Summary of main advantages and disadvantages of different MRI techniques in evaluating patients with NAFLD.
\r\n\tAnimal food additives are products used in animal nutrition for purposes of improving the quality of feed or to improve the animal’s performance and health. Other additives can be used to enhance digestibility or even flavour of feed materials. In addition, feed additives are known which improve the quality of compound feed production; consequently e.g. they improve the quality of the granulated mixed diet.
\r\n\r\n\tGenerally feed additives could be divided into five groups:
\r\n\t1.Technological additives which influence the technological aspects of the diet to improve its handling or hygiene characteristics.
\r\n\t2. Sensory additives which improve the palatability of a diet by stimulating appetite, usually through the effect these products have on the flavour or colour.
\r\n\t3. Nutritional additives, such additives are specific nutrient(s) required by the animal for optimal production.
\r\n\t4.Zootechnical additives which improve the nutrient status of the animal, not by providing specific nutrients, but by enabling more efficient use of the nutrients present in the diet, in other words, it increases the efficiency of production.
\r\n\t5. In poultry nutrition: Coccidiostats and Histomonostats which widely used to control intestinal health of poultry through direct effects on the parasitic organism concerned.
\r\n\tThe aim of the book is to present the impact of the most important feed additives on the animal production, to demonstrate their mode of action, to show their effect on intermediate metabolism and heath status of livestock and to suggest how to use the different feed additives in animal nutrition to produce high quality and safety animal origin foodstuffs for human consumer.
",isbn:"978-1-83969-404-2",printIsbn:"978-1-83969-403-5",pdfIsbn:"978-1-83969-405-9",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,hash:"8ffe43a82ac48b309abc3632bbf3efd0",bookSignature:"Prof. László Babinszky",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/10496.jpg",keywords:"Technological Feed Additives, Feed Industry, Quality of Compound Feed, Non-Antibiotic Growth Promoter, Product Quality, Additive Enzymes, Digestibility of Nutrients, NSP Enzymes, Farm Animals, Livestock, Immunity, Microbiome",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"November 24th 2020",dateEndSecondStepPublish:"December 22nd 2020",dateEndThirdStepPublish:"February 20th 2021",dateEndFourthStepPublish:"May 11th 2021",dateEndFifthStepPublish:"July 10th 2021",remainingDaysToSecondStep:"2 months",secondStepPassed:!0,currentStepOfPublishingProcess:4,editedByType:null,kuFlag:!1,biosketch:"Professor Emeritus from the University of Debrecen, Hungary who authored 297 publications (papers, book chapters) and edited 3 books. Member of various committees and chairman of the World Conference of Innovative Animal Nutrition and Feeding (WIANF).",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"53998",title:"Prof.",name:"László",middleName:null,surname:"Babinszky",slug:"laszlo-babinszky",fullName:"László Babinszky",profilePictureURL:"https://mts.intechopen.com/storage/users/53998/images/system/53998.jpg",biography:"László Babinszky is Professor Emeritus of animal nutrition at the University of Debrecen, Hungary. From 1984 to 1985 he worked at the Agricultural University in Wageningen and in the Institute for Livestock Feeding and Nutrition in Lelystad (the Netherlands). He also worked at the Agricultural University of Vienna in the Institute for Animal Breeding and Nutrition (Austria) and in the Oscar Kellner Research Institute in Rostock (Germany). From 1988 to 1992, he worked in the Department of Animal Nutrition (Agricultural University in Wageningen). In 1992 he obtained a PhD degree in animal nutrition from the University of Wageningen.He has authored 297 publications (papers, book chapters). He edited 3 books and 14 international conference proceedings. His total number of citation is 407. \r\nHe is member of various committees e.g.: American Society of Animal Science (ASAS, USA); the editorial board of the Acta Agriculturae Scandinavica, Section A- Animal Science (Norway); KRMIVA, Journal of Animal Nutrition (Croatia), Austin Food Sciences (NJ, USA), E-Cronicon Nutrition (UK), SciTz Nutrition and Food Science (DE, USA), Journal of Medical Chemistry and Toxicology (NJ, USA), Current Research in Food Technology and Nutritional Sciences (USA). 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It is defined by lipid droplet accumulation within hepatocytes in the absence of substantial alcohol intake. NAFLD comprises a disease spectrum ranging from simple steatosis to nonalcoholic steatohepatitis (NASH), which may progress into liver fibrosis and even end-stage cirrhosis [1]. NAFLD is becoming a major concern with the increasing incidence of obesity in Europe. Available data suggest that the global prevalence of NAFLD is estimated at 24%, being the leading cause of CLD in the USA and Europe [2].
The differentiation of simple steatosis from NASH has a great clinical importance. Additionally to liver steatosis, NASH presents inflammation and hepatocellular injury [3]. The differentiation between both entities is routinely made by histopathological analysis after liver biopsy. However, it is an invasive method, with inherent risks that include sampling error and serious complications [4].
Currently, there is an urgent need for a noninvasive method to accurately assess liver fibrosis and liver steatosis. Ultrasonography (US)-based and computer tomography (CT)-based modalities can demonstrate the morphologic alterations of cirrhosis, but they are limited in evaluating patients with earlier stages of liver disease [5].
Advancements in magnetic resonance imaging (MRI), with its unique and intrinsic imaging features, have provided the opportunity to revolutionize how we image and evaluate patients with diffuse liver diseases. In addition, with the development of new antifibrotic therapeutic agents, MRI-based techniques may play a central role in monitoring treatment response and in the clinical management of patients with NAFLD [6, 7].
The recent technical developments in MRI hardware and software, including the use of three Tesla MR devices in daily routine work, have significantly improved the temporal and spatial resolutions, especially in the case of contrast-enhanced T1-weighted 3D sequences. The use of various liver-specific hepatobiliary contrast agents enables not only morphological characterization but also a functional assessment of all liver lesions and also characterization of diffuse parenchymal changes [8].
Currently, liver biopsy is the reference standard for the diagnosis and staging of liver fibrosis [4]. However, this procedure has several major limitations, including its invasive nature, risk for potential complications, poor patient acceptance, interobserver variability, and possible sampling errors [4, 9].
Liver biopsy captures only a tiny fraction of the liver (roughly 1/50.000), leading to sampling errors [10]. In an attempt to reduce sampling variability, it is recommended that liver biopsy specimens be at least 2.0 cm long and contain at least 11 portal triads. Biopsy specimens that do not meet these criteria are associated with a high risk of under staging (false negative) [11].
In contrast to fibrosis in chronic viral hepatitis, fibrosis in alcoholic hepatitis and in the adult form of NAFLD begins adjacent to the central veins. The fibrosis is laid down in a perisinusoidal manner, and the scar tissue surrounds individual hepatocytes. As the disease advances, perisinusoidal fibrosis accumulates adjacent to portal tracts, and the fibrotic tissue eventually coalesces into fibrous bridges connecting portal triads and central veins, ultimately culminating in cirrhosis [3]. As cirrhosis develops, the characteristic histologic features of fatty liver disease may be lost. The perisinusoidal may no longer be apparent, and other features (e.g., inflammatory cells, ballooned hepatocytes, and steatosis) may subside. Thus, cirrhosis due to fatty liver disease may be indistinguishable from cirrhosis due to viral hepatitis or other causes [12].
The search for the best diagnostic technique in terms of noninvasiveness and accuracy is still a major concern in recent research activity. In the recent literature, the role of several imaging diagnosis tools and specific contrast agents is reported in the evaluation of diffuse liver diseases such as steatosis, fibrosis, and cirrhosis.
The differentiation of prognostically relatively benign simple steatosis from potentially progressive NASH is a crucial issue [13, 14]. Moreover, NAFLD is a reversible condition, especially during the early onset of the disease; therefore diagnosing and correct staging of patients with NAFLD are essential in order to prevent the development of an irreversible advanced liver disease.
Routine biochemical laboratory tests and conventional imaging, including US, CT, and non-specific gadolinium-enhanced MRI, cannot distinguish between these entities with sufficient confidence [15, 16]. Therefore, the differentiation between both entities is routinely made by histopathological analysis after liver biopsy. Liver biopsy is still considered the reference standard for the diagnosis of NASH [4]. There are several histological scoring systems to grade NASH, and the most commonly used is the so-called NAFLD activity score (NAS) [17]. The steatosis activity and fibrosis score (SAF) are a newly developed system for categorizing liver histology in NAFLD patients [18]. The lack of reliable, noninvasive methods for the diagnosis of disease severity and prediction of prognosis is one of the major drawbacks in the clinical management of patients with NAFLD [19].
Magnetic resonance elastography (MRE) assesses viscoelastic properties of soft tissues [20], offering a direct insight into the liver parenchymal stiffness. First step in the MRE technique is generating mechanical waves in the liver tissue. Then gradient-echo sequences are used to image wave motion, while a specialized software utilizing inversion algorithms transforms the images obtained into elastograms, revealing the tissues’ stiffness quantitative map, expressed in kilopascals [21].
