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Respiratory symptoms and pulmonary function among cotton textile workers at Misr Company for Spinning and Weaving EL-Mahalla, Egypt
Egyptian Journal of Chest Diseases and Tuberculosis 66 (2017) 369–376
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Respiratory symptoms and pulmonary function among cotton textile workers at Misr Company for Spinning and Weaving EL-Mahalla, Egypt Mohamed Awad Tageldin a, Ashraf Adel Gomaa a,⇑, Eman Ahmed Mohammed Hegazy b a b
Chest Department, Faculty of Medicine, Ain Shams University, Egypt EL-Mahalla Chest Hospital, Egypt
a r t i c l e
i n f o
Article history: Received 4 March 2017 Accepted 12 March 2017 Available online 5 April 2017 Keywords: Cotton Spirometric functions Spinning Weaving Carding Cotton bales
a b s t r a c t Background: This study aimed to assess the effect of cotton dust on respiratory symptoms and spirometric functions test among cotton textile workers. Patients and Methods: This prospective study was conducted at El-Mahalla Chest Hospital on 115 subjects (100 workers exposed to cotton dust from Misr Company for Spinning and Weaving and 15 healthy subject not exposed to cotton dust). All subjects, were subjected to a standardized questionnaire which was patterned according to American Thoracic Society questionnaire and spirometric functions test [Forced expiratory in the first second (FEV1), forced vital capacity (FVC), FEV1/FVC ratio, peak expiratory flow rate (PEFR)% and maximum midexpiratory flow (MMEF) %]. Results: There was a highly significant statistical difference on comparing presence of respiratory symptoms between control group and cotton exposed groups. There was significant statistical difference on comparing the presence of respiratory symptoms between control group and weaving, spinning, opening of cotton bales and carding groups. Respiratory symptom was the highest prevalent in spinning and weaving workers. Cough, expectoration and chest tightness were the highest prevalent symptoms in cotton exposed groups. Cough, expectoration were the highest prevalent in spinning and weaving workers. There was significant statistical difference on comparing FEVI%, FVC%, FVC/FEV1% and PEFR % between control group and cotton exposed groups. There was no significant statistical difference on comparing MMEF% between control group and cotton exposed groups. There was positive correlation between presence of respiratory symptoms and duration of exposure to cotton dust, the longer the duration of exposure to cotton dust the higher the presence of respiratory symptoms. There was no correlation between period of exposure to cotton dust and spirometric functions. Conclusion: Cotton workers are at risk for developing respiratory symptoms. Respiratory symptoms was highest prevalent in worker works at spinning and weaving. Spirometric functions were less in cotton exposed workers as compared to control. Ó 2017 The Egyptian Society of Chest Diseases and Tuberculosis. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-ncnd/4.0/).
Introduction Textile industry is one of the most vital industries in Egypt. The workers are exposed to different environmental factors, especially in the spinning and weaving sections, which play a role in the high incidence of industrial health hazards [1]. Industrial production of textiles, occupational exposures to the raw materials, cotton dust and products of several chemicals, had been associated with respiratory tract infections, bronchoconstriction, cough, excessive Peer review under responsibility of The Egyptian Society of Chest Diseases and Tuberculosis. ⇑ Corresponding author. E-mail address: [email protected] (A.A. Gomaa).
mucus, nasal stuffiness, and nocturnal asthma [2]. Byssinosis has been defined as a respiratory disease associated with inhalation of cotton, flax, and hemp. The disease is found in many cotton processing countries. Some called it cotton dust asthma. Chest tightness, cough, wheezing, and dyspnea in varying degrees are the initial symptoms. The characteristic symptoms of byssinosis are shortness of breath and tightness of the chest on returning to the work after a period of absence [3]. Byssinosis is characterized clinically as occasional (early) and then regular (late) chest tightness toward the end of the first day of work week (Monday chest tightness) [3]. Various longitudinal and cross-sectional studies have shown changes in lung functions in cotton textile workers as compared to controls. These studies have shown that there is
http://dx.doi.org/10.1016/j.ejcdt.2017.03.004 0422-7638/Ó 2017 The Egyptian Society of Chest Diseases and Tuberculosis. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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a decline in FEV1 and FVC values across a work shift especially on Monday [4]. This study aimed to assess the effect of cotton dust on respiratory symptoms and spirometric functions test among cotton textile workers. Patients and methods This study was conducted at El-Mahalla Chest Hospital on 115 subjects (100 workers exposed to cotton dust from Misr Company for Spinning and Weaving and 15 healthy subject not exposed to cotton dust in the period from July 2013 to February 2014. The study protocol was approved by ethical committee Faculty of Medicine, Ain Shams University. These subjects were classified in to 5 groups: Group I (control group): 15 healthy subjects not exposed to cotton dust. Group II (weaving group): 25 workers works at weaving. Group III (spinning group): 25 workers works at spinning. Group IV (opening of cotton bales group): 25 workers works at opening of cotton bales. Group V (carding group): 25 workers works at carding. Exclusion criteria
Statistical analysis Data were tabulated, coded then analyzed using the computer program SPSS (Statistical package for social science) version 17.0 to obtain. Descriptive statistics were calculated in the form of: mean Standard deviation (SD) for parametric data. Median and range (Minimum–maximum) for non-parametric data. Frequency (Number-percent) for qualitative data. Analytical statistics In the statistical comparison between the different groups, the significance of difference was tested using one of the following tests: ANOVA (analysis of variance): Used to compare between more than two groups of numerical (parametric) data followed by post-hoc tukey for multiple comparisons. Mann-Whitney U test: Used to compare between two groups of numerical (nonparametric) data. Kruskal-wallis test: Used to compare between more than two groups of numerical (non-parametric) data. Intergroup comparison of categorical data was performed by using chi square test (X2-value). Pearson’s correlation coefficient Ò test was used correlating different parameters. A P value <0.05 was considered statistically significant and a P value <0.0001 was considered highly significant in all analyses. Results
1. Previous exposure to other occupational dust such as Silica, Coal dust. 2. Those with history of smoking. 3. Those with previous history of asthma or COPD before Joining to the work. Patients were subjected to the following:1. Full history taken. 2. A standardized questionnaire was patterned according to American Thoracic Society (ATS) questionnaire [5]. Questionnaire collected general information, complete occupational history and exposure, respiratory symptoms such as (cough, expectoration (sputum), wheezing, dyspnea, chest tightness), and smoking history in addition to past illness. 3. Physical measurements: including weight, and height of each subject and body mass index (BMI). 4. Clinical examination of chest. 5. Plain chest X ray (postero-anterior) view. 6. Spirometric pulmonary functions test aimed at establishing the status of the respiratory system including forced expiratory in the first second (FEV1), forced vital capacity (FVC), FEV1/FVC ratio, peak expiratory flow rate (PEFR)% and maximum midexpiratory flow (MMEF)% were measured using the spirometry system (CHEST GRAPH H I – 105-Japan) according to the guidelines of the American Thoracic Society (ATS) [6].
