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Health-related disorders on occupational exposure to chromium in a leather tanning factory (Menoufia, Egypt).

Authors:
  • Faculty of medicine Menoufia University

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Objectives The aim of this study was to study health disorders among workers in a leather tanning industry and its relation with workplace environment in the same factory. Background Leather tanning industry wastes pose serious environmental effect on water, land, and air. Leather tanning manufacture processes are also associated with a number of human health risks. Chromium (Cr) is the commonest used tanning agent to stabilize leather against biodegradation. Prolonged exposure to Cr compounds leads to long-term toxic effects in humans. Participants and methods A cross-sectional comparative study was conducted on 304 workers in a leather tanning factory and 304 nonoccupationally exposed subjects as control. Air samples for Cr (VI) were carried out. Biological monitoring of Cr in blood and urine of participants was done. Spirometric measurements and hematological investigations were applied. Results The mean value of airborne Cr (VI) concentration was higher than the international permissible levels. There were higher serum and urinary Cr levels among exposed workers than controls (P = 0.000). Leather tanning factory workers had a higher significant prevalence of respiratory and skin-related manifestations as well as decreased spirometric measurements and abnormal hematological findings (P = 0.000). Conclusion Exposure to high level of Cr is blamed to increase the frequency of skin-related and respiratory manifestations, early spirometric changes, and abnormal hematological findings. Regular wearing of good-quality personal protective equipment, especially masks and gloves, to decrease Cr exposure is highly recommended.
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92 Original article
1110‑2098 © 2017 Faculty of Medicine, Menoua University DOI: 10.4103/1110‑2098.211508
Introduction
Tanning leather is the process of treating skins and
hides of animals to produce leather, which is more
durable and less susceptible to decomposition [1].
e tanning industry forms the backbone of the
Egyptian leather industry. Egyptian hides are known
for a unique leather texture owing to the moderate
climate. Approximately 300 tanneries are located in
the ‘Old Cairo District’ in Cairo city. e labor force
comprises250000 workers[2].
Chromium (Cr) exits in two stable oxidation states,
namely, the trivalent(III) and hexavalent(VI) forms.
Hexavalent Cr is more toxic than trivalent Cr owing
to its oxidizing ability and high solubility [3,4].
Chrome tanning is the most common technique in
leather processing; 90% of tanning industries use basic
Cr (III) sulfate instead of other tanning agents to
obtain better‑quality leather[5]. Hexavalent Cr(VI)
is produced industrially when Cr (III) is heated
in the presence of mineral bases and atmospheric
oxygen [6]. Tannery workers are mainly exposed to
Cr in the inorganic or protein‑bound form (leather
dust) [7]. Occupational exposure to Cr is generally
through inhalation and dermal absorption, although
ingestion is also possible where there is poor personal
hygiene[7–9].
Cell toxicity caused by Cr is attributed to oxidants
over antioxidants. Cr(VI) enters many types of cells
and under physiological conditions can be reduced
by hydrogen peroxide (H2O2), glutathione reductase,
and glutathione to produce reactive intermediates.
Any of these species could attack DNA, proteins, and
membrane lipids, thereby disrupting cellular integrity
Health-related disorders on occupational exposure to chromium
in a leather tanning factory (Menoua, Egypt)
Gaafar M. Abdel Rasoul, Mahmoud E. Abou Salem, Heba K. Allam,
Zeinab A. Kasemy, Faten E. Younis
Objectives
The aim of this study was to study health disorders among workers in a leather tanning industry
and its relation with workplace environment in the same factory.
Background
Leather tanning industry wastes pose serious environmental effect on water, land, and air.
Leather tanning manufacture processes are also associated with a number of human health
risks. Chromium (Cr) is the commonest used tanning agent to stabilize leather against
biodegradation. Prolonged exposure to Cr compounds leads to long-term toxic effects in
humans.
Participants and methods
A cross-sectional comparative study was conducted on 304 workers in a leather tanning
factory and 304 nonoccupationally exposed subjects as control. Air samples for Cr (VI) were
carried out. Biological monitoring of Cr in blood and urine of participants was done. Spirometric
measurements and hematological investigations were applied.
Results
The mean value of airborne Cr (VI) concentration was higher than the international permissible
levels. There were higher serum and urinary Cr levels among exposed workers than controls
(P=0.000).Leathertanningfactoryworkershadahighersignicantprevalenceofrespiratory
and skin-related manifestations as well as decreased spirometric measurements and abnormal
hematologicalndings(P = 0.000).
