Wah Medical College Research

WAH MEDICAL COLLEGE, WAH CANTT DEPARTMENT OF COMMUNITY MEDICINE

WAH MEDICAL COLLEGE, WAH CANTT

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FREQUENCY AND PATTERN OF DISEASES AMONG FACTORY WORKERS OF PAKISTAN ORDNANCE FACTORIES (POF) WAH CANTT. [HOSPITAL BASED STUDY]

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RESEARCH DONE BY: BATCH C, 4TH YEAR MBBS, Farkhanda Jabeen Henna Azmat Muhammad Anwar ul haq Muhammad Majid Mehmood Muhammad Nasir Nawaz Muhammad Obaid-ur-Rehman Salahuddin Khan

Roll no. 05016 Roll no. 05019 Roll no. 05076 Roll no. 05077 Roll no. 05079 Roll no. 05107

RESEARCH SUPERVISOR: Dr. Ambreen Ansar Post Graduate Trainee (PGT) Community Medicine Department.

RESEARCH MONITOR: Dr. Babar Mumtaz Malik Assistant Professor Community Medicine Department.

RESEARCH INCHARGE: Prof. Dr. Musarrat Ramzan Head of Community Medicine Department, Vice Principal WMC

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ACKNOWLEDGEMENTS: We express great gratitude for the unwavering support and guidance, to Professor Dr. Musarrat Ramzan, Dr. Babar Mumtaz Malik and Dr. Ambreen. We are also very thankful for the help and professional insight by Syed Hammad Masood (General Manager, Explosives Factory) and Dr. Riaz Bhatti (General Manager, R&D). In addition we are grateful to Brig. Arshad (commandant, POF Hospital, Wah Cantt.) for the help provided in data collection.

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TABLE OF CONTENTS

CONTENTS

PAGE NO.

LIST OF FIGURES

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LIST OF ABBREVIATIONS

6

ABSTRACT

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INTRODUCTION

8

LITERATURE REVIEW

9

OBJECTIVE

10

METHODS AND MATERIAL

10

RESULTS

11

DISCUSSION

15

CONCLUSION

16

REFERENCES

16

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LIST OF FIGURES FIGURES

PAGE NUMBER 12 Fig- Bar graph showing percentage and number of patients of different disease groups in Explosives Factory 1 13 Fig- Bar graph showing percentage and number of patients of different disease groups in Filling Factory 2 14 Fig- Bar graph showing percentage and number of patients of different disease groups in Brass Mill 3

LIST OF ABBREVIATIONS ATSDR CCF CHE CNS COPD CVS DNS ENT GIT IHD MSDS NEQ’s PETN POF QHSE RDX T.B. TNT U.S. UV

Agency For Toxic Substances and Disease Registry Congestive Cardiac Failure Collaborative on Health and Environment Central Nervous System Chronic Obstructive Pulmonary Diseases Cardiovascular system Deviated Nasal Septum Ear, Nose and Throat Gastrointestinal System Ischemic Heart Disease Material Safety Data Sheet National Environmental Quality Standards Pentaerythritoltetranitrate Pakistan Ordnance Factories Quality Health Safety and Environment Cyclotrimethylene-trinitramine Tuberculosis Trinitrotoluene United States Ultra Violet

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FREQUENCY AND PATTERN OF DISEASES AMONG FACTORY WORKERS OF PAKISTAN ORDNANCE FACTORIES (POF) WAH CANTT. [HOSPITAL BASED STUDY]

ABSTRACT INTRODUCTION: Some occupations result in specific diseases called occupational diseases. Research on these diseases has been carried out for past few centuries. Defence productions are the major share of industrial revolution of today. A lot of chemicals like TNT, PETN, RDX, Nitric acid, phosphorous and zinc oxide etc have been identified as a risk factor for workers related to this industry. OBJECTIVE: To know frequency and pattern of diseases and their association with risk factors among factory workers of POF admitted to POF hospital Wah Cantt. METHOD: A cross-sectional descriptive study was carried out from 1st January, 2008 to 31st December, 2008, on workers of Brass Mill, Explosives Factory and Filling Factory, who were admitted to POF Hospital Wah Cantt. Data of 216 patients was provided by the HMIS department of POF Hospital on request, through proper channel. RESULTS: Out of total 216 patients, 102 were from Explosives Factory, 78 from Filling Factory, and 36 were from Brass Mill. Most of the patients, 39.22%, from Explosives Factory and 33.33% from Filling Factory, had CVS related problems while, 22.22% were surgical cases in Brass Mill. 7

CONCLUSION: A major correlativity exists between occupational hazards and disease cases reported.

