Dust and flour aeroallergen exposure in flour mills and bakeries

Case Report: Occupational Dust Exposure Among Bakery Workers in Perth, Western Australia

Occupational dust exposure can occur in various settings, including bakeries. A case study was conducted in an industrial bakery in Perth, Western Australia, to assess exposure to particulate dust concentration. The factory was separated into three production zones and an office area which represented as a control zone. Results indicated that bakery workers in the production zones were exposed to higher ambient dust particle concentrations compared to those from the office environment. Coarse particles (>10 μm in aerodynamic diameter) were the predominant particle size fraction measured in all studied areas with the highest median exposure level recorded in the dough room (0.181 mg/m3, interquartile range 0.283). High personal concentration of respirable particles was also measured in the dough room (median 2.26 mg/m3) which exceeded the recommended limit of 1.5 mg/m3 and was more than 50 times higher than the concentration recorded in the office (0.04 mg/m3). The variation in dust concentrations between production zones underlines the need of more knowledge about how aerosol fractions are distributed across the production process. The findings also suggest that bakery workers are exposed to high dust levels that may increase their risk of developing respiratory diseases and the decrease of present exposure levels is imperative.

Bakers' exposure to flour dust

We aimed to characterize bakers' personal exposure to airborne flour dust with respect to the health-related aerosol fractions inhalable, extrathoracic, and thoracic dust, and to examine possible production-related determinants of dust exposure. Sixty-eight bakers from 7 bakeries in Bergen, Norway (2009-2012) participated in the exposure assessment, comprising full-shift personal samples of inhalable dust (n = 107) and thoracic dust (n = 61). The relation between possible determinants and exposure was estimated using mixed effects models, while associations between the various aerosol fractions across task groups and type of bakeries were described by Pearson's correlation coefficients. Bakers' overall geometric mean personal exposure to inhalable, extrathoracic, and thoracic dust were 2.6 mg/m³ (95% CI: 2.0, 3.2), 2.2 mg/m³ (95% CI: 1.9, 2.7), and 0.33 mg/m³ (95% CI 0.3, 0.4), respectively. A total of 29% of the measurements of inhalable dust were above the Norwegian Occupational Exposure Limit of 3 mg/m³. The exposure variability of inhalable dust could not be explained by any of the examined production-related determinants, while the daily production volume explained 18% of the variance in thoracic dust exposure. Overall, the thoracic dust represented 15% of the inhalable dust, being rather stable across the production-related determinants. The overall correlation between inhalable and thoracic dust was nevertheless moderate (r = 0.52, p < 0.001), with the highest correlation for craft bakers (r = 0.62) and no correlation during dough forming (r = 0.01). Bakers are exposed to flour dust at a level that most likely represents an excess risk of developing chronic diseases of the respiratory system, and a decrease of present exposure level is imperative. Extrathoracic dust-likely the most relevant sub-fraction in respect to flour-induced sensitization and occupational rhinitis-represented the main proportion of the measured inhalable dust. The variation in correlation coefficients between the dust fractions across bakery types and task groups underlines the need of more knowledge about how these aerosol fractions are distributed across the production process and bakery types.

Exposure to flour dust in the occupational environment

Exposure to flour dust can be found in the food industry and animal feed production. It may result in various adverse health outcomes from conjunctivitis to baker's asthma. In this paper, flour dust exposure in the above-mentioned occupational environments is characterized and its health effects are discussed. A peer-reviewed literature search was carried out and all available published materials were included if they provided information on the above-mentioned elements. The hitherto conducted studies show that different components of flour dust like enzymes, proteins and baker's additives can cause both non-allergic and allergic reactions among exposed workers. Moreover, the problem of exposure to cereal allergens present in flour dust can also be a concern for bakers' family members. Appreciating the importance of all these issues, the exposure assessment methods, hygienic standards and preventive measures are also addressed in this paper.

