J Sumner

Work-related symptoms in nail salon technicians

BACKGROUND Nail salons are a rapidly expanding small business sector. Environmental health practitioners have raised concerns about potential health and safety issues. AIMS To establish the extent of work-related health issues reported by nail salon technicians, their knowledge of health and safety regulations and of the products used. METHODS Nail technicians completed a researcher-administered questionnaire, and responses were compared to those of non-exposed office-based control subjects. RESULTS In all, 39 of 588 nail salons approached agreed to participate (7%), with all 71 (100%) of the available nail technicians within these salons completing study questionnaires. The majority of the nail technicians (99%) had received training that had included aspects of health and safety and most reported being aware of the Control of Substances Hazardous to Health regulations (59/70, 84%) and risk assessments (65/70, 93%). Compared to the control group, the nail technicians reported statistically significant increased levels of work-related neck (OR 5.0, 95% CI 1.6-15.6), shoulder (15.0, 3.1-71.8), wrist/hand (3.6, 1.2-10.7) and lower back problems (3.5, 1.0-12.5). Work-related nasal symptoms were also significantly more common in nail technicians (6.2, 1.3-30.7). CONCLUSIONS This study demonstrated a higher prevalence of a range of musculoskeletal problems and respiratory symptoms reported by nail technicians compared to office-based controls. An ergonomic and exposure assessment of work practices in this industry is warranted to identify the working practices associated with these symptoms, in order to inform best practice, supplement industry and regulatory guidance and develop appropriate practical work-based training.

Occupational chronic obstructive pulmonary disease: a standard of care

BACKGROUND Consistent evidence from population studies report that 10-15% of the total burden of chronic obstructive pulmonary disease (COPD) is associated with workplace exposures. This proportion of COPD could be eliminated if harmful workplace exposures were controlled adequately. AIMS To produce a standard of care for clinicians, occupational health professionals, employers and employees on the identification and management of occupational COPD. METHODS A systematic literature review was used to identify published data on the prevention, identification and management of occupational COPD. Scottish Intercollegiate Guidance Network grading and the Royal College of General Practitioner three star grading system were used to grade the evidence. RESULTS There are a number of specific workplace exposures that are established causes of COPD. Taking an occupational history in patients or workers with possible or established COPD will identify these. Reduction in exposure to vapours, gases, dusts and fumes at work is likely to be the most effective method for reducing occupational COPD. Identification of workers with rapidly declining lung function, irrespective of their specific exposure, is important. Individuals can be identified at work by accurate annual measures of lung function. CONCLUSIONS Early identification of cases with COPD is important so that causality can be considered and action taken to reduce causative exposures thereby preventing further harm to the individual and other workers who may be similarly exposed. This can be achieved using a combination of a respiratory questionnaire, accurate lung function measurements and control of exposures in the workplace.

COPD Causation and Workplace Exposures: An Assessment of Agreement among Expert Clinical Raters

Abstract Background. Although occupational exposure is a known risk factor for Chronic Obstructive Pulmonary Disease (COPD), it is difficult to identify specific occupational contributors to COPD at the individual level to guide COPD prevention or for compensation. The aim of this study was to gain an understanding of how different expert clinicians attribute likely causation in COPD. Methods. Ten COPD experts and nine occupational lung disease experts assigned occupational contribution ratings to fifteen hypothetical cases of COPD with varying combinations of occupational and smoking exposures. Participants rated the cause of COPD as the percentage contribution to the overall attribution of disease for smoking, occupational exposures and other causes. Results. Increasing pack-years of tobacco smoking was associated with significantly decreased proportional occupational causation ratings. Increasing weighted occupational exposure was associated with increased occupational causation ratings by 0.28% per unit change. Expert background also contributed significantly to the proportion of occupational causation rated, with COPD experts rating on average a 9.4% greater proportion of occupational causation per case. Conclusion. Our findings support the notion that respiratory physicians are able to assign attribution to different sources of causation in COPD, taking into account both smoking and occupational histories. The recommendations on whether to continue to work in the same job also differ, the COPD experts being more likely to recommend change of work rather than change of work practice.

