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com
Original article
1
Occupational and
Environmental Health Unit,
Department of Social and
Preventive Medicine, Faculty of
Medicine, University of Malaya,
Kuala Lumpur, Malaysia
2
Faculty of Medicine,
Department of Social and
Preventive Medicine, University
of Malaya, Kuala Lumpur,
Malaysia
Correspondence to
Dr Ting Anselm Su,
Occupational and Environmental
Health Unit, Department of
Social and Preventive Medicine,
Faculty of Medicine, University
of Malaya, 50603 Kuala Lumpur,
Malaysia;
anselmsuting@yahoo.com
Accepted 17 June 2010
Published Online First
8 October 2010
58
Hand-arm vibration syndrome among a group of
construction workers in Malaysia
Ting Anselm Su,1 Victor Chee Wai Hoe,2 Retneswari Masilamani,2
Awang Bulgiba Awang Mahmud2
ABSTRACT
Objectives To determine the extent of hand transmitted
vibration exposure problems, particularly hand-arm
vibration syndrome (HAVS), among construction workers
in Malaysia.
Methods A cross-sectional study was conducted on
a construction site in Kuala Lumpur, Malaysia. 243
workers were recruited. Questionnaire interviews and
hand examinations were administered to 194
respondents. Vibration magnitudes for concrete breakers,
drills and grinders were measured using a 3-axis
accelerometer. Clinical outcomes were compared and
analysed according to vibration exposure status.
Results Vibration total values for concrete breakers,
impact drills and grinders were 10.02 ms
2, 7.72 ms
2
and 5.29 ms
2, respectively. The mean 8 h time-
weighted hand transmitted vibration exposure, A(8),
among subjects on current and previous construction
sites was 7.52 (SD 2.68) ms
2 and 9.21 (SD 2.48)
ms
2, respectively. Finger tingling, finger numbness,
musculoskeletal problems of the neck, finger coldness,
abnormal Phalen’s test and abnormal light touch
sensation were significantly more common in the high
vibration exposure group (n¼139) than the
lowemoderate vibration exposure group (n¼54). Mean
total lifetime vibration dose among exposed subjects
was 15.2 (SD 3.2) m2 h3 s
4 (ln scale). HAVS
prevalence was 18% and the prevalence ratio of stage 1
and higher disease in the high vibration exposure group
versus the lowemoderate vibration exposure group was
4.86 (95% CI 1.19 to 19.80).
Conclusions Hand transmitted vibration is
a recognisable problem in tropical countries including
Malaysia. The current study has identified clinical
symptoms and signs suggesting HAVS among
construction workers exposed to hand transmitted
vibration in a warm environment.
INTRODUCTION
Hand-arm vibration syndrome (HAVS) is a disabling
clinical condition characterised by a complex of
signs and symptoms in the vascular, neurological
and musculoskeletal systems of the upper limbs due
to prolonged exposure to hand transmitted vibra-
tion. The prevalence of HAVS ranged from 5% to
more than 80% globally depending on the types of
tools, extent of vibration exposure and climatic
factors.1e7 The condition is widely recognised in
temperate zones due to the presence of its well-
known clinical featuredvibration white finger
(VWF)dwhich is now known to be provoked by
low ambient temperature.8e12 Its prevalence in
warm countries is not well established because
What this paper adds
< Large numbers of industrial workers in tropical
countries are at risk of exposure to hand
transmitted vibration.
< However, the prevalence of HAVS and its typical
clinical manifestations in warm environments
have not been properly established.
< This study shows that HAVS is a recognisable
condition in warm environments but manifests
with different clinical signs and symptoms
compared to cold environments.
< The findings of this first study on HAVS in
Malaysia will serve as a baseline for further
research and may stimulate local authorities to
tackle the problem of hand transmitted vibration.
VWF13e16 does not typically occur and the available
literature on HAVS in tropical countries is
limited.13e18 Recent data from South Africa5
showed that the prevalence of HAVS among gold
miners exposed to hand transmitted vibration from
rock drills in warm environments was 15%.
