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From: Franklin Mirer <[log in to unmask]>
Date: Dec 31, 2007 12:51 PM
Subject: [occ-env-med-l] HP and MWF
To: Occ-Env-Med-L <[log in to unmask]>
Cc: O'Neill Rory <[log in to unmask]>
Information continues to emerge on metalworking fluid related
respiratory disease.
The second publication regarding an outbreak at a British machining
plant has emerged in the literature. Readers should note that hundreds
of workers complained of symptoms, 481/808 who completed a
questionaire. A minority met the definition of "disease," but symptoms
are what impairs your life. Of the 87 who met the definition of
occupational lung disease, the large majority, 74 had a diagnosis of
occupational asthma.
The initial publication reported an extensive effort to find
mycobacteria but failed. This deals a blow to the hypothesis that
mycobacteria are necessary for an MWF HP outbreak. Emphasis on MWF
microbial management by many authorities is a way to dodge a
requirement for ventilation and other MWF airborne exposure controls.
The publication lags the outbreak by several years. We wonder what
actual measures were taken to contain the problem, and what the
current prevalence of symptoms might be.
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
Robertson, W.; Robertson, A. S.; Burge, C. B.; Moore, V. C.;
Jaakkola, M. S.; Dawkins, P. A.; Burd, M.; Rawbone, R.; Gardner, I.;
Kinoulty, M.; Crook, B.; Evans, G. S.; Harris-Roberts, J.; Rice, S.,
and Burge, P. S. Clinical investigation of an outbreak of alveolitis
and asthma in a car engine manufacturing plant. Thorax. 2007 Nov;
62(11):981-90.Abstract: BACKGROUND: Exposure to metal working fluid
(MWF) has been associated with outbreaks of extrinsic allergic
alveolitis (EAA) in the USA, with bacterial contamination of MWF being
a possible cause, but is uncommon in the UK. Twelve workers developed
EAA in a car engine manufacturing plant in the UK, presenting
clinically between December 2003 and May 2004. This paper reports the
subsequent epidemiological investigation of the whole workforce. The
study had three aims: (1) to measure the extent of the outbreak by
identifying other workers who may have developed EAA or other
work-related respiratory diseases; (2) to provide case detection so
that those affected could be treated; and (3) to provide
epidemiological data to identify the cause of the outbreak. METHODS:
The outbreak was investigated in a three-phase cross-sectional survey
of the workforce. In phase I a respiratory screening questionnaire was
completed by 808/836 workers (96.7%) in May 2004. In phase II 481
employees with at least one respiratory symptom on screening and 50
asymptomatic controls were invited for investigation at the factory in
June 2004. This included a questionnaire, spirometry and clinical
opinion. 454/481 (94.4%) responded and 48/50 (96%) controls. Workers
were identified who needed further investigation and serial
measurements of peak expiratory flow (PEF). In phase III 162 employees
were seen at the Birmingham Occupational Lung Disease clinic. 198
employees returned PEF records, including 141 of the 162 who attended
for clinical investigation. Case definitions for diagnoses were
agreed. RESULTS: 87 workers (10.4% of the workforce) met case
definitions for occupational lung disease, comprising EAA (n = 19),
occupational asthma (n = 74) and humidifier fever (n = 7). 12 workers
had more than one diagnosis. The peak onset of work-related
breathlessness was Spring 2003. The proportion of workers affected was
higher for those using MWF from a large sump (27.3%) than for those
working all over the manufacturing area (7.9%) (OR = 4.39, p<0.001).
Two workers had positive specific provocation tests to the used but
not the unused MWF solution. CONCLUSIONS: Extensive investigation of
the outbreak of EAA detected a large number of affected workers, not
only with EAA but also occupational asthma. This is the largest
reported outbreak in Europe. Mist from used MWF is the likely cause.
In workplaces using MWF there is a need to carry out risk assessments,
to monitor and maintain fluid quality, to control mist and to carry
out respiratory health surveillance.
Dawkins, P.; Robertson, A.; Robertson, W.; Moore, V.; Reynolds, J.;
Langman, G.; Robinson, E.; Harris-Roberts, J.; Crook, B., and Burge,
S. An outbreak of extrinsic alveolitis at a car engine plant. Occup
Med (Lond). 2006 Dec; 56(8):559-65.Abstract: BACKGROUND: Twelve
workers from a car engine-manufacturing plant presented with extrinsic
allergic alveolitis (EAA), with heterogeneous clinical, radiological
and pathological findings. They were exposed to metalworking fluids
(MWF) that cooled, lubricated and cleaned the machines. METHODS: They
were characterized by history, examination, lung function testing,
radiology, bronchoscopic lavage, lung biopsy and serology. Sera were
tested for precipitins to a crude extract of used MWF and to reference
cultures of bacteria suspected to be implicated. RESULTS: All were
males and none were current smokers. All had dyspnoea, many had weight
loss and cough, but only half had influenza-like symptoms. Only half
had auscultatory crackles. Five had peak flow variability, four with
an occupational component. There was overall restrictive spirometry,
decreased lung volumes and reduced gas transfers. Ten had radiological
evidence of interstitial lung disease. Seven (of eight) had
lymphocytosis on bronchial lavage, including the two with inconclusive
radiology. Seven (of 11) had lung biopsies showing inflammatory
infiltrates, two with fibrosis and one with granulomas. Three (of 11)
had strong positive precipitins to an extract of the used MWF from the
plant. Molecular biological analysis of the MWF revealed Acinetobacter
and Ochrobactrum. Precipitins to Acinetobacter were detected in seven
of 11 workers tested (and four of 11 control workers). Precipitins to
Ochrobactrum were detected in three of 11 workers tested (and three of
11 control workers). CONCLUSION: This is the largest series reported
in Europe of EAA due to an aerosol of microbiologically contaminated
MWF in heavy manufacturing industry.
Franklin E. Mirer, PhD, CIH
Professor, EOH Program
Hunter School of Health Sciences
425 E. 25 Street
New York, NY 10010-2547
mail to Box 925
For more information about the Urban Public Health Program, please visit our
website at: http://www.hunter.cuny.edu/schoolhp/uph/index.htm
Room 1030 A west building, brookdale
phone 212-481-7651
fax 212-481-5260
email: [log in to unmask]
--
Gary N. Greenberg, MD MPH Sysop / Moderator Occ-Env-Med-L MailList
Univ. N. Carolina School Public Health
Medical Director http://www.UrbanMin.org
Urban Ministries of Wake County Open Door Clinic http://www.OpenDoorDocs.org
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