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Occupational Medicine 2005;55:275–281 doi:10.1093/occmed/kqi109 Work-related infectious disease reported to the Occupational Disease Intelligence Network and The Health and Occupation Reporting network in the UK (2000–2003) S. Turner, S. Lines, Y. Chen, L. Hussey and R. Agius ............................................................................................................................................................ Background Infectious diseases remain an important cause of self-reported work-related illness, with socioeconomic consequences, including sickness absence. Reporting of infectious disease by occupational and specialist physicians is an important tool in the investigation of occupationally related infections and is relevant in their management. ............................................................................................................................................................ Aims To examine the reporting of cases of infectious disease by occupational and specialist physicians to schemes collecting data on occupational ill-health. ............................................................................................................................................................ Methods Cases of infectious disease reported by occupational and specialist physicians to the UK based schemes, Occupational Disease Intelligence Network (ODIN) and The Health and Occupation Reporting network (THOR), from 2000 to 2003 were analysed by reporting patterns, diagnosis, single case or outbreak reporting and industry. ............................................................................................................................................................ Results The total number of estimated cases of infectious disease reported to ODIN and THOR from 2000 to 2003 was 5606; 74.9% cases were diarrhoeal disease, and 11.1% scabies. The majority (81.4%) of cases were reported in SIDAW, where the participation rate for reporters was 55%. Reporting rates were much higher in OPRA, SWORD and EPIDERM (ranging from 86 to 96%). The most frequently reported industrial sectors were social care (39.5%) and health (29.4%); while the manufacture of chemical products contributed 4.3% overall, but 33.8% to estimated cases in OPRA. ............................................................................................................................................................ Conclusions Despite limitations related to under reporting, the occupational and specialist physician schemes in ODIN and THOR provide data that may be used to look at patterns of case reporting for occupational ill-health, including infectious disease. The reporting schemes also provide an important means of alerting peers about potential novel causes, precipitating factors, or industrial sectors associated with occupational disease. ............................................................................................................................................................ Key words Epidemiology; incidence; infection; occupational disease; respiratory; skin disease; surveillance; work. ............................................................................................................................................................ Introduction In a recent survey of self-reported work-related illness an estimated 32.9 million days were lost in 2001 – 2002 in Great Britain through illness caused or made worse by work, involving an estimated 2 328 000 people [1]. The most commonly reported reasons were musculoskeletal disorders and psychological ill-health (estimated at 1 126 000 and 563 000 people ever employed, Centre for Occupational and Environmental Health, University of Manchester, Manchester, UK. Correspondence to: S. Turner, University of Manchester, Centre for Occupational and Environmental Health, 4th Floor, C Block, Humanities Building, Devas Street, Oxford Road, Manchester M13 9PL, UK. e-mail: [email protected] respectively), while a prevalence estimate for infectious diseases was 33 000. In addition to these data based on self-reporting, there are surveillance schemes operating in the UK involving specialist physicians. Occupationally related infectious disease is reported by specialists to the following schemes; occupational physicians to OPRA, consultants in communicable disease control (CCDCs) and public health medicine to SIDAW, dermatologists to EPIDERM and respiratory physicians to SWORD. There are a further three surveillance schemes for rheumatologists (MOSS), psychiatrists (SOSMI) and consultants in audiological medicine (OSSA), but these are involved in reporting of non-infective work-related cases. These q The Author 2005. