A cross-sectional survey of sensitization to Aspergillus oryzae-derived lactase in pharmaceutical workers

Safety evaluation of the food enzyme β-galactosidase from the genetically modified Bacillus licheniformis strain DSM 34099

The food enzyme β-galactosidase (β-d-galactoside galactohydrolase; EC 3.2.1.23) is produced with the genetically modified Bacillus licheniformis strain DSM 34099 by Kerry Group Services International, Ltd. (KGSI). The genetic modifications do not give rise to safety concerns. The food enzyme is free from viable cells of the production organism and its DNA. The production strain met the requirements for the qualified presumption of safety (QPS) approach. The food enzyme is intended to be used in two food manufacturing processes. Dietary exposure was estimated to be up to 7.263 mg total organic solids/kg body weight per day in European populations. Given the QPS status of the production strain and the absence of concerns resulting from the food enzyme manufacturing process, toxicity tests, other than an assessment of allergenicity, were considered unnecessary by the Panel. A search for the identity of the amino acid sequence of the food enzyme to known allergens was made and one match with a food allergen from kiwi fruit was found. The Panel considered that a risk of allergic reactions upon dietary exposure to this food enzyme, particularly in individuals sensitised to kiwi fruit, cannot be excluded. Based on the data provided, the Panel concluded that this food enzyme does not give rise to safety concerns, under the intended conditions of use.

Safety evaluation of the food enzyme α-galactosidase from the genetically modified Saccharomyces cerevisiae strain CBS 615.94

The food enzyme α-galactosidase (α-d-galactoside galactohydrolase; EC 3.2.1.22) is produced with the genetically modified Saccharomyces cerevisiae strain CBS 615.94 by Kerry Ingredients & Flavours Ltd. The production strain of the food enzyme contains multiple copies of a known antimicrobial resistance gene. However, based on the absence of viable cells and DNA from the production organism in the food enzyme, this is not considered to be a risk. As no other concerns arising from the genetically modified microbial source or from the manufacturing process have been identified, the Panel considered that toxicological tests were not needed for the assessment of this food enzyme. The food enzyme is intended to be used in guar gum processing. The dietary exposure was estimated to be up to 0.828 mg TOS/kg body weight per day in European populations. A search for the similarity of the amino acid sequence of the food enzyme to known allergens was made and no match was found. The Panel considered that a risk of allergic reactions by dietary exposure cannot be excluded, but the likelihood is low. Based on the data provided, the Panel concluded that this food enzyme does not give rise to safety concerns under the intended conditions of use.

Safety evaluation of the food enzyme β-galactosidase from the non-genetically modified Papiliotrema terrestris strain AE-BLC

The food enzyme β-galactosidase (β-d-galactoside galactohydrolase; EC 3.2.1.23) is produced with the non-genetically modified Papiliotrema terrestris strain AE-BLC by Amano Enzyme Inc. The food enzyme was considered free from viable cells of the production organism. It is intended to be used in the production of galacto-oligosaccharides (GOS) from lactose. Dietary exposure to the food enzyme-total organic solids (TOS) was estimated to be up to 0.441 mg TOS/kg body weight (bw) per day in European populations. Genotoxicity tests did not indicate a safety concern. The systemic toxicity was assessed by means of a repeated dose 90-day oral toxicity study in rats. The Panel identified a no observed adverse effect level of 1800 mg TOS/kg bw per day, the highest dose tested, which, when compared with the estimated dietary exposure, resulted in a margin of exposure of at least 4082. A search for the similarity of the amino acid sequence of the food enzyme to known allergens was made and no match was found. The Panel considered that a risk of allergic reactions upon dietary exposure to this food enzyme cannot be excluded, but the likelihood is low. Based on the data provided, the Panel concluded that this food enzyme does not give rise to safety concerns under the intended conditions of use.

The cow's milk allergy that wasn't: allergy to supplemental oral lactase enzyme

BACKGROUND

Allergy to supplemental lactase is sparsely reported in the literature with only one prior case of anaphylaxis documented [2]. Reactions to this agent can occur following cow's milk ingestion which could lead to an erroneous diagnosis of cow's milk allergy in the absence of another explanation.

