Safety and Health at Work 6 (2015) 56e61

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Safety and Health at Work

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Original Article

Cold Exposure and Health Effects Among Frozen Food Processing

Workers in Eastern Thailand
Anamai Thetkathuek 1,*, Tanongsak Yingratanasuk 1, Wanlop Jaidee 2,
Wiwat Ekburanawat 3
1
Department of Industrial Hygiene and Safety, Faculty of Public Health, Burapha University, Chonburi, Thailand
2
Department of Public Health Foundations, Faculty of Public Health, Burapha University, Chonburi, Thailand
3
Occupational Medicine Center, Samitivej Sriracha Hospital, Chonburi, Thailand

articleinfo
abstract
Article history:
Received 1 August 2014 Frozen food processing workers work under a cold environment which can cause several adverse health
Received in revised form effects.This study explored factors affecting workers’ health in the frozen food industry in Thailand.
8 September 2014 Participants comprised 497 workers exposed to a cold working environment and 255 office workers who
Accepted 3 October 2014 served as the controls.
Available online 18 October 2014 Data were collected by a survey on the work environment, and the interview of workers for abnormal
symptoms. The exposed group had the following characteristics: 52.7% male, overall average age of 27
Keywords: (SD 6.6) years old, attained elementary education (Grade 4 and Grade 6) (54.1%), married (48.9%),
cold smokers (21.3%), alcohol consumption (31.0%), duration of work was between 1 and 5 years (65.2%),
illness working 6 days a week (82.7%), 1e5 hours of overtime per week (33.8%), office workers (33.9%); work
health surveillance category: sizing (6.9%), peeling (28.3%) dissecting (22.2%), and in the warehouse (8.6%). The
temperature
○ ○ ○
in the work environment ranged from 17.2 C to 19.2 C in most sections, —18.0 C in the warehouse,
○
and 25 C in the office areas. Warehouse workers had more abnormal symptoms than controls
including
repeated pain in the musculoskeletal system (OR 11.9; 95% CI 6.12e23.45), disturbance throughout the
body (OR 4.60; 95% CI 2.00e10.56), respiratory symptoms (OR 9.73; 95% CI 3.53e26.80), episodic finger
symptoms (OR 13.51; 95% CI 5.17e35.33).
The study results suggest that workers’ health should be monitored especially with regard to back
and muscle pain, respiratory symptoms, episodic finger symptoms, and cardiovascular symptoms.
Health promotion campaigns such as antismoking and reduction of alcohol consumption should be
established because smoking and alcohol consumption are contributing factors to the pathogenesis of
Raynaud’s phenomenon and peripheral vascular disorders such as hypertension and heart disease.
© 2014, Occupational Safety and Health Research Institute. Published by Elsevier. All rights reserved.

1. Introduction
maintains the quality of fresh food for longer. However, it can
be dangerous causing the body core temperature to drop.
As one of the world’s main food production hubs, Thailand is
Accompa- nied with wind speed and humidity levels, low
famous for its frozen food industry. The seafood industry
temperature can affect workers’ health [1,3e7].
inevitably needs labor to work in many different sections like
Although there has been no report on work-related cold
shrimp beheading, peeling, sizing, dissecting, and so on.
stress in Thailand [8], there are several studies that examine the
Frozen food processing workers have been exposed to potential
effects of a low temperature working environment and its
health hazards including physical, biological, chemical, and psy-
impact on heath in other locations [3e9]; therefore we should
chosocial work environments [1,2]. Low temperatures are neces-
pay attention to these impacts because there are a large number
sary in the production of industrial frozen food, which keep the
of warehouse workers whose jobs are located in low
temperature work environments [9].

* Corresponding author. Department of Industrial Hygiene and Safety, Faculty of Public Health, Burapha University, Chonburi 20131, Thailand.
E-mail address: [email protected] (A. Thetkathuek).

