Agricultural Health and Safety as part of Rural HealthUMD Medical School Talk Sept. 11,2007

Steven Kirkhorn, MD, MPHMedical Director National Farm Medicine

Center-Marshfield Clinic

Clinical Associate Professor University of Minnesota Family Medicine/Cmmty

Health

Is Farming a Healthy Occupation?Is Farming a Healthy Occupation?

What does Agriculture include Production agriculture Processing Fisheries Silviculture Greenhouses, nurseries, horticulture Ag-related industries

Veterinary, seed and feed, custom applicating

Grain storage

Agriculture in Wisconsin

Christmas tree planting

Christmas tree planting

Migrant farm worker housing

Amish farmer plowing

Is this practice acceptable?

Changes in Agriculture Fewer but bigger farms Increased animal density More indoor work Less physical exertion Aging farmer owners/principle

operators Farm labor younger, male, non-US

born

Health issues Increased

respiratory disease, arthritis, hearing loss, skin cancer

Migrant health clinic issues-dermatitis, enteric infectious diseases, respiratory, musculoskeletal, diabetes

Decreased generally decreased mortality of all causes tobacco and alcohol-related cancers cardiovascular

Agricultural Health/Safety Issues:higher prevalence Hearing loss Cancer-non-Hodgkin’s lymphoma Injuries Arthritis Respiratory

Asthma/Wheeze Chronic bronchitis

Occupational Conditions Injury

treatment/prevention

Confined spaces Ergonomics Hearing Respiratory

hazards

Toxicology of chemicals/pesticides

Contact dermatitis Zoonoses Tuberculosis in

migrant workers Mental health

conditions

Community/Environmental Health Concerns from Ag Air contamination from gases,

particulates, odors Water contamination

Drinking water Fish kills from eutrophication or major

contamination Nitrates in private wells Antimicrobial resistance

ANIMAL CONFINEMENT ODORS Do they cause health problems? Depression, fatigue, moods

affected Respiratory symptoms of cough No studies with actual dose-

response measurements have been performed

How to approach agricultural health High index of suspicion Obtain occupational/environmental

history Spirometry Audiometry Prevention

Teachable moments Ask about work practices and PPE

Overlapping Clinical Presentations (Viral/bronchitis) Myalgias, fever,

chills, cough, chest pain, headache, shortness of breath

Organic Dust Toxic Syndrome

Silo Unloaders’ Disease

Farmer’s Hypersensitivity Pneumonitis

Organophosphate pesticide poisoning

Ornithosis

Agricultural Respiratory Diseases Organic Dust Toxic Syndrome (ODTS)-molds Hypersensitivity Pneumonitis-organic dust Nondifferentiated

bronchospasm-dusts/gases Asthma-like syndrome

Acute/Chronic Bronchitis-dusts/gases Reactive Airway Dysfunction Syndrome-

strong irritants Occupational Asthma-sensitization

Respiratory Infectious disease Ornithosis (Psittacosis)-poultry Q fever-sheep, placentas-spread

by spores Anthrax-skin form much more

common

Indoor Air Issues-AG Increasing time indoors-40-50 hours Gases and fumes Allergens Dusts and molds

Beta glucans Endotoxins from bacteria-

inflammation

Swine confinement-long building in summer

Long building in winter

Dangerous Gases on Farms All require self-contained breathing

apparatus Carbon monoxide-heaters, pressure wash Hydrogen sulfide-manure pits, lagoons Nitrogen oxides-silos Lack of oxygen

Harvestore silos Manure pits, lagoons

SILO GAS

Silo-Fillers Disease Nitrogen oxides (NOx) gases within hours of

filling for 2 weeks Highest at 4-5 days

Heavier than air Severe respiratory irritant Bleach-like/ Reddish-yellow vapor odor if

high Blowers should be run for 30 min before

entering in first 10 days of filling if gas concentration not monitored and known to be safe

