Rajiv Gandhi University of Health Sciences s69

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA.

PROFORMA FOR REGISTRATION OF

SUBJECTS FOR DISSERTATION

Mr. ASKAR ALI. L

1st YEAR M.Sc NURSING

COMMUNITY HEALTH NURSING

Year 2011-2013

CAUVERI COLLEGE OF NURSING,

TERISIAN COLLEGE CIRCLE,

SIDHARTHANAGAR,

MYSORE.

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore.

PROFORMA SYNOPSIS FOR REGISTERATION OF SUBJECT FOR DISSERTATION

1. NAME OF THE MR. ASKAR ALI. L CANDIDATE AND 1ST YEAR M.SC NURSING ADDRESS CAUVERI COLLEGE OF NURSING,

MYSORE.

2. NAME OF THE CAUVERI COLLEGE OF NURSING, INSTITUTION MYSORE- 570007 3. COURSE OF STUDY AND MASTER OF NURSING- COMMUNITY HEALTH SUBJECT NURSING. 4. DATE OF ADMISSION TO 17-10-2011 COURSE 5. TITLE OF THE TOPIC: TO ASSESS THE EFFECTIVENESS OF 1 STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE OF SEWAGE WORKERS OF MYSORE CITY CORPORATION REGARDING DERMATITIS.

5. STATEMENT OF THE A STUDY TO ASSESS THE EFFECTIVENESS OF 2 PROBLEM STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE OF SEWAGE WORKERS OF MYSORE CITY CORPORATION REGARDING DERMATITIS.

2 6. BRIEF RESUME OF THE INTENDED WORK. 6.1 INTRODUCTION Anybody could say anything they want about me,

and it literally never penetrates my skin. Ron White

An occupational disease is any chronic ailment that occurs as a result of work or occupational activity, Occupational diseases may occur in varying time frames, from the instantaneous development of illness following exposure to toxic chemicals to decades between onset of exposure and the development of disease, as occurs with many occupationally related cancers.

Among the occupational diseases most commonly reported, those relating to repeated trauma, such as carpal tunnel syndrome, tendonitis, and noise induced hearing loss, accounted for more than 60 percent. Carpal tunnel syndrome alone accounted for almost 30,000 cases with days away from work. For those cases of carpal tunnel syndrome with workplace absence, half needed twenty-five or more days away from work. Skin diseases represented about 13 percent (58,000 cases) of work related illnesses. Dermatitis, or inflammation of the skin, resulted in more than 6,500 cases that required time away from work.1

Contact dermatitis, the most common occupational skin disease, is characterized by clearly demarcated areas of rash at sites of exposure. The rash improves on removal of the offending agent. In allergic contact dermatitis, even minute exposures to antigenic substances can lead to a skin rash. Common sensitizing agents include nickel and members of the Rhus genus (e.g., poison ivy, poison oak). Severe skin irritants tend to cause immediate red blisters or burns, whereas weaker irritants produce eczematous skin changes over time. An occupational cause should be suspected when rash occurs in areas that are in contact with oil, grease, or other substances. Direct skin testing (patch or scratch) or radioaller-gosorbent testing may help to identify a specific trigger.2

Dermatitis is an inflammation of the skin, that may start with symptoms of redness, itching, swelling, and a burning or hot sensation. Without treatment, dermatitis can progress

3 to broken or blistering skin, scaling, infection, eczema, or psoriasis. Prognosis can be poor, and many who develop dermatitis can develop long-term skin disease.3

A sanitary worker is a person employed, as by a municipality or private company, to collect and dispose of garbage. These sanitary workers or scavengers are more prone to get a contact dermatitis and other diseases which involves skin and other systems

