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Paul Cullinan Imperial College and Royal Brompton Hospital London p.cullinan@imperial.ac.uk

LUNGS AT WORK. www.lungsatwork.org.uk. Asthma and employment Trent OH October 2010. Paul Cullinan Imperial College and Royal Brompton Hospital London p.cullinan@imperial.ac.uk 020 7351 8341. PEGASUS: rationale. pre-employment/pre-placement screening for asthma happens: frequently

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Paul Cullinan Imperial College and Royal Brompton Hospital London p.cullinan@imperial.ac.uk

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  1. LUNGS AT WORK www.lungsatwork.org.uk Asthma and employment Trent OH October 2010 Paul Cullinan Imperial College and Royal Brompton Hospital London p.cullinan@imperial.ac.uk 020 7351 8341

  2. PEGASUS: rationale • pre-employment/pre-placement screening for asthma happens: • frequently • uncertainly • inconsistently • for many different reasons • available guidance is: • limited • often of uncertain logic • often ‘dated’ • there have been important changes in: • ‘asthma’ • attitudes to discrimination • relevant legislation

  3. ‘asthma’ • I have asthma • my doctor thinks I have asthma • I had asthma • I sometimes have asthma • I take treatment that is (used) for asthma

  4. ‘asthma’ • asthma is variable • people with asthma are not • most asthma is readily treatable

  5. survey: summary SOM/SOHN/AOHNP n=664 (30%) • concerns were: • variable • specific • largely predictable • alleviated by experience • logistics re. employing persons with asthma • OH: screening; monitoring; risk assessment • employer: fitness; cost

  6. survey: median ‘concern’ scores 1 none 2 mild 3 moderate 4 very 5 extremely

  7. evidence review

  8. evidence review: does asthma increase the risk of hypersensitive OA? • we don’t know • atopy does • most people with asthma are atopic • (so are lots of people without asthma) • studies of asthma do not adjust for atopy • Canadian animal work apprentices: BHR

  9. evidence review: how common are workplace irritant responses in asthma? • common (30%-40%) • real in half • mostly mild (10% more Rx) • little sector-specific information • related to likely exposure(s) • no reference • beware ‘aggravation’

  10. evidence review: do persons with asthma have an increased rate of sickness absence? • essentially, No • few referenced • skewed • (‘productivity’ data similar)

  11. evidence review: do people with asthma retire early because of asthma? • very little evidence • available, No • ‘grey’ literature

  12. evidence review: do persons with asthma cost an employer more? • very little evidence • US • incomplete costings • Yes, but not for asthma

  13. evidence review: what is the value of provocation testing? • ‘non-specific’ (histamine/metacholine/mannitol) • broadly distinguishes current asthma from non-asthma • broadly distinguishes ‘severe’ asthma from ‘not severe’ asthma • unclear whether it correlates with responses to ‘dust and fumes’ • ‘more-specific’ (exercise/cold air) • more difficult to standardise (especially outside hospital) • physical capacity vs asthma

  14. evidence review: what is the value of provocation testing? my asthma will come back 30% - I had asthma my asthma went away 30% histamine test + (10%) my asthma will come back 85% 3 12 21 26 • if it comes back: • it’s usually mild • and easy to manage

  15. registration date left practice qualifying date past medical history “future” exacerbations 1.07.1998 1.07.2000 qualification window in current asthma, what is the risk of future serious events? can they be predicted? THIN database: 5.5 million patients from 350 participating GP practices in the UK. • aged 16-40 between 1998 and 2000 • ≥1 asthma prescription during the qualification window • 5 years pre and post follow up

  16. definitions of exacerbations ‘hospital’ exacerbations • asthma events resulting in attendance at A&E or admission GP exacerbations • asthma events during out-of-hours consultation or • asthma events suggestive of an emergency exacerbation ‘prednisolone ‘exacerbations • acute prednisolone prescription for asthma • (reliever prescribed within 30 days)

  17. trajectories: findings 1

  18. trajectories: findings 2

  19. trajectories: findings 2

  20. trajectories: findings 3

  21. 0.33% 0.27% 0.23% 0.29% 0.25% trajectories: findings 4 hospital exacerbations (%) represents 0.01% year 1 year 2 year 3 year 4 year 5

  22. Results: Exacerbations in the first year post-qualification – summary • the overall incidence of exacerbations is low • the (relative) future risk can be related to past experience ... • those with more asthma prescriptions in the last year • those with previous exacerbations ... • ... and those with recent exacerbations • (women) • ... but in absolute terms most exacerbations are not predictable

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