Journal of Occupational & Environmental Medicine:
Characterizing the Burden of Occupational Injury and Disease
Schulte, Paul A. PhD
From the National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Cincinnati, Ohio.
The findings and conclusions in this report are those of the author and do not necessarily represent the views of the National Institute for Occupational Safety and Health.
Address correspondence to: Paul A. Schulte, PhD, NIOSH, MS-C14, 4676 Columbia Pkwy., Cincinnati, OH 45226; E-mail: firstname.lastname@example.org.
Objectives: To review the literature on the burden of occupational disease and injury and to provide a comprehensive characterization of the burden.
Methods: The scientific and governmental literature from 1990 to the present was searched and evaluated. Thirty-eight studies illustrative of the burden of occupational disease were reviewed for findings, methodology, strengths, and limitations.
Results: Recent U.S. estimates of occupational mortality and morbidity include approximately 55,000 deaths (eighth leading cause) and 3.8 million disabling injuries per year, respectively. Comprehensive estimates of U.S. costs related to these burdens range between $128 billion and $155 billion per year. Despite these significant indicators, occupational morbidity, mortality, and risks are not well characterized in comparative burden assessments.
Conclusions: The magnitude of occupational disease and injury burden is significant but underestimated. There is a need for an integrated approach to address these underestimates.
The burden of occupational injury and illness is substantial among America’s 139 million workers.1–7 For 2002, the Bureau of Labor Statistics (BLS) reported 5524 fatal work injuries, 4.4 million nonfatal injuries, and 294,500 illnesses.2 The National Institute for Occupational Safety and Health (NIOSH) estimates that 3.6 million occupational injuries and illnesses are treated annually in U.S. hospital emergency rooms.4 Estimates for occupational disease mortality vary, although recent estimates suggest that occupational disease deaths exceed 55,000 per year.5 Employers paid $72.9 billion in workers’ compensation premiums in 2002, with total direct and indirect costs estimated to range between $128 and $155 billion.6,7 Using 1992 data, Leigh et al estimated that the cost of occupational morbidity and mortality was more than five times the cost of HIV/AIDS, three times the cost of Alzheimer’s disease, 91% of the cost of cancer, and 82% of the cost of heart disease.7 Despite these relatively large numbers, ranked lists of the causes of disease or disability (such as shown in Table 1) make no explicit mention of occupational factors (risks, diseases, or injuries). The reason, in part, is that occupational risk factors and associated health conditions contribute to various causes of death and generally are not captured as a unique category in International Classification of Diseases codes. It is widely appreciated that one risk factor can lead to many outcomes, and one outcome can be caused by many factors.9–11 Clearly, occupational causes exist for cardiovascular diseases (stress, carbon monoxide, carbon disulfide), road traffic collisions (construction work, long work hours for truck drivers), lung cancer (asbestos, crystalline silica, hexavalent chromium), and so on. Nearly every cause of death or disability ranked in Table 1 may have an occupational component, but these are not characterized in the ranked lists.
Nonetheless, there is value in assessing risk factors in a unified framework so that comparisons can be made within and across countries so that there is an evidence base for priority setting and resource allocation.9 However, this comparative assessment of the burden of disease and injury is an infant and problematic science.12 Only recently has the World Health Organization started to assess occupational risk factors on a global basis.10,11
There is a need for further characterization of the burden of occupational injury and disease to meet the requirements of public and private decision-makers.13 This article begins to address that need by reviewing studies of the burden as a result of occupational disease and injury and identifying important methodologic issues. The article provides an overview of the burden in terms of magnitude, attributable risks (ARs), and disability-adjusted life-years (DALYs) and then in terms of costs, social consequences, and disparities. Ultimately, the article provides an approach for improving the characterization of burden.
Assessments of the Burden of Disease and Injury Resulting From Occupation
A summary of recent assessments of the burden of disease and injury resulting from occupational exposure are shown in Table 2 and Figures 1 and 2. Some of these are highlighted here for consideration.
