Electronic case reporting (eCR) (1) is a promising rapid reporting mechanism, whereby electronic health records (EHRs) automatically generate and transmit a disease report to jurisdictional public health agencies in real time using previously established criteria. All 50 U.S. states and other jurisdictions are connected to the eCR infrastructure. The Reportable Conditions Knowledge Management System (RCKMS),* a component of the eCR infrastructure, is a real-time decision support service that processes reports according to jurisdictional reporting requirements with criteria defined by Council of State and Territorial Epidemiologists’ position statements (1). Health care organizations automatically generate and send an initial case report to the eCR infrastructure when trigger criteria, such as diagnosis codes or laboratory results, are met within their EHRs. Therefore, for all participating California health care organizations, if a health care encounter involves COVID-19 or mpox, an initial case report is generated and sent to the eCR infrastructure for processing. When there is a match between the initial case report triggered by an EHR, and a reportable condition rule is entered into RCKMS by a jurisdictional public health agency, the initial case report is routed by the eCR infrastructure to the public health agency. Other conditions can be added to public health agency reporting rules. | | Silicosis is a progressive, incurable, fibrotic lung disease caused by inhalation of respirable crystalline silica dust produced in industries such as construction, quarrying, and coal mining (2). A resurgence of silicosis among young workers fabricating engineered stone (quartz) countertops in California and in countries including Australia, Israel, and Spain has focused attention on the need for timely case identification for primary and secondary prevention (2–5). In December 2022, the California Department of Public Health (CDPH) added reporting rules for silicosis to RCKMS, so that any initial case report received by the eCR infrastructure from health care provider EHRs that includes a silicosis diagnosis in the patient’s problem list is sent to CDPH for silicosis surveillance. The purpose of this study was to evaluate the utility of eCR for identifying cases of silicosis in California. This study was reviewed and approved by the California Committee for the Protection of Human Subjects institutional review board.†

The Centers for Disease Control and Prevention's Epidemic Intelligence Service (EIS)is a fellowship in applied epidemiology for physicians, veterinarians, nurses, scientists, and other health professionals. Each EIS fellow is assigned to a position at a federal, state, or local site for 2 years of on-the-job training in outbreak investigation, epidemiologic research, surveillance system evaluation, and scientific communication. Although the original focus of the program on the control of infectious diseases remains salient, positions are available for training in other areas of public health, including occupational respiratory disease. In this Perspective, we describe the EIS program, highlight three positions (one federal and two state-based) that provide training in occupational respiratory epidemiology, and summarize trainees' experiences in these positions over a30-year period. For early-career health professionals interested in understanding and preventing occupational respiratory hazards and diseases, EIS offers a unique career development opportunity.

Workers in the coffee industry face a variety of inhalational hazards. These range from predominantly organic dust, endotoxin, and green and castor bean allergen exposures in the primary processing factories to dusts, gases, and vapors including α-diketones in coffee production facilities (1–5). Previously documented respiratory health effects include symptoms such as wheeze, cough, and dyspnea, bronchial hyperresponsiveness, reduced spirometric parameters, and chronic lung diseases including asthma and obliterative bronchiolitis (OB) (3, 5–10). Some of these studies are decades old, while some are notable for small size and limited exposure assessments. In this special issue of Frontiers in Public Health on “Investigating exposures and respiratory health in coffee workers”, a series of articles explores in detail the exposures, emissions, engineering controls, and health consequences across the contemporary coffee industry by describing studies of primary processing in 16 factories in two African countries and coffee production in 17 facilities in the United States.

Coffee production workers are exposed to complex mixtures of gases, dust, and vapors, including the known respiratory toxins, diacetyl, and 2,3-pentanedione, which occur naturally during coffee roasting and are also present in flavorings used to flavor coffee. This study evaluated the associations of these two -diketones with lung function measures in coffee production workers. Workers completed questionnaires, and their lung function was assessed by spirometry and impulse oscillometry (IOS). Personal exposures to diacetyl, 2,3-pentanedione, and their sum (Sum(DA+PD)) were assigned to participants, and metrics of the highest 95th percentile (P95), cumulative, and average exposure were calculated. Linear and logistic regression models for continuous and binary/polytomous outcomes, respectively, were used to explore exposure-response relationships adjusting for age, body mass index, tenure, height, sex, smoking status, race, or allergic status. Decrements in percent predicted forced expiratory volume in 1 second (ppFEV(1)) and forced vital capacity (ppFVC) were associated with the highest-P95 exposures to 2,3-pentanedione and Sum(DA+PD). Among flavoring workers, larger decrements in ppFEV(1) and ppFVC were associated with highest-P95 exposures to diacetyl, 2,3-pentanedione, and Sum(DA+PD). Abnormal FEV(1), FVC, and restrictive spirometric patterns were associated with the highest-P95, cumulative, and average exposures for all -diketone metrics; some of these associations were also present among flavoring and non-flavoring workers. The combined category of small and peripheral airways plus small and large airways abnormalities on IOS had elevated odds for highest-P95 exposure to -diketones. These results may be affected by the small sample size, few cases of abnormal spirometry, and the healthy worker effect. Associations between lung function abnormalities and exposure to -diketones suggest it may be prudent to consider exposure controls in both flavoring and non-flavoring settings.

