Prevalence of occupational skin diseases among rice field workers in Haryana

Abstract

Background: The objective of the study was to estimate the risk of occupational skin diseases among workers who were exposed to animal manure during rice cultivation in India.
Methods: Questionnaire based six month follow up study with weekly assessment of skin diseases in rice field workers from village Dabra, in Haryana state of India who were exposed to animal manure was carried out among the agricultural workers working in rice field along with dermatological examination of exposed parts.
Results: Out of total 574, workers, 90 were excluded as per exclusion criteria. 71 workers out of 370 workers who were free from diseases at baseline survey data develop a new disease with cumulative incidence of 19.1%. There was higher prevalence of dermatitis among all of reported skin diseases.
Conclusions: Exposure to animal manure mixed with standing water is a major risk factor among the workers working in rice field and attempt should be made to identify the type of dermatitis and relate its causative agent with any specific biological or chemical agents present in animal manure mixed with standing water of rice field.

Full text

International Journal of Community Medicine and Public Health | April 2017 | Vol 4 | Issue 4 Page 1011
International Journal of Community Medicine and Public Health
Shiva et al. Int J Community Med Public Health. 2017 Apr;4(4):1011-1017
http://www.ijcmph.com
pISSN 2394-6032 | eISSN 2394-6040
Original Research Article
Prevalence of occupational skin diseases among rice field
workers in Haryana
Shiva, Sumitra Singh*, Shailendra Kumar Singh
INTRODUCTION
Dairy animals produce about 12.0 galon of fresh manure
(faeces and urine) per 1,000 lb average live weight per
day.1 The addition of animal manures to soils have a
direct effect on soil organic matter content, can improve
soil fertility, soil physical characteristics, and facilitate
microbial activities.2-4 Addition of cow dung increases
nitrogen content and decreases pH of soil.5 In recent
times, organic manures in conjunction with or as an
alternative to chemical fertilizers as a source of plant
nutrients for cultivation of field crops has received
worldwide recognition because of rising costs of
chemical fertilizers, rapid nutrient loss of added fertilizers
and inauspicious environmental impacts from inorganic
fertilizers.6-7 Human health risks may be caused due to
use of wastewater and excreta in agriculture, although the
risk for certain gastrointestinal diseases like
helminthiasis has been established, the information on
other potential human health risks is still unknown.8
Studies in many countries on farmers using wastewater
suggested a high prevalence of the skin diseases.9-11 In
general, main causes of these skin ailments remained
unknown.12 Also, workers involved in manual handling
activities (e.g. cleaners) often complain about skin
diseases caused by various irritants and allergens, like
sun, bacteria as biological agent and chemicals including
pesticides and heavy metals.13-18 India is one of the
leading producer of rice and Haryana is second largest
contributor to India's central pool of food grains.19,20 The
‘Green Revolution’ in the state gave a major boost to the
growth of rice production.21 Agricultural workers suffer
from highest numbers of skin diseases out of all industrial
sector workers since the skin of workers are in direct
contact with materials at workplace.22 As the rice field
workers work for long duration in rice fields where the
environmental conditions are conducive to growth of
microorganisms, therefore, need for research on
ABSTRACT
Background: The objective of the study was
to estimate the risk of occupational skin diseases among workers who
were exposed to animal manure during rice cultivation in India.
Methods:
Questionnaire based six month follow up study with weekly assessment of skin diseases in rice field
workers from village Dabra, in Haryana state of India who were exposed to animal manure was carried out among the
agricultural workers working in rice field along with dermatological examination of exposed parts.
Results:
Out of total 574, workers, 90 were excluded as per exclusion criteria. 71 workers out of 370 workers who
were free from diseases at baseline survey data develop a new disease with cumulative incidence of 19.1%. There was
higher prevalence of dermatitis among all of reported skin diseases.
