Prevalence of respiratory morbidity among children working in filature units of the sericulture industry and the effects on general health of the children.
Item
- Title
-
Prevalence of respiratory morbidity among children working
in filature units of the sericulture industry and the effects on
general health of the children.
- extracted text
-
RF_CH_17_SUDHA
Prevalence of respiratory morbidity among children working
in filature units of the sericulture industry and the effects on
•. - general health of the children.
Dr. R. R. Patil5*, M.Sc (Epid), Research Assistant
Dr. S. Lewin, MD DNB, Associate Professor
Dr. S.D. Subba Rao, DCh DNB, Professor and Head
Dr. Om Prakash, MD, Consultant Physician
Dr. Peter Prashanth DCh, Consultant Paediatrician
Dr. Chitra Dinakar, DCh DNB, Lecturer
Dr. C.M. Francis*, MD, Advisor
Dr. Thelma Narayan*, AID, Advisor
Concept, Design (Drs. RP, SL, SDSR), Acquisition of data (Drs. RP, PP), Analysis,
Interpretation (Drs. RP, SL, SDSR, CD), Drafting (Drs. RP, SL, CD), Final Approval
(Drs. RP, SL, SDSR)
* Community Health Cell
" .
367, Srinivasa Nilaya, 1st Main, 1st Block, Jakkasandra, Bangalore 560 034
Karnataka, India '
And
Department of Pediatrics
St. Johns Medical College and Hospital, Sarjapur Road, Bangalore 560034
Karnataka, India
Corresponding Author:
Dr..Rajan R Patil
Research Assistant, Community Health Cell, 367, Srinivasa Nilaya, 1st Main, 1st
Block, Jakkasandra, Bangalore 560 034. Ph.: 5525372 / 5531518
Email: ’sQchara@vsnl.com
Sponsored by Movement for Alternatives and Youth Awareness (MAYA), #111, 5th
Block, 5th Main, Jayanagar, Bangalore, Karnataka 560041.
- Only Dr. Peter Prashanth received a honoraria for the fieldwork involved in the
study. Social workers utilized during fieldwork were members of MAYA, the
sponsor. None of the other authors had any conflict of interest in the outcome of
the, study and the sponsor.
.3^0^
Word count
3565
1
Introduction:
Karnataka contributes to nearly 70% of the country’s total mulberry silk
production and the town of Ramanagaram is among the largest cocoon-marketing centre
in Asia. The cocoon market averages a daily transaction upto 30 tonnes per day. The
town has a population of 79,382 with 6,478 child laborers, 2138 reelers and 915
charkhas, 1500 filature units and 102 grainage units. Children are employed in all stages
of the silk processing, making sericulture a child-based industry. About 80 % of the
individuals involved in reeling silk are between the ages of 10-15 years [*Human rights
report, 1999], Children usually are involved in the filature unit tasks of cooking/boiling.
During this process of‘cooking’, the silkworms emit a protein called sericin in the form
of foul-smelling vapors that pervade not only the silk units but also the entire region
surrounding the units. It is this protein vapor that has been attributed to cause chronic
bronchitis and asthma.
There are few studies on occupational health among children in this industry. .An
earlier study among adults reported that 16.9% of the total subjects from sericulture
industry could be clinically categorized as having occupational asthma free from
symptoms while away from work, with exacerbations upon resumption of occupation. At
least 21.8% of the persons employed in silk filatures responded positively to both cocoon
and pupal allergens [2], Studies have shown that children develop sensitization to indoor
allergens as they grow older in that atmosphere. Sensitivity of 1.5% at 1 yr age increases
to 90% at 8-11 yrs of age [3]. In the sericulture sector, the child grows up working at the
cost of the health, education, and social opportunities of children. Recent
epidemiological studies of naturally occurring and occupational asthma have shown the
importance of allergic factors in the pathogenesis. The research question this study set
out to answer was “Is the prevalence of health problems (especially respiratory
morbidity) more in children working in the filature units of sericulture industries at
Ramanagaram town as compared to the children who are not working in filature units9”
Findings of such a study is hoped to strengthen the policy action vis a vis child labour in
sericulture.
Objectives:
The primary objective was to study the comparative prevalence of Respiratory morbidity’
especially Hyperactive Airways among children working in filature units. The secondary
objective was to study the comparative general health status among children working in
the filature units.
Methodology:
Design
The study was designed as a cross-sectional (prevalence) study of environmental
conditions at work/home and the presence of clinical evidence of health problems with
special reference to hyper reactive airways as determined by symptoms, signs and peak
expiratory flow rates. The definition of 'exposure’ in our study was children working in
filature units for at least 3 months and definition of ‘control’ (non-exposed) was school
children not working in filature units. The significant difference in the number of
functioning units in the two town appeared to permit a comparison between groups exposed, internal non-exposed (internal control group) in Ramanagaram and external
non-exposed (external control group) in Malvalli. The study population was divided into
three groups: Group I included were children working in the filature unit of the local
sericulture industry at Ramanagaram for at least 3 months; Group II included controls
from among neighbours at home not working in a similar allergen industry (internal
controls); and, Group III included Malavalli children not exposed to a similar
environment (external control). A sample size of 276 children based on known incidence
of 4-5% and an expectation of 20-25% incidence of hyperactive airways was obtained by
consecutive sampling of children of consenting parents (power 80). As controls from the
home locality and the identified external control (Malavalli, 50 kms away, 2 filature
units, 13 Charkhas and 3 grainage units, no child labour), a minimum of 100 children was
examined on a similar basis in each of the control groups. During the pilot study,
randomization and stratified selection of study subjects led to operational problems due to
community members questioning the rationale behind the selection process, which then
had to be changed to a simple first come first serve basis.
j Study Groups
Filature unit working
children - R’nagaram
Non-filature unit working
children - R’nagaram
No working
children - NF vaili
Questionnaire
The questionnaire used was a modification of the subjective ISAAC and a
Bangladesh questionnaires (ISAAC Lancet 1985, Hassan et al Int J Epidemio 2002) and
factors associated with asthma as described by Parmesh (Ind J Ped 2002) along with
objective physician clinical examination similar to those utilized in clinics to suspect and
diagnose children with respiratory disease especially hyper reactive airways.
Inclusion/Exclusion Criteria
The inclusion criteria was all children aged >5 to 18 years, who have worked for more
than 3 months in the filature units of the sericulture industry at Ramanagaram town as the
exposed group. Exclusion criteria were those who were acutely ill; asymptomatic but
unable to perform peak flows satisfactorily; and, those who refused to consent.
Methods
Initially, standardization and training for data collection (demographic, symptoms,
environmental factors) and measurements (clinical, peak flow rates before and after
inhaled broncho-dilator, silk skin test) was carried out in the field for the social workers
and field investigator. A local Rotary Hospital was utilized for baseline blood
investigations, skin testing, education and medication. Social workers made contact with
parents of potential study children and obtained a written informed consent for
examination and testing utilizing information printed in appropriate local languases
including a separate consent form. Utilizing a questionnaire, the field investigators and
social workers documented a clinical history, including symptoms and environmental
factors, with specific reference to hyperactive airways. A detailed examination including
anthropometry, PEFR before and 20 mins after two beta agonist (Salbutamol) inhalations
using a standard spacer device and a silk skin test. Blood samples (Hb, TC, DC and ESRi
were collected in open vials for manual counts by technicians in the local Rotary
Hospital. The study began in Ramanagaram with a pilot study on 12th December 2002
and concluded on 9th Jan 2003 in Malvalli.
