Beskæftigelsesudvalget 2020-21
BEU Alm.del Bilag 110
Offentligt
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Received: 9 July 2020
DOI: 10.1111/cod.13719
Revised: 6 October 2020
Accepted: 10 October 2020
ORIGINAL ARTICLE
Degree of employment, sick leave, and costs following
notification of occupational contact dermatitis—A register-
based study
Jojo B. Dietz
1
| Torkil Menné
1
|
| Harald W. Meyer
2
|
| Sven Viskum
3
|
|
Mari-Ann Flyvholm
4
Jeanne D. Johansen
1
1
Ulrik Ahrensbøll-Friis
1
Swen M. John
5
National Allergy Research Centre,
Department of Dermatology and Allergy,
Copenhagen University Hospital Herlev-
Gentofte, Hellerup, Denmark
Department of Occupational and
Environmental Medicine, Bispebjerg and
Frederiksberg Hospital, University of
Copenhagen, Copenhagen, Denmark
Unit of Social Medicine, Copenhagen
University Hospital Frederiksberg,
Frederiksberg, Denmark
National Research Centre for the Working
Environment, Copenhagen, Denmark
Department of Dermatology, Environmental
Health and Health Theory, University of
Osnabrück and Institute of Interdisciplinary
Dermatological Prevention and Rehabilitation
(iDerm) at the University of Osnabrück,
Osnabrück, Germany
Correspondence
Dr Jojo B. Dietz, Gentofte Hospital, National
Allergy Research Centre, Gentofte
Hospitalsvej 20A, 1. Sal, DK-2900 Hellerup,
Denmark.
Email: [email protected]
Funding information
The Danish Working Environment Research
Fund, Grant/Award Number: 41-2016-09
20165103816
Abstract
Background:
Occupational contact dermatitis (OCD) is the most commonly recog-
nized occupational disease in Denmark.
Objectives:
To examine the impact of recognized OCD on degree of employment,
sick leave, unemployment, and job change.
Methods:
Data on all recognized individuals with OCD notified in Denmark between
2010 and 2015 (n = 8940) were linked to information on social transfer payments in
the years before and after notification. The number of weeks on unemployment ben-
efits or sick leave and the degree of employment during the 2 years prior to notifica-
tion was compared with the 2 years following notification.
Results:
The degree of employment decreased by on average 8.9 work-hours/month,
corresponding to an average annual loss of income per worker of approximately
€1570.
The average number of weeks that workers were receiving unemployment
benefits and paid long-term sick leave rose by 2.5 and 3.4 weeks, respectively,
corresponding to an average additional annual cost per worker of approximately
€420
and
€770,
respectively. Longer case-processing time was significantly associ-
ated with lower degree of employment and higher levels of unemployment and sick
leave.
Conclusions:
OCD has a significant negative impact on employment and economics,
thus highlighting the need for a national, strategic action plan for effective prevention
of OCD.
KEYWORDS
2
3
4
5
allergic contact dermatitis, degree of employment, irritant contact dermatitis, job loss, labor
market affiliation, occupational, prognosis, sick leave
1
|
I N T RO DU CT I O N
cases have eczema on the hands.
2,3
The 1-year prevalence of hand
eczema in the general population is approximately 10% and twice as
high in high-risk occupations such as health care and hairdressing.
4-6
OCD often has an early onset in life, the average age at debut
being 25 to 36 years.
2,7
Furthermore, OCD often debuts during
© 2020 John Wiley & Sons A/S . Published by John Wiley & Sons Ltd
1
Occupational contact dermatitis (OCD) is the most commonly recog-
nized occupational disease in Denmark, comprising around one-third
of all recognized occupational diseases. More than 90% of all OCD
Contact Dermatitis.
2020;1–12.
wileyonlinelibrary.com/journal/cod
1
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training or within the first few months of working in high-risk occupa-
tions. OCD is often a chronic relapsing condition with a poor progno-
sis, and considerable impact on the quality of life and the work-life of
the individual.
4,8-10
In Germany, the socioeconomic costs of OCD
have been estimated to exceed
€1.5
billion.
11
In Denmark, the socio-
economic costs have been suggested to be close to
€100
million a
year, but this estimate is based on assumptions made more than
20 years ago.
12
In several countries, different kinds of prevention programs aimed
at reducing the burden of OCD have been tested.
11,13-16
Considering
the impact of OCD, surprisingly few investigations into the potentially
derived inequality in health, and societal and personal costs exist. The
aim of this study was to investigate the occupational and socioeco-
nomic consequences of having OCD and to examine the indicators of
potential inequality due to OCD using Danish official registers of
OCD, sick leave, and social benefits in order to estimate societal
costs.
2
TABLE 1
Study definitions
Number of hours the worker has been
working in a given month (work-hours/
month).
The time between notification and
recognition. As all doctors are required
by law to notify the DLMI at the first
suspicion of occupational contact
dermatitis (OCD), we use the time
between notification and recognition as
a proxy for the time between the first
visit to a doctor with symptoms of OCD
and the final diagnosis. A long case-
processing time is therefore indicative
of a complex disease and/or that the
worker has had a longer way through
the medical system. The case-processing
time was dichotomized to
≤1
year (short
case-processing time) or >1 year (long
case-processing time).
The period that a worker is required to be
on sick leave before being eligible for
paid long-term sick leave. During the
employer sick leave period, the worker's
sick leave is covered by the employer.
Changing legal reforms have resulted in
differing employer sick leave periods
during the period being evaluated in this
study.
The 25% of the workers in our study
population who experienced the
greatest decrease in degree of
employment during the 2 years after
notification decreased with
≥21
work-
hours/month. For this reason, we chose
a decrease in degree of employment of
≥21
work-hours/month as the cut-off
point when evaluating which
occupational groups were most affected
by their OCD.
