Agriculture, Forestry, and Fishing Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health (2008)

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6 Review of Health Effects Research The National Institute for Occupational Safety and Health (NIOSH) Agricul- ture, Forestry, and Fishing Program (AFF Program) has been an important and effective program that has addressed health effects in a practical and responsible manner. The major portion of the budget has been allocated for agriculture, and the results of NIOSH investment are most visible in that sector although some notable achievements in commercial fishing are evident; the attention to forestry has been more limited. Because of the historic funding placed in agriculture, the committee focused to a considerable extent on the agriculture sector and on the health effects research conducted intramurally by NIOSH scientists and extramu- rally through research development and support in university-based Centers for Agricultural Disease and Injury Research, Education, and Prevention (Ag Centers) and among researchers in the broader community; the committee also evaluated health effects research in forestry and fishing to the extent that the available infor- mation permitted. STRATEGIC GOALS AND OBJECTIVES Goal 3:  Health Effects of Agricultural Agent Exposures—Reduce injuries and illnesses by understanding the long-term, chronic effects of exposure from agriculture-related chemical or physical agents to farmers, their families, and ap- plicators so as to implement controls that prevent harmful exposures. 94 

Review of H e a lt h E f f e c t s R e s e a r c h 95 The AFF Program appears to have commenced with a somewhat narrow focus in health effects research. Despite its stated goal, the AFF Program, particularly the extramural component, came to encompass a wide array of exposures and their effects that contribute to the risk of injury and illness in AFF workers. However, it is possible that NIOSH, because of the discrepancy between the stated goal and program inputs, failed to exert the kind of focused leadership that would be necessary for a cohesive national research agenda. Production inputs reflect the fact that many AFF researchers have understood that, but the AFF Program would have benefited from stronger direction in evolving goals and greater com- munication, both between the intramural and extramural components and among the university-based NIOSH Ag Centers. The extramurally funded Ag Centers routinely compiled detailed annual reports and generated specific planning docu- ments, but it is difficult to ascertain evidence that the information was used in a constructive manner. An apparent managerial deficiency of the program was the lack of resources allocated by NIOSH to archive documentation and organize such materials for strategic and planning purposes. In fact, one of the challenges that the committee faced was obtaining program information and documentation from the intramural AFF Program or extramural Ag Centers. The apparent lack of resources and staff to adequately catalogue a history of funded projects and their products has lead to an institutional memory deficit that is a major deficiency of the overall AFF Program. Given the size of the task, addressing the needs of the entire AFF worker population is difficult. The requirement for prudent allocation of resources underscores the need for strong leadership. LOGIC SUBMODEL Information received from the NIOSH AFF Program (NIOSH, 2006a) related to inputs, activities, outputs, intermediate outcomes, and end outcomes in health effects research is summarized in the health effects research logic submodel (Fig- ure 6-1). INPUTS Planning, production, and other input data were assessed and found to be ad- equate in part; however, it was not clear that the data were gathered by NIOSH in an organized manner. Staffing appears to have been adequate in some well-defined subprograms, but resources in many other parts of the AFF Program did not ap- pear to permit adequate staffing. Surveillance data were gathered by intramural and extramural investigators; however, an overall surveillance scheme was not apparent in the evidence. Stakeholder needs of various sectors were taken into consideration 