Conclusion
Exposure to high level of Cr is blamed to increase the frequency of skin-related and respiratory
manifestations,earlyspirometricchanges, and abnormalhematologicalndings.Regular
wearing of good-quality personal protective equipment, especially masks and gloves, to
decrease Cr exposure is highly recommended.
Keywords:
chromium, hematological investigations, leather tanning, spirometry
Department of Public Health and Community
Medicine, Faculty of Medicine, Menoua
University, Menoua, Egypt
Correspondence to Faten Ezz El‑Arab Younis,
MSc, Department of Public Health and
Community Medicine, Faculty of Medicine,
Menoua University, Shebin Al‑Kom, 232511,
Menoua, Egypt
Tel: +20 1066058005; fax: 0482317508;
e‑mail:fatenyounis@yahoo.com
Received 28 September 2016
Accepted 04 December 2016
Menoua Medical Journal 2017, 30:92–98
Menoua Med J 30:92–98
© 2017 Faculty of Medicine, Menoua University
1110‑2098
This is an open access arcle distributed under the terms of the Creave
Commons Aribuon‑NonCommercial‑ShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, as
long as the author is credited and the new creaons are licensed under
the idencal terms.
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Health effects of leather tannery Abdel Rasoul et al. 93
and functions. Many forms of DNA damage can
be produced: oxidative DNA lesions such as strand
breaks, Cr–DNA adducts, DNA–DNA interstrand
cross‑links, and DNA–protein cross‑links[10,11].
Dermatological eects of Cr compounds may
include ulcerations, dermatitis, and allergic skin
reactions[12,13]. Localized erythematous or vesicular
lesions at points of contact or generalized eczematous
dermatitis should suggest sensitization[14].
Respiratory eects of Cr compounds can result in
ulceration and perforation of the mucous membranes
of the nasal septum, irritation of the pharynx and
larynx, asthmatic bronchitis, bronchospasms, and
edema[15].
Other health problems caused by Cr are weakened
immune systems, kidney and liver damage[6], alteration
of genetic material[16], and lung cancer[17,18].
Cr measurements in blood and urine are considered
most reliable for detecting elevated level of exposures
to Cr[19]. ere is a paucity of research studies done
in this eld among Egyptian workers, so this study is
intended to be performed to provide further evidence
of the possible adverse eects of Cr in leather tannery
workers.
Participants and methods
is study took place in a leather tanning factory
(in industrial zone, Queisna City, Menoua
Governorate, Egypt), between September 2014 and
September 2016. A cross‑sectional comparative
study was designed to study all occupationally
exposed male workers from tanning department
in the studied factory (174 workers), and an equal
number (174 workers) was chosen randomly
(simple random sample) from the preparatory
and nishing departments (87 workers from each
department). After exclusion of nonresponders, with
response rate of 94.3%, and application of exclusion
criteria which included worker who had any chest,
skin, neurobehavioral, hematological, liver or kidney
diseases; diabetes mellitus; and hypertension before
employment in the factory, the recruited workers from
the studied factory were 304(152, 79, and 73 workers
from tanning, preparatory, and nishing departments,
respectively). Acontrol group of 304male individuals
was selected from the relatives of the exposed group,
who had never worked at leather tanning factory;
they were matched with the exposed group for age,
residence, education, and income. Participants were
interviewed between 7:00 a.m. and 3:00 p.m.
Questionnaire
In the questionnaire interviews, detailed descriptive
information was collected, including personal descriptive
characteristics, occupational lifestyles, working
positions, working environment, and personal hygiene.
Direct observations were also made and recorded to
conrm the questionnaire results. Also, medical history
of respiratory, skin, and hematological diseases and
past history of other diseases(e.g.,mental and nervous
diseases, hypertension, diabetes mellitus, and liver and
kidney diseases or use of antipsychotic drugs as well as
skin, chest, or eye allergies) were gathered.
Spirometric measurements
Spirometric measurements were taken by using the
MIR (Medical International Research) company,
Rome, Italy to determine forced vital capacity (FVC%),
forced expiratory volume at the rst second (FEV1%),
forced expiratory ratio (FEV1/FVC%), forced
expiratory ow (FEF25–75%), and peak expiratory ow
(PEF%). e best value of three technically acceptable
maneuvers was recorded. Percentages were reported,
and the results were compared with predictive values
based on age, sex, and height of the participant.
