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