Rhinitis in subjects with work-exacerbated asthma

Comparison of high- and low-molecular-weight sensitizing agents causing occupational asthma: an evidence-based insight

INTRODUCTION

The many substances used at the workplace that can cause sensitizer-induced occupational asthma are conventionally categorized into high-molecular-weight (HMW) agents and low-molecular-weight (LMW) agents, implying implicitly that these two categories of agents are associated with distinct phenotypic profiles and pathophysiological mechanisms.

AREAS COVERED

The authors conducted an evidence-based review of available data in order to identify the similarities and differences between HMW and LMW sensitizing agents.

EXPERT OPINION

Compared with LMW agents, HMW agents are associated with a few distinct clinical features (i.e. concomitant work-related rhinitis, incidence of immediate asthmatic reactions and increase in fractional exhaled nitric oxide upon exposure) and risk factors (i.e. atopy and smoking). However, some LMW agents may exhibit 'HMW-like' phenotypic characteristics, indicating that LMW agents are a heterogeneous group of agents and that pooling them into a single group may be misleading. Regardless of the presence of detectable specific IgE antibodies, both HMW and LMW agents are associated with a mixed Th1/Th2 immune response and a predominantly eosinophilic pattern of airway inflammation. Large-scale multicenter studies are needed that use objective diagnostic criteria and assessment of airway inflammatory biomarkers to identify the pathobiological pathways involved in OA caused by the various non-protein agents.

Aziz SF, Aizad Za’bah AK, Dapari R, Hassan MR, Che Dom N, Syed Abdul Rahim SS. Factors associated with occupational asthma among food industry workers: A systematic review

INTRODUCTION

Occupational asthma (OA) is a type of Work-Related Asthma characterised by variable airflow limitation and/or inflammation due to causes and conditions attributable to a particular occupational environment, and not to stimuli encountered outside the workplace. There is an increasing need to extend the depth of knowledge of OA to better manage this condition, especially among food industry workers who are affected by it.

OBJECTIVE

This systematic review aimed to determine the factors associated with occupational asthma among food industry workers by electronically collecting articles from two databases (Medline and Scopus).

METHODS

This systematic review was prepared in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta Analyses) updated guideline. Two independent reviewers screened the titles and abstracts of the collected data, which were then stored in Endnote20 based on the inclusion and exclusion criteria. The included articles have been critically appraised to assess the quality of the studies using the Mixed Methods Appraisal Tool (MMAT).

RESULT

The search yielded 82 articles from Medline and 85 from SCOPUS, resulting in 167 unique hits. Only 22 articles have been included in the full-text assessment following a rigorous selection screening. Of the 22 articles identified, five were included in the final review. Several factors were found to have contributed to occupational asthma among food industry workers. They were classified into two categories: (1) work environment-related factors; and (2) individual factors.

CONCLUSION

Several work environment and individual-related factors were found to be associated with OA among food industry workers. A better understanding of the development of the disease and its potential risk factors is needed because it can affect worker's quality of life. Pre-employment and periodic medical surveillance should be conducted to assess and detect any possible risk of developing occupational asthma among workers.

Endotyping asthma related to three different work exposures

BACKGROUND

Work exposures play a significant role in adult-onset asthma, but mechanisms of work-related asthma are not fully elucidated.

OBJECTIVE

We aimed to reveal the molecular mechanisms of work-related asthma associated with flour (FA), isocyanate (IA) or welding fume (WA) exposures and identify potential biomarkers that distinguish these groups from each other.

METHODS

We used a combination of clinical tests, transcriptomic analysis and associated pathway analyses to investigate underlying disease mechanisms of the blood immune cells and the airway epithelium of 61 men.

RESULTS

Compared to the healthy controls, the WA patients had more differentially expressed genes than the FA and IA patients both in the airway epithelia and in the blood immune cells. In the airway epithelia, active inflammation was detected only in WA patients. In contrast, large number of differentially expressed genes were detected in all asthma groups in blood cells. Disease-related immune functions in blood cells were suppressed in all the asthma groups including leukocyte migration and inflammatory responses and decreased expression of upstream cytokines such as TNF and IFNγ. In transcriptome-phenotype correlations, hyperresponsiveness (R∼|0.6|) had the highest clinical relevance and associated with a set of exposure-group specific genes. Finally, biomarker subsets of only 5 genes specifically distinguished each of the asthma exposure group.