Studies comparing healthy volunteers and patients with CLD established that the shear viscoelastic parameters of the liver increased according to the stage of liver fibrosis, and a statistically significant difference between the patients with Metavir scores F0–F1 fibrosis versus F2–F3, F2–F3 versus F4, and F0–F1 versus F4 was found [20, 22]. MRE also proved to be superior to biochemical testing using the aspartate aminotransferase-to-platelet ratio index [22]. Most importantly the authors could clearly separate the intermediate fibrosis stages, using MRE elasticity measurements.
Chen et al. [23] demonstrated that MRE-based assessments of liver stiffness in patients with NAFLD may have a high diagnostic accuracy (AUC 0.93) for discriminating NASH from simple steatosis, with a cutoff value of 2.74 kPa reaching 94% sensitivity and 73% specificity. However, a more recent study suggested that the performance of MRE for diagnosis of NASH versus simple steatosis was rather modest and did not provide a high level of accuracy. Using 2D-MRE (60 Hz), 3D-MRE (60 Hz), and 3D-MRE (40 Hz), the AUROC for diagnosing definite NASH was 0.754, 0.757, and 0.736, respectively [24].
In a prospective study, Cui et al. [25] proved that the diagnostic accuracy of 2D-MRE for the noninvasive evaluation of advanced fibrosis in patients with biopsy-proven NAFLD was significantly higher than five clinical prediction rules, widely validated for the assessment of fibrosis in patients with NAFLD, such as the NAFLD fibrosis score, the BARD score, the AST-to-ALT ratio, FIB-4, and AST-to-platelet ratio index. Using the cutoff value for 2D-MRE of 3.64 kPa, the AUROC of 2D-MRE for predicting advanced fibrosis was 0.957. This proved to be significantly higher than FIB-4 score with AUROC of 0.861, the best-of-all analyzed clinical prediction rules. Therefore, 2D-MRE is a promising noninvasive imaging-based biomarker for the diagnosis of advanced fibrosis in NAFLD patients used additionally to clinical prediction rules, especially when the latter have indeterminate values.
The cutoff values proposed by Loomba et al. [26] for the prediction of each fibrosis stage using 2D-SWE in patients with NAFLD were 3.02 kPa for early fibrosis, 3.58 kPa for significant fibrosis, 3.64 kPa for advanced fibrosis, and 4.67 kPa for the prediction of cirrhosis, with areas under the ROC curve of 0.838, 0.856, 0.924, and 0.894, respectively. The most promising results were obtained for discriminating advanced fibrosis (F3–F4) from fibrosis stages 0–2 with a sensitivity of 0.86 (95% confidence interval [CI]: 0.65–0.97) and a specificity of 0.91 (95% CI, 0.83–0.96).
Kim et al. showed, however, that the best cutoff for detecting advanced fibrosis value was 4.15 kPa (AUROC = 0.954, sensitivity = 85%, specificity = 92%). The performance of this technique for discriminating between other fibrosis stages was also satisfactory [27].
Nevertheless, this ability to stage pre-cirrhotic disease could make MRE very useful for the assessment of therapeutic success and disease progression [28].
More advanced versions of the imaging modality such as 3D-MRE allow the evaluation of a larger volume of liver parenchyma than 2D-MRE, being significantly more accurate for diagnosis of advanced fibrosis in NAFLD patients [24].
As it is not affected by the absence of an ultrasound window, MRE is more precise than ultrasonographic elastographic techniques. In patients with obesity to morbid obesity, MRE proved to have a better success rate than vibrant-controlled transient elastography (95.8 versus 81.3%) and a higher interobserver agreement than liver biopsy (intraclass correlation coefficient, 0.95 versus 0.89) [29].
Acute inflammation, passive liver congestion caused by cardiac insufficiency, or obstructive cholestasis leads to a false increase of liver stiffness values [30]. Moreover, on a gradient-echo MRE sequence, certain conditions such as iron overload states may lead to a lower MRI signal intensity, which does not allow shear wave recognition. This leads to a decrease in MRE diagnostic accuracy. Thus, using spin-echo or echo-planar sequences with lower T2* effect susceptibility can alleviate this problem [30].
The technique has the advantage of not being influenced by the patient’s weight or the presence of ascites. MRE remains expensive and not widely accessible in the everyday imaging routine of patients with NAFLD.
MR spectroscopy (MRS) enables the noninvasive measurement of concentrations of different chemical components within tissues, which are displayed as a 1D spectrum with peaks consistent with the various chemicals detected. The major problem in obtaining MRS signals from abdominal organs is sensitivity to physiologic movement during the scan time usually exceeding several minutes [31]. Usually, the measurement is performed by manually placing a single voxel into the liver parenchyma far from the liver capsule, in an area free of large vessels or bile ducts [32].
While proton MRS is a very useful technique for the quantification of hepatic fat, its use for the estimation of hepatic fibrosis appears to be limited [33, 34].
According to Abrigo et al. [34], phosphorus-MRS (31P-MRS) shows distinct biochemical changes in different NAFLD states and has fair diagnostic accuracy for NASH. However, this technique requires considerable operator skills (sequence programming, shimming, analysis of spectra) and access to special equipment (scanner, 31P coil) [28].
31P-MRS permits in vivo evaluation of energy metabolism and intracellular compartment division through different signals and provides metabolic information, which is useful when assessing fibrogenesis [28]. A significant correlation between phosphodiester concentration and the stage of fibrosis and a correlation between “anabolic charge” (phosphomonoester/[phosphomonoester + phosphodiester]) and the stage of fibrosis were found in a study comparing a group of patients with steatosis and no to moderate inflammation to a group of patients with severe fibrosis or cirrhosis [35].
Hydrogen 1 MRS (1H-MRS) has proven its efficiency in quantifying liver steatosis, by measuring lipid peaks, identified in the liver at 0.9, 1.3, 2.0, 2.2, and 5.3 parts per million. The dominant lipid peaks are caused by the resonance of methyl (-CH3) protons and methylene (-CH2) in the triglyceride molecule [36].
The absolute fat concentration can be therefore calculated using the following formula:
As the steatosis grade increases, the size of the lipid peaks relative to the water peak increases as well [36].
The advantages of 1H-MRS are the very high sensitivity, a good correlation with histological analysis, and the method’s independency of confounders such as fibrosis and iron or glycogen depositions. On the other side, MRS has currently a limited clinical availability, and it is prone to sampling error, when a single-voxel liver spectroscopy is performed [36].
Furthermore, authors assessed the diagnostic accuracy of a novel magnetic resonance protocol for liver tissue characterization, using T1 mapping, 1H spectroscopy, and T2* mapping, which quantified liver fibrosis, steatosis, and hemosiderosis, respectively [37]. According to their results, the novel scanning method provides high diagnostic accuracy for the assessment of all three histology variables.
In a recent study, Idilman et al. [38] analyzed the efficiency of MRI-proton density fat fraction (MRI-PDFF) and MRS-determined liver fat content in patients with NAFLD in comparison with liver biopsy-determined steatosis.
No superiority between the two imaging methods was observed. This study emphasized that the estimation of fat liver content using both MR imaging techniques was more accurate in the absence of liver fibrosis. MRS showed promising results for discriminating moderate/severe steatosis from none/mild steatosis with an AUROC of 0.857. A cutoff value of 9% provided a sensitivity of 92%, negative predictive value of 83.3%, specificity of 71%, and positive predictive value of 84.6%.
The accurate assessment of liver fat content in patients with NAFLD is essential in identifying those who are at greater risk of progressing into advanced fibrosis stages, being also of great value in evaluating the response to therapy. Liver steatosis also influences the successful rate of liver transplantation (LT); one of the necessary requirements in many centers is that the living donor liver must not exceed 5% steatosis, as greater values are associated with increased recipient liver dysfunction [38].
MRS proves to be a highly accurate noninvasive technique, which allows us to distinguish between individuals with simple steatosis and steatohepatitis who may benefit from early intervention and more aggressive therapy.
Diffusion-weighted imaging (DWI) is a noninvasive method that allows measurement of the microscopic motion of water in tissue and generates representative apparent diffusion coefficient (ADC) values. DWI uses very fast scans with an additional series of (diffusion) gradients rapidly turned on and off [28].
Within tissues with highly cellular component and therefore a narrowed extracellular space, the water molecule motion is impeded leading to restricted water diffusion in such tissues. In contrast, fluid-rich or necrotic structures are associated with a greater freedom of motion of water molecules, and the water diffusion in such tissues is considered to be “free.” Therefore, on DWI sequences, the signal intensity reflects the tissue diffusion characteristics, which is influenced by cellularity and the integrity of cell membranes [39].