Outcome variables
The clinical endpoints in this study were predominantly respiratory symptoms in view
of the nature of the occupation under scrutiny. Hyper reactive airways would be clinicailv
suspected if a child has presenting symptoms of recurrent episodes of night cough,
wheeze, fast breathing or chest retractions in isolation or in combination with the
examination finding of rhonchi. A child who keeps presenting with the production of
sputum (phlegm) and cough could have episodes of bronchitis, while those with recurrent
coryza, running nose, nose blocks, sneezing could indicate allergic rhinitis. The presence
of non-painful itching eyes with redness and watering would point to allergic
conjunctivitis. .All these conditions would be health problems probably attributed due to
occupational effects of working in filature units. In view of the portability, ease of use
and the field study conditions, we chose to use PEFR [5] as an objective assessment for
airway hyper-reactivity. A onetime PEFR variability of > 15% was to be taken as
significant objective evidence of bronchial hyperreactivity [4 Evaluation of asthma and
allergy, awww.wnmeds.ac.nz/academic med/warg/adv.html] before and after inhales
beta- agonist. In addition, to attribute anv allergic manifestation to the silk utilized in the
industry, a silk skin test was compared in all with a saline and histamine skin test
Outcome variables were hence defined as follows: Hyperactive airway disease was
suggested by episodes of wheeze, cough, fast breathing, chest retractions, night cough
and/or rhonchi. Allergic symptoms of frequent colds and sneezing; red eyes with itching
and watering and no pain; itching skin rash were defined for the questionnaire.
Skin Test
For the silk skin test, the allergen extract is obtained from Silkworm pupae. Silkworm
pupae are separated from cocoons, immersed in liquid nitrogen and crushed into a fine
powder. Water is added to the powder till it forms a slurry and squeezed through a two
layered muslin cloth. Four volumes of chilled acetone are added to one volume of the
extract and after stirring, the mixture is filtered though Whatman No. 3 filter paper under
suction. The residue is washed several times with chilled acetone and finally with chilled
peroxide-free diethyl ether. The resultant powder is dried and kept at -20 degrees Celsius
for further use. For use, the acetone-dried powder of pupae is stirred for two hours at
room temperature with 20 ml of 100 mg sodium phosphate buffered saline, pH 7.4. The
slurry is centrifuged at 20,000xg for 15 minutes. The crude extract thus obtained (1:2.'
wt/vol) is filter sterilized and used for pnck skin tests after diluting with an equal volume
of sterile glycerin to give a 1:40 wt/vol. [2] Allergy for silk was tested by placing 0.1 mi
silk antigen, Histamine and Normal saline on the volar surface of the forearm. A skin
prick test was carried out on all three drops on the arm. The skin reaction of silk antigen
:*
was read after 15 minutes by comparing with Histamine and Normal saline, which served
as positive and negative controls. The interpretation of positive reaction to silk antigen
was based on comparative size of wheal formation at the site of skin prick test. If wheal
formed by silk antigen was equal to or more than wheal produced by the histamine it was
taken to be positive. The test was performed by a single observer (Dr. PP) to avoid inter
observer variability.
Statistical Analysis
Data collected was independently analyzed using EPI Info -6 and probability calculated.
Differences between the groups were considered statistically significant if the p value
was <0.05.
Ethics
The study included a Subject Information Form and Informed Consent in the local
language and confidentiality' of all data was maintained. Our study was cleared by the
Institution Ethical Review Board.
Results:
A total of 401 children were selected from Ramanagaram (279:122 workers: non
workers; 192:209 male: female)and 142 from Malavalli (all non workers; 71:71 male:
female).
Table I: Baseline external factors that may affect the study clinical outcomes
R’nagaram
workers
R’nagaram non
workers
Malavalli non-workers
Use of Agarbathi
87.8% 245/279
89.3% 109/22
46.5% 66/142
Gas, cooking fuel :
0.0% 0/275
3.4% 4/118
8.6% 11/128
Kerosene,
cooking fuel
23.3% 64/275
24.6% 29/118
35.2%45/128
Wood, cooking
fuel
76.7% 211/275
72.0% 85/118
56.3%72/lZS
Exposure to
heavy traffic
66.3% 185/279
55.7% 68/122
54.9% 78/142
5
J
38.0% 106/279
39.3% 48/122
j Exposure to
? smoker at home
76.3% 213/279
79.5% 97/122
Exposure to
smoker at
work/school.
93.5% 261/279
41.0% 50/122
69.9% 195/279
68.0%83/122
100.0% 276/276
99.2% 119/120
88.9% 248/279
80.3% 98/122
5.7% 9/159
5.5% 4/73
94.3% 150/159
94.5% 69/73
Exposure to Pets
Use of Mosquito
Rep ell ants
■1
i
j Diet, non-veg
1 Diet, Eggs
i
1 Diet, Milk buffalo i
Diet, Milk cow
I
I
I
28.9% 41/142
I
42.3% 60/142
I
I
unavailable
I
41.5% 59/142
99.2% 127/128
I
I
!
84.5% 120/142
10.1% 11/109
89.9%88/109
These factors (Table I) may interfere with the outcome frequencies. Many of these factors
are related to potential hyperreactive airway disease such as exposure to the utilization of
wood for cooking, exposure to pets, exposure to smokers at home/work/school and use of
mosquito repellants that were more common in Ramanagaram compared with Malavalli.
These factors may by themselves or at least predispose as factors triggering hyperreactive
airway disease. Many of these factors may also reflect the effects of industry on
traditional households being associated with an increased earning capacity and
urbanization of the township associated with similar occupations within the town limits.
Table II: Clinical Features (Symptoms. Signs, basic tests) results:
MALVA
RAMNAGARAM
LLI
SI.
Control
Control (C)
SYMPTOMS Working
No
(C)
(W)
1.
2.
13.3%
Recurrent
(37/279)
Wheeze
Recurrent Fast : 14.0%
Breath________| (39/279>
7.4%
2.2%
(9'122)
(3/136)
8.3%
2.9%
10/121)
(4/136)
STATISTICAL
SIGNIFICANCE__________
R’Nagar indicates between W
and C, Malavalli indicates W
and Malavalli C.
R’Nagar p=.09
Malvalli p=<0.01___________
R’nagar p=0.11
Malvalli p=<0.01
6
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
16.
Clinically
defined
53.4%
(149/279)
hyperactive
airways
of
(presence
Wheeze,
fast
breathing,
chest
retraction,
cough,
night
cough,
rhonchi, chest i
retraction._____[
Family history 25.9%
(72'278)
of
asthma/allergy
Pallor
73%
17.
Eosinophils
14.
15.
!
