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Are Welders More at Risk of Respiratory Infections?

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Are Welders More at Risk of Respiratory Infections? Editorial Against this background, a new paper Thorax: first published as 10.1136/thoraxjnl-2016-208464 on 21 April 2016. Downloaded from Are welders more at risk of respiratory published in this edition of Thorax suggests that welders also have higher rates of upper infections? respiratory infections.15 The findings come from two parallel lines of investigation, David Coggon, Keith T Palmer both focusing on employees at a shipyard in the Middle East. In a cross-sectional survey, welders reported a significantly higher Welding of metals generates a complex mix lobar pneumonia, is clearly affected, but prevalence of respiratory symptoms than of noxious gases and fumes,1 and has been data on mortality by occupation suggest an other manual labourers in winter months linked with various respiratory diseases increased risk also of non-bronchial pneu- (OR 2.31). And in a longitudinal analysis of including metal fume fever,2 asthma,3 monia caused by other microorganisms.56 consultations at the staff medical centre, COPD4 and possibly bronchial carcin- Various mechanisms have been pro- welders consulted for respiratory infections oma.12In addition, there is now strong posed that might explain the hazard. One (mainly of the upper respiratory tract) more and consistent epidemiological evidence theory is that inhaled iron acts as a nutri- frequently than other manual labourers. that welders are at increased risk of infec- ent for microorganisms, promoting their Again, the difference was greater in winter tious, lobar pneumonia. Originally growth.12 This would accord with the (adjusted incidence rate ratio 1.47) than in detected in national analyses of occupa- observations that propensity to infections summer (1.33), but it was significant in tional mortality,5 the hazard was confirmed is increased in patients with sickle cell both seasons. by a large case–control study of men admit- disease who release free iron into the The study had a number of limitations, ted to hospitals in the English West blood during haemolytic crises, and in which the authors acknowledge. In the Midlands with community-acquired pneu- patients with haemochromatosis who cross-sectional survey, symptoms might monia,6 and is supported by findings from absorb dietary iron excessively.12 not have been a reliable marker of respira- more recent epidemiological investigations Moreover, the reversibility of the increase tory infections; the data on medical con- – in the UK78and other countries.9 11 in susceptibility could be explained if fol- sultations relied on the accuracy of The elevation of risk is associated spe- lowing cessation of exposure, free iron in diagnostic coding, which is unlikely to cifically with recent exposure,6 and is not the lung over time became bound to have been entirely consistent and accurate; apparent in former welders after normal carrier proteins, making it inaccessible to and no information was available on retirement age,57suggesting that it pathogens. This hypothesis would accom- smoking habits. reflects a reversible increase in susceptibil- modate an effect on a range of microor- Another concern is the possibility of ity to infection. Moreover, it extends to ganisms, but could not account for a confounding by differences in propensity other occupations such as furnacemen and hazard from non-ferrous metals. to report or consult for symptoms, par- moulders in foundries, who are exposed Another possibility is that metal fume ticularly as workers’ consultation behav- to metal fume but not to welding impairs immune responses in the lung. The iour differed according to their country of 512 gases. It is demonstrable in men who oxidative stress that is generated by transi- origin, and a relatively high proportion of http://thorax.bmj.com/ work with ferrous metals,612but the tion metals on the surface of ultrafine parti- welders came from Bangladesh. However, involvement of other metals cannot be cles in such fume would be expected to risk estimates were adjusted for nationality ruled out. Resolution of this uncertainty stimulate an acute inflammatory response. as well as season and exposure time. with adequate statistical power is a chal- However, analysis of blood and induced Furthermore, the differential effect in lenge because lobar pneumonia is uncom- sputum from a group of long-term welders winter as compared with summer was not mon, and relatively few workers are showed no difference in inflammatory a prior hypothesis. The authors note that exposed to fume exclusively from non- markers from unexposed controls,13 in the United Arab Emirates, seasonal ferrous metals. In Britain, larger numbers prompting the hypothesis that long-term influenza peaks in the winter months. on September 30, 2021 by guest. Protected copyright. of workers were employed in metal manu- inhalation of welding fume might blunt the However, they do not present data on facture historically, and before 1960 statis- normal acute response to inhaled particu- consultation