3 Chapter 1 OVERVIEW 1.1. REALITY OF WORKING ENVIRONMENT, ALLERGIC RHINITIS, AND SOME RELATED FACTORS a. The reality of the working environment The

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1 1 LIST OF ACRONYMS ARIA : Allergic Rhinitis and its Impact Asthma - Research Institute Impact of allergic rhinitis on bronchial asthma CysLTs : Cysteinyl-leukotrienes DN : Allergens DNBB : Cotton dust allergen DNNN : Occupational allergens HPQ : Bronchial asthma IR : Index of Reactivity KLPT : Molecular mass KN-KT : Antigen-antibody LTA4 : Leukotriene A 4 LTRAs : Anti-leukotrienes MDDH : Specific immunology TCVSCP : Sanitary standards allow VKM : Conjunctivitis VMDU : Allergic rhinitis VMDUNN : Occupational allergic rhinitis WHO : World Health Organization

2 2 INTRODUCTION In our country, the textile industry is playing an increasingly important role in the national economy. Due to being continuously exposed to textile dust at work, workers are vulnerable to occupational allergic diseases such as allergic rhinitis, bronchial asthma... There have been many studies on the relationship between the labor environment and allergic rhinitis among garment workers, but there is no study evaluating the effectiveness of s in the prevention and treatment of these diseases, From the above situation, we conducted a research on " the reality of allergic rhinitis among industrial textile workers and the effectiveness of some s in 2016" with the objectives: 1. Describe the current situation of labor environment, allergic rhinitis and some factors related to diseases of workers at Hoang Thi Loan Textile-Garment Jointstock Company, Nghe An, Describe the clinical and laboratory characteristics of allergic rhinitis among workers at Hoang Thi Loan Textile Joint Stock Company, Evaluate the effectiveness of s in the prevention and treatment of allergic rhinitis among employees at Hoang Thi Loan Textile Joint Stock Company. The study, therefore, recommends the application of s to protect and promote worker s health in a feasible and scientific way. * New contributions of the thesis: This is the first thesis to use nasal wash and Avamys nasal spray to prevent and treat allergic rhinitis in industrial textile workers. * Thesis structure: The thesis has 126 pages including: Problem: 02 pages; Overview: 36 pages; Study method: 23 pages; Study results: 29 pages; Comment: 33 pages; Conclusion: 2 pages; Recommendation: 1 page. The thesis has 35 tables, 11 figures, and 118 references.

3 3 Chapter 1 OVERVIEW 1.1. REALITY OF WORKING ENVIRONMENT, ALLERGIC RHINITIS, AND SOME RELATED FACTORS a. The reality of the working environment The microclimate factors directly affect the health of industrial textile workers include temperature, humidity and wind speed in the factory. As the temperature rises, the wind speed decreases as well as the high moisture of workers dehydration, fatigue, reduced resistance, susceptible to respiratory diseases. Cotton dust generated during production process can cause respiratory diseases such as allergic rhinitis, bronchial asthma, pneumoconiosis. Studies show that when high dust concentrations, the incidence of allergic rhinitis in workers increase. b. The condition of allergic rhinitis In Vietnam, according to various studies, the incidence of allergic rhinitis is between 10% and 18% of the population. In Japan, 20% of the population regularly suffer from AR. According to Kim BK et al (2014) in Korea, the rate of AR is 13.3%. In China, the study by Su N, Lin J et al shows that the rate of allergic rhinitis is 17.6%. Chaari et al. (2009) in France found that there is 8.5% of textile workers have allergic rhinitis. The study of Vu Minh Thuc, Pham Van Thuc in 2002, the rate of occupational allergic rhinitis due to cotton dust was 32.5% c. Relationships between many factors and allergic rhinitis There are many factors that are associated with allergic rhinitis in textile workers: climate microbiology, sex, age, working seniority, masks use and KAP about allergic rhinitis CLINICAL AND SUBCLINICAL CHARACTERISTICS OF ALLERGIC RHINITIS Clinical features Allergic rhinitis is characterized by the following symptoms: itchy nose, sneezing, runny nose and nasal congestion. Howeverthe severity of these symptoms varies among patients. Through the clinical examination of allergic rhinitis patients, especially endoscopy, see the following symptoms: nasal mucosa varies from light purple to pale; swelling or hypertrophy of inferior turbinate; The nasal cavity has many secretions. Septal deviation and nasal polyps can also be observed. Allergic rhinitis is often associated with allergic manifestations in other organs such as allergic conjunctivitis (itching of the eyes, tearing of the eyes, redness of the eyes, swelling of the eyes), bronchial asthma and atopic dermatitis (allergic rash) Subclinical characteristics a. Skin prick test is a basic test and is first performed to diagnose allergic rhinitis. If the mast cells in the skin of patients carry on their surface IgEs specific for

