Assessment of pulmonary function and respiratory symptoms among INDIAN textile sizing mill workers

Abstract

BACKGROUND:

Textile-sizing mill workers are exposed to various hazards in the sizing units during their working hours and are at risk of acquiring lung impairments due to the usage of sizing chemicals in the sizing process.

OBJECTIVE:

The main aim of this study is to assess the influence of cotton dust and sizing agents on lung function and breathing difficulties among Indian textile sizing mill workers.

METHODS:

This cross-sectional study was carried out at a textile-sizing mill from August 2022 to September 2022. A modified questionnaire based American Thoracic Society’s standard was used to assess respiratory symptoms among sizing mill workers and the pulmonary function test was conducted Spirometry. The chi-square test was used to find the difference between respiratory symptoms and the t-test was used to find the difference between spirometric parameters.

RESULTS:

Textile sizing mill workers showed significant (P < 0.0001) decline in peak expiratory flow rate, forced vital capacity (FVC), ratio of FEV₁ and forced vital capacity, and forced expiratory volume in 1 s (FEV₁). There was an association between symptoms and duration of exposure to pulmonary abnormality. Sizing mill workers showed a significant decline in lung functions and an increase in pulmonary symptoms. As the service duration of exposure in terms of years increased, respiratory symptoms increased and spirometric abnormality also increased.

CONCLUSION:

This study confirms that sizing agents such as polyvinyl alcohol (PVA), emulsifier, wax, carboxymethyl cellulose (CMC), and starch used in sizing mills are also responsible for respiratory illness and lung impairment among textile workers.

Keywords

Textiles;sizing mill;cotton dust;respiratory symptoms;pulmonary function;spirometry

1 Introduction

The development of industrialization was made to best meet the requirements of people. Some industries adversely affect people’s health over the long run [1, 2]. According to the International Labour Organisation (ILO), respiratory tract disorders account for 21% of all work-related deaths and according to the World Health Organisation (WHO), exposure to chemicals and particulates results in three million deaths annually [3, 4]. Numerous illnesses caused by breathing in dust and chemicals are referred to as occupational lung disorders. Inappropriate control of toxic chemical substances can be a big threat to textile mill workers because the majority of them are unaware of this potentially hazardous influence on their health [5 –7].

Airborne dusts are of particular concern to health regulators since they have been related to occupational lung diseases because textile sizing mills expose workers to cotton dust and chemicals [8, 9]. The cotton mill workers are exposed to raw cotton dust and chemicals when working in several departments of the textile mill, including opening, picking, combing, weaving, slashing, sizing, and spinning. The cotton dust exposure might result in chest tightness, coughing, wheezing, phlegm production, and breathing difficulties [10 –13]. When exposed to cotton dust over an extended period, there may be an excessive chronic yearly decrease in forced expiratory volume in 1 second (FEV₁) as well as a higher percentage of persistent respiratory symptoms [14 –16]. The workers exposed to cotton dust and chemicals produced in the textile industry throughout the textile production process were also observed to have airway allergies and positive skin reactions in addition to respiratory symptoms and lung damage [17 –19].

The sizing is a preparatory process of weaving that comes after warping. The sizing process is the method of coating the surface of the yarn with a thin layer of adhesive and binder to increase the wearability of the yarn. The textile industry regularly uses a variety of sizing agents, including starch, carboxymethyl cellulose (CMC), wax, emulsifiers, and polyvinyl alcohol (PVA). Over a period of time, textile workers are at risk of acquiring lung impairments due to the use of sizing chemicals in the sizing process [20]. Numerous occupational respiratory illnesses, including occupational asthma (OA), byssinosis, allergic alveolitis, chronic bronchitis, and the organic dust toxic syndrome, have been linked to exposure to organic dust [21, 22]. Cross-sectional investigations of employees exposed to grain dust, wood dust, and other chemical exposure have all shown breathing difficulties resembling those observed in textile sizing mill workers [23, 24].

The most frequent respiratory symptoms among employees exposed to particulate dust are coughing, dyspnea, chest tightness, wheezing, coughing up phlegm, etc. The sizing chemicals used in the sizing processes were the main responsible compounds for the cause of respiratory disorders and decline’s the pulmonary function of sizing mill workers. The working conditions in the sizing mill sectors of textile manufacturing industries are detrimental, and the remuneration level for employees in this sector is extremely low to meet the minimum standards of society. In addition, a research in textile industry finds that health issues and medical costs were linked to an excessive workload and mental strain at work [25 –27].

