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Occupation and Pneumonia
Kjell Torén, MD, PhD
Professor, Section of Occupational and Environmental Medicine
Institute of Medicine, Sahlgrenska Academy at University of Gothenburg
Gothenburg, Sweden
I have nothing to disclose in relation to this topic
Norway1923Ferromanganese plantSauda – narrow valley
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Smoke from factory80% manganese/ferromanganese
1939;3:2527-2533
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?
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1960sExposure to manganese dust increase the risk for lobar pneumonia
Established risk factors;SmokingAlcoholismDiabetesImmunodeficiencies
Not mentioned;Occupational exposures??
Penumonia and occupation??Literature search
Very few studies
*Associations with welding/metal fumes British studies
*Associations with occupational exposures togas, dust and fumes
* Animals and excrements
*Case reportsLegionella pneumophilaeRhodococcus equi
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Ship-yard workers from Bay area.18% of the lobar pneumonia occurred among welders. But welders were 18% of the workforce.
Welders (Seattle area)SMR 167
Welders, shipyard NE England SMR 184
Coggon et al Lancet 1994
Mortality (PMR) from lobar pneumonia
LobarWelders, cutters 255Foundry-workers 292Sheet-metal workers 190
Case-control studyWest MidlandsAdmitted to any of 11 hospitals 1996-1999Men 20-64 yrsSymptoms + X-ray +(fever or leukocytosis)525 cases1122 controls (patients admitted for non-respiratory conditions)
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OccupationsLast exposure to metal fume (several items)
Pneumonia OR
>1 year before onset 1.1 (0.8-1.4)8 days-1 year b. o. 1.8 (0.4-4.2)Within 7 days b. o. 1.6 (1.0-2.4)
Different exposures and morbidity from pneumonia with control for overlapping exposures
Exposure N OR 95% CI
Metal fume 58 1.4 0.8-2.3Metal dust 75 1.2 0.7-1.8Wood dust 38 0.8 0.5-1.4Cement dust 46 1.1 0.7-1.9Asbest 26 1.2 0.7-2.1
Metal fume and morbidity from lobar pneumonia or bronchopneumonia
Lobar BronchopneuExposure OR 95% CI OR 95% CI
Any metal fume 1.8 1.0-3.3 1.3 0.8-2.3No alloys 3.0 1.4-6.7 1.6 0.8-3.0
Thorax 2009;64:983-986
PMR (16-64 yrs)
Welders 242, p<0.05Furnace operators 96, NSMoulders/coremakers 300, p<0.05Other metal workers 46, NSSheet metal workers 268, p<0.05
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All patients with invasive pneumococcal disease 2000-2004.Alberta, Canada
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)
1768 cases, of these 863 in working age
8.7/100 000
Thorax 2011;66:992-996Construction workers
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Construction worker Study population
• 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
Exposure medio 1970s
214 occupational codes
Each factor exp/unexp
Job‐exposure matrix
Inorganic dust (MMMF, Cement dust, Concrete dust, Asbestos, Quartz)
Chemicals (Epoxy, diisocyanates, organic solvents)
Metal fume
Wood dust
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Swedish National Cause of Death Register
Infectious pneumonia ICD 8-9 471, 481-483, 485-486, 487AICD 10 J10-J16, J18
Lobar pneumoniaICD 8-9 481ICD 10 J18.9
Pneumococcal pneumoniaICD 8-9 481ICD 10 J13
Mortality 1971‐2003
Incidence of death from pneumonia in the exposed and unexposed cohorts
Standardised mortality rate ratios (SRR)
Poisson regression models
Stratifying for smoking, age (5 yrs).
Risk for pneumonias in relation to occupational exposures
Infectious Lobar Pneumococcal
20-64 yrsInorganic dust 1.9 3.4 4.3Chemicals 1.9 4.5 5.8Metal fume 2.3 3.7 5.8
65-84 yrsInorganic dust 1.4 N.a. N.a.Chemicals 1.4 N.a. N.a.Metal fume 1.2 N.a. N.a.
