[Endemic air-borne contact dermatitis? Frequent occurrence of a rare contact allergy in a waste collection facility]. / "Endemisches" aerogenes allergisches Kontaktekzem? Gehäuftes Auftreten einer seltenen Kontaktallergie in einem Betrieb der Müllentsorgung.

Numerous cases of work-related air-borne contact dermatitis of the face were encountered in a waste collection facility. Potential allergens contained in the dust at the facility could be identified. In 5 of 7 symptomatic workers a type-IV sensitization to p-aminodiphenylamine could be documented. Since there is no commercial patch test preparation for p-aminodiphenylamine available, it had to be prepared for each patient individually. After identifying the allergen, a change in the work routine led to a reduction of dust emissions and afterwards no cases of air-borne contact dermatitis of the face recurred.

Sustainability of an interdisciplinary secondary prevention program for hairdressers.

OBJECTIVE: Two hundred and fifteen hairdressers suffering from occupational skin diseases (OSD) have attended a 6-month combined dermatological and educational prevention program with an education and counseling scheme as well as an intervention in the respective hairdressers' shops. The aim of this program, conducted from 1994 to 1997, was to enable the affected hairdressers to remain at work without suffering from major OSD. METHODS: To assess the sustainability of this interdisciplinary medical and educational training program, the intervention group (IG, N = 215) and a control group (CG, hairdressers with OSD who solely received dermatological treatment, N = 85) were followed up 9 month and 5 years after their individual project participation by a standardized questionnaire. A subcohort of the intervention group (IG(1994), participants in 1994, N = 62) was followed up again 10 years after their participation. RESULTS: The follow-up survey 9 months after the beginning of the program (response rate: IG: N = 163, 75.8%; CG: N = 80, 94.1%) showed that 71.8% (N = 117) of the intervention group could remain in work as opposed to 60.0% (N = 48) in the control group. In the intervention group 14.7% gave up work due to OSD versus 22.5% in the control group (no statistically significant effect). In the 5-year follow-up (response rate: IG: N = 172, 80%; CG: N = 55, 64.7%) 58.7% (N = 101) of the IG remained at work versus 29.1% (N = 16) of the CG. In the IG 12.8% had stopped work because of OSD versus 27.3% in the CG (p < 0.001, Cramer's V = 0.26). Ten years after intervention, the follow-up showed a stabilization of the effects shown by the 5-year follow-up results. In addition to the criteria 'remaining' or 'not remaining at work' the results show that our interdisciplinary intervention program led to an increased and sustained knowledge on OSD and more adequate prevention at the work place in the IG. The results confirm that interdisciplinary training can be successful in effecting self-protection against workplace hazards by using positive approaches that include the learning of "safe" behavior and insuring transferability to real workplace settings ("empowerment"). Combined preventive measures as studied in this program have recently become the standard offered by different statutory accident liability insurances for patients in different wet work occupations with OSD in Germany.

[Optimal care of patients with occupational hand dermatitis: considerations of German occupational health insurance]. / Optimierte Versorgung von Patienten mit berufsbedingten Handekzemen: Hautarztverfahren und Stufenverfahren Haut der gesetzlichen Unfallversicherung.

Occupational dermatoses (OD) have been at the top of all occupational diseases in Germany for years (>25% of all occupational diseases officially reported annually to the public statutory employers' liability insurance bodies). More than 90% of OD-cases are hand eczema. Several pilot initiatives to improve prevention of occupational skin diseases have been developed and funded since 2005 by the statutory employers' liability insurance schemes. The concept underpinning these initiatives is a nationwide multi-step intervention approach recently implemented by the public statutory insurance system administration ("step- wise procedure") which aims at offering quick and specific preventive help at all levels of severity of OD. The dermatologist has a pivotal function in this concept; for early secondary prevention, the so-called dermatologist's procedure was recently updated in order to provide more rapid and concise dermatological consultations and care. Additionally, combined outpatient dermatological and educational intervention seminars ("secondary individual prevention", SIP) and interdisciplinary inpatient prevention measures have been developed ("tertiary individual prevention", [TIP]) and are currently being further evaluated in multicenter studies.

Tertiary individual prevention of occupational skin diseases: a decade's experience with recalcitrant occupational dermatitis.

