InputsActivitiesOutputsIn
Goal 3: 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.
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
FIGURE 6-1Health 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.
InputsActivitiesOutputsIntermediate OutcomesEnd Outcomes Planninginputs: 1.Surveillancedata 2.Stakeholder needs 3.Otherpartnersinterestedinsafetyand health 4.Symposiaandconferences 5.Programevaluations 6.Programgoals Productioninputs: 1.Budget 2.Staff 3.Facilities 4.Managementstructure 5.Extramuralentities 6.Partners
1. NationalTraumaticOccupationalFatalities (NTOF) 2. Industryspecificprograms: vAgriculture oCommunitypartnersforhealthyfarming interventionresearch oChildhoodAgriculturalInjuryPrevention Initiative oErgonomicinterventionsforyouth workinginagriculture oFarmFamilyHealthandHazard Surveillance oOHNAC oHHEs oFACEreports oSENSOR-Pesticides oAgSafetyPromotionSystem oAg Centers oAgriculturalHealthStudy(in collaborationwithNCI) oRegionalRuralInjuryStudyII oLaboratory-basedintramuralinitiativeson biomonitoringandexposureassessment vForestry oAlaskainteragencyworkinggroup oState-basedFACEinvestigationreports oEvaluationofmechanicalharvesting techniques vFishing oAlaskaTraumaRegistryandAlaska OccupationalInjurySurveillanceSystem oInteragencyworkinggroup (including USCG, AMSEA, and NPFVOA) 1. PublicationsinscientificjournalsfromNIOSH- fundedworkinthefollowingareaswith referencetoAFF vRespiratory vCancer vNeurological oVibration-inducedinjury oParkinson’sdisease vReproductive vChronicmusculoskeletalconditions vHearing vDermatological vTraumaticinjuries vPoisonings oPesticide oCarbonmonoxide oTilmicosin vInfectiousdiseases vGene-environmentalinteractionstudies vPsychologicaleffects oDepressionandsuicide vWorkplaceviolence vSleepdeprivation 2. NIOSHpublications vNIOSH Alerts vNIOSHmonographs vNIOSH FACE reports vWeb-basedinformationandnewsletters 3.MMWRreports 4.NAGCAT 5. Symposiaandworkshops vSurgeonGeneralConferenceonAgricultural SafetyandHealth(1991) vNationalandinternationalfishingindustry safetyandhealthworkshops(1992,1997,2000, 2003,2006) vSummitonChildhoodAgriculturalInjury Prevention (2001) vHelicopter Logging SafetyWorkshop (2005) 1. Trainingandeducationoutputs vERCs oEducationalcurriculum vExtramuralAgCenterinitiatives oSymposiaandotherprofessional careerdevelopmentopportunities oAgroterrorism vOHNAC outreach (currently activeonly inOhio) 2. Interventions vCertifiedSafeFarms vPublicpolicyforROPSimplementation vFarmer cancer controlinitiatives (6 projects) vErgonomicinnovationsforsaferharvest vInjuryprevention throughsafe play areas vConfinedspaceentryinterventions vDevelopmentofrespiratoryPPE vDevelopmentofmethodsfordust reductioninCAFOs vWorkorganizationinterventions 3. Uniquestaffandlaboratorycapability vAgCenterlabs oBiomechanicslab oBasicsciencelabs vEpidemiologyprojects 4. Partnershipswithstakeholders vNationalInstituteforFarmSafety vFarmSafety4JustKids vFarmhealthsafetyprojectsfundedby W.K. KelloggFoundation(suchasthe AgriculturalSafetyandHealthNetwork (Petrea, 2003), which is no longer active) vWorkers’compensationinsurance companypartnerships vAmericanThoracicSociety (EnvironmentalandOccupational Health)
1.Decrease inhelicopter logging fatalities. 2.Decrease in fishingvesselsinkings. 3.Ingeneral,morbidityandmortalitydue toagricultural,forestry,andfishing exposureshavebeenextremelydifficult toquantify.Deathfromcancerand traumahavebeeneasiertoquantifythan otheroutcomes. Ithasnotalwaysbeen possible tomake clear-cutassociations betweenAFFexposuresandcancer deathinspecificcases. Thus,ithasnot been possibletodescribe specific end outcomesassociatedwithmanyhealth effectsresearchprojects. 4.Morbidityandmortalitystatisticsfrom respiratorydiseaseshaverecentlybeen describedindocumentspublishedby NIOSH(2002,2007). Thesedocuments donotcontaininformationfromall states,includingagroupofstatesthat producethemajorityofagricultural products. Thepublishedresultsindicate thatratesofrespiratoryillnessand injuryinagriculturalworkershavenot changedgreatlybetween1995-2001. However,thesedocumentsmaynot offeracompletepicture. 5.See sublogicmodelinChapter7for specificinjurypreventionendoutcomes. 6.Relativelylittleisknownaboutillnesses associatedwithworkinforestryand fishing. vTimeneededtobuild relationshipswithpartners and constituentsvCurrent politicalclimatevFarmsbecominglargerwithlessrelianceonchildlabor vLack of resources and interestinfundingsurveillancev Seasonalityof industries,weather,climatechangevFundingperiodslimitabilitytoevaluatelong-termeffectsof intervention vNegativeeffectofeconomicdownturnvUncertaintyregardingimmigration issuesvPoornational/politicalunderstandingofscopeandcostofoccupational External Factors
disease and public health
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-
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.
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.
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
TABLE 6-1 Research Emphases of Some NIOSH Ag Centers
Ag Center Research Strength or Emphasis
Pacific Northwest Agricultural Safety and Health Center, Washington
Prevention of occupational disease and injury in farmers, fishermen, forestry operators through occupational medicine, epidemiology, industrial hygiene Western Center for Agricultural
Health and Safety, California
Health promotion and disease prevention, injury and ergonomics, neurotoxicity and pesticides, respiratory diseases, industrial hygiene and exposure assessment, evaluation, biostatistics
Southwest Center for Agricultural Health, Injury Prevention, and Education, Texas
Farm-family health and injury control, hired farmworker health and safety, animal-handling injuries, stress, health and safety training and education
Deep-South Center for Agricultural Disease and Injury Research, Education, and Prevention, Florida
Asthma, ergonomic injuries, heat stress in farm workers;
prostatic cancer in licensed pesticide applicators; health, exposure assessment of poultry producers; incidence of logging-related injuries; safety of farm children Southeast Center for Agricultural
Health and Injury Prevention, Kentucky
Special populations, community-based interventions, engineering, ergonomics, green tobacco sickness, environmental health
Northeast Center for Agricultural and Occupational Health, New York
Hearing loss, arthritis, skin cancer, allergies, mechanical injuries, migrant farm workers, older farmers, women, children
Midwest Center for Agricultural Research, Education, and Disease and Injury Prevention, Wisconsin
Infectious pathogens, women, developing and evaluating health promotion and disease and injury prevention programs, engineering control technologies, injuries in children
High Plains Intermountain Center for Agricultural Health and Safety, Colorado
Engineering, industrial hygiene, education, toxicology, social work, epidemiology, environmental health, agricultural sciences
Great Plains Center for Agricultural Health, Iowa
Environmental health, health and safety of farmers, occupational health, injury prevention, rural health National Children’s Center for Rural
and Agricultural Health and Safety, Wisconsin
Health and safety issues for farm children, guidelines for acceptable agricultural tasks
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.
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 0 Years of Age on Minority Farm Operations in the United States, 000), 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,