The document discusses occupational disease reporting schemes in Ireland that are part of THOR (The Health & Occupation Reporting network). It describes several challenges with existing data sources on occupational illnesses, including underreporting, discrepancies between reported and actual cases, and differences between data sources. It also outlines several specialist reporting schemes in Ireland, including OPRA, MOSS, EPIDERM and SWORD, that aim to improve surveillance of occupational diseases by collecting medically-validated data directly from physicians.

1. Thor and icebergs ofThor and icebergs of
occupational diseaseoccupational disease
LFOM Course, 1LFOM Course, 1stst
February 2014February 2014
Faculty of Occupational Medicine, RCPI,Faculty of Occupational Medicine, RCPI,
Dr Peter Noone,Dr Peter Noone,
Consultant Occupational Physician,Consultant Occupational Physician,
H.S.E Dublin North-EastH.S.E Dublin North-East

2. ObjectivesObjectives
 To describe the Irish occupational reporting
schemes within THOR (The Health &
Occupation Reporting network),
 To discuss the benefits, advantages and
disadvantages of the schemes in providing
epidemiologic information regarding Occ Dse,
 To discuss steps to improve the quality and
value of the Irish reporting schemes
 To discuss future challenges/opportunities.

3. Looking out on the tips of the icebergsLooking out on the tips of the icebergs

4. BackgroundBackground
 Occupational diseases (ODs) and work-related injuries (WRI) impose aOccupational diseases (ODs) and work-related injuries (WRI) impose a
heavy burden on both workers and employers and represent enormousheavy burden on both workers and employers and represent enormous
economic costs.economic costs.
 In general the information on incidence and prevalence of occupationalIn general the information on incidence and prevalence of occupational
diseases is rather poor and fragmented.diseases is rather poor and fragmented.
 There is an urgent need to improve that, but in particular toThere is an urgent need to improve that, but in particular to
develop methods and instruments to trace new and emergingdevelop methods and instruments to trace new and emerging
occupational health (OH) risks.occupational health (OH) risks.
 The EU strategy for health and safety at work 2007-2012 underlinedThe EU strategy for health and safety at work 2007-2012 underlined
the need to reduce the incidence of ODsthe need to reduce the incidence of ODs
 A pre-requisite for realization of this new EU policy is a reliable andA pre-requisite for realization of this new EU policy is a reliable and
comparable system for monitoring ODs that makes it possible tocomparable system for monitoring ODs that makes it possible to
determine Europe wide trends using consistent methodologydetermine Europe wide trends using consistent methodology

5. Monitoring trends in Occupational DiseasesMonitoring trends in Occupational Diseases
and tracing new and Emerging Risks in aand tracing new and Emerging Risks in a
NETworkNETwork
 Modernet started in 2007 with a meeting between personnelModernet started in 2007 with a meeting between personnel
from the Coronel Institute on Work and Health, Amsterdamfrom the Coronel Institute on Work and Health, Amsterdam
University and staff from the Centre of Occupational andUniversity and staff from the Centre of Occupational and
Environmental Health (COEH), the University of ManchesterEnvironmental Health (COEH), the University of Manchester
 The Netherlands and the UK were shortly joined byThe Netherlands and the UK were shortly joined by
members from France and Italymembers from France and Italy
 Modernet gained COST (European Cooperation in ScienceModernet gained COST (European Cooperation in Science
and Technology) funding in 2010and Technology) funding in 2010
 Currently 19 countries within the EU participateCurrently 19 countries within the EU participate

6. Participating countries
UK
Republic of Ireland
Iceland
Spain
France
Norway
Finland
Italy
Belgium
Romania
The Netherlands
Germany
Czech Republic
Albania
Macedonia
Croatia
Bosnia & Herzegovina
Malta
Switzerland

7. Modernet working groupsModernet working groups
Working Group Name Aim
1 Quality of data Improvement of the quality of data
collection in occupational diseases
2 Trends analysis New techniques for analysis of trends in
occupational diseases
3 Tracing new risks New techniques for tracing newly
occurring occupational diseases
4 Dissemination Dissemination and implementation of
new knowledge on occupational diseases