L
i
14.7%
Recurrent
chest retraction (41/279)
Recurrent
31.5%
Cough_______ (88/279)
Recurrent
19.4%
Phlegm______ (54/279)
Recurrent
21.6%
(60/278)
Night Cough
Frequent colds, 35%
(97/277)
sneeze,
Recurrent Eye ; 15.8%
red/itch/water ' (44/278)
Recurrent
13% •
Itching
skin (36/278)
rash
Recurrent
8.9%
(25/279)
Oozing Skin
Hospital
7.2%
(20/279)
admission for
any of above
problems_____
PEFR cut off
20.0%
(54/270)
15%
Silk
antigen I 33.1%
(92'278>
+ve
(219/279)
11.5%
5.1%
(14/122)
(7136)
20.5%
4.4%
(25/122)
(6 136)
9%
2.2%
(11/122)
(3 136)’
15.7%
2.3%
(19121)
(3 136)
27.3%
16.9%
(33 121)
(23 136)
9%
5.9%
(11 122)
(8 136)
9%
3.7%
(11.122)
(5 136)
2.5%
0.7%
(3 122)
(1.136)
6.6%
2.9%
(8,122)
(4 136)
24%
20%
(27 114)
(21 105)
29.17%
27.9%
(35 120)
(26.93)
41.8%
19%
(51/122)
(27/142)
23.7%
11.8%
(29 122)
(16/136)
73%
69%
(90 122)
(98/142)
3.96%
4.5%
3.5%
(n=250)
(n=114)
(n=127)
R’Nagar p= 0.38
Malvalli p= <0.01
R’nagar p=0.02
Malavalli p<0.01
R’Nagar p=<0.01
Malvalli p=<0.01
I R’Nagar p=0.17
! Malvalli p=<0.01
! R’Nagar p=0.13
Malvalli p=<0.01
i R’Nagar p=<0.06
Malvalli p=<0.01
i R’Nagar p=<0.27
! Malvalli p=<0.01
! R’Nagar p=0.02
! Malvalli p=<0.01
! R’Nagarp=0.8
I Malvalli p=0.08
i R’Nagar p=0.32
I Malvalli p=0.84
R’Nagar p=0.91
Malvalli p=0.57
R’nagar p=0.042
Malvalli p=<0.01
I_________
R’nagar p=0.65
Malvalli p=<0.01
No significant difference
Normal range 1-6%
7
18. Hb
19 a. NCHS
Hb=<8 gm%
Hb=8-10
gm%
Hb=10-12
gm%
6-10 yrs
Mean
Ht (SD) cms
Mean
Wt (SD) Kgs
19 b. NCHS
19 c. NCHS
10-12 yrs
Mean
Ht
(SD)
in cms (n=
Mean
wt
(SD)
in Kgs
12-14yrs
Mean
Ht
(SD)
in cms
13.6%
16.1%
16.7%
(n=37/272)
(19/118)
(22/132)
65.8%
66.9%
76.5%
(n= 179/272)
(79/118)
(101/132)
20.8%
16.9%
(n=56/272)
(20/118)
6.8%
(9/132)
132.3(10.3)
122.9(7.2)
(n=37)
122.4(9.9)
(n=57)
(n=51)
23.9(3.2)
20.3 (3)
20.4(4)
(n=38)
(n=58)
(n=51)
Percentile
l07-148cm
5(h - 95 ’h
Percentile
|
17-45 kg
5'*' - ’ 95ih
141(7.9)
138.7(9.8)
(n=114)
135.6(5.5)
(n=52)
(n=67)
28.4(4.7)
27.6 (5.9)
26.9(3.7)
(n=114)
(n=58)
(n=68)
Percentile
24-58 kg
IE
5^ Percentile
137-177 cm
149.4(8)
143(8.4)
142.6(6.4)
(n=105)
(n=10)
(n=18)
Percentile
127-162 cm
5,h
gtb
20.
Mean
wt 34.4 (5.6)
(n=106'»
(SD)
in Kgs
Vitamin B
I 9.6%
(27 279^
Deficiency
29.05 (6.3)
30(3.8)
(n=10)
(n=18)
7.3%
I 2.3%
(9/122)
| (3/142)
-
_
95,h 1
95lh
Percentile
30-72 kg
R’Nagar.
p=0.45
Malvalli
p=0.04
.All the above mentioned parameters (Table II) suggestive of hyperreactive airwav
disease, bronchitis and allergic rhinitis obtained were most prevalent among children
working in the filature units at Ramanagaram compared to both internal and external
controls. Except for recurrent cough among working children at Ramanagaram no other
parameter was statistically significantly different when compared to the internal non
workers in Ramanagaram. When the workers at Ramanagaram were compared with the
controls at Malavalli there was statistical significant difference among the groups and
their prevalence of ‘allergic’ manifestations. However, the objective Eosinophil counts,
PEER variability and Silk antigen testing did not differ between the groups. Moderately
Q
severe anaemia (Hb < 10 gm/dl) was the commonest health problem with > 78% of all
children needing treatment and advice. Children > 10 years showed a reduction in
expected heights and weights progressively worsening with age. Vitamin B complex
deficiency was significantly more common in the Ramanagaram population compared to
Malavalli (9% versus 2%).
Discussion:
There have been few attempts to study occupational health status among sericulture
workers (Harindranath et al [2]). Clinical survey of sericulture workers at Kollegal and
Chikkaballapur led by PV Subbarao et al [6], and an Interns'* project study in Kamagere
village of Kollegal taluk by Ananthraman et al [7] are some documented work. However
all these studies were done on the adult workers. The uniqueness of present study stems
from the fact that it is a community based occupational health study carried out on
children working in filature units of sericulture industry.
Symptoms
In all those children with symptoms, those working in the filature units of
Ramanagaram (WR) are more frequently affected than those non working (NWR) but
residing in Ramanagaram. though apart from recurrent oozing skin lesions the difference
was not statistically significant between these groups. The results did reveal that there
was a significant difference between working children from Ramanagaram and the
external control group from Malvalli (MAL). Respiratory morbidity was more frequent
among the population of children living in Ramanagaram when compared to Malavalli.
Respiratory morbidity
These symptoms suggest that working children show higher proportion
respiratory problems when compared to non-working children both in Ramanagaram and
Malvalli. Bronchial hyp erreact ivity was significantly increased in the study population of
working children at Ramanagaram in comparison to those from the external control at
Malavalli. In comparison, reponed prevalence of respiratory morbidity in an intern's
study conducted in Kamagere village in Kollegal District of Karnataka among reelers and
non reelers, prevalence of wheezing was 26%-8%, nocturnal cough 8%-4% and phlegm
22%-8% respectively. Except for wheezing none of the difference was statisticallv
significant [7]. Harindranath et al findings revealed that 36% of the workers in reeling
units were suffering from asthma of varying severity [2].
In comparison, most of the reponed prevalence studies on asthma in children are
generally studied among school children by administering questionnaires. The ISAAC
study revealed an overall range for Indian cities a prevalence of 2%-18%. This study was
restricted to age group of 13-14 years. Associated conditions in childhood asthma are
allergic rhinitis 75%, serious otitis media 22.5% sinusitis 9% and eczema 8% [8],
Parmesh et al reported a study in the age group 6-15 years children a prevalence of
asthma 16.6% in urban and 5.7% in rural children in Kamataka[3],
10
Allergy
Allergic symptoms pertaining to upper respiratory tract, allergic bronchitis, skin rash
were prominent in our study. These symptoms suggest that there was a significant
difference of increased “allergic” symptoms (Allergic Rhinitis, Conjunctivitis,
Bronchitis, Atopic skins lesions) among working children living in Ramanagaram versus
those in Malvalli control. In all those children with symptoms, those working in the
filature units of Ramanagaram were more frequently affected than non-filature workers
of Ramanagaram, though apart from recurrent oozing skin lesions the results were not
statistically significant between these groups. It must be remembered that even on using
validated questionnaires, the findings may not be applicable to countries that have a
prevalence of infectious diseases with similar symptoms (ISAAC Lancet 1998). Other
health conditions like anemia, poor growth were seen in all groups described above.
Working children of Ramanagaram show significantly higher proponion of Vitamin B
deficiency than control children in Ramanagaram as well as Malvalli ( P<0.05)
Asthma/Hyperreactive airway disease
The hallmark of asthma has always been the concept of reversible airway obstruction.
PEFR appeared similar in all groups working/non-working in RAM and those in MAL
(20%, 24%, 20%). It is possible that a single PEFR variability exercise has its limitations
in the detection of hyper-reactive airways and that a comparison with a personal best, not
possible with a cross sectional study in our set-up would be needed to objectively clarify
the presence of hyper-reactive airways. .An intermittent asthma or hyper-reactivity rather
than a persistent state could also be reason for the lack of differences between PEFR
variability of groups.
