Asthma increase among farmers: a 12-year follow-up

Lessons from Dairy Farmers for Occupational Allergy and Respiratory Disease

PURPOSE OF REVIEW

Exposure to bioaerosols at dairies has long been associated with allergy, respiratory disease, and decreases in lung function. Recent advancements in exposure assessments have aided our understanding on the size distribution and composition of these bioaerosols, but investigations focusing solely on exposures may overlook important intrinsic factors impacting worker's susceptibility to disease.

RECENT FINDINGS

In our review, we discuss the most recent studies examining the exposures and genetic factors that contribute to occupational disease in dairy work. We also review more recent concerns in livestock work associated with zoonotic pathogens, antimicrobial resistant genes, and the role of the human microbiome. The studies highlighted in this review demonstrate the need for further research to better understand bioaerosol exposure-response relationships in the context of extrinsic and intrinsic factors, antibiotic-resistant genes, viral pathogens, and the human microbiome to help inform effective interventions that improve respiratory health among dairy farmers.

Airway Symptoms among Farmers in Central Norway. A Comparative Study of Risks. The HUNT Study

OBJECTIVES

The objective of this study was to compare the risk of developing respiratory symptoms in farmers and other occupational groups over a period of 11 to 23 years.

METHODS

The study includes data from questionnaires and interviews in HUNT1-3 in The Trøndelag Health study (HUNT). In all three surveys, farmers can be identified. Two control groups are used. Control group 1 consists of all HUNT participants who are not farmers or fishermen. Control group 2 consists of occupational groups who presumably have low exposure to dust, chemicals or gases, but similar educational status as farmers. The data are analysed in SPSS 25 (IBM, Armonk NY), with use of frequency analyses and multiple binary logistic regressions.

RESULTS

Our main finding is that healthy farmers have increased risk of developing respiratory symptoms as wheezing or breathlessness over a period of 11 and 23 years. This increased risk is statistically significant after 11 years of follow-up (HUNT1 to HUNT2), and also after 23 years (HUNT1 to HUNT3). Corresponding results regarding wheezing and breathlessness are found for healthy farmers in HUNT2 after 12 years of follow-up in HUNT3. In a subgroup analysis, we find a highly significant difference in both wheezing and shortness of breath when at work, in believing that the symptoms are caused by work, and in having to change jobs or quit because of breathing problems.

CONCLUSION

Farmers have more respiratory symptoms than controls, and the main symptom is attacks of wheezing or breathlessness. Preventive measures such as ventilation and respiratory protection should be implemented on the farm.

Asthma and Chronic Obstructive Pulmonary Disease Associated With Occupational Exposure in Dairy Farmers - Importance of Job Exposure Matrices

AIM

To evaluate the prevalence of chronic respiratory symptoms, lung function impairment, and chronic obstructive respiratory diseases in dairy farmers. Our objective is to then examine their relation to exposure duration and to explore the usefulness of job exposure matrices as tools for exposure assessment, and predictors for respiratory health impairment.

METHODS

A cross-sectional study was performed, including 83 dairy farmers (mean age: 52.6 ± 8.7 years; mean exposure duration: 23.7 ± 7.6 years) and 80 office workers as a control group (mean age: 52.7 ± 8.2 years) matched for age, smoking habits, and socioeconomic status. Methods of evaluating examined subjects included a questionnaire on respiratory symptoms in the last 12 months, spirometry and histamine challenge, as well as the use of job exposure matrices (JEM).

RESULTS

Dairy farmers had a significantly higher prevalence of cough (38.5), phlegm (27.7%), and wheezing (21.7%), than controls (p < 0.05). All mean baseline spirometric parameters were lower in dairy farmers compared to the controls, but statistical significance was confirmed only for MEF25, MEF50, and MEF75% (p = 0.010, p = 0.001, and p = 0.004, respectively). The prevalence of bronchial hyperresponsiveness, asthma, and chronic obstructive pulmonary disease was higher in dairy farmers but without statistical significance. JEM were useful tools for exposure assessment and predictors of factors for asthma and COPD development.