BACKGROUND: Workers fabricating engineered stone face high risk for exposure to respirable crystalline silica (RCS) and subsequent development of silicosis. In response, the California Division of Occupational Safety and Health (Cal/OSHA) performed targeted enforcement inspections at engineered stone fabrication worksites. We investigated RCS exposures and employer adherence to Cal/OSHA's RCS and respiratory protection standards from these inspections to assess ongoing risk to stone fabrication workers. METHODS: We extracted employee personal air sampling results from Cal/OSHA inspection files and calculated RCS exposures. Standards require that employers continue monitoring employee RCS exposures and perform medical surveillance when exposures are at or above the action level (AL; 25 μg/m(3) ); exposures above the permissible exposure limit (PEL; 50 μg/m(3) ) are prohibited. We obtained RCS and respiratory protection standard violation citations from a federal database. RESULTS: We analyzed RCS exposures for 152 employees at 47 workplaces. Thirty-eight (25%) employees had exposures above the PEL (median = 89.7 μg/m(3) ; range = 50.7-670.7 μg/m(3) ); 17 (11%) had exposures between the AL and PEL. Twenty-four (51%) workplaces had ≥1 exposure above the PEL; 7 (15%) had ≥1 exposure between the AL and PEL. Thirty-four (72%) workplaces were cited for ≥1 RCS standard violation. Twenty-seven (57%) workplaces were cited for ≥1 respiratory protection standard violation. CONCLUSIONS: Our investigation demonstrates widespread RCS overexposure among workers and numerous employer Cal/OSHA standard violation citations. More enforcement and educational efforts could improve employer compliance with Cal/OSHA standards and inform employers and employees of the risks for RCS exposure and strategies for reducing exposure.

OBJECTIVES: To determine whether engineering controls and respiratory protection had measurable short-term impact on indium exposure and respiratory health among current indium-tin oxide production and reclamation facility workers. METHODS: We documented engineering controls implemented following our 2012 evaluation and recorded respirator use in 2012 and 2014. We measured respirable indium (In(resp)) and plasma indium (In(P)) in 2012 and 2014, and calculated change in In(resp) (∆In(resp)) and In(P) (∆In(P)) by the 13 departments. We assessed symptoms, lung function, serum biomarkers of interstitial lung disease (Krebs von den Lungen (KL)-6 and surfactant protein (SP)-D) and chest high-resolution CT at both time points and evaluated workers who participated in both 2012 and 2014 for changes in health outcomes (new, worsened or improved). RESULTS: Engineering controls included installation of local exhaust ventilation in both grinding departments (Rotary and Planar) and isolation of the Reclaim department. Respiratory protection increased in most (77%) departments. ∆In(P) and ∆In(resp) often changed in parallel by department. Among 62 workers participating in both 2012 and 2014, 18 (29%) had new or worsening chest symptoms and 2 (3%) had functional decline in lung function or radiographic progression, but average KL-6 and SP-D concentrations decreased, and no cases of clinical indium lung disease were recognised. CONCLUSIONS: Increased engineering controls and respiratory protection can lead to decreased In(resp), In(P) and biomarkers of interstitial lung disease among workers in 2 years. Ongoing medical monitoring of indium-exposed workers to confirm the longer-term effectiveness of preventive measures is warranted.

Coffee production is a global industry with roasteries throughout the world. Workers in this industry are exposed to complex mixtures of gases, dusts, and vapors including carbon monoxide, carbon dioxide, coffee dust, allergens, alpha-diketones, and other volatile organic compounds (VOCs). Adverse respiratory health outcomes such as respiratory symptoms, reduced pulmonary function, asthma, and obliterative bronchiolitis can occur among exposed workers. In response to health hazard evaluations requests received from 17 small- to medium-sized coffee facilities across the United States, the National Institute for Occupational Safety and Health conducted investigations during 2016-2017 to understand the burden of respiratory abnormalities, exposure characteristics, relationships between exposures and respiratory effects, and opportunities for exposure mitigation. Full-shift, task-based, and instantaneous personal and area air samples for diacetyl, 2,3-pentanedione and other VOCs were collected, and engineering controls were evaluated. Medical evaluations included questionnaire, spirometry, impulse oscillometry, and fractional exhaled nitric oxide. Exposure and health assessments were conducted using standardized tools and approaches, which enabled pooling data for aggregate analysis. The pooled data provided a larger population to better address the requestors' concern of the effect of exposure to alpha-diketones on the respiratory heath of coffee workers. This paper describes the rationale for the exposure and health assessment strategy, the approach used to achieve the study objectives, and its advantages and limitations.

