Annals of Occupational and Environmental Medicine

Research Article

Difference in health status of Korean farmers according to gender: Ho Lee, Seong-yong Cho, Jin-seok Kim, Seong-yong Yoon, Bu-il Kim, Jong-min An, Ki-beom Kim; Ann Occup Environ Med 2019;31:7. Published online March 8, 2019; DOI: https://doi.org/10.1186/s40557-019-0287-7

Background

The objective of this study was to compare differences in lifestyle diseases, musculoskeletal pain, psychosocial stress, and self-health awareness according to gender in Korean farmers.

Methods

The study population comprised 436 farmers residing in rural areas in Korea. A self-administered questionnaire was used to survey demographic characteristics, health-related behaviors, and musculoskeletal pain. The psychosocial well-being index short form (PWI-SF) was used to survey psychosocial stress, and the 12-item short form health survey (SF-12) was used to survey self-health awareness. In addition, a clinical examination was performed for each participant, and lifestyle diseases were identified through a health checkup.

Results

Among lifestyle diseases, females showed a significantly higher proportion than males for metabolic syndrome (OR: 4.57 [95% CI, 1.67–12.51]). For musculoskeletal pain, females again showed significantly higher proportion than males for hand pain (OR: 16.79 [95% CI, 3.09–91.30]), and pain in at least one body part (OR: 2.34 [95% CI, 1.16–4.70]). For psychosocial stress, females showed a significantly higher proportion than males for high-risk stress (OR: 3.10 [95% CI, 1.17–8.24]). Among the items in self-health awareness, females showed significantly higher proportion than males for mental component score (MCS) (OR: 3.10 [95% CI, 1.52–6.31]) and total score (OR: 2.34 [95% CI, 1.11–4.90]).

Conclusions

For all items that showed significant differences, females showed higher proportion than males, which indicates that female farmers tended to have poorer overall health than male farmers. Therefore, specialized programs will have to be developed to improve the health of female farmers.

Citations

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Older Female Farmers and Modeling of Occupational Hazards, Wellbeing, and Sleep-Related Problems on Musculoskeletal Pains
Dong Seok Shin, Byung Yong Jeong
International Journal of Environmental Research and Public Health.2022; 19(12): 7274. CrossRef
Autopercepción del Nivel de vida en los asociados a gremios agrícolas en Tungurahua, Ecuador
Carlos Fabricio Gavilanes Carvajal, Janneth Maricela Illapa Atupaña, María Dolores Guamán Guevara, César Andrés Guerrero Velástegui
Religación. Revista de Ciencias Sociales y Humanidades.2022; 7(34): e210983. CrossRef
Comparisons of working conditions and health-related problems between older male and female crop farmers
Byung Yong Jeong
Work.2022; 72(3): 1025. CrossRef
Key Risk Factors Affecting Farmers’ Mental Health: A Systematic Review
Sahar Daghagh Yazd, Sarah Ann Wheeler, Alec Zuo
International Journal of Environmental Research and Public Health.2019; 16(23): 4849. CrossRef

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Research Article

Factors related with quality on sleep of daytime workers: Bu-il Kim, Seong-yong Yoon, Jin-seok Kim, Kuck-Hyeun Woo, Seong-yong Cho, Ho Lee, Jong-min An; Ann Occup Environ Med 2018;30:63. Published online October 23, 2018; DOI: https://doi.org/10.1186/s40557-018-0271-7

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Background

This study was conducted to identify the sleep status of daytime workers who do not work in shifts. This study analyzed factors affecting sleep duration and sleep quality.

Methods

This study was conducted on 1171 daytime workers at a manufacturing workshop. We used a self-administered questionnaire to investigate demographic variables, work type, working period, musculoskeletal symptoms and the Pittsburgh Sleep Quality Index to assess sleep. Regular health checkup was conducted for the worker’s clinical examination.

Results

The mean sleep duration was 6.36 h and the mean score on the Pittsburgh Sleep Quality Index was 4.46. Work type and obesity were related to sleep duration. Age, obesity and musculoskeletal pain were significantly related to sleep quality. The prevalence ratio of researcher group for short sleep duration was 1.27 (95% confidence interval: 1.02–1.58). The prevalence ratio of those aged 50 years and over was 0.47 (0.25–0.91) and of those in their 40s was 0.56 (0.35–0.91) for poor sleep quality compared to those in their 20s. The prevalence ratio of the obesity group for poor sleep quality was 1.53 (1.10–2.12). The prevalence ratio of musculoskeletal pain group for poor sleep quality was 1.92 (1.29–2.84).