Several studies investigated the respiratory symptoms and pulmonary function status among textile processing industries like cotton ginning mill, weaving mill, spinning mill and dyeing mill but there has been little research on respiratory symptoms and lung function among textile sizing mill workers [28 –31]. As a result, the goal of this research was to identify respiratory symptoms and pulmonary function of sizing mill workers who exposed to organic dust. The current study will be useful in assessing the health issues faced by sizing mill workers as a result of exposure to volatile organic compounds emitted from sizing chemicals and fine particulate dust generated in the sizing mill workplace environment. Because sizing mill units in the textile manufacturing industry are one of the most important textile processing industries, employing many people in rural and semi-urban areas.

The present study aims to investigate the prevalence of lung function impairment and respiratory symptoms among INDIAN textile-sizing mill workers. This paper is the initial step in filling the research gap because no prior studies have been published in the area of Indian sizing mill workers’ respiratory health and lung function. Further research examining the relationship between exposure to chemical dust and respiratory health impacts, particularly lung function outcomes is needed. In this study, we have examined workers in a textile-sizing mill in India with the aim to determine the extent to which exposure to chemical dust emitted during sizing process which is associated with pulmonary health effects.

2 Methods

2.1 Study design and study setting

This cross-sectional study was performed in the textile sizing mill situated in Erode city at Tamil Nadu state of INDIA from August 2022 to September 2022. The industry uses cotton as a raw materials to produce fabrics and using sizing agents like starch, carboxymethyl cellulose, wax, emulsifiers, polyvinyl alcohol and other sizing chemicals for improving the strength and wearability of the yarn. The industry is divided into administrative section and production section (sizing process section). Workers at production section alternate in two 12-h shifts per day to maintain a 24-h continuous production. The sizing mill workers doesn’t use any personal protection equipment (PPE) during working hours and there is no proper exhaust ventilation system.

2.2 Study population

The study population consist of 75 textile workers who were working in sizing mill at Tamil Nadu, India. Target population were male textile workers exposed to cotton dust in the studied factory, because the only male workers are employed in textile sizing mill. The absence of female participants in the study is justified by the nature of sizing mill work, which involves heavy manual labor traditionally performed by males. Societal norms and physical differences lead to a predominantly male workforce in such environments, aligning with the study’s focus on male participants. The sizing mill workers (males) in the age range of 20–50 who had been employed in a textile size mill for at least a year and those who provided written informed consent were included in this study. The workers who had a history of thoracic surgery, asthma, heart disease, chronic respiratory illness and those with history of smoking is excluded from this study.

After considering the inclusion and exclusion criteria, eligible candidates of 60 employees were recruited for the study. Administrative office workers from the same factory, free of organic dust exposure, age- and sex-matched, were selected as the control group. The control group included 60 office staff (males) having more than one year of work experience without a history of heart or respiratory disease and should not exposed to chemical exposure were the inclusion and exclusion criteria for control groups. The general characteristics of the exposed sizing mill workers and controlled office workers is shown in Table 1.

Table 1
General characteristics of the exposed (sizing mill workers) groups and control (administrative workers) groups

Characteristics Mean±SD p-value

Sizing mill workers Control subjects

(N = 60) (N = 60)

Age (years) 41±7.56 39.56±7.23 0.49

Height (cm) 172±4.56 170±5.23 0.41

Weight (kg) 65.48±5.98 70±7.98 0.68

BMI (kg/m³) 22.45±1.12 23±85 0.97

Characteristics	Mean±SD	p-value
Age (years)	41±7.56	39.56±7.23	0.49
Height (cm)	172±4.56	170±5.23	0.41
Weight (kg)	65.48±5.98	70±7.98	0.68
BMI (kg/m³)	22.45±1.12	23±85	0.97

p > 0.05 = not significant, p < 0.05 = statistically significant, S.D: Standard deviation, BMI: Body mass index.

2.3 Sample size determination and sampling procedure

The double population proportion method was used to calculate the study’s sample size, taking into account of the assumptions such as P1 = 0.465 [the percentage of people with respiratory symptoms in the exposed (sizing mill workers) group] and P2 = 0.173 [the percentage of respiratory symptoms in the control (administrative workers) group] [32]. Based on a 1 : 1 ratio of exposed to unexposed groups, a 95% confidence interval, and a 5% non-response rate, the final sample size was determined to be 120 participants (60 in each group).