CONCLUSIONS

This study provides novel data on the molecular mechanisms underlying work-related asthma. We identified set of 5 promising biomarkers in asthma related to flour, isocyanate and welding exposure to be tested and clinically validated in future studies.

Occupational Rhinitis

There is convincing evidence that tight relationships between the upper and lower airways also apply to the workplace context. Most patients with occupational asthma (OA) also suffer from occupational rhinitis (OR), although OR is 2 to 3 times more common than OA. OR most often precedes the development of OA, especially when high-molecular-weight protein agents are involved, and longitudinal cohort studies have confirmed that OR is associated with an increased risk for the development of OA. The level of exposure to sensitizing agents at the workplace is the most important determinant for the development of IgE-mediated sensitization and OR. Atopy is a risk factor for the development of IgE-mediated sensitization only to high-molecular-weight agents. In workers with work-related rhinitis symptoms, documentation of IgE-mediated sensitization to a workplace agent via skin prick testing or serum specific IgE confirms a diagnosis of probable OR, whereas specific nasal provocation testing in the laboratory remains the reference method to establish a definite diagnosis of OR. Complete avoidance of exposure to the causal agent is the most effective therapeutic option for controlling work-related nasal symptoms and preventing the development of OA. If complete elimination of exposure is expected to induce meaningful adverse socioeconomic consequences, reduction of exposure can be considered as an alternative approach, but it is important to consider the individual risk factors for the development of OA to implement a more personalized management of OR.

Are high- and low-molecular-weight sensitizing agents associated with different clinical phenotypes of occupational asthma?

BACKGROUND

High-molecular-weight (HMW) proteins and low-molecular-weight (LMW) chemicals can cause occupational asthma (OA) although few studies have thoroughly compared the clinical, physiological, and inflammatory patterns associated with these different types of agents. The aim of this study was to determine whether OA induced by HMW and LMW agents shows distinct phenotypic profiles.

METHODS

Clinical and functional characteristics, and markers of airway inflammation were analyzed in an international, multicenter, retrospective cohort of subjects with OA ascertained by a positive inhalation challenge response to HMW (n = 544) and LMW (n = 635) agents.

RESULTS

Multivariate logistic regression analysis showed significant associations between OA caused by HMW agents and work-related rhinitis (OR [95% CI]: 4.79 [3.28-7.12]), conjunctivitis (2.13 [1.52-2.98]), atopy (1.49 [1.09-2.05]), and early asthmatic reactions (2.86 [1.98-4.16]). By contrast, OA due to LMW agents was associated with chest tightness at work (2.22 [1.59-3.03]), daily sputum (1.69 [1.19-2.38]), and late asthmatic reactions (1.52 [1.09-2.08]). Furthermore, OA caused by HMW agents showed a higher risk of airflow limitation (1.76 [1.07-2.91]), whereas OA due to LMW agents exhibited a higher risk of severe exacerbations (1.32 [1.01-1.69]). There were no differences between the two types of agents in the baseline sputum inflammatory profiles, but OA caused by HMW agents showed higher baseline blood eosinophilia and a greater postchallenge increase in fractional nitric oxide.

CONCLUSION

This large cohort study describes distinct phenotypic profiles in OA caused by HMW and LMW agents. There is a need to further explore differences in underlying pathophysiological pathways and outcome after environmental interventions.

Occupational Asthma From Epoxy Compounds

BACKGROUND

Two-component epoxy resin systems (ERSs) composed of epoxy resin and polyamine hardeners are extensively used in industrial and construction coating. Triglycidyl isocyanurate (TGIC) is another type of epoxy derivative, mostly encountered in polyester powder paints. Epoxy compounds are well-known skin sensitizers, but their respiratory-sensitizing potential is largely unknown.

OBJECTIVE

To report patients examined for occupational asthma (OA) from epoxy compounds.

METHODS

We retrospectively reviewed patient files of cases tested with a placebo-controlled specific inhalation challenge (SIC) according to their workplace exposure-either by mixing epoxy resin and the polyamine hardener of a 2-component paint or by dusting or heating TGIC-containing powder paint. The data were collected from the Finnish Institute of Occupational Health, Helsinki, Finland, and at Fundación Jiménez Díaz Hospital, Madrid, Spain, during 1997 to 2018. We also measured airborne polyamine and solvent vapors at the workplace and during SIC with ERSs.

