Assessing the Feasibility of a Multifaceted Intervention Package for Improving Respiratory Health of Textile Workers: Findings From the MultiTex Pilot Study in Karachi, Pakistan.

We piloted the development and implementation of a multifaceted intervention package for improving respiratory health among textile workers using a pre-post design at six mills in Karachi. The intervention, implemented following a baseline survey (n = 498), included health and safety training of workers and managers, promotion of cotton dust control measures, and the provision of facemasks. Follow-up surveys were conducted at 1, 6, and 12 months post-intervention. Knowledge, attitude, and practice (KAP) scores and respiratory symptoms were assessed through a questionnaire and spirometry was conducted. The intervention was provided to 230 workers and led to an improvement in KAP scores that was more likely among workers with a higher educational status, spinners, smokers, those with a permanent employment status, working in morning shifts, and with ⩾5 years of textile experience. We found the intervention acceptable and feasible in these textile mills henceforth, trials are required to determine its effectiveness.

Prevalence of chronic cough, its risk factors and population attributable risk in the Burden of Obstructive Lung Disease (BOLD) study: a multinational cross-sectional study.

Background: Chronic cough is a common respiratory symptom with an impact on daily activities and quality of life. Global prevalence data are scarce and derive mainly from European and Asian countries and studies with outcomes other than chronic cough. In this study, we aimed to estimate the prevalence of chronic cough across a large number of study sites as well as to identify its main risk factors using a standardised protocol and definition. Methods: We analysed cross-sectional data from 33,983 adults (≥40 years), recruited between Jan 2, 2003 and Dec 26, 2016, in 41 sites (34 countries) from the Burden of Obstructive Lung Disease (BOLD) study. We estimated the prevalence of chronic cough for each site accounting for sampling design. To identify risk factors, we conducted multivariable logistic regression analysis within each site and then pooled estimates using random-effects meta-analysis. We also calculated the population attributable risk (PAR) associated with each of the identifed risk factors. Findings: The prevalence of chronic cough varied from 3% in India (rural Pune) to 24% in the United States of America (Lexington,KY). Chronic cough was more common among females, both current and passive smokers, those working in a dusty job, those with a history of tuberculosis, those who were obese, those with a low level of education and those with hypertension or airflow limitation. The most influential risk factors were current smoking and working in a dusty job. Interpretation: Our findings suggested that the prevalence of chronic cough varies widely across sites in different world regions. Cigarette smoking and exposure to dust in the workplace are its major risk factors. Funding: Wellcome Trust.

An assessment of public experiences and expectations with physicians: a cross sectional study from Karachi, Pakistan.

BACKGROUND: Although physicians are highly regarded members of society, patients are not always satisfied with their care, suggesting a mismatch between the public's expectations and reality. Thus, the aim of this study was to determine the public's expectations regarding roles and responsibilities of a physician, to assess patient experiences, and to evaluate factors associated with the two outcomes. METHODS: A cross-sectional study was conducted via face-to-face structured interviews from July 14th to August 2nd, 2023, in Karachi, Pakistan. The study sample comprised 424 consenting adults enrolled by visiting public spaces (malls, parks, hospitals, and residential areas). A modified version of 'Exceptionally Good Doctor Likert scale', and 'Patient Picker-15' (PPE-15) questionnaires was used. The Likert and PPE-15 sections were scored through pre-decided criteria for expectations and experience, respectively, and categorized using a median cut-off into high and low expectations and negative and positive experiences, respectively for simple and multivariable logistic regression. RESULTS: A median score of 30.5/ 34 (IQR = 3.3) was found for expectations and 4/ 14 (IQR = 4) for experiences. Significant factors associated with expectations were older age groups (OR = 4.54 [1.18-17.50]) and higher monthly household incomes (0.40 [0.20-0.79]), while the odds of negative experiences were lower after visits to emergency departments (0.38 [0.18-0.84]) and private health care centers (0.31 [0.13-0.70]). CONCLUSION: These results suggest that the public has high expectations from physicians, however their experiences are not always positive. Initiatives to develop a patient-centric ethos are needed for which we outline recommendations to both the public and physicians, respectively.