Conclusions

Age, obesity and musculoskeletal pain were factors affecting the poor quality on sleep of daytime workers. In addition, work type related to short sleep duration.

Citations

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Mental Health and Psychosocial Factors that Influence Sleep Quality among Indonesian Farmers
Nur Hidaayah, Binti Nur Kholifah, Eppy Setiyowati, Wesiana Heris Santi, Lilik Supriati, Iswatun
Revista de Gestão Social e Ambiental.2024; 18(5): e05630. CrossRef
Ağrı Sorunu Olan Ofis Çalışanlarında Yorgunluk, Uyku ve Kavrama Kuvvetinin İncelenmesi: Kontrollü Çalışma
Ayşenur Baysal Yiğit, Gamze Ekici
Fenerbahçe Üniversitesi Sağlık Bilimleri Dergisi.2024; 4(2): 230. CrossRef
The Relationship of Musculoskeletal System Disorders with Sleep Quality among Office Workers
Fatih OKAN
Genel Tıp Dergisi.2023; 33(3): 316. CrossRef
Vegetarians have an indirect positive effect on sleep quality through depression condition
Xiaodi Wang, Fangfang Song, Bian Wang, Lei Qu, Zhiping Yu, Xiuhua Shen
Scientific Reports.2023;[Epub] CrossRef
The prevalence and determining factors of sleep disorders vary by gender in the Egyptian public officials: a large cross-sectional study
Ehab Salah Eshak
Bulletin of the National Research Centre.2022;[Epub] CrossRef
Association of sleep characteristics and respiratory symptoms at a smelting factory
Mohammad Mehdi Mehrabi Nejad, Arezu Najafi, Abdolkarim Haji Ghadery, Nazanin Izadi, Zahra Banafsheh Alemohammad, Mahya Shabani, Maryam Saraei
Work.2022; 72(2): 737. CrossRef
Exploration of individualized goals and ergonomic modifications to address sedentary behaviors and perceived health and well-being among office workers
Allison Naber, Logan Willhite, Whitney Lucas Molitor
Work.2021; 68(4): 1133. CrossRef
Poor Sleep Quality and Daytime Sleepiness in Health Professionals: Prevalence and Associated Factors
Vergílio Pereira Carvalho, Kênia Alves Barcelos, Ely Paula de Oliveira, Sarah Nogueira Marins, Isabella Beatriz Silva Rocha, Daniel Ferreira Moraes de Sousa, Bruno Cabral Moreira, Gunther Abreu de Almeida, Marina Luana Silva Carneiro, Jéssica Duarte de Fr
International Journal of Environmental Research and Public Health.2021; 18(13): 6864. CrossRef
Sleep quality and health-related quality of life in workers of Kermanshah Industrial Town: A correlation study
Seyed-Ramin Ghasemi, Mehdi Khezeli, Nader Rajabi-Gilan, Manoochehr Koulani, Nooshin Moloudi-Safa, Ali Hemati, Mojgan Afkari, Fatemeh Zolfaghari
Indian Journal of Occupational and Environmental Medicine.2020; 24(2): 72. CrossRef
Shift rotation, circadian misalignment and excessive body weight influence psychomotor performance: a prospective and observational study under real life conditions
Dayane Eusenia Rosa, Luisa Pereira Marot, Marco Túlio de Mello, Fernanda Veruska Narciso, Bruno da Silva Brandão Gonçalves, Elaine Cristina Marqueze, Cibele Aparecida Crispim
Scientific Reports.2019;[Epub] CrossRef

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Research Article

Psychological effects of a disastrous hydrogen fluoride spillage on the local community: Seung-Hyun Yoo, Seong-Yong Yoon, Kuck-Hyun Woo, Jin-Seok Kim, Seong-Yong Cho, Sung-Soo Lee, Hyun-Sul Lim, Yeon-Soon Ahn, Won-Ho Yang; Ann Occup Environ Med 2017;29:40. Published online September 11, 2017; DOI: https://doi.org/10.1186/s40557-017-0196-6

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Background

On September 27, 2012, at 3:43 pm, a hydrogen fluoride spill occurred in a manufacturing plant located at the 4th complex of the Gumi National Industrial Complex in Gumi City, South Korea. The present study aimed to evaluate the psychological effects of the hydrogen fluoride spill on the members of the community and to investigate their relationships with physical symptoms and changes in psychological effects occurring as time passed after the accident.