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0)
which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2093-7911/$ e see front matter © 2014, Occupational Safety and Health Research Institute. Published by Elsevier. All rights
reserved. http://dx.doi.org/10.1016/j.shaw.2014.10.004
 A. Thetkathuek et al / Cold Exposure in Frozen Food Workers
5
After exposure to low temperature, symptoms may not appear
respiratory symptoms (asthma, respiratory wheezing, cough,
immediately. This delay period might distract health care
excessive sputum, runny nose), episodic finger symptoms (darkening
personnel from considering low temperature as the cause of
of fingers, reddening of fingers, finger pain, toe pain), face and skin
adverse health effects [3,4,9].
symptoms (urticarial, face pain), peripheral circulation symptoms
Low temperature working environments can cause various
(blurry vision, headache, confusion), cardiovascular system (pallor
diseases [3e7,9] if there is no proper policy in place to control the
adverse health effects from cold exposure. Cold exposure may of fingers, chest pain, arrhythmia). The symptoms were rated by a
affect various organs such as the respiratory system, score of two levels (0e1); where ¼ 0 no symptoms and 1¼ has
musculoskeletal system (usually at temperature below 10 degrees symptom. The interview schedule was verified by two occupational
[2]), and cause skin disorders such as rash and hives (urticaria) [11], medicine physicians, and an occupational health specialist, then
and cold- associated trauma such as Raynaud’s phenomenon [12], underwent a trial before use.
frostbite, trench foot, chilblains, and hypothermia.
It is evident that cold work environments can cause adverse 2.2.2. Working environment data
health effects [1,4e7,9,10,13]; however, in Thailand, studies on cold Secondary data of workplace temperature monitoring were
exposure and health effects are limited. This study aims to explore used in this study. A real-time digital thermometer was used to
the health effects of working in cold environments, to determine monitor workplace temperature.
factors causing abnormal symptoms in frozen food industrial
workers, and to provide basic information to monitor health risks 2.3. Data analysis
resulting from cold exposure.
A statistical analysis package (IBM Corp. Released 2012. IBM
2. Materials and methods SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM
Corp.) was used for data analysis. Sociodemographic
This is a cross-sectional study in which data were collected characteristics, work history, and health effects were described
from April to September 2013. in terms of percentages, means and standard deviations. Factors
affecting health were analyzed using logistic
2.1. Study population and participants regressionebackward
¼ elimination (p- remove 0.10) to determine
the relationships between age, sex, smoking, drinking, duration
The study population comprised workers exposed to cold work of work (years) and seven types of abnormal symptoms: (1)
environments who worked in two frozen food factories in Rayong repeated pain in the musculoskeletal system, (2) symptoms
Province, Thailand. The study participants were calculated using throughout the body, (3) respiratory symp- toms, (4) episodic
the formula for simple logistic regression analysis [14], where n was finger symptoms, (5) face and skin symptoms, (6) peripheral
the sample size required, P was the rate of the event based on circulation symptoms, (7) cardiovascular system symptoms.
Lekcharoen et al [15] who found that the proportion of workers
who were exposed to cold frequently for more than 3 hours a day 3. Results
was 61.4% (p¼0.614) and P1 P2 is the difference of the event
between physical hazard exposed and nonexposed groups in 3.1. Demographic characteristics
which the minimum difference was 0.15.
Substituting the values in the formula thus defined the error (a) Although 886 was calculated as the sample size for this study,
of 5% (¼1.96) and the statistical power (1 b) —
of 90% ( 1.28).¼The there were 752 (85%) participants which consisted of 497 in-
calculated sample size was 442.7 y 443. Because this study dividuals exposed to cold and 255 controls who worked in offices.
explored many variables, therefore, the sample size [14] when np Among the exposed group, 52.7% were male, 62.0% were 21e30
was the adjusted sample size, and n1 was the calculated sample size years old, 54.1% attained elementary education, 48.9% were mar-
was made using the formula for simple logistic regression analysis. ried, 21.3% were smokers with a mean smoking duration of 8.45
R2 was the coefficient of multiple logistic regression, and for this (SD 6.63) years, 31.4% was drinkers (Table 1).
study was set at 50% (R2¼ 0.50). The calculated sample size using
the formula was 886 individuals. 3.2. Current work history
All participants were permitted to decline or withdraw at any
time from the study without penalty. Those who agreed to partic- Duration of work among the study group ranged from 0.08
ipate signed an informed consent form. The Institutional Review to 22 years, with an average of 2.23 (2.70) years, working 8 hours
Board of Burapha University provided ethical approval for the a day or more. The majority (82.7%) worked 6 days per week.
study protocol. The average amount of overtime was 3.48 hours per week
(Table 2).
2.2. Tools and data collection The temperature in the work environment of the study subjects
○ ○ ○
ranged from 17.2 C to 19.2 C in most sections, and—18.0 C in the
2.2.1. Interview
warehouse. Workers in sizing, peeling, dissecting, and warehouse
Participants were recruited to the study based on voluntary
sections were exposed to cold hazards from the work environment,
basis and informed consent was obtained. The interview process water, and processing products. The temperature in the
schedule consisted of five parts: Part 1dSociodemographic ○
characteristics such as sex, age, education, marital status, office areas was 25 C.
smoking history, and drinking history. Part 2dCurrent working
history, number of working hours per day, number of working 3.3. Health effects resulting from cold exposure
days per week, time to relax outside of work per day. Part
3dHealth effects; cold exposure symptoms such as repeated pain The participants reported that they had abnormal symptoms,
in the musculoskeletal system (back pain and muscular pain), which included musculoskeletal system symptoms, discomfort,
symptoms throughout the body (discom- fort, shivering, itching respiratory symptoms, episodic finger symptoms, face and skin
after cold exposure, entire body cold), symptoms, peripheral circulation symptoms, and cardiovascular
symptoms (Table 3).
Table 1
Worker’s characteristics