The Abbott BinaxNOW rapid antigen test is cheaper and faster than real-time reverse transcription PCR (rRT-PCR) for detecting severe acute respiratory syndrome coronavirus 2. We compared BinaxNOW with rRT-PCR in 769 paired specimens from 342 persons during a coronavirus disease outbreak among horse racetrack workers in California, USA. We found positive percent agreement was 43.3% (95% CI 34.6%-52.4%), negative percent agreement 100% (95% CI 99.4%-100%), positive predictive value 100% (95% CI 93.5%-100%), and negative predictive value 89.9% (95% CI 87.5%-92.0%). Among 127 rRT-PCR-positive specimens, the 55 with paired BinaxNOW-positive results had a lower mean cycle threshold than the 72 with paired BinaxNOW-negative results (17.8 vs. 28.5; p<0.001). Of 100 specimens with cycle threshold <30, a total of 51 resulted in positive virus isolation; 45 (88.2%) of those were BinaxNOW-positive. Our comparison supports immediate isolation for BinaxNOW-positive persons and confirmatory testing for negative persons.

Occupational exposure to diacetyl, a butter flavor chemical, can result in obliterative bronchiolitis. Obliterative bronchiolitis is characterized by exertional dyspnea, fixed airflow obstruction, and histopathologic constrictive bronchiolitis, with bronchiolar wall fibrosis leading to luminal narrowing and obliteration. We describe a case of advanced lung disease with histopathology distinct from obliterative bronchiolitis in a 37-year-old male coffee worker following prolonged exposure to high levels of diacetyl and the related compound 2,3-pentanedione, who had no other medical, avocational, or occupational history that could account for his illness. He began working at a coffee facility in the flavoring room and grinding area in 2009. Four years later he moved to the packaging area but continued to flavor and grind coffee at least 1 full day per week. He reported chest tightness and mucous membrane irritation when working in the flavoring room and grinding area in 2010. Beginning in 2014, he developed dyspnea, intermittent cough, and a reduced sense of smell without a work-related pattern. In 2016, spirometry revealed a moderate mixed pattern that did not improve with bronchodilator. Thoracoscopic lung biopsy results demonstrated focal mild cellular bronchiolitis and pleuritis, and focal peribronchiolar giant cells/granulomas, but no evidence of constrictive bronchiolitis. Full-shift personal air-samples collected in the flavoring and grinding areas during 2016 measured diacetyl concentrations up to 84-fold higher than the recommended exposure limit. Medical evaluations indicate this worker developed work-related, airway-centric lung disease, most likely attributable to inhalational exposure to flavorings, with biopsy findings not usual for obliterative bronchiolitis. Clinicians should be aware that lung pathology could vary considerably in workers with suspected flavoring-related lung disease.

Silicosis is a progressive and incurable, but preventable, occupational respiratory disease caused by respirable crystalline silica exposure. Over the past decade, outbreaks of silicosis have been reported in several countries among workers who cut and finish engineered stone slabs for countertops (1–3). Many affected workers have been young, with rapidly progressive disease (4, 5). Engineered stone is a composite material made of crushed quartz bound together with polyester resins and pigments, with significantly higher silica content than natural stone materials; engineered stone typically contains >90% silica, compared with <45% in granite and <5% in marble (3, 6). Workers can be exposed to markedly elevated levels of respirable crystalline silica when cutting and finishing engineered stone materials (7, 8).

Occupational bronchiolitis is characterized by inflammation of the small airways, and represents a heterogeneous set of lung conditions that can occur following a range of inhalation exposures related to work. The most common clinical presentation includes insidious onset of exertional dyspnea and cough. Multiple reports in recent years have drawn attention to previously unrecognized risk factors for occupational bronchiolitis following exposures in several settings. Both current and past occupational exposures, including prior military deployment-related exposures, should be considered in patients undergoing evaluation for unexplained dyspnea. Diagnostic testing for potential bronchiolitis should include a thorough assessment of the small airways.

Roasted coffee and many coffee flavorings emit volatile organic compounds (VOCs) including diacetyl and 2,3-pentanedione. Exposures to VOCs during roasting, packaging, grinding, and flavoring coffee can negatively impact the respiratory health of workers. Inhalational exposures to diacetyl and 2,3-pentanedione can cause obliterative bronchiolitis. This study summarizes exposures to and emissions of VOCs in 17 coffee roasting and packaging facilities that included 10 caf&#233;s. We collected 415 personal and 760 area full-shift, and 606 personal task-based air samples for diacetyl, 2,3-pentanedione, 2,3-hexanedione, and acetoin using silica gel tubes. We also collected 296 instantaneous activity and 312 instantaneous source air measurements for 18 VOCs using evacuated canisters. The highest personal full-shift exposure in part per billion (ppb) to diacetyl [geometric mean (GM) 21 ppb; 95th percentile (P95) 79 ppb] and 2,3-pentanedione (GM 15 ppb; P95 52 ppb) were measured for production workers in flavored coffee production areas. These workers also had the highest percentage of measurements above the NIOSH Recommended Exposure Limit (REL) for diacetyl (95%) and 2,3-pentanedione (77%). Personal exposures to diacetyl (GM 0.9 ppb; P95 6.0 ppb) and 2,3-pentanedione (GM 0.7 ppb; P95 4.4 ppb) were the lowest for non-production workers of facilities that did not flavor coffee. Job groups with the highest personal full-shift exposures to diacetyl and 2,3-pentanedione were flavoring workers (GM 34 and 38 ppb), packaging workers (GM 27 and 19 ppb) and grinder operator (GM 26 and 22 ppb), respectively, in flavored coffee facilities, and packaging workers (GM 8.0 and 4.4 ppb) and production workers (GM 6.3 and 4.6 ppb) in non-flavored coffee facilities. Baristas in caf&#233;s had mean full-shift exposures below the RELs (GM 4.1 ppb diacetyl; GM 4.6 ppb 2,3-pentanedione). The tasks, activities, and sources associated with flavoring in flavored coffee facilities and grinding in non-flavored coffee facilities, had some of the highest GM and P95 estimates for both diacetyl and 2,3-pentanedione. Controlling emissions at grinding machines and flavoring areas and isolating higher exposure areas (e.g., flavoring, grinding, and packaging areas) from the main production space and from administrative or non-production spaces is essential for maintaining exposure control.