For enlist textile sizing mill workers for the exposed group, two industries were randomly selected from the three textile sizing mill at Erode city of Tamil Nadu state, India. Participants were then recruited using a simple random sampling technique. Controls were selected through convenience sampling, ensuring matching in terms of sex, and age with the textile sizing workers during the recruitment process for the study.

2.4 Questionnaire-based data collection

The modified structured questionnaire was prepared based on the guidelines of the American Thoracic Society (ATS) standard [33]. The questionnaire includes general characteristics of workers (age, height, weight, and experience) and respiratory symptoms (chest tightness, wheezing, phlegm and cough). Since numerous researchers have employed the ATS standard questionnaire for evaluating respiratory symptoms, its validity, and reliability have been established [34]. The occurrence of every respiratory symptom (cough, phlegm, wheezing, dyspnea, and tightness in the chest) among the workers that persisted for three months was evaluated. The existence of at least one respiratory symptom was required to define an overall respiratory symptom. Before gathering data, a clear introduction was given by outlining the goal and purpose of the study to the participants and written consent was obtained.

2.5 Anthropometric measurements

The weight of the sizing mill employees is obtained by using Weighing Scale HealthSense PS 126 Ultra-Lite Personal Scale and height of the worker is measured by using Standiometer.

2.6 Pulmonary function test

The pulmonary function test (PFT) was conducted using “Minispir PC-Based Spirometer (Medical International Research (MIR), Italy) with bi-directional digital turbine as flow sensor; volume range and accuracy of 10 L and±2.5%; flow range and accuracy of ±16 L/s and ±5%. The procedures and standardization of spirometry were based on the standards of American Thoracic Society-European Respiratory Society (ATS-ERS) 2019 is shown in Fig. 1. Body mass index is determined by measuring height and weight using a stadiometer and a digital scale, respectively (BMI) [35]. PFT parameters studied were FVC-Forced Vital Capacity; the maximum amount of air that can be expelled in one go through forced expiration, FEV₁-Forced expiratory volume in one second; the amount of air forced out in the first moment following a maximal inhalation., FEV₁/FVC; the percentage of the FVC expired in one second and PEFR- Peak expiratory flow rate; the amount of air that is pushed out of the lungs quickly in one forceful exhalation.

Fig. 1

Pulmonary function test conducted among sizing mill worker.

The test was performed with participants in a sitting position as shown in Fig. 1. Each participant was instructed to take a deep breath and then blow as forcefully and quickly as he or she could into the mouthpiece. In each new candidate, a fresh disposable mouthpiece was used. At least three trials were conducted, and the best of the three was chosen for analysis based on the ATS/ERS 2019 Standardization of Spirometry Study [36]. The Pulmonary indicators of exposed people were compared with the control group that was selected from the administrative department and their exposure level was much lower than the standard.

2.7 Data analysis

Spirometric indices such as PEFR, FEV₁/FVC, FEV₁, and FVC were utilized as outcome measures in addition to respiratory symptoms like dyspnea, coughing, and chest tightness. The evaluation of respiratory symptoms and pulmonary function associated with exposure of chemical dust from the sizing process is need to be addressed. Data were analyzed performed using SPSS Version 22 (IBM Corporation, USA). The chi-square test was used to find the difference between respiratory symptoms and the t-test was used to find the difference between spirometric parameters.

3 Results

This cross-sectional study was performed textile sizing mill situated in Tamil Nadu from August 2022 to September 2022. A 60 sizing mill workers (males) in the age range of 20–50 who had been employed in a textile size mill for at least a year were as study population The spirometric parameter values obtained for the textile sizing mill workers and control groups is shown in Table 2 as predicted and observed values. All of the spirometric parameters’ observed values were statistically different from their expected values. Workers at textile sizing mills had considerably lower observed values of spirometric measures like FEV₁, FEV₁/FVC, and PEFR compared to expected values. Because the lung damage was obstructive, there was no significant difference in FVC across the groups.