Work sections Nonexposed Exposed

Office Sizing Peeling Dissecting Warehouse Total

n ¼ 255 (%) n ¼ 52 (%) n ¼ 213 (%) n ¼ 167 (%) n ¼ 65 (%) N ¼ 497 (%)

Sex
Male 56 (22.0) 29 (55.8) 98 (46.0) 83 (49.7) 52 (80) 262 (52.7)
Female 199 (78.0) 23 (44.2) 115 (54.0) 84 (50.3) 13 (20) 235 (47.3)
Age
Mean (SD) years 31.03 (6.78) 27.77 (6.56) 27.5 (6.60) 27 (6.3) 30.11 (6.99) 27.94 (6.66)
Median (Max, Min) years 30.00 (19e53) 27 (19e48) 26 (15e47) 26 (18e50) 29 (19e50) 27.00 (15e50)
Education
No education 0 (0.0) 2 (3.8) 23 (10.8) 9 (5.4) 2 (3.1) 36 (7.2)
Elementary (Grade 4/6) 9 (3.6) 28 (53.8) 112 (52.6) 118 (73.3) 11 (16.9) 269 (54.1)
Junior/senior high/diploma 97 (38.1) 74 (42.3) 75 (35.3) 37 (22.2) 41 (63.1) 175 (35.3)
Bachelor degree or higher 149 (58.4) 0 (0.0) 3 (1.4) 3 (1.8) 11 (16.9) 17 (3.4)
Marital status
Single 149 (58.4) 21 (40.4) 96 (45.1) 70 (41.9) 37 (56.9) 224 (45.1)
Married 91 (35.7) 30 (57.7) 99 (46.5) 91 (54.5) 23 (35.4) 243 (48.9)
Widow/Divorce/Separated 15 (6) 1 (1.9) 18 (8.4) 6 (3.6) 5 (7.7) 30 (6.0)
Smoking history
Current smoker 20 (7.8) 14 (26.9) 41 (19.2) 36 (21.6) 32 (49.6) 106 (21.3)
Nonsmoker 235 (92.2) 38 (73.1) 172 (80.8) 131 (78.4) 33 (50.8) 371 (74.6)
Mean (SD) (y) 8.20 (4.78) 6.08 (3.32) 9.27 (7.15) 8.30 (6.23) 8.58 (7.51) 8.45 (6.63)
Median (max, min) 8 (2e18) 5 (2e13) 6 (1e29) 6 (2e25) 7 (1e26) 6 (1e29)

