Establishing The Work-Relatedness of Diseases

Establishing
Work-Relatedness of a
Disease
Marissa G. Lomuntad-San Jose, MD, MOH
Objectives
At the end of this session, participants
will be able to:
Discuss the factors that
Discuss the evidence-based approach
in establishing work-connection of
diseases
Department of Labor and Employment

OCCUPATIONAL SAFETY AND HEALTH CENTER
Why Establishing Work-Connection

of Disease is Difficult?
1.
2.
Cause-effect relationship between

disease and an agent or conditions in
the workplace may not be clear
Occupational disease may be slow to
develop

Why Establishing Work-Connection

3.
4.
symptoms of disease may be

confused with changes that are due to
the aging process, or with the effects
of smoking or alcohol abuse
Information on past work exposures
often unavailable, inadequate, or
incomplete

Why Establishing Work-Relatedness

5.
6.
not all individuals react in the same

way to similar exposures to diseaseproducing agents
off-the-job exposures may contribute
or be a primary cause of illnesses and
accidents

Decision-Making
decision must be based on an

evaluation of the available information
an equitable decision is likely to result
when:
appropriate evidence is presented in a
logical and orderly sequence
major issues are identified, and
the basis for any presumption is defined

Six Basic Steps

1.
2.
3.
consideration of evidence of disease,

consideration of epidemiologic data,
consideration of evidence of
exposure,

Six Basic Steps

4.
5.
6.
consideration of validity of testimony,

consideration of other relevant
factors, and
evaluation and conclusion.

1.
Evidence of Disease
The first consideration:

that a disease condition does, in fact,
exist, and
that the particular manifestations of the
disease appear to be the result of
exposure to a specific harmful agent.

1.
Evidence of Disease
Generally, a medical evaluation should

include:
An analysis of the employee's medical,
personal, family, and occupational
histories;
a thorough physical examination and
clinical evaluation (analysis of signs and
symptoms); and

Occupational History

Factors Affecting Validity of

Occupational History
Occupational history may be

insufficient
Lack of specificity about the identity of
hazards
Inadequate information about
exposure level
Recall biases
Other biases -e.g. fear of job loss
1.
Evidence of Disease
Generally, a medical evaluation should

include: (cont)
a laboratory evaluation (analysis of the

results of specific tests).

1.
Evidence of Disease
Other work-related medical

information
timing of symptoms
existence of symptoms in co-workers

1.
Evidence of Disease
Inquiry on timing of symptoms:

1. Change in the symptoms during the work
day
2. Change in symptoms over the work week
3. Change in symptoms on weekends and on
vacation
4. Onset of symptoms away from work
5. Other work-related experiences
Example: Occupational
Asthma
Initiated or provoked by agents found in the work environment
causing asthmatic signs and symptoms
either due to excessive concentrations of these agents
or because of exaggerated response by the individual worker

Considetations
Presence of asthma-causing agent in
the workplace
No previous history of asthma prior to
exposure
Improvement in symptoms with
cessation of exposure

Considetations
Recurrence of symptoms upon
returning to work
Worsening symptoms toward end of
week or start of week

2.
Evidence of Exposure
The best evidence to confirm the

exposure of a worker to an agent is
measurements (such as air samples,
noise levels or radiation
measurements) obtained at the
worker's actual job stations, past and
present.

2.
Evidence of Exposure
Identification of agents/ factors that a

person has been exposed to
Information from industrial hygiene
studies
Data on work exposure evaluation
Work environment condition

3.
Epidemiology
The study of distribution and

determinants of health-related events
in specified populations.
Concerned not only with illnesses,
injuries and death, but with means to
improve health

Epidemiology
3.
Point to high PROBABILITY or

ASSOCIATIONS of agents/ factors with
certain diseases
Studies
Demonstration of effects after (prolonged)
exposure
Descriptive accounts of observed effects

EPIDEMIOLOGICAL
APPROACH TO DISEASE
CAUSATION
Disease Causation
CAUSE (of disease) event, condition,

characteristic or combination of these
factors which plays an important role
in producing health outcome
SUFFICIENT cause - produces or initiates
an outcome
NECESSARY cause must be present for
an outcome to occur

Disease Causation
Ex. foodborne disease outbreak
(Salmonella diarrhea)
Sufficient causes:
chicken salad and cream desert
Necessary cause:
Salmonella spp.