A cluster randomised controlled trial to reduce respiratory effects of cotton dust exposure among textile workers: the MultiTex RCT study.

BACKGROUND: We determined the effectiveness of an intervention to reduce cotton dust-related respiratory symptoms and improve lung function of textile workers. METHODS: We undertook a cluster randomised controlled trial at 38 textile mills in Karachi, Pakistan. The intervention comprised: training in occupational health for workers and managers, formation of workplace committees to promote a health and safety plan that included wet mopping and safe disposal of cotton dust, provision of simple face masks, and further publicity about the risks from cotton dust. Participating mills were randomised following baseline data collection. The impact of the intervention was measured through surveys at 3, 12 and 18 months using questionnaires, spirometry and dust measurements. The primary outcomes were 1) changes in prevalence of a composite respiratory symptom variable, 2) changes in post-bronchodilator percentage predicted forced expiratory volume in 1 s (FEV1) and 3) changes in cotton dust levels. These were assessed using two-level mixed effects linear and logistic regression. RESULTS: Of 2031 participants recruited at baseline, 807 (40%) were available at the third follow-up. At that point, workers in the intervention arm were more likely to report an improvement in respiratory symptoms (OR 1.58, 95% CI 1.06-2.36) and lung function (FEV1 % pred: ß 1.31%, 95% CI 0.04-2.57%). Personal dust levels decreased, more so in intervention mills, although we did not observe this in adjusted models due to the small number of samples. CONCLUSION: We found the intervention to be effective in improving the respiratory health of textile workers and recommend scaling-up of such simple and feasible interventions in low- and middle-income countries.

Isolated small airways obstruction predicts future chronic airflow obstruction: a multinational longitudinal study.

BACKGROUND: Chronic airflow obstruction is a key characteristic of chronic obstructive pulmonary disease. We investigated whether isolated small airways obstruction is associated with chronic airflow obstruction later in life. METHODS: We used longitudinal data from 3957 participants of the multinational Burden of Obstructive Lung Disease study. We defined isolated small airways obstruction using the prebronchodilator mean forced expiratory flow rate between 25% and 75% of the forced vital capacity (FVC) (FEF25-75) if a result was less than the lower limit of normal (

Chronic airflow obstruction attributable to poverty in the multinational Burden of Obstructive Lung Disease (BOLD) study.

Poverty is strongly associated with all-cause and chronic obstructive pulmonary disease (COPD) mortality. Less is known about the contribution of poverty to spirometrically defined chronic airflow obstruction (CAO)-a key characteristic of COPD. Using cross-sectional data from an asset-based questionnaire to define poverty in 21 sites of the Burden of Obstructive Lung Disease study, we estimated the risk of CAO attributable to poverty. Up to 6% of the population over 40 years had CAO attributable to poverty. Understanding the relationship between poverty and CAO might suggest ways to improve lung health, especially in low-income and middle-income countries.

The association of spirometric small airways obstruction with respiratory symptoms, cardiometabolic diseases, and quality of life: results from the Burden of Obstructive Lung Disease (BOLD) study.