An overview of epidemiological studies shows
that sensorineural disorders tend to appear earlier
than vascular disorders and that these disorders
develop independently of each other at different
rates.19 Neurological and musculoskeletal signs of
HAVS are more common than vascular symptoms
in tropical countries because the critical ambient
temperature for the provocation of VWF is around
158C.20 The low rate of VWF could explain the low
disease prevalence in tropical countries since the
classical diagnosis of HAVS includes VWF.
No information on HAVS is available to date for
Malaysia. Information from the Department of
Statistics, Malaysia shows that about 2.3 million
workers were employed in agriculture, forestry,
construction, mining and quarrying in 2005.21
Despite so many being employed in industries
where hand transmitted vibration hazards are
common, only 15 workers applied to the Social
Security Organization (SOCSO), Malaysia for
compensation claims under the item ‘diseases
caused by vibration (disorders of muscles, tendons,
bones, joints, peripheral blood vessels or peripheral
nerves)’ in 2006.22
This study was conducted to determine the
prevalence of HAVS and its clinical manifestations
among a group of construction workers in a warm
environment. The results of this study will also add
to the existing literature on the characteristics of
HAVS in tropical countries.
Occup Environ Med 2011;68:58e63. doi:10.1136/oem.2009.052373
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METHODS
This is a cross-sectional study. A large construction site covering
13 acres in Kuala Lumpur city centre was selected for this study.
Average ambient temperature is above 258C throughout the
year, varying from 248C at night to 338C during the day. Average
relative humidity is 85% throughout the year. All construction
work on the project was carried out by one main subcontractor.
All plant operators working for the main subcontracting
company were recruited into the study. The plant operators
were involved in general operations and construction of the
building including assisting with or laying bricks, concrete
finishing, non-specialised woodwork, demolition and repairing,
and area cleaning. Some of the plant operators worked at dril-
ling, concrete breaking, steel cutting and metal grinding, and
hence were exposed to hand transmitted vibration. Adminis-
trative officers and non-manual support staff were not included
in the study as their work was very different from that of plant
operators. Female subjects and those with a history of injury or
surgery with residual complications involving muscles, nerves
and bony structures of the hands, forearms and arms were
excluded. A total of 243 eligible plant operators worked on the
construction site during the data collection period of 3 January
2007 to 24 April 2007.
All respondents were interviewed using a modified question-
naire with Malay translation based on the Hand-Transmitted
Vibration Health Surveillance - Initial Questionnaire and Clin-
ical Assessment, created by the Research Network on Detection
and Prevention of Injuries due to Occupational Vibration
Exposures (Vibration Injury Network). The questionnaire was
pretested and pilot tested using a subsample of the study
population and found to be reliable and suitable for use in the
current study.23
The interview included questions on basic demographic
information, occupational, social and medical histories, detailed
vibration exposure information including employment duration,
duration of employment at the current construction site, type of
vibratory tools used and daily duration of operation for each
vibratory tool, yearly exposure and total number of years of
exposure in both current and previous construction sites.
Subjects were asked specifically to recall and report as accurately
as possible the daily duration of operation for each vibratory tool
after excluding all work breaks including all rest periods, lunch
hours, tea breaks and dinner time.
Information on HAVS symptoms was obtained from the
interview and from physical examination of the hand, with
specific hand function assessment using the Purdue Pegboard,
the Rolyan Hot and Cold Discrimination Kit, Semmes Weinstein
monofilaments, the Touch-Test Two-Point Discriminator and
a tuning fork. All hand function assessments were carried out at
room temperature at 278C. For the Purdue Pegboard test, the
discriminating threshold for abnormal findings was 1 SD below
the normative population means for male maintenance and
service employee data (means 13.61 and 13.45 for the right and
left hands, respectively) as provided in the operator’s manual.
The discriminating temperatures for cold and hot sensation
using the Rolyan aluminium temperature probes were 258C and
378C, respectively. The Semmes Weinstein monofilaments test
was recorded as abnormal if the subject’s threshold of response
was monofilament 3.61 and above (based on the Touch-Test
Sensory Evaluator Chart). The upper limit for normal static
two-point discrimination was set at 6 mm. Vibration sensation
was considered abnormal if the subject perceived no vibration at
the distal interphalangeal joints of the index and little fingers
Occup Environ Med 2011;68:58e63. doi:10.1136/oem.2009.052373
Original article
following application of a 128 Hz tuning fork. The interview
and physical examination were conducted by two different
researchers who were blinded to each other’s results.
