Wood-dust exposure and respiratory health among particleboard workers in Ethiopia

Background Work in the wood industry is often associated with exposure to wood dust, endotoxins and formaldehyde, which may cause respiratory health problems. Particleboard is a type of wood product manufactured primarily from wood chips, glued with urea formaldehyde resin and bonded under heat and pressure. In Ethiopia the manufacturing sector, like the wood industry, is growing. However, there is a scarcity of Knowledge, Attitude and Practice (KAP) concerning chemical health hazards and personal protective equipment (PPE) among particleboard workers. On top of this, workers’ exposure to inhalable wood dust, endotoxins and formaldehyde and their effect on respiratory health has been insufficiently studied. Objectives The aim of this thesis was to assess exposure to wood dust, endotoxins and formaldehyde, respiratory health and KAP regarding chemical hazards and use of PPE among Ethiopian particleboard workers. Method and materials The thesis consist of three papers conducted in three phases from 2016 to 2017 at the two largest particleboard factories in Ethiopia. In Phase One a cross-sectional study design was used for collection of data on KAP concerning chemical health hazards and PPE in production and administrative workers (n=172), and the study used both closed-ended and open-ended questions. Both permanent and temporary employees were included in the study. In Phase Two an exposure study was performed. A total of 152 dust and endotoxin samples were collected using a conductive plastic inhalable conical sampler (CIS) in the two largest particleboard factories. One field blank sample was taken per day (n=18). In addition, 45 stationary formaldehyde samples were taken using Dräger tubes. Inhalable dust was analysed using the gravimetric method in a room with controlled climatic conditions using an analytical balance with 0.1 μg readability, and the concentration was estimated in mg/m3. Endotoxins were analysed using the Kinetic Amoebocyte Lysate test, and the concentration was estimated in EU/m3. In Phase Three a cross-sectional study involving 74 workers from two particleboard factories and 73 controls from two water-bottling factories was performed. Respiratory symptoms were collected using the American Thoracic Society’s (ATS) standard questionnaire. A lung-function test was performed using spirometry following ATS guidelines. Data was analysed using descriptive statistics, content analysis, the Chi-square test or Fisher’s exact test, the t-test, Pearson’s correlation analysis, regression analysis and mixed-effects models. Results For Paper I the mean age of the respondents was 28, and the average years of service was 3.7. The permanent workers were older than the temporary workers (29 vs 26 years, p= 0.001), and a very high proportion of the permanent workers had completed vocational education (90%), compared with the temporary workers (11%). The permanent production workers had significantly more knowledge of topics related to chemical hazards than did temporary workers, as well as more positive responses than temporary workers to questions about attitudes related to reduction of chemical hazards and the general work environment. Educational status was significantly associated with a total knowledge score. PPE was provided for permanent workers, but few temporary workers reported PPE provision from the factory. Neither permanent nor temporary workers were using a full set of PPE. The frequency of medical check-up at the health institution was reported as being 25% for temporary and 37% for permanent workers. The administrative personnel are aware of the chemical hazards in their factory. However, the majority of them believe all PPE offers the same level of protection, and they purchase PPE without any safety and quality specification. There was no regular training on occupational safety and health in the factory. In Paper II the overall geometric mean (GM) of 142 personal inhalable dust and endotoxin exposure were 4.66 mg/m3 (range 0.47 to 184) and 62.2 EU/m3 (range 0.9 to 9202) respectively. The highest exposure to inhalable dust was found among workers performing sizing, forming, flaking and chipping. The highest endotoxin exposure was found in chipping and flaking workstation workers. Of the 142 samples, 93% exceeded 1 mg/m3, the TLV set by ACGIH for inhalable dust, and 41% samples exceeded 90 EU/m3, the occupational exposure limit for endotoxins set by the Netherlands. The correlation between dust and endotoxin level was relatively high (r= 0.68). Factories and downtime explained 27% of the total variability in inhalable dust level, while workstations explained 34% of the total variability in endotoxin level. The highest median concentration of formaldehyde was recorded at blending workstations (3.5 ppm). Formaldehyde was detected at all the selected workstations except the first and last, i.e. chipping and sizing. Of the 45 samples, 13% exceeded the Norwegian peak exposure limit of 1 ppm. In Paper III particleboard workers were older than the controls (28 vs 25 years; p= 0.006). The exposed workers had also more years of service than the controls (4 vs 2 years; p< 0.001). The prevalence of all recorded respiratory symptoms, wheezing, cough, cough with sputum production, phlegm and shortness of breath was significantly higher in particleboard workers (range of prevalence: 24% to 45%) than in controls (2.7% to 15%). Lung-function status was not statistically different when comparing the exposed persons and the controls, and did not appear to be associated with inhalable dust, endotoxins or formaldehyde exposure. Conclusions The study revealed that permanent production workers had significantly more knowledge of topics related to chemical hazards, and more a positive response to attitudes related to reduction of chemical hazards and the general working environment than temporary workers. Practice in use of PPE depended on the access to PPE. The geometric mean exposure levels to inhalable dust exposure in the particleboard factories were above the Threshold Limit Value (TLV) of 1 mg/m3 set by the American Conference of Governmental Industrial Hygienists (ACGIH). The geometric mean endotoxin level was lower than the recommended Dutch occupational exposure limit (OEL) of 90 EU/m3. However, the endotoxin levels exceeded this limit at chipping and flaking workstations. The highest median formaldehyde concentration was found in blending workstations (3.5 ppm) – a level above the peak exposure limit value of 1 ppm set by Norway. There was a higher prevalence of respiratory symptom in particleboard workers than in water-bottling workers. However, lung function status was similar in both groups. The symptoms might be related to the high dust-exposure levels found in the factories, but the results must be interpreted with caution because of the cross-sectional study design

