Bronchiolitis Obliterans and Food Flavorings - Diacetyl

Bronchiolitis Obliterans and Food Flavorings - Diacetyl

Kathleen Kreiss, MD

Division of Respiratory Disease Studies

kkreiss@cdc.gov

304-285-5800

Kathleen Kreiss, MD

Division of Respiratory Disease Studies

kkreiss@cdc.gov

304-285-5800

“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”

No relationships to disclose

2Context for Recognition of Bronchiolitis Obliterans

Context for Recognition of Bronchiolitis Obliterans

Irreversible airways obstruction

Endemic and rare

Severe: lung transplant listing

490,000 food production workers

Irreversible airways obstruction

Endemic and rare

Severe: lung transplant listing

490,000 food production workers

3

OverviewOverview

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

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 factorsEpidemiologic 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

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

5Effective interventions: Reducing flavoring exposure

Effective interventions: Reducing flavoring exposure

Company implementation of engineering controls

ConAgra company-wide program

CA flavoring companies’ exposure assessment

Respiratory protection

Company implementation of engineering controls

ConAgra company-wide program

CA flavoring companies’ exposure assessment

Respiratory protection

Average Diacetyl Concentrations by Survey

Date and Job

0.001

0.01

0.1

1

10

100

00-

NOV

O1-

APR

O1-

SEP

O1-

NOV

O2-

MAR

O2-

AUG

O3-

JAN

O3-

JULY

DATE

PP

M

MIXER MACHINE OP QC

6Preventing flavoring-related BO Preventing flavoring-related BO

Prevention of decrements in FEV1

Only 1 reported case in microwave popcorn since 2003

Kreiss K.Current Opin Aller Clin Immunol 2007;7:162-7

Prevention of decrements in FEV1

Only 1 reported case in microwave popcorn since 2003

Kreiss K.Current Opin Aller Clin Immunol 2007;7:162-7

0

20

40

60

80

100

120

140

160

2001 2002 2003

An

nu

aliz

ed

los

s (m

l/ye

ar)

FEV1 Decrements by Follow-up Year

7Effective interventions:Secondary prevention by screening

Effective interventions:Secondary prevention by screening

Affected workers removed from exposure in microwave popcorn plants

Screening implemented in flavoring plants

Pulmonary function quality improvement

Affected workers removed from exposure in microwave popcorn plants

Screening implemented in flavoring plants

Pulmonary function quality improvement

0

10

20

30

40

50

60

70

80

90

100

Nov-

00

Apr-0

1

Aug-

01

Nov-

01

Apr-0

2

Aug-

02

Feb-

03

Aug-

03

FEV1

(% p

redic

ted)

0

10

20

30

40

50

60

70

80

90

100

Nov-

00

Apr-0

1

Aug-

01

Nov-

01

Apr-0

2

Aug-

02

Feb-

03

Aug-

03

FEV1

(% p

redic

ted)

↓Left employment Sep-01

Percent Predicted FEV1 by Survey Date

)

8Extent of risk in food production:6 microwave popcorn plants*

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

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 risksOther 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

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

10Extent of risk in diacetyl and flavoring production

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

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

11Medical surveillance example in California flavoring company

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%)

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 1Case 1 1995: 26 year old man

with dyspnea 1 year into employment

2003 rhinitis; 2004 bronchitis

2005 FEV1 20%; ratio 47%; no BD response

Bronchiectasis, 2 hospitalizations

2006 FEV1 17.9%; ratio 37.4%

Bronchiolitis obliterans syndrome

1995: 26 year old man with dyspnea 1 year into employment

2003 rhinitis; 2004 bronchitis

2005 FEV1 20%; ratio 47%; no BD response

Bronchiectasis, 2 hospitalizations

2006 FEV1 17.9%; ratio 37.4%

Bronchiolitis obliterans syndrome

Plastic curtain

Exhaust hood

Ribbon blender

Ribbon blender

13

Case 2Case 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

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

14What’s next in prevention of flavoring-induced bronchiolitis obliterans?

What’s next in prevention of 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

Control technology study for flavoring industry

Improvement of sampling method for diacetyl

Inhalation toxicology of additional flavoring ingredients

OSHA special emphasis program

Regulatory approaches