Asthma presentation in children is varied; thus determining asthma by a single
parameter may not be correct. When symptoms suggestive of asthma taken in
combination (wheeze, chest retraction, fast breathing, night cough and clinical findings of
rhonchi and chest retraction) for clinical definition of hyperactive airways, Ramanagaram
working children had statistically significant higher proportion 53% when compared to
control children both in Ramanagaram 41% OR 1.6 P=0.042 and Malvalli 19%
OR=4.86, P=<0.01 respectively. In comparison, Harindranath et al (.Ann Allergy 1985)
revealed that 36% of adult workers were suffering from asthma of varying severity. It is
also obvious that the longer the duration of exposure the more likely is the manifestations
of asthma. Does this mean that children may not objectively manifest the effects of the
exposure to the allergen early and only after years of exposure would permit
documentation of the disorder during adulthood. It is known that many workers of
sericulture start working in childhood and could be afflicted with asthma by their early
twenties causing disability and degrading the quality of life (Inbanathan A et al
Benficiary Assessment Report Inst of Social and Eco Change, Bangalore, 1995; 1
Sec/BA/74:1). There is also postulated that children already exposed and sick due to
allergy may no longer be permitted to work in the industry and not be recorded as a part
of the actively working study population..
11
Skin Tests
Skin test is an independent predictor of asthma and the association becomes stronger
with the addition of raised eosinophil counts and history of a parasitic disease (Celedon et
al Ped 2001). Skin prick antigen testing noted that l/3rd of working children in
Ramanagaram (33%) showed sensitization, similarly high proportion of sensitization was
seen among the controls (29% in Ramanagaram and 28% in Malvalli). In the study
reported by Harindranath et al silk antigen positivity was 21.8% of the persons employed
in silk filatures responded skin prick test. 28% of the total subjects screened responded
positively to either or both of the antigens. High sensitization in Malvalli control group
could not be explained only by very small number of silk units in Malvalli. Possibility of
cross reactivity to other allergens such as due to the fluttering of insects raising scales
(moths) will have to be looked into (ISEC report, BA 074: 23). All these possible
explanation can only be proved by extensive immunological studies. The detection of
allergen specific blood (serum) Immunoglobulins could provide good supplement data in
future studies with regards the specific nature of the allergen causing the problems.
Ramanagaram versus Malavalli
It now appears that the entire study population in Ramanagaram had similar features,
irrespective of work or no work in filature units and they significantly differed by being
more frequent than the group from Malvalli. One possible explanation would be, the
allergens causing the allergic respiratory manifestations seen in Ramanagaram appear to
be widespread in the environment. If silk as a known antigen is one such allergen, it is
too extensive in the environment at Ramanagaram to show a significant difference among
children actually working and not working in filature units. It could be postulated that the
silk industry being the major allergen industry in the area of Ramanagaram could just be
the reason for this environment. Malvalli on the other hand with far less numbers of silk
units had lower respiratory morbidity as compared to study groups of Ramanagaram. In
addition, factors like the utilization of wood for fuel, exposure to pets, exposure to
smokers at home/work/school and the use of mosquito repellants were commoner in
Ramanagaram may add to the differences between groups. Parmesh (Pulm Pharmac Ther
2002) clearly states that urbanization, air pollution and environmental tobacco smoke
contribute to the increased prevalence of asthma among children. The preexisting
exposure to atopy may constitute an increased risk factor for asthma caused by
occupational hazards.
General Health Indicators
General health indicators documented indicate that the entire study population,
irrespective of residence or work, were anemic and in need of iron/anti-helminthics
which were provided as an interventional component of the study. Physical growth as
measured by height and weight remained on an average between the 5th and 95th
percentile of NCHS standards and results even showed a physically healthier child among
workers at Ramanagaram. This may simply be because of the industry’s selection of
children to work being the ones who appear physically fit to maintain productivity.
12
Child Labour
More importantly, the issue of child labor in silk industry needs to be addressed.
Children are employed in all stages of the silk processing, making sericulture a child
based industry. Child labour in the country is prohibited and regulated in various
processes sectors by the Child Labour (Prohibition and Regulation) Act. The Act
classifies various sectors and processes as ‘hazardous’ or ‘non-hazardous only based on
the physical-working environment. However, such a perspective fails to recognize that
any process involving child labour is detrimental to the child, since it hinders the overall
development and health of the child; health in this context refers to the physical,
emotional and social well being of the child (as defined by the WHO) [12],
Conclusions:
In conclusion, children in Ramanagaram had a significantly higher frequency of
respiratory morbidity compared with those in Malavalli. Ramanagaram’s children with
“allergic” symptoms (Airway - upper/lower; skin, eye) were significantly higher as
compared to those residing in Malavalli. These frequencies were highest among those
working in filature units as a group. It is obvious that there must be a common
environmental factor in Ramanagaram that differentiates it from Malavalli. One major
factor could be the number of silk units in the region. This study suggests that health
hazards due to an allergen industry such as sericulture has a far wider impact than on the
individual, but on the environment affecting the entire community. Certainly more
extensive studies utilizing a longitudinal design, detailed pulmonary function tests, serial
monitoring and serum silk specific antigens may be called for to study the problem. Until
then it would be prudent to initiate measures in protecting the working child population in
filature units of the Silk industry from continuing their exposure to allergens that in the
years to come will be the cause of further respiratory morbidity/disability in adulthood.
13
References:
1. Anand Inbanathan, Om Prakash, Sudhamani N, Lokesh CA, Saraswathi G.
Sericulture and Health: Rearing, reeling and working in Grainages: A
Beneficiary Assessment Report. Institute For Social and Economic
Change, Nagarbhavi, Bangalore. Dec 1995.
2. Harindranath N, Om P, Subba Rao PV. Prevalence of Occupational
Asthma in Silk filature. Annals of Allergy 1985;55(3):511-15.
3. Parmesh H. Epidemiology of Asthma in India. Ind J Ped 2002;69:309-12
4. Global strategy for asthma measurement and prevalence; NHLBIAXHO
workshop report 1997.
5. Spahn JD : yearbook of allergy, asthma and clinical immunology : ED
Rosenwadden LJ et al, Mosby publication 2000.
6. Subbarao PV, Prakash O. A report on Clinical survey done at Kollegal and
Chikkaballapur Oct-Dec 93. (unpublished)
7. AnanthRaman R et al. A study of Respiratory Morbidity and Asthma in a
silk reeling population in Rural Karnataka. Interns’ project Report.
February-April,2002.
8. The international study of asthma and allergies in childhood ( ISAAC)
Steering committee. Worldwide variation in prevalence of symptoms of
asthma allergic rhinoconjuctivitis, and atopic eczema:ISAAC. Lancet 1998
;351:1225-32.
9. Barbara Butland K David Strachan P, RoSs Anderson H. The home
environment and asthma symptoms in childhood: two population based
case control studies 13 years apart. Thorax 1997;52:618-24.
10. Chakravarthy SK, Singh RB, Soumya S, Venkatesan P. Prevalence of
Asthma in urban and rural children in Tamil Nadu. NMJI 2002; 15(3):260263
H.Rahshidul Hassan M, Luthlul Kabir ARM, Mahmud AM, Fazalur
Rahman, Ali Hossain M, Saifiidding Bennoor K et al. Self-reported
asthma symptoms in children and adults of Bangladesh: findings of the
National Asthma Prevalence Study. Int J Epidemiology2002;31:483-88.
14
PREVALENCE OF HYPER-REACTIVE AIRWAY DISEASE IN CHILDREN
WORKING IN THE FILATURE UNITS IN THE SERICULTURE INDUSTRY
AND THE EFFECTS ON THE GENERAL HEALTH OF THE CHILDREN
Report of a study
Conducted by :
Community Health Cell
# 367, Srinivasa Nilaya,
Jakkasandra 1st Main
Kormangala 1st Block
Bangalore-360034.
And
Department of Pediatrics
St. Johns Medical College and Hospital
Sarjapur Road
Bangalore -560034
Sponsored by :b
Movement for Alternatives and Youth Awareness (MAYA)
#111, 5th Block, 5th Main
Jayanagar 560041.