CASE PRESENTATION

Our patient, a 48-year-old male with eczema, exercise-induced asthma and rhinoconjunctivitis, presented with four episodes of systemic reactions characterized by mucosal swelling and asthma symptoms following ice-cream exposure. It was later recognized that he had been taking a lactase enzyme supplement just prior to all of his reactions. Epicutaneous testing was strongly positive to a saline slurry of the lactase supplement he had been using. The patient has been avoiding supplemental lactase since with no subsequent reactions.

DISCUSSION

Our patient was diagnosed with an allergy to supplemental lactase enzyme on the basis of convincing Immunoglobulin E (IgE) mediated symptoms and positive skin testing. He continued to eat cow's milk products, ruling out an IgE-mediated allergy to cow's milk. In the literature, there is one prior case of anaphylaxis documented. Another case of localized oropharyngeal symptoms described in the literature was thought to be a form of oral allergy syndrome as the patient had positive epicutaneous testing to Aspergillus oryzae-derived lactase as well as Aspergillus species. Occupational sensitization, rhinitis/asthma, and protein contact dermatitis have also been detailed in the literature. Although rare, this case highlights the importance of a thorough history of over-the-counter supplements when assessing a patient with features of anaphylaxis.

Safety evaluation of the food enzyme β-galactosidase from the non-genetically modified Aspergillus sp. strain GD-FAL

The food enzyme β-galactosidase (EC 3.2.1.23) is produced with the non-genetically modified Aspergillus sp. strain GD-FAL by Godo Shusei Co., Ltd. The food enzyme is intended to be used in milk processing for the hydrolysis of lactose. The absence of viable cells of the production organism in the food enzyme was not demonstrated. Based on the assumption that all milk/dairy products are enzymatically treated, dietary exposure to the food enzyme-total organic solids (TOS) was estimated to be up to 0.301 mg TOS/kg body weight per day in European populations. The data provided did not allow concerns of genotoxicity of the food enzyme to be excluded. The systemic toxicity could not be assessed in the absence of an appropriate repeated dose 90-day oral toxicity study. Consequently, a margin of exposure was not calculated. A search for the similarity of the amino acid sequence of the food enzyme to known allergens was made and no match was found. The Panel considered that, under the intended conditions of use, the risk of allergic reactions by dietary exposure cannot be excluded, but the likelihood for this to occur is low. Based on the remaining concerns on genotoxicity, the inadequacies of the 90-day repeated dose oral toxicity study in rats and the missing data regarding the absence of viable cells of the production strain in the food enzyme, the Panel could not conclude on the safety of this food enzyme.

Safety evaluation of the food enzyme β-galactosidase from the non-genetically modified Kluyveromyces lactis strain AE-KL

The food enzyme β-galactosidase (β-d-galactoside galatohydrolase, EC 3.2.1.23) is produced with the non-genetically modified Kluyveromyces lactis strain AE-KL by Amano Enzyme Inc. As the production strain meets the requirements for a Qualified Presumption of Safety (QPS) approach to safety assessment and as no other issues of concern were identified, the Panel considered that toxicological tests were not needed for the assessment of this food enzyme. The food enzyme is intended to be used for lactose hydrolysis in milk processing (including infant formulae), production of fermented milk products and manufacture of galacto-oligosaccharides (GOS). The dietary exposure to the food enzyme-total organic solids (TOS) was estimated to be up to 7.933 mg TOS/kg body weight (bw) per day in European populations. A search for similarity of the amino acid sequence of the food enzyme to known allergens was made and no match was found. The Panel considered that, under the intended conditions of use, the risk of allergic reactions by dietary exposure cannot be excluded, but the likelihood for this to occur is considered to be low. Based on the QPS status of the production strain and the data provided, the Panel concluded that this food enzyme does not give rise to safety concerns, under the intended conditions of use.

Safety evaluation of the food enzyme β-galactosidase from the non-genetically modified Aspergillus oryzae strain GL 470

