Direct cost of occupational asthma and associated factors in the private sector in central Tunisia

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In Tunisia, the direct costs of OA have not been previously evaluated, despite its economic impact on both the healthcare system and workers. This study aimed to estimate the direct cost of OA in the private sector in central Tunisia and to identify the factors associated with this cost. Methods: A cross-sectional analytical study was conducted using data from the National Health Insurance Fund (CNAM) on OA cases recognised between 2015 and 2017 in the governorates of Sousse, Monastir, Mahdia, and Kairouan. Data on sociodemographic, occupational, clinical, and paraclinical characteristics were collected, alongside the direct costs related to OA. Direct costs included in-kind benefits (medical care, medicines, hospitalisation, transport) and cash benefits (temporary and permanent work indemnities) from the date of disease recognition to December 2020. Statistical analyses included univariate tests and multiple linear regression. Results: A total of 157 OA cases were analysed, predominantly female (75.8%), with a mean age of 43.41 ± 7.29 years. The textile sector accounted for 72% of cases. High-molecular-weight allergens, particularly vegetable textile dust, were the main causative agents (70.7%). The median total direct cost of OA was 4,593.525 TND [IQR: 3,408.003–6,871.725], with CNAM compensating a total of 1,029,200.1 TND for these patients. Lower forced expiratory volume in one second (FEV1) and higher rates of permanent partial disability (PPD) were independently associated with higher direct costs of OA (p < 0.001). Conclusions: This study highlights the considerable direct costs associated with occupational asthma in central Tunisia’s private sector, emphasising the burden on the healthcare system and workers. These findings underscore the need for strengthened preventive measures, early detection, and effective workplace interventions to reduce the impact of OA and guide evidence-based occupational health policies. Occupational asthma Direct cost Economic burden Tunisia Work-related respiratory diseases Figures Figure 1 INTRODUCTION Occupational asthma (OA) is a major public health problem due to its high prevalence and significant social and economic burden [ 1 , 2 ]. In central Tunisia’s private sector, the incidence of OA is estimated to be 24.42 cases per million workers annually [ 3 , 4 ]. However, this condition is frequently underestimated and underreported [ 5 ]. Once OA is diagnosed, occupational physicians must intervene promptly by providing medical and technical guidance to improve patient outcomes. The diagnosis of OA has major consequences for both employees and employers, including job loss, financial repercussions, and the need for new hires [ 6 , 7 ]. In addition to its physical health implications, OA also has a substantial socioeconomic impact. Studies have shown that 25–38% of individuals with OA experience prolonged work interruptions, and 42–78% report a loss of income [ 8 ]. Socioeconomic evaluations must distinguish between direct and indirect costs [ 9 ]. The evaluation of these socioeconomic impacts distinguishes between direct costs (medical expenses, compensation, etc.) and indirect costs (job loss, reduced productivity, etc.) [ 7 ]. The total cost of OA is influenced by multiple factors, including disease incidence and patient management practices [ 9 ]. To our knowledge, no Tunisian study has estimated the cost of OA to date. Therefore, this study aimed to assess the direct cost of OA in central Tunisia’s private sector and identify factors influencing this cost. METHODS I- Study type : This cross-sectional analytical study examined asthmatic patients whose respiratory conditions were recognized as occupational diseases by the National Health Insurance Fund (CNAM) in central Tunisia between 2015 and 2017. II- Study population : All patients working in the private sector who were diagnosed with OA during the specified years in central Tunisia were included. 1- Inclusion criteria : OA cases are recognized by the two medical commissions of occupational accidents and occupational diseases (OA/OD) in Sousse and Monastir, which assess permanent partial disability (PPD) rates according to the administrative, technical, and medical criteria outlined in Law 94 − 28 (February 21, 1994) [ 10 ]. Both compensated and noncompensated OA cases were included. 2- Noninclusion criteria: Asthma cases not recognized as occupational diseases were not included in this study. 3- Sample size calculation: The minimum sample size was calculated via the following formula: n=(Zα/2) 2 ⋅p⋅q/i 2 where: Zα/2: is the confidence level (1.96 for a 95% confidence rate), p: estimated proportion of OA among occupational diseases (7.17%, on the basis of national data [ 3 ]), q = 1 − p, i: is the desired precision (set at 5%). The calculation yielded a minimum sample size of 102 cases. 4- Sampling: An exhaustive sampling approach was used, including all CNAM-recognized OA cases (2015–2017) from the governorates of Sousse, Monastir, Mahdia, and Kairouan. III- Data collection : Data were collected from CNAM’s Oracle database, via a structured synoptic sheet divided into two main sections: • The first section captured information about the study population, including the following: Sociodemographic details (e.g., gender and age), Professional characteristics (e.g., sector of activity, job position, professional seniority, and exposure to occupational hazards), Medical and legal information (e.g., personal history, symptoms, physical examination findings, ongoing treatments, respiratory function test results, dates of initial medical certificate and consolidation/recovery, OA declaration table number, duration of temporary work disability (TWD), and percentage of permanent partial disability (PPD) awarded). • The second section focused on calculating the direct costs associated with OA, which included the total payments made by CNAM for medical care coverage and both temporary and permanent work indemnities from the date of disease recognition until December 31, 2020. Data were extracted from multiple sources, including: Medical certificates of OA declarations submitted to regional CNAM offices, Technical investigation reports conducted by CNAM engineers for each case, Medical and administrative records from the OA/OD medical commission secretariat. IV- Operational definition of variables : The total direct cost of OA was calculated from the date of disease declaration until the end of 2020, considering the sum of the following: In-kind benefits : include pharmaceutical expenses, medical costs, hospitalization fees, and transportation expenses. Cash benefits : comprising amounts paid by the CNAM as temporary work indemnities (daily allowances for TWD) and permanent work indemnities (annuity for IPP when the rate is ≥ 15% or a lump sum for rates between 6% and 14%). Ethical considerations : The study was approved by the Ethics Committee of Sahloul University Hospital, as well as by the General Director of Medical Control and the Central Medical Control District Director. As the study was based on the retrospective analysis of anonymized administrative data from the CNAM database, the requirement for informed consent was waived. Confidentiality and anonymity of all patient data were strictly maintained in accordance with Tunisian regulations and the Declaration of Helsinki. VI- Statistical analysis : The data were entered and analysed via SPSS version 21.0. Qualitative variables were presented as frequencies and percentages. The normality of the quantitative variables was evaluated using the one-sample Kolmogorov‒Smirnov test. Normally distributed quantitative variables are expressed as the means and standard deviations, whereas nonnormally distributed variables are expressed as medians with interquartile ranges [Q1–Q3]. Comparisons of means were performed using the Student's t-test for two independent groups and one-way ANOVA (Fisher-Snedecor test) for more than two groups. Comparisons of percentages were carried out using Pearson's Chi-square test. The relationships between two quantitative variables were assessed using Pearsons's correlation coefficient. For nonnormally distributed variables, the Mann‒Whitney U test (for two groups), the Kruskal‒Wallis test (for more than two groups), and Spearman's rho (ρ) test were used for correlations. Multiple linear regression analysis was performed to identify variables independently associated with the direct cost of OA. Variables with p-value < 0.2 in the univariate analysis were included in the model. A p-value of < 0.05 was considered to indicate statistical significance. RESULTS I. Descriptive analysis : A total of 157 cases of occupational asthma (OA) recognized by the CNAM between 2015 and 2017 were included in this study. OA accounted for 6% of all recognized occupational diseases and 46.9% of all recognized occupational respiratory diseases in central Tunisia during the study period. Most OA cases originated from the Monastir governorate (60.5%), followed by Sousse (31.8%) and Mahdia (6.4%). 1. Sociodemographic and professional characteristics: The study population was predominantly female (75.8%), with a sex ratio of 0.32. The mean age was 43.41 ± 7.29 years (range 29–61 years). The textile industry was the most represented sector (72%), followed by the food (7%), and furniture (5.7%) industries. The mean professional seniority was 15.82 ± 8.9 years (range: 1–37 years). High-molecular-weight agents were involved in 80.9% of the cases. The most common allergen was vegetable textile dust (70.7%), followed by flour and cereals (5.7%). Isocyanates and heated rosin accounted for 4.5% of the cases. 2. Clinical and paraclinical characteristics: A personal history of allergies was noted in 12.7% of the patients. Most of patients presented typical wheezing and dyspnoea episodes (87.3%). Chest tightness was reported by 44.6% of patients, and coughing was reported by 31.2%. Approximately 60% of patients experienced nasal symptoms. Over half of the patients (59.7%) were receiving maintenance asthma therapy. The mean forced expiratory volume in one second (FEV1) was 2.24 ± 0.44 litres, representing 71.41 ± 18.71% of the predicted value. The mean Tiffeneau index (FEV1/Forced vital capacity) was 76.66 ± 12.14%. A proximal obstructive ventilatory defect was identified in 50.7% of the patients. A nonspecific bronchial hyperresponsiveness test was performed in 47 patients (29.9%). Positive results were obtained in all cases, with a mean PD20 value (Provocative Dose causing a 20% fall in FEV1) of 529.24 ± 491.87 µg. 3. Declaration and recognition: Seventy percent of OA cases were declared under Table no. 53 ("Vegetable Textile Dusts"), whereas 10.2% were declared under Table no. 58 ("Other Agents Responsible for Respiratory Allergic Mechanism Diseases"). OA declarations were associated with allergic rhinitis in 62.4% of the patients and allergic conjunctivitis in 1.3%. The PPD rate was 96.8% of patients, with a median rate of 20% [18% − 25%]. 