High Prevalence of Respiratory Symptoms among Particleboard Workers in Ethiopia: A Cross-Sectional Study

Work in the wood industry might be associated with respiratory health problems. The production of particleboard used for furniture making and construction is increasing in many countries, and cause dust, endotoxin and formaldehyde exposure of the workers. The aim of the study was to assess the prevalence of respiratory symptoms and to measure lung function among Ethiopian particleboard workers using Eucalyptus trees as the raw material. In total 147 workers, 74 from particleboard production and 73 controls, participated in the study. Mean wood dust in the particleboard factories was measured to be above recommended limit values. Particleboard workers had a mean age of 28 years and the controls were 25 years. They had been working for 4 and 2 years, respectively. Lung function test was done using spirometry following American Thoracic Society (ATS) recommendations. Respiratory symptoms were collected using a standard questionnaire of ATS. Particleboard workers had higher prevalence of wheezing, cough, cough with sputum production, phlegm, and shortness of breath compared to controls. Lung function status was similar in the two groups. The symptoms might be related to the work in the factories. Longitudinal studies are recommended to explore the chronic impact of work in particleboard factories on respiratory health.publishedVersio

Days away from work injury and associated factors among waste collectors in Mekelle city, Northern Ethiopia

Introduction: In most cities of low-income countries, waste management procedures are characterized by the dominance of manual labor tasks, which therefore exposes waste professionals to numerous occupational hazards of variable nature, occurring at every stage of the waste management process. This study is aimed at investigating the days away from work injuries and associated factors among organized waste collectors in Mekelle city, Northern Ethiopia. Method: Cross-sectional study design was used from June 1 to 30, 2017. A pre-tested questionnaire and observation checklist was used to collect data. Data were analyzed using SPSS for windows 20.0. Descriptive statistics and logistic regression methods were used to describe the study population and assess the association between dependent and independent variables, respectively. Result: In this study, 279 waste collectors were involved as a study participant. Sixty-nine (69.5%) of the participants were female. Ten percent of the workers reported they had experienced at least one day away from work injuries during the last twelve months. Sex, marital status, personal protective equipment utilization, and monthly salary were statistically associated with an injury. Conclusion: Days away from work injury among waste collectors is a public health problem and might have the economic and social well-being of the workers. Thus, strengthening the provision of personal protective devices and ensuring its utilization is highly recommended

