Arriericain Joun oEp democ›gy

Vol. 158, No. 10

Copyright © 2003 by the Johns Hopkins l3loomberg School of Public Health

Printed in U.S.A.

All rights reserved

DOl: 10.1093/aje/kwg238

Occupatiori and Asthma: A Population-based lncident Case-Control Study

Jouni J. K. J‹ akkola 1 2 Ritva Piipari³, and Maritta S. Jaakkola³
' Institute of Occupational Health, The University of Birmingham, Birmingham, United Kingdom.
² Environmental Epidemiology Unit, Department of Public Health, University of Helsinki, Helsinki,
Finland. ³ Finnish Institute of Occupational Health, Helsinki, Finland.

The authors assessed the relations between occupation and risk of developing asthma in adulthood in a 1997
— 2000 p‹›puIation-based incident case-control study of 521 cases and 932 controls in south Finland. The
occupations were c.lassified according to potential exposure to asthma-causing inhalants. Asthma risk was
increased consist‹9ntly for both men and women in the chemical (adjusted odds ratio (OR) = 5.69, 95%
confidence interval (CI): 1.fJ8, 29.8), rubber and plastic (OR = 2.61, 95% Cf: 0.92, 7.42), and wood and paper (OR
= 1.72, 95 Cl: 0.71, 4.17) iridustries, Risk in relation to occupation was increased only for men—for bakers and
food processors (OR = 8.62, 95
Cl: 0.86, 86.5), textile workers (OR = 4.70, 95% Cl: 0.29, 77.1), electrical
and electronic production

worker!s (OR = 2.83, 95 Cf: 0.82, ú.93), laboratory technicians (OR = 1.66, 95% Cl: 0.17, 16.6), and storage
worker.s (OR = 1.57, 95% Cl: 0.40, 6.19). Of the predominantly men’s occupations, metal (OR = 4.52, 95% Cl:
2.35, 8.70) and forestry (OR = 6.00, 95 Cl: 0.96, 37.5) work were the strongest determinants ot asthma. For
women, asthmu risk íncreased for waiters (OR = 3.03, 95% CI: 1.10, 8.31), cleaners (OR = 1.42, 95% Cl: 0.81,
2.48), and dental workers (OR = 4.74, 95% Cl: 0.48, 46.5). Results suggest an increased asthma risk both
in traditional industries and forestry and in several nonindustrial occupations.
asthm« : case-control studies; occupational diseases; occupations

Asthma is a common chronic disease in aiJults and consequently has a substantial impact on public health and health
care expendittires. Between 200 and 300 agents are encountered at worf: that have been reported t‹a cause asthma

through respii atory sensitization (1, 2). A few population—
based epidem iologic studies have investigated the relations

incident rather than prevalent—cases would reduce such
selection bias and provide more accurate effect estimates.
We conducted a population-based incident case-control
study in Finland to assess the relations between occupation
and the risk of asthma.

between long term occupational exposures and the risk of

asthma (3—15 ). They were reviewed recently by a working

group of the American Thoracic Society (lb).
Previous studies assessing the effect of occupational exposures on the risk of asthma have focused on ¡›reva1ent
asthma and applied a cross-sectional study design. Crosssectional studies are known to be sensitive to selection bias.
This bias has sometim‹•s been referred to as the “healthy
worker effect.” that is, selection to work according to health
status, which means that subjects with early symptoms and
signs of asthma leave their jobs before the diagnosis,
masking an efect of exposure on asthma. A study of newly
diagnosed—

MATERIALS AND METHODS

Study design

Ours was a population-based incident case-control study.
The source population consisted of adults 21—63 years of
age living in a geographically defined administrative area
of south Finland, where the 1997 population was 440,913.
The study was approved by the ethics committees of the
Finnish Institute of Occupational Health and the Tampere
University Hospital.

Reprint requests to Prot. Jouni J. K. Jaakkola, Institute of Occupational Health, The University of Birmingham, Edgbaston, Birmingham B15
277, United Kingdom (e-mail: j.jaakkola © bham.nc.uk).