This study included 115 subjects who were classified into 5 groups: control group I, weaving group II, spinning group III, opening of cotton bales group IV, carding group V. Sex distribution among different groups Sex distribution among different groups are shown in Table 1. There was no significant statistical difference on comparing age between different groups, also there was no significant statistical difference on comparing body mass index between different groups (Table 2). There was a highly significant statistical difference on comparing presence of respiratory symptoms between control group and cotton exposed groups (Table 3). While, comparison between control group and other groups as regard presence of respiratory symptoms are presented in Table 4. Respiratory symptoms were more prevalent in spinning and weaving workers. There was significant statistical difference on comparing the presence of respiratory symptoms between control group and weaving, spinning, opening of cotton bales and carding groups. There was no significant statistical difference on comparing the presence of respiratory symptoms between weaving and spinning, opening of cotton bales and carding workers. There was no significant statistical difference on comparing the presence of respiratory symptoms between spinning and opening of cotton bales and carding workers. There was no significant statistical difference on comparing the presence of respiratory symptoms between opening of cotton bales and carding workers. Respiratory symptoms in different cotton exposed groups by nature of the work are illustrated in Fig. 1. Cough, expectoration
Table 1 Sex distribution among different groups. Workers Control
Gender
Male Female Total
Opening of cotton bales
Carding
No
%
No
Weaving %
No
Spinning %
No
%
No
%
10 5 15
66.7% 33.3% 100.0%
17 8 25
68.0% 32.0% 100.0%
18 7 25
72.0% 28.0% 100.0%
19 6 25
76.0% 24.0% 100.0%
20 5 25
80.0% 20.0% 100.0%
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M.A. Tageldin et al. / Egyptian Journal of Chest Diseases and Tuberculosis 66 (2017) 369–376 Table 2 Comparison between control and cotton exposed groups as regard age and body mass index. Workers Control
Weaving
Spinning
Opening of cotton bales
Carding
ANOVA P
Age (years)
Mean SD
39.33 ±6.69
41.60 ±11.51
42.72 ±12.99
38.32 ±12.65
41.56 ±11.09
0.67
BMI
Mean SD
25.67 ±3.27
24.62 ±1.33
25.44 ±2.89
26.18 ±4.65
25.04 ±2.34
0.45
P: Probability, Test used: ANOVA, SD: standard deviation.
Table 3 Comparison between control and cotton exposed groups as regard presence of respiratory symptoms. Symptoms
P
No
Control Exposed
Yes
No
%
No
%
15 41
100.0% 41.0%
0 59
0.0% 59.0%
<0.0001**
P: Probability, Test used: Qui-square test. ** High significance.
Table 4 Comparison between control group and other groups as regard presence of respiratory symptoms. Respiratory symptoms No
Yes
P
P1
<0.0001**
<0.001*
P2
P3
P4
0.05 0.07
0.8
Total
No
%
No
%
No
Control Weaving Spinning Opening of cotton bales
15 10 6 13
100% 40% 24% 52%
0 15 19 12
0.0% 60% 76% 48%
15 25 25 25
Carding
12
48%
13
52%
25
<0.001*
0.2
0.001* <0.001*
0.4 0.6
Test used: Qui-square test, P: Probability. P1: significance relative to control group. P2: significance relative to Weaving group. P3: significance relative to Spinning group. P4: significance relative to opening of cotton bales group. * Significance. ** High significance.
Fig. 1. Respiratory symptoms in different cotton exposed groups by nature of the work.
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Table 5 Comparison between control group and cotton exposed groups as regard forced expiratory volume in 1st second % (FEV1%). Workers
FEV1%
Mean SD
Control
Weaving
Spinning
Opening of cotton bales
Carding
ANOVA P
85.00 2.62±
74.60 ±10.25 <0.0001**
75.20 ±8.68 0.001* 0.99
77.55 ±6.33 0.02* 0.63 0.8
76.72 ±5.84 0.009* 0.86 0.95 0.99
0.009*
P1 P2 P3 P4 P: Probability, Test used: ANOVA, SD: standard deviation. P1: P4 comprise post hoc tukey. P1: significance relative to control group. P2: significance relative to Weaving group. P3: significance relative to Spinning group. P4: significance relative to opening of cotton bales group. * Significance. ** High significance.
Table 6 Comparison between control group and cotton exposed groups as regard forced vital capacity % (FVC%). Workers
FVC%
Mean SD
Control
Weaving
Spinning
Opening of cotton bales
Carding
ANOVA P
85.07 ±2.34
74.61 ±10.22 <0.0001**
78.15 ±5.35 0.001* 0.003
77.32 ±4.29 <0.0001** 0.62 0.98
76.41 ±6.64 <0.001* 0.095 0.77 0.97
<0.0001**
P1 P2 P3 P4 P: Probability, Test used: ANOVA, SD: standard deviation. P1: P4 comprise post hoc tukey. P1: significance relative to control group. P2: significance relative to Weaving group. P3: significance relative to Spinning group. P4: significance relative to opening of cotton bales group. * Significance. ** High significance.
Table 7 Comparison between control group and cotton exposed groups as regard FEV1/FVC%. Workers
FEV1/FVC
Mean SD
Control
Weaving
Spinning
Opening of cotton bales
Carding
ANOVA P
83.60 ±3.14
75.31 ±7.52 0.001*
73.21 ±8.47 <0.0001** 0.7
77.70 ±4.21 0.03* 0.6 0.07
75.90 ±4.29 0.002* 0.99 0.5 0.8
<0.0001**
P1 P2 P3 P4 P: Probability, Test used: ANOVA, SD: standard deviation. P1: P4 comprise post hoc tukey. P1: significance relative to control group. P2: significance relative to Weaving group. P3: significance relative to Spinning group. P4: significance relative to opening of cotton bales group. * Significance. ** High significance.