RESULTS

Altogether 113 patients with work-related asthma symptoms underwent SIC with ERSs. Fifteen cases (13%) had positive SIC reactions confirming OA; in 12 cases reactions were late-type, in 1 case early, and in 2 cases combined. The median duration of exposure for patients with OA was 10 years; 2 of them (13%) had a diagnosis of allergic contact dermatitis from ERS compounds. In addition, 3 cases had a positive SIC reaction to TGIC. The airborne polyamine levels measured were low.

CONCLUSION

ERSs and TGIC can cause sensitizer-induced OA in some exposed workers. Respiratory exposure to ERSs is difficult to demonstrate using air measurements.

Nasal protein profiles in work-related asthma caused by different exposures

BACKGROUND

The mechanisms of work-related asthma (WRA) are incompletely delineated. Nasal cell samples may be informative about processes in the lower airways. Our aim was to determine the nasal protein expression profiles of WRA caused by different kind of exposures.

METHODS

We collected nasal brush samples from 82 nonsmoking participants, including healthy controls and WRA patients exposed to (i) protein allergens, (ii) isocyanates and (iii) welding fumes the day after relevant exposure. The proteome changes in samples were analysed by two-dimensional difference gel electrophoresis, and the differentially regulated proteins found were identified by mass spectrometry. Immunological comparison was carried out using Western blot.

RESULTS

We detected an average of 2500 spots per protein gel. Altogether, 228 protein spots were chosen for identification, yielding 77 different proteins. Compared to the controls, exposure to protein allergens had the largest effects on the proteome. Hierarchical clustering revealed that protein allergen- and isocyanate-related asthma had similar profiles, whereas asthma related to welding fumes differed. The highly overrepresented functional categories in the asthma groups were defence response, protease inhibitor activity, inflammatory and calcium signalling, complement activation and cellular response to oxidative stress. Immunological analysis confirmed the found abundance differences in galectin 10 and protein S100-A9 between the groups.

CONCLUSIONS

Work-related asthma patients exposed to protein allergens and isocyanates elicit similar nasal proteome responses and the profiles of welders and healthy controls were alike. Revealed biological activities of the protein expression changes are associated with allergic inflammation and asthma.

Diagnosing occupational asthma

Making an accurate diagnosis of occupational asthma (OA) is, generally, important. The condition has not only significant health consequences for affected workers, but also substantial socio-economic impacts for workers, their employers and wider society. Missing a diagnosis of OA may lead to continued exposure to a causative agent and progressive worsening of disease; conversely, diagnosing OA when it is not present may lead to inappropriate removal from exposure and unnecessary financial and social consequences. While the most accurate investigation is specific inhalation challenge in an experienced centre, this is a scarce resource, and in many cases, reliance is on other tests. This review provides a technical dossier of the diagnostic value of the available methods which include an appropriate clinical history, the use of specific immunology and measurement of inflammatory markers, and various methods of relating functional changes in airway calibre to periods at work. It is recommended that these approaches are used iteratively and in judicious combination, in cognizance of the individual patient's circumstances and requirements. Based on available evidence, a working diagnostic algorithm is proposed that can be adapted to the suspected agent, purpose of diagnosis and available resources. For better or worse, many of the techniques - and their interpretation - are available only in specialized centres and where there is room for doubt, referral to such a centre is probably wise. Accordingly, the implementation or development of such specialized centres with appropriate equipment and expertise should greatly improve the diagnostic evaluation of work-related asthma.

Occupational allergic disease: socio-epidemiological aspects from a specialized outpatient clinic in the city of Sao Paulo, Brazil

Background

Occupational diseases involving the immune system are considered to be occupational allergic diseases (OAD); 15% of occupational diseases are allergic. The social consequences of OAD are significant for both workers and employers.

Objectives

To describe demographic and clinical characteristics of patients with OAD and their social outcomes.

Methods

Descriptive and retrospective study of the medical records of patients diagnosed with OAD cared at the occupational allergy clinic of a university hospital in São Paulo, Brazil.