April 2003
c«jJ
1
Prevalence of respiratory morbidity among children working
in filature units of the sericulture industry and the effects on
general health of the children.
Dr. R. R. Patil*, M.Sc (Epid), Research Assistant
Dr. S. Lewin, MD DNB, Associate Professor
Dr. S.D. Subba Rao, DCh DNB, Professor and Head
Dr. Om Prakash, MD, Consultant Physician
Dr. Peter Prashanth DCh, Consultant Paediatrician
Dr. Chitra Dinakar, DCh DNB, Lecturer
Dr. C.M. Francis*, MD, Advisor
Dr. Thelma Narayan*, MD, Advisor
Concept, Design (Drs. RP, SL, SDSR), Acquisition of data (Drs. RP, PP), Analysis,
Interpretation (Drs. RP, SL, SDSR, CD), Drafting (Drs. RP, SL, CD), Final Approval
(Drs. RP, SL, SDSR)
* Community Health Cell
367, Srinivasa Nilaya, 1st Main, 1st Block, Jakkasandra, Bangalore 560 034
Karnataka, India
And
Department of Pediatrics
St. Johns Medical College and Hospital, Sarjapur Road, Bangalore 560034
Karnataka, India
Corresponding Author:
Dr..Rajan R Patil
Research Assistant, Community Health Cell, 367, Srinivasa Nilaya, 1st Main, 1st
Block, Jakkasandra, Bangalore 560 034. Ph.: 5525372 / 5531518
Email: sochara@vsnl.com
Sponsored by Movement for Alternatives and Youth Awareness (MAYA), #111,5
Block, 5thMain, Jayanagar, Bangalore, Karnataka 560041.
Only Dr. Peter Prashanth received a honoraria for the fieldwork involved in the
study. Social workers utilized during fieldwork were members of MAYA, the
sponsor. None of the other authors had any conflict of interest in the outcome of
the study and the sponsor.
Word count
3565
Introduction:
Karnataka contributes to nearly 70% of the country’s total mulberry silk
production and the town of Ramanagaram is among the largest cocoon-marketing centre
in Asia. The cocoon market averages a daily transaction upto 30 tonnes per day. The
town has a population of 79,382 with 6,478 child laborers, 2138 reelers and 915
charkhas, 1500 filature units and 102 grainage units. Children are employed in all stages
of the silk processing, making sericulture a child-based industry. About 80 % of the
individuals involved in reeling silk are between the ages of 10-15 years [* Human rights
report, 1999], Children usually are involved in the filature unit tasks of cooking/boiling.
During this process of ‘cooking’, the silkworms emit a protein called sericin in the form
of foul-smelling vapors that pervade not only the silk units but also the entire region
surrounding the units. It is this protein vapor that has been attributed to cause chronic
bronchitis and asthma.
There are few studies on occupational health among children in this industry. An
earlier study among adults reported that 16.9% of the total subjects from sericulture
industry could be clinically categorized as having occupational asthma free from
symptoms while away from work, with exacerbations upon resumption of occupation. At
least 21.8% of the persons employed in silk filatures responded positively to both cocoon
and pupal allergens [2], Studies have shown that children develop sensitization to indoor
allergens as they grow older in that atmosphere. Sensitivity of 1.5% at 1 yr age increases
to 90% at 8-11 yrs of age [3], In the sericulture sector, the child grows up working at the
cost of the health, education, and social opportunities of children. Recent
epidemiological studies of naturally occurring and occupational asthma have shown the
importance of allergic factors in the pathogenesis. The research question this study set
out to answer was “Is the prevalence of health problems (especially respiratory
morbidity) more in children working in the filature units of sericulture industries at
Ramanagaram town as compared to the children who are not working in filature units?’
Findings of such a study is hoped to strengthen the policy action vis a vis child labour in
sericulture.
Objectives:
The primary objective was to study the comparative prevalence of Respiratory morbidity
especially Hyperactive Airways among children working in filature units. The secondary
objective was to study the comparative general health status among children working in
the filature units.
Methodology:
Design
The study was designed as a cross-sectional (prevalence) study of environmental
conditions at work/home and the presence of clinical evidence of health problems with
special reference to hyper reactive airways as determined by symptoms, signs and peak
expiratory flow rates. The definition of ‘exposure’ in our study was children working in
filature units for at least 3 months and definition of ‘control’ (non-exposed) was school
children not working in filature units. The significant difference in the number of
"1
functioning units in the two town appeared to permit a comparison between groups exposed, internal non-exposed (internal control group) in Ramanagaram and external
non-exposed (external control group) in Malvalli. The study population was divided into
three groups: Group I included were children working in the filature unit of the local
sericulture industry at Ramanagaram for at least 3 months; Group II included controls
from among neighbours at home not working in a similar allergen industry (internal
controls); and, Group III included Malavalli children not exposed to a similar
environment (external control). A sample size of 276 children based on known incidence
of 4-5% and an expectation of 20-25% incidence of hyperactive airways was obtained by
consecutive sampling of children of consenting parents (power 80). As controls from the
home locality and the identified external control (Malavalli, 50 kms away, 2 filature
units, 13 Charkhas and 3 grainage units, no child labour), a minimum of 100 children was
examined on a similar basis in each of the control groups. During the pilot study,
randomization and stratified selection of study subjects led to operational problems due to
community members questioning the rationale behind the selection process, which then
had to be changed to a simple first come first serve basis.
Study Groups
Filature unit working
children - R’nagaram
Non-filature unit working
children - R’nagaram
No working
children - M’valli
Questionnaire
The questionnaire used was a modification of the subjective ISAAC and a
Bangladesh questionnaires (ISAAC Lancet 1985, Hassan et al Int J Epidemio 2002) and
factors associated with asthma as described by Parmesh (Ind J Ped 2002) along with
objective physician clinical examination similar to those utilized in clinics to suspect and
diagnose children with respiratory disease especially hyper reactive airways.
Inclusion/Exclusion Criteria
The inclusion criteria was all children aged >5 to 18 years, who have worked for more
than 3 months in the filature units of the sericulture industry at Ramanagaram town as the
exposed group. Exclusion criteria were those who were acutely ill; asymptomatic but
unable to perform peak flows satisfactorily; and, those who refused to consent.
Methods
Initially, standardization and training for data collection (demographic, symptoms,
environmental factors) and measurements (clinical, peak flow rates before and after
inhaled broncho-dilator, silk skin test) was carried out in the field for the social workers
and field investigator. A local Rotary Hospital was utilized for baseline blood
investigations, skin testing, education and medication. Social workers made contact with
parents of potential study children and obtained a written informed consent for
examination and testing utilizing information printed in appropriate local languages
including a separate consent form. Utilizing a questionnaire, the field investigators and
A
social workers documented a clinical history, including symptoms and environmental
factors, with specific reference to hyperactive airways. A detailed examination including
anthropometry, PEFR before and 20 mins after two beta agonist (Salbutamol) inhalations
using a standard spacer device and a silk skin test. Blood samples (Hb, TC, DC and ESR)
were collected in open vials for manual counts by technicians in the local Rotary
Hospital. The study began in Ramanagaram with a pilot study on 12th December 2002
and concluded on 9th Jan 2003 in Malvalli.
Outcome variables
The clinical endpoints in this study were predominantly respiratory symptoms in view
of the nature of the occupation under scrutiny. Hyper reactive airways would be clinically
suspected if a child has presenting symptoms of recurrent episodes of night cough,
wheeze, fast breathing or chest retractions in isolation or in combination with the
examination finding of rhonchi. A child who keeps presenting with the production of
sputum (phlegm) and cough could have episodes of bronchitis, while those with recurrent
coryza, running nose, nose blocks, sneezing could indicate allergic rhinitis. The presence
of non-painfiil itching eyes with redness and watering would point to allergic
conjunctivitis. All these conditions would be health problems probably attributed due to
occupational effects of working in filature units. In view of the portability, ease of use
and the field study conditions, we chose to use PEFR [5] as an objective assessment for
airway hyper-reactivity. A onetime PEFR variability of > 15% was to be taken as
significant objective evidence of bronchial hyperreactivity [4 Evaluation of asthma and
allergy, awww.wnmeds.ac.nz/academic/med/warg/adv.html ] before and after inhaled
beta- agonist. In addition, to attribute any allergic manifestation to the silk utilized in the
industry, a silk skin test was compared in all with a saline and histamine skin test.