and chest tightness were more prevalent in cotton exposed groups. Cough, expectoration and chest tightness were more prevalent in spinning and weaving workers. Comparison between control group and cotton exposed groups as regard forced expiratory volume in 1st second % (FEV1%) are shown in Table 5. There was significant statistical difference on comparing FEV1% between control group and weaving, spinning, opening of cotton bales, and carding groups. There was no significant statistical difference on comparing FEV1% between weaving and spinning, opening of cotton bales and carding workers. There was no significant statistical difference on comparing FEV1%
between spinning and opening of cotton bales and carding workers. There was no significant statistical difference on comparing FEV1% between opening of cotton bales and carding workers. Comparison between control group and cotton exposed groups as regard forced vital capacity% (FVC%) are plotted in Table 6. There was significant statistical difference on comparing FVC% between control group and weaving, spinning, opening of cotton bales and carding groups. There was no significant statistical difference on comparing FVC% between weaving and spinning, opening of cotton bales and carding workers. There was no significant statistical difference on comparing FVC% between spinning and opening of
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M.A. Tageldin et al. / Egyptian Journal of Chest Diseases and Tuberculosis 66 (2017) 369–376 Table 8 Comparison between control group and cotton exposed groups as regard peak expiratory flow rate %(PEFR%). Workers
PEFR%
Mean SD
Control
Weaving
Spinning
Opening of cotton bales
Carding
ANOVA P
78.53 ±2.77
69.72 ±6.14 <0.0001**
67.28 ±4.75 <0.0001** 0.3
70.56 ±3.63 <0.0001** 0.96 0.07
67.76 ±3.46 <0.0001** 0.5 0.99 0.17
<0.0001**
P1 P2 P3 P4 P: Probability, Test used: ANOVA, SD: standard deviation. P1: P4 comprise post hoc tukey. P1: significance relative to control group. P2: significance relative to Weaving group. P3: significance relative to Spinning group. P4: significance relative to opening of cotton bales group. ** High significance.
Table 9 Correlation between period of exposure to cotton dust and respiratory symptoms. Respiratory symptoms
P
No
Exposure period (years)
Yes
Median
Range
Median
Range
12.00
3.00–34.00
24.00
5.00–35.00
0.001*
P: Probability, Test used: Mann-Whitney. * High significance.
Fig. 2. Correlation between period of exposure to cotton dust and spirometric functions.
cotton bales and carding workers. There was no significant statistical difference on comparing FVC% between opening of cotton bales and carding workers. Comparison between control group and cotton exposed groups as regard FEV1/FVC% are shown in Table 7. There was significant statistical difference on comparing FEV1/FVC% between control group and weaving, spinning, opening of cotton bales and carding groups. There was no significant statistical difference on compar-
ing FEV1/FVC% between weaving and spinning, opening of cotton bales and carding workers. There was no significant statistical difference on comparing FEV1/FVC% between spinning and opening of cotton bales and carding workers. There was no significant statistical difference on comparing FEV1/FVC% between opening of cotton bales and carding workers. There was highly significant statistical difference on comparing PEFR% between control group and weaving, spinning, opening of
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Table 10 Comparison between control group and cotton exposed groups as regard spirometric functions. Control
FVC% FEV1% FEV1/FVC% PEFR% MMEF%
Exposed
P
Median
Minimum
Maximum
Median
Minimum
Maximum
85.00 86.00 85.00 78.00 85.00
82.00 81.00 78.00 75.00 80.00
92.00 89.00 88.00 84.00 91.00
76.38 78.95 77.00 70.00 80.00
59.25 48.00 53.25 60.00 77.00
88.02 91.00 85.00 79.00 90.00
<0.001* <0.001* <0.001* <0.001* 0.11
Test used: Mann-Whitney, P: Probability. * High significance.
Fig. 3. Spirometric functions in cotton exposed workers.
cotton bales and carding groups. There was no significant statistical difference on comparing PEFR% between weaving and spinning, opening of cotton bales and carding workers. There was no significant statistical difference on comparing PEFR% between spinning and opening of cotton bales and carding workers. There was no significant statistical difference on comparing PEFR% between opening of cotton bales and carding workers (Table 8). There was no significant statistical difference on comparing MMEF% between control group and other groups (p = 0.7). There was positive correlation between period of exposure to cotton dust and respiratory symptoms. The longer the duration of exposure to cotton dust the higher the presence of respiratory symptoms (Table 9). There was no correlation between period of exposure to cotton dust and spirometric functions Fig. 2. Comparison between control group and cotton exposed groups as regard spirometric functions are shown in Table 10. There was significant statistical difference on comparing (FEV1%, FVC%, FEV1/FVC% and PEFR%) between control group and cotton exposed groups, also there was no significant statistical difference on comparing MMEF% between control group and cotton exposed groups. Spirometric functions patterns in cotton exposed workers are illustrated in Fig. 3. Discussion Cotton spinning industry is the most important industry in Egypt, with rapid industrialization and mechanization in textile industries occupational health hazards are becoming more prominent. Respiratory tract diseases represent the most important group of occupational diseases in spinning factories as a result of inhalation of cotton fibers and dust in work place [7]. Invisible small cotton dust particles enter into the alveoli of the lung through inhalation and accumulate in the lymph causing damage to the alveoli and reducing the capacity of retain oxygen. As the cotton dust accumulates the worker develops a brown lung and suffers from byssinosis [8].