981

Am J Epídemíol 2003;158:981—987

to March 31. Definition an‹d selection of cases We svstem‹itically recruited all new asthma cases. 1998. 80 percent of those who had a telephone number in the Pirkanmaa area). the total was 521 cases. At the TamJ›ere University Hospital. peak expiratory flow. The lung function criteria are presented in table 1. Eligible subjects were invitecl to participate in the study. letter sent by the National Social Insurance Institution.500 controls from the source population by using the national population registró.he other health care facilities. six were older than age 63 years. Information on informed consent was sent in the letter. FVC. or noctumal cou. F'or alt. After as many as three invitation letters were sent and telephone calls were made. Siqnificant improvement in spirometric lung tunction (for percentage criteria. Thus. our study population included 932 controls. The ques- tionnaire included six sections: l) personal characteristics. Controls were recruited at regular intervals throughout the study period. } Calculated according to the standard practice of the Tampere University Hospital (19): maximum daily variation = (highest PEF value ‹Juring the day — lowest PEF value during the day)/highest PEF value during the day. Patients were recruited at all health care facilities diagnosing asthrria. we used the population registró to check whether the person was still living in the Pirkanmaa region. forced vital capacity. Selection of controls We randomly selected 1.gh or wheezing). cases were recruited at their first visit due to suspected asthma. 3) active smoking and environmental tobacco smoke exposure. which was returned in a prepaid envelope to the study project research nurse. The Finnish Environment and Asthma Study. Study subjects answered a self-administered questionnaire modified from the Helsinki Office Environment Study ques- The diagno . The Occupational groups and exposures cases answere‹l the questionnaire at the time of recruitment.016 controls participated in the study (response rate.TABLE 1. ?20% daily variation] and/or ?15% improvement{ in response to short-acting bronchodilating medication during at least 2 days in a 2-week diurnal PEF follow-up and/or 3. At i. we verified from their medical records that they did not have a previous asthma diagnosis. and the diagnosis was verified in clinical examinations. and informed cons ent was asked by their physician or through a gations. 4) occupation and work environ- .5 percent). and 2) demonstration of reversibilitv ot‘ airways obstruction in lung function investi- tionnaire for use in a general population (20. and two returned incomplete questionnaires. attacks of or exercise-induced dyspnea. including spirometry and bronchodilation test. in the whole Pirkanmaa He spital District ( 17. 1. the criteria for significant changes were 2. and a 2-week peak expiratory flow follow-up (19). 90 percent) participated through the health care system and 159 cases through the National Social Insurance Institution (responde rate. cases were recruited immediately when the asthma diagnc›sis was verified. The general eligibility criteria were also applied for controls. first in the city of Tampere beginning on September 15. A total of 362 cases (response rate. 1997—May 1. cases. including the Department of‘ Pulmonary Medicine at the 4’ampere Univer. and thcn from March 10. The National Social Insurance Insütution invited the cases 6 months to 2 y‹•ars after their diagnosis was established. The same protocol for diagnosing asthma was applied at all health care facilities. 78 percent). bronchodilator response = (highest PEF value after bronchodilating medication — highest PEF value before medication)/highest PEF value before medication.tic criteria applied for asthma íncluded 1) presence of at least one asthma-like sympt. 1999 . 1997. As an additional route of case selection.om (prolonged coug°h. wheezi:ug. the date and criterio of the asthma diagnosis were confirmed from their medical records so that the diagnosis ot’ asth:matics included in our study fulfilled our eri teria. and public health care centers. Previous or current asthma was reported by 76 (7. offices of the private-practicing pulmonary physicians in the region. with full coverage of the population. For these patients. 21). 2000. 18).ind who had not vet participated. 2) health information. 1997-2000 Lung function criteria "1Í Significant improvement in response to short-acting bronchodilating medication in a bronchodilator test. After we excluded these persons. the National Social Insurance Inst:itution of Finland invited all patients whose reimbursement rights for asthma medication began during the period September 1. Before sending each round of recruitment letters.sity Hospital. PEF. refer to improvement in average PEF level in response to a 2-week oral steroid treatment * FEV„ forced expiratory volume in 1 second. Lung function findings confirming reversibility of obstruction among asthma cases.

158:981—987 .Am J Epidemiol 2003.

The Finnish Environment and Asthma Study. The section on occupation and work environment inquired about current occupation and previous occupations throughout a subject's working history. Characteristics of the study population. starting with the current one and recalling occupational history backward. Additional questions 983 TABLE 2. % No. % . 1997—2000 Cases (n = 521) Controls (n = 932) Characteristic No. and 6) dietary questions.Occupation and Asthma men 5) hcim‹' envi onment.