Occupations with incidence rates of OCD
≥7
cases per 10 000 workers per year.
Occupations with incidence rates of OCD
3–7 cases per 10 000 workers per year.
Periods of time during which the worker is
not given any form of government
subsidy.
All forms of governmental subsidies given
during periods during which the worker
is not employed.
Governmental subsidy given during sick
leave stretching beyond the initial
employer sick leave period.
Degree of employment
Case-processing time
Employer sick leave
period
2
|
METHODS
Study definitions can be found in Table 1.
2.1
|
Study population
Decrease in degree of
employment of
≥21
work-hours/month
The study population consisted of all workers with OCD, who were
notified to the Danish Labour Market Insurance (DLMI) from January
1, 2010 to December 31, 2015. Only cases later recognized as being
occupational diseases were included in the study population (latest
recognition date was December 31, 2018) resulting in 8940 cases.
2.2
|
Data from the Danish Labour Market
Insurance (DLMI) register
The DLMI register comprises all notified and recognized cases of
occupational diseases in Denmark. In Denmark, anyone can notify the
DLMI of an occupational disease, whereas doctors and dentists are
obliged by law to notify all suspected cases without delay. Almost all
notifications are made by doctors. Individuals with suspected OCD
are patch tested and examined by a dermatologist. In most cases, the
DLMI will ask for a dermatologist's statement as the basis for their
case handling. A lawyer, supported by medical specialists, is responsi-
ble for the final decision regarding recognition. The main criteria for
recognition of OCD are that the disease should present itself with
typical symptoms documented in the patient's files by a doctor, and
that a relationship in time is established between the OCD and the
documented exposures at the workplace, and that these exposures
are known to cause contact dermatitis. The contact dermatitis can be
recognized as occupational if the above-mentioned criteria are met,
and this can result in compensation to the worker. It is possible also
to have a worsening of a pre-existing skin disease recognized as a
Exceedingly high-risk
occupations
High-risk occupations
Self-supporting
Unemployment
benefits
Paid long-term sick
leave
partly occupational disease. The data used in this study were obtained
from the DLMI register, and included demographic information such
as sex and age at onset, diagnosis, and information on industry of
employment. The classification of the industry of employment was
based on the Danish Industry Code year 2007 (DB07). The 726 differ-
ent industries of employment in DB07 were for analysis purposes
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categorized into 24 main occupational groups with inspiration from
the literature.
7,17
notification of the OCD, or age <18 years 2 years before notification
(Appendix S1), leaving 6685 workers for analysis.
Paired sample
t
test was used to compare the degree of
employment (work-hours/month) and the average number of
weeks that workers were self-supporting, obtaining unemployment
benefits, or paid long-term sick leave during the 2 years before and
after notification. The changing length of the employer sick leave
Some workers occurred several times in the register,
and to avoid duplicates, workers with both a recognized occupational
irritant contact dermatitis (OICD) and a recognized occupational aller-
gic contact dermatitis (OACD) were coded as having an OACD.
2.3
|
Data from the Danish Register for Evaluation
of Marginalization
Data from the DLMI register was transferred to Statistics Denmark,
and Statistics Denmark linked the data from the DLMI register to the
information from the Danish Register for Evaluation of Marginaliza-
tion (DREAM) on an individual level. DREAM comprises information
on the weekly social transfer payments for all inhabitants in Den-
mark (such as paid long-term sick leave, disability pension, education
grant, unemployment benefits, and maternity pay), and the degree of
employment for each month (work-hours/month). Only paid long-
term sick leave is registered in the DREAM register. Before being eli-
gible for paid long-term sick leave, the worker must receive sick
leave for a set period of time covered by their employer, called the
employer sick leave period. Changing legal reforms have resulted in
different employer sick leave periods between January 2008 and
December 2017. The employer sick leave period was 15 days
between April 2007 and June 2008, 21 days between June 2008
and January 2012, and 30 days between January 2012 and ongo-
ing.
18
period during the period of evaluation in this study represented a
problem. A worker being on sick leave for 30 days would be regis-
tered in the DREAM registry with three different durations
depending on when he was sick (15 days if he was sick between
January 2008 and June 2008, 9 days if he was sick between June
2008 and January 2012, and 0 days if he was sick between January
2012 and December 2017). In addition, the problem could not be
solved by adding the known length of the employer sick leave
period to the registered data, as the earlier described worker would
figure in the data with 30 days if he was sick between January
2008 and January 2012, and 0 days if he was sick between January
2012 and December 2017. For this reason we decided to compare
only the amount of paid long-term sick leave before and after noti-
fication of OCD on workers, who had the same employer sick leave
period during the 2 years before and after notification—that is,
workers with OCD notified between January 2014 and December
2015 (n = 2172).
Two-way ANOVA was used to examine the effect of long vs
short case-processing time (duration of time between notification and
recognition) on the monthly degree of employment and the number
of weeks that workers were self-supporting, obtaining unemployment
benefits or paid long-term sick leave during the 2 years after notifica-
tion adjusted for age and sex. To avoid misleading results because of
the changing duration of the employer sick leave period, we compared
only the amount of paid long-term sick leave after notification of
OCD on workers, with the same employer sick leave period in the
2 years after notification—that is, workers with OCD that was
The length of the employer sick leave period and the reasons
for paid long-term sick leave are not registered in the DREAM regis-
ter. Moreover, the DREAM data included demographic information
about sex, origin, citizenship, place of residency (municipality), place
of work (municipality), and industry of employment for each
month (DB07).
2.4
|
Data analysis and statistics
reported between January 2012 and December 2015 (n = 4503).