Rescue operation in CAFO or recently filled silo: rescue harness, SCBA

Grain Dust Complex mixture of organic and

inorganic dusts, molds, insect parts, bacteria

Explosive under right conditions Can cause acute and chronic bronchitis Exacerbate asthma Nasal irritation and rhinitis Inflammatory response from endotoxins

Symptoms of Dust/Mold Delayed response of 2-6 hours Cough, chest tightness Malaise, headache, Myalgia, arthralgia, fever Flu-like symptoms

Respiratory Protection Conditions range from simple dust to

oxygen deficient (< 19.5%) and immediately dangerous to life and health (IDLH)

Availability and access of respirators Proper fit testing, use, and

maintenance Emergency SCBA for manure pits,

silos, and other confined spaces

Respirators N-95

Full-face Chemical cartrige respirator

Powered air-purifying Respirator (PAPR)

Self-contained breathing apparatus (SCBA)

4

3

12

15

21

25

0 10 20 30

General Industry

Manufacturing

Transportation

Construction

Agriculture

Mining

Source: 1997 Accident Facts, National Safety CouncilSource: 1997 Accident Facts, National Safety Council

710 deaths, 150,000 disabling injuries710 deaths, 150,000 disabling injuries

Death Rates - by IndustryDeath Rates - by IndustryNumber of Deaths Per 100,000 Number of Deaths Per 100,000 WorkersWorkers

Death Rates - by IndustryDeath Rates - by IndustryNumber of Deaths Per 100,000 Number of Deaths Per 100,000 WorkersWorkers

MN Agricultural Fatalities Highest in agriculture, forestry, fishing

category of all occupational categories 22 fatalities in 2002 98 from 1998-2002

Construction 78 Transportation & public utilities-52

Highest numbers related to highway accidents

MN 2002 Workplace Safety Report July 2004.

http://www.doli.state.mn.us/pdf/saferpt02.pdf

Examples of agricultural deaths 79 yo male enveloped by anhydrous

ammonia expelled from plugged nozzle died of RADS in burn unit

68 yo male died from tractor rollover mowing ditches

16 yo male suffocated in moving grain on family farm

6 yo male died when riding in front end loader bucket

Modern TractorModern Tractor

3-15 tonscrushing injuriesaverage tractor is more than 25 yrs. old

3-15 tonscrushing injuriesaverage tractor is more than 25 yrs. old

1930’s to 1970’s1930’s to 1970’s•high CGhigh CG•narrow front endnarrow front end•no ROPSno ROPS

1970’s and beyond1970’s and beyond•wider base of stabilitywider base of stability•ROPS mandatedROPS mandated•cabs - ergonomicallycabs - ergonomically friendlyfriendly

Newer tractor with ROPS (roll-over protective structure) factory installed

Result when pulling with load hitched too high or going up hill: Almost always fatal

Overturn without ROPSSide overturns most common

Other mechanical Power take-offs (PTO) Rotating shafts Grain augers Corn/bean heads Balers

The Power of a PTOThe Power of a PTO= 100+ hp= 100+ hp

= 1 hp= 1 hp

= .10 hp= .10 hp

•Speed -- 540 rpm is 9 Revolutions per Second! Speed -- 540 rpm is 9 Revolutions per Second!

• Horsepower

Result is OftenResult is Often

FracturesLacerationsSpinal cord injuryAmputation

FracturesLacerationsSpinal cord injuryAmputation

How Does This Injury Compare With One in a Typical Industrial Environment?

How Does This Injury Compare With One in a Typical Industrial Environment?