BACKGROUND: Spirometric small airways obstruction (SAO) is common in the general population. Whether spirometric SAO is associated with respiratory symptoms, cardiometabolic diseases, and quality of life (QoL) is unknown. METHODS: Using data from the Burden of Obstructive Lung Disease study (N = 21,594), we defined spirometric SAO as the mean forced expiratory flow rate between 25 and 75% of the FVC (FEF25-75) less than the lower limit of normal (LLN) or the forced expiratory volume in 3 s to FVC ratio (FEV3/FVC) less than the LLN. We analysed data on respiratory symptoms, cardiometabolic diseases, and QoL collected using standardised questionnaires. We assessed the associations with spirometric SAO using multivariable regression models, and pooled site estimates using random effects meta-analysis. We conducted identical analyses for isolated spirometric SAO (i.e. with FEV1/FVC ≥ LLN). RESULTS: Almost a fifth of the participants had spirometric SAO (19% for FEF25-75; 17% for FEV3/FVC). Using FEF25-75, spirometric SAO was associated with dyspnoea (OR = 2.16, 95% CI 1.77-2.70), chronic cough (OR = 2.56, 95% CI 2.08-3.15), chronic phlegm (OR = 2.29, 95% CI 1.77-4.05), wheeze (OR = 2.87, 95% CI 2.50-3.40) and cardiovascular disease (OR = 1.30, 95% CI 1.11-1.52), but not hypertension or diabetes. Spirometric SAO was associated with worse physical and mental QoL. These associations were similar for FEV3/FVC. Isolated spirometric SAO (10% for FEF25-75; 6% for FEV3/FVC), was also associated with respiratory symptoms and cardiovascular disease. CONCLUSION: Spirometric SAO is associated with respiratory symptoms, cardiovascular disease, and QoL. Consideration should be given to the measurement of FEF25-75 and FEV3/FVC, in addition to traditional spirometry parameters.

Effect Of Cotton Dust Exposure On Respiratory Health Outcomes Among Textile Workers.

BACKGROUND: Cotton dust is generated during various textile manufacturing processes. Only a few studies from Pakistan assessed cotton dust exposure and explored the relationship of duration of work in the textile industry with respiratory health outcomes. We aimed to assess cotton dust exposure and its association with lung function and respiratory symptoms among textile workers in Pakistan. METHODS: We report findings from the baseline survey of the larger study, MultiTex, among 498 adult male textile workers from six mills conducted between October 2015-March 2016 in Karachi, Pakistan. Data collection included the use of standardized questionnaires; spirometry, and area dust measurements through UCB-PATS. Multivariable logistic and linear regression models were developed to assess the association of risk factors with respiratory symptoms and illnesses. RESULTS: We found the mean age of workers to be 32.5 (±10) years; around 25% were illiterate. The prevalence of COPD, asthma, and byssinosis was 10%, 17%, and 2%, respectively. The median cotton dust exposure was 0.33 mg/m3 (IQR: 0.12-0.76). Increased duration of work among non-smokers was associated with a decline in lung function, FVC (-245 ml; 95% CI: -385.71, -104.89) and FEV1 (-200 ml; 95% CI: -328.71, -841.1). Workers with certain job titles (machine operators, helpers, and jobbers), those with greater duration of work, and higher dust exposure, were more likely to report respiratory symptoms and illnesses. CONCLUSIONS: We report a high prevalence of asthma and COPD and a low prevalence of byssinosis. Cotton dust exposure and duration of employment were associated with respiratory health outcomes. Our findings highlight the need for preventive interventions in the textile industry in Pakistan.

Byssinosis and lung health among cotton textile workers: baseline findings of the MultiTex trial in Karachi, Pakistan.

OBJECTIVES: To assess the association of exposure in cotton mills in Karachi with different definitions of byssinosis and lung health. METHODS: This cross-sectional survey took place between June 2019 and October 2020 among 2031 workers across 38 spinning and weaving mills in Karachi. Data collection involved questionnaire-based interviews, spirometry and measurements of personal exposure to inhalable dust. Byssinosis was defined using both WHO symptoms-based (work-related chest tightness), and Schilling's criteria (symptoms with decreased forced expiratory volume in 1 s (FEV1). Values of FEV1/forced vital capacity ratio below the lower limit of normality on postbronchodilator test were considered as 'chronic airflow obstruction' (CAO). RESULTS: 56% of participants had at least one respiratory symptom, while 43% had shortness of breath (grade 1). Prevalence of byssinosis according to WHO criteria was 3%, it was 4% according to Schilling's criteria, and likewise for CAO. We found low inhalable dust exposures (geometric mean: 610 µg/m3). Cigarette smoking (≥3.5 pack-years), increasing duration of employment in the textile industry and work in the spinning section were important factors found to be associated with several respiratory outcomes. CONCLUSION: We found a high prevalence of respiratory symptoms but a low prevalence of byssinosis. Most respiratory outcomes were associated with duration of employment in textile industry. We have discussed the challenges faced in using current, standard guidelines for identifying byssinosis.