4. Direct cost of occupational asthma : In-kind benefits : None of the patients received coverage for hospitalization or transport costs during the study period. The median in-kind benefit was 282.337 TND (Tunisian Dinars) [103.252–1,622.235] (Table I). Cash benefits : Temporary work disability (TWD) : Twenty-one percent of patients received temporary work indemnities. The median duration of work stoppage was 29 days [14–61.5] (range: 0 to 715 days), with a median payment of 359.366 TD [221.827–948.636]. Permanent work disability (PWD) : The median payment for permanent work indemnities was 4,500.880 TND [3,232.440–6,268.594]. Total cash benefits : The median total cash benefits (combining TWD and PWD) was 4,510.698 TND [3,388.417–6,353.352] (Table I). Total direct cost of OA : The median total direct cost was 4,593.525 TND [3,408.003–6,871.725] (Table 1 ), with CNAM paying a total of 1,029,200.120 TND for 157 patients from disease declaration until the end of 2020. Table 1 Summary of in-kind and cash benefits provided to our patients throughout the study duration Amount (TND) n (%) Median [Q1-Q3] Minimum Maximum In-kind benefits Pharmaceutical Expenses 22 (14%) 597.109 [210.905–1,715.693] 40.800 2,896.113 Medical Expenses 21 (13.4%) 120.000 [49.25–289.79] 10.000 2,294.460 Total In-Kind Benefits 36 (22.9%) 282.337 [103.252–1,622.235] 10.000 2,896.113 Cash benefits TWD (Temporary work disability) Total TWD amount 33 (21%) 359.366 [221.827–948.636] 99.396 1,1613.030 PPD Permanent partial disability) Total rent amount 41 (89.8%) 4,505.083 [3,350.454–6,239.676] 830.324 52,012.761 Capital 1 (7%) 910.519 [2,450.817–7,770.918] 1994.055 8,031.767 Total PPD amount 52 (96.8%) 4,500.880 [3,232.440–6,268.594] 830.324 52,012.761 Total Cash Benefits 152 (96.8%) 4,510.698 [3,388.417–6,353.352] 583.130 52,012.761 Total direct cost 153 (97.4%) 4,593.525 [3,408.003–6,871.725] 101.860 52,109.850 * n: Number of patients who received coverage for expenses TND: Tunisian Dinars II- Analytical Section : II-1 Univariate Study : II-1-1 Direct cost of OA in relation to sociodemographic, occupational, and medical characteristics : The analysis revealed that the direct cost of OA was significantly greater in men than in women (p = 0.04). However, no significant correlation was found between cost and age (p = 0.08). Table 2 provides a detailed breakdown of the direct costs by patient characteristics. Table 2 Direct cost of occupational asthma based on sociodemographic, occupational, and medical patient characteristics Characteristics n Median (TND) [Q1 – Q3] p Sociodemographic characteristics Gender Male 37 5,944.241 [4,094.556–7,603.516] 0.04 Female 116 4,477.809 [3,361.518–6,313.460] Age ≤ 43 years 80 4,436.544 [3,062.654–6,894.335] 0.09 > 43 years 73 5,105.196 [3,869.207–6,916.464] Governorate Monastir 93 4,587.287 [3,828.054–6,742.802] 0.053 Sousse 48 4,701.081 [2,976.851–7,095.912] Mahdia 10 5,556.463 [3,099.719–21,199.914] Kairouan 2 3,588.672 [2,129.387–5,047.957] Professional characteristics Activity Sector Textile 111 4,554.091 [3,577.479–6,724.034] 0.11 Agroalimentary 11 5,665.908 [2,162.658–7,217.955] Furniture Industry 9 4,290.024 [3,061.501–7,520.379] Automotive/Electrical 5 5,105.196 [3,644.993–8,334.746] Electronic Industry 5 4,000.853 [2,783.107–14,899.246] Plastics Industry 3 7,073.501 [2,737.388–29,591.673] Metallurgy 2 7,553.660 [7,118.243–7,989.078] Paper Industry 2 3,912.460 [2,493.821–5,331.099] Professional Seniority ≤ 15 years 78 4,828.778 [3,803.662–6,724.570] 0.76 > 15 years 75 6,724.034 [3,029.024–7,039.229] Etiological Agents Plant Textile Dusts 109 4,554.091 [3,583.662–6,725.105] 0.07 Flour and Cereals 9 5,944.241 [4,444.211–7,800.553] Isocyanates 7 5,105.196 [3,854.377–8,031.767] Heated Rosin 7 4,853.747 [3,353.449–7,073.501] Wood Dust 6 3,726.783 [2,868.545–5,168.542] Aerosol Proteins 3 2,295.743 [899.994–2,474.770] Enzymes 2 5,416.970 [3,745.183–7,088.758] Methacrylates 2 37,017.992 [21,926.140–52,109.845] Sulfites and Bisulfites 2 4,806.032 [2,493.821–7,118.243] Formaldehyde 2 3,892.672 [2,737.388–5,047.957] Molecular Weight High-Molecular-Weight 125 4,587.287 [3,451.632–6,725.105] 0.99 Low-Molecular-Weight 28 6,725.105 [3,211.019–7,683.825] Clinical and Paraclinical characteristics History of occupational diseases No 122 5,039.149 [3,766.401–7,047.797] 0.001 Yes 31 3,884.038 [2,910.519–5,362.985] Wheezing Yes 133 4,697.425 [3,408.003–6,871.725] 0.79 No 17 4,404.999 [3,258.795–6,650.269] Chest Tightness Yes 68 4,457.142 [3,305.919–7,075.655] 0.86 No 82 4,985.116 [3,536.784–6,452.256] Cough Yes 49 4,587.287 [3,495.577–7,052.647] 0.29 No 101 4,603.690 [3,400.213–6,725.105] Nasal Symptoms Yes 94 4,853.747 [3,451.632–7,074.937] 0.15 No 60 4,548.416 [3,398.898–6,126.219] Tachypnea Yes 3 7,675.879 [7,118.243–8,233.516] 0.73 No 108 4,650.557 [3,473.903–6,487.306] Wheezing Yes 38 4,914.607 [3,927.175–8,016.820] 0.11 No 71 4,603.690 [3,163.543–6,268.594] Bronchial Rales Yes 7 4,593.525 [2,829.567–7,118.243] 0.96 No 102 4,775.586 [3,592.311–6,586.747] FEV1 (%) ≥ 70 54 4,347.511 [2,917.569–6,167.628] 0.07 60–69 20 3,891.563 [2,591.005–6,045.956] 50–59 12 5,358.395 [4,254.573–7,878.313] 35–49 13 6,916.944 [3,994.297–13,735.097] < 35 2 6,250.435 [4,469.103–8,031.767] Background Treatment Yes 87 4,512.110 [3,488.566–6,826.507] 0.42 No 14 5,814.015 [3,678.931–6,824.193] Associated Rhinitis Yes 98 4,598.607 [3,407.456–7,047.797] 0.23 No 55 4,587.287 [3,401.308–6,133.973] Associated Conjunctivitis Yes 2 12,442.800 [9,959.460–19,926.140] 0.72 No 151 19,926.140 [19,926.140–26,826.507] * FEV1: The mean forced expiratory volume in one second TND: Tunisian Dinars II-1-2 Direct cost of OA and spirometry data : The direct cost of OA was significantly associated with the percentage of FEV1 relative to the predicted value (p = 0.02, rho= -0.22). However, there was no statistically significant correlation between the direct costs of OA and the percentage of vital capacity relative to the predicted value, the Tiffeneau index, or the percentage of peak expiratory flow rate relative to the predicted value (p = 0.16, p = 0.07, and p = 0.06, respectively). II-1-3 Direct cost of OA and the PPD rate : A significant positive association was observed between the direct cost of OA and the PPD rate (p < 0.001, rho = 0.36), indicating that the direct cost increases with higher PPD rates across governorates (Fig. 1 ). II-2 Multivariate analytical study : Multiple linear regression analysis demonstrated that the direct cost of OA was independently associated with the percentage of FEV1 relative to the predicted value (p < 0.001, beta = -1.45) and the PPD rate (p < 0.001, beta = 1.22) with an R 2 = 0.41 (Table 3 ). Table 3 Variables independently associated with the direct cost of occupational asthma after multiple linear regression analysis Variable p-value beta coefficient 95% CI FEV1 (%) < 0.001 -1.45 [-7.12 ; -0.28] PPD Rate (%) < 0.001 1.22 [1.1 ; 6.12] *95% CI: 95% confidence interval FEV1: The mean forced expiratory volume in one second PPD: Permanent partial disability DISCUSSION I- Strengths and limitations of the study : The cost of occupational asthma (OA) has received limited attention in the scientific literature. This study makes a significant contribution by addressing this gap, as it is the first study to estimate OA costs in Tunisia. The use of comprehensive data sources, including medical and administrative records from CNAM centers, strengthens the reliability of our findings [ 11 ]. However, several limitations may have resulted in an underestimation of the direct costs: Only CNAM-recognized OA cases were included, potentially excluding legitimate cases denied due to administrative issues. Underreporting may have occurred due to misdiagnosis, lack of awareness, or voluntary reporting systems [ 12 ]. Some workers may choose not to report their illness out of fear of job loss or because they believe that the compensation offered is inadequate. II - Estimation of the direct cost of OA : Occupational exposures are estimated to account for 15–20% of asthma cases [ 13 – 20 ]. A systematic analysis reported that approximately 16.3% of all adult-onset asthma cases are attributable to occupational exposures [ 16 ]. Once diagnosed, OA has significant socioeconomic implications for employees, employers, and the healthcare system [ 6 ]. This disease has serious social and professional consequences, especially since it affects active and often young individuals. Moreover, OA can persist even after exposure to triggering risk has ended [ 21 ]. While various studies have examined the costs associated with asthma [ 22 – 26 ], differences in methodology, care considerations, data sources, and sampling conditions necessitate caution when comparing findings. For example, in 1996, the cost of OA in the United States was estimated at $ 1.6 billion, with 74% attributed to direct costs [ 27 ]. According to a study conducted by Birnbaum HG et al., the total expenses for workers with asthma were found to be approximately three times greater than those for disability claimants with other medical conditions [ 28 ]. The costs associated with wage replacement for missed workdays were nearly as significant as the expenses associated with medical care among asthmatic workers [ 28 ]. In Spain, work-related asthma costs range from €155.8 million to €174.3 million depending on diagnostic criteria [ 29 ]. In the UK, OA incurs costs of £70–100 million annually [ 7 ]. In Quebec, the total direct cost of OA was estimated at 61,300 Canadian dollars between 1988 and 2002 [ 30 ]. In Tunisia, there is a lack of statistical data regarding the cost of occupational diseases. CNAM statistics indicate that technical expenses for workplace accidents and occupational diseases doubled from 72.9 million dinars in 2008 to 160.1 million dinars in 2017 [ 31 ]. III- Factors associated with the direct cost of OA : Our univariate analysis revealed significant associations between direct cost and factors such as gender, history of occupational diseases, PPD percentage, and FEV1 percentage. The higher cost observed in men may reflect higher compensation for income loss due to generally higher salaries [ 30 ]. Although no significant relationship was found between age or professional seniority and direct cost in our study, previous research has noted higher costs among older workers [ 30 , 32 ]. Furthermore, our results revealed no significant relationship between professional seniority and the direct cost of OA. Similarly, Miedinger D et al. reported that the number of years with an employer did not significantly alter compensation for income loss, compensation for functional impairment, or total costs [ 32 ]. Within our study population, we observed that the median direct cost of OA was greater for low-molecular-weight (LMW) allergens. However, the molecular weight of the causative agent itself does not seem to have a direct correlation with the cost of OA. Similar findings were reported in Quebec, where compensation programs for income loss were more costly