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(Chest. 1999;116:614-618.)
© 1999 American College of Chest Physicians

The Occurrence, Recrudescence, and Worsening of Asthma in a Population of Young Adults*

Impact of Varying Types of Occupation

Ido Katz, MD; Shlomo Moshe, MD; Jacob Sosna, MD; Gerald L. Baum, MD, FCCP; Gershon Fink, MD and Joshua Shemer, MD

* From the Israel Defense Force Medical Corps (Drs. Katz, Moshe, Sosna, and Shemer), the Israel Lung Association, Tel Aviv (Dr. Baum), and the Pulmonary and Exercise Physiology unit (Dr. Fink), Rabin Medical Center, Beilinson Campus, Petah-Tikva, affiliated to the Sackler school of medicine, Tel-Aviv University, Tel-Aviv, Israel.

Correspondence to: Ido Katz, MD, 61 Ha'Amakim St, PO Box 3502,Ganney-Tikva, Israel 55900; e-mail: mosheshl{at}actcom.co.il


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
Objective: To describe the rates of exacerbation of existing asthma and incidence of new disease in Israeli men during military service.

Design: All 17-year-old Israeli nationals are obliged by law to appear at the Israel Defense Forces (IDF) recruiting office for medical examination. The medical history of army recruits was noted during the 30-month period after their induction into the IDF, and medical examinations were performed by pulmonary specialists in all suspected cases of asthma. The duty status of the soldiers in combat units (CUs), maintenance units (MUs), and clerical tasks was related to their asthma status.

Results: Of a total of 59,058 recruits, 1.0% developed asthma during the 30 months of this study; of those in CUs, 1.2% developed asthma; of those in MUs, 0.8% developed asthma; and of those performing clerical tasks, 0.6% developed asthma. The relative risk for developing or worsening of asthma was related to both the preexisting asthma status of the recruit and the environment in which he carried out his military service. The annual incidence of occupational-related asthma in MUs was found to be 800/million: five to six times the rates reported elsewhere.

Conclusions: Service in CUs was associated with an increased frequency of exacerbation of asthma among recruits with previous disease and with the appearance of disease de novo. "Normal" conscripts with a history of childhood asthma are at a higher risk of developing overt asthma when compared to subjects with no such history. We found a 25% relative excess of incident cases of asthma in soldiers posted in MUs compared to those performing clerical tasks [(0.8 to 0.6%)/0.8%]. This difference is probably attributed to the difference in occupational hazards in these categories. Further studies are needed to determine if this represents the elicitation of underlying preexisting airway lability by new work demands or other environmental conditions, or if this represents a new development of airway lability because of specific immune or nonimmune factors.

Key Words: army recruits • asthma • epidemiology • incidence • occupational exposure • prevalence • recrudescence • risks • young adults


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
Asthma is a common chronic disease of childhood and adolescence.1 2 There have been many reports of increases in the prevalence of asthma, especially in affluent regions throughout the world.3 4 5 6 7 The epidemiologic evidence suggests that most variations in the prevalence of asthma are due to environmental and not genetic factors.4 8 9 10

The prevalence of occupational asthma (OA) is estimated to be 1.2 to 15.4% of all asthmatics.11 12 13 14 15 16 17 Many young asthmatics have the dilemma of having to choose a profession in which their performance will not be limited by the disease. Several studies have found underdiagnoses of asthma in both adolescents and young adults. Cases of mild asthma and exercise-induced asthma were the types of asthma most frequently overlooked.4 9 10 17 18

Many individuals enter military service each year with undiagnosed asthma, which subsequently limits the performance of their duty.5 6 7 18 19 20 Military service may be especially dangerous to individuals with a disease that is so unpredictable as asthma and so prone to exacerbations caused by factors common in the military environment. For that reason, asthma has been a reason for rejection from military service in many countries.18 19 20 The occurrence, recrudescence, and worsening of asthma during 30 months of military service were noted in a group of new army recruits aged 18 to 21 years old.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 Conclusion
 References
 