Wood-dust exposure and respiratory health among particleboard workers in Ethiopia

Background Work in the wood industry is often associated with exposure to wood dust, endotoxins and formaldehyde, which may cause respiratory health problems. Particleboard is a type of wood product manufactured primarily from wood chips, glued with urea formaldehyde resin and bonded under heat and pressure. In Ethiopia the manufacturing sector, like the wood industry, is growing. However, there is a scarcity of Knowledge, Attitude and Practice (KAP) concerning chemical health hazards and personal protective equipment (PPE) among particleboard workers. On top of this, workers’ exposure to inhalable wood dust, endotoxins and formaldehyde and their effect on respiratory health has been insufficiently studied. Objectives The aim of this thesis was to assess exposure to wood dust, endotoxins and formaldehyde, respiratory health and KAP regarding chemical hazards and use of PPE among Ethiopian particleboard workers. Method and materials The thesis consist of three papers conducted in three phases from 2016 to 2017 at the two largest particleboard factories in Ethiopia. In Phase One a cross-sectional study design was used for collection of data on KAP concerning chemical health hazards and PPE in production and administrative workers (n=172), and the study used both closed-ended and open-ended questions. Both permanent and temporary employees were included in the study. In Phase Two an exposure study was performed. A total of 152 dust and endotoxin samples were collected using a conductive plastic inhalable conical sampler (CIS) in the two largest particleboard factories. One field blank sample was taken per day (n=18). In addition, 45 stationary formaldehyde samples were taken using Dräger tubes. Inhalable dust was analysed using the gravimetric method in a room with controlled climatic conditions using an analytical balance with 0.1 μg readability, and the concentration was estimated in mg/m3. Endotoxins were analysed using the Kinetic Amoebocyte Lysate test, and the concentration was estimated in EU/m3. In Phase Three a cross-sectional study involving 74 workers from two particleboard factories and 73 controls from two water-bottling factories was performed. Respiratory symptoms were collected using the American Thoracic Society’s (ATS) standard questionnaire. A lung-function test was performed using spirometry following ATS guidelines. Data was analysed using descriptive statistics, content analysis, the Chi-square test or Fisher’s exact test, the t-test, Pearson’s correlation analysis, regression analysis and mixed-effects models. Results For Paper I the mean age of the respondents was 28, and the average years of service was 3.7. The permanent workers were older than the temporary workers (29 vs 26 years, p= 0.001), and a very high proportion of the permanent workers had completed vocational education (90%), compared with the temporary workers (11%). The permanent production workers had significantly more knowledge of topics related to chemical hazards than did temporary workers, as well as more positive responses than temporary workers to questions about attitudes related to reduction of chemical hazards and the general work environment. Educational status was significantly associated with a total knowledge score. PPE was provided for permanent workers, but few temporary workers reported PPE provision from the factory. Neither permanent nor temporary workers were using a full set of PPE. The frequency of medical check-up at the health institution was reported as being 25% for temporary and 37% for permanent workers. The administrative personnel are aware of the chemical hazards in their factory. However, the majority of them believe all PPE offers the same level of protection, and they purchase PPE without any safety and quality specification. There was no regular training on occupational safety and health in the factory. In Paper II the overall geometric mean (GM) of 142 personal inhalable dust and endotoxin exposure were 4.66 mg/m3 (range 0.47 to 184) and 62.2 EU/m3 (range 0.9 to 9202) respectively. The highest exposure to inhalable dust was found among workers performing sizing, forming, flaking and chipping. The highest endotoxin exposure was found in chipping and flaking workstation workers. Of the 142 samples, 93% exceeded 1 mg/m3, the TLV set by ACGIH for inhalable dust, and 41% samples exceeded 90 EU/m3, the occupational exposure limit for endotoxins set by the Netherlands. The correlation between dust and endotoxin level was relatively high (r= 0.68). Factories and downtime explained 27% of the total variability in inhalable dust level, while workstations explained 34% of the total variability in endotoxin level. The highest median concentration of formaldehyde was recorded at blending workstations (3.5 ppm). Formaldehyde was detected at all the selected workstations except the first and last, i.e. chipping and sizing. Of the 45 samples, 13% exceeded the Norwegian peak exposure limit of 1 ppm. In Paper III particleboard workers were older than the controls (28 vs 25 years; p= 0.006). The exposed workers had also more years of service than the controls (4 vs 2 years; p< 0.001). The prevalence of all recorded respiratory symptoms, wheezing, cough, cough with sputum production, phlegm and shortness of breath was significantly higher in particleboard workers (range of prevalence: 24% to 45%) than in controls (2.7% to 15%). Lung-function status was not statistically different when comparing the exposed persons and the controls, and did not appear to be associated with inhalable dust, endotoxins or formaldehyde exposure. Conclusions The study revealed that permanent production workers had significantly more knowledge of topics related to chemical hazards, and more a positive response to attitudes related to reduction of chemical hazards and the general working environment than temporary workers. Practice in use of PPE depended on the access to PPE. The geometric mean exposure levels to inhalable dust exposure in the particleboard factories were above the Threshold Limit Value (TLV) of 1 mg/m3 set by the American Conference of Governmental Industrial Hygienists (ACGIH). The geometric mean endotoxin level was lower than the recommended Dutch occupational exposure limit (OEL) of 90 EU/m3. However, the endotoxin levels exceeded this limit at chipping and flaking workstations. The highest median formaldehyde concentration was found in blending workstations (3.5 ppm) – a level above the peak exposure limit value of 1 ppm set by Norway. There was a higher prevalence of respiratory symptom in particleboard workers than in water-bottling workers. However, lung function status was similar in both groups. The symptoms might be related to the high dust-exposure levels found in the factories, but the results must be interpreted with caution because of the cross-sectional study design

