Population-attributable fraction for occupation and asthma

  • Kjell Torén
  • Paul D. Blanc
Part of the Progress in Inflammation Research book series (PIR)


Here we review the use of the concept of population-attributable risk (PAR) of asthma associated with occupation and give the context for its interpretation. For asthma there is major interest in delineating the “burden of disease”, because such assessments can inform health care priorities, intervention policies, and assessment of impact once such steps are implemented. For asthma, the burden of disease from occupational factors is of particular relevance because asthma is a common disease that affects persons of working age and because asthma can be associated with major morbidity and economic cost. In 1999, we carried out a systematic review of the published literature relevant to the occupational PAR in asthma. Of 23 published PAR estimates identified, the median value was 9%, but among those, the 10 estimates based on population-based studies yielded a median PAR estimate of 15%. A few years later a task force of the American Thoracic Society (ATS) summarized the general population-based studies in this field, ending up with a median value of 15%. We have summarized data from publications that have appeared since 2000 and the median value from these publications is 14.4% (range 6–31%).

We show in this analysis that 3 in 20 cases of asthma among adults are likely to be linked to occupational factors. Longitudinal incidence-based estimates, which should be the most reliable, suggest that, if anything, the actual PAR may even be higher. Other measures such as impaired quality of life and economic disadvantage are also important, but are not addressed in this review as there is lack of studies. This points to future research needs to address this knowledge gap in the field of work-related asthma. In the meantime, the consistency of the PAR data that we do have certainly underscores the importance of workplace factors in the overall burden of asthma.