Conclusions:
Exposure to animal manure mixed with standing water is a major risk factor among the workers
working in rice field and attempt should be made to identify the type of dermatitis and relate its causative agent with
any specific biological or chemical agents present in animal manure mixed with standing water of rice field.
Keywords: Skin diseases, Occupational diseases, Animal manure, Cohort study
Department of Pharmaceutical Sciences, GJUS&T, Hisar, Haryana, India
Received: 25 January 2017
Accepted: 07 March 2017
*Correspondence:
Prof. Sumitra Singh,
E-mail: sumitra.singh32@gmail.com
Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.
DOI: http://dx.doi.org/10.18203/2394-6040.ijcmph20171316

Shiva et al. Int J Community Med Public Health. 2017 Apr;4(4):1011-1017
International Journal of Community Medicine and Public Health | April 2017 | Vol 4 | Issue 4 Page 1012
prevalence of skin diseases in those rice field workers
who are exposed to animal manure mixed with standing
water is desired.
METHODS
Study area
Village Dabra was selected as study area. The native
language of workers is Hindi (National language) but
most of people speaks the Haryanvi dialect (Local
Language). Rice crop is usually sown with the beginning
of the first rains in May-July, during the south-west
monsoon season. Dabra is a large village located in Hisar
district, Haryana with total 869 families residing. Out of
total population, 1709 were engaged in work activities.
84.61 % of workers describe their work as Main Work
(Employment or Earning more than 6 Months) Out of
1709 workers engaged in Main Work, 574 were totally
dependent on Agriculture.23
Period of study
During May 2016 to October 2016 (6 months)
Selection criteria
Male and female workers employed in agricultural work
for the last 5 years were included in present study. Part
time workers were excluded from the study. Pregnant and
lactating females were also excluded from present study.
Ethical aspect
Study was conducted according to guidelines of indian
council of medical research(ICMR) after obtaining
permission in written from Institutional Ethics
Committee of GJUS&T, Hisar and local
authority(village head/Sarpanch).Consent were obtained
from each and individual human subject in written and
their identity was not disclosed. Every member of study
population who reported any skin disease were
sanctioned to physical examination by dermatologist and
treatment free of charge
Questionnaire
Questions were designed and selected in accordance with
the Nordic Occupational Skin Questionnaire (NOSQ-
2002), an internationally validated questionnaire for
surveys on occupational skin diseases and exposure to
environmental factors and was made understable by
workers in their local understable language.24 Study
workers were followed weekly for kharif season duration
(6 months) by a team of health workers. At the first visit
of agricultural site, questionnaire was used to access their
baseline data about history of occupational skin diseases
if any, along with detail regarding working environment
and different agricultural activity performed by them on
regular basis. On every subsequent week, workers were
visited to obtain information about the status of their
reported skin disease and exposure during work.
Data analysis
Skin diseases were expected to be recurrent in nature as
they are constantly exposed to occupational hazard, so
the person who reported one or more skin diseases at any
of interview was considered one response. NOSQ score
was calculated based on subjects’ response. Results were
analyzed statistically to evaluate the level of significance.
Information from the questionnaire was coded and
entered into SPSS version 16 software. Cumulative
incidence was calculated and considered as measure of
disease frequency. Univariable analysis using modified
poisson regression were performed for estimation of
possible association between the outcome variable of our
interest (occupational skin disease: yes/no) and
explanatory variables.25 Variables with P value <0.5 were
considered statistically significant.
RESULTS
Characteristics of study population
Study cohort consists of all 574 individuals who were
totally dependent on agriculture. Out of these, 90 were
excluded as per exclusion criteria. A baseline survey
(before the start of study) was done In this, questionnaire
were presented to 484 workers out of which 290 were
those workers who were exposed to animal manure
mixed with standing water in their rice field and 194 were
exposed to standing water only and data were collected
which include detail about their age, sex, education and
type of exposure. There was no difference between two
groups in respect of distribution of their age, sex,
education and are described in Table 1.
