title: Increased respiratory disease mortality at a microwave popcorn production facility with worker risk of bronchiolitis obliterans.
abstract: BACKGROUND
  Bronchiolitis obliterans, an irreversible lung disease, was first associated with inhalation of butter flavorings (diacetyl) in workers at a microwave popcorn company. Excess rates of lung-function abnormalities were related to cumulative diacetyl exposure. Because information on potential excess mortality would support development of permissible exposure limits for diacetyl, we investigated respiratory-associated mortality during 2000-2011 among current and former workers at this company who had exposure to flavorings and participated in cross-sectional surveys conducted between 2000-2003.
  
  
  METHODS
  We ascertained workers' vital status through a Social Security Administration search. Causes of death were abstracted from death certificates. Because bronchiolitis obliterans is not coded in the International Classification of Disease 10(th) revision (ICD-10), we identified respiratory mortality decedents with ICD-10 codes J40-J44 which encompass bronchitis (J40), simple and mucopurulent chronic bronchitis (J41), unspecified chronic bronchitis (J42), emphysema (J43), and other chronic obstructive pulmonary disease (COPD) (J44). We calculated expected number of deaths and standardized mortality ratios (SMRs) with 95% confidence intervals (CI) to determine if workers exposed to diacetyl experienced greater respiratory mortality than expected.
  
  
  RESULTS
  We identified 15 deaths among 511 workers. Based on U.S. population estimates, 17.39 deaths were expected among these workers (SMR = 0.86; CI:0.48-1.42). Causes of death were available for 14 decedents. Four deaths among production and flavor mixing workers were documented to have a multiple cause of 'other COPD' (J44), while 0.98 'other COPD'-associated deaths were expected (SMR = 4.10; CI:1.12-10.49). Three of the 4 'other COPD'-associated deaths occurred among former workers and workers employed before the company implemented interventions reducing diacetyl exposure in 2001.
  
  
  CONCLUSIONS
  Workers at the microwave popcorn company experienced normal rates of all-cause mortality but higher rates of COPD-associated mortality, especially workers employed before the company reduced diacetyl exposure. The demonstrated excess in COPD-associated mortality suggests continued efforts to lower flavoring exposure are prudent.
authors.affiliation: Epidemic Intelligence Service Program, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America. vgx5@cdc.gov
authors.forename: Cara N
authors.initials: CN
authors.lastname: Halldin
authors.forename: Eva
authors.initials: E
authors.lastname: Suarthana
authors.forename: Kathleen B
authors.initials: KB
authors.lastname: Fedan
authors.forename: Yi-Chun
authors.initials: YC
authors.lastname: Lo
authors.forename: George
authors.initials: G
authors.lastname: Turabelidze
authors.forename: Kathleen
authors.initials: K
authors.lastname: Kreiss
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001989:Bronchiolitis Obliterans / Q000209:etiology / Q000401:mortality*; D015331:Cohort Studies; D005260:Female; D005502:Food; D006801:Humans; D008297:Male; D008872:Microwaves; D008875:Middle Aged; D016273:Occupational Exposure / Q000009:adverse effects*; D012306:Risk; D055815:Young Adult