Source of Data
All 17-year-old Israeli nationals are obliged by law to appear at the Israel Defense Forces (IDF) recruiting office for medical examination. We included in the current study all the recruits to the IDF between January 1, 1992, and December 31, 1994 (> 95% of the Jewish male population aged 18 years old). We made use of the IDF database and followed up all the soldiers 6 weeks after their induction into the IDF in order to eliminate cases of asthma and/or bronchial hyperreactivity overlooked at the time of the initial examination. Subsequently, the subjects posted in combat units (CUs), maintenance units (MUs), and clerical tasks were followed up for 30 months, and we noted newly diagnosed asthma, recrudescence, or worsening of known asthma that required a change in asthma category and often a change in duty assignment. Recrudescence is defined in this study as the appearance of asthma symptoms in a person who had been symptom free for at least 3 years.

The Medical Surveillance and Disease Categories
Medical history was obtained from the family physicians of most conscripts. During the examination, the subjects were asked specifically whether they had ever received diagnosis of asthma, and whether they had ever suffered from recurrent wheezing, nocturnal cough, or cough or wheeze after exertion. If a positive reply to any of the questions was obtained either directly from the conscript or from the history given by his family physician, which implies the possibility of asthma in the past or present, the conscript was referred for a second examination by a trained respiratory physician. Subjects were instructed not to take any medication for asthma on the day of the examination. The second examination included further detailed history, physical examination, and spirometry at rest.

All subjects except those with overt clinical signs and spirometric evidence of severe airway obstruction also underwent an exercise test. The test comprises 6 min of treadmill running at a speed of 5 km/h arriving at an incline of 10° while breathing room air (22°C; 50% relative humidity). Lung function was measured 5 min and 10 min after the exercise to determine the percentage of fall in FEV1.

As a result of these examinations, the subjects were classified into the following categories:

  1. O: All subjects that had no evidence of past and/or present asthma. This category has been created for this study only and is not used in routine practice in the IDF.
  2. A: Asthma in total clinical remission for at least 3 years with normal spirometry (FEV1 > 70% of predicted) and a normal response to exercise (decrease in FEV1 after exercise of < 10%).
  3. B: Rare and mild attacks of dyspnea with normal spirometry and normal response to exercise.
  4. C: Mild asthma that does not require regular daily medications and either mild impairment in spirometry or evidence of moderate bronchial hyperactivity.
  5. D: Active asthma that requires regular daily treatment or moderate impairment in spirometry, or evidence of severe bronchial hyperactivity.
  6. E: Steroid-dependent asthma or severe asthma that requires hospitalizations. This status excludes the possibility of service in the IDF.

The evaluation of impairment caused by respiratory disease was based on American Thoracic Society standards valid at the time of the study.21

The medical examinations of conscripts in the recruiting office were performed by military physicians, and the conscripts were classified according to the strictly defined guidelines and the regulations that were also valid during their military service.

A chest physician routinely followed up newly diagnosed cases of asthma and all soldiers who used respiratory medications. Whenever needed, the chest physician recommended a change in the asthma category according to the classification guidelines mentioned above. In order to properly post the soldiers according to their asthma category, an independent military medical committee evaluated the chest physicians' recommendations on the basis of the objective clinical findings and the medical criteria mentioned above and then updated the IDF database online in real time. The decisions of the military medical committee were routinely supervised by a well-trained medical officer. In case of disagreements, the decision was reevaluated.

Occupational Categories
The recruits in asthma categories O, A, and B were posted to all types of duty according to their qualifications. Those in asthma category C were not posted in a CU, and those in category D were not posted in either a CU or an MU.

