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4 Review of Surveillance Research Surveillance is a cornerstone of public health and provides evidence of emerg- ing hazards, illnesses, and injuries as well as providing baseline information from which to evaluate the success of intervention programs. Occupational illness, injury, and hazard surveillance has developed over the past 35 years, but due to reliance on the Bureau of Labor Statistics (BLS) Survey of Occupational Illnesses and Injuries, standard surveillance has not provided adequate information on populations who work in AFF sectors. To address the issues related to the AFF sector, AFF Program staff have attempted to identify alternative data collection systems to augment the more traditional approaches. STRATEGIC GOALS AND OBJECTIVES Goal 1: Hazard Surveillance—Reduce injuries and illnesses in the agriculture, forestry, and fishing workforce by understanding the characteristics of those inju- ries and illnesses so as to target research and interventions that reduce hazardous exposures. The strategic goal related to hazard surveillance is critical to the development, implementation, and evaluation of all AFF sector efforts. The AFF Program goal has been met with mixed results that differ by sector, population at risk, and hazardous exposures. Overall, the focus of the program has been primarily on agricultural production, pesticide exposures, Alaska fishing, children, and hired workers. Where efforts have been focused clear progress in surveillance-based 69

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a g r i c u lt u r e , f o r e s t r y , fishing research niosh and at 0 information is evident, but other areas need better and more surveillance data. Further, the surveillance data need to be used in a more systematic manner for the development of research agendas and for the development and evaluation of intervention programs. LOGIC SUBMODEL Information received from the NIOSH AFF Program (NIOSH, 2006a) related to inputs, activities, outputs, intermediate outcomes, and end outcomes in sur- veillance is summarized in the surveillance logic submodel (Figure 4-1). Several factors were missing in the creation of an accurate logic submodel to evaluate the program’s surveillance efforts. No formal infrastructure for the coordination of surveillance activities was described. A schema for identification of populations at risk that merited surveillance was not provided. And, planning input from stake- holders regarding surveillance activity was not identified. INPUTS Planning Inputs Congress spelled out a specific charge to NIOSH for conducting surveillance in the Senate appropriations language of 1990 (as quoted in http://www.cdc.gov/ niosh/nas/agforfish/pdfs/app-0.pdf): Funds were specifically earmarked for a “U.S. farm family health and hazard” surveillance program. Testimony rendered by agricultural safety and public health professions in support of the legislation was explicit that surveillance of these worksites was central to all ensuing effort. The phrase farm family was not intended to refer only to farmers, ranchers, and their families; rather, it referred to all persons performing tasks or residing on a farm, including hired laborers and accompanying family members. The other planning input that was referred to in the evidence package was the National Coalition for Agricultural Safety and Health report (Appendix 2-01 in NIOSH, 2006a), which suggested that adequate population-based rates were not available for agriculturally related diseases and injuries, therefore health and hazard surveys of agricultural workers needs to be conducted. In forestry, strategic planning evidence came from the Pacific Northwest Center and addressed northwest forestry only. Significant efforts related to fatal injury surveillance in the Alaska fishing sector have been conducted with evidence that Gulf Coast fishing is being addressed by one of the NIOSH Centers for Agricultural Disease and Injury Research, Education, and Prevention (Ag Centers).

