The experience of SWORD in the United Kingdom San Sebastian, 26 June 2014, Dr Melanie Carder Centre for Occupational and Environmental Health The University of Manchester http://www.medicine.manchester.ac.uk/oeh (La experiencia SWORD del Reino Unido) 1
History and background Overview of cases Asthma Asbestos related diseases Other respiratory diagnoses Other THOR sources of respiratory data Data requests Discussion 2
History and background Surveillance of Work-Related and Occupational Respiratory Disease (SWORD) Founded by Professor J Corbett McDonald in 1989 Endorsed by the British Thoracic Society and Society of Occupational Medicine Voluntary participation of specialists in Respiratory Medicine (& initially Occupational Medicine) Physicians asked to report incident cases of workrelated and occupational respiratory disease Initially all participating specialists returned a postal card once a month Initially no set criteria / guidelines for reporting 3
SWORD as part of THOR The Health and Occupation Research (THOR) network Name of scheme Reporting specialists Date operational SWORD Surveillance of work-related and occupational respiratory disease EPIDERM Surveillance of work-related skin disease OPRA Occupational physicians reporting activity SIDAW - Surveillance of infectious diseases at work Consultant chest physicians 1989- Consultant dermatologists 1993- Occupational physicians 1996- Consultants in communicable diseases 1996- THORGP THOR in General Practice General practitioners 2005- OSSA Occupational surveillance scheme for audiological physicians MOSS Musculoskeletal occupational surveillance scheme SOSMI Surveillance of occupational stress and mental illness Consultant audiologists 1997-2006 Consultant rheumatologists 1999-2009 Consultant psychiatrists 1999-2009 4
THOR-GP The Health & Occupation Reporting network in General Practice General Practitioner EPIDERM Occupational Skin Surveillance Occupational Physician Clinical Specialist OPRA Occupational Physicians Reporting Activity SWORD Surveillance of Workrelated & Occupational Respiratory Disease
Aims and objectives of SWORD The overall aim of SWORD is to determine nationally representative and statistically robust estimates of the incidence of occupational and workrelated respiratory disease, including any change or trend in incidence over time. Other objectives include; Establishing links between the distribution of the above diseases and occupation (jobs), industry and exposures Helping identify new causes of disease Evaluating interventions Providing an information resource and network for the participating physicians 6
The physicians participating in SWORD ~450 chest physicians (voluntarily) participating (as of June 2014) Approximately 70% of UK chest physicians Average response rate (i.e. number of cards returned/number sent out) for 2013 = 63% 7
How to get good results Engagement with key bodies (British Thoracic Society, Society of Occupational Medicine, Health and Safety Executive) Participation in meetings/decision making Dissemination of material via newsletters etc Offers of partnership in data sharing, publication etc Engagement with the participating physicians Different and easy reporting options: post or web form or email attachment Communication before report is due and follow up if report is overdue Regular quarterly and annual reports and thank you letters to all participants Free CPD (Continuing Professional Development) certification for those who participate at our meetings Data enquiry service Encourage co-authoring of publications Engagement with the wider scientific community Presentations at meetings of Societies / professional bodies etc 8
SWORD reporting card - front Surveillance of Work-Related & Occupational Respiratory Disease A constituent scheme of The Health and Occupation Research network (THOR) SWORD Please record below the number of NEW cases first diagnosed by you during to be a disease or illness caused by work IT IS IMPORTANT THAT YOU DO NOT INCLUDE ANY CASE FIRST DIAGNOSED BEFORE OR SINCE THE MONTH IN QUESTION A Asthma due to F Non-malignant pleural disease sensitisation - A1 predominantly plaques - F1 Irritation (RADS) - A2 predominantly diffuse - F2 B Inhalation accidents asbestos related pleural effusion - F3 C Allergic alveolitis G Mesothelioma D Bronchitis/emphysema H Lung cancer - Partly or wholly work-related E Infectious disease e.g.ornithosis, Q fever, I Pneumoconiosis TB, legionella J Other - e.g. rhinitis, byssinosis etc. 1 2 I have nothing to report Reason (optional) Initials Date Please give the diagnosis and other brief details for each reported case overleaf THOR, Centre for Occupational & Environmental Health, The University of Manchester, Block C, 4th Floor, Ellen Wilkinson Building, Oxford Road, Manchester, M13 9PL. Tel: 0161 275 7103 Fax: 0161 275 5506 www.medicine.manchester.ac.uk/oeh/research/thor