70. women in the chemical (adjusted odds ratio (OR) = 5. 95 percent CI: 0. 17) industries. For women.69. the strongest determinants of asthrria were forestry (adjusted OR = 6. 86. 2. 95 percent CI: 0.64.2 College level 113 21. textile workers (adjusted OR = 4. the risk of asthma was increased for waiters (adjusted OR = 3. professionals.80) and construction workers (adjusted OR = 1. to indicate the job and describe the 21—29 108 20. 16.5).5). 95 percent CI: 0. 6. 19).83. 1). The adjusted odds ratios were elevated also for painters (adjusted OR — 1. 95 percent CI: 0. and smoking in unconditional 1o_qistic regres sion analysis.7 271 29.40. These subject.8 tional group and the risk of asthma. we used the current job (at the time of asthma diagnosis or up ter 3 months prior to it) or the mc›st recent one that the subject liad quit because 50—59 140 26. cleaners (adjusted OR = 1.9 240 25. 95 percent confidence interval (CI): 1. percentages of cases and controls in each occupational group.0 40-49 125 24. The reference category included profes— sionals. including damJaness and mold problems.8 60--64 41 7.s of cases and controls Characteristics of the cases and controls are presented in table 2.nts. The risk of asthma was increased consistently f‹ar both men and 4m J Epidemiol 2008.1 61 11. 46. and we used odds ratios as a measure of the relation between an occupa- Ex-smoker Current smoker (regular 133 25.8 138 14.6 89 17. and those on maternal or long-term sick leave.71. RESULTS Characteristi‹.30.1 104 11.61.9 ‹»f respiratory symptoms.74.4 We compared the risk of asthma between the selected ‹Occupational groups and the reference categc›ry. and dental workers (adjusted OR = 4.66.37. . The risk in relation to occupation was increased only for men among bakers and food processors (adjusted OR = 8.4 494 53.7 141 15.5) and metal work (adjusted OR = 4. The proportion of women was greater among cases than controls. We applied International Standard Classification of Occu- 30—39 107 20.31). 37. clerks. Ex-smoking ariel smoking were more commor among cases than controls. 95 percent CI: 0.6 154 16.72.7 203 21. 95 percent CI: 0. 95 percent CI: 0.2 240 25.48. rubber and plastic (adjusted OR = 2. clerk .96).8 146 28.03. A total of 30 cases (5.86. We were al›1e to calculate effect estimatos for both man and women fc›r 12 occupational groups.8 261 28.5 224 24..inquired about details of the indoor environment at work. Education* No vocational schooling Vocational course University or corresponding Smoking{ Statistical methods No 239 46.70).96. 7. To classify cach subject irito an occupational group.1 symptoms. Cin the basis of previous epidemiologic studies and the national reports of occupational asthma.2 Vocational institution 149 28.35. and wood and paper (adjusted OR — 1. laboratory technicians (adjusted OR = l .48). are also given.00. and some other specific occupational exposures. We systematically adjusted for age.0 254 27.93).0 Age (years) a confirmatory answer. 95 percent CI: 0. and administrative personriel.7 percent) had chan¡.81. exposure to environ— mental tobacco› smoke.82. 2.57.8 percent) and 16 controls (1.8).9 73 7.8 107 20.62.0 Female 346 66.42. The proportions of students. and storage workers (adjusted OR = 1.08. gender.6). 8. 29. 4.29. 8. 77. we identified 25 groups of occupations with potential exposure to asthmacausing inhala. 95 percent CI: 0.158:981—987 or occasional) * Information on education was missing for three subjects. in the case of Gender Mate 175 33.1 487 52.ed jobs because of respir:itory symptoms. The subjects were asked whether they had changed their work because of respiratory problems and. 95 percent CI: 0. 95 percent CI: 1. and admínistrative workers were considered the reference category.42). Occupational groups and the risk of asthma Table 3 pre!›ents the. 95 percent CI: 0. as well as these who were retired or unemployed. 95 percent CI: 0. Table 4 shows the adjusted odds ratios of asthma in different occupational groups. Among the predominantly men’s occupations. whereas six groups included mair ly men and seven groups mainly women.6 438 47. and the cases tended to be younger and have a higher level of education. housewives. } Information on smoking was missing for five subjects. 8.10.17.62.3 pations-88 classification to code the reported occupations.› were classified according to the most recent job they had quit because of these symptoms. electrical and electronic production workers (adjusted OR = 2.52. 2.92. 95 percent CI: 2.

1 3. We studied incident rather than .3 3.2 93 06 65 00 6.1 1.2 4. 0.7 4. 0.8 Fhysicians 0.2 0.5 1.3 2.4 0.8 7.0 0.8 0.3 Farmers and agricultural workers 2. .0 0.5 3.2 1.8 4.8 1. 1 5. 0.8 2.6 0. and mineral workers 1. The i isk increased among both mate and female prevalent cases of asthma and thus improved the validity of workers in the chemical. 1.•roups.3 0.6 .9 On maternity leave 0.3 0.7 5.1 Day-care workers ” Cases (n= 346) Total Controls (n= 494) Cases• Controls* (n= 521) (n= 932) 12 ©9 12 02 1.9 3.4 1.5 9.4 0. cleaners.2 Cleaners 0.9 2.9 .9 93 Information on occupation was missing for 18 (3.6 Hairdressers 0.0 0.7 . for mate forestry and metal workers.4 V/aiters 0.5 7.0 0.9 31.1 .7 0.0 0.1 .6 Glass. and wood and the risk estimates compared with many earlier crosspaper industries.0 5.2 1.7 .1 .7 1.158:981—987 . TAB LE 3.9 F ubber and plastic workers 1.6 ©9 0.2 Fur and leather workers 0.2 Ó0 LJ nemployed 4.8 E'tudents 5. 0.6 1.2 O hemical industry workers 1. and administrative} 23.4 Painters 1.5 Textile workers 0.0 0.0 1.9 4.7 2.5 Electrical and electronic production workers 3.9 Fletired 5. .3 1.8 1.3 7.4 0.6 On sick leave 0.1 5.3 7.5%) cases and 32 (3.2 26.9 6.6 1.0 1.9 0.6 2. .4 37.4 27 0. Drivers .2 1.8 4.8 3.9 1.4 0.4 0. Dentists and dental workers .7 2.0 .1 5. The Finnish Environment and Asthma Study. ] Reference category in the multiv‹3riate analyses.6 ©7 0.4 0.4 2.2 25. 0.4%) controls.8 1.9 7.8 2. and dental workers.6 0.4 1.5 Engine workshop workers 3.0 09 1.8 14.5 0.8 Storage workers 1.5 lVtetal workers N‹urses and nursing associates F'rofessionals. cte rks.8 ©0 63 71 .4 0.1 4. Percentages of cases and controls in each occupational group.5 7. cient design compared with a cohort study yielding a similar Am J Epídemíol 2003. The incident case-control study is an effifor female waiters.2 2.8 0.7 7.6 .3 1.3 2.7 1.6 Laboratory technicians 0.3 0.8 Forestry and related workers 1.5 0.2 2.2 2.0 0.984 Jaakkola et al. .8 02 02 3.2 0.3 0.8 0.5 1.3 09 03 1.5 0.9 F rinters 0.9 1. ceramic. rubber and p1asti‹'.1 Flousewives 0. and sectional studies.0 0. 2. 0.6 0.4 0. DISCUSSION Validity of the results Our results provide evidence that the risk of adult-onset We reduced the likelihood of selection bias in both the asthma is grc'ater than expected for several occupational design and analysis phases.9 5.0 1. 1997—2000 Women Men O‹:cupational group Cases Controls (n = 175) (n = 438) Bakers an‹J food 1 . Constructi‹›n and mining workers 6.3 0.7 1.0 0.4 4.5 3.6 0.0 0.5 0.5 4. C)ther 6.8 VVood and paper workers 3.7 1.2 02 02 1.6 2.5 0.3 1. 0.0 0.0 .