for influenza specifically. tics were published on mortality among late.Suchaneffectcouldoccurfromvarious In view of these limitations, and the men employed specifically in non-ferrous metals and affect various microorganisms. absence of increased sickness absence for foundries. However, data on pneumonia A third hypothesis is that metal fume respiratory disease in an earlier study of are inconsistent. Brass moulders and non- enhances the binding of the pneumococ- welders,16 there is a need for confirmation ferrous foundry workers had significantly cus to lung tissue. Some strains of by independent research in other popula- elevated death rates in 1930–1932, but no pneumococci adhere firmly to and invade tions, before an increased risk of upper excess during 1949–1953.12 bronchial epithelium by co-opting host respiratory infections among welders can Also uncertain is the range of infectious proteins, including the platelet-activating be considered established. If there is agents to which susceptibility is increased. factor receptor (PAFR), which becomes indeed a hazard, it would not of itself be a Streptococcus pneumoniae, which is the stimulated by a bacterial phospholipid major concern—a potentially increased bacterium that most commonly causes that mimics the natural ligand risk of upper respiratory infections is platelet-activating factor. Mild steel accepted, for example, in occupations welding fumes have been found in vitro entailing contact with infants and children. MRC Lifecourse Epidemiology Unit, University of and in mouse models to promote PAFR However, it could provide further import- Southampton, Southampton, UK protein expression, pneumococcal adhe- ant clues to the mechanisms underlying Correspondence to Professor D Coggon, Medical sion and cell invasion.14 A mechanism of the hazard of lobar pneumonia, with the Research Council Lifecourse Epidemiology Unit, this sort would not necessarily be limited possibility of a shared pathogenesis that University of Southampton, Southampton General fi Hospital, Southampton SO16 6YD, UK; to ferrous fume, but would apply speci c- was not specific to the pneumococcus. A [email protected] ally to pneumococcal infections. better understanding of the mechanisms is Coggon D, Palmer KT. Thorax July 2016 Vol 71 No 7 581 Editorial needed because the rarity of lobar pneu- with deaths from asthma in occupations exposed to Thorax: first published as 10.1136/thoraxjnl-2016-208464 on 21 April 2016. Downloaded from monia makes it difficult to establish expos- respiratory sensitisers. Thorax 2009;64:983–6. – 8 Coggon D, Harris EC, Cox V, et al. Pneumococcal ure response relationships directly by vaccination for welders. Thorax 2015;70:198–9. epidemiological investigations. With ▸ http://dx.doi.org/10.1136/thoraxjnl-2015-207912 9 Wergeland E, Iversen BG. Deaths from pneumonia knowledge of mechanism, it might be pos- after welding. Scand J Work Environ Health. sible to develop biomarkers for the Thorax 2016;71:581–582. 2001;27:353. increase in susceptibility to infection, doi:10.1136/thoraxjnl-2016-208464 10 Wong A, Marrie TJ, Garg S, et al. Welders are at increased risk for invasive pneumococcal disease. which could then be related to the levels of REFERENCES Int J Infect Dis. 2010;14:e796–9. exposure. The information thus generated 1 International Agency for Research on Cancer. IARC 11 Torén K, Qvarfordt I, Bergdahl IA, et al. Increased would then guide limits on exposure to Monographs on the evaluation of carcinogenic risks mortality from infectious pneumonia after control the risk. to humans. Volume 49 Chromium, nickel and occupational exposure to inorganic dust, metal fumes welding. Lyon: IARC, 1990. http://monographs.iarc.fr/ and chemicals. Thorax 2011;66:992–6. ENG/Monographs/vol49/ 12 Palmer K, Coggon D. Does occupational exposure to Contributors The commentary was jointly written by 2 Antonini JM, Lewis AB, Roberts JR, et al. Pulmonary iron promote infection? Occup Environ Med the two authors. effects of welding fumes: review of worker and 1997;54:529–34. Funding Medical Research Council. experimental animal studies. Am J Indust Med 13 Palmer KT, McNeill Love RM, Poole JR, et al. 2003;43:350–60. Inflammatory responses to the occupational inhalation Competing interests None declared. 3 Baur X. A compendium of causative agents of of metal fume. Eur Respir J 2006;27:366–73. Provenance and peer review Commissioned; occupational asthma. J Occup Med Toxicol 2013;8:15. 14 Suri R, Periselneris J, Lanone S, et al. Exposure to welding externally peer reviewed. 4 Rushton L. Occupational causes of chronic fumes and lower airway infection with Streptococcus obstructive pulmonary disease. Rev Environ Health pneumoniae. J Allergy Clin Immunol 2016;137: 2007;22:195–212. 527–34. 5 Coggon D, Inskip H, Winter P, et al. Lobar 15 Marongiu A, Hasan O, Ali A, et al. Are welders more pneumonia: an occupational disease in welders. at risk of respiratory infections? Findings from a Lancet 1994;344:41–3. cross-sectional survey and analysis of medical records 6 Palmer KT, Poole J, Ayres JG, et al. Exposure to in shipyard workers: the WELSHIP project.
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