We found that the 25% of workers with OCD in our data set who
had experienced the greatest drop in degree of employment in the
2 years after notification were working on average 21 hours a month
less compared to before the notification of OCD. To examine which
of the 24 occupational groups experience the greatest drop in degree
of employment after notification, a log-binomial regression analysis
was performed for each of the occupational groups adjusted for sex
and dichotomized age (≤ vs. >35 years) and with all other workers in
the data set as the reference group. A decrease in degree of employ-
ment during the 2 years after notification of
≥21
or <21 hours was
modeled as outcome. The log-binomial regression analysis yielded
(adjusted) prevalence ratios (PRs) as risk estimates with accompanying
confidence intervals (CIs).
Information on the average number of inhabitants and the aver-
age yearly income before taxes in each municipality in Denmark
between 2010 and 2015 was provided by Statistics Denmark in
February 2020. A linear regression analysis was performed to investi-
gate the relation between the average yearly income before taxes and
The statistical analyses were made in SPSS version 24. Analyses
comprised prevalence proportions (PPs), paired sample
t
test, inde-
pendent samples
t
test, two-way analysis of variance (ANOVA), and
binary logistic regression models. All
P-values
are two-sided, and a
5% level of statistical significance was used. The estimated incidence
rates of OCD (cases per 10 000 person-years) according to the occu-
pational groups were calculated based on the average yearly num-
bers of full-time employees in the various occupational groups
between 2010 and 2015. These data were provided by estatistik.dk
in March 2020.
In this study, we used the workers with OCD as their own con-
trols, as we compared the degree of employment and the number of
weeks self-supporting or on unemployment benefits or paid long-term
sick leave in the 2 years after notification with the 2 years before
notification of OCD. To avoid misleading results, the following exclu-
sion criteria were applied: death, emigration, maternity leave, or
retirement on age pension (public) within 2 years before or after
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the number of OCD cases per 10 000 persons per year in the munici-
palities of Denmark. The study was approved by the Danish Data Pro-
tection Board (no. HGH-2017-093, I-suite no. 05911).
25.0%, respectively). The distribution of men and women and the esti-
mated incidence rates of OCD per 10 000 workers per year for the
24 different occupational groups are listed in Table 3. We found
16 occupational groups to be exceedingly high-risk and 4 occupa-
tional groups to be high-risk occupations. We found especially high
3
3.1
|
|
RESULTS
Study population
incidence rates among hairdressers (136 per 10 000 workers per
year), leather tanning and processing workers (99 per 10 000
workers per year), beauticians (76 per 10 000 workers per year),
bakers (59 per 10 000 workers per year), florists (57 per 10 000
workers per year), and glue manufacture workers (52 per 10 000
workers per year).
There was a marked difference in the distribution of men and
women in the different occupational groups; for example, 1915
women and 139 men were working in health care, whereas
497 men and 82 women were working as metalworkers. There
were more than six times as many men than women working as
mechanics, fitters and technicians, craftsmen and builders, and
metalworkers, whereas more than 10 times as many women than
men were working as hairdressers, beauticians, florists, and
healthcare workers. The five most common occupational groups in
The characteristics of the study population are shown in Table 2. The
study population consisted of 67.3% (6020) women and 32.7% (2920)
men (female/male ratio approximately 2:1). The mean age at notifica-
tion was 37.4 years (median 36, quartiles 26–48): 37.2 years for
women (median 36, quartiles 26–48) and 37.9 years for men (median
37, quartiles 26–49). Occupational irritant contact dermatitis (OICD)
was recognized in 72.6%, whereas occupational allergic contact der-
matitis (OACD) was recognized in 27.4%. The majority of workers
were Danish (89.6%) and had a Danish citizenship (94.5%).
3.2
|
Incidence rates
the data set for men were metalworkers, craftsmen and builders,
factory workers, restaurant workers, and sales assistants, whereas
the five most common occupational groups for women were
healthcare workers, hairdressers, restaurant workers, daycare and
nursery workers, and sales assistants.
The prevalence proportion (or PP) of OICD in the study population
was 75.0% among women and 67.7% among men, whereas the PP of
OACD was higher among men compared to women (32.3% and
T A B L E 2
Characteristics of the study population: Workers with
recognized occupational contact dermatitis and notification date
between January 1, 2010 and December 31, 2015 (N = 8940)
Characteristics
Male, % (n)
Female, % (n)
Age ± SD (years)
Age
≤35
years, % (n)
Diagnoses
OICD, % (n)
OACD, % (n)
Case-processing time ± SD (months)
Origin
Danish, % (n)
Immigrant from non-Western country, % (n)
Immigrant from Western country, % (n)
Descendant from non-Western country, % (n)
Descendant from Western country other than
Denmark, % (n)
Citizenship
Denmark, % (n)
Non-Western country, % (n)
Western country other than Denmark, % (n)
94.5 (8445)
2.8 (248)
2.8 (247)
89.6 (8009)
1.1 (98)
0.2 (16)
6.1 (541)
3.1 (276)
72.6 (6492)
27.4 (2448)
10.6 ± 7.0
Total
32.7 (2920)
67.3 (6020)
37.4 ± 12.9
48.7 (4357)
3.3
|
Degree of employment
The average degree of employment during the 2 years prior com-
pared to the 2 years following notification fell from 122.7 to 113.7
work-hours/month (mean difference of 8.9 work-hours/month, 95%
CI: 7.8–10.0;
P
< .001; n = 6685). Results are shown in Table 4. In
Denmark, the minimum wage was
€14.72
per hour in 2015. If the
workers in the study population were working at minimum wage, the
average annual loss of income per worker was
€1570,
corresponding
to a total loss of income for the whole group (n = 6685) in the
2 years after notification of at least
€21
000 000. Estimates of the
economic costs of OCD for the individual worker and society are
shown in Table 5.
