Tag: UK

Occupational Health and the Law: UK vs. US; I ask a question


A UK case report on Occupational Health and Safety, published in August, came to my attention today. Two NHS Occupational Health investigators from UK, Charles Poole of the Northern General Hospital, Sheffield, and M Wong of the Dudley & Walsall NHS Trust Health Center, presented two clinical cases associated with a relatively new occupational industry in that nation: “The separation of garden waste from domestic waste, its collection and processing in industrial composting sites, so as to reduce biodegradable waste going to landfill“.

It is well known that any kind of disturbance created in a given environment, for any reason, can often potentially release harmful substances in air in form of aerosols, or minute particles capable of floating in air. We have seen that with the yeast-like fungal pathogen, Cryptococcus gattii, which was found, via environmental studies, to be present in high concentrations in the soil of Vancouver Island (British Columbia, Canada), and to spread during dry summer weather likely as airborne particles (a.k.a. “propagules”). Release and dispersal of spores of various molds during large-scale air-disturbing activities such as construction, renovation and/or demolition of buildings is a well-studied phenomenon in the fields of Infection Control and Epidemiology; for example, see Krasinski et al., 1985; Streifel et al., 1983. The waste separation, collection and processing appear to be no different. The investigators write:

The process of composting organic matter encourages the production of bacteria, fungi, spores and endotoxins, which may be released to air in bioaerosols. Levels of bacteria and fungi up to 106 colony forming units/m3 in ambient air have been reported in relation to composting…

The problem has not been studied well at all in the population of waste-composting workers, because – as the investigators indicate – reports of illness in these workers are relatively rare. As a result, no safe levels of exposure to such potentially hazardous aerosols have been defined in this context, nor have been the exact conditions conducive to exposure; we don’t know if, and/or how much of, the exposure depends on variables such as composition of the compost, weather conditions, steps and systemic controls engaged during the separation and collection process.

In the existing clinical literature, one of the major culprits implicated in these environment-related diseases is the ubiquitous, spore-producing mold, Aspergillus, in form of its various species, mostly commonly Aspergillus fumigatus which is the etiological agent behind various diseases involving the upper (nose and upper part of the air-tube) and lower (lower part of the air-tube and the lungs) respiratory tract. Untreated or incompletely treated, these diseases can be severe and chronic. One particularly important manifestation is the Allergic Broncho-Pulmonary Aspergillosis (ABPA, in short), which is a complex or multi-component, immunologic, inflammatory response similar to allergies or hypersensitivities – which if not detected and treated early (with antifungals and steroid immune-suppressants) can lead to serious lung damage. ABPA is generally observed in people with certain debilitating conditions, such as cystic fibrosis, or immunosuppression, but rarely in otherwise healthy individuals. In ABPA, apart from classical respiratory symptoms, reduction in lung functions, and lung abnormalities observed under X-ray, certain allergy-related responses are noted in blood (more precisely, serum) – such as:

  • Type I hypersensitivity to bits and pieces of Aspergillus (all recognized as antigens by the immune system), leading to the excessive generation of allergy-associated antibody, called Immunoglobulin E (IgE). By its action, IgE causes release of highly inflammatory mediators, such as histamine, leukotriene, and prostaglandin, from immune cells, which have both immediate and long term deleterious effects.
  • Type III hypersensitivity to Aspergillus antigens, in which small complexes of these antigens with antibody run amok through the body, depositing in blood vessels, kidneys and joints – eventually leading to immune-mediated destruction of tissues at those sites.
  • Eosinophilia, in which eosinophils, a type of white blood cells, markedly increase in number in blood and/or tissues, a common occurrence in allergy and asthma, and in parasitic (worm) infections. Activated eosinophils, a member of immune defence, are capable of causing tissue damage by various mechanisms.

The UK case report describes two late-thirties, early-forties patients, both garden waste collectors by profession, and both diagnosed with ABPA at occupational health clinics; both responded to treatment and were released with the advice not to work with waste and compost. Another member of their team, who though not ill had symptoms of asthma and tested positive for high serum IgE to Aspergillus antigens (indicating exposure) was given the same advice.

The investigators go on to make some recommendations at the end of the report. They write:

Until the results of large epidemiological studies of garden waste collectors and industrial compost workers are known, the few case reports of ABPA […] would indicate that workers with asthma who are sensitized to A. fumigatus or who have cystic fibrosis, bronchiectasis or are immunosuppressed should not work with garden waste or compost, unless their exposure to airborne fungi can be controlled. Whether asthmatics who are SPT positive or specific IgE positive to A. fumigatus will go on to develop ABPA is unknown, but they should be made aware of the theoretical risk.

Annual health surveillance by way of a respiratory questionnaire and skin prick testing is also recommended for these workers. Other cases of ABPA or EAA in garden waste and compost workers should be sought and reported, until such time that the results of a national study of UK compost workers are known.

The recommendations gave rise to some germane questions in my mind. These are, of course, valid from a clinical standpoint, and made keeping the health and welfare of the patients in mind. But given that these are related to occupational health, how do these situations play out from the perspective of the employer? How are these situations different in the UK as opposed to in the United States? For example:

  • Can/should the employers (say, a waste management firm) mandate pre-employment testing for Aspergillus-specific IgE and skin prick hypersensitivity testing?
  • Can/should the employers refuse employment to a person who tests positive for IgE and hypersensitivity because of a theoretical risk? Relatedly, can/should such an employee be made aware of this theoretical risk?
  • Should such an employee choose to ignore this theoretical risk and accept the job (or continue on the job after a diagnosis) and become inflicted with ABPA, can/should the employee be able to claim occupational exposure and Worker’s Compensation?
  • Specifically in the US context, can a Health Insurance company demand the results of these surveillance tests for a person engaged in the waste management profession, and if positive, treat this as a pre-existing condition and refuse payment in the event the employee becomes ill and needs treatment?

