Annals of Burns and Fire Disasters - vol. XII - n. 1 - March 1999

A STUDY OF BURNS AMONG WORKERS IN ASSIUT CEMENT FACTORY
EGYPT, 1998

EI-Megeed H.S.A.,* EI-Din S.M.A.,** Kotb S.A.,* EI-Oteify M.A.***

*Community Medicine Department, Faculty of Medicine, Assiut University, Egypt
**Community Health Nursing, High Institute of Nursing, Assiut University
***Plastic Surgery and Burns Unit, Faculty of Medicine, Assiut University

SUMMARY. The cement industry is one of the most vital industries for the Egyptian economy, and occupational injuries constitute a major health problem for the working population. Burn injuries in the cement industry are among the main causes of economic loss to the country. This retrospective study of the period from 1991 to 1995 was conducted throughout the year 1995. The aims of the work were to determine the incidence and causes of burn accidents and the financial loss due to absence from work and to the cost of treatment and to define primary preventive measures against this type of burn. The mean annual number of factory workers in the 5-yr period period was 3200. The total number of burn accidents was 155. Most of the burn accidents occurred in the production department. The commonest cause of burn was contact with hot clinker or cement powder. The ankles and feet were the commonest parts of the body to be affected by burn, followed by the hands and wrists, and the head and neck. The total number of working days lost due to burns over the five years was 4776, with a mean of 31.0 ± 30.8 days per case. Despite the lack of specific training programmes and insufficient protective measures, the decreasing incidence of burn accidents towards the end of the period of study is a good sign that the factory authorities have become more aware of the importance of reducing the number of these catastrophic accidents.

In Egypt, injuries are a significant source of morbidity and mortality. They are the fifth leading cause of death and the leading cause of hospitalization, and account for at least a quarter of all out-patient visits.
The setting-up and development of the cement industry in any country is considered a sign of progress, to such an extent that the degree of a country's civilization can be measured by the amount of cement it produces.
Cement burns constitute a particular type of injury that not only differs from other types of burn but also may be manifest in different forms, depending on the cause of injury, which is partly dependent on the environmental conditions at the time of accident.
The causes of accidents have been linked to ignorance of the industrial processes among half-educated or uneducated workers and to apathy on the part of the management. There is a proliferation of factories that manufacture or make use of potentially hazardous products such as cement, wood, and petrochemicals, and the workers in these industries are, in most cases, unprotected from the hazardous agents that are known to impair their health. The problem is made worse by the absence of effective systems of factory inspection, partly because of an acute shortage of such inspectors and partly because of the inspectors' inability to enforce the laws governing health, safety, and welfare provision in the factories.'

Cement burns can be divided into three types, depending on the causes and circumstances of injury: abrasion, heat, and explosion.

• Abrasion type: this is a variety of contact dermatitis and is caused by prolonged contact with wet cement and by rubbing of the skin during use of cement in building work.
• Heat type: this form is secondary to skin contact with extremely high-temperature cement powder escaping from a kiln following manufacture. This may not contain hot or harmful gases.
• Explosion type: this type of injury is caused by the accidental explosive discharge of cement powder from a kiln during the manufacture of cement. This kind of injury occurs in an enclosed area and differs from other types of cement burn.'

The injury factors for each type of cement burn vary according to the cause of the injury. The abrasion type depends on three factors:

• alkalinity
• abrasion
• prolonged contact

All three factors are needed to cause burns.
The activities of occupational health nurses have changed and their scope is now much wider than before, including not only the prevention of occupational hazards but also the promotion of the workers' general health and the adaptation of work to man and of man to work.
The health and safety of the adult working population are essential to the economy, and occupational health nurses play a key role in helping to maintain workers' health in all occupations. In general, occupational health services concern themselves with the effect of work on health and of health on work.
Occupational health nurses and primary care workers are two categories of health professionals who have played and will continue to play an important and critical role in health services in all countries.
In the Assiut University Hospital Burns Unit in Egypt we have observed a growing number of burn cases referred from the cement factory, with a trend that is higher than in any other factory within the Assiut Governorate.
Preliminary visits to the cement factory in 1994 revealed that many workers were exposed to different types of burns, mostly due to clinker. The aim of the present work is to therefore to determine the incidence of burn injuries in the Assiut Cement factory during the period 1991-1995, to identify causes that precipitate the burn mechanism, to determine the cost of treatment of burn cases and the indirect economic loss due to absence from work, and to define primary preventive measures against this type of burn.