Underestimation of spirometry if recommended testing guidance is not followed

Background Lung function measured at work is used to make important employment decisions. Improving its quality will reduce misclassification and allow more accurate longitudinal interpretation over time. Aims To assess the amount by which lung function (forced expiratory volume in 1 second [FEV1] and forced vital capacity [FVC]) values will be underestimated if recommended spirometry testing guidance is not followed. Methods Lung function was measured in a population of workers. Knowledge of the final reproducible FEV1 and FVC for each worker allowed estimation of the underestimates that would have occurred if less forced manoeuvres than recommended had been performed. Results A total of 667 workers (661 males, mean age 43 years, range 18-66) participated. Among them, 560 (84%) achieved reproducible results for both FEV1 and FVC; 470 (84%) of these did so after three technically acceptable forced expiratory manoeuvres, a cumulative total of 533 after four, 548 after five, 557 after six, 559 after seven and 560 after eight blows. If only one (or first two) technically acceptable blow(s) had been performed, mean underestimates were calculated for FEV1 of 115.1 ml (35.4 ml) and for FVC of 143.4 ml (42.3 ml). Conclusions In this study, reproducible spirometry was achievable in most workers. Not adhering to standards underestimates lung function by clinically significant amounts.

S105 Respiratory symptoms, lung function and sensitisation across different exposure groups of british woodworkers

Background Wood dust is a leading cause of occupational asthma (OA) in the UK, with over 2 00 000 people exposed annually. There have been no recent studies examining respiratory health in British woodworkers. Aim We surveyed British woodworkers to examine how respiratory symptoms, airway inflammation, lung function and sensitisation relate to wood dust exposure. Methods British woodworkers were recruited to a cross-sectional study. All workers underwent a validated respiratory symptom questionnaire, job history and exposure measurement. Spirometry and fractional exhaled nitric oxide (FENO) were recorded to American Thoracic Society (ATS) standards. Blood was taken for total and specific IgE to hard and soft wood. Results 269 workers participated (Table 1). Most were men (n=261, 97%), with a mean age of 42.4 years (SD 12.6) and 18.9 (12.8) years woodworking. Mean current wood dust exposure was 1.9 mg/m3 (SD 0.9, IQR 1.4). Current asthma symptoms (CAS, defined as wheezing, nocturnal chest tightness, exertional/nocturnal/resting breathlessness, or asthma medication use within the last 12 months) were common, reported by 123 (46%). Work-related respiratory symptoms were less common, reported by 29 (11%). Forty one (18%) people had a FENO ≥40 ppb. Only one worker had a positive IgE to soft wood. Ten (4%) had an FEV1/FVC less than the lower limit of normal (<LLN). In adjusted regression models, workers in the highest exposure quartile were at lower risk of work-related respiratory symptoms (WRRS) than those in the lowest quartile (OR 0.16 , 95% CI 0.03–0.81). Workers in the low exposure group were more likely to have a FENO ≥40 ppb (OR 3.59, 95% CI 1.09–11.77). However, there was no clear exposure response relationship when looking at percent predicted FEV1 or FVC (for FEV1β=0.05, p=0.41). Conclusion CAS are common among British woodworkers, reported by nearly half. One fifth fulfilled BTS criteria for high FENO despite low sensitisation rates. The highest exposed were at lower risk for WRRS, suggesting a healthy worker effect. No clear relationship between exposure and lung function was identified. Mechanisms for asthma among woodworkers may not be IgE mediated, and longitudinal studies are needed to clarify the exposure response relationship. Abstract S105 Table 1 Table showing population characteristics of 269 British woodworkers across exposure quartiles Total (n=269) Lowest exposure (0–1.19 mg/m3) n=67 Low exposure (1.20–2.00 mg/m3) n=72 Medium exposure (2.01–2.32 mg/m3) n=63 Highest exposure (2.33–5.44 mg/m3) n=67 Demographics Age, years (SD) 42.4 (12.6) 42.45 (10.51) 44.64 (13.69) 41.31 (13.00) 40.93 (12.68) Sex, m (%) 261 (97) 65 (97) 71 (99) 62 (98) 63 (94) Current smoker (%) 70 (26) 17 (25) 22 (30) 14 (22) 17 (25) Ever smoked more than 1 pack year (%) 140 (52) 34 (51) 46 (64) 27 (43) 33 (49) Exposure Currently uses RPE (%) 207 (77) 44 (66) 55 (76)* 51 (81)* 57 (85)* Mean current exposure, mg/m3 (SD) 1.9 (0.9) 0.69 (0.37)** 1.74 (0.27)** 2.12 (0.09)** 2.98 (0.80)** Total time in woodworking industry, years (SD) 18.9 (12.8) 17.95 (11.03) 19.71 (12.52) 20.86 (14.58) 17.11 (12.90) Health Current asthma symptoms (%) 123 (46) 34 (50) 34 (47) 29 (46) 26 (39) Any work-related respiratory symptom (%) 29 (11) 11 (16) 8 (11) 8 (13) 2 (3) Work-related nasal symptoms (%) 35 (13) 5 (8) 8 (11) 11 (18) 11 (16) Work-related ocular symptoms (%) 37 (14) 6 (9) 13 (18) 3 (5) 15 (22)* Physician diagnosed asthma (%) 22 (8) 6 (9) 10 (14) 4 (6) 2 (3) Current asthma under ECRHS (%) 40 (15) 11 (16) 16 (22) 8 (13) 5 (8) FEV1/FVC<LLN (%) 10 (4) 4 (7) 3 (5) 1 (2) 2 (4) Physician diagnosed COPD (%) 4 (2) 3 (5) 0 (0) 1 (2) 0 (0) Positive IgE to hardwood (%) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Positive IgE to softwood (%) 1 (1) 0 (0) 0 (0) 1 (2) 0 (0) TIgE, kU (SD) 133.5 (632.2) 138.72 (305.23) 95.95 (148.18) 236.75 (1223.90) 61.40 (108.90) Atopic (%)+ 53 (20) 13 (21) 17 (26) 16 (27) 7 (13) AM FEno# 27.2 (27.7) 24.40 (23.90) 32.45 (32.31) 24.90 (20.29) 26.39 (32.45) FENO>40 ppb (%) 41 (18) 7 (13) 15 (25) 9 (17) 10 (16) Mean FEV1 (%)^ 99.8 (12.7) 99.90 (13.45) 98.61 (12.34) 99.35 (12.25) 101.41 (13.09) Mean FVC (%) 102.9 (12.8) 103.48 (12.52) 101.16 (12.16) 101.63 (12.81) 105.41 (13.59) Mean PEF (%) 108.5 (15.9) 108.16 (16.91) 109.80 (16.63) 107.56 (13.86) 108.27 (16.14) Mean FEV1, mls (SD) 3824 (699) 3809 (658) 3697 (720) 3823 (656) 3986 (739) Mean FVC, mls (SD) 4813 (854) 4825 (818) 4658 (899) 4759 (750) 5027 (905) Mean PEF, mls (SD) 588 (102) 584 (116) 587 (98) 581 (95) 588 (102) *p<0.05, **p<0.01 +atopy was defined as total IgE >100 kU/L # Valid FENOmeasurements were made in 225 workers. ^ Valid spirometry was measured in 228 workers.