I don’t have the answers to any of these questions. Perhaps someone conversant with labor and/or occupational health-related laws would care to illuminate me in the comments?

Poole CJ, & Wong M (2013). Allergic bronchopulmonary aspergillosis in garden waste (compost) collectors–occupational implications. Occupational medicine (Oxford, England) PMID: 23975883

In two minds… about BioEthics

I am really in two minds as I write this.

This post was prompted by a news item on Teh Grauniad this morning, brought to my attention by that esteemed daily’s twitterfeed. The title and the byline goes as:

Girl, nine, benefits from UK’s first IVF ‘saviour sibling’ therapy
Doctors treat girl with rare blood disorder by transfusing healthy bone marrow from baby brother created at IVF clinic

Intrigued, I read through the report.

The story, reporting a first-of-its-kind-in-UK procedure, is of a nine-year old girl with congenital Fanconi’s anemia, an autosomal recessive (or X-linked recessive in ~2% cases) disorder that can result in bone marrow failure; younger patients eventually develop acute myelogenous leukemia (AML), various other hematological abnormalities, kidney problems, and developmental issues, while older patients often develop carcinoma of head and neck, GI, or genito-urinary tract.

The 13 genes involved in Fanconi’s anemia (including 1 that is identical to the well-known breast-cancer-susceptibility gene, BRCA2) encode proteins that assist the recognition and repair of damaged DNA; one or more of these genes are inactivated in Fanconi’s anemia, a relatively rare disease, with a prevalence of 1-5 cases per 1 million persons (N Engl J Med 2010; 362:1909-1919). In this girl’s case, the poor parents were possibly unwitting hapless carriers (a copy each) of the inactivated gene(s), so that the girl received no active copy at all.

Therapy with androgens and hematopoietic growth factors may be effective for treating bone marrow failure in Fanconi’s anemia; however, the disease often becomes refractory to these treatments. For such patients, hematopoietic stem-cell (bone-marrow) transplantation is the only viable option, if a matched donor is available. Preimplantation genetic diagnosis is a new approach for identifying potential sibling donors for patients with Fanconi’s anemia (See the NEJM Paper above). However, the older brother of this girl was found to be an unsuitable donor, and a worldwide search also failed to find a suitable tissue donor match.

The young parents, in their 30s, chose to have an baby by in vitro fertilization (IVF), in which doctors implanted two out of 6 embryos created by IVF. Several tests showed that the implanted embryo was free of the genetic defect. One year after the boy was born and found to be a good tissue match for this sister, the doctors at the Bristol Royal Hospital treated the girl by transfusing healthy bone marrow from him. She has been monitored carefully for six-months, and is now well enough to consider returning to school.

This is a life-affirming story, as well as one of the wonders of modern medicine and applied biology. I am genuinely happy for the little girl, who got better, as well as a baby brother as a bonus out of it.

Yet, I am ashamed to admit, I cannot shake off a nagging feeling.

I have grown up on a staple of Bollywood (Hindi) movies, where sisters, brothers, parents, children were all ready to sacrifice themselves for the good of their [insert appropriate] family members. ‘Self-abnegation’ and ‘renunciation for the good of humanity’ and so forth are concepts that my parents, followers of Hindu philosophy and spiritual beliefs, drilled into me through endless mythological stories and parables and fables. So I should be comfortable with this situation where the younger brother saves the elder sister’s life, right?

And yet, I can come to no easy terms with the ideas that:

  • This child, the youngest son, was not borne out of love, but merely as a tool to be utilized, even if the cause was noble.
  • The bone-marrow was drawn from the child (a painful procedure per se) when he was just one-year old, much below an age where he was capable of giving consent. The boy was simply not in a position to agree or disagree to the procedure, a fact that is unaltered by the parents being empowered by law to provide proxy consent on his behalf. So, even though the son may have happily donated all his organs or even his life for his sister (à la my Hindi films), what if he refused, what if he could refuse? We will never know, will we?

Those who know me well know that I am not, I repeat, not, anti-abortion (those of you who are aware of the US scenario will appreciate the full force of that statement). I don’t consider a ball of cells (morula, gastrula, blastula) to be a living individual. I do draw a line at the fully-formed fetus, with neurological and cardiac activity, but to me, pre-partum, the mother’s health, well-being and wishes are paramount. But this is not one of those situations.

Here is a child who was created with the specific purpose of saving his sister’s life (hence the somewhat awful news-media moniker, ‘saviour sibling’). The fact that he had no say in being used thusly gives me a pause. How ethical was it to do that? Does the successful end (remission of his sister’s disease) justify the means? Will his life be just like anyone else’s? Will his parents love and cherish him like his elder siblings? Will his parents and sister be eternally grateful to him, thereby spoiling him silly and making a brat out of him? I don’t have any answer to these questions. Perhaps only time can tell.

How did you react to this news? Did any of you face the same ethical dilemma as I did? Or, am I just over-reacting or confused? Please let me know in the comments.