INTRODUCTION: Workers' exposure to metalworking fluid (MWF) has been associated with respiratory disease. As part of a public health investigation of a manufacturing facility, we performed paired environmental and human sampling to evaluate cross-pollination of microbes between environment and host and possible effects on lung pathology present among workers. METHODS: Workplace environmental microbiota was evaluated in air and MWF samples. Human microbiota was evaluated in lung tissue samples from workers with respiratory symptoms found to have lymphocytic bronchiolitis and alveolar ductitis with B-cell follicles and emphysema, lung tissue controls, and in skin, nasal and oral samples from 302 workers from different areas of the facility. In vitro effects of MWF exposure on murine B-cells were assessed. RESULTS: Increased similarity of microbial composition was found between MWF samples and lung tissue samples of case workers compared to controls. Among workers in different locations within the facility, those that worked in machine shop area had skin, nasal and oral microbiota more closely related to the microbiota present in MWF samples. Lung samples from four index cases, and skin and nasal samples from workers in machine shop area were enriched with Pseudomonas, the dominant taxa in MWF. Exposure to used MWF stimulated murine B-cell proliferation in vitro, a hallmark cell subtype found in pathology of index cases. CONCLUSIONS: Evaluation of a manufacturing facility with a cluster of workers with respiratory disease supports cross-pollination of microbes from MWF to humans and suggests the potential for exposure to these microbes to be a health hazard.

OBJECTIVE: The aim of this study was to compare spirometry results in microwave popcorn and flavoring manufacturing workers. METHODS: We used NIOSH data on current and former microwave popcorn workers (MPWs) and surveillance data on flavoring manufacturing workers (FMWs). RESULTS: Former MPW had higher prevalence of mixed and high severity abnormalities, some had excessive lung function drops. Current MPW had lowest occurrence of excessive lung function drops. FMW with excessive drops and spirometric abnormalities at last test had developed a restrictive pattern. Spirometric abnormalities and excessive drops were associated with work-related factors. CONCLUSION: There was evidence of a healthy worker survivor effect in MPW. Importantly, removal from exposure did not always stabilize lung function decline indicating a need for continued monitoring. The development of a restrictive pattern should raise the level of suspicion for possible work-related disease in flavoring-exposed workers.

Importance: Since August 2019, more than 2700 patients have been hospitalized with e-cigarette, or vaping, product use-associated lung injury (EVALI) across the United States. This report describes the outbreak in California, a state with one of the highest case counts and with a legal adult-use (recreational) cannabis market. Objective: To present clinical characteristics and vaping product exposures of patients with EVALI in California. Design, Setting, and Participants: Case series describing epidemiologic and laboratory data from 160 hospitalized patients with EVALI reported to the California Department of Public Health by local health departments, who received reports from treating clinicians, from August 7 through November 8, 2019. Exposures: Standardized patient interviews were conducted to assess vaping products used, frequency of use, and method of product acquisition. Vaping products provided by a subset of patients were tested for active ingredients and other substances. Main Outcomes and Measures: Demographic and clinical characteristics, level of care, and outcomes of hospitalization were obtained from medical record review. Results: Among 160 patients with EVALI, 99 (62%) were male, and the median age was 27 years (range, 14-70 years). Of 156 patients with data available, 71 (46%) were admitted to an intensive care unit, and 46 (29%) required mechanical ventilation. Four in-hospital deaths occurred. Of 86 patients interviewed, 71 (83%) reported vaping tetrahydrocannabinol (THC)-containing products, 36 (43%) cannabidiol (CBD)-containing products, and 39 (47%) nicotine-containing products. Sixty-five of 87 (75%) THC-containing products were reported as obtained from informal sources, such as friends, acquaintances, or unlicensed retailers. Of 87 vaping products tested from 24 patients, 49 (56%) contained THC. Vitamin E or vitamin E acetate was found in 41 (84%) of the THC-containing products and no nicotine products. Conclusions and Relevance: Patients' clinical outcomes and vaping behaviors, including predominant use of THC-containing products from informal sources, are similar to those reported by other states, despite California's legal recreational cannabis market. While most THC products tested contained vitamin E or vitamin E acetate, other underlying cause(s) of injury remain possible. The California Department of Public Health recommends that individuals refrain from using any vaping or e-cigarette products, particularly THC-containing products from informal sources, while this investigation is ongoing.