Nurminen and Karjalainen14 calculated that 4% (1800) of all the deaths in Finland in 1996 were attributed to occupational factors. They estimated that the number of occupational deaths was larger than those for suicide (1247) or diabetes (593). Relatively rigorous criteria were used for selecting component studies. Selected occupational attributable risks identified by Nurminen and Karjalainen included 18% for asthma, 12% for chronic obstructive pulmonary disease (COPD), and 17% for cardiovascular disease.14 However, two biases could have affected the findings. First is the criteria by which occupational exposures were accepted as causes of diseases, and second is the dichotomous classification of exposures (present or absent), when for almost all hazards, the risk may vary according to the intensity and duration of exposure.56 Conversely, the exclusion of the age category of ≥65 years for cancer could have resulted in a marked underestimation of the total number of work-related cancer deaths, many of which may not occur until after age 65.
Steenland et al5 calculated that 7.4% (55,200 of 738,000) of deaths among people aged 15 to 69 years in 1997 were estimated to result from occupational injury and disease. They determined that occupational deaths were the eighth leading cause in the United States after diabetes (64,751) and greater than motor vehicle accidents (43,501) and suicides (30,573). The limitations of this study are 1) that there were incomplete data for many of the underlying epidemiologic studies because the United States lacks a comprehensive national mortality surveillance system for occupational diseases, 2) that this analysis depends on accepted causal linkages and estimates of the prevalence of exposure, 3) that many diseases were not included, and 4) the study only included mortality, not morbidity data.5 Attributable fractions were restricted to only diseases with well-established occupational causes and likely to be underestimated.
The global burden of disease and injury resulting from occupational factors was reported by Leigh et al. in 1999.36 Using the published literature, it was estimated that 100 million injuries and 11 million occupational diseases occur each year in the world leading to 800,000 deaths.
Subsequently, the World Health Organization examined the burden of disease for selected occupational risk factors by assessing the contribution of 26 risk factors to the global burden of disease and injury.15 Similar exposure and risk information was put in a single model to make comparisons possible. The study indicated that selected occupational risk factors were responsible for approximately 37% of low back pain, 16% for hearing loss, 13% for COPD, 11% for asthma, and 8% for injuries.15
The limitations of both of these studies are that they may underestimate the magnitude of occupational deaths (eg, ILO57 estimates 2 million occupational deaths per year; however, these estimates may be limited by the quality of the source data).58 Also, many occupational risk factors were not included nor were data on child workers.
An extensive visual characterization of the burden of occupational morbidity and mortality is in the NIOSH publication “Worker Health Chartbook, 2004.” This document includes more than 400 figures and tables describing the magnitude, distribution, and trends of U.S. occupational injuries, illnesses, and fatalities.1 In addition to the charts, electronic versions of the chartbook allow linkage of the summary statistics back to the original data.
Costs of Occupational Injury and Disease
Leigh et al have provided the most thorough cost assessments (Table 2).7,45,47,48,50–52,54 As noted earlier, using 1992 data, Leigh et al reported a combined direct and indirect cost of $155.5 billion per year.7 Direct costs included medical care and workers’ compensation.7 Indirect costs included wage and productivity losses, higher consumer prices, and nonworkers’ compensation costs borne by the medical insurance systems. The Human Capital approach, which has been applied to a variety of injuries and illnesses, was used in part because it allowed for comparison of costs of occupational and nonoccupational diseases and injuries; however, it is limited in not including costs related to productivity, pain, and suffering.59,60 In 2003, Leigh et al assessed the medical cost associated with 14 occupational illnesses in the United States using 1999 data.48 The population attributable risk (PAR) model with PARs based on the study by Nurminen and Karjalainen14 estimated that medical costs were $14.5 billion ($9.6–$19.7 billion) with the largest being $4.7 billion (circulatory diseases), $4.3 billion (cancer), $2.2 billion (COPD), and $1.5 billion (asthma). These studies are dependent on the quality of the available cost data, which are most likely underestimates of true costs. The analysis by Leigh et al7 was also limited by: 1) inability to account for the economic effects of occupational injuries and illnesses on the relatives of victims or the cost of caregivers’ time and energy,61 2) restriction of job-related circulatory disease deaths to under age 75 years, 3) ignoring costs of pain and suffering and those transferred from employers to society, and 4) omission of reproductive problems from disease calculations.7 In addition, data sources had well-known deficiencies such as the inability of Occupational Safety and Health Administration statistics to capture occupational transportation injuries and deaths, work-related assaults, and violent acts leading to significant underestimation of these events.
