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• Berylliosis, hard-metal/cobalt lung disease, other metals, …
• Extrinsic allergic alveolitis
• Other occupational ILD (Ardystil s., flock worker’s, …)
• Bronchopulmonary cancer• Pleural disease
“Common” respiratory diseases and occupation
• Respiratory infections
• COPD
• Asthma
• Lung cancer
Respiratory infections and work
Pneumonia and occupation
• Coggon et al. Lobar pneumonia: an occupational disease in welders. Lancet, 1994, 41-43• Excess mortality (SMR 182-157) from pneumonia in
metal-working occupations (welders) (< 65 y)• Coggon et al. Exposure to metal fume and infectious
pneumonia. Am J Epidemiol 2003, 157, 227-33• 1996-1999, 11 hospitals in West-Midlands, UK• 525 cases of CAP / 1,122 controls• Occupational exposure in past 6 months?• Exposure to metal fumes: adjusted O.R. 1.6 • Recent exposure to Fe: adj O.R. 2.3 (lobar pneumonia)
SARS and occupation
• The first pandemic of the 21st century was, in part, an occupational disease• Contact with wild animals (zoonosis)• Contact with affected patients
• Health care workers (21% of all reported cases)• Household members (« para-occupational »)• Transportation (personnel, passengers)
• Laboratory workers
SARS and health care workers
• Health care workers represented 21% of worldwide reported cases• China 1002 / 5327 (19%)• Hong Kong 326 / 1755 (19%)• Canada 109 / 251 (43%)
Avian Influenza A
• 2003: outbreak of fowl plague in commercial poultry farms in The Netherlands (& Belgium)• Highly pathogenic avian influenza A virus H7N7• 30,000,000 chickens killed• « Human transmission of this virus is low »
yet, clinical disease (mainly conjunctivitis, also flu-like disease) occurred in 453 persons handling infected poultry / estimated 4,500 exposed persons
• Farmers + family, cullers, veterinarians• + medical and laboratory personnel
Koopmans et al. Lancet 2004; 363: 587-93
Fouchier et al. PNAS 2004; 101: 1356-61
Fatal pneumonia in previously healthy 57 y-old veterinarian
Avian influenza A
• Since 2003: outbreaks of avian influenza A (H5N1) in Vietnam & Far East → rest of Asia & Europe • Fatal infections children & adults• Mainly if close contact with poultry• Some person-to-person transmission (?)
Asthma and COPD
Asthma and COPD
• [Balmes J. (chair) et al.] American Thoracic Society Statement: Occupational contribution to the burden of airway disease. Am J Respir Crit Care Med 2003, 167, 787-797
• Literature-based estimation of population attributable risk (PAR) for asthma and COPD due to occupational exposures COPD: approximately 15%
• Chronic bronchitis: median 19% (8 studies)• Lung function impairment: median 19% (5 studies)
Asthma: median 15% (21 studies)
Asthma and occupation
If asthma is “severe”, then there is a high likelihood of exposure to known causes of occupational asthma *
* Le Moual N. et al. Asthma severity and exposure to occupational asthmogens.Am J Respir Crit Care Med 2005, 172, 440-5.
