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ARTICLE IN PRESS International Journal of Hygiene and Environmental Health xxx (2014) xxx–xxx

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Noise and cardiovascular effects in workers of the sanitary fixtures industry Capozzella Assunta a , Samperi Ilaria a , De Sio Simone a , Tomei Gianfranco b , Casale Teodorico a,∗ , Sacco Carmina a , Suppi Anastasia a , Giubilati Roberto a , Tomei Francesco a , Rosati Maria Valeria a a University of Rome “Sapienza”, Department of Anatomy, Histology, Medical-Legal and the Orthopedics, Unit of Occupational Medicine (Dir: Prof. F. Tomei), Viale Regina Elena 336, 00161 Rome, Italy b University of Rome “Sapienza”, Department of Psychiatric and Psychological Science, Piazzale Aldo Moro 5, 00185 Rome, Italy

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Article history: Received 13 February 2014 Received in revised form 29 September 2014 Accepted 30 September 2014 Keywords: Cardiovascular disease Hypertension Lead Noise Sanitary fixtures industry

The aim of the present study is to evaluate whether workers in the sanitary fixtures industry are a category at risk of developing cardiovascular diseases, and in particular, whether chronic noise exposure may play a role in cardiovascular effects in exposed workers. Seventy-five employees engaged in sanitation fixtures production and a control group of sixty-four office workers, who were not exposed to agents that could damage the cardiovascular system, participated in our study. The selected workers completed a clinical-anamnestic questionnaire, and underwent a medical examination, blood pressure test, electrocardiogram (ECG), blood tests, and audiometry. Measurements of environmental noise, dust, and lead were also carried out. The exposed workers, in comparison to the control group, showed a higher frequency of hypertension, systolic and diastolic blood pressure (p < 0.05, p < 0.05), as well as electrocardiographic abnormalities (p < 0.05). There was also a higher frequency of hypertension and electrocardiographic abnormalities among subjects with audiometric deficit compared to normoacoustic subjects (p < 0.05 and p < 0.05). Results: from our study suggest that work activity in the sanitary fixtures industry can have an influence on the cardiovascular system, and noise can be the main cause of damage for the cardiovascular system in exposed workers, as cardiovascular damage seems to be linked to hearing loss. © 2014 Elsevier GmbH. All rights reserved.

Introduction Cardiovascular diseases (CVDs) are some of the most important and frequent chronic non-communicable diseases (World Health Organization, 2008). The risk factors for cardiovascular disease, such as hypertension and cardiac arrhythmias, can be avoidable (for example smoking, obesity, and hypertension) or not avoidable (such as age, sex, race, and lifestyle). In addition to these wellknown risk factors, other occupational hazards related to the job include: shift work and/or night work, noise, and high temperature. Risk factors associated with work tasks can be identified and in many cases they can be eliminated. Workers employed in the manufacturing sector are exposed to severe occupational hazards such as noise, heat stress, physical

∗ Corresponding author. Tel.: +39 0649912540. E-mail address: [email protected] (C. Teodorico).

effort and dust (Gradinariu et al., 2006). Specific studies about the cardiovascular system in the sanitary fixtures sector are lacking. Undoubtedly, the risk factor most studied in the field of ceramic work is represented by exposure to dust containing silica dioxide (Monti et al., 2008) although studies on the cardiovascular system in the field of ceramics are also very few. It is well known that noise may seriously damage hearing. However, its role in arterial hypertension and cardiovascular diseases has been studied only recently. Some extra-auditory effects of noise influence the gastro-enteric system (Tomei et al., 1994), respiratory system (Castelo Branco et al., 1999), immune system (Zheng and Ariizumi, 2007), endocrine system (Tomei et al., 2003), reproductive system (Hrubá et al., 1999), the nervous (Tomei et al., 2010) and cognitive systems (Belojevic et al., 2003). In recent years several studies have been conducted on relationships between noise exposure and cardiovascular pathologies; many of these studies found that noise exposure may alter arterioles (Tomei et al., 1991), heart rate (Raggam et al., 2007), blood pressure (Aydin and Kaltenbach, 2007; Sancini et al., 2011, 2012;

http://dx.doi.org/10.1016/j.ijheh.2014.09.007 1438-4639/© 2014 Elsevier GmbH. All rights reserved.

