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Evaluation of exposures and respiratory health concerns in a paper converting equipment manufacturing facility
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    "In January 2012, the National Institute for Occupational Safety and Health received a confidential employee request for a health hazard evaluation at a paper tissue converting equipment manufacturing facility regarding concerns about lung disease and air quality, with exposures to coolants, oils, solvents, paper dust, exhaust fumes, welding and plasma cutting fumes, and lacquer thinner encountered during production activities. In June 2012, we toured the facility; interviewed employees, managers, and the company's nurse; observed employees at work; assessed some of the mist collectors and vacuum pumps; and collected bulk samples of unused (neat) and in-use process fluids. Gram-negative bacteria, particularly Pseudomonas oleoverans/pseudoalcaligenes, were present in all in-use fluid samples ranging from 140 million colony forming units per milliliter to 1.4 billion colony forming units per milliliter. Concentrations of endotoxin, a component of gram-negative bacterial cell walls, in the fluid samples ranged from 3,001 endotoxin units per milliliter to 108,017 endotoxin units per milliliter. We identified four nonsmoking employees who had severe lung disease, including one employee who required lung transplantation. In response, we conducted medical record reviews and obtained reviews of lung tissue specimens for the four employees with severe lung disease. Lung tissue specimens from the employees, obtained by lung biopsy or at the time of lung transplantation, were reviewed by five pulmonary pathologists at three different institutions.The pathologists found the tissue samples demonstrated an unusual pattern of lung disease involving lymphocytic bronchiolitis with extension into alveolar ducts and emphysema. Chest computed tomography scans primarily demonstrated centrilobular emphysema. Spirometry demonstrated airways obstruction and that diffusing capacity of the lung for carbon monoxide was decreased, consistent with small airways disease and emphysema. In an effort to better understand what might have caused the cases of severe lung disease and to prevent future cases of illness, we conducted a detailed industrial hygiene survey in February 2013 and a medical survey in March 2013. The industrial hygiene survey involved collecting personal and area air samples for thoracic aerosol, metalworking fluids, and endotoxin; area air samples for bioaerosols, volatile organic compounds, and metals, and total particulate (collected with closed-face cassette) for microbiome analysis; realtime measurements of volatile organic compounds and size-selective particulate; collection of bulk process fluids for analysis of culturable bacteria, culturable fungi, endotoxin, and microbiome; and examination of the airflow using a safe tracer gas. The medical survey involved administering a health questionnaire and breathing tests to employees. In addition, a microbiome analysis of lung tissue specimens from the four employees with severe lung disease was performed. Local and state health officials, and physicians who worked in the local community, including a regional medical center and tertiary care referral center, were contacted regarding their awareness of other cases of this severe lung disease occurring in the surrounding region. During the 2013 survey, we identified a variety of processes with the potential to generate airborne exposures. For example, metals (steel [85-90%], aluminum [10-15%], and cast iron [less than 1%]) and plastics (less than 1%) were cut using saws, pressurized water, or plasma technology. Cut pieces were then processed into parts using grinders, mills, and lathes. Welding and painting were performed. Assembled machines were tested for functionality using customers' paper. We also found the facility used two metalworking fluids, preserved and non-preserved. The preserved metalworking fluid was designed for use with a bactericide and the non-preserved metalworking fluid did not require bactericide. Most process fluid bulk samples demonstrated growth of gram-negative bacteria, particularly Pseudomonas oleovorans/pseudoalcaligenes, at levels ranging from 70 colony forming units per milliliter to 57 million colony forming units per milliliter. Concentrations of endotoxin in the fluid samples ranged from 338 endotoxin units per milliliter to 390,633 endotoxin units per milliliter. Thoracic aerosol, metalworking fluids, metals, and volatile organic compounds were measureable in air at levels below occupational exposure limits and were highest in production areas. Two personal endotoxin samples from employees in the machine shop were above the Dutch Expert Committee on Occupational Safety (DECOS) recommended exposure limit of 90 endotoxin units per cubic meter (EU/m3). Assessment of the ventilation in the production area using a safe tracer gas demonstrated flow from the machine shop to the assembly area, highlighting opportunities for air contaminants in the machine shop area to reach assembly employees. Among current employees, some symptoms were more common than expected, while spirometric abnormalities were not in excess. Physicians and public health practitioners in the community and surrounding region had not observed cases of severe lung disease involving lymphocytic bronchiolitis with extension into alveolar ducts and emphysema occurring outside of employees