Community-acquired pneumonia and welding

Editor – We read with interest the recent review of community-acquired pneumonia (CAP) (Clin Med December 2012 pp 538–43) and write to draw attention to a relatively neglected risk factor for CAP that physicians may wish to learn about.

Relative to their social class peers, welders have been dying of pneumonia in excess for at least eight decades.¹ Evidence for this comes mainly from successive national analyses of occupational mortality in England and Wales, which have clarified that risk particularly relates to lobar and pneumococcal pneumonia, and is short-term and reversible (evident in current welders but not in retired welders).^2,3 Welders are also more commonly admitted to hospital with CAP, especially lobar pneumonia, as demonstrated by a large case-control study from the West Midlands.⁴ Risks in relation to microbiologically confirmed pneumococcal infection tripled, although were also apparent for a range of other microorganisms, including Legionella, Mycoplasma and Haemophilus influenzae.⁴ Similar reports relating to lobar and pneumococcal infection in welders subsequently emerged from Sweden⁵ and Canada.⁶

Britain has some 70,000 at-risk workers in welding occupations. Other at-risk groups include a range of workers who share occupational exposure to metal fumes in common (eg moulders and core makers, and furnace men in foundries).^2,3

In response to growing evidence on risk, the Joint Committee on Vaccination and Immunisations (JCVI), on behalf of the Department of Health in England, recommended in 2011 that all welders be offered a single dose of the pneumococcal polysaccharide vaccine PPV-23.⁷ This advice was modified in 2012, extending recommended use to a broader range of workers with exposure to metal fumes. Further details and a discussion of the potential strengths and limitations of PPV-23 vaccination in at-risk occupations have been published elsewhere.¹

• © 2013 Royal College of Physicians