The food enzyme β-galactosidase (β-d-galactoside galactohydrolase; EC 3.2.1.23) is produced with the Aspergillus oryzae strain GL 470 by Shin Nihon Chemical Co., Ltd. The food enzyme is free from viable cells of the production organism. It is intended to be used in five food manufacturing processes; lactose hydrolysis in milk processing, production of fermented milk products, whey processing, manufacture of enzyme-modified dairy ingredients and in the manufacture of galacto-oligosaccharides. Dietary exposure to the food enzyme-total organic solids (TOS) was estimated to be up to 1.388 mg TOS/kg body weight (bw) per day in European populations. Genotoxicity tests did not raise a safety concern. The systemic toxicity was assessed by means of repeated dose 90-day oral toxicity studies in rats. The Panel identified a no observed adverse effect level of 7,000 mg TOS/kg bw per day, the highest dose tested, which when compared with the estimated dietary exposure, results in a margin of exposure of at least 5,043. A search for similarity of the amino acid sequence of the food enzyme to known allergens was made and no match was found. The Panel concluded that, under the intended conditions of use, the risk of allergic reactions by dietary exposure cannot be excluded, but the likelihood for this to occur is considered to be low. Based on the data provided and considering the most recent complete toxicological data set, the Panel concluded that this food enzyme does not give rise to safety concerns under the intended conditions of use.

Safety of proline-specific oligopeptidase as a novel food pursuant to Regulation (EC) No 258/97

Following a request from the European Commission, the EFSA Panel on Dietetic Products, Nutrition and Allergies (NDA) was asked to deliver an opinion on proline-specific oligopeptidase (Tolerase® G) as a novel food ingredient submitted pursuant to Regulation (EC) No 258/97 of the European Parliament and of the Council, taking into account the comments and objections of a scientific nature raised by Member States. The novel food is an enzyme preparation of prolyl-oligopeptidase produced with a genetically modified Aspergillus niger self clone strain. The target population is the general adult population. The results from a bacterial reverse mutation test and of an in vitro chromosome aberration test did not indicate genotoxicity. The Panel considers that the reported effects observed in a 90-day rat study are treatment-related effects and can be attributed to the higher energy consumption by these animals. Taking into account the intended maximum use level for Tolerase® G, its daily consumption would correspond to 2,746 mg TOS/person or to 39.2 mg TOS/kg body weight (bw) per day, when considering a default body weight of 70 kg for an adult person. The margin between this value and the dose in the rats, which caused effects attributable to the excess energy intake, is approximately 45. Noting this margin, the Panel considers that it is unlikely that such effects would occur in human at the intended use levels. The Panel concludes that the NF, Tolerase® G, is safe for the intended use at the intended use level.

Anaphylaxis to supplemental oral lactase enzyme

Background

Anaphylactic reactions involving IgE mediated hypersensitivity have been frequently reported for a number of uncommon foods. However, cases of anaphylaxis to over the counter vitamins and oral supplements have been rarely published. Lactose intolerance affects approximately 20% of Canadians and roughly 70% of the world’s population of any age. Lactose intolerance develops primarily due to the absence of the enzyme lactase and treatment involves avoidance of lactose-containing foods or ingestion of commercially available lactase enzyme preparations prior to their consumption. This case report represents the first documented evidence of anaphylaxis after exposure to supplemental lactase enzyme preparation.

Case presentation

A 38 years old Caucasian female presented with a history of self-diagnosed adult-onset lactose intolerance and a suspected allergy to lactase containing tablets. She reported an episode of bilateral orbital swelling, shortness of breath, and throat constriction after oral ingestion of a supplemental lactase enzyme tablet. Her symptoms slowly resolved with the administration of inhaled salbutamol and oral diphenhydramine. She handled lactase tablets for years to her children who were lactose intolerant, but had never ingested the tablets herself prior to the reported episode. In clinic, physical examination was benign, and skin prick testing to a slurry of the lactase tablet revealed a strongly positive reaction wheal size of 10 mm and flare of 60 mm with normal controls. The patient reported throat tightness and constriction after skin prick testing and required cetirizine treatment and observation in clinic. Subsequent skin testing was performed with individual ingredients of the lactase tablet provided by the manufacturer and Aspergillus niger, a common bacteria used in lactase preparations. Only concentrated lactase enzyme elicited a positive response. The patient was diagnosed with lactase tablet induced anaphylaxis due to synthetic lactase enzyme IgE mediated allergy, and was advised to avoid all products containing lactase enzymes as an ingredient and to carry an epinephrine auto-injector.

Conclusion

This is the first documented case report of an anaphylactic reaction to supplemental lactase enzyme. This case report reinforces the importance of thorough allergy assessment, education on avoidance of triggers, in particular with uncommon allergens.