P252 Accurate measurement of lung function in the workplace and potential effects of underestimation

Introduction Accurate workplace spirometry measurement is key to giving workers the best clinical assessment of their respiratory health. We were interested in the underestimation of spirometry that occurs if best practice is not adhered to and the significance of this on assessment of health at work. Methods 667 stone, brick and foundry workers (with varying spirometry experience), carried out lung function testing as part of a larger cross sectional workplace study. Each performed a minimum of 3 forced expirations. Testing continued until each worker had met the ATS/ERS guidance. The final FEV1 and FVC recorded was the maximum value attained from 3 technically acceptable blows, and that the two highest FEV1 and FVC values were within 150 mls. Using the final FEV1 and FVC for each worker, it was then possible to calculate the underestimate of both measures, had only the first blow, or the maximum of the first two blows, been used for interpretation. Results 613 of the 669 (91.6%) attained the ATS/ERS criteria based on FEV1. Analysis of the first actual blow, regardless of technical quality, showed an FEV1 mean underestimate of 250 mls (median = 80 mls, IQR = 210 mls). If only the first technically acceptable blow had been carried out, the FEV1 would have been underestimated by a mean of 114 mls (60 mls, 150 mls). If only two technically acceptable blows had been carried out, and the maximum of these used, the FEV1 would have been underestimated by a mean of 36 mls (0 mls, 50 mls). Similarly, the FVC would have been underestimated by a mean of 131 mls (75 mls, 180 mls) if only the first technically acceptable blow had been used for interpretation. If only two technically acceptable blows were carried out, the FVC would have been underestimated by a mean of 43 mls (0 mls, 50 mls). Conclusion Non adherence to ATS/ERS lung function testing guidance at work can cause the FEV1 and FVC to be underestimated by clinically significant amounts.

