I have nothing to disclose in relation to Kjell Torn, MD, PhD this - PDF document

2017-02-28 Occupation and Pneumonia I have nothing to disclose in relation to Kjell Torén, MD, PhD this topic Professor, Section of Occupational and Environmental Medicine Institute of Medicine, Sahlgrenska Academy at University of Gothenburg Gothenburg, Sweden Norway 1923 Ferromanganese plant Sauda – narrow valley 1

2017-02-28 1939;3:2527-2533 Smoke from factory 80% manganese/ferromanganese First year – six lethal cases of lobar pneumonia Coming 15 years – 8 times higher mortality rate of lobar pneumonia Cases in the smoke direction. Relation production volume Workers? 2

2017-02-28 Established risk factors; Smoking Alcoholism Diabetes Immunodeficiencies 1960s Exposure to manganese dust increase the Not mentioned; risk for lobar pneumonia Occupational exposures?? Penumonia and occupation?? Very few studies Literature search *Associations with welding/metal fumes British studies *Associations with occupational exposures to gas, dust and fumes * Animals and excrements *Case reports Legionella pneumophilae Rhodococcus equi 3

2017-02-28 Welders (Seattle area) SMR 167 Ship-yard workers from Bay area. 18% of the lobar pneumonia occurred among welders. But welders were 18% of Welders, shipyard NE England the workforce. SMR 184 Coggon et al Lancet 1994 Mortality (PMR) from lobar pneumonia Lobar Case-control study Welders, cutters 255 West Midlands Foundry-workers 292 Admitted to any of 11 hospitals 1996-1999 Sheet-metal workers 190 Men 20-64 yrs Symptoms + X-ray +(fever or leukocytosis) 525 cases 1122 controls (patients admitted for non-respiratory conditions) 4

2017-02-28 Occupations Different exposures and morbidity from Last exposure to metal fume (several pneumonia with control for overlapping items) exposures Pneumonia OR Exposure N OR 95% CI >1 year before onset 1.1 (0.8-1.4) Metal fume 58 1.4 0.8-2.3 Metal dust 75 1.2 0.7-1.8 8 days-1 year b. o. 1.8 (0.4-4.2) Wood dust 38 0.8 0.5-1.4 Within 7 days b. o. 1.6 (1.0-2.4) Cement dust 46 1.1 0.7-1.9 Asbest 26 1.2 0.7-2.1 Thorax 2009;64:983-986 Metal fume and morbidity from lobar pneumonia or bronchopneumonia Lobar Bronchopneu Exposure OR 95% CI OR 95% CI PMR (16-64 yrs) Any metal fume 1.8 1.0-3.3 1.3 0.8-2.3 No alloys 3.0 1.4-6.7 1.6 0.8-3.0 Welders 242, p<0.05 Furnace operators 96, NS Moulders/coremakers 300, p<0.05 Other metal workers 46, NS Sheet metal workers 268, p<0.05 5

2017-02-28 1768 cases, of these 863 in working age 8.7/100 000 Occupation Cases Incidence OR Welder 18 22.7/100 000 2.6 (1.7-4.2) Electrician 6 12.2/100 000 1.4 (0.6-3.1) Farmer 7 3.1/100 000 0.4 (0.2-0.7) Day care worker 8 10.5/100 000 1.2 (0.6-2.4) All patients with invasive pneumococcal disease 2000-2004. Alberta, Canada Construction workers Thorax 2011;66:992-996 6

2017-02-28 Study population Construction worker • 320 143 males occupationally exposed to inorganic dust, chemicals, metal fume (welding fumes, diesel exhaust and solvents • 79 305 white collar workers Job ‐ exposure matrix Job ‐ exposure matrix Inorganic dust (MMMF, Cement dust, Concrete dust, Asbestos, Quartz) Exposure medio 1970s 214 occupational codes Chemicals (Epoxy, diisocyanates, organic solvents) Each factor exp/unexp Metal fume Wood dust 7

2017-02-28 Swedish National Cause of Death Mortality 1971 ‐ 2003 Register Infectious pneumonia Incidence of death from pneumonia ICD 8-9 471, 481-483, 485-486, 487A in the exposed and unexposed ICD 10 J10-J16, J18 cohorts Lobar pneumonia Standardised mortality rate ratios ICD 8-9 481 (SRR) ICD 10 J18.9 Poisson regression models Pneumococcal pneumonia ICD 8-9 481 Stratifying for smoking, age (5 yrs). ICD 10 J13 Risk for pneumonias in relation to occupational exposures Infectious Lobar Pneumococcal 20-64 yrs Inorganic dust 1.9 3.4 4.3 Chemicals 1.9 4.5 5.8 Metal fume 2.3 3.7 5.8 65-84 yrs Inorganic dust N.a. N.a. 1.4 Chemicals N.a. N.a. 1.4 Metal fume 1.2 N.a. N.a. 8