INTRODUCTION: Since the very inception of mankind, he has indulged himself into scores of different occupations to earn his living. These chores come with a specific price of occupational diseases. According to ILO/WHO Committee “occupational health should aim at the promotion and maintenance of the highest degree of physical, mental and social well being of workers in all occupations; the prevention among workers of departures from health caused by their working condition; the protection of workers in their employment from risks resulting from factors adverse to health; the placing and maintenance of the worker in an occupational environment adapted to his physiological and psychological equipment, and, to summarize, the adaptation of work to man and of each man to his job”.1 Hippocrates admonished his followers to observe the environment to understand the origins of illnesses in their patients. From Agricola, 15th century, who observed that miners in Joachimsthal frequently became short of breath and died prematurely (due to silico-tuberculosis) to Alice Hamilton, 20th century, who was the first U.S. physician to devote her life to the practice of industrial medicine, physicians have always been intrigued by the phenomenon of occupational health.2 In today’s industrial revolution occupational health has come up again with a far more significance than ever before. Physical, chemical, biological, mechanical and psychosocial hazards from industry have been the part and parcel of modern day research. Phenomena like pneumoconiosis, lead poisoning, cancer, radiation hazards and accidents in industry have now become prevalent in the working class exposed to these hazards.2 In Pakistan, occupational hazards have also been explored with cases being reported of byssinosis from cotton spinning factories, anthracosis from coal mines, bagassosis from sugar-cane industry and asbestosis from asbestos industry. 8

A major share of today’s industrial revolution is defence productions. Considerable numbers of chemicals like TNT, RDX, PETN, Nitric acid, White phosphorus and zinc oxide etc have been identified as a major risk factor for workers related to this industry. In addition to these chemicals workplace hazards like accidents, burns and radiations are also rampant among this industry’s workers. Therefore the significance of occupational health and safety in today’s era cannot be understated. Pakistan also joined the elite club of nations by establishing Pakistan Ordnance Factories (POF) Wah Cantt in 1951. Our research, based on the patient data from POF workers admitted in POF Hospital, Wah Cantt, primarily analyses diseases prevalent in these workers and their association with risk factors.

LITERATURE REVIEW: Workers of ordnance factories are exposed to a number of risk factors. Out of these risk factors, TNT (trinitrotoluene), RDX (cyclotrimmethylene-trinitramine), PETN (pentaerythritoltetranitrate), Nitric acid, white phosphorus, Zinc oxide, copper, Ultraviolet (UV) light and accidents are the most significant ones. TNT (trinitrotoluene), an explosive by nature, has nitric oxide fumes in it which when exposed to causes respiratory tract irritation, nausea, headache, reduced blood pressure and possible CVS effects.3,4,5,6,7 It is also a factor in the development of cataracts.8,9 Similarly RDX (cyclotrimmethylene-trinitramine) is also an explosive which causes convulsions, lung congestion and psychoses. 10,11,12 PETN (pentaerythritoltetranitrate), an explosive and used in detonating devices, is also a respiratory tract irritant and a known coronary vasodilator causing lowering of blood pressure, headache or faintness. Repeated over-exposure with PETN may result in chest pains later, even in the absence of exposure.13,14 Nitric acid, a well known respiratory irritant and congestant and a corrosive by nature, is a potential hazard for accidental injuries in concentrated form and potentially very toxic in case of inhalation.15 9

White phosphorus, used in making gas bombs, is very toxic if swallowed or inhaled and may cause severe burns. In addition to this, it causes a condition known as “phossy jaw”, if inhaled for a long time.16,17 Zinc oxide fumes, used in brass mill, cause a condition well known as “metal fume fever” or “inhalation fume syndrome” resembling an asthma like allergic condition and other systemic adverse effects like headache, fever, chills, muscle aches, chest soreness, GIT pain and tiredness.18,19,20 While discussing most of the chemical hazards to which the workers are exposed to, it is noteworthy to mention here the role of ultraviolet irradiation as a risk factor in cataractogenesis.21 This happens possibly due to the damage to ion pumps and channels caused by UV light that accumulates over the years as repair processes incompletely restore membrane function. This peroxidative damage is likely to be the cause of UV-induced lipid peroxides in the lens epithelial membranes causing opacification.22,23,24,25

OBJECTIVE: To know frequency and pattern of diseases and their association with risk factors among factory workers of Pakistan Ordnance Factories, Wah Cantt, admitted to POF hospital Wah Cantt.