Cotton workers are at risk for occupational lung disease, including byssinosis and chronic bronchitis. The initial phase of byssinosis is characterized by acute reversible symptoms, such as wheezing, chest tightness, shortness of breath, or cough, and is typically evident on the first day back to work after an absence of 48 h or more, these early symptoms are generally accompanied by reversible changes in pulmonary function, with continued exposure the disease may progress to a stage in which symptoms are present throughout the work week and may eventually result in severe pulmonary disability [9]. In addition excess nonspecific respiratory symptoms such as chronic cough, phlegm, and dyspnea were reported in cotton textile workers compared with non exposed populations [10,11]. This study was done to observe the effects of cotton dust on respiratory symptoms and spirometric functions among cotton workers. In the present study the prevalence of respiratory symptoms was higher in exposed group as compared to control group (59.0% vs 0.0%) probably due to inhalation of cotton dust. The prevalence of respiratory symptoms varied among various sections of the company, with the highest respiratory symptoms among spinning workers (76.0%) and weaving workers (60.0%). This was probably because these sections were dustier than other sections. Cough was found in (35.0%) of workers, expectoration was found in (22.0%) of all exposed workers so cough and expectoration were the most prevalent symptoms in this study. The results of this study were in agreement with the results of the study done by Abdel Rahman, et al., whom studied the effect of exposure to cotton dust on health of workers in ESCO Company in Kaliubia on 150 cotton workers and 81 subjects as control group. Their results showed higher prevalence of chest symptoms among exposed workers than control [12]. Also the results of the current study were matched with the results of the study done by Khan, et al. whom studied 800 workers in Pakistani cotton industry and found that the prevalence of respiratory symptoms was high in cotton exposed workers [13]. These results were also compatible with the results carried out by Hinson et al. which was done on 109 workers exposed to cotton dust and 107 unexposed workers in Company of Textile of Benin, and found that the exposed workers had significantly more respiratory symptoms compared to the unexposed workers [14]. Also these results coincide with the results of the study done by Osibogun et al. whom studied the prevalence of respiratory problems among textile mill workers in Asaba, Nigeria. Their results showed that the prevalence of respiratory symptoms in the exposed group were higher than in the control group (38%), and cough, phlegm were most common symptoms [15]. The results of this study were in agreement with the results of the study done by Raza et al. (1999) in Lancashire textile weavers, England who found that the prevalence of respiratory symptoms was high in the spinning department, and workers in the spinning
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department were more likely than other departments to have cough, phlegm, chest tightness and dyspnea [16]. Also the results of the current study were compatible with the results of the study done by Ghasemkhani et al. on 880 cotton workers who work in cotton industries of south Tehran, Iran, and found that the prevalence of respiratory symptoms was high among textile industrial workers, and cough was present in (30.8%), phlegm was present in (53.8%) of cotton workers [17]. Also these results were the same results of the study carried out by Alemu et al. whom studied the prevalence of respiratory symptoms among workers in cotton mills of Akaki textile factory Ethiopia, who found that the prevalence of respiratory symptoms were high in the spinning department [18]. The results of this study coincide with the results of the study done by Nagoda et al. whom studied 200 workers exposed to cotton dust and 200 unexposed workers in Kano, Nigeria, and their results showed that exposed workers generally complained of cough, phlegm production, wheezing, and breathlessness, also their results showed higher prevalence of respiratory symptoms in the spinning and weaving sections [19]. In this study FEV1%, FVC%, FEV1/FVC%, and PEFR% were significantly less in cotton workers as compared to controls also MMEF% didn’t differ significantly between cotton workers and controls. This may be due to endtoxin present in cotton which responsible for inflammation of airway, also chronic occupational exposure to endotoxin is associated with faster decline in lung functions. These results were in agreement with the results of the study done by Abebe and Seboxa on 433 workers whom were occupationally exposed to cotton dust in Bahr Dar textile mill, north-west Ethiopia and 101 non exposed workers were included as controls, and they found that FEV1 and FVC were a significant reduced in the exposed groups compared with controls [20]. Also these results coincide with the results of the study done by Aminian et al. on 140 cotton textile workers and 150 office workers as control group to evaluate the effect of exposure to cotton dust on respiratory health and pulmonary function in Tehran, Iran. Their results showed that cotton workers had more respiratory symptoms as compared to control groups and greater declines were seen in forced vital capacity (FVC), forced expiratory volume in first second (FEV1) and FEV1/FVC in cotton workers [21]. These results were compatible with the results carried out by Hinson, et al. whom studied the prevalence of byssinosis among cotton workers in the north of Benin. Their results showed that the exposed workers had a lower FEV1 compared to the unexposed workers [14]. Also these results were the same results of the study carried out by Nagoda et al. whom found that FEV1, FVC, PEFR were significantly lower in cotton workers as compared to control [19]. The results of the current study were matched with the results of the study carried out by Jiang et al. on 1320 cotton textile workers and 1306 controls in China. Their results showed fall of FEV1 and FEV1/FVC in cotton textile workers as compared by control. Also the prevalence of respiratory abnormalities was increased with duration of exposure to cotton dust [22]. Also the results of this study were in agreement with the results of the study done by Abdel Rahman et al. whom found that the FEV1% was significantly lower among exposed workers than control [12]. These results were in agreement with the results of the study done by Narsimha and Tandon on 198 textile workers and 50 subjects as control, and found that FEV1 was significantly lower in exposed group as compared to control [23]. Also these results were compatible with the results of the study carried by Singh et al. whom studied the lung functions among 7 cotton spinners exposed to cotton and 7 subjects as
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control. Their results showed that PEFR was significantly lower in cotton spinners as compared to control [24]. These results coincide with the results reported by Ahasan et al. whom studied 210 subjects working in textile mills in Bangladesh, and found that PEFR was low in exposed groups as compared to control [25]. Also these results were in agreement with the results of study done by Anupama and Kammar on 100 cotton workers and 100 subjects not exposed to cotton, and they found that FVC, FEV1, FEV1/FVC, PEFR were significantly lower in cotton workers as compared to controls, also no statistically significant difference on MMEF in cotton workers and control [26]. In this study there was positive correlation between respiratory symptoms and duration of exposure to cotton dust, the longer the duration of exposure the higher presence of respiratory symptoms. These results were compatible with the results of the study carried by Nectarios et al. in the cotton textile industry of Greece, who found that the frequency of cough, phlegm, dyspnea, were affected by duration of exposure to cotton dust [27]. Also the results of the current study were matched with the results of the study done by Abdel Rahman et al. who found that the longer the duration of exposure to cotton dust the more chest symptoms [12]. Also these results were in agreement with the results of the study carried out by Venkatakrishna Bhatt et al. on 24 cotton workers compared with 15 subjects not exposed to cotton dust. Their results showed that the duration of constant exposure to cotton dust is an important factor in causation and development of respiratory symptoms [28]. These results were similar to the results of the study done by Cinkotai et al. whom studied the prevalence of respiratory symptoms in the Lancashire textile industry England, and found that respiratory symptoms were related to years in the industry and degree of dust exposure [29]. In the present study there was no correlation between spirometric functions (FVC%, FEV1%, PEFR%, FEV1/FVC, and MMEF%) and duration of exposure to cotton dust. These results were compatible with the results of study carried out by Nagoda et al. whom studied the prevalence of respiratory symptoms and pulmonary functions among textile workers in Kano, Nigeria, and found that there is no correlation between pulmonary function (PEFR, FVC, FEV1 and FEV1/FVC ratio) and duration of employment in the factory [19]. Also these results were in agreement with the results of study done by Anupama and Kammar whom found that the PEFR was decreased significantly with increase in duration of exposure to cotton dust, also no other spirometric functions showed a significant correlation with duration of exposure to cotton dust [26]. In the present study spirometric functions in cotton exposed workers showed that normal pattern present in 82 (82%) of workers, obstructive pattern present in 9 (9%) of workers, restrictive pattern present in 5 (5%) of workers and mixed pattern present in 4 (4%) of cotton exposed workers. These results were compatible with the results of study carried out by Nagoda et al. whom found that an obstructive pattern present in (10%) exposed workers on spirometry and a restrictive pattern present in (40%) exposed workers [19]. Also these results were in agreement with the results of study done by Aminian et al. whom found that (77.66%) of cotton exposed workers had normal pulmonary functions pattern and (22.34%) had abnormal pattern on spirometry [21]. In conclusion, cotton workers are at risk for developing respiratory symptoms. Respiratory symptoms was highest prevalent in worker works at spinning and weaving. Spirometric functions were less in cotton exposed workers as compared to control.
