Respiratory disease in cotton textile workers in the People's Republic of China. II. Pulmonary function results

Prevalence of skin test reactivity to aeroallergens in the Pakistani population

OBJECTIVES

The prevalence of allergies has increased in all parts of the world. The present study was conducted to determine the prevalence of sensitivity to common aeroallergens, pollen, thresher dust and cotton dust, in Pakistan.

STUDY-DESIGN

Retrospective cohort study.

METHOD

Record of 65067 who attended the Allergy Centre, National Institute of Health, Islamabad, Pakistan from January 2007 to August 2008 was retrieved. Subjects that were skin prick test (SPT) negative and those that were SPT positive to aeroallergens were extracted and subcategorized on the basis of the 8 provinces of Pakistan, including, Islamabad Capital Territory, Punjab, Baluchistan, Sindh, Northern Areas, Kashmir, North Western Frontier Province (NWFP) and Federally Administered Tribal Areas (FATA). Monthly analysis of prevalence of allergies was also determined.

RESULTS

Of the total, 68.6% were SPT positive. The highest number of affected individuals was from the Punjab region (41%). The highest number of cases of all aeroallergens was reported in the month of August (3532, 13.7%). Significant high correlations were observed between mixed pollen, thresher dust and raw cotton and allergic rhinitis, asthma, uriticaria and allergic conjunctivitis. There was no significant correlation between allergen sensitivity and atopic edema.

CONCLUSION

A high prevalence of sensitivity to aeroallergens is observed in the Punjab Province of Pakistan.

Long-term effects of work cessation on respiratory health of textile workers: a 25-year follow-up study

RATIONALE

The degree to which chronic respiratory health effects caused by exposures to cotton dust and endotoxin is reversible after cessation of textile work is unknown.

OBJECTIVES

To investigate changes in lung function and respiratory symptoms after cessation of textile work and to determine whether past exposure to cotton dust and endotoxin or smoking history modify the associations.

METHODS

We performed a prospective cohort study consisting of 447 cotton textile workers exposed to cotton dust and 472 unexposed silk textile workers, with a 25-year follow-up. Spirometry testing and respiratory questionnaires were conducted at 5-year intervals. Generalized estimated equations were used to model the average 5-year change in FEV(1) and odds ratios of respiratory symptom prevalence.

MEASUREMENTS AND MAIN RESULTS

Years since cessation of textile work was positively associated with 11.3 ml/yr and 5.6 ml/yr gains in 5-year FEV(1) change for cotton and silk workers, respectively. Among male cotton workers, smokers gained more FEV(1) per year after cessation of exposure than did nonsmokers, and the risk of symptoms of chronic bronchitis and byssinosis was larger for smoking than for nonsmoking male cotton workers.

CONCLUSIONS

Cessation of textile work was significantly associated with improvement in lung function and respiratory symptoms. The positive effect of work cessation was greater for cotton workers than for silk workers. For cotton workers, the improvement in lung function loss after cessation of textile work was greater among smokers, but no differences were observed for silk workers.

Occupational causes of chronic obstructive pulmonary disease

The relation between Chronic Obstructive Pulmonary Disease (COPD, including chronic bronchitis and emphysema (CBE), and exposure to coal dust is well established. This paper reviews the evidence relating to other occupational causes of COPD, including industries associated with exposure to fumes, chemical substances, and dusts. A review of key literature has been carried out with a focus on the magnitude of risks and levels of exposure causing disabling health effects. The literature suggests that elevated risks of developing COPD are clearly associated with several occupations, with risk estimates being high in some, even after taking into account the effect of confounders, such as smoking. Of particular concern are agricultural workers who can be exposed to a variety of gases and organic dusts, among whom CBE is clearly elevated, particularly for pig farmers and exposure to endotoxins, with an increased annual decline in lung function. Similarly, cotton textile workers are exposed to a mixture of substances affecting development of atopy, byssinosis, and CBE, and across-shift and long-term decline in lung function. Atopy also has an important role in the development of COPD in flour mill workers and bakers, with those sensitized to bakery allergens having a greater lung function decline than non-sensitized individuals. Welding processes involve a range of potential chemical, physical and radiation hazards. The average reduction in FEV1 associated with welding fumes is similar to that associated with smoking. Challenges in assessing the evidence include variation in diagnostic methods; concurrent exposure to cigarette smoke (direct or second-hand) and multiple work-place irritants; healthy worker selection/survivor effects; poor exposure definition. Raising awareness of occupational causes of COPD among employers, employees, and health service professionals is important.

Occupational exposures and risks of liver cancer among Shanghai female textile workers--a case-cohort study

BACKGROUND

Liver cancer is the fifth most frequent malignancy worldwide. Viral hepatitis B and C, alcohol, and aflatoxin are the major established risk factors. Little is known about the aetiological contributions of occupational exposures, as previous occupational epidemiological studies of liver cancer suggest few agent-specific associations. We investigated associations of occupational exposures to dusts and chemicals in a cohort of female textile workers.