Assessment of workplace tool use revealed that vibratory
tools of the same type and model were used in both current
and previous construction sites as equipment was procured in
bulk for use throughout the company. The most common
vibratory tools used by subjects in any construction project
were concrete breakers, impact drills and grinders. The most
frequent tasks using these tools were demolishing concrete
structures, hole drilling and steel cutting. Hence, the vibrations
produced by these three tools were measured using a VI-400Pro
3-axial human vibration monitor (Quest Technologies, Ocono-
mowoc, Wisconsin, USA) under actual operating conditions.
Measurements were conducted by a qualified technician
according to ISO 5439-2:2001. The accelerometer was firmly
attached to an adaptor (HAV Sensor Mounting Block and
Clamp Assembly, part no. 072-005, Quest Technologies) and
clamped to the tool handle according to ISO 5439-2:2001. The
signal cables were taped to the vibrating surface as near to
the mounted accelerometer as possible to avoid the triboelectric
effect. A mechanical filter constructed of butyl rubber sheeting
was placed between the adaptor and the tool handle to avoid
overloading and DC-shift caused by percussive tools. A
minimum of three readings were taken for each tool and each
reading was taken at least 1 min. The measurements and
information on daily vibration exposure duration obtained
from the questionnaire were used to calculate the daily 8 h
time weighted average vibration exposure level, A(8), of each
subject.
The majority of the workers used more than one tool. The
A(8) of each subject was calculated based on the following
mathematical formula:
rffiffiffi
1 n 2
A8 ¼ + a Ti
8 i ¼ 1 hni
where ahni is the vibration total value for each tool and Ti is
the duration of exposure for each tool. The vibration total value,
ahn, is the square root of the sum of the squares of the acceler-
ation magnitudes of each tool in three orthogonal axes and is
given by the mathematical formula:
qffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
ahn ¼ a2hwx þ a2hwy þ a2hwz
where ahwx, ahwy and ahwz are the frequency weighted root
mean square accelerations in the x-axis, y-axis and z-axis,
respectively. The personal life time vibration dose (LVD) was
also calculated based on formula suggested by Griffin24 25 as
follows:
 n qffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi2
LVD ¼ + a2hni thi $tdi $tyi
i¼1
where thi is the daily vibration exposure duration of each
tool (hours/day), tdi is the number of working days per year
for each tool and tyi is the total number of years use for each
tool.
Plant operators whose A(8) in current or previous construc-
tion sites was equal to or exceeded the American Conference of
Governmental Industrial Hygienist (ACGIH) recommended
threshold limit value (TLV) of 4 ms
2 were categorised as the
high exposure group. Those whose A(8) was less than 4 ms
2 or
who had not used any vibratory tools were categorised as the
59
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Original article

lowemoderate exposure group. The TLV recommended by the Table 1 Characteristics of the study subjects
ACGIH was used as the cut-off value because it is used by the Lowemoderate
Malaysian Department of Occupational Safety and Health as exposure High exposure
Characteristics/risk factors group (n[54) group (n[139) p value
a guide for hand transmitted vibration exposure. The outcome
variables were compared and tested between the two groups of
workers. Age (years), mean (SD) 31.2 (6.4) 29.3 (6.3) 0.056
This study obtained written approval from the main Educational level, n (%)
contractor prior to conduct of the study. Informed consent was No formal education 4 (7.4) 1 (0.7) 0.070*
obtained from each subject before interview and physical Primary 16 (29.6) 44 (31.7)
examination. An explanation was provided to subjects Secondary 34 (63.0) 93 (66.9)
concerning the purpose of the study which was also stated on Tertiary 0 (0.0) 1 (0.7)
the subject information sheet. This was followed by written
Height (cm), mean (SD) 163.8 (6.3) 163.1 (5.4) 0.434
consent once the subjects understood the purpose and conduct
Weight (kg), mean (SD) 56.5 (6.1) 54.9 (6.9) 0.148