8. Date range of computed data for independentDate range of computed data for independent
systemssystems

10. I = Incidence, P= Prevalence, B= Both, N=Neither

11. I = Incidence, P= Prevalence, B= Both, N=Neither

12. Levels of indicator dataLevels of indicator data
Work and health country profiles, Research Reports 44, Finnish Institute of occupational Health Helsinki 2001

13. Workers' Health Surveillance ILO 1997Workers' Health Surveillance ILO 1997
“Indicators are an essential tool in occupational health surveillance
including workers' health surveillance and work environment surveillance. It is the
ongoing systematic collection, analysis, interpretation, and dissemination of data
for the purpose of prevention, improving the health, work ability and wellbeing of
the labour force. Surveillance is essential for the planning, implementation and
evaluation of occupational health programmes, and the control of work-related ill
health and injuries, as well as the protection and promotion of the workers'
health”
Technical and Ethical Guidelines for Workers' Health Surveillance Report. International Labour Organisation, Geneva, 2–9 September 1997.
http://www.ilo.org/public/english/protection/ safework/health/whsguide.htm.

14. Information required toInformation required to
 Set priorities for preventive policy,Set priorities for preventive policy,
 To evaluate interventions,To evaluate interventions,
 To determine severity and duration of disease,To determine severity and duration of disease,
 To estimate the social and economicTo estimate the social and economic
consequences,consequences,
 To pick up newly emerging diseases andTo pick up newly emerging diseases and
 To communicate this to all stakeholders.To communicate this to all stakeholders.

15. Prevention of occupational illnessPrevention of occupational illness
 Societal/national level:Societal/national level:
 Regulatory action,Regulatory action,
 National policy,National policy,
 What’s needed;What’s needed;
 Incidence of OD,Incidence of OD,
 By economic sector,By economic sector,
 By occupations,By occupations,
 Information on,Information on,
 Consequences- absence,Consequences- absence,
compensation,compensation,
 New hazards/risksNew hazards/risks
 Workplace level:Workplace level:
 Nature of hazard,Nature of hazard,
 Where encountered,Where encountered,
 Options for health riskOptions for health risk
management.management.

16. OH&S surveillance Indicators(1)OH&S surveillance Indicators(1)
 An indicator indicates some quality, change, etc., of a
situation or system, and draws attention or gives
warning,
 Ideally quantitative, but maybe qualitative,
 WHO has proposed four categories of indicators:
 health policy indicators;
 Social and economic indicators;
 indicators of health care delivery; and
 indicators of health status , including quality of life.

17. OH&S surveillance Indicators(2)OH&S surveillance Indicators(2)
 Valid:Valid: - measures what it is supposed to measure
 Objective:Objective: - precise, reliable- low inter/intra rater variability.
 Sensitive:Sensitive: - low FN, and
 Specific:Specific: - low FP, reflects changes only in the situation or
phenomenon concerned.

18. The 2 purposes of surveillanceThe 2 purposes of surveillance
 Monitor:Monitor:
 Nature,Nature,
 Magnitude,Magnitude,
 Distribution of disease byDistribution of disease by
 Sector,Sector,
 Occupation,Occupation,
 Age,Age,
 Gender,Gender,
 Other groups.Other groups.
 Alert:Alert:
 to new agents orto new agents or
 interaction betweeninteraction between
existing occupational riskexisting occupational risk
factors and diseases.factors and diseases.

19. Occupational illnessOccupational illness
 OSHA defines: “OSHA defines: “any abnormal condition/disorder, apartany abnormal condition/disorder, apart
from occupational injuries, caused by factors associated withfrom occupational injuries, caused by factors associated with
employment”,employment”,
 Occupational disease is difficult to recognise,Occupational disease is difficult to recognise,
 OD’s challenge successful OH&S programmes,OD’s challenge successful OH&S programmes,
 Beneath the surface lurks large numbers of OD’sBeneath the surface lurks large numbers of OD’s
that fail to be recognised or reported,that fail to be recognised or reported,
 Cases reported in statistics are the tip of the iceberg.Cases reported in statistics are the tip of the iceberg.