Table 2
Lung function parameters among the sizing mill worker and control groups

Spirometry Indexes Sizing mill Workers Control Groups

Mean±SD p-value Mean±SD p-value

Predicted Observed Predicted Observed

FVC (L) 4.88±0.41 4.57±0.65 0.90 5.1±0.42 5.02±0.52 <0.0001

FEV₁ (L) 3.28±0.40 3.18±0.08 0.008 4.68±0.39 4.48±0.58 <0.0001

FEV₁/FVC% 91.24±2.45 82.87±7.5 0.001 95.56±3.54 91.23±2.76 <0.0001

PEFR (L/S) 9.78±0.06 8.78±0.07 <0.0001 8.53±0.08 9.13±0.08 0.51

Spirometry Indexes	Sizing mill Workers	Control Groups
FVC (L)	4.88±0.41	4.57±0.65	0.90	5.1±0.42	5.02±0.52	<0.0001
FEV₁ (L)	3.28±0.40	3.18±0.08	0.008	4.68±0.39	4.48±0.58	<0.0001
FEV₁/FVC%	91.24±2.45	82.87±7.5	0.001	95.56±3.54	91.23±2.76	<0.0001
PEFR (L/S)	9.78±0.06	8.78±0.07	<0.0001	8.53±0.08	9.13±0.08	0.51

p > 0.05 = not significant, p < 0.05 = statistically significant.

The prevalence of respiratory symptoms experienced by the sizing mill workers and control subjects is shown in Table 3. Out of 60 subjects in the experimental group, 55 reported having trouble breathing, 45 reported having a cough, and 35 reported having trouble breathing. Only 8 subjects in the control group reported breathlessness, 18 subjects coughed, and no subjects reported feeling tight in the chest. When respiratory symptoms were compared between groups using the Chi-square test, a statistically significant difference (P < 0.0001) was discovered.

Table 3

Comparison of respiratory symptoms between sizing mill workers and control groups

Respiratory	Sizing mill workers		Control groups		p-value
symptoms	Present	Absent	Present	Absent
Breathlessness	55	5	8	52	0.0001
Cough	45	15	18	48	0.0001
Chest tightness	35	25	0	60	0.0001

p < 0.05 = statistically significant.

Symptomatic workers and asymptomatic workers were the categories based on the presence or absence of symptoms among sizing mill workers. Among 52 out of 60 employees of a textile sizing mill had respiratory symptoms, while 8 had no symptoms. Both 5 asymptomatic and 10 symptomatic workers had normal spirometry. Three asymptomatic employees and 42 symptomatic employees both had abnormal spirometry. Associations between spirometry results and the presence or absence of symptoms in sizing mill workers are shown in Table 4. The chi-square test revealed that spirometric abnormality was more common in symptomatic workers (P < 0.0001), which is statistically significant.

Table 4

Chi-square test according to the presence or absence of symptoms

Parameters	Sizing mill Workers		Total	p-value
	Asymptomatic	Symptomatic
Normal spirometry	5	10	15	<0.0001
Abnormal spirometry	3	42	45
Total	8	52	60

p < 0.05 = statistically significant.

Textile-sizing mill employees were separated into two groups based on how long they had been exposed to it: 5 years and >5 years. The relationship between spirometry results and exposure duration is shown in Table 5. Spirometric abnormalities and exposure length are statistically significantly associated, according to the Chi-square test (P < 0.0001). It demonstrates that spirometric abnormalities increased as exposure duration increased. Table 6 shows the Spearman correlation test-calculated correlation between age and exposure time. Age and exposure time were positively correlated with one another.

Table 5

Chi-square test to identify the correlation between pulmonary function and exposure duration

Parameters	Sizing mill Workers		Total	p-value
	≤5 years exposure	>5 years exposure
Normal spirometry	9	6	15	<0.0001
Abnormal spirometry	8	37	45
Total	17	43	60

p < 0.05 = statistically significant.

Table 6

Correlation between duration of exposure and age among sizing mill workers

Variables	Mean±SD	Correlation coefficient	p-value
Age (years)	41±7.56	0.8712	<0.0001
Duration of exposure (years)	9.56±1.12

p < 0.05 = statistically significant.

4 Discussion

The current study aims to determine the influence of dust and chemical exposure on respiratory symptoms and pulmonary function among textile sizing mill workers. The exclusion of female participants in this study necessitates scientific justification, primarily stemming from the operational context of the sizing mill process. Within this industrial setting, the workload involves substantial material handling and predominantly manual tasks, thus establishing a distinct gender-oriented employment pattern. Due to societal norms and physical aptitudes have predisposed male workers to undertake roles demanding intensive labor and dexterity, a trend reflected in the composition of the workforce within sizing mills.

