Bronchiolitis Obliterans and Food Flavorings - Diacetyl by cYzNZE4

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									   Bronchiolitis Obliterans
and Food Flavorings - Diacetyl
                       Kathleen Kreiss, MD

               Division of Respiratory Disease Studies
                           kkreiss@cdc.gov
                            304-285-5800

                   No relationships to disclose
“The findings and conclusions in this report are those of the author and do not necessarily
   represent the views of the National Institute for Occupational Safety and Health”
                                     2
        Context for Recognition of
         Bronchiolitis Obliterans
 Irreversible airways
  obstruction
 Endemic and rare
 Severe: lung
  transplant listing
 490,000 food
  production workers
                                             3
                 Overview

 Epidemiologic risk factors
 Effective interventions
 Extent of risk in food production
 Extent of risk in flavoring and chemical
  production
 Challenges of surveillance
 What’s next in prevention
                                                  4
          Epidemiologic risk factors

Job titles:
 Mixers of flavorings; quality control workers
 Powder compounders in flavoring plants*
 Process operators in diacetyl manufacture**
Diacetyl:
 Cumulative and average
 Peak

*Kanwal R. AJRCCM 2007;175:A27
**van Rooy F. AJRCCM 2007;176: in press
                                                                                               5
         Effective interventions:
       Reducing flavoring exposure
                                 Average Diacetyl Concentrations by Survey
 Company                                        Date and Job
  implementation of               100
                                                                  MIXER     MACHINE OP    QC
  engineering controls             10


 ConAgra company-                  1




                           PPM
  wide program
                                   0.1

 CA flavoring
                                  0.01
  companies’ exposure
  assessment                     0.001
                                         00-   O1-   O1-   O1-   O2-      O2-   O3-      O3-

 Respiratory protection                 NOV   APR   SEP   NOV   MAR   AUG      JAN   JULY

                                                            DATE
                                                                                                   6
       Preventing flavoring-related BO


                                                               FEV1 Decrements by Follow-up Year
 Prevention of                                                160
  decrements in FEV1




                                   Annualized loss (ml/year)
                                                               140
                                                               120
 Only 1 reported case                                         100
  in microwave popcorn                                         80
  since 2003
                                                               60
                                                               40
                                                               20
Kreiss K.Current Opin Aller Clin                                0
   Immunol 2007;7:162-7
                                                                      2001     2002     2003
                                                                                                                                7
        Effective interventions:
   Secondary prevention by screening
                        Percent Predicted FEV1 by Survey Date
 Affected workers
                                             100
  removed from                               90
                                                                                  Left
  exposure in
                                                                              ↓   employment
                                             80
                                                                                  Sep-01




                        )
  microwave popcorn



                        FEV1 (% predicted)
                                             70
                                             60
  plants                                     50

 Screening
                                             40
                                             30
  implemented in                             20

  flavoring plants                           10
                                              0

 Pulmonary function                               Nov-00




                                                                                   Nov-01




                                                                                                              Feb-03
                                                            Apr-01



                                                                     Aug-01




                                                                                            Apr-02



                                                                                                     Aug-02




                                                                                                                       Aug-03
  quality improvement
                                              8
   Extent of risk in food production:
    6 microwave popcorn plants*
 5 plants had BO cases
 19.2% of ever-mixers (>12 mo.) obstructed
 14% of packaging workers where mixing
  tanks not isolated
 85% QC workers in index plant
 Maintenance workers had excess symptoms

*Kanwal. AJOEM 2006;48:149-157
                                             9
    Other food production risks

Popcorn popping plant *
 3 of 3 workers had work-related asthma
 2 of 3 had findings consistent with BO
 Exposure profile different: aldehydes
  predominant
 Diacetyl present but unmeasurable
Food production with heated flavors
 Hard candy, potato chips
*Sahakian. Yatsko Health Hazard Evaluation
                                                      10
        Extent of risk in diacetyl and
            flavoring production
Netherlands diacetyl manufacturing cohort*
 4 severe BO cases in 102 workers
Flavoring manufacturing workers in 11 companies**
 19% obstructed among 650 flavoring workers
Case reports
 NJ, MD, OH, CA in flavoring manufacturing workers
 Cal/OSHA and CA Dept of Health Services mandated
   screening***

* van Rooy F. AJRCCM 2007;176: in press
**Rose C. AJRCCM 2007;175:A17
***Materna B. MMWR 2007;56:390-3
                                                 11
   Medical surveillance example in
    California flavoring company
October 2006 screening
 2 of 12 production workers obstructed
 Case 1: FEV1 17.9% predicted (ratio 37.4%)
 Case 2: FEV1 86.5% predicted (ratio 64.4%)
March 2007 screening
 Case 2: 1 liter drop FEV1 to 64.5% predicted
  (ratio 51.3%)
                                                                               12
                        Case 1
 1995: 26 year old man
  with dyspnea 1 year into
  employment                 Exhaust hood


 2003 rhinitis; 2004                       Plastic curtain   Ribbon blender

  bronchitis
 2005 FEV1 20%; ratio       Ribbon blender

  47%; no BD response
 Bronchiectasis, 2
  hospitalizations
 2006 FEV1 17.9%; ratio
  37.4%
 Bronchiolitis obliterans
  syndrome
                                    13
                           Case 2

 25 year old man without
  symptoms 2 years into
  employment
 10/31/06: abnormal ratio
  of 64.4%
 3/14/07: fixed FEV1
  64.5% predicted; ratio
  51.3%
 Relocated to warehouse
        What’s next in prevention of                14


flavoring-induced bronchiolitis obliterans?


 Control technology study for flavoring industry
 Improvement of sampling method for diacetyl
 Inhalation toxicology of additional flavoring
  ingredients
 OSHA special emphasis program
 Regulatory approaches

								
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