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: [email protected] 276 OCCUPATIONAL MEDICINE seven reporting schemes made up the Occupational Disease Intelligence Network (ODIN) that operated until 2002 when ODIN was succeeded by The Health and Occupation Reporting network (THOR). Recent data (from 2003) show that more than 2000 physicians throughout the UK are reporters to THOR. The reporting schemes provide estimates of the incidence of occupational disease or disorders and information to further the understanding of causation (or aggravation) of conditions by work. In 1996 –1997, 1037 (80.1%) of the 1294 cases of occupationally acquired infectious disease were reported to SIDAW (rather than to OPRA, EPIDERM, or SWORD) [2]. The majority of cases and information collected by OPRA, EPIDERM and SWORD [3 –5] involved non-infectious diseases, for example workrelated musculoskeletal disorders, contact dermatitis and occupational lung diseases for each of these schemes, respectively. However, the potential impact of transmitted infective diseases on an individual worker (for example, hepatitis and HIV) and the workforce or general public [for example, influenza and methicillin-resistant Staphylococcus aureus (MRSA)] cannot be overestimated. This paper provides information on work-related infectious diseases reported to SIDAW, OPRA, EPIDERM and SWORD from 2000 to 2003, including reporting of outbreaks as well as single cases of disease. Methods Reporters to OPRA, EPIDERM, SWORD and SIDAW are asked to report new cases of occupationally acquired disease, and the methodology has been described in detail previously [2 – 5]. In all four reporting schemes the physician is asked to return information on age, gender, geographical location (‘first half ’ of postcode, i.e. area and district or town), occupation, workplace and agent (for example, TB). For the purpose of this study infectious disease cases including infestation (commonly scabies) that were returned to the reporting schemes have been analysed. Participating consultants are asked to report diseases based on their clinical judgement that have either been caused or aggravated by work. Precise criteria and definitions are not imposed. In addition, reporters are not requested to carry out investigations beyond those necessary on clinical grounds (for example, in order to confirm a diagnosis). When SIDAW was set up (in 1996) the reporting group was largely made up of CCDCs in public health medicine. Data from March 2004 gave the breakdown of reporters in SIDAW as CCDCs (72%), consultants in health protection (15%), public health consultants (8%) and a miscellaneous category making up the remaining 5%. In SIDAW reporters allocate cases into eight specified disease categories (plus 1 for ‘other’ diseases that the reporter is asked to specify). The disease categories are: brucellosis, hepatitis, legionellosis, leptospirosis, ornithosis, pulmonary TB, Q fever and diarrhoeal disease. Further information on single sporadic cases or outbreaks (of two or more associated cases) is also requested. Reporters are asked to return a reporting card each month, including blank returns. In EPIDERM and SWORD, participating physicians are asked to report on a full range of occupational skin and respiratory diseases respectively, with infective causes making up one of the major sub groups on the reporting card. In OPRA, occupational physicians are asked to return case details for all causes of occupational ill-health including: respiratory, skin, musculoskeletal, hearing loss, stress/mental illness and ‘other’ diseases (infection is included in this category). Information on diagnoses is coded using the International Classification of Disease, 10th Revision (ICD-10) [6], to allow comparison of data between specialist reporting schemes. In SIDAW, all participating physicians are requested to return a reporting card every month, while in OPRA, EPIDERM and SWORD there are two groups of reporters; ‘core’ reporters who return a reporting card every month and ‘sample’ reporters who return a reporting card for one randomly selected month per calendar year. In SIDAW, as all participating physicians are ‘core’ reporters the actual number of cases reported is used to produce an annual rate. In OPRA, EPIDERM and SWORD an estimated number of cases reported in a calendar year is calculated by multiplying the number of cases returned by ‘sample’ reporters by 12, and adding this subtotal to the number of cases returned by ‘core’ reporters to produce an estimated total. Information on occupation is coded using the Standard Occupational Classification [7 – 8], and that on workplace or industry