Methods

The 1st phase involved a survey of 1359 individuals that was conducted 1 month after the spill, and the 2nd phase involved a survey of 711 individuals that was conducted 7 months after the accident. The questionnaires included items for assessing demographic characteristics, hydrogen fluoride exposure level, physical symptoms, and psychological status. Physical symptoms were assessed to determine the persistence of irritations. Psychological status was assessed to investigate the impact of event level using the Impact of Event Scale – Revised Korean version (IES-R-K), and the anxiety level was assessed using the Beck Anxiety Inventory (BAI).

Results

As the hydrogen fluoride exposure level increased, the impact of event and anxiety levels increased significantly both 1 and 7 months after the accident (p < 0.05). The mean score of the impact of event levels decreased significantly from 33.33 ± 14.64 at 1 month after the accident to 28.68 ± 11.80 at 7 months after the accident (p < 0.05). The mean score of the anxiety levels increased significantly from 5.16 ± 6.59 at 1 month after the accident to 6.79 ± 8.41 at 7 months after the accident (p < 0.05). The risk of persistent physical symptoms at 7 months after the accident was significantly higher in females. The risk of persistent physical symptoms also increased significantly, with increasing age, hydrogen fluoride exposure, and impact of event levels (p < 0.05).

Conclusions

The present study found that the impact of event level and anxiety level increased with increasing hydrogen fluoride exposure. Anxiety levels persisted even after time passed. The risk of persistent physical symptoms at 7 months after the accident was higher in females, and it increased with increasing age, hydrogen fluoride exposure level, and impact of event levels.

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The influence of chemical and thermal modifications of ordered mesoporous carbon on the melting processes of water confined in pores
A. Bosacka, M. Zienkiewicz-Strzalka, A. Derylo-Marczewska, M. Sliwinska-Bartkowiak, A. Sterczynska, D. Sternik, K. Rotnicki
Microporous and Mesoporous Materials.2023; 351: 112477. CrossRef
Comparative Analysis of Hydrogen Fluoride-Exposed Patients Based on Major Burn Criteria After the 2012 Gumi City Chemical Leak Disaster
Heejun Shin, Se Kwang Oh, Han You Lee, Heajin Chung, Seong Yong Yoon, Sung Yong Choi
Journal of Burn Care & Research.2022; 43(4): 834. CrossRef
Classification of Human Failure in Chemical Plants: Case Study of Various Types of Chemical Accidents in South Korea from 2010 to 2017
Seungho Jung, Seungkyoo Pak, Kwanwoo Lee, Chankyu Kang
International Journal of Environmental Research and Public Health.2021; 18(21): 11216. CrossRef
Chemical pneumonitis by prolonged hydrogen fluoride inhalation
Young Jin Lee, In Beom Jeong
Respiratory Medicine Case Reports.2021; 32: 101338. CrossRef
Lessons learned from reviewing a hospital’s disaster response to the hydrofluoric acid leak in Gumi city in 2012
Heejun Shin, Se Kwang Oh, Han You Lee, Heajin Chung, Seong Yong Yoon, Sung Yong Choi, Jae Hyuk Kim
BMC Emergency Medicine.2021;[Epub] CrossRef
Increased risk to people around major hazardous installations and the necessity of land use planning in South Korea
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A Survey on the Public Perceptions of Disaster-Related Mental Health Service
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Journal of Korean Neuropsychiatric Association.2021; 60(1): 53. CrossRef
Obituary: Dr. Hyun-Sul Lim’s (1952-2018) life as an epidemiologist, occupational and environmental medicine researcher, and family physician
Sun Huh
Epidemiology and Health.2018; 40: e2018033. CrossRef

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Research Article

Risks of borderline liver enzyme abnormalities to the incidence of impaired fasting glucose and diabetes mellitus: a 7 year follow up study of workers: Jin-Hyun Yu, Jin-Seok Kim, Mee-Ra Lee, Seong-Yong Yoon, Seong-Yong Cho, Seung-Hyun Yoo, Boo-Il Kim; Ann Occup Environ Med 2016;28:18. Published online April 7, 2016; DOI: https://doi.org/10.1186/s40557-016-0105-4

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Background

The aim of this study was to identify the relationships between borderline serum liver enzyme abnormalities and the incidence of impaired fasting glucose (IFG) and diabetes mellitus (DM) during a 7-year follow-up of workers, and to evaluate the quantitative level of risks.