Inputs Activities Outputs Intermediate Outcomes End Outcomes Planning inputs: 1. Publications in scientific journals from NIOSH- 1. Training and education outputs 1. Decrease in helicopter logging fatalities. 96 1. National Traumatic Occupational Fatalities 1. Surveillance data (NTOF) funded work in the following areas with ERCs 2. Decrease in fishing vessel sinkings. 2. Stakeholder needs reference to AFF o Educational curriculum 3. In general, morbidity and mortality due 2. Industry specific programs: Respiratory Extramural Ag Center initiatives to agricultural, forestry, and fishing 3. Other partners interested in safety and Agriculture Cancer o Symposia and other professional exposures have been extremely difficult health Community partners for healthy farming Neurological career development opportunities to quantify. Death from cancer and 4. Symposia and conferences trauma have been easier to quantify than intervention research o Vibration-induced injury o Agroterrorism 5. Program evaluations other outcomes. It has not always been Childhood Agricultural Injury Prevention o Parkinson’s disease OHNAC outreach (currently active only 6. Program goals in Ohio) possible to make clear- cut associations Initiative Reproductive 2. Interventions between AFF exposures and cancer Ergonomic interventions for youth Chronic musculoskeletal conditions Production inputs: Certified Safe Farms death in specific cases. Thus, it has not working in agriculture Hearing 1. Budget Public policy for ROPS implementation been possible to describe specific end Farm Family Health and Hazard Dermatological outcomes associated with many health 2. Staff Traumatic injuries Farmer cancer control initiatives (6 Surveillance effects research projects. 3. Facilities Poisonings projects) OHNAC Ergonomic innovations for safer harvest 4. Morbidity and mortality statistics from 4. Management structure o Pesticide respiratory diseases have recently been HHEs o Carbon monoxide Injury prevention through safe play areas 5. Extramural entities described in documents published by 6. Partners FACE reports o Tilmicosin Confined space entry interventions NIOSH (2002, 2007). These documents SENSOR-Pesticides Infectious diseases Development of respiratory PPE do not contain information from all Ag Safety Promotion System Gene-environmental interaction studies Development of methods for dust states, including a group of states that Ag Centers Psychological effects reduction in CAFOs produce the majority of agricultural o Depression and suicide Work organization interventions products. The published results indicate Agricultural Health Study (in Workplace violence 3. Unique staff and laboratory capability that rates of respiratory illness and collaboration with NCI) Sleep deprivation Ag Center labs injury in agricultural workers have not Regional Rural Injury Study II 2. NIOSH publications o Biomechanics lab changed greatly between 1995-2001. Laboratory-based intramural initiatives on However, these documents may not NIOSH Alerts o Basic science labs biomonitoring and exposure assessment offer a complete picture. NIOSH monographs Epidemiology projects Forestry NIOSH FACE reports 5. See sublogic model in Chapter 7 for 4. Partnerships with stakeholders Alaska interagency working group Web-based information and newsletters specific injury prevention end outcomes. National Institute for Farm Safety 6. Relatively little is known about illnesses State-based FACE investigation reports 3. MMWR reports 4. NAGCAT Farm Safety 4 Just Kids associated with work in forestry and Evaluation of mechanical harvesting 5. Symposia and workshops Farm health safety projects funded by fishing. techniques Surge on General Conference on Agricultural W.K. Kellogg Foundation (such as the Fishing Agricultural Safety and Health Network Safety and Health (1991) Alaska Trauma Registry and Alaska National and international fishing industry (Petrea, 2003), which is no longer Occupational Injury Surveillance System safety and health workshops (1992, 1997, 2000, active) Interagency working group (including 2003, 2006) Workers’ compensation insurance USCG, AMSEA, and NPFVOA) Summit on Childhood Agricultural Injury company partnerships Prevention (2001) American Thoracic Society Helicopter Logging Safety Workshop (2005) (Environmental and Occupational Health) Time needed to build relationships with partners and constituents Current political climate Farms becoming larger with less reliance on child labor Lack of resources and interest in funding surveillance Seasonality of industries, weather, climate change Funding periods limit ability to evaluate long-term effects of intervention Negative effect of economic downturn Uncertainty regarding immigration issues Poor national/political understanding of scope and cost of occupational disease and public health External Factors FIGURE 6-1  Health effects research logic submodel. AMSEA = Alaska Marine Safety Education Association, CAFO = concentrated animal feeding operation, CES = Cooperative Extension Service, ERC = Education and Research Centers, FACE = Fatality Assessment and Control Evaluation , FOPS = falling object protective structure, HHE = Health Hazard Evaluation, MMWR = Morbidity and Mortality Weekly Report, NCI = National Cancer Institute, NPFVOA = North Pacific Fishing Vessel Owner’s Association, NTOF = National Traumatic Occupational Fatality, OHNAC = Occupational Health Nurses in Agricultural Com- munities, PPE = personal protective equipment, ROPS = rollover protective structure, SENSOR = Sentinel Event Notification of Occupational Risk , USCG = U.S. Coast Guard. 