4 4 this site, the cells will drain the seeds causing a papular reaction for minutes after the skin prick test. b. IgE levels: normal human IgE levels are below 100 IU / ml, with elevated IgE levels in patients with allergic rhinitis. treatment, the level of IgE decreased. c. IgG dosage is the protective antibody that replaces the IgE antibody. The IgG protects the body: preventing IgE from attaching to the mast cells and basophil, thus not causing cell death. treatment, the amount of IgG increased PREVENTIVE AND TREATMENT SOLUTIONS FOR ALLERGIC RHINITIS a. Personal Precaution (wearing mask) As one of the measures to prevent harmful factors directly affect the health of employees. For textile workers, wearing masks at work is an effective way to reduce respiratory diseases. b. Nasal irrigation: Nasal Irrigation is a personal hygiene procedure performed by filling the nasal cavity with warm salt water. The purpose of nasal irrigation is to clean the dirt, excess mucosa small particles; moisten the nasal cavity and restore the physiological state of the nasal mucosa, to reduce the incidence of sinusitis. Currently, there are a number of nasal irrigation methods, in which the Netti (Netti pot) procedure is clinically proven to be safe, beneficial and have no significant side effects. c. Nasal spray with Avamys This is a nasal spray that contains the fluticasone furoate from GlaxoSmithKline, which was launched in Studies have shown that Avamys helps improve nasal and ocular symptoms that are maintained more than 24 hours after spraying

5 5 Chapter 2 METHODOLOGY 2.1. STUDY SITES The research was carried out at 02 factories of Hoang Thi Loan textile-garment Joint Stock Company, Nghe An province: Halotex Garment Factory and Hoang Thi Loan Knitting Factory STUDY TIME The study was conducted from August 2016 to August STUDY SUBJECTS The subjects described are the working environment and sewing workers. Participants in the study were selected from allergic rhinitis workers 2.4. STUDY DESIGN Cross-sectional descriptive design combined with comparative research STUDY SAMPLE SIZE Sample size descriptive study * Sample size for worker health research: Sample size: calculated according to the following formula: [22] 2 p(1 p) n Z1 /2 d 2 n: Study sample rounded to 900 workers; α: 0.05; Z1-a / 2: 1.96; p = Actually took all 1040 workers * Sample size for environmental testing study: according to the formula: s 2 n = Z21-α / 2 2 ( X ) n: research sample size is 30; average value in the research on the environmental dust of Nguyen Dinh Dung = 15 mg / m3 air; s: standard deviation also in this study s = 6; ε: relative deviation between sample and population parameters. Assignment ε = The sample size for the study n= Z 1 α 2 2 2p 1 p + Z 1 β p 1 1 p 1 + (p 2 (1 p 2 ) p 1 p 2 2 Inside: n: is the minimum sample size, the number of patients with one of the four symptoms of allergic rhinitis during the period (referred to as allergic rhinitis). Z = 1.96; Z1-β = 0.84 (β = 0.20, sample force is usually chosen to be 80%) p1: Based on our initial survey results in this study (Table 3.25): Percentage of patients At least one of the four symptoms of occupational allergic rhinitis was 77% (p1 = 0.77) before ; 75% rhinitis (p1 = 0.75); nasal obstruction 54% (p1 = 0.54); runny nose 30% (p1 = 0.30).

6 6 p2: The post- estimation suggested that the proportion of patients with 1 in 4 symptoms of allergic rhinitis in workers would be reduced by 23%. Thus, p2 (sneezing) = 0.54 (54%); p2 (nose itching) = 0.52 (52%); p2 (nose congestion) = 0.31 (31%); p2 (nasal discharge) = 0.07 (7%). Replacing the data, results are calculated: n (sneezing) = 52 people; n (nose itching) = 54; n (nosebleed) = 54 people; n (nosebleeds) = 35 people. The minimum sample size was n = 54 patients. In fact, the number of workers per standard group, do not give up and good long-term good practice in the group to take and statistical analysis: group 1 (AVAMYS + nasal wash) = 54; Group 2 (Health Education Communication + Labor Protection) = 37 people HOW TO CONDUCT STUDY a. How to conduct the study for Objective 1 and 2: + Measurement of temperature, humidity, wind speed, dust concentration of working environment. + General health and ENT endoscopy to determine the rate of allergic rhinitis, general rhinitis, nasal polyps and nasal septum deformity. + Prick test, quantify IgE, IgG. + Ask to determine the history of asthma, rash. + Interviews to determine the working seniority, working time per day, the use of masks, knowledge of the practice of allergic rhinitis. b. How to conduct the study for objective 3: + Select allergic rhinitis as two groups: group 1 includes 34 people were educated communication and wearing the medical mask; Group 2 consisted of 54 subjects with nasal irrigation with physiological saline and the nasal spray of Avamys Endoscopic examination after 6 months of to redefine the clinical manifestations and quantification of IgE, IgG. From there, we calculate the effectiveness of the