The National Safety Council, using the Census of Fatal Occupational Injuries (CFOI) for 1997, estimated the costs of occupational injuries to be $127.7 billion (NSC, 1998).39 This included wage and productivity losses of $63.4 billion, medical costs of $20.7 billion, and administrative expenses of $11.9 billion.
Weil reviewed the methods for valuing the economic costs of occupational injury and illness and found most studies tended to underestimate the true economic costs from a social welfare perspective, particularly in how they accounted for occupational fatalities and losses arising from work disabilities.62 Many of the estimates of costs of occupational disease and injury depend on a combination of methodologic assumptions, extrapolation methods, and known and unknown biases. Weil found that there were significant divergences between theoretical and actual valuation in the area of occupational fatalities, workplace disabilities, and nonworkplace disabilities.62
Social Consequences of Occupational Illness and Injuries
In assessing the burden of occupational illnesses and injuries, most of the focus has been on the magnitude in terms of morbidity, mortality, and direct costs. Despite the large descriptive literature on the impact of disease and injury on patients’ emotional health, family dynamics, and social networks as well as the longstanding recognition of social impacts of occupational injuries and disease, there is not an extensive body of literature documenting significant social costs of work-related illness and injury. Dembe has developed a conceptual framework for identifying and analyzing the “hidden” social consequences of occupational injuries and illnesses.63 The investigation of the social consequence of occupational injury and illness is complicated by the multifactorial influence of personal, social, organizational, and environmental variables. These consequences can include implications of work-induced disorders for labor relations, family dynamics, domestic activities, community involvement, and personal mental health.64–66
Disparities in Population Burdens
The burden of occupational injury and disease can be portrayed by its uneven distribution in various populations and work environments. Despite social and economic determinants, an extensive but incomplete scientific literature documents work-related racial, ethnic, and gender health disparities between groups.67–77
Impediments to Collection of Valid Occupational Injury and Disease Data
Occupational injuries and disease are often underreported.78–83 This has been well documented and particularly well described by Azaroff et al,79 who concluded that “the lack of a comprehensive occupational health data collection system in the United States has led to reliance on piecemeal data sets produced by systems not designed for surveillance. These systems filter out work-related health problems at each step.”79
Limitations of Burden Statistics
The methodology for determining DALYs and ARs (defined in Table 2) can lead to uneven treatment of different risk factors or may not provide a complete picture of occupational or other environmental risks.84–86 The definition of DALYs combines information on morbidity and mortality with value choices such as disability weighting, age weighting, and discounting.84–86 These value choices may lead to an inaccurate portrayal of the true burden of occupational disease and injury because of differential valuation of effects on young workers and failure to account for long-term effects in older workers and retirees.
The standard definitions of attributable fraction of disease, resulting from an exposure, capture only excess cases and not all cases that are etiologically linked by the exposures in question.87 The extent to which cases are attributable to exposure is time-dependent, with only those cases occurring by some time after exposure being counted as attributable.87,88 More recent efforts to assess occupational burden have used adjustment by occupational turnover to account for turnover in jobs with exposure to occupational carcinogens or to selected respirable particulates (silica, asbestos, and dust).89 This approach may allow for a more accurate estimate of the proportion of a population exposed to occupational hazards and may result in better attribution of putative occupational cases if there is a long period between exposure and diagnosis/reporting.