Workers with case-processing time >1 year were on average
working 5.5 fewer hours per month (95% CI 2.6–8.3,
P
<.001)
adjusted for sex and age in the 2 years after notification than workers
with case-processing time
≤1
year (Table 6). This corresponds to
workers with case-processing time >1 year earning approximately
€970
less per year than workers with case-processing time
≤1
year
during the 2 years after notification.
The following occupational groups had a significantly higher risk
of working at least 21 hours less per month after notification of an
OCD: florists (PR 2.3, 95% CI: 1.02–5.03;
P
= .045), cleaning person-
nel (PR 2.2, 95% CI: 1.63–2.86;
P
< .001), hairdressers (PR 2.19, 95%
CI: 1.64–9.91;
P
< .001), bakers (PR 2.03, 95% CI: 1.39–2.97;
P
< .001), butchers and slaughterhouse workers (PR 1.94, 95% CI:
Abbreviations: OACD, occupational allergic contact dermatitis; OICD,
occupational irritant contact dermatitis; SD, standard deviation.
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TABLE 3
The distribution of occupational contact dermatitis according to occupational group, sex, and estimated incidence rates (n = 8940)
No. of males
with OCD (%)
<3
b
4 (0.1)
-
58 (2.0)
-
5 (0.2)
9 (0.3)
206 (7.1)
37 (1.3)
71 (2.4)
No. of females
with OCD (%)
>370
b
-
21 (0.3)
110 (1.8)
45 (0.7)
-
164 (2.7)
354 (5.9)
81 (1.3)
47 (0.8)
No. of workers
with OCD (%)
374 (4.2)
4 (<0.1)
21 (0.2)
168 (1.9)
45 (0.5)
5 (0.1)
173 (1.9)
560 (6.3)
118 (1.3)
118 (1.3)
Number of full-time
employees in Denmark
a
4590
67
462
4758
1315
161
11 782
38 939
12 742
14 865
Estimated rates (cases per
10 000 workers per year)
135
99
76
59
57
52
24
24
15
13
Occupation
Hairdressers
Leather tanning and
processing
Beauticians
Bakers
Florists
Glue manufacture
Dentists and dental
assistants
Restaurant workers
Hotel workers
Butchers/
slaughterhouse
workers
Cleaning personnel
Healthcare workers
Metalworkers
Mechanics/fitters/
technicians
Food production
workers (factory
workers)
Agricultural workers/
farmers/gardeners
Daycare/nursery
workers
Craftsmen and builders
Sale assistants
Factory workers
Other occupations
Postal workers
Teachers
Office workers
a
65 (2.2)
139 (4.8)
497 (17.0)
149 (5.1)
80 (2.7)
208 (3.5)
1915 (31.8)
82 (1.4)
10 (0.2)
69 (1.1)
273 (3.1)
2054 (23.0)
579 (6.5)
159 (1.8)
149 (1.7)
38 765
293 636
89 308
25 785
27 204
12
12
11
10
9
82 (2.8)
15 (0.5)
386 (13.2)
205 (7.0)
235 (8.0)
488 (16.7)
25 (0.9)
69 (2.4)
93 (3.2)
79 (1.3)
316 (5.2)
53 (0.9)
277 (4.6)
168 (2.8)
1254 (20.8)
26 (0.4)
241 (4.0)
128 (2.1)
161 (1.8)
331 (3.7)
439 (4.9)
482 (5.4)
403 (4.5)
1742 (19.5)
51 (0.6)
310 (3.5)
221 (2.5)
31 597
83 704
122 208
137 897
117 192
581 194
18 691
205 095
275 718
8
6
6
6
6
5
4
2
1
Abbreviations: OCD, occupational contact dermatitis.
Information obtained from estatistik.dk, the average number of full-time employees during 2010–2015.
b
Exact numbers cannot be disclosed due to discretion rules.
1.24–3.01;
P
= .003), and craftsmen and builders (PR 1.48, 95% CI:
1.15–1.89;
P
= .002), while healthcare workers had a significantly
lower risk (PR 0.62, 95% CI: 0.53–0.72,
P
< .001) (Table 7).
There are different degrees of unemployment benefits depending,
among other factors, on the age of the worker and if they are the sole
provider of their family. A worker over the age of 30 years without chil-
dren was in 2015 given approximately
€1451
a month in unemploy-
ment benefits. If, hypothetically, the workers in the study population
3.4
|
Unemployment benefits
were all given this standard rate when on unemployment benefits, the
average additional annual costs per worker would be
€420
during the
2 years after notification compared to the 2 years before notification,
corresponding to a total additional societal cost for the whole group
(n = 6685) during the 2 years after notification compared to the 2 years
prior to notification of at least
€5
600 000 (Table 5).
Workers with case-processing time >1 year were self-supporting on
average 3.0 weeks less during the 2 years after notification (95% CI: 0.9–
The number of weeks the workers were self-supporting during the
2 years prior compared to the 2 years following notification fell from
81.4 to 73.9 weeks (mean difference of 7.4 weeks, 95% CI: 6.6–8.2;
P
< .001). In turn, the number of weeks the workers were obtaining
unemployment benefits rose significantly from 9.7 to 12.2 weeks
(mean difference of 2.5 weeks, 95% CI: 1.9–3.0;
P
< .001) (Table 4).
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T A B L E 4
Paired-samples
t
test examining the average monthly degree of employment, the average number of weeks self-supporting, on
unemployment benefits and paid long-term sick leave during the 2 years prior to notification compared to the 2 years after notification of an
occupational contact dermatitis (n = 6685)
Variable
Average monthly degree of employment (work-
hours/month)
Average number of weeks self-supporting (weeks)
Average number of weeks on unemployment
benefits (weeks)
Average number of weeks on paid long-term sick
leave (weeks)
a
a
Two years prior to notification
122.7
81.4
9.7
4.2
Two years after notification
113.7
73.9
12.2
7.0
Mean difference (95% CI)
−
8.9 (−10.0 to
−
7.8]
−7.4
(−8.2 to
−
6.6)
2.5 (1.9 to 3.0)
2.8 (2.1 to 3.5)
Note:
Result in bold were statistically significant (P < .05).