Blood collection
From each participant, 10ml of venous blood was taken
through a vein puncture using a dry plastic disposable
syringe under complete aseptic condition. Of that, 3ml
of blood was kept in a tube, allowed to clot, and then
centrifuged to separate the serum for determination
of Cr level. Another 3ml of blood was dispensed in
a sterile glass test tube containing potassium EDTA,
as an anticoagulant, for the analysis of dierent
hematological parameters (complete blood count).
e remaining 4 ml of blood was kept in a tube,
allowed to clot, and then centrifuged to separate the
serum, and an aliquot of serum samples was stored
in a freezer (−20°C) until biochemical analysis [liver
function tests including serum glutamic‑oxaloacetic
transaminase(SGOT) and serum glutamate pyruvate
transaminase(SGPT); renal functions including blood
urea nitrogen (BUN) and creatinine; serum ferritin;
and serum iron]. e samples for hematological and
biochemical measurements were analyzed at Clinical
Pathology Department, Menoua University Hospital.
e air, urinary, and blood Cr samples were analyzed at
the National Research Center, Cairo, Egypt.
Urine collection
For each participant, spot urine sample (30 ml) was
taken. e urine samples were kept in polypropylene
sampling vessels and stored at−20°C before analysis.
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94 Menoua Medical Journal, Volume 30 | Number 1 | January-March 2017
Environmental measurement
Air samples at breathing zone of the workers in
dierent departments of the factory were obtained
by the use of atomic absorption spectrophotometry
(SOLAAR‑UNICAM 989) Perkin Elmer, Jena,
Germany at the National Research Center, Cairo,
Egypt. ree readings were reported from the factory,
where the mean value was recorded for regular work
duration of 8 h (e breathing zone is the area
immediately surrounding a worker’s nose and mouth
where the majority of air is drawn into their lungs.
is zone is the area monitored during an industrial
hygiene survey to aid in determining the presence of
airborne contaminants.).
Ethical approval
is study was approved by the Menoua Faculty of
Medicine Committee for Medical Research Ethics. All
of the participants received a clear explanation of the
purpose of this study and agreed to participate using
signed consent forms. All personal information about
the study participants was kept condential. Approval
from the factory management was obtained.
Data management
Analyses were conducted with the statistical
package for social sciences, version 22 (SPSS Inc.,
Chicago, Illinois, USA). Student’s t‑test was used for
comparison between the two means of continuous
quantitative parametric variables and Mann–Whitney
U‑test for nonparametric variables. c2Test was used
for categorical variables and Fisher exact test for
categorical variables when the expected value was less
than 5. Spearman correlation coecient(r) was used
to measure the association between two quantitative
variables. Multiple linear regressions were applied to
detect the relationship between two variables by tting
a linear equation to observed data. Alinear regression
line had an equation of the form Y=a+bX, where
X was the independent (explanatory) variable and Y
was the dependent variable. Statistical signicance was
accepted for Pvalue 0.05 or less for results that were
two tailed.
Results
Overall, 304male workers in a leather tanning factory
and 304 matched controls were included in this study.
Exposed group and controls were matched for age, sex,
socioeconomic standard, educational level, residence,
and marital status (P > 0.05). e environmental
measurements recorded that the mean value of Cr
concentration was 10.4±0.63μg/m3(Table1), which
was higher than recommended exposure limit set by the
National Institute for Occupational Safety and Health
and the Occupational Safety and Health Administration.
Also, there was signicantly higher serum and urine
Cr levels among exposed(3.1±2.2 and 2.6±2.5μg/l,
respectively)(Table1) than controls (0.15± 0.08 and
0.38±0.44μg/l, respectively; P<0.001).
e present respiratory manifestations including
rhinitis, cough, expectoration, wheezes, dyspnea, chest
pain, chronic bronchitis, and asthma were signicantly
more prevalent among exposed group(11.2, 21.7, 9.2,
9.9, 8.6, 4.9, 6.9, and 7.6%, respectively) than controls
(3.3, 12.2, 3, 1.6, 0.7, 0.3, 0.0, and 0.0%, respectively;
P<0.001) (Fig.1). Also, skin manifestations among
the exposed workers experienced a signicantly higher
prevalence of skin redness(8.2%), itching(5.9%), and
papules and vesicles(4.6%) than controls(3.3, 2.3, and
1.0%, respectively; P<0.05)(Fig.1).
e spirometric measurements between exposed
workers and controls revealed that there was signicantly
Table 1 Mean airborne, blood, and urinary chromium levels
among studied groups
Parameters Tannery
workers
Controls Mann-Whitney
U-test
P
Airborne
chromium (VI)
levels(μg/m3)
Mean±SD 10.4±0.63 –
Range 9.9-11.1
Serum chromium
levels(μg/l)
Mean±SD 3.1±2.2 0.15±0.08 17.89 0.000**
Range 0.01–10.3 0.02-0.6
Urine chromium
levels(μg/l)
Mean±SD 2.6±2.5 0.38±0.44 15.34 0.000**
Range 0.02-8.6 0.02-1.4
**P<0.001,highlysignicant.
Respiratory and skin manifestations among studied groups.