20. ILO dataILO data
 Estimates of work-related disease mortality use
attributable fractions (AF) for specific disease categories and
injuries.
 AF is the fraction of a disease [or injury] which would notwould not
have occurredhave occurred but for the factor being in the population
studied. AFs expressed as percentage for different diseases.
 Categories are based on existing exposure data to known
work-related disease factors and the impact on exposure -
outcome relationship and morbidity to these diseases, mainly
in industrialized countries.
Nurminen M, Karjalainen A.: Epidemiologic estimate of the proportion of fatalities related to
occupational factors in Finland. Scand J., Work Environment Health 2001; 27(3):161-213

21. AF or PARAF or PAR
 The strength of the AF method is that it looks at the
total burden of disease related to work,
 Weakness of PAR is whether studies defining RR
generalize to exposures in other countries/populations,
 conversely, expediting studies of RR on a population for
which relevant exposure data is available.
 the weakness of the method is the difficulty of obtaining
reliable estimates of risk and of exposure, given that
both are continuous rather than discrete variables.

22. Global burdenGlobal burden
 The ILO estimatesThe ILO estimates
globally, 2.2 millionglobally, 2.2 million
people die annually frompeople die annually from
occupational injury andoccupational injury and
illness. illness.
 Of this about 350,000Of this about 350,000
deaths are due to fataldeaths are due to fatal
occupational injuries;occupational injuries;
 ILO estimates 1,224ILO estimates 1,224
deaths/annum in ROIdeaths/annum in ROI
due to WRIdue to WRI

23. EU Stats on OD/illnessEU Stats on OD/illness
 EU list of OD’s but effectiveness limited;EU list of OD’s but effectiveness limited;
 Differences in diagnostic guidelines,Differences in diagnostic guidelines,
 criteria for notification,criteria for notification,
 Culture, legislation, social security regulations,Culture, legislation, social security regulations, ((Blandin et al 2002).Blandin et al 2002).
 Greece incidence OD in 2001 was 3.4/100,000Greece incidence OD in 2001 was 3.4/100,000
employee years,employee years, (Axelopoulus et al 2005).(Axelopoulus et al 2005).
 Finland in 2002 was 200/100,000Finland in 2002 was 200/100,000 employee years,employee years,
(Riihimaki et al 2004),(Riihimaki et al 2004),
 EU Mean 2001 was 37/100,000 employee yearsEU Mean 2001 was 37/100,000 employee years..
(Karjalainen & Niederlaender, 2004).(Karjalainen & Niederlaender, 2004).

24. Sources of data on occupational illness ROISources of data on occupational illness ROI
 Central Statistics Office (CSO) through the
Quarterly National Household Survey (QNHS),
 The DSFA through the Occupational Injuries
Benefit (OIB) (illness) and Disability Benefit
schemes,
 Death certification data,
 Focused Epidemiological studies,
 Specialist reporting schemes: Epiderm, SWORD,
OPRA.

25. Critical analysis of data sources(1)Critical analysis of data sources(1)
 CSO data representative of the working population butCSO data representative of the working population but
relies on lay perceptions without objective validation,relies on lay perceptions without objective validation,
overestimate work, downplay lifestyleoverestimate work, downplay lifestyle.(Abba et al 2004).(Abba et al 2004)
 Incomplete statutory notification of OD disease withIncomplete statutory notification of OD disease with
numerous biases interposing between the occurrence of thenumerous biases interposing between the occurrence of the
disease and administrative recording,disease and administrative recording,
 Death registration and cause specific mortality dataDeath registration and cause specific mortality data
associated with specific occupations (the decedent’s lastassociated with specific occupations (the decedent’s last
full-time occupation) can indicate possible occupationalfull-time occupation) can indicate possible occupational
health risks. Last or most prestigious occupation may behealth risks. Last or most prestigious occupation may be
recorded rather than job(s) done for the greater part of life,recorded rather than job(s) done for the greater part of life,
 Reporting of compensation from courts or PIAB has biasReporting of compensation from courts or PIAB has bias
due to the official bureaucratic and common law selectiondue to the official bureaucratic and common law selection
mechanisms.mechanisms.

26. Critical analysis of data sources(2)Critical analysis of data sources(2)
 Focussed epidemiologic studies: cross-sectional orFocussed epidemiologic studies: cross-sectional or
longitudinal provide most valid data on frequencylongitudinal provide most valid data on frequency
(prevalence or incidence) of OD, but expensive, time(prevalence or incidence) of OD, but expensive, time
consuming,consuming,
 Reporting schemes based on confidential anonymousReporting schemes based on confidential anonymous
reports from physicians and a range of hospital basedreports from physicians and a range of hospital based
specialities can provide national surveillance of medicallyspecialities can provide national surveillance of medically
validated data on reported incidence of occupational orvalidated data on reported incidence of occupational or
work-related disease.work-related disease.