2017-02-28 Risk for infectious pneumonia in relation to non- overlapping exposures Exposure All 20-64 yrs 65-84 yrs Inorganic dust (n=350) 1.4 1.7 1.4 Chemicals (n=7) 1.1 N.A. N.A Metal fumes (n<3) N.A N.A. N.A Three cases of lobar pneumonia Wood dust (n=51) 1.3 1.2 1.3 Referents (n=125) 1.0 1.0 1.0 among welders Conclusions (so far); Norwegian Labour Inspection Agency Exposure to welding fumes/work as a welder Three independent reports about deaths from pneumonia with septicemia increase the risk for pneumonia/lobar pneumonia. Previously healthy men The effect of welding fumes may be an effect 50 to 55 years of age of exposure to inorganic dust. Welders Probably a multifactorial etiology Two shipyard welders Helper in a workshop for heavy trucks What do we know about dust exposure and risk for pneumonia? 9

2017-02-28 Subjects aged 65 and older 717 cases 867 controls Two of; Temp>38°C, cough, chest påain, dysponoea, crackles on auskultation New opacity on a chest radiograph Interviews Multivariate regression models Exposure OR Farr BM, et al Immunosuppressive Risk factors for community-acquired medications 15.1 (4.7-48.3) pneumonia diagnosed upon hospital admission. Smoking>100 cigarettes 2.0 (1.3-3.4) Respir Med 2000;94:954-963 Second hand smoke 1.8 (1.0-2.9) BTS cohort of primary community-acquired Alcohol, 5 g/month 1.7 (1.1-2.6) pneumonia Two controls from the same catchment area Occupational exposure to VGDF 3.7 (2.4-5.8) Solvents or gasoline around home 3.3 (1.6-6.9) 10

2017-02-28 Predictor OR 95% CI Unmarried 1.7 1.2-4.0 Manufacturing workers undergoing mandatory Unemployed 2.2 1.2-4.0 health examinations Dusty occupation 2.5 1.6-3.8 Men Women Heavy smoking 3.2 2.0-5.3 Cement, lime, plaster 1.5 3.2 Cast metals 1.6 ---- Conclusion; There is data supporting a relation with exposure to gas, dust and fumes and increased risk for pneumonia Exposure to livestock, animals and excrements seems to increase the risk for pneumonia 11

2017-02-28 Exposures increasing the risk for pneumonia Work with pigeon loft and attending birth of piglets (Thomas 1994) Exposure to animals, excrements and Cases – Laboratory confirmed tularemia visceras (Almirall 2008) cases (n=227) Controls - matched age, sex and residency Questionnaires All tularemia Pneumonic (n=227) cases (n=20) Outdoor activities 1.8 in forests Farming 2.3 Handling hay 6.6 Exists in soils in cattle farm and stables Handling dead Occupational risk factor among immuno- Animals 4.1 compromised persons Mosquito bites 4.6 Cattle farmers, horse breeders, stable workers, cleaning animal pens 12

2017-02-28 Mechanisms? Pneumonias among working men and women. Zhou and Kobzik: AJRCMB 2007 Search after an occupational exposure Alveolar macrophages – internalization of bacteria Especially welding fumes, inorganic dust and farming activities Hampered by concentrated ambient particles (CAP) Soluble fraction Be aware of the increased risk among immunocompromised subjects. Chelation of iron reversed the effect Lobar pneumonia among men should be Soluble metals, especially iron, decreased the killing of Streptococcus pneumonie regarded as an occupational lung disease Lungs of mice was inoculated with Listeria. There were significantly more bacterial colonies in lungs of mice pre- exposed to welding fumes compared to control animals Lungs of mice was inoculated with Listeria. There were significantly more bacterial colonies in lungs of mice pre- exposed to welding fumes compared to control animals 13

2017-02-28 Animal studies support the mechanism that exposure to welding fumes as well as ambient particles decrease the antibacterial function of the alveolar macrophages making animals more susceptible to bacterial inefctions Priming with interferon- γ and exposure to concentrated ambient particles caused loss of phagocytosis in alveolar macrophages Which of the following work exposures is not associated with increased epidemiologic risk of pneumonia? A. Welding fumes B. Inorganic dust C. Lead D. Manganese 14

2017-02-28 Which of the following organisms has not been Occupational exposures have been associated with associated with increased epidemiologic risk of which pattern or type of pneumonia? work ‐ related pneumonia? A. Lobar pneumonia only A. Hanta virus B. Multi ‐ lobar only B. Pneumococcus C. Pneumococcal pneumonia only C. Legionella D. Multiple organisms and various radiographic types D. Tularemia 15