using the Standard Industrial Classification [9]. Postcode data is used to group information according to the geographical classification used by the Labour Force Survey (LFS) [10]. Prior to 2003, duplicate reports were identified and excluded by searching the ODIN and THOR databases. This checking process was discontinued in 2003, as the information that allowed duplicates to be detected (such as date of birth) could no longer be recorded according to the ethical approval given to THOR. However, based on the assessment of reported cases 1999 – 2002 in ODIN and THOR, the proportion of duplicate reporting within groups of specialists was 2.4% for ‘core’ reporting and 0.4% for ‘sample’ reporting. Summaries of information collected from all the schemes are produced every 3 months and the results are circulated to reporting physicians. In addition, these S. TURNER ET AL.: WORK-RELATED INFECTIOUS DISEASE 277 quarterly reports provide updates on reporting scheme developments and commentaries on cases or topics of interest. Multicentre Research Ethics Committee approval has been given for the THOR project. Results Within THOR as a whole, the proportion of cases reported via SIDAW is small (only 4.9% in 2003). In comparison, occupational physicians reporting to OPRA contributed the highest overall proportion of cases (49.2% in THOR in 2003), with OPRA cases encompassing a wide range of occupational diseases, and infectious disease making up only 0.3% of OPRA case reports. From 2000 to 2003, the total number of estimated cases of infectious disease reported to the surveillance schemes in ODIN and THOR was 5606. The majority (81.4%) were reported in SIDAW, with 12.7% in OPRA, 2.4% in SWORD and 3.4% in EPIDERM. Overall, diarrhoeal disease was the most frequently reported disease category with 4197 estimated cases (74.9% of the total estimated cases), followed by scabies with 623 (11.1%) estimated cases (Table 1). Infectious diseases categorized as ‘other’ in the reporting schemes Diseases categorized as ‘other’ within SIDAW accounted for 38 cases; 13 cases of malaria, 5 of meningitis, 3 of varicella, 2 of paratyphoid and the rest were either single cases (including one report of MRSA) or the agent was unspecified. In OPRA, all cases within the ‘other’ infective disease category were reported by ‘sample’ reporters (23 reports, 276 estimated cases), with MRSA being most frequently reported along with dermatophytoses (60 estimated cases each), followed by varicella (24 estimated cases). Again the remainder comprised single case reports of specific diseases, or the reporter did not specify the infective agent. There were only five reports (38 estimated cases) from SWORD physicians in the ‘other’ infection category; four reports where the agent/diagnosis was unspecified and one of atypical mycobacterial infection. In EPIDERM, the 25 ‘other’ infective reports (168 estimated cases) were largely made up of warts (61 estimated cases) and tinea (32 estimated cases), with staphylococcal infections contributing 25 estimated cases (including one case of MRSA) and orf adding a further 13. Reporting patterns Participation by reporters, calculated from the mean number of cards returned per year, was 55% within SIDAW but much higher (ranging from 86 to 98%) for OPRA, SWORD and EPIDERM. The proportion of cards containing case reports was also lowest for SIDAW (15%), and ranged from 26 to 83% for the other groups of reporters (Table 2). Within SIDAW, reporting patterns throughout two calendar years (2002– 2003) were studied; 54.3% reporting cards were returned (80.5% nil returns, 19.5% with cases). The total number of cases reported in this time period was 2252, with an average of 188 cases each month. The number of physicians participating in SIDAW in 2002 – 2003 ranged from 87 to 100. The percentage of reporting cards returned each month over this period did not show any particular trend, while the percentage of cards returned with no cases to report rose marginally. The proportion of cases reported each month Table 1. Infectious disease cases reported to SIDAW, OPRA, SWORD and EPIDERM by disease category (2000– 2003) Disease category SIDAW OPRA a Actual Estimated Actual Estimated Actual Estimated 26 7 12 1 1 8 1 2 2 4 12 7 83 268 84 12 12 12 19 1 24 2 48 144 84 710 0 0 0 0 6 1 3 12 0 5 0 0 27 0 0 0 0 17 1 3 78 0 38 0 0 137 0 3 0 0 0 0 0 0 0 0 25 0 28 0 25 0 0 0 0 0 0 0 0 168 0 193 Actual Diarrhoeal disease Scabies Brucellosis Hepatitis Legionellosis Leptospirosis Ornithosis Pulmonary TB Q Fever Other—respiratory Other—skin Other—unspecified Total a 3929 514 15 3 13 16 6 29 3 0 0 38 4566 SWORD There are no ‘sample’ reporters in SIDAW, therefore no estimated cases in this reporting scheme. EPIDERM 