7 7 Chapter 3 RESULTS 3.1. REALITY OF WORKING ENVIRONMENT, ALLERGIC RHINITIS, AND SOME RELATED FACTORS Working environment Microclimate Table 3.1. Meteorological results at factories No Measurement location Measurement sample Average temperature (X±SD) Moisture (%) Wind speed (m/s) QCVN 26/ o C ,1 1,5 A. HTLFiber Factory X ± SD X ± SD X ± SD 1 Outdoor 03 33,17 ± 2,3 68,9 ± 6,02 0,55 ± 0,1 2 Fiber factory I Cotton Plant 12 33,21 ± 1,06 69,78 ± 3,79 0,32 ± 0,09 Brush machine area 12 34,53 ± 0,96 61,98 ± 3,5 0,47 ± 0,1 Crude assembly 09 34,18 ± 0,91 65,49 ± 4,51 0,36 ± 0,07 area Sub machine area 09 36,52 ± 1,05 56,06 ± 6,37 0,43 ± 0,09 Connected area 03 35,43 ± 0,96 64,53 ± 3,59 0,95 ± 0,06 3 Fiber factory II Cotton plant 03 32,57 ± 1,79 65,23 ± 1,79 0,26 ± 0,01 OE plant 12 33,38 ± 2,15 67,75 ± 7,79 0,36 ± 0,09 B. HalotexcoGarment Factory 1 Outdoor 03 38,87 ± 1,27 76,13 ± 5,32 1,12 ± 0,18 2 Garment plant I Cutting plant 03 31,7 ± 1,1 70,93 ± 1,68 0,48 ± 0,01 Selective embryos area 03 30,03 ± 0,35 76,53 ± 2,68 0,62 ± 0,01 Machine units 12 29,59 ± 1,06 76,97 ± 2,26 0,62 ± 0,13 packaging area 03 29,37 ± 0,65 78,73 ± 0,67 0,87 ± 0,03 3 Garment plant II Cutting plant 03 30,5 ± 0,61 76,44 ± 2,00 0,59 ± 0 Selective embryos area 03 33,97 ± 0,49 75,53 ± 1,65 0,63 ± 0,04 Machine units 12 30,42 ± 2,36 77 ± 2,05 0,5 ± 0,05 Packaging area 03 30,3 ± 1,04 73,97 ± 2,3 0,37 ± 0,03 4 Fiber factory MURATA machine 09 33,5 ± 0,74 73,21 ± 2,06 0,25 ± 0,02 KAMITSU machine 06 32,98 ± 0,87 73,98 ± 2,31 0,2 ± 0,01 Production area 03 32,87 ± 1,5 74,1 ± 1,68 0,16±0,006 Remarks: The temperature indices at 4/5 of the measured locations in the factory of HTL Spinning Factory exceeded the allowable limits as specified in QCVN 26/2016, including: Brush machine area (34.53 ± 0.96 ); Crude assembly area(34.18 ± 0.91); Submachine area (36.52 ± 1.05) and Connected area (35.43 ± 0.96). At the rest of the plants, the temperature indexes were below the allowed standard. Average humidity and wind speed at all measurement points reach permitted sanitation standards.

8 Dust in the working environment Table 3.2: Cotton dust in the working environment of the company No Measurement location Cotton Dust QCVN 26/2016/TT-BYT 1 (mg/m 3 ) A. HTL Fiber Factory 1 Fiber factory I Cotton Plant 1,34 ± 0,24 Brush machine area 0,62 ± 0,09 Crude assembly area 0,74 ± 0,06 Sub machine area 0,58 ± 0,11 Connected area 0,72 ± 0,02 2 Fiber factory II Cotton plant 0,75 ± 0,03 OE plant 0,57 ± 0,12 B. Halotexco Garment Factory 1 Garment plant I 8 Cutting plant 0,62 ± 0,03 Selective embryos area 0,35 ± 0,04 Machine units 0,39 ± 0,06 packaging area 0,38 ± 0,02 2 Garment plant II Cutting plant 0,75 ± 0,03 Selective embryos area 0,43 ± 0,01 Machine units 0,36 ± 0,12 Packaging area 0,44 ± 0,02 3 Fiber factory MURATA machine 0,79 ± 0,06 KAMITSU machine 0,8 ± 0,06 Production area 0,69 ± 0,04 Comment: The highest average density of cotton dust was determined at Cotton Plant in Textile Factory, Hoang Thi Loan Textile Company (1.34 ± 0.24mg / m3); Particularly in 11/12 samples exceeded permitted sanitation standards, only one sample produced mg / m3 under permitted sanitation standards, but also very high, approximately permitted sanitation standards. The rest of the plants, the concentration of cotton dust is lower than permitted sanitation standards (01 mg / m3).

9 Current status of allergic rhinitis and some related factors 9 Table 3.3. The rate of allergic rhinitis HTL Factory Halotexco Factory The company Allergic rhinitis Frequenc Frequency % y % Total % Yes , , ,5 No , , ,5 Total Comment: The rate of the whole company is 30.5% in which rate of allergic rhinitis Hoang Thi Loan and Halotexco garment companies are respectively 26.7% and 34.7%. Table 3.4. The relationship between allergic rhinitis and sex Allergic rhinitis Noneallergic rhinitis OR Basis survey Sex Frequency % Frequency % 95%CI Female 73 25, ,2 0,91 Male 73 27, ,3 0,62 1,33 HTL fiber factory Halotexco Female , ,6 2,03 garment 1,06-3,86 factory Male 13 22, ,0 The company Female , ,8 1,31 Male 86 26, ,4 1,01 1,75 Comment: At Halotexco Garment Factory, women workers are at risk of allergic rhinitis 2.03 times higher than male workers (p <0.05), at the same time Hoang Thi Loan Company, Women workers were 1.31 times more likely than men to have allergic rhinitis. This difference was statistically significant at p <0.05. Table 3.5. The relationship between allergic rhinitis and age Allergic rhinitis None allergic rhinitis OR Ages Frequency % Frequency % 95%CI , , , ,4 1,27 0,95 1, , ,6 1,79 1,19 2,71 > , ,5 0,99 0,45 2,19 Comment: Workers in the age group were 1.27 times more likely to have allergic rhinitis than those less than 30 years of age with a 95% CI of 0.95 to 1.71 (p> 0,05); Age group was associated with an increased risk of allergic rhinitis by 1.79 times compared to those under 30 years of age with a 95% CI of 1.19 to 2.71 (p = 0.006).