An estimated 1.2 million scavengers in the country are involved in the sanitation of our surroundings. The working conditions of these sanitary workers have remained virtually unchanged for over a century. Apart from the social atrocities that these workers face, they are exposed to certain health problems by virtue of their occupation. These health hazards include exposure to harmful gases such as methane and hydrogen sulfide, cardiovascular degeneration, musculoskeletal disorders like osteoarthritic changes and intervertebral disc herniation, infections like hepatitis, leptospirosis and helicobacter, skin problems, respiratory system problems and altered pulmonary function parameters. This can be prevented through engineering, medical and legislative measures. While the engineering measures will help in protecting against exposures, the medical measures will help in early detection of the effects of these exposures. This can be partly achieved by developing an effective occupational health service for this group of workers. Also, regular awareness programs should be conducted to impart education regarding safer work procedures and use of personal protective devices.4

A study on Airborne irritant contact dermatitis due to sewage sludge tells that outbreaks of cases of airborne irritant contact dermatitis developed among incinerator workers employed in a sewage treatment facility. Contamination of the workplace and workers' clothing by sludge from the interstices of an incinerator exhaust fan proved to be the cause of the problem. The irritancy of the sludge was determined by tests in rabbits. There was no recurrence of the problem after the institution of hygienic measures designed to control contact with the sludge during subsequent fan maintenance procedures.5

The prevalence of atopic dermatitis was more common among the Chinese (21.6%) and Malays (19.8%) compared with the Indians (16%) and other races (14%)6.

Contact dermatitis is the most frequent type of occupational skin disease. Although prevention of contact dermatitis in the workplace should ideally be accomplished through total elimination of cutaneous exposure to hazardous substances, this is often not feasible. Therefore eight basic elements of a multidimensional approach to prevention have been identified. These elements include recognition of potential cutaneous irritants and allergens, 4 engineering controls or chemical substitution to prevent skin exposure, personal protection with appropriate clothing or barrier creams, personal and environmental hygiene, regulation of potential allergens and irritants within the workplace, educational efforts to promote awareness of potential allergens and irritants, motivational techniques to promote safe work conditions and practices, and pre employment and periodic health screening. A comprehensive prevention program based on this multidimensional approach requires the cooperative efforts of employees, employers, engineers, chemists, industrial hygienists, safety and supervisory personnel, union representatives, governmental agencies, and occupational health practitioners7.

6.2 NEED FOR THE STUDY: India is developing country with a vide opportunity in variety of occupations like agriculture, sericulture, horticulture, tanning industry, textiles etc. Each occupations are associated with different kinds of occupational diseases depending upon the nature of allergens present in the occupation. In India the traditional public health concerns likes communicable diseases, malnutrition, poor environmental sanitation and reproductive health care get emphasis and priorities in the health policy. Recent industrialization and globalizations changing the occupational morbidity drastically, the new pathologies like cancers, stress, AIDS, geriatrics, psychological disorders and heart diseases are on raise. With this new transition pose challenges to health care system with new concepts of environmental legislation, ethical issues, new safety regulations, insurance and high costs of healthcare8. Municipal sewage treatment plant workers are potentially exposed to a multitude of industrial chemicals and pathogenic microorganisms. A questionnaire survey of working habits, lifestyle and symptoms of illness was conducted among 189 municipal sewage treatment plant workers processing between three and ten million gallons of wastewater daily in 16 plants in New York State between March and July of 1984. Water treatment plant workers in the same cities comprised the comparison group. Sewage workers reported a significantly higher frequency of headache, dizziness, sore throat, skin irritation and diarrhea within the month immediately preceding receipt of the questionnaire, after controlling for various possible confounders. Eye and skin irritation were significantly associated with exposure to mutagens. The health significance of these findings and possible sources of error in assessing risk are discussed.9 During the last decade, a growing interest in recycling of domestic waste has emerged, and action plans to increase the recycling of domestic waste have been agreed by many