In a prospective study, Guiu et al. [40] demonstrated that both pure molecular diffusion and perfusion-related diffusion were significantly lower in the steatotic liver than in the normal liver. On a group of 89 NAFLD patients who underwent liver biopsy, Murphy et al. [41] also found a good correlation between histologic features of NAFLD liver and DWI-derived quantitative measures. Molecular diffusivity was significantly decreased with steatosis, while perfusion fraction decreased with fibrosis degree. Same associations were found between pediatric NAFLD histologic features and DWI parameters, with a high interobserver reproducibility [42]. As far as the apparent diffusion coefficient is concerned, studies show inconsistent results. One study in adults with NAFLD found that ADC decreased with steatosis, while others found no significant relationship [40, 41].
Several studies have evaluated the use of DWI and ADC values for the diagnosis of hepatic fibrosis or cirrhosis in patients with diffuse hepatopathies. The complex assembly of collagen fibers, glycosaminoglycan, and proteoglycans that constitutes liver fibrosis may restrict the molecular diffusion measured by DWI [43].
DWI has been successfully applied to differentiate cirrhotic from healthy tissue. Girometti et al. reported a positive predictive value of 100%, a negative predictive value of 99.9%, and an overall accuracy of 96.4% in cirrhotic patients compared to healthy controls [44].
A recent meta-analysis suggests that DWI parameters can reliably stage hepatic fibrosis, having a good diagnostic accuracy with areas under the SROC curve between 80 and 90%. A high b value for liver fibrosis imaging (between 800 and 1000 s/mm2) could significantly increase the diagnostic accuracy of diffusion imaging in differentiating between significant and severe fibroses (>F2). For diagnosing liver cirrhosis (F4), the use of 3T MRI equipment has also proved to optimize the DWI diagnostic accuracy, compared to 2T MRI [45].
Lewin et al. found a significant relationship between the ADC values and necroinflammatory scores and suspected an influence of steatosis on apparent diffusion coefficient values [46]. In addition, the ADC of fibrotic livers was decreased as the fibrosis scores increased in some studies [46], but not in others [43].
However, differences in MR equipment and sequence parameters make it difficult to compare studies. Clearly, more research is needed to create a standard setup for DWI sequence acquisition to make studies comparable and to determine whether or not DWI can be a useful tool for the diagnosis and staging of diffuse liver diseases.
Furthermore, DWI imaging is susceptible to artifacts (e.g., blurring, ghosting, and distortions) and offers a limited image quality; therefore, DWI is currently used as complementary and not as a replacement to conventional sequences in the evaluation of NAFLD [47].
DWI does not require administration of intravenous contrast; consequently the technique might represent a reasonable option for patients with kidney failure, where gadolinium-based contrast substances represent a contraindication due to the increased risk of developing nephrogenic systemic fibrosis, while iodinated CT contrast might lead to an even greater impairment of renal function, being also contraindicated [47].
It is known that, among other factors, increased iron content of the liver and secondary changes manifesting in progressive collagen deposition are important background alterations in the development of liver fibrosis [48].
Susceptibility-weighted imaging (SWI) is well known as a three-dimensional (3D) gradient-echo (GRE) technique utilizing phase information to increase sensitivity for detecting susceptibility changes that result from, for example, iron, hemoglobin, and calcification. Initially used for neuroimaging [49, 50], recent technical advances allow for possible abdominal applications.
SWI is based on T2*-weighted GRE sequences and exploits both magnitude and phase information. Traditionally SWI sequences are high-resolution 3D sequences. Employing 3D sequences for abdominal imaging is not feasible because of long acquisition times and the large B0 variations encountered in this body area. With the advent of a multi-breath-hold GRE-sequence-based SWI, a two-dimensional (2D) sequence was developed for abdominal imaging [51]. SWI utilizes the differences in the magnetic susceptibilities of different tissues and produces a contrast superior to conventional T1- and T2-weighted MR imaging in the detection of structures that cause susceptibility artifacts [52].
The superiority of SWI over the T2*-weighted sequence has been shown, both in the detection and conspicuity of increased liver iron deposition and siderotic nodules [51] and in the detection of intratumoral hemorrhage in hepatocellular carcinoma (HCC) [53].
The liver-to-muscle signal intensity ratio on SWI proved to be a reliable measurement in grading liver fibrosis in patient with diffuse liver disease, with a high-diagnostic accuracy for the differentiation of moderate to advanced (F2 and F3) liver fibrosis from liver cirrhosis (F4) (AUROC = 0.93). The multiple regression analysis showed that liver fibrosis independently influenced SWI measurements, being a main contributor to the decreasing liver-to-muscle SI ratio, followed by iron overload and necroinflammatory activity, when compared with histopathologic findings [52].
The relationship between iron load and fibrogenesis has multiple considerations. The increased iron content in the liver, either diffusely distributed or in the form of numerous siderotic nodules, does not represent the entire transformation of liver fibrosis. In the process of fibrogenesis, hepatic stellate cells are also activated by other factors such as inflammation, genetic determinants, and the immune system [52].
Using a multiparametric approach, a recent study proved that liver SWI signal intensity enhanced the diagnostic performance in diagnosing and staging liver fibrosis, when used together with the apparent diffusion coefficient of the liver parenchyma on DWI and the degree of liver enhancement on the hepatobiliary phase of dynamic contrast-enhanced MRI. The three MRI techniques used together were able to assess the severity of liver fibrosis with an AUC ranging from 0.90 to 0.95, and the best performance was obtained in predicting moderate fibrosis (F2 or greater), with a sensitivity of 86% and a specificity of 94%. This reflects the clinical significance of this diagnostic tool, as F2 or greater is the stage in which therapeutic action should be taken [54].
Proton density fat fraction (PDFF) measurement is a multi-echo chemical shift-encoded MRI method for quantitatively assessing hepatic steatosis, being available as an option from several manufacturers of MRI scanners. PDFF is defined as the ratio of the density of mobile protons from triglycerides and the total density of protons from mobile triglycerides and mobile water. It is expressed as an absolute percentage (%) and ranges from 0 to 100% [7].
This sequence allows the measurement of fat fraction in any segment of the liver, generating a fat mapping of the entire hepatic parenchyma. This is of great value, as several studies proved the heterogeneous intrahepatic fat distribution [55].
The advantages of PDFF calculation are its ability to be completely obtained during a short breath-hold (in less than 25 s) and the fact that it minimizes the errors from confounders of fat quantification encountered using conventional MRI methods (Dixon and fat saturation) such as T1 bias, T2* decay, or spectral complexity of lipid [38].
Emerging data support the use of MRI-PDFF in evaluating the response to treatment in the setting of early-phase clinical trials in NASH, using drugs with an anti-steatotic mechanism of action [7].
In a recent study, the mean fat fraction was significantly lower in the left lobe than it was in the right, while liver segments 4 and 5 proved to be the most adequate to estimate the entire hepatic lipid content [55].
Regarding technical parameters, using a six-echo map proved to have a higher diagnostic accuracy than three, four, or five echoes [56].
Permutt et al. showed a good correlation between MRI-PDFF and histology-determined steatosis grade in adults with NAFLD. They observed an increasing average value of MRI-determined PDFF with increasing steatosis grade (8.9% for grade 1, 16.3% for grade 2, and 25% for grade 3 steatoses) [57]. PDFF was effective in differentiating moderate or severe hepatic steatosis from mild or no hepatic steatosis, with area under the curve of 0.95 and 93% sensitivity and 85% specificity. However, the correlation between biopsy and PDFF-determined steatosis was less pronounced when fibrosis was present (r = 0.60) than when fibrosis was absent [58].
When comparing the efficiency of MRI-PDFF to magnetic resonance spectroscopy, both techniques proved to strongly correlate with the histology-determined steatosis, with no superiority between them [38]. But the PDFF maps have the advantage of being automatically reconstructed without user input or post-processing, unlike MR spectroscopy-based methods.
Therefore, MR-PDFF represents another novel, noninvasive, and practical imaging tool in assessing patients with NAFLD, as the entire liver can be covered in assessment with a great accuracy in quantifying total hepatic fat amount [38, 55].
In the liver, contrast agents are categorized into non-specific agents that distribute into the vascular and extravascular extracellular spaces (such as the linear gadopentetate dimeglumine (Gd-DTPA) and the macrocyclic gadobutrol (Gd-DO3A-butrol) and gadoterate dimeglumine (Gd-DOTA)) and liver-specific agents taken up by liver cells. These liver-specific agents are either taken up by Kupffer cells (such as the super paramagnetic iron oxide particles ferumoxides and ferucarbotran) or by hepatocytes (such as gadolinium ethoxybenzyl dimeglumine or gadoxetic acid (Gd-EOB-DTPA) and gadobenate dimeglumine (Gd-BOPTA)) [8].
Gadoxetic acid (Gd-EOB-DTPA, Eovist® in the USA, Primovist® in Europe) is a liver-specific MRI contrast agent which provides both morphological and functional information and can be used as an imaging biomarker in the diagnostic workup of liver fibrosis [8].