Based on the subgroup of workers, who were under the same employer sick leave period reform during the 2 years before and after notification—that is,
workers with OCD that was notified between January 2014 and December 2015 (n = 2172).
T A B L E 5
Estimates of the economic costs of OCD to the
individual worker and society (n = 6685)
Total for the whole
group during the 2-year
follow-up period after
notification (n = 6685
and n = 2171,
respectively)
21 000 000
T A B L E 6
Two-way ANOVA examining the effect of case
processing time >1 year on monthly degree of employment, number
of weeks self-supporting, on unemployment benefits and long-term
paid sick leave during the 2 years after notification (n = 6685)
Effect of case
processing
time >1 year on the
variable during the
2 years after
notification of OCD
(95% CI)
a
−5.5
(−8.3 to
−
2.6)
Variable
Loss of
income,
€
a
Unemployment
benefits,
€
b
Paid long-term
sick leave,
€
c
a
b
Average per
worker per year
1570
420
770
Variable
5 600 000
3 300 000
Monthly degree of
employment
(work-hours/
month)
b
Weeks self-
supporting
(weeks)
Weeks on
unemployment
benefits (weeks)
c
Weeks on long-term
paid sick leave
(weeks)
d
Additional cost per
worker per year,
€
970
Based on the minimum wage in Denmark in 2015 (€14.72/hour).
Based on the standard rate of unemployment benefits in Denmark in 2015
for a worker without children who is over the age of 30 years (€1451/month).
c
Based on the standard rate of paid long-term sick leave in Denmark in
2015 (€553/week) and on the subgroup of workers, who were under the
same employer sick leave period reform during the 2 years before and
after notification—that is, workers with OCD that was notified between
January 2014 and December 2015 (n = 2172).
−3.0
(−5.1 to
−
0.9)
-
2.7 (1.3 to 4.1)
450
1.4 (0.4 to 2.4)
390
5.1,
P
= .004) adjusted for sex and age compared to workers with
case=processing time
≤1
year. Furthermore, workers with case-
processing >1 year were on unemployment benefits for on average
of 2.7 weeks (95% CI: 1.3–4.1) more during the 2 years after notifi-
cation than workers with case-processing time
≤1
year. This corre-
sponds to workers with case-processing time >1 year, costing
society
€450
more per year after notification than workers with
case-processing time
≤1
year (Table 6).
3.5
|
Paid long-term sick leave
Note:
Result in bold were statistically significant (P< .05).
Abbreviations: CI, confidence interval; OCD, occupational contact
dermatitis.
a
Adjusted for sex and dichotomized age.
b
Based on the minimum wage in Denmark in 2015 (€14.72/hour).
c
Based on the standard rate of unemployment benefits in Denmark in
2015 for a worker without children over the age of 30 years (€1451/
month).
d
Based on the standard rate of paid long-term sick leave in Denmark in
2015 (€553/week) and on the subgroup of workers, who were under the
same employer sick leave period reform during the 2 years after
notification—that is, workers with OCD that was notified between
January 2012 and December 2015 (n = 4503).
Paid long-term sick leave was registered for 31.9% of the study popu-
lation (n = 2133) at some point during the 2 years before notification
compared to 35.8% of the study population (n = 2396) during the
2 years after notification. The number of weeks the workers were on
paid long-term sick leave during the 2 years prior compared to after
notification rose from 4.2 to 7.0 weeks (mean difference of 2.8 weeks,
95% CI: 2.1–3.5;
P
< .001; n = 2172) (Table 4).
The standard amount a person on paid long-term sick leave was
granted in 2014 and 2015 was
€553
a week. If, hypothetically, the
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T A B L E 7
Average decrease in work-hours/month and the risk of experiencing a drop of
≥21
work-hours/month in the 2 years after
notification of occupational contact dermatitis for the 24 occupational groups (n = 6685)
Average decrease in work-hours/month
per worker in the 2 years after
notification, work-hours/month
14.9
19.7
9.5
23.6
18.3
12.4
8.2
14.1
10.1
9.3
7.3
2.9
29.4
3.5
10.5
0.9
9.0
10.7
5.6
4.3
22.3
6.1
4.8
8.5
Occupation
Agricultural workers, farmers,
and gardeners
Bakers
Beauticians
Butchers and slaughterhouse
workers
Cleaning personnel
Craftsmen and builders
Daycare and nursery workers
Dentists and dental assistants
Factory workers
Florists
Food production workers
(factory)
Glue manufacture workers
Hairdressers
Healthcare workers
Hotel workers
Leather tanning and processing
workers
Mechanics, fitters, and
technicians
Metalworkers
Office workers
Teachers
Postal workers
Restaurant workers
Sale assistants
Other occupations
a
No. of workers, with employment
decrease
≥21
work-hours/month (%)
34 (33)
49 (43.8)
6 (37.5)
33 (38.4)
87 (40.8)
110 (33.4)
54 (22.0)
39 (29.1)
77 (22.6)
11 (44)
26 (21)
< 5
b
93 (44.7)
276 (18.5)
27 (32.9)
< 5
b
24 (20.9)
119 (25.0)
35 (19.1)
47 (21.4)
12 (27.9)
125 (31.2)
82 (24.3)
319 (22.8)
Prevalence ratio
(95% CI)
a
1.3 (0.8–1.9)
2.0 (1.4–2.9)
1.5 (0.5–4.2)
1.9 (1.2–3.0)
2.2 (1.6–2.9)
1.5 (1.1–1.9)
0.9 (0.6–1.2)
1.2 (0.8–1.8)
0.9 (0.7–1.2)
2.3 (1.0–5.0)
0.8 (0.5–1.3)
-
2.2 (1.6–2.9)
0.6 (0.5–0.7)
1.3 (0.8–2.1)
-
0.7 (0.5–1.1)
1.0 (0.8–1.3)
0.7 (0.5–1.0)
0.8 (0.6–1.1)
1.2 (0.6–2.4)
1.2 (0.9–1.4)
0.8 (0.6–1.1)
0.9 (0.8–1.0)
Note:
Result in bold were statistically significant (P < .05). CI, confidence interval.
