1	National Health Interview Survey (NHIS) Mortality & Disability among US Farmers & Pesticide Applicators Gomez-Marin G, Zheng D, LeBlanc W, Lee D, Fangchao Ma , Lee D, Fleming LE, Ma F, Pitman T, Jane D Dept of Epidemiology & Public Health University of Miami School of Medicine Miami, FL
2	Outline Background Objectives Methods Results Conclusions Recommendations
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4	Background: Pesticides & Health Pesticides & Human Health Acute Disease Chronic Disease?? Disability? Mortality? Occupational Exposed Groups Manufacturers Farmers Pesticide Applicators
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6	Background: Morbidity/Mortality Risks Farmers & Pesticide Applicators ê Tobacco & Ethanol Diseases Cardiovascular disease COPD é Accidents é Neurologic Diseases é Respiratory & Infectious Diseases
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8	Background: é Cancer Risk Farmers Skin Stomach Brain Prostate Multiple Myeloma Leukemia Pesticide Applicators Skin Stomach Brain Testicular Soft Tissue Sarcoma Non Hodgkins Lymphoma
9	Background: Methodologic Issues Farmers & Pesticide Applicators Bias Healthy Worker Effect Population Small sample sizes Variable populations by geography Inadequate follow up Exposure Inadequate exposure assessment Variable exposures
10	Background National Health Interview Survey (NHIS) Annual national estimates on disease, injury, impairment, disability, and related issues on a uniform basis for the entire US population
11	Background National Health Interview Survey (NHIS) Multi-purpose household survey Probability sampling US civilian non-institutionalized population Conducted Annually since 1957 95-98% Response rate
12	Background National Health Interview Survey (NHIS) Periodic Supplements on subpopulations Aggregate Morbidity Data Annual Cross-Sectional Mortality Follow Up through 1997 1986-1994 Longitudinal Mortality Data
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14	Objectives 1) NHIS Cross Sectional: Acute & Chronic Disability & Health Assessment 2) NHIS Mortality Follow Up: Overall & Cause-Specific Mortality Farmers & Pesticide Applicators vs Other US Workers Farmers vs Pesticide Applicators
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16	Methods: National Health Interview Survey (NHIS) Probability sampling US Population Self Reported Data Individual Identifier & Weights Household Survey Proxy information Annual Sub Population Supplements Longest Held Job (1986) Occupational Health (1988) Smoking & other Confounders
17	National Health Interview Survey (NHIS) 1986-1994: > 450,000 US workers > 18 yrs Employment status during 2 weeks prior to interview Standardized Occupational & Industry Codes All, 46 & 16 SOC & SIC re-Codings Farmers and Pesticide Applicators
18	National Health Interview Survey (NHIS) Demographic Variables Age Gender Race Ethnicity Socio-Economic Education Family Income Geographic Region Urban/Rural
19	National Health Interview Survey (NHIS) Morbidity & Mortality (ICD 9) Acute & Chronic Conditions 6 Lists of Chronic Conditions Various Recodes Injury Job related Self Assessed Health Rating Reporting Health Condition
20	National Health Interview Survey (NHIS) Acute Disability (<2 Weeks) Days Restricted Activity Days Bed Days Lost Work Chronic Disability (<12 Months) Doctor Visits Hospitalizations
21	National Health Interview Survey (NHIS) Mortality Follow Up National Death Index (NDI) linkage January 1, 1986 - December 31, 1997 Computerized Linkage algorithm Match class & score 97% complete > 18 yrs
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25	Example of Hypothesis Pesticide Applicators & Farmers: é Prostate Cancer Risk Detect Risk Ratio = 1.54 Alpha level of 0.05 with 90% Power
26	Statistical Methods Create Database Exclude: Unemployed, <18 yrs, inadequate data Create Pooled Dataset Link Annual Survey & Mortality Follow up (1986-97) Multi-stage sampling design Adjustments for sample weights & design effects SUDAAN Statistical Package Further adjustment of sample weights for analysis of data from combined survey years (Botman 1995) Biases Proxy Interaction Morbidity/Mortality analyses Cox Regression models (SUDAAN Proc Survival)
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28	Results Farmers N 9576 Deaths 503 Women 1772 (18.5%) Mean Age 44.1 ± 16.2* ± SD Pest All Other Work 180 453,219 9 8078 7 (3.9%) 214,063 (47.2%) 38.6 ± 12.7* 38.8 ±12.8* * p<0.001