OBJECTIVE: If employees are threatened to loose their job due to a severe occupational skin disease (OSD), intensive interdisciplinary measures of tertiary individual prevention (TIP) are required. TIP comprises 2-3-weeks in-patient treatment plus intensive health-pedagogic counseling, and consecutive 3-weeks out-patient treatment by the local dermatologists. Each patient (pt) will stay off work for a total of usually 6 weeks to allow full barrier-recovery. METHODS: All 1,486 TIP-pts from various high-risk-professions, treated in our institution in the period 1994-2003, were followed up 1 year after the TIP by a standardised questionnaire, which was returned by 1,164 (78%) pts. RESULTS: Seven hundred and sixty-four (66%) of the responding 1,164 TIP-pts had successfully remained in their (risk-)professions. It could be demonstrated that to remain in the workplace was dependent on the individual motivation to use skin protection (P < 0.001), the provision of skin protection by the employer (P < 0.001), (higher) age of pt (P < 0.001) and the duration of continued out-patient-treatment by the local dermatologist (P < 0.001). However, there were no significant differences concerning the likelihood of successful job-continuation in the various high-risk-professions, e.g. hairdressers, nurses, metal-workers, food handlers, construction-workers. CONCLUSION: The obtained data from TIP reveal remarkable pertinent options for interdisciplinary pt-management in severe OSD in all risk-professions.

Inhaled corticosteroids reduce the progression of airflow limitation in chronic obstructive pulmonary disease: a meta-analysis.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a syndrome of chronic progressive airflow limitation which occurs as a result of chronic inflammation of the airways and lung parenchyma. However, the role of inhaled corticosteroids in the treatment of COPD is controversial. We hypothesised that inhaled corticosteroids reduce the progression of airflow limitation in COPD. METHODS: A comprehensive literature search was conducted and data were analysed using random effects methodology. The effect of inhaled steroids on annual change in forced expiratory volume in 1 second (FEV1) was determined for all trials, for trials with high dose treatment regimens, and for trials in subjects with moderate to severe airflow limitation. RESULTS: Data from eight controlled clinical trials of > or =2 years were included (n=3715 subjects). Meta-analysis of all study data revealed that inhaled corticosteroids reduce the rate of FEV1 decline by 7.7 ml/year (95% confidence interval (CI) 1.3 to 14.2, p=0.02). Meta-analysis of studies with high dose regimens revealed a greater effect of 9.9 ml/year (95% CI 2.3 to 17.5, p=0.01) compared with the meta-analysis of all studies. CONCLUSIONS: Inhaled corticosteroid treatment for > or =2 years slows the rate of lung function decline in COPD. The effect observed with high dose regimens is greater than that with all regimens combined. These data suggest a potential role for inhaled corticosteroids in modifying the long term natural history of COPD.

Wearing test with 2 different types of latex gloves with and without the use of a skin protection cream.

72 subjects reporting symptoms indicating Type I hypersensitivity reactions to natural rubber latex (NRL) gloves were included in this study. 44 of them had a positive prick test to NRL. They underwent wearing tests using 2 types of NRL gloves with high (n=63) and low (n=70) allergen contents. Unigloves Malaysia with a high allergen content caused positive skin reactions in 47% of SPT-positive and no IgE-negative subjects. After application of Hand Sense skin protection cream, the frequency of positive skin responses in wearing tests decreased to 30% in prick-test-positive subjects. The Biogel Diagnostic gloves with low allergen caused hypersensitivity with and without Hand Sense in 2 cases (5%) of the prick-test-positive. 60% of all test participants had a positive prick test to NRL. No prick-test-negative subjects showed any urticaria during the glove-wearing test. Our study demonstrates that high allergen contents in latex gloves frequently elicit skin responses in NRL-sensitized subjects. Since other skin protection creams have shown to increase allergic symptoms, it is encouraging to report that Hand Sense skin cream may hamper the uptake of allergens from gloves, thus decreasing allergic reactions.

Challenge from methacholine, natural rubber latex, or 4,4-diphenylmethane diisocyanate in workers with suspected sensitization affects exhaled nitric oxide [change in exhaled NO levels after allergen challenges].