CONCLUSION

The results suggest that occupational exposure among crop farmers is associated with a higher prevalence of respiratory symptoms, lung function impairment, and a higher prevalence of chronic respiratory diseases. JEM showed good potential for farming exposure evaluation and promoted their applicability within the diagnostic algorithm focused on respiratory health assessment.

Exposure to field vs. storage wheat dust: different consequences on respiratory symptoms and immune response among grain workers

PURPOSE

The aim of this study was to understand the differential acute effects of two distinct wheat-related dusts, such as field or stored wheat dust handling, on workers' health and how those effects evolved at 6 month intervals.

METHODS

Exposure, work-related symptoms, changes in lung function, and blood samples of 81 workers handling wheat and 61 controls were collected during the high exposure season and 6 months after. Specific IgG, IgE, and precipitins against 12 fungi isolated from wheat dust were titrated by enzyme-linked immunosorbent assay, dissociation-enhanced lanthanide fluorescence immunoassay, and electrosyneresis. The level of fungi was determined in the workers' environment. Levels of exhaled fraction of nitrogen monoxide (F_ENO) and total IgE were obtained. Exposure response associations were investigated by mixed logistic and linear regression models.

RESULTS

The recent exposure to field wheat dust was associated with a higher prevalence for five of six self-reported airway symptoms and with a lower F_ENO than those in the control population. Exposure to stored wheat dust was only associated with cough. No acute impact of exposure on respiratory function was observed. Exposure to field wheat dust led to workers' sensitization against the three field fungi Aureobasidum, Cryptococcus, and Phoma, although exposure to storage wheat dust was associated with tolerance. The level of Ig remained stable 6 months after exposure.

CONCLUSION

The clinical picture of workers exposed to field or storage wheat dust differed. The systematic characterization of the aerosol microbial profile may help to understand the reasons for those differences.

Career Advice for Young Allergy Patients

BACKGROUND

One-third of all young persons entering the work force have a history of atopic disease. Occupationally induced allergy and asthma generally arise in the first few months on the job, while pre-existing symptoms tend to worsen. Young persons with a history of an atopic disease should receive evidence-based advice before choosing a career.

METHODS

We systematically searched PubMed for cohort studies investigating the new onset of asthma, rhinitis, or hand eczema among job trainees from before the start of training and onward into the first few years on the job. The search revealed 514 articles; we read their abstracts and selected 85 full-text articles for further analysis. 24 of these met the inclusion criteria.

RESULTS

According to present evidence, atopy and a history of allergic disease (allergic rhinitis, atopic dermatitis) are the main risk factors for occupationally induced disease. The predictive value of a personal history of allergic diseases for the later development of an occupationally induced disease varies from 9% to 64% in the studies we analyzed. It follows that only young people with severe asthma or severe atopic eczema should be advised against choosing a job that is associated with a high risk of allergy, e.g., hairdressing or working with laboratory animals. Young people with a history of other atopic diseases should be counseled about their individual risk profile.

CONCLUSION

In view of the relatively poor predictive value of pre-existing atopic disease, secondary prevention is particularly important. This includes frequent medical follow-up of the course of symptoms over the first few years on the job. If sensitization or allergic symptoms arise, it should be carefully considered whether exposure reduction will enable the apprentice to stay on the job.

Airborne and Grain Dust Fungal Community Compositions Are Shaped Regionally by Plant Genotypes and Farming Practices