Small airways obstruction and its risk factors in the Burden of Obstructive Lung Disease (BOLD) study: a multinational cross-sectional study.

BACKGROUND: Small airways obstruction is a common feature of obstructive lung diseases. Research is scarce on small airways obstruction, its global prevalence, and risk factors. We aimed to estimate the prevalence of small airways obstruction, examine the associated risk factors, and compare the findings for two different spirometry parameters. METHODS: The Burden of Obstructive Lung Disease study is a multinational cross-sectional study of 41 municipalities in 34 countries across all WHO regions. Adults aged 40 years or older who were not living in an institution were eligible to participate. To ensure a representative sample, participants were selected from a random sample of the population according to a predefined site-specific sampling strategy. We included participants' data in this study if they completed the core study questionnaire and had acceptable spirometry according to predefined quality criteria. We excluded participants with a contraindication for lung function testing. We defined small airways obstruction as either mean forced expiratory flow rate between 25% and 75% of the forced vital capacity (FEF25-75) less than the lower limit of normal or forced expiratory volume in 3 s to forced vital capacity ratio (FEV3/FVC ratio) less than the lower limit of normal. We estimated the prevalence of pre-bronchodilator (ie, before administration of 200 µg salbutamol) and post-bronchodilator (ie, after administration of 200 µg salbutamol) small airways obstruction for each site. To identify risk factors for small airways obstruction, we performed multivariable regression analyses within each site and pooled estimates using random-effects meta-analysis. FINDINGS: 36 618 participants were recruited between Jan 2, 2003, and Dec 26, 2016. Data were collected from participants at recruitment. Of the recruited participants, 28 604 participants had acceptable spirometry and completed the core study questionnaire. Data were available for 26 443 participants for FEV3/FVC ratio and 25 961 participants for FEF25-75. Of the 26 443 participants included, 12 490 were men and 13 953 were women. Prevalence of pre-bronchodilator small airways obstruction ranged from 5% (34 of 624 participants) in Tartu, Estonia, to 34% (189 of 555 participants) in Mysore, India, for FEF25-75, and for FEV3/FVC ratio it ranged from 5% (31 of 684) in Riyadh, Saudi Arabia, to 31% (287 of 924) in Salzburg, Austria. Prevalence of post-bronchodilator small airways obstruction was universally lower. Risk factors significantly associated with FEV3/FVC ratio less than the lower limit of normal included increasing age, low BMI, active and passive smoking, low level of education, working in a dusty job for more than 10 years, previous tuberculosis, and family history of chronic obstructive pulmonary disease. Results were similar for FEF25-75, except for increasing age, which was associated with reduced odds of small airways obstruction. INTERPRETATION: Despite the wide geographical variation, small airways obstruction is common and more prevalent than chronic airflow obstruction worldwide. Small airways obstruction shows the same risk factors as chronic airflow obstruction. However, further research is required to investigate whether small airways obstruction is also associated with respiratory symptoms and lung function decline. FUNDING: National Heart and Lung Institute and Wellcome Trust. TRANSLATIONS: For the Dutch, Estonian, French, Icelandic, Malay, Marathi, Norwegian, Portuguese, Swedish and Urdu translations of the abstract see Supplementary Materials section.

Association of respiratory symptoms and lung function with occupation in the multinational Burden of Obstructive Lung Disease (BOLD) study.