5 governments. A common feature of these plans is the implementation of new systems and equipment for the collection of domestic waste which has been separated at source. However, only limited information exists on possible occupational health problems related to such new systems. Occupational accidents are very frequent among waste collectors. In 1975, an excess risk for chronic bronchitis was reported for waste collectors in Geneva (Rufèner-Press et al., 1975) and data from the Danish Registry of Occupational Accidents and Diseases also indicate an excess risk for pulmonary problems among waste collectors compared with the total work force. Surprisingly few measurements of potentially hazardous airborne exposures have been performed, and the causality of work-related pulmonary problems among waste collectors is unknown. Recent studies have indicated that implementation of some new waste collection systems may result in an increased risk of occupational health problems. High incidence rates of gastrointestinal problems, irritation of the eye and skin, and perhaps symptoms of organic dust toxic syndrome (influenza-like symptoms, cough, muscle pains, fever, fatigue, headache) have been reported among workers collecting the biodegradable fraction of domestic waste. The few data available on exposure to bio-acrosols and volatile compounds have indicated

that these waste collectors may be simultaneously exposed to multiple agents such as dust containing bacteria, endotoxin, mould spores, glucans, volatile organic compounds, and diesel exhaust. Several studies have reported similar health problems as well as high incidence rates of pulmonary diseases among workers at plants recycling domestic waste. Large scale research activities including surveys and analytical epidemiologic studies are needed to identify the actual causes of these occupational diseases aiming at the prevention of occupational health problems when new waste collection systems are implemented.10

A study was conducted on Work related symptoms among sewage workers shows that Employees at six sewage treatment plants and three drinking water plants were interviewed for the presence of specific medical symptoms. Serum immunoglobulin concentrations, white blood cell counts and fibrinogen degradation product concentrations (FDP) in urine were determined as were the number and species of airborne Gram negative rods in order to characterize exposure to aerosols of sewage water. The highest number of bacteria was found in areas where the sewage water was agitated. A significantly higher proportion of employees at sewage treatment plants reported skin disorders, diarrhoea, and other gastrointestinal symptoms than the control group. No significant differences were found between the groups for white blood cell count or serum immunoglobulin concentrations, except that IgM concentrations were slightly higher in the sewage workers. Some workers had serum

6 transaminase concentrations in excess of normal; some of these returned to normal after the summer holiday. Among non-smokers a higher proportion of sewage treatment workers had increased amounts of FDP in urine. It is conceivable that the symptoms observed were caused by toxins from Gram negative bacteria.11

A Study conducted by Purushottam A. Giri , Abhiram M. Kasbe , Radha Y. Aras on morbidity Profile of Sewage Workers in Mumbai City shows that, Skin morbidities includes itching (57.6%), tineasis (34.6%), followed by rash (25.6%) and dermatitis (19.2%). These finding are comparable to studies by Zuskin E et al had reported dermatitis (22.6 - 26.9%) among sewage workers. A study by the Occupational Health and Safety Centre in Mumbai reported that skin itching in (30%) of the workers. A study on sewage workers by Central Public Health Engineering Research Institute Nagpur revealed that 22.3% of sewage workers suffered from skin rash and dermatitis. Scarlett-Kranz J.M. et al revealed that sewage workers had a higher frequency of skin irritation and dermatitis12.

Hence the contact dermatitis is the most frequent type of occupational skin disease. Although prevention of contact dermatitis in the workplace should ideally be accomplished through total elimination of cutaneous exposure to hazardous substances, this is often not feasible. Therefore eight basic elements of a multidimensional approach to prevention have been identified. These elements include recognition of potential cutaneous irritants and allergens, engineering controls or chemical substitution to prevent skin exposure, personal protection with appropriate clothing or barrier creams, personal and environmental

hygiene, regulation of potential allergens and irritants within the workplace, educational efforts to promote awareness of potential allergens and irritants, motivational techniques to promote safe work conditions and practices, and preemployment and periodic health screening. A comprehensive prevention program based on this multidimensional approach requires the cooperative efforts of employees, employers, engineers, chemists, industrial hygienists, safety and supervisory personnel, union representatives, governmental agencies, and occupational health practitioners.13