After intravenous injection, the gadoxetic acid (GA) distributes into the vascular and extravascular spaces during the arterial, portal venous, and late dynamic phases and progressively into the hepatocytes and bile ducts during the hepatobiliary phase. GA enhancement depends mainly on liver perfusion, vascular permeability, extracellular diffusion, and hepatocyte transporter expression [8, 59].
All these functions are disturbed in diffuse liver diseases, and there may be a decrease in the balance between uptake and excretion of the contrast media by the impaired hepatocytes.
The transport of GA in the hepatocytes is mediated by two different transport systems located at the sinusoidal and canalicular membranes of the cell [60]. The contrast agent enters the hepatocytes through two organic anion-transporting polypeptide transporters (OATP1B1 and OATP1B3) [61], and it is excreted into the bile via the multidrug resistance protein 2 (MRP2) [62].
In patients with liver cirrhosis, the upregulation of MRP2 is associated with significant signal loss on gadoxetic acid-enhanced MR images [63]. Organic acid efflux from hepatocytes may also occur through the sinusoidal membrane because the transport through OATP is bidirectional and because the sinusoidal membrane also contains multidrug resistance proteins (MRP3 and MRP4), as it is illustrated in Figure 1. These efflux pumps are normally expressed at low levels in normal hepatocytes but can be upregulated in pathologic conditions, such as cholestasis. GA is not metabolized within hepatocytes [64].
Cellular pharmacology of Gd-EOB-DTPA—figure adapted after Van Beers et al. [8].
With GA, approximately 50% of the administered dose in the normal human liver is transported through the hepatocytes and excreted into the bile, and the percentage of the contrast agent that is not cleared by the hepatobiliary system is excreted by glomerular filtration in the kidneys [65].
Hepatobiliary MR contrast agents can be used to characterize liver functional properties, and the relative enhancement quantification is a reflection of hepatocyte malfunction as a result of liver fibrosis accumulation and increased necroinflammatory activity [66].
Several MR-derived parameters can be used to estimate the amount of GA uptake, such as the relative liver enhancement, hepatic uptake index, and T1 mapping during hepatobiliary phase—on static images or the hepatic extraction fraction and liver blood flow—by using dynamic assessment [67]. Importantly, there is currently no clear consensus as to which of these MR-derived parameters is the most suitable for assessing liver dysfunction.
The relative liver enhancement (RLE), the most commonly used parameter, is calculated by subtracting the signal intensity (SI) on the unenhanced images from the SI in the HBP, and dividing the difference by the SI of the unenhanced images, using the following formula [67]:
In order to avoid bias due to liver parenchyma inhomogeneity, several regions of interest (ROI) are placed in different segments of both liver lobes.
Indeed, reports on animal models also proved that gadoxetic acid-enhanced MRI could differentiate simple steatosis from NASH by comparing the signal profile or the time of maximum relative enhancement [68]. Furthermore, several recent studies have shown the ability of gadoxetic acid-enhanced MRI to evaluate patients with CLD, particularly for the staging of hepatic fibrosis, and to obtain global and territorial liver function information [69].
In a retrospective, proof-of-concept study, the mean relative enhancement of the whole liver after GA administration was significantly lower in patients with NASH (0.82 ± 0.22), compared to those with simple steatosis (1.39 ± 0.52) [70]. Therefore, the relative enhancement measurements could potentially be used to differentiate between simple steatosis and NASH [AUC = 0.85 (95% CI 0.75–0.91)], providing a high sensitivity of 97% but a low specificity of 63% [70].
Histology parameters used to stage NASH, such as lobular inflammation, hepatocellular ballooning, and the degree of liver fibrosis, proved to be independent factors that negatively correlated with RLE. On the other side, fatty liver infiltration did not correlate with the relative enhancement. Due to its low specificity, GA-MRI cannot be used at this moment as the only criterion by which to differentiate simple steatosis and NASH. However, GA-MRI can be used as a valuable screening tool in identifying which NAFLD patients need to perform liver biopsy and which do not [70].
With regard to liver fibrosis staging, the contrast enhancement index (method that uses the paraspinal muscles’ signal intensity as a reference for liver) proved to be an efficient biomarker, with higher diagnostic accuracy than other enhancement parameters or hematologic markers [71]. RLE is best suited for detecting moderate to advanced fibrosis, but the interpretation of results should consider laboratory parameters, with special attention to liver function. Elevated levels of aspartate aminotransferase, gammaglutamyl transpeptidase, and alkaline phosphatase levels were independent predictors of false-negative results [69].
The main advantages and disadvantages of each magnetic resonance imaging technique currently used in the noninvasive assessment of NAFLD are briefly synthetized in Table 1.
Imaging technique | Advantages | Disadvantages |
---|---|---|
MRE |
|
|
MRS |
|
|
DWI |
|
|
SWI |
|
|
PDFF |
|
|
Liver-specific contrast MRI |
|
|
Summary of main advantages and disadvantages of different MRI techniques in evaluating patients with NAFLD.
MRE, magnetic resonance elastography; MRS, magnetic resonance spectroscopy; DWI, diffusion-weighted MR imaging; SWI, susceptibility-weighted MR imaging; PDFF, proton density fat fraction.
MRI is currently increasingly used in the assessment of NAFLD. Although all methods have their own advantages and disadvantages, the noninvasive diagnosis of NAFLD using innovative applications of MRI-based methods presents a promising future. Liver fibrosis can be accurately assessed using MRI methods that do not require contrast media administration, such as MRE, diffusion-weighted MRI, and susceptibility-weighted MRI, while quantitative detection of liver steatosis is better performed using MRS or chemical shift-based MRI techniques such as proton density fat fraction. Moreover, GA-enhanced MRI provides both morphological and functional information and can be used as an imaging biomarker in the diagnostic workup of liver fibrosis and may help to distinguish between the two subgroups of NAFLD, simple steatosis and nonalcoholic steatohepatitis.
There is none to declare.
ADC | Apparent diffusion coefficient |
CLD | Chronic liver disease |
CT | Computer tomography |
DWI | Diffusion-weighted imaging |
GA | Gadoxetic acid |
GRE | Gradient echo |
LT | Liver transplantation |
MRE | Magnetic resonance elastography |
PDFF | Proton density fat fraction |
MRI | Magnetic resonance imaging |
MRP2 | Multidrug resistance protein 2 |
MRS | Magnetic resonance spectroscopy |
NAFLD | Nonalcoholic fatty liver disease |
NASH | Nonalcoholic steatohepatitis |
RLE | Relative liver enhancement |
ROI | Region of interest |
SI | Signal intensity |
SWI | Susceptibility-weighted imaging |
US | Ultrasonography |
The enormous burden of poor working conditions stated by several studies and with the latest estimates provided by the International Labour Organization (ILO) that somewhere 2.3 million working people around the world capitulate to work-related accidents or diseases every year; this links to over 6000 deaths every single day. Worldwide, there are around 340 million occupational accidents and 160 million fatalities of work-related illnesses annually [1]. While improved and harmless workplaces can avoid at least 1.2 million deaths every year, according to 2018 world health organization (WHO) study [2]. Many causalities can be prevented through addressing significant health dangers, which is directly associated with the workplace, and the exposures such as stress, long working hours and shift work, prolonged sitting at work, work-related climate-sensitive diseases, such as heat and cold stress, as well as workplace air pollution [3, 4, 5, 6].
\nOccupational health covers all aspects of health and safety in the workplace and has a strong focus on primary prevention of hazards. Depending on workplace conditions, there are several health risks: cancers, injuries/accidents, musculoskeletal disorders, respiratory problems, mental health disorders, skin ailments, infectious diseases, etc. Employment conditions in both formal and informal sectors are also significant factors: working hours, salary, and policies that cover such aspects as maternity leave, and provisions for protecting and promoting employee health [2]. Occupational health is a grave concern in developing countries, but there have been few studies of health issues faced by tannery workers because of which the problems are largely unknown. Further, the workers’ health issues have not received sufficient attention from employers. The place and work environment are crucial influences on the extent of health risks faced by tannery workers. According to WHO, occupational health problems accounted for about 1.5 percent of the total burden of disease regarding disability adjusted life years (DALYs), particularly in occupational health, which included work-related injuries, and exposure to risks such as carcinogens, airborne particulates, ergonomic stressors, and noise [7].
\nTannery workers are susceptible to multiple chemical and physical hazards in their work. Direct exposure to hazardous materials significantly increases health risks. The workers are exposed to chromium during the tanning process, leather dust, and various chemical agents. There are also ergonomic stressors that increase susceptibility to numerous health issues. Workers involved in multiple operations like material transfer, wet finishing, dry finishing, etc. are particularly vulnerable to harm. The risks associated with the tanning work is included in the proposed research paper examines the health hazards of tannery work Kanpur (India), and the preventive actions that are taken.