Occupational sensitization to lactase in the dietary supplement industry

Aerogen lactase exposure carries a risk for the development of allergic asthma and rhinitis; only a few occupationally affected patients have been reported. The authors report the results of allergy testing with employees of a lactase tablets manufacturing plant. The survey involved 13 workers, including a questionnaire, spirometry, basophil activation test (BAT), and skin prick tests (SPTs) with lactase and a panel of common aeroallergens. Furthermore, lactase-specific immunoglobulin E (IgE) antibodies were analyzed. Sensitization to lactase could be proven for 9 workers by SPT and BAT; specific IgE antibodies could be detected in serum samples of all sensitized. However, IgE levels ≥0.35 kU/L were only found in 4 sera. These data confirm that occupational exposure to lactase can induce IgE-mediated respiratory sensitization resulting in allergic diseases. Protective measures should thus be obligatory when working with lactase.

Pharmaceutical dust exposure at pharmacies using automatic dispensing machines: a preliminary study

Automatic dispensing machines (ADMs) used in pharmacies concentrate and dispense large volumes of pharmaceuticals, including uncoated tablets that can shed dust. We evaluated 43 employees' exposures to pharmaceutical dust at three pharmacies where ADMs were used. We used an optical particle counter to identify tasks that generated pharmaceutical dust. We collected 72 inhalable dust air samples in or near the employees' breathing zones. In addition to gravimetric analysis, our contract laboratory used internal methods involving liquid chromatography to analyze these samples for active pharmaceutical ingredients (APIs) and/or lactose, an inactive filler in tablets. We had to choose samples for these additional analyses because many methods used different extraction solvents. We selected 57 samples for analysis of lactose. We used real-time particle monitoring results, observations, and information from employees on the dustiness of pharmaceuticals to select 28 samples (including 13 samples that were analyzed for lactose) for analysis of specific APIs. Pharmaceutical dust was generated during a variety of tasks like emptying and refilling of ADM canisters. Using compressed air to clean canisters and manual count machines produced the overall highest peak number concentrations (19,000-580,000 particles/L) of smallest particles (count median aerodynamic diameter ≤ 2 μm). Employees who refilled, cleaned, or repaired ADM canisters, or hand filled prescriptions were exposed to higher median air concentrations of lactose (5.0-12 μg/m(3)) than employees who did other jobs (0.04-1.3 μg/m(3)), such as administrative/office work, labeling/packaging, and verifying prescriptions. We detected 10 APIs in air, including lisinopril, a drug prescribed for high blood pressure, levothyroxine, a drug prescribed for hypothyroidism, and methotrexate, a hazardous drug prescribed for cancer and other disorders. Three air concentrations of lisinopril (1.8-2.7 μg/m(3)) exceeded the lower bound of the manufacturer's hazard control band (1-10 μg/m(3)). All other API air concentrations were below applicable occupational exposure limits. Our findings indicate that some pharmacy employees are exposed to multiple APIs and that measures are needed to control those exposures.

Old and new causes of occupational asthma

International reviews suggest that the median proportion of adult cases of asthma attributable to occupational exposure is between 10% and 15%. Therefore, it is essential that clinicians have a broad knowledge of the various causes associated with occupational asthma. Occupational asthmagens are categorized as low-molecular-weight (LMW, ≤1000 kd) and high-molecular-weight (HMW, ≥1000 kd) antigens. The purpose of this article is to review the most common representative LMW and HMW causes of occupational asthma over the past 70 years, with specific emphasis on newer causes reported over the past 5 years.

Industrial fungal enzymes: an occupational allergen perspective

Occupational exposure to high-molecular-weight allergens is a risk factor for the development and pathogenesis of IgE-mediated respiratory disease. In some occupational environments, workers are at an increased risk of exposure to fungal enzymes used in industrial production. Fungal enzymes have been associated with adverse health effects in the work place, in particular in baking occupations. Exposure-response relationships have been demonstrated, and atopic workers directly handling fungal enzymes are at an increased risk for IgE-mediated disease and occupational asthma. The utilization of new and emerging fungal enzymes in industrial production will present new occupational exposures. The production of antibody-based immunoassays is necessary for the assessment of occupational exposure and the development of threshold limit values. Allergen avoidance strategies including personal protective equipment, engineering controls, protein encapsulation, and reduction of airborne enzyme concentrations are required to mitigate occupational exposure to fungal enzymes.