6.3 REVIEW OF LITERATURE:

A study reports on the prevalence of respiratory symptoms, skin disorders, status of spirometric lung functions, and amino acid profiles among sewage workers. The data showed that sewage workers had a higher prevalence of respiratory symptoms than manual workers, being significantly greater for chronic cough (p<0.02), chronic phlegm (p<0.03), chronic

7 bronchitis (p<0.02), asthma (p<0.02), dyspneoa (p0.001), and nasal catarrh (p<0.001). Also, a higher prevalence of all acute symptoms of pruritus (p<0.003), tinea (p<0.004), dermatitis (pO.001), and nose irritation (p<0.005) was recorded among sewage workers than in manual workers (non‐sewage workers). Furthermore, all forced spirometric tests in the exposed sewage workers tended to be lower than in manual workers. Finally, the results revealed that the most plasma amino acid concentrations were higher among sewage workers than those among manual workers. All essential amino acids except two (valine and arginine) were significantly higher among the sewage workers than those among the manual workers. The present study suggests that a high prevalence of respiratory symptoms is associated with an exposure to sewage as a working place.14

This survey describes respiratory and mucosal symptoms of garbage-handling and recycling workers in Denmark. The study includes 20 paper-sorting workers, eight compost workers, and 44 garbage-handling workers. As a control group, 119 workers from water purification plants of Copenhagen were chosen; workers in our study had a lower mean age and shorter mean employment time than did members of the control group. There was no significant difference in tobacco consumption between the groups. Garbage-handling workers were exposed to a significantly higher mean concentration (SD) of total dust than were water supply workers-0.74 (0.77) mg/m3 compared with 0.42 (0.25) mg/m3 (p < 0.05). Total count of microorganisms was significantly higher in garbage-handling and composting areas compared with paper-sorting as well as water supply areas 0.46 (0.125) x 10(5), 0.54 (0.77) x 10(5), 4.7 (5.89) x 10(3), and 0.08 (0.04) x 10(3) cfu/m3, respectively (p < 0.05). This difference could not be explained as an effect of differential growth requirements. Significantly higher amounts of gram-negative bacteria were found in composting and garbage-handling plants than in water-supply plants. In garbage-handling plants only, there

were significantly higher amounts of endotoxins than in paper-sorting plants. Significantly higher prevalence of chest tightness (14%), flu-like symptoms (14%), itching eyes (27%), itching nose (14), and sore or itching throat (21%) were found among garbage- handling workers, compared with, respectively, 1, 1, 11 and 0% among water-supply workers. Furthermore, prevalence of nausea and vomiting or diarrhea rose from 2% and 7% among the water-supply workers to 19% and 27% among the garbage workers.15 In a cross-sectional survey health complaints among 418 laborers in 15 Indian tanneries were studied. Low-back pain (61%), asthma (38%), dermatitis (23%), and chronic bronchitis (14%) were the most frequently reported complaints in the 12 months prior to the 8 survey. In general, beamhouse workers reported the highest prevalence but only chronic low- back pain was significantly elevated compared with workers in the finishing departments. When using individual exposure estimates, clear associations were presented among manual lifting over 20 kg and low-back pain (OR = 3.5) and skin exposure and dermatitis (OR = 2.6). Frequent lifting of loads was also associated with self-reported asthma. About 44% of the laborers reported at least one period of sickness absence, and 17% were involved in a serious occupational accident that required a visit to the local physician. Logistic regression analysis showed that sickness absence occurred more often in small tanneries (OR = 2.7) and also was significantly associated with low-back pain (OR = 3.3) and occupational accidents (OR = 2.2). This epidemiologic survey on health complaints in tannery workers is among the few in occupational populations in low-income countries. For many reasons these populations are easily overlooked. The results of this descriptive study indicate that there is a clear need for epidemiologic surveys in these countries to obtain information on working conditions and associated health problems.16