10 10 Table 3.6. The relationship between allergic rhinitis and two age groups Ages Allergic rhinitis None allergic rhinitis OR Frequenc % Frequency % 95%CI y 30 YO , ,1 1,35 < 30 YO , ,4 1,03 1,78 Comment: Workers over 30 years old were at 1.35 times more likely to be infected with the VMD than those under age 30 with p <0.05 (OR = 1.35; 95% CI: ). Table 3.7. The relationship between allergic rhinitis and work seniority Work Allergic rhinitis None allergic rhinitis OR seniority Frequency % Frequency % 95%CI < 5 years , ,1 1 5-<10 years 48 27, ,7 0,97 0,65 1, years 87 32, ,2 1,26 0,91 1,48 > 20 years 1, , ,3 1,03 2,20 Comment: A group of workers aged 10 to under 20 years had an increased risk of allergic rhinitis, which was 1.26 times higher than the age group less than five years with a 95% CI of ,48; Groups of 20 years or older were 1.50 times more likely to suffer from allergic rhinitis than those less than 5 years of age with a 95% confidence interval of OR ( ). p = 0.038). Table 3.8. The relationship between workers wearing masks and allergic rhinitis Mask wearing None allergic Allergic rhinitis OR rhinitis 95%CI Frequency % Frequency % None 24 27, ,4 0,858 Yes , ,3 0,53 1,40 Irregular 53 29, ,9 0,924 Regular , ,2 0,65 1,31 Popular mask , ,8 2,030 Professional mask 26 19, ,0 1,29 3,18 Comment: Workers wearing masks have a 2.03 times higher risk of having the VMDU than those who use specialized masks with p <0.05.

11 11 Table 3.9. The relationship between one-day exposure to dust of workers and allergic rhinitis Exposure Time Allergic rhinitis None allergic rhinitis OR Frequency % Frequency % 95%CI >= 8 hours , ,2 2,034 < 8 hours 19 18, ,4 1,21 3,41 Comment: Workers exposed to dust> 8 h per day have a 2.03-fold higher risk of VMDU than workers with dust exposure less than 8 hours per day. This difference was statistically significant at p <0.05. Table The relationship between the medical history of asthma and allergic rhinitis Asthma history Allergic rhinitis None allergic rhinitis OR Frequency % Frequency % 95%CI Yes 3 33,3 6 66,7 1,14 No , ,5 0,29 4,60 Comment: Workers with a history of asthma were 1.14 times more likely to have a history of asthma than those who did not have asthma in the past, which was not statistically significant with OR 95% confidence intervals. is , p> Table The relationship between a history of rash and allergic rhinitis Allergic rhinitis None allergic rhinitis OR Rash history Frequency % Frequency % 95%CI Yes 91 44, ,6 2,15 No , ,9 1,57 2,95 Comment: Workers with a history of acute redness have a 2.25-fold higher risk of viral hepatitis than in the past, with no difference in the risk of allergic rhinitis. <0.05 (CI: 95%; OR: ) Clinical and subclinical characteristics of allergic rhinitis Clinical symptoms Table Nasal symptoms (n = 317) Degrees Severe Moderate Mild None Total Symptoms Sneezing Itchy nose Stuffy nose Runny nose Frequency % Frequency % Frequency % Frequency % Frequency % , , , , , , , , , , , , ,6 16 5, , ,

12 12 Comment: Patients with severe sneezing and nasal congestion were 62.8% and 60.6%, respectively. Severe nasal congestion 41.0% and 32.8% with no congestion. Patients with no nasal discharge accounted for a rate of 39,2%. Table Degrees of symptoms of the eye (n = 317) Symptoms/ Degrees Regularly Occasionally None appearance Total appearance Frequency % Frequency % Frequency % Frequen Tears 65 20,5 15 4, , itchy eyes ,2 12 3, , Red eyes 82 25,9 4 1, , Swollen years 40 12,6 4 1, , Comment: Frequent ocular itching is the most prominent symptom, accounting for 49.2%. Table The proportion of nasal septal deformation Halotexco garment HTL fiber factory Status factory The company Frequency % Frequency % Frequency % Septal deformation 68 46, , ,23 Normal 78 53, , ,77 Total Comment: There are 31.23% of VMDU cases are deformed partition, in which the proportion of deformed partition at Hoang Thi Loan spinning factory is 46.58% higher than this ratio at Halotexco garment factory 18,13%. Table The rate of workers suffering from nasal polype Halotexco garment HTL fiber factory Status factory The company Frequency % Frequency % Frequency % Nasal polype 8 5, ,7 None nasal polype , ,3 Total Comment: 4.7% of cases of nasal polyps were treated with nasal polyps, of which the rate at Hoang Thi Loan fiberglass plant was 5.5% higher than that of the 4% Halotexco garment factory Subclinical results Table Prick test results with cotton dust allergen Results Positive Negative Total Frequency % Frequency % Frequency % Prick test , , Comment: There are 50.8% of cases where VMDU has a positive test prick. cy