Please cite this article in press as: Assunta, C., et al., Noise and cardiovascular effects in workers of the sanitary fixtures industry. Int. J. Hyg. Environ. Health (2014), http://dx.doi.org/10.1016/j.ijheh.2014.09.007

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Tomei et al., 2013) and urinary concentration of catecholamines (Babisch et al., 2001; Sancini et al., 2011). Recently, several studies have been carried on relationships between noise exposure and cardiovascular pathology (Aydin and Kaltenbach, 2007; Raggam et al., 2007). The aim of the present study is to evaluate whether the category of sanitary fixtures workers is at risk of developing cardiovascular diseases. Materials and methods In this study, we evaluated whether chronic exposure to noise can play a role in the development of cardiovascular effects in exposed workers compared to a group of non-exposed workers. Population and setting

• Workshop activities that use various tools (drills, cutters, whisks, mole wrench). Work areas are provided with appropriate ventilation systems and air conditioning. The tunnel-type ovens are equipped with a rapid cooling system recirculating preheated hot air; the introduction of the material to be fired is carried out by use of machinery. The firing areas are placed in separate rooms from the rest of the production cycle and surrounding areas are large, so they allow heat dissipation; the company has been structured in such a way that these areas are not affected by excessive heat from the sun. For the control group, 207 office workers from a large company originally participated; the company from which the control group was selected was chosen randomly among the companies with administrative activities that are located in the same geographic area of the sanitary fixtures factory. Workers who perform administrative activities are exposed only to occupational risks of visual fatigue, and are not exposed to occupational hazards such as noise, lead, dust and micro-climate with high temperatures (Table 1).

A total of 132 male subjects were studied originally, working for a large company of sanitary fixtures and exposed to the following risks: dust, lead, noise and microclimate with high temperatures (Gradinariu et al., 2006). Employees rotate to perform different tasks and are engaged in a number of activities. These include:

Questionnaire

• Modeling and mother mould, where models are prepared to shape the product • Mixing, where clays are mixed for the preparation of ceramic to be cast later • Molding or casting, for the realization of crude product by the fluidization of clays with special mixers that use water (an operation which takes place manually and automatically) • Manual and wet finishing with hands and metal spatulas to remove burrs or imperfections (the product is aged for natural drying inside or outside the company) • First firing in the oven (950–1000 ◦ C), a tunnel type with a continuous conveyor belt • Production of the so-called biscuit • Enameling carried out in booths, using spray guns with compressed air • Glazing • Second firing (annealing) when there is the stabilization of enamels, which occurs at a temperature of about 50 ◦ C lower than the first firing in order to determine changes in the biscuit • Testing of the product and cleaning • Palletizing and warehouse operations (storage and retrieval with forklift)

All workers completed a clinical-anamnestic questionnaire (instrument used to obtain medical-scientific information from patients regarding personal data, general data, voluptuary habits, previous and/or current health status, history of some diseases, etc.) in the presence of a physician with items aimed at characterizing the job and exposure. Use of personal protective equipment was also investigated. The confounding factors (or confounders: factors that intervene to confuse the association between exposure and outcome. The confounding factor is independently associated with both exposure and outcome) were identified in the process of the study design, in order to exclude cases with cardiovascular and/or audiological diseases due to known factors unrelated to the job; identification was made through medical documentation and consultation of scientific literature. The purpose of the clinical medical history questionnaire is twofold: - The exclusion of confounding factors for audiological risk: use of ototoxic drugs (i.e. streptomycin, neomycin, erythromycin, furosemide, phenylbutazone), acoustic trauma, exposure to blast bombs, mines, use of firearms (pistols, rifles, etc.), previous ear infections (bacterial etiology: Staphylococcus aureus, Haemophilus

Table 1 Characteristics of the study population.