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Risk for infectious pneumonia in relation to non-overlapping exposures
ExposureAll 20-64 yrs 65-84 yrs
Inorganic dust (n=350) 1.4 1.7 1.4Chemicals (n=7) 1.1 N.A. N.AMetal fumes (n<3) N.A N.A. N.AWood dust (n=51) 1.3 1.2 1.3Referents (n=125) 1.0 1.0 1.0
Three cases of lobar pneumonia among welders
Norwegian Labour Inspection Agency
Three independent reports about deaths from pneumonia with septicemia
Previously healthy men
50 to 55 years of age
WeldersTwo shipyard weldersHelper in a workshop for heavy trucks
Conclusions (so far);
Exposure to welding fumes/work as a welder increase the risk for pneumonia/lobar pneumonia.
The effect of welding fumes may be an effect of exposure to inorganic dust.
Probably a multifactorial etiology
What do we know about dust exposure and risk for pneumonia?
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Subjects aged 65 and older717 cases867 controls
Two of; Temp>38°C, cough, chest påain, dysponoea, crackles on auskultationNew opacity on a chest radiograph
Interviews
Multivariate regression models
Exposure OR
Immunosuppressive medications 15.1 (4.7-48.3)
Smoking>100 cigarettes 2.0 (1.3-3.4)
Second hand smoke 1.8 (1.0-2.9)
Alcohol, 5 g/month 1.7 (1.1-2.6)
Occupational exposure to VGDF 3.7 (2.4-5.8)
Solvents or gasoline around home 3.3 (1.6-6.9)
Farr BM, et alRisk factors for community-acquired pneumonia diagnosed upon hospital admission.Respir Med 2000;94:954-963
BTS cohort of primary community-acquired pneumoniaTwo controls from the same catchment area
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Predictor OR 95% CI
Unmarried 1.7 1.2-4.0Unemployed 2.2 1.2-4.0Dusty occupation 2.5 1.6-3.8
Heavy smoking 3.2 2.0-5.3
Manufacturing workers undergoing mandatory health examinations
Men Women
Cement, lime, plaster 1.5 3.2Cast metals 1.6 ----
Conclusion;
There is data supporting a relation with exposure to gas, dust and fumes andincreased risk for pneumonia
Exposure to livestock, animals and excrements seems to increase the risk for pneumonia
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Exposures increasing the risk for pneumonia
Work with pigeon loft and attending birth of piglets (Thomas 1994)
Exposure to animals, excrements and visceras (Almirall 2008) Cases – Laboratory confirmed tularemia
cases (n=227)Controls - matched age, sex and residencyQuestionnaires
All tularemia Pneumonic(n=227) cases (n=20)
Outdoor activities 1.8in forests
Farming 2.3
Handling hay 6.6
Handling dead Animals 4.1
Mosquito bites 4.6
Exists in soils in cattle farm and stablesOccupational risk factor among immuno-compromised persons
Cattle farmers, horse breeders, stable workers, cleaning animal pens
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Pneumonias among working men and women.
Search after an occupational exposureEspecially welding fumes, inorganic dust and farming activities
Be aware of the increased risk among immunocompromised subjects.
Lobar pneumonia among men should be regarded as an occupational lung disease
Mechanisms?
Zhou and Kobzik: AJRCMB 2007
Alveolar macrophages – internalization of bacteria Hampered by concentrated ambient particles (CAP)Soluble fractionChelation of iron reversed the effect
Soluble metals, especially iron, decreased the killing of Streptococcus pneumonie
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
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Priming with interferon-γ and exposure to concentrated ambient particles caused loss of phagocytosis in alveolar macrophages
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
Which of the following work exposures is notassociated with increased epidemiologic risk of
pneumonia?
A. Welding fumes
B. Inorganic dust
C. Lead
D. Manganese
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Which of the following organisms has not been associated with increased epidemiologic risk of
work‐related pneumonia?
A. Hanta virus
B. Pneumococcus
C. Legionella
D. Tularemia
Occupational exposures have been associated with which pattern or type of pneumonia?
A. Lobar pneumonia only
B. Multi‐lobar only
C. Pneumococcal pneumonia only
D. Multiple organisms and various radiographic types