33.13. 4. 2. 2. and administrative 1.13.17. 92 0.66 1. We the study to the participants as a solely on registries.000 person-years. and mineral workei s Flairdressers hlurses and nursing associates VVaiters VVood and paper workers 1.47.23 0.1 0.48.88 0.40.8 5.58. 3.22.03 1.1 1.00 0.37 1.000 adults for 5 years if we assume a realistic asthma incidence of one case per 1.00 0.19 0. gender.69 0.19 0.12.70 F'rofessionals.62 0. 16.1 1. 10. 3. 2.91 1. 4.83 0.7 2. 1997—2000 Men Occupational group Women Total OR].35. 12.57 0.49.81. The confidence intervals for the risk estimates ential information on current or previous occupations cannot be fully excluded. Wc attempled to reduce information bias by introducing ence of some specific occupational exposures per se.71 0. 77.75 F'ainters 1. 37.99 2. 1.95 0. 2. A‹:ljusted odds ratios of asthma in different occupational groups.70 1.29. 8.70 0.73 0.1 1.63 0.58.96.59.77 Farmers and agricultural workers 1.15 2. 8.24. 4.72 0.04 0.6 0.01 0.85.{ 95% Clt OR/ 95% CI OR§ 95%• Cl 8. 3.80 F'hysicians 1. 6.04 0.5 0. 5. 2.70 0. 6.48.14 0.93 0.34.22. Cl.04.75 0.8 1. confidence interval. ] OR. 3.10. 2.31 0.05 1 .6 0.05.10.86.80 1.9 2.84 1.12 1éxtile workers 4. with no special emphasis on occupaiional ex posures.27 Laboratory technicians 1.70.57 2.61 0. ] Adjusted for age and smoking.39 0.CO • Professionals. 2. for our cases (u = 159) recruited study on environmental factors in general.46. Adjusted for age. 1.14 Forestry and related workers 6. 46. 1 .60.88 3. 3. 2.52 0. but.70 0.15.88 0.04. Information bias could also result from basing the diagnosis through the National Social Insurance Institution. and srrioking. Our study tt›ok into account a change in job after appearance of' respiratory symptoms to reduce potential bias related to avoidance of occupational exposures.71.82 0. 2.Occupation and Asthma 985 TAEILE”4I.61 .52.4 1.42 0.* The Finnish Environment and Asthma Study. 5. and administrative workers were considered the reference category.44 0. .08. 55.80 0.14 0. 3.17 C)ther occupations 1 . we veri- fied the diagnosis by reviewing the medical records of each potential case.02 0.62 0.66 0. 33.37 E rivers 0. 86.74 fv1etal workers 4.64.7 5. 8.52 Ftubber and plastic workers 2.52 0. but occupational category is likely to be tess sensitive to bias than reported information on the pres — were relativel y wide.52 2.69 1.92.27.42 E›torage workers 1.09 0.82. 3.58.30.03 0. Informatic›n on exposures was collected from cases and controls in a similar way. 10.54. The possibility of differé/n Epiderriiol 2003. 2.33. The present study corresponds to a follow—up of ‹ipproximately 100.00 0. 7. 3. 29.23 0.98 0.5 Bakers and food processors Chemical industry workers Cleaners Construction and mining workers 1.58. 2. which could result if persons with occupational exposures interpreted their respiratory symptoms as asthma.62 0.92 0.83 0.61 0.58.96 0. 3.74 0.51 1. odds ratio.83 0.56 0. 10. 2.12 0. ceramic. clerks. 12. 64.15. 1.1 58:981 —987 defined asthma on the basis of clinical and lung function findings to eliminate information bias conceming the outcome.04 F'rinters 1 . 2.21 0.64 0.10 5. indicating low precisi‹›n due to a small number of w‹›rkers in many of the 25 occupational groups assessed.5 0.31 Electrical nnd electronic production workers Engine workshop workers Fur and leather workers Cilass.36. 3.39. amount of information.48 E ay-care workers 0.52 0.2 0.26 1.34. clerks.60 1.99 E'entists and dental workers 4.