OBJECTIVE: Nitric oxide (NO) levels in the exhaled air of asthmatic patients have been shown to be increased. This observation has also been reported in workers who are allergic to laboratory animals. To determine if a challenge test with natural rubber latex (NRL) or 4,4'-diphenylmethane diisocyanate (MDI) would also produce an increase of NO exhalation in sensitized patients, we carried out this study. METHODS: Nine subjects with suspected occupational asthma were exposed to MDI, and 18 took part in a challenge test with gloves powdered with NRL. Nineteen subjects underwent a challenge test with methacholine (MCh). Exhaled NO was measured by a modified chemiluminescence analyzer according to the European Respiratory Society guidelines. RESULTS: We found that there was a decrease in exhaled NO concentrations 16-18 h after MCh challenge testing and subsequent bronchodilation with salbutamol, in three subjects. Three of nine participants had a significant immediate bronchial obstruction after exposure to MDI, of those three, two had MDI-specific IgE antibodies. After 22 h, their levels of exhaled NO had increased > 10 parts per billion (ppb). Eight of the 18 subjects participating in the NRL challenge test displayed an NO concentration increase of at least 10 ppb after 22 h (seven had NRL-specific IgE antibodies). A significant decrease in the one-second forced expiratory volume (FEV1) was documented in four of those eight participants after NRL challenge. CONCLUSIONS: There was no clear relationship between bronchial response, substance-specific IgE antibodies and an increase in exhaled NO levels. However, there was a tendency for subjects with substance-specific IgE antibodies and bronchial reaction to develop an increase in exhaled NO concentration. Further studies are needed to determine if analysis of NO from the lower respiratory tract can become a useful non-invasive tool for detecting lower airway inflammatory response even before clinical symptoms occur.

[Randomized double-blind study (third place blinded) to examine the effectiveness and side effects of methacholine in the nonspecific bronchial provocation test]. / Randomisierte Doppelblindstudie (third place blinded) zur Untersuchung der Wirksamkeit und Nebenwirkungen von Methacholin im unspezifischen bronchialen Provokationstest.

Softly and effectiveness of methacholine for the diagnosis of non-specific bronchial hyperresponsiveness [BHR] were tested in a third place blinded study. 61 patients suspected to suffer from BHR took part. 56 subjects provided complete data and were included in the study. 27 participants were challenged with methacholine 0.33% (verum) and 29 patients received NaCl 0.9% (placebo). The challenge was applied as 5-step-test using a storage bag. The doses were elevated by doubling the aerosol volume. A positive test result was assumed when basal specific airway resistance (sRt) reduplicated and simultaneously 2.0 (kPa*s) was attained. Ten out of 27 subjects in the verum group (33.3%) had a positive test result whereas in the placebo group only one subject showed a reaction (3.5%). A statistically significant association between the change of sRt and the cumulative methacholine dose was confirmed in the verum group (p < 0.002), whereas this effect could not be observed in patients challenged with placebo (p = 0.20). Side effects did not occur. We conclude that inhalative challenge with methacholine 0.33% applied as a 5-step-test is suitable to objectify BHR. The substantial benefit of the applied test scheme is the short range of time in which the challenge can be performed (approximately 20 min) and that dilution series of the test substance (methacholine 0.33%) are not required.

Two year follow-up of a garbage collector with allergic bronchopulmonary aspergillosis (ABPA).

BACKGROUND: Separate collection of biodegradable garbage and recyclable waste is expected to become mandatory in some western countries. A growing number of persons engaged in garbage collection and separation might become endangered by high loads of bacteria and fungi. Case history and examination A 29 year old garbage collector involved in emptying so-called biological garbage complained of dyspnea, fever, and flu-like symptoms during work beginning in the summer of 1992. Chest x-ray showed streaky shadows near both hili reaching into the upper regions. IgE- and IgG-antibodies (CAP, Pharmacia, Sweden) were strongly positive for Aspergillus fumigatus with 90.5 kU/L and 186%, respectively. Total-IgE was also strongly elevated with 5430 kU/L. Bronchial challenge testing with commercially available Aspergillus fumigatus extract resulted in an immediate-type asthmatic reaction. Two years later he was still symptomatic and antibodies persisted at lower levels. CONCLUSIONS: Our diagnosis was allergic bronchopulmonary aspergillosis (ABPA) including asthmatic responses as well as hypersensitivity pneumonitis (extrinsic allergic alveolitis) due to exposure to moldy household waste. A growing number of persons engaged in garbage collection and handling are exposed and at risk to develop sensitization to fungi due to exposure to dust of biodegradable waste. Further studies are necessary to show if separate collection of biodegradable waste increases the health risks due to exposure to bacteria and fungi in comparison to waste collection without separation.

