In this issue of Occupational Medicine
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Occupational allergy or sensitization, and the diseases that can accompany this, remain an important topic in occupational medicine. New causes of occupational allergy continue to be described, and much remains to be learnt about the mechanisms of allergy, particularly allergy to low-molecular-weight substances. While allergy to low-molecular-weight substances is not new, the growing importance of some of these low-molecular-weight substances, specifically disinfecting and cleaning agents, is emphasized in this issue of the journal.
Chlorhexidine is a low-molecular-weight antimicrobial disinfecting agent widely used in health care. A number of low-molecular-weight antimicrobial disinfecting and sterilizing agents used in health care have previously been described as causes of ‘allergic’ disease including some aldehydes and quaternary amine compounds [1–3]. The mechanism of allergy for the majority of individuals affected by these agents remains obscure, although IgE antibodies to glutaraldehyde-modified albumin may be important in some individuals with glutaraldehyde asthma [4]. Occupational allergic disease in the presence of specific IgE antibodies to chlorhexidine has not to date been reported. Nagendran et al. [5], in this issue of Occupational Medicine, describe four cases of sensitization to chlorhexidine among health care workers with dermatitis. Clear evidence of an IgE-mediated mechanism was present in that all of the four had measurable specific IgE antibodies to chlorhexidine in serum, and three of the four had a positive skin prick test also (one was not available for testing). However, the four represent only a minority of the 14 individuals who reported a clinical history suggestive of hypersensitivity, suggesting that as with other low-molecular-weight allergens, while IgE mechanisms may play a role, as yet uncharacterized mechanisms of allergy also remain important.
Lynde et al. [6] report findings from a group of cleaners with exposure to a variety of cleaning agents. A postal questionnaire was sent to 1396 indoor cleaners and 1271 comparison workers, the majority working for a school board. The questionnaire elicited details of both dermal and respiratory symptoms as well as specifically asking about asthma. Generally, cleaners were more likely to report rash than the comparison workers, and this was more likely to be on their hands, and more likely to be reported to be work related. Not surprisingly, cleaners also washed their hands more often than the comparison workers and there was a suggestion that some specific tasks increased the risk of developing a rash: spot cleaning carpets for males, and polishing furniture for females. Interestingly, skin rash was related to both respiratory symptoms and asthma. Male cleaners with a rash in the last 12 months also reported significantly more respiratory symptoms, and these were more likely to be reported as work related than for cleaners without rash. In addition, the cleaners with a rash in the last 12 months were more likely to have both physician reported asthma and new onset asthma than those without rash. This apparent interaction may simply represent poor control of both dermal and airborne exposure, but it also raises the possibility of a shared mechanism in both skin and lungs.
Other papers in this issue report 30% of museum workers at the National Museum in Warsaw sensitized to fungi, the risk of sensitization being 14-fold more for workers with more than 5 years of occupational exposure compared with 5 years or less [7], two cases of occupational asthma in paper re-cycling workers, the suspected causative agent being the de-inking agent hydroxylamine [8], and a 25% risk of sensitization for workers exposed to Artemia fish fry used as a feed for aquarium fish [9]. Clearly, occupational allergies and sensitization remain an important source of disease.
The paper by Sauni et al. [10] raises some important additional concerns about occupational allergy and asthma. This paper presents findings of an audit of the records of 150 patients referred to the Finnish Institute of Occupational Health with suspected occupational asthma. The use and quality of diagnostic testing, and time taken in the diagnostic process were assessed. Of the 150 patients with suspected occupational asthma, 41% were thought likely to be due to low-molecular-weight or irritant substances, and a further 37% due to suspected mould exposure. The quality of diagnostic testing was generally considered to be relatively high, although quality criteria with regard to serial peak flow testing were met less often than others. However, in terms of time to diagnosis, only 28% of cases progressed from initial symptoms to final diagnosis within the target time of 2 years, and median time from onset of symptoms to final diagnosis was 3.0–3.2 years. The authors write that other papers have reported similar periods from symptom onset to diagnosis, and given that time from first symptom to cessation of exposure is important in determining the outcome of occupational asthma, this is one area where care could be could improved.
To complement this issue's focus on allergy and asthma, our website review considers an important website for those interested in occupational asthma, the OASYS site. Finally, to prove that there's more to occupational respiratory disease than asthma, elsewhere in this issue we publish research on airways disease symptoms in equine barn workers [11], the respiratory health of welders in Sri Lanka [12] and spot welders from an automobile factory [13], and a paper on lung cancer among workers exposed to arsenic in cadmium recovery [14]. All these are areas where there are complex exposures and it is likely that a number of different mechanisms may lead to disease.
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- Hendrick DJ, Lane DJ. Occupational formalin asthma. Br J Ind Med (1977) 34:11–18.[Web of Science][Medline]
- Gannon PF, Bright P, Campbell M, O'Hickey SP, Burge PS. Occupational asthma due to glutaraldehyde and formaldehyde in endoscopy and x ray departments. Thorax (1995) 50:156–159.
[Abstract/Free Full Text] - Bernstein JA, Stauder T, Bernstein DI, Bernstein IL. A combined respiratory and cutaneous hypersensitivity syndrome induced by work exposure to quaternary amines. J Allergy Clin Immunol (1994) 94:257–259.[Web of Science][Medline]
- Curran AD, Burge PS, Wiley K. Clinical and immunologic evaluation of workers exposed to glutaraldehyde. Allergy (1996) 51:826–832.[Web of Science][Medline]
- Nagendran V, Wicking J, Ekbote A, et al. IgE mediated chlorhexidine allergy: a new occupational hazard? Occup Med (Lond) (2009) 59:270–272.
- Lynde CB, Obadia M, Liss GM, Ribeiro M, Holness DL, Tarlo SM. Cutaneous and respiratory symptoms among professional cleaners. Occup Med (Lond) (2009) 59:249–254.
- Wiszniewska M, Walusiak-Skorupa J, Pannenko I, Draniak M, Palczynski C. Occupational exposure and sensitization to fungi among museum workers. Occup Med (Lond) (2009) 59:237–242.
- Tran S, Francis H, Hoyle J, Niven R. Occupational asthma and the paper recycling industry. Occup Med (Lond) (2009) 59:277–279.
- Granslo J-T, Do TV, Aasen TB, Irgens Å, Florvaag E. Occupational allergy to Artemia fish fry feed in aquaculture. Occup Med (Lond) (2009) 59:243–248.
- Sauni R, Kauppi P, Helaskoski E, Virtema P, Verbeek J. Audit of quality of diagnostic procedures for occupational asthma. Occup Med (Lond) (2009) 59:230–236.
- Mazan MR, Svatek J, Maranda L, et al. Questionnaire assessment of airway disease symptoms in equine barn personnel. Occup Med (Lond) (2009) 59:220–225.
- Jayawardana P, Abeysena C. Respiratory health of welders in a container yard, Sri Lanka. Occup Med (Lond) (2009) 59:226–229.
- Loukzadeh Z, Sharifian SA, Aminian O, Shojaoddiny-Ardekani A. Pulmonary effects of spot welding in automobile assembly. Occup Med (Lond) (2009) 59:267–269.
- Sorahan T. Lung cancer mortality in arsenic-exposed workers from a cadmium recovery plant. Occup Med (Lond) (2009) 59:264–266.
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