Document 7Rdr5oG4Ge5V655KO903BrJbB

Repnntd from 13ime CONG RES INTERNATIONAL DE MEDICINE DU TRAVAIL 13. CONGRESO INTERNACIONAL SOBRE SALUD OCUPACIONAL 13. 1NTERNAT1QNALER KONGRESS FUR ARBEITSMEDIZIN 13th INTERNATIONAL CONGRESS ON OCCUPATIONAL HEALTH I9 60 * CHRONIC PULMONARY DISEASE IN AN INDUSTRIAL POPULATION John J. Thorre. M-D_, and Neill K. 'Weaver, M.D. / U.S. A. Copyri$hi O 1961 by the U. S. Executive Committee o! the Thirteenth International C^>pTca on Occupational Health EXX-MOR-003854 JO 1 CHRONIC PULMONARY DISEASE EN AN INDUSTRIAL POPULATION John J. Thom^e, M.D_, and Neill K. Weave*, M.D. U.S. A. AV UVTRODUCnON In previous studio chronic pulmonary disease hu been identified as a relatively frequent cause of ucknew absenteeism and of permanent incapacity for certain kinds of wort. A review of all such casa was undertaken in order to improve our undemanding of the epidemiology 2ncl the early clinical manifesta tions as well as the effect of such disease on job performance and life expectancy. This added informa tion might suggest better methods for coping with similar asm in the future. METHOD OF STUDY The study population totaled 23.H2 mala engaged in refining and marketing petroleum in 18 of the eastern and southern United Stato. Climatic condi tions varied, as did the distribution wbetween rural and urban environments. Diagnoaa-selected for study were restricted to the following: (a) bronchiectasis, (b) bronchitis, (c) asthma, and (d) -emphysema, pul monary fibrosis, and cystic disease of the lung. Pul monary tuberculosis and cancer of the lung were excluded, since they have different etiologic back grounds and clinical courses than the group* under discusBon and. therefore, are the subjects of other studio by our group. Three major sources were used in finding: 1. All deaths and retirements occurring dunng ihe period 1910-1938. 2. Sickness absences during the period 1954--1958. 3. Periodic examinations performed dunng the same period. Cases were accepted is "chronic" where the clinical course of the disease was one of progressive deteriora tion. where findinp of wheeiex. rhonchi. or impaired ventilation were detected at the time of periodic examination or x-ray evidences of increased aeration or fibrosis were noted. RESULTS Epidemiology Pbxtalxmci--Three hundred and twenty-eight cm- EXX-MOR-003855 iruuiaton. and S. Metal-trado i. and boilcr- 20.7. Chemical ' -acchinia `vents. 14.6 ber. etc. were oleum products nd purification mechanical de r in the dusty ilax prevalence tdoor sales cm- puma crt ua ua. -- *ua I1J. lie o*ai prevalence rate of 7.0 occurred m l&c jdmuuitnuTf denmi group. occupational group* working out of doon either full or part time, had approximateiv the ome jm-rrifner f 1"6j6 -and 17.11, whereas the indoor gioup prevalence only 7.Q. Prevalence yu raaenuaHy the use in the scrend major geographical arena. Enouxac Facto**--Accurate identification of the euologic ficora of each cue would require detailed ciirual uudia involving allergenic testing, sputum cultures. bronchoscopy. bronchograpfav. etc Such dau were not `available. On the bins of history. physical findings, usd routine laboratory and x-ray examina tion!. however, we catcgoriaed members of the uudy group into four ategorieu Allergy. Infection. Com bined Allergy and Infection, and Unknown (Table I). pftTicna group ot 101 pauraito. Allergy u>d Combined euotogic factors icmtinird for 2 per cent and 5 per cent respeenvety: Z5J per cent had a hiarorr wgyrat ing repeated eptwiea of pulmonojv infection. In 67.2. however, there w* no antecedent history of febrile pulmonary diarasr or allergic manifestation* but merely an insidious onset of dyspnea and cough with i-rav changes of increased aeration of the lungs. Although a majority of the emphysema patients re gressed slowly in their downhill course, their were a lew who deteriorated rapidly from apparent rigorous health to complete invalidism within a period of several months. The relationship of the four possible diologic factors (Allergy. Infection, etc.) to the occu pational groups shown in Figure 2 was reviewed. The findings are not remarkable except for the absence of Allergy in the dusty tiada group and iu Allergy Inf ecuon Combined Unknown Tool Tajlx I POSSIBLE mOLOGIC FACTORS. 