Causes of Tuberculosis
Sufficient Causes
malnutrition
Necessary Cause
Mycobacterium tuberculosis
genetic factors
EXPOSURE TO
BACTERIA
SUSCEPTIBLE
HOST
crowded
housing
TISSUE
INVASION
INFECTION
TUBERCULOSIS
poverty
RISK FACTORS FOR TUBERCULOSIS
MECHANISMS FOR TUBERCULOSIS
Causal Inference
Process of
determining whether
observed
associations are
likely to be causal
A. Bradford Hill
(1897-1991)
Commonly used
approach on causal
inference using a set
of considerations
for causation is
Hills criteria

Considerations for Causation

1. STRENGTH
What is the strength of association between the cause and

effect?
2. CONSISTENCY
Have similar results been shown in other studies ?
3. SPECIFICITY
Is the effect only from one cause?
4. TEMPORAL
RELATION
Does the cause precede the effect ?
5. DOSE-RESPONSE Is increased exposure to the possible cause associated with

increased effect ?
6. PLAUSIBILITY
Is association consistent with other knowledge? (evidence from

animal studies)
7. COHERENCE
Is association coherent (do not conflict) with other knowledge?

Strength
(What is the strength of association between the cause and effect?)
Strength of association between

possible cause and effect is measured
by risk ratio
Strong association (risk of >2) is
More likely to be causal than weak
association
Ex. The lung cancer rate for smokers is

about 10 times (RR = 10) higher than for
non-smokers
Consistency
(Have similar results been shown in other studies ?)
Different studies showing similar

findings in different populations under
increase the credibility of causal
finding
Examples:
Pesticide exposure and neurotoxicity
Organic solvents and neurotoxicity
Hypertension and noise

Specificity
(Is the effect from only one cause?)
Showing that an
outcome is best
predicted by one
factor adds
credibility to a
causal claim
Ex. Silica and

Silicosis

Temporal Relationship
(Does the cause precede the effect ?)
The disease follows after exposure and

with an appropriate time interval
Ex. Person smoking for many years

results to his being diagnosed with cancer

Dose-Effect Relationship
(Is increased exposure to the possible cause associated with increased effect?)
The greater the level of exposure, the

greater the prevalence of severity of
disease

Biological Plausibility
Is association consistent with other knowledge? (evidence from animal studies)
An association is plausible/believable,
and thus more likely to be causal, if
consistent with other knowledge
Plausible
Benzene and malignancies
Asbestos and mesothelioma
Anthrax and animal handlers
Not plausible
trauma and breast cancer

Coherence
Is association coherent/do not conflict with other knowledge?
Clear association when it does not

conflict with what is already known
Smoking as cause of lung cancer is

based on epidemiologic, laboratory
animal, pharmacokinetic, clinical and
other biological data. It shows that all
available facts stuck together as a
coherent whole.

4.
Validity of Testimony
Non-professional persons cannot be

expected to collect and evaluate all of
the information needed.

4.
physicians will provide testimony on

medical conditions and laboratory and
other medical tests
industrial hygienists will testify
concerning evidence of exposure

4.
epidemiologists give testimony on

epidemiologic data
professionals must consider all
pertinent points in their area of
expertise in order to present an
accurate and meaningful evaluation of
the available data

4.
The examiner, board, commissioner, or

officer should verify:
the professional qualifications of those

testifying, and

4.
the basis of the testimony, that is, the

importance attributed to various areas of
the information reviewed, and the
conclusions that were drawn.