[Risk to employees in garbage collection and transport from pathogen exposure]. / Gefährdung von Beschäftigten bei der Abfallsammlung und -abfuhr durch Keimexpositionen.

In a current study funded by the Federal Institute of Occupational Safety and Hygiene the microbial exposure during waste collection and the health of waste collectors are being examined. The investigation of the exposure is carried out in standard experiments and in field studies. It should give information about the extent of emissions of bacteria and fungi spores und confounding factors. Medical examinations of waste collectors will show if there are special health risks attributable to waste collection.

Reduction of latex aeroallergens and latex-specific IgE antibodies in sensitized workers after removal of powdered natural rubber latex gloves in a hospital.

BACKGROUND: Respiratory symptoms of natural rubber latex (NRL) allergy in health care workers (HCWs) have been reported in rooms with a detectable allergen load. Preventive measures have been proposed to reduce the risk of NRL sensitization. OBJECTIVES: Eliminating powdered NRL gloves from the workplace and giving NRL-free material to sensitized workers has been among proposed preventive measures. To appraise the success of such procedures among HCWs, a prospective study was carried out. METHODS: Sensitization of HCWs to NRL was determined by skin prick tests and measurements of specific IgE antibodies. NRL allergen concentrations in room air were measured before and after substitution of powdered NRL gloves with powder-free or synthetic gloves in different departments of a hospital and determined by a competitive inhibition immunoassay. RESULTS: The prevalence of HCWs with positive skin prick test responses and NRL-specific IgE-positive HCWs was 8% (n = 7) among the 90 examined staff members before the intervention started. All 7 reported glove-related allergic symptoms. Six of 7 sensitized subjects had a significant decrease of latex-specific IgE antibody concentrations during follow-up examinations in April and September 1997 (P <.003). Within 24 hours after substitution took place, NRL aeroallergen levels (up to 49.9 ng/m3) fell below the detection limit in areas with synthetic gloves or powder-free NRL gloves alike. Use of asthma medication and antiallergic drugs could be discontinued by 2 HCWs with NRL-related respiratory tract symptoms. CONCLUSIONS: Our results demonstrate that elimination of powdered NRL gloves is a useful device in reducing aerogen NRL allergen loads below the detection limit and permitting sensitized or allergic personnel to remain on the job.

Results of wearing test with two different latex gloves with and without the use of skin-protection cream.

A total of 109 subjects reporting symptoms indicating type I hypersensitivity reactions to natural rubber latex (NRL) gloves was included in this study, and 66 of them had latex-specific IgE antibodies. They underwent provocation tests by wearing two types of NRL gloves with high (n=103) and low (n=75) allergen contents. The first glove type caused positive skin reactions in 30% of IgE-positive and in 3% of IgE-negative subjects. After application of a commercially available skin protection (barrier) cream, the frequencies of positive skin responses in wearing tests increased to 41% and 7%, respectively. The gloves with low allergen content did not cause hypersensitivity without skin-protection cream but induced responses in 5% of IgE-positive subjects when this cream was applied. Corresponding findings were obtained in intraindividual comparisons of test results, which were possible in 69 cases. Of all wearing-test responders, 92% had latex-specific IgE antibodies. Our results demonstrate that high allergen contents in latex gloves frequently elicit skin responses in NRL-sensitized subjects, and that skin-protection creams may favor the uptake of allergens from gloves, thus increasing allergic reactions. The stipulation of a legally binding threshold limit value (TLV) for allergens in NRL products is urgently needed. This TLV should not be set above 2 microg allergen/g rubber.

Can a threshold limit value for natural rubber latex airborne allergens be defined?