Evaluation of Dust Exposure among the Workers in Agricultural Industries in North-East India

This study aims to quantify dust exposure among the workers in four different industrial settings: rice mills, flour mills, oil mills, and tea factories and to compare the obtained data with the permissible exposure limit (PEL) of Indian Union Ministry of Labour as well as to compare the dust exposure across activities and seasons. RespiCon(TM) particle sampler was used for collecting dust concentration in the breathing zone of the workers. In total, 149 workers participated in the study and 204 samples were collected. Samples were collected in the vicinity of different processing operations. Samples in the rice mills were collected for two consecutive years in two seasons; however samples from other industries were collected for 1 year. The results indicate that geometric mean (GM) of dust exposure was significantly (P < 0.0001) different among industrial settings. Respirable dust were 8.22, 5.76, 2.98, and 6.34mg m(-3) and total dust exposure were 81.05, 111.02, 56.68, and 39.85mg m(-3) in the rice mills, oil mills, flour mills, and tea factories, respectively. Considerable variations in dust exposure were observed in different activities in the rice and oil mills; however variation was relatively less in the flour mills and tea factories. In the rice mills, dust concentration was higher in winter than those obtained in autumn and it is significantly different (P < 0.05) for inhalable dust and total dust. Positive correlation was obtained in thoracic dust (r (2) = 0.94) and inhalable dust (r (2) = 0.97) with total dust and thoracic dust with inhalable dust (r (2) = 0.89). The results show that majority of the workers are exposed to higher level of respirable dust as compared to the PEL, while total dust exposure to all the workers were higher than the PEL; thus, immediate reduction of dust exposure among the workers is necessary for preventing respiratory system impairment.

Exposure to flour dust and sensitization among bakery employees

BACKGROUND

The National Institute for Occupational Safety and Health conducted a study to determine prevalences of sensitization to bakery-associated antigens (BAAs) and work-related respiratory symptoms at a large commercial bakery.

METHODS

The following measurements were carried out: personal breathing zone (PBZ) and general area (GA) monitoring for inhalable flour dust, α-amylase and wheat, a questionnaire, and blood tests for IgE specific to flour dust, wheat, α-amylase, and common aeroallergens.

RESULTS

Of 186 bakery employees present during our site visit, 161 completed the questionnaire and 96 allowed their blood to be drawn. The geometric mean PBZ and GA inhalable flour dust concentrations for the lower-exposure group was 0.235 mg/m(3), and for the higher-exposure group was 3.01 mg/m(3). Employees in the higher-exposure group had significantly higher prevalences of work-related wheezing, runny nose, stuffy nose, and frequent sneezing than the lower-exposure group. The prevalence of IgE specific to wheat was significantly higher among employees who ever had a job in the higher-exposure group or in production at another bakery at both the ≥ 0.10 kU/L and the ≥ 0.35 kU/L cutoffs, and to flour dust and α-amylase at the ≥ 0.10 kU/L cutoff, compared to the lower-exposure group.

CONCLUSIONS

Despite knowledge of the risks of exposure to flour being available for centuries, U.S. employees are still at risk of sensitization and respiratory symptoms from exposure to high levels of BAA.

Exposure of bakery and pastry apprentices to airborne flour dust using PM2.5 and PM10 personal samplers

Background

This study describes exposure levels of bakery and pastry apprentices to flour dust, a known risk factor of occupational asthma.

Methods

Questionnaires on work activity were completed by 286 students. Among them, 34 performed a series of two personal exposure measurements using a PM_2.5 and PM₁₀ personal sampler during a complete work shift, one during a cold ("winter") period, and the other during a hot ("summer") period.

Results

Bakery apprentices experience greater average PM_2.5 and PM₁₀ exposures than pastry apprentices (p < 0.006). Exposure values for both particulate fractions are greater in winter (average PM₁₀ values among bakers = 1.10 mg.m^-3 [standard deviation: 0.83]) than in summer (0.63 mg.m^-3 [0.36]). While complying with current European occupational limit values, these exposures exceed the ACGIH recommendations set to prevent sensitization to flour dust (0.5 mg.m^-3). Over half the facilities had no ventilation system.

Conclusion

Young bakery apprentices incur substantial exposure to known airways allergens, a situation that might elicit early induction of airways inflammation.