Results

A total of 72 patients exhibited OAD, with age 21 to 89 years old; 52% were male. Atopic antecedents were described for 35% of patients. Most patients worked in the chemical industry (17%), cleaning (15%), construction (11%) and health care (8%). Occupational rhinitis was found in 26% of the patients, work-related asthma in 18%, asthma and rhinitis in 25%, and allergic contact dermatitis in 13%. In regard to the social outcomes, 36 (50%) workers remained in their jobs, 19 (26%) changed function, 7 (10%) changed occupation, 7 (10%) were fired and 3 (4%) retired.

Conclusions

In the present study, OAD prevailed among males and within the economically active age; cases of occupational rhinitis were the most frequent. Half of the employees remained in the same job position even after diagnosis.

CHRODIS criteria applied to the MASK (MACVIA-ARIA Sentinel NetworK) Good Practice in allergic rhinitis: a SUNFRAIL report

A Good Practice is a practice that works well, produces good results, and is recommended as a model. MACVIA-ARIA Sentinel Network (MASK), the new Allergic Rhinitis and its Impact on Asthma (ARIA) initiative, is an example of a Good Practice focusing on the implementation of multi-sectoral care pathways using emerging technologies with real life data in rhinitis and asthma multi-morbidity. The European Union Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS) has developed a checklist of 28 items for the evaluation of Good Practices. SUNFRAIL (Reference Sites Network for Prevention and Care of Frailty and Chronic Conditions in community dwelling persons of EU Countries), a European Union project, assessed whether MASK is in line with the 28 items of JA-CHRODIS. A short summary was proposed for each item and 18 experts, all members of ARIA and SUNFRAIL from 12 countries, assessed the 28 items using a Survey Monkey-based questionnaire. A visual analogue scale (VAS) from 0 (strongly disagree) to 100 (strongly agree) was used. Agreement equal or over 75% was observed for 14 items (50%). MASK is following the JA-CHRODIS recommendations for the evaluation of Good Practices.

Work productivity in rhinitis using cell phones: The MASK pilot study

Allergic rhinitis often impairs social life and performance. The aim of this cross-sectional study was to use cell phone data to assess the impact on work productivity of uncontrolled rhinitis assessed by visual analogue scale (VAS). A mobile phone app (Allergy Diary, Google Play Store and Apple App Store) collects data from daily visual analogue scales (VAS) for overall allergic symptoms (VAS-global measured), nasal (VAS-nasal), ocular (VAS-ocular) and asthma symptoms (VAS-asthma) as well as work (VAS-work). A combined nasal-ocular score is calculated. The Allergy Diary is available in 21 countries. The app includes the Work Productivity and Activity Impairment Allergic Specific Questionnaire (WPAI:AS) in six EU countries. All consecutive users who completed the VAS-work from 1 June to 31 October 2016 were included in the study. A total of 1136 users filled in 5818 days of VAS-work. Symptoms of allergic rhinitis were controlled (VAS-global <20) in approximately 60% of the days. In users with uncontrolled rhinitis, approximately 90% had some work impairment and over 50% had severe work impairment (VAS-work >50). There was a significant correlation between VAS-global calculated and VAS-work (Rho=0.83, P<0.00001, Spearman's rank test). In 144 users, there was a significant correlation between VAS-work and WPAI:AS (Rho=0.53, P<0.0001). This pilot study provides not only proof-of-concept data on the work impairment collected with the app but also data on the app itself, especially the distribution of responses for the VAS. This supports the interpretation that persons with rhinitis report both the presence and the absence of symptoms.

Transfer of innovation on allergic rhinitis and asthma multimorbidity in the elderly (MACVIA-ARIA) - EIP on AHA Twinning Reference Site (GARD research demonstration project)

The overarching goals of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) are to enable European citizens to lead healthy, active and independent lives whilst ageing. The EIP on AHA includes 74 Reference Sites. The aim of this study was to transfer innovation from an app developed by the MACVIA-France EIP on AHA reference site (Allergy Diary) to other reference sites. The phenotypic characteristics of rhinitis and asthma multimorbidity in adults and the elderly will be compared using validated information and communication technology (ICT) tools (i.e. the Allergy Diary and CARAT: Control of Allergic Rhinitis and Asthma Test) in 22 Reference Sites or regions across Europe. This will improve the understanding, assessment of burden, diagnosis and management of rhinitis in the elderly by comparison with an adult population. Specific objectives will be: (i) to assess the percentage of adults and elderly who are able to use the Allergy Diary, (ii) to study the phenotypic characteristics and treatment over a 1-year period of rhinitis and asthma multimorbidity at baseline (cross-sectional study) and (iii) to follow-up using visual analogue scale (VAS). This part of the study may provide some insight into the differences between the elderly and adults in terms of response to treatment and practice. Finally (iv) work productivity will be examined in adults.