OBJECTIVES: Four machine manufacturing facility workers had a novel occupational lung disease of uncertain aetiology characterised by lymphocytic bronchiolitis, alveolar ductitis and emphysema (BADE). We aimed to evaluate current workers' respiratory health in relation to job category and relative exposure to endotoxin, which is aerosolised from in-use metalworking fluid. METHODS: We offered a questionnaire and spirometry at baseline and 3.5 year follow-up. Endotoxin exposures were quantified for 16 production and non-production job groups. Forced expiratory volume in one second (FEV1) decline >/=10% was considered excessive. We examined SMRs compared with US adults, adjusted prevalence ratios (aPRs) for health outcomes by endotoxin exposure tertiles and predictors of excessive FEV1 decline. RESULTS: Among 388 (89%) baseline participants, SMRs were elevated for wheeze (2.5 (95% CI 2.1 to 3.0)), but not obstruction (0.5 (95% CI 0.3 to 1.1)). Mean endotoxin exposures (range: 0.09-28.4 EU/m(3)) were highest for machine shop jobs. Higher exposure was associated with exertional dyspnea (aPR=2.8 (95% CI 1.4 to 5.7)), but not lung function. Of 250 (64%) follow-up participants, 11 (4%) had excessive FEV1 decline (range: 403-2074 mL); 10 worked in production. Wheeze (aPR=3.6 (95% CI 1.1 to 12.1)) and medium (1.3-7.5 EU/m(3)) endotoxin exposure (aPR=10.5 (95% CI 1.3 to 83.1)) at baseline were associated with excessive decline. One production worker with excessive decline had BADE on subsequent lung biopsy. CONCLUSIONS: Lung function loss and BADE were associated with production work. Relationships with relative endotoxin exposure indicate work-related adverse respiratory health outcomes beyond the sentinel disease cluster, including an incident BADE case. Until causative factors and effective preventive strategies for BADE are determined, exposure minimisation and medical surveillance of affected workforces are recommended.

Introduction: Respiratory hazards in the coffee roasting and packaging industry can include asthmagens such as green coffee bean and other dust and alpha-diketones such as diacetyl and 2,3-pentanedione that can occur naturally from roasting coffee or artificially from addition of flavoring to coffee. We sought to describe the burden of respiratory abnormalities among workers at 17 coffee roasting and packaging facilities. Methods: We completed medical surveys at 17 coffee roasting and packaging facilities that included interviewer-administered questionnaires and pulmonary function testing. We summarized work-related symptoms, diagnoses, and spirometry testing results among all participants. We compared health outcomes between participants who worked near flavoring and who did not. Results: Participants most commonly reported nose and eye symptoms, and wheeze, with a work-related pattern for some. Symptoms and pulmonary function tests were consistent with work-related asthma in some participants. About 5% of workers had abnormal spirometry and most improved after bronchodilator. Health outcomes were similar between employees who worked near flavoring and who did not, except employees who worked near flavoring reported more chronic bronchitis and ever receiving a diagnosis of asthma than those who did not work near flavoring. Conclusion: The symptoms and patterns likely represent overlapping health effects of different respiratory hazards, including green coffee bean and other dust that can contribute to work-related asthma, and diacetyl and 2,3-pentanedione that can contribute to obliterative bronchiolitis. Healthcare providers and occupational health and safety practitioners should be aware that workers at coffee roasting and packaging facilities are potentially at risk for occupational lung diseases.

Increased global demand for touch screens, photovoltaics, and optoelectronics has resulted in an increase in the production of indium-tin oxide (ITO). Occupational exposure to indium compounds is associated with the development of indium lung disease. Although many previous epidemiologic investigations highlight an excess of lung abnormalities in workplaces where ITO is produced, few assessments of occupational exposure to respirable and inhalable indium are reported to date. The objective of this study was to identify the determinants of respirable and inhalable indium at an ITO production facility to target exposure interventions. In 2012 and 2014, we conducted exposure assessments at an ITO production facility and collected full-shift personal respirable (n = 159) and inhalable (n = 57) indium samples. We also observed workers and recorded information on task duration and location, materials used, and use of personal protective equipment (PPE). Tasks (n = 121) recorded in task diaries were categorized into 40 similar task groups using the Advanced REACH Tool and process-related information. Mixed-effects models were fit separately for log-transformed respirable and inhalable indium, with random effect of subject and fixed effects of task groups. Overall, respirable and inhalable indium measurements ranged from 0.1 to 796.6 microg m-3 and 1.6 to 10 585.7 microg m-3, respectively, and were highly correlated with Spearman correlation coefficient of 0.90. The final model for respirable indium explained 36.3% of total variance and identified sanding, powder transfer tasks in reclaim, powder transfer tasks in refinery, handling indium materials, and liquid transfer tasks in ITO production as tasks associated with increased respirable indium exposure. The final model for inhalable indium explained 24.6% of total variance and included powder transfer tasks in ITO production, cleaning cylinder or tile, and handling indium material tasks. Tasks identified as strong predictors of full-shift exposure to respirable and inhalable indium can guide the use of engineering, administrative, and PPE controls designed to mitigate occupational exposure to indium. Moreover, since the tasks were aligned with REACH activities, results from this study can also be used to inform REACH activity scenarios.

