Introduction
In India, the Social Security Act, Employees State Insurance Act, 1948 applies to non-seasonal factories employing 10 or more persons. The ESI Act covers workers in the organized sector only. As on 31/03/2012, the scheme applied to 5.80 lakh employers employing 1.71 crore insured persons at 807 centres7. The Employees’State Insurance scheme provides comprehensive medical care to insured persons and also to their dependants. ESI Corporation has set up five zonal Occupational Disease centers for providing occupational health management and medical treatment thus having pan-India presence. By virtue of their job all our insured persons are exposed to various kind of noxious gases, fumes dusts and particles. With various upper and lower respiratory tract involvement they attend outdoor and inpatient of the hospitals through dispensaries.
Material method
For this questionnaire and onsite observational study the centers selected was ESIC super specaiality hospital Kollam Kerala in collaboration with Institute of Occupational Health & Environment Research, ESIC model Hospital Basaidarapur Delhi.
Duration One Year: October 2012–September 2013.
Inclusion criteria: All our insured persons who have valid insurance(IP) number with
1. Age more than 35.
2. Non-smoker .
3. Working in industry for more then 5 yrs
4. Male/female.
5. Can understand English/Hindi/ local language.
Exclusion criteria
1. Invalid IP no.
2. Uncooperative patient
3. Unable to perform spirometery despite best effort by technician on three occasions on three different days.
All subjects surveyed with
- COPD diagnostic tool
(i) Questionnaire. (Basic history and job profile)
(ii) Spirometery (Gold criteria for defining COPD) after taking informed consent.
Definitions
Chronic obstructive pulmonary diseases (COPD): COPD is a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. Exacerbations and co-morbidities contribute to overall severity in individual patients.
A clinical diagnosis of COPD should be considered in any patient who has dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors for the disease.
Spirometry is required to make the diagnosis; the presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation and thus of COPD.
Occupational COPD: Chronic obstructive pulmonary diseases caused by inhalation of coal dust, dust from stone quarries, wood dust, dust from cereals and agricultural work, dust in animal stables, dust from textiles, and paper dust, arising from work activities. (LIST OF OCCUPATIONAL DISEASES (revised 2010) Identification and recognition of occupational diseases: Criteria for incorporating diseases in the ILO list of occupational diseases)
Assessment of COPD
To assess symptoms- The COPD Assessment Test(CAT)18 was administered
Assess degree of airflow limitation using spirometry-
In patients with FEV1/FVC < 0.70:
GOLD 1: Mild; FEV1 > 80% predicted
GOLD 2: Moderate; 50% ≤ FEV1 < 80% predicted
GOLD 3: Severe; 30% ≤ FEV1 < 50% predicted
GOLD 4: Very Severe; FEV1 ≤ 30% predicted
*Based on Post-Bronchodilator FEV1
Statistical analysis
We had 78 consecutive subjects in factory site visits out of which 64(82%) were females and 14 (18%) were
males with the mean age of subjects-48 yrs. The average duration in job was 18 years in cashew industry and
the majority of the workers were engaged in jobs of sorting, roasting, peeling shelling and segregation of cashew
nuts. Peculiarity of the findings were more female workers than male workers. The mean (N=78) FVC% observed-
64.26%, the mean FEV1% was 56.26% and the mean% ratio of FEV1/FVC was 83.28%.
Mean COPD Assessment test (CAT) score were 23.20, less than 10 were 3 (3.85%), between 10-20 were 21
(26.92%), between 20-30 were 46 (58.97%). More than 30 were 8 (10.26%). 17 out of 78 (21.79%) qualified for
the definition of COPD.
The reduced values of mean FVC, FEV1 suggests the involvement of airway along with the lung parenchyma.
Limitations of this observational study were
1. More elaborate workup for categorizing of obstructive/restrictive/mixed disorder of the lungs with complete PFT.
And for indicated patients the diffusion capacity of carbon monoxide to assess the integrity of alveolo capillary
membrane.
2. Radiological studies including CT chest for those who have presented severe lung function disorders as indicated.
Discussion
Chronic Obstructive Pulmonary Disease (COPD) is the fourth leading cause of death worldwide.1 In the UK, COPD is given as the cause of death on about 30 000 death certificates annually.2 This represents 5.1% of all deaths. The prevalence of COPD is difficult to determine because the condition does not usually manifest until mid-life, when it is already moderately advanced. In England and Wales, it is estimated that there are currently 900 000 diagnosed cases, and allowing for under-diagnosis the true prevalence is estimated to be 1.5 million.3
Occupations linked to increased prevalence of COPD include construction,4,5,6 leather, rubber, plastics manufacturing,4 plastics and rubber workers,5 textiles,4 12 food products,4 7,8 spray painters,7 and welders.7 Specific substances linked to higher prevalence of COPD include quartz,6 ,9 welding fumes,11 wood dust,11 sawdust,10 asbestos,6, 9 and solvents.6
Our study population of 78 persons 17 (21.79%) qualified for the definition of COPD .Though the number is small but a fair indicator of the presence of the disorder . The non copd group also have fall in FVC( FVC% observed 64.26%,) and FEV1(the mean FEV1% observed 56.26%) which also is a pointer towards the insult on lung architecture.
One should consider COPD and perform spirometery in any patient whose age is more than 40 yrs and having following indicators as mentioned below .
The recognition of a disease as being occupational is a specific example of clinical decision-making or applied clinical epidemiology. Deciding on the cause of a disease is not an “exact science” but rather a question of judgement based on a critical review of all the available evidence.In Bhopal gas tragedy victims in a paper by Sajal De17 showed that the obstructive pattern was the commonest spirometric abnormality among the surviving gas victims , compared to non-exposed subjects .Thus environment plays a contributing factor.
Large number of COPD patients remain undiagnosed or wrongly diagnosed in clinical practice due to one of the reasons that that COPD is only caused by tobacco smoking, this leads to under-diagnosis of COPD in never smokers. this contribute to around half of all COPD cases ,underutilization of Spirometry as a diagnostic tool mainly due to lack of knowledge and availability of spirometers, and difficulty in differentiating it from asthma.12
COPD kills half a million people in India every year, more than those who die due to Tuberculosis, Malaria or HIV-AIDS. Moreover, these numbers are expected to grow by 160% over the next 2 decades, in contrast to the decline in the number of deaths anticipated due to malaria, TB or HIV-AIDS.13 reviewing the population studies available from India; Of the 14 studies which were reviewed, there were 11 conducted in general populations. The median values of different prevalence rates (i.e. 5 percent in male and 2.7 percent in female population) were accepted as the most appropriate figures to calculate the overall estimates.14 The COPD prevalence varied from 3% to 8% amongst Indian males and approximately 2.5% to 4.5 % among Indian females. 15
COPD is now a much better understood disease than before. Most COPD patients do not die because of the lung disease, but because of the other co-morbid conditions that accompany COPD16.
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18. http://www.catestonline.org/images/pdfs/CATest.pdf
Source(s) of Funding
None
Competing Interests
None