SWORD reporting card - back DETAILS OF ALL CASES. If one line per case is not sufficient, use the line below. Group (A-J) Referenc e Number Gender Age Postcode (first half) e.g. M13 Industry Job Suspected agent Symptom onset date
History and background Overview of cases Asthma Asbestos related diseases Other respiratory diagnoses Other THOR sources of respiratory data Data requests Discussion 11
Estimated diagnoses by category SWORD (2002-2013) SWORD: Annual average cases = 2422 4% 7% 3% 12% 1% 2% 2% 1% Actual and estimated cases in 2013 core reporters (every month) = 317 sample reporters (one month in 12) = 140 28% Total actual cases = 457 Total estimated cases = 317 + (140 *12) = 1997 40% Asthma Inhalation accidents Allergic alveolitis Bronchitis/emphysema Infectious disease Non-malignant pleural disease Mesothelioma Lung cancer Pneumoconiosis Other 12
Proportion of estimated cases by gender SWORD (2002-2013) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 1646 91 133 207 46 3906 1687 243 741 566 Number of actual cases Female Male 13
Estimated cases (and 95% CIs) of ALL respiratory disease by year reported to SWORD, 1996-2013 14
Number of actual cases per active* reporter per month SWORD January 2009 to December 2013 *Active reporter defined as someone who either returns cases or declares I have nothing to report during their reporting month
History and background Overview of cases Asthma Asbestos related diseases Other respiratory diagnoses Other THOR sources of respiratory data Data requests Discussion 16
Estimated cases (and 95% CIs) of occupational asthma by years in SWORD, 1996-2013
Trends in incidence A multi-level statistical model was employed to allow for any changes over time in the number of reporters and also for changes over time in reporter characteristics which could independently impact on case density, e.g. some reporters may cover larger populations than others Without allowance for such factors, a false time trend could be produced. 18
Relative rates by year (2012 estimate = 1), with 95% confidence intervals, asthma Estimated annual change (1999-2012) = -7.3% (95% CI: -8.7%, -5.9%) * Results from multi level models adjusted for reporter type (core sample), first report, first core 19 report, season, number of reporters and underlying population changes
Actual and estimated cases of asthma by major industrial division, reported to SWORD (2002-2013) 20
Asthma incidence rates (per 100,000 employed)* by major industrial division, SWORD (2002-2013) Actual cases *Labour force survey data (2002-2008) used as the denominator 21
Actual and estimated cases of asthma by most frequently reported occupations, reported to SWORD (2002-2013) 22
Asthma incidence rates (per 100,000 employed)* for most frequently reported occupations, SWORD (2002-2013) Actual cases *Labour force survey data (2002-2012) used as the denominator 23
Most frequently reported suspected agents (actual cases) for work-related asthma SWORD (2002-2013) 24
Actual cases of asthma attributed to exposure to selected agents reported to SWORD (1996-2013) 25
Recent applications of multi-level model (MLM) 1. Extension of trends methods to controlled interrupted time series analysis to investigate the effects of interventions to reduce asthma attributed to specific agents, for example latex glove use gluaraldehyde spray painting in motor vehicle repair workers metal working fluids flour in craft bakeries rosin based solder flux fume wood dust 2. Comparison of European trends in work-related asthma Modernet (Monitoring trends in Occupational Diseases and tracing new and Emerging Risks in a Network) consortium (20 EU countries, Prof Agius chairs) WG2 trends: Dr Roseanne McNamee and Dr Jill Stocks
Proportional time lapse between month of symptom onset* and reporting month for actual cases of asthma reported to SWORD (2006-2013) SWORD median 22 27
History and background Overview of cases Asthma Asbestos related diseases Other respiratory diagnoses Other THOR sources of respiratory data Data requests Discussion 28
Estimated cases (and 95% CIs) of non-malignant pleural disease reported to SWORD (1996-2013) 30
Relative rates by year (2012 estimate = 1), with 95% comparison intervals, non-malignant pleural disease Estimated annual change (1999-2012): -0.5% (95% Cis: -1.7%, 0.8%) * Results from multi level models adjusted for reporter type (core sample), first report, first core 31 report, season, number of reporters and underlying population changes
Estimated cases (and 95% CIs) of mesothelioma reported to SWORD (1996-2013) 32
Relative rates by year (2012 estimate = 1), with 95% comparison intervals, mesothelioma Estimated annual change (1999-2012): -2.6% (95% CI: -4.1%, 0.3%) 33