Review of H e a lt h E f f e c t s R e s e a r c h 97 to various extents over the life of the AFF Program. Stakeholders with whom it was more difficult to hold a discussion, such as farm workers and forestry work- ers, did not appear to be consulted during planning. The array of other partners was large, and some were not consulted by AFF Program staff during planning. The Alaska fishing safety program has been quite successful, because it began with good surveillance and progressed to the design and implementation of research in an organized way, which contributed greatly to its efficacy. A pivotal NIOSH-sponsored symposium on agriculture was the 1991 Surgeon General’s Conference on Agricultural Safety and Health. It came at a critical point in the history of the discipline and had far-reaching favorable consequences for the agriculture component of the AFF Program. The national and international workshops on commercial fishing safety also came at a critical point in establish- ing plans for the Alaska Field Station. While local and regional impact has clearly been made, it is not clear that NIOSH has had a similar impact on a national level in forestry or other aspects of fishing. Planning, production, and other inputs were used effectively to promote the major activities in the Alaska fishing program. It is a well-defined program with a small scope that effectively addresses risk of death by drowning, hypothermia, or traumatic injury in a small number of workers. In contrast, the forestry compo- nent attempts to address the safety and health needs of a larger number of workers without the benefit of surveillance or well-articulated planning. Agriculture is a vast topic with diverse worker populations and exposures; surveillance has been fragmented in agriculture. It has at times been effective but not consistently. Inputs, including surveillance, were used effectively to plan and implement some projects, such as the Childhood Agricultural Injury Prevention initiative. For projects tar- geting adult workers, the benefits gained from planning and production resources have been less obvious because outcome measures are not available. Some sources of inputs were adequate. For example, inputs from the Alaska fishing program were excellent. Other AFF projects had less adequate inputs, par- tially because of cultural, geographic, financial, and other types of barriers; the pau- city of interventions aimed directly at farm workers is evidence of the limitation. Overall, a lack of evidence of strategic planning and coordination was apparent and may explain some of the variability in the quality of inputs. There is little evidence that input was obtained from vulnerable working populations, such as farm or forestry workers, owners of small farms or forestry enterprises, the elderly, and non-English speaking workers. ACTIVITIES Activities are defined as the effort and work of the AFF Program, its staff, and its extramural partners. The committee has defined health effects research activi- 

98 A g r i c u lt u r e , F o r e s t r y , and Fishing Research at NIOSH ties as surveillance of injuries and illness; identification and characterization of the unique health and safety risks faced by special populations; identification and characterization of health effects associated with chemical, physical, and biological agents encountered in AFF occupations; development of methods to characterize and measure potentially hazardous substances and exposures; and development of methods and strategies for the transfer of health effects knowledge to others who design and evaluate interventions and outreach mechanisms. The AFF Program has at best modest reach into some AFF sectors. For example, geographic dispersion of AFF worksites, rural isolation, non-English dialects, so- cial dynamics, access to workers at occupational sites, the undocumented status of some exposed AFF workers, and patterns of worksite task organization may militate against effective penetration. Nevertheless, Congress’s intent was clear: to safeguard and promote the safety and health of AFF worker populations in the nation’s fundamental interest. The committee separated its assessment of the health effects research portion of the AFF Program into review of National Traumatic Occupational Fatality (NTOF) Surveillance System activities and industry-specific activities. NTOF is an intramu- ral effort that relies on state-level death certification programs and, for the purposes of the AFF Program, appears to have focused largely on agricultural events with a secondary emphasis on forestry-related fatalities. The limitations of the system are openly acknowledged and include the lack of program-related comprehensiveness given the gaps in industry and occupation coding in state vital-statistics programs. States with some of the nation’s leading agricultural and forestry production do not code their death certificates for industry or occupation. In addition, because data are provided by key informants, such as family members of the deceased or local coroners, key occupational features and exposures may be missing. The use of NTOF data to target Fatality Assessment and Control Evaluation (FACE) pro- gram initiatives and portions of the Occupational Health Nurses in Agricultural Communities (OHNAC) program appears problematic because the methods used by NTOF were flawed. Industry-specific health effects programs encompassed both intramural and extramural activity and were highly varied. In forestry, there were activities in- volving interagency working groups, FACE investigation reports, and machine harvesting exposure assessment. In agriculture, some research programs focused on disease and injury surveillance, biomonitoring and exposure assessment, and haz- ard surveillance. In fishing, surveillance of worksite trauma and interagency policy working group activity occurred. Collectively, those activities expanded program effort well beyond the narrow goal specified by NIOSH for the AFF Program. In total, the industry-specific activities were much more congruent with congressional intent than with the narrow NIOSH-defined focus. 

