Clinical investigation of an outbreak of alveolitis and asthma in a car engine manufacturing plant

Wendy Robertson ^1*, Alastair S Robertson ², Cedd BSG Burge ², Vicky C Moore ², Maritta S Jaakkola ³, Paul A Dawkins ⁴, Mike Burd ⁵, Roger Rawbone ⁵, Ian Gardner ⁵, Mary Kinoulty ⁵, Brian Crook ⁶, Gareth S Evans ⁶, Joanne Harris-Roberts ⁶, Simon B Rice ⁷ and Peter Sherwood Burge ²

¹ Warwick Medical School, University of Warwick, United Kingdom
² Occupational Lung Disease Unit, Birmingham Heartlands Hospital, United Kingdom
³ Institute of Occupational Health, the University of Birmingham, United Kingdom
⁴ Department of Medicine, University of Birmingham, United Kingdom
⁵ Health and Safety Executive, Birmingham, United Kingdom
⁶ Health and Safety Laboratory, Buxton, United Kingdom
⁷ Health and Safety Laboratory, United Kingdom

^* To whom correspondence should be addressed. E-mail: w.robertson{at}warwick.ac.uk.

Accepted 6 April 2007

Abstract

Background Exposure to metal working fluid (MWF) has been associated with outbreaks of EAA in the US, with bacterial contamination of MWF being a possible cause, but was uncommon in the UK. Twelve workers developed extrinsic allergic alveolitis (EAA) in a car engine manufacturing plant in the UK, presenting clinically between December 2003 and May 2004. This paper reports the subsequent epidemiological investigation of the whole workforce. This had three aims: - To measure the extent of the outbreak by identifying other workers who may have developed EAA or other work-related respiratory diseases. - To provide case-detection so that those affected can be treated. - To provide epidemiological data to identify the cause of the outbreak.

Methods The outbreak was investigated in a three-phase cross-sectional survey of the workforce. Phase I A respiratory screening questionnaire was completed by 808/836 workers (96.7%) in May 2004. Phase II 481 employees with at least one respiratory symptom on screening and 50 asymptomatic controls were invited for investigation at the factory in June 2004. This included a questionnaire, spirometry and clinical opinion. 454/481(94.4%) responded along with 48/50(96%) controls. Workers were identified who needed further investigation and serial measurements of peak expiratory flow (PEF). Phase III 162 employees were seen at the Birmingham Occupational Lung Disease clinic. 198 employees returned PEF records, including 141 of the 162 who attended for clinical investigation. Case definitions for diagnoses were agreed.

Results 87 workers (10.4% of workforce) met case definitions for occupational lung disease, comprising EAA(19), occupational asthma(74) and humidifier fever(7). 12 workers had more than one diagnosis. The peak onset of work-related breathlessness was Spring 2003. The proportion of workers affected was higher for those using metal working fluid (MWF) from a large sump(27.3%) compared with working all over the manufacturing area (7.9%) (OR=4.39,p<0.001). Two workers had positive specific provocation tests to the used but not the unused MWF solution.

Conclusions Extensive investigation of the outbreak of EAA detected a large number of affected workers, not only with EAA but also occupational asthma. This is the largest reported outbreak in Europe. Mist from used MWF is the likely cause. In workplaces using MWF, there is a need to carry out risk assessments, to monitor and maintain fluid quality, to control mist and to carry out respiratory health surveillance.

Keywords: Automobile workers, Extrinsic allergic alveolitis, Metal working fluid, Occupational asthma, Outbreak investigation

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