BACKGROUND: Chronic obstructive pulmonary disease has been associated with exposures in the workplace. We aimed to assess the association of respiratory symptoms and lung function with occupation in the Burden of Obstructive Lung Disease study. METHODS: We analysed cross-sectional data from 28 823 adults (≥40 years) in 34 countries. We considered 11 occupations and grouped them by likelihood of exposure to organic dusts, inorganic dusts and fumes. The association of chronic cough, chronic phlegm, wheeze, dyspnoea, forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1)/FVC with occupation was assessed, per study site, using multivariable regression. These estimates were then meta-analysed. Sensitivity analyses explored differences between sexes and gross national income. RESULTS: Overall, working in settings with potentially high exposure to dusts or fumes was associated with respiratory symptoms but not lung function differences. The most common occupation was farming. Compared to people not working in any of the 11 considered occupations, those who were farmers for ≥20 years were more likely to have chronic cough (OR 1.52, 95% CI 1.19-1.94), wheeze (OR 1.37, 95% CI 1.16-1.63) and dyspnoea (OR 1.83, 95% CI 1.53-2.20), but not lower FVC (ß=0.02 L, 95% CI -0.02-0.06 L) or lower FEV1/FVC (ß=0.04%, 95% CI -0.49-0.58%). Some findings differed by sex and gross national income. CONCLUSION: At a population level, the occupational exposures considered in this study do not appear to be major determinants of differences in lung function, although they are associated with more respiratory symptoms. Because not all work settings were included in this study, respiratory surveillance should still be encouraged among high-risk dusty and fume job workers, especially in low- and middle-income countries.

Indoor Air Pollution and Respiratory Health in a Metropolitan City of Pakistan.

OBJECTIVE: We assessed the association of formaldehyde, carbon monoxide (CO), and particulate matter (PM 2.5 ) with respiratory symptoms, asthma, and post-bronchodilator reversibility. METHODS: We included 1629 adults in a community-based cross-sectional study in Karachi in 2015. Data were collected using the American Thoracic Society respiratory questionnaire and spirometry (available for 930 participants). YesAir eight-channel monitor was used for measuring concentrations of formaldehyde and CO, whereas PM 2.5 was measured using UCB PATS. RESULTS: Higher levels of formaldehyde and CO were associated with cough, phlegm, and wheeze, whereas those of PM 2.5 were associated with shortness of breath and presence of any of the respiratory symptoms (combined), as well as a "lower" risk of cough, phlegm, and bronchitis. CONCLUSION: Poorer household air quality was associated with poorer respiratory health in this population; however, further studies with a robust exposure assessment are required.

Contemporary Prevalence of Byssinosis in Low- and Middle-Income Countries: A Systematic Review.

We aimed to identify the contemporary prevalence of byssinosis through a systematic review. Medline, Web of Science, Embase, and Global Health databases were used to identify studies published in any language between 2000 and 2019, reporting primary data on byssinosis among adults. We used the Joanna Briggs Institute checklist to estimate the risk of bias in studies and undertook a qualitative, narrative data analysis. The review considered the prevalence of byssinosis, chest tightness, and airflow obstruction in textile workers in low- and middle-income countries (LMICs). We found 26 relevant studies that included 6930 workers across 12 countries. Most of the studies (n = 19) were from Asia, and seven from African countries. Twenty-five studies were cross-sectional surveys while one was a cohort study. The prevalence of byssinosis was reported by 18 studies, and ranged from 8% to 38%, without any clear associations, at the group level, between the prevalence of byssinosis and durations of workers' exposures. Prevalence of chest tightness ranged between 4% and 58% and that of airflow obstruction between 10% and 30%. A strong correlation (r = 0.72) was found between prevalence of byssinosis and cotton dust levels. Our findings indicate that byssinosis remains a significant, contemporary problem in some parts of the textile sector in LMICs.

Use of Low-Cost Particle Counters for Cotton Dust Exposure Assessment in Textile Mills in Low- and Middle-Income Countries.