\nAs mentioned earlier, there have been a limited number of studies of perceived health risks and preventive measures among tannery workers in the developing world. This research work investigates the work experience, working hours, type of job contract, and the type of work the tannery employees are usually engaged in. At the same time, it also examines their awareness of the hazardous work environment, the effect of exposure to chemicals, dangerous tissues involved in the tanning process. It also studies their perceptions of the effects of exposure to chemicals and contact with them, airborne dust, and ergonomic stressor. The objective of the study was to understand the extent of awareness about occupational health risks and adopted preventive measures during working hours among male tannery workers of Kanpur, India.
\nInformation for the present research was strained from a cross-sectional household study of tannery workers in the Jajmau area of Kanpur, India. The survey was piloted through the period January–June 2015 and was a portion of a Ph.D. database. All total of 284 tannery workers from the study area were questioned. Rigorous pre-testing was completed with the tannery workers of the Jajmau area for testing the internal uniformity of schedule. Beforehand starting the interviews, we have clarified the tenacity of the survey and requested to contribute to the study by giving the proper information. After that, face-to-face discussions were piloted among those who agreed to participate in the study by using a structured pre-tested questionnaire on the tannery workers.
\nThis study has adopted a three-stage sampling design. At the first stage, seven localities in the Jajmau area, namely Tadbagiya, Kailash Nagar, J.K. colony, Asharfabad, Motinagar, Chabeelepurwa, and Budhiyaghat, were selected based on a higher concentration of leather tannery worker’s population in these areas as reported by various stakeholders in the city. In the second stage, three out of the seven localities, namely Budhiyaghat, Tadbagiya, and Asharfabad, were selected by probability proportional to size (PPS) sampling technique after arranging them in increasing order of estimated number of HHs of leather tannery workers. Subsequently, a comprehensive household listing and mapping were completed in each of the three localities, and all the household were classified into three groups- households having at least one tannery worker, irrespective of having or not having any non-tannery worker, households having non-tannery worker (s) and households having no worker. The first two groups of households constituted two independent sampling frame in each of the three selected localities. While the third group of households was excluded from the study. Once the updated and comprehensive sampling frames were developed in each of the three areas included in the study, a circular systematic random sampling was used for the selection of households at the third and the last stage. In case, if more than one worker were in a household, the target respondent was selected using KISH table. In each of the three selected areas, 100 households were selected for each of the two categories i.e., a tannery as well as non-tannery workers, using a circular systematic random sampling procedure. Thus, a total of 600 HHs were selected for the interview, and a total of 284 HHs having at least tannery workers, and 289 HHs of non-tannery workers (s) were interviewed successively. In the paper, we have tried to understand the level of awareness among the leather tannery workers. Bivariate analysis and logistic regression analysis were performed.
\nQualitative measurement of environmental exposures have been classified as follows: Chemicals in the air (no exposure, low exposure, moderate exposure, high exposure, very high exposure) was based on qualitative rating of exposure assessment as [0] No exposure: no contact with agent, agent is used in workplace but is very unlikely to result in exposure to workers involved. [1] Low exposure: infrequent contact with agent at low concentrations, Agent is used in a closed/controlled system; there are no specific activities that enhance exposure; exposure takes place because of presence at the shop floor. [2] Moderate exposure: frequent contact with agent at low concentrations, Agent is used throughout the closed/controlled process and exposure mainly occurs by passive contact; infrequent contact is needed with the agent. [3] High exposure: Frequent contact with agent at high concentrations, Nature of the production process and associated manual activities makes regular contact necessary; agent causes exposure during manual activities and around particular sources such as presses, drums. [4] Very high exposure: Frequent contact with agent at very high concentrations, Agent is used in manual activities that introduce frequent peak exposures such as cleaning, opening a press, spraying paint. 2Dermal exposure to chemicals (no exposure, moderate exposure, high exposure) was based on qualitative rating of exposure assessment as [0] No skin contact: no contact with agent. [1] Moderate exposure: infrequent skin contact with agent contact occurs during specific activities that are not part of the daily work routine. [2] High exposure: frequent skin contact with agent regular contact is unavoidable due to particular activities in daily work practice. 3Another important variable airborne dust (no exposure, low exposure, moderate exposure, high exposure, very high exposure) was based on qualitative rating of exposure assessment as [0] No exposure: clear visibility. [1] Low exposure: visibility more than 10 m. [2] Moderate exposure: visibility between 5 to 10 m. [3] High exposure: visibility between 1 to 5 m. [4] Very high exposure: visibility less than 1 m. 4Ergonomic stressors (no exposure, low exposure, moderate exposure, high exposure, very high exposure) was based on qualitative rating of exposure assessment as [0] No exposure: does not occur (< 10% of work time). [1] Low exposure: less than 25% of daily work time. [2] Moderate exposure: 25–49% of daily work time. [3] High exposure: 50–74% of daily work time. [4] Very high exposure: 75% or more of daily work time. Exposure of waste water of chromium (no exposure, moderate exposure, high exposure) was based on qualitative rating of exposure assessment as [0] No exposure: no contact with chromium water. [1] Moderate exposure: infrequent contact with chromium water. [2] High exposure: frequent contact with chromium water.
\nWe begin with the descriptive analysis (frequency distribution) to present the sample. Further, cross-tabulation was done to study the association with the dependent variable and predictor variables included in the study. Adjusted odds ratio from the binary logistic regression was executed to determine the associated factors. Data were analyzed using STATA 14 software.
\nThe work-related characteristics of tannery workers are presented in Table 1. Tannery operations was categorized into four broad categories: Beam house work (8% of workers in a tannery unit), wet finishing (25%), dry finishing (50%), and miscellaneous work (17%).
\nVariables | \nPercentage (%) | \nNumber (N) | \n
---|---|---|
Type of job within tannery occupation | \n||
Beam house | \n8.4 | \n24 | \n
Wet finishing | \n24.5 | \n70 | \n
Dry finishing | \n50.4 | \n142 | \n
Miscellaneous | \n16.7 | \n48 | \n
Work experience in current tannery | \n||
Up to 5 years | \n34.3 | \n96 | \n
6 to 10 years | \n33.5 | \n96 | \n
11 to 20 years | \n22.4 | \n64 | \n
20+ years | \n9.8 | \n28 | \n
Work experience in previous tannery | \n||
Up to 5 years | \n43.4 | \n43 | \n
6 to 10 years | \n38.4 | \n38 | \n
11 to 20 years | \n13.1 | \n13 | \n
20+ years | \n5.1 | \n5 | \n
Type of job contract | \n\n | \n |
Temporary job (daily wages) | \n89.2 | \n253 | \n
Permanent job | \n10.8 | \n31 | \n
Working hours in day | \n\n | \n |
7 to 8 hours | \n47.2 | \n134 | \n
9 to 10 hours | \n25.5 | \n73 | \n
11 to 12 hours | \n27.3 | \n77 | \n
Working days in a week | \n\n | \n |
Six days in a week | \n48.3 | \n137 | \n
Seven days in a week | \n51.7 | \n147 | \n
Total | \n100.0 | \n284 | \n
Work related characteristics of tannery workers.
We collected information on total work experience (in the present job and previous ones) in tanneries. Around 15 percent of the tannery workers surveyed were engaged in the occupation for more than 20 years, and about one-third of workers were involved for 20 years in the tannery occupation. Most of the workers (89%) were working as daily wage laborers, while only 11 percent were permanent employees. Over one-fourth (27%) worked for 11 to 12 hours a day, and 52 percent reported that they worked for all seven days in the week.
\nThe nature of the work done is shown in Figure 1. For this study, the job contract was divided into two categories—temporary (daily wages) and permanent. Most workers were engaged in works on a temporary basis. In the beam house, where the work is particularly hazardous, 96 percent of the workers were employed temporarily, with permanent employees making up the remainder. The nature of the job contract was heavily skewed in the other sections also: wet finishing work (84% and 16 percent respectively of temporary and permanent workers), dry finishing (89% and 11%), and miscellaneous work (94% and 6%).
\nPercent distribution of job contract by their type of work they usually do in tannery reported by tannery workers.
Workers’ awareness of hazards involve in tannery operation is presented in Table 2. About 79 percent of the workers in the age group of 16–24 years agreed with the statement that “tannery work is very hazardous in nature” found to be highest. Awareness of the above statement varies from 73 to 93 percent for the educational attainment, religion, caste, media exposure, and standard of living index among the tannery workers. It was found that tannery workers having a middle-school level of education were 3.01 times more likely to be aware of the hazards as compared to the illiterate or less educated ones. Those with a comparatively higher standard of living were 2.08 times more likely to agree that “tannery work is very hazardous in nature” than those having a lower standard of living. Agreement with the statement that “tannery workers work in the very hazardous work environment” ranges from 55 to 79 percent for the predictors such as age, education, religion, caste, media exposure, and standard of living index. Tannery workers aged 36 and above were 0.34 times, and those who had a medium level of media exposure were 0.58 times less likely to aware of a hazardous work environment. We also examined the perceptions about exposure to hazardous chemicals in tanning processes. The awareness varied between 40 and 69 percent according to selected background variables. Odds ratio show that workers having a middle level of education were 0.43 times, and those with a medium level of media exposure are 0.54 times less likely to aware of the exposure of hazardous chemicals used in the tanning process. We also tried to understand the awareness of exposure to hazardous tissues involved in the tanning process. It was found that awareness ranged from 40 to 65 percent, depending on age, education, religion, caste, media exposure, and standard of living index. The odds ratio shows that tannery workers aged 36 years and above were 0.44 times less likely to aware of the hazardous tissues involved in the tanning process.