for workers with OA caused by LMW agents [ 30 ]. It is possible that in some cases, workers with OA due to isocyanates, one of the most common LMW etiological agents in our study, may encounter additional challenges in reclassification [ 30 ]. These findings suggest that the type of allergen causing OA could affect the financial burden on affected workers. Our research also revealed that the direct cost of OA was independently associated with FEV1 as a percentage of the predicted value. Malo JL et al. reported that the direct costs of OA were greater among workers with more severe asthma characterized by impaired lung function, bronchial hyperreactivity, and the use of steroids [ 30 ]. VI- Prevention and recommendations : Prevention plays a crucial role in the field of occupational medicine, with a focus on key areas that must always be addressed. It involves a combination of medical and technical aspects that are closely intertwined. In terms of medical prevention, the first step is guiding workers towards suitable professions. Early exposure to manual labor is often linked to a higher risk of allergies. Studies have shown that half of individuals with asthma working in manual professions face challenges in their work [ 33 ]. The role of the occupational physician is crucial in directing collective technical prevention by recommending the elimination or substitution of allergens, as well as advising on the best ventilation and filtration systems to combat dust, fumes, vapours, and allergenic gases [ 2 , 34 ]. They also educate workers about the risks associated with OA. Individual technical prevention for OA involves selecting appropriate respiratory protection [ 2 , 35 ]. During various medical examinations, occupational physicians assesse workers' fitness and identify early signs of OA [ 36 – 38 ]. Furthermore, OA costs can be reduced by improving therapeutic practices and patient education programs [ 39 ]. Given that OA primarily affects young workers [ 40 ], ensuring a swift return to work without loss of productivity or income is crucial [ 41 ]. Employers should prioritize improving working conditions and implement strategies to reduce disease, control exposure, and change work processes [ 7 ]. CONCLUSION OA is a common respiratory disease that significantly impacts young workers both personally and economically. Evaluating the impact of OA is crucial for implementing appropriate preventive measures. The median total direct cost of OA in central Tunisia during the study period was 4,593.525 TND [3,408.003–6,871.725], with CNAM compensating for 1,029,200.120 TND for 157 patients from diagnosis until the end of 2020. Direct cost was independently associated with reduced FEV1 and increased PPD rate. A comprehensive evaluation of the total financial and human costs of OA is essential to inform effective prevention strategies. Given the substantial economic and social impacts, all stakeholders must collaborate to implement intervention strategies that reduce both the financial burden and adverse health outcomes associated with OA. Abbreviations OA Occupational Asthma CNAM Caisse Nationale d'Assurance Maladie (National Health Insurance Fund) OA/OD Occupational accidents and occupational diseases PPD Permanent Partial Disability TWD Temporary Work Disability TND Tunisian Dinar FEV1 Forced Expiratory Volume in one second VC Vital Capacity PD20 Provocative Dose causing a 20% fall in FEV1 PWD Permanent work disability SPSS Statistical Package for the Social Sciences LMW Low-Molecular-Weight HMW High-Molecular-Weight Declarations Data availability The data sets used or analysed during this study are available from the corresponding author upon reasonable request. Ethics approval and consent to participate The study was approved by the Ethics Committee of Sahloul University Hospital, as well as by the General Director of Medical Control and the Central Medical Control District Director. As the study was based on the retrospective analysis of anonymized administrative data from the CNAM database, the requirement for informed consent was waived. Confidentiality and anonymity of all patient data were strictly maintained in accordance with Tunisian regulations and the Declaration of Helsinki. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors' information Authors and Affiliations Chayma Sridi 1,2,3 , Amene Fki 1,3 , Imene Kacem 1,2,4 , Farah Chelly 1,2,3 , Narjes Belhaj 1,2,3 , Marwa Bouhoula 1,2,4 , Baraa Ben Bdira 1,5 , Sana Aissa 1,5 , Souhaiel Chatti 1,2,4 , Ahmed Jabrane Mlaouah 6 , Ahmed Abdelghani 1,5 , Najib Mrizak 1 , Maher Maoua 1,2,3 1 University of Sousse, Faculty of Medicine of Sousse , Tunisia 2 Research Laboratory LR19SP03 «Study of Risks and Prevention Perspectives for Non-communicable Diseases in the Workplace» 3 Occupational Medicine Department, Sahloul University Hospital, Sousse, Tunisia 4 Occupational Medicine Department, Farhat Hached University Hospital, Sousse, Tunisia 5 Pneumology Department, Farhat Hached University Hospital, Sousse, Tunisia 6 Medical Commission of Occupational Accidents and Diseases, Sousse, Tunisia Corresponding author Chayma Sridi , E-mail : [email protected] ; ORCID ID: https://orcid.org/0000-0003-1718-0952 C ontributions: CS, AF, and IK contributed to the conceptualisation, methodology, investigation, data curation, formal analysis, and writing – original draft. FC, NB, MB, and BBB contributed to methodology, validation, and writing – review & editing. SA, SC, AJM, AA, NM, and MM contributed to supervision, project administration, and writing – review & editing. All authors have read and approved the final version of the manuscript. Acknowledgements The authors thank the staff of the National Health Insurance Fund (CNAM) for their valuable support. We are particularly grateful to Mr. Riadh Cheriat for his help with data collection and to Mr. Anis Kammoun for his assistance during this work. References Tarlo SM, Lemiere C, Occupational Asthma. N Engl J Med. 2014;370:640–9. https://doi.org/10.1056/NEJMra1301758 . Tiotiu AI, Novakova S, Labor M, Emelyanov A, Mihaicuta S, Novakova P, et al. Progress in Occupational Asthma. Int J Environ Res Public Health. 2020;17:4553. https://doi.org/10.3390/ijerph17124553 . Maher M, Olfa EM, Wided B, Souhail C, Ezzeddine G, Houda K, et al. 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Occupational Asthma in Adults in Six Canadian Communities. Am J Respir Crit Care Med. 2000;162:2058–62. https://doi.org/10.1164/ajrccm.162.6.9805079 . Blanc PD, Torén K. How much adult asthma can be attributed to occupational factors? Am J Med. 1999;107:580–7. https://doi.org/10.1016/s0002-9343(99)00307-1 . Kogevinas M, Zock J-P, Jarvis D, Kromhout H, Antó JM. Exposure to substances in the workplace and new-onset asthma: an international prospective population-based study (ECRHS-II). Lancet. 2007;370:336–41. https://doi.org/10.1016/s0140-6736(07)61164-7 . Chan-Yeung M. Assessment of Asthma in the Workplace. ACCP Consensus Statement. American College of Chest Physicians. Chest. 1995;108:1084–117. Chouaid C, Vergnenègre A, Vandewalle V, Liebaert F, Khelifa A. Coûts de l’asthme en France: modélisation médico-économique par un modèle de Markov. Rev Mal Respir. 2004;21:493–9. https://doi.org/10.1016/S0761-8425(04)71353-4 . Marcellusi A, Viti R, Incorvaia C, Mennini FS. [Direct and indirect costs associated with respiratory allergic diseases in Italy. A probabilistic cost of illness study]. Recenti Prog Med. 2015;106:517–27. https://doi.org/10.1701/2032.22086 . Nurmagambetov T, Kuwahara R, Garbe P. The Economic Burden of Asthma in the United States, 2008–2013. Ann Am Thorac Soc. 2018;15:348–56. https://doi.org/10.1513/AnnalsATS.201703-259OC . Godard P, Chanez P, Siraudin L, Nicoloyannis N, Duru G. Costs of asthma are correlated with severity: a 1-yr prospective study. Eur Respir J. 2002;19:61–7. https://doi.org/10.1183/09031936.02.00232001 . Smith DH, Malone DC, Lawson KA, Okamoto LJ, Battista C, Saunders WB. A national estimate of the economic costs of asthma. Am J Respir Crit Care Med. 1997;156:787–93. https://doi.org/10.1164/ajrccm.156.3.9611072 . Leigh JP, Romano PS, Schenker MB, Kreiss K, Chest. 2002;121:264–72. https://doi.org/10.1378/chest.121.1.264 Birnbaum HG, Berger WE, Greenberg PE, Holland M, Auerbach R, Atkins KM, et al. Direct and indirect costs of asthma to an employer. J Allergy Clin Immunol. 2002;109:264–70. https://doi.org/10.1067/mai.2002.121310 . García Gómez M, Garrido RU, López RC, Menduiña PL. Direct Health Care Costs of Occupational Asthma in Spain: An Estimation From 2008. Archivos de Bronconeumología. (English Edition). 2012;48:355–61. https://doi.org/10.1016/j.arbr.2012.07.010 . Malo J-L, L’Archevêque J, Ghezzo H. Direct Costs of Occupational Asthma in Quebec between 1988 and 2002. Can Respir J. 2008;15:413–6. https://doi.org/10.1155/2008/324305 . Données relatives à l’activité de la CNAM. Available from: http://www.cnam.nat.tn/doc/upload/indicateursglobaux2018.pdf (accessed August 19, 2021). Miedinger D, Malo J-L, Ghezzo H, L’Archeveque J, Zunzunegui M-V. Factors influencing duration of exposure with symptoms and costs of occupational asthma. Eur Respir J. 2010;36:728–34. https://doi.org/10.1183/09031936.00198209 . Deschamps F, Deschamps-Boulanger S. L’asthme professionnel en 1997. Rev fr Allergol. 1997;37:279–85. Cullinan P, Muñoz X, Suojalehto H, Agius R, Jindal S, Sigsgaard T, et al. Occupational lung diseases: from old and novel exposures to effective preventive strategies. Lancet Respiratory Med. 2017;5:445–55. https://doi.org/10.1016/S2213-2600(16)30424-6 . Cormier M, Lemière C. Occupational asthma. Int J Tuberc Lung Dis. 2020;24:8–21. https://doi.org/10.5588/ijtld.19.0301 . Keefe AR, Demers PA, Neis B, Arrandale VH, Davies HW, Gao Z, et al. A scoping review to identify strategies that work to prevent four important occupational diseases. Am J Ind Med. 2020;63:490–516. https://doi.org/10.1002/ajim.23107 . Lau A, Tarlo SM, Allergy. Asthma Immunol Res. 2019;11:188–200. https://doi.org/10.4168/aair.2019.11.2.188 . Barber CM, Cullinan P, Feary J, Fishwick D, Hoyle J, Mainman H, et al. British Thoracic Society Clinical Statement on occupational asthma. Thorax. 2022;77:433–42. https://doi.org/10.1136/thoraxjnl-2021-218597 . Barnes PJ, Jonsson B, Klim JB. The costs of asthma. Eur Respir J. 1996;9:636–42. 10.1183/09031936.96.09040636 . Dewitte JD, Chan-Yeung M, Malo JL. Medicolegal and compensation aspects of occupational asthma. Eur Respir J. 1994;7:969–80. https://doi.org/10.1183/09031936.94.07050969 . Burge PS. Who bears the costs of occupational asthma? Thorax. 2011;66:92–3. https://doi.org/10.1136/thx.2010.151506 . Additional Declarations No competing interests reported. 