Review of H e a lt h E f f e c t s R e s e a r c h 99 The activities addressed some of the most important exposures in AFF work- sites. However, when reviewing the array of outputs described in the evidence package, the committee noted some gaps and uneven emphases. For example, sleep deprivation and the effects of nightshift work have not been extensively explored, workplace violence has received little attention, the health impact of volatile organic chemicals and solvents that are ubiquitous in AFF worksites remains unknown, infectious disease has received little exploration, and reproductive health effects have received only sporadic support in both the intramural and extramural parts of the AFF Program. The study of gene-environment interactions is a nascent program; it has become clear that research in this field requires large numbers of subjects to generate useful results, so there is a need to conduct well-organized multicenter studies with careful exposure assessment and characterization of dis- ease phenotypes. The AFF Program has given substantial attention to respiratory disease and traumatic injury, some cancer end points, childhood exposure, hear- ing loss, selected dermatoses, and some neurological conditions. Program efforts have also been devoted, through the extramural Ag Centers, to employed workers (as distinct from owners or managers) in all three AFF sectors. The Agricultural Health Study is an important collaborative prospective cohort study—cosponsored with the National Cancer Institute (NCI), the National Institute of Environ­mental Health Sciences (NIEHS), and the U.S. Environmental Protection Agency (EPA)— of nearly 90,000 farmers and their wives to explore the potential causes of cancer and other diseases (National Cancer Institute, 2007). In addition, other epidemio- logical ­studies conducted through the Ag Centers serve as valuable program-wide resources. Emphases on AFF sex-specific exposure, common disease end points, and serious health consequences have been noted, but the evidence presented to the committee suggests limited reach. Evidence of AFF stakeholder input into research activity varied. Beginning with the Surgeon General’s Conference on Agricultural Safety and Health in 1991 (for the agricultural sector), the FACE-based logging initiative in five key industry states (for the forestry sector), and an interagency working group (for the Alaska fishing sector), stakeholder input appears to have been consistently sought by NIOSH scientists. Indeed, that may be one of the AFF Program’s strengths. Some rural populations represented by, for example, voluntary agricultural organiza- tions initially declined to participate in NIOSH initiatives, believing them to be programmatic extensions of the nation’s occupational safety and health regulatory mechanism. Other populations, such as employed workers, appear to have been underrepresented in advisory structures convened by NIOSH to secure stake- holder input. To its credit, NIOSH has recently convened an AFF-sector advisory mechanism; it could profit from more thorough representation of AFF employed worker domains. 

100 A g r i c u lt u r e , F o r e s t r y , and Fishing Research at NIOSH The participation of potential AFF partners has ebbed and flowed. When state-level agricultural safety specialist offices were receiving U.S. Department of Agriculture funding, numerous agricultural extension safety professionals were directly involved in research conducted by the extramurally funded Ag Centers. Organizations such as Farm Safety 4 Just Kids, the National Institute for Farm Safety, and the W. K. Kellogg Foundation have partnered with the AFF Program on strategic initiatives. Other professional organizations—such as the Environmental and Occupational Health Assembly (of the American Thoracic Society), the Ameri- can Industrial Hygiene Association, and the American Society of Agricultural and Biological Engineers—have provided insight into and critiques of both planned and current activities. More recent stakeholder involvement has positioned ­workers’ compensation insurance entities in roles complementary to research endeavors through their deployment of experimental translational programs. The committee has noted that, in light of the plethora of potential AFF Program initiatives, prudent allocation of resources is required. Lacking formal continuing disease surveillance in agriculture, forestry, and fishing, NIOSH has crippled its ca- pability for allocation of resources in a manner consistent with sound public health principles. Only top-level management in NIOSH can fix that dilemma; anything less than a fix would mean the loss of an irreplaceable opportunity to realign the sector initiatives in keeping with the original congressional intent. As mentioned in Chapter 3, the regional focus of the Ag Centers has produced a diversity of approaches and issues and has been a strong suit of the AFF Program (see Table 6-1). The committee reviewed copious documentation of peer-reviewed publica- tions capable of rendering programmatic advice, and it is unclear whether such activity affected the direction of the AFF Program. NIOSH has used internal re- view mechanisms through the National Occupational Research Agenda that have resulted in program redirection. Other external reviews include a commission chaired by Susan Kennedy that issued a seminal report in 1995 calling for program adjustment in both the intramural and extramural venues (Kennedy, 1995). Cyclic review, through external peer-review mechanisms, has been applied repeatedly to the extramurally funded Ag Centers, childhood agricultural injury initiatives, other R01 initiatives, and the NIOSH Education and Research Centers (ERCs). Such re- view has resulted in some redirection of program effort, including discontinuation of funding of some extramural partners. Evidence presented to the committee suggests that NIOSH-sponsored AFF research has typically used quality-assurance procedures for surveillance activity, basic laboratory science, and intervention research. The exception of which the committee is aware involved the six state-level Farm Family Health and Hazard Surveillance projects funded in the first 5 years of AFF Program effort. Created 