BACKGROUND: The burden and prognosis of malignant mesothelioma in the United States have remained largely unchanged for decades, with approximately 3200 new cases and 2400 deaths reported annually. To address care and research gaps contributing to poor outcomes, in March of 2019 the Mesothelioma Applied Research Foundation convened a workshop on the potential usefulness and feasibility of a national mesothelioma registry. METHODS: The workshop included formal presentations by subject matter experts and a moderated group discussion. RESULTS: Workshop participants identified top priorities for a registry to be: (a) connecting patients with high-quality care and clinical trials soon after diagnosis and (b) making useful data and biospecimens available to researchers in a timely manner. Existing databases that capture mesothelioma cases are limited by factors such as delays in reporting, de-identification, and lack of exposure information critical to understanding as yet unrecognized causes of disease. National disease registries for amyotrophic lateral sclerosis in the United States, and for mesothelioma in other countries, provide examples of how a registry could be structured to meet the needs of patients and the scientific community. CONCLUSIONS: Small-scale pilot initiatives should be undertaken to validate methods for rapid case identification, develop procedures to facilitate patient access to guidelines-based standard care and investigational therapies, and explore approaches to data-sharing with researchers. Ultimately, federal coordination and funding will be critical to the success of a national mesothelioma registry in improving mesothelioma outcomes and preventing future cases of this devastating disease.

Flavorings-related lung disease is a potentially disabling and sometimes fatal lung disease of workers making or using flavorings. First identified almost 20 years ago in microwave popcorn workers exposed to butter-flavoring vapors, flavorings-related lung disease remains a concern today. In some cases, workers develop bronchiolitis obliterans, a severe form of fixed airways disease. Affected workers have been reported in microwave popcorn, flavorings, and coffee production workplaces. Volatile alpha-dicarbonyl compounds, particularly diacetyl (2,3-butanedione) and 2,3-pentanedione, are implicated in the etiology. Published studies on diacetyl and 2,3-pentanedione document their ability to cause airway epithelial necrosis, damage biological molecules, and perturb protein homeostasis. With chronic exposure in rats, they produce airway fibrosis resembling bronchiolitis obliterans. To add to this knowledge, we recently evaluated airway toxicity of the 3-carbon alpha-dicarbonyl compound, methylglyoxal. Methylglyoxal inhalation causes epithelial necrosis at even lower concentrations than diacetyl. In addition, we investigated airway toxicity of mixtures of diacetyl, acetoin, and acetic acid, common volatiles in butter flavoring. At ratios comparable to workplace scenarios, the mixtures or diacetyl alone, but not acetic acid or acetoin, cause airway epithelial necrosis. These new findings add to existing data to implicate alpha-dicarbonyl compounds in airway injury and flavorings-related lung disease.

BACKGROUND: A cluster of severe lung disease occurred at a manufacturing facility making industrial machines. We aimed to describe disease features and workplace exposures. METHODS: Clinical, functional, radiologic, and histopathologic features were characterized. Airborne concentrations of thoracic aerosol, metalworking fluid, endotoxin, metals, and volatile organic compounds were measured. Facility airflow was assessed using tracer gas. Process fluids were examined using culture, polymerase chain reaction, and 16S ribosomal RNA sequencing. RESULTS: Five previously healthy male never-smokers, ages 27 to 50, developed chest symptoms from 1995 to 2012 while working in the facility's production areas. Patients had an insidious onset of cough, wheeze, and exertional dyspnea; airflow obstruction (mean FEV1 = 44% predicted) and reduced diffusing capacity (mean = 53% predicted); and radiologic centrilobular emphysema. Lung tissue demonstrated a unique pattern of bronchiolitis and alveolar ductitis with B-cell follicles lacking germinal centers, and significant emphysema for never-smokers. All had chronic dyspnea, three had a progressive functional decline, and one underwent lung transplantation. Patients reported no unusual nonoccupational exposures. No cases were identified among nonproduction workers or in the community. Endotoxin concentrations were elevated in two air samples; otherwise, exposures were below occupational limits. Air flowed from areas where machining occurred to other production areas. Metalworking fluid primarily grew Pseudomonas pseudoalcaligenes and lacked mycobacterial DNA, but 16S analysis revealed more complex bacterial communities. CONCLUSION: This cluster indicates a previously unrecognized occupational lung disease of yet uncertain etiology that should be considered in manufacturing workers (particularly never-smokers) with airflow obstruction and centrilobular emphysema. Investigation of additional cases in other settings could clarify the cause and guide prevention.