Nasal indices of eosinophilic and exudative inflammation in bakery-workers

AIMS

Rhinitis symptoms frequently occur in bakery-workers. Yet, little is known about the pathophysiology of this condition. The objective of the present study was to examine nasal indices of inflammation in relation to occupational dust exposure, occupational rhinitis according to defined criteria, rhinitis symptoms associated to the workplace, and occupational sensitization in bakery-workers.

METHODS

Bakery-workers (n = 197) were subjected to interviews, questionnaires, workplace dust measurements, allergy tests, and nasal lavages with and without histamine. alpha(2)-Macroglobulin and eosinophil cationic protein (ECP) were measured in saline lavages as indices of plasma exudation and eosinophilic activity, respectively. Histamine lavages were employed to explore the nasal exudative responsiveness.

RESULTS

alpha(2)-Macroglobulin and ECP increased significantly by increased workplace dust exposure (P< or =0.035). Furthermore, the exudative responsiveness to histamine increased significantly by such exposure (P< or =0.016). Similar patterns were seen in workers with occupational rhinitis and in subjects with rhinitis symptoms associated to the workplace, but not in workers with occupational sensitization.

CONCLUSIONS

We conclude that occupational dust exposure in bakery-workers is associated with nasal eosinophilic exudative inflammation. In contrast, occupational sensitization is not a discriminating factor with regard to indices of eosinophilic, exudative inflammation in the present material.

Micro-organisms and dust exposure in an Italian grain mill

AIMS

In order to assess possible occupational risk for workers in a grain mill, we evaluated aerial microbiological contamination in different areas of the mill and at different points of the production line. We also measured the concentration of aerodispersed dust particles.

METHODS AND RESULTS

An assessment of microbiological contamination levels based on a Global Index of Microbial Contamination per cubic metre (GIMC per m3), an Index of Mesophilic Bacterial Contamination, and an Amplification Index is proposed. The indices were obtained from total and fungal counts. The cleaning sector is the most contaminated area of the mill: the mean GIMC per m3 was 17,213.6. In this area, the average microbial contamination was 11.41 times higher than that in the external environment. The highest concentrations of aerodispersed dust (inhalable 2.763 mg m(-3); respirable 1.400 mg m(-3)) were found in the cleaning area.

CONCLUSIONS

The proposed microbiological indices and the concentrations of aerodispersed dust particles show that the most hazardous section of the mill is the cleaning area. The large variation in the data does not depend on seasonal factors, but rather on not easily identifiable conditions of the internal environment which facilitate diffusion and/or proliferation of the micro-organisms.

SIGNIFICANCE AND IMPACT OF THE STUDY

The proposed microbiological contamination indices and the evaluation of the concentration of dust particles allow the identification of critical positions during the production cycle so that suitable measures to prevent the aerial contamination can be taken.

I are we closer to developing threshold limit values for allergens in the workplace?

OBJECTIVE

To define threshold limit values and legally binding occupational exposure limits.

DATA SOURCES

Review of suitable literature.

STUDY SELECTION

Studies based on detailed descriptions and/or measurements of airborne allergenic dust, total allergens, or even key allergens were selected.

RESULTS

Prevalences of IgE-mediated sensitization and occupational asthma are related to the aeroallergen load in workplaces. Data to set threshold limit values for flour, latex, a-amylase, and isocyanates are already sufficiently available.

CONCLUSIONS

To optimize primary prevention in workplaces,health-based occupational exposure limits should be set for major occupational allergens.

Exposure-response relations among laboratory animal workers exposed to rats

AIM

To explore exposure-response relations in a cohort of laboratory animal workers.

METHODS

Exposure-response modelling was carried out in a cohort of 342 laboratory animal workers. Three exposure indices, divided into different exposure categories, were used in the analyses: intensity of exposure to rat urinary aeroallergen (RUA, the main allergen workers were exposed to), weekly duration of exposure to rats, and the product of the intensity and weekly duration of exposure. Outcomes studied were work related chest, eyes and nose, and skin symptoms that had started after employment at the sites, specific sensitisation, and a combination of symptoms and sensitisation. Cox proportional hazard modelling was used to explore exposure-response relations. Smoking, atopic status, age, and gender were taken into account.