MATERIALS AND METHODS: • Study Design Cross-sectional descriptive study

• Setting 1. Three factories among Pakistan Ordnance Factories namely Brass mill, Explosives and Filling factories 2. POF Hospital Wah Cantt

• Duration of study

1 year (1st January 2008 to 31st December 2008) 10

• Sample size 216(two hundred and sixteen only)

• Sampling technique Convenient method

• Inclusion criteria Male patients from Brass Mill, Explosives and Filling factories admitted in various wards of POF Hospital Wah Cantt. • Data collection procedure Data was obtained from the HMIS department of POF Hospital, Wah Cantt. Permission to get the data was granted by the competent authority, after applying for it through proper channel.

RESULTS: A total of 216 patients were scrutinized for the study from the three major factories namely Brass Mill, Explosives and Filling factory. We divided the patients into ten major disease groups. Out of 216 patients, 102 were registered with Explosives factory. Among them 40 (39.22%) were CVS cases (17 cases of Ischemic Heart Diseases (IHD), 16 cases of hypertension, & 7 cases of congestive cardiac failure) 15 (14.71%) had infections (mainly of respiratory (5) and urinary tract(10), 10 (9.8%) were surgical cases (3 abdominal surgeries, 4 abscess drainage procedures, & 3 cases of orthopedic surgeries), 10 (9.8%) CNS cases (mainly depression and acute psychosis), 7 (7.14%) diabetics, 6 (6.12%) had cataracts, 3 (3.06%) with GIT problems, 3 (3.06%) had cancer, 5 (5.1%) had respiratory problems (majority i.e. about 70% presented with COPD) and 3 (3.06%) presented with ENT related problems.

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Explosives Factory 45 40

39.22%

35

No. of Patients

30 25 20 14.71%

15

9.8%

10

0 CVS No. Of patients

7.14%

5.1%

5

40

15

6.12% 3.06% 3.06%

3.06%

Respir Infecti ation ons 5

9.8%

GIT

Surge ry

Diabe tics

Cance r

ENT

Catar acts

CNS

3

10

7

3

3

6

10

Disease Groups

Fig-1: Percentage and no. of patients of different disease groups in explosives factory

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78 patients were from the filling factory. Out of these, 26 (33.33%), patients were of CVS diseases (19 cases of Ischemic Heart Diseases (IHD), 7 cases of hypertension), 9 (11.53%) respiratory cases, 14 (17.94%) with infections (mainly of respiratory (7) and urinary tract(7), 2 (2.56%) with GIT problems, 9 (11.53%) had undergone surgery (1 case of abscess drainage procedure & 8 cases of laprotomies), 5 (6.41%) were diabetics, 1 (1.28%) cancer case, 1 (1.28%) ENT case (DNS), 8 (10.25%) with cataract, and 3 (3.84%) CNS cases (acute psychosis).

Filling Factory 30 33.33% 25

No. Of Patients

20

17.94%

15

11.53%

10

11.53%

10.25% 6.41%

5

3.84%

2.56% 0 CVS No. Of patients

26

Respi Infect rator ions y 9

14

GIT

1.28%% 1.28% Surge Diabe ry tes

2

9

5

Canc er

ENT

Catar acts

CNS

1

1

8

3

Disease Groups

Fig-2: Graph showing percentage and no. of patients of different disease groups in filling factory 13

Out of a total of 36 registered patients from Brass Mill, there were 5 (13.88%) CVS cases (all were cases of IHD), 6 (16.66%) respiratory cases ( 3 T.B. patients & 3 cases of COPD), 7 (19.44%) infections (all respiratory), 6 (16.66%) GIT cases, 8 (22.22%) surgical cases (6 cases of orthopedic surgeries & 2 cases of Laprotomies), 2 (5.55%) cataracts, 2 (5.55%) CNS cases and 0% diabetic, cancer and ENT cases.