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Inputs Activities Outputs Intermediate Outcomes End Outcomes 1. MMWR 1. FFHHS spirometry and 1. Reduction of pesticide Planning inputs: 1. FFHHS 2. 185 peer-reviewed journal audiometry protocols poisonings 1. Agriculture: 2. NTOF articles 2. CAST materials and training 2. Reduction in fatal injuries in • NCASH report 3. OHNAC 3. 6 NIOSH updates 3. Work-related lung- disease farm youth • Senate appropriation 4. Child Agricultural Injury 4. Alert on carbon monoxide report 3. Reduction in logging 2. Forestry: Surveillance poisoning 4. OHNAC materials accidents and helicopter • Northwest forestlands 5. FACE 5. How-to guide on pesticide 5. Safety day-camp materials crashes strategic document 6. Occupational Injury surveillance (drowning in farm ponds) and 4. Declines in deaths from 3. Fishing: None reported Surveillance of 6. 4 “other” NIOSH safety day camps fishing and accidents in Production Agriculture publications 6. SENSOR report generated fishing 7. Traumatic Injury Surveillance 7. 150 presentations adoption of IPM programs in Production inputs: of Farmers 8. Unpublished reports schools 1. Budget 8. National Electronic Injury 9. Web sites 7. Data used to prepare National 2. Intramural staff Surveillance 10. Policy briefing in California Agenda for Action-land grant 3. Extramural researchers 9. National Agricultural Workers 11. Brochures, checklists, fact research 4. Infrastructure Survey 12. sheets, white papers • No infrastructure described 10. Emerging Issues in Injury 13. 12. OHNAC exhibits Surveillance 11. WoRLD 12. SENSOR-Pesticides 13. AOISS 14. The Keokuk Rural Health Study 15. The Farmer Health Study 16. The Regional Rural Injury Study Social and economic conditions Regulatory environment State and local differences in information, such as mismatched public health Seasonality of work practices, diverse workforce information systems External Factors FIGURE 4-1 Surveillance logic submodel. AOISS = Alaska Occupational Injury Surveillance System, CAST = Cooperative Agricultural Surveillance Training, FACE = Fatality Assessment and Control Evaluation Program, FFHHS = Farm Family Health and Hazard Surveillance, IPM = integrated pest management, MMWR = Morbidity and Mortality Weekly Report, NCASH = National Coalition for Agricultural Safety and Health, NTOF = National Traumatic Occupational Fatal- ity Surveillance System, OHNAC = Occupational Health Nurses in Agricultural Communities, SENSOR = Sentinel Event Notification System for  Occupational Risk, WoRld = Work-Related Lung Disease Surveillance Report.

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a g r i c u lt u r e , f o r e s t r y , fishing research niosh and at  Production Inputs Production inputs include staff time, external investigators’ time, and intra- mural and extramural budgets. ACTIVITIES Activities and funding related to surveillance identified in the evidence pack- age (NIOSH, 2006a) and through review of other materials provided by NIOSH and available on the NIOSH Web site are detailed in Table 4-1. There has been substantial activity related to determining the hazards and injuries associated with agriculture, with less relative to forestry and fishing. There is little evidence of work on the surveillance for illnesses other than respiratory diseases. Absent from sur- veillance activities cited in the evidence package and supplemental materials were other disease and injury outcomes on the National Occupation Research Agenda (1996 to date) list (allergic and irritant dermatitis, hearing loss, infectious disease, musculoskeletal disease, and reproductive outcomes). Research on surveillance methods was also limited. AFF surveillance needs to be a major priority of the intramural program activities so that the appropriate information is used to plan future directions. Hazard surveillance has included extensive work related to the leading causes of injury-related deaths, tractors, and has focused on rollover pro- tective structures (ROPS). FACE investigations have identified emerging problems related to AFF sector injury deaths. Farm Family Health and Hazard Surveillance (FFHHS): These surveys were conducted with no planned long-term surveillance, and only six states were funded across the nation. A number of important issues for agricultural safety and health were identified by investigators involved in these survey and publications from these surveys continue to provide important information (NIOSH, 2006a). The de- gree to which the FFHHS programs interacted with the NIOSH Ag Centers has not been evaluated. Although NIOSH staff attempted to standardize data elements and definitions across the six efforts, that effort was not entirely successful, but there is limited evidence that the uniform elements were used effectively in comparative analyses (Zwerling et al., 1997b; Scarth et al., 2000). How successful the FFHHS programs were in completing surveys and generating information also varied by state. NIOSH has ensured that data obtained from the surveys can be accessed on a Web site (http://wwwa.cdc.gov/ffhhs/dictmain.asp). The committee identified barriers to the recommended surveillance activities. The evidence package indicates the full extent of underfunding of surveillance of hired farm laborer occupational safety (NIOSH, 2006a). The allocation of resources described in the document “Composite of Ag Budget by Goals and Program Areas”