Consequently, the male-exclusive sample aligns with the empirical reality of occupational segregation prevalent in such environments. Moreover, acknowledging the inherent physiological disparities between genders regarding strength and endurance further supports the rationale behind focusing solely on male participants for this investigation. However, acknowledging this limitation, the study’s focus on male participants was driven by the practical reality of the industry and aimed at providing insights tailored to this specific context.

The findings of the current study indicate that, as compared to control groups, textile sizing mill workers reported higher respiratory symptoms such as coughing, chest tightness, and shortness. The results of this study demonstrate that when compared to control subjects, the spirometric measures PEFR, FEV₁, and FEV₁/FVC were significantly lower in textile sizing mill workers. The value of FVC did not significantly differ across the two groups and this shows that employees of sizing mills for textiles have abnormal lung function of the obstructive type.

Chest tightness, coughing, and dyspnea were the majority of the acute respiratory symptoms experienced by textile workers after exposure to dust and sizing chemicals [37]. In the present study, 58.8% had chest tightness, 75.2% had cough and 91.2% had shortness of breath were the breathing difficulties experienced by sizing mill workers. A study done in Pakistan among textile workers was consistent with current findings which stated that exposed textile groups had prevalence of respiratory symptoms than the unexposed control groups [38].

The results of the Fletcher et al study, which are congruent with our findings, demonstrate a decline in pulmonary function in the exposed chemical group compared to unexposed subjects [39]. An asymptomatic worker should decrease FEV₁ at a rate of 8 to 20 ml/year less than a symptomatic worker. The findings of the present investigation were in accord with those of a previous study which found that silk workers saw smaller but considerably higher adjusted yearly reductions in FEV₁ and FVC than cotton employees [40]. This could be the result of both the buildup of dust in the respiratory system and increased dust exposure in the workplace. The lungs were injured by dust particles or dust-containing macrophages, and subsequent functional impairment was provided by fibrous lung tissue.

The findings of Yih-Ming Su et al. study on pulmonary function, which are consistent with our findings, indicated declines in FVC, PEFR, FEV₁, and FEV₁/FVC% among textile workers who were exposed to dust and chemicals [41]. Zuskin and Valic’s study found similar results that, long exposure to cotton dust and sizing chemicals significantly decreased mean FEV₁, FVC, and PEFR in textile workers exposed to dust and chemicals [42]. This might be a result of increased chemical exposure from sizing agents used in the sizing process in textile processing and the chemical exposure can affect the pulmonary system which may lead to the development of respiratory disorders and a decline in pulmonary function. This lung functional impairment was caused by fibrous lung tissue when chemical particles or chemical dust-containing macrophages injured the lungs.

Exposure to organic dust and the endotoxin it produces has been linked to chronic bronchitis and byssinosis in research conducted by Wai and Tarlo on occupational lung disease in women [43]. Results of the current study demonstrate reduced pulmonary function efficiency among textile sizing mill workers. Most textile workers who were exposed to higher concentrations of respirable dust experienced a significant reduction in lung functions, as demonstrated by the spirometric data of the current study. It corroborated the Taiwan study’s findings that cotton textile workers with higher dust exposure had a higher prevalence of lung function impairments [41]. This result corroborated the findings of a Pakistani study that found that textile workers’ lung functions are impacted by their mean level of dust exposure, and that their lung functions decline more rapidly at higher dust concentrations [44]. Strong evidence of a correlation between decreased lung functions and increased respirable dust exposure was provided by this consistent finding.

The sizing workers with pulmonary symptoms were more prone to decline respiratory function than those who had no pulmonary systems. The results of the present investigation were compatible with Mansouri et al research [45] which stated that prolonged exposure to particulate dust and chemicals is linked to an obstructive condition that worsens with time. The findings of the current investigation were consistent with a study conducted in Nigeria, which found that textile workers with breathing difficulties may have obstructive airway disease and had fewer FEV₁ predicted values [46]. The study of Nagoda et al. states that exposed textile workers reported more respiratory symptoms than unexposed workers, including coughing, and shortness of breath, and had lower PEFR, FEV₁, and FVC values which is consistent with the present study [46, 47].

The present investigation was also consistent with the study of Altin et al and Wang et al which states that the worker in the textile sector exposed to chemicals and dyes during occupation reported having chest tightness, persistent cough, and wheezing [48, 49]. This demonstrates that chemicals and dust generated during textile processing in occupational places can cause byssinosis and other acute airway reactions when exposed for a longer duration. Anita et al. examined how cotton dust exposure affected PFT in spinners and observed larger reductions in FEV₁ and FVC [50]. Indicative of an early obstructive pattern in the exposed group, this drop in FEV₁/FVC was considerable. In line with our findings, FVC declines and displays a restrictive pattern as exposure time increases [51]. Also, even for individuals exposed to concentrations below 3 mg/m³, textile size mill workers appear to be more likely to have rhinitis and other irritative upper respiratory symptoms.