Age (years) Mean ± sd (min–max) Body mass index (kg/m2 ) Mean ± sd (min–max) Length of service (years) Mean ± sd (min–max) Smokers No. of subjects (%) Alcohol consumption No. of subjects (%) Familiarity for cardiovascular diseases No. of subjects (%) Blood glucose >5.5 mmol/l No. of subjects (%) Total cholesterol >5.2 mmol/l No. of subjects (%) Triglycerides >1.7 mmol/l No. of subjects (%) HDL < 1.03 mmol/l No. of subjects (%)

Workers exposed (N. 75)

Workers non-exposed (N. 64)

p-Value

41.36 ± 9.4 (21–59)

38.8 ± 7.9 (23–53)

>0.05

25.79 ± 2.63 (21.14–32.78)

25.7 ± 2.5(19.4–32.1)

>0.05

15.93 ± 9.72 (1–39)

13.1 ± 9.7 (1–30)

>0.05

35 (46.7%)

35 (54%)

>0.05

21 (28%)

15(23.4%)

>0.05

17 (22.7%)

24 (37.5)

>0.05

9 (12%)

11 (17.2%)

>0.05

15 (20%)

18 (28.1%)

>0.05

22 (29.3%)

21 (32.8%)

>0.05

11 (14.7%)

10 (15.6%)

>0.05

Please cite this article in press as: Assunta, C., et al., Noise and cardiovascular effects in workers of the sanitary fixtures industry. Int. J. Hyg. Environ. Health (2014), http://dx.doi.org/10.1016/j.ijheh.2014.09.007

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influenzae; viral etiology: rhinovirus, parainfluenza virus), severe head trauma. All workers with these features were excluded from the study, so they were not subject to analysis. - The individuation of cardiovascular risk factors: familiarity with cardiovascular diseases (represents a greater risk for the development of coronary artery disease and for early manifestation of heart disease), regular physical activity, alcohol consumption (subjects who are regular consumers of alcohol, as defined by the National Institute of Research on Food and Nutrition – INRAN2003 [http://www.inran.it/files/download/linee guida/lineeguida 07.pdf], are those who appear to have exceeded the moderate consumption of not more than 2 alcoholic units/day for men and not more than 1 alcoholic unit/day for women, where 1 unit corresponds to about 12 grams of ethanol), smoking habit as defined by New York State BRFSS – Behavioral Risk Factor Surveillance System – 1985–2001 [http://www.health.ny.gov/nysdoh/tobacco/reports/ brfss2001.htm], (a smoker is someone who has smoked at least 100 cigarettes in a lifetime and currently smokes every day or almost every day). The questionnaire items also excluded from the study employees working shifts and/or night work, which may give additional work-related stress and cardiovascular risk factors (Caciari et al., 2013; Violanti et al., 2009). Blood tests and other clinical measures All workers underwent medical examination with body mass index (BMI) evaluation. Blood pressure was measured in the supine position. The workers were asked to fast for 10 h, rest for at least 15 min, and to refrain from smoking for at least 15 min before the medical examination, in order to avoid situations that could cause artificial variations of blood pressure and other parameters. A mercury sphygmomanometer was used to measure blood pressure. In the morning from 8 am to 10 am three measures of blood pressure were taken, avoiding postural variations: the first after 5 min from the supine position, the second one 3 min after the first, and the third measurement 3 min after the second. To evaluate changes in pressure due to postural changes, blood pressure was taken after 1 min, and again after 5 min after assuming an upright position, in accordance with the European Society of Hypertension (ESH) guidelines and the European Society of Cardiology (ESC) guidelines (ESH/ESC guidelines, 2007). Considering the mean of the three measures, the rates of basal hypertensive subjects were calculated according to ESC/ESH 2007 classification, simplifying and defining as hypertensive subjects with a systolic blood pressure (SBP) >140 mm Hg and a diastolic blood pressure (DBP) >90 mmHg. Blood samples were taken using standard techniques such as an ELAN analyzer (Eppendorf Merck), in order to perform the following examinations: blood glucose (SI 3.9–5.5 mmol/L), total cholesterol (SI < 5.2 mmol/L), triglycerides (SI < 1.7 mmol/L), and high density liprotein, HDL, (SI > 1.03 mmol/L). Blood samples were obtained from workers in the sanitary fixtures industry belonging to the spray and glaze preparation departments, in order to evaluate blood lead levels. Blood samples were analyzed with an atomic absorption spectrophotometer (Perkin-Elmer 3110) coupled with a graphite furnace (HGA 600, Perkin-Elmer); lead concentration in blood samples was expressed in micrograms per deciliter. Exposed workers included in the study were compared with control subjects who had not been exposed, by age, body mass index (BMI), length of service, familiarity with cardiovascular diseases, blood glucose, total cholesterol, HDL, triglycerides, smoking habits, and alcohol consumption.