BACKGROUND: Recent studies have shown that systemic or respiratory occupational responses to latex can be induced by inhalation of latex aeroallergens. OBJECTIVE: Our objectives were to study the relationship between exposure to different latex aeroallergen levels and type I allergic reactions in subjects with occupational contact with latex and to assess a threshold value for latex airborne allergens required for sensitization and symptom elicitation. METHODS: We screened 145 subjects working in 32 hospitals or operating rooms with different latex aeroallergen levels. The quantified latex aeroallergen concentrations in the 32 rooms were compared with latex-related allergic symptoms. RESULTS: Different latex aeroallergen concentrations could be detected in rooms where powdered latex gloves were used and no effective ventilation systems were installed. In environments with latex aeroallergen levels of 0.6 ng/m3 or greater, the reported workplace-related symptoms were significantly increased (p < 0.02). All 22 subjects with latex-specific IgE antibodies worked in rooms contaminated with latex aeroallergens (p < 0.05). CONCLUSIONS: Our results demonstrate that symptoms and presence of latex-specific IgE antibodies in subjects are significantly associated with measurable levels of latex aeroallergens. A latex aeroallergen level of 0.6 ng/m3 is a critical threshold, especially for health care workers who are sensitized to natural rubber latex.

Relation between occupational asthma case history, bronchial methacholine challenge, and specific challenge test in patients with suspected occupational asthma.

Inhalative methacholine challenge (MC) was performed in 229 subjects presumed to suffer from occupational asthma due to exposure to airborne latex allergens (n = 62), flour (n = 28), isocyanates (n = 114), or irritants in hairdressers' salons (n = 25). They were also subjected to specific challenges with the occupational agents they were exposed to, completed a questionnaire using an abbreviated version of the ATS-DLD, and were interviewed by an experienced physician. Bronchial hyperresponsiveness in MC was defined by the results obtained in a previous study with 81 healthy volunteers. The threshold in these controls was set at a cumulative MC dose of 0.3 mg, corresponding to a sensitivity of 95%. The main purpose of the study was to investigate whether the MC and/or the occupational asthma case history are reliable predictors of the specific challenge test outcomes. In 40-72% of examined subjects, workplace-related asthma complaints occurred, with bronchial hyperreactivity in the MC ranging from 48% to 61%. However, only 12-25% demonstrated a significant bronchoconstructive reaction in the specific challenge test. MC results are only moderately associated with workplace-related asthma case histories. Positive outcomes of challenges with occupational agents are well correlated with positive MC results plus occupational asthma case histories. The combination of MC and occupational asthma case history shows a relatively high specificity (62%, 86%, 80%), but the sensitivity was moderately low (83%, 71%, 52%). MC sensitivities were 92%, 71%, and 62% (case histories of hairdressers were not available). We conclude that in most cases, occupational asthma (as defined by a specific challenge test response) is combined with bronchial hyperresponsiveness and workplace-related asthmatic symptoms. However, subjects of each exposure group demonstrated bronchial hyperresponsiveness and complained of workplace-related asthmatic symptoms, but occupational asthma could not be proved in the specific challenge test. In subjects with a positive occupational asthma case history, a negative MC test result can almost rule out a positive specific challenges test result. Hence, the MC test can reduce performance of the laborious specific challenge test.

[Exposure testing with powdered gloves in 60 health care workers with latex allergy]. / Expositionstestungen mit gepuderten Handschuhen bei 60 Latexallergikern aus dem Gesundheitswesen.

BACKGROUND AND OBJECTIVE: Type 1 sensitization to natural rubber latex occurs in up to 22% of health care workers. Most sensitizations are due to the use of powdered latex gloves. Work place-associated exposure tests were performed to ascertain how frequently persons who developed breathing difficulties, rhinitis/conjunctivitis or obstructive respiratory tract illness when using powdered latex gloves are allergic to latex. PATIENTS AND METHODS: 60 persons (48 women and 12 men; mean age 29 +/- 7 years) with type 1 sensitization to natural rubber latex were studied. The past history was obtained through a questionnaire specially designed for those with latex allergy. Diagnostic measures included prick tests with different latex allergens, measuring the concentrations of total and latex-specific IgE and exposure trials, related to the work place, with powdered vinyl and latex gloves. RESULTS: The prick tests with various latex allergens produced significant skin reactions in 59 subjects, 58 had latex-specific IgE antibodies (0.47 kU/l- > 100 kU/l). Exposure tests with powdered latex gloves produced rhinitis in 55 and conjunctivitis in 38 persons, urticaria in 3 and cough in 19. Whole-body plethysmography demonstrated a significant rise in respiratory tract resistance in 13, a reduction in 1-second expiratory volume of at least 20% in 15. Abnormal values in both tests were noted in 8 subjects. CONCLUSION: The breathing difficulty reported by all subjects was in most cases due not to bronchial obstruction but to obstructed nasal breathing. In cases with breathing difficulty on exposure to latex gloves a latex allergy should be considered as the cause. Powdered latex gloves present a danger to health care personnel and should no longer be used.