Increased cough and sneezing prevalence has been noted among workers who are more highly exposed and it causes psychological irritations which affects productivity [52, 53]. It has also been reported that the use of sizing chemical agents may have contributed to an instance of potential occupational asthma. According to our findings, there is more proof that prolonged exposure to the tiny particulate matter and chemical dust produced during the textile mill’s sizing process irritates the airways, damages lung function, and raises the possibility of air limitation. Slightly elevated risk of COPD may also result from prolonged exposure to volatile organic compounds (VOC) and particle dust among textile sizing mill workers [28, 54].

In the present study, the age is positively correlated with the respiratory symptoms and pulmonary functions. Workers with ages greater than 40 years are at risk of developing chronic obstructive pulmonary disorders and respiratory illness. The results of the present study were in agreement with research done by Thiwari et al. which showed that workers having age greater than 40–50 years reported respiratory morbidity and decline in pulmonary function than other age groups [55]. As a result, in addition to occupational exposure, aging may also play a role in obstructive lung disease since it lowers the FEV₁/FVC ratio in this study [55, 56].

The outcomes of this study may apply to other settings where workers are engaged in similar occupational activities. Nonetheless, the outcomes could differ based on the variety of fundamental traits, risky behaviors, exposure to respirable chemical dust of fine particulate matters, and the application of workplace safety precautions. There were some limitations of this study. The study group had not undergone postbronchodilator spirometry. Future research involving the addition of postbronchodilator spirometry can be done to determine if chronic obstructive pulmonary disease (COPD) or asthma is present because textile dust-related occupational illness exhibits both characteristics of asthma and COPD.

5 Conclusions

The present study demonstrates that respiratory symptoms and pulmonary function impairments are present among INDIAN textile sizing mill workers. The study demonstrates that spirometric abnormalities increased along with exposure time and illness severity. The lung function impairment in the textile sizing mill workers was present despite the use of face masks, age, and other factors. The spirometric measures PEFR, FEV₁, FEV₁/FVC, and FVC were significantly lower in INDIAN textile sizing mill workers. The length of the task and the number of hours worked extend the period of exposure to particulate matter and sizing chemicals, considerably raising the risk of respiratory illness among workers at textile sizing mills.

Employers should investigate engineering control measures, occupational safety standards, and administrative controls to prevent exposure to dust and sizing chemicals. According to this study, respiratory ailments and lung impairment among workers in INDIAN textile sizing mills are also brought on by sizing compounds such as polyvinyl alcohol (PVA), emulsifier, wax starch, and carboxymethyl cellulose (CMC). Additionally, textile workers should have routine spirometry lung function tests to screen for occupational lung disorders.

There were some limitations of this study. The study groups had not undergone postbronchodilator test. The environmental exposure measurements were not performed in this investigation, it was not able to assess respiratory morbidity in connection to the amount of exposure to respirable dust. Furthermore, absence of measurement of endotoxin exposure in the workplace was a further limitation of this study, as airborne endotoxin is more likely to cause occupational respiratory disorders than respiratory dust itself. Future research involving the addition of postbronchodilator spirometry can be done to determine COPD. In addition, this research is required to correlate indoor respirable dust exposure measurements and occupational airborne endotoxins measurements with respiratory morbidity and pulmonary impairments among textile sizing mill workers.

Ethical approval

This study was conducted as per the recommendations from the ethics committee of the Kongu Engineering College which was approved by the Institute Ethical Committee (KEC/R&D/EC/2022-23/002). The confidentiality of the collected data was ensured throughout all stages of the study.

Informed consent

Informed consent was obtained from all individual participants included in the study

Conflict of interest

The authors have no relevant financial or non-financial interests to disclose

Footnotes

Acknowledgments

We express our sincere thanks to all the workers for their cooperation in our field study and Management of Sizing Mills to provide necessary permission to execute this work.

Funding

This work was supported by Indian Council for Medical Research (5/8-4/30/ENV/2020-NCD-II) and Shankar Subramaniam, and Naveenkumar Raju has received the funding support.

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