of the study. Subjects were given assurance that all reported
symptoms or physical examination findings were confidential
Employment duration (months)
and the information would not be revealed to their employer, to
Mean (SD) 30.0 (25.3) 36.8 (31.6) 0.159
prevent any possibility of employment discrimination. Subjects Median (IQR) 24.1 (12.0e34.5) 24.0 (20.7e48.8) 0.293y
were also informed that any information provided or obtained in
the study could not be used for the purpose of compensation. Current site duration (months)
Data entry was validated using the double entry method. Mean (SD) 12.6 (8.0) 9.6 (8.6) 0.028
Analysis was carried out using SPSS V.15.0. Categorical data Median (IQR) 11.0 (6.0e19.0) 7.3 (2.0e14.0) 0.011y
from the different exposure groups were compared using c2
analysis with relevant Yates correction or Fisher’s exact test. Smoking status, n (%)
Student t tests and ANOVA were used to compare the means of Current smoker 39 (72.2) 96 (69.1) 0.691
two and more than two groups of data, respectively. The Previous smoker 3 (5.6) 13 (9.4)
corresponding non-parametric tests such as the ManneWhitney Non-smoker 12 (22.2) 30 (21.6)
test and KruskaleWallis test were used where data were not
normally distributed. Crude and adjusted prevalence ratios were For current smokers, mean (SD)
calculated for all outcome variables by the log binomial regres- Smoking duration (years) 9.6 (7.0) 9.8 (5.8) 0.812
sion method with SAS V.9.1 using the procedure PROC Number of cigarettes/day 9 (7) 10 (7) 0.565
GENMOD with dist¼bin and link¼log. The significance level
for all statistical tests was set at 0.05 unless specified. Chewing tobacco, n (%)
Yes 0 (0.0) 2 (1.4) 1.000*
No 54 (100.0) 137 (98.6)
RESULTS
A total of 194 eligible plant operators responded to the study Alcohol consumption, n (%)
(response rate 80%). All subjects were foreigners, with 95% Yes 0 (0.0) 5 (3.6) 0.324*
being from Indonesia and the rest from Bangladesh. The mean No 54 (100.0) 134 (96.4)
age of subjects was 29.9 (SD 6.4) years. Most of the workers
Chemical exposure at work, n (%)
(96%) had achieved at least primary education, while the
Yes 6 (11.1) 9 (6.5) 0.368*
majority (66%) had achieved secondary education. All were
No 48 (88.9) 130 (93.5)
fluent in Malay and understood the questionnaire except for one
whose data were excluded from subsequent analysis. All subjects
History of long term medical illness, n (%)
were of medium build (average BMI 20.9) with a dominant right Yes 1 (1.9) 1 (0.7) 0.482*
hand. Median duration of employment and mean duration of No 53 (98.1) 138 (99.3)
working at the current construction site were 24.0 (range
0.1e174.0) and 9.5 (range 0.1e36.0) months, respectively. History of injury to neck and upper limbs, n (%)
Seventy per cent of the subjects were current smokers, but very Yes 2 (3.7) 10 (7.2) 0.515*
few had a history of tobacco chewing, alcohol consumption or No 52 (96.3) 129 (92.8)
chemical exposure at work. None of the subjects had a second
job or history of vibration exposure during their spare time. History of surgery to neck and upper limbs, n (%)
There were 139 (72%) workers in the high exposure group. Yes 0 (0.0) 2 (1.4) 1.000*
Table 1 compares the basic characteristics of subjects between No 54 (100.0) 137 (98.6)
the two groups.
The main sources of hand transmitted vibration exposure in Short term medication, n (%)
the current study were concrete breakers, grinders and impact Yes 24 (44.4) 45 (32.4) 0.116
drills. The frequency weighted vibration magnitudes of the three No 30 (55.6) 94 (67.6)
vibratory tools are shown in table 2. The mean A(8) for hand
transmitted vibration for the high exposure group in current and Long term medication, n (%)
previous construction sites were 7.52 (SD 2.68) ms
2 and 9.21 Yes 0 (0.0) 2 (1.4) 1.000*
(SD 2.48) ms
2, respectively. No 54 (100.0) 137 (98.6)

Neurological and musculoskeletal symptoms were more prev- p Values were derived from either of two independent t tests for quantitative data or the c2
test for categorical data unless otherwise specified.
alent than vascular symptoms. Finger tingling and numbness *Fisher’s exact test.
were experienced by 16% and 14% of all subjects, respectively. yManneWhitney test.

