A cross sectional study on morbidities among sugar cane factory workers in Mandya district, Karnataka, India

Introduction   

Sugar industry is a growing sector to combat increasing demands of sweeteners throughout the world.1 Sugar industry is one of the important agro-based industries not only in India but also in the world as it directly contributes in creating employment, income and social developments in the rural areas of the country. Both skilled and unskilled workers from rural areas are engaged in this sector.² India is the second largest producer of sugarcane in the world after Brazil. Sugar cane industries are highly diverse places where workers are exposed to different health risks depending on the type of work. Poor working condition can result in musculoskeletal disorderand accidents.3 Sugarcane industry workers are directly involved in the production process and are therefore exposed to most of the linked risk factors.⁴

Repeated exposure to dusty environment in an industry is known to cause airway diseases which has a negative impact on the pulmonary function in the long run. Bagassosis is a respiratory disease caused by inhalation of bagasse dust.^5-7 Bagasse, a type of organic dust, is a by-product of sugar cane crushing, ranging from 0.5–3 microns in size. They are also termed as respirable dust, to which sugar factory workers are exposed by virtue of their occupation.8 Workers in these factories habitually give little importance for preventive measures such as wearing of masks or hearing muffs, etc. Exposure in this environment for a long period of time is known to cause health hazards. Hence in this regard, the present study is being taken up.

Objectives

• To describe the socio demographic characteristics of the factory workers.
• To assess the burden of morbidity among the sugar cane factory workers.
• To assess the common morbidities observed among the factory workers.

Material and methods 

This cross-sectional study was done in a sugarcane factory situated in Mandya district, Karnataka, India during the first quarter of 2017. All the workers present and available during the teams’ visit (on 3 different days) were included in the study.

A total of 172 subjects working in the different divisions of the factory were available and interviewed using a pre-tested structured questionnaire and basic information on socio demographic profile was obtained. A detailed history and clinical examination of the workers was done by a team of doctors and common morbidities observed were recorded. The workers who were found to be clinically positive for symptoms, were further subjected to laboratory investigations such as Haemoglobin estimation using Sahli’s haemoglobinometer, Blood sugar estimation using Glucometer, Audiometry in a reasonably sound proof room using a pure tone audiometer (Advanced digital audio meterAD2100) and assessment of pulmonary function using computerised Spirometry (nddMedizintechnik AG Spirometer). A walkthrough survey of the factory was done and possible hazards the workers were exposed to in the different sections was noted.

Ethical considerations: The ethical clearance was obtained for the study. Permission was taken from the management of the Sugar cane factory for conduction of the study. Informed consent was taken from all the subjects and confidentiality of data was maintained at all stages.

Analysis of data: Data was entered in an excel sheet and analysed using Stata 12.1 Texas, USA. The statistical test used to describe the data were percentages, proportions, mean and standard deviation. The association between the work place and clinical symptomswas calculated using univariate and multinomial logistic regression.

Results        

Majority of workers numbering 82 (47.7%) were aged between 31 to 40yrs.The mean age of the workers in different work stations are described in Table I. The Mean age of the workers was 39 + 8.34 yrs. The youngest worker was 19 years old and the oldest worker was 64 years of age. All 172(100%) workers were males. Majority of workers numbering 72(41.9%) were educated up to diploma/Degree and least 2(1.2%) were illiterate. 95.9% of the workers were Hindu by religion followed by Muslims (3.5%). 90.1% of the workers consumed non-vegetarian diet. The mean income was `18,850 (292 US$) and the range was from `10,000 to 20,000 per month. Minimum Income was `2,200 (34 US$) & Maximum Income was `75,000 (1162 USD). About 79 (45.9%) workers reported using at least one substance of abuse and 93 (54.1%) workers had never used any substance. Alcohol was the main substance of abuse (74.7%) followed by tobacco Smoking (49.4%).

The workers average period of work was 10.5 years in the factory and the average duration of work was 8 hours per day. 109 (63.3%) workers were working in hazard prone sections of the factory as depicted in Table 1.

The mean BMI among the workers working in Mill section of the factory was significantly higher compared to workers in other sections of the factory according to the Asia-Pacific guidelines 2017.9 95(55.2%) workers had one or other morbidity as depicted in Table-2. There was no statistically significant association observed between work area and individual health problem, BMI and health problems, work area and BMI.

Majority 40(23.2%) workers were obese, 38(22.1%) workers were overweight and least 1(0.6%) worker had allergic bronchitis as shown in Table 3.

23 (13.4%) workers had refractive error, 6 (3.5%) had watering of eyes, 4 (2.3%) had burning sensation of eyes, 3 (1.7%) had cataract and 1(0.6%) had allergic conjunctivitis.