29	Results Farmers Hispanic 1175 (12.3%) Black 376 (3.9%) >12 Grade 2322 (24.5%) Pest All Other Work 21 (11.7%) 33,066 (7.3%)* 27 (15.0%) 56,157 (12.4%)* 59 (32.9%) 211,384 (47.1%)* * p<0.001
30	Results: Acute Disability Farmer Pest Restricted 0.78 (0.70-0.87) 0.83 (0.45-1.53) Bed 0.71 (0.61-0.82) 0.81 (0.35-1.85) Lost Work 0.73 (0.65-0.83) 0.90 (0.45-1.80) Model = Occupation, Age, Gender, Race-Ethnicity, Education (compared to All Other Workers)
31	Results: Chronic Disability Farmer Pest MD Visit 0.82 (0.76-0.88) 1.21 (0.80-1.83) Hospital 1.04 (0.92-1.16) 0.88 (0.42-1.86) Model = Occupation, Age, Gender, Race-Ethnicity, Education (compared to All Other Workers)
32	Results: Health Assessment Farmer Pest Self 1.08 (0.96-1.23) 1.35 (0.80-2.30) Condition 0.92 (0.86-0.98) 1.34 (0.97-1.86) Model = Occupation, Age, Gender, Race-Ethnicity, Education (compared to All Other Workers)
33	Results: High Risk Reported Disability & Health Age Sex Race/Eth Educ Acute Y F WNH Low Chronic O F WNH Low Health O F H/B Low OVERALL: Non Hispanic Older Woman Worker of Lower Education
34	Results: Overall & Cause-specific Number of Deaths by Occupation & Gender Pesticide Exposed Other M F M F All Deaths 512 59 8078 3914 Infectious 9 0 454 116 Heart 211 20 2729 1084 Respiratory 16 2 394 198 Nervous 5 1 83 46 MVA/Accidents 37 7 630 223
35	Results: Cancer-specific Number of Deaths by Occupation & Gender Pesticide Other M F M F Overall cancer 161 23 2515 1699 Nervous system 9 2 86 55 Digestive 37 4 682 333 Respiratory 45 1 884 391 Breast 0 2 7 382 Prostate 22 -- 177 -- Genital 22 1 182 183 Urinary 5 1 112 35 Lymph/Hemat 20 7 226 150
36	General Mortality Results Pesticide Exposed vs Other Age Adjusted RR (95% CI) Disease Male Female Total Overall Mortality 1.2 (1.1-1.3) 1.1 (0.8-1.4) 1.3 (1.2-1.5) Infectious 0.5 (0.3-1.0) 0.6 (0.3-1.2) Heart 1.2 (1.0-1.4) 1.1 (0.7-1.8) 1.4 (1.2-1.7) Respiratory 0.6 (0.4-1.0) 0.5 (0.1-2.1) 0.7 (0.4-1.1) Nervous System 1.4 (0.6-3.3) 1.1 (0.4-2.9) 1.7 (0.2-13.3) MVA/Accidents 1.6 (1.2-2.2) 3.2 (1.5-6.9) 2.1 (1.6-2.8)
37	Cancer Mortality Results: Pesticide Exposed vs Other Age Adjusted RR (95% CI) Disease Male Female Total Overall Cancer 1.2 (1.0-1.4) 1.0 (0.7-1.5) 1.2 (1.1-1.4) Nervous 2.1 (1.0-4.5) 2.4 (0.6-8.8) 1.2 (1.1-1.4) Digestive 0.9 (0.3-2.8) 0.7 (0.3-1.7) 1.0 (0.7-1.4) Respiratory 1.0 (0.7-1.3) 0.2 (0.02-1.3) 1.0 (0.8-1.4) Breast 0.4 (0.1-1.5) Prostate 1.3 (0.8-2.2) Genital 1.3 (0.8-2.2) 0.4 (0.1-2.7) 1.3 (0.8-2.1) Urinary 1.2 (0.4-3.6) 1.6 (0.2-10.5) 1.6 (0.6-4.1) Lymphatic/Hemat 1.7 (1.1-2.7) 3.6 (1.6-8.2) 2.2 (1.5-3.2)
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39	NHIS Limitations Self Report & Proxy Access to Care (Disability) Self Employment (Disability) Lack of individual exposure measures Confounding Pesticide exposure Relatively small numbers of deaths Probability Sample of US Worker Population as the major comparison population is appropriate for issues of the healthy worker effect and other biases
40	Conclusions: Reported Disability Risk NHIS population-based sample US workers Pesticide Exposed vs Other Workers é Aging Farmers ê Acute Disability ê Chronic Disability Poor Health Assessment ê Conditions é Non Hispanic Older Woman Worker of Lower Education
41	Conclusions: Mortality Risk NHIS population-based sample US workers Pesticide Exposed vs Other Workers é Overall Mortality é Cardiovascular disease ê Tobacco-related diseases ê Infectious diseases é Nervous system diseases é Motor vehicles & accidents é Overall Cancer é Nervous System Cancer é Lymphocytic/Hematopoietic Cancer
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43	Future Work National Health Interview Survey (NHIS): Research Potential Probability Sample ALL US Workers Supplemental Surveys Confounding information Prevalence of Acute & Chronic Morbidity Cross Sectional Trends over Time Mortality Follow Up Longitudinal Cohort Study PMR, SMR Study Website http://www.rsmas.miami.edu/groups/niehs/niosh/
44	Acknowledgments Data Inter-University Consortium for Political & Social Research US Dept of Health & Human Services National Center for Health Statistics Funding National Institute of Occupational Safety & Health (NIOSH)-funded R01 0H03915-01 National Institute of Occupational Safety & Health (NIOSH)-funded Deep South Agricultural Center (University of South Florida)
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