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Original article

Table 2 Average frequency weighted vibration acceleration
magnitudes for vibratory tools
Single-axis root mean square
(r.m.s.) frequency weighted
acceleration in three orthogonal
directions (msL2), mean (SD)
Samples,
Vibratory tool n ahwx ahwy ahwz
Concrete breaker 4 4.06 (0.90) 3.10 (1.58) 9.31 (2.84) 10.02
(Hilti TE706)
Impact drill 4 4.05 (1.39) 5.31 (1.12) 4.35 (0.44)
(Hilti TE25)
Grinder 3 4.61 (1.66) 1.54 (0.54) 1.60 (0.56)
(Black & Decker)
Measured using a VI-400Pro 3-axis accelerometer (Quest Technologies, Oconomowoc,
Wisconsin, USA).
Only three subjects reported finger colour change at least once in
their lifetime. Other reported symptoms related to HAVS were
musculoskeletal problems of the upper limbs (19%), musculo-
skeletal problems of the neck (14%), hand grip weakness (18%),
finger coldness (13%), difficulty handling small objects (2%) and
difficulty opening tight jars (4%). Physical examination revealed
no digital pallor or cyanosis in any subject. Tinel’s and Phalen’s
tests were positive in at least one hand in 15% and 13% of
subjects, respectively, with 11% having both tests positive and
6% only one test positive. There was no significant difference in
the distribution of positive tests between right and left hands.
Neurological assessment of the hands showed abnormal findings
only in light touch, temperature sensation and hand dexterity.
There was no muscle wasting and the mean hand grip
strengths of the left and right hands were 40.1 (SD 6.0) and
41.5 (SD 6.1) kg, respectively.
The prevalence of finger tingling, finger numbness, musculo-
skeletal problems of the neck, finger coldness, abnormal Phalen’s
test and abnormal light touch sensation was significantly higher
in the high exposure group than in the lowemoderate exposure
group. Although the prevalence of abnormal symptoms and
signs was also higher in the high exposure group, the findings are
not statistically significant. The results are shown in table 3.
The mean total LVD among the high exposure group was
15.2 (3.2) m2 h3 s
4 (ln scale). Simple regression analysis of total
LVD and prevalence of HAVS related symptoms showed that
finger tingling, finger numbness, hand grip weakness, finger
coldness and abnormal Tinel’s and Phalen’s test were related to
the trend of total LVD. Table 4 shows the prevalence ratio of
HAVS related symptoms and signs for each unit increase in the
logarithmic scale of total LVD.
Subjects were also classified according to their neurological
Vibration
total symptoms (tingling and numbness) and hand assessment find-
value, ings (Semmes Weinstein monofilament test, Purdue Pegboard
ahv (msL2)
test and two-point discrimination test) into different stages
based on the Stockholm Workshop Scales (table 5). The preva-
lence of HAVS among subjects with high vibration exposure was
7.75
18%. The prevalence ratio of stage 1 and higher disease among
5.29 subjects in the high vibration group versus the lowemoderate
group was 4.86 (95% CI 1.19 to 19.80).
DISCUSSION
The exact prevalence of HAVS in this study is undetermined. If
we restrict our definition of HAVS to the occurrence of symp-
toms in all three components of the hand (vascular, neurological
and musculoskeletal), the prevalence of HAVS in this study was
zero. The absence of vascular symptoms alone does not
conclusively exclude pathology caused by hand transmitted
vibration. Since 72% of subjects were exposed to hand trans-
mitted vibration exceeding the recommended TLV and the
prevalence of neurological and musculoskeletal symptoms was
significantly higher among exposed subjects, it is very likely that
these abnormal outcomes are due to hand transmitted vibration.