A study carried out in Vietnam Skin disease among farmers using wastewater in rice cultivation shows out of the 1103 individuals aged ≥15 years, 381 reported a skin problem at baseline or at any of the monthly visits, primarily dermatitis (eczema) and superficial fungal infections. Among the 874 subjects who were free from skin disease at baseline and who could be followed up ≥11 months, 183 developed a new skin disease (cumulative incidence 21%). Exposure to wastewater was a major risk factor for skin disease with a relative risk (RR) of 1.89 [95% confidence interval (CI) 1.39–2.57] in multivariable analysis. Other risk factors for skin disease were involvement in agriculture in general (RR = 2.59, 95% CI 1.11– 6.02), flower cultivation (RR = 1.36, 95% CI 1.01–1.83), vegetable farming (RR = 1.47, 95% CI 1.04–2.08), and a history of eczema (RR = 1.47, 95% CI 1.05–2.05). The study concludes that Exposure to wastewater is a major risk factor for skin disease. In future studies, an attempt should be made to link specific chemical or biological agents in the wastewater to specific skin diseases17.

A study conducted in Toronto on Health Status of a Group of Sewage Treatment Workers reveals that 50 randomly selected workers in a sewage treatment plant using a heat treatment method for processing sewage sludge in Toronto, Canada were assessed. This investigation revealed that many workers reported “influenza-like” symptoms, cough, sputum production, wheezing, sore throat and skin complaints. The workers tended to have somewhat reduced lung function. Workers in the area of the plant where boiled sewage sludge was dried frequently reported an intermittent, acute illness characterized by cough,

9 fever and sore throat. Workers in the area of the plant where the dried sludge was incinerated tended to have reduced lung function. The basis for the possible health effects demonstrated has not been established, and further investigation is suggested. The mean level of

polychlorinated biphenyls (PCBs) detected in the workers' serum was 6±5 ppb. The PCB

levels could not be related to symptoms or clinical findings in the workers studied18.

The aim of this study was to investigate some of the health problems among cement workers in the United Arab Emirates (UAE). A cross-sectional sample of 304 work ers was selected randomly from four cement factories in four Emirates. Most of the workers (88%) were from India, married (84%) and had received primary education or above (93%). Smoking was prevalent among 27% of the workers and about 24% consumed alcoholic beverages. Personal hygiene was found to be satisfactory among the workers. The main health symptoms reported by the cement workers were chronic cough, chronic bronchitis, burning, itching and runny eyes, headache and fatigue. Chronic bronchitis (p<0.007), burn ing, itching and runny eyes (p<0.002) and fatigue (p<0.004) were significantly increased with age of workers. Smoking was significantly associated with chronic cough (p<0.03) and chronic bronchitis (p<0.01). However, the chance of smokers getting respiratory health problems was two to five times greater compared with non-smokers. Future studies on the health of workers in UAE should include more investigations using specialised equipment to detect and diagnose health problems19.

Employees at 6 sewage treatment plants and three drinking water plants were interviewed for the presence of specific medical symptoms. Serum immunoglobulin concentrations, white blood cell counts and fibrinogen degradation product concentrations (FDP) in urine were determined as were the number and species of airborne Gram negative rods in order to characterise exposure to aerosols of sewage water. The highest number of bacteria was found in areas where the sewage water was agitated. A significantly higher proportion of employees at sewage treatment plants reported skin disorders, diarrhoea, and other gastrointestinal symptoms than the control group. No significant differences were found between the groups for white blood cell count or serum immunoglobulin concentrations, except that IgM concentrations were slightly higher in the sewage workers. Some workers had serum transaminase concentrations in excess of normal; some of these returned to normal after the summer holiday. Among non-smokers a higher

10 proportion of sewage treatment workers had increased amounts of FDP in urine. It is conceivable that the symptoms observed were caused by toxins from Gram negative bacteria20.

In a cross sectional study, work related health complaints and diseases of 58 compost workers and 53 biowaste collectors were investigated and compared with 40 control subjects. Levels of specific IgG antibodies to moulds and bacteria were measured as immunological markers of exposure to bioaerosols. Compost workers had significantly more symptoms and diseases of the airways (p=0.003) and the skin (p=0.02) than the control subjects. Health complaints of biowaste collectors did not differ significantly from those of the control group. Subjects with atopic diseases were underrepresented in the compost workers (p=0.003). Significantly increased antibody concentrations against fungi and actinomycetes were measured in workers at composting plants. The concentrations in biowaste collectors did not differ significantly from those in the control subjects. A significant association between the diseases and increased antibody concentrations were found in the compost workers21.