Occupational Exposure American Thoracic Society Occupational Asthma Occup Environ Occupational Factor 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Rowe AK, Powell KE, Flanders D. Why population attributable fractions can sum to more than one. Am J Prev Med 2004; 26: 243–9CrossRefPubMedGoogle Scholar
  2. 2.
    Blanc PD, Toren K. Occupation in COPD and chronic bronchitis: An update. Int J Tuberc Lung Dis 2007; 11: 251–7PubMedGoogle Scholar
  3. 3.
    Greenland S, Robins JM. Conceptual problems in the definition and interpretation of attributable fractions. Am J Epidemiol 1988; 128: 1185–97PubMedGoogle Scholar
  4. 4.
    Benichou J. Biostatistics and epidemiology: Measuring the risk attributable to an environmental or genetic factor. C R Biologies 2007; 220: 281–98CrossRefGoogle Scholar
  5. 5.
    Blanc PD, Torén K. How much adult asthma can be attributed to occupational factors? Am J Med 1999; 107: 580–587CrossRefPubMedGoogle Scholar
  6. 6.
    Balmes J, Becklake M, Blanc P, Henneberger P, Kreiss K, Mapp C, Milton D, Schwartz D, Torén K, Viegi G. American Thoracic Society Statement: Occupational contribution to the burden of airway disease. Am J Respir Crit Care Med 2003; 167: 787–797CrossRefPubMedGoogle Scholar
  7. 7.
    Kogevinas M, Antó JM, Sunyer J, Tobias A, Kromhout H, Burney P. A population-based study on occupational asthma in Europe and other industrialised countries. Lancet 1999; 353: 1750–1754CrossRefPubMedGoogle Scholar
  8. 8.
    Ng TP, Hong CY, Koh KTC, Ling SL. Risk of asthma associated with occupation in a community-based case-control study. Am J Ind Med 1994; 25: 709–718CrossRefPubMedGoogle Scholar
  9. 9.
    Isoaho R, Puolijoki H, Huhti E, Kivelä SL, Tala E. Prevalence of asthma in elderly Finns. J Clin Epidemiol 1994; 47: 1109–1118CrossRefPubMedGoogle Scholar
  10. 10.
    Flodin U, Ziegler J, Jönsson P, Axelson O. Bronchial asthma and air pollution at workplaces. Scand J Work Environ Health 1996; 22: 451–456PubMedGoogle Scholar
  11. 11.
    Reijula K, Haahtela T, Klaukka T, Rantanen J. Incidence of occupational asthma and persistent asthma in young adults has increased in Finland. Chest 1996; 110: 50–61CrossRefGoogle Scholar
  12. 12.
    Torén K, Balder B, Brisman J, Lindholm N, Löwhagen O, Palmqvist M, Tunsäter A. The risk of asthma in relation to occupational exposures: A case-control study. Eur Respir J 1999; 13: 496–501CrossRefPubMedGoogle Scholar
  13. 13.
    Katz I, Moshe I, Sosna J. The occurrence, recrudescence and worsening of asthma in a population of young adults. Chest 1999; 116: 614–618CrossRefPubMedGoogle Scholar
  14. 14.
    Blanc PD. Occupational asthma in a national disability survey. Chest 1987; 92: 613–617CrossRefPubMedGoogle Scholar
  15. 15.
    Viegi G, Prediletto R, Paoletti P, Carozzi L, di Pede F, Vellutini M, di Pede C, Giuntini C, Lebowitz M. Respiratory effects of occupational exposure in a general population sample in North Italy. Am Rev Respir Dis 1991; 143: 510–515PubMedGoogle Scholar
  16. 16.
    Bakke P, Eide GE, Hanoa G, Gulsvik A. Occupational dust or gas exposure and the prevalences of respiratory symptoms and asthma in the general population. Eur Respir J 1991; 4: 273–278PubMedGoogle Scholar
  17. 17.
    Xu X, Christiani D. Occupational exposures and physician-diagnosed asthma. Chest 1993; 104: 1364–1370CrossRefPubMedGoogle Scholar
  18. 18.
    Neijari C, Tessier JF, Letenneur L, Datigues JF, Salamon R. Prevalence of self-reported asthma symptoms in a French elderly sample. Respir Med 1996; 90: 401–408CrossRefGoogle Scholar
  19. 19.
    Monso E, Munoz-Rino F, Izquierdo J, Roca J, Masia N, Rosell A, Morera J. Occupational asthma in the community: Risk factors in a western Mediterranean population. Arch Environ Health 1998; 53: 93–98PubMedGoogle Scholar
  20. 20.
    Forastiere F, Balmes J, Scarinci M, Tager IB. Occupations, asthma and chronic respiratory symptoms in a community sample of older women. Am J Respir Crit Care Med 1998; 157: 1864–1870PubMedGoogle Scholar
  21. 21.
    Eagan T, Gulsvik A, Eide GE, Bakke PS. Occupational airborne exposure and the incidence of respiratory symptoms and asthma. Am J Respir Crit Care Med 2002; 166: 933–938CrossRefPubMedGoogle Scholar
  22. 22.
    Ehrlich RI, White N, Norman R, Laubscher R, Steyn K, Lombard C, Bradshaw D. Wheeze, asthma diagnosis and medication use: A national adult survey in a developing country. Thorax 2005; 60: 895–901CrossRefPubMedGoogle Scholar
  23. 23.
    Caldeira RD, Bettiol H, Barboeri MA, Terra-Filho J, Garcia CA, Vianna EO. Prevalence and risk factors for work related asthma in young adults. Occup Environ Med 2006; 63: 694–699CrossRefPubMedGoogle Scholar
  24. 24.
    Kogevinas M, Zock J-P, Jarvis D, Kromhout H, Lillienberg L, Plana E, Radon K, Torén K, Allikso A, Benke G, et al. Exposure to substances in the workplace and new-onset asthma: An international prospective population-based study (ECRHS-II). Lancet 2007; 370: 336–341CrossRefPubMedGoogle Scholar
  25. 25.
    Karjalainen A, Kurppa K, Martikainen R, Klaukka T, Karjalainen K. Work is related to a substantial portion of adult-onset asthma incidence in the Finnish population. Am J Respir Crit Care Med 2001; 164: 565–568PubMedGoogle Scholar
  26. 26.
    Johnson A, Toelle BG, Yates D, Belousova E, Ng K, Corbett S, Marks G. Occupational asthma in New South Wales (NSW): A population-based study. Occup Med 2006; 56: 258–262CrossRefGoogle Scholar
  27. 27.
    Le Moual N, Kennedy SM, Kauffmann F. Occupational exposures and asthma in 14,000 adults from the general population. Am J Epidemiol 2004; 160: 1108–1116CrossRefPubMedGoogle Scholar
  28. 28.
