Occupational Epidemiology

MOHAMAD AZFAR ZAINUDDIN PUD 0015/11

List of Content
Introduction

Differences between Clinical & Epidemiological

approach Types of study in OE Problems in OE Benefits of OE Conclusion References

Introduction
Occupational epidemiology involves the application of

epidemiologic methods to populations of workers. Occupational epidemiologic studies may involve looking at workers exposed to a variety of chemical, biological or physical (e.g., noise, heat, radiation) agents to determine if the exposures result in the risk of adverse health outcomes. Alternatively, epidemiologic studies may involve the evaluation of workers with a common adverse health outcome to determine if an agent or set of agents may explain their disease. There are currently no specific OSHA standards for occupational epidemiology. However, a variety of hazards are addressed in specific standards for OSHA access to employee medical records, recordkeeping, general industry, shipyard employment, and the construction industry.

 Every year, millions of worker throughout the world

complain of ill-health which is caused or aggravated by work. Occupational Epidemiology has an important role notably in:
1) 2) 3)

establishing the causes and determinants of this ill-health, ensuring adequate recognition and quantification of (1) determining appropriate occupational exposure limits.

 However, occupational epidemiology may be of value

beyond the worker and the workplace. E.g. by contributing to the setting of exposure limits such as air quality guidelines for the population at large. To gain full benefit from this resource it is important to have an understanding of epidemiologic concepts, notably causal associations, and to be aware of issues which may influence apparent association, notably bias, confounding, and chance.

Drawing analogies between the clinical and epidemiologic approach

The logic including data gathering, data processing,

interpretation, intervention and hence change has a lot in common between the clinical and the epidemiologic method, as illustrated in the following table:

Analogies between dealing with individual patients and with populations in occupational epidemiology

Consulting with an individual patient Process: Taking the individual's symptom history* Taking the individual's exposure history (and getting information about the work/environment) Carrying out a physical examination and tests Exercising 'clinical judgement'*

Contending with a group of workers or other people Administering a questionnaire, (and collating the replies) As above by a questionnaire, but also by an objective assessment of work/environmental exposures Gathering data from health surveillance tests etc Analysis of the data

Note*: The above analogies can be extended to the history taking process.

Analogies between dealing with individual patients and with populations in occupational epidemiology (2)
Consulting with an individual patient Output: Diagnosis Prognosis Treatment Contending with a group of workers or other people Description of profile of health and disease Prediction of risk Intervention

Analogies between dealing with individual patients and with populations in occupational epidemiology (3)
Consulting with an individual patient Outcome: Change in patient's condition Contending with a group of workers or other people Change in profile of health and disease

Types of studies in OE
Case control studies

Cross sectional studies

Cohort studies

Case control studies

The accompanying image shows an

occupational cancer - of the nasal sinuses - which is fortunately rarer now than it used to be. In a case-control approach, 'cases' of this disease are compared to a carefully matched reference population of 'controls' (or 'referents') to determine retrospectively what differences there may have been in their occupational exposure histories.

 For example in one study it was shown that patients

with one type of this tumour (an adenocarcinoma) had a disproportionately greater likelihood of having worked in the hardwood industry, when compared to referent patients with other pathology. Subsequently cohort studies were conducted which supported the hypothesis of a causal association by showing that this type of tumour was much commoner in hardwood workers than in other people.

Cross sectional studies

In a cross-sectional study, the prevalence of a

particular disease or of a set of symptoms or other indication of ill-health is investigated in a single time-point (or over a relatively narrow period of time). Comparisons can then be made in the frequency of ill-health. E.g. comparisons between workers exposed to a particular hazard, and those who are not, or - better still - between workers experiencing different degrees of exposure.

 A cross sectional study can determine the prevalence

rate, which is defined as the number of EXISTING cases of disease divided by the population at a specified time point. E.g. a chest X-ray survey of quarry workers is conducted it might show that workers in quarries with high exposure to quartz (a crystalline form of silica) might have a higher prevalence of pneumoconiosis than those in quarries with little or no such exposure.

Cohort studies
The term cohort is applied epidemiologically to a clearly

defined population who prospectively share a common experience -say an occupational exposure. Comparisons in the incidence of ill-health, or in mortality can be made between exposed and nonexposed cohorts or between subsets of the same cohort but with different degrees of exposure. In the context of a cohort study the term 'control' has a different meaning from the meaning in a case-control study. In a cohort study, the 'controls' are those people who are not (or have not been) exposed to the agent under investigation.

 Some cohort studies measure mortality, others measure

incidence of disease. The incidence rate is defined as the number of NEW cases of a disease divided by the population at risk over a given period of time. In OE, it is important to be able to characterise the exposure of the 'population at risk'. E.g. a study was conducted in which workers were followed up during their employment in a factory bin which they were exposed to benzene. It showed that those categories of workers with a high cumulative exposure to benzene had a higher mortality from certain types of leukaemia than the control population.

Problems in occupational epidemiology

The Healthy Worker Effect

Other problems

The healthy worker effect

Workers differ from the general population from

which they are drawn, and especially from unemployed people in many ways. This differences can result in serious bias in occupational epidemiology. Can you consider some of these differences, and how they can contribute to bias? E.g. are there socio-economic differences between the employed and the unemployed (can these differences influence health, and if so - in what way?)