13 13 Table IgE test results for patients with allergic rhinitis (n=317) Results Min Max X±SD(mg/dl) IgE 3, ,9 ± 511,8 Comment: The average IgE test result was ± UI / ml; The highest was 2814 UI / ml and the lowest was 3.8 UI / ml Table Total IgG test results for allergic rhinitis (n=317) Results Min Max X±SD(mg/dl) IgG ,7 ± 313,3 Comment: The average IgG test result was ± mg/dl; The highest was 2660 mg/dl and the lowest was 809 mg/dl 3.3. Intervention efficiency assessment Clinical efficacy Avamys +Nasal wash No more symptome s 5% Education and mask wearing No more sympto mes 54% Still sympto mes 46% Still symptom es 95% Figure 3.2. Clinical results after Comment: the Avamys + nasal wash, 53.7% of workers no longer complained of symptoms; only 5.4% of the respondents did not complain of allergic rhinitis. Table Intervention effectiveness of sneezing symptoms of two groups before and after treatment Degrees Study group 1 Education + labor protection Study group 2 Avamys + nasal wash Frequency % Frequency % Frequency % Frequency % Effectiveness of (%) Severe 12 32,4 8 21, ,5 5 9,2 37,8 Moderate 19 51, , , ,5 32,7 Mild 4 10,8 5 13,5 5 9,2 9 16,7 56,5 None 2 5, ,7 4 7, ,6 201,3

14 14 Comment: Highest effectiveness of the among non-sneezing nose was 201.3%; Subsequently, mild sneezing nose was slightly increased (56.5%). Table The effectiveness of s in the degree of itchy nose in both groups before and after treatment Degrees Study group 1 Education + labor protection Study group 2 Avamys + nasal wash Frequency Frequency Frequency Frequency Frequency % Frequency % Effectiveness of (%) Severe 9 24,3 4 10, ,9 4 7,4 15,8 Moderate 17 45,9 9 24, , ,4 2,2 Mild 7 19,0 8 21,6 9 16, ,4 8,5 None 4 10, , , ,8 147,0 Comment: Highest effectiveness of the among allergic rhinitis with nonitchy nose was 147.0%; Subsequently, the symptoms of allergic rhinitis with severe itchy nose was significantly reduced with the effectiveness of the : 15.8%. Table The effectiveness of on the degrees of nasal congestion symptoms in both pre and post treatment groups Degrees Study group 1 Education + labor protection Study group 2 Avamys + nasal wash Frequency % Frequency % Frequency % Frequency % Effectiveness of (%) Severe 2 5,4 1 1,3 8 14,8 0 0,0 24, 1 Moderate 20 54, , ,1 7 13,0 52,9 Mild 11 29, , , ,0 22,3 None 4 10,5 5 16,3 3 5, ,0 505,5 Comment: Highest effectiveness of the in people with allergic rhinitis not stuffy nose is 505.5%; followed by moderate congestion significantly decreased with the effectiveness of the 52.9%. Table The effectiveness of s for runny nose in both treatment groups before and after treatment Degrees Study group 1 Education + labor protection Study group 2 Avamys + nasal wash Frequency % Frequency % Frequency % Frequency % Effectiveness of (%) Severe 2 5,4 2 5,4 9 16,6 0 0,0 100,0 Moderate 19 51, , ,0 2 3,7 74,6 Mild 15 42, , , ,4 17,6 None 1 1,3 3 8,2 6 9, ,9-78,7

15 15 Comment: Highest effectiveness of the in people with the severe runny nose is 100.0%; followed by a moderate runny nose of 74.6%. Table The effectiveness of on the level of symptoms of loss/smelling of two groups before and after treatment Degrees Study group 1 Study group 2 Frequency Frequency % Frequency Frequency % Frequency % Effectiveness of (%) Lost smell 1 1,3 1 1,3 4 7,4 4 7,4 0,0 Decreased smell Normal smell 11 29, , , ,5 39, , , , ,1 24,8 Comment: HQCT with smell reduction is 39.7%; The normal group rate increased with the effect of 24.8%. Table The effective of nasal mucosal status between the two groups before then after treatment Status of the nasal mucosa Study group 1 Study group 2 (n=54 n % n % n % Effectiveness of (%) Severe 11 29, , ,34 4 7,41 40,1 Moderate 16 43, , , ,22 10,3 Normal 10 27, , , ,37 92,3 Comment: The above table shows that the effect had the best effect on the improvement of the normal mucosa with the efficiency index of 92.3%. Table The effective of hypertrophy of inferior turbinate between the two groups before and after treatment Degree of inferior turbinate hypertrophy Study group 1 Study group 2 Frequency % Frequency % Frequency % Frequency % Effectiveness of (%) Severe 2 5,4 2 5,4 5 9,2 2 3,7 59,8 Moderate 19 52, , , ,1 58,5 Normal 16 43, , , ,2 28,9 Comment: The above table shows that the effect had the best effect on the inferior turbinate hypertrophy with severe and moderate degree with an index of 59.8% and 50.6%.

16 Subclinical efficacy Table IgE levels before and after IgE levels 16 Study group 1 Study group 2 Min 144,0 128,0 106,0 58,0 Max 2814,0 1298,0 2014,0 1432,0 Median 536,0 580,0 360,5 207,0 X±SD (IU/ml ) 523,6 ± 467,7 361,1 ± 360,1 680,2 ± 610,2 603,0 ± 368,5 Comment:, IgE levels decreased significantly in group 2 with X ± SD from ± to ± (IU / ml), while group 1 decreased slightly from ± to ± (IU / ml). Table IgG levels before and after IgE levels Study group 1 Study group 2 Min Max Median X±SD (IU/ml ) ± ± ± ± Comment: the, two groups of patients with IgG serum levels were significantly (± SD) ± and ± mg/dl, respectively.

