Help Set the Research Priorities for Occupational Respiratory Diseases

Posted on by Paul Henneberger, ScD, and David Weissman, MD


Work-related respiratory diseases include both those that are uniquely caused by work, such as coal workers pneumoconiosis, and those that are caused by both work and non-work factors. Asthma is an example of this second type of condition.  Work-related asthma is the most common respiratory disease treated in occupational health clinics in the United States.  An estimated 15% of asthma among adults is attributable to work, and 23% of working asthmatics experience exacerbation at work.  Extrapolated to all working asthmatics, this could affect 2.25 million Americans between the ages of 15 and 65. The medical costs for work-related asthma were estimated to be $2.29 billion in 2007.1 Total economic impact, including medical and non-medical costs, would be even greater.  Other types of respiratory diseases potentially impacted by workplace exposures include chronic obstructive pulmonary disease (or COPD), hypersensitivity pneumonitis, silicosis, lung cancer, and bronchiolitis obliterans.

The National Occupational Research Agenda (NORA) is a partnership program to stimulate innovative research and improved workplace practices. Unveiled in 1996, NORA has become a research framework for the National Institute for Occupational Safety and Health (NIOSH) and the nation. Diverse parties collaborate to identify the most critical issues in workplace safety and health. Participation in NORA is broad, including stakeholders from universities, large and small businesses, professional societies, government agencies, and worker organizations.

As we prepare to start the Respiratory Health Program in the third decade of NORA, we want to hear the opinions of all interested individuals and stakeholder groups about what is needed to improve respiratory health in the workplace. We want to learn from the perspectives of many groups, including workers, employers, occupational safety and health professionals, academics and researchers, and others interested in work-related respiratory health issues. Which exposures and associated respiratory diseases should we focus on in creating the NORA research goals?  Which methods for assessing exposure and health should be highlighted?  What type of scientific approaches need more attention to better understand and prevent occupational respiratory diseases?  What type of intervention research is needed?

You are invited to voice your opinions in the comment box below. While we will take comments indefinitely, we would appreciate comments before August 1, 2016, so they can be used to help create a draft plan for Respiratory Health in the third decade of NORA.  If you want to communicate with us individually rather than in the blogosphere, please email your comments to:

Please forward this blog to others who may want to contribute.

Thanks for taking part!

Paul Henneberger, ScD, is Senior Science Advisor in the NIOSH Respiratory Health Division.

David Weissman, MD,  is Director of the NIOSH Respiratory Health Division.



  1. Leigh JP. Economic burden of occupational injury and illness in the United States. Milbank Q. 2011 Dec;89(4):728-72.
Posted on by Paul Henneberger, ScD, and David Weissman, MD

20 comments on “Help Set the Research Priorities for Occupational Respiratory Diseases”

Comments listed below are posted by individuals not associated with CDC, unless otherwise stated. These comments do not represent the official views of CDC, and CDC does not guarantee that any information posted by individuals on this site is correct, and disclaims any liability for any loss or damage resulting from reliance on any such information. Read more about our comment policy ».

    Most of what is used and known today is pretty much outdated information. Unfortunately, just like “pain management” it makes tons of money NOT to solve the problem but to “treat it”. When and if ever the government ever decides to actually resolve or end the issue, there are solutions. Having fixed any number of asthmatics through technique, it always fails to impress me that YOU, the government would choose to continue doing whatever has been done and insanely keep going with the same solution– which isn’t a solution. IF you had a solution that you could televise, would you? That is the real question. Would you help those millions of people who are really suffering from asthma? IF you had a 60 minute special TV show that fixed millions of people, would you actually show that it can be FIXED at home or at a doctor’s office in one or two 20 minute sessions? The answer is NO, you wouldn’t. You may not even print this. I don’t mind signing something I know, works.

    Richard Rossiter

    I recommend all spirometry technicians responsible for testing workers are certified through a NIOSH approved course.

    An often ignored but important area for NORA to focus on is work-related COPD. Although the burden of work-related asthma and work-related COPD is both about 15%, work-related COPD has not been given as much attention in the literature or by the American Thoracic Society as work-related asthma has. The phenotype of work related COPD has not been adequately delineated.

    There is an important interaction between work-related exposures and smoking on risk for COPD. Similarly, there is an important interaction between work-related exposures and biomass smoke exposure on risk for COPD. Finally, since minority populations as well as lower socioeconomic status populations are at greater risk for work related COPD, the interaction between race/ethnicity and work-related exposures on risk for COPD is an important consideration. By setting the research priority of NORA on work related COPD, NIOSH would make a tremendous contribution to this field of research.