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review surveillance research of 3 TABLE 4-1 NIOSH Programs with Surveillance Activities Program or Project Division Dates Funding Farm Family Health and Hazard Surveillance DSHEFS 1990-2000 $1,540,907-2,000,000 per year for 10 years Agriculture research, development, and planning use of DSHEFS 1998-2004 $1,001,616 state farm-family health and hazard surveys National Traumatic Occupational Fatality Surveillance DSR 1984-2003 $226,663; System 1990-1996, $300,000 in agriculture industry Occupational Health Nurses in Agricultural DSHEFS 1990-2000 $15,000,000- Communities 16,000,000 Community Partners for Healthy Farming DSHEFS 1996-2007 $6,550,341 Keokuk County (Iowa) Rural Health Study — 1990- Extramural unknown The Farmer Health Study (California) — 1990- Extramural unknown The Regional Rural Injury Study (Minnesota) — 1990-1993 Extramural unknown NEISS-CPSC sample of emergency department records DSR 1991-2010 $1,019,019 and follow-up Work-related lung disease surveillance report DRDS 2005-2010 Unknown Respiratory health and hazards in agriculture report DRDS 2000-2005 $496,321 National Agricultural Worker Survey DSHEFS 1998-2008 $2,345,448 Childhood Agricultural Injury Prevention Initiative DSR 2006-2015 $8,455,000 Child Agriculture Injury Prevention Initiative DSR 1996-2010 $1,107,379 Surveillance of Occupational Injuries among Children DSR 1995-1999 $13,827; and Adolescents 1995-1996, $9,300 in agriculture Occupational traumatic injury surveillance of farmers DSR 1993-1997 $40,374; 1993-1996, $1,160,000 in agriculture industry Occupational injury surveillance in production DSR 2001-2015 $1,725,687 agriculture Emerging problems in occupational injury epidemiology DSR 1990-2004 $237,222 Injury risk factors in migrant and seasonal workers DSR 1997-1998 $57,635 Traumatic injury surveillance of farmers DSR 1993-1997 $40,374; 1993-1996, $1,160,000 in agriculture industry continued

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a g r i c u lt u r e , f o r e s t r y , fishing research niosh and at 4 TABLE 4-1 Continued Program or Project Division Dates Funding Fatality Assessment and Control Evaluation (FACE)— DSR 1983-2010 $406,113; technical assistance 1990-1996, $552,000 in agriculture industry Fatality Assessment and Control Evaluation (FACE)— DSR 1988-2010 $3,476,602; state-based model 1990-1996, $1,200,000 in agriculture industry Emerging Issues in Injury Surveillance DSR 1985-2015 $213,751 Workplace Hazards to Children and Adolescents in DART 1997-2000 $1,127,468 Agricultural Work Settings Occupational Injury Prevention in Alaska Alaska 1990-2010 $3,388,092 Field Station SENSOR-Pesticides DSHEFS 1987-2010 $1,554,918 NOTE: CPSC = Consumer Product Safety Commission, DART = Division of Applied Research and Technology, DRDS = Division of Respiratory Disease Studies, DSHEFS = Division of Surveillance, Hazard Evaluations, and Field Studies; DSR = Division of Safety Research, NEISS = National Electronic Injury Surveillance System, SENSOR=Sentinel Event Notification of Occupational Risk. indicates that the cumulative total agriculture program funding allocated to the cat- egory “Migrant & Minority” was less than 10 percent of all its resources dedicated to “Priority Populations”. In 1995, NIOSH staff convened a 12-member advisory group to recommend priorities for surveillance among hired farm laborers. This effort could be a model for future surveillance. NIOSH Cincinnati brought together a group of nationally known researchers and medical practitioners with many years of experience both studying occupational safety in this population and/or provid- ing health services. The effort was chaired by noted stakeholders (Valerie Wilk of the Farmworker Justice Fund and Rose Holden of the Rural Community Assistance Corporation), and the California Institute for Rural Studies was eventually com- missioned to prepare the report of this task force and forward the final document in 1998. The report and some of its recommendations were briefly mentioned in the evidence package (page 174 of NIOSH, 2006a). National Agricultural Workers Survey (NAWS): NIOSH partnered with the U.S. Department of Labor (DOL) for the purpose of adding an occupational health and safety supplement to DOL’s ongoing National Agricultural Workers Survey (NAWS) of hired crop farm workers during 1999.

