional radiographic findings consistent with lung cancer or mesothelioma A histopathologic diagnosis of lung cancer or malignant mesothelioma

32 Industry-based Surveillance Flow for Medical Surveillance Identification of Industry/Company with asbestos-containing materials or with processes with asbestos exposure Secure a list of At-risk workers (with occup asbestos exposure) Coordinate with company to schedule At-risk workers for Medical Surveillance Conduct of Medical Surveillance: Baseline Screening- Questionnaire, Physical exam, Chest x-ray, Lung function tests Recording of Results Reporting of Results to worker and Recommendations to employer

33 Industry-based Surveillance Workplace Environment Monitoring For selected industries with asbestos-exposed workers so that appropriate controls can be put in place and to prevent ARDs. To be conducted as frequently as necessary to determine the adequacy of control measures, and monitor their continued effectiveness. Basic steps are: Determine frequency, type and what activity or area to sample Sample and record the process Engage a qualified laboratory for sample analysis Interpret standards and sample results Communicate sampling results Establish dust controls when sampling indicates the need

34 Industry-based Surveillance Flow for Workplace Environment Monitoring Identification of Industry/Company with asbestos exposure to workers Coordinate with company to Identify procedures/areas with asbestos exposure Conduct of Workplace Environment Monitoring Recording of Results Reporting to Employer and worker Periodic Monitoring and Publication of Results

35 Program Components B. Sentinel Health Care Provider-based Surveillance Target population : Current or former asbestos-exposed workers with or without signs/symptoms of ARDs or with a clinical diagnosis of ARDs Data sources : Physician s Clinic records Occupational physician s employees records Hospital discharge data Requires cooperation of : Physicians on the regional level (in regional and provincial hospitals) representing the government/public sector All occupational health physicians in pertinent industries, pulmonary specialists/oncologists (identified through medical specialty societies) representing the private sector Target hospital records sections

36 Sentinel Health Care Provider-based Surveillance Reporting of ARDs should (ideally) be declared mandatory A standard Surveillance reporting form will be utilized Selection, recruitment, orientation and training of reporters in completion of forms and reporting procedures Periodic follow-up and collection of reporting forms by the Surveillance team Promotion of reporting by reminders, incentives for the sentinel health care provider

37 Flow for Sentinel Health care Provider Reporting RECOGNITION Sentinel HC Provider REPORTING ANALYSIS SURVEILLANCE CENTER* ACTION Individual worker Work site Coworkers *SURVEILLANCE CENTER : Screens, analyzes case reports, set priorities, and coordinates follow-up to include additional data gathering, case-finding among co-workers, medical examinations, worksite investigations or industry-wide prevention activities. Maizlish, NA, Workplace health surveillance, 2000

38 NPEAD : Program Evaluation Periodic evaluation to assess the impact and functioning of the Asbestos Medical Surveillance Program and institute necessary modifications to improve the system This will answer the following questions: Effective in identifying problem worksites? Recommendations made on improving working conditions in these workplaces? Hospital reporting of cases complete? Reporting of nonhospitalized cases complete? Database on incidence of ARDs?

39 Projected Benefits of the NPEAD 1. Early recognition of those affected and appropriate medical monitoring for those individuals with asbestos-related disease Providing advice on important modifications of current exposure conditions, lifestyle factors and smoking cessation, when appropriate Referral for non-medical (compensation and disability) services for individuals with asbestosrelated disease

40 Projected Benefits of the NPEAD 2. Identification of opportunities for workplace intervention to prevent further exposure where the potential for ongoing exposure exists 3. Identification of additional groups of workers at risk for asbestos-related diseases 4. Surveillance data on incidence and trends of asbestos-related diseases in the Philippines

41 Challenges in Medical Surveillance for ARDs 1) Low level of recognition of ARDs : Inadequate education and training of clinical practitioners in occupational health Long latency period makes it more difficult to link illness to work

42 Challenges in Medical Surveillance for ARDs 2) Under-reporting of cases is often the norm. Health care professionals have no time, lack motivation, have no adequate knowledge of reporting procedures Company MDs may be biased in favor of the employer Problems from the employer and employee Poor record-keeping of data sources 3) Barriers related to technical / organizational skills, logistics, manpower resources needed in conducting surveillance

43 The Future of Asbestos in the Philippines A gradual phase-out of asbestos use in country The Phil. National Surveillance Program for Asbestosrelated Diseases (PNPEAD) should help improve recognition and management and may address gaps in prevalence data, reporting and surveillance. Formulation and enactment of additional legislative measures and their strict implementation to help minimize current and future exposures, both occupational and environmental.

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