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08:38:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7056697/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7056697/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89394693,"identity":"4c9d965c-c7a4-41a2-9cd5-dcc0823c3183","added_by":"auto","created_at":"2025-08-19 13:35:50","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":73620,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDirect costs of occupational asthma by PPD rate in various governorates of central Tunisia\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7056697/v1/2de188f0f666b7d435f89e5c.png"},{"id":89397973,"identity":"da27cabc-726f-4dca-9a84-56721703ab8b","added_by":"auto","created_at":"2025-08-19 13:51:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1716758,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7056697/v1/ad80ebc7-d40c-4f55-b820-887ebcffd82d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Direct cost of occupational asthma and associated factors in the private sector in central Tunisia","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eOccupational asthma (OA) is a major public health problem due to its high prevalence and significant social and economic burden [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In central Tunisia\u0026rsquo;s private sector, the incidence of OA is estimated to be 24.42 cases per million workers annually [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, this condition is frequently underestimated and underreported [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOnce OA is diagnosed, occupational physicians must intervene promptly by providing medical and technical guidance to improve patient outcomes. The diagnosis of OA has major consequences for both employees and employers, including job loss, financial repercussions, and the need for new hires [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn addition to its physical health implications, OA also has a substantial socioeconomic impact. Studies have shown that 25\u0026ndash;38% of individuals with OA experience prolonged work interruptions, and 42\u0026ndash;78% report a loss of income [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSocioeconomic evaluations must distinguish between direct and indirect costs [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The evaluation of these socioeconomic impacts distinguishes between direct costs (medical expenses, compensation, etc.) and indirect costs (job loss, reduced productivity, etc.) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe total cost of OA is influenced by multiple factors, including disease incidence and patient management practices [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. To our knowledge, no Tunisian study has estimated the cost of OA to date. Therefore, this study aimed to assess the direct cost of OA in central Tunisia\u0026rsquo;s private sector and identify factors influencing this cost.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cb\u003eI- Study type\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eThis cross-sectional analytical study examined asthmatic patients whose respiratory conditions were recognized as occupational diseases by the National Health Insurance Fund (CNAM) in central Tunisia between 2015 and 2017.\u003c/p\u003e\u003cp\u003e\u003cb\u003eII- Study population\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eAll patients working in the private sector who were diagnosed with OA during the specified years in central Tunisia were included.\u003c/p\u003e\u003cp\u003e\u003cb\u003e1- Inclusion criteria\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eOA cases are recognized by the two medical commissions of occupational accidents and occupational diseases (OA/OD) in Sousse and Monastir, which assess permanent partial disability (PPD) rates according to the administrative, technical, and medical criteria outlined in Law 94\u0026thinsp;\u0026minus;\u0026thinsp;28 (February 21, 1994) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eBoth compensated and noncompensated OA cases were included.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\n\u003ch3\u003e2- Noninclusion criteria:\u003c/h3\u003e\n\u003cp\u003eAsthma cases not recognized as occupational diseases were not included in this study.\u003c/p\u003e\n\u003ch3\u003e3- Sample size calculation:\u003c/h3\u003e\n\u003cp\u003eThe minimum sample size was calculated via the following formula:\u003c/p\u003e\u003cp\u003en=(Zα/2)\u003csup\u003e2\u003c/sup\u003e\u0026sdot;p\u0026sdot;q/i\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\u003cp\u003ewhere:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eZα/2: is the confidence level (1.96 for a 95% confidence rate),\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ep: estimated proportion of OA among occupational diseases (7.17%, on the basis of national data [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]),\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eq\u0026thinsp;=\u0026thinsp;1\u0026thinsp;\u0026minus;\u0026thinsp;p,\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ei: is the desired precision (set at 5%).\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eThe calculation yielded a minimum sample size of 102 cases.\u003c/p\u003e\n\u003ch3\u003e4- Sampling:\u003c/h3\u003e\n\u003cp\u003eAn exhaustive sampling approach was used, including all CNAM-recognized OA cases (2015\u0026ndash;2017) from the governorates of Sousse, Monastir, Mahdia, and Kairouan.\u003c/p\u003e\u003cp\u003e\u003cb\u003eIII- Data collection\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eData were collected from CNAM\u0026rsquo;s Oracle database, via a structured synoptic sheet divided into two main sections:\u003c/p\u003e\u003cp\u003e\u0026bull; The first section captured information about the study population, including the following:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eSociodemographic details (e.g., gender and age),\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eProfessional characteristics (e.g., sector of activity, job position, professional seniority, and exposure to occupational hazards),\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eMedical and legal information (e.g., personal history, symptoms, physical examination findings, ongoing treatments, respiratory function test results, dates of initial medical certificate and consolidation/recovery, OA declaration table number, duration of temporary work disability (TWD), and percentage of permanent partial disability (PPD) awarded).\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003e\u0026bull; The second section focused on calculating the direct costs associated with OA, which included the total payments made by CNAM for medical care coverage and both temporary and permanent work indemnities from the date of disease recognition until December 31, 2020.\u003c/p\u003e\u003cp\u003eData were extracted from multiple sources, including:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eMedical certificates of OA declarations submitted to regional CNAM offices,\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eTechnical investigation reports conducted by CNAM engineers for each case,\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eMedical and administrative records from the OA/OD medical commission secretariat.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eIV- Operational definition of variables\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eThe total direct cost of OA was calculated from the date of disease declaration until the end of 2020, considering the sum of the following:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eIn-kind benefits\u003c/b\u003e: include pharmaceutical expenses, medical costs, hospitalization fees, and transportation expenses.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eCash benefits\u003c/b\u003e: comprising amounts paid by the CNAM as temporary work indemnities (daily allowances for TWD) and permanent work indemnities (annuity for IPP when the rate is \u0026ge;\u0026thinsp;15% or a lump sum for rates between 6% and 14%).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eEthical considerations\u003c/b\u003e:\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003e The study was approved by the Ethics Committee of Sahloul University Hospital, as well as by the General Director of Medical Control and the Central Medical Control District Director. As the study was based on the retrospective analysis of anonymized administrative data from the CNAM database, the requirement for informed consent was waived. Confidentiality and anonymity of all patient data were strictly maintained in accordance with Tunisian regulations and the Declaration of Helsinki.\u003c/p\u003e\u003cp\u003e\u003cb\u003eVI- Statistical analysis\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eThe data were entered and analysed via SPSS version 21.0. Qualitative variables were presented as frequencies and percentages. The normality of the quantitative variables was evaluated using the one-sample Kolmogorov‒Smirnov test. Normally distributed quantitative variables are expressed as the means and standard deviations, whereas nonnormally distributed variables are expressed as medians with interquartile ranges [Q1\u0026ndash;Q3]. Comparisons of means were performed using the Student's t-test for two independent groups and one-way ANOVA (Fisher-Snedecor test) for more than two groups. Comparisons of percentages were carried out using Pearson's Chi-square test. The relationships between two quantitative variables were assessed using Pearsons's correlation coefficient.\u003c/p\u003e\u003cp\u003eFor nonnormally distributed variables, the Mann‒Whitney U test (for two groups), the Kruskal‒Wallis test (for more than two groups), and Spearman's rho (ρ) test were used for correlations. Multiple linear regression analysis was performed to identify variables independently associated with the direct cost of OA. Variables with p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.2 in the univariate analysis were included in the model. A p-value of \u0026lt;\u0026thinsp;0.05 was considered to indicate statistical significance.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cb\u003eI. Descriptive analysis\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eA total of 157 cases of occupational asthma (OA) recognized by the CNAM between 2015 and 2017 were included in this study. OA accounted for 6% of all recognized occupational diseases and 46.9% of all recognized occupational respiratory diseases in central Tunisia during the study period. Most OA cases originated from the Monastir governorate (60.5%), followed by Sousse (31.8%) and Mahdia (6.4%).\u003c/p\u003e\n\u003ch3\u003e1. Sociodemographic and professional characteristics:\u003c/h3\u003e\n\u003cp\u003eThe study population was predominantly female (75.8%), with a sex ratio of 0.32. The mean age was 43.41\u0026thinsp;\u0026plusmn;\u0026thinsp;7.29 years (range 29\u0026ndash;61 years). The textile industry was the most represented sector (72%), followed by the food (7%), and furniture (5.7%) industries. The mean professional seniority was 15.82\u0026thinsp;\u0026plusmn;\u0026thinsp;8.9 years (range: 1\u0026ndash;37 years).\u003c/p\u003e\u003cp\u003eHigh-molecular-weight agents were involved in 80.9% of the cases. The most common allergen was vegetable textile dust (70.7%), followed by flour and cereals (5.7%). Isocyanates and heated rosin accounted for 4.5% of the cases.