Workers in specific settings and activities are at increased risk for certain infectious diseases. When an infectious disease case occurs in a worker, investigators need to understand the mechanisms of disease propagation in the workplace. Few publications have explored these factors in the United States; a literature search yielded 66 investigations of infectious disease occurring in US workplaces during 2006-2015. Reported cases appear to be concentrated in specific industries and occupations, especially the healthcare industry, laboratory workers, animal workers, and public service workers. A hierarchy-of-controls approach can help determine how to implement effective preventive measures in workplaces. Consideration of occupational risk factors and control of occupational exposures will help prevent disease transmission in the workplace and protect workers' health.

Rationale: Workplace inhalational hazards remain common worldwide, even though they are ameliorable. Previous American Thoracic Society documents have assessed the contribution of workplace exposures to asthma and chronic obstructive pulmonary disease on a population level, but not to other chronic respiratory diseases. The goal of this document is to report an in-depth literature review and data synthesis of the occupational contribution to the burden of the major nonmalignant respiratory diseases, including airway diseases; interstitial fibrosis; hypersensitivity pneumonitis; other noninfectious granulomatous lung diseases, including sarcoidosis; and selected respiratory infections. Methods: Relevant literature was identified for each respiratory condition. The occupational population attributable fraction (PAF) was estimated for those conditions for which there were sufficient population-based studies to allow pooled estimates. For the other conditions, the occupational burden of disease was estimated on the basis of attribution in case series, incidence rate ratios, or attributable fraction within an exposed group. Results: Workplace exposures contribute substantially to the burden of multiple chronic respiratory diseases, including asthma (PAF, 16%); chronic obstructive pulmonary disease (PAF, 14%); chronic bronchitis (PAF, 13%); idiopathic pulmonary fibrosis (PAF, 26%); hypersensitivity pneumonitis (occupational burden, 19%); other granulomatous diseases, including sarcoidosis (occupational burden, 30%); pulmonary alveolar proteinosis (occupational burden, 29%); tuberculosis (occupational burden, 2.3% in silica-exposed workers and 1% in healthcare workers); and community-acquired pneumonia in working-age adults (PAF, 10%). Conclusions: Workplace exposures contribute to the burden of disease across a range of nonmalignant lung conditions in adults (in addition to the 100% burden for the classic occupational pneumoconioses). This burden has important clinical, research, and policy implications. There is a pressing need to improve clinical recognition and public health awareness of the contribution of occupational factors across a range of nonmalignant respiratory diseases.

The year 2017 marked the 50th anniversary of NIOSH's Respiratory Health Division (RHD). RHD began in 1967 as the Appalachian Laboratory for Occupational Respiratory Diseases (ALFORD), with a focus on coal workers' pneumoconiosis. ALFORD became part of NIOSH in 1971 and added activities to address work-related respiratory disease more generally. Health hazard evaluations played an important role in understanding novel respiratory hazards such as nylon flock, diacetyl, and indium-tin oxide. Epidemiologic and laboratory studies addressed many respiratory hazards, including coal mine dust, silica, asbestos, cotton dust, beryllium, diesel exhaust, and dampness and mold. Surveillance activities tracked the burden of diseases and enhanced the quality of spirometry and chest radiography used to screen workers. RHD's efforts to improve scientific understanding, inform strategies for prevention, and disseminate knowledge remain important now and for the future.

Objectives: Workers using flavoring formulations containing diacetyl and 2,3-pentanedione may be at risk of inhalational exposure, as these volatile hazardous chemicals are emitted from the bulk material, especially at elevated temperatures. However, flavoring formulations that contain diacetyl and 2,3-pentanedione might not list these ingredients because they are generally recognized as safe to ingest, may be part of a proprietary mixture deemed a trade secret, or may not be required to be listed if they are present at <1% composition. The objective of this study was to investigate whether potential inhalational hazards present in flavoring samples were reported as chemical ingredients on their corresponding safety data sheets (SDSs). Methods: A convenience sample of 26 bulk liquid flavorings obtained from two coffee roasting and packaging facilities in the USA was analyzed for 20 volatile organic chemicals present in the headspaces of vials containing flavoring liquids using gas chromatography-mass spectrometry. Flavoring samples were included in the study if headspace analysis results and SDSs were available. Flavoring samples included hazelnut, French vanilla, amaretto, chocolate, and caramel as well as some flavoring mixtures containing added fruit flavors such as cherry and raspberry. The presence of a chemical in the flavoring formulation was then compared to the ingredient list on the SDSs. Results: All the flavoring SDSs contained trade secret designations. None of the SDSs listed diacetyl or 2,3-pentanedione. Headspace analyte concentrations revealed that diacetyl was present in 21 of 26 samples (81%) with a maximum concentration of 5.84 x 104 microg m-3 in flavor 18 (caramel). 2,3-Pentanedione was present in 15 flavors (58%) with a maximum concentration of 3.79 x 105 microg m-3 in flavor 24 (oatmeal cookies). Conclusions: A majority of the flavorings tested had diacetyl, 2,3-pentanedione, or both as volatile constituents in the headspace. These chemicals were not listed on the SDSs, but inclusion of diacetyl and 2,3-pentanedione on SDSs would serve to protect downstream users from unrecognized exposure and potential respiratory disease. The headspace technique presented here is a viable tool to rapidly screen for volatile hazardous chemicals that may be present in flavoring formulations. Facilities that use flavorings should be aware that constituents in flavorings may present a potential inhalational hazard even if not identified as such by the SDS. A precautionary approach is warranted when working with flavorings, including exposure monitoring and effective exposure control strategies such as containment and local exhaust ventilation.