Log-binomial regression analysis performed for each of the occupational groups with decrease in employment of
≥
or <21 work-hours/month modelled as
outcome. The reference group for the analysis was all other workers. Results have been adjusted for sex and dichotomized age.
b
Exact numbers cannot be disclosed due to discretion rules.
workers in the study population on paid long-term sick leave were all
given this standard rate, this would result in an average annual addi-
tional cost per worker of
€770
during the 2 years after notification
compared to the 2 years before notification, corresponding to a total
additional societal cost for the whole group (n = 2172) during the
2 years after notification compared to the 2 years prior to notification
of at least
€3
300 000 (Table 5).
Workers with case-processing time >1 year were on long-term
paid sick leave for on average of 1.4 weeks more during the
2 years after notification (95% CI: 0.4–2.4;
P
= .007) adjusted for
sex
and
age
compared
to
workers
with
case-processing
time
≤1
year (Table 6). This corresponds to workers with case-
processing time >1 year costing society
€390
more per year after
notification than workers with case-processing time
≤1
year. This
analysis was based only on the workers who were under the same
employer sick leave period reform during the 2 years after
notification—that is, workers with OCD who were notified
between January 2012 and December 2015 (n = 4503).
3.6
|
Job change
The industry of employment (DB07) at the time of notification was
known for all the workers in the study population (n = 8940). Two
years after notification, the industry of employment (DB07) was
known for 4704 of the workers. Of these 4704 workers, 47.9%
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intervention study.
16
However, no actions have been taken to edu-
cate employers in the hairdressing trade, which may impair the impact
of educating apprentices. Another reason for the higher incidence rate
of OCD among hairdressers in Denmark in 2010–2015 compared to
2001–2002 could be that a higher level of attention on work-related
skin disease in the hairdressing field has resulted in more cases being
notified, or the reason could be different definitions of the number of
hairdressers in Denmark in the two studies.
The second highest incidence rate in our study was found among
leather tanning and processing workers (99 per 10 000 workers),
which was substantially higher than the incidence rate found in
Northern Bavaria between 1990 and 1999 (5 per 10 000 workers).
7
Because of the small size of the group of leather workers in this study
(4/67), the difference may be due to random variation; however, tan-
ning is an occupation with potentially high risk exposures, for exam-
ple, to chromium VI, and it is of concern that several cases are seen
from such as small trade, indicating lack of proper protection.
Also top-ranking were bakers, florists, and dentists and dental
assistants; incidence rates in our study (59, 57, and 24 cases per
10 000 workers, respectively) were twice as high as those in Northern
F I G U R E 1
Number of OCD cases per year per 10 000 persons in
relation to the average income in the municipality (€)
Bavaria between 1990 and 1999 (33.2, 23.9, and 10.8 cases per
10 000 workers, respectively),
7
but were approximately half of the
incidence rates in Denmark in 2001–2002 (83.7 cases per 10 000
workers for bakers and 41.8 cases per 10 000 workers for dental
(n = 2255) were employed in the same industry of employment
2 years after notification, whereas 52.1% (n = 2449) were employed
in a different or unknown industry. The reason for job change is not
known.
technicians; no incidence rates for florists exists).
2
Previously, acry-
lates were a major source of allergic contact dermatitis in dentist and
dental technicians,
19
however, becoming much less after no-touch
techniques were introduced. By contrast, no specific prevention pro-
grams have been launched in bakers.
The incidence rates among healthcare workers and metalworkers
3.7
|
Inequality in health in relation to OCD
(12 and 11 cases per 10 000 workers, respectively) were comparable
with the incidence rates in Northern Bavaria 1990–1999 (7.3 and
9 cases per 10 000 workers, respectively) and in Denmark
2001–2002 (6.8 cases per 10 000 workers for healthcare work-
ers).
2,7
Trends in OCD during the observation period will be the sub-
ject of a separate paper.
The average yearly income before taxes was compared with the num-
ber of OCD cases per 10 000 persons per year in the different munici-
palities in Denmark using a linear regression analysis. We found that
the rates of OCD cases fell, with 0.362 (95% CI 0.074–0.651) cases
per 10 000 persons when the average yearly income before taxes
rose with
€10
000 (P = .014), thus indicating a tendency toward lower
rates of OCD in high-income municipalities (Figure 1.).
4.2
|
Loss of income
The monthly degree of employment of all the workers fell on average
4
4.1
|
|
DISCUSSION
Incidence rates
8.9 work-hours in the 2 years after notification compared to the
2 years prior to notification, corresponding to a yearly loss of income
of approximately
€1570
per worker.