32* EMPLOYEES 3roo<nwtmi -% -- 20 74.1 l 3.7 6 22-2 27 loo.o Sranautu =s ---- 36 52.0 l 1.6 4 6.4 61 100.0 Ajchma - ** 36 23.9 17 12.3 70 30.0 16 1L6 139 100.0 Eupftyi--i =% 2 2.0 26 23 J 3 3.0 6a 67.2 101 100.0 Tool r- % 31 IL6 119 364 77 23-3 94 23.3 323 100.0 In the 27 patients with bronchiectasis, infection was recognised as a likely etiologic factor in 74 per cent. Among the 61 caso of bronchitis, evidences of infec tion were present in 95 per cent. Allergy was con sidered the major etiologic factor in 23B per cent of the asthmatics, and allergy plus infection was present in another 50 per cent. Infection alone was considered the responsible factor in 12J5 per cent- 11.6 per cent fell into the unknown category. In the cm- presence in about a quarter of the admirdicrative- dericnl group. This may represent some degree of job-selection on the part of those patients with allergic rhinitis or asthma predating employment. Although the working environment of these em ployee-patients has been under continued scrutiny and control by the industrial hygiene staff, it is obviously necessary to consider the possible relationship of these to occupational opowro c-g, dusu. Dust/ Trodts ! Prevalence /1000 Employ*** ! 123.8 Mata/ Trodts Chtmcai Products Proctss Pttro/tum Products Proctss Othtr Mtchonied/ Groups -------- 1 "1 1 I I 1 TI i1 1 lzo-7 1 119-3 116.3 T 16-3 Outdoor Salts i Admmistrattr*/ Cltricd/ 1 n : i i-6 1 1 1 7.0 | |-- 1 | In/tction \Alltnir Ftcuai 3--Prevalence by Occupational Croups, 306 Employees T EXX- 898COO"dOIAI"XX3 334 MEDICAL PRACTICES ultra metal fumes. acid mist*. etc. Thirty six per cent of the cases of bronchitis worked where such exposures could have occurred, but only 20 per cent of the other diagnostic groups had such a work history. \bout 60 per icent of the employees studied showed no unusual environmental exposure. In about 20 per crni of the casa the data were inadequate to make any judgment about their work environment. Tobacco consumption was one of the factors studied. Information was available for the total em ployee population at onlv a single location--the Baton Rouge Refinery. Since 40 per cent of the group under studv was derived from this loation. ibe findings are probably significant. The first column in Table II outlines the tobacco consumption history of the 328 members of the total study group. The second column shows the same data for the members of the studv group at Baton Rouge. The third col umn lists smoking data on the total plant population at that location. The percentage of nonsaokers in the three groups given category (Figure 4). Normal findings were reported in 26 per cent of the osci of bronchiectasis, 46 per cent of individuals with bronchitis, and 61 per cent of the asthmatics. Increased aeration, alone pre dominated in emphysema but was also present in onesixth of the cases with bronchitis and asthma. In creased aeration plus increased hilar markinp was reported in a thtid of the cases of emphysema and a sixth of the employees with bronchiectasis and asthma. Increased hilar markinp predominated in bronchiectasis and bronchitis. Infiltration of lung parenchyma was more common in bronchiectasis but also occurred transiently in several patients with bronchitis, asthma, and emphysema. Ejlxctxocabdsociam -- Although electrocardiograms were done in 75 per cent of the studv group, they proved to be of positive value in the interpretation of pulmonary change only in the emphysema group. About 60 per cent of the tradnp in this group were normal. 7 per cent showed a pattens compatible with right ventricular hypertrophy, and 3 per cent Tobacco History None Cigarettes Less than 1 pk_/day More than 1 pkjdxy Amount Unknown Pipe or Cigars (Singly or in Combination) Unknown Total Table II TOBACCO USE HISTORY Entire Sniir Grown s% Bato* Rowe* Kf. Srwbr Grown a% 41 12.5 2< 17.7 61 19.7 140 42-9 17 ij. 21 1.6 31 23.1 51 36.1 6 4.3 U 10.4 37 11.1 328 100.0 8 fi-2 1*4 100.0 Sttoa Jtmifc Rtf. Cn. Popwlatiow S% 988 19.1 2811 839 -- 320 M.4 16.2 -- 10.3 -- 3138 -- 100.0 was cucndally the same, but of those who smoked. 54.4 per cent of the control group smoked less than a pack of cigarettes a day. compared to 23.1 per cent of the study group at Baton Rouge and 19.7 per cent of the toul study group. Conversely. 16.2 per cent of the total refinery population were in the pack or more a day group, compared to 38.1 per cent of the study group at Baton Rouge and 42J9 per cent of the general study group. Pipe, cigar, and miscellaneous tobacas assumption wis essentially the same in the three population groups. Qinicsl Observation* HuTOtr and Physical Signs--Dapite the pre- .ominance of certain symptoms and signs in each diagnostic group, these tended to overlap. Cough u a common denominator in all. Hemoptysis wu noted most often in bronch lectuij, occurring n about 25 per cent of ojq,, Fever vai most mmon in bronthitu. Dvtpnea waj the characteristic ivmptom of asthma and eruphvjcm.a. wheeling the distinctive finding in asthma Oth X IAT demonstrated the high peaked P-waves frequently associated with cor pulmonale. ^ork Experience AaicxmisM--Two hundred ninery-seven of the 306 employees with chronic pulmonary disease lost time due to respiratory illness, on the average. 