Prevalence of allergic rhinitis based on the SACRA questionnaire among Japanese nursing professionals with asthma

Although adult asthma is attributable to occupational factors and asthma and rhinitis are related, relatively few studies have investigated the prevalence of occupational rhinitis based on occupation, and knowledge of occupational rhinitis in Japan is currently limited. The objective of this cross-sectional study was to estimate the prevalence of allergic rhinitis among Japanese nursing professionals with asthma. A postal survey was conducted from October to December 2013 using translated versions of the European Community Respiratory Health Survey for the prevalence of asthma and State of the Impact of Allergic Rhinitis on Asthma Control questionnaire for the prevalence of rhinitis. Of 4,634 Japanese nursing professionals, 497 subjects had asthma, and 270 of these 497 subjects had allergic rhinitis (54.3%; 95% confidence interval [CI], 49.7-58.7). Latex allergy was significantly associated with allergic rhinitis (odds ratio, 1.77; 95% CI, 1.21-2.60). There was no relationship between employment period and prevalent allergic rhinitis. The results of this study provide fundamental information regarding occupational health among Japanese nursing professionals, including the prevalence of allergic rhinitis among Japanese nursing professionals with asthma and latex allergy as a potential risk factor for prevalent allergic rhinitis.

Occupational Rhinitis Revisited: Emphasis on the Risk Factors in Saudi Industry

The European Academy of Allergy and Clinical Immunology (EAACI) Task Force defines occupational rhinitis (OR) as "an inflammatory disease of the nose, which is characterized by intermittent or persistent symptoms (i.e., nasal congestion, sneezing, rhinorrea, itching), and/or variable nasal airflow limitation and/or hypersecretion arising out of causes and conditions attributable to a particular work environment and not to stimuli encountered outside the workplace." The objectives of this review are to highlight the causes of OR in industrial settings in Saudi Arabia in order to alert primary healthcare physicians and other healthcare providers of the importance of diagnosing and managing OR to prevent further complications and present to the General Organization for Social Insurance (GOSI) evidence of the existence of OR in Saudi industrial sector. The literature search yielded no publications from Saudi Arabia that have investigated the prevalence of OR, but it is expected to be high judging from the high prevalence of allergic rhinitis in the country. The occupational groups that are at risk of developing OR include workers in the petrochemical industry, healthcare personnel, livestock and bird breeders, bakers, farmers, housewives and other occupations all of which are present in Saudi Arabia. Clinic and industry based research within Saudi Arabia is recommended to determine the prevalence of OR and to alert healthcare providers to suspect OR in all symptomatic working adults, including housewives and domestic helpers. Use of EAACI algorithm for the diagnosis and management of this condition will help to manage the condition and prevent the deterioration and further complications. Furthermore, diagnosis using internationally recognized guidelines and the results of the suggested epidemiologic surveys may convince GOSI to recognize OR as an occupational disease.

[Occupational asthma: Clinical and professional profile of the Tunisian asthmatic worker]

INTRODUCTION

Asthma takes up a great importance in occupational diseases but remains underestimated as it is insufficiently diagnosed.

OBJECTIVE

We aimed to access the clinical and professional profile of the Tunisian asthmatic worker.

MATERIALS AND METHODS

It was a retrospective descriptive study in a professional pathology unit in a university hospital. All patients referred by their doctor for symptoms suggestive of occupational asthma, during a period from 2000 to 2008, were included.

RESULTS

Forty-eight patients were selected from 172. The mean age was 40 years, with a male predominance (56 %). In 2/3 of the cases, it was the textile workers, food and chemical industry. The etiological agents incriminated were textile dust in 18.8 % of cases followed by isocyanates and flour. Typical episodes of wheezing dyspnea were present in 52 % and atopy in 54.2 % of workers. In 2 % of cases, symptoms disappeared and worsened in 18.8 %.

CONCLUSIONS

The prognosis of OA depends on early end accurate diagnosis. The physician's role is to initiate the appropriate diagnostic approach, which must comply with the Tunisian conditions.