Methods

A total of 749 workers in an electronics manufacturing company were divided into the normal fasting blood glucose (n = 633), IFG (n = 98), and DM (n = 18) groups, according to the results of their health checkup in 2006. Among 633 workers in the normal group, excluding 55 workers who were impossible to follow, incidence rate and relative risks of 578 workers to the IFG or DM in 2013 according to the levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and gamma-glutamyltransferase (γ-GTP) were investigated. The liver enzyme levels were categorized as A (normal), B (borderline elevation), and R (definite elevation) following the standard of the National Health Insurance Service of Korea.

Results

The incidence rate of IFG or DM based on ALT level was 9.7 % for the A, 30.0 % for B, and 15.4 % for R. According to γ-GTP, the incidence rate was 9.8 % for A, 34.5 % for B, and 25.0 % for R. The relative risk(RR) to the incidence of IFG or DM depending on the level of ALT were 3.09 in B and 1.59 in R compared to A. According to γ-GTP, RR was 3.52 in B and 2.55 in R compared to A. AST level was not related to the incidence of IFG or DM. A multiple logistic regression analysis with the incidence of IFG or DM as a dependent variable resulted in an odds ratio of 2.664(1.214–5.849) for B level ALT, 3.685(1.405–9.667) for B level of γ-GTP even after adjustment for other variables such as age, sex, body mass index, AUDIT score, systolic blood pressure, and triglyceride.

Conclusions

Even borderline elevations of ALT and γ-GTP, but not AST, increased the incidence and risk of IFG or DM after 7 years. Borderline elevation of ALT and γ-GTP was identified as an independent risk factor of IFG or DM.

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Considering serum alanine aminotransferase and gamma-glutamyltransferase levels together strengthen the prediction of impaired fasting glucose risk: a cross-sectional and longitudinal study
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Scientific Reports.2021;[Epub] CrossRef
Association of liver enzymes levels with fasting plasma glucose levels in Southern China: a cross-sectional study
Ling-Ling Huang, Dong-Hui Guo, Hui-Yan Xu, Song-Tao Tang, Xiao Xiao Wang, Yong-Ping Jin, Peixi Wang
BMJ Open.2019; 9(10): e025524. CrossRef
Statin use and the risk of hepatocellular carcinoma in patients at high risk: A nationwide nested case-control study
Gyuri Kim, Suk-Yong Jang, Chung Mo Nam, Eun Seok Kang
Journal of Hepatology.2018; 68(3): 476. CrossRef

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Case Report

Acute health effects of accidental chlorine gas exposure: Joo-An Kim, Seong-Yong Yoon, Seong-Yong Cho, Jin-Hyun Yu, Hwa-Sung Kim, Gune-Il Lim, Jin-Seok Kim; Ann Occup Environ Med 2014;26:29-29. Published online October 1, 2014; DOI: https://doi.org/10.1186/s40557-014-0029-9

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Objectives

This study was conducted to report the course of an accidental release of chlorine gas that occurred in a factory in Gumi-si, South Korea, on March 5, 2013. We describe the analysis results of 2 patients hospitalized because of chlorine-induced acute health problems, as well as the clinical features of 209 non-hospitalized patients.

Methods

We analyzed the medical records of the 2 hospitalized patients admitted to the hospital, as well as the medical records and self-report questionnaires of 209 non-hospitalized patients completed during outpatient treatment.

Results

Immediately after the exposure, the 2 hospitalized patients developed acute asthma-like symptoms such as cough and dyspnea, and showed restrictive and combined pattern ventilatory defects on the pulmonary function test. The case 1 showed asthma-like symptoms over six months and diurnal variability in peak expiratory flow rate was 56.7%. In case 2, his FEV1 after treatment (93%) increased by 25% compared to initial FEV1 (68%). Both cases were diagnosed as chlorine-induced reactive airways dysfunction syndrome (RADS) on the basis of these clinical features. The most frequent chief complaints of the 209 non-hospitalized patients were headache (22.7%), followed by eye irritation (18.2%), nausea (11.2%), and sore throat (10.8%), with asymptomatic patients accounting for 36.5%. The multiple-response analysis of individual symptom revealed headache (42.4%) to be the most frequent symptom, followed by eye irritation (30.5%), sore throat (30.0%), cough (29.6%), nausea (27.6%), and dizziness (27.3%).