The major differences in stress imposed by the three categories of duty are indicated by the following descriptions:

  1. CU: Characterized by very intensive physical activities, living in the field, and exposure to both specific and nonspecific environmental hazards.
  2. MU: Characterized by moderate physical activities and exposure to nonspecific environmental hazards (mostly gases, fumes, grease, etc). MU workers were engaged in fixing, reconditioning and lubrication, welding and braising, painting under open sheds, etc. The soldiers were exposed to mixtures of organic solvents that usually included toluene and xylene. Exposure was routinely monitored by qualified and approved laboratories. Air samples were usually around 10% (range, 1 to 20%) of the threshold limit value. Low levels (< 5% of threshold limit value) of ferrum oxides, lead, nickel, and cadmium were observed. These levels are in accordance with the accepted levels of the American Conference of Governmental Industrial Hygienists.
  3. Clerical tasks: Characterized by sedentary office work.
    Both CU and MU work require specific (and different) training, qualifications, and certification. Therefore, soldiers stay in the same duty category unless they are disqualified.

Statistical Analysis
All data were recorded on a computer and analyzed later. Statistical analysis was carried out on a software package for the personal computer (SAS V.6.03; Institute; Cary, NC). Percentages were compared by using the {chi}2 test. In some cases, we performed proportion tests. p values of < 0.05 in 2-tailed tests were considered to be significant.

The issue of multiple testing was considered in two ways. Firstly, we examined our overall findings by using a {chi}2 test. Secondly, we compared the differences between the subgroups by using the proportion test.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 Conclusion
 References
 
Table 1 summarizes the follow-up results in subjects with no history of asthma (category O). One percent of subjects with a negative asthma history at the time of induction developed new asthma. The relative risk (RR) for developing asthma was significantly higher among subjects posted in CUs and MUs than it was among subjects performing clerical tasks (2.04 and 1.4, respectively).


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  		Table 1. Newly Diagnosed Asthma in Soldiers With Negative Asthma History at Time of Induction*

 
Table 2 shows the results in subjects with clinical remission for at least 3 years (category A). The recrudescence of asthma was significantly more prevalent among those posted in CUs (12.7%) than among those posted in MUs or those performing clerical tasks. The RR of CUs as compared to that of MUs or clerical tasks was 1.99 and 2.78, respectively.


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  		Table 2. Recrudescence of Asthma in Soldiers With Asthma in Total Clinical Remission for at Least 3 Years With Normal Spirometry and a Normal Response to Exercise Challenge at Time of Induction (Category A)*

 
Table 3 shows the recrudescence of asthma among recruits with a history of rare and mild attacks of dyspnea (category B). Overt asthma appeared in 21.1% of subjects posted in CUs, 15.3% of subjects posted in MUs, and 5.7% of subjects performing clerical tasks. The RR of serving in CUs as compared to the RR of serving in MUs and clerical tasks was 3.7 and 2.7, respectively.


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  		Table 3. Asthma in Soldiers With a History of Rare and Mild Attacks of Dyspnea With Normal Spirometry and Normal Response to Exercise at Time of Induction (Category B)*

 
Table 4 summarizes the follow-up results of subjects who received a diagnosis of mild asthma at the time of induction (category C). The status of the disease worsened in 19.4% of subjects posted in MUs and in 18.6% of subjects performing clerical tasks. The difference between the groups was not significant.


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  		Table 4. Recrudescence in Asthma Activity in Soldiers Who at Induction Had Mild Asthma That Did Not Require Regular Daily Medications and Either Mild Impairment in Spirometry or Evidence of Moderate Bronchial Hyperactivity (Category C)*

 
Table 5 summarizes the worsening of preexisting asthma in CUs and MUs as it relates to a disease category of the subjects on entrance into the IDF. In both of the duty categories, the amount of worsening was directly related to the asthma category at the beginning of service.


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  		Table 5. Morbidity or Worsening According to Military Duty and Disease Severity*

 
The RR for developing asthma or worsening of the disease during military service is summarized in Table 6 for CUs and MUs. It is clear that the more severe the category of asthma at induction, the greater the RR for worsening of asthma status.


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  		Table 6. The RR of Developing or Worsening Asthma Within the Types of Military Duty*

 
Table 7 summarizes the various relationships between asthma severity and the service categories in the present study.


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  		Table 7. The RR of Developing or Worsening of Asthma Within the Disease Categories as Determined by Comparing Different Types of Occupations

 

   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
Conclusion
 References
 
The current study has documented the fate of a group of almost 60,000 young adults with varying degrees of morbidity due to asthma after their induction to the IDF and for 30 months thereafter. The risk of either developing asthma de novo or of worsening of preexisting asthma has been related to service in CUs, which is more risky than service in MUs, which in turn is more risky than service in clerical tasks.