Lymphocyte proliferation response to extracts from different latex materials and to the purified latex allergen Hev b 1 (rubber elongation factor).

BACKGROUND: Type I allergy to latex is a growing problem, especially among health care workers. A detailed study of the peripheral blood cell responses to latex allergens has not been reported. METHODS: Peripheral blood mononuclear cells of patients and healthy subjects were isolated and stimulated with protein extracts from latex sap and latex gloves and the purified latex allergen Hev b 1 (rubber elongation factor) at different concentrations to determine the antigen-specific proliferation response. The examined patients were sensitized to latex by occupational exposure (n = 23) and had rhinitis, conjunctivitis, contact urticaria, and/or asthma. Two control groups of nonsensitized subjects were studied: one occupationally exposed to latex (n = 8), and the second, not exposed to latex (n = 8). RESULTS: In general, only latex-exposed subjects responded to the different latex antigen preparations. Lymphocyte proliferation responses to latex sap extract were found in 65% of latex-sensitized subjects and in 37.5% of the latex-exposed healthy subjects. Latex glove extract induced a significant proliferative responses in 47.8% of latex-sensitized patients and in 25% of the latex-exposed individuals. Hev b 1 induced lymphocyte proliferation responses in 52% of the latex-sensitized patients and in 25% of the latex-exposed subjects indicating that Hev b 1 is relevant antigen in these latex-sensitized and latex-exposed groups. Peripheral blood mononuclear cells of 39.1% of the latex-sensitized subjects responded to all three allergen preparations (latex sap and latex glove extract, as well as Hev b 1). We could find no correlation between latex-specific IgE level and latex-induced lymphocyte proliferation response. CONCLUSION: Our data indicate that the 14 kd protein Hev b 1 is a relevant allergen in health care workers. It can be detected by specific IgE antibodies to Hev b 1, as well as in lymphocyte proliferation assay. In addition, our study suggests that antigen-specific proliferation response to latex is associated with exposure to latex, but not with the level of specific latex IgE. This may be useful for the evaluation and prediction of latex hypersensitivity development.

[The latency period between exposure and the symptoms in allergy to natural latex. Suggestions for prevention]. / Latenzzeit zwischen Exposition und Symptomen bei Allergie gegen Naturlatex. Vorschläge zur Prävention.

BASIC PROBLEM AND OBJECTIVE OF STUDY: Among persons working in the health care system allergies caused by natural rubber latex (NRL) are more common than among the general population, because the frequent use of latex gloves and other latex articles may cause sensitisation. A retrospective study was undertaken to determine the period before such an allergy occurs. PATIENTS AND METHODS: 63 patients (53 women and 10 men; mean age 31.3 +/- 8.3 years) with symptoms of type 1 (immediate response; IgE-mediated) allergy to NRL filled in a special questionnaire asking, among other items, about occupational history, duration and frequency of contact with latex gloves, as well as the course of occupational or other symptoms. All but five of the group had been in their job for less than 15 years. A prick test with 21 ubiquitous environmental allergens was performed on 62 of the patients. RESULTS: Two thirds of the patients had atopy. First symptoms of an allergy to latex developed at an average of 5 years (58.7 +/- 59.3 months) after starting work involving contact with latex products. In 59 persons the first symptoms were contact urticaria, in some together with rhinitis or dyspnea. The interval until onset of symptoms relating to the lower respiratory tract averaged a further 25.3 +/- 34.6 months. Symptoms developed earlier in patients with atopy than in those without (51.9 +/- 54.3 vs 76 +/- 69 months). CONCLUSIONS: The use of powdered natural rubber latex gloves should be discontinued to prevent the increasing incidence of sensitization to aerogenic latex and to protect those already sensitized from developing allergic bronchial asthma.