Conclusions

The 2 patients hospitalized after exposure to chlorine gas at the leakage site showed a clinical course corresponding to RADS. All of the 209 non-hospitalized patients only complained of symptoms of the upper airways and mucous membrane irritation.

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Chlorine gas exposure and evolutive patterns of reactive airways dysfunction syndrome: a systematic review
Angelica dos Santos Vianna, Ana Clara Poyares de Mello Bhering, Fernanda Cavalcante Antunes da Silva, Rosa Cristina dos Santos Vianna, Aline de Souza Espindola Santos
Revista Brasileira de Saúde Ocupacional.2023;[Epub] CrossRef
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Research Article

Occupational Factors Associated with Changes in the Body Mass Index of Korean Male Manual Workers: In-Woong Song, Kuck-Hyun Woo, Jin-Seok Kim, Seong-Yong Yoon, Joo-Yong Na, Jin-Hyun Yu, Seong-Yong Cho; Ann Occup Environ Med 2013;25:40-40. Published online December 27, 2013; DOI: https://doi.org/10.1186/2052-4374-25-40

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Objectives

This study was carried out to analyze and compare the occupational factors that could influence changes in body mass index (BMI) in male manual workers stratified into short-term and long-term work experience groups.

Methods

The subjects were 299 male manual workers (sampled systematically) from 27 workplaces, who had undergone travelling medical examinations at a university hospital between March 28 and May 10, 2013, and had also undergone medical examinations at the same hospital in 2012. Their general and occupational characteristics were investigated through a structured, self-administered questionnaire. The BMI at each point in time was calculated based on the anthropometric results of the medical examinations. Multiple regression analyses were conducted on outcomes of the BMI change and predictors composed of the general and occupational characteristics, with the subjects stratified into groups with 5 years or less (short-term) versus more than 5 years (long-term) of work experience at the present post.

Results

In the short-term work experience group, the BMI increases of 3-shift workers and groups reporting disagreement with feeling “insufficient job control” and “lack of reward” at work, two of the subscales of job stress, were significantly higher than those of daytime workers and high-stress groups, respectively. In the long-term work experience group, However, although the BMI increase for 3-shift workers was also significantly higher than that of daytime workers, none of the job stress factors were significantly associated with a BMI increase, whereas the social factors of education and marital status were significant, and some lifestyle factors (such as smoking and regular exercise) were also significant.

Conclusion

This study showed that, except for 3-shift work, the factors associated with BMI increase could differ depending on the length of job experience. Consequently, different strategies may be needed for workers with short-term versus long-term job experience when designing interventions for preventing their obesity.

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Job Stress and Job Satisfaction among Health-Care Workers of Endoscopy Units in Korea
Seung-Joo Nam, Hoon Jai Chun, Jeong Seop Moon, Sung Chul Park, Young-Jae Hwang, In Kyung Yoo, Jae Min Lee, Seung Han Kim, Hyuk Soon Choi, Eun Sun Kim, Bora Keum, Yoon Tae Jeen, Hong Sik Lee, Chang Duck Kim
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Demographic, health-related, and work-related factors associated with body mass index and body fat percentage among workers at six Connecticut manufacturing companies across different age groups: a cohort study
Jennifer L. Garza, Alicia G. Dugan, Pouran D. Faghri, Amy A. Gorin, Tania B. Huedo-Medina, Anne M. Kenny, Martin G. Cherniack, Jennifer M. Cavallari
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ManKi Son, Byeong Jin Ye, Jung-Il Kim, ShinUk Kang, Kap-Yeol Jung
Annals of Occupational and Environmental Medicine.2015;[Epub] CrossRef

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Research Article

Acute Symptoms in Firefighters who Participated in Collection Work after the Community Hydrogen Fluoride Spill Accident: Seong-Yong Cho, Kuck-Hyun Woo, Jin-Seok Kim, Seong-Yong Yoon, Joo-Yong Na, Jin-Hyun Yu, Yong-Bae Kim; Ann Occup Environ Med 2013;25:36-36. Published online November 28, 2013; DOI: https://doi.org/10.1186/2052-4374-25-36

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Objectives

This study aimed to analyze the relationship between clinical status and work characteristics of firefighters and other public officers who engaged on collection duties in the site of the hydrogen fluoride spill that occurred on September 27, 2012, in Gumi City, South Korea.

