Bronchiolitis Obliterans and Food Flavorings - Diacetyl

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Bronchiolitis Obliterans and Food Flavorings -
Diacetyl

• Kathleen Kreiss, MD
• Division of Respiratory Disease Studies
• kkreiss_at_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
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Context for Recognition of Bronchiolitis
Obliterans

• Irreversible airways obstruction
• Endemic and rare
• Severe lung transplant listing
• 490,000 food production workers

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Overview

• Epidemiologic risk factors
• Effective interventions
• Extent of risk in food production
• Extent of risk in flavoring and chemical
  production
• Challenges of surveillance
• Whats next in prevention

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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 2007175A27
• van Rooy F. AJRCCM 2007176 in press

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Effective interventions Reducing flavoring
exposure

• Company implementation of engineering controls
• ConAgra company-wide program
• CA flavoring companies exposure assessment
• Respiratory protection

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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
  20077162-7

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Effective interventionsSecondary prevention by
screening
Percent Predicted FEV1 by Survey Date

• Affected workers removed from exposure in
  microwave popcorn plants
• Screening implemented in flavoring plants
• Pulmonary function quality improvement

Left employment Sep-01
?
)
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Extent of risk in food production6 microwave
popcorn plants

• 5 plants had BO cases
• 19.2 of ever-mixers (gt12 mo.) obstructed
• 14 of packaging workers where mixing tanks not
  isolated
• 85 QC workers in index plant
• Maintenance workers had excess symptoms
• Kanwal. AJOEM 200648149-157

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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

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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 2007176 in press
• Rose C. AJRCCM 2007175A17
• Materna B. MMWR 200756390-3

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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)

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Case 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

Exhaust hood
Plastic curtain
Ribbon blender
Ribbon blender
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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

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Whats 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