27. Reasons for discrepancyReasons for discrepancy
 Natural history and causation of disease
 Long latency, e.g .mesothelioma after asbestos exposure
 Multi-factorial aetiology, eg tobacco smoking may be blamed for symptoms of occupational lung
disease
 Workers’ attitudes and knowledge
 Unawareness of the links between work and health
 Fear of the consequences of reporting
 Not perceived as worthwhile to pursue compensation
 Employers’ attitude and knowledge
 Unawareness or ignorance or lack of concern regarding the links between work and health
 Fear of the consequences of reporting
 Doctors’ attitudes, skills and knowledge
 Unawareness of the links between work and health
 Not enough time and/or skills for adequate medical history
 Quicker to prescribe treatment for back pain, asthma, dermatitis, etc than to fully investigate the
cause

28. Discrepancy(2)Discrepancy(2)
 Governmental and other organisational
factors
 Death registration in UK/ROI only requires
notification of last full-time job
 No automatic linkage between NHS/health service
information about people’s health and information
relating to their employment (eg National
Insurance/PPSN No.)

29. IncidenceIncidence
 Numerator: Number of cases (definition, recognition,
ascertainment) divided by,
 …Denominator: Number of workers in the population from
which the cases arose (definition, ascertainment,
categorisation), per
 …Unit time: (usually per annum)
 (Related parameters: especially exposure modelling)

30. The general principle: Numerator/DenominatorThe general principle: Numerator/Denominator

31. Underestimating the numeratorUnderestimating the numerator

32. Overestimating the denominatorOverestimating the denominator

34. General Practitioner
Clinical Specialist
Occupational Physician
THOR-GP
The Health & Occupation
Reporting network in
General Practice
SWORD
Surveillance of Work-
related & Occupational
Respiratory Disease
OPRA
Occupational Physicians
Reporting Activity
EPIDERM
Occupational Skin
Surveillance
MOSS
Musculoskeletal
Occupational
Surveillance
Scheme
SOSMI
Surveillance of
Occupational Stress &
Mental Illness

35. OPRA
(Occupational Physicians
Reporting Activity)
MOSS
(Musculoskeletal Occupational
Surveillance Scheme)
Rheumatologists
OSSA & ENT
(Occupational Surveillance
Scheme for Audiological &
Ear, Nose & throat physicians)
ENT & Audiological Physicians
SIDAW
(Surveillance of Infectious
Diseases At Work)
Consultants in Communicable
Disease Control
EPIDERM
(Occupational Skin Surveillance)
Dermatologists
SWORD
(Surveillance of Work-related
and Occupational Respiratory Disease)
Chest Physicians
SOSMI
(Surveillance of Occupational
Stress and Mental-illness)
Psychiatrists
THOR
The Health & Occupation Reporting network
THOR-GP
(THOR in General Practice)
General Practitioners

36. Irish specialist physician schemesIrish specialist physician schemes
 EPIDERM and SWORD in the Republic of Ireland began in JanuaryEPIDERM and SWORD in the Republic of Ireland began in January
20052005
 2007 funding award from the Republic of Ireland2007 funding award from the Republic of Ireland
Health and Safety Authority to continue and expandHealth and Safety Authority to continue and expand
the Irish schemesthe Irish schemes
 OPRA in the Republic of Ireland began in January 2007OPRA in the Republic of Ireland began in January 2007
 The webform can be accessed via the following address:The webform can be accessed via the following address:
http://www.medicine.manchester.ac.uk/coeh/thor/schemes/irelandhttp://www.medicine.manchester.ac.uk/coeh/thor/schemes/ireland
 Each reporter has their own individual username and passwordEach reporter has their own individual username and password

39. ROI NI GB
Occupational Physicians 23 22 485
Dermatologists 14 9 269
Chest physicians 11 15 660
TOTAL 48 43 1366
Population 4.5M 2M 60M
Number of chest physicians, dermatologists and
occupational physicians participating in THOR
ROI, NI and GB as of December 2012

40. OPRA

44. Reports (cases and nil returns) in ROI-EPIDERM (2005-2012), ROI-SWORD (2005-
2012) and ROI-OPRA (2007-2012)
SWORD and
EPIDERM start

45. Cases per active reporter* in ROI-EPIDERM (2005-2012), ROI-SWORD (2005-2012)
and ROI-OPRA (2007-2012)
*An active reporter is defined as someone who returns a case report or a
response of ‘I have nothing to report’ response in a calendar year.