4.
the basis of the testimony, that is, the

importance attributed to various areas of
the information reviewed, and the
conclusions that were drawn.

Other Relevant Factors
5.
special circumstances
unusual events at work that reduced the
effectiveness of protective equipment
if the employee is a woman, are there
special risks to women from exposure to
the agent

6.
Conclusion
decision made would be based on

evidences presented

6.
1.
2.
3.
Conclusion
Has a disease condition been clearly
established?
Has it been shown that the disease
can result from the suspected
agent(s)?
Has exposure to the agent been
demonstrated? (by work history,
sampling data, expert opinion?)
6.
4.
Conclusion
Has exposure to the agent been
shown to be of sufficient degree
and/or duration to result in the
disease condition? (by scientific
literature, epidemiologic studies,
special sampling, replication of work
conditions?)

6.
5.
Conclusion
Has non-occupational exposure to
the agent been ruled out as a
causative factor?

6.
6.
Conclusion
Have all special circumstances been
weighed? Were there any -unusual
events at work that reduced the
effectiveness of protective
equipment? Of ventilation? Of safe
work practices? If the employee is a
woman, are there special risks to
women from exposure to the agent?
If so, this factor must be evaluated.
6.
7.
Conclusion
Has the burden of proof been met did the evidence prove that the
disease resulted from, precipitated by,
or was not aggravated by, conditions
at work?

Summary of Determining WorkRelatedness of Disease
Determination of accurate diagnosis

Occupational history/ Description of
working conditions

Summary of Determining WorkRelatedness of Disease
Literature review of materials/

substances used in work processes
Information on dose-response
relationship

Remember!!!!
Evaluation of diseases for workrelatedness must be based on sound

and logical medical and epidemiologic
evidences
The likelihood that an illness/ disorder
is from occupation depends on the
strength of supporting evidences

Remember!!!!
The concept of disease aggravation

from work exposure should be
considered in the medical assessment
for work-relatedness

THANK YOU!

Establishing The Work-Relatedness of Diseases

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Establishing

Department of Labor and Employment

Why Establishing Work-Connection

Cause-effect relationship between

Department of Labor and Employment

Why Establishing Work-Connection

symptoms of disease may be

Department of Labor and Employment

Why Establishing Work-Relatedness

not all individuals react in the same

Department of Labor and Employment

decision must be based on an

Department of Labor and Employment

Six Basic Steps

consideration of evidence of disease,

Department of Labor and Employment

Six Basic Steps

consideration of validity of testimony,

Department of Labor and Employment

The first consideration:

Department of Labor and Employment

Generally, a medical evaluation should

Department of Labor and Employment

Department of Labor and Employment

Factors Affecting Validity of

Occupational history may be

Generally, a medical evaluation should

a laboratory evaluation (analysis of the

Department of Labor and Employment

Other work-related medical

Department of Labor and Employment

Inquiry on timing of symptoms:

causing asthmatic signs and symptoms

either due to excessive concentrations of these agents

or because of exaggerated response by the individual worker

Department of Labor and Employment

Department of Labor and Employment

Department of Labor and Employment

The best evidence to confirm the

Department of Labor and Employment

Identification of agents/ factors that a

Department of Labor and Employment

The study of distribution and

Department of Labor and Employment

Point to high PROBABILITY or

Department of Labor and Employment

CAUSE (of disease) event, condition,

Department of Labor and Employment

Ex. foodborne disease outbreak

chicken salad and cream desert

Department of Labor and Employment

MECHANISMS FOR TUBERCULOSIS

Department of Labor and Employment

Considerations for Causation

What is the strength of association between the cause and

Have similar results been shown in other studies ?

Is the effect only from one cause?

Does the cause precede the effect ?

5. DOSE-RESPONSE Is increased exposure to the possible cause associated with

Is association consistent with other knowledge? (evidence from

Is association coherent (do not conflict) with other knowledge?

Strength of association between

Ex. The lung cancer rate for smokers is