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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