Agents frequently associated with cases of pneumoconiosis*, reported to SWORD 1996-2013 Agent Actual cases Percentage Asbestos 980 75% Coal 132 10% Silica 139 11% *A case can be associated with >1 agent 34
Relative rates by year (2012 estimate = 1), with 95% comparison intervals, pneumoconiosis Estimated annual change (1999-2012): 0.9% (95% CIs: -1.6%, 3.3%) * Results from multi level models adjusted for reporter type (core sample), first report, first core 35 report, season, number of reporters and underlying population changes
Actual and estimated cases of asbestos related respiratory diseases by major industrial division, reported to SWORD, 2002-2013 36
Actual and estimated cases of asbestos related respiratory disease by most frequently reported occupations, reported to SWORD (2002-2013) 37
Incidence rates (per 100,000 employed)* for asbestos related respiratory disease for most frequently reported occupations, SWORD, 2002-2012 Metal working production and maintenance fitters Electricians, electrical fitters Carpenters and joiners Estimated Actual Plumbers, heating and ventilating engineers Labourers in other construction trades n.e.c. Labourers in building and woodworking trades Labourers in process and plant operations n.e.c. Metal plate workers, shipwrights, riveters Construction trades n.e.c. Stevedores, dockers and slingers 0 100 200 300 400 500 600 700 800 Incidence rate per 100,000 employed *Labour force survey data (2002-2009) used as the denominator BUT: long latency diseases are these denominators appropriate? 38
Proportional time lapse between month of symptom onset and reporting month for actual cases of asbestos related respiratory disease reported to SWORD (2006-2013) Actual cases Month + Year Year only No S.O. data Benign pleural plaques 1928 979 (51%) 213 (11%) 736 (38%) Mesothelioma 821 711 (87%) 43 (5%) 67 (8%) Pneumoconiosis 460 281 (61%) 112 (24%) 39 67 (15%)
History and background Overview of cases Asthma Asbestos related diseases Other respiratory diagnoses Other THOR sources of respiratory data Data requests Discussion 40
Other respiratory diagnoses reported in 2013 SWORD Diagnosis No. Agents Inhalation accidents 1 Chlorine Allergic alveolitis 10 Hay, Bird proteins, Pigeons, Moulds, MDI, Aspergillus Clavatus Bronchitis/ emphysema 3 Silica/asbestos, Radiation, Wood dust Infectious disease 3 Mycobacterium tuberculosis, Metal dust, Legionella Lung cancer 12 Asbestos Rhinitis 37 Flours/amylase, Rats/mice, Peracetic acid, Plastic fumes, Bakery enzymes, Detergent enzymes Other respiratory Toxoid reaction (cannabis), Obliterative bronchiolitis (metal working fluid), Interstitial lung disease (unclear agent), Hypersensitivity/pneumonitis (metal working fluid, fabric dust, unclear agent) 41
History and background Overview of cases Asthma Asbestos related diseases Other respiratory diagnoses Other THOR sources of respiratory data Data requests Discussion 42
Other THOR sources of respiratory data Occupational physicians reporting to OPRA since 1996 General practitioners reporting to THOR-GP since June 2005 Annual average (2006-2013) = 6317 (OPRA), 772 (THOR-GP) 43
Cases of respiratory disease reported to SWORD, OPRA and THOR-GP (2006-2013) OPRA annual average =168 THORGP annual average = 19 30% 45% 44% 27% <1% 2% 4% 2% 4% 8% 3% 11% 1% 2% 2% 7% 2% 1% 6% 1% 1% 8% 3% 5% 5% 27% 41% SWORD annual average = 2223 Asthma Inhalation accidents Allergic alveolitis Bronchitis/emphysema Infectious disease Non-malignant pleural disease Mesothelioma Lung cancer Pneumoconiosis
Sickness absence certified, respiratory cases THOR-GP 2006 to 2013 Allergic alveolitis in a farmer attributed to mouldy hay FN: wear PPE 2 dust mask Wheeze and rhinitis in an hospital administrator, onset after redeployment to paper records store FN: awaiting outcome of OH liaison Chemical laryngitis in a laundry worker attributed to detergent/bleach fumes FN: work without further exposure to chemical fumes Cough/wheeze in a joiner attributed to spray at work FN: avoid duties involving spraying N=160 cases
Comparing incidence rates Triangulation of incidence rates derived from THOR data and comparison with other external sources e.g. the survey of Selfreported Work-related Illness (SWI). 46
History and background Overview of cases Asthma Asbestos related diseases Other respiratory diagnoses Other THOR sources of respiratory data Data requests Discussion 47
Sources of requests for THOR Data (2013) Other 10% N = 41 Other THOR reporters 5% SWORD reporters 19% Occupational physicians 4% HSE 27% Research 17% 48