3.4. Factors affecting health effects

1.888 (95% CI: 1.227e2.905), 1.607 (95% CI: 0.924e2.793), and 9.731
(95% CI: 3.534e26.797), respectively.
Multiple logistic regression analysis revealed that factors
Factors affecting episodic finger symptoms were sex and work
affecting repeated pain in the musculoskeletal system were sex and
section. Women working in the sizing and warehouse sections
work section. Women working at sizing, peeling, dissecting, and in
were at higher risk of having hand and finger disorders with the
the warehouse sections has a higher risk of having back and muscle
odds of 1.645 (95% CI: 1.119e2.419), 2.479 (95% CI: 1.113e5.438),
pain with the odds of 1.816 (95% CI: 1.186e2.781), 5.966 (95% CI:
and 13.514 (95% CI:5.169e35.327), respectively.
3.045e11.691), 1.433 (95% CI: 0.866e2.371), 3.436 (95% CI: 2.097e
Factors affecting face and skin symptoms were sex, age, and
5.629), and 11.962 (95% CI: 6.123e23.445), respectively.
section. Being female, older workers, and working in the
Factors affecting symptoms throughout the body were sex and
warehouse section resulted in a higher risk of having face and skin
work section. Men working in the warehouse were at higher risk of
symptoms with the odds of 1.932 (95% CI: 0.936e3.987), 3.509
having symptoms throughout the body with the odds of 1.794 (95%
(95% CI: 1.323-
CI: 1.219e2.641), and 4.597 (95% CI: 2.002e10.556), respectively.
9.308) and 7.858 (95% CI: 3.171e19.471), respectively.
Factors affecting respiratory symptoms were gender, smoking,
Factors affecting peripheral circulation symptoms were sex and
and section. Female, smokers, and working in the warehouse were
smoking. Women and smokers were at higher risk of having
at higher risk of having respiratory symptoms with the odds of
neurological disorders with the odds of 1.63 (95% CI: 1.045e2.541)
and 1.949 (95% CI: 1.061e3.581), respectively.

Table 2
Work history

Factors Nonexposed Exposed

Office Sizing Peeling Dissecting Warehouse Total

n ¼ 255 (%) n ¼ 52 (%) n ¼ 213 (%) n ¼ 167 (%) n ¼ 65 (%) N ¼ 497 (%)
Work duration (y)
<1 48 (18.8) 19 (36.5) 75 (35.2) 29 (17.4) 9 (13.8) 132 (26.6)
1e5 90 (35.3) 32 (61.5) 138 (64.8) 116 (69.5) 38 (38.5) 324 (65.2)
>5 117 (45.9) 1 (1.9) 0 (0.0) 22 (13.2) 18 (27.7) 41 (8.2)
Mean (SD) 3.47 (4.33) 1.31 (1.32) 1.38 (0.72) 2.65 (2.23) 4.69 (5.54) 2.23 (2.70)
Median (max, min) 1.92 (0.08e24) 1.04 (0.50e10) 1.25 (0.08e4.67) 2 (0.42e9) 2.17 (0.08e22.67) 1.75 (0.08e22.67)
Work hours
<8 0 (0.0) 0 (0.0) 1 (0.5) 0 (0.0) 1 (1.5) 2 (0.4)
≤8 255 (100) 52 (100) 212 (99.5) 167 (100) 31 (100) 295 (99.6)
Mean (SD) 8.20 (0.60) 8 (0.0) 7.99 (0.14) 8.01 (0.07) 8.11 (0.59) 8.01 (0.237)
Median (max, min) 8 (8e12) 8 (8e8) 8 (6e8) 8 (8e9) 8 (7e12) 8 (6e12)
Work days per week
5 3 (1.2) 16 (30.8) 41 (19.2) 26 (15.6) 0 (0.0) 83 (16.7)
6 251 (98.4) 36 (69.2) 171 (80.3) 141 (84.4) 63 (96.9) 411 (82.7)
7 1 (0.4) 0 (0.0) 1 (0.51) 0 (0.0) 2 (3.1) 3 (0.6)
Overtime per week (h)
1e5 4 (1.6) 4 (7.7) 20 (9.4) 4 (2.4) 3 (4.6) 168 (33.8)
6e10 217 (85.1) 48 (92.3) 127 (59.6) 39 (23.4) 52 (80) 43 (8.7)
>10 34 (13.3) 0 (0.0) 66 (31.0) 124 (74.3) 10 (15.4) 2 (0.4)
Mean (SD) 1 (0.0) 3.52 (2.87) 3 (2.58) 3.56 (2.50) 5.21 (3.85) 3.48 (2.72)
Median (max, min) 1 (1e1) 3 (1e12) 2 (1e18) 2 (1e10) 3 (1e14) 2 (1e18)
Table 3
Health effects