12 times per year during the period 19M-195B. Other em ployees averaged only 0.39 absences per year due to respiratory illness. There was no significant differ ence in absence pattern of the four diagnostic gorups studied. The average number of dan lost due to alt respiratory disease in this selected group was 12.7 davs per employee, while the average number of days lost per employee due to all causes in the entire Esso population for was 8 7 days, of which only 1.6 davi wi for respirator* disease. Partial Disability: Jo* Rtmucno*---Of the indi viduali with chronic pulmonarv disease. 22.6 per cent had or developed >omc degree of permanent diaa- bility during the follow-up penod. In a number of instances ihe job demands did not exceed the phvsi- cal capacity of che partiallv disabled anplonn Since rhu fort.j:rn.,. . -_ _ ----- ------1* ------------------ - i i 1 I Normt lncr. L IW.H lncr. A Hilar Infiltri Infillr Iner. A Untnc 9 Ficvu 5-- Average 9 FiGL*t G--Aver each oxk in lermi * have been imoonj 698COO"dOIAI"XX3 thorpe and weaver 385 Normal Bronchiectasis Bronchitis | Asthma | Emphysema 253% T7 46.0% 1 51.0% | 93% t incr. Aeration 7.4% ib.1% j---q 16.5% , - i | 423% j | Incr. Hilar Mornings 25.9% 23p%(--q 10.7% - 4.0% ^_____ Incr. Aeration & Hilar Markings 14.8%,---- B.1%^^^ _l5-,% 1------- 1 33.6% | | Infiltration 'trotion S Aeration IB.B%. 4.8% 23% _____ 4.0% ---- -- -- 1.4% 3.0% Unknown 7.4% -- -- 2.2% 3-0% _____ Ficuxi 4--Radiologic Findings, 321 Employees inL disabled employes were classified u to the de gree of work restriction which would have been necessary were they to work at one of these jobs. Of -the mure group. 77.4 per cent had no lignifiant limitation in their work capacity. Major limitations regarding climbing, carrying and walking were neces sary most frequently among the emphysema group *aDd*aesxnai2 number of the asthmatics. Minor restric tions '"pertaining mainly to exposure to inclement weather, dusts, fuoa. and very heavy effort were -<fairly^Dmmon in all groups. wfOLL0W-UV 5--Avenge Number of Absences per Employee W.7 Q ir -Of 'ihe '506 employees with chronic pulmonary dis^casesavho-were working at the beginning of the five* year-cpchod. 55.9 per cent continued at work at the end of that time. 62 per cent in a restricted mparitr and 49.7 per cent carrying out regular jobs. Prema ture medial retirements due to pumonary disrate were neemaary in 10.8 per cent of the group over the five-year period. Deaths due (o pulmonary dis ease totaled two or 07 per ernt. The remainder, or 125 per cent, listed as "Other" were lost for follow up due to nonpulmonan* medial retirement, non* medial retirement, layoff, resignation, or nonpulmonary death, C--Avenge Number of Day Lost per Emptovee *e tn irmn of the job (Jeraandi which oulil vn imprjtoJ had each of the men l*-t-n p 0 *ort aj a rrrinrn mechanic rr nr-mn DISCUSSION On reviewing this group of patients with chronic pulmonary disease, wf were most tmprened bv the fact that a clearcut diagnosis wax made infrequently and a satis/acion response io treatment was rarelv obtained. In a few miuncn. localized bronchiectasis w]t identified and extirpated turgicalls In approvimaielv a fourth of the asthmatic patients the major cju>c was identified a allergic in nature, and some of them were helped b% JncnutLaion or rernoial of the perific allrrTvn from the rn\ i ronment These aJlertms vfrr rarrl\ arvoruird wih the wort cn\ i ronment Emphvvma app^art-d aa a nnirio or u--0ncarv il-jpimi, , n / i I J \V 386 MEDICAL PRACTICES NO , Restriction Number of Employees IOO 200 --i__________________________i--------- MINOR Restriction 7.0% MODERATE Restriction j=0 7.o% MAJOR Restriction 8.6% Ii FidUU 7--Partial "Disability**--Job Restriction 328 Employees 300 ____________i___ 077.4% siriin specifically ir like manner, x-rav arcas of increased a attention as dues t xt.ru ciive measures initiaie to minimis asm of chronic pul employees affected? Environmental Go In aaopention > local wort environ critically. In addicic recognized rapirato vapors), a continuir irol exposures to Sweepinp from a oj-penur'x bench n of ux. but to the pj dpitate a bout of vironmental control the susceptible emp. be necessary. Individual Health While control of t edly important. cv given the patient a matters require his i 1. Eau-lu cox r on the alert to elia respiratory disease physical and laborat long natural hixtorv 2. .WotDANCt or r EWVItONMC^T -- Whil older age groups leads us to expect that the number of caso of emphnerna and pulmonary insufficiency *-ill increase in any group such as Lhu with the of time. None of these patients had the .meal finding of pncumocomosii. We