Based on the Stockholm Workshop Scales for classification of
neurological symptoms, the prevalence of HAVS was found
to be 18% in this study. This result corresponds with the
prevalence of HAVS among gold miners working in a warm
environment in South Africa.5
There were three cases of finger colour changes in the current
study. However, review of clinical descriptions and exposure
information suggested only one (0.5%) possible case of VWF,
although 18% of the vibration exposed subjects complained of
finger coldness. Previous studies in warm countries such as
Papua New Guinea, Indonesia,14 India13 and Vietnam15 did not
report VWF among vibration exposed workers. The current
subject reported finger whiteness over the distal phalanges of the
right index to little fingers and left middle fingers several times
per week, with the longest colour change (which occurred early
in the morning) lasting about 7 min. While this subject might be
more susceptible to early morning cold weather, other affected
individuals might not have been exposed to colder environments

Table 3 Prevalence ratio (PR) of symptoms and signs of hand-arm vibration syndrome among subjects with high versus lowemoderate vibration
exposure
Vibration exposure, n (%)
Symptoms Lowemoderate group (n[54) High group (n[139) Crude PR (95% CI) Adjusted PR (95% CI)
Finger colour change* 0 (0.0) 3 (2.2) 1.17 (0.12 to 10.96) 1.11 (0.12 to 10.70)
Finger tingling 2 (3.7) 28 (20.1) 5.44 (1.34 to 22.05) 5.66 (1.40 to 22.97)
Finger numbness 2 (3.7) 25 (18.0) 4.86 (1.19 to 19.80) 4.78 (1.17 to 19.54)
Musculoskeletal problems of the upper 6 (11.1) 31 (22.3) 2.01 (0.89 to 4.54) 1.90 (0.84 to 4.31)
limbs
Musculoskeletal problems of the neck 3 (5.6) 24 (17.3) 3.11 (0.98 to 9.90) 3.22 (1.01 to 10.32)
Hand grip weakness 6 (11.1) 29 (20.9) 1.88 (0.83 to 4.27) 1.91 (0.83 to 4.37)
Finger coldness 1 (1.9) 25 (18.0) 9.71 (1.35 to 69.92) 9.17 (1.27 to 66.08)
Difficulty handling small objects* 0 (0.0) 3 (2.2) 1.17 (0.12 to 10.96) 1.05 (0.11 to 10.05)
Difficulty opening tight jars* 0 (0.0) 8 (5.8) 3.11 (0.40 to 24.26) 3.01 (0.38 to 23.77)
Positive Tinel’s test 5 (9.3) 2 (17.3) 1.86 (0.75 to 4.64) 1.80 (0.72 to 4.50)
Positive Phalen’s test 2 (3.7) 23 (16.5) 4.47 (1.09 to 18.30) 4.34 (1.05 to 17.88)
Abnormal dexterity 33 (61.1) 99 (71.5) 1.17 (0.92 to 1.48) 1.18 (0.93 to 1.49)
Abnormal temperature sensation 22 (40.7) 76 (54.7) 1.34 (0.94 to 1.92) 1.27 (0.90 to 1.85)
Abnormal light touch sensation 21 (38.9) 79 (56.8) 1.46 (1.02 to 2.10) 1.46 (1.01 to 2.11)
*PR (95% CI) was obtained by adding 1 to zero value cell.

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Table 4 Prevalence ratio (PR) of symptoms and signs of hand-arm both of which, however, are difficult; caseecontrol studies
vibration syndrome for each unit increase in the logarithmic scale of total require case finding and cohort studies are very labour extensive
lifetime vibration dose and long follow-up.
HAVS related symptoms and signs Crude PR (95% CI) Adjusted PR (95% CI) Since the study population consisted of construction workers
Finger colour change 1.02 (0.88 to 1.19) 1.02 (0.87 to 1.19) on a Kuala Lumpur construction site, the result cannot be
Finger tingling 1.14 (1.05 to 1.24) 1.14 (1.05 to 1.23) generalised to all construction workers in Malaysia. Besides, as
Finger numbness 1.14 (1.04 to 1.24) 1.13 (1.04. 1.23) the study subjects were all foreigners, mainly from Indonesia, the
Musculoskeletal problems of the 1.07 (1.01 to 1.13) 1.06 (1.01 to 1.12) results do not reflect the health outcomes of the local population.
upper limbs However, the study does raise issues regarding the health of the
Musculoskeletal problems of the neck 1.08 (1.01 to 1.16) 1.08 (1.01 to 1.15) large number of migrant workers employed in civil construction
Hand grip weakness 1.08 (1.02 to 1.15) 1.08 (1.02 to 1.15) in Malaysia and other newly industrialised countries.