Chronic exposure to airborne fungi has been associated with different respiratory symptoms and pathologies in occupational populations, such as grain workers. However, the homogeneity in the fungal species composition of these bioaerosols on a large geographical scale and the different drivers that shape these fungal communities remain unclear. In this study, the diversity of fungi in grain dust and in the aerosols released during harvesting was determined across 96 sites at a geographical scale of 560 km(2) along an elevation gradient of 500 m by tag-encoded 454 pyrosequencing of the internal transcribed spacer (ITS) sequences. Associations between the structure of fungal communities in the grain dust and different abiotic (farming system, soil characteristics, and geographic and climatic parameters) and biotic (wheat cultivar and previous crop culture) factors were explored. These analyses revealed a strong relationship between the airborne and grain dust fungal communities and showed the presence of allergenic and mycotoxigenic species in most samples, which highlights the potential contribution of these fungal species to work-related respiratory symptoms of grain workers. The farming system was the major driver of the alpha and beta phylogenetic diversity values of fungal communities. In addition, elevation and soil CaCO3 concentrations shaped the alpha diversity, whereas wheat cultivar, cropping history, and the number of freezing days per year shaped the taxonomic beta diversity of these communities.

The human microbiome, asthma, and allergy

The human microbiome can be defined as the microorganisms that reside within and on our bodies and how they interact with the environment. Recent research suggests that numerous mutually beneficial interactions occur between a human and their microbiome, including those that are essential for good health. Modern microbiological detection techniques have contributed to new knowledge about microorganisms in their human environment. These findings reveal that the microbiomes of the lung and gut contribute to the pathogenesis of asthma and allergy. For example, evidence indicates that the microbiome of the gut regulates the activities of helper T cell subsets (Th1 and Th2) that affect the development of immune tolerance. Moreover, recent studies demonstrate differences between the lung microbiomes of healthy and asthmatic subjects. The hygiene and biodiversity hypotheses explain how exposure to microorganisms is associated with asthma and allergy. Although those living in developed countries are exposed to fewer and less diverse microorganisms compared with the inhabitants of developing countries, they are experiencing an increase in the incidence of asthma and allergies. Detailed analyses of the human microbiome, as are being conducted under the auspices of the Human Microbiome Project initiated in 2007, promise to contribute insights into the mechanisms and factors that cause asthma and allergy that may lead to the development of strategies to prevent and treat these diseases.

Wheezing in tobacco farm workers in southern Brazil

BACKGROUND

Tobacco workers are exposed to several respiratory occupational sensitizers.

METHODS

A representative cross-sectional study was carried out on 2469 tobacco family farming growers. Gender-stratified multivariate analyses evaluated the association between wheezing and socio-demographic, behavioral, and occupational variables.

RESULTS

Wheezing prevalence was 11.0% with no difference between genders. Among men, age, smoking, strenuous work, pesticide use, contact with vegetable dust and dried tobacco dust, lifting sticks with tobacco leaves to the curing barns, and green tobacco sickness (GTS) were risk factors for wheezing. Among women, family history of asthma, tying hands of tobacco, strenuous work, contact with chemical disinfectants, and GTS were positively associated with wheezing. Harvesting lower tobacco leaves was a protective factor for the outcome in both genders.

CONCLUSIONS

Pesticides, dusts exposure, and GTS were risk factors for wheezing. The synergic effect of these factors needs to be better evaluated to improve prevention.

Particulate matter, endotoxin, and worker respiratory health on large Californian dairies

OBJECTIVE

To assess respiratory exposures and lung function in a cross-sectional study of California dairy workers.

METHODS

Exposure of 205 dairy and 45 control (vegetable processing) workers to particulate matter and endotoxin was monitored. Pre- and postshift spirometry and interviews were conducted.

RESULTS

Geometric mean inhalable and PM2.5 concentrations were 812 and 35.3 μg/m3 versus 481.9 and 19.6 μg/m3, respectively, for dairy and control workers. Endotoxin concentrations were 329 EU/m3 or 1122 pmol/m3 and 13.5 EU/m3 or 110 pmol/m3, respectively, for dairy and control workers. In a mixed-effects model, forced vital capacity decreased across a work shift by 24.5 mL (95% confidence interval, -44.7 to -4.3; P = 0.018) with log10 (total endotoxin) and by 22.0 mL (95% confidence interval, -43.2 to -0.08; P = 0.042) per hour worked.

CONCLUSIONS

Modern California dairy endotoxin exposures and shift length were associated with a mild acute decrease in forced vital capacity.