METHODS

Cancer incidence was determined among 267,400 female textile workers in Shanghai, China, who had been enrolled in an intervention trial of breast self-exam efficacy during 1989-98. Subjects were interviewed at baseline regarding basic demographics, smoking habits, alcohol consumption, and contraceptive practices. A case-cohort study of 360 liver cancer cases and 3,186 age-stratified randomly chosen subcohort subjects was conducted within this cohort. Exposures to workplace dusts and chemicals were reconstructed from complete work history data, historical exposure monitoring data for selected agents, and a specially designed job-exposure matrix for the textile industry. Relative risks and dose-response trends were estimated by Cox proportional hazards modelling, adapted for the case-cohort design. Latency analyses with different lag years were also applied.

RESULTS

2,095,904 person-years were contributed by this female cohort. The results of the case-cohort analysis revealed a protective effect of cotton fibre exposure years [adjusted hazards ratio (HR) = 0.64; 95% confidence interval (95% CI) 0.44-0.92] or endotoxin exposure (adjusted HR = 0.60; 95% CI 0.41-0.88) for the fourth quartile with significant trends for 20 year exposure lags.

CONCLUSIONS

This study suggests that chronic exposure to endotoxin or some other component of cotton dust exposure may have reduced liver cancer risk in this population.

Is Chronic Airway Obstruction From Cotton Dust Exposure Reversible?

BACKGROUND

Exposure to cotton dust is known to cause chronic airway obstruction, but there is little information on whether the obstructive impairment is reversible after the exposure stops.

METHODS

Longitudinal changes in lung function were evaluated among 429 cotton textile workers and 449 silk workers in Shanghai, China, beginning in 1981. Both active and retired workers were tested every 4 to 6 years for 15 years.

RESULTS

Overall, cotton workers had greater annual declines in forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC). Compared with active workers, retired cotton workers had lower annual loss of FEV1, although the retired workers had a greater loss during their active employment than the currently active workers. No such trends were detected in silk workers. Annual declines in FEV1 in retired cotton workers were smaller with increasing time since retirement. Multivariate analysis showed that retirement was a substantial contributing factor for improved FEV1 and FVC in the cotton workers, especially among those who did not smoke. Correspondingly, remission of airflow obstruction, defined as a ratio of FEV1 and FVC of less than 70%, was more common in retirees than in the active workers, and more common in nonsmokers than in smokers.

CONCLUSION

Chronic airway obstruction related to long-term exposure to cotton dust may be partially reversible after the exposure ceases, although lung function does not return to the level found in unexposed workers.

Cotton dust and endotoxin exposure and long-term decline in lung function: results of a longitudinal study

BACKGROUND

To evaluate the relationship between long-term exposure to cotton dust and Gram-negative bacterial endotoxin on lung function, we conducted an 11-year follow-up study of cotton textile workers in Shanghai, China.

METHODS

Workers at a nearby silk-thread manufacturing mill were used as a referent population. Ninety percent of the original cohort of 445 cotton and 467 silk textile workers--both active and retired--were identified for testing in the 11th year. Questionnaires and spirometric testing were performed, as well as cotton dust and endotoxin sampling at three points over the 11-year follow-up period: at baseline, at Year 5, and at Year 11. After excluding deaths and subjects on sick-leave, 84% of the original cohort had complete health and environmental data.

RESULTS

The data were reanalyzed using generalized estimating equations feedback model which allow for subject transfer over time between work areas, various exposure levels to dust and endotoxin, and FEV1. Cotton workers had a larger loss of FEV1 during the first 5 years of study (-40 mls/yr) as compared with the second 6 years of follow-up (-18 mls/yr). During the same periods, the average decline among silk workers was slightly higher in the first period, but was more consistent (-30 mls/yr vs. -27 mls/yr), and these differences could not be explained by worker selection or dropout. When cumulative exposure to dust and endotoxin were estimated and used in a multivariate model (GEE) for FEV1 loss, cumulative dust, but not endotoxin, was associated with 11-year loss in FEV1 after adjustments for confounders. There was evidence of feedback between dust-exposure levels and FEV1, indicating the existence of a healthy-worker survivor effect. After accounting for a healthy-worker survivor effect, we found a significant relationship between dust exposure and FEV1 decline.

CONCLUSIONS

Our results suggest that cotton dust is more strongly associated with chronic airflow limitation than associated endotoxins. Further work is needed to clarify potential reversibility after cessation of exposure, and the relative contributions of dust, endotoxin, and tobacco to chronic respiratory impairment in cotton and other vegetable-exposed workers.

