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Ten years of the SWORD project

Occupational respiratory disease results from exposure to identifiable environmental agents and so is preventable. Since 1989, the Surveillance of Work-related and Occupational Respiratory Disease (SWORD) [1] project has provided a consistent and reliable estimate of the incidence and pattern of occupational respiratory disease. This was the model for similar schemes for the surveillance of occupational skin disease (EPIDERM 1993), for workrelated diseases of all types seen by occupational physicians (Occupational Physicians Reporting Activity — OPRA 1995), for occupationally acquired infectious disease (Surveillance of Infectious Diseases at Work — SIDAW 1996) [2] and for schemes for occupationally acquired auditory, musculoskeletal and neuropsychiatric diseases (1997). Before the advent of SWORD, scant information on the incidence of occupational respiratory disease was derived from several sources. Estimates for occupational asthma were derived from studies in single industries or specialist clinics, from compensation statistics or from RIDDOR (Reporting of Industrial Diseases and Dangerous Occurrences Regulations). None was representative of all patients with occupational asthma and led to the scale of the problem being seriously underestimated. Mortality provided a reasonable guide to the incidence of such diseases as mesothelioma, but was quite unhelpful for most other respiratory diseases. The SWORD reporting scheme was established in 1988 with the support of the British Thoracic Society and the Society of Occupational Medicine, and has been funded throughout by the Health and Safety Executive (HSE) [1]. Its aims were to provide a better estimate of the incidence of work-related respiratory diseases and to facilitate the early recognition of new agents and effects. Rapid feedback of information to participating physicians was considered essential and it was envisaged that collaborative investigations might be undertaken where appropriate. All consultants in respiratory and occupational medicine were invited to participate and it is estimated that 85–90% do so [1]. National coverage allows the census and labour force data for the UK to be used as denominators to calculate incidence rates. However, reporting may well be uneven across the country and there are reasons to believe that the true incidence is at least double that reported [3]. Participants are asked to report all newly diagnosed cases of occupational respiratory disease on a simple reporting card with brief details of the diagnosis, suspected agent, occupation and industry, along with age, sex and postal code. Since 1992, a small core group (around two dozen) with a special interest in occupational disease have reported every month, but the majority of chest physicians report for a single randomly selected month each year [4]. The number reported from the sample is multiplied by 12 to give an estimate of the annual incidence [4,5]. In 1996, this method of random sampling was extended to occupational physicians, who now report work-related disease of all types to a separate scheme, although data are shared. Confidentiality has been crucial to the success of SWORD. Patients and employers remain anonymous, and the success of this policy has been reflected in the number of (initially hesitant) occupational physicians who participate on a voluntary basis. There is the possibility that cases might be reported from more than one source, but sufficient details are reported to enable such duplication to be detected (about 1–2% of reports). The description of surveillance as ‘ongoing scrutiny, generally using methods distinguished by their practicality, uniformity and frequently their rapidity, rather than by complete accuracy’ [6] applies to SWORD, and there may be some errors in our data. By no means will all patients see a consultant, and the consultant may not report the case. On the other hand, studies have suggested that in only some 4% of cases is the diagnosis of occupational asthma subsequently revised [7]. When sampling was introduced, there was some concern that cases from outside the allocated month might be included; this was addressed by allocating space on the reporting card for such cases, and analysis of over 1000 cases in a follow-up study showed no increase in the proportion of cases reported in the very month when sampling began. The strength of SWORD, and some might consider its weakness, lies in the criteria for definition of cases — there are none. SWORD relies on the professional opinion of