Finger coldness 1.19 (1.08 to 1.32) 1.21 (1.08 to 1.35) Risk factors which could effect the prevalence of HAVS
Difficulty handling small objects 1.05 (0.89 to 1.25) 1.05 (0.88 to 1.25) symptoms in this study were smoking, tobacco chewing, alcohol
Difficulty opening tight jars 1.10 (0.96 to 1.26) 1.10 (0.96 to 1.27) consumption, chemical exposure at work, non-work exposure to
Abnormal Tinel’s test 1.09 (1.02 to 1.17) 1.09 (1.02 to 1.18)
hand transmitted vibration, past medical and surgical history
Abnormal Phalen’s test 1.15 (1.05 to 1.27) 1.15 (1.05 to 1.27)
involving the upper limbs, vascular and neurological disease
HAVS, hand-arm vibration syndrome with residual organ dysfunction, and medication with neuro-
toxic side effects. In this study, few of these risk factors were
triggering VWF, and hence the low reporting of finger whiteness present and differences were not significant between exposed
in this study. and unexposed subjects (table 2). Hence, the effects of these risk
The prevalence of neurological symptoms was much higher in factors on the outcome are negligible.
this study, being 20% and 18% for finger tingling and finger A cross-sectional study is of limited use for ascertaining the
numbness, respectively. In previous studies on HAVS5 13e15 causeeeffect relationship between exposure and outcome.
among tropical rain forestry workers and rock drillers in a warm Despite significant findings, this study can only detect the
climate, the prevalence of neurological symptoms, particularly association between vibration exposure level and the occurrence
finger tingling, numbness and paraesthesia, varied from 13% to of signs and symptoms related to HAVS.
18%. In this study, the prevalence of musculoskeletal problems This study is subject to recall bias because most of the infor-
in the upper limbs, in the neck and hand grip weakness was mation on duration and frequency of vibration exposure was
23%, 17% and 21%, respectively. The most common upper limb obtained from a questionnaire. A previous history of vibration
and neck symptoms included pain and stiffness of the elbow, exposure requires subjects to recall prior use of vibratory tools
shoulder and neck. Other studies13 15 reported different types of and duration and frequency of use, and is liable to bias especially
symptoms as proxy for upper limb and neck musculoskeletal if the subject is aware of the study hypothesis. This will give rise
disorders; the prevalence of musculoskeletal problems in other to differential misclassification bias and may cause a false positive
studies ranged from 7% to 30% and commonly reported symp- association. Recall bias was minimised as far as practicable by
toms were upper limb pain and stiffness. Current findings on the using visual aids to identify vibratory tools and concealing the
prevalence of HAVS related symptoms correspond to those in study hypothesis from participants. It is thus assumed that by
other studies from other tropical countries. concealing the study hypothesis, the chances of incorrect recall
The mean total LVD found in this study was lower than those regarding vibratory tool usage are similar across exposed and
from other studies which ranged from 19.1 to 21.4 m2h3s
4 (ln unexposed workers thus reducing differential misclassification
scale).26e28 The reason for the lower LVD is that the year of bias. Although there may still be non-differential misclassifica-
exposure to vibration among subjects in this study was rela- tion bias, this is of less importance as it shifts the result towards
tively short compared to other studies. Despite the low LVD, the null.
increasing HAVS prevalence with increasing LVD is still This study was considered to have interviewer bias because
apparent. A cross-sectional study design is not appropriate for only one interviewer conducted interviews and collected
determining doseeresponse relationships due to recall bias and information on exposure and outcome for all subjects. This
lack of a temporal causeeeffect relationship. Although a signifi- limitation was minimised by the use of standardised questions on
cant association was found between total LVD and some HAVS vibration exposure and outcome variables.23 The use of a single
symptoms in this study, the results are subject to study design interviewer also prevented inter-observer bias during the clinical
limitations and bias in data collection. A more appropriate examination of study subjects. Measurement bias may occur if
research design would be a cohort study or a caseecontrol study, different techniques or operators or inaccurate equipment is
used for vibration measurement. In this study, all measurement
Table 5 Prevalence of neurological outcomes based on the Stockholm was carried out by one trained technician according to ISO
Workshop Scales among study subjects 5439-2:2001. The accelerometer used was calibrated annually
Subjects, n (%) according to the standard requirement. Hence, inter-observer bias
was eliminated and measuring equipment error was minimised.