and Marita Aalto and all the health care workers who participated in recruiting study subjects at the Tampere University Hospital. although the confidence intervals included the EU study estimates. we found a 42 percent increase in the risk of asthma among female cleaners. New Zealand 18). 95 percent CI: 1. 95 percent Cf: 0.41 for men and women.00) for men. The paper and pulp industry constitutes the major branch of traditional industry in Finland. The first cross-sectional studies from Italy. but it also reported an increased risk of 1. The authors thank research nurses Leena Yrjanheikki. 4. and China provided estiinates for the relation between the risk of asthma and self-repoi ted occiipational exposure to dust. ACKNOWLEDGMENTS This study was suppoited by grants from the Ministry of Social Affairs and Health of Finland and the Finnish Work Environment Fund. nonsignificant increase in the risk of asthma among welders (12). For example. 10. the United States (10).82. in relation to living in the vicinity of pulp mills (22. Newman Taylor AJ.22).97. Most pulp The present results provide evidence of the role of several occupations in the development of asthma. and.36 and 1. and some evidence suggests that such exposure in adulthood increases the risk of asthma (25). Marika Soukkanen. the EU study reported a slight. an‹1 gender.pean Union (.ence categoç . 13). In the present study. 12). as well as the EU study (adjusted OR = l . respecti vely). 8. iuch as hydrogen sulfides. The Finnish registró linkage study reported incident rate ratios of 1 . 2. private practices. or gases (3—5). 1

). we were able to adjust for age. This study based the diagnosis of asthma. of an increased risk of asthma among mate metal workers (adjusted OR = 4. study was increased for won:ers in the chem. results of a registró linkage of the Medical Reimbursement Register and the Finnish Register of Occupational Diseases for 1986—1998 were publislied (14). Cullinan P. Exposure to environmental tobacco smoke has been a predominant occu— pational hazard for waiters. Clin Exp Allergy 1997. the risk of :isthma according study provided a somewhat tower risk estimate of 1.91. study investigators were not able to adjust for smc›king because of a lack of individual information on smoking habits. where the risks of asthma in different occ upational groups were compared. These studies were followed by crosssectional studies conducted in Singapore (6). 1. Recently. as well as an interaction between irritative chemicals and dust exposure.03. health care centers. 2. chemicals. methylmercaptans. Research mills produce sulfate cellulose and emit malodorous sulfur compounds. However. on register data only.158:981—987 . Spain (7). Aetiology of occupational asthma.72. Am J Epídemíol 2003. Chan-Yeung M. and sulfur di‹›xide.43.14. Occupational asthma.20. to the present.10.ical industry and the rubber and plastic industry. The risk estimates from the Finnish registró-linkage study were of the same magnitude (adjusted OR = 1.adjusted inciclence rate ratios for men and women in different occupational groups using administrative workers as a refer. This observation supports the hypothesis about the occupational hazards related to cleaning work.’. N Eng1 J Med 1995. The Conclusion effect estimates in the present study were substantially higher (OR = 5. The asthma risk was also increased substantially among female waiters (adjusted OR = 3. Potential mechanisms include a strong irrita- tive effect on the airway epithelium due to a mixture of several irritative chemicals.52. identi— fying previously unknown causes of asthma is warranted so that workers’ protection measures can be developed. The fo‹:us on prevalent cases of asthma in the EU study may have led to some under. this finding is original. 95 percent CI: 0. 95 percent CI: 1. in collaboration. We also found an increase in the risk of asthma related to the wood and paper industry (adjusted OR = 1. we canntit totally exclude the possibility of confounding due to other personal or envi- ronmental factors. smoking. To our knowledge. Norway.EU) countries (12). the role of environmental tobacco smoke and chemicals used by cleaners should be evaluated further.cstimation in the presence of selection cit occupation or change of joli due to early symptoms and signs of asthma.99) and Spain (adjusted OR = 1. 23). Our finding.97).63 for women (95 percent CI: 1.70) is consistent with findings from the population-based study conducted in Spain (7).35. since previous epidemiologic studies on occupation-related asthma did not focus on this occupational group.27(suppl l):41 —6. 95 percent CI: 1. Hand1ing• of pulp and paper is likely to result in exposure to paper dust. such as cough and wheezing. In addition. in 12 Euro. Cross-section al studies from Finland have shown an increased risk of lower respiratory symptoms. reported an increased risk of asthma among cleaners (6. in the chemical industry (14). 12.40. Consistent with the EU study. Malo J. 7.In multivariate analyses. 2. and the National Social Insurance Institution of Finland.²0 for the rubber and plastic industry) than in the EU study (OR = 1.50. Workplace exposure to environmental tobacco smoke has been linked with asthma in some previous studies (26—28).7 1.33 and OR = 2. This study provided age.31).33) (14).69 tor the chemical and OR = 2. Synthesis with previous knowledge We identified nine studies that investigated the relations between occiapational exposures and the risk of prevalent asthma in population-based settings (3—8. 2. 8. In additiori.22. Studies conducted in Singapore (adjusted OR = 1. thus being vulnerable to misclassification of both exposure and outcome.333: 107—12.78.57) (24).33. 95 percent CI: 1. 95 percent CI: 2. 4. 2. respectively. as well as the cl assilication of occupation.70 (95 percent CI: 1. The Finnish registry linkage REFERENCES 1.