46. Disease categories reported by dermatologists to
EPIDERM GB, NI and ROI (2005-2012)
N = 365
N = 15847 N = 436

48. Skin and respiratory disease reported toSkin and respiratory disease reported to
OPRA ROI, 2007-2012OPRA ROI, 2007-2012
90 skin diagnoses
• 80/90 (89%) CD. Other diagnoses included, contact urticaria,
infective (tinea and scabies), mechanical (scratch)
• Most frequently reported agents were wet work (30% of cases),
protective clothing and equipment (25%), soaps and detergents (21%),
sterilising and disinfecting agents (16%) and rubber materials and chemicals
(12%). Other agents included bleach, hairdressing chemicals, preservatives,
high temperature, synthetic coolants, platinum, pesticides, insect bites
and epoxy resins.
17 respiratory diagnoses
• 6/17 (35%) asthma, 4/17 (24%) inhalation accidents, 3/17 (18%)
bronchitis, 1 each of sinusitis, rhinitis, tuberculosis and upper respiratory
tract infection
• Agents included: chlorine disinfectant, acetic acid, wood dust,
chlorine dioxide, grain, potassium dichromate, sanitizer fumes, cleaning
agents, denatured ethanol (IMS)/isopropyl alcohol (IPA), and high
temperatures.

49. Disease categories reported by occupational physicians
to OPRA GB, NI and ROI (2007-2012)
N = 33273 N = 3344
N = 963

52. EPIDERM

53. N= 182ROI
Contact dermatitis 320 (96%)
• Allergic • 170 (53%)
• Irritant • 122 (38%)
• Mixed • 27 (8%)
• Unclear • 1 (<1%)
Contact urticaria 3 (<1%)
Folliculitis/acne 1 (<1%)
Infective 0
Mechanical 0
Nail 0
Neoplasia 0
Other dermatoses 0
Total cases 333
Total diagnoses 324 (100%)
Number and type of diagnoses reported by
dermatologists to EPIDERM (2005-2011)

54. Proportion of cases of contact dermatitis reported to ROIProportion of cases of contact dermatitis reported to ROI
EPIDERM by Standard Industrial Classification (SIC)EPIDERM by Standard Industrial Classification (SIC)
2005-20112005-2011

55. Proportion of cases of contact dermatitis reported to ROIProportion of cases of contact dermatitis reported to ROI
EPIDERM by Standard Occupational Classification (SOC)EPIDERM by Standard Occupational Classification (SOC)
2005-20112005-2011

56. Proportion of cases of contact dermatitis reported to ROIProportion of cases of contact dermatitis reported to ROI
EPIDERM by age and gender (2005-2011)EPIDERM by age and gender (2005-2011)

57. Most frequently reported agents for contact dermatitis, reported by dermatologists to ROI
EPIDERM (2005-2011)
Number / %age
Rubber chemicals & materials 64 (20%)
Wet work 52 (16%)
Nickel & its compounds 49 (15%)
Chromium & its compounds 36 (11%)
Preservatives 31 (10%)
Cobalt & its compounds 22 (7%)
Hairdressing chemicals 15 (5%)
PPE 15 (5%)
Foods, additives & flavourings 13 (4%)
Soaps & detergents 13 (4%)
Drugs & medicaments 13 (4%)
Epoxy resins 14 (4%)
Perfumes & fragrances 11 (3%)
PPD 11 (3%)
Plants 8 (3%)
Number of cases 318

82. SWORD

83. Number and type of diagnoses reported by chest physicians to ROI
SWORD (2005-2011)
ROI
Asthma 43 (41%)
Inhalation accidents 9 (9%)
Allergic alveolitis 3 (3%)
Bronchitis/ emphysema 3 (3%)
Infectious disease 0
Non-malignant pleural
disease
18 (17%)
Mesothelioma 5 (5%)
Lung cancer 6 (6%)
Pneumoconiosis 10 (10%)
Other respiratory 7 (7%)
Total cases 94
Total diagnoses 104 (100%)