Example 2013 (respiratory) data requests Asthma attributed to isocyanates Trends in incidence of short latency respiratory disease in welders Asthma and CD incidence rates in chemical industry Occupational farmer's lung Asbestos disease in fire fighters Pulmonary fibrosis attributed to inhalation of metal dust Asthma and rhinitis attributed to epoxy resin Asthma attributed to sulphur dioxide / sulphite / bisulphite / metabisulphite / thiosulphate in prawn processing Asthma, rhinitis and conjunctivitis from cleaning chemicals Lung fibrosis attributed to ceramic fibre, crystalline silica, mineral fibre dust 49
History and background Overview of cases Asthma Asbestos related diseases Other respiratory diagnoses Other THOR sources of respiratory data Data requests Discussion 50
Discussion and Conclusion Voluntary reporting by trained physicians provides data which can: Identify occupations, industries or exposures associated with increased incidence of occupational disease or other work related illness Demonstrate generic trends in incidence of occupational disease and work related ill health Demonstrate changes in incidence following specific interventions Investigate factors influencing certified sickness absence associated with work related illness THOR is an invaluable source of data on work-related illness and occupational disease in the UK
Examples of THOR data informing UK policy on work-related respiratory disease Bakers! Time to clear the air pocket book which was developed in response to THOR data identifying bakers & confectioners as a high risk group. http://www.hse.gov.uk/pubns/indg429.pdf Asthma Workplace Charter which was developed by Asthma UK in consultation with HSE and lists the main occupations at risk from developing occupational asthma main (at the time), based on THOR data. http://www.asthma.org.uk/document.rm?id=668 THOR has also influenced the topics under Your Trade and Case Studies on HSE s Asthma Website. http://www.hse.gov.uk/asthma The report from the House of Lords Science and Technology Committee inquiry into allergy cited THOR as a source for its statistics. http://www.publications.parliament.uk/pa/ld200607/ldselect/ldsctech/166/1 66i.pdf 52
Further reading 1. Stocks SJ et al. Assessing the impact of national level interventions on workplace respiratory disease in the UK: part 1- changes in workplace exposure legislation and market forces. Occup Environ Med 2013;70(7):476-82. 2. Stocks SJ et al. Assessing the impact of national level interventions on workplace respiratory disease in the UK: part 2 - regulatory activity by the Health and Safety Executive. Occup Environ Med 2013;70(7):483-90 3. Enoch SJ et al. Development of Mechanism-Based Structural Alerts for Respiratory Sensitization Hazard Identification. Chem Res Toxicol 2012; 25:2490-98. 4. Turner S et al. Evaluating interventions aimed at reducing occupational exposure to latex and rubber glove allergens Occup Environ Med 2012; 69: 925-931 5. Carder M et al. Improving estimates of specialist-diagnosed, work-related respiratory and skin disease. Occup Med 2011; 61 (1): 33-39. 6. Turner S et al. Investigation of occupational asthma diagnoses using respiratory case studies: SWORD and OPRA. Occup Environ Med 2010; 67:471-488. 7. McNamee R et al. Measurement of trends in incidence of work-related skin 53 and respiratory diseases, UK 1996 2005. Occup Environ Med; 65(12): 808-814.
Gracias por su atencion! Funded partly by the UK Health & Safety Executive, Republic of Ireland Health & Safety Authority, Charitable income EU In the past also by: Dept of Health Thanks to all participating physicians And to other members of the THOR team: Professor Raymond Agius, Dr Louise Hussey, Dr Annemarie Money, Ms Christina O Connor, Ms Susan Taylor, Dr Roseanne McNamee, Mr Matt Gittins, Dr Jill Stocks,, Dr Susan Turner, Ms Nazia Zarin et al
RESERVE SLIDES 55
Percentage of actual cases Proportional time lapse between month of symptom onset* and reporting month for actual cases of asbestos related respiratory disease reported to SWORD (2006-2011) 100 90 80 Benign pleural plaques (median:4, mean:18 months) 70 60 50 Mesothelioma (median:3, mean:6) Pneumoconiosis (median:12, mean: 25) 40 30 20 10 0 0-12 13-24 25-36 37-48 >48 Months *Based on both full (month, year) and partial (year) symptom onset data 56
Percentage of returns by method of reporting - SWORD 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Phone Card Email Webform 2013 2012 2011 2013 2012 2011 2010 2009 2008 2007 CORE 2010 2009 2008 2007 SAMPLE
Trends in mesothelioma from ML model and number of deaths per year from mesothelioma death register 1999 = base year RR in 1999 = 1 58
Number of cases Actual cases of non-malignant pleural disease in Scotland 40 35 Predominantly plaques 30 Predominantly diffuse 25 20 15 10 5 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Total = 365 actual cases (279 predominantly plaques, 59 predominantly diffuse) 59