Baseline data from questionnaire
Majority of workers from the group of animal manure
user perform their wet work in standing water mixed with
animal manure because majority of workers from both
groups cultivated rice as main kharif crop and very few
workers work in other kharif crops which don’t require
wet work. At the start point of study 33% workers from
animal manure user group reported in questionnaire that
they ever had skin diseases as compared to 12% of
second group. Workers from animal manure user
explained that contact with material at their workplace
cause worsening of their skin diseases. Most common
worsening agent were standing water mixed with animal
manure (163),standing water (147), dry animal manure
(6),But in second group (143) mentioned the standing
water as possible cause which make their diseases worse.
Out of total 44.0 % reported itching after work of
harvesting and thrashing means non wet work and 61.8%
reported itching after wet work. Some workers from both
groups (15 from animal manure user) and (11 from
animal manure non-user) reported that contact with

Shiva et al. Int J Community Med Public Health. 2017 Apr;4(4):1011-1017
International Journal of Community Medicine and Public Health | April 2017 | Vol 4 | Issue 4 Page 1013
certain material outside their work make their diseases
worse. Out of total, 46% show improvement in diseases
when they were away from field work In group of
workers exposed to standing water only 53%
improvement occurs when away from field work. In first
visit, workers were asked to tell about their reported
symptoms of possible skin disease and finding were
itching, burning sensation on exposed area of body, pus
formation, redness, pain, small wound, mosquito bite, and
itching after sweat on exposed parts of body.
Characteristics of symptoms of possible skin disease as
mentioned during first visit are shown in Table 2.
Table 1: Characteristics of study population as reported during baseline data.
Animal manure user (n=290)
Animal manure non-user (n=194)
P-value*
Characteristics
(n)
(%)
(n)
(%)
Mean age
32
33
Gender
Male
163
(56.20)
109
(56.18)
<0.05
Female
127
(43.79)
81
(41.75)
<0.05
Education
Not educated
51
(17.58)
29
(14.94)
<0.05
Educated
239
(82.41)
161
(82.98)
<0.05
Exposure
Standing water only
0
(0)
149
(76.80)
<0.05
Animal manure only
4
(1.37)
0
(0)
<0.05
Standing water mixed
with animal manure
221
(76.2)
0
(0)
<0.05
(*P value based on chi-squared test)
Table 2: Characteristics of workers reporting skin disease from baseline data.
Animal manure user (n=290)
Animal manure non-user (n=194)
Characteristics
(n)
(%)
(n)
(%)
P-value
Time of last skin disease occurrence
At Present
152
(52.4)
129
(66.5)
<0.05
Within last one month
89
(30.7)
28
(14.4)
<0.05
Between 1 and 3 months ago
33
(11.3)
25
(12.9)
<0.05
More than 3 months ago
16
(5.6)
12
(6.2)
<0.05
Localisation of skin diseases
Feet
164
(56.5)
103
(53.0)
<0.05
Leg
107
(36.9)
93
(47.9)
<0.05
Hand
49
(16.9)
19
(9.8)
<0.05
Forearm
09
(3.10)
07
(3.6)
<0.05
Nature of work at time of skin diseases
Wet Work
248
(85.5)
139
(71.6)
<0.05
Other than wet work
42
(14.4)
55
(28.3)
<0.05
Treatment required
Yes
114
(34.6)
51
(22.9)
<0.05
No
215
(74.1)
170
(76.5)
<0.05
Incidence of new skin diseases
Study population consist of workers who were free from
skin disease at time of first visit in May, 2016 and then
over six month period of study, skin diseases were
reported 1074 times by 123 workers with 78 from animal
manure user group and 45 were from second group of
workers. At starting point of study, 96 workers had a skin
diseases out of 484 so they were not included and 18 left
from the follow-up (follow up period <22 weeks). Out of
these only 370 were available for further analysis.
