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The Effects of Arc Welding on Cardio-Respiratory Health in Shipyard Workers

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The Effects of Arc Welding on Cardio-Respiratory Health in Shipyard Workers Imperial College London National Heart and Lung Institute Department of Respiratory Epidemiology, Occupational Medicine and Public Health MRC-PHE Centre for Environment and Health Arc welding and the risk of airways and cardiovascular diseases: WELSHIP study by Andrea Marongiu A thesis submitted for the degree of Doctor of Philosophy Dedication In memory of my father Vittorio ‘No sentía cà moria càntu impàru ancora bollia’ Declaration I herewith certify that this dissertation is my original work and that all material included that is not my own work has been properly acknowledged. Copyright declaration The copyright of this thesis rests with the author and is made available under a Creative Commons Attribution Non-Commercial No Derivatives licence. Researchers are free to copy, distribute or transmit the thesis on the condition that they attribute it, that they do not use it for commercial purposes and that they do not alter, transform or build upon it. For any reuse or redistribution, researchers must make clear to others the licence terms of this work. Abstract Globally there are around 10 million workers who routinely weld and are exposed to a metal fume aerosol of small particles of largely metal oxides and gases. Their medium- and long-term cardiorespiratory risks are incompletely understood. This thesis describes a programme of novel research carried out in a large Middle Eastern shipyard. Four studies were completed. First, a systematic review of published cross-sectional surveys (N: 38) in welders were identified; a meta-analyses of 34 publications showed a clear excess of asthma (OR 1.65; 95% CI 1.14, 2.37) and chronic bronchitis (OR 1.92; 1.50, 2.45) that could not be explained by smoking. In contrast, there was remarkably, little summary evidence of deficits in lung function in welders. Second, a cross-sectional survey of shipyard workers (N: 529, response rate 93%) showed no evidence of any decrements in lung or cardiac function in welders but suggested that symptoms of respiratory infections in winter were more common in this group (OR 2.65; 1.22, 5.78) than in matched referent workers. Support for this novel finding came from the third study, of clinical records held by the yard’s medical centre over an eleven-year period (N: 15,954). Consultations for respiratory infections were 72% higher in welders compared to office workers; there was a clear exposure-response relationship across workers with different intensities of welding. The fourth study, of a panel of 50 shipyard workers (response rate 100%) suggested a small cross-shift decline in lung function and increase in arterial stiffness. These findings suggest, for the first time, that welders are susceptible to a wide range of respiratory infections. High quality, collaborative research in this setting is feasible; future studies could usefully examine in more detail – including microbiological - the relationship between welding fume exposure and respiratory infections. The potential health-benefits to the global community of welders are substantial. iv Acknowledgements I would like to thank my supervisors Prof Paul Cullinan, Dr Cosetta Minelli, Dr Jo Zram and Dr Cristina Canova, their encouragement, patience and willingness to share their experience has been invaluable for the completion of this very ambitious project. I am particularly indebted to Prof Paul Cullinan for the opportunity. Without the enthusiasm, commitment, hard work and professionalism demonstrated by the WELSHIP team in Dubai this research would have not been a success. I am grateful to Dr Omer Imtiaz Hasan, Ms Anila Ali, Mr Sharoon Bakhsh, Mr Bobby George and Mr Nabeel Irfan for being outstanding colleagues and remarkable friends. I would like to thank Magda Wheatley for her time in helping with the arrangement of payments to the study participants and to Stephanie MacNeill for her support and never-ending encouragement. Many thanks go to Susie Schofield for her statistical advice and help with the systematic literature review duplicate extraction of data. For their time and willingness to share their knowledge, I wish to thank a panel of experts: Dr David Green and Dr Ben Barratt for the collection of environmental exposure data and Dr Andre Amaral for the collection of bio-samples. I am particularly grateful to Dr Martin Cosgrove for sharing his experience and enthusiasm on welding and for his advice during the writing up stage. I am grateful to the MRC-PHE Centre for Environment and Health for awarding me a studentship and to DryDocks World Dubai for their partnership and commitment while conducting the WELSHIP study. Finally I would like to express how deeply indebted I