Innate Immune Sensing of Fusarium culmorum by Mouse Dendritic Cells

Chronic inhalation of grain dust is associated with asthma and chronic bronchitis in grain worker populations. Exposure to fungal particles was postulated to be an important etiologic agent of these pathologies. Fusarium species frequently colonize grain and straw and produce a wide array of mycotoxins that impact human health, necessitating an evaluation of risk exposure by inhalation of Fusarium and its consequences on immune responses. Data showed that Fusarium culmorum is a frequent constituent of aerosols sampled during wheat harvesting in the Vaud region of Switzerland. The aim of this study was to examine cytokine/chemokine responses and innate immune sensing of F. culmorum in bone-marrow-derived dendritic cells and macrophages. Overall, dendritic cells and macrophages responded to F. culmorum spores but not to its secreted components (i.e., mycotoxins) by releasing large amounts of macrophage inflammatory protein (MIP)-1α, MIP-1β, MIP-2, monocyte chemoattractant protein (MCP)-1, RANTES, and interleukin (IL)-12p40, intermediate amounts of tumor necrosis factor (TNF), IL-6, IL-12p70, IL-33, granulocyte colony-stimulating factor (G-CSF), and interferon gamma-induced protein (IP-10), but no detectable amounts of IL-4 and IL-10, a pattern of mediators compatible with generation of Th1 or Th17 antifungal protective immune responses rather than with Th2-dependent allergic responses. The sensing of F. culmorum spores by dendritic cells required dectin-1, the main pattern recognition receptor involved in β-glucans detection, but likely not MyD88 and TRIF-dependent Toll-like receptors. Taken together, our results indicate that F. culmorum stimulates potently innate immune cells in a dectin-1-dependent manner, suggesting that inhalation of F. culmorum from grain dust may promote immune-related airway diseases in exposed worker populations.

A comparison of health, health behavior, and access between farm and nonfarm populations in rural New York state

BACKGROUND

Recent technological and demographic changes in US agriculture raise questions about whether the previously observed benefits of the agricultural lifestyle persist.

METHODS

In 2009, researchers conducted a household survey of 9,612 adults (aged 20+) in a rural region of Upstate New York. Data on health status, health behaviors, and health care access among farmers and rural nonfarm residents were compared.

RESULTS

After adjustment for age, gender, education, and having a regular health care provider, male farmers had elevated prevalence of asthma (OR: 1.82, 95% CI: 1.05-3.16) and untreated chronic obstructive pulmonary disease (COPD) (OR: 3.17, 95% CI: 1.12-9.01). Farmers had significantly lower hypercholesterolemia (OR: 0.70, 95% CI: 0.50-0.99), but not lower prevalence of heart disease or stroke. Farmers had lower rates of smoking (OR: 0.60, 95% CI: 0.40-0.89) and higher rates of hard physical labor (OR: 2.61, 95% CI: 1.83-3.72) than nonfarmers, but they had notably worse health behavior prevalence relative to various types of screening, vaccinations, and having a regular medical care provider (OR: 0.53, 95% CI: 0.39-0.71).

CONCLUSIONS

The farm population is becoming more like the rural nonfarm population with regard to health outcomes and lifestyle, yet it remains notably poorer with regard to prevention. Targeted outreach is needed to increase prevention within the agricultural community.

Risk factors for nonwork-related adult-onset asthma and occupational asthma: a comparative review

PURPOSE OF REVIEW

To identify the similarities and differences between nonwork-related adult-onset and occupational asthma from various literature sources published between 2010 and 2013, with respect to the epidemiology, phenotypic manifestations, and risk factors for the disease.

RECENT FINDINGS

The incidence of adult-onset asthma from pooled population studies is estimated to be 3.6 per 1000 person-years in men and 4.6 cases per 1000 person-years in women. In adults with new-onset asthma, occupational asthma is a common asthma phenotype. Work-related factors are estimated to account for up to 25% of adult cases of asthma and occupational asthma comprising about 16% of adult-onset asthma cases. The review finds that nonwork-related adult-onset asthma is a heterogenous entity and that environmental exposure factors (aside from occupational exposures) appear to have a lesser role than host factors when compared with occupational asthma.