6.4 STATEMENT OF THE PROBLEM

“A Study To Assess The Effectiveness Of Structured Teaching Programme On Knowledge Of Sewage Workers Of Mysore City Corporation Regarding Dermatitis.”

6.5 OBJECTIVES OF THE STUDY:

1. To assess the pre-test knowledge of sewage workers of Mysore city corporation regarding dermatitis.

2. To administer the Structured Teaching Program on Dermatitis to the sewage workers of Mysore city corporation

3. To assess the post test knowledge of sewage workers of Mysore city corporation regarding dermatitis

4. To find out the effectiveness of STP.

5. To find out the association between the knowledge of sewage workers regarding dermatitis with their selected demographic variables.

6.6 HYPOTHESIS OF THE STUDY: 11 H1: The mean post test score will be higher than the mean pre test score of knowledge of sewage workers regarding dermatitis.

H2: There will be a significant association between pre test score and selected demographic variables. 6.7 OPERATIONAL DEFINITIONS:

a) Assess : It is the organised and continuous process of collecting data. b) Structured teaching program: It refers to teaching program for the sewage workers of Mysore City Corporation regarding Dermatitis. c) Effectiveness: It refers to the extent to which the Structured teaching program has achieved the desired effect in terms of improve in knowledge of workers. d) Knowledge: It refers to the right response given by the sewage workers of Mysore City Corporation regarding Dermatitis. e) Workers: The employee of the Mysore City Corporation who handles waste, treats sewage, handle garbage, handles waste water. f) Dermatitis: dermatitis is inflammation of the skin characterised by rashes which may be itchy, red, and may or may not have distinct margins.

6.8 DELIMITATION: 1. The study is delimited to the sewage workers of Mysore City Corporation.

2. The study should complete within 6 weeks.

6.9 PILOT STUDY:

The pilot study will be conducted with 10 samples. The purpose to conduct pilot study is to findout feasibility for conducting the study and design and plan of statistical analysis.

7. MATERIALS AND METHODS: 7.1 SOURCES OF DATA: The data will be collected from the sewage workers of Mysore City Corporation, Mysore.

7.2 REASEARCH APPROACH: The research approach adopted in this study was an Evaluative Research Approach, as the study aims to evaluate the effectiveness of STP on the knowledge of sewage workers of Mysore City Corporation regarding dermatitis. 12 7.3 RESEARCH DESIGN: The research design adopted for the study is one group pre test post test design.

Quasi Experimental 02 group (60 samples) 01 X

01 – Pre test knowledge of the workers

X - Intervention through Structured teaching Program

02- Post test knowledge of the workers

7.4 METHOD OF DATA COLLECTION:

LEVEL 1: Prior to the data collection permission will be obtained from the concerned authority of the Mysore city corporation for conducting the study. Subject will be selected according to the selection criteria of the study. Consent of the workers will be obtained.

LEVEL 2: Structured teaching Program on Dermatitis to the sewage workers of the Mysore city corporation will be performed

7.5 SAMPLING CRITERIA:

INCLUSIVE CRITERIA: a) Workers who handles waste, treats sewage, handle garbage, handles waste water in Mysore City Corporation. b) Workers who are willing to participate in the study. c) Workers who are available at the time of study. d) Workers who are able to speak and understand Kannada and English.

13 EXCLUSIVE CRITERIA:

a) Workers who are not exposed to sewage sludge and waste water

b) Workers who are not willing to participate in the study.

7.5(1) SETTING OF THE STUDY: The study will be conducted in Mysore city Corporation, Mysore.

7.5(2) POPULATION:

The population for the study was Sewage workers of Mysore City Corporation.