\nBackground Variables | \nTannery work is very hazardous in nature | \nTannery workers work in hazardous work environment | \nTannery workers are exposed to many hazardous chemicals | \nHazardous tissues involve in tanning process | \n||||
---|---|---|---|---|---|---|---|---|
\n | Percent (%) | \nOdds CI | \nPercent (%) | \nOdds CI | \nPercent (%) | \nOdds CI | \nPercent (%) | \nOdds CI | \n
Age in years | \n\n | \n | \n | \n | \n | \n | \n | \n |
16–24 | \n79.3 | \n\n | 79.3 | \n\n | 68.9 | \n\n | 65.5 | \n\n |
25–35 | \n78.6 | \n1.23 [0.42–3.65] | \n65.0 | \n0.54 [0.20–1.49] | \n59.2 | \n0.71 [0.28–1.78] | \n55.3 | \n0.66 [0.27–1.62] | \n
36+ | \n74.3 | \n0.89 [0.31–2.57] | \n55.2 | \n0.34**[0.13–0.93] | \n52.6 | \n0.55 [0.22–1.35] | \n46.0 | \n0.44*[0.18–1.07] | \n
Education | \n\n | \n | \n | \n | \n | \n | \n | \n |
Illiterate | \n73.8 | \n\n | 59.3 | \n\n | 57.7 | \n\n | 50.8 | \n\n |
Up to primary | \n78.9 | \n1.27 [0.52–3.12] | \n63.1 | \n0.98 [0.46–2.10] | \n60.5 | \n0.98 [0.46–2.09] | \n55.2 | \n1.08 [0.51–2.28] | \n
Middle school | \n88.0 | \n3.01* [0.73–12.34] | \n60.0 | \n0.94 [0.36–2.46] | \n40.0 | \n0.43* [0.16–1.14] | \n40.0 | \n0.66 [0.25–1.73] | \n
High school & above | \n78.7 | \n1.23 [0.40–3.79] | \n69.7 | \n1.31 [0.49–3.49] | \n57.5 | \n0.78 [0.30–2.00] | \n57.5 | \n1.27 [0.50–3.23] | \n
Religion | \n\n | \n | \n | \n | \n | \n | \n | \n |
Hindu | \n83.3 | \n\n | 64.5 | \n\n | 59.3 | \n\n | 47.9 | \n\n |
Muslim | \n72.8 | \n0.63 [0.31–1.26] | \n59.5 | \n0.94 [0.53–1.66] | \n55.3 | \n0.94 [0.53–1.66] | \n53.1 | \n1.51 [0.86–2.66] | \n
Caste | \n\n | \n | \n | \n | \n | \n | \n | \n |
Schedule caste | \n80.6 | \n\n | 61.8 | \n\n | 58.6 | \n\n | 51.0 | \n\n |
Other backward class | \n65.3 | \n0.41** [0.20–0.86] | \n59.6 | \n0.80 [0.41–1.57] | \n63.4 | \n1.14 [0.58–2.24] | \n61.5 | \n1.31 [0.67–2.55] | \n
Others | \n93.7 | \n4.60 [0.56–37.80] | \n62.5 | \n1.21[0.39–3.76] | \n50.0 | \n0.84 [0.28–2.50] | \n50.0 | \n0.92 [0.31–2.74] | \n
Media exposure | \n\n | \n | \n | \n | \n | \n | \n | \n |
Low | \n76.9 | \n\n | 64.6 | \n\n | 61.5 | \n\n | 53.8 | \n\n |
Medium | \n74.6 | \n0.74 [0.35–1.59] | \n55.8 | \n0.58* [0.30–1.11] | \n52.1 | \n0.54* [0.28–1.03] | \n47.1 | \n0.59 [0.31–1.12] | \n
High | \n79.0 | \n0.64 [0.22–1.77] | \n67.9 | \n0.66 [0.28–1.57] | \n60.4 | \n0.83 [0.35–1.97] | \n56.7 | \n0.79 [0.34–1.85] | \n
Standard of living index | \n\n | \n | \n | \n | \n | \n | \n | \n |
Low | \n73.8 | \n\n | 56.0 | \n\n | 52.3 | \n\n | 46.7 | \n\n |
Medium | \n75.2 | \n1.17 [0.58–2.39] | \n60.6 | \n1.34 [0.73–2.49] | \n56.1 | \n1.18 [0.64–2.18] | \n50.5 | \n1.07 [0.58–1.98] | \n
High | \n80.6 | \n2.08* [0.92–4.72] | \n68.1 | \n1.94*\n [0.98–3.81] | \n62.5 | \n1.46 [0.75–2.83] | \n57.9 | \n1.42 [0.74–2.75] | \n
Total | \n76.0 | \n\n | 61.0 | \n\n | 57.0 | \n\n | 51.0 | \n\n |
Awareness among the tannery workers about the involvement of hazards in tannery work by some selected background characteristics.
\np < 0.1.
\np < 0.05.\n
The awareness of potential health hazards involved in the tanning process by type of work is presented in Table 3. It is seen that 83 wet finishing and dry finishing (about 80%) workers were aware that the tannery work is hazardous. Similarly, 66 and 64 percent wet finishing and dry finishing workers engaged in tannery workers accepted that they worked in an unsafe work environment. Most of the workers (69%) in the wet finishing section reported that tannery workers were exposed to several hazardous chemicals during the tanning process, which was following by workers engaged in dry finishing (55%), Beam house work (50%), and workers engaged in miscellaneous work (49%). Around two-thirds of the workers involved in wet finishing were agreed that hazardous tissue engaged in the tanning process.
\nStatements | \nBeam house | \nWet finishing | \nDry finishing | \nMiscellaneous | \nOverall | \n(N) | \n
---|---|---|---|---|---|---|
Tannery work is very hazardous in nature | \n||||||
Agree | \n62.5 | \n82.9 | \n80.4 | \n61.7 | \n51.4 | \n217 | \n
Disagree | \n37.5 | \n17.1 | \n19.6 | \n38.3 | \n48.6 | \n67 | \n
Tannery workers work in hazardous work environment | \n||||||
Agree | \n58.3 | \n65.7 | \n63.6 | \n48.9 | \n56.7 | \n174 | \n
Disagree | \n41.7 | \n34.3 | \n36.4 | \n51.1 | \n43.3 | \n110 | \n
Tannery workers are exposed to many hazardous chemicals | \n||||||
Agree | \n50.0 | \n68.6 | \n54.6 | \n48.9 | \n61.3 | \n161 | \n
Disagree | \n50.0 | \n31.4 | \n45.5 | \n51.1 | \n38.7 | \n123 | \n
Hazardous tissues involve in tanning process | \n||||||
Agree | \n41.7 | \n58.6 | \n50.3 | \n48.9 | \n76.4 | \n146 | \n
Disagree | \n58.3 | \n41.4 | \n49.7 | \n51.1 | \n23.6 | \n138 | \n
Total | \n100.0 | \n100.0 | \n100.0 | \n100.0 | \n100.0 | \n284 | \n
Awareness about the health hazard involved in tanning process by their type of work they usually do in tannery.
\nAwareness about the health hazard due to work in tannery occupation.\n
\nThis research work examined awareness of health problems that may occur in tannery work. Various health issues like respiratory trouble, skin complaints, eye-related, and gastrointestinal issues were observed, which are presented in Table 4. Tannery workers who belong to the younger cohort (16–24 years) reported a higher awareness of respiratory problems (38%), skin complaints (59%), and gastrointestinal issues (21%) than those aged 36 years and above. There is an increasing awareness of educational attainment. Workers with high school education and more showed higher awareness of respiratory problems (52%), skin complaints (67%) in comparison to illiterate workers. Further, Hindu workers were more aware of respiratory problems (33%), skin complaints (55%), and gastrointestinal problems (16%) as compared to Muslim workers. Similarly, other caste group workers were also more aware of respiratory problems (29%), eye-related issues (46%), and the gastrointestinal problem (19%) compared to the schedule caste and other caste group workers.