Outcome variables were hence defined as follows: Hyperactive airway disease was
suggested by episodes of wheeze, cough, fast breathing, chest retractions, night cough
and/or rhonchi. Allergic symptoms of frequent colds and sneezing; red eyes with itching
and watering and no pain; itching skin rash were defined for the questionnaire.
Skin Test
For the silk skin test, the allergen extract is obtained from Silkworm pupae. Silkworm
pupae are separated from cocoons, immersed in liquid nitrogen and crushed into a fine
powder. Water is added to the powder till it forms a slurry and squeezed through a two
layered muslin cloth. Four volumes of chilled acetone are added to one volume of the
extract and after stirring, the mixture is filtered though Whatman No. 3 filter paper under
suction. The residue is washed several times with chilled acetone and finally with chilled
peroxide-free diethyl ether. The resultant powder is dried and kept at -20 degrees Celsius
for further use. For use, the acetone-dried powder of pupae is stirred for two hours at
room temperature with 20 ml of 100 mg sodium phosphate buffered saline, pH 7.4. The
slurry is centrifuged at 20,000xg for 15 minutes. The crude extract thus obtained (1:20
wt/vol) is filter sterilized and used for prick skin tests after diluting with an equal volume
of sterile glycerin to give a 1:40 wt/vol. [2] Allergy for silk was tested by placing 0.1 ml
silk antigen. Histamine and Normal saline on the volar surface of the forearm. A skin
prick test was carried out on all three drops on the arm. The skin reaction of silk antigen
was read after 15 minutes by comparing with Histamine and Normal saline, which served
as positive and negative controls. The interpretation of positive reaction to silk antigen
was based on comparative size of wheal formation at the site of skin prick test. If wheal
formed by silk antigen was equal to or more than wheal produced by the histamine it was
taken to be positive. The test was performed by a single observer (Dr. PP) to avoid inter
observer variability.
Statistical Analysis
Data collected was independently analyzed using EPI Info -6 and probability calculated.
Differences between the groups were considered statistically significant if the p value
was < 0.05.
Ethics
The study included a Subject Information Form and Informed Consent in the local
language and confidentiality of all data was maintained. Our study was cleared by the
Institution Ethical Review Board.
Results:
A total of 401 children were selected from Ramanagaram (279:122 workers: non
workers; 192:209 male: female)and 142 from Malavalli (all non workers; 71:71 male:
female).
Table I: Baseline externa! factors that may affect the studyclinical outcomes
R’nagaram
workers
R’nagaram non
workers
Malavalli non-workers
Use of Agarbathi
87.8% 245/279
89.3% 109/22
46.5% 66/142
Gas, cooking fuel
0.0% 0/275
3.4% 4/118
8.6% 11/128
Kerosene,
cooking fuel
23.3% 64/275
24.6% 29/118
35.2%45/128
Wood, cooking
fuel
76.7% 211/275
72.0% 85/118
56.3%72/128
Exposure to
heavy traffic
66.3% 185/279
55.7% 68/122
54.9% 78/142
£
Exposure to Pets
38.0% 106/279
39.3% 48/122
28.9% 41/142
Exposure to
smoker at home
76.3% 213/279
79.5% 97/122
42.3% 60/142
Exposure to
smoker at
work/school.
93.5% 261/279
41.0% 50/122
unavailable
Use of Mosquito
Repellants
69.9% 195/279
68.0%83/122
Diet, non-veg
100.0% 276/276
99.2% 119/120
99.2%127/128
Diet, Eggs
88.9% 248/279
80.3% 98/122
84.5% 120/142
41.5% 59/142
-
Diet, Milk buffalo
5.7% 9/159
5.5% 4/73
10.1% 11/109
Diet, Milk cow
94.3% 150/159
94.5% 69/73
89.9%88/109
These factors (Table I) may interfere with the outcome frequencies. Many of these factors
are related to potential hyperreactive airway disease such as exposure to the utilization of
wood for cooking, exposure to pets, exposure to smokers at home/work/school and use of
mosquito repellants that were more common in Ramanagaram compared with Malavalli.
These factors may by themselves or at least predispose as factors triggering hyperreactive
airway disease. Many of these factors may also reflect the effects of industry on
traditional households being associated with an increased earning capacity and
urbanization of the township associated with similar occupations within the town limits.
Table II: Clinical Features Symptoms, Sigps, basic tests) results:
MALVA
RAMNAGARAM
LLI
SI.
Control (C) Control
SYMPTOMS Working
No
(Q
(W)
1.
2.
Recurrent
Wheeze______
Recurrent Fast
Breath
2.2%
13.3%
7.4%
(37/279)
(9/122)
(3/136)
8.3%
2.9%
14.0%
(39/279)
(10/121)
(4/136)
STATISTICAL
SIGNIFICANCE_________
R’Nagar indicates between W
and C; Malavalli indicates W
and Malavalli C.___________
R’Nagar p=.O9
Malvalli p=<0.01__________
R’nagar p=0.11
Malvalli p=<0.01
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.7%
Recurrent
(41/279)
chest retraction
31.5%
Recurrent
(88/279)
Cough_______
19.4%
Recurrent
(54/279)
)hlegm______
21.6%
Recurrent
(60/278)
Night Cough
Sequent colds, 35%
sneeze,______ (97/277)
Recurrent Eye 15.8%
(44/278)
red/itch/water
13%
Recurrent
(36/278)
skin
Itching
rash
8.9%
Recurrent
(25/279)
Oozing Skin
7.2%
Hospital
admission for (20/279)
any of above
problems_____
20.0%
PEFR cut off
(54/270)
15%
antigen 33.1%
Silk
(92/278)
+ve
16.
Clinically
53.4%
defined
(149/279)
hyperactive
airways
of
(presence
fast
Wheeze,
breathing,
chest
retraction,
night
cough,
cough,
rhonchi, chest
retraction.
Family history 25.9%
(72/278)
of
asthma/allergy
73%
Pallor
17.
Eosinophils
14.
15.
(219/279)
3.96%
(n 250)
11.5%
5.1%
(14/122)
(7/136)
20.5%’
4.4%
(25/122)
(6/136)
9%
2.2%
(11/122)
(3/136)
15.7%’
2.3%
(19/121)
(3/136)
27.3%
16.9%
(33/121)
(23/136)
9%
5.9%
(11/122)
(8/136)
9%
3.7% "
(11/122)
(5/136)
2.5%
0.7%
(3/122)
(1/136)
6.6%
2.9%
(8/122)
(4/136)
24%
20%
(27/114)
(21/105)
29.17%
27.9%
(35/120)
(26/93)
41.8%
(51/122)
19%
(27/142)
R’Nagar p= 0.38
Malvalli p= <0.01
R’nagar p=0.02
Malavalli p<0.01
R’Nagar p=<0.01
Malvalli p=<0.01
R’Nagar p=0.17
Malvalli p=<0.01
R’Nagar p=0.13
Malvalli p=<0.01
R’Nagar p=<0.06
Malvalli p=<0.01
R’Nagar p=<0.27
Malvalli p=<0.01
R’Nagar p=0.02
Malvalli p=<0.01
R’Nagar p=0.8
Malvalli p=0.08
R’Nagar p=0.32
Malvalli p=0.84
R’Nagar p=0.91
Malvalli p=0.57
R’nagar p=0.042
Malvalli p=<0.01
(29/122)
(16/136)
R’nagar p=0.65
Malvalli p=<0.01
73%
69%
No significant difference
(90/122)
(98/142)
4.5%
3.5%
Normal range 1-6%
23.7%
(n=114)
11.8%
(n=127)
Q
18. Hb
19 a. NCHS
Hb=<8 gm%
Hb=8-10
gm%
Hb=10-12
gm%
6-10 yrs
Mean
Ht (SD)cms
Mean
Wt (SD) Kgs
19 b. NCHS
19 c. NCHS
20.