S118 Can fractional exhaled nitric oxide help predict asthma in british foundry workers

Background Foundry work may involve exposure to respiratory sensitisers and irritants. There is limited evidence for the use of FENO in occupational settings, and particularly in foundries. Aim To examine the usefulness of FENO in identifying foundry workers at risk of asthma. Methods Foundry workers undertook a respiratory questionnaire. Spirometry (Ndd Easy on-PC Spirometer, Zurich) and FENO (NOBreath, Bedfont Scientific, Kent) were measured to ATS/ERS standards. The ATS upper limit of normal (ULN) of 50 parts per billion (ppb), or 45.9ppb for current smokers, determined the high FENO category (FENO >ULN). Workers with FENO >ULN were compared with those with at least one work-related respiratory symptom (WRRS) and those with obstructive lung function (FEV1/FVC <0.7) using Chi Square and Fisher’s Exact Tests. Results 351 workers (350 men, 99%) participated. 350 workers had a valid FENO performed. Arithmetic mean FENO was 30.2ppb (95% CI: 27.3–33.2); geometric mean (GM) FENO20.8 (18.9–22.9) ppb. FENO exceeded the ULN in 61 (17%) workers. Average age for the FENO >ULN group was 41.5 (95% CI: 38.3–44.7), with a mean of 15.8 (12.4 – 19.2) years working in the foundry industry. Workers in the FENO >ULN group were significantly more likely to have a current diagnosis of asthma (12% vs 5%, p < 0.05), have ever suffered allergies (55% vs 31%, p < 0.01), or report work-related shortness of breath (3% vs 0%, p < 0.05). Fourteen workers (4%) had a FENO >ULN and WRRS (Figure1). Of these 14, only 2 (14%) had a current diagnosis of asthma (Fisher’s p = 0.20). Eight (2%) workers had a FENO > ULN and FEV1/FVC <0.7, though only 2 (25%) had a current asthma diagnosis (Fisher’s p = 0.08). Conclusion A significant proportion of foundry workers have FENO levels that exceed the ATS cut point for likely eosinophilic airway inflammation. Of these workers, most had a raised FENO but no WRRS or obstructive lung disease. Only a minority of workers with FENO >ULN and either WRRS or obstruction had a current diagnosis of asthma. FENO may be useful in identifying foundry workers at risk of asthma and warrants further study. Abstract S118 Figure 1 Overlap between FENO>ULN, work-related respiratory symptoms and obstructive spirometry in foundry workers. Total numbers in each group (%of total): FENO >ULN: n=61 (17%); >1 WRRS: n = 69(20%); FEV1/FVC <0.7 = n = 34 (10%). FENO>ULN = FENO above 50ppb or 45.9ppb in current smokers; WRRS = at least one work-related respiratory symptom

P54 Respiratory symptoms, lung function and quality of life in British foundry workers

Introduction Foundry work is associated with exposure to potentially harmful substances that may cause occupational asthma (OA). Aim To record respiratory symptoms, lung function and health-related quality of life (HRQoL) in a group of exposed British foundry workers, and investigate their associations and causes. Method A workplace-based study was conducted, where participants were delivered a researcher-administered questionnaire in order to record individual job exposures, respiratory and general health, and HRQoL (the EQ-5D). Spirometry was performed using a Ndd Easy on-PC Spirometer according to ATS/ERS guidelines. Fractional exhaled nitric oxide (FENO) was measured using a NOBreath device to ATS standards. Results 351 (65%) of a possible 539 workers participated. 350 (99.7%) were men, with a mean age of 42.4 (SD 12.5) years. The average length of employment in the foundry industry was 14.8 (SD 12.7) years. Twenty-one (6%) workers self-reported a diagnosis of current asthma, and six (1.7%) self-reported COPD. 139 (40%) participants had at least one respiratory symptom, of which wheeze was the most prevalent (n = 114, 33%). One-in-five participants reported work-related respiratory symptoms (WRRS) (n = 69, 20%), of which work-related cough was the most prevalent (n = 45, 13%; Table 1). Significantly more workers reporting WRRS were ever smokers (chi squared = 5.1, p = 0.02).Abstract P54 Table 1 Demographic data for British foundry workers with and without work-related respiratory symptoms (WRRS) WRRS (n = 69) No WRRS (n = 282) Age, years (SD) 41.1 (12.3) 42.7 (12.5) Length of employment, years (SD) 15.4 (12.3) 14.7 (12.8) Current smoker, n (%) 25 (36) 71 (25) Ever smoker, n (%) 48 (70) 154 (55)* Self-reported current asthma, n (%) 8 (12) 13 (5) FEV1/FVC <0.7, n (%) 3 (4) 31 (11) Mean% predicted FEV1 (SD) 98.3 (10.5) 98.4 (14.1) Mean% predicted FVC (SD) 103.1 (9.8) 103.6 (12.8) Mean% predicted PEF (SD) 106.2 (17.1) 108.3 (18.2) Mean FENO, ppb (SD) 31.1 (24.2) 29.9 (29.0) Mean EQ-5D VAS (SD) 76.6 (15.8) 83.5 (11.0)** *p = < 0.05, **p = 0.001. 155 (44%) workers had a FENO above 25 ppb, the suggested ATS cut off for a low probability of eosinophilic airway inflammation. No difference in FENO was found between those with and without WRRS (chi squared for FENO above or below 25 ppb = 1.50, p = 0.22). However, WRRS were associated with significantly lower mean scores on the EQ-5D visual analogue scale (VAS; 77 vs 84, p = 0.001, 95% CI 2.89 – 11.01). In contrast, no difference in VAS was observed between those with and without an obstructive lung defect (FEV1/FVC <0.7), (mean 83 vs 82, p = 0.63, 95% CI -5.48 – 3.33). Conclusion Work-related respiratory symptoms among foundry workers were common and associated with impaired HRQoL. More work is required to better understand the cause of such symptoms in foundry workers, and their relationship with workplace exposures.