This study was conducted in the Assiut Cement Factory, which employs about 3200 workers and office staff, about 800 of whom work in the production department. This study includes all burn cases (155) that occurred among factory workers during the period 19911995. The workers were in the production department, which includes sub-areas such as kilns and thermal mills, which are the highest risk areas,for burns, where the men are exposed to heat directly from the clinker and cement powder.
Data were collected in a pre-designed questionnaire through personal interviews, on the basis of retrospective data from Assiut Health Insurance Hospital records, and using records from the cement factory's Industrial Clinic.
Data collection went on from January to December 1995. The data were revised and an EPI info program was used for data entry and analysis. A descriptive analysis was applied (i.e., frequency, percentage, mean and standard deviation).

Table I shows that the incidence of burn cases was highest in 1993 (1.23%). This decreased in the following two years to 0.81% and 0.75% in 1994 and 1995, respectively. Two patients died as a consequence of burns, one in 1991 (case fatality rate, 3.2%) and the other in 1994 (case fatality rate, 3.8 %).

The great majority of burn accidents (81.9%) occurred in the cement factory's production department, where the five-year burn incidence was 15.9%, compared with 1.6%, 1.2% and 0. 1% respectively in the electricity, maintenance, and other departments (Table II).

Exposure to clinker and cement powder was responsible for 73.5% of burn injuries, and electricity for 15.5% of burn Injuries. The remaining cases (11 %) were due to various accidental causes. There was no significant distribution of cases in the study years from 1991 to 1995 (Table III).

Table IV shows that the commonest sites of burn were the ankles and feet (48.4%), wrist and hands (34.2%), and head and neck (20.6%).

Table V shows the distribution of burn cases according to the number of working days lost for treatment. The total number of days lost in the five years was 4776, with a mean number of days per case of 31.0 days. The highest number of lost days was observed in 1993 (mean, 38.8 days) and the lowest mean number in 1995 (13.7 days). Table V also shows that 28 (18.1%) cases needed hospitalization and were treated as in-patients and that 81.9% of cases were treated as out-patients. 

The mean cost for treatment per day was £E (Egyptian pounds) 100 for each in-patient stay and £E 20 for each out-patient visit. The estimated cost for treatment of all cases over the five years was quite enormous (£E 71,100 for in-patients and £E 80,660 for out-patients, for a total of £E 151,760). The highest cost for treatment was in 1993 (£E 51,340) and the lowest in 1995 (£E 6,500) (Table VI).
Table VII shows that the mean cost to the factory due to absence from work was £E 30 per day. The estimated cost due to absence from work for all cases over the five years of study was £E 143,280. The total cost was £E 295,040.