am to my family and friends, Marian for always being there, Bianca and Shanae for giving me shelter while in Dubai and for being good listeners and Louise for proofreading the final draft. Above all, I am thankful to my mother Lalla, Piero, Jason and Tess whose constant, unconditional love and support got me through tough times. v Abbreviations ACGIH American Conference Of Governmental Hygienists AIx Augmentation Index Al Aluminium aPWV Aortic Pulse Wave Velocity ATS American Thoracic Society bBP Brachial Blood Pressure bDBP Brachial Diastolic Blood Pressure bMAP Brachial Mean Arterial Pressure BP Blood Pressure bSBP Brachial Systolic Blood Pressure cBP Central (Aortic) Blood Pressure cDBP Central (Aortic) Brachial Diastolic Blood Pressure COPD Chronic Obstructive Pulmonary Disease cSBP Central Systolic Blood Pressure DDW-D DryDocks World-Dubai DIP Desquamative Interstitial Pneumonia FCAW Flux-Core Arc Welding FEF25-75% Forced Expiratory Flow At 25–75% Of Forced Vital Capacity FEV1 Forced Expiratory Volume In 1 Second FFR Fume Formation Rate FP Fractional Polynomials FVC Forced Vital Capacity GMAW Gas Metal Arc Welding - MIG/MAG GTAW Gas Tungsten Arc Welding - See TIG HRV Heart Rate Variability IHD Ischaemic Heart Disease IPD Invasive Pneumococcal Disease IRR Incidence Rate Ratio LEV Local Exhaust Ventilation LRT Lower Respiratory Tract LRTI Lower Respiratory Tract Infection MFF Metal Fume Fever MI Myocardial Infarction MIG/MAG Metal Inert Gas/Metal Active Gas - See GMAW μm Micrometre MMA Manual Metal Arc Welding - See SMAW Or Stick MS Mild Steel OH Occupational Health OR Odds Ratio P P-Value PEFR Peak Expiratory Flow Rate PM Particulate Matter PPE Personal Protective Equipment PWA Pulse Wave Analysis PWV Pulse Wave Velocity SBP Systolic Blood Pressure vi SD Standard Deviation SDNN Standard Deviation Of Normal-To-Normal Intervals Between Heartbeats SE Standard Error SMAW Shielded Metal Arc Welding - See MMA or Stick SS Stainless Steel Stick welding Welding With Flux Coated Consumable Electrode - See SMAW or MMA TIG Tungsten Inert Gas Welding - See GTAW TLV® Threshold Limit Values Set By ACGIH UAE United Arab Emirates UFP Ultrafine Particles (<0.1 μm) ULCC Ultra Large Crude Carrier URT Upper Respiratory Tract URTI Upper Respiratory Tract Infection VLCC Very Large Crude Carrier WHR Waist-To-Hip Ratio vii Contents DEDICATION II DECLARATION III COPYRIGHT DECLARATION III ABSTRACT IV ACKNOWLEDGEMENTS V ABBREVIATIONS VI CHAPTER 1: BACKGROUND 14 1.1 ARC WELDING 14 1.1.1 Metal dust, fine particles and welding fume 15 1.1.2 Health and arc welding: an overview 16 1.2 RESEARCH HYPOTHESIS 17 1.3 AIMS AND OBJECTIVES 17 1.4 DATA SOURCES AND FIELDWORK 17 1.5 THESIS PLAN 21 1.6 RESEARCH IN A ‘REAL WORLD’ SETTING 21 CHAPTER 2: SYSTEMATIC LITERATURE REVIEW AND META-ANALYSIS ON LUNG FUNCTION AND OBSTRUCTIVE PULMONARY DISEASE IN ARC WELDERS 23 2.1 METHODS 23 2.1.1 Search strategy 23 2.1.2 Inclusion and exclusion criteria 24 2.1.3 Outcome measures 24 2.1.4 Data extraction 25 2.1.5 Statistical analyses 25 2.2 RESULTS 36 2.2.1 Characteristics of the studies included in the review 36 2.2.2 Meta-analysis results for lung function 38 2.2.3 Meta-analysis results for respiratory symptoms 41 2.2.4 Publication and small studies bias: asymmetry analysis 45 2.3 DISCUSSION 48 2.3.1 Lung function 48 2.3.2 Asthma and respiratory symptoms 49 2.3.3 Respiratory health of shipyard welders 50 2.3.4 Limitations 50 2.3.5 Strengths 51 2.4 CONCLUSION 52 CHAPTER 3: CROSS-SECTIONAL SURVEY 54 3.1 RESEARCH AIM AND OBJECTIVES 54 3.2 METHODS 54 8 3.2.1 Fieldworkers’ training and survey pilot 54 3.2.2 Sample selection and sample size 55 3.2.3 Survey process, data collection and storage 58 3.2.4 Data analysis 63 3.3 RESULTS 66 3.3.1 Sample characteristics 66 3.3.2 Cardiorespiratory health 70 3.3.3 Secondary analyses results 74 3.4 DISCUSSION 77 3.5 LIMITATIONS 83 3.6 CONCLUSION AND FUTURE RESEARCH 84 CHAPTER 4: RESPIRATORY INFECTIONS AND WELDING FUME EXPOSURE - AN EXAMINATION OF A WORKPLACE DATABASE. 86 4.1 RESEARCH AIM AND OBJECTIVES 86 4.2 METHODOLOGY 86 4.2.1 Target population, employment and medical data 86 4.2.2 Employment records data handling 87 4.2.3 Medical records data handling 89 4.2.4 Recoding of diagnosis for the 2000-2005 period 90 4.2.5 Diagnostic code assignment database 92 4.2.6 Data analyses 94 4.3 RESULTS 96 4.3.1 Primary analysis results 97 4.3.2 Secondary analysis results 99 4.4 DISCUSSION AND CONCLUSIONS 100 4.5 LIMITATIONS 101 4.6 CONCLUSIONS 101 CHAPTER 5: PANEL (PILOT) STUDY 103 5.1 RESEARCH AIMS AND OBJECTIVES 103 5.2 METHODS 103 5.2.1 Sample selection and target population 103 5.2.2 Survey timeline and fieldworkers’ training 104 5.2.3 Study process, data collection and storage 105 5.2.4 Statistical analysis 111 5.3 RESULTS 113 5.3.1 Sample characteristics 113 5.3.2 Cardiorespiratory health analyses 115 5.3.3 Overview of remaining collected
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