SUMMARY

Large-scale general population studies are needed to identify the similarities and differences between nonwork-related adult-onset and occupational asthma, which may enable a better understanding of these entities and promote efforts towards holistic management approaches for these asthma phenotypes.

Systematic review of respiratory health among dairy workers

The dairy industry is changing on a global scale with larger, more efficient operations. The impact of this change on worker health and safety, specifically, associations between occupational lung disease and inhalation exposures, has yet to be reported in a comprehensive review of the scientific literature. Therefore, a three-tier process was used to identify information using a keyword search of online databases of scientific literature. Of the 147 citations reviewed, 52 met initial screening criteria, and 30 were included in this review. Dairy workers experience lung conditions such as asthma, chronic obstructive pulmonary disease, hypersensitivity pneumonitis, chronic bronchitis, and cancer. Recent pulmonary function studies have identified obstructive lung changes among dairy farm workers. The increased scale of dairy production with significant changes in technology and work practices has altered inhalation exposure patterns among dairy workers. The inhalation exposure in the dairy work environment may elicit differing inflammatory responses in relation to timing of initial exposure as well as to repeated exposures. Few studies have measured inhalation exposure while simultaneously assessing the impact of the exposure on lung function of dairy farm workers. Even fewer studies have been implemented to assess the impact of aerosol control technology to reduce inhalation exposure. Future research should evaluate worker exposure to aerosols through a task-based approach while utilizing novel methods to assess inhalation exposure and associated inflammatory responses. Finally, potential solutions should be developed and tested to reduce inhalation exposure to inflammatory agents and respiratory diseases in the dairy farm work environment.

Respiratory disease in United States farmers

OBJECTIVES

Farmers may be at increased risk for adverse respiratory outcomes compared with the general population due to their regular exposures to dusts, animals and chemicals. However, early life farm exposures to microbial agents may result in reduced risk. Understanding respiratory disease risk among farmers and identifying differences between farmers and other populations may lead to better understanding of the contribution of environmental exposures to respiratory disease risk in the general population.

METHODS

We compared the prevalence of self-reported respiratory outcomes in 43548 participants from the Agricultural Health Study (AHS), a prospective cohort of farmers and their spouses from Iowa and North Carolina, with data from adult participants in the National Health and Nutrition Examination Survey (NHANES) over the same period (2005-2010).

RESULTS

AHS participants had lower prevalences of respiratory diseases (asthma, adult-onset asthma, chronic bronchitis and emphysema), but higher prevalences of current respiratory symptoms (wheeze, cough and phlegm) even after controlling for smoking, body mass index and population characteristics. The overall prevalence of asthma in the AHS (7.2%, 95% CI 6.9 to 7.4) was 52% of that in NHANES (13.8%, 95% CI 13.3 to 14.3), although the prevalence of adult-onset asthma among men did not differ (3.6% for AHS, 3.7% for NHANES). Conversely, many respiratory symptoms were more common in the AHS than NHANES, particularly among men.

CONCLUSIONS

These findings suggest that farmers and their spouses have lower risk for adult-onset respiratory diseases compared with the general population, and potentially higher respiratory irritation as evidenced by increased respiratory symptoms.

Exacerbation of symptoms in agricultural pesticide applicators with asthma

PURPOSE

Exacerbation is a critical event in asthma management. We investigated whether exacerbation of symptoms is associated with farming exposures among agricultural pesticide applicators with asthma.

METHODS

Participants were pesticide applicators with active asthma (wheezing and breathing problems in past 12 months) who completed enrollment questionnaires for the Agricultural Health Study (AHS). Exacerbation of asthma was defined as having visited a hospital emergency room or doctor for an episode of wheezing or whistling in the past 12 months. Exposures of interest were using 36 specific pesticides in the past 12 months and conducting various agricultural activities. Adjusted odds ratios (ORs) were estimated by logistic regression while controlling for potential confounders.