Symptoms Nonexposed Exposed

Office Sizing Peeling Dissecting Warehouse Total

n ¼ 255 (%) n ¼ 52 (%) n ¼ 213 (%) n ¼ 167 (%) n ¼ 65 (%) N ¼ 497 (%)

Musculoskeletal system (back pain/muscular pain)

No 208 (81.6) 25 (48.1) 171 (80.3) 102 (61.1) 21 (32.3) 319 (64.2)
Yes 47 (18.4) 27 (51.9) 42 (19.7) 65 (38.9) 44 (67.7) 178 (35.8)
Symptoms throughout the body (discomfort/shivering/itching after cold exposure/entire body cold)
No 38 (39.6) 28 (57.1) 145 (68.1) 62 (37.6) 12 (18.8) 247 (50.3)
Yes 58 (60.4) 21 (42.9) 68 (31.9) 103 (62.4) 52 (81.3) 244 (49.7)
Respiratory symptoms (asthma/respiratory wheezing/cough/excessive sputum/runny nose)
No 32 (33.3) 24 (49.0) 125 (58.7) 57 (34.5) 6 (9.4) 212 (43.2)
Yes 64 (66.7) 25 (51.0) 88 (41.3) 108 (65.5) 58 (90.6) 279 (56.8)
Finger symptoms episodic (darkening of fingers/reddening of fingers/finger pain/toe pain/hands and legs sensitive to cold/fingers and toes sensitive to cold)
No 48 (50.0) 20 (40.8) 150 (70.4) 80 (48.5) 7 (10.9) 257 (52.3)
Yes 48 (50.0) 29 (59.2) 63 (29.6) 85 (51.5) 57 (89.1) 234 (47.7)
Face and skin symptoms (urticaria/face pain)
No 70 (72.9) 47 (95.9) 199 (93.4) 157 (95.2) 28 (43.8) 431 (87.8)
Yes 26 (27.1) 2 (4.1) 14 (6.6) 8 (4.8) 36 (56.3) 60 (12.2)
Peripheral circulation symptoms (blurry vision/headache/confusion)
No 47 (49.0) 24 (49.0) 15 (70.9) 135 (81.8) 33 (51.6) 243 (69.9)
Yes 49 (51.0) 25 (51.0) 62 (29.1) 30 (18.2) 31 (48.4) 148 (30.1)
Cardiovascular system (pallor of fingers/chest pain/arrhythmia)
No 73 (76.0) 30 (61.2) 172 (80.8) 148 (89.7) 42 (65.6) 42 (65.6)
Yes 23 (24.0) 19 (38.8) 41 (19.2) 17 (10.3) 22 (34.4) 22 (34.4)

