The aim of this study was to investigate health symptoms in sewage treatment workers. A health questionnaire was distributed among 147 sewage treatment workers. Correlating symptoms were clustered using principal component analysis and the association with self-reported exposure was assessed by calculating prevalence odds ratios (OR). Endotoxin was measured in two treatment plants. Personal endotoxin exposure was low (<10 Endotoxin Units/m³). Factor analysis of 29 symptoms resulted in four clusters of highly correlating symptoms: 'flu-like symptoms'; 'higher airway symptoms'; 'lower airway symptoms'; and 'neurological symptoms'. These clusters were positively associated with working with sewage, but only significant for 'flu- like symptoms' (OR=5.0; 95%CI=1.4-17.6; p<0.05) and 'neurological symptoms' (OR=4.2; 95%CI=1.5-11.7; p<0.01). Chemical exposure was associated with 'neurological symptoms' (OR=8.4; 95%CI=1.1-65.7; p<.05). The use of daily washed working clothes was negatively associated with 'flu-like symptoms' (OR=0.3; 95%CI=0.1-0.6; p<0.01). In conclusion, sewage treatment workers develop a large variety of work-related symptoms that are not likely caused by endotoxin exposure only. Good hygienic practice at the workplace may prevent some of these symptoms