Mechanical Injuries Fractures, amputations, death PTOs, shafts rotate at 540-1000

RPM 7-12 feet/sec Takes 1 second to release grip

Lack of repair/replacement of damaged parts or after repairs

Farm Machinery Issues Heavy construction makes “Jaws of

Life” rescue equipment insufficient Equipment may still may be running

Who knows how to turn it off? Spilled fuel, hydraulic fluid,

pesticides Sharp knives, crushing rollers, flails

and other dangerous moving equipment pose hazard to rescuers

Issues in Rural Trauma Longer time to discovery and rescue Larger proportion of deaths occur at

the scene Longer time to definitive care Variable trauma experience by

providers Heavy equipment not amenable to

usual extrication techniques

Hydraulic Fluid injection injurySource:FARMEDIC

All ages may be affected

ChildrenChildren

~100 deaths per year

20-25,000 injuries

age-based limitations of kids

see Web page - “Is Your Child Protected…”

~100 deaths per year

20-25,000 injuries

age-based limitations of kids

see Web page - “Is Your Child Protected…”

Hazardous OperationsChildren under 16 Operating tractors over 20 PTO hp Connecting disconnecting above Operating corn picker, grain combine,

hay mower, auger conveyor Working inside grain storage with

oxygen deficient environment Handling agricultural chemicals Transporting anhydrous

Animal injuries-recognizing animal behavior-flight zone

Animal injuries in pediatricsSmith et al. 2004 Clin Pediatr 43(4):335-42

Animals, particularly horses, accounted for a large percentage of farm-related injuries. 41% of admissions to pediatric level 1 trauma

center in Ohio from animal-related injury Included head/maxillo-facial trauma,

deaths Horse-related injuries higher in Amish

children than non-Amish

Repetitive heavy work can lead to back and joint injury

NCCRAHS Year 7 Start Up

Manure pit fatalities 4 fatalities in Minnesota 1992 from 2

incidents 1 Rescuer fatality in each incident

12 deaths in Minnesota since 1994 3 in children less than 6 years of age Most fatalities/incidents occur during

summer months Serial fatalities have occurred in other

states

Occupational health concerns Concentrations are higher during

hot humid summer days May have previously entered during

other weather conditions with no effects

Increased generation of H2S during summer conditions

Less dispersal by winds

2-3” to react, 4-6” trapped at waist, 10-20” engulfed. 800 lbs force to pull up if engulfed at waist level.

Bridging from moldy grain will hide air pockets, collapse and engulf and suffocate

CASE STUDY 6 wk old female

Normal birth, appropriate for gestational age

Began vomiting at 5 weeks Diarrhea, failure to thrive

Bottle-fed Appeared dusky, cachetic

RESIDENCE Rural Wisconsin

Across from dairy farm-80 cattle Sandpoint well-28 feet deep Septic site 50 feet from well Reverse osmosis unit in residence Well water 58 mg/L NO3-N (9.9

mg/L) pH 6.3, corrosivity 16 mg/L

Sources of nitrogen

SOURCES OF NITRATES One of three principle water quality issues

coliforms, toxic chemicals other 2 Feedlots, barnyards, chemical fertilizers,

sewage disposal systems Risks-shallow wells < 35 feet deep up to 95

feet Boiling increases concentration Droughts, after heavy rains 2 SW rural MN counties had 4 x greater

nitrate levels > 10 mg/l than 2 metro counties

PREVENTION Check well for nitrates every several years

if < 5 mg/L, yearly if infant < 6 months or pregnancy or between 6-10 mg/L 10 mg/L NO3-N State HRL, Federal MCL

Reverse osmosis or deionization Proper placement- wells and septic tanks Proper manure storage Appropriate application of manure, fertilizer

Petroleum products Aspiration pneumonitis Contact dermatitis CNS depressant Respiratory irritant

Disinfectants Hypchlorite, iodine, phenols Contact dermatitis Respiratory irritation

Chlorine gas RADS

Classes of Pesticides Organophosphates Carbamates Organochlorines Pyrethrum/Synthetic Pyrethroids Dipyridyl/Chlorphenoxy Herbicides Fungicides Fumigants Disinfectants

Insecticides

Cholinesterase Inhibitors Carbamates Organophosphates

Pyrethrins & Pyrethroids

Organochlorines

Anhydrous ammonia (NH3) Applied under pressure in the soil

in liquid form Hygroscopic-causes burns/freezing

Freezing of tissue, laryngeal edema, corneal burns

Intubation may be necessary-ARDS Later bronchiolitis obliterans, RADS