Brass Mill 9 22.22%

8 19.44%

7 16.66%

No. Of Patients

6 5

16.66%

13.88%

4 3 5.55%

5.55%

ENT

Catarac ts

CNS

0

2

2

2 1 0.00%

0 CVS No. Of Patients

5

Respira Infectio tory ns 6

7

GIT

Surgical

6

8

0.00%

Diabete Cancer s s 0

0

0.00%

Disease Groups

Fig-3: Graph showing percentage and no. of patients of different disease groups in Brass Mill

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DISCUSSION: The analysis of data was difficult as we were not allowed full access to the inside of factories due to security reasons. However, while analyzing the data, we came to know that majority of patients from Explosives and Filling factories were CVS cases, i.e. 39.22% and 33.33% respectively (This can be attributed to the presence of TNT), whose fumes contain nitric oxide, which reduces blood pressure, causes headache, vomiting, and cyanosis and therefore possible CVS manifestations. 3,4,5,6,7 Similarly PETN has a role in decreasing blood pressure and causing headache, and also some CNS manifestations. 13,14 There was also a significantly high prevalence of CNS cases (9.8%) in Explosives factory owing to the blood pressure lowering effects of TNT and PETN. Similarly RDX can also be regarded as a causative factor for CNS disorders, including anxiety psychoses and abnormal reflexes. 10,11,12 A large number of surgical cases were reported from all the three factories particularly Brass mill (22.22%). This can be imputed to the occurrence of accidents due to highly explosive materials and in particular the blast furnaces present in Brass Mill. Another perpetrator, white phosphorus, which is highly toxic and causes burns, can also be held responsible for accidents and consequently surgical cases. 16,17 We noticed an alarmingly high incidence of cataracts in Explosives factory (6.12%), Filling factory (10.25%) and Brass Mill (5.55%), which is self explanatory due to UV light emitted by explosions and welding procedures and also partly due to exposure to TNT. A considerable proportion (11.53%) of respiratory cases in Filling factory can be related to the presence of nitric acid (irritant and corrosive) and RDX (causes lung congestion). In Brass Mill, what seemed particularly important was the presence of 16.66% respiratory cases specifically including “INHALATION FUME SYNDROME”, caused by Zinc Oxide fumes. It is worth mentioning here that POF has enforced strict safety measures and precautions, including protective wear, minimizing amount and duration of exposure to risk factors. This is according to 15

QHSE (Quality Health Safety and Environment) standards and safety recommendations of NEQ’s (National Environmental Quality Standards).26 Still there is considerable prevalence of occupational diseases among factory workers and this can be ascribed to personal negligence and lack of health education.

CONCLUSION: After calculating and analyzing the frequencies and pattern of diseases, our study supports the fact that there is a positive association between different chemicals and other material used in Pakistan Ordnance Factories, Wah Cantt, and several diseases. The prevalence of occupational disease is very high for a state of the art facility like Pakistan Ordnance Factories. It is need of the hour that emphasis should be given on health education of the workers and stringent regulations be imposed to reduce these problems.

REFERENCES: 1. K.Park, K. Park’s Textbook of Preventive And Social Medicine. 18th edition, chapter 15, p 606. 2. William N, Rom. Environmental And Occupational Medicine. 4th edition, unit 1, chapter 1, p.4, 5. 3. Material Safety Data Sheet (MSDS), Clayton Associates, Inc. USA. Issued 19/02/2005;http://www.jclayton.com/ProductPDFs/3-74137MSDSTNTPLUS.pdf; (visited on: May 20, 2009, 7:26pm) 4. The Collaborative on Health and the Environment (CHE). http://database.healthandenvironment.org/index.cfm ; (visited on: May 20, 2009, 7:03pm) 5. Haidee Williams. Contact Dermatitis within the Explosives Industry. Current Allergy and Clinical Immunology, August 2007 volume 20, No. 3. 6. Material Safety Data Sheet, Hamilton Drywall Products. USA. http://www.hamiltonnw.com/MSDS/MSDS_TNTTapingAndToppingJointCo mpound.pdf ; (visited on: May 20, 2009, 7:27pm) 7. C Hogstedt, B Soderholm, L Bodin. 48-hour ambulatory electrocardiography in dynamite workers and controls. British Journal of Industrial Medicine 1980; 37:299-306.