10-12 yrs
Mean
Ht
(SD)
in cms (n=
13.6%
16.1%
16.7%
(n=37/272)
(19/118)
(22/132)
65.8%
66.9%
76.5%
(n=179/272)
(79/118)
(101/132)
20.8%
16.9%
(n=56/272)
(20/118)
6.8%
(9/132)
132.3(10.3)
122.9 (7.2)
122.4(9.9)
(o=37)
(o=57)
(o=51)
23.9(3.2)
20.3 (3)
20.4(4)
(o=38)
(o=58)
(o=51)
141(7.9)
138.7(9.8)
135.6(5.5)
(o=114)
(o=52)
(o=67)
wt 28.4 (4.7)
Mean
(o=114)
(SD)
in Kgs
12-14yrs
Ht 149.4 (8)
Mean
(o=105)
(SD)
in cms
27.6 (5.9)
26.9(3.7)
(o=58)
(o=68)
143(8.4)
142.6(6.4)
(n=10)
(o=18)
wt
Mean
(SD)
in Kgs
Vitamin B
Deficiency
34.4 (5.6)
29.05 (6.3)
30(3.8)
(o=106)
(n=10)
(o=18)
9.6%
7.3%
2.3%
(27/279)
(9/122)
(3/142)
5^ — 95th
Percentile
107- 148cm
5th _ 95th
Percentile
17-45 kg
5th - 95'TE
Percentile
127-162 cm
5th - 95th
Percentile
24-58 kg
5th - 95 th
Percentile
137-177 cm
5th _ 95th
Percentile
30-72 kg
R’Nagar,
p=0.45
Malvalli
p=0.04
All the above mentioned parameters (Table II) suggestive of hyperreactive airway
disease, bronchitis and allergic rhinitis obtained were most prevalent among children
working in the filature units at Ramanagaram compared to both internal and external
controls. Except for recurrent cough among working children at Ramanagaram no other
parameter was statistically significantly different when compared to the internal non
workers in Ramanagaram. When the workers at Ramanagaram were compared with the
controls at Malavalli there was statistical significant difference among the groups and
their prevalence of ‘allergic’ manifestations. However, the objective Eosinophil counts,
PEFR variability and Silk antigen testing did not differ between the groups. Moderately
1 A
severe anaemia (Hb < 10 gm/dl) was the commonest health problem with > 78% of all
children needing treatment and advice. Chfidren > 10 years showed a reduction in
expected heights and weights progressively worsening with age. Vitamin B complex
deficiency was significantly more common in the Ramanagaram population compared to
Malavalli (9% versus 2%).
Discussion:
There have been few attempts to study occupational health status among sericulture
workers (Harindranath et al [2]). Clinical survey of sericulture workers at Kollegal and
Chikkaballapur led by PV Subbarao et al [6], and an Interns’ project study in Kamagere
village of Kollegal taluk by Ananthraman et al [7] are some documented work. However
all these studies were done on the adult workers. The uniqueness of present study stems
from the fact that it is a community based occupational health study carried out on
children working in filature units of sericulture industry.
Symptoms
In all those children with symptoms, those working in the filature units of
Ramanagaram (WR) are more frequently affected than those non working (NWR) but
residing in Ramanagaram, though apart from recurrent oozing skin lesions the difference
was not statistically significant between these groups. The results did reveal that there
was a significant difference between working children from Ramanagaram and the
external control group from Malvalli (MAT). Respiratory morbidity was more frequent
among the population of children living in Ramanagaram when compared to Malavalli.
Respiratory morbidity
These symptoms suggest that working children show higher proportion
respiratory problems when compared to non-working children both in Ramanagaram and
Malvalli. Bronchial hyperreactivity was significantly increased in the study population of
working children at Ramanagaram in comparison to those from the external control at
Malavalli. In comparison, reported prevalence of respiratory morbidity in an intern’s
study conducted in Kamagere village in Kollegal District of Karnataka among reelers and
non reelers, prevalence of wheezing was 26%-8%, nocturnal cough 8%-4% and phlegm
22%-8% respectively. Except for wheezing none of the difference was statistically
significant [7]. Harindranath et al findings revealed that 36% of the workers in reeling
units were suffering from asthma of varying severity [2],
In comparison, most of the reported prevalence studies on asthma in children are
generally studied among school children by administering questionnaires. The ISAAC
study revealed an overall range for Indian cities a prevalence of 2%-18%. This study was
restricted to age group of 13-14 years. Associated conditions in childhood asthma are
allergic rhinitis 75%, serious otitis media 22.5% sinusitis 9% and eczema 8% [8],
Parmesh et al reported a study in the age group 6-15 years children a prevalence of
asthma 16.6% in urban and 5.7% in rural children in Kamataka[3].
11
Allergic symptoms pertaining to upper respiratory tract, allergic bronchitis, skin rash
were prominent in our study. These symptoms suggest that there was a significant
difference of increased -‘allergic” symptoms (AUergic Rhinitis, Conjunctivitis,
Bronchitis, Atopic skins lesions) among working children living in Ramanagaram versus
those in Malvalli control. In all those children with symptoms, those working in the
filature units of Ramanagaram were more frequently affected than non-filature workers
of Ramanagaram, though apart from recurrent oozing skin lesions the results were not
statistically significant between these groups. It must be remembered that even on using
validated questionnaires, the findings may not be applicable to countries that have a
prevalence of infectious diseases with similar symptoms (ISAAC Lancet 1998). Other
health conditions like anemia, poor growth were seen in all groups described above.
Working children of Ramanagaram show significantly higher proportion of Vitamin B
deficiency than control children in Ramanagaram as well as Malvalli ( P<0.05)
Asthma/Hyperreactive airway disease
The hallmark of asthma has always been the concept of reversible airway obstruction.
PEFR appeared similar in all groups working/non-working in RAM and those in MAL
(20% 24%, 20%). It is possible that a single PEFR variability exercise has its limitations
in the detection of hyper-reactive airways and that a comparison with a personal best, not
possible with a cross sectional study in our set-up would be needed to objectively clarity
the presence of hyper-reactive airways. An intermittent asthma or hyper-reactivity rather
than a persistent state could also be reason for the lack of differences between PEFR
.
.
variability of groups.
Asthma presentation in children is varied; thus determining asthma by a single
parameter may not be correct. When symptoms suggestive of asthma taken in
combination (wheeze, chest retraction, fast breathing, night cough and clinical findings of
rhonchi and chest retraction) for clinical definition of hyperactive airways, Ramanagaram
working children had statistically significant higher proportion 53% when compared to
control children both in Ramanagaram 41% OR 1.6 P=0.042 and Malvalh 19/o
ORM.86, P=<0.01 respectively. In comparison, Harindranath et al (Ann Allergy 1985)
revealed that 36% of adult workers were suffering from asthma of varying severity. It is
also obvious that the longer the duration of exposure the more likely is the manifestations
of asthma. Does this mean that children may not objectively manifest the effects of the
exposure to the allergen early and only after years of exposure would permit
documentation of the disorder during adulthood. It is known that many workers of
sericulture start working in childhood and could be afflicted with asthma by their early
twenties causing disability and degrading the quality of life (Inbanathan A et al
Benficiary Assessment Report Inst of Social and Eco Change, Bangalore, 1995;
Sec/BA/74:1). There is also postulated that children already exposed and sick due to
allergy may no longer be permitted to work in the industry and not be recorded as a part
of the actively working study population..