7.5 (3) SAMPLE SIZE:

Samples consist of 60 sewage workers of Mysore City Corporation who fulfil the inclusion criteria.

7.5 (4) SAMPLING TECHNIQE:

Using simple random sampling technique the samples will be selected and the sample size will be 60 workers.

7.5 (5) SETTINGS

The setting selected for the study is Mysore City Corporation.

7.6 VARIABLES:

 Independent variables: Structured teaching program  Dependent variables: Knowledge of Sewage workers regarding Dermatitis.

7.7 DATA ANALYSIS METHOD:

The data collected will be analysed using descriptive and inferential statistics. Descriptive statistics:

Demographic variable, effectiveness will be analysed using frequency percentage mean and standard deviation.

Inferential statistics: 14 Pre test and post test differences will be analysed by paired t- test, association between pre test and scores and demographic variables will be analysed using chi-square test.

7.8 PROJECTED OUTCOME:

1. After the study the researcher will know the level of knowledge of sewage workers regarding meaning. Definition, causes, signs and symptoms, prevention of dermatitis.

2. The knowledge of the workers will be improved.

7.9 ETHICAL OUTCOMES:

1. DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTIONS TO THE PATIENTS OR OTHER HUMAN BEINGS OR ANIMALS?

Yes, questionnaire will be used to assess knowledge and observation checklist for practice of workers.

2. HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION?

Yes. Ethical clearance is obtained from concerned authorities.

15 8. LIST OF REFERENCE: [VANCOUVER STYLE FOLLOWED]:

1. E notes, Worker Chartbook, occupational diseases,National Institute for Occupational Safety and Health (2000). [full text]. Available from: URL:http://www.enotes.com/occupational-disease-reference/occupational-disease 2. PEATE W.F. American family physician. [Online]. 2002 Sep [cited 2012 may 20]; Available from: URL: http://www.aafp.org/afp/2002/0915/p1025.html 3. SHAPP, Occupational skin disorders. [full text]. 1998 june [2012 may 22]; 48(1):287-306. Available from: URL: http://www.lni.wa.gov/Safety/Research/Dermatitis/files/osd98.pdf 4. Tiwari R. Rajnarayan. Occupational health hazards in sewage and sanitary workers. [abstract] 2008 April [cited 2012 may 24]; 64(3);112-15. Available from: URL:http://www.ijoem.com/article.asp?issn=0019- 5. Journal of Occupational Medicine. Journal of Occupational Medicine. : Official Publication of the Industrial Medical Association. Airborne irritant contact dermatitis due to sewage sludge [online]. 1981 [cited 2012 May 21];23(11):771-4. Available from: http://ukpmc.ac.uk/abstract/MED/6459432/reload=0;jsessionid=PyPcFUrYt4lu9yUhOru0.16

6. Tay YK, Kong KH, Khoo L, Goh CL, Giam YC. The prevalence and descriptive epidemiology of atopic dermatitis in Singapore school children [full text]. Jan 2002 [cited 2012 May];146(1):101-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11841373

7. Prevention of occupational contactdermatitis. Journal of the American Academy of Dermatology [full text]. October 1990 [cited 2012 May 23];23(4).742–48. Available from: http://www.sciencedirect.com/science/article/pii/019096229070284O 8. Agnihotram V. Ramanakumar. An occupational health research in India. Indian journal of occupational and environmental medicine [full text]. 2005 oct [cited 2012 may];9(1).10-14. Available from: http://ijoem.com/article.asp?issn=0019- 5278;year=2005;volume=9;issue=1;spage=10;epage=14;aulast=Agnihotram 9. Scarlett. M Janet. Health Among Municipal Sewage and Water Treatment Workers. Toxicology and industrial health [abstract]. July 1987 [cited 2012 may]; 3(3). 311- 19. Available from: http://tih.sagepub.com/content/3/3/311.abstract