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Respiratory symptoms and pulmonary function among cotton textile workers at Misr Company for Spinning and Weaving EL-Mahalla, Egypt Mohamed Awad Tageldin a, Ashraf Adel Gomaa a,⇑, Eman Ahmed Mohammed Hegazy b a b
Chest Department, Faculty of Medicine, Ain Shams University, Egypt EL-Mahalla Chest Hospital, Egypt
a r t i c l e
i n f o
Article history: Received 4 March 2017 Accepted 12 March 2017 Available online 5 April 2017 Keywords: Cotton Spirometric functions Spinning Weaving Carding Cotton bales
a b s t r a c t Background: This study aimed to assess the effect of cotton dust on respiratory symptoms and spirometric functions test among cotton textile workers. Patients and Methods: This prospective study was conducted at El-Mahalla Chest Hospital on 115 subjects (100 workers exposed to cotton dust from Misr Company for Spinning and Weaving and 15 healthy subject not exposed to cotton dust). All subjects, were subjected to a standardized questionnaire which was patterned according to American Thoracic Society questionnaire and spirometric functions test [Forced expiratory in the first second (FEV1), forced vital capacity (FVC), FEV1/FVC ratio, peak expiratory flow rate (PEFR)% and maximum midexpiratory flow (MMEF) %]. Results: There was a highly significant statistical difference on comparing presence of respiratory symptoms between control group and cotton exposed groups. There was significant statistical difference on comparing the presence of respiratory symptoms between control group and weaving, spinning, opening of cotton bales and carding groups. Respiratory symptom was the highest prevalent in spinning and weaving workers. Cough, expectoration and chest tightness were the highest prevalent symptoms in cotton exposed groups. Cough, expectoration were the highest prevalent in spinning and weaving workers. There was significant statistical difference on comparing FEVI%, FVC%, FVC/FEV1% and PEFR % between control group and cotton exposed groups. There was no significant statistical difference on comparing MMEF% between control group and cotton exposed groups. There was positive correlation between presence of respiratory symptoms and duration of exposure to cotton dust, the longer the duration of exposure to cotton dust the higher the presence of respiratory symptoms. There was no correlation between period of exposure to cotton dust and spirometric functions. Conclusion: Cotton workers are at risk for developing respiratory symptoms. Respiratory symptoms was highest prevalent in worker works at spinning and weaving. Spirometric functions were less in cotton exposed workers as compared to control. Ó 2017 The Egyptian Society of Chest Diseases and Tuberculosis. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-ncnd/4.0/).
Introduction Textile industry is one of the most vital industries in Egypt. The workers are exposed to different environmental factors, especially in the spinning and weaving sections, which play a role in the high incidence of industrial health hazards [1]. Industrial production of textiles, occupational exposures to the raw materials, cotton dust and products of several chemicals, had been associated with respiratory tract infections, bronchoconstriction, cough, excessive Peer review under responsibility of The Egyptian Society of Chest Diseases and Tuberculosis. ⇑ Corresponding author. E-mail address: [email protected] (A.A. Gomaa).
mucus, nasal stuffiness, and nocturnal asthma [2]. Byssinosis has been defined as a respiratory disease associated with inhalation of cotton, flax, and hemp. The disease is found in many cotton processing countries. Some called it cotton dust asthma. Chest tightness, cough, wheezing, and dyspnea in varying degrees are the initial symptoms. The characteristic symptoms of byssinosis are shortness of breath and tightness of the chest on returning to the work after a period of absence [3]. Byssinosis is characterized clinically as occasional (early) and then regular (late) chest tightness toward the end of the first day of work week (Monday chest tightness) [3]. Various longitudinal and cross-sectional studies have shown changes in lung functions in cotton textile workers as compared to controls. These studies have shown that there is
http://dx.doi.org/10.1016/j.ejcdt.2017.03.004 0422-7638/Ó 2017 The Egyptian Society of Chest Diseases and Tuberculosis. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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a decline in FEV1 and FVC values across a work shift especially on Monday [4]. This study aimed to assess the effect of cotton dust on respiratory symptoms and spirometric functions test among cotton textile workers. Patients and methods This study was conducted at El-Mahalla Chest Hospital on 115 subjects (100 workers exposed to cotton dust from Misr Company for Spinning and Weaving and 15 healthy subject not exposed to cotton dust in the period from July 2013 to February 2014. The study protocol was approved by ethical committee Faculty of Medicine, Ain Shams University. These subjects were classified in to 5 groups: Group I (control group): 15 healthy subjects not exposed to cotton dust. Group II (weaving group): 25 workers works at weaving. Group III (spinning group): 25 workers works at spinning. Group IV (opening of cotton bales group): 25 workers works at opening of cotton bales. Group V (carding group): 25 workers works at carding. Exclusion criteria
Statistical analysis Data were tabulated, coded then analyzed using the computer program SPSS (Statistical package for social science) version 17.0 to obtain. Descriptive statistics were calculated in the form of: mean Standard deviation (SD) for parametric data. Median and range (Minimum–maximum) for non-parametric data. Frequency (Number-percent) for qualitative data. Analytical statistics In the statistical comparison between the different groups, the significance of difference was tested using one of the following tests: ANOVA (analysis of variance): Used to compare between more than two groups of numerical (parametric) data followed by post-hoc tukey for multiple comparisons. Mann-Whitney U test: Used to compare between two groups of numerical (nonparametric) data. Kruskal-wallis test: Used to compare between more than two groups of numerical (non-parametric) data. Intergroup comparison of categorical data was performed by using chi square test (X2-value). Pearson’s correlation coefficient Ò test was used correlating different parameters. A P value <0.05 was considered statistically significant and a P value <0.0001 was considered highly significant in all analyses. Results
1. Previous exposure to other occupational dust such as Silica, Coal dust. 2. Those with history of smoking. 3. Those with previous history of asthma or COPD before Joining to the work. Patients were subjected to the following:1. Full history taken. 2. A standardized questionnaire was patterned according to American Thoracic Society (ATS) questionnaire [5]. Questionnaire collected general information, complete occupational history and exposure, respiratory symptoms such as (cough, expectoration (sputum), wheezing, dyspnea, chest tightness), and smoking history in addition to past illness. 3. Physical measurements: including weight, and height of each subject and body mass index (BMI). 4. Clinical examination of chest. 5. Plain chest X ray (postero-anterior) view. 6. Spirometric pulmonary functions test aimed at establishing the status of the respiratory system including forced expiratory in the first second (FEV1), forced vital capacity (FVC), FEV1/FVC ratio, peak expiratory flow rate (PEFR)% and maximum midexpiratory flow (MMEF)% were measured using the spirometry system (CHEST GRAPH H I – 105-Japan) according to the guidelines of the American Thoracic Society (ATS) [6].