Review of H e a lt h E f f e c t s R e s e a r c h 101 TABLE 6-1  Research Emphases of Some NIOSH Ag Centers Ag Center Research Strength or Emphasis Pacific Northwest Agricultural Safety Prevention of occupational disease and injury in farmers, and Health Center, Washington fishermen, forestry operators through occupational medicine, epidemiology, industrial hygiene Western Center for Agricultural Health promotion and disease prevention, injury and Health and Safety, California ergonomics, neurotoxicity and pesticides, respiratory diseases, industrial hygiene and exposure assessment, evaluation, biostatistics Southwest Center for Agricultural Farm-family health and injury control, hired farmworker Health, Injury Prevention, and health and safety, animal-handling injuries, stress, health Education, Texas and safety training and education Deep-South Center for Agricultural Asthma, ergonomic injuries, heat stress in farm workers; Disease and Injury Research, prostatic cancer in licensed pesticide applicators; health, Education, and Prevention, Florida exposure assessment of poultry producers; incidence of logging-related injuries; safety of farm children Southeast Center for Agricultural Special populations, community-based interventions, Health and Injury Prevention, engineering, ergonomics, green tobacco sickness, Kentucky environmental health Northeast Center for Agricultural Hearing loss, arthritis, skin cancer, allergies, mechanical and Occupational Health, New York injuries, migrant farm workers, older farmers, women, children Midwest Center for Agricultural Infectious pathogens, women, developing and evaluating Research, Education, and Disease health promotion and disease and injury prevention and Injury Prevention, Wisconsin programs, engineering control technologies, injuries in children High Plains Intermountain Center Engineering, industrial hygiene, education, toxicology, for Agricultural Health and Safety, social work, epidemiology, environmental health, Colorado agricultural sciences Great Plains Center for Agricultural Environmental health, health and safety of farmers, Health, Iowa occupational health, injury prevention, rural health National Children’s Center for Rural Health and safety issues for farm children, guidelines for and Agricultural Health and Safety, acceptable agricultural tasks Wisconsin in response to an explicit directive of Congress, those surveillance efforts could have shaped the direction of the program for years to come. Instead, data remain unanalyzed in several of the states, and one state experienced such basic difficulty in planning, organizing, and directing the effort that little could be salvaged. 

102 A g r i c u lt u r e , F o r e s t r y , and Fishing Research at NIOSH Transfer of research findings has been implemented through the OHNAC program; the Agricultural Safety Promotion System (direct funding of state-level agricultural safety specialists in land-grant institutions); fishing and forestry inter- agency working groups; explicit funding of such projects as ergonomic interven- tions for youth working in agricultural worksites and ergonomic designs for tools and work areas in nurseries, turf and garden entities, and orchards; and specific ERC-sponsored symposia and other training initiatives. The reach of those efforts has been nation-wide for the agricultural sector and largely regional for the forestry and fishing sectors. Stakeholders have been involved, particularly when the regional Ag Centers and the ERCs anchored the transfer activity. Research and educational capability were enhanced extramurally, and intramural capability in NIOSH also expanded. Numerous basic scientists, clinicians, engineers, and other researchers now active in the AFF arena received their original impetus from those efforts. OUTPUTS Major outputs of the AFF Program have been publications in scientific jour- nals, fact sheets on the NIOSH Web site, summaries of disorder- or organ-system- focused epidemiological projects (for example, the documents Epidemiology of Farm-Related Injuries: Bibliography with Abstracts and Injury and Asthma Among Youth Less Than 20 Years of Age on Minority Farm Operations in the United States, 2000), and monographs (such as Simple Solutions: Ergonomics for Farm Workers, 2001; Guide to Evaluating the Effectiveness of Strategies for Preventing Work Injuries, 2001; and Childhood Agricultural Injury Prevention: Issues and Interventions from Multiple Perspectives, 1992) designed to serve as tools for translating research to practice. The degree to which those outputs addressed clinical problems varied greatly, so each category of output is discussed separately below. Injury Research and Ergonomics The AFF Program has stimulated extensive research across the nation on trau- matic injuries; deaths and disabling injuries account for a considerable proportion of the intramural and extramural research. National Safety Council statistics in- dicate that agriculture continues to rank as one of the most dangerous industries. However, lack of a cohesive surveillance program makes it difficult to track the effectiveness of the programs. Nonetheless, the AFF Program has attempted to focus on some important subjects, such as tractor safety and rollover protection structures (ROPS), for which cause and effect have been demonstrated. Research in ergonomics seems to have been much more limited—despite its importance to health and safety and to the mission of NIOSH—with several notable exceptions, 

Review of H e a lt h E f f e c t s R e s e a r c h 103 such as the development of handles for flower pots in the greenhouse industry, smaller fruit containers that result in lighter loads, and longer rake handles. Respiratory Disorders NIOSH AFF staff and the leadership of the NIOSH Ag Centers gave respira- tory disorders high priority. They have been leaders in characterizing respiratory exposures to organic dust by using modern industrial hygiene methods. They have also helped to describe disease phenotypes associated with those exposures and to define the epidemiology of the respiratory disorders of interest. The AFF Program was one of the first to fund a study of gene-environment interactions in the farm setting. Work in respiratory disorders has been done by intramural researchers and NIOSH-funded extramural researchers that generally have worked well together. Overall, the publications have had a large impact on the national and international scientific community. That impact was amplified through funding of well-attended national and international conferences on agricultural safety and health in which respiratory disease was one of the main themes. The impact of the output on farm- ers and farm workers is much more difficult to assess but does not appear to be as great as it could be. The AFF Program effort in respiratory disease appears to be limited almost completely to agriculture except for some work in asthma caused by exposure to snow crabs. Cancer The AFF Program has not had a major focus on research in occupational cancer detection or prevention since the 1990s except through its partnership with NCI and NIEHS in the Agricultural Health Study (AHS). That illustrates a reasonable approach to division of health effects research among partner agencies in theory, but it suffers from the lack of any reported intentional decisionmaking on the part of NIOSH. The AHS is a prospective study of pesticide health effects in over 88,000 people. Subjects include private and commercial pesticide applicators and their spouses living in Iowa and North Carolina, most of whom are farmers. The major focus has been on defining associations between pesticide exposure and cancer. To date, much less effort has been devoted to creating recommendations, devising interventions, and building capacity. Neurological Disease The AFF Program has not had a major focus on research on occupational neurological disease detection or prevention. NIOSH has had some activity in this 