 The HWE refers to the observation that employed pop tend to

have lower mortality experience then the general pop. HWE is 1 of the factors that may reduce the validity of exposure data. The HWE may have an impact on occupational mortality studies in several ways Example:

People whose life expectancy is shortened by dz are less likely to be employed than healthy person. This phenomenon lead to reduced measure of effect for an exposure that increases morbidity & mortality. Why? Because general pop includes both employed & unemployed ind, the mortality rate of that pop may be somewhat elevated compared with a pop in which everyone is health enough to work. As a result, any excess mortality a/w a given occupational exposure is more difficult to detect when the HWE is operative

 The HWE is likely to be stronger for nonmalignant causes

of mortality (which usually produce worker attrition/withdrawal during an earlier career phase), than for malignant causes of mortality (which typically have longer latency periods & occur later in life). In addition, healthier workers may have greater total exposure to occupational hazards than those who leave work force at an earlier age because of illness.
Trying to understand HWE was not easy considering the

ongoing debate on its nature. Some scientists consider HWE a source of selection bias; others consider it confounding. A third group considers it a mix of both while some others look at it as a comparison problem

Healthy User Bias

The healthy user bias is a bias that can damage the validity

of epidemiologic studies testing the efficacy of particular therapies or interventions. Specifically, it is a sampling bias: the kind of subjects that voluntarily enroll in a clinical trial & actually follow the experimental regimen are not representative of the general pop. They can be expected to on average be healthier as they are concerned for their health & are predisposed to follow medical advice, both factors that would aid one's health. In a sense, being healthy/active about one's health is a precondition for becoming a subject of the study, an effect that can appear under other conditions such as studying particular groups of workers (i.e. someone in ill-health is unlikely to have a job as manual laborer).

Other problems
Various difficulties can affect the design and

interpretation of studies in occupational epidemiology. Can you consider some of these? For example how comparable is an occupational population to the general public in terms of age, and sex? Bias, confounding and chance are considered briefly elsewhere.

Chance
Example - To determine the frequency of back pain

among employees in a particular workplace. Rather than questioning all the employees, it would be easier to administer questionnaires to only a sample of this pop, & from them, estimate the frequency of back pain in the workers. However, CHANCE may have affected the results because of random variation in the population It could be that, by CHANCE, the sample were a particularly fit & healthy group. The larger the size of the sample, the smaller the effect that CHANCE will have on the results.

Bias
A further important factor to consider is whether

some aspect of the design, or conduct of the study has introduced a systematic error or BIAS into the results. BIAS is most easily understood if you think in terms of the danger of not comparing 'like with like'. 'BIAS' in an epidemiologic context has a specific meaning which does not necessarily imply bad faith. IOW, a criticism of a study as having been biased does not necessarily nor usually mean that the investigators set out with the intent of swaying the results or interpretation one way or the other. Types of Bias: Selection & Participation Bias, Observation Bias & Recall Bias

Bias Types: Selection & Participation Bias

Occurs if the study pop being compared are not

strictly comparable ('not comparing like with like)

Example: In a study to determine the effect of a

Workplace Health Promotion (WHP) program on 'sickness absence', the rate of subsequent sickness absence might have been compared between those who participated in the WHP program & those who did not.
group had lower rates of sickness absence?

Results might appeared to show that the WHP

Bias Types: Selection & Participation Bias (2)

However, bias may well have been present in this

study because those who took part in the WHP may, for other reasons, such as their smoking habits, diet, or psychological factors, have been at a lower likelihood of sickness absence even before joining the WHP. IOW, bias would have risen through not comparing like with like.
Selection bias also may occur if some workers are

excluded because their records have been purged from the companys database.

Bias Types: Observation Bias

Occurs if non-comparable info is obtained from each

study group. Example In a case-control study to determine whether scleroderma (systemic sclerosis) is a/w occupational exposure to certain hazards (e.g trichloroethylene or silica) If the interviewer knew (or could tell) which people were the cases & which were the controls then interviewer might seek more detail about exposures from the cases than the controls (referents) Thus observer bias would have influenced the results.

Bias Types: Recall Bias

Recall bias might arise if the cases (suffering from the

disease) having previously pondered about possible causes of their misfortune, were to recollect more detail about their past exposures, than the controls (who may have no real motivation to reflect at length on their past occupations).
(Exposure Assessment) rely on surveys & the recall of the exposed persons. This latter method, is the least reliable & 1 reason that data from some epidemiologic studies cannot always be used for quantitative risk assessment.

E.g. some retrospective studies of human exposure

Confounding
Results from multiple associations bet the

exposure, the dz, & a 3rd factor (i.e. the CONFOUNDING variable') which is a/w both the exposure, & independently affects the risk of developing the dz.

The application of occupational epidemiology

Benefit for the workers Occupational epidemiology has a great deal to contribute to the reduction of risks to health from work, through reducing exposure, and in other ways. Benefit for the community at large Various direct & indirect benefits can accrue to the population at large. E.g. through the derivation and application of exposure limits the recommendations of the Expert Panel on Air Quality Standards in relation to benzene were largely based on occupational epidemiology.

Conclusion
Occupational epidemiology is an important aspect of

clinical epidemiology and of occupational hygiene since it provides:

powerful and practical information to understand the causes and determinants of work related ill-health, to help establish what steps should be taken to reduce those risks, and to evaluate interventions for the benefits of workers, and of the community at large.

References
Friss, RH (2009). Epidemiology for Public Health Practice. Fourth

edition. Jones and Bartlett. Rothman, KJ (1998). Modern Epidemiology. Second edition. Lippincott Raven. Ladou, J (2007). Current Occupational & Environmental Medicine. Fourth edition. Mc Graw Hill. Agius, R (2006). Association and Cause. [Online] www.agius.com/hew/resource/assoc.htm accessed on 6 Disember 2011. Shah, D (2009). Healthy worker effect phenomenon. PubMed Central. [Online] www.ncbi,nlm.nih.gov/pmc/articles/PMC2847330 accessed on 7 Disember 2011. Li, CY (1999). A review of the healthy worker effect in occupational epidemiology. Occup Med 49: 225-229.

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