This study included 115 subjects who were classified into 5 groups: control group I, weaving group II, spinning group III, opening of cotton bales group IV, carding group V. Sex distribution among different groups Sex distribution among different groups are shown in Table 1. There was no significant statistical difference on comparing age between different groups, also there was no significant statistical difference on comparing body mass index between different groups (Table 2). There was a highly significant statistical difference on comparing presence of respiratory symptoms between control group and cotton exposed groups (Table 3). While, comparison between control group and other groups as regard presence of respiratory symptoms are presented in Table 4. Respiratory symptoms were more prevalent in spinning and weaving workers. There was significant statistical difference on comparing the presence of respiratory symptoms between control group and weaving, spinning, opening of cotton bales and carding groups. There was no significant statistical difference on comparing the presence of respiratory symptoms between weaving and spinning, opening of cotton bales and carding workers. There was no significant statistical difference on comparing the presence of respiratory symptoms between spinning and opening of cotton bales and carding workers. There was no significant statistical difference on comparing the presence of respiratory symptoms between opening of cotton bales and carding workers. Respiratory symptoms in different cotton exposed groups by nature of the work are illustrated in Fig. 1. Cough, expectoration
Table 1 Sex distribution among different groups. Workers Control
Gender
Male Female Total
Opening of cotton bales
Carding
No
%
No
Weaving %
No
Spinning %
No
%
No
%
10 5 15
66.7% 33.3% 100.0%
17 8 25
68.0% 32.0% 100.0%
18 7 25
72.0% 28.0% 100.0%
19 6 25
76.0% 24.0% 100.0%
20 5 25
80.0% 20.0% 100.0%
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M.A. Tageldin et al. / Egyptian Journal of Chest Diseases and Tuberculosis 66 (2017) 369–376 Table 2 Comparison between control and cotton exposed groups as regard age and body mass index. Workers Control
Weaving
Spinning
Opening of cotton bales
Carding
ANOVA P
Age (years)
Mean SD
39.33 ±6.69
41.60 ±11.51
42.72 ±12.99
38.32 ±12.65
41.56 ±11.09
0.67
BMI
Mean SD
25.67 ±3.27
24.62 ±1.33
25.44 ±2.89
26.18 ±4.65
25.04 ±2.34
0.45
P: Probability, Test used: ANOVA, SD: standard deviation.
Table 3 Comparison between control and cotton exposed groups as regard presence of respiratory symptoms. Symptoms
P
No
Control Exposed
Yes
No
%
No
%
15 41
100.0% 41.0%
0 59
0.0% 59.0%
<0.0001**
P: Probability, Test used: Qui-square test. ** High significance.
Table 4 Comparison between control group and other groups as regard presence of respiratory symptoms. Respiratory symptoms No
Yes
P
P1
<0.0001**
<0.001*
P2
P3
P4
0.05 0.07
0.8
Total
No
%
No
%
No
Control Weaving Spinning Opening of cotton bales
15 10 6 13
100% 40% 24% 52%
0 15 19 12
0.0% 60% 76% 48%
15 25 25 25
Carding
12
48%
13
52%
25
<0.001*
0.2
0.001* <0.001*
0.4 0.6
Test used: Qui-square test, P: Probability. P1: significance relative to control group. P2: significance relative to Weaving group. P3: significance relative to Spinning group. P4: significance relative to opening of cotton bales group. * Significance. ** High significance.
Fig. 1. Respiratory symptoms in different cotton exposed groups by nature of the work.
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Table 5 Comparison between control group and cotton exposed groups as regard forced expiratory volume in 1st second % (FEV1%). Workers
FEV1%
Mean SD
Control
Weaving
Spinning
Opening of cotton bales
Carding
ANOVA P
85.00 2.62±
74.60 ±10.25 <0.0001**
75.20 ±8.68 0.001* 0.99
77.55 ±6.33 0.02* 0.63 0.8
76.72 ±5.84 0.009* 0.86 0.95 0.99
0.009*
P1 P2 P3 P4 P: Probability, Test used: ANOVA, SD: standard deviation. P1: P4 comprise post hoc tukey. P1: significance relative to control group. P2: significance relative to Weaving group. P3: significance relative to Spinning group. P4: significance relative to opening of cotton bales group. * Significance. ** High significance.
Table 6 Comparison between control group and cotton exposed groups as regard forced vital capacity % (FVC%). Workers
FVC%
Mean SD
Control
Weaving
Spinning
Opening of cotton bales
Carding
ANOVA P
85.07 ±2.34
74.61 ±10.22 <0.0001**
78.15 ±5.35 0.001* 0.003
77.32 ±4.29 <0.0001** 0.62 0.98
76.41 ±6.64 <0.001* 0.095 0.77 0.97
<0.0001**
P1 P2 P3 P4 P: Probability, Test used: ANOVA, SD: standard deviation. P1: P4 comprise post hoc tukey. P1: significance relative to control group. P2: significance relative to Weaving group. P3: significance relative to Spinning group. P4: significance relative to opening of cotton bales group. * Significance. ** High significance.
Table 7 Comparison between control group and cotton exposed groups as regard FEV1/FVC%. Workers
FEV1/FVC
Mean SD
Control
Weaving
Spinning
Opening of cotton bales
Carding
ANOVA P
83.60 ±3.14
75.31 ±7.52 0.001*
73.21 ±8.47 <0.0001** 0.7
77.70 ±4.21 0.03* 0.6 0.07
75.90 ±4.29 0.002* 0.99 0.5 0.8
<0.0001**
P1 P2 P3 P4 P: Probability, Test used: ANOVA, SD: standard deviation. P1: P4 comprise post hoc tukey. P1: significance relative to control group. P2: significance relative to Weaving group. P3: significance relative to Spinning group. P4: significance relative to opening of cotton bales group. * Significance. ** High significance.