    Kennedy SM, Le Moual N, Choudat D, Kauffmann F. Development of an asthma specific job exposure matrix and its application in the epidemiological study of genetic and environment in asthma (EGEA). Occup Environ Med 2000; 57: 635–41CrossRefPubMedGoogle Scholar
  29. 29.
    Arif AA, Whitehead LW, Delclos GL, Tortolero SR, Lee ES. Prevalence and risk factors of work-related asthma by industry among united Sates workers: Data from the third national health and nutrition examination survey (1988-94). Occup Environ Med 2002; 59: 505–511CrossRefPubMedGoogle Scholar
  30. 30.
    Arif AA, Delclos GL, Whitehead LW, Tortolero SR, Lee ES. Occupational exposures associated with work-related asthma and wheezing among U.S. workers. Am J Ind Med 2003; 44: 368–76CrossRefPubMedGoogle Scholar
  31. 31.
    Flodin U, Jönsson P. Non-sensitizing air pollution at workplaces and adult-onset asthma. Int Arch Occup Environ Health 2004; 77: 17–22CrossRefPubMedGoogle Scholar
  32. 32.
    Blanc PD, Eisner MD, Balmes JR, Trupin L, Yelin EH, Katz PP. Exposure to vapours, gas, dust or fumes: Assessment by a single survey item compared to a detailed exposure battery and a job exposure matrix. Am J Ind Med 2005; 48: 110–117CrossRefPubMedGoogle Scholar
  33. 33.
    Quinlan PJ., Earnest G, Eisner MD, Yelin EH, Katz PP, Balmes JR, Blanc PD. Performance of self-reported occupational exposure compared to a job exposure matrix approach in asthma and chronic rhinitis. Occup Environ Med 2009; 66: 154–160CrossRefPubMedGoogle Scholar
  34. 34.
    LeVan TD, Koh W-P, Lee H-P, Koh D, Yu MC, London SJ. Vapor, dust, and smoke exposure in relation to adult-onset asthma and chronic respiratory symptoms. Am J Epidemiol 2006; 163: 1118–28CrossRefPubMedGoogle Scholar
  35. 35.
    Vollmer WM, Heumann MA, Breen VR, Henneberger PK, O’Connor EA, Villnave JM, Frazier EA, Buist AS. Incidence of work-related asthma in members of a health maintenance organization. J Occup Environ Med 2005; 47: 1292–97CrossRefPubMedGoogle Scholar
  36. 36.
    Sama SR, Milton DK, Hunt PR, Houseman EA, Henneberger PK, Rosiello RA. Caseby-case assessment of adult-onset asthma attributable to occupational exposures among members of a health maintenance organization. J Occup Environ Med 2006; 48: 400–407CrossRefPubMedGoogle Scholar
  37. 37.
    Leira HL, Bratt U, Slåstad S. Notified cases of occupational asthma in Norway: Exposure and health consequences for health and income. Am J Ind Med 2005; 48: 359–64CrossRefPubMedGoogle Scholar
  38. 38.
    Amielle J, Pauli G, Calastren-Crinquand A, Vervloët D, Iwatsubo Y, Popin E, et al. Reported incidence of occupational asthma in France, 1996-99: The ONAP program. Occup Environ Med 2003; 60: 136–41CrossRefGoogle Scholar
  39. 39.
    Vandenplas O, Larbanois A, Bugli C, Kempeneers E, Nemery B. Épidémiologie de l’asthme professionel en Belgique. Rev Mal Respir 2005; 22: 421–30PubMedGoogle Scholar
  40. 40.
    Bena A, D’Errico A, Mirabelli D. Un sistema di rilevazione atriva dell’asma bronchiale professionale: I resultati di due anni di attività del programma PRiOR. Med Lav 1999; 90: 4: 556–571PubMedGoogle Scholar
  41. 41.
    Orriols R, Costa R, Albanell M, Alberti C, Castejon J, Monso E, et al. Reported occupational respiratory diseases in Catalonia. Occup Environ Med 2006; 63: 255–260CrossRefPubMedGoogle Scholar
  42. 42.
    Elder D, Abramson M, Fish D, Johnson A., McKenzie D, Sim M. Surveillance of Australian workplace Based Respiratory Events (SABRE): Notifications for the first 3.5 years and validation of occupational asthma cases. Occup Med 2004; 54: 395–00CrossRefGoogle Scholar
  43. 43.
    Walls C, Crane J, Gillies J, Wilsher M, Wong C. Occupational asthma cases notified to OSH from 1996 to 1999. N Z Med J 2000; 113: 491–2PubMedGoogle Scholar
  44. 44.
    Hnizdo E, Esterhuizen TM, Rees D, Lalloo UG. Occupational asthma as identified by the Surveillance of Work-related and Occupational Respiratory Diseases programme in South Africa. Clin Expir Allergy 2001; 31: 32–9CrossRefGoogle Scholar
  45. 45.
    Karjalainen A, Kurppa K, Martikainen R, Karjalainen J, Klaukka T. Exploration of asthma risk by occupation — Extended analysis of an incidence study of the Finnish population. Scand J Work Environ Health 2002; 28: 49–57PubMedGoogle Scholar
  46. 46.
    Flattery J, Davis L, Roseman KD, Harrison R, Lyon-Callo S, Filios M. The proportion of self-reported asthma associated with work in three states: California, Massachusetts, and Michigan, 2001. J Asthma 2006; 43: 213–8CrossRefPubMedGoogle Scholar
  47. 47.
    Kunzli N, Perez L, Lurmann F, Hricko A, Penfld B, McConnell R. An attributable risk model for exposures assumed to cause both chronic disease and its exacerbations. Epidemiology 2008; 19: 179–85CrossRefPubMedGoogle Scholar
  48. 48.
    Greenland S. Attributable fractions: Bias from broad definition of exposure. Epidemiology 2001; 12: 518–520CrossRefPubMedGoogle Scholar
  49. 49.
    Wacholder S, Benichou J, Heineman EF, Hartge P, Hoover RN. Attributable risk: Advantages of a broad definition of exposure. Am J Epidemiol 1994; 140: 303–309PubMedGoogle Scholar
  50. 50.
    Driscoll T, Nelson DI, Steenland K, Leigh J, Concha-Barrientos M, Fingerhut M, Prüssüstün A. The global burden of non-malignant respiratory disease due to occupational airborne exposures. Am J Ind Med 2005; 48; 432–45CrossRefPubMedGoogle Scholar

Copyright information

© Birkhäuser / Springer Basel 2010

Authors and Affiliations

  • Kjell Torén
    • 1
  • Paul D. Blanc
    • 2
  1. 1.Department of Occupational and Environmental MedicineSahlgrenska University HospitalGöteborgSweden
  2. 2.Division of Occupational and Environmental MedicineUniversity of California San FranciscoSan FranciscoUSA

Personalised recommendations