\u003c/p\u003e\n\u003ch3\u003e2. Clinical and paraclinical characteristics:\u003c/h3\u003e\n\u003cp\u003eA personal history of allergies was noted in 12.7% of the patients. Most of patients presented typical wheezing and dyspnoea episodes (87.3%). Chest tightness was reported by 44.6% of patients, and coughing was reported by 31.2%. Approximately 60% of patients experienced nasal symptoms. Over half of the patients (59.7%) were receiving maintenance asthma therapy. The mean forced expiratory volume in one second (FEV1) was 2.24\u0026thinsp;\u0026plusmn;\u0026thinsp;0.44 litres, representing 71.41\u0026thinsp;\u0026plusmn;\u0026thinsp;18.71% of the predicted value. The mean Tiffeneau index (FEV1/Forced vital capacity) was 76.66\u0026thinsp;\u0026plusmn;\u0026thinsp;12.14%. A proximal obstructive ventilatory defect was identified in 50.7% of the patients.\u003c/p\u003e\u003cp\u003eA nonspecific bronchial hyperresponsiveness test was performed in 47 patients (29.9%). Positive results were obtained in all cases, with a mean PD20 value (Provocative Dose causing a 20% fall in FEV1) of 529.24\u0026thinsp;\u0026plusmn;\u0026thinsp;491.87 \u0026micro;g.\u003c/p\u003e\n\u003ch3\u003e3. Declaration and recognition:\u003c/h3\u003e\n\u003cp\u003eSeventy percent of OA cases were declared under Table no. 53 (\"Vegetable Textile Dusts\"), whereas 10.2% were declared under Table no. 58 (\"Other Agents Responsible for Respiratory Allergic Mechanism Diseases\"). OA declarations were associated with allergic rhinitis in 62.4% of the patients and allergic conjunctivitis in 1.3%. The PPD rate was 96.8% of patients, with a median rate of 20% [18% \u0026minus;\u0026thinsp;25%].\u003c/p\u003e\u003cp\u003e\u003cb\u003e4. Direct cost of occupational asthma\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eIn-kind benefits\u003c/b\u003e:\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eNone of the patients received coverage for hospitalization or transport costs during the study period. The median in-kind benefit was 282.337 TND (Tunisian Dinars) [103.252\u0026ndash;1,622.235] (Table I).\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eCash benefits\u003c/b\u003e:\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eTemporary work disability (TWD)\u003c/b\u003e :\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eTwenty-one percent of patients received temporary work indemnities. The median duration of work stoppage was 29 days [14\u0026ndash;61.5] (range: 0 to 715 days), with a median payment of 359.366 TD [221.827\u0026ndash;948.636].\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003ePermanent work disability (PWD)\u003c/b\u003e :\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eThe median payment for permanent work indemnities was 4,500.880 TND [3,232.440\u0026ndash;6,268.594].\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eTotal cash benefits\u003c/b\u003e:\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eThe median total cash benefits (combining TWD and PWD) was 4,510.698 TND [3,388.417\u0026ndash;6,353.352] (Table I).\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eTotal direct cost of OA\u003c/b\u003e:\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eThe median total direct cost was 4,593.525 TND [3,408.003\u0026ndash;6,871.725] (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), with CNAM paying a total of 1,029,200.120 TND for 157 patients from disease declaration until the end of 2020.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSummary of in-kind and cash benefits provided to our patients throughout the study duration\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAmount (TND)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMedian\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e[Q1-Q3]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eMinimum\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eMaximum\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eIn-kind benefits\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePharmaceutical Expenses\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22 (14%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e597.109\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e[210.905\u0026ndash;1,715.693]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e40.800\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e2,896.113\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMedical Expenses\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21 (13.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e120.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e[49.25\u0026ndash;289.79]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e10.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e2,294.460\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eTotal In-Kind Benefits\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e36 (22.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e282.337\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e[103.252\u0026ndash;1,622.235]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e10.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e2,896.113\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cb\u003eCash benefits\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTWD\u003c/p\u003e\u003cp\u003e(Temporary work disability)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTotal TWD amount\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e33 (21%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e359.366\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e[221.827\u0026ndash;948.636]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e99.396\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1,1613.030\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003ePPD\u003c/p\u003e\u003cp\u003ePermanent partial disability)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTotal rent amount\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e41 (89.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4,505.083\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e[3,350.454\u0026ndash;6,239.676]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e830.324\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e52,012.761\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCapital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e910.519\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e[2,450.817\u0026ndash;7,770.918]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1994.055\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e8,031.767\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTotal PPD amount\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e52 (96.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4,500.880\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e[3,232.440\u0026ndash;6,268.594]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e830.324\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e52,012.761\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eTotal Cash Benefits\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e152 (96.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4,510.698\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e[3,388.417\u0026ndash;6,353.352]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e583.130\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e52,012.761\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTotal direct cost\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e153 (97.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4,593.525\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e[3,408.003\u0026ndash;6,871.725]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e101.860\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e52,109.850\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003e* n: Number of patients who received coverage for expenses\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003eTND: Tunisian Dinars\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eII- Analytical Section\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eII-1 Univariate Study\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eII-1-1 Direct cost of OA in relation to sociodemographic, occupational, and medical characteristics\u003c/strong\u003e :\u003c/p\u003e\n\u003cp\u003eThe analysis revealed that the direct cost of OA was significantly greater in men than in women (p\u0026thinsp;=\u0026thinsp;0.04). However, no significant correlation was found between cost and age (p\u0026thinsp;=\u0026thinsp;0.08). Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e provides a detailed breakdown of the direct costs by patient characteristics.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDirect cost of occupational asthma based on sociodemographic, occupational, and medical patient characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMedian (TND)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[Q1 \u0026ndash; Q3]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSociodemographic characteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5,944.241\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[4,094.556\u0026ndash;7,603.516]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e0.04\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e116\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,477.809\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[3,361.518\u0026ndash;6,313.460]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;43 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,436.544\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[3,062.654\u0026ndash;6,894.335]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;43 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5,105.196\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[3,869.207\u0026ndash;6,916.464]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGovernorate\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMonastir\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,587.287\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[3,828.054\u0026ndash;6,742.802]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e0.053\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSousse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,701.081\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[2,976.851\u0026ndash;7,095.912]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMahdia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5,556.463\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[3,099.719\u0026ndash;21,199.914]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKairouan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3,588.672\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[2,129.387\u0026ndash;5,047.957]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eProfessional