believe, how ever, that in the working population studied ap proximately l per cent have a lower respiratory tract susceptible to chronic disease. The basic causes for thij response arc obscure. In some infection in the bronchial tree or accessory nau I imuxa is probablv a major comnbuung or eitolospc factor In others an allergic response to tnnaiann at home or at work, mu be pnmanr The orsver^ed prevalence n the occudj uonal gToutyi out- containing dusu. fumes, or mists which we believe to be nontoxic or of a nuisance character may aggravate the underlying disease state, whatever the basic cause. Exposure to cold and damp environment etther on or off the job also has an adverse influence. There are more heavy smokers in the "pulmonary'* group than in the general employee population. To* bacco smoke probablv has an aggravating effect similar to that ascribed to other environmental imotei or fumes. Clinical manifestations in most cases are not dramatic or specific: chronic cough a often dismissed as imoker s cough"'; recurrent, pro-* longed epuodea of bronchitis arc interpreted as a "'tendency to cheii coUlj wheeling or mild dvspnex EXX-MOR-003860 |,9800-yOIAI"XX3 300 387 naan tpemficaflv inquires about juch irmofomi. In like manner, x-rav finding of hilar thickening or areas of increased aerauon mav not be given proper attention as clues to underline disease. What con* uructive measurei can the phvucian in induxtrr initiate to minimize the number and severitY of Oses of chronic pulmonary disease and to help those employees affected? Euvtronmenul Control In cooperation with the industrial hvgiemst. the local work environment should be evaluated very entiailv. In addition to the elimination of the well* recognized respiratory imtanu (eg- rilica or add vapon). a continuing effort should be made to con* trol exposures to other atmospheric contaminants. Sweepings from a shop Aoor or sawdust from the carpenters bench may be nuisance factors to most of us. but to the patient with asthma thev mar pre* Qpitate a bout of serious illness. If adequate en vironmental control is impossible, then removal of the susceptible employee from the environment may be neemsary. Individual Health Promotion While control of the work environment is undoubt* edfy important, even greater attention should be given the patient as an individual Many of these matters require his interest and initiative: 1. aiuei case nNDi.NC -- The physician must be on the alert to elid: details of repeated epuoda of respiratory disease and to evaluate more critically physical and laboratory findings in the light of the long natural history of the disease. 2. Avoidance or fboionccd cxnosuu to wrr. cou> Cnvisonmc-ht -- While it is not possible 10 surround everv individual *uh an ideal milieu, manv respiratorv disease prone individuals ihoulil give special attention io wearing warm drv clothing, headgear, and proper footwear when going out of doors. 3. Co.vraoL or homi tNviaoNwt>r -- Although the present dav uudv concerns itself pnmanlv with workers and their work environment, it was obvious in manv instances that household dust. pet. and pollen exposures played an important role in ac centuating symptoms of a resptratory nature. 4.. EuaitNATiow or Tci-sceo -- Manv victims of res* piratorv disease smoke m excess of those without such disease. The inhalation of all forms of tobacco smoke should be discouraged. . PixviNTTvt iMNtuntiATm* -- While the over-all vali*c of prophylactic immunization against respira tor* viral agents and the common bacterial agents j( secondary infection may still be in doubt, we have observed enough clinical benefit in individual cases to recommend these measures to many pauenu with chronic, recurrent respiratory disease. . Eaily adequate T1ZATMC.NT Many prolonged periods of illness due to bronchitis, asthma, etc. fol lowed neglect of the early stages of a common cold. Appropriate early treatment under the guidance of an interested personal physician mar mean the differ ence between a minor illness and a lengtbv disability. A severe cold may initiate pulmonarv insuffidenev which is permanently disabling in patients with moderate to marked emphysema. 7. Jot flaQme*t -- Selective placement has been mentioned as the possible solution to the problem of certain occupational exposures In addition, job placement is important in the tarer stages of chronic pulmonarv disease where partial disability is sull compatible with productive employment. which we believe e character may tee. whatever the amp environment adverse influence, the "pulmonary-* r population. To* ^raviung effect :r environmental stations in most chrome cough it recurrent, prointerpreted as a or mild dyspnea st unless the phy-