Estimating the population distribution of exposure to various occupational risk factors also is a major challenge.10 Recent efforts have used the concept of “economically active” populations to characterize the fraction of the population exposed to occupational hazards.89 This approach allows for a comprehensive accounting of persons who may be exposed to occupational hazards.
The burden of occupational disease and injury is not distributed equally over the population, but rather generally occurs in various sectors or occupations characterized by occupational-specific exposure and risk. For example, although healthcare workers globally are 0.6% of the population, they experience an appreciable proportion of disease from bloodborne pathogens acquired through “sharps” contacts.11 Worldwide, it has been estimated that approximately 40% of hepatitis C virus and hepatitis B virus infections and 2.5% of HIV infections are attributable to occupational exposure to sharps and needles.11
Nature of Occupational Disease
The methods for estimating the proportion of deaths and diseases attributable to occupational exposures are limited by the fact that many diseases have multiple potential causes, including lifestyle factors and a long latency period, that makes it difficult to establish whether the disease is work-related.79 Moreover, many primary care providers are not trained in occupational medicine and may not recognize a disease as being occupationally related. Therefore, underreporting is likely.80 There are many issues that make the collection and attribution of occupational disease data difficult. In addition to the multifactorial nature, other factors include difficulty in defining diagnostic criteria, difficulty in relating disease to exposure at the individual level, and difficulty identifying subtle changes in physical function.90
Need for an Integrated Approach
It is important for occupational safety and health practitioners to be able to effectively characterize the burden of occupational injury and disease and to have that information accepted and used in the allocation of public- and private-sector resources. There is a need for an integrated approach that brings together investment and activity in two aspects of characterizing burden of occupational injury and disease. These aspects include efforts to 1) obtain and analyze the full range of surveillance and cost data related to occupational exposures and outcomes and 2) identify the extent to which occupational morbidity and mortality is avoidable.
Obtaining and Analyzing Surveillance and Cost Data
To clearly characterize the magnitude and burden of occupational morbidity and mortality, it will be necessary to increase the availability of data and information on which to make those assessments.91–95 This will require better reporting of the occupational relationship of death, injuries, and illnesses. Clearly, these represent three very different sets of surveillance issues.96–98 For instance, occupational injury and injury mortality surveillance are much more advanced compared with occupational disease surveillance. Portrayal of burden will also involve more epidemiologic research to provide further evidence of occupational causality and more research to disentangle complex interactions among socioeconomic factors, personal factors, and job-related factors. This is particularly true for multifactorial diseases. There is also a need for better and more current data on hazard exposure and prevalence and cost of illness.14,95,98–100 Of particular importance is the need to link work history to individual medical records, which may be more feasible with the wide use of electronic health record systems.80,101 Also, there is a need to assess costs that may be shifted from workers’ compensation to Medicare and personal insurance.48,54 Reville et al have provided guidance on using limited administrative data (such as the Health and Retirement Survey; the Survey of Income and Program Participation; and the National Longitudinal Study of Youth, 1979) to explore earnings and employment consequences of workplace injuries.102
Identifying the Extent to Which Occupational Morbidity and Mortality Are Avoidable
The concept of attributable risk is often interpreted as the fraction of disease that can be eliminated if exposure is totally removed. Generally, effective interventions can rarely achieve anything near complete exposure removal, may have untoward side effects, and may affect the size of the population at risk.103 Nonetheless, much of occupational morbidity and mortality is avoidable if exposures are controlled. For example, the World Health Organization estimates, based on several observational studies, that a 74% reduction in occupational back pain incidence would be obtained from implementation of a full ergonomics program.11 The World Bank has estimated that up to two thirds of occupationally determined loss of DALYs could be prevented by occupational safety and health programs.104 Occupational safety and health professionals have long established a hierarchy of controls that progress downward from substitution, through engineering controls, to use of personal protective equipment.105–107 Clearly, there is strong evidence for the efficacy of controlling occupational hazards, but this has not been described comprehensively in terms of attributable risks, preventive fractions, or other means of comparison.48 One approach toward this end, described by Park et al,108 involved assessing years of potential life lost among uranium miners (approximately 86 months for 10 years of underground mining) and comparing it with gains in life expectancy from common medical interventions.109