and chest tightness were more prevalent in cotton exposed groups. Cough, expectoration and chest tightness were more prevalent in spinning and weaving workers. Comparison between control group and cotton exposed groups as regard forced expiratory volume in 1st second % (FEV1%) are shown in Table 5. There was significant statistical difference on comparing FEV1% between control group and weaving, spinning, opening of cotton bales, and carding groups. There was no significant statistical difference on comparing FEV1% between weaving and spinning, opening of cotton bales and carding workers. There was no significant statistical difference on comparing FEV1%
between spinning and opening of cotton bales and carding workers. There was no significant statistical difference on comparing FEV1% between opening of cotton bales and carding workers. Comparison between control group and cotton exposed groups as regard forced vital capacity% (FVC%) are plotted in Table 6. There was significant statistical difference on comparing FVC% between control group and weaving, spinning, opening of cotton bales and carding groups. There was no significant statistical difference on comparing FVC% between weaving and spinning, opening of cotton bales and carding workers. There was no significant statistical difference on comparing FVC% between spinning and opening of
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M.A. Tageldin et al. / Egyptian Journal of Chest Diseases and Tuberculosis 66 (2017) 369–376 Table 8 Comparison between control group and cotton exposed groups as regard peak expiratory flow rate %(PEFR%). Workers
PEFR%
Mean SD
Control
Weaving
Spinning
Opening of cotton bales
Carding
ANOVA P
78.53 ±2.77
69.72 ±6.14 <0.0001**
67.28 ±4.75 <0.0001** 0.3
70.56 ±3.63 <0.0001** 0.96 0.07
67.76 ±3.46 <0.0001** 0.5 0.99 0.17
<0.0001**
P1 P2 P3 P4 P: Probability, Test used: ANOVA, SD: standard deviation. P1: P4 comprise post hoc tukey. P1: significance relative to control group. P2: significance relative to Weaving group. P3: significance relative to Spinning group. P4: significance relative to opening of cotton bales group. ** High significance.
Table 9 Correlation between period of exposure to cotton dust and respiratory symptoms. Respiratory symptoms
P
No
Exposure period (years)
Yes
Median
Range
Median
Range
12.00
3.00–34.00
24.00
5.00–35.00
0.001*
P: Probability, Test used: Mann-Whitney. * High significance.
Fig. 2. Correlation between period of exposure to cotton dust and spirometric functions.
cotton bales and carding workers. There was no significant statistical difference on comparing FVC% between opening of cotton bales and carding workers. Comparison between control group and cotton exposed groups as regard FEV1/FVC% are shown in Table 7. There was significant statistical difference on comparing FEV1/FVC% between control group and weaving, spinning, opening of cotton bales and carding groups. There was no significant statistical difference on compar-
ing FEV1/FVC% between weaving and spinning, opening of cotton bales and carding workers. There was no significant statistical difference on comparing FEV1/FVC% between spinning and opening of cotton bales and carding workers. There was no significant statistical difference on comparing FEV1/FVC% between opening of cotton bales and carding workers. There was highly significant statistical difference on comparing PEFR% between control group and weaving, spinning, opening of
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Table 10 Comparison between control group and cotton exposed groups as regard spirometric functions. Control
FVC% FEV1% FEV1/FVC% PEFR% MMEF%
Exposed
P
Median
Minimum
Maximum
Median
Minimum
Maximum
85.00 86.00 85.00 78.00 85.00
82.00 81.00 78.00 75.00 80.00
92.00 89.00 88.00 84.00 91.00
76.38 78.95 77.00 70.00 80.00
59.25 48.00 53.25 60.00 77.00
88.02 91.00 85.00 79.00 90.00
<0.001* <0.001* <0.001* <0.001* 0.11
Test used: Mann-Whitney, P: Probability. * High significance.
Fig. 3. Spirometric functions in cotton exposed workers.
cotton bales and carding groups. There was no significant statistical difference on comparing PEFR% between weaving and spinning, opening of cotton bales and carding workers. There was no significant statistical difference on comparing PEFR% between spinning and opening of cotton bales and carding workers. There was no significant statistical difference on comparing PEFR% between opening of cotton bales and carding workers (Table 8). There was no significant statistical difference on comparing MMEF% between control group and other groups (p = 0.7). There was positive correlation between period of exposure to cotton dust and respiratory symptoms. The longer the duration of exposure to cotton dust the higher the presence of respiratory symptoms (Table 9). There was no correlation between period of exposure to cotton dust and spirometric functions Fig. 2. Comparison between control group and cotton exposed groups as regard spirometric functions are shown in Table 10. There was significant statistical difference on comparing (FEV1%, FVC%, FEV1/FVC% and PEFR%) between control group and cotton exposed groups, also there was no significant statistical difference on comparing MMEF% between control group and cotton exposed groups. Spirometric functions patterns in cotton exposed workers are illustrated in Fig. 3. Discussion Cotton spinning industry is the most important industry in Egypt, with rapid industrialization and mechanization in textile industries occupational health hazards are becoming more prominent. Respiratory tract diseases represent the most important group of occupational diseases in spinning factories as a result of inhalation of cotton fibers and dust in work place [7]. Invisible small cotton dust particles enter into the alveoli of the lung through inhalation and accumulate in the lymph causing damage to the alveoli and reducing the capacity of retain oxygen. As the cotton dust accumulates the worker develops a brown lung and suffers from byssinosis [8].