1o
Skin Tests
Skin test is an independent predictor of asthma and the association becomes stronger
with the addition of raised eosinophil counts and history of a parasitic disease (Celedon et
al Ped 2001). Skin prick antigen testing noted that l/3rd of working children in
Ramanagaram (33%) showed sensitization, similarly high proportion of sensitization was
seen among the controls (29% in Ramanagaram and 28% in Malvalli). In the study
reported by Harindranath et al silk antigen positivity was 21.8% of the persons employed
in silk filatures responded skin prick test. 28% of the total subjects screened responded
positively to either or both of the antigens. High sensitization in Malvalli control group
could not be explained only by very small number of silk units in Malvalli. Possibility of
cross reactivity to other allergens such as due to the fluttering of insects raising scales
(moths) will have to be looked into (ISEC report, BA 074: 23). All these possible
explanation can only be proved by extensive immunological studies. The detection of
allergen specific blood (serum) Immunoglobulins could provide good supplement data in
future studies with regards the specific nature of the allergen causing the problems.
Ramanagaram versus Malavalli
It now appears that the entire study population in Ramanagaram had similar features,
irrespective of work or no work in filature units and they significantly differed by being
more frequent than the group from Malvalli. One possible explanation would be, the
allergens causing the allergic respiratory manifestations seen in Ramanagaram appear to
be widespread in the environment. If silk as a known antigen is one such allergen, it is
too extensive in the environment at Ramanagaram to show a significant difference among
children actually working and not working in filature units. It could be postulated that the
silk industry being the major allergen industry in the area of Ramanagaram could just be
the reason for this environment. Malvalli on the other hand with far less numbers of silk
units had lower respiratory morbidity as compared to study groups of Ramanagaram. In
addition, factors like the utilization of wood for fuel, exposure to pets, exposure to
smokers at home/work/school and the use of mosquito repellants were commoner in
Ramanagaram may add to the differences between groups. Parmesh (Pulm Pharmac Ther
2002) clearly states that urbanization, air pollution and environmental tobacco smoke
contribute to the increased prevalence of asthma among children. The preexisting
exposure to atopy may constitute an increased risk factor for asthma caused by
occupational hazards.
General Health Indicators
General health indicators documented indicate that the entire study population,
irrespective of residence or work, were anemic and in need of iron/anti-helminthics
which were provided as an interventional component of the study. Physical growth as
measured by height and weight remained on an average between the 5 and 95
percentile of NCHS standards and results even showed a physically healthier child among
workers at Ramanagaram. This may simply be because of the industry s selection of
children to work being the ones who appear physically fit to maintain productivity.
1 Q
Child Labour
More importantly, the issue of child labor in silk industry needs to be addressed.
Children are employed in all stages of the silk processing, making sericulture a child
based industry. Child labour in the country is prohibited and regulated in various
processes sectors by the Child Labour (Prohibition and Regulation) Act. The Act
classifies various sectors and processes as ‘hazardous’ or ‘non-hazardous’ only based on
the physical-working environment. However, such a perspective fails to recognize that
any process involving child labour is detrimental to the child, since it hinders the overall
development and health of the child; health in this context refers to the physical,
emotional and social well being of the child (as defined by the WHO) [12],
Conclusions:
1. Children working in filature units in the sericulture industry have a higher
prevalence of respiratory morbidity than the non-working (School children)
children both in Ramanagaram and Malvalli towns. The difference was
statistically significant among the Ramnagaram working and Malvalli non
working children, whereas the difference between working and non working
children in Ramanagaram was not statistically significant.
2. Children in Ramanagaram whether working or non working in the filature units
had significantly higher frequency of respiratory and other allergic symptoms
(airway, skin and eye) as compared with the children in Malvalli.
3. The over all risk appears to be related to the number of filature units in the area.
4. Anaemia is prevalent in almost all the children, whether working or non-working..
The height and weight for age of working children were better than those of non
working children. This is probably due to the preferential employment of robust
children by the employers and drop out of children who become unhealthy.
5. Skin antigen tests, baseline and post-bronchodilator PEFR were inadequate to
further confirm and support the proposed association recognized in the study. This
will need more elaborate longitudinal, hospital-based investigations, including
serial monitoring, spirometry and allergen specific IgE serum immunoglobulin
levels.
’ '
r on the children of the area (in addition
'
6. The health impact of sericulture
industry
to occupation group) must be kept in mind in any move to reduce health hazards.
1 A
In conclusion, children in Ramanagaram had a significantly higher frequency of
respiratory morbidity compared with those in Malavalli. Ramanagaram’s children with
“allergic” symptoms (Airway - upper/lower; skin, eye) were significantly higher as
compared to those residing in Malavalli. These frequencies were highest among those
working in filature units as a group. It is obvious that there must be a common
environmental factor in Ramanagaram that differentiates it from Malavalli. One major
factor could be the number of silk units in the region. This study suggests that health
hazards due to an allergen industry such as sericulture has a far wider impact than on the
individual, but on the environment affecting the entire community. Certainly more
extensive studies utilizing a longitudinal design, detailed pulmonary function tests, serial
monitoring and serum silk specific antigens may be called for to study the problem. Until
then it would be prudent to initiate measures in protecting the working child population in
filature units of the Silk industry from continuing their exposure to allergens that in the
years to come will be the cause of further respiratory morbidity/disability in adulthood.
References:
1. Anand Inbanathan, Om Prakash, Sudhamani N, Lokesh CA, Saraswathi G.
Sericulture and Health: Rearing, reeling and working in Grainages: A
Beneficiary Assessment Report. Institute For Social and Economic
Change, Nagarbhavi, Bangalore. Dec 1995.
2. Harindranath N, Om P, Subba Rao PV. Prevalence of Occupational
Asthma in Silk filature. Annals of Allergy 1985;55(3):511-15.
3. Parmesh H. Epidemiology of Asthma in India. Ind J Ped 2002;69:309-12
4. Global strategy for asthma measurement and prevalence; NHLB1/WHO
workshop report 1997.
1 c
5. Spahn JD : yearbook of allergy, asthma and clinical immunology : ED
Rosenwadden LJ et al, Mosby publication 2000.
6. Subbarao PV, Prakash O. A report on Clinical survey done at Kollegal and
Chikkaballapur Oct-Dec 93. (unpublished)
7. AnanthRaman R et al. A study of Respiratory Morbidity and Asthma in a
silk reeling population in Rural Karnataka. Interns’ project Report.
February-April,2002.
8. The international study of asthma and allergies in childhood ( ISAAC)
Steering committee. Worldwide variation in prevalence of symptoms of
asthma allergic rhinoconjuctivitis, and atopic eczema:ISAAC. Lancetl998
;351:1225-32.
9. Barbara Butland K, David Strachan P, Ross Anderson H. The home
environment and asthma symptoms in childhood: two population based
case control studies 13 years apart. Thorax 1997;52:618-24.
10. Chakravarthy SK., Singh RB, Soumya S, Venkatesan P. Prevalence of
Asthma in urban and rural children in Tamil Nadu. NMJI 2002;15(3):260263
ll.Rahshidul Hassan M, Luthfol Kabir ARM, Mahmud AM, Fazalur
Rahman, Ali Hossain M, Saifiidding Bennoor K et al. Self-reported
asthma symptoms in children and adults of Bangladesh: findings of the
National Asthma Prevalence Study. Int J Epidemiology2002;31:483-88.
12. Movement for Alternative and Youth Awareness. Which silk route this? A
situational analysis of child labor in the sericulture industry. Bangalore.
MAYA 2000
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