at this facility. Lung tissue samples from the four employees with severe lung disease involving lymphocytic bronchiolitis with extension into alveolar ducts and emphysema were more enriched with Pseudomonas bacteria compared with lung tissue samples obtained from patients who did not work at the facility and underwent lung biopsies at the same nearby regional hospital. Because there was a cluster of workers with unusual lung disease, the cause of the lung disease was uncertain, and organized medical surveillance of the workforce was not in place, we conducted follow-up medical and industrial hygiene surveys in September 2016. The industrial hygiene survey consisted of collecting area air samples to analyze for thoracic aerosol, metalworking fluid and endotoxin, and bulk process fluid samples analyzed for culturable bacteria, culturable fungi, bacterial populations (microbiome) using molecular methods, and endotoxin. The medical survey consisted of a health questionnaire and breathing tests, and analysis of microbiome using molecular methods for samples taken from the skin, nose, and mouth of employees. The medical records for an additional employee identified as having severe lung disease were reviewed and lung tissue specimens were reviewed by the same five pathologists that had previously reviewed lung tissue from four employees. The overall concentrations of thoracic aerosol and extracted metalworking fluid in the air samples were lower during the 2016 survey compared with the 2013 survey. The installation of nine new mist collectors and the natural ventilation from open windows and bay doors might have contributed to the decrease in these concentrations. Pseudomonas oleoverans/ pseudoalcaligenes was the only type of gram-negative bacteria identified by culture with concentrations ranging from 370 colony forming units per milliliter to greater than 30 million colony forming units per milliliter. Endotoxin concentrations ranged from 35 endotoxin units per milliliter to 10,059 endotoxin units per milliliter. Microbiome analyses identified differences in the types of bacteria between the two types of metalworking fluids. Preserved metalworking fluid samples were enriched with different types of bacteria, including Brevundinomonas, Alcaligenaceae (u.g.), and Sphingobacterium. In contrast, non-preserved metalworking fluid samples were predominantly enriched with Pseudomonas. Among the total population of current employees who participated in the 2016 medical survey, the occurrence of wheeze in the last 12 months was more common than expected while spirometric abnormalities were not in excess relative to the general population. Twelve participants had declines in lung function exceeding 10% between 2013 and 2016, including two employees in the production area with marked declines of approximately one-third or more of their lung function. Ten of the 12 employees with declines in lung function exceeding 10% worked in the assembly or machine shop areas. One of the employees who had an excessive decline in lung function was a nonsmoker who worked in the production area and had a lung biopsy demonstrating the same pattern of disease previously identified among four employees. Samples of non-preserved metalworking fluids had greater bacterial similarity with human samples (skin, nasal passage, and oral cavity) taken from employees in the machine shop compared with samples taken from employees in administration. Thus, a total of five nonsmoking employees who worked in either the assembly or machine shop areas were diagnosed with an unusual and advanced lung disease characterized by lymphocytic bronchiolitis with extension into alveolar ducts and emphysema; each had chronic breathing difficulty, and one underwent lung transplantation. Although evaluation of this single case cluster did not identify a definitive specific cause for the five cases of a rare, severe lung disease, the occurrence of this cluster indicates that production-related inhalational exposures at this facility were contributory. The occurrence of a new case between 2013 and 2016 raises concerns for ongoing risk. Given the small proportion of production workers who have developed this unusual and advanced lung disease, some asyet unidentified susceptibility factor might be present in those employees who developed disease. In the absence of certainty regarding the specific agent or combination of agents responsible for the cluster of lung disease identified in this facility, we recommend engineering controls to maintain production-related airborne exposures to the lowest level feasible and administrative controls to ensure that only those who need to be in production areas are present. We also recommend consideration of providing respiratory protection in the form of disposable filtering facepiece respirators with any P- or R-series particulate filter for voluntary use by employees who enter the production area. We also recommend implementing a medical monitoring program that includes periodic spirometry for employees who work in the production area so that disease can be detected early, should it occur again." - NIOSHTIC-2

    NIOSH no. 20054729

    Recommended citation for this report: NIOSH [2019]. Health hazard evaluation report: Evaluation of exposures and respiratory health concerns in a paper converting equipment manufacturing facility. By Stanton ML, Nett RJ. Morgantown, WV: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, NIOSH HHE Report No. 2012-0055-3337.

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