Clinical aspects of work-related asthma: past achievements, persistent challenges, and emerging triggers

OBJECTIVE

The aim of this article was to address common clinical questions pertaining to work-related asthma (WRA).

METHODS

This review is based on a presentation on WRA at the American College of Chest Physicians Course on Clinical Aspects of Occupational and Environmental Lung Disease, held in Toronto in 2013, and supplemented by a PubMed search of publications to 2013.

RESULTS

Seven clinical questions are addressed in relation to definitions, causes, diagnosis, management and emerging triggers, and challenges of WRA.

CONCLUSIONS

Although knowledge is expanding in this area, there remain challenges and uncertainties, particularly in the prevention of WRA.

Occupational rhinitis: an update

Occupational rhinitis is characterized by nasal congestion, rhinorrhea, nasal itching, and/or sneezing that occur secondary to exposures in the workplace. This disease can be classified into allergic or nonallergic subgroups based upon the underlying disease pathogenesis as well as the type of causative agent. While the true prevalence of occupational rhinitis is unknown, there are certain professions and occupational exposures that place workers at a higher risk for developing the disease. Additionally, occupational rhinitis can be associated with occupational asthma and upper airway symptoms may precede those of the lower respiratory tract. Taken together, occupational rhinitis is an important disease for study given its medical as well as socioeconomic implications. This review will focus on the classification of occupational rhinitis as well the prevalence, diagnosis, and treatment strategies.

Work aggravated asthma; a review of the recent evidence

BACKGROUND

The link between asthma and inhaled workplace exposures has been long appreciated, and yet aggravation of asthma symptoms by work conditions, known as work-aggravated asthma (WAA), remains relatively common.

SOURCES OF DATA

A review of the literature published over the last 3 years was carried out, and additional key articles were included from outside this timeframe.

AGREEMENT

WAA is commonly reported by workers with asthma. One published assessment of 12 studies identified a median prevalence of 21.5% among workers with asthma. Commonly reported causes included a variety of inhaled dusts, smoke, vapours, fumes, gases and mists, common and workplace-specific aeroallergens, physical environmental factors including temperature and humidity and physical activity at work.

CONTROVERSY

Remains in relation to definition, and how to distinguish WAA from occupational asthma in which there is sensitization to an agent in the workplace. Both these areas, and the development of workplace interventions to reduce WAA, are timely topics for future research.

EAACI Position Paper on assessment of cough in the workplace

Cough is a nonspecific and relatively common symptom that can present difficulties in diagnosis and management, particularly when it is reported to be associated with the workplace. The present consensus document, prepared by a taskforce of the Interest Group on Occupational Allergy of the European Academy of Allergy and Clinical Immunology by means of a nonsystematic review of the current literature, is intended to provide a definition and classification of work-related chronic cough (WRCC) to assist the daily practice of physicians facing with this symptom. The review demonstrates that several upper and lower airway work-related diseases may present with chronic cough; hence, the possible link with the workplace should always be considered. Due to the broad spectrum of underlying diseases, a multidisciplinary approach is necessary to achieve a definite diagnosis. Nevertheless, more epidemiological studies are necessary to estimate the real prevalence and risk factors for WRCC, the role of exposure to environmental and occupational sensitizers and irritants in its pathogenesis and the interaction with both upper and lower airways. Finally, the best management option should be evaluated in order to achieve the best outcome without adverse social and financial consequences for the worker.

Non-IgE-mediated and irritant-induced work-related rhinitis

PURPOSE OF REVIEW

Recently there has been growing interest in non-IgE-mediated and irritant-induced occupational rhinitis due to old and new low-molecular-weight and irritant agents. The purpose of this review is to summarize the scientific evidence on agents and work activities responsible for non-IgE-mediated and irritant-induced occupational rhinitis and work-exacerbated rhinitis published in 2011 and 2012.

RECENT FINDINGS

Several epidemiological, surveillance and experimental studies, case reports and reviews showed that workers exposed to drugs, wood dust, chemicals, metals and biocides are at high risk of non-IgE-mediated and irritant-induced occupational rhinitis; among activities at risk are healthcare, antibiotic manufacturing and cleaning workers. Work-exacerbated rhinitis has not been specifically studied, but it is reasonable to expect that it is frequently associated with work-exacerbated asthma. Recently, work-related anosmia/microsmia, nasal polyps and sinusitis have also been described. Reducing or eliminating workplace exposure to the specific agent has been confirmed to be effective in preventing symptoms of nonallergic occupational rhinitis.