Respiratory symptoms and pulmonary function among Chinese rice-granary workers

The authors conducted a cross-sectional study of 474 rice-granary workers and 235 non-granary worker controls in a rural area near Shanghai, the People's Republic of China. Responses to a respiratory-symptom questionnaire and pre- and post-shift spirometry were obtained for all subjects. Area sampling was performed for total and vertically elutriated (</= 15 micrometer) dust levels. Total dust levels were high, ranging from 6.6 mg/m(3) to 59.8 mg/m(3), with vertical elutriated dust concentrations ranging from 2.0 to 10. 4 mg/m(3). The granary workers reported significantly more respiratory symptoms, including chronic cough, sputum production, chronic bronchitis, grain fever (ODTS), and nasal and skin irritation. Grain dust and tobacco smoking were more than additive for the prevalence of chronic cough and chronic bronchitis. After adjusting for confounders, the granary workers had lower mean FEV&inf1;/FVC values both pre- and post-shift, indicating an association between chronic grain-dust exposure and chronic airway obstruction. The results suggest that exposure to rice dust can induce pulmonary responses similar to those observed with exposures to other types of grains.

Occupational and Environmental Risk Factors for Asthma in Rural Communities in China

Respiratory allergens such as dust, gases/fumes, and hay smoke, which are frequently present in agricultural settings, can cause or aggravate asthma. The purpose of this study was to examine the relationships between occupational and environmental exposures and asthma in Chinese rural communities. The study population consisted of 28,946 people 15 years old or older, living in rural areas of Anhui province, China. A modified Mandarin translation of the ATS-DLD questionnaire was administered by trained interviewers to request information about exposures to specific occupational/environmental agents and respiratory disorders. In Huaining, the prevalence of wheezing was 3.8% for men; 2.1% for women; the prevalence of asthma was 1.6% for men; 1.8% for women. In Zongyang, the prevalence of wheezing was 2.7% for men; 1.9% for women; the prevalence of asthma was 1.7% for men; 1.2% for women. With control for potential confounders such as gender, age, residential area, education level, and smoking status, the pooled adjusted odds ratios (ORs) of wheezing and asthma for the group exposed to wood/hay smoke were 1.36 (95% CI: 1.14-1.61) and 1.27 (95% CI: 1.02-1.58), respectively. For coal-stove users, the pooled adjusted ORs were 1.47 (95% CI: 1.09-1.98) for wheezing and 1.51 (95% CI: 1.05-2.17) for asthma. After stratification of the subjects by dust type, the estimated ORs for wheezing were 1.58 (95% CI: 1.02-2.44) among the group exposed to inorganic dust and 3.03 (95% CI: 1.25-7.33) among the group exposed to metal dust. Asthma was not shown to be significantly associated with any specific dust type. Findings of the present study are consistent with previously reported adverse respiratory health effects related to occupational/environmental exposures to wood/hay smoke and dust, and indicate the need for further occupational disease surveillance in rural communities.

Byssinosis in Guangzhou, China

OBJECTIVES

To study the prevalence of byssinosis and other respiratory abnormalities in workers exposed to cotton dust in Guangzhou in two factories that processed purely cotton.

METHODS

All the 1320 workers exposed were included. The controls were 1306 workers with no history of occupational dust exposure. Total dust and inhalable dust were measured by Chinese total dust sampler and American vertical elutriator respectively. A World Health Organisation questionnaire was used. Forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) were measured by a Vitalograph spirometer.

RESULTS

The median inhalable dust concentrations ranged from 0.41 to 1.51 mg/m3 and median total dust concentrations from 3.04 to 12.32 mg/m3. The prevalence of respiratory abnormalities in the cotton workers were (a) typical Monday symptoms 9.0%; (b) FEV1 fall by > or = 5% after a shift 16.8%; (c) FEV1 fall by > or = 10% after a shift 4.2%; (d) FEV1 < 80% predicted 6.1%; (e) FEV1/FVC < 75% 4.0%; (f) cough or phlegm 18.2%; (g) chronic bronchitis 10.9%; and (h) byssinosis, defined by (a) plus (b) 1.7%. With the exception of (d), most of the prevalences increased with increasing age, duration of exposure, and cumulative inhalable dust exposure. No increasing trends of respiratory abnormalities were found for current total dust, inhalable dust, and cumulative total dust concentrations. Compared with controls, after adjustment for sex and smoking, with the exception of (d), all the pooled relative risks of respiratory abnormalities were raised for cotton exposure.

CONCLUSION

It is concluded that cumulative inhalable cotton is likely to be the cause of byssinotic symptoms, acute lung function decrements, cough, or phlegm, and chronic bronchitis.