€1570
is a considerable amount
for the average worker, and as not all workers are affected, the sum
may be even higher. Some of this loss might have been mitigated by
either paid long-term sick leave or unemployment benefits, but the
subsidies given during paid long-term sick leave and unemployment
will always be significantly lower than a worker's previous income. It
has earlier been reported that the average delay from onset of OCD
to notification to the DLMI is around 4.5 years (median 2 years),
2
so it
is reasonable to assume that the degree of employment has been
affected by OCD not only in the 2 years after notification, but also in
The highest incidence rate in our study was found among hairdressers
(135 per 10 000 workers), which was higher than the incidence rate in
Northern Bavaria between 1990 and 1999 (97.4 per 10 000
workers), and more than twice as high as the incidence rate among
hairdressers found in a Danish study examining the incidence rates in
different occupations in 2001–2002 (56.1 per 10 000 workers). This
is of major interest, as a prevention program was launched in 2011 in
all hairdressing schools in Denmark, based on positive results from an
2
7
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9
the 2 years prior to notification. For this reason, the loss of income
found in this study is more likely to be an underestimation than an
overestimation. In this study, we do not know the reason for the drop
in monthly degree of employment, or if OCD was the main driving
factor. Meding et al
3
found that the personal economic situation
worsened for 32% of workers because of their OCD, and 45% of the
workers with worsened personal economy reported a loss of income
of 25% or more. Mälkönen et al
20
term sick leave, which means that OCD is a significant cause of
production loss, which is a serious negative effect.
4.4
|
Job change and unemployment
The number of weeks that workers were obtaining unemployment
benefits rose significantly by 2.5 weeks in the 2 years following notifi-
cation. Furthermore, we found that 52.6% of workers with OCD were
employed in a different or unknown industry of employment 2 years
after notification. These results are similar to the results found in a
Danish study from 2017 where 48.7% of workers with recognized
OCD were still in the same profession 5 years after recognition,
whereas 32.6% had changed their profession and 18.8% were outside
the labor market.
23
We do not know the reason for the change in
industry of employment, but it is not unlikely that OCD was a contrib-
uting or driving factor. A number of studies have found that
23–
25% of workers with OCD lose their job because of OCD, with 15%
ending up unemployed or on disability pension, and 34–82% of
workers make occupational changes (most commonly change of job)
because of their OCD.
20,22
Among high-risk occupations, the numbers
are even worse. In a study from 2011, 44.3% of hairdressers left the
hairdressing field after an average of 8.4 years, 45.5% because of
hand eczema.
6
Across studies and countries it is shown that OCD is a cause of
unemployment; this affects the worker and their families, as unem-
ployment is linked to impaired mental health.
24
In our study many
workers had changed their industry of employment 2 years after noti-
fication of OCD. It has been shown that change of work improves
OCD; however, it is also associated with a negative impact on the
found similar results, with a wors-
ened economic situation for 23% of OCD patients. It could be consid-
ered that the average monthly degree of employment would drop
naturally with age, but we confer that this should not be of signifi-
cance when looking at a 4-year period.
The risk of a decreased degree of employment of
≥21
hours/
month after notification differs between the various occupational
groups. We found that florists, hairdressers, cleaning personnel,
bakers, butcher and slaughterhouse workers, and craftsmen and
builders had a significantly higher risk, whereas healthcare workers
had a significantly lower risk of experiencing a decrease in degree of
employment of
≥21
hours/month. Florists, hairdressers, bakers, and
butchers often work in smaller enterprises, where it can be difficult to
relocate the worker with OCD to another function, and in particular it
can be difficult to find a position with less skin exposures to relocate
to. This may also apply to larger enterprises, as exposure to allergens
and irritants is tightly linked to core tasks of the trade. Healthcare
workers on the other hand often work in a bigger hospital setting
where it can be easier to relocate the worker to a different function.
Moreover, some healthcare workers may also have a higher level of
education making it easier for them to find different work tasks.
4.3
|
Sick leave
workers' quality of life.
23
Workers with OCD were on paid long-term sick leave significantly
more weeks (3.4 weeks) during the 2 years after notification com-
pared to the 2 years prior to notification. Only the amount of paid
long-term sick leave extending past the employer sick leave period
is registered in the DREAM register. A Danish report on the sick-
ness absence of workers in Denmark showed that long-term sick-
ness absence (over 30 days) represents 39% of the total sickness
absence in Denmark.
21
Considering this, the amount of sick leave
in our study is grossly underestimated. A German study examining
the degree of sickness absence during the last 12 months among
patients with OCD, showed that 62.9% of the patients had at least
one absence day because of OCD during the previous 12 months—
the average amount of sickness absence being 76.4 days, whereas
11.5% had extremely long sickness absence of 6 months or lon-
ger.
10
4.5
|
Case-processing time
Case-processing time was shown to be significantly related to the
monthly degree of employment and the number of weeks on unem-
ployment benefits and paid long-term sick leave. Workers with long
case-processing time (>1 year) worked on average 5.5 hours less a
month and were on unemployment benefits and paid long-term sick
leave for 2.7 and 1.2 weeks more, respectively, than workers with
short case-processing time (≤1 year). These results support earlier
studies that have found that the time between debut and diagnosis
has an influence on the prognosis of the contact dermatitis,
25
and
underscore the need for reducing the case-processing time in the
future.
Meding et al found in a 12-year follow-up study of patients
3
with occupational skin disease that 48% had been on sick leave for
at least one period of 7 days due to their occupational skin disease
during the follow-up period. A questionnaire study examining Dan-
ish workers with OCD that had been recognized by the DLMI
found that 19.9% reported prolonged sick leave of >5 weeks per
year due to OCD.
22
4.6
|
Inequality in health in relation to OCD
We found that the incidence of OCD correlated negatively with yearly
income before taxes, with higher rates in low-income municipalities
and lower rates in high-income municipalities, suggesting a social
The employers are only compensated for long-
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inequality in the incidence of OCD. These results can be explained by
the fact that compared to high-income work, low-income work more
often involves wet work and chemical exposures. Furthermore,
Noiesen et al
26
study design it is not possible to evaluate the potential causal relation-
ship between OCD and the social benefits, as the reasons for paid
long-term sick leave or disability pension are not registered and could
be due to a different independent disease. Moreover, not all data rele-
vant for a complete economic analysis was available in the registers.
For example, only sick leave extending past the employer sick leave
period is registered in the DREAM register, making it impossible to
make assumptions about the productivity loss costs, which have ear-
lier been shown to be substantial in OCD cases.