104 A g r i c u lt u r e , F o r e s t r y , and Fishing Research at NIOSH field primarily through its partnership with NCI and NIEHS—a reasonable divi- sion of labor. As noted above, the major focus of the joint effort through the AHS has been on defining associations between pesticide exposure and cancer; research on neurological disease outcomes related to pesticide exposure, such as Parkinson’s disease, has been a secondary interest. Much less effort has been devoted to creat- ing recommendations, devising interventions, and building capacity in this field as well. However, the effort in general is an excellent example of NIOSH collabo- ration with other government agencies interested in the health and well-being of AFF workers. The AHS has collected a wealth of data that can ultimately be used to address clinically important questions. The information generated would then be used to create recommendations for dissemination to farm communities. Little work has been done through the AFF Program to assess workers in forestry or fish- ing for evidence of neurological disease. Revisiting vibration-induced neurological disease may be appropriate. Reproductive Health Modest AFF Program funding has been devoted to studying reproductive outcomes in farm families. No firm conclusions have been drawn from the work, and no recommendations have been formulated by NIOSH. The committee is not aware of any NIOSH-funded work in this field in forestry and fishing. Chronic Musculoskeletal Conditions Osteoarthritis of weight-bearing joints is an important problem in farmers. Scientific work on it has been done mostly in Europe. There is no NIOSH-funded work in this field in forestry or fishing. Noise-Induced Hearing Loss The epidemiology of hearing loss and strategies for hearing conservation are important topics for the AFF sector. NIOSH has a separate Hearing Loss Program, which underwent program review in 2006 (IOM and NRC, 2006). Within the AFF Program, there has been a relatively small but steady stream of projects character- izing hearing loss and use of personal protective devices, mostly conducted through the Ag Centers. Research outputs—which include published reports, scientific manuscripts, training materials, and dissemination of these products—address hearing conservation, hearing loss as a risk factor for injury, comparisons of self- reported hearing to audiometric testing, prevalence of noise-induced hearing loss, and task-based and animal-based exposure assessment. While the majority of activ- 

Review of H e a lt h E f f e c t s R e s e a r c h 105 ity has been in agriculture, a few studies have looked at noise in forest harvesting and aboard catcher-processor fishing vessels. Dermatological Disorders Dermatological disorders are known to be an important problem in produc- tion agriculture. Less is known about their impact on the health of workers in forestry and fishing. The AFF Program does not appear to have generated major outputs in this field. Traumatic Injury The epidemiology of traumatic injury and death on farms and in the Alaska fishery has received a great deal of emphasis in the AFF Program. Much less infor- mation was available about this topic with reference to forestry. Important contri- butions to the understanding of the problem have been made by intramural and extramural NIOSH investigators, particular those working in the fishing industry in Alaska. In that arena, the research has led to the development of solutions for the problem and to a large reduction in death rates. Finding a way to reduce injury and death from trauma on farms has proved more difficult except for injury to children and tractor rollovers, in which considerable progress has been made. Much work remains to be done to extend the fishery work to other regions; to devise effective ways of reducing injuries in all farm populations, including farm workers; and to address the large problem of traumatic injury in forestry workers. Poisonings Poisoning from exposure to high concentrations of toxicants remains an impor- tant problem in AFF workers, primarily related to exposure to pesticides. NIOSH has funded extensive work in agricultural pesticide poisoning, including epidemiology, identifying clinically relevant biomarkers, and training workers to avoid causative pesticide exposure. Some of the work has been done in effective interagency collab- orative relationships, particularly through the AHS. NIOSH has also helped to raise awareness of the problem of carbon monoxide poisoning in production agriculture through the publication of a NIOSH Alert on the topic. There has also been an effort to educate fishermen about it. NIOSH’s response to emerging problems regard- ing poisonings in the AFF sector has not always been rapid. For example, several years elapsed between the deaths of two farmers from unintentional injection of tilmicosin, a veterinary antibiotic, and the publication of a NIOSH Update report containing recommendations to prevent poisoning with it. 