characteristics\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eActivity Sector\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTextile\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e111\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,554.091\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[3,577.479\u0026ndash;6,724.034]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"7\" rowspan=\"8\"\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAgroalimentary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5,665.908\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[2,162.658\u0026ndash;7,217.955]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFurniture Industry\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,290.024\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[3,061.501\u0026ndash;7,520.379]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAutomotive/Electrical\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5,105.196\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[3,644.993\u0026ndash;8,334.746]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eElectronic Industry\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,000.853\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[2,783.107\u0026ndash;14,899.246]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePlastics Industry\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7,073.501\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[2,737.388\u0026ndash;29,591.673]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMetallurgy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7,553.660\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[7,118.243\u0026ndash;7,989.078]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePaper Industry\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3,912.460\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[2,493.821\u0026ndash;5,331.099]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eProfessional Seniority\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;15 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,828.778\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[3,803.662\u0026ndash;6,724.570]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.76\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;15 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6,724.034\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[3,029.024\u0026ndash;7,039.229]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEtiological Agents\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePlant Textile Dusts\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e109\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,554.091\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[3,583.662\u0026ndash;6,725.105]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"9\" rowspan=\"10\"\u003e\u003cp\u003e0.07\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFlour and Cereals\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5,944.241\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[4,444.211\u0026ndash;7,800.553]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIsocyanates\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5,105.196\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[3,854.377\u0026ndash;8,031.767]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeated Rosin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,853.747\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[3,353.449\u0026ndash;7,073.501]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWood Dust\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3,726.783\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[2,868.545\u0026ndash;5,168.542]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAerosol Proteins\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2,295.743\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[899.994\u0026ndash;2,474.770]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEnzymes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5,416.970\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[3,745.183\u0026ndash;7,088.758]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMethacrylates\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e37,017.992\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[21,926.140\u0026ndash;52,109.845]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSulfites and Bisulfites\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,806.032\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[2,493.821\u0026ndash;7,118.243]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFormaldehyde\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3,892.672\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[2,737.388\u0026ndash;5,047.957]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMolecular Weight\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh-Molecular-Weight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e125\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,587.287\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[3,451.632\u0026ndash;6,725.105]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.99\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLow-Molecular-Weight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6,725.105\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[3,211.019\u0026ndash;7,683.825]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eClinical and Paraclinical characteristics\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHistory of occupational diseases\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e122\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5,039.149\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[3,766.401\u0026ndash;7,047.797]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3,884.038\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[2,910.519\u0026ndash;5,362.985]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eWheezing\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e133\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,697.425\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[3,408.003\u0026ndash;6,871.725]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.79\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,404.999\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[3,258.795\u0026ndash;6,650.269]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eChest Tightness\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,457.142\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[3,305.919\u0026ndash;7,075.655]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.86\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,985.116\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[3,536.784\u0026ndash;6,452.256]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCough\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,587.287\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[3,495.577\u0026ndash;7,052.647]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.29\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e101\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,603.690\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[3,400.213\u0026ndash;6,725.105]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNasal Symptoms\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,853.747\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[3,451.632\u0026ndash;7,074.937]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,548.416\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[3,398.898\u0026ndash;6,126.219]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTachypnea\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7,675.879\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[7,118.243\u0026ndash;8,233.516]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.73\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e108\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,650.557\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[3,473.903\u0026ndash;6,487.306]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eWheezing\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,914.607\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[3,927.175\u0026ndash;8,016.820]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,603.690\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[3,163.543\u0026ndash;6,268.594]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBronchial Rales\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,593.525\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[2,829.567\u0026ndash;7,118.243]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.96\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e102\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,775.586\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[3,592.311\u0026ndash;6,586.747]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFEV1 (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,347.511\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[2,917.569\u0026ndash;6,167.628]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e0.07\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e60\u0026ndash;69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3,891.563\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[2,591.005\u0026ndash;6,045.956]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e50\u0026ndash;59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5,358.395\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[4,254.573\u0026ndash;7,878.313]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e35\u0026ndash;49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6,916.944\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[3,994.297\u0026ndash;13,735.097]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6,250.435\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[4,469.103\u0026ndash;8,031.767]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBackground Treatment\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,512.110\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[3,488.566\u0026ndash;6,826.507]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.42\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5,814.015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[3,678.931\u0026ndash;6,824.193]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAssociated Rhinitis\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,598.607\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[3,407.456\u0026ndash;7,047.797]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.23\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,587.287\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[3,401.308\u0026ndash;6,133.973]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAssociated Conjunctivitis\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12,442.800\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[9,959.460\u0026ndash;19,926.140]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.72\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e151\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e19,926.140\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e[19,926.140\u0026ndash;26,826.507]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e* FEV1: The mean forced expiratory volume in one second\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eTND: Tunisian Dinars\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eII-1-2 Direct cost of OA and spirometry data\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eThe direct cost of OA was significantly associated with the percentage of FEV1 relative to the predicted value (p\u0026thinsp;=\u0026thinsp;0.02, rho= -0.22). However, there was no statistically significant correlation between the direct costs of OA and the percentage of vital capacity relative to the predicted value, the Tiffeneau index, or the percentage of peak expiratory flow rate relative to the predicted value (p\u0026thinsp;=\u0026thinsp;0.16, p\u0026thinsp;=\u0026thinsp;0.07, and p\u0026thinsp;=\u0026thinsp;0.06, respectively).