    Thank you for your comment. We agree that work-related COPD is a very important problem caused by a variety of occupational exposures. The reference cited in our blog (Leigh 2011) estimated the cost of work-related COPD ($3.94 billion in 2007) to be even greater than for work-related asthma ($2.29 billion in 2007). In addition, there are other work-related airways diseases that can be confused with COPD in affected individuals, such as obliterative bronchiolitis caused by diacetyl. We invite readers to offer suggestions on the specific types of research and service needed to reduce the burden of this very important problem.

    My suggestions for priorities:

    1. Indium Tin Oxide lung disease
    2. Nano/Ultrafine particles a) what is their toxicity– should it be assessed by the chemical composition or by size or other factors b) how can exposure be prevented?
    3. Flavoring disease: still no OSHA standard. What can be done?
    4. High risk industries (e.g. hard metal, ITO, nano technologies): would an approach other than RELs be more likely to prevent disease?

    Thank you for doing this!

    Bill Beckett

    Thank you for your suggestions. These are all important, emerging issues. And as suggested by your last priority, addressing them will require comprehensive approaches to prevention.

    I believe that the changing human population and environmental dynamics affect the occupational health. Therefore I would like to suggest including these global challenges in the priority areas such as
    1. Climate change and occupational respiratory diseases
    2. Emerging infectious diseases and occupational respiratory diseases
    3. Global burden of occupational respiratory diseases
    I also believe that r2p approach needs to be emphasized.
    Thank you very much for the opportunity to share our thoughts.

    Thank you for these suggestions! Climate change is already causing many work-related respiratory hazards. Wildland fire fighters exposed to smoke from forest fires, outdoor workers exposed to dust storms resulting from desertification, and construction workers exposed to mold during efforts to recover from extreme storm and flooding events are all examples of these emerging climate change-related hazards. Emerging work-related respiratory diseases remain an important challenge. A recent example is the threat to healthcare workers posed by Middle East Respiratory Syndrome Coronavirus (MERS-CoV). Responses to emerging infectious diseases often require a global approach. You may be interested in the blog post Climate Change and Occupational Safety and Health.

    Paul & David,
    Thank you for this open comments format. One area of respiratory exposure that has been overlooked can be found within commercial and municipal refueling of buses and trucks. Fugitive Transfer Emissions occur with all current dispensing equipment. The exposure to workers within these facilities regularly exceed all regulatory PEL levels and is accepted without question.
    Beyond respiratory and dermal exposures to fuels which contain benzene and other neurological toxins, slip and fall risks can also be reduced if dispensing processes can be improved.
    Here is a link to an observational article which explains:
    I welcome your comments.
    Chris Hollerback
    Arvada, CO

    Thank you for your comments! They highlight the importance of strengthening hazard surveillance and health surveillance of workers for chronic diseases, including diseases potentially caused by the exposures described in your comments and in the link that you have provided. In particular, we have only very limited information about the burden of chronic disease, including potentially work-related respiratory disease, in commercial drivers and other workers who perform tasks related to commercial and municipal refueling. Chronic diseases can be particularly challenging, since they may not become clinically apparent until after a worker has left their job or even until after retirement. Strengthening work-related respiratory health surveillance of workers and former workers would help greatly in documenting burden, which in turn can help to set priorities and track progress.

    We need to develop a new way of assessing effects of exposure to agents that cause pneumoconiosis in coal mining. Chest x-ray and spirometry detect changes once damage has already been done. We need new screening tools such as urinary biomarkers of exposure associated with oxidative stress, this will also account for individual variations in susceptibility.

    Thank you for your comment! Our group in the US has followed reports of coal workers’ pneumoconiosis (CWP) in Australia with great interest. Primary prevention based on reducing inhalation of coal mine dust will always be the most important way to prevent CWP. However, secondary prevention through early detection of disease is also extremely important. Early detection can help individuals to take steps to reduce (preferably eliminate) further exposure and can help to identify failures of primary prevention needing to be corrected. Thus, development and validation of sensitive and specific diagnostic tools to detect CWP early, without harmful side effects and at low cost would certainly be desirable.

    Respiratory diseases are quite common in the industrial workers who inhale poisonous gases and particles during their working hours. The management has to take major steps towards the safety of health of its workers by placing safety checks and real-time monitors and sensors which give warning signals when the air gets polluted beyond the permissible limits.