Pulmonary function among cotton textile workers. A study of variability in symptom reporting, across-shift drop in FEV1, and longitudinal change

Longitudinal variability in respiratory responses, including symptom reporting and across-shift change in ventilatory function, were examined in relation to long-term loss of ventilatory function in a group of 447 cotton textile workers in Shanghai, China. The study used a standardized respiratory questionnaire and standardized spirometric testing before and after a work shift on the first day of the workweek. Prediction equations for FEV1 were generated from a group of silk textile workers from the same city. Environmental samples included both vertical elutriated cotton dust and endotoxin levels. There was considerable variability in symptom reporting between the baseline and 5-year follow-up survey for all symptoms. However, subjects who consistently reported symptoms had a significantly accelerated 5-year loss in FEV1 compared with those who never reported symptoms. Subjects with symptoms of chest tightness or dyspnea at one survey lost FEV1 at a rate intermediate between the never or both groups. Moreover, subjects with an across-shift change in FEV1 of more than 5 percent at both surveys had the greatest loss in FEV1 over 5 years (-267 ml) when compared with one-time responders (-224 ml), and nonresponders (-180 ml), though the differences were not significant. Workers with chest tightness and chronic bronchitis in both surveys were overrepresented in the high dust and endotoxin areas. Our results indicate that even with substantial survey-to-survey variability in responses, there is important information contained in both questionnaires and across-shift spirometry. Among cotton workers, consistent responders to either symptom questionnaire or across-shift FEV1 decrements of > or = 5 percent appear to be at increased risk for lung function impairment.

Occupational lung diseases in the industrializing and industrialized world: commonalities and contrasts: measurement tools

Research on occupational lung disease has been a growing challenge over the past 4 decades. Exposure to respiratory toxins has increased in many industrializing countries of the world while new and old hazards continue to exist in the industrialized world. The focus of this paper is on measurement tools commonly used in the study of occupational lung diseases. The emphasis is on epidemiology, a discipline which has contributed to the understanding and control of occupational lung disease. An examination of these tools reveals that (1) there are more commonalities than contrasts in available methods; (2) researchers in industrializing settings can contribute much to our understanding of occupational lung diseases; (3) international collaboration is needed in refining measurement tools; and (4) international collaboration should proceed on studies of preventive strategies.

Immunological findings and respiratory function in cotton textile workers

Immunological parameters were studied in a group of 24 cotton textile workers. These were volunteers from a cohort of 106 (83 women and 23 men) previously studied textile workers. A group of 30 employees from a bottle packing plant served as a control for the immunologic studies. The subgroup of volunteers undergoing immunologic testing did not differ from the original cohort of textile workers in age, sex, smoking history, or prevalence of most chronic respiratory symptoms, nor were there any significant differences in baseline lung function or across-shift changes. The 24 cotton worker volunteers underwent skin testing with extracts of cotton dust and cotton seed. Eight of these 24 (33.3%) had positive tests, and 5 of the 8 had elevated serum immunoglobulin E (IgE) levels. Only one of the 8 skin-test-positive workers had symptoms of byssinosis. Only 1 of 30 control workers' skin tested with cotton extract reacted, and none had an increased serum IgE level (P less than 0.01). Both baseline lung function and across-shift changes did not differ between workers with positive and negative skin test reactions or between workers with normal and elevated IgE levels. Additionally, we studied the response in vitro of nonsensitized guinea pig trachea to cotton bract extract and demonstrated a dose-dependent contractile response. These data suggest that while immunological findings are frequent in textile workers, they correlate poorly with respiratory symptoms and function and may not be the basis for the airway obstruction seen in this disease.

Respiratory disease in a textile factory in Nicaragua

This is the first epidemiologic study conducted in a textile mill in Nicaragua using techniques and diagnostic criteria similar to those used in the United States and England. The prevalence of byssinosis and nonspecific respiratory symptoms were studied in 194 workers in a cotton mill in Managua. Limited environmental sampling, performed using a vertical elutriator in yarn preparation and weaving areas, indicated that exposures were similar to those reported in other parts of the developing world. A modified translated version of the Medical Research Council respiratory questionnaire was administered. Pulmonary function tests were performed before and after the Monday workshift to measure across-shift change in ventilatory function. The prevalence of byssinosis was 5.9% and all the cases occurred among exposed women. Nonspecific respiratory symptoms were also more prevalent among exposed workers. After adjusting for age, gender, smoking habit, and work tenure, the exposure odds ratios for usual cough and usual phlegm were 3.3 and 2.2, respectively. The association between exposure and across-shift decrement in FEV1 was not significant. Byssinotic workers, however, had greater decrements in FEV1% than those without byssinosis: 5.5% versus 1.8%. A consistent gender effect was observed in which both exposed and unexposed women were found to have greater across-shift decrements in FEV1 than men. The gender difference existed among long-term workers as well as workers who had been employed less than 2 years. Results are related to cotton dust exposure, as has been documented elsewhere. The poorer health status of the women in this study population deserves follow-up.