10,30,32
Some costs
were estimated using assumptions, as explained above. These
assumptions have in general been conservative, making an underesti-
showed that individuals with lower socioeconomic
status had more difficulty reading cosmetic ingredient labels and, for
this reason, had more difficulty complying with the medical instruc-
tions. The prognosis has also been described to be poorer among
workers with lower socioeconomic status in terms of severity, quality
of life, and sick leave.
27-29
4.7
|
Socioeconomic costs
mation of costs more likely than an overestimation.
We did not include a separate control group, but instead the per-
son served as their own control before and after recognition of OCD
over a reasonably short period. Having a separate control group could
have supported the results further, but would entail a risk that cases
would also be present in the control group because all data were han-
dled anonymized. Another problem would be the presence of workers
with not-yet recognized OCD in the control group. We believe that
the current analysis represents the best possible and conservative
estimate of some of the costs of OCD to society and the individual.
We found that the socioeconomic costs connected with OCD are
substantial. The additional costs to society during the 2-year period
after notification compared to the 2-year period before notification of
unemployment benefits for the whole group of workers (n = 6685)
were
€5
600 000, whereas it was only possible to calculate the total
cost of paid long-term sick leave for a subgroup of the workers
because of the changing duration of the employer sick leave period.
The total cost for the 2172 workers with OCD notified between
January 2014 and December 2015 was approximately
€3
300 000.
The annual costs per worker with OCD were estimated to be approxi-
mately
€1200
in socioeconomic costs (€420/year unemployment ben-
efits and
€770/year
paid long-term sick leave), and approximately
€1570
in lost income. These results are not comparable to cost-of-
illness studies, as they do not take into account the direct costs of
OCD (costs associated with medical care), or the indirect costs (costs
associated with loss of productivity due to sick leave). The cost-of-
illness of OCD in Denmark has earlier been estimated to
€724
in
direct costs for the 4 years prior to patch testing and the year after
patch testing, with productivity costs for the same period of
€10
722.
30
4.9
|
Conclusion
Occupational contact dermatitis (or OCD) has a significant negative
impact on the occupational and economic situation of the afflicted
workers and cause substantial costs for society. We found that while
the degree of employment falls, the unemployment and sick leave
rises after notification of OCD, especially for workers with long case-
processing time. Some occupations were high risk and more affected
than others. We also found that the duration of the case-processing
time is associated with worsened outcome for the worker, indicating a
need to lower the case processing time. The case cannot be con-
cluded before a final diagnosis has been made; this is why a speedier
diagnosis and treatment may be of benefit. The results of the study
highlight the need for a national action plan for effective prevention
of OCD, preventing new cases as well as reducing the consequences
in those who have acquired the disease.
AC KNOWLEDG EME NT S
This study is independent research funded by the Danish Working
Environment Research Fund (Arbejdsmiljøforskningsfonden). Grant
In comparison, the cost-of-illness in Germany has been
calculated to be
€5358.4
per patient in the year leading up to a
3-week interdisciplinary inpatient rehabilitation (with 80% attributable
to indirect costs).
31
This suggests that the total cost of OCD in Den-
mark is significantly higher than the initial calculations made in this
study. Further studies into the cost-of-illness of OCD focusing on the
productivity loss due to sick leave and the cost of medical care in
Denmark are necessary to completely illuminate the socioeconomic
costs of OCD in Denmark.
4.8
|
Strength and weaknesses
number: 41-2016-2109 20165103816.
AUTHOR CONTRIBU TIONS
Jojo Biel-NielsenDietz:
Conceptualization; Data Curation; Formal
Analysis; Methodology; Project Administration; Writing-original draf;
Writing-review & editing.
Torkil Menné:
Conceptualization; method-
ology; writing-review and editing.
Harald Meyer:
Writing-review and
editing.
Sven Viskum:
Writing-review and editing.
Mari-Ann
Flyvholm:
Conceptualization; funding acquisition; writing-review and
editing.
Ulrik Ahrensbøll-Friis:
Writing-review and editing.
Swen
The strengths of this study are the large size of the study population, com-
prising all patients with recognized OCD in Denmark between 2010 and
2015, and the use of reliable register data of high quality. Because the
DREAM register provides objective measures on social transfer payments,
there was no recall bias regarding the degree of employment or the num-
ber of weeks on unemployment benefits or paid long-term sick leave.
Although the Danish registers are generally of a high standard,
there are well-known limitations in a register-based study. In this
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Malte John:
Writing-review and editing.
Jeanne Duus Johansen:
Con-
ceptualization; formal analysis; funding acquisition; methodology; pro-
ject administration; writing-original draft; writing-review and editing.
CONF LICT S OF INTE R ES T
The authors declare no conflicts of interest.
DATA AVAI LAB ILITY S TATEMENT
The data that support the findings of this study are available from the
Danish Labour Market Insurance Register and Statistics Denmark
(DREAM). Restrictions apply to the availability of these data, which
were used under license for this study. Data are available from the
Danish Labour Market Insurance and Statistics Denmark with the per-
mission of the Danish Data Protection Board.
ORCID
Jojo B. Dietz
https://orcid.org/0000-0002-3138-4591
https://orcid.org/0000-0002-8942-754X
https://orcid.org/0000-0003-4181-0926
https://orcid.org/0000-0002-3537-8463
Mari-Ann Flyvholm
Ulrik Ahrensbøll-Friis
Swen M. John
Jeanne D. Johansen
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How to cite this article:
Dietz JB, Menné T, Meyer HW, et al.
Degree of employment, sick leave, and costs following
notification of occupational contact dermatitis—A register-
based study.
Contact Dermatitis.
2020;1–12.
https://doi.org/
10.1111/cod.13719
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