\n\n | Respiratory Problems | \nSkin Complaints | \nEye related problems | \nGastrointestinal problems | \n||||
---|---|---|---|---|---|---|---|---|
Background Variables | \nPercent (%) | \nChi-square | \nPercent (%) | \nChi-square | \nPercent (%) | \nChi-square | \nPercent (%) | \nChi-square | \n
Age in years | \n\n | \n | \n | \n | \n | \n | \n | \n |
16–24 | \n37.9 | \nχ2 = 4.56 p < 0.335 | \n58.6 | \nχ 2 = 1.76 p < 0.780 | \n24.1 | \nχ2 = 13.89 p < 0.008 | \n20.6 | \nχ2 = 2.19 p < 0.700 | \n
25–35 | \n25.2 | \n53.4 | \n34.9 | \n13.5 | \n||||
36+ | \n23.6 | \n53.9 | \n38.1 | \n12.5 | \n||||
Education | \n\n | \n | \n | \n | \n | \n | \n | \n |
Illiterate | \n19.2 | \nχ2 = 19.48 p < 0.003 | \n54.5 | \nχ2 = 8.46 p < 0.206 | \n37.4 | \nχ2 = 4.47 p < 0.613 | \n11.7 | \nχ 2 = 11.86 p < 0.065 | \n
Up to primary | \n23.6 | \n39.4 | \n31.5 | \n7.8 | \n||||
Middle school | \n40.0 | \n56.0 | \n36.0 | \n24.0 | \n||||
High school & above | \n51.5 | \n66.6 | \n27.2 | \n21.2 | \n||||
Religion | \n\n | \n | \n | \n | \n | \n | \n | \n |
Hindu | \n33.3 | \nχ2 = 18.91 p < 0.000 | \n55.2 | \nχ2 = 1.14 p < 0.566 | \n22.9 | \nχ2 = 10.71 p < 0.005 | \n15.6 | \nχ2 = 1.11 p < 0.575 | \n
Muslim | \n21.8 | \n53.7 | \n42.0 | \n12.7 | \n||||
Caste | \n\n | \n | \n | \n | \n | \n | \n | \n |
Schedule caste | \n22.5 | \nχ2 = 26.26 p < 0.000 | \n54.3 | \nχ2 = 7.65 p < 0.265 | \n34.4 | \nχ2 = 22.02 p < 0.001 | \n10.2 | \nχ 2 = 24.80 p < 0.000 | \n
Other backward class | \n28.8 | \n57.6 | \n46.1 | \n19.2 | \n||||
Others | \n12.5 | \n62.5 | \n6.25 | \n0.0 | \n||||
Media exposure | \n\n | \n | \n | \n | \n | \n | \n | \n |
Low | \n36.9 | \nχ2 = 23.45 p < 0.000 | \n61.5 | \nχ2 = 5.48 p < 0.241 | \n35.3 | \nχ2 = 6.67 p < 0.154 | \n21.5 | \nχ 2 = 14.24 p < 0.007 | \n
Medium | \n13.0 | \n51.4 | \n39.8 | \n6.5 | \n||||
High | \n38.2 | \n53.0 | \n28.4 | \n19.7 | \n||||
Standard of living index | \n\n | \n | \n | \n | \n | \n | \n | \n |
Low | \n28.0 | \nχ2 = 5.47 p < 0.242 | \n50.4 | \nχ2 = 3.47 p < 0.483 | \n28.9 | \nχ 2 = 5.16 p < 0.271 | \n14.9 | \nχ2 = 9.34 p < 0.053 | \n
Medium | \n20.2 | \n53.9 | \n41.5 | \n11.2 | \n||||
High | \n28.4 | \n59.0 | \n37.5 | \n14.7 | \n||||
Total | \n25.7 | \n\n | 54.2 | \n\n | 35.5 | \n\n | 13.7 | \n\n |
Percent distribution of tannery workers who were aware about the health problems involve in tannery work.
The chemicals used in tanning processes are not consumed but discharged into the environment as effluents. Effluents contain organic matter, chromium, sulphides, and solid waste. Qualitative assessment of exposure at the workplace may be a useful tool for evaluating hazardous working conditions. Table 5 presents qualitative measures of environmental exposure by different work categories. The results show that more than half (54%) of the workers engaged in beam housework followed by wet finishing (44%) and miscellaneous work (43%) had moderate to high exposure to chemicals. About one-third of Beamhouse workers (33%) and over a quarter (26%) of the wet finishing had moderate to high dermal contact with the chemicals. Further, 63 percent of the workers engaged in Beamhouse work, 51 percent doing miscellaneous work, 47 percent in wet finishing, and 36% in dry finishing reported exposure to dust. Furthermore, 50 percent of the beam house workers, 43 percent workers in wet finishing, 34 percent in miscellaneous work, and 30 percent in dry finishing had moderate to high exposure to ergonomic stressors.
\n\n | Beam house | \nWet finishing | \nDry finishing | \nMiscellaneous work | \nChi-square | \nN | \n
---|---|---|---|---|---|---|
Chemicals in the Air\n1\n\n | \n\n | \n | \n | \n | \n | \n |
No exposure | \n25.0 | \n24.3 | \n30.1 | \n17.0 | \nχ2 = 8.09 p < 0.231 | \n74 | \n
Low exposure | \n20.8 | \n31.4 | \n37.1 | \n40.4 | \n99 | \n|
Moderate/ High exposure | \n54.2 | \n44.3 | \n32.8 | \n42.6 | \n111 | \n|
Dermal exposure to chemicals\n2\n\n | \n||||||
No exposure | \n33.3 | \n24.3 | \n32.2 | \n17.0 | \nχ2 = 16.43 p < 0.012 | \n79 | \n
Low exposure | \n33.3 | \n50.0 | \n49.0 | \n74.5 | \n148 | \n|
Moderate/ High exposure | \n33.4 | \n25.7 | \n18.8 | \n8.5 | \n57 | \n|
Airborne dust\n3\n\n | \n\n | \n | \n | \n | \n | \n |
No exposure | \n25.0 | \n21.4 | \n34.3 | \n17.0 | \nχ2 = 12.28 p < 0.056 | \n78 | \n
Low exposure | \n12.5 | \n31.4 | \n29.3 | \n31.9 | \n82 | \n|
Moderate/ High exposure | \n62.5 | \n47.2 | \n36.4 | \n51.1 | \n124 | \n|
Ergonomic stressors\n4\n\n | \n\n | \n | \n | \n | \n | \n |
No exposure | \n20.8 | \n18.6 | \n37.1 | \n19.2 | \nχ2 = 14.15 p < 0.028 | \n80 | \n
Low exposure | \n29.2 | \n38.6 | \n32.8 | \n46.8 | \n103 | \n|
Moderate/ High exposure | \n50.0 | \n42.8 | \n30.1 | \n34.0 | \n101 | \n|
Total | \n100.0 | \n100.0 | \n100.0 | \n100.0 | \n\n | 284 | \n
Qualitative measures of environmental exposure by their type of work among the tannery workers.
Chemicals in the air (no exposure, low exposure, moderate exposure, high exposure, very high exposure) was based on qualitative rating of exposure assessment as [0] No exposure: no contact with agent, agent is used in workplace but is very unlikely to result in exposure to workers involved. [1] Low exposure: infrequent contact with agent at low concentrations, Agent is used in a closed/controlled system; there are no specific activities that enhance exposure; exposure takes place because of presence at the shop floor. [2] Moderate exposure: frequent contact with agent at low concentrations, Agent is used throughout the closed/controlled process and exposure mainly occurs by passive contact; infrequent contact is needed with the agent. [3] High exposure: Frequent contact with agent at high concentrations, Nature of the production process and associated manual activities makes regular contact necessary; agent causes exposure during manual activities and around particular sources such as presses, drums. [4] Very high exposure: Frequent contact with agent at very high concentrations, Agent is used in manual activities that introduce frequent peak exposures such as cleaning, opening a press, spraying paint.
Dermal exposure to chemicals (no exposure, moderate exposure, high exposure) was based on qualitative rating of exposure assessment as [0] No skin contact: no contact with agent. [1] Moderate exposure: infrequent skin contact with agent contact occurs during specific activities that are not part of the daily work routine. [2] High exposure: frequent skin contact with agent regular contact is unavoidable due to particular activities in daily work practice.
Another important variable airborne dust (no exposure, low exposure, moderate exposure, high exposure, very high exposure) was based on qualitative rating of exposure assessment as [0] No exposure: clear visibility. [1] Low exposure: visibility more than 10 m. [2] Moderate exposure: visibility between 5 to 10 m. [3] High exposure: visibility between 1 to 5 m. [4] Very high exposure: visibility less than 1 m.
Ergonomic stressors (no exposure, low exposure, moderate exposure, high exposure, very high exposure) was based on qualitative rating of exposure assessment as [0] No exposure: does not occur (< 10% of work time). [1] Low exposure: less than 25% of daily work time. [2] Moderate exposure: 25–49% of daily work time. [3] High exposure: 50–74% of daily work time. [4] Very high exposure: 75% or more of daily work time. Exposure of waste water of chromium (no exposure, moderate exposure, high exposure) was based on qualitative rating of exposure assessment as [0] No exposure: no contact with chromium water. [1] Moderate exposure: infrequent contact with chromium water. [2] High exposure: frequent contact with chromium water.