Figure 1
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Health effects of leather tannery Abdel Rasoul et al. 95
lower mean values of FVC%, FEV1%, FEV1/FVC%,
FEF25–75%, and PEF% in exposed workers (77.4±9.3,
77.9±9.8, 81.9±13.9, 73.9±17.1, and 59.9±22.1,
respectively) than controls (83.6 ± 6.7, 85.6 ± 5.6,
90.5±14.2, 86.1±16.5, and 72.9±17.2, respectively;
P<0.001)(Table2).
On comparing exposed workers and controls regarding
the hematological and biochemical ndings, there were
signicant lower mean values of red blood cells(RBCs),
hemoglobin (Hb), serum iron, and serum ferritin
among exposed(4.6±0.76×106/mm3, 13.6±1.2g/dl,
67.7±21.5μg/dl, and 29.8±17.03ng/ml, respectively)
than controls(5.1 ±0.66×106/mm3, 14.5±1.2g/dl,
77.7±27.2μg/dl, and 42.8±21.9ng/ml, respectively;
P<0.001)(Table3). ere were signicant higher mean
values of BUN and creatinine level among exposed
group(18.01±5.2 and 0.61±0.26mg/dl, respectively)
than controls (15.5 ± 4.8 and 0.49 ± 0.19 mg/dl,
respectively; P<0.05)(Table3) but the mean values
of SGOT, SGPT, BUN, and creatinine level among
exposed workers were still within the reference
range(reference values of creatinine and BUN levels
are 0.7–1.2 and 7–20mg/dl, respectively).
In this study, there were signicant positive correlations
between urinary as well as serum Cr levels(μg/l) with
duration of current employment (years) (r = 0.128,
P < 0.05 and r = 0.187, P < 0.001, respectively)
(Figs.2 and 3).
On application of multiple linear regressions to
determine which selected variables were signicantly
inuencing either of the serum or urinary Cr levels
after adjusting for all the confounders, there was a
signicant relationship between serum Cr and either
of current employment duration(regression coecient
= 0.295) or mean concentration of Cr in air
(regression coecient = 0.339; P<0.05). Also, there
was a signicant relationship between urinary Cr and
mean concentration of Cr in air(regression coecient
= 0.435; P<0.05)(Table4).
Discussion
Cr is used as a basic tanning pigment, so it represents
an important health risk factor for the tannery workers.
e present work was undertaken to provide more
information on possible health eects of Cr in tannery
workers. Overall, 608 individuals were included in the
study, of which 304 were those who worked in this
tannery and had occupational hazards of exposure and
direct contact with the chemicals used in tanneries, and
the other 304 were from the relatives of the studied
group, who had no direct exposure or contact.
In the studied factory, environmental measurements
recorded that mean value of airborne Cr (VI) level
exceeded the accepted 8‑h time‑weighted average
Table 2 Mean spirometric measurements among studied
groups
Parameters Tannery workers Controls t-Test P
FVC% 77.4±9.3 83.6±6.7 7.93 0.000**
FEV1% 77.9±9.8 85.6±5.6 9.84 0.000**
FEV1/FVC% 81.9±13.9 90.5±14.2 6.32 0.000**
FEF25-75% 73.9±17.1 86.1±16.5 7.57 0.000**
PEF% 59.9±22.1 72.9±17.2 4.64a0.000**
Values are expressed as mean±SD. FEV, forced expiratory volume
attherstsecond;FVC,forcedvitalcapacity;PEF,peakexpiratory
ow.aMann-Whitney U-test. **P<0.001,highlysignicant.