SUMMARY

In consideration of the relevance of non-IgE-mediated and irritant-induced work-related rhinitis, physicians should recognize work-related rhinitis symptoms due to old and new low-molecular-weight and irritant agents. The mechanisms of non-IgE-mediated and irritant-induced occupational rhinitis remain largely unclear and need to be studied further. Substitution of responsible agents, reduction or elimination of exposure at the workplace should be enforced as effective measures.

Work-exacerbated asthma

A task force of the American Thoracic Society has defined work-exacerbated asthma (WEA) as the worsening of asthma caused by conditions at work. Occupational asthma (OA) is asthma that is initiated by occupational exposures in people without prior asthma. In contrast, WEA is asthma (already present or coincident [new onset]) that is worsened because of conditions at work. This difference is critical because asthma is a common disease (present in approximately 7% of working adults). Among working adults with asthma, approximately 20% may have WEA. WEA has potential implications regarding asthma morbidity, health care use, and the economy.

Occupational asthma and occupational rhinitis: the united airways disease model revisited

OBJECTIVES

Whereas accumulating evidence indicates close associations between rhinitis and asthma, little is known about the relationships between occupational rhinitis (OR) and occupational asthma (OA). This study analyses the prevalence of OR associated with OA, globally and according to the various causal agents, and investigates the temporal relationships between these two conditions.

METHODS

Data on incident cases of OA (2008-2010) were collected through the French national occupational disease surveillance and prevention network, using a standardised form including information on occupation, causal agents, presence of OR, and respective dates of occurrence of rhinitis and asthma.

RESULTS

Among the 596 reported OA cases with latency period, 555 could be attributed to identified agents: high molecular weight (HMW) agents (n=174); low molecular weight (LMW) agents (n=381). Overall, OR was associated with OA in 324 (58.4%) cases. The frequency of association was significantly higher for HMW agents than for LMW agents (72.2% vs 51.5%, p<0.001). OR occurred before OA significantly more frequently for HMW agents than for LMW agents (p<0.01).

CONCLUSIONS

These results show that OR is frequently associated with OA, especially when HMW agents are involved. They are consistent with the hypothesis that OR, in conjunction with OA, is more likely to be caused by sensitisers that cause disease via IgE-mediated mechanisms and suggest that symptoms of OR should be taken into account in the medical surveillance of workers exposed to HMW agents.

Upper airway symptoms among workers with work-related respiratory complaints

BACKGROUND

Work-related rhinitis and asthma symptoms frequently co-exist.

AIMS

To determine the prevalence and nature of nasal, pharyngeal, laryngeal and sinus symptoms among individuals with work-related respiratory symptoms.

METHODS

Individuals referred to a tertiary occupational asthma clinic for investigations with specific inhalation challenges were evaluated using the RHINASTHMA quality of life questionnaire and a questionnaire that assessed the nature and frequency of upper airway symptoms, their relationship to the workplace and their temporal relationship with the onset of asthma symptoms.

RESULTS

There were 83 study participants. At least one upper airway symptom was reported by all of these individuals: nasal in 92%; pharyngeal in 82%; laryngeal in 65% and sinus in 53% of participants. Overall, there were no significant differences in the frequencies of nasal, pharyngeal, laryngeal and sinus symptoms when comparing these with occupational asthma (OA), work-exacerbated asthma (WEA) and work-related respiratory symptoms (WRS), except that nasal bleeding was most frequent among those with WRS. The presence of laryngeal symptoms was significantly associated with rhinitis-specific quality of life impairment. Individuals with workplace exposures to high molecular weight agents had greater impaired quality of life than those who were exposed to low molecular weight agents (RHINASTMA Upper Airway sub-scores: 24.0±10.4 versus 19.8±6.8; P < 0.05).

CONCLUSIONS

Individuals who were referred for work-related respiratory symptoms experienced high rates of work-related nasal, pharyngeal, laryngeal and sinus symptoms, regardless of having OA, WEA or WRS.