Overall cumulative incidence of occupational skin
diseases was found to be 19.1%. 71 workers out of 370
developed a new skin diseases (in group of animal
manure user, 49 workers with 125 reports and 22 workers
from animal manure non user group with 59 reports).It
shows highly significant difference (RR= 1.20, 95% CI).
Physical examination
Out of 123 workers who reported about skin diseases at
first visit, over six month follow up study, 96 turned up

Shiva et al. Int J Community Med Public Health. 2017 Apr;4(4):1011-1017
International Journal of Community Medicine and Public Health | April 2017 | Vol 4 | Issue 4 Page 1014
for physical examination before dermatologist. 96
workers were appeared for 266 times before
dermatologist. Out of which 187 were from animal
manure user group and 79 from non-user group. Age of
registered patient range from 18 to 50 years with mean
age of 37.2 and out of total, 76% was male. Dermatitis
was the most common skin diagnoses but other were in
small no and most cases were of workers from group of
animal user (Table 3). Most affected workers were from
group of animal manure user mostly affecting exposed
area of their body particularly feet and legs. Similarly
fungal and bacterial skin diseases mostly affected feet
and legs. Paronychia was common in nails of feet while
urticaria was common on forearm of workers.
Table 3: Occupational skin disease after diagnosis of patient by dermatologist.
Animal manure user (n=290)
Animal manure non-user (n=194)
Skin diseases Diagnosis
(n)
(%)
(n)
(%)
P-value
Dermatitis
67
(23.1)
17
(9.0)
<0.05
Fungal skin diseases
40
(13.8)
7
(3.8)
<0.05
Bacterial skin diseases
41
(14.0)
8
(4.1)
<0.05
Urticaria
3
(1.1)
1
(0.6)
<0.05
Paronychia
14
(4.6)
7
(3.4)
<0.05
Other skin diseases
1
(0.4)
1
(0.6)
<0.05
Table 4: Univariable analysis of risk factors for occupational skin diseases in 370 workers.
Variables
Skin diseases
No skin diseases
Cumulative incidence
Relative risk(RR)
Gender
Male
76
152
33.3
0.95(0.58-1.54)
Female
43
99
30.0
1
Age
< 35 years
171
99
63.3
0.78(0.51-1.20)
> 35 years
81
19
81.0
1
Socioeconomic status
Low
66
132
33.3
1.03(0.193-5.487)
High
56
116
32.4
1
Education
Not educated
190
80
70.4
1.17(0.66-2.05)
Educated
60
40
60.0
1
History of Disease
Yes
170
60
73.9
1.29(0.77-2.16)
No
80
60
57.1
1
Involved in agriculture
Yes
169
81
68.0
1.02(0.63-1.65)
No
80
40
66.7
1
Animal manure exposure
Yes
86
31
73.7
1.20(0.76-1.90)
No
155
98
61.1
1
Wet work
Yes
240
110
68.6
1.37(0.33-5.58)
No
10
10
50.0
1
Body washing after work
Infrequent
200
60
76.9
1.69(0.85-3.34)
Frequent
50
60
45.5
1
Risk factors for occurrence of skin disease
Risk factors were assessed from univariable analysis for
developing skin diseases with various risk factors like
gender, age group, education, previous history of any
skin disease, socioeconomic status, education, animal
manure exposure, involvement in agriculture in general,
wet work and habit of body wash after work and the
result were obtained in terms of (RR) relative risk (Table
4).Working in contact with standing water mixed with
animal manure was significantly associated with
occurrence of skin diseases. Assessment of exposure to
animal manure mixed with standing water from baseline
data at first visit and during weekly monitoring of contact

Shiva et al. Int J Community Med Public Health. 2017 Apr;4(4):1011-1017
International Journal of Community Medicine and Public Health | April 2017 | Vol 4 | Issue 4 Page 1015
with animal manure using the scoring system proclaimed
the same results regarding skin diseases. Involvement in
agriculture, in general and wet work in field were
significantly associated with risk of skin diseases .Gender
and age group of workers was not significantly associated
with risk of skin diseases. Education and socioeconomic
status were factors significantly associated with
occurrence of skin diseases. Habit of infrequent body
washing after work and previous history of any skin
diseases were strongly associated with risk of occurrence
of skin diseases
DISCUSSION
This study showed a clear difference in the occurrence of
occupational skin diseases (dermatitis) between two
group of workers and exposure to animal manure mixed
with standing water of rice field appeared to be an
important factor for this difference. Most of farmers
prefer to store cattle dung usually in stockpile on farms
for many months.26 Stockpiles consist of heaps of solid
cattle dung manure above ground.27 Stored manure will
eventually be applied on land manually by broadcasting
method (spreading the manure evenly on top of the soil).
