title: Systematic review of respiratory outbreaks associated with exposure to water-based metalworking fluids.
abstract: BACKGROUND
  Potential demographic risk factors for outbreaks of respiratory disease due to water-based metalworking fluids (MWFs) were investigated through systematic review of published outbreak investigations.
  
  
  METHODS
  Search terms were selected by a multidisciplinary team, assisted by an experienced library information service. Several computerized literature databases were searched for articles published between January 1990 and October 2011, relating to ill health outbreaks due to MWFs. Papers meeting the search criteria were reviewed in detail, and their references checked for additional articles. Study design and demographic details of the outbreak were extracted from the selected articles and entered into standardized evidence tables.
  
  
  RESULTS
  Thirty-five articles relating to investigations of 27 outbreaks of respiratory ill health attributed to MWF exposure were identified. The majority of reports were case series of disease or observational cross-sectional studies of symptoms and hygiene measurements. Eight of the outbreak investigations included an element of case-control analysis. Most outbreaks were from the USA, had occurred in large car- or aeronautical-manufacturing plants, and were associated with the use of central shared sumps. Hygiene studies have not demonstrated consistent risk factors for respiratory outbreaks, in terms of the type of MWF utilized, degree of microbial contamination, or levels of personal exposure. Six studies were identified that found workers with MWF exposure during outbreaks were more likely to report respiratory or systemic symptoms than unexposed control workers. Six case-control analyses were also identified that found workers with extrinsic allergic alveolitis (EAA) were more likely to demonstrate certain immune responses to microbial contaminants and/or used MWFs than workers without EAA.
  
  
  CONCLUSIONS
  Despite a number of detailed workplace and immunological studies of asthma and alveolitis outbreaks in MWF-exposed workforces, our understanding of their aetiology remains limited.
authors.affiliation: Centre for Workplace Health, Health and Safety Laboratory, Harpur Hill, Buxton, Derbyshire, UK.
authors.forename: Clare M
authors.initials: CM
authors.lastname: Burton
authors.forename: Brian
authors.initials: B
authors.lastname: Crook
authors.forename: Helena
authors.initials: H
authors.lastname: Scaife
authors.forename: Gareth S
authors.initials: GS
authors.lastname: Evans
authors.forename: Christopher M
authors.initials: CM
authors.lastname: Barber
mesh_terms: D004196:Disease Outbreaks; D006801:Humans; D008669:Metallurgy; D008670:Metals; D009784:Occupational Diseases / Q000139:chemically induced / Q000453:epidemiology*; D012140:Respiratory Tract Diseases / Q000139:chemically induced / Q000453:epidemiology*; D012307:Risk Factors
chemical_list: D008670:Metals