EAACI consensus statement for investigation of work-related asthma in non-specialized centres

Work-related asthma (WRA) is a relevant problem in several countries, is cause of disability and socioeconomic consequences for both the patient and the society and is probably still underdiagnosed. A correct diagnosis is extremely important to reduce or limit the consequences of the disease. This consensus document was prepared by a EAACI Task Force consisting of an expert panel of allergologists, pneumologists and occupational physicians from different European countries. This document is not intended to address in detail the full diagnostic work-up of WRA, nor to be a formal evidence-based guideline. It is written to provide an operative protocol to allergologists and physicians dealing with asthma useful for identifying the subjects suspected of having WRA to address them to in-depth investigations in a specialized centre. No evidence-based system could be used because of the low grade of evidence of published studies in this area, and instead, 'key messages' or 'suggestions' are provided based on consensus of the expert panel members.

Epidemiology of allergic conjunctivitis

PURPOSE OF REVIEW

To describe currently available epidemiological data on the prevalence of allergic conjunctivitis. Allergic conjunctivitis is often underdiagnosed and consequently undertreated except when it is severe and the chief complaint of a consultation in a specialty clinic. Use of healthcare resources and reduced quality of life of affected individuals justify studies on the prevalence of allergic conjunctivitis.

RECENT FINDINGS

The association of allergic nasal and ocular symptoms (rhinoconjunctivitis) is common. Most children with allergic conjunctivitis have allergic rhinitis. Older population studies estimate a prevalence of 15-20% of allergic conjunctivitis, but more recent studies implicate rates as high as 40%. Ocular symptoms are common and contribute to the burden of allergic rhinitis and lower quality of life. Ocular allergies rank a very close second and at times may overcome the primary complaints of nasal congestion in rhinoconjunctivitis patients.

SUMMARY

Little focus has been set on the impact of allergic conjunctivitis as comorbidity to asthma and rhinitis in atopic patients. Conjunctivitis symptoms are at least as severe as rhinitis symptoms in patients with 'hay fever' and some have even generated the term of conjunctivorhinitis stressing the ocular symptoms. Prevalence studies should be specifically addressed to ocular allergy symptoms.

Occupational asthma: etiologies and risk factors

The purpose of this article is to critically review the available evidence pertaining to occupational, environmental, and individual factors that can affect the development of occupational asthma (OA). Increasing evidence suggests that exploration of the intrinsic characteristics of OA-causing agents and associated structure-activity relationships offers promising avenues for quantifying the sensitizing potential of agents that are introduced in the workplace. The intensity of exposure to sensitizing agents has been identified as the most important environmental risk factor for OA and should remain the cornerstone for primary prevention strategies. The role of other environmental co-factors (e.g., non-respiratory routes of exposure and concomitant exposure to cigarette smoke and other pollutants) remains to be further delineated. There is convincing evidence that atopy is an important individual risk factor for OA induced by high-molecular-weight agents. There is some evidence that genetic factors, such as leukocyte antigen class II alleles, are associated with an increased risk of OA; however, the role of genetic susceptibility factors is likely to be obscured by complex gene-environment interactions. OA, as well as asthma in general, is a complex disease that results from multiple interactions between environmental factors and host susceptibilities. Determining these interactions is a crucial step towards implementing optimal prevention policies.

Occupational rhinitis: consensus on diagnosis and medicolegal implications

PURPOSE OF REVIEW

Work-related rhinitis is a common disease in many working groups, frequently associated with asthma. The purpose of this review is to summarize the specific literature published within the past 12 months, to discuss the diagnostic workup and to illustrate the medicolegal aspects pertaining to this disease.

RECENT FINDINGS

Recently, there has been a growing scientific interest in work-related rhinitis, which includes both occupational rhinitis and work-exacerbated rhinitis. The epidemiological relevance and the relationships to asthma have been evaluated. New etiologic agents and populations at risk have been identified. A new definition and classification, and a diagnostic algorithm, have been proposed.

SUMMARY

In consideration of the epidemiological relevance and of the medicolegal implications, occupational rhinitis should be considered in daily clinical practice by all physicians. In adults with late-onset rhinitis, occupational causes should be queried and patients in whom an occupational association is suspected should be referred for specific assessments.

Asthma and rhinitis in the workplace

Accumulating evidence indicates that the workplace environment substantially contributes to the global burden of asthma and rhinitis. Work-related asthma and rhinitis represent a public health concern due to their health and socioeconomic impacts. This article summarizes the scientific evidence on sensitizer-induced occupational asthma and rhinitis that has been published during the past 5 years. The review addresses the strategies for diagnosing and managing these highly prevalent occupational diseases.