4(2.3%) workers had dental caries and 1 worker (0.6%) each had Paronychia, Pyoderma & Vitiligo each. Among the workers with respiratory symptoms (n= 25), majority, 11(44.0%) workers had cough of more than 3 weeks duration, followed by wheezing10(40.0%) and least 2(8.0%) workers had early morning breathlessness. None of the workers were positive for AFB.There was statistically significant association observed between tobacco consumption & early morning phlegm by univariate logistic regression (p<0.05).

Among the 172 workers who underwent Haemoglobin estimation, none of them had anaemia.  Out of the 172 subjects who underwent random Blood sugar estimation, 15 (8.7%) subjects had raised blood sugar levels. Lastly, 37 (21.5%) subjects were found to have High Blood Pressure.

On clinical evaluation, 16 workers were found to have positive Rinne’s and Weber’s test. These workers further underwent Audiometric evaluation using a pure tone audiometer (Advanced digital audiometerAD2100). 12 (75%) subjects had normal hearing capacity and 2 (12.5%) subjects each had conductive deafness and noise induced hearing loss.

Spirometry was done among those workers who had positive chest symptoms on applying the questionnaire. 15 (8.7%) workers were found to be questionnaire positive. Pulmonary impairment was found in 5 (2.9%) workers. Among the 5 workers, 3(60.0%) workers had obstructive ventilatory pattern of pulmonary impairment and 2 (40.0%) workers had mixed ventilatory pattern of pulmonary impairment (according to Global Initiative for Chronic Obstructive Lung Disease guidelines).

Discussion    

In a walk-through survey of the factory, the investigators had observed workers in the cane section were exposed to dust, workers in the milling section were exposed to dust, noise and mechanical injuries, workers in the processing section were exposed to noise, high temperature and mechanical injuries, workers in theEthanol treatment plant were at risk of exposure to chemical related injuries and those working in the ware house were at risk of encountering mechanical injuries. However, in the present study it was observed that there was no significant health problem that can be attributed to the work area among the workers. This could be due to good housekeeping practices and regular use of Personnel Protective Equipment(PPE). Organic dust contains high concentrations of bioaerosols, such as bacteria, actinomycetes and fungi of plant and animal origin. The concentration and pathogenicity of these bioaerosols depend on source materials, method of storage, technology used in processing materials and their disposal.¹¹ Examples of some of the physical hazards that workers face include lifting and carrying heavy loads, working with the trunk frequently flexed, risk of trips and falls on slippery and uneven walkways.^12,13

The mean age of the workers was less than 40 years indicating a younger workforce in the factory. This is in contrast to the studies done by Nitin Nikhade et al (50yrs) and Rahul Bisht et al (52yrs).^14,15 An interesting observation in the current study was that the factory had only male employees and this could be due to the nature of work in sugar cane factories which inhibit women from joining.

The overall burden of morbidity among sugarcane factory workers was more than fifty percent. Obesity and overweight was the major health problem identified unlike results from other studies. The reasons could be due to the predominant nonvegetarian diet, substance use like alcohol and lack of exercise among the workers.  Musculoskeletal Disorder observed in the current study were discordant to the study done by Amandeep Singh et al (80%), Vasave et al (50.0%) and Choobineh et al (87.1%).^16-18

The few existing studies show that sugarcane work is characterized by extreme repetition, forceful movements, continuous body contortions, awkward postures, high workloads and psychosocial pressures.⁴

In the current study, the overall prevalence of pulmonary impairment was 8.7%.This was much lower compared to the study done by Nitin et al (32%). Mixed ventilatory pattern was the most common type which was contrast to the study done by Nitin S et al where obstructive pattern was the most common type.14Low pulmonary function parameters viz TV, IRV, ERV, ICV and VC are usually found among the sugar industry workers and may be due to inhalation of bagasse.^19,20,21

There were no workers who were anaemic. Good number of the workers had raised blood sugar and blood pressure in the present study. This could be explained by the same reasons as given for obesity and overweight. The percentage of workers with noise induced hearing loss was very minimal and could be explained by regular use of PPE. Impaired visual acuity was observed in one tenth of the workers and was mainly due to age related causes. According to a study done by Rahul Bisht et al 52% of the subjects had vision problems, 15% had hearing problems, 20% were suffering from Hypertension.¹⁵There was no episode of heat stress in the current study unlike the higher risk of heat stress found among the sugarcane workers in Costa Rica, USA.^22,23,24

Improved awareness regarding the health problem and timely referral and treatment can go a long way in reducing the symptoms and improving the quality of life of workers.

Conclusion

The overall burden of morbidity was more than fifty percent. Obesity and overweight were the predominant morbidities observed. Pulmonary impairment was found in 8.7% of the workers.

Recommendations

A wider study involving larger number of sugar cane factories need to be done for generalization of the results. Proper intervention in the form of health and dietary education is needed to effectively tackle the problem of overweight and obesity.