OBJECTIVE: There is a lack of consensus on methods for cotton dust measurement in the textile industry, and techniques vary between countries-relying mostly on cumbersome, traditional approaches. We undertook comparisons of standard, gravimetric methods with low-cost optical particle counters for personal and area dust measurements in textile mills in Pakistan. METHODS: We included male textile workers from the weaving sections of seven cotton mills in Karachi. We used the Institute of Occupational Medicine (IOM) sampler with a Casella Apex 2 standard pump and the Purple Air (PA-II-SD) for measuring personal exposures to inhalable airborne particles (n = 31). We used the Dylos DC1700 particle counter, in addition to the two above, for area-level measurements (n = 29). RESULTS: There were no significant correlations between the IOM and PA for personal dust measurements using the original (r = -0.15, P = 0.4) or log-transformed data (r = -0.32, P = 0.07). Similarly, there were no significant correlations when comparing the IOM with either of the particle counters (PA and Dylos) for area dust measurements, using the original (r = -0.07, P = 0.7; r = 0.10, P = 0.6) or log-transformed data (r = -0.09, P = 0.6; r = 0.07, P = 0.7). CONCLUSION: Our findings show a lack of correlation between the gravimetric method and the use of particle counters in both personal and area measurements of cotton dust, precluding their use for measuring occupational exposures to airborne dust in textile mills. There continues to be a need to develop low-cost instruments to help textile industries in low- and middle-income countries to perform cotton dust exposure assessment.

Impact of using different predictive equations on the prevalence of chronic byssinosis in textile workers in Pakistan.

OBJECTIVE: Byssinosis remains a significant problem among textile workers in low/middle-income countries. Here we share our experience of using different prediction equations for assessing 'chronic' byssinosis according to the standard WHO classification using measurements of forced expiratory volume in 1 s (FEV1). METHODS: We enrolled 1910 workers in a randomised controlled trial of an intervention to improve the health of textile workers in Pakistan. We included in analyses the 1724 (90%) men who performed pre-bronchodilator spirometry tests of acceptable quality. We compared four different equations for deriving lung function percentage predicted values among those with symptoms-based byssinosis: the third US National Health and Nutrition Examination Survey (NHANES-III, with 'North Indian and Pakistani' conversion factor); the Global Lung Function Initiative (GLI, 'other or mixed ethnicities'); a recent equation derived from survey of a western Indian population; and one based on an older and smaller survey of Karachi residents. RESULTS: 58 men (3.4%) had symptoms-based byssinosis according to WHO criteria. Of these, the proportions with a reduced FEV1 (<80% predicted) identified using NHANES and GLI; Indian and Pakistani reference equations were 40%, 41%, 14% and 12%, respectively. Much of this variation was eliminated when we substituted FEV1/forced vital capacity (FVC) ratio (

Violence and abuse among working children in urban and suburban areas of lower Sindh, Pakistan.

BACKGROUND: Child labourers are exposed to an insecure environment and higher risk of violence. Violence among child labourers is an under-studied phenomenon which requires contextual assessment. AIMS: We applied Bronfenbrenner's ecological model (micro-, exo- and macro-system) to understand the interplay of individual, community, societal and policy context fuelling violence. METHODS: Focus group discussions and family ethnographies of child-labourers working in common occupational sectors of suburban areas of Sindh were carried out to gain in-depth understanding of their immediate environment and abuse (micro-system). Frequency of emotional, physical and sexual violence (5-14 years; n = 634) was also determined. Indepth interviews with employers (exo-system, n = 4) and key-informant-interviews of prominent stakeholders in Pakistan (macro-system, n = 4) working against labour/violence were carried out Thematic-content analysis was performed using MAXQDA, version 8.0. RESULTS: We estimated that 21%, 19% and 9% of children suffered from emotional, physical and sexual violence respectively. Child labourers' interviews indicated the existence of all forms of abuse at home and in the workplace; sexual violence by grandfathers was highlighted (micro-system). Children reported frequent scolding and insults in the workplace along with physical violence that could be fatal (exo-system). The legal environment of violence in Pakistan was considered deficient as it did not address the hidden forms (touching, kissing, etc.; macro-system). CONCLUSION: We documented that all forms of violence were rampant among the child labourers, and improved efforts and comprehensive legislation is direly needed to alleviate the situation.