106 A g r i c u lt u r e , F o r e s t r y , and Fishing Research at NIOSH Infectious Diseases The output of the NIOSH AFF Program with respect to infectious diseases has been modest. NIOSH did sponsor one conference on agroterrorism. There may have been unexplored potential to partner with the Department of Homeland Security in additional work on the topic. The growing concern about avian influ- enza and the extensive planning already in progress for dealing with it in a possible pandemic may provide NIOSH with additional opportunities for collaboration. Gene-Environment Interaction NIOSH funded early investigations in gene-environment interactions as they pertain to work in production agriculture. In doing so, it demonstrated its abil- ity to take advantage of opportunities created by an increase in knowledge about agricultural exposures gained through the AFF Program and new technologies in genetics. The next challenge is to conduct scientifically important studies on gene- environment interactions with larger populations of AFF workers. Doing so would require collecting data from multiple sites and demonstrating a level of cooperation and coordination that has not been evident in some of the other research funded through the AFF Program. Psychological Effects The effects of psychological stressors on the AFF workforce have not been ex- tensively explored with NIOSH AFF Program resources. It is known that farmers have a high rate of suicide, and a link to pesticide exposure has been proposed. The AFF Program has the potential to explore the effect of occupational exposures and psychological stressors on health outcomes in the AFF workforce. Workplace Violence NIOSH has made recommendations in an effort to reduce the impact of work- place violence. Workplace violence occurs occasionally among hired farm laborers, but there is very little evidence in literature regarding prevalence and reports are anecdotal. In the California Agricultural Worker Health Survey, only 0.7 percent of male workers reported ever having been a victim of workplace violence (Brammeier et al., in press; Villarejo and McCurdy, in press). Data similarly shows that there were no reported cases of workplace violence for fishermen from 2001-2007 nor does it occur enough to be included as a question in the U.S. Coast Guard’s accident in- vestigation forms or databases (Lieutenant Commander Vasquez, U.S. Coast Guard 

Review of H e a lt h E f f e c t s R e s e a r c h 107 Commercial Fishing Vessel Safety Office, personal communication, November 1, 2007). The AFF sector is not currently viewed as one in which workplace violence is a large concern. Sleep Deprivation There is a growing understanding of the health effects of sleep deprivation, from trauma (Stallones et al., 2006) to obesity. It is known that workers in specific industries in which long hours and shift work are common, including healthcare, are at increased risk for adverse health outcomes directly associated with sleep de- privation. NIOSH has not extensively addressed the issue in the AFF sector, even though accounts of long workdays and workweeks are noted in employee activity logs and are legion in the sector. Aging The AFF workforce is aging; a disproportionate number of the workers actively employed in this sector are in their 50s or older. Aging contributes to the risk of poor outcomes because of work exposures in a variety of ways, from increased risk of traumatic injury to higher morbidity from sleep disorders. Age-related health risks in AFF workers and possible solutions are topics that merit more attention. Children and Adolescents Infants and toddlers are not workers, but may be brought into work environ- ments and may also incur exposures at home, particularly if living in housing ad- jacent to areas of aerial spraying. They are also vulnerable to inadvertent exposures to chemicals stored and utilized in the agricultural workplace. Small children incur differential exposures due to their physiology, metabolism, and diet (NRC, 1993). Their increased respiratory rates relative to adults have implications for respira- tory exposures, and oral behaviors of the young increase their risk of ingestion of any hazardous materials in their environment. Concerns have been raised that these findings have applicability to agricultural work settings that include children. Children as young as preschoolers may work with crops or animals, and the issues of differential risk may apply to these children. Risk due to a child operating adult- sized machinery or with large animals may outweigh exposure risks. Adolescents are also considered vulnerable to occupational exposures. A Na- tional Research Council report (1998a) noted the lack of definitive research on the difference between adolescent and adult immune and other systems that would lead to increased vulnerabilities in adolescents, and subsequently suggested that research 