RESULTS

The 926 AHS adult pesticide applicators with active asthma included 202 (22%) with exacerbation. Inverse associations with exacerbation were observed for two herbicides [glyphosate, odds ratio (OR) = 0.5, 95% confidence interval (CI) 0.3, 0.8, and paraquat, OR = 0.3, 95% CI 0.1, 0.9] and several agricultural activities (repairing engines, grinding metal, driving diesel tractors, and performing veterinary procedures). Only asthma cases with allergies (i.e., doctor-diagnosed hay fever or eczema, 46%) had positive exacerbation-pesticide associations, with OR = 2.1 (95% CI 1.1, 4.1) for the herbicide pendimethalin and OR = 10.2 (95% CI 1.9, 55) for the insecticide aldicarb.

CONCLUSIONS

The inverse associations with two pesticides and specific farm activities are consistent with the possibility that asthma cases prone to exacerbation may avoid exposures that trigger symptoms. Although limited by small sample size and a cross-sectional design, our study suggests that use of specific pesticides may contribute to exacerbation of asthma among individuals with allergies.

Bronchial asthma and COPD due to irritants in the workplace - an evidence-based approach

BACKGROUND

Respiratory irritants represent a major cause of occupational obstructive airway diseases. We provide an overview of the evidence related to irritative agents causing occupational asthma or occupational COPD.

METHODS

We searched MEDLINE via PubMed. Reference lists of relevant reviews were also screened. The SIGN grading system was used to rate the quality of each study. The modified RCGP three-star system was used to grade the body of evidence for each irritant agent regarding its causative role in either occupational asthma or occupational COPD.

RESULTS

A total of 474 relevant papers were identified, covering 188 individual agents, professions or work-sites. The focus of most of the studies and the predominant diagnosis was occupational asthma, whereas occupational COPD arose only incidentally.The highest level assigned using the SIGN grading was 2+ (well-conducted systematic review, cohort or case-control study with a low risk of confounding or bias). According to the modified RCGP three-star grading, the strongest evidence of association with an individual agent, profession or work-site ("**") was found for 17 agents or work-sites, including benzene-1,2,4-tricarboxylicacid-1,2-anhydride, chlorine, platinum salt, isocyanates, cement dust, grain dust, animal farming, environmental tobacco smoke, welding fumes or construction work. Phthalic anhydride, glutaraldehyde, sulphur dioxide, cotton dust, cleaning agents, potrooms, farming (various), foundries were found to be moderately associated with occupational asthma or occupational COPD ("*[+]").

CONCLUSION

This study let us assume that irritant-induced occupational asthma and especially occupational COPD are considerably underreported. Defining the evidence of the many additional occupational irritants for causing airway disorders will be the subject of continued studies with implications for diagnostics and preventive measures.

Lesson from the farm environment

PURPOSE OF REVIEW

Several population-based studies have replicated the finding that exposure to a farm environment is protective against the development of atopic diseases. From these studies, novel insights into potential allergy-protective mechanisms were retrieved. This review focuses on consistent and novel findings of immune mechanisms involved in the 'farm effect'.

RECENT FINDINGS

The most recent studies suggest that the 'farm effect' mediated by microbial exposure may be attributed to both microbial diversity and species specificity. There is convincing evidence that farm milk components and grass arabinogalactan, commonly found in cowshed, may be important. Furthermore, early exposure to a farming environment, in particular in utero, showed stronger effects than exposure later in life, potentially through modulation of the immature immune system by microbes, also involving epigenetic changes. This protective 'farm effect' remains in later adulthood. Regarding gene-environment interactions, polymorphisms in GRM1 interacted with farming in a genome-wide interaction scan for asthma.

SUMMARY

The novel studies strengthen the role of microbial exposure and farm milk and grass components, especially early in life, in the modulation of the immune system towards a Th1/Treg predominance. This may subsequently lead to a long-lasting lower risk of developing atopic diseases.