Methods

We investigated the clinical status, personal history, and work characteristics of the study subjects and performed physical examination and several clinical examinations, including chest radiography, echocardiography, pulmonary function test, and blood testing in 348 firefighters, police officers, volunteer firefighters, and special warfare reserved force who worked at the hydrogen fluoride spill area.

Results

The subjects who worked near the accident site more frequently experienced eye symptoms (p = 0.026), cough (p = 0.017), and headache (p = 0.003) than the subjects who worked farther from the accident site. The longer the working hours at the accident area, the more frequently the subjects experienced pulmonary (p = 0.027), sputum (p = 0.043), and vomiting symptoms (p = 0.003). The subjects who did not wear respiratory protective devices more frequently experienced dyspnea than those who wore respiratory protective devices (p = 0.013). In the pulmonary function test, the subjects who worked near the accident site had a higher decease in forced vital capacity than the subjects who worked farther from the site (p = 0.019); however, no statistical association was found between serum calcium/phosphate level, echocardiography result, chest radiographic result, and probation work characteristics.

Conclusions

The subjects who worked near the site of the hydrogen fluoride spill, worked for an extended period, or worked without wearing respiratory protective devices more frequently experienced upper/lower respiratory, gastrointestinal, and neurological symptoms. Further follow-up examination is needed for the workers who were exposed to hydrogen fluoride during their collection duties in the chemical plant in Gumi City.

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Research Article

Acute Symptoms after a Community Hydrogen Fluoride Spill: Joo-Yong Na, Kuck-Hyun Woo, Seong-Yong Yoon, Seong-Yong Cho, In-Ung Song, Joo-An Kim, Jin-Seok Kim; Ann Occup Environ Med 2013;25:17-17. Published online September 19, 2013; DOI: https://doi.org/10.1186/2052-4374-25-17

Abstract PDF PubReader ePub

Objectives

This study was conducted to describe the demographic characteristics, and clinical signs and symptoms of patients who visited a general hospital because of the release of chemically hazardous hydrogen fluoride that occurred on September 27, 2012 in Gumi City, Korea.

Methods

The medical records at 1 general hospital 9 km from the accident site were reviewed using a standardized survey format. There were 1,890 non-hospitalized and 12 hospitalized patients exposed to hydrogen fluoride between September 27 and October 13 2012.

Results

Among the 12 hospitalized patients, 11 were discharged within 1 week and the other was hospitalized for 10 days. The chief complaints were respiratory symptoms such as hemoptysis and shortness of breath, gastrointestinal symptoms, neurologic symptoms, sore throat, and lip burn.

The number of non-hospitalized patients exhibited a bimodal distribution, peaking on the first and twelfth days after the accident. Their chief complaints were sore throat (24.1%), headache (19.1%), cough (13.1%), and eye irritation (9.2%); some patients were asymptomatic (6.2%). Patients who visited the hospital within 3 days (early patients) of the spill more often had shortness of breath (27.0%) and nausea (6.3%) as the chief complaints than patients who visited after 3 days (late patients) (3.5% and 2.6%, respectively). However, cough and rhinorrhea were more common in the late patients (14.0% and 3.3%, respectively) than in the early patients (5.0% and 0.0%, respectively). Patients who were closer to the accident site more often had shortness of breath and sputum as the chief complaints than patients who were farther away. The mean serum calcium concentration was 9.37 mg/dL (range: 8.4–11.0 mg/dL); none of the patients had a decreased serum calcium level. Among 48 pulmonary function test results, 4 showed decreased lung function. None of the patients had abnormal urine fluoride levels on the eighth day after exposure.

Conclusions

Patients hospitalized due to chemical hazard release of hydrogen fluoride had acute respiratory, gastrointestinal, and neurologic health problems. Non-hospitalized patients have acute symptoms mainly related to upper respiratory irritation.

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