Many mild asthmatics suffer from exercise-induced asthma, and it is important to use exercise testing during the initial screening of recruits in order to unmask the asthma situation.19 20

The results tend to justify both the continued inclusion of mild asthmatics in routine army service and the use of the severity of asthma as a guide to duty assignment. This also emphasizes the importance of the liberal use of exercise challenge to unmask mild cases that might otherwise go undiagnosed.

OA is defined as a disease characterized by variable airflow limitation and/or bronchial hyperresponsiveness due to causes and conditions attributable to a particular working environment and not to stimuli encountered outside of the workplace.15

The exact contribution of OA to the prevalence of asthma is unknown. The prevalence of OA is estimated to be 1.2 to 15.4% of all asthmatics.11 12 13 14 15 16 17 The information about the prevalence of OA is limited and based on the data of workers receiving compensation and reports given to surveillance schemes, both of which are likely to provide underestimation of the true frequency of the disease.11 Prevalence studies of OA usually underestimate the problem because affected workers leave the industry, and there are problems of identifying subjects with asthma in population studies. Most of the epidemiologic studies have relied on the use of the questionnaire rather than on objective tests. Some studies have included the measurement of nonspecific bronchial hyperresponsiveness, and very few studies included a specific challenge test.15

The difference during 30 months of follow-up between soldiers posted in MUs and soldiers performing clerical tasks in the O category (no background of asthma) was 0.2% (p < 0.0001). The annual incidence of OA calculated out of the attributable incidence in MUs is 800/million/yr. This rate is higher than the rate reported in Sweden (80/million),11 the United Kingdom (24/million),12 the West Midlands Health Region of the United Kingdom (43/million)17 and Finland (152/million).11 The incidence of new onset asthma in MUs and CUs was found to be 0.8% and 0.6%, respectively (p < 0.05). This difference of 25% in the annual incidence of the two categories (0.2%/0.8%) represents the relative excess of incident cases of asthma in soldiers posted in MUs compared to those performing clerical tasks, and it is most probably attributed to the difference in occupational hazards in these categories. In another study in the same age group, the proportion of newly diagnosed OA out of all new cases was found to be 4.8%,22 which is much less than that found in our study. In other reports, this high rate of OA was found only in high-risk occupations like bakers and welders.13 In this study, the soldiers working in MUs did the regular maintenance work and not especially high-risk work. The advantage of this study is that it includes all soldiers occupied in different occupations. All the known biases that cause underdiagnosis of OA, such as diagnosis by questioners, lack of awareness of OA by general clinicians and patients, and the unwillingness of patients to relate their symptoms to their work for fear of losing their job, are highly minimized in this study23 24 because this survey is based on an objective computerized database. We assume that the minute incidence of false-positive diagnosis (malingerers) is similar to the minute incidence of the false-negative diagnosis (highly motivated individuals), and therefore, we conclude that we have described the true incidence of OA in this age group.

We found that occupational factors explain 25% of apparently new cases. This study did not attempt to differentiate the possibility that this represents the elicitation of underlying preexisting airway lability by new work demands or other environmental conditions, as opposed to the new development of airway lability because of specific immune or nonimmune factors. Further studies are needed to clarify this point.


   Conclusion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
References
 
Service in CUs tends to unmask previously mild cases of asthma that were not disabling, and to induce the appearance of asthma in subjects who had never suffered from the disease previously. Service in MUs and in a clerical situation poses less threat than the CU environment with the risk being the slightest in the group performing clerical tasks. According to this study, 25% of new onset asthma in subjects occupied in maintenance jobs is probably attributed to the difference in the occupational hazards.


   Footnotes
 
Abbreviations: CU = combat unit; IDF = Israel Defense Force; MU = maintenance unit; OA = occupational asthma; RR = relative risk

Received for publication September 1, 1998. Accepted for publication April 7, 1999.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 

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