17 17 Chapter 4 DISCUSSION 4.1. Reality of working environment, allergic rhinitis, and some relevant factors About the current situation of the working environment About microclimate The results showed that the samples of temperature index at Hoang Thi Loan fiber factory exceeded the limit. Caused by the hot sun, the factory does not have air condition, some areas are not equipped with fans. Moisture and wind speed in the two plants reached the permitted standars. The results also show that in general, the microclimatic factor of Hoang Thi Loan Textile and Garment Corporation is better than the garment factories in Thai Nguyen in the study by Hoang Thi Thuy Ha in However, compared with the results of the study published in 2017 by Bui Hoai Nam, the sample of temperature in the working environment was reached by the employer. the sample of moisture exceeded permitted standars 14.3%, these positions exceed %; Wind speed samples were 26.9% lower than those under permitted standars About dust in working environment Our results show that most of the cotton dust concentrations in the two factories are lower than the TC. The highest density of cotton dust in Cotton Plant was 1.29 ± 0.24mg / m3 and exceeded permitted sanitation standars at 11/12 samples and 1 sample for mg / m3. This result is lower than that of Nguyen Huy Dan (1988), which indicates that the working environment is usually between 2.2 and 56 mg / m3. Compared with previous research results show that: Equivalent to the research results of Nguyen Duc Trong (2004), the concentration of respiratory dust and total dust in May II factory of Ha Textile Company In all cases, the concentration of dust was about ,02 mg / m3, total dust concentration ranged from 0.2 to 0.35 mg / m About the condition of allergic rhinitis and related factors a. The condition of allergic rhinitis Our results show that 30.5% of patients with Allergic rhinitis. This result is higher than the result in research by Hoang Thi Thuy Ha (2015) is 19.3%; Chaari et al. (2009) is 8.5%. The research conducted by the Department of Allergy and Otorhinolaryngology for factory workers in 8/3 and Nam Dong wool carpets in 1976, the rate of MES was 39%. According to B..Boggs, occupational health workers have ranged from 20% to 30%, and many other studies have produced similar results. b. The relationship between allergic rhinitis and other factors * With working environment In our study, correlations between microclimate conditions and AR were not correlated (p> 0.05). Although all locations of cotton dust concentrations in the cotton sector of the HTL Fibers Factory exceeded permitted standars, averaging 1.1 to 1.7 times, however, correlation analysis was not available. (p <0.05). Research by Bui Hoai Nam also reveals the relationship between dust in the working environment

18 18 and the symptoms of itchy / stuffy nose and blurred vision. Study by Lai PS also confirms that textile workers who stop contact with cotton dust contribute to improved respiratory function. Mberikunshe J et al (2010) also found that cotton dust was the leading cause of Allergic rhinitis and bronchial asthma in Zimbabwe. * Sex Analyze the association between allergic rhinitis and sex,table 3.4 shows that at the Halotexco Garment Factory, female workers were at risk for allergic rhinitis 2.03 times higher than male workers (p <0, 05), and at the same company Hoang Thi Loan, female workers are at risk of allergic rhinitis workers 1.31 times higher. This difference was statistically significant at p <0.05. This is a characteristic of the textile and garment industry. There are steps that require skill and meticulousness, so the number of female workers is higher. * Year old Table 3.5 shows that workers in the age group were 1.27 times more likely to have allergic rhinitis than those under 30 years of age with a 95% confidence interval of OR (0.95) (p> 0.05); The age group was 1.79 times more likely to develop allergic rhinitis than the 30-year-old group with a 95% confidence interval (OR) of 1.19 to 2.71 (p = 0.006). ); Thus, the higher the risk of allergic rhinitis in workers Hoang Thi Loan Company the greater the risk, the highest risk of allergic rhinitis is group year-old. * The relationship between allergic rhinitis and work seniority The higher the work seniority, the greater the risk of allergic rhinitis. When analyzing the relationship between the two age groups with the Allergic rhinitis, workers with 10 years of seniority and older were 1.26 times more likely to develop allergic rhinitis (OR = 1.36, 95% CI = 1, and p = 0.024) compared to workers under 10 years of seniority. Study results of author Hoang Thi Thuy Ha in Thai Nguyen garment company in 2015 also showed that the incidence of bronchial diseases and lung disease of Thai Nguyen garment workers increases with work seniority is relatively clear (p <0, 05). * The relationship between workers wearing masks and allergic rhinitis Workers wearing popular face masks are at risk of allergic rhinitis 2.03 times higher than those who use specialized masks with p <0.05. Currently, almost every garment factory in Vietnam has mandated workers to wear a mask. However, the majority of masks used by apparel workers today are the "four no masks": No standard quality; no manual; no place of production; no seller information. Denis Hadjiliadis et al (2013) found that although organic dust can be prevented by masking up to 80%, for sensitive workers only inhaling small amounts can cause respiratory tract disease. * Relationship between exposure time in a day with dust When analyzing each link between the risk of allergic rhinitis and the duration of exposure to dust daily, workers exposed to an 8-hour or more exposure had a higher