Chronic airflow obstruction and ambient particulate air pollution.

Smoking is the most well-established cause of chronic airflow obstruction (CAO) but particulate air pollution and poverty have also been implicated. We regressed sex-specific prevalence of CAO from 41 Burden of Obstructive Lung Disease study sites against smoking prevalence from the same study, the gross national income per capita and the local annual mean level of ambient particulate matter (PM2.5) using negative binomial regression. The prevalence of CAO was not independently associated with PM2.5 but was strongly associated with smoking and was also associated with poverty. Strengthening tobacco control and improved understanding of the link between CAO and poverty should be prioritised.

Prevalence and Population-Attributable Risk for Chronic Airflow Obstruction in a Large Multinational Study.

Rationale: The Global Burden of Disease program identified smoking and ambient and household air pollution as the main drivers of death and disability from chronic obstructive pulmonary disease (COPD). Objectives: To estimate the attributable risk of chronic airflow obstruction (CAO), a quantifiable characteristic of COPD, due to several risk factors. Methods: The Burden of Obstructive Lung Disease study is a cross-sectional study of adults, aged ≥40, in a globally distributed sample of 41 urban and rural sites. Based on data from 28,459 participants, we estimated the prevalence of CAO, defined as a postbronchodilator FEV1-to-FVC ratio less than the lower limit of normal, and the relative risks associated with different risk factors. Local relative risks were estimated using a Bayesian hierarchical model borrowing information from across sites. From these relative risks and the prevalence of risk factors, we estimated local population attributable risks. Measurements and Main Results: The mean prevalence of CAO was 11.2% in men and 8.6% in women. The mean population attributable risk for smoking was 5.1% in men and 2.2% in women. The next most influential risk factors were poor education levels, working in a dusty job for ≥10 years, low body mass index, and a history of tuberculosis. The risk of CAO attributable to the different risk factors varied across sites. Conclusions: Although smoking remains the most important risk factor for CAO, in some areas, poor education, low body mass index, and passive smoking are of greater importance. Dusty occupations and tuberculosis are important risk factors at some sites.

Malnutrition and food insecurity in child labourers in Sindh, Pakistan: a cross-sectional study.

BACKGROUND: Child labour is common in low- and middle-income countries. Although child labour is widespread in Pakistan, no data are available on the health of child labourers. AIMS: This study aimed to assess the food security, food intake and nutritional status of child labourers aged 5-14 years working in lower Sindh, Pakistan. METHODS: Child labourers aged 5-14 years working in agriculture, manufacturing industry, hotels and restaurants, domestic work and migrant child labourers working in vegetable markets were recruited using a respondent-driven sampling technique. Sociodemographic and nutrition information was obtained by an interviewer questionnaire. The children's height and weight were measured to assess stunting (height-for-age z scores less than -2) and wasting (weightfor- height z scores less than -2). RESULTS: A total of 634 child labourers were included: 184 worked in agriculture, 120 in industry, 67 in hotels and restaurants, 63 in domestic work and 200 were migrant child labourers. Overall, 15.5% of the children were stunted and 30.0% were wasted. The prevalence of stunting was highest in children working in agriculture (27.2%) and the prevalence of wasting was highest in migrant child workers (35.0%). About half the children (51.1%) were suffering from food insecurity. Food inadequacy was mainly in consumption of vegetables/potatoes (98% of the children had inadequate intake), legumes (97%), fruits (96%), meat/ poultry (95%) and milk/dairy products (82%). CONCLUSION: The nutritional status and food insecurity of the child labourers of Pakistan are comparable with the general population, highlighting the grave situation of the country with regard to food security.