Jaakkola UK. Occupational exposures and physíciandiagnosed a. 1994. Occupational asthma in Europe ancl other industrialised areas: a population-based study. Am J Respir Crit Care Med 1998. 26. Blanc P.tion-based incident case-control study.35:909— IS. et al. Pearce N. 162:2058-62.28(suppl 2):54-72. 27. Am R‹:v Respir Dis 1991. Respiratory effects of way disease. et al. et al. et al. Jaakkola UK. et al.vous symptoms in adults. (Publication no. Xu X. The South Air Pollution Study: low-leve1 exposure to malodorous sulfur compounds as a determinant of eye. Am J Respir Crit Care Med 2000. and chronic respiratory symptoms in a comrriunity sample of and molds and development of adult-onset asthma: a popula. Exposure to potential occupation‹i1 asthmogens: prevalence data fr‹im the National Occupational Exposure Survey. 164:565— 8.107:58D-7. Martikainen R. respiratory and central ner. Partti-Pellinen K. Youny RO.5›4: 301—6. Jaakkola MS. Jaakkola N. et al. 28. Jaakkola MS. Committee on National Asthma Program in Finland. de la Hoz RE. Jaakkola UK.51: 315— 20. Helsinki. 143:51O-15. 9. Kogevinas M. Jaakkola MS. Jaakkola UK. Kaijalainen J. et al.4:273-8.53:93—8. 13.tional asthma in adults in six Canadían cominunities. I3ecklake M. American Thoracic Soci. et al. et al. Piipari R. Balmes J. Eur Respir J 2002. Monso E. Eiide GE. et al. Jaakkola N. Pete. et al. Scarinci M. Environmental 16. et al.tional and ambient air pollutants in nonsmokers. Occupational dust or gas exposure an›J prevalences of respiratory symptoms and asthma in a general population. Marttila O. Am J Epidemiol 1995. Martikaineii R. Indoor dampness Italy. Karjalainen A. Am J Respir Crit Care J'vled 2001.353: 1750W. Environ Health Perspect 2002. Auto IM. Goh LG. J Occup Med 1993.157: 1864— 70. Izquierdo J. Hanoa R.25:709—18. Miettinen P. Arch Environ Health 1998. Dimicli-Ward HD. 5.154: 137--43. Asthma related to occupa. Manfreda J. Cliest 1993. Jaakkola MS. D’Souza W. The risk of asthma attributable to occupational exposures. et al. Bakke P. 167:787—97. 15. to a substaiitial portion of adult-onset asthmii incidence in the epidemiologic study Finnish poJiulation.1 58:981—987 .19:90-5. Toren K. Asthma program 1994-2004. Occupa. 16). Epidemiology 1995. Kurppa K. Nordman H. An of bronchial asthma and smoking. Am J Ind Med 1994.104: 1364—70. Burchette RJ. Greer JR. Auto IM. Jiinsson P.6:503— 5. Abbey DE. Chrisñani DC. The South Karelia Air Pollution Study: the effects of malodorous sulfur compounds from pulp mills on the respiratory symptoms and other symp. J Allergy Clin Immunol 2002. 14. l\dunoz-Rino F. 25. et al. Piipari R. A populañonbased study in Sp‹iin. et al. How much adult asthma can be attributed to occupational factors? Am J Med l999. Ng TP. Finland: Ministry of Social Affairs and Health. 23. Piipari R. Balmes J. older womc:n. Risks of asthma associated with occupations in a community-based case-control study. Work is related 24. Flodin U.31: 195— 2111. Occupafional asthma in the community: risk factors in a western Mediterraincinean population.toms in adults.Occupation and Asthma 987 Vi gr G. Am J Respir Crit Care Med 1996. 7. Excess dence of asthma among Finnish cleaners employed in different indusiries. Am J Respir Crit Care Med 2003. parental atopy and asthma in adults. et al. Marttila O. Oc‹:upation. 4. Office equipment and modern occupatíonal health concern? Am J Epidemiol 1999. Effects of environmental tobacco smoke on respiratory health in adults. 109:784-8. 110:543—7. Jaakkola UK.sthma. Predl ttoRPaoetP. Pedersen DH. Karelia 10. Blanc PM. Vilkka V.ety Statement: occupational contribution to the burden of air- Am J Epidemiol 2003. Karjalaineri A. 142:1344—50. 12. Scand J Work Environ Health 2002. Eur Respir J 1991. Occup Environ Med 1997. Oc‹:upational asthma in New Zealanders: a population based study. supplies: a 8. Sunyer J. 150: 1223—8. occupational exposure in a general population sample in north 17. Vilkka V. et al. Am Rev Respir Dis 1990. Arch Environ Health l996. Forastiere I'. Johnson AH. Fishwick D. Type of ventilation system in office buildings and sick building syndrome. Am J Ind Med 1997. Soriano JB. 141:755--65. (In Finnish). Hong CY. Lane:et 1999. et al. 19. 21. 1 1. 6. asthma. Kogevínas lvI. Ziepgler J.