84. Proportion of cases of respiratory disease reported to ROIProportion of cases of respiratory disease reported to ROI
SWORD by Standard Industrial Classification (SIC) 2005-2011SWORD by Standard Industrial Classification (SIC) 2005-2011

85. Proportion of cases of respiratory disease reported to ROIProportion of cases of respiratory disease reported to ROI
SWORD by Standard Occupational Classification (SOC)SWORD by Standard Occupational Classification (SOC)
2005-20112005-2011

86. Frequently reported suspected agentsFrequently reported suspected agents
for cases of occupational asthma in ROIfor cases of occupational asthma in ROI
 43 diagnoses of occupational asthma associated with 3743 diagnoses of occupational asthma associated with 37
different agents...different agents...
 Isocyanates most frequently reported.Isocyanates most frequently reported.
 Other reported suspected agents:Other reported suspected agents:
 inks; cement, plaster and masonry; acids;inks; cement, plaster and masonry; acids;
ammonia; hairdressing chemicals and dyesammonia; hairdressing chemicals and dyes
and pigments.and pigments.

91. Issues(1)Issues(1)
 STRUCTURALSTRUCTURAL
 Participation of physicians (proportion of potentialParticipation of physicians (proportion of potential
reporters),reporters),
 Criteria or guidelines for notification,Criteria or guidelines for notification,
 Education and training for reporting physicians,Education and training for reporting physicians,
 PROCESSPROCESS (dx and notification)(dx and notification)
 Coverage- employee access to reporting physicians,Coverage- employee access to reporting physicians,
 Completeness of registration, (participation rates),Completeness of registration, (participation rates),
 Investigation of special cases.Investigation of special cases.

92. Issues (2)Issues (2)
 PROCESSPROCESS Contd:Contd:
 All companies in Netherlands >1 employee legallyAll companies in Netherlands >1 employee legally
required to have OH provider, 6.116 million employees,required to have OH provider, 6.116 million employees,
1774 OH physicians. No compensation for OD and1774 OH physicians. No compensation for OD and
notification only for preventive purposes.notification only for preventive purposes.
 OUTCOME:OUTCOME:
 OD incidence rates and distribution for working pop,OD incidence rates and distribution for working pop,
 OD incidence rates by sector and by occupation,OD incidence rates by sector and by occupation,
 OD distribution by age, gender other socio-OD distribution by age, gender other socio-
demographic factors.demographic factors.
 Avoid poor registration interpreted as ‘low level of risk’,Avoid poor registration interpreted as ‘low level of risk’,
‘registration paradox’.‘registration paradox’.

93. ConclusionConclusion
 A sentinel surveillance group comprising ofA sentinel surveillance group comprising of
motivated trained physicians provides moremotivated trained physicians provides more
notifications per employee/year than nationalnotifications per employee/year than national
administrative registers.administrative registers.
 No perfect alternatives- no other reliable nationalNo perfect alternatives- no other reliable national
estimates of incidence or trends in presentations ofestimates of incidence or trends in presentations of
OD,OD,
 Other sources of info but all designed for differentOther sources of info but all designed for different
purposes and inherent problems of their own.purposes and inherent problems of their own.

94. Is the iceberg melting?

95. AcknowledgementsAcknowledgements
 EPIDERM, OPRA, SWORD participants,EPIDERM, OPRA, SWORD participants,
 Health & Safety Authority,Health & Safety Authority,
 Prof Raymond Agius, Dr M Carder, AnneMarieProf Raymond Agius, Dr M Carder, AnneMarie
Money, THOR team, Centre for Occupational andMoney, THOR team, Centre for Occupational and
Environmental Health, University of Manchester,Environmental Health, University of Manchester,
http://www.medicine.manchester.ac.uk/coeh/thor/http://www.medicine.manchester.ac.uk/coeh/thor/
 Dick Spreeuwers, Coronel Institute ofDick Spreeuwers, Coronel Institute of
Occupational Health, University of Amsterdam, theOccupational Health, University of Amsterdam, the
NetherlandsNetherlands

96. Thank-you for listening!Thank-you for listening!