278 OCCUPATIONAL MEDICINE Table 2. Participation by reporters in SIDAW, OPRA, SWORD and EPIDERM (2000 –2003) SIDAW OPRA sample OPRA core SWORD sample SWORD core EPIDERM sample EPIDERM core Mean number of reporters/year Mean number (%) of cards returned/year Mean number (%) of cards returned with case reports 102 592 13 428 22 183 24 57 (55) 519 (88) 13 (86) 366 (86) 21 (96) 153 (86) 23 (98) 10 (15) 259 (50) 3 (26) 100 (27) 15 (71) 56 (37) 19 (83) ranged from less than 1 to 26%, with a rise seen over the winter period 2002 –2003 (Figure 1). Distribution of cases by industry Overall, cases from the social care and health sectors made up the majority of reports to ODIN and THOR between 2000 and 2003 (39.5% in social care and 29.4% in health). In SIDAW this pattern of the social care and health sectors contributing the highest proportions of cases was repeated, with 47.7 and 28.6% cases, respectively (Table 3). Health care was also the most frequently reported industrial group in SWORD (55.5%) and EPIDERM (19.7%) and second (32.1%) only to manufacture of chemical products (33.8%) in OPRA. However, in OPRA this high frequency in the manufacture of chemical products sector resulted from a single reporter returning 95% cases; these cases of infectious Cards returned * 120 Cards returned without cases+ Cases reported^ 100 Percentage 80 60 40 20 p ov N Se ar n ay Ju l M M p ov Ja N l Ju Se ar ay M M Ja n 0 Figure 1. Reporting patterns within SIDAW in 2002 and 2003. *Calculated by (cards returned/cards sent to reporters) £ 100. þ Calculated by (cards returned without cases/cards returned) £ 100. ^Calculated by (number of cases/number of cases per calendar year) £ 100. disease were not specifically related to the industry (the diagnosis given was viral gastroenteritis). Within EPIDERM, the two other industrial groups that were frequently reported were the manufacture of food products and beverages (18.7%) and social care (12.4%). Of note, the 400 cases in ‘financial intermediation’ in SIDAW are explained by a single outbreak of diarrhoeal disease attributed to a Small Round Structured Virus. Outbreaks and single case reporting Information relating to outbreaks and single cases of infection is requested on the SIDAW reporting card, with 4566 cases reported (2000 –2003). The majority (3929, 86.0%) of SIDAW cases were diarrhoeal disease, with scabies being the next most frequently reported disease category (514 cases, 11.3%), and a miscellaneous group comprising the 123 (2.7%) remaining cases. In SIDAW the number of outbreaks reported was 430, while the number of single cases was 356 (Table 4). Outbreaks made up the vast majority of diarrhoeal disease cases (3683/3929; 93.7%) and scabies cases (490/514; 95.3%) reported to SIDAW, but only 30.1% (37/123) of the miscellaneous case reports. For diarrhoeal disease, reported outbreaks varied in size from two to more than 100 cases, with 355 outbreaks of diarrhoeal disease being reported in total (Table 5). The majority (79.4%) of diarrhoeal outbreaks contained between 2 and 10 cases. As expected, however, outbreaks involving large numbers contributed substantially to the total number of cases reported, with the two outbreaks containing over 100 cases (144 and 400 cases) making up 11.9% of all cases reported to SIDAW (2000 – 2003). The pattern of outbreaks for scabies cases (62 in total) is also shown in Table 5, with 66.1% of outbreaks containing between 2 and 10 cases. The two largest outbreaks (of 30 and 42 cases) contributed 1.6% to the total number of cases reported to SIDAW in the 4 year period 2000 – 2003. There were 13 miscellaneous outbreaks (cases that were not diarrhoeal disease or scabies), all containing fewer than 10 cases (Table 5). The largest outbreak was S. TURNER ET AL.: WORK-RELATED INFECTIOUS DISEASE 279 Table 3. Distribution of infectious disease cases reported to four schemes within THOR by industry Industry SIDAW cases (actual) n (%) OPRA cases (estimated) n (%) Social care Health Financial intermediation Hotels and restaurants Manufacture of food products and beverages Education Agriculture Public administration and defence Retail Manufacture of chemical products Other industries Unspecified Total 2176 (47.7) 1305 (28.6) 400 (8.8) 246 (5.4) 83 (1.8) 12 228 0 0 8 (1.7) (32.1) (0.0) (0.0) (1.1) SWORD cases (estimated) n (%) EPIDERM cases (estimated) n (%) 0 (0.0) 76 (55.5) 0 (0.0) 12 (8.8) 0 (0.0) 24 38 0 0 36 (12.4) (19.7) (0.0) (0.0) (18.7) 71 (1.6) 63 (1.4) 25 (0.5) 13 (1.8) 8 (1.1) 62 (8.7) 12 (8.8) 0 (0.0) 3 (2.2) 12 (6.2) 16 (8.3) 12 (6.2) 20 (0.4) 1 (0.0) 0 (0.0) 240 (33.8) 12 (8.8) 0 (0.0) 12 (6.2) 0 (0.0) 64 (1.4) 112 (2.5) 4566 (100) 139 (19.6) 0 (0.0) 710 (100) 21 (15.3) 1 (0.7) 137 (100) 31 (16.1) 12 (6.2) 