Dust Exposure and Respiratory Health among Selected Factories in Ethiopia: Existing Evidence, Current Gaps and Future Directions

Workers who are working in dusty environments might be associated with respiratory health problems. In Ethiopia, factories processing wood, textile, coffee, flour, cement and other materials are associated with dust emission. Furthermore, despite the adoption of the International Labor Organization (ILO) convention, the available constitution and labor proclamation, there are a lot of gaps in terms of occupational health and safety measures in Ethiopia. The current review aims to examine the existing evidence, current challenges and future direction regarding dust exposure and respiratory health in selected Ethiopian factories. Searches of peer-reviewed articles with full-length papers were made in online databases such as PubMed, Web of Science, MEDLINE, EMBASE and Google Scholar with a key words “Dust exposure”, “Respiratory health”, “Respiratory symptom”, “Ethiopia” and “Factory workers” from January 2000 to March 2023. The review found that excessive dust exposure is associated with a high prevalence of respiratory health problems. Lack of personal protective equipment and absence of safety and health training were the main occupational health deficits identified in most factories. Actions that focus on these deficiencies are commendable. Interventions focused on safety and health trainings, and the provision of adequate personal protective equipment of the required quality is recommended. In addition, administrative solutions and longitudinal studies on dust exposure and respiratory health are suggested

Status of infection prevention and control (IPC) as per the WHO standardised Infection Prevention and Control Assessment Framework (IPCAF) tool: existing evidence and its implication

Summary: Healthcare settings have a high prevalence of infectious agents. This narrative review examines the existing evidence regarding infection prevention and control (IPC) using the WHO Infection Prevention and Control Assessment Framework (IPCAF) tool in healthcare facilities. A total of 13 full length papers from Africa, Asia and Europe were considered for this review. The findings showed that there are discrepancies in the IPCAF values from insufficient to advanced level. The current review shows an advanced IPCAF level in middle income and high income countries. Low income countries showed a lower IPCAF score. There is a need to enhance the IPC capacity building and to supply infection prevention resources to prevent healthcare associated infection (HAI) with a focus on low income countries

Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

Background: Understanding the health consequences associated with exposure to risk factors is necessary to inform public health policy and practice. To systematically quantify the contributions of risk factor exposures to specific health outcomes, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 aims to provide comprehensive estimates of exposure levels, relative health risks, and attributable burden of disease for 88 risk factors in 204 countries and territories and 811 subnational locations, from 1990 to 2021. Methods: The GBD 2021 risk factor analysis used data from 54 561 total distinct sources to produce epidemiological estimates for 88 risk factors and their associated health outcomes for a total of 631 risk–outcome pairs. Pairs were included on the basis of data-driven determination of a risk–outcome association. Age-sex-location-year-specific estimates were generated at global, regional, and national levels. Our approach followed the comparative risk assessment framework predicated on a causal web of hierarchically organised, potentially combinative, modifiable risks. Relative risks (RRs) of a given outcome occurring as a function of risk factor exposure were estimated separately for each risk–outcome pair, and summary exposure values (SEVs), representing risk-weighted exposure prevalence, and theoretical minimum risk exposure levels (TMRELs) were estimated for each risk factor. These estimates were used to calculate the population attributable fraction (PAF; ie, the proportional change in health risk that would occur if exposure to a risk factor were reduced to the TMREL). The product of PAFs and disease burden associated with a given outcome, measured in disability-adjusted life-years (DALYs), yielded measures of attributable burden (ie, the proportion of total disease burden attributable to a particular risk factor or combination of risk factors). Adjustments for mediation were applied to account for relationships involving risk factors that act indirectly on outcomes via intermediate risks. Attributable burden estimates were stratified by Socio-demographic Index (SDI) quintile and presented as counts, age-standardised rates, and rankings. To complement estimates of RR and attributable burden, newly developed burden of proof risk function (BPRF) methods were applied to yield supplementary, conservative interpretations of risk–outcome associations based on the consistency of underlying evidence, accounting for unexplained heterogeneity between input data from different studies. Estimates reported represent the mean value across 500 draws from the estimate's distribution, with 95% uncertainty intervals (UIs) calculated as the 2·5th and 97·5th percentile values across the draws. Findings: Among the specific risk factors analysed for this study, particulate matter air pollution was the leading contributor to the global disease burden in 2021, contributing 8·0% (95% UI 6·7–9·4) of total DALYs, followed by high systolic blood pressure (SBP; 7·8% [6·4–9·2]), smoking (5·7% [4·7–6·8]), low birthweight and short gestation (5·6% [4·8–6·3]), and high fasting plasma glucose (FPG; 5·4% [4·8–6·0]). For younger demographics (ie, those aged 0–4 years and 5–14 years), risks such as low birthweight and short gestation and unsafe water, sanitation, and handwashing (WaSH) were among the leading risk factors, while for older age groups, metabolic risks such as high SBP, high body-mass index (BMI), high FPG, and high LDL cholesterol had a greater impact. From 2000 to 2021, there was an observable shift in global health challenges, marked by a decline in the number of all-age DALYs broadly attributable to behavioural risks (decrease of 20·7% [13·9–27·7]) and environmental and occupational risks (decrease of 22·0% [15·5–28·8]), coupled with a 49·4% (42·3–56·9) increase in DALYs attributable to metabolic risks, all reflecting ageing populations and changing lifestyles on a global scale. Age-standardised global DALY rates attributable to high BMI and high FPG rose considerably (15·7% [9·9–21·7] for high BMI and 7·9% [3·3–12·9] for high FPG) over this period, with exposure to these risks increasing annually at rates of 1·8% (1·6–1·9) for high BMI and 1·3% (1·1–1·5) for high FPG. By contrast, the global risk-attributable burden and exposure to many other risk factors declined, notably for risks such as child growth failure and unsafe water source, with age-standardised attributable DALYs decreasing by 71·5% (64·4–78·8) for child growth failure and 66·3% (60·2–72·0) for unsafe water source. We separated risk factors into three groups according to trajectory over time: those with a decreasing attributable burden, due largely to declining risk exposure (eg, diet high in trans-fat and household air pollution) but also to proportionally smaller child and youth populations (eg, child and maternal malnutrition); those for which the burden increased moderately in spite of declining risk exposure, due largely to population ageing (eg, smoking); and those for which the burden increased considerably due to both increasing risk exposure and population ageing (eg, ambient particulate matter air pollution, high BMI, high FPG, and high SBP). Interpretation: Substantial progress has been made in reducing the global disease burden attributable to a range of risk factors, particularly those related to maternal and child health, WaSH, and household air pollution. Maintaining efforts to minimise the impact of these risk factors, especially in low SDI locations, is necessary to sustain progress. Successes in moderating the smoking-related burden by reducing risk exposure highlight the need to advance policies that reduce exposure to other leading risk factors such as ambient particulate matter air pollution and high SBP. Troubling increases in high FPG, high BMI, and other risk factors related to obesity and metabolic syndrome indicate an urgent need to identify and implement interventions

Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations. METHODS The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds. FINDINGS The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles. INTERPRETATION Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere. FUNDING Bill & Melinda Gates Foundation

Knowledge, attitude and practice related to chemical hazards and personal protective equipment among particleboard workers in Ethiopia: a cross-sectional study

Background: Work in the wood industry is often associated with exposure to wood dust and formaldehyde. The aims of this study were to describe the Knowledge, Attitude and Practice (KAP) concerning chemical health hazards among particleboard workers and to compare the KAP among temporary and permanent workers. Methods: A cross-sectional study design was used to collect data by structured questionnaires in two particleboard factories in Ethiopia. A total of 159 workers and 13 management personnel participated in this study. Both closed-ended and open-ended questions were included in the interviews. Chi-square tests, T tests and correlation analyses were used for categorical and continuous data. Total knowledge score (range 0–8) was calculated as the sum score of 8 items weighing one point each. Multiple linear regression was applied to estimate the impact of employment status on total knowledge score adjusted for level of education. Content analysis was applied to analyse collected data from open-ended questions. Results: The mean age of the respondents was 28 (SD = 6) years and on average they had 3.7 [3] years of service. The permanent workers were older than the temporary workers (29 vs 26 years, p = 0.001), and a considerably high fraction of the permanent workers had vocational education (90%) compared to the temporary workers (11%). Permanent workers had higher proportion of response on knowledge of 10 of 12 topics regarding chemical hazards and attitudes on 6 of 11 of these topics than temporary workers. Permanent workers had higher knowledge scores (3.7) compared to temporary workers (1.3) (p < 0.001), also after adjusting for education (p = 0.011). Permanent workers were provided with personal protective equipment (PPE) while temporary workers were not. The qualitative data helps to understand the workers and administrative personnel attitude and thinking regarding chemical hazards and PPE. Conclusions: The findings revealed that permanent workers have higher proportion of positive response on knowledge and attitude towards chemical health hazards than temporary workers. However, practice in use of PPE depended on access to PPE. Few temporary workers were provided with PPE

High Prevalence of Respiratory Symptoms among Particleboard Workers in Ethiopia: A Cross-Sectional Study

Work in the wood industry might be associated with respiratory health problems. The production of particleboard used for furniture making and construction is increasing in many countries, and cause dust, endotoxin and formaldehyde exposure of the workers. The aim of the study was to assess the prevalence of respiratory symptoms and to measure lung function among Ethiopian particleboard workers using Eucalyptus trees as the raw material. In total 147 workers, 74 from particleboard production and 73 controls, participated in the study. Mean wood dust in the particleboard factories was measured to be above recommended limit values. Particleboard workers had a mean age of 28 years and the controls were 25 years. They had been working for 4 and 2 years, respectively. Lung function test was done using spirometry following American Thoracic Society (ATS) recommendations. Respiratory symptoms were collected using a standard questionnaire of ATS. Particleboard workers had higher prevalence of wheezing, cough, cough with sputum production, phlegm, and shortness of breath compared to controls. Lung function status was similar in the two groups. The symptoms might be related to the work in the factories. Longitudinal studies are recommended to explore the chronic impact of work in particleboard factories on respiratory health