Asthma risk by occupation
• Karjalainen et al. AJRCCM 2001, 164, 565-8 • 3 cohorts of all employed Finns (25 - 59 y)
without preexisting asthma in 1985, 1990, 1995• followed for incident asthma for 4 years• 49,575 incident cases of adult asthma in Finland• 1.65 (M) - 2.47 (F) / 1,000 / year• 2,464 cases of recognized occupational asthma
Asthma risk by occupation
• Karjalainen et al. • attributable fraction of occupation for adult-onset
asthma (controls = administrative w.): • 29 % (men) - 17 % (women)• not confounded by smoking• known sectors (agriculture, manufacture,
services) and occupations (bakers, …), but also less known jobs (cleaners, …)
• share of recognised cases of OA << 50 %
Asthma and cleaning agents
• Higher risk of asthma in female cleaners• Zock et al. SJWEH 2001; 27: 76-81: P.R. 1.7• Karjalainen et al. ERJ 2002; 19: 90-5: R.R. 1.50• Medina-Ramón et al. Thorax 2003; 58: 950-4: O.R. 1.46
y) – 45 non-exposed controls (33.9 y)• Questionnaire• Spirometry & DLco• Chest x-ray and HRCT (10 subjects with low
DLco)• Serum TNF- and IL-8• Dust measurements and microscopy of flock
Atis S. et al. ERJ, 2005, 25, 110-7
• No abnormal chest x-ray
• HRCT in 10 subjects with low DLco: suggestive of (mild) ILD or bronchiolitis
Atis S. et al. ERJ, 2005, 25, 110-7
TNF- IL-8
Popcorn worker’s lung
Popcorn worker’s lung
• May 2000: • report of 8 persons with severe airway obstruction
(bronchiolitis obliterans)• all employed 1993-2000 at microwave-popcorn
plant in Missouri: • 4 worked in flavor-mixing room• 4 worked in packaging areas only
• no reported incident or apparent overexposure• mostly nonsmokers• cause ?
Popcorn worker’s lung
• Kreiss et al. Clinical bronchiolitis obliterans in workers at a microwave-popcorn plant. N Engl J Med. 2002, 347, 330-8. • Survey of current workers (n=117/135)
• overall (compared to NHANESIII)– chronic cough & dyspnea: x 2.6
– MD-diagnosed asthma & chronic bronchitis: x 2
– airway obstruction: x 3.3 (x 10.8 in nonsmokers)
• higher risk if direct exposure to microwave-popcorn production (compared to other areas)
– FEV1 decrease // with cumulative exposure (quartiles)
– no confounding by smoking
Popcorn worker’s lung
• Hubbs et al. Necrosis of nasal and airway epithelium in rats inhaling vapors of artificial butter flavoring. Toxicol Appl Pharmacol. 2002,185,128-35.• Rats exposed for 6h to vapors of butter
flavoring• necropsy after 24 h• necrosuppurative rhinitis + multifocal,
necrotizing bronchitis (diacetyl = 203-371 ppm)
Popcorn worker’s lung
• Akpinar-Elci et al. Bronchiolitis obliterans syndrome in popcorn production workers. Eur Respir J. 2004,24, 298-302.• 9 cases (27-51 y; 1-17 y in popcorn industry)• 3 never smokers, five ex-smokers, 1 smoker
• FEV1 14 – 67% pred
• HRCT bronchial wall thickening, air trapping• Lung biopsy: constrictive bronchiolitis• Stabilisation after leaving employment
Popcorn worker’s lung
Akpinar-Elci et al.
Eur Respir J. 2004, 24, 298-302
Other microwave popcorn plants
• Kanwal et al. JOEM 2006, 48, 149-157• Cross-sectional study in 6 plants (n=708)• Respiratory symptoms and airways obstruction
related to exposure to oil and flavorings (mixers)
Multa sunt quae medicus ad aegrotum Multa sunt quae medicus ad aegrotum accedens, ab aegro ipso seu accedens, ab aegro ipso seu assendentibus, sciscitari debet ex divini assendentibus, sciscitari debet ex divini Praeceptoris oraculo. Praeceptoris oraculo. Cum ad aegrotum Cum ad aegrotum deveneris, interrogare oportet quae deveneris, interrogare oportet quae patiatur, et ex qua causa, et quot jam patiatur, et ex qua causa, et quot jam diebus, et an venter secedat, et quo victu diebus, et an venter secedat, et quo victu utatur, utatur, verba sunt HIPPOCRATIS in verba sunt HIPPOCRATIS in librolibro De Affectionibus; De Affectionibus; liceat quoque liceat quoque interrogationem hanc adjicereinterrogationem hanc adjicere: : et quam et quam artem exerceatartem exerceat..
There are many things that a doctor, on his first visit to a patient, ought to find out, either from the patient or from those present. For so runs the oracle of our inspired teacher: “When you come to a patient’s house, you should ask him what sort of pains he has, what caused them, how many days he has been ill, whether his bowels are working and what sort of food he eats.” So says Hippocrates in his work Affections. I may venture to add one more question: “What occupation does he follow?”