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review surveillance research of 5 Childhood Agricultural Injury Survey (CAIS): The definitions used for children in this survey were nonstandard. Child workers are legally minors and under 18 years of age. The inclusion of 18- and 19-year-olds created confusion because of the different legal status of child workers in agriculture under the Fair Labor Stan- dards Act. In fact, the 1998 General Accounting Office (GAO, now the Government Accountability Office) report clearly states that the best available data indicated that there were about 155,000 15- to 17-year-olds working in agriculture in 1997; most (116,000) were hired workers (GAO, 1998). About 39,000 were self-employed and unpaid family workers (GAO, 1998). Workers under the age of 15 years need to also be considered, and the GAO report acknowledges that the finding is an underestimate. Work-Related Lung Disease (WoRLD) Surveillance Report and System: This report (NIOSH, 2000b) contains data collected from only 22 states. Of the 22, only one corn-belt state was included, and most of the nation’s major agricultural states were not included: Texas, Florida, and California were excluded. The authors grouped all crops together, even though “crop” could be anything from vegetables to citrus to soybeans. From the committee’s perspective, the document is an ex- ample of a weak study design and of release of information by NIOSH that is not representative and therefore not as useful as it could be. Alaska Occupational Injury Surveillance System (AOISS): This surveillance sys- tem includes fatal occupational injuries. Information provided focused on fishing- related fatalities. Oral testimony provided by AFF Program staff to the committee suggested a potential for replication of its design for the West Coast, Gulf, and North Atlantic fisheries. No details about how the effort would be expanded to national or regional settings outside Alaska were provided (NIOSH, 2006a). OUTPUTS Historical institutional experience may be helpful in assessing the adequacy of surveillance definitions routinely used by NIOSH as it implemented the 1990 congressional mandate for the AFF sector. Six years before the mandate, J. Donald Millar, former director of NIOSH, stated: “in the practice of epidemiological sur- veillance, the field of occupational safety and health is at least 70 years behind the field of communicable disease and control” (Halperin et al., 1992). The committee’s review of materials relevant to surveillance for occupational illnesses and injuries related to AFF suggests this is still true. NIOSH documents provided to the committee (NIOSH, 2006a) suggest there is no ongoing national health, hazard, or injury surveillance in agriculture, fish- ing, and forestry. There is little emphasis on hazard surveillance; the surveys have mostly collected disease and injury data with little attention to hazards and poten-