16 10. Science of The Total Environment. Review of occupational health problems and their possible causes [online]. Aug 1995 [cited 2012 May]; 170(2).1-19. Available from: http://www.sciencedirect.com/science/article/pii/0048969795045245 11. M Lundholm, R Rylander. Occupational and environmental medicine. Work related symptoms among sewage workers [abstract]. Jul1983 [cited 2012 may]; 40(2).325- 29. Available from: http://oem.bmj.com/content/40/3/325.abstract 12. Purushottam A. Giri, Abhiram M. Kasbe, Radha Y. Aras. A Study on Morbidity Profile of Sewage Workers in Mumbai City. International Journal of Collaborative Research on Internal Medicine & Public Health [abstract]. May 2010 [cited 2012 May]; 10(2).450-63. Available from: http://www.iomcworld.com/ijcrimph/ijcrimph-v02-n12-04- f.htm 13. Toby Mathias C.G, Cincinnati. Prevention of occupational contact dermatitis. Journal of the American Academy of Dermatology [ abstract ]. Oct 1990 [cited 2012 May]; 23(4).742-48. Available from: http://www.sciencedirect.com/science/article/pii/019096229070284O 14. Bener. A et al. Respiratory symptoms and skin disorders in sewage workers. Journal of Environmental Science and Health [abstract]. Oct 1998 [cited 2012 May]; 33(8). 1657-74. Available from: http://www.tandfonline.com/doi/abs/10.1080/15298668891379873 15. Sigsgaard T, Malmros P, Nersting L and Petersen C. Respiratory disorders and atopy in Danish refuse workers [abstract]. Jun 1994 [cited 2012 May 20];149(6). 1407- 12. Available from: http://ajrccm.atsjournals.org/content/149/6/1407.short

16. Ory F. G, Rahman F. U, Katagade V, Shukla A & Burdorf A. Respiratory Disorders, Skin Complaints, and Low-Back Trouble Among Tannery Workers in Kanpur [Online]. Jun 1997 [cited 2012 may];58(10).740-46. Available from: http://www.tandfonline.com/doi/abs/10.1080/15428119791012397 17. Trang Do Thuy et al. Skin disease among farmers using wastewater in rice cultivation. Tropical Medicine & International Health [Abstract]. Dec 2007 [cited 2012 May];12(2).51-58. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1365- 3156.2007.01941.x/full 18. NETHERCOTT JAMES R. & LINN HOLNESS D. Health Status of a Group of Sewage Treatment Workers in Toronto. American Industrial Hygiene Association Journal [abstract]. Jun 1988 [cited May 2012];49(7).346-50 Available from: http://www.tandfonline.com/doi/abs/10.1080/15298668891379873

17 19. Ahmed N. M. , Abdulrahman O. Roushdy Musaiger B. Abdelmoneim. Perspectives in public health Health status of cement workers. [Abstract ]. Jan 2001 [cited may 2012];132(3):25-29. Available from: http://rsh.sagepub.com/content/115/6/378.short 20. Lundholm M, Rylander R. Work related symptoms among sewage workers. Occupational and environmental medicine [Abstract ]. Jan 1983 [Cited may 2012];40(3):325- 29. Available from: http://oem.bmj.com/content/40/3/325.abstract 21. Bünger a Jürgen et al. Health complaints and immunological markers of exposure to bioaerosols among biowaste collectors and compost workers. Occupational and environmental medicine [Abstract ]. Feb 2000 [Cited May 2012];57(7):458-64. Available from: http://oem.bmj.com/content/57/7/458.abstract

9. SIGNATURE OF THE CANDIDATE

10. REMARKS OF THE GUIDE

NAME AND DESIGNATION 11. OF THE GUIDE (IN BLOCK LETTERS)

11.1. GUIDE

18 11.2. SIGNATURE

11.3. CO-GUIDE (IF ANY)

11.4. SIGNATURE

11.5. HEAD OF THE DEPARTMENT

11.6. SIGNATURE

12. REMARKS OF THE CHAIRMAN AND PRINCIPAL

12.1. SIGNATURE