RESULTS

We observed the clearest exposure-response relations for the intensity of exposure to RUA and the various endpoints. No clear exposure-response relations were observed for the weekly duration of exposure or the product of the intensity and weekly duration of exposure. The strongest and clearest exposure-response relations for symptoms were observed among rat sensitised workers, while the non-sensitised workers only showed small increased risks of developing symptoms without clear exposure-response relations. Sensitised workers were almost four times more likely to go on to develop chest symptoms compared to non-sensitised workers.

Diagnosis of flour-induced occupational asthma in a cross-sectional study

The diagnosis of occupational asthma is usually performed in epidemiology using a combination of symptoms and bronchial hyperresponsiveness, while in a clinical setting the 'gold standard' for the diagnosis of occupational asthma is the specific bronchial challenge test in the laboratory The aim of this study was to detect new cases of flour-induced occupational asthma (OA) in a group of workers exposed to grain and/or flour dust, by means of a step-by-step approach, as used in a clinical setting. In an epidemiological study, III millers and 186 bakers were examined by means of questionnaire, pulmonary function tests and skin-prick tests (SPT) to common allergens and to wheat flour dust extracts. From the whole sample, 82 subjects who showed asthma-like symptoms in the questionnaire and/or low forced expiratory volume in 1 sec (FEV1) were selected. Selected subjects underwent methacholine challenge test, and hyperreactive subjects underwent specific bronchial challenge with flour dust in the laboratory. Sixty-two of the selected subjects performed the methacholine challenge test, and 22 (33 8%) were hyperreactive (PD20 FEV1 <1 mg of methacholine). Fifteen of 22 hyperreactive subjects underwent specific bronchial challenge test (s BCT) with flour dust; a positive response was elicited in six subjects. These subjects can be diagnosed as having flour-induced occupational asthma. Atopy and skin sensitivity to flour was partially related to the response to flour bronchial challenge. Bronchial hyperreactivity can be observed in a small percentage of subjects with asthma-like symptoms and/or low FEV1, and a positive response to s BCTwas observed in a subgroup of hyperreactive subjects.Therefore, using these selection criteria, a diagnosis of flour-induced OA, as commonly performed in a clinical setting, can be performed in few previously undiagnosed subjects.This approach could be relevant for an early diagnosis ofoccupational asthma.

Exposure assessment of high molecular weight sensitisers: contribution to occupational epidemiology and disease prevention

An important group of sensitising agents are so called high molecular weight sensitisers--proteins or glycoproteins with molecular weights in the 5-70 kDa range that can provoke a specific IgE response in workers exposed to these agents. Exposure to high molecular weight sensitisers could only be evaluated indirectly in the recent past. Few measurement techniques existed that made it possible to measure the allergens directly. As a result, few studies focused on establishing exposure-response relations, and exposure standards have not been established for high molecular weight sensitisers, or those that have are of doubtful scientific basis. Recent use of immunoassays changed this perspective dramatically. Antibodies used in the assays can originate from human serum (sensitized workers), serum from sensitised animals (rabbits producing polyclonal antibodies), or animal derived cell cultures producing monoclonal antibodies. Although few comparative studies exist, the available evidence suggests that although the correlation of allergen concentrations obtained with different assays is good, large systematic differences occur. The use of conversion factors to make data from previously performed allergen measurements comparable or exchangeable is limited and thorough standardization of assays is preferred. Validation and comparison of different assays by comparisons between laboratories seem important issues that have not received the attention needed. Epidemiological studies in several industries that used immunoassay for the exposure characterisation have shown that risk of sensitisation increases with increasing exposure to allergens. Several studies have also shown that clear differences in potency seem to exist. Sensitisation to rat urinary allergens and fungal alpha-amylase occurred in the pg/m3 and ng/m3 range. The main research questions of the near future have to focus on the prevention of occupational sensitisation. Standard setting seems possible for some allergenson the basis of the available scientific evidence for the existence of exposure response relations. However, assays for characterising exposure to allergens have to be rigorously standardised before they can be used under field conditions.

Exposure-response relations of alpha-amylase sensitisation in British bakeries and flour mills

OBJECTIVES

To describe the levels of exposure to fungal alpha-amylase in British bakeries and flour mills, and to describe the relation between exposure to alpha-amylase and sensitisation to fungal alpha-amylase.

