title: Clinical investigation of an outbreak of alveolitis and asthma in a car engine manufacturing plant.
abstract: BACKGROUND
  Exposure to metal working fluid (MWF) has been associated with outbreaks of extrinsic allergic alveolitis (EAA) in the USA, with bacterial contamination of MWF being a possible cause, but is uncommon in the UK. Twelve workers developed 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. The study had three aims: (1) to measure the extent of the outbreak by identifying other workers who may have developed EAA or other work-related respiratory diseases; (2) to provide case detection so that those affected could be treated; and (3) 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. In phase I a respiratory screening questionnaire was completed by 808/836 workers (96.7%) in May 2004. In 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 and 48/50 (96%) controls. Workers were identified who needed further investigation and serial measurements of peak expiratory flow (PEF). In 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 the workforce) met case definitions for occupational lung disease, comprising EAA (n = 19), occupational asthma (n = 74) and humidifier fever (n = 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 MWF from a large sump (27.3%) than for those 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.
authors.affiliation: Department of Public Health, Health Sciences Research Institute, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK. W.Robertson@warwick.ac.uk
authors.forename: W
authors.initials: W
authors.lastname: Robertson
authors.forename: A S
authors.initials: AS
authors.lastname: Robertson
authors.forename: C B S G
authors.initials: CB
authors.lastname: Burge
authors.forename: V C
authors.initials: VC
authors.lastname: Moore
authors.forename: M S
authors.initials: MS
authors.lastname: Jaakkola
authors.forename: P A
authors.initials: PA
authors.lastname: Dawkins
authors.forename: M
authors.initials: M
authors.lastname: Burd
authors.forename: R
authors.initials: R
authors.lastname: Rawbone
authors.forename: I
authors.initials: I
authors.lastname: Gardner
authors.forename: M
authors.initials: M
authors.lastname: Kinoulty
authors.forename: B
authors.initials: B
authors.lastname: Crook
authors.forename: G S
authors.initials: GS
authors.lastname: Evans
authors.forename: J
authors.initials: J
authors.lastname: Harris-Roberts
authors.forename: S
authors.initials: S
authors.lastname: Rice
authors.forename: P S
authors.initials: PS
authors.lastname: Burge
mesh_terms: D000368:Aged; D000542:Alveolitis, Extrinsic Allergic / Q000139:chemically induced / Q000453:epidemiology*; D001249:Asthma / Q000139:chemically induced / Q000453:epidemiology*; D001336:Automobiles / Q000706:statistics & numerical data*; D003430:Cross-Sectional Studies; D004196:Disease Outbreaks; D004739:England / Q000453:epidemiology; D005260:Female; D006801:Humans; D007219:Industrial Oils / Q000633:toxicity*; D008297:Male; D008670:Metals / Q000633:toxicity*; D008875:Middle Aged; D009784:Occupational Diseases / Q000139:chemically induced / Q000453:epidemiology*; D016273:Occupational Exposure / Q000009:adverse effects; D012120:Respiration Disorders / Q000139:chemically induced / Q000453:epidemiology; D012129:Respiratory Function Tests
chemical_list: D008670:Metals