Table 3 Mean hematological and biochemical measurements among studied groups
Parameters Tannery workers Controls Reference range for adult male Mann-Whitney U-test P
RBCs (×106/μl) 4.6±0.76 5.1±0.66 4.7-6.1 7.17a0.000**
Hb(g/dl) 13.6±1.2 14.5±1.2 13.8-17.2 8.80a0.000**
Serumiron (μg/dl) 67.7±21.5 77.7±27.2 65-176 6.61 0.000**
Serumferritin (ng/ml) 29.8±17.03 42.8±21.9 12-300 7.81 0.000**
SGOT(IU/l) 24.2±10.4 23.9±10.8 10-40 0.41 0.68
SGPT(IU/l) 22.5±10.4 21.7±8.9 10-42 0.59 0.53
BUN(mg/dl) 18.01±5.2 15.5±4.8 7-20 6.24a0.000**
Creatinine(mg/dl) 0.61±0.26 0.49±0.19 0.7-1.2 5.44 0.000**
Values are expressed as mean±SD. BUN, blood urea nitrogen; Hb, hemoglobin; SGOT, serum glutamic-oxaloacetic transaminase;
SGPT, serum glutamate pyruvate transaminase; RBC, red blood cell. aStudent’s t-test. **P<0.001,highlysignicant.
Table 4 Multiple linear regression model for detecting predictors for serum and urine chromium levels among exposed workers
Serumchromium (μg/l) Urinechromium (μg/l)
Parameters βt P 95% CI βt P 95% CI
Age (years) 0.58 0.82 0.40 (−0.37‑0.89) 0.098 1.326 0.10 (−0.02‑0.09)
BMI 1.02 1.00 0.38 (−0.97‑2.99) 0.056 1.085 0.23 (−0.05‑0.19)
Smoking index 0.191 1.85 0.52 (−0.001‑0.02) −0.026 −0.248 0.15 (−0.01‑0.01)
Duration of current employment (years) 0.295 5.37 0.03* (0.14-0.30) −0.04 −0.298 0.07 (−0.27‑0.19)
Meanconcentration ofchromium levelin air(μg/m3) 0.339 2.97 0.01* (0.06-0.34) 0.435 3.18 0.02* (0.11-0.45)
β,standardizedregressioncoefcient;CI,condenceinterval.*P<0.05,signicant.
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96 Menoua Medical Journal, Volume 30 | Number 1 | January-March 2017
exposure limit of 5 μg of Cr(VI) per cubic meter of
air (5 μg/m3) recommended by Occupational Safety
and Health Administration [20] and 0.2 μg/m3
recommended by National Institute for Occupational
Safety and Health [21]. Previous two studies[8–22]
have reported the levels of Cr in tannery plants inKenya,
which found higher mean Cr levels in breathing zone
air of the workers than those of the control group.
e results of the present study showed that the serum
and urinary Cr levels of the exposed participants
were higher than those in the matched control
participants. e mean levels of Cr in serum and urine
of general populations were 0.10–0.16 and 0.22 μg/l,
respectively[19]. ese results of the exposed workers
were attributed from increased air levels of Cr at the
workplace through inhalation, absorption through the
skin, and possibly through ingestion.
Another study among tannery workers in Egypt [3]
reported a signicant increase in Cr level in their
serum when compared with the control group. Similar
studies [8–22] of dierent tannery plants in Kenya
reported higher mean Cr levels in urine of exposed
workers.
is is supported by Zailina et al.[23], who studied
machinists in Malaysia and recorded higher blood Cr
level and urine Cr level among them. e printing
workers in Southern ailand [24] had higher urinary
Cr levels and serum Cr levels than the control group.
is claries that the highest exposure to air Cr level
in either tannery, machinists, or printing environment
could be blamed for increase in the serum and urinary
Cr levels among exposed workers.
In this study, present respiratory manifestations were
signicantly more prevalent among exposed group than
controls. is may be contributed to ventilation errors
in the factory environment, added eects of chronic
exposure to Cr, and synergistic eect of smoking.
ese results agree with those reported by Subodh
etal. [25] and Were etal.[8,22] who reported higher
prevalence of respiratory manifestations in exposed
tannery workers than controls in Kanpur and Kenya,
respectively.
e spirometric measurements between exposed
workers and controls revealed that there were
signicantly lower mean values in exposed workers
than controls. Also, the spirometric measurements
of exposed tannery workers in Kenya [22] showed
signicantly lower mean values among them than
controls. Overall, 197male workers [25] drawn from
leather tanneries in Kanpur had signicant lower
spirometric measurements than controls. Issever
et al. [15] studied respiratory problems in tannery
workers in Istanbul and found decreased pulmonary
function results than controls.
e use of spirometry is an important tool for
assessment of lung function due to exposure of the
workers to various metals at dierent workplaces.
is is in agreement with Abdel‑Rasoul et al. [26]
who studied workers in a uorescent lamp factory
and found early changes in ventilatory functions in
the form of FVC, FEV1, FEV1/FVC%, and FEF25–75%
among exposed workers owing to mercury.