METHODS

495 personal flour dust samples were taken in seven British bakeries and flour mills and analysed for alpha-amylase with an immunoassay. Workers at the sites were asked to fill out questionnaires on work related symptoms, smoking history, and work history, and they were skin prick tested with common allergens and fungal alpha-amylase to assess sensitisation.

RESULTS

Exposure to high concentrations of alpha-amylase occur in a few areas of British bakeries and flour mills, and there can be considerable differences in exposures to alpha-amylase between sites and between exposure groups, and even within similar exposure groups from different sites. Exposure to the highest concentrations of alpha-amylase was found in the dispensing and mixing areas of the bakeries (geometric mean (GM) 39.7 ng/m3). Exposure to alpha-amylase showed only a moderate correlation with concentrations of dust (r = 0.42) and flour aeroallergen (r = 0.46). The results also showed a relation between exposure to alpha-amylase and sensitisation to fungal alpha-amylase (prevalence ratio (PR) for medium exposure 3.9, 95% confidence interval (95% CI) 0.8 to 20.2, PR for high exposure 9.9, 95% CI 2.8 to 34.6) compared with the low exposure category). Atopic subjects had an increased risk of sensitisation, but this was not significant.

CONCLUSION

This study suggests that exposure to alpha-amylase is a considerable health risk in British bakeries and flour mills. A small proportion of workers are exposed to alpha-amylase at concentrations that result in high rates of sensitisation. A reduction in exposure to alpha-amylase is likely to reduce this risk.

Exposure-response relationships of occupational inhalative allergens

Only a few threshold limit values exist at present for allergens in the workplace known to cause bronchial asthma. This contrasts with the great number of occupational asthma cases observed in industrialized countries. Recently published studies provide clear evidence for exposure intensity response relationships of occupational allergens of plant, microbiological, animal or man-made origin. If allergen exposure levels fall short of determined limit values, they are not associated with an increased risk of occupational asthma. Corresponding data are available for wheat flour (1-2.4 mg/m3), fungal alpha-amylase (0.25 ng/m3), natural rubber latex (0.6 ng/m3), western red cedar (0.4 mg/m3) and rat allergens (0.7 microg/m3). It is suggested to stipulate legally binding threshold limit values (TLV/TWA) on this basis in order to induce more effective primary preventive measures. If no reliable data on the health risk of an occupational airborne noxa exist, the lowest reasonably practicable exposure level has to be achieved. Appropriate secondary preventive measures have to be initiated in all workplaces contaminated with airborne allergens. Verified exposure-response relationships provide the basis for risk assessment and for targeted interventions to reduce the incidence of occupational asthma also in consideration of cost benefit aspects. 'Occupational asthma is a disease characterized by variable airflow limitation and/or airway hyperresponsiveness due to causes in a working environment. These causes can give rise to asthma through immunological or non-immunological mechanisms. Up to 15% of all asthma cases are of occupational origin or have at least a significant causal occupational factor. According to the New Zealand part of the European Respiratory Health Survey, an increased risk of asthma prevalence was found for several occupations such as laboratory technicians, food producers, chemical workers, plastic and rubber workers. The Spain part of this study comprising 2646 Spanish subjects showed an asthma risk to be attributed to occupational exposures between 5 and 6.7%. Main asthma-inducing agents in the workplace are flour, grain and feed dust, animal dander/urinary proteins and isocyanates. Further, several inhalative irritants such as chlorine, acid or alkaline aerosols play a pivotal role. Many low molecular weight chemicals have irritative as well as allergenic effects on the airways, e. g. isocyanates and acid anhydrides. In addition to chronic or repetitive exposures, also singular accidental exposure to high concentrations of irritative or toxic airborne substances can cause occupational asthma. This condition is frequently called reactive airways dysfunction.

Enzyme exposure and enzyme sensitisation in the baking industry

OBJECTIVES

To assess the exposure to enzymes and prevalence of enzyme sensitisation in the baking industry.