When crop is irrigated, microorganisms in stored manure
decompose the organic matter and release a number of
pollutants in water.28 The greatest proportion of
emissions from manure takes place because it is
concentrated and continuous , putting field workers at
high risk.29 Agricultural workers suffer from a large
number of occupation related hazard skin diseases may
be caused due to standing water in rice field which is the
major risk factor and irritant31along with sun exposure
during sowing of seed, harvesting, weed removal,
irrigation of field, and harvesting.30-32 Dermatitis may be
caused due to contact with plant leaves during weed
removal and threshing. Skin lesions and small cuts are
caused either due to spiky nature of leaves also due to
any thorn present in mud, or due to strong ammonia.
Ammonia gas can cause severe skin irritation or burns
due to its high solubility in water. Because of this, skin
irritation can occur after sweating if the skin is in contact
with ammonia.33 Irritation due to ammonia can also affect
eyes, causing watering and lead to Glaucoma after a long-
term exposure to ammonia.34-35 India possess hot climate
due to which maximum numbers of workers prefers to
work barefoot and without protective gloves. manual
workers may suffer from a skin infection of the fingers,
known as paronychia.36 All this scenario along with lack
of education and awareness about severity of occupation
related disease make high prevalence of occupational
skin diseases in rice field workers of Haryana. According
to an earlier report, self reporting of skin diseases is good
indicator of prevalence of skin diseases in agricultural
workers.37 Human subjects in rural Haryana were more
willing to participate in interview based study as
compared to other method of intervention.38 All physical,
biological and chemical factor like hot and humidity
caused due to standing water as irritant and sunlight, can
play role in occurrence of skin diseases.39 In a earlier
report conducted on paddy field workers of southern
India ,low prevalence of dermatitis were shown while in
our study paddy field workers in Haryana showed
maximum prevalence of skin dermatitis.32 Some
pathogens like virus, bacteria and parasites in animal
manure pose potential risks to human health.40
CONCLUSION
The present study shows different types of skin diseases
commonly occurred due to occupation related factors in
agricultural workers. Observation and discussion with
workers result in conclusion that agricultural workers
perform more manual labour and remained in continuous
contact with standing water, spiky leaves, and intense
sunlight along with animal manure, but we cannot define
exact cause of all these reported symptoms. Based on this
study, further research work will focus on identification
of type of dermatitis and their relation with particular
biological or chemical substance present in mixture of
animal manure and standing water.
ACKNOWLEDGEMENTS
Dr Surender Gupta from the Gupta skin clinic and Dental
Hospital, Hisar examined the skin patients. We thank the
helping staff for their hard work in data collection during
weekly visits and interview. We are thankful to local
authority of village for their support. Study received
financial support from DST, Government of India in form
of DST-INSPIRE fellowship with registration no.
IF140587.
Funding: Funding agency is DST, Government of India
in form of DST-INSPIRE fellowship
Conflict of interest: None declared
Ethical approval: The study was approved by the
Institutional Ethics Committee
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Cite this article as: Shiva, Singh S, Singh SK.
Prevalence of occupational skin diseases among rice
field workers in Haryana. Int J Community Med
Public Health 2017;4:1011-7.