193 (100) of malaria in members of the armed forces, and involved eight cases. A breakdown of diagnoses for these 13 miscellaneous outbreaks is shown in Table 6. Discussion Underestimation of disease using this methodology is inevitable (for example, if ODIN and THOR data are used to calculate incidence rates), as might be extrapolated from the proportion of cards enclosing case reports. However, there is a very high return rate for cards (of 86% or more) for all groups of reporters in OPRA, SWORD and EPIDERM. In addition, the continued participation of specialists within the occupational disease surveillance schemes in the UK is encouraging, especially as these four voluntary reporting schemes have all run in excess of 8 years, and some for considerably longer (SWORD originated in 1989) [5]. The lower return rate seen for SIDAW reporters (55%) might be explained by there being other reporting schemes in existence for infectious diseases, for example the surveillance of significant exposure to bloodborne viruses in health care workers [11] and the mandatory MRSA surveillance system for patients [12]. Alternatively, in comparison to the other groups of reporters (occupational physicians, respiratory physicians and dermatologists) SIDAW reporters are most frequently CCDCs (72% of SIDAW reporters in 2004), may have less face-to-face contact with patients and therefore not necessarily link illness with employment. This may be important as the association between illness and occupational ill-health is fundamental to the reporting schemes in ODIN and THOR, especially with respect to an individual physician’s opinion about work attribution. CCDCs reporting to SIDAW may also be more likely to see infections requiring a relatively high degree of attention or intervention; this may be influenced by the severity or duration of the infection, or its impact on an individual’s employment [13]. The distribution of reported cases of infectious disease by industry is influenced by hazards inherent to the work or workplace (for example, scabies in health and social care), but also by whether or not workers within an industrial group have access to the physicians who report to the schemes. The geographical areas covered by clinical specialists within SIDAW, SWORD Table 4. Reporting of outbreaks and single cases in SIDAW (2000– 2003) Disease category Number of cases reported as part of an outbreak Number of outbreaks Mean number of cases per outbreak Number of single case reports Diarrhoeal disease Scabies Miscellaneous Total 3683 490 37 4210 355 62 13 430 10.4 7.9 2.8 9.8 246 24 86 356 280 OCCUPATIONAL MEDICINE Table 5. Distribution of cases within outbreaks in SIDAW (2000– 2003) Number of cases per outbreak 2– 5 6– 10 11– 20 21– 50 51– 100 .100 Total Number of outbreaks Diarrhoeal disease n (%) Scabies n (%) Miscellaneous diagnoses n (%) 172 110 51 13 7 2 355 33 (53.2) 8 (12.9) 18 (29.0) 3 (4.8) 0 (0.0) 0 (0.0) 62 (100) 12 (92.3) 1 (7.7) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 13 (100) (48.5) (31.0) (14.4) (3.7) (2.0) (0.6) (100) and EPIDERM correspond on the whole to those in the national LFS [10], but in comparison occupational physicians reporting to OPRA only provide services for subsections of the employed population. The proportion of employees having access to an occupational physician has been estimated at 12% for the general working population; but is higher in some sectors (for example health and social services 43%) than others (, 1% of workers in agriculture, forestry and fishing) [14]. Reporting to these four schemes may also be affected by physicians seeing different levels of disease severity, or else as a result of attrition on ascending the referral pyramid. Thus occupational physicians are perhaps most likely to see primary referrals, with respiratory physicians seeing secondary (or tertiary) referrals and reporters to SIDAW mainly receiving tertiary referrals. One obvious gap in the reporting of work-related infectious disease is the caseload seen by general practitioners (GPs) and a new reporting scheme is currently being set up (THORGP) to gain information from this very important source. THOR-GP will be a UK-wide scheme that aims to collect information on the wide range of work-related disease seen by GPs. It will involve electronic (rather than paperbased) collection methods, and should provide valuable information that can be used to compare with data obtained from the extant schemes, involving occupational and specialist physicians. In addition to providing information that can be used to look at patterns of reported cases of occupational illhealth, the surveillance schemes allow reporters to alert their peers about potential novel causes, precipitating