19 19 risk of allergic rhinitis 2.03 times more than workers with dust exposure times less than 8 hours per day with p <0.05. The results of our study are also consistent with research by Bui Hoai Nam at 2 garment companies in Hung Yen showing that most workers work 8 hours per day, but still, nearly 20% have to work 10 hours a day 4.2. Clinical and subclinical characteristics of allergic rhinitis Clinical characteristics The results showed that sneezing, itching, nasal congestion, runny nose accounted for 89,9%; 89,6%; 67,2% and 60,8% respectively. As for nasal symptoms, this finding is consistent with that of Phan Quang Doan with 86.9% of patients having triad of symptoms, sneezing and itching at frequent incidence 62.8% and 60.6% respectively. Our study found that 317 cases of Allergic rhinitis were 31.23% with septal malformation. This finding is lower than the study by Sumit Prasad et al. (2013) in 120 allergic rhinitis patients with 52.5% cases of septal malformations. Research by Vu Trung Kien showed that students with turbinate malformation had an allergic rhinitis rate of 78.2%, while those with no turbinate malformation had an allergic rhinitis rate of 12, 4%. The difference with OR = and p <0.01. Through the nasal cavity endoscopy, we found that 4.7% of the subjects had nasal polyps, of which the rate at Hoang Thi Loan fiber factory was 5.5% higher than Halotexco factory: 4%. This finding is consistent with the results of Gelardi M, Iannuzzi L et al. (2014), which showed an increase in nasal polyps in patients with chronic rhinitis, particularly allergic rhinitis. Allergic rhinitis is accompanied by allergic conjunctivitis (characterized by pruritus, tearing, redness, and even swelling of the eye). In our study, frequent eye irritation was the most prominent symptom, accounting for 49.2%. The study by Michael R. Perkin et al. (2015) in 1043 families with children aged 5-11 indicated that 13% had both allergic conjunctivitis and allergic rhinitis. Studies by Asher MI, Barry D et al. (2001) on participants in six cities of Newzealand found that 19% of allergic rhinitis was associated with allergic conjunctivitis. Bronchial asthma is also a common allergic disease in textile workers. In our study in Table 3.14, workers with a history of asthma were 1.14 times more likely to have allergic rhinitis than those who had not had asthma in the past. Similarly, in a study by Huynh Khac Cuong, Pham Kien Huu (2001), about 28-78% of patients with bronchial asthma were accompanied by allergic rhinitis and vice versa, only 5-15% of patients with allergic rhinitis were diagnosed with bronchial asthma. The study by Settipane RJ et al. (1994), which lasted 23 years for 2000 students, found that students with allergic rhinitis were three times more likely to have bronchial asthma than students without allergic rhinitis. Atopic dermatitis is also common in patients with Allergic rhinitis. Table 3.18 shows that workers with a history of rash were 2.15 times more likely to have allergic rhinitis than those in the past (OR: , p <0.05). The results of our study are

20 20 consistent with the results of other authors, such as Stipić-Marković A et al (2003) found that 7.83% of allergic rhinitis combined with Atopic dermatitis; Asher MI, Barry D et al (2001) found 15% of allergic rhinitis associated with Atopic dermatitis Subclinical characteristics The positive test result in the group of allergic rhinitis patients was This finding was consistent with Nguyen Nhat Linh (2001) in 128 patients with Allergic rhinitis who had 66.41% for positive skin test with house dust. Similarly, study by Vu Trung Kien also found that 56.9% of the Allergic rhinitis cases had positive skin test. The results of our study of IgE averaged ± UI / ml, which was similar to that of Pham Van Thuc's quantitative study of feather allergic rhinitis of ± 389 IU / ml. Thus, total IgE levels were not significantly different among the study groups in allergic patients but were higher than those in the control group (p <0.01). Meanwhile, half of the patients in our study had low serum IgG levels Effective s Clinical efficacy In our study, before : 100% of patients in both groups had clinical symptoms of allergic rhinitis. the, the incidence of no symptoms: Avamys + Nasal wash group: 53.7% of patients no longer complain about symptoms of Allergic rhinitis; whereas the Communication + labor protection group only 5.4% of patients no longer complained about the symptoms. However, this is just a subjective feeling of the patient. Symptoms of runny nose In our study, the symptoms of runny nose after 6 months of treatment in both groups showed improvement in nasal discharge symptoms at different rates but the improvement in group 2 was statistically significant <0.01. The effectiveness of in group 2 was significantly higher than in group 1. In patients with severe nasal discharge, the flow of the nasal discharge was continuous continuously into stream. Those who have runny nose are completely free of symptoms of runny nose. This shows the effect of nasal wash. This result is consistent with the results of the study by Vu Trung Kien showed that after treatment of symptoms of severe nose drops significantly reduced from 51.06% to 8.51% with p <0.01; 27.66% of patients no longer run nose after treatment. Stiffness / congestion In our study this ratio was 70%. 6 months of treatment, the stuffy nose in both groups showed improvement at different rates, but the improvement in group 2 was statistically significant p <0.01. The effectiveness of in group 2 was significantly higher than in group 1. In patients with severe asphyxia, after s the patient only occasionally mild obstruction. This result is consistent with the study by Vu Trung Kien in 47 patients treated with specific hypersensitivity showed that after treatment the number of patients with nasal congestion decreased to