    The NIOSH commitment to protecting the health and safety of all workers in the United States includes improving the identification of harmful airborne agents. A useful resource is the webpage NIOSH Center for Direct Reading and Sensor Technologies Also, NIOSH recently published research on the first iteration of a wearable device that monitors chemical vapors and location for workers. NIOSH is working with stakeholders to further develop the device and adapt it for the oil and gas industry and laboratory safety. For those who work alone, research is underway on a device to measure worker location and exposure in the time of an incapacitating, serious, or fatal events

    In the last thirty years, as pneumologist and epidemiologist, I have tried hard to study the relationships between environmental exposuresand health outcomes. Participating in several medical congresses, I have come to the conclusion that the most urgent action is to fill the knowledge gap of the importance of environmental exposures (including occupation) among clinicians. This is essential because they visit patients with chronic respiratory diseases at different stage of the disease. The cited lack of knowledge hampers the efficacy of the medical intervention, based almost exclusively on prescribing medicines, whose effect often is smaller than the one obtainable by avoidance or attenuation of environmental exposures.
    Another important research item is the so called “FEV1 dominance”. In other words, it is the impossibility to get thorough information on lung function if the examination is limited to forced expirograms. Although in 2005 the ATS-ERS documents on standardization of lung function measurement had suggested to perform at least spirometry, lung volumes and diffusing capacity, the reality is stick to the FEV1 dominance.

    Indeed, it is important for clinicians to consider relevant occupational and environmental exposures when evaluating patients and developing treatment plans. One way NIOSH provides education and raises awareness is by funding 18 university-based Education and Research Centers (ERC) for Occupational Safety and Health across the United States, with the goal of providing education for occupational health and safety professionals. We will keep in mind the importance of additional outreach and communication.

    We appreciate your comment that spirometry findings other than FEV1 can be useful. NIOSH is undertaking several efforts to improve non-invasive evaluation of the respiratory system, such as by impulse oscillometry or through development and validation of biomarkers of exposure and disease. We will consider your comments as we develop a new NORA agenda.

    Several “strategic” suggestions for consideration:

    1. Encourage RHD to maintain the DRDS’s emphasis on high quality epidemiologic and case investigation scientific endeavors.

    2. Move from broad classes to actionable specific health-exposure assessment: Earlier extensive studies associating broad categories such as “dust” and “vapors” with asthma and COPD have convincingly demonstrated the importance of occupational exposure. However, they are too broad to lead to specific preventive actions (e.g., an OEL for “gases” would be meaningless). We now need more specificity (e.g., indium or Portland cement). Modern information science (see below) can identify specifics within large data sets.

    3. Move beyond the simple “Exposure –> disease” paradigm to consider factors affecting the relationship (personal, lifetime exposure history, social context, access to exposure controls). This will help align occupational lung disease research with the principles of precision medicine.

    4. Frontline clinical care providers play a critical role in public health surveillance since their sensitivity is the first step in reporting most modern occupational lung diseases (e.g., WRA). They are also critical for encouraging workers to recognize and remediate their adverse work conditions. However, they are overworked and often have inadequate time and technical acumen in OEM to provide the data to support surveillance systems. Methods to provide them the needed occupational respiratory health expertise on a just in time basis are needed. (While mesothelioma and advanced CWP may be captured using existing approaches, WRA surveillance and prevention require complementary methods).

    5. Apply modern information science methods to automatically acquire specific information from EHR’s, large databases, and worker generated text. Use these methods to provide workers and frontline clinical providers with case specific information when needed. (E.g., exhortation to “take an occupational lung history” is less likely to be useful than advising, “this worker has probably been exposed to indium, which produces…”). This requires both development of the systematic knowledge base(ontology) and bona fide pragmatic/effectiveness intervention trials.

    My suggestions for priorities:

    1. Indium Tin Oxide lung disease
    2. Nano/Ultrafine particles a) what is their toxicity– should it be assessed by the chemical composition or by size or other factors b) how can exposure be prevented?
    3. Flavoring disease: still no OSHA standard. What can be done?
    Thank you

    Recognizing that Bronchiolitis obliterans, aka Constrictive Bronchiolitis aka Popcorn lung are no longer just a flavor related lung disease but also has been found in First responders to the 9/11 attacks in NYC and also in returning military that was exposed to the Burn Pits in Iraq and Afghanistan would be nice. I never worked in a factory around flavoring, had great lungs. I was sent to Iraq and worked daily downwind of the Burn Pit and in the Burn Pit weekly, on my base from August 2005- August 2006. Started having breathing problems there and it continued after coming back. Because of my age and not being a smoker, I had to endure years of tests before the VA would approve a lung biopsy. The results Constrictive Bronchiolitis and a few other things, interstitial fibrosis, minute meningothelial nodules, and small airway injury just to name a few.

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