Lactase-induced occupational protein contact dermatitis and allergic rhinoconjunctivitis

Enzymes are high-molecular-weight proteins and highly sensitizing occupational allergens used widely in industrial processes. Lactase has been described to cause work-related respiratory and conjunctival immunoglobulin (Ig)-E-mediated sensitizations in workers in the pharmaceutical industry. In these previous reports, allergic rhinoconjunctivitis or asthma was confirmed with prick tests but not by challenge tests. Lactase previously has not been described as a cause of immediate or delayed contact skin reaction. Furthermore, there are no previous reports of lactase-specific IgE. We report a case of protein contact dermatitis and allergic rhinoconjunctivitis from occupational exposure to lactase in a pharmaceutical worker. The patient exhibited strong positive responses to lactase in prick tests. In an open application test, lactase elicited whealing, and in patch testing, lactase elicited an eczematous reaction. Serum lactase-specific IgE antibodies were demonstrated in immunospot and radioallergosorbent test assays, and lactase-IgE-binding fractions and their specificities were examined in immunoblot and immunoblot inhibition assays. The chamber challenge test was performed to detect the association between lactase sensitization and rhinoconjunctival symptoms. Our results have confirmed the previous observations that lactase can induce occupational IgE-mediated respiratory and conjunctival sensitizations, but they show that contact skin reactions caused by lactase may also occur.

The spectrum of fungal allergy

Fungi can be found throughout the world. They may live as saprophytes, parasites or symbionts of animals and plants in indoor as well as outdoor environment. For decades, fungi belonging to the ascomycota as well as to the basidiomycota have been known to cause a broad panel of human disorders. In contrast to pollen, fungal spores and/or mycelial cells may not only cause type I allergy, the most prevalent disease caused by molds, but also a large number of other illnesses, including allergic bronchopulmonary mycoses, allergic sinusitis, hypersensitivity pneumonitis and atopic dermatitis; and, again in contrast to pollen-derived allergies, fungal allergies are frequently linked with allergic asthma. Sensitization to molds has been reported in up to 80% of asthmatic patients. Although research on fungal allergies dates back to the 19th century, major improvements in the diagnosis and therapy of mold allergy have been hampered by the fact that fungal extracts are highly variable in their protein composition due to strain variabilities, batch-to-batch variations, and by the fact that extracts may be prepared from spores and/or mycelial cells. Nonetheless, about 150 individual fungal allergens from approximately 80 mold genera have been identified in the last 20 years. First clinical studies with recombinant mold allergens have demonstrated their potency in clinical diagnosis. This review aims to give an overview of the biology of molds and diseases caused by molds in humans, as well as a detailed summary of the latest results on recombinant fungal allergens.

[Occupational rhinitis]

INTRODUCTION

Rhinitis is one of the most common occupational diseases. It is often neglected by those affected because it causes little disability. It is poorly understood by doctors who have insufficient experience of occupational diseases and their causes. However it is often the first manifestation of a respiratory disorder that may cause physical complications and socio-economic disability.

BACKGROUND

Numerous diverse agents are potential causes of rhinitis. The diagnosis of occupational rhinitis should be considered when sneezing, rhinorrhoea or nasal obstruction are associated with work. The causal agent can be identified by ta-king a careful history. When the mechanism of the disease is immunologic the suspected antigen can be confirmed by skin testing, specific IgE or nasal provocation. The respiratory disorder of which rhinitis is the first manifestation may progress to asthma if the exposure continues. The prevention of occupational rhinitis depends on the reduction of exposure to allergens and/or irritants. When it has developed removal of the causative agent is essential to prevent progression to asthma.

Investigation on possible allergenicity of 19 different commercial enzymes used in the food industry

The aim of the study was to investigate the safety to allergic patients of 19 commercially available and authority-approved enzymes used in the food industry. Enzymes produced by genetically modified organisms were included. Four hundred consecutive adult patients with a diagnosed allergy to inhalation allergens, food allergens, bee or wasp were included. All had at least one positive skin prick test to the above allergens. Skin prick testing with the 19 enzymes was performed on the forearm and if positive (in 13 patients), in vitro histamine release from blood basophils were performed. Patients with positive results in skin prick test were subsequently reinvestigated with further purified enzymes and finally challenged orally with the enzymes in a double-blind, placebo-controlled protocol. Only one reaction to a placebo challenge was seen. In some instances a positive skin prick test result or a positive histamine release was seen elicited by the enzymes, but since none of the patients were positive to any of the commercial enzymes in the subsequent oral challenges using exaggerated dosages of the enzymes compared to normal daily intake, the findings are without clinical relevance. A wide variety of enzyme classes and origins was included in the study. Because there were no allergenic findings of clinical relevance it is concluded that ingestion of food enzymes in general is not considered to be a concern with regard to food allergy.