Cotton workers are at risk for occupational lung disease, including byssinosis and chronic bronchitis. The initial phase of byssinosis is characterized by acute reversible symptoms, such as wheezing, chest tightness, shortness of breath, or cough, and is typically evident on the first day back to work after an absence of 48 h or more, these early symptoms are generally accompanied by reversible changes in pulmonary function, with continued exposure the disease may progress to a stage in which symptoms are present throughout the work week and may eventually result in severe pulmonary disability [9]. In addition excess nonspecific respiratory symptoms such as chronic cough, phlegm, and dyspnea were reported in cotton textile workers compared with non exposed populations [10,11]. This study was done to observe the effects of cotton dust on respiratory symptoms and spirometric functions among cotton workers. In the present study the prevalence of respiratory symptoms was higher in exposed group as compared to control group (59.0% vs 0.0%) probably due to inhalation of cotton dust. The prevalence of respiratory symptoms varied among various sections of the company, with the highest respiratory symptoms among spinning workers (76.0%) and weaving workers (60.0%). This was probably because these sections were dustier than other sections. Cough was found in (35.0%) of workers, expectoration was found in (22.0%) of all exposed workers so cough and expectoration were the most prevalent symptoms in this study. The results of this study were in agreement with the results of the study done by Abdel Rahman, et al., whom studied the effect of exposure to cotton dust on health of workers in ESCO Company in Kaliubia on 150 cotton workers and 81 subjects as control group. Their results showed higher prevalence of chest symptoms among exposed workers than control [12]. Also the results of the current study were matched with the results of the study done by Khan, et al. whom studied 800 workers in Pakistani cotton industry and found that the prevalence of respiratory symptoms was high in cotton exposed workers [13]. These results were also compatible with the results carried out by Hinson et al. which was done on 109 workers exposed to cotton dust and 107 unexposed workers in Company of Textile of Benin, and found that the exposed workers had significantly more respiratory symptoms compared to the unexposed workers [14]. Also these results coincide with the results of the study done by Osibogun et al. whom studied the prevalence of respiratory problems among textile mill workers in Asaba, Nigeria. Their results showed that the prevalence of respiratory symptoms in the exposed group were higher than in the control group (38%), and cough, phlegm were most common symptoms [15]. The results of this study were in agreement with the results of the study done by Raza et al. (1999) in Lancashire textile weavers, England who found that the prevalence of respiratory symptoms was high in the spinning department, and workers in the spinning
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department were more likely than other departments to have cough, phlegm, chest tightness and dyspnea [16]. Also the results of the current study were compatible with the results of the study done by Ghasemkhani et al. on 880 cotton workers who work in cotton industries of south Tehran, Iran, and found that the prevalence of respiratory symptoms was high among textile industrial workers, and cough was present in (30.8%), phlegm was present in (53.8%) of cotton workers [17]. Also these results were the same results of the study carried out by Alemu et al. whom studied the prevalence of respiratory symptoms among workers in cotton mills of Akaki textile factory Ethiopia, who found that the prevalence of respiratory symptoms were high in the spinning department [18]. The results of this study coincide with the results of the study done by Nagoda et al. whom studied 200 workers exposed to cotton dust and 200 unexposed workers in Kano, Nigeria, and their results showed that exposed workers generally complained of cough, phlegm production, wheezing, and breathlessness, also their results showed higher prevalence of respiratory symptoms in the spinning and weaving sections [19]. In this study FEV1%, FVC%, FEV1/FVC%, and PEFR% were significantly less in cotton workers as compared to controls also MMEF% didn’t differ significantly between cotton workers and controls. This may be due to endtoxin present in cotton which responsible for inflammation of airway, also chronic occupational exposure to endotoxin is associated with faster decline in lung functions. These results were in agreement with the results of the study done by Abebe and Seboxa on 433 workers whom were occupationally exposed to cotton dust in Bahr Dar textile mill, north-west Ethiopia and 101 non exposed workers were included as controls, and they found that FEV1 and FVC were a significant reduced in the exposed groups compared with controls [20]. Also these results coincide with the results of the study done by Aminian et al. on 140 cotton textile workers and 150 office workers as control group to evaluate the effect of exposure to cotton dust on respiratory health and pulmonary function in Tehran, Iran. Their results showed that cotton workers had more respiratory symptoms as compared to control groups and greater declines were seen in forced vital capacity (FVC), forced expiratory volume in first second (FEV1) and FEV1/FVC in cotton workers [21]. These results were compatible with the results carried out by Hinson, et al. whom studied the prevalence of byssinosis among cotton workers in the north of Benin. Their results showed that the exposed workers had a lower FEV1 compared to the unexposed workers [14]. Also these results were the same results of the study carried out by Nagoda et al. whom found that FEV1, FVC, PEFR were significantly lower in cotton workers as compared to control [19]. The results of the current study were matched with the results of the study carried out by Jiang et al. on 1320 cotton textile workers and 1306 controls in China. Their results showed fall of FEV1 and FEV1/FVC in cotton textile workers as compared by control. Also the prevalence of respiratory abnormalities was increased with duration of exposure to cotton dust [22]. Also the results of this study were in agreement with the results of the study done by Abdel Rahman et al. whom found that the FEV1% was significantly lower among exposed workers than control [12]. These results were in agreement with the results of the study done by Narsimha and Tandon on 198 textile workers and 50 subjects as control, and found that FEV1 was significantly lower in exposed group as compared to control [23]. Also these results were compatible with the results of the study carried by Singh et al. whom studied the lung functions among 7 cotton spinners exposed to cotton and 7 subjects as
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control. Their results showed that PEFR was significantly lower in cotton spinners as compared to control [24]. These results coincide with the results reported by Ahasan et al. whom studied 210 subjects working in textile mills in Bangladesh, and found that PEFR was low in exposed groups as compared to control [25]. Also these results were in agreement with the results of study done by Anupama and Kammar on 100 cotton workers and 100 subjects not exposed to cotton, and they found that FVC, FEV1, FEV1/FVC, PEFR were significantly lower in cotton workers as compared to controls, also no statistically significant difference on MMEF in cotton workers and control [26]. In this study there was positive correlation between respiratory symptoms and duration of exposure to cotton dust, the longer the duration of exposure the higher presence of respiratory symptoms. These results were compatible with the results of the study carried by Nectarios et al. in the cotton textile industry of Greece, who found that the frequency of cough, phlegm, dyspnea, were affected by duration of exposure to cotton dust [27]. Also the results of the current study were matched with the results of the study done by Abdel Rahman et al. who found that the longer the duration of exposure to cotton dust the more chest symptoms [12]. Also these results were in agreement with the results of the study carried out by Venkatakrishna Bhatt et al. on 24 cotton workers compared with 15 subjects not exposed to cotton dust. Their results showed that the duration of constant exposure to cotton dust is an important factor in causation and development of respiratory symptoms [28]. These results were similar to the results of the study done by Cinkotai et al. whom studied the prevalence of respiratory symptoms in the Lancashire textile industry England, and found that respiratory symptoms were related to years in the industry and degree of dust exposure [29]. In the present study there was no correlation between spirometric functions (FVC%, FEV1%, PEFR%, FEV1/FVC, and MMEF%) and duration of exposure to cotton dust. These results were compatible with the results of study carried out by Nagoda et al. whom studied the prevalence of respiratory symptoms and pulmonary functions among textile workers in Kano, Nigeria, and found that there is no correlation between pulmonary function (PEFR, FVC, FEV1 and FEV1/FVC ratio) and duration of employment in the factory [19]. Also these results were in agreement with the results of study done by Anupama and Kammar whom found that the PEFR was decreased significantly with increase in duration of exposure to cotton dust, also no other spirometric functions showed a significant correlation with duration of exposure to cotton dust [26]. In the present study spirometric functions in cotton exposed workers showed that normal pattern present in 82 (82%) of workers, obstructive pattern present in 9 (9%) of workers, restrictive pattern present in 5 (5%) of workers and mixed pattern present in 4 (4%) of cotton exposed workers. These results were compatible with the results of study carried out by Nagoda et al. whom found that an obstructive pattern present in (10%) exposed workers on spirometry and a restrictive pattern present in (40%) exposed workers [19]. Also these results were in agreement with the results of study done by Aminian et al. whom found that (77.66%) of cotton exposed workers had normal pulmonary functions pattern and (22.34%) had abnormal pattern on spirometry [21]. In conclusion, cotton workers are at risk for developing respiratory symptoms. Respiratory symptoms was highest prevalent in worker works at spinning and weaving. Spirometric functions were less in cotton exposed workers as compared to control.
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