“For example: quitting smoking in 35-year old men is estimated to add 10 months of life from averted heart disease in populations at average risk, or 28 months in populations at high risk; annual fecal occult blood test plus tri-annual x-ray or colonoscopy in 50-year olds adds 2.8 months; chemotherapy in patients with extensive small cell carcinoma of the lung adds about 7 months; implantation of pace-makers in survivors of cardiac arrest with recurrent arrhythmias adds 36–46 months; bone marrow transplant (compared with chemotherapy) in patients with relapse non-Hodgkins lymphoma adds 72 months. The loss of potential years of life from working 10 years in Colorado uranium mines generally greatly exceeds gains resulting from a variety of major medical interventions and preventive strategies, including quitting smoking.”108
There is an absence of cost-effectiveness statistics for many types of occupational safety and health interventions; therefore, decision-makers have limited information on which to make evidence-based decisions.110 There is a need to characterize the effectiveness, feasibility, and impact of occupational interventions.111–113 One area where this type of discussion has occurred involved the development of the Community Guide to Preventive Services: Systematic Reviews and Evidence-Based Recommendations.114–116 This is a broad effort to develop and disseminate evidence-based public health recommendations for practitioners and decision-makers. To date, some perceive that occupational safety and health has been underemphasized in this process, although as many as 30 to 40 of 171 existing Task Force on Community Preventive Services’ findings may be applicable to worksites, albeit focusing on workplace health promotion for the most part. Some of the gaps may be the result of the lack of information about attributable risk and preventive fractions; this is likely to be truer for workplace safety than for worksite health promotion. One positive step would be to address occupational interventions such as those that were identified as topics for consideration in the first volume but not included. These include allergic and irritant dermatitis, asthma and COPD, fertility and pregnancy abnormalities, hearing loss, infectious disease, pneumoconiosis, and low back disorders and injuries.116 Additional candidates for consideration might arise from the growing body of literature indicating an important role of psychosocial factors at work leading to disease.22–24,117,118 This particularly has been observed for job strain and cardiovascular disease.22,23
As the need increases for stronger evidence on which to base policy choices, it is important for the occupational safety and health community to be able to portray the extensive burden of occupational injury and disease and have that information accepted and used in allocation of public and private sector resources. To achieve this, policymakers, practitioners, and investigators need to champion heightened surveillance, further epidemiologic assessment of causality and the use of comprehensive information in comparative burden assessments. Extensive underreporting, long latencies, and multifactorial influences obfuscate the characterization of the entire burden of occupational disease and injury.
Employers are primarily responsible for providing a safe and healthy workplace, and thus there is a multiplier effect from public investments in occupational safety and health research, information, guidance, and regulation that impacts employers. The relatively small amounts of public funds invested in these efforts set targets and provide guidance for employers to invest in occupational safety and health controls and interventions. This approach has contributed to the reduction of occupational morbidity and mortality in the last 35 years.119–130
A hallmark of the occupational safety and health field is the long experience with developing and implementing controls that are effective.119–130 As Hernberg has noted, “… work-related means preventable, and removing the work-related factor, if it is a so-called necessary factor, could reduce incidence of occupational injuries and disease.”131 Demonstrating how workplace interventions enhance public health will help policymakers direct resources appropriately toward where they will have the greatest impact.
The author is grateful for comments on earlier drafts of the manuscript by the following: Aaron Blair, John Bailer, Elizabeth Ward, Kathleen Rest, Rosemary Sokas, Sheldon Samuels, Peter Briss, Andrea Okun, Anne Hamilton, Jane Weber, Kyle Steenland, Marilyn Fingerhut, Lee Sanderson, Barbara Silverstein, William Halperin, Christine Sofge, Robert Park, Alma McLemore, Alva Toles, Nancy Stout, John Sestito, Timothy Driscoll, Faye Rice, Knut Ringen and Anne Stirnkorb (graphics).
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