\u003c/p\u003e\u003cp\u003e\u003cb\u003eII-1-3 Direct cost of OA and the PPD rate\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eA significant positive association was observed between the direct cost of OA and the PPD rate (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, rho\u0026thinsp;=\u0026thinsp;0.36), indicating that the direct cost increases with higher PPD rates across governorates (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eII-2 Multivariate analytical study\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eMultiple linear regression analysis demonstrated that the direct cost of OA was independently associated with the percentage of FEV1 relative to the predicted value (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, beta = -1.45) and the PPD rate (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, beta\u0026thinsp;=\u0026thinsp;1.22) with an R\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.41 (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eVariables independently associated with the direct cost of occupational asthma after multiple linear regression analysis\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ebeta coefficient\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFEV1 (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-1.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[-7.12 ; -0.28]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePPD Rate (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[1.1 ; 6.12]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e*95% CI: 95% confidence interval\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFEV1: The mean forced expiratory volume in one second\u003c/p\u003e\u003cp\u003ePPD: Permanent partial disability\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003e\u003cb\u003eI- Strengths and limitations of the study\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eThe cost of occupational asthma (OA) has received limited attention in the scientific literature. This study makes a significant contribution by addressing this gap, as it is the first study to estimate OA costs in Tunisia. The use of comprehensive data sources, including medical and administrative records from CNAM centers, strengthens the reliability of our findings [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, several limitations may have resulted in an underestimation of the direct costs:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eOnly CNAM-recognized OA cases were included, potentially excluding legitimate cases denied due to administrative issues.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eUnderreporting may have occurred due to misdiagnosis, lack of awareness, or voluntary reporting systems [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSome workers may choose not to report their illness out of fear of job loss or because they believe that the compensation offered is inadequate.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eII - Estimation of the direct cost of OA\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eOccupational exposures are estimated to account for 15\u0026ndash;20% of asthma cases [\u003cspan additionalcitationids=\"CR14 CR15 CR16 CR17 CR18 CR19\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. A systematic analysis reported that approximately 16.3% of all adult-onset asthma cases are attributable to occupational exposures [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOnce diagnosed, OA has significant socioeconomic implications for employees, employers, and the healthcare system [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This disease has serious social and professional consequences, especially since it affects active and often young individuals. Moreover, OA can persist even after exposure to triggering risk has ended [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhile various studies have examined the costs associated with asthma [\u003cspan additionalcitationids=\"CR23 CR24 CR25\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], differences in methodology, care considerations, data sources, and sampling conditions necessitate caution when comparing findings. For example, in 1996, the cost of OA in the United States was estimated at \u003cspan\u003e$\u003c/span\u003e1.6\u0026nbsp;billion, with 74% attributed to direct costs [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. According to a study conducted by Birnbaum HG et al., the total expenses for workers with asthma were found to be approximately three times greater than those for disability claimants with other medical conditions [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The costs associated with wage replacement for missed workdays were nearly as significant as the expenses associated with medical care among asthmatic workers [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In Spain, work-related asthma costs range from \u0026euro;155.8\u0026nbsp;million to \u0026euro;174.3\u0026nbsp;million depending on diagnostic criteria [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. In the UK, OA incurs costs of \u0026pound;70\u0026ndash;100\u0026nbsp;million annually [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In Quebec, the total direct cost of OA was estimated at 61,300 Canadian dollars between 1988 and 2002 [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn Tunisia, there is a lack of statistical data regarding the cost of occupational diseases. CNAM statistics indicate that technical expenses for workplace accidents and occupational diseases doubled from 72.9\u0026nbsp;million dinars in 2008 to 160.1\u0026nbsp;million dinars in 2017 [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cb\u003eIII- Factors associated with the direct cost of OA\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eOur univariate analysis revealed significant associations between direct cost and factors such as gender, history of occupational diseases, PPD percentage, and FEV1 percentage. The higher cost observed in men may reflect higher compensation for income loss due to generally higher salaries [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Although no significant relationship was found between age or professional seniority and direct cost in our study, previous research has noted higher costs among older workers [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFurthermore, our results revealed no significant relationship between professional seniority and the direct cost of OA. Similarly, Miedinger D et al. reported that the number of years with an employer did not significantly alter compensation for income loss, compensation for functional impairment, or total costs [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWithin our study population, we observed that the median direct cost of OA was greater for low-molecular-weight (LMW) allergens. However, the molecular weight of the causative agent itself does not seem to have a direct correlation with the cost of OA. Similar findings were reported in Quebec, where compensation programs for income loss were more costly for workers with OA caused by LMW agents [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. It is possible that in some cases, workers with OA due to isocyanates, one of the most common LMW etiological agents in our study, may encounter additional challenges in reclassification [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. These findings suggest that the type of allergen causing OA could affect the financial burden on affected workers.\u003c/p\u003e\u003cp\u003eOur research also revealed that the direct cost of OA was independently associated with FEV1 as a percentage of the predicted value. Malo JL et al. reported that the direct costs of OA were greater among workers with more severe asthma characterized by impaired lung function, bronchial hyperreactivity, and the use of steroids [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cb\u003eVI- Prevention and recommendations\u003c/b\u003e:\u003c/p\u003e\u003cp\u003ePrevention plays a crucial role in the field of occupational medicine, with a focus on key areas that must always be addressed. It involves a combination of medical and technical aspects that are closely intertwined. In terms of medical prevention, the first step is guiding workers towards suitable professions. Early exposure to manual labor is often linked to a higher risk of allergies. Studies have shown that half of individuals with asthma working in manual professions face challenges in their work [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe role of the occupational physician is crucial in directing collective technical prevention by recommending the elimination or substitution of allergens, as well as advising on the best ventilation and filtration systems to combat dust, fumes, vapours, and allergenic gases [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. They also educate workers about the risks associated with OA.\u003c/p\u003e\u003cp\u003eIndividual technical prevention for OA involves selecting appropriate respiratory protection [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. During various medical examinations, occupational physicians assesse workers' fitness and identify early signs of OA [\u003cspan additionalcitationids=\"CR37\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFurthermore, OA costs can be reduced by improving therapeutic practices and patient education programs [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Given that OA primarily affects young workers [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], ensuring a swift return to work without loss of productivity or income is crucial [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Employers should prioritize improving working conditions and implement strategies to reduce disease, control exposure, and change work processes [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eOA is a common respiratory disease that significantly impacts young workers both personally and economically. Evaluating the impact of OA is crucial for implementing appropriate preventive measures.