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Eventually, seventy-five exposed employees from sanitary fixtures production were included in the study, together with sixtyfour unexposed office workers. Characteristics of these groups are shown in Table 1. All participants underwent electrocardiogram (ECG) and electrocardiographic abnormalities were classified as follows: disorders of ventricular repolarization, left axis deviation for fascicular disorder, grade I atrioventricular conduction disturbances, right and left intraventricular conduction disturbances, atrial and ventricular arrhythmias (sporadic and multiple), serious disturbances of rhythm (bigeminal rhythm due to ventricular extrasystoles), left or right ventricular effort, II and III level atrioventricular block, coronary insufficiency, and previous myocardial necrosis. Audiometry Workers underwent tonal audiometry from 125 to 8000 Hz after an acoustic rest of at least 16 h in a silent booth. Audiometric curves for workers exposed to noise were classified according to Klockhoff’s classification modified by Merluzzi et al. (1987): Class 0, normal bilateral hearing with thresholds 25 dB, frequency 4000 Hz; Class 2, involvement 3000 Hz; Class 3, involvement 2000 Hz; Class 4, involvement 1000 Hz; Class 5, involvement 500 Hz; Class 6, noise and not noise-induced hearing loss; Class 7, not noise-induced hearing loss. Classes 1–5 are considered noise-induced hearing loss, whereas Class 6 includes other forms of noise-induced hearing loss. In summary, Classes 1–5 are all hearing loss caused by exposure to noise; Class 7 includes hearing loss exclusively determined by different causes to noise (such as otosclerosis, tympanosclerosis, etc.); Class 6 includes hearing loss determined by exposure from both noise and other causes. The frequency of hearing loss in relation to hypertension was evaluated. The distribution of subjects in various classes, as well as the percentage of patients with hypertension, was calculated. Environmental evaluation For phonometric measurements, a Bruel & Kjaerr 2231 phonometer with a Bruel & Kjaerr 4155 condenser microphone connected to the phonometer using a Bruel & Kjaerr AO 0027 connection cable were used. The microphonic capsule was placed in a hat with appropriate support at a distance of 0.1 m from the ear exposed to noise. The equivalent continuous noise level (Leq) was rated as the average intensity of a variable noise integrated over time in different activities and phases of work, which is expressed in dB (A). The level of individual daily exposure (Lep,d) was therefore calculated; the level of daily exposure to noise Lep,d dB (A) is the equivalent noise exposure of a worker for an 8-h shift. The associations between levels of noise, noise-induced hearing loss, blood pressure, and electrocardiographic abnormalities were evaluated. Concerning exposure to lead-based paint, this is a metal which is dense, ductile and malleable whose threshold limit value-time weighted average (TLV-TWA), established by the American Conference of Governmental Industrial Hygiene (ACGIH) is equal to 0.15 mg/m3 . Its evaluation was performed in order to emphasize that the risk was present exclusively in the spray and glaze preparation departments. Therefore, environmental sampling was conducted only in these departments. Samples were analyzed by atomic absorption spectrophotometry (Perkin-Elmer mod. 403) with a detection limit equal to 10 ppb. Environmental sampling for dust present in the workplace was also carried out. According to UNI-EN 481:1994 (Workplace atmospheres. Definitions of granulometric fractions for the measurement of airborne

Please cite this article in press as: Assunta, C., et al., Noise and cardiovascular effects in workers of the sanitary fixtures industry. Int. J. Hyg. Environ. Health (2014), http://dx.doi.org/10.1016/j.ijheh.2014.09.007

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Table 2 Mean values of systolic and diastolic blood pressure among workers exposed compared with workers non-exposed.

Systolic blood pressure (mmHg) min–max Mean ± sd Diastolic blood pressure (mmHg) Mean ± sd min–max

Workers exposed (N. 75)

Workers non-exposed (N. 64)

p-Value

132 ± 12.22

110–185

125.31 ± 12.43

20 ␮m, (TLV-TWA = 10 mg/m3 ), and respirable particles, the fraction of inhaled particles that can penetrate deeply into the lungs, size of

Noise and cardiovascular effects in workers of the sanitary fixtures industry.

The aim of the present study is to evaluate whether workers in the sanitary fixtures industry are a category at risk of developing cardiovascular dise...
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