Occupational asthma

Substantial epidemiologic and clinical evidence indicates that agents inhaled at work can induce asthma. In industrialized countries, occupational factors have been implicated in 9 to 15% of all cases of adult asthma. Work-related asthma includes (1) immunologic occupational asthma (OA), characterized by a latency period before the onset of symptoms; (2) nonimmunologic OA, which occurs after single or multiple exposures to high concentrations of irritant materials; (3) work-aggravated asthma, which is preexisting or concurrent asthma exacerbated by workplace exposures; and (4) variant syndromes. Assessment of the work environment has improved, making it possible to measure concentrations of several high- and low-molecular-weight agents in the workplace. The identification of host factors, polymorphisms, and candidate genes associated with OA is in progress and may improve our understanding of mechanisms involved in OA. A reliable diagnosis of OA should be confirmed by objective testing early after its onset. Removal of the worker from exposure to the causal agent and treatment with inhaled glucocorticoids lead to a better outcome. Finally, strategies for preventing OA should be implemented and their cost-effectiveness examined.

Toxicity evaluation of a beta-galactosidase preparation produced by Penicillium multicolor

Tilactase is a beta-galactosidase enzyme preparation having lactase activity produced from the fungus Penicillium multicolor. The safety of tilactase was investigated in rats, dogs, and rabbits. Adult and juvenile rats administered 0, 500, 1000, or 4000 mg/kg bw/day of the enzyme preparation by gavage for 35 days, and dogs administered 0, 200, 500, or 1000 mg/kg bw/day in capsules for 30 days, exhibited no significant dose-related changes in body weights, feed consumption, organ weights, urinalysis, hematological profiles, clinical chemistry, or histopathological profiles. Rats receiving the same doses for 6 months also exhibited no dose-related effects, except for a small increase in the weight of the large intestine, an effect considered to be a physiological reaction to passage of a large amount of a non-absorbable substance. The no-observable-adverse-effect level (NOAEL) was 4000 mg/kg bw/day for rats and 1000 mg/kg bw/day for dogs. In three separate studies to examine reproductive and developmental toxicity, rats received 0, 250, 1000 or 4000 mg/kg bw/day by gavage up to the 7th day of pregnancy, during days 7-17 of pregnancy, and from day 17 of pregnancy to 21 days after delivery. There were no treatment-related effects on the dams, gestation period, numbers of implantations, parturition rates, sex ratios, or survival of offspring in any of the studies. No treatment-related external, internal, or skeletal abnormalities were observed in fetuses from any of the three studies. The NOAEL was 4000 mg/kg bw/day. In addition to the three rat studies, rabbits received 0, 250, 500, or 1000 mg/kg bw/day by gavage from the 6th to 18th day of pregnancy. No treatment-related changes were observed in the dams, or fertility indices; nor were there any treatment-related fetal abnormalities. The NOAEL was 1000 mg/kg bw/day. When viable P. multicolor spores were injected into the tail veins of mice, no deaths occured, no fungal cells were observed in various organs, and histopathology showed only focal necrosis in the liver of some of the animals, including the controls. Similar effects were observed when spores were administered to mice in a single dose by gavage. The particular strain of P. multicolor used to prepare tilactase is not pathogenic.

Respiratory findings in pharmaceutical workers

BACKGROUND

Pharmaceutical workers may be at risk for the development of respiratory problems as a result of their work environment.

METHODS

This study investigated 163 female and 35 male workers, employed in a pharmaceutical plant processing different types of medication, primarily antibiotics, in order to characterize the risk of this environment. Chronic respiratory symptoms were recorded by using the British Medical Research Council questionnaire. Acute symptoms, which developed during the work shift, were also recorded. Ventilatory capacity was measured by recording maximum expiratory flow-volume (MEFV) curves on which FVC, FEV1, FEF50, and FEF25 were measured. Controls (113) were selected from a food packing facility.