factors, or industrial sectors relating to occupational disease. This is achieved through the regular reports posted by the THOR team and additionally through the internet/web-based interface [15]. A recent example of this was associated with free movement of workers within the European Union from an area with a high incidence of TB, to another where the incidence was considerably lower that resulted in disease transmission to the local workforce, and also affected planning and provision of Table 6. Breakdown of ‘miscellaneous’ outbreaks within SIDAW by disease Disease Number of outbreaks Number of cases within outbreaks Brucellosis Conjunctivitis Legionellosis Malaria Meningitis Paratyphoid Pulmonary TB Unspecified viral illness Varicella Total 1 1 2 1 2 1 3 1 1 13 3 3 4 8 4 2 9 2 2 37 medical services [16– 18]. The early warning facility is important for both the individual reporter, and, for the workforce. The individual reporter has a means of benchmarking his/her practice against that of others that is becoming increasingly important for continual professional development, audit and revalidation. At a workforce level, highlighting potential new factors relating to occupational diseases could have a substantial impact on their prevention, but some caution should be applied in view of recent ‘epidemics’ of work-related illhealth following increased awareness of a condition or possible causal factors, for example, that of work-related upper limb disorder in Australia in the 1980s [19]. Despite the reservations outlined above about the data within ODIN and THOR, the reporting schemes have provided valuable information on occupationally related ill-health that has been used when planning service provision, and by national bodies such as the Health & Safety Executive in target setting to improve health and safety within the workplace [20]. Department of Work and Pensions data and information from the Reporting of Injuries, Diseases and Dangerous Occurrences also provide sources of information about occupational infections, although these give even lower annual S. TURNER ET AL.: WORK-RELATED INFECTIOUS DISEASE 281 estimates than THOR [13]. For example, for infections that are prescribed diseases [21], over recent years the total annual number for these prescribed infections has fallen to single or very low double figures, although there is no evidence of strong temporal trends in these data. The schemes can provide details about diseases or conditions ranging from those that may be clinically mild and self limiting (for example, diarrhoeal disease) to more serious clinical entities (for example, TB), but diagnoses at both ends of this spectrum may have substantial effects within the workplace, especially for force planning. The range of diseases reported to the occupational surveillance schemes is therefore one of its strengths. For individual physicians, especially those practising occupational health medicine, involvement in the reporting schemes is associated with activities that scored highly as priority areas for continuing professional development [22], and as such, with ongoing support from reporters, should ensure the continued success of schemes such as OPRA, SWORD, SIDAW and EPIDERM. Acknowledgements We are grateful to Professors Corbett McDonald and Nicola Cherry for access to data collected in 2000 and 2001. Corbett McDonald initiated both the SWORD and SIDAW reporting schemes; Nicola Cherry established EPIDERM. They were codirectors of ODIN from 1996 to 2002. The THOR project is funded by a grant (D5044) from the UK Health & Safety Executive awarded to Professor Raymond Agius and coinvestigators. This paper expresses the views of the authors and not necessarily of the funding body. We are grateful to all physicians in the UK who participate in the reporting schemes, for their invaluable contribution and co-operation. Physicians who wish to join THOR and participate in reporting can find further details at http://www.coeh.man.ac.uk/thor. Thanks are also due to Susan Taylor, Catherine Roberts and Lisa Fulluck for their research and administrative assistance. References 1. Jones JR, Huxtable CS, Hodgson JT, Price MJ. Self-reported Work-related Illness in 2001/02: Results from a Household Survey. Norwich: The Stationery Office, 2003. 2. Ross DJ, Cherry NM, McDonald JC. Occupationally acquired infectious disease in the United Kingdom: 1996 to 1997. Commun Dis Public Health 1998;1:98– 102. 3. Cherry NM, Meyer JD, Holt DL, Chen Y, McDonald JC. Surveillance of work-related diseases by occupational physicians in the UK: OPRA 1996– 1999. Occup Med (Lond) 2000;50:496 – 503. 4. Cherry N, Meyer JD, Adisesh A, et al. 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