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8. Kruse A, Hertel, M, Hindsholm M, Biskum S. TNT-induced Cataract in Danish Arms Factory Workers. Acta Ophthalmol scand, 2005 Feb; 83(1):2630. 9. Zhou AS. A Clinical Study of Trinitrotoluene Cataract. Pol J Occup Med, 1990; 3(2):171-6. 10. Material Safety Data Sheet (MSDS), Owen Compliance Services, Inc. USA. http://www.ocsresponds.com/ref/msds/msds-rdx.pdf ; (visited on: 20 May, 2009, 11:40pm) 11. Material Safety Data Sheet (MSDS), Ordnance System Inc. USA. http://www.petroexplo.com/catalog/RDX-MSDS.pdf ; (visited on: 20 May, 2009, 11:41pm) 12. Material Safety Data Sheet (MSDS), Polymath Interscience, LLC. USA. http://www.scentlogix.com/ScentLogixK9%20Untagged%20RDX%20MSDS%20Sheetv1.1.pdf ; (visited on: 20 May, 2009, 11:42pm) 13. Material Safety Data Sheet (MSDS), Dyno Noble Inc. USA. http://www.dynonobel.com/NR/rdonlyres/4C3D45B5-90E9-4EA6-8B62F89F27C7C607/0/1126DetCord012405.pdf ; (visited on: 20 May, 2009, 11:52pm) 14. Material Safety Data Sheet (MSDS), Detotec North America, Inc. USA. http://www.detotec.com/pdf/petn.pdf ; (visited on: 20 May, 2009, 11:54pm) 15. Wikipedia- the free encyclopedia, http://en.wikipedia.org/wiki/Nitric_acid ; (visited on: 27 June, 2009, 3:15am) 16. Material Safety Data Sheet (MSDS), Mallinckrodt Baker, Inc. USA. http://www.jtbaker.com/msds/englishhtml/p4017.htm ; (visited on: 21 May, 2009, 12:27am) 17. Agency for Toxic Substances and Disease Registry (ATSDR), US department of health and human services, CAS No. 7723-14-0, 1997. 18. Ai Q Truong-tran, Joanne carter, Richard Ruffin and Peter D Zalewski. New Insights into the Role of Zinc in Respiratory Epithelium. Immunology and Cell Biology (2001) 79, 170-177; doi: 10.1046. J.1414-1711.2001.00986.x 19. Fuortes L, Schenck D. Marked elevation of urinary Zinc levels and pleuralfriction rub in Metal Fume Fever. Vet Hum Toxicol, 2000 Jun; 42 (3): 164-5. 20. Safety and health fact sheet No. 25, Metal Fume Fever, American Welding Society, Jan 2002. http://files.aws.org/technical/facts/FACT-25.pdf ; (visited on: 26 May, 2009, 11:09pm) 21. Hightower KR. A Review of the evidence that Ultraviolet irradiation is a risk factor in cataractogenesis. Doce Ophthalmol, 1994-1995; 88 (3-4) : 205-20. 22. Hightower KR, Reddan JR, McCready JP, Dziedzic DC. Lens epithelium: a primary target of UVB irradiation. Exp I res, 1994 Nov; 59 (5): 557-64. 23. HR Taylor, SK West, FS Rosenthal, B Munoz, HS Newland, H Abbey, and EA Emmett. Effect of ultraviolet radiation on cataract formation. The New England Journal of Medicine, 1988, Dec Vol 319:1429-1433, No. 22. 24. Hightower KR. The role of the lens epithelium in development of UV cataract. Curr Eye Res, 1995 Jan; 14 (1): 71-8. 25. Xiuqin Dong, Marcelo Ayala, Stefan Lo¨fgren, and Per G. So¨derberg. ltraviolet Radiation–Induced Cataract: Age and Maximum Acceptable Dose. IOVS, March 2003, Vol. 44, No. 3. 26. Quality assurance in Pakistan Ordnance Factories. http://www.pof.gov.pk/maboutus.htm# (visited on: 27 June, 2009, 4:49am) 17

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