OBJECTIVES: Diacetyl, a butter flavour compound used in food and flavouring production, is a respiratory toxin. We characterised the burden of respiratory abnormalities in workers at popcorn and flavouring manufacturing facilities that used diacetyl as evaluated through US National Institute for Occupational Safety and Health (NIOSH) health hazard evaluations. METHODS: We performed analyses describing the number and percentage of current and former workers from popcorn and flavouring manufacturing facilities where NIOSH administered a respiratory health questionnaire and spirometry testing who met case definitions of suspected flavouring-related lung disease. Case definitions were pathologist reported: lung biopsy pathology report stating supportive of/consistent with constrictive bronchiolitis or bronchiolitis obliterans; probable: obstructive/mixed spirometric pattern with forced expiratory volume in 1 s (FEV1) <60% predicted; possible: obstructive/mixed spirometric pattern with FEV1 >/=60% or any spirometric restriction; symptoms only: normal spirometry plus exertional dyspnoea or usual cough. RESULTS: During 2000-2012, NIOSH collected questionnaire and spirometry data on 1407 workers (87.0% current, 13.0% former) at nine facilities in eight states. After applying case definitions, 4 (0.3%) were classified as pathologist reported, 48 (3.4%) as probable, 234 (16.6%) as possible and 404 (28.7%) as symptoms only. The remaining 717 (51.0%) workers had normal spirometry without exertional dyspnoea or usual cough. Seven of 11 workers with biopsies did not meet the pathologist-reported case definition, although four met probable and three met possible. CONCLUSIONS: This approach demonstrates the substantial burden of respiratory abnormalities in these workers. A similar approach could quantify the burden of respiratory abnormalities in other industries that use diacetyl.

At least four workers at a metal recycling facility were hospitalized and one died after exposure to chlorine gas when it was accidentally released from an intact, closed-valved cylinder being processed for scrap metal. This unintentional chlorine gas release marks at least the third such incident at a metal recycling facility in the United States since 2010. We describe the fatal case of the worker whose clinical course was consistent with acute respiratory distress syndrome (ARDS) following exposure to high concentrations of chlorine gas. This case report emphasizes the potential risk of chlorine gas exposure to metal recycling workers by accepting and processing intact, closed-valved containers. The metal recycling industry should take steps to increase awareness of this established risk to prevent future chlorine gas releases. Additionally, public health practitioners and clinicians should be aware that metal recycling workers are at risk for chlorine gas exposure.

In April 2016, a Virginia dentist who had recently received a diagnosis of idiopathic pulmonary fibrosis (IPF) and was undergoing treatment at a specialty clinic at a Virginia tertiary care center contacted CDC to report concerns that IPF had been diagnosed in multiple Virginia dentists who had sought treatment at the same specialty clinic. IPF is a chronic, progressive lung disease of unknown cause and associated with a poor prognosis (1). Although IPF has been associated with certain occupations (2), no published data exist regarding IPF in dentists. The medical records for all 894 patients treated for IPF at the Virginia tertiary care center during September 1996-June 2017 were reviewed for evidence that the patient had worked as a dentist, dental hygienist, or dental technician; among these patients, eight (0.9%) were identified as dentists and one (0.1%) as a dental technician, and each had sought treatment during 2000-2015. Seven of these nine patients had died. A questionnaire was administered to one of the living patients, who reported polishing dental appliances and preparing amalgams and impressions without respiratory protection. Substances used during these tasks contained silica, polyvinyl siloxane, alginate, and other compounds with known or potential respiratory toxicity. Although no clear etiologies for this cluster exist, occupational exposures possibly contributed. This cluster of IPF cases reinforces the need to understand further the unique occupational exposures of dental personnel and the association between these exposures and the risk for developing IPF so that appropriate strategies can be developed for the prevention of potentially harmful exposures.

Past studies have demonstrated that cleaning in a variety of work settings is a risk factor for adverse respiratory health effects, most notably asthma (1, 2). Excess asthma and respiratory symptoms have also been documented in persons cleaning at home (2, 3). In this issue of the Journal, Svanes and colleagues (pp. 1157 – 1163) examine the long-term effects of cleaning, using data from the European Community Respiratory Health Survey (ECRHS) (4). The authors showed that for women, but not men, both occupational and domestic cleaning were associated with accelerated declines in spirometric parameters over the course of 20 years. They found that the size of the effect was comparable to smoking 10 to 20 cigarettes daily during the study period.