108 A g r i c u lt u r e , F o r e s t r y , and Fishing Research at NIOSH be conducted on exposures to substances associated with latent diseases (such as cancer, hearing loss, repetitive motion injuries, and back injury) at a time of rapid growth and cell turnover, and also on endocrine disruptors at a time of puberty. INTERMEDIATE OUTCOMES The intermediate outcomes span unique staff and laboratory capability for AFF worksite exposure assessment, explicit worksite interventions and fruitful partner- ships with AFF stakeholders, professional and clinical training at academic health centers, and symposia and other professional career-development opportunities. Prevention or mitigation of exposure is reflected in a hierarchy that begins with AFF worksite exposure assessment, moves to testable interventions, continues with stakeholder partnerships if interventions are effective, and culminates in training of and clinical awareness in rural practitioners, agricultural extension leadership and staff, local public health nurses, agricultural engineers, and voluntary agriculture and forestry association staff and general membership. NIOSH public affairs staff repeatedly rejected advice from Ag Center scientists encouraging intramural staff to produce materials that farmers could relate to and understand. AFF worksite exposure assessment needs to involve unique biomechanics, basic science, and epidemiological assessment. NIOSH and the extramurally funded Ag Centers have developed and deployed biomechanics and basic science capability. Substantial activity has also occurred in design of rural epidemiological surveil- lance, sometimes without NIOSH assistance or support but still able to elucidate the epidemiology of disease states and injury of disabling conditions of interest in agriculture and forestry populations. NIOSH funding has been invested in AFF worksite interventions, such as de- sign of a Certified Safe Farms initiative, tractor ROPS public policy development, rural cancer control intervention development, ergonomic tool design, develop- ment of respiratory and hearing personal protective equipment, organic dust re- duction in AFF worksites through animal housing engineering, injury prevention through redesign of worksite facilities and methods of work, design of safe play areas for children in agricultural worksites, design of helicopter logging injury countermeasures, and use of enhanced deck safety technologies for fishermen. Those initiatives have generally been scientifically robust and clinically relevant and have reflected input of AFF stakeholders whose perspective governed identification and priority-setting of interventions and the actual deployment process. Feedback from AFF stakeholders as varied as the National Institute for Farm Safety and the U.S. Coast Guard about the utility of the interventions has generally been favor- able. Other AFF stakeholders—including agricultural engineers, rural clinicians, 

Review of H e a lt h E f f e c t s R e s e a r c h 109 public health and clinical nurses, extension safety personnel, and voluntary and professional organization staff—have professed encouragement of the efforts and suggested more rapid deployment and greater penetration in AFF worksites. Of particular interest to the committee were instances in which engineering standards, regulations, and other guidelines were developed and deployed across time in all three AFF sectors. The most robust activity occurred in the fishing sector, and activity was somewhat more limited in the logging sector, but in both instances the NIOSH intramural program led the way. Most AFF resources al- located by Congress were directed toward the agricultural sector; however, this sector has been the most timid in these matters. Clearly, agricultural worksites are complex, and liability concerns of agricultural technology developers and machin- ery manufacturers are ever present and the failure to unify the communities of science and agriculture, forestry, and fishing for the common good has hindered new initiatives and the flow of information and technology at institutional, local, state, and national levels. END OUTCOMES In general, trends in morbidity and mortality related to AFF exposures have been difficult to quantify. However, mortality due to cancer and trauma has been more readily quantified than other outcomes, even though it has not always been possible to identify clear-cut associations between AFF exposures and cancer death. Trends in other disease end points resulting from occupational exposures remain elusive, including neurological, reproductive, musculoskeletal, dermatological, in- fectious, psychological, and physiological (sleep-deprivation) outcomes. Trends in mortality and morbidity resulting from worksite injury have been documented in the Alaska commercial fishing industry and the West Virginia log- ging industry. Evidence provided by NIOSH confirmed that interventions designed and field-tested by the AFF Program have reduced mortality and morbidity there. The challenge is to amplify that impact by expanding the interventions into other geographic regions in those sectors. Trends in morbidity and mortality resulting from respiratory diseases have re- cently been described in NIOSH documents (2000b, 2007c). The documents do not contain data from all states (including a group of states that produce the majority of agricultural and forestry products), but the data indicate that rates of respiratory illness and injury in agricultural workers did not change appreciably from 1995 to 2001. Given the data limitations, the analyses do not offer a comprehensive review of outcomes in the AFF workforce. 

110 A g r i c u lt u r e , F o r e s t r y , and Fishing Research at NIOSH Mortality resulting from cancer is generally lower in AFF populations than in the overall American population (Hanrahan et al., 1996). That may be due in part to greater use of preventive measures and clinical screening in some AFF worker populations than in other working populations. It could also be due to the protec- tive effect of some AFF exposures—a phenomenon that deserves further explora- tion (NIOSH, 2007c). The higher incidence of primary intracranial glioma among male farmers compared to the general population led to the design and implemen- tation of a case-control study conducted jointly by NIOSH and two extramurally funded Ag Centers (Great Plains Center for Agricultural Health in Iowa and the National Farm Medicine Center in Wisconsin). Results of the effort are emerging. In general, cancer mortality in American males has declined (American Cancer Society, 2007), so any decline attributed to occupational exposure needs to exceed historically observed declines.