Factors affecting cardiovascular system symptoms were sex,

Harcombe et al [25] also found that 70% (n¼310) of workers had at
smoking, and work section. Women, smokers, working in the
least one musculoskeletal symptom (OR ¼1.35, 95% CI: 1.14e1.6).
sizing and warehouse sections resulted in a higher risk of having
Factors affecting symptoms throughout the body were gender,
car- diovascular disorders with the odds of 1.717 (95% CI:
age, and work section in which females had more abnormal symp-
1.033e2.855), 2.147 (95% CI: 1.029e4.482), 2.516 (1.143e5.538), and
toms than males (OR¼ 1.794, 95% CI: 1.2.19e2.641). Elderly workers
2.826 (95%
reported more abnormal symptoms (OR ¼ 0.934, 95% CI: 0.904e
CI: 1.275e6.264), respectively (Table 4).
0.964). Shivering was normally caused by cold exposure [26].
This study found that workers in extremely low temperatures
— (
4. Discussion ○
18 C in the warehouse section) experienced more abnormal
symptoms than
This study found that the factors most associated with back and
controls (OR ¼4.597, 95% CI: 2.002e10.556) regardless of personal
muscular pain was sex. Female workers had more abnormal
protective equipment provided. Physiologically, body temperature
symptoms than males. This was consistent with the studies by
regulation caused muscle strain and shivering [4,27].
Nagasu et al [16] who revealed that sex was associated with the
prevalence of low back pain during 1 month of work (prevalence Cold exposure induced symptoms throughout the body such
as discomfort which gradually worsened when the temperature
ratio, PR ¼1.32; 95% CI, 1.03e1.68) and Tomita et al [17] who ○
studied low back pain in migrant workers who worked in the was below —10 C [2], while itching did not occur [4] because
seafood production industry in Thailand. They found that being when skin
○
female was a risk factor for low back pain (OR 2.77, CI 95%: 0.79e temperature was below 20 C this could reduce the symptom by
¼ 50% [28].
9.75) and that musculoskeletal disorders were related to working in
cold environments [9,18]. Factors affecting respiratory symptoms were sex, age, smoking,
We found that age was not associated with low back and and work section. Women had more abnormal symptoms than
muscular pain. Apparently age was a risk factor of back pain, men ¼(OR 1.888, 95% CI: 1.227e2.905). A previous study indicated a
however; the participants in this study were male, mostly higher prevalence of asthma and bronchitis in female workers.
around 21e30 years of age, without significantly degenerated Abnormal symptoms proportionally increased with age [29].
spinal bone and intervertebral discs [19]. Moreover, back pain Workers who smoked had more abnormal symptoms than non-
was commonly found in adult workers. Low back pain smokers (OR ¼1.607, 95% CI: 0.924e2.793) Smoking aggravated
prevalence was at a peak around the ages of 40e69, and female respiratory symptoms while working cold environments. Chronic
workers were at higher risk than males [20]. This was not diseases such as musculoskeletal pain, respiratory disease, Ray-
consistent with previous studies which indicated that age was naud’s phenomenon, cardiovascular disease could become worse
related to low back pain among Thai workers [21] and Western while working under cold condition [2,5,13,30]. Moreover, smoking
workers [22,23]. Nevertheless follow-up studies in middle age was a risk factor of Raynaud’s phenomenon [12].
and elderly workers should be conducted. This study indicated that warehouse workers had more
Sizing, peeling, dissecting, and warehouse workers had more abnormal symptoms than controls (OR¼ 9.731, 95% CI: 3.534e
abnormal symptoms than the controls (OR 26.797). Cold and dry air inspiration caused acute and chronic
¼ 5.966, 95% CI: 3.045e
11.691; OR ¼ 1.1816, 95% CI: 1.186e2.781; OR ¼ 3.436, 95% CI: 2.097e symptoms of the upper and lower respiratory tract. Higher
5.629; OR ¼11.962, 95% CI: 6.123e23.445) respectively. Different morbidity and mortality in the winter [31] was indicated by
sections had different cold levels by which the musculoskeletal sys- 160,000 deaths in Michigan with chronic obstructive disease who
○ were at higher risk on colder days [32]. Respiratory disease among
— 10 C environment
tem could be affected, which was worst in the ○
[2]. employees became worse below — 15 C [33], however; differences
Workers in frozen food industries who are repeatedly exposed to in sensitivity of each and ventilation were associated with the
cold, humidity, and repetitive work, possibly faced muscle strain symptoms [34].
[23,24].
 Factors affecting episodic finger symptoms were sex, duration of

Ref1.949 (1.061e3.581) Ref2.147 (1.029e4.482)

1.339 (.643e2.789)Ref 2.516 (1.143e5.538)Ref

1.717 (1.033e2.855)Ref
work, and work section. Female workers had more abnormal
symptoms than their counterparts (OR¼1.645, 95% CI: 1.119e2.419).
Kaminski et al [35] found that cold sensitivity of the fingers was the
chief complaint among can manufacturing workers. Raynaud’s
phenomenon was mostly found among female workers with
gangrenous fingers, toes, nose tip, earlobes, and nipples [36].

e
Warehouse workers had more abnormal symptoms than con-
trols (OR ¼ 13.514, 95% CI: 5.169e35.327). The temperature in the
1.63 (1.045e2.541)Ref