.tobacco smoke and development of adult-onset asthma: a pop.ulation-based incident case-control study. Eur Respir J 2001. 14(suppl):Pl906.

Related Interests

). we were able to adjust for age. This study based the diagnosis of asthma. of an increased risk of asthma among mate metal workers (adjusted OR = 4. study was increased for won:ers in the chem. results of a registró linkage of the Medical Reimbursement Register and the Finnish Register of Occupational Diseases for 1986—1998 were publislied (14). Cullinan P. Exposure to environmental tobacco smoke has been a predominant occu— pational hazard for waiters. Clin Exp Allergy 1997. the risk of :isthma according study provided a somewhat tower risk estimate of 1.91. study investigators were not able to adjust for smc›king because of a lack of individual information on smoking habits. where the risks of asthma in different occ upational groups were compared. These studies were followed by crosssectional studies conducted in Singapore (6). 1. Recently. as well as an interaction between irritative chemicals and dust exposure.03. health care centers. 2. chemicals. methylmercaptans. Research mills produce sulfate cellulose and emit malodorous sulfur compounds. However. on register data only.158:981—987 . Spain (7). Aetiology of occupational asthma.72. Am J Epídemíol 2003. Chan-Yeung M. and sulfur di‹›xide.43.14. Occupational asthma.20. to the present.10.ical industry and the rubber and plastic industry. The risk estimates from the Finnish registró-linkage study were of the same magnitude (adjusted OR = 1.adjusted inciclence rate ratios for men and women in different occupational groups using administrative workers as a refer. This observation supports the hypothesis about the occupational hazards related to cleaning work.’. N Eng1 J Med 1995. The Conclusion effect estimates in the present study were substantially higher (OR = 5. The asthma risk was also increased substantially among female waiters (adjusted OR = 3. Potential mechanisms include a strong irrita- tive effect on the airway epithelium due to a mixture of several irritative chemicals.52. identi— fying previously unknown causes of asthma is warranted so that workers’ protection measures can be developed. The fo‹:us on prevalent cases of asthma in the EU study may have led to some under. this finding is original. 95 percent CI: 0. 95 percent CI: 1. in collaboration. We also found an increase in the risk of asthma related to the wood and paper industry (adjusted OR = 1. we canntit totally exclude the possibility of confounding due to other personal or envi- ronmental factors. smoking. To our knowledge. Norway.EU) countries (12). the role of environmental tobacco smoke and chemicals used by cleaners should be evaluated further.cstimation in the presence of selection cit occupation or change of joli due to early symptoms and signs of asthma.99) and Spain (adjusted OR = 1. 23). Our finding.97).63 for women (95 percent CI: 1.70) is consistent with findings from the population-based study conducted in Spain (7).35. since previous epidemiologic studies on occupation-related asthma did not focus on this occupational group.27(suppl l):41 —6. 95 percent CI: 1. Hand1ing• of pulp and paper is likely to result in exposure to paper dust. such as cough and wheezing. In addition. in 12 Euro. Cross-section al studies from Finland have shown an increased risk of lower respiratory symptoms. reported an increased risk of asthma among cleaners (6. in the chemical industry (14). 12.40. Consistent with the EU study. Malo J. 7.In multivariate analyses. 2. and the National Social Insurance Institution of Finland.²0 for the rubber and plastic industry) than in the EU study (OR = 1.50. Workplace exposure to environmental tobacco smoke has been linked with asthma in some previous studies (26—28).7 1.33 and OR = 2. This study provided age.31).33) (14).69 tor the chemical and OR = 2. Synthesis with previous knowledge We identified nine studies that investigated the relations between occiapational exposures and the risk of prevalent asthma in population-based settings (3—8. 2. 8. In additiori.22. Studies conducted in Singapore (adjusted OR = 1. thus being vulnerable to misclassification of both exposure and outcome.333: 107—12.78.57) (24).33. 95 percent CI: 1. 95 percent CI: 2. 4. 2. respectively. as well as the cl assilication of occupation.70 (95 percent CI: 1. The Finnish registry linkage REFERENCES 1.