In the present work, the skin manifestations among
the studied groups showed that the exposed workers
experienced a signicantly higher prevalence than
controls. Cr(VI) when in contact with the skin may
trigger inammatory skin reactions. Also, Cr has
the potential to bind with skin proteins of tannery
Spearman correlation between urinary chromium and duration of
current employment among exposed group.
Figure 2 Figure 3
Spearman correlation between serum chromium and duration of
current employment among exposed group.
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Health effects of leather tannery Abdel Rasoul et al. 97
workers to produce complex antigens which lead to
hypersensitivity. Similarly, the tannery workers in
Kenya [22] showed a signicantly higher prevalence
of dermatological symptoms (rashes and itching)
compared with the control group. However, 472
workers at two leather factories in Indonesia [27]
were studied, and 7.4% had an occupational contact
dermatitis. Of the 197male workers from 10 tanneries
in India, 9% had skin rash, papules, and itching.
In this study, on comparing exposed and controls
regarding the hematological and biochemical ndings,
there were signicant lower mean values of RBCs, Hb,
serum iron, and serum ferritin among exposed than
controls. ere were signicantly higher mean values of
BUN and creatinine level among exposed participants
than controls, but the mean values of SGOT, SGPT,
BUN, and creatinine level among exposed workers
were still within the reference range. e exposed
workers had signicantly raised Cr levels in their
biological uids that led to adverse health eects
owing to enhanced oxidative stress and inammatory
changes. So, the hematological, hepatic, and renal
function impairments because of oxidative stress on
body systems may act as an indicator of Cr toxicity.
Previous study among Egyptian leather tannery
workers [3] reported signicant hematological defects
and recorded a signicant dierence between tannery
workers and control group regarding white blood cells,
platelet counts, and Hb concentration, but there was no
signicant dierence in RBC count between tannery
workers and control group. Similar investigations
among tannery workers of Kasur industrial area,
Pakistan [28], found that studied parameters were
within the reference range, but SGPT and SGOT
showed higher values among factory workers aged
from 21 to 40 years and from 41 to 60 years than
nonworkers of the same age. On the contrary, Ramzan
etal. [29] found no signicant changes in the values of
Hb, mean corpuscular volume, and mean corpuscular
Hb concentration between tannery workers and
control individuals.
is study shows that with increased duration of
employment, urinary and serum Cr levels (μg/l)
increased. is correlation is supported by the ndings
of machinists in Malaysia [23], which recorded that
positive correlation was present between blood and
urinary Cr levels with employment years.
Conclusion
is study revealed occupational exposures to Cr
and the related health eects among workers in a
leather tanning factory, Egypt. It is suggested that a
combination of inadequate engineering controls, work
practices, and personal hygiene, together with high
exposures to Cr in air, resulted in the related health
eects among workers. Based on the ndings of the
study, it is recommended that monitoring and Cr
regulation compliance levels in tanneries, along with
the relevant training support mechanisms, should
therefore be designed and implemented in the tanning
industry.
Acknowledgements
e author thank all the workers and the participants
who generously agreed to participate and also the
administrators of the factory who facilitated the access
to the study group.
Financial support and sponsorship
Nil.
Conicts of interest
ere are no conicts of interest.
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... welding on stainless steel or mild steel, hard or decorative chrome plating) is provided in the Supplementary Material S9 (Column "Study Characteristics"). Eight studies (Pesch et al., 2018;Stanislawska et al., 2020;Weiss et al., 2013;Riccelli et al., 2018;Goldoni et al., 2010;Beattie et al., 2017;Leese et al., 2017;Genovese et al., 2015) were performed in European countries, twelve studies (Golbabaei et al., 2012;Balachandar et al., 2010;Pan et al., 2018;Zhang et al., 2011;Xia et al., 2019;Jia et al., 2020;Song et al., 2012;Decharat, 2015;Hu et al., 2018;Li et al., 2016;Xiaohua et al., 2012;Wang et al., 2011a) in Asian countries, four studies (Were et al., 2013(Were et al., , 2014Abdel Rasoul et al., 2017;El Safty et al., 2018) in African countries and one study (Muller et al., 2020) in a South-American country. Overall, the reported median or mean urinary Cr levels (20 out of 25 articles) were lower in European countries (ranging from 0.96 μg/l to ca. 5.81 μg/l) compared to non-European countries (ranging from 1.66 μg/l to 48.4 μg/l). ...
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