\u003c/p\u003e\u003cp\u003eThe median total direct cost of OA in central Tunisia during the study period was 4,593.525 TND [3,408.003\u0026ndash;6,871.725], with CNAM compensating for 1,029,200.120 TND for 157 patients from diagnosis until the end of 2020. Direct cost was independently associated with reduced FEV1 and increased PPD rate. A comprehensive evaluation of the total financial and human costs of OA is essential to inform effective prevention strategies. Given the substantial economic and social impacts, all stakeholders must collaborate to implement intervention strategies that reduce both the financial burden and adverse health outcomes associated with OA.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eOA\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eOccupational Asthma\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eCNAM\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e\u003cem\u003eCaisse Nationale d'Assurance Maladie\u003c/em\u003e (National Health Insurance Fund)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eOA/OD\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eOccupational accidents and occupational diseases\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003ePPD\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePermanent Partial Disability\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eTWD\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTemporary Work Disability\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eTND\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTunisian Dinar\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eFEV1\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eForced Expiratory Volume in one second\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eVC\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eVital Capacity\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003ePD20\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eProvocative Dose causing a 20% fall in FEV1\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003ePWD\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePermanent work disability\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eSPSS\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eStatistical Package for the Social Sciences\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eLMW\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eLow-Molecular-Weight\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eHMW\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHigh-Molecular-Weight\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data sets used or analysed during this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethics Committee of Sahloul University Hospital, as well as by the General Director of Medical Control and the Central Medical Control District Director. As the study was based on the retrospective analysis of anonymized administrative data from the CNAM database, the requirement for informed consent was waived. Confidentiality and anonymity of all patient data were strictly maintained in accordance with Tunisian regulations and the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors and Affiliations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChayma Sridi\u003csup\u003e1,2,3\u003c/sup\u003e, Amene Fki\u003csup\u003e1,3\u003c/sup\u003e, Imene Kacem\u003csup\u003e1,2,4\u003c/sup\u003e, Farah Chelly\u003csup\u003e1,2,3\u003c/sup\u003e, Narjes Belhaj\u003csup\u003e1,2,3\u003c/sup\u003e, Marwa Bouhoula\u003csup\u003e1,2,4\u003c/sup\u003e, Baraa Ben Bdira\u003csup\u003e1,5\u003c/sup\u003e, Sana Aissa\u003csup\u003e1,5\u003c/sup\u003e, Souhaiel Chatti\u003csup\u003e1,2,4\u003c/sup\u003e,\u0026nbsp;Ahmed Jabrane Mlaouah\u003csup\u003e6\u003c/sup\u003e, Ahmed Abdelghani\u003csup\u003e1,5\u003c/sup\u003e, Najib Mrizak\u003csup\u003e1\u003c/sup\u003e, Maher Maoua\u003csup\u003e1,2,3\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e University of Sousse, Faculty of Medicine of Sousse , Tunisia\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003e Research Laboratory LR19SP03 \u0026laquo;Study of Risks and Prevention Perspectives for Non-communicable Diseases in the Workplace\u0026raquo;\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3\u0026nbsp;\u003c/sup\u003eOccupational Medicine Department, Sahloul University Hospital, Sousse, Tunisia\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e4\u003c/sup\u003e Occupational Medicine Department, Farhat Hached University Hospital, Sousse, Tunisia\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e5\u003c/sup\u003e Pneumology Department, Farhat Hached University Hospital, Sousse, Tunisia\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e6\u003c/sup\u003e Medical Commission of Occupational Accidents and Diseases, Sousse, Tunisia\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorresponding author\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChayma Sridi , E-mail : [email protected] ; ORCID ID: https://orcid.org/0000-0003-1718-0952\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eC\u003c/strong\u003e\u003cstrong\u003eontributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCS, AF, and IK contributed to the conceptualisation, methodology, investigation, data curation, formal analysis, and writing \u0026ndash; original draft. FC, NB, MB, and BBB contributed to methodology, validation, and writing \u0026ndash; review \u0026amp; editing. SA, SC, AJM, AA, NM, and MM contributed to supervision, project administration, and writing \u0026ndash; review \u0026amp; editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll authors have read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the staff of the National Health Insurance Fund (CNAM) for their valuable support. We are particularly grateful to Mr. Riadh Cheriat for his help with data collection and to Mr. Anis Kammoun for his assistance during this work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTarlo SM, Lemiere C, Occupational Asthma. 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Thorax. 2011;66:92\u0026ndash;3. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/thx.2010.151506\u003c/span\u003e\u003cspan address=\"10.1136/thx.2010.151506\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Occupational asthma, Direct cost, Economic burden, Tunisia, Work-related respiratory diseases","lastPublishedDoi":"10.21203/rs.3.rs-7056697/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7056697/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003eOccupational asthma (OA) is a significant public health concern due to its high prevalence and socioeconomic burden. In Tunisia, the direct costs of OA have not been previously evaluated, despite its economic impact on both the healthcare system and workers. This study aimed to estimate the direct cost of OA in the private sector in central Tunisia and to identify the factors associated with this cost.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eA cross-sectional analytical study was conducted using data from the National Health Insurance Fund (CNAM) on OA cases recognised between 2015 and 2017 in the governorates of Sousse, Monastir, Mahdia, and Kairouan. Data on sociodemographic, occupational, clinical, and paraclinical characteristics were collected, alongside the direct costs related to OA. Direct costs included in-kind benefits (medical care, medicines, hospitalisation, transport) and cash benefits (temporary and permanent work indemnities) from the date of disease recognition to December 2020. Statistical analyses included univariate tests and multiple linear regression.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eA total of 157 OA cases were analysed, predominantly female (75.8%), with a mean age of 43.41\u0026thinsp;\u0026plusmn;\u0026thinsp;7.29 years. The textile sector accounted for 72% of cases. High-molecular-weight allergens, particularly vegetable textile dust, were the main causative agents (70.7%). The median total direct cost of OA was 4,593.525 TND [IQR: 3,408.003\u0026ndash;6,871.725], with CNAM compensating a total of 1,029,200.1 TND for these patients. Lower forced expiratory volume in one second (FEV1) and higher rates of permanent partial disability (PPD) were independently associated with higher direct costs of OA (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e\u003cp\u003eThis study highlights the considerable direct costs associated with occupational asthma in central Tunisia\u0026rsquo;s private sector, emphasising the burden on the healthcare system and workers. These findings underscore the need for strengthened preventive measures, early detection, and effective workplace interventions to reduce the impact of OA and guide evidence-based occupational health policies.\u003c/p\u003e","manuscriptTitle":"Direct cost of occupational asthma and associated factors in the private sector in central Tunisia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-19 13:35:45","doi":"10.21203/rs.3.rs-7056697/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-10T11:06:23+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-25T09:05:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-21T18:20:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-21T06:56:50+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-20T10:48:21+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-18T13:20:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"225461901544776353977388903185139887674","date":"2025-08-13T07:57:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"176583475012578574072279385999376386128","date":"2025-08-12T14:19:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"322339786902616133932577027834137953808","date":"2025-08-12T07:32:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"16962226892809365192495525894595574935","date":"2025-08-12T04:40:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"44024933664965313388495978125219456838","date":"2025-08-11T18:14:53+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-11T15:38:37+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-15T13:42:15+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-15T07:25:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-15T07:22:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-07-06T08:26:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b1012088-57ea-4aac-9510-ba2e4c5e19ad","owner":[],"postedDate":"August 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-14T06:24:08+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-19 13:35:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7056697","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7056697","identity":"rs-7056697","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}