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a g r i c u lt u r e , f o r e s t r y , fishing research niosh and at 6 tially hazardous jobs, so it has been difficult to meet surveillance goals. Although NIOSH was encouraged as early as 1992 to address bias in surveillance effort related to Midwestern, Caucasian perspectives and values, the preponderance of the ef- forts reviewed suggests that such perspectives persist in the agriculture sector (Lee and Gunderson, 1992). The committee notes three exceptions. NIOSH has made some effort to obtain information on the number of tractors in use in the United States that lack ROPS. In the SENSOR-pesticides program, a surveillance system has been established with well-developed case definitions, and materials have been developed from which comparable data could be collected on pesticide poisoning and illness cases. And the occupational fatal injury surveillance system in Alaska appears to be well developed and comprehensive with regard to injuries and the dissemination of summary information; it might be possible to expand to other regions of the country. Sentinel Event Notification System for Occupational Risks (SENSOR)-Pesticides Database: There is a how-to guide for developing a state-based surveillance pro- gram which includes a SENSOR case definition of acute pesticide-related illness and injury, signs and symptoms associated with several pesticides, a severity index for acute pesticide-related illness and injury, a flow diagram for assigning severity to cases, tables of signs and symptoms by severity category, and software to assist states in entering data (NIOSH, 2006a). A number of Morbidity and Mortality Weekly Report (MMWR) articles have been published on pesticide illnesses and injuries and are available on the Centers for Disease Control and Prevention Web site (http://www.cdc.gov/mmwr). Peer-review articles are also available. Web sites for state-based pesticide poisoning surveillance programs, general pesticide resources, and other materials are also provided on the Web site. Childhood Agricultural Injury Survey (CAIS): There were government reports based on the CAIS for 1998, 2001, and 2004 (NIOSH, 2006a,b). Fatality Assessment and Control Evaluation (FACE) program: From 1986 to 2003, there were 16 investigations conducted by NIOSH staff related to agricul- ture and 360 state-based investigations (NIOSH, 2006a). From 1983 to 2004, there were 28 logging-related deaths investigated by NIOSH staff and 67 state-based investigations. From 1992 to 1999, there were two NIOSH staff and 11 state-based investigations of fishing-related fatalities; only two of the state-based investigations were conducted outside Alaska (both in Massachusetts) and both NIOSH staff investigations were conducted in Alaska (NIOSH, 2006a). Occupational Health and Safety Supplement to the National Agricultural Work- ers Survey (NAWS): In 1999, an Occupational Health and Safety Supplement was added to the NAWS (NIOSH, 2006a). Results have not yet been published, but a final report was prepared and is undergoing internal review in NIOSH. Several oral presentations of initial results were offered at various conferences on hired farmworker health.

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review surveillance research of  INTERMEDIATE OUTCOMES The AFF Program has not yet made extensive use of surveillance to produce intermediate outcomes. In the evidence package (NIOSH, 2006a), the program staff list as intermediate outcomes related to hazard surveillance one NIOSH Hazard Alert on farm machinery (1993), one state FACE investigation related to the use of Micotil 300® (tilmicosin) in cattle (to prevent shipping fever) that resulted in a farmer’s death from self-injection, and the resulting workplace-solutions document and additional warnings by Elanco to all Micotil purchasers (NIOSH, 2006a). The most logical intermediate outcome would be the use of surveillance data in developing and evaluating intervention programs. The fishing program in Alaska was the only program that used surveillance data to develop and monitor inter- ventions in which the intermediate outcomes of the use of surveillance data were clearly evident (NIOSH, 2006a). To a lesser degree, traumatic injury surveillance data related to tractors were used to identify commonly used farm tractors without ROPS. This information became the basis for providing low-cost designs to encourage farmers to retrofit tractors. END OUTCOMES The AFF Program staff provided evidence of the following changes (NIOSH, 2006a): • A reduction in acute pesticide poisoning from 13.1 to 8.9 cases per 100,000 as a result of surveillance and research activities. • A reduction, in both absolute numbers and rates, in youth injuries. • Reductions in logging accidents and helicopter crashes. • Significant reductions in fishery accidents and deaths brought about as a result of safety training and inspections. Only the reductions in fishing accidents and deaths were linked with a spe- cific intervention and the surveillance system (NIOSH, 2006a). The reduction in pesticide poisonings may have been due to the reduced use of organophosphate pesticides or due to decreased reporting resulting from increased healthcare costs; thus the reduction in poisonings may not be directly related to the work of the AFF Program.

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a g r i c u lt u r e , f o r e s t r y , fishing research niosh and at 8 OTHER OUTCOMES Reports cited in documents provided to the committee (NIOSH, 2006a) related to agriculture (1986-2003) and logging (1983-2004) are sporadic. NIOSH Alerts oc- curred in 1986, 1988, 1990, 1994, and 1998 and appear to have been linked to some extent with the OHNAC programs (that is, they were agriculture-related) and to have ended when program funding ended. Hazard identifications and monographs (1994, 1998, and 2000) also are sporadic, and agricultural equipment was the only specifier that related to AFF.