21 %, lower than preceding treatment with p <0.01. The study by Tomooka LT and colleagues on nasal irrigation also yielded similar results to this study. Symptoms are poor / loss of smell In our study, the comparison between the two groups showed that the effectiveness of the in allergic rhinitis among the two groups was 39.7%; The normal group rate increased with the effect of 24.8%. Our findings are consistent with the study of olfactory dysfunction in chronic rhinitis patients by Argentine authors María V. Sasnchez-Vallecillo (2012), of 33 patients in the age group from 18 to 39, 9% of normal smell, 73% of anosmia and 18% of decrease in smell (P <0.001) were statistically significant. * Mucosal status:, group 2: the proportion of people with normal nasal mucosa increased from 24.07% to 70.37%; The percentage of moderate mucosa decreased from 42.59% to 22.2%;. The results showed that the effect had the best effect on the improvement of the normal nasal mucosa with the efficiency index of 92.3%. This finding is consistent with the study by Vu Trung Kien (2013). treatment, 53.19% of cases of nasal mucosa have returned to normal, the degree of nasal mucosa is severe also decreased from 31.91% before treatment to 17.02%. Inferior turbinate hypertrophy for group 1, situation of inferior turbinate hypertrophy was almost unchanged. However, for group 2, the prevalence of inferior turbinate hypertrophy was significantly lower and the mean was significantly reduced with the respective efficacy index of 59.8% and 60.9%. The results of our study are consistent with the study by Vu Trung Kien (2013), before treatment 46.8% of patients with inferior turbinate hypertrophy. treatment, there were 19.14% of cases of inferior turbinate hypertrophy at levels and the improvement of nasal congestion was reduced by 1 degree % Clinical efficacy In our study, pretreatment: mean serum IgE was ± IU / ml; the lowest is 3.8 IU / ml; The highest is IU / ml., Study 2 obtained: the lowest value of serum IgE was 58.0 IU / ml, the highest was IU / ml, the mean was ± In Study 1, the pre-treatment and post-treatment IgE levels were negligible at ± and ± IU / ml, respectively. Our results were also consistent with Doan Thi Thanh Ha's study of 30 patients receiving immunosuppressive therapy who showed a pre-treatment serum IgE level of ± IU / ml. Treatment was reduced to ± IU / ml. Serum IgG results, before : both groups had serum Ig levels of X ± SD of 1200 UI / ml. : serum IgG levels were ± 1300 UI / ml. Thus, after the, the IgG index increased but less. Our results were consistent with

22 22 the pretest score of 923 ± 149 mg / dl. 24 months of immunotherapy, IgG increased 1347 ± 153 mg / dl.

23 23 CONCLUDE 1. Reality of working environment, allergic rhinitis, and related factors 1.1. Situation of the working environment - Generally, the conditions at the factories surveyed are standard conditions for the working environment of the workers. - The microclimate of the factory HTL fibers is higher than the permitted standard, while the humidity and average wind speed of the workshops in the two plants are lower than the sanitary standards allowed. Most of the cotton dust concentrations in the two factories are lower than the sanitary standards. However, the density of cotton dust in Cotton Plant in HTL Factory exceeded the permitted hygiene standard (1.34 ± 0.24mg / m3) The Allergic rhinitis and related factors - The incidence of allergic rhinitis among factory workers is 30.5%. - Workers aged years were at risk for allergic rhinitis 1,27 times higher than those under 30 years of age; years of age were at risk for allergic rhinitis 1.79 times higher than those under 30 years of age. - Female workers were at risk for allergic rhinitis higher than male workers 1.31 times with p < The higher the occupational age, the higher the incidence of allergic rhinitis: workers with a job age of 10 years or more are at risk for allergic rhinitis, which is 1.36 times higher than that of workers under age 10 years with p < The percentage of workers wearing masks is high, accounting for 92.1%, but only 5.3% use specialized masks. Workers wearing popular masks are at risk of allergic rhinitis 2.03 times higher than those who use specialized masks with p < There were 9.8% of workers exposed to dust more than 8 hours per day. These workers were 2.03 times more likely to have allergic rhinitis than workers with dust exposure less than 8 hours per day with p < Factory workers with KAP of Allergic rhinitis account for a very low rate of 1-3%, mainly workers who have been diagnosed with Allergic rhinitis before. 2. Clinical and subclinical characteristics of allergic rhinitis 2.1. Clinical features - Symptoms in the nose at high rates: sneezing (89,9%), nasal itching (89,2%), nasal congestion (61,2%). - Eye irritation is most common eye allergy, accounting for 53%. - There were 31.23% of workers with allergic rhinitis and 4.7% had nasal polyps. - Workers with a history of asthma were 1.14 times more likely to have allergic rhinitis than those who did not have asthma in the past with p> 0.05.

24 24 - Workers with a history of atopic dermatitis were 2.15 times more likely to have allergic rhinitis than those who did not experience a rash in the past with p < Subclinical characteristics - Prick positive test for cotton dust allergen is 50.8%. - In patients with allergic rhinitis, total IgE level was ± UI / ml higher than that of normal subjects. 3. Effectiveness of Clinical symptoms were significantly improved in the Avamys + Nasal wash group (53.7% no symptomatic complaints) in all functional symptoms (itching, sneezing, runny nose and nasal congestion) and physical symptoms (nasal mucosa, inferior turbinate hypertrophy). Study group using Communication + Labor protection is less improved. the, IgE levels were markedly reduced in the study group using nasal wash and Avamys spray. However, the levels of IgG increased slightly in both groups.

25 25 RECOMMENDATIONS From the results obtained, we recommend: 1. For laborers - Maintain regular health check-ups so that new cases of illness can be detected early. - Maintain good use of labor protection equipment to prevent dust from entering the airways, especially specialized equipment. - Maintain a nasal wash every day after work to prevent and treat allergic rhinitis. 2. For employers - Hoang Thi Loan Fiber Factory should improve the technological process. - Improved working conditions including improved ventilation, and filtering/vacuuming 3. For factory health - Implement periodic health checks for workers to be able to detect early cases of Allergic rhinitis. - Management of cases of Allergic rhinitis, repeated communication and mobilization of workers involved in protection and treatment activities of Allergic rhinitis