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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. No relationships to disclose. “The findings and conclusions in this report are those of the author and do not necessarily

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Bronchiolitis Obliterans and Food Flavorings - Diacetyl

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  1. 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 Date and Job 100 MIXER MACHINE OP QC 10 1 PPM 0.1 0.01 0.001 00- O1- O1- O1- O2- O2- O3- O3- NOV APR SEP NOV MAR AUG JAN JULY DATE • Company implementation of engineering controls • ConAgra company-wide program • CA flavoring companies’ exposure assessment • Respiratory protection

  6. Preventing flavoring-related BO FEV1 Decrements by Follow-up Year 160 140 120 100 80 Annualized loss (ml/year) 60 40 20 0 2001 2002 2003 • 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

  7. Effective interventions:Secondary prevention by screening • Affected workers removed from exposure in microwave popcorn plants • Screening implemented in flavoring plants • Pulmonary function quality improvement Percent Predicted FEV1 by Survey Date Left employment Sep-01 ↓ )

  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 Exhaust hood • 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 Ribbon blender Ribbon blender

  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

  14. 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

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