○
warehouse was normally lowest at — 18 C. Hassi [13], Holmér [4]
found that wind speed, humidity, and cold temperature increased
the cooling rate of skin and tissues resulting in increasing sensi-
tivity to cold, dermal vasoconstriction especially at the hands, feet,
nose, and ears and musculo-skeletal pain in the fingers [2,30].
e

○
These abnormal symptoms occurred below 15 — C [33].
Factors affecting face and skin symptoms (urticaria) were
0.11 (0.024e0.51)Ref
1.932 (0.936e3.987)Ref

gender, age, and work section. Those who were female, of older
0.99 (0.99e1.001)

age, and who were working in the warehouse had more abnormal
symptoms than controls (OR¼ 1.932, 95% CI: 0.936e3.987;
OR 3.509,
¼ 95% CI: 1.323e9.308; OR 7.858, 95% ¼ CI: 3.171e
Number Musculoskeletal system Symptoms throughout Respiratory
19.471), respectively. Finger symptoms
With low enough Face Peripheral
temperatures, urticariaandandCardiovascular
skin circulation
aOR (95% CI) the body symptoms episodic symptoms
system
reddened and swelled skin could occur [11].
e

0.025 (0.095e0.44)

aOR (95% CI) Factors affecting

aOR (95%peripheral
CI) circulation
aOR (95%symptoms
CI) aOR (95%
were sex andCI) aOR (95% CI)
Ref

smoking. Women and smokers had more abnormal symptoms

1.888 (1.227e2.905)Ref 1.645 (1.119e2.419)Ref

1.009 (1.003e1.015)

2.479 (1.13e5.438)

(OR ¼1.63, 95% CI: 1.045e2.541; OR 1.949, ¼ 95% CI: 1.061e3.581),

respectively. Bird et al [37] indicated that cold induced migraine-
like headache. The result of this study show that working in the
warehouse section was not associated with peripheral circulation
symptoms. Abdel-Hamid et al [38] found that those working in the
office environment had a higher incidence of headache as a result
e

0.742 (0.41e1.349)

of poor illumination, bad ventilation, noise, smoking, and dust.

Ref

Factors affecting cardiovascular system symptoms were sex,

Ref1.607 (0.924e2.793)

0.66 (0.31e1.404)

smoking, and work section. Those who were female, smokers, and
worked at sizing and in the warehouse had more abnormal
symptoms than controls (OR ¼ 1.717, 95% CI: 1.033e2.855;
OR ¼ 2.147, 95% CI: 1.029e4.482; OR ¼ 2.516, 95% CI: 1.143e5.538;
OR ¼ 2.826, 95% CI: 1.275e6.264), respectively. Exposure to very low
e

temperature would aggravate heart disease. Swoap et al [39] found

0.487 (0.277e0.856)

○ ○
that ambient air temperatures below 6 C or over 29 C
Ref
1.794 (1.219e2.641)Ref

resulted in changes in blood pressure and heart rate of mice. In

0.638 (0.291e1.395)
1.005 (0.99e1.01)

clinical observation, cold exposure induced sympathetic

Factors were removed from the logistic model (p > 0.10).

activities causing a higher risk of hypertension [40]. Moreover,

Kawahara et al [41] reported that cold exposure was possibly
involved in abnormal heart-indicated parameters.
This study is limited by the relatively short duration of
e

employment. Adverse health effects resulting from working in cold

environments usually have a long latency period. Moreover, the
5.966 (3.045e11.691)Ref
434 (57.7) 318 (42.3) 1.816 (1.186e2.781)Ref

abnormal symptoms were self-reported by the individuals. There

525 (69.8)227 (30.2) Ref0.69 (0.448e1.064)

was no medical evaluation by physicians.

It is suggested that workers’ health should be monitored,
especially back and muscle pain, respiratory symptoms, darkening
of the fingers and toes, and disorders of the heart. As the cofactors
Ref

of cold-related diseases, those who work in cold environments

should avoid smoking and drinking to reduce the risk of cardio-
vascular disorders.
Factors affecting abnormal symptoms Table 4

567 (75.4)117 (15.6)

52 (6.9)255 (33.9)

Conflicts of interest
Sex

All authors declare no conflicts of interest.

Male Female

Acknowledgments

This work was supported by Burapha University and National

Age (y)

Research Council of Thailand (NRCT), 2013.

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