High exposure Lowemoderate
Stage Clinical description group exposure group This study used the ACGIH recommended TLV of 4 ms
2 for
8 h TWA hand transmitted vibration exposure as the cut-point
0SN Vibration exposure but no symptoms 114 (82.0) 52 (96.3)
for dividing subjects into high and lowemoderate vibration
1SN Intermittent numbness, with or without 7 (5.0) 1 (1.9)
tingling exposure groups. This value is one unit lower than the upper
2SN Intermittent numbness; reduced sensory 5 (3.6) 0 (0.0) limit recommended by the European Directive, which however
perception agreed on a daily hand arm vibration exposure limit value (ELV)
3SN Intermittent numbness; reduced tactile 13 (9.4) 1 (1.9) of 5 ms
2. In the current study, the five subjects exposed to daily
discrimination or manipulative dexterity vibration of between 4 ms
2 and 5 ms
2 all reported negative
or both
symptoms (data not shown). Hence, it is of little significant

62 Occup Environ Med 2011;68:58e63. doi:10.1136/oem.2009.052373

 Downloaded from http://oem.bmj.com/ on April 13, 2015 - Published by group.bmj.com
whether the European Directive or ACGIH standard is used in
this study because the number of subjects falling between the
two values was too small, and shifting negative responses
towards the lowemoderate exposure group only increases the
strength of association in the high exposure group. In practice,
the ACGIH standard seems to be more stringent and for
a country such as Malaysia without local data to justify either
standard, selecting the lower limit is appropriate for prevention.
Further research with a larger sample and wider coverage
should be conducted to establish the actual prevalence of HAVS
in common industries such as construction, logging, mining and
manufacturing in tropical countries as well as to determine to
what extent common vibratory tools are used in these indus-
tries. The data collected could then be used to establish the TLV
for an Asian population working with vibratory tools in a trop-
ical climate as compared to Western countries. Further research
should also be directed towards determining doseeresponse
relationships and the prognosis of HAVS in tropical countries.
CONCLUSION
HAVS is a recognisable problem in Malaysia. The current study
has identified clinical symptoms and signs suggesting a diagnosis
of HAVS among a group of construction workers exposed to
hand transmitted vibration in a warm environment. These
findings are comparable to those from studies in other countries
with similar climates. Since this study was conducted in
a limited group of construction workers, further research with
a larger sample and wider coverage is required to better under-
stand the actual prevalence and extent of HAVS in common
local industries such as construction, logging, mining and
manufacturing.
Acknowledgements We would like to thank Mr Mohd Rosdi for helping with
vibration measurements, and the Malaysia Construction Industry Development
Board (CIDB) for their supporting letter to enter the selected construction site.
Funding This study was partially funded by a Postgraduate Research Fund from the
Institute of Research and Consultancy Management, University of Malaya. The funding
source had no involvement in the study design; in the collection, analysis, and
interpretation of data; in the writing of the report; and in the decision to submit the
paper for publication.
Competing interests None.
Contributorship statement Dr Anselm Su Ting, the main researcher, was involved in
all phases of the study, including study design, literature search, conduct of the study,
data analysis and final article write up. Dr Victor Hoe Chee Wai supervised the study
and reviewed the manuscript. Associate Professor Retneswari Masilamani also
supervised the study and reviewed the manuscript. Professor Awang Bulgiba Awang
Mahmud supervised the study, performed statistical analysis and reviewed the
manuscript. Mr Mohd Rosdi assisted in vibration measurement.
Provenance and peer review Not commissioned; externally peer reviewed.
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63
 Downloaded from http://oem.bmj.com/ on April 13, 2015 - Published by group.bmj.com

Hand-arm vibration syndrome among a group

of construction workers in Malaysia
Ting Anselm Su, Victor Chee Wai Hoe, Retneswari Masilamani and
Awang Bulgiba Awang Mahmud

Occup Environ Med 2011 68: 58-63 originally published online October 8,
2010
doi: 10.1136/oem.2009.052373

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