RESULTS

A significantly higher prevalence of chronic respiratory symptoms was recorded among workers (compared to controls), the highest being for sinusitis, nasal catarrh, and dyspnea. There was also a high prevalence of acute symptoms recorded during the workshift. Odds ratio showed that the most significant risk factors for these respiratory findings were smoking and length of time worked in the pharmaceutical industry, particularly in men. Pulmonary function testing demonstrated significantly decreased measured values in comparison to predicted European pulmonary function measurements (P < 0.01). This was particularly pronounced for FEF50 and FEF25, suggesting obstructive changes in smaller airways.

CONCLUSIONS

Our data suggest that workers employed in the pharmaceutical industry may develop respiratory symptoms accompanied by ventilatory impairment.

Occupational asthma caused by exposure to low-molecular-weight chemicals

Chemical agents cause approximately 40% of cases of occupational asthma (OA). Diagnosis of OA caused by chemicals relies on the demonstration of decrements in lung function at the workplace or during a controlled specific inhalation challenge to the suspect chemical agent. Evaluation of workers is accomplished best with a stepwise algorithmic approach and while the worker is symptomatic and still exposed at work. An early diagnosis followed by cessation of exposure can result in asthma remission and is likely to prevent progression to chronic disabling obstructive disease.

Occupational asthma and allergy in the detergent industry: new developments

This review highlights the latest developments in the control of enzyme-induced occupational asthma and allergy (rhinitis and conjunctivitis) in the detergent industry. The industry has developed guidelines for the safe handling of enzymes in order to reduce the risk of occupational allergy and asthma. Those manufacturing facilities that follow all of the guidelines enjoy very low or no cases of asthma and allergy among workers exposed to enzymes. The key to the success of the management of enzyme-induced allergy and asthma is prospective surveillance for the development of enzyme-specific IgE antibody before the onset of allergic symptoms. This allows for continuing interventions to reduce exposures, so as to minimize or eliminate those associated with symptoms. Workers with IgE to enzymes can still continue to work in the industry symptom-free for their entire career. This indicates that exposures needed to induce sensitization are different and probably lower than exposures needed to elicit enzyme allergic symptoms. The experience of the detergent enzyme industry in controlling occupational allergens can be applied to other industries. The detergent enzyme story can be viewed as a model for the control of type 1 protein allergens in the workplace.

Occupational asthma

The workplace can be responsible for approximately one in 10 cases of adult-onset asthma. Two types of occupational asthma (OA) are distinguished by whether they arise after a latency period that is necessary for acquiring sensitization or as a result of acute exposure to irritant materials (irritant-induced asthma). The pathophysiology of OA with a latency period is similar to that of nonoccupational asthma, whereas the mechanism of irritant-induced asthma is still uncertain. HLA haplotypes and other genetic polymorphisms have been found to be associated with OA. According to various sources of data, the overall frequency of OA has remained stable in the last 10 years, although the frequency of causal agents vary. Registers of causal occupations and agents have been issued on Web sites (eg, www.asmanet.com ). Improved sampling methods have shown that the degree of exposure plays a key role in the onset of the disease, whereas prospective data collected in high-risk workplaces have also identified personal risk factors (eg, atopy, smoking, and rhinoconjunctivitis). A diagnosis of OA should no longer be based on a compatible history only but should be confirmed by means of objective testing. Once the diagnosis is confirmed, the worker should be removed from exposure, and satisfactory compensation programs should be offered, the most important being retraining programs with financial compensations because affected workers are generally young. The cost-effectiveness of prevention programs in high-risk workforces should be assessed.

Recent advances in occupational asthma

In the past year, many advances were made in occupational asthma (OA). As in previous years, several new causes of OA were described and the prevalences of some causes of OA were studied. Animal studies suggested possible mechanisms for the induction of sensitization to low-molecular-weight chemicals, and a study in humans indicated the ability of diisocyanates to bind with lung epithelial cells and stimulate mononuclear cells in sensitized patients with OA. New diagnostic and research methods, such as induced-sputum assessment and measurement of exhaled nitric oxide, were evaluated. The effectiveness of protective respiratory devices in patients with OA was shown to be suboptimal (although these devices are necessary in some cases), and the need to prevent OA by reducing or eliminating exposures remains paramount.