The preventive and safety measures appropriate for the work are presented in Table 6. The highest use of gloves and masks is seen in Beamhouse work (12 & 13% respectively), wet finishing (10 & 16%), miscellaneous (9 & 17%), and dry finishing (6.3 and 9%). Most tannery workers (69–92%), temporary as well as permanent, reported that they were involved in loading and unloading of raw hides manually in tannery premises. Only a small proportion (4.3–10%) used trolleys for loading and unloading. A substantial proportion of tannery workers had high exposure to humidity (69–88%), heat (69–84%), noise (78–87%). Additionally, most (51–63%) had become accustomed to the smell of hide. Most tannery workers also reported that exhaust fans (88–99%).
\nVariables | \nBeam house | \nWet finishing | \nDry finishing | \nMiscellaneous work | \nOverall | \nNumber (N) | \n
---|---|---|---|---|---|---|
Use of glove | \n||||||
Often | \n12.5 | \n10.0 | \n6.3 | \n8.5 | \n8.1 | \n23 | \n
Sometimes | \n41.7 | \n50.0 | \n51.7 | \n42.6 | \n48.9 | \n139 | \n
Never | \n45.8 | \n40.0 | \n42.0 | \n48.9 | \n43.0 | \n122 | \n
Use of mask | \n||||||
Often | \n12.5 | \n15.7 | \n9.0 | \n17.0 | \n12.3 | \n35 | \n
Sometimes | \n29.2 | \n48.6 | \n49.0 | \n42.6 | \n46.1 | \n131 | \n
Never | \n58.3 | \n35.7 | \n42.0 | \n40.4 | \n41.6 | \n118 | \n
Involved in loading and unloading of raw hides manually | \n||||||
Yes | \n91.7 | \n90.0 | \n69.2 | \n87.2 | \n79.2 | \n225 | \n
No | \n8.3 | \n10.0 | \n30.8 | \n12.8 | \n20.8 | \n59 | \n
Involved in loading and unloading of raw hides by trolley | \n||||||
Yes | \n8.3 | \n8.6 | \n9.8 | \n4.3 | \n8.5 | \n24 | \n
No | \n91.7 | \n91.4 | \n90.2 | \n95.7 | \n91.5 | \n260 | \n
Feeling humidity in tannery premises | \n||||||
Yes | \n87.5 | \n84.3 | \n68.5 | \n72.3 | \n74.7 | \n212 | \n
No | \n12.5 | \n15.7 | \n31.5 | \n27.7 | \n25.3 | \n72 | \n
Feeling heat in tannery premises | \n||||||
Yes | \n79.2 | \n84.3 | \n69.2 | \n80.8 | \n75.7 | \n215 | \n
No | \n20.8 | \n15.7 | \n30.8 | \n19.2 | \n24.3 | \n69 | \n
Feeling extreme noise in tannery premises | \n||||||
Yes | \n83.3 | \n87.1 | \n78.3 | \n85.1 | \n82.0 | \n233 | \n
No | \n16.7 | \n12.9 | \n21.7 | \n14.9 | \n18.0 | \n51 | \n
Comfortable with smell of hides | \n||||||
Yes | \n62.5 | \n51.4 | \n54.6 | \n53.2 | \n54.2 | \n154 | \n
No | \n37.5 | \n48.6 | \n45.5 | \n46.8 | \n45.8 | \n130 | \n
Exhaustive fan | \n||||||
Yes | \n87.5 | \n98.6 | \n96.5 | \n95.7 | \n96.3 | \n273 | \n
No | \n12.5 | \n1.4 | \n3.5 | \n4.3 | \n3.7 | \n11 | \n
Total | \n100.0 | \n100.0 | \n100.0 | \n100.0 | \n100.0 | \n284 | \n
Percentage of tannery workers who use preventive measures and experienced different environmental conditions in tannery premises by their type of work.
The results from this study of male tannery workers revealed that the workers were exposed to chemicals, leather dust, which contains chromium, and physical hazards. A substantial proportion of the tannery workers reported awareness of the health risks of the various tanning processes. The physical and cognitive difficulty levels of the job in tanneries were like previous studies [8, 9, 10]. It is essential to mention here that there are very few studies conducted on tannery workers in the Indian context.
\nThe results of our study validate the need for further efforts to minimize hazardous occupational health risks among tannery workers. However, findings depict tannery workers aged 36 years & above are less likely to be aware of the hazardous work environment, and malignant tissues involved in the tanning process, lack of protective equipment and safety devices showed a significant double risk for occupational health and injuries [11, 12, 13, 14]. Previous findings agree with a study on salt workers found that there is a considerable gap between their knowledge and practices, along with protective measures [15]. Furthermore, a study conducted on chronic conditions, workplace safety, and job demands in Colorado revealed that non-provision of workplace safety led to employees’ chronic health conditions and contributed to absenteeism and poor job performance. It also influences the physical and cognitive difficulties of the workers associated with the work [16]. Other factors also significantly affect the perceptions of health risks: age, education, religion, caste, media exposure, and standard of living index. Workers reported that they are aware that they have the chance of getting respiratory problems, skin complaints, eye-related, and gastrointestinal problems from the tannery. A substantial proportion of workers experienced severe conditions, such as humidity (69–88% of those surveyed), heat (69–84%), noise (78–87%); they had also got used to the smell of hides (51–63%). Comparable outcomes found by a study led in some developing countries concentrating on the upshot of work-related acquaintance to noise and heat on the health of the workers. Results portray that those who worked in the foundry had high thermal stress, high noise levels, high visual defects, high muscle cramps problem, high visual disability and describe non-use of protective equipment and poor occupational hygiene and safety measures were also affected the health problem among workers [17, 18, 19, 20]. Our study recommended that leather dust exposure be reduced by providing gloves and masks and by installing a hood duct to provide better ventilation and removal of leather dust from the work area as also recommended by previous researches [21].
\nThis research also suggested risks should be assessed for their potential consequences on health. Liquid effluents contain organic matter, chromium, sulfides, and solid wastes. A qualitative assessment of exposure showed that moderate to high exposure to chemicals and also contacted them. It has been reported from the literature that the workers on exposure to leather dust, which contains chromium in the protein-bound form, exhibited a higher mean concentration of urinary and blood chromium [8]. The workers engaged in beam housework, miscellaneous work, wet finishing, and dry finishing also reported moderate to high exposure to dust and ergonomic stressors. The use of safety gear was the highest in beam housework, followed by wet finishing, miscellaneous work, and dry finishing. This study also recognized a lack of awareness of the health risks in tannery operations and shortcomings in the use of preventive measures. Employers must raise awareness of health risks and ensure compliance with safety measures. But at the same time, qualitative results of focused group discussion with workers from small scale industries in Tanzania show high levels (>90%) of self-reported exposure to health problems, and low use of protective measures [22]. In continuation of the previous findings, a case study of electroplating sector workers in the United Kingdom showed that the employees had sound knowledge of the hazardous nature of chemicals used at the workplace [23].
\nAn intervention study focused on prevention of work-related skin problems assessed the occupational health and safety among wet workers. The study found significant behavior change and fewer skin problems among workers in the intervention group as compared to the control group. The intervention was successful in enhancing knowledge and changing behavior [24]. Literature suggests most workers had an essential awareness of the existence of occupational health and safety legislation, but they were unaware of their legal responsibilities. They were found to have minimal occupational and safety training [25, 26, 27, 28, 29].
\nThe findings of this study reveal that the tannery workers work in a very hazardous work environment and susceptible to health risks. Although, tannery workers are less aware of the health hazard involved in the tanning process and even not aware of the exposure to hazardous chemicals at the work place. Evidence from the qualitative measures of environmental exposure pointed out that they work in different activities at the tannery and having different exposures. Further, the study findings reveal that tannery workers are not utilizing the appropriate preventive measures as per the protocol. The outcomes of the study give a clear indication of the effect of the workstation environment on the health status of workers and require the use of adequate measures to improve the facilities and thereby the health status of tannery workers.
\nWe have received ethical approval from the board. The Student Research Ethics Committee approved the study of the International Institute for Population Sciences Mumbai, India. We have also obtained consent to participate from each of the respondents before starting the interview. The confidentiality of information has been maintained.
\nNot applicable.
\nThis research is based on primary data.
\nNot received any funding.
\nGCK developed the questionnaire, collected the data, contributed in acquisition of data. SKS PC conceived and designed the experiments. GCK PC analyzed the data. GCK PC wrote the manuscript. SKS critically revised the draft.
\nILO | International Labour Organization |
WHO | World Health Organizations |
DALY | disability adjusted life years |
PPS | probability proportional to size |
OR | odds ratio |
CI | confidence interval |
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