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Identification of Bronchiolitis Obliterans (BO) in California. 29 y/o Male in August 200440 y/o Female in April 2007Powder-flavor mixersNon-smokers, no prior chemical exposureSymptoms after 2 ? 5 yrs exposureBO diagnosis based on history, fixed airways obstruction and high resolution CT (HRCT) findings.
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1. Medical Surveillance for Flavorings-Related Lung Disease in Flavor Manufacturing Workers: The CA Department of Public Health Experience Thomas J. Kim, MD, MPH
Epidemic Intelligence Service Officer
California Department of Public Health
Occupational Health Branch
2. Identification of Bronchiolitis Obliterans (BO) in California 29 y/o Male in August 2004
40 y/o Female in April 2007
Powder-flavor mixers
Non-smokers, no prior chemical exposure
Symptoms after 2 – 5 yrs exposure
BO diagnosis based on history, fixed airways obstruction and high resolution CT (HRCT) findings
3. The California Response Cal/OSHA citations and special order
Diacetyl hazard factsheet
Identification of diacetyl users in CA
Collaboration among
Cal/OSHA
Industry and medical consultant
CA Department of Public Health
Technical assistance from NIOSH
4. CA Response: Industry Special Emphasis Program Companies agreed to
Undergo IH assessment
Start a medical surveillance program
Implement exposure controls
Otherwise be subject to compliance inspections
Data obtained from 21 companies
Approximately 530 workers
5. Goals of Medical Surveillance Primary
Identify BO at earliest onset
Industry-wide analysis to identify risk factors to guide prevention measures
Secondary
Identify other occupational lung disease related to flavor manufacturing
Improve longitudinal surveillance and spirometry quality in CA occupational health clinics
6. Surveillance Description Role of companies
Role of providers
Role of the CA Department of Public Health
7. Role of Companies Appropriately identify workers at potential risk and enroll in surveillance
Contract with qualified clinical services
Ensure surveillance occurs at recommended intervals
Train workers
Communicate with health provider, IH, and Cal/OSHA on necessary interventions
8. Role of Providers Implement recommended guidelines
Administer questionnaire and spirometry
Educate workers at each visit
Maintain good spirometry quality
Initiate further evaluation in workers with abnormal screening
Protect workers through duty modifications or removal
Workplace visits and ensure good communication with companies
9. Role of CDPH Serve as a consultant to local providers
Develop surveillance guidelines
Provide central review of spirometry quality
Analyze industry wide surveillance data
Work with Cal/OSHA and NIOSH to prevent disease via control measures
10. Surveillance Overview
11. Abnormal Spirometry Evaluation
12. Abnormal Spirometry Evaluation
13. FEV1 and FEV1/FVC Obstructive pattern:
FEV1/FVC = LLN
Interval FEV1 decline > 15% from baseline
FEV1/FVC alone
Provides increased sensitivity
For the elderly
And young healthy males
FEV1/FVC
>70%
LLN (90% NHANES predicted) per ATS
14. Advantage of Using Longitudinal Decline in FEV1
15. Abnormal Spirometry Evaluation
16. Bronchiolitis Obliterans Case Obstructive pattern on spirometry
Fixed obstruction on pre/post bronchodilation spirometry
On High Resolution Chest CT (HRCT)
Mosaic pattern of attenuation
Air trapping on expiratory views
Cylindrical bronchiectasis
others
17. Abnormal Spirometry Evaluation: Asthma
18. Concurrent Lung Conditions: Asthma Communicate with PMD
Workplace hazard education
Higher threshold for suspicion
Further evaluation warranted
Newly diagnosed through surveillance
Any post-hire onset
Worsening medical control
19. The Reality of Surveillance from the Public Health Perspective Non-uniform data collection of symptoms, work information and exposures
Poor timeliness of medical records
Until recently, lack of recommended guidelines
Spirometry quality
Unacceptable curves
Poor repeatability
Improper instrument set up for result printout
20. Continuing Efforts Finalize database and analyze questionnaire and spirometry data
Cross-sectional analysis
Longitudinal analysis
Work with providers on improving spirometry quality
Continue to serve in consulting role
21. Acknowledgements CA Dept of Public Health
Barbara Materna
Janice Prudhomme
Egils Kronlins
NIOSH
Kay Kreiss
Nancy Sahakian
Kathy Fedan
Brian Tift
Eva Hzindo
Lee Petsonk Consulting Experts
Cecile Rose
Leslie Israel
Paul Enright
Phil Harber
John Balmes
Cal/OSHA
Dan Leiner
Kelly Howard and other HIs
EIS Field Assignments Branch
Sheryl Lyss