Jaakkola UK. Occupational exposures and physíciandiagnosed a. 1994. Occupational asthma in Europe ancl other industrialised areas: a population-based study. Am J Respir Crit Care Med 1998. 26. Blanc P.tion-based incident case-control study.35:909— IS. et al. Pearce N. 162:2058-62.28(suppl 2):54-72. 27. Am R‹:v Respir Dis 1991. Respiratory effects of way disease. et al. et al. et al. Jaakkola UK. et al.vous symptoms in adults. (Publication no. Xu X. The South Air Pollution Study: low-leve1 exposure to malodorous sulfur compounds as a determinant of eye. Am J Respir Crit Care Med 2000. and chronic respiratory symptoms in a comrriunity sample of and molds and development of adult-onset asthma: a popula. Exposure to potential occupation‹i1 asthmogens: prevalence data fr‹im the National Occupational Exposure Survey. 164:565— 8.107:58D-7. Martikainen R. respiratory and central ner. Partti-Pellinen K. Youny RO.5›4: 301—6. Jaakkola MS. Jaakkola N. et al. 28. Jaakkola MS. Committee on National Asthma Program in Finland. de la Hoz RE. Jaakkola UK.51: 315— 20. Helsinki. 143:51O-15. 9. Kogevinas M. Jaakkola MS. Jaakkola UK. Kaijalainen J. et al.4:273-8.53:93—8. 13.tional asthma in adults in six Canadían cominunities. I3ecklake M. American Thoracic Soci. et al. et al. Piipari R. Balmes J. Eur Respir J 2002. Monso E. Eiide GE. et al. Jaakkola N. Pete. et al. Scarinci M. Environmental 16. et al.tional and ambient air pollutants in nonsmokers. Occupational dust or gas exposure an›J prevalences of respiratory symptoms and asthma in a general population. Marttila O. Am J Epidemiol 1995. Martikaineii R. Indoor dampness Italy. Karjalainen A. Am J Respir Crit Care J'vled 2001.353: 1750W. Environ Health Perspect 2002. Auto IM. Goh LG. J Occup Med 1993.157: 1864— 70. Izquierdo J. Hanoa R.25:709—18. Miettinen P. Arch Environ Health 1998. Dimicli-Ward HD. 5.154: 137--43. Asthma related to occupa. Manfreda J. Cliest 1993. Jaakkola MS. D’Souza W. The risk of asthma attributable to occupational exposures. et al. Bakke P. 167:787—97. 15. to a substaiitial portion of adult-onset asthmii incidence in the epidemiologic study Finnish poJiulation.1 58:981—987 .19:90-5. Toren K. Asthma program 1994-2004. Occupa. 16). Epidemiology 1995. Kurppa K. Nordman H. An of bronchial asthma and smoking. Am J Ind Med 1994.104: 1364—70. Burchette RJ. Greer JR. Auto IM. Jiinsson P.6:503— 5. Abbey DE. Chrisñani DC. The South Karelia Air Pollution Study: the effects of malodorous sulfur compounds from pulp mills on the respiratory symptoms and other symp. J Allergy Clin Immunol 2002. 14. l\dunoz-Rino F. 25. et al. Piipari R. A populañonbased study in Sp‹iin. et al. How much adult asthma can be attributed to occupational factors? Am J Med l999. Ng TP. Finland: Ministry of Social Affairs and Health. 23. Piipari R. Balmes J. older womc:n. Risks of asthma associated with occupations in a community-based case-control study. Work is related 24. Flodin U.31: 195— 2111. Occupafional asthma in the community: risk factors in a western Mediterraincinean population.toms in adults.Occupation and Asthma 987 Vi gr G. Am J Respir Crit Care Med 1996. 7. Excess dence of asthma among Finnish cleaners employed in different indusiries. Am J Respir Crit Care Med 2003. parental atopy and asthma in adults. et al. Marttila O. Oc‹:upation. 4. Office equipment and modern occupatíonal health concern? Am J Epidemiol 1999. Effects of environmental tobacco smoke on respiratory health in adults. 109:784-8. 110:543—7. Jaakkola UK.sthma. Predl ttoRPaoetP. Pedersen DH. Karelia 10. Blanc PM. Vilkka V.ety Statement: occupational contribution to the burden of air- Am J Epidemiol 2003. Karjalaineri A. 142:1344—50. 12. Scand J Work Environ Health 2002. Eur Respir J 1991. Occup Environ Med 1997. Oc‹:upational asthma in New Zealanders: a population based study. supplies: a 8. Sunyer J. 150: 1223—8. occupational exposure in a general population sample in north 17. Vilkka V. et al. Am Rev Respir Dis 1990. Arch Environ Health l996. Forastiere I'. Johnson AH. Fishwick D. Type of ventilation system in office buildings and sick building syndrome. Am J Ind Med 1997. Soriano JB. 141:755--65. (In Finnish). Hong CY. Lane:et 1999. et al. 19. 21. 1 1. 6. asthma. Kogevínas lvI. Ziepgler J.

.tobacco smoke and development of adult-onset asthma: a pop.ulation-based incident case-control study. Eur Respir J 2001. 14(suppl):Pl906.

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