METHODS

A cross sectional study was conducted in four bakeries, one flour mill, and one crispbread factory. Sensitisation to enzymes, flours, and storage mites was examined by skin prick and radioallergosorbent (RAST) tests. 365 workers were tested. The workers were interviewed for work related respiratory and skin symptoms. Total dust concentrations were measured by a gravimetric method, and the concentration of alpha-amylase in air was measured by a catalytic method. An immunochemical method was used for measuring cellulase and xylanase in air.

RESULTS

Total measured dust concentrations were from 0.1 to 18 mg/m3, with highest values in dough making areas of bakeries. The alpha-amylase concentrations generally followed the total dust concentrations and reached the highest values < 6.6 micrograms/m3 in the same areas. Cellulase and xylanase varied with concentrations < 180 ng/m3 and < 40 ng/m3, respectively, in the flour mill and the crispbread factory. No cellulase, but concentrations of 1-200 ng/m3 xylanase, were found in the bakeries, probably indicating the natural xylanase activity of wheat. 12 workers (8%) in the bakeries, three (5%) in the flour mill, and four (3%) in the crispbread factory were skin prick positive to enzymes. The corresponding percentages of positive reactions to flours were 12%, 5%, and 8%.

CONCLUSIONS

The study confirmed that industrial enzymes in baking used as additives in a powdered form pose a risk of sensitisation. The no effect air concentrations for industrial enzymes are not known. Based on present knowledge, however, lowering exposures and eliminating short and high peaks by technical measures would lower the risk of sensitisation. This would be most effectively accomplished by shifting to non-dusty products.

Wheat antigen exposure assessment for epidemiological studies in bakeries using personal dust sampling and inhibition ELISA

BACKGROUND

Asthma in bakery workers caused by exposure to wheat flour proteins is an important occupational health problem. Until recently, gravimetric dust measurements were the only available technique for quantitative exposure assessment in bakeries. However, it is questionable whether dust levels are a good exposure parameter or only give a crude approximation of the actual flour allergen concentration.

OBJECTIVE

In the present study we have investigated a method to measure wheat flour antigens with immunochemical methods.

METHODS

Wheat flour antigens were measured in 449 personal dust samples taken in bakeries, using enzyme-linked immunosorbent assay (ELISA) inhibition and an anti-wheat IgG4 serum pool. Western-blotting was performed to compare the wheat flour proteins detected by IgE and IgG4.

RESULTS

Electrophoresis and immunoblotting showed that many wheat flour proteins can bind IgG4 and IgE, but also a reasonable similarity in major allergens detected by our IgG4-serum pool and IgE-positive sera. Inhibition tests showed some cross-reactivity with some cereal species, but not with other ingredients used in bakeries. In bakeries, large differences in personal airborne flour levels were found between occupational titles. For several groups clear differences in wheat antigen exposure levels existed, where no differences in dust exposure levels could be found. The relationship between dust and wheat antigen exposure varied considerably, depending on the specific bakery occupation, the size of the bakery, and the type of product produced by the bakery. This study also shows that personal sampling of wheat antigens is possible on a large scale and can be used for epidemiological field studies.

CONCLUSION

Measurement of airborne wheat antigens in bakeries is a more specific and sensitive measurement tool than measuring dust samples, and will probably be essential for epidemiologic field studies focusing on exposure-response relationships.

Work related symptoms, sensitisation, and estimated exposure in workers not previously exposed to flour

Findings are presented from the initial cross sectional phase of a cohort study of employees exposed to flour in bakeries or mills. Of 401 eligible workers in seven sites 344 (86%) were surveyed; symptoms assessed by self completed questionnaire, and sensitisation measured by the response to skin prick tests, were related to intensity of exposure both to total dust and to flour aeroallergen. Among 264 subjects without previous occupational exposure to flour, work related symptoms which started after first employment at the site were related to exposure intensity, especially when exposure was expressed in terms of flour aeroallergen. The relations with eye/nose and skin symptoms were independent of atopic status and cigarette smoking. Positive skin test responses to mixed flour and to alpha amylase were also more frequent with increasing exposure intensity, although this was confounded by atopic status. There was only a weak association between symptoms and specific sensitisation.