P65 Respiratory ill health in the silica exposed stone working sector

Introduction Exposure at work to inhaled respirable crystalline silica (RCS) has previously been linked with silicosis, tuberculosis, lung cancer and COPD. Whilst the risk of developing silicosis is largely a function of cumulative lifetime RCS exposures, current workplace exposures contribute to this risk. New cases of silicosis continue to be reported in the UK. The stone working sector is one where exposures to RCS continue to place workers at risk. Methods A cross sectional GB based workplace study of stone workers was carried out, in order to identify a subsequent longitudinal cohort. Consenting workers were asked to complete an interviewer led questionnaire, undergo lung function testing and complete a full occupational history including details of lifetime exposure to RCS. Consenting workers had a PA Chest Radiograph using a mobile facility, and levels of RCS exposure in the personal breathing zone were measured. Results 128 workers took part; with a mean age of 40.1 years and 11 years median (range 0.5–44) years worked overall in industry. One had radiological evidence of silicosis. Respiratory symptoms were common; for example 22.7% reported cough, 33.6% wheeze in the last 12 months, 16.4% reported ever having asthma. 14.1% reported at least one work related respiratory symptom. Mean lung function values (n = 127) were as follows; mean (SD) percentage predicted FEV1 97.5 (14.5) and FVC 103.6 (12.2). Twenty four workers had measured airways obstruction (as defined by an FEV1/FVC <0.7); in this cross sectional analysis its presence did not significantly relate to current smoking status or duration of RCS exposure, although was associated with the reporting of a diagnosis of (ever having) asthma or chest tightness and difficulty in breathing. Conclusions This cross sectional study of stone workers has identified a cohort for longer term follow up. Future work will allow the development dose response relationships (using measured current, and historic, RCS levels) corrected for other relevant factors, between cumulative RCS exposure and FEV1 decline. These approaches will assist in the development of future workplace interventions to reduce the health risks associated with RCS exposure in stone workers.

P61 Respiratory ill health in the silica exposed brick manufacturing sector

Introduction Exposure at work to inhaled respirable crystalline silica (RCS) has previously been linked with silicosis, tuberculosis, lung cancer and COPD. Whilst the risk of developing silicosis is largely a function of cumulative lifetime RCS exposures, current workplace exposures contribute to this risk. Methods A cross sectional GB based workplace study of brick manufacturers was carried out, in order to identify a subsequent longitudinal cohort. Participating worksites were using silica to make bricks for various uses. Consenting workers were asked to complete an interviewer led questionnaire, undergo lung function testing and complete a full occupational history including details of lifetime exposure to RCS. Consenting workers had a PA Chest Radiograph using a mobile facility, and levels of RCS exposure in the personal breathing zone were taken. Results 189 workers took part, with a mean age of 45.9 years and 22 years median (range 0.08–47) years worked overall in industry. Three had radiological evidence of silicosis (ILO standards used; 2 definite and one probable case). Respiratory symptoms were common; for example 14.3% reported cough, 21.2% wheeze in the last 12 months, 14.3% reported ever having asthma. 13.2% reported at least one work related respiratory symptom. Mean lung function values were as follows; mean (SD) percentage predicted FEV1 98.1 (15.2) and FVC 102.4 (13.9). Fourteen workers had measured airways obstruction (as defined by an FEV1/FVC <0.7); in this cross sectional analysis its presence did not significantly relate to current smoking status or lifetime duration of RCS exposure, although was significantly associated with an increased time worked in the current work area. Airways obstruction was also associated with the reporting of a diagnosis of (ever having) asthma and wheeze in the last 12 months. Conclusions This cross sectional study of silica exposed brick workers has identified a cohort for longer term follow up. Future work will allow the development of dose response relationships, corrected for other relevant factors, between cumulative RCS exposure and FEV1 decline and will assist in the development of workplace interventions to reduce the health risks associated with RCS exposure in this group of workers.