The present study is the first report on contact burns from hot cement powder or clinker occurring in the Assiut Cement Factory in Egypt. This is in agreement with reports in the Chinese literature, which has classified burns as heat and explosion injuries.
The total numbers of workers burned in the five years of study were successively 3100, 3350, 3240, 3220, and 3200, with a mean number of around 3200. The total number of burn cases in the five years was 155.
The incidence rates for burns among the workers were 1.0%, 1.01%, 1.23%, 0.81%, and 0.75% for the five respective years. The highest incidence of burns occurred in the production department, where the workers were accordingly considered to constitute a high-risk group for cement burns. The increasing incidence rate from 1991 to 1993 was due to the recurrent explosion of hot cement after manual removal of the obstructed pathway of the clinker inside the kilns and to the reluctance of the workers to wear the proper uniform for the job. Subsequently, maintenance and repair ceased to be performed manually and strict regulations are now enforced by the factory in order to prevent the occurrence of such accidents. Further protective measures have also been also introduced.
Regarding the precise location of the burn accidents, 81.9% occurred in the production department. This can be explained by the fact that the main bulk of the work is performed by workers in this particular department. The work load sometimes increases during the periodic maintenance and repair of the kiln. It is therefore postulated that the incidence of burns may increase as a result of mistakes committed owing to haste in order to fulfil a required quota of work in a specified short time, especially in the presence of harmful material such as clinker or hot cement powder.
The incidence rate of burns in 1991-95 was 15.9% in the production department and much lower in other departments (electricity department: 1.6%; maintenance department: 1.2%). These results are similar to those obtained by Kamel et al.," who reported that workers using machinery are more exposed to accidents.
The present study showed that clinker and cement powder were the commonest causes of burn injury in the cement factory (73.5%). Electricity caused 15.5% of the accidents and other causes (hot water or tea, benzene, etc.) were responsible in I I% of the cases. These last two causes are purely accidental, as with any other burn occurring elsewhere.
As stated by the Occupational Security Officer at Assiut Cement Factory, burn injury due to clinker or cement occurs as a result of the explosion of hot cement powder (at a temperature of about 1500 'C). Such explosions occur when there is forced air and water in the narrow tube to remove the blocking of powder during the passage of cement in the rotatory kiln. This blocking occurs suddenly and causes delay in the production cycle (with loss of time and money).
The present study shows that the ankles and feet and the wrists and hands were the parts of the body most commonly affected by burns (48.3% and 34.2%, respectively). The higher incidence of burn injury affecting mainly the lower limbs may be related to the wearing of improper shoes (made of plastic or rubber), which immediately stick to the skin when exposed to hot cement, thus maximizing the burn injury's detrimental effects. This finding is consistent with that of Oleske et al.," who stated that lower limb injuries, especially of the foot, can be attributed to hot cement particles which may cause thermal injuries.
This finding also agrees with those of Rowe and Williams,' Wilson and Davidson,' and Feldlberg et al.,' who found that the lower limbs, particularly the feet, were the regions most commonly burned by hot cement in factories. However, Farahat" reported another opinion, having found that the upper limbs were the part most commonly injured, followed by the lower limbs.
During the period of study two workers died as a result of cement burn injury. This may have been due to respiratory failure, occurring as a result of the inhalation of hot gases during the accidental explosive discharge of cement powder from a kiln during the manufacture of cement. The explosive type is the most serious variety of cement burn injury because when an explosion occurs, particularly in an enclosed space, the victims frequently sustain both an inhalation injury and a thermal injury. With a kiln temperature of about 1500 'C, the explosive discharge of cement from a kiln, usually into a relatively confined space from which escape may be difficult, with visibility limited by smoke and dust, exposes both the skin and the respiratory tract to burn injury.
The number of working days lost due to such injuries is considered an index of the severity of the accident. Absence from work is a major problem in industry, especially for its sanitary and economic implications. It is a complicated problem, with a wide variety of duration and frequency. In the present study, the total number of days lost due to burns over the five-year period was 4776, with a mean of 31 ± 30.8 days for each case. The highest number of days lost was in 1993 (38.8 ± 59.3 days) and the lowest in 1995 (13.6 ± 6.3 days).
In the present study, the estimated cost for treatment per day was EE 100 for in-patients and f-E 20 for outpatients, since most of the burns were minor and needed only dressing and occasionally grafting, without any intensive care management. The average estimated cost for treatment of all cases over the five years was FE 151,760 (71,100 for in-patients and 80,660 for out-patients). The mean cost of the factory due to a worker's absence from work was EE 30 per day. The estimated economic loss to the factory due to absences for all cases over the live years was fE 143,280. The total cost for both treatment and absences was f-E 295,040.

The present study concluded that there is no specific training programme for safety education, protective measures, or accident prevention. There is increasing awareness on the part of the factory administration authority with regard to preventive measures against injury in the factory, as shown by the gradually decreasing incidence rates of burn injury observed since 1993.
We recommend that health education and training programmes should be regularly carried out, with an emphasis on the use of personal protective measures and on the serious complications that may occur if such measures are not observed. Modem machinery and equipment fitted with automatic release of the block should always be used in order to minimize the possibility of breakdown or explosion during cement manufacture procedures. Protective measures should be freely used and applied. Prompt first-aid measures should be available, since any delay in the management of burn injuries can worsen the victim's medical condition. A qualified nurse should be assigned to safeguard the workers' health and to improve the factory's health facilities. A health unit should be established in the factory in order to manage minor injuries and to refer other injuries after the necessary first-aid measures have been provided.

RESUME. L'industrie du ciment est une des industries les plus vitales de l'économie égyptienne, et les accidents du travail constituent un problème important pour la population active. Les brûlures dans l'industrie du ciment sont une des causes principales des pertes économiques en Egypte. Cette étude rétrospective de la période 1991-1995 a été effectuée pendant toute l'année 1995. Les Auteurs se sont proposés de déterminer la fréquence et les causes des brûlures accidentelles et les pertes économiques dues l'absence du travail et au coût du traitement et de définir les mesures primaires préventives contre ce type de brûlure. Le numéro moyen annuel des ouvriers pendant la période quinquennale était 3200. Le numéro total des brûlures etait 155. La plupart des accidents se sont vérifiés dans le rayon de la production. La cause la plus commune des brûlures était le contact avec le clinker ou la poudre de ciment. Les chevilles et les pieds étaient les parties corporelles intéressées le plus fréquemment par les brûlures, suivis par la tête et le cou. Le numéro total de journées de travail perdues à cause des brûlures pendant la période d'étude était 4776, avec un numéro moyen de 31,0 ± 30,8 jours par cas. Malgré l'absence de programmes spécifiques de fon-nation et l'insuffisance des mesures de prévention, la fréquence décroissante des accidents par brûlure vers la fin de la période indique que la direction de l'usine est devenue plus sensible à l'importance de la réduction du numéro de ces accidents catastrophiques.

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