National Health Interview Survey (NHIS) Mortality among US Farmers and Pesticide Applicators

1. National Health Interview Survey (NHIS) Mortality among US Farmers and Pesticide Applicators Orlando Gomez-Marin, Fangchao Ma , Lora E. Fleming, David Lee Dept of Epidemiology and Public Health University of Miami School of Medicine Miami, FL

2. Outline • Background • Objectives • Methods • Results • Conclusions • Recommendations

4. Background: Pesticides & Health • Pesticides & Human Health • Acute Disease • Chronic Disease?? • Occupational Exposed Groups • Manufacturers • Farmers • Pesticide Applicators

6. Background: Mortality Risks Farmers & Pesticide Applicators Mortality •  Tobacco & Ethanol Diseases • Cardiovascular disease • COPD •  Accidents •  Neurologic Diseases •  Respiratory & Infectious Diseases

8. Farmers Skin Stomach Brain Prostate Multiple Myeloma Leukemia Pesticide Applicators Skin Stomach Brain Testicular Soft Tissue Sarcoma Non Hodgkins Lymphoma Background:  Cancer Risk

9. Background: Methodologic Issues Farmers & Pesticide Applicators • Healthy Worker Effect • Small sample sizes • Variable populations by geography • Inadequate exposure assessment • Variable exposures

10. 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

11. 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

12. Background National Health Interview Survey (NHIS) • Aggregate Morbidity Data • Cross-Sectional Study & Trend Analysis • Periodic Supplements on subpopulations • Mortality Follow Up through 1995 • Longitudinal Mortality Data • Retrospective Cohort Study

14. Objectives Use the NHIS Mortality Follow Up to Assess Overall & Cause-Specific Mortality • Farmers & Pesticide Applicators vs Other US Workers • Farmers vs Pesticide Applicators

16. Methods National Health Interview Survey (NHIS) • Probability sampling of the US Population • 1986-1994: > 450,000 US workers > 18 yrs • Employment status during the 2 weeks prior to interview for all persons > 18 years • Standardized Occupational & Industry Codes • Farmers and Pesticide Applicators • Morbidity & Mortality (ICD 9) • Acute & Chronic Conditions

17. Methods National Health Interview Survey (NHIS) • Mortality Follow Up through • National Death Index (NDI) linkage • January 1, 1986 through December 31, 1995 • Computerized Linkage algorithm • Match class & score • 97% complete • > 18 yrs

22. Example of Hypothesis Pesticide Applicators & Farmers will have  Prostate Cancer Risk • Sample Size Sufficient • Detect Risk Ratio of 1.54 • At an Alpha level of 0.05, with 90% Power

24. Statistical Methods • Create Database • Exclude: Unemployed, <18 yrs, inadequate data • Link Annual Survey Data & Mortality Follow up (1986-95) • Due to the 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 (Botman1995) • Mortality analyses • Cox Regression models (SUDAAN Proc Survival)

26. Results All Workers • 450,540 persons > 18 yrs • 8304 deaths • 209,908 (46.6%) women • Mean age+SD = 38.9+12.9 years.

27. Farmers N 4783 Deaths 250 Women 798 (16.7%) Mean Age 49.7+15.4 ** Pest. Appltors All Other Workers 4790 440,967 128 7926 946 (19.8%) 208,164 (47.2%) 38.2+14.9** 38.8+12.8** ** p<0.001 Results

28. ResultsOverall and Cause-specific Number of Deaths by Occupation and Gender Pesticide Farmers Other M F M F M F All Deaths 116 12 228 22 5372 2554 Infectious disease 4 0 2 0 316 75 Heart disease 36 6 105 7 1822 716 Respiratory Disease 2 0 8 1 252 131 Nervous System 1 0 1 0 43 24 MVA/Accidents 10 1 18 4 435 138

29. ResultsCancer -specific Number of Deaths by Occupation and Gender Pesticide Farmers Other M F M F M F Overall cancer 41 3 71 9 1713 1131 Nervous system 2 0 2 2 72 35 Digestive 9 0 18 2 460 211 Respiratory 10 0 20 0 294 264 Breast 0 0 0 1 1 263 Prostate 9 -- 8 -- 120 -- Genital 9 1 8 0 122 124 Urinary 0 0 3 0 71 17 Lymphatic& Hematopoietic 3 1 10 2 182 100

30. Results Pesticide Exposed vs Other Age Adjusted RR (95% CI) Disease Male Female Total Overall Mortality 1.0 (0.9-1.1) 0.8 (0.6-1.2) 1.0 (0.9-1.1) Infectious 0.5 (0.2-1.1) * 0.4 (0.2-1.0) Heart 0.9 (0.8-1.2) 1.0 (0.6-1.7) 0.9 (0.8-1.1) Respiratory 0.6 (0.3-1.1) 0.4 (0.1-2.8) 0.5 (0.3-1.0) Nervous System 0.6 (0.2-2.7) * 0.6 (0.1-2.5) MVA/Accidents 1.8 (1.3-2.6) 3.9 (1.6-9.4) 2.0 (1.4-2.8)

31. Results Pesticide Exposed vs Other Age Adjusted RR (95% CI) Disease Male Female Total Overall Cancer 0.9 (0.7-1.1) 0.6 (0.3-1.1) 0.9 (0.7-1.0) Nervous 0.9 (0.3-2.8) 2.8 (0.7-11.4) 1.2 (0.5-2.8) Digestive 0.7 (0.5-1.0) 0.4 (0.1-1.7) 0.7 (0.5-1.0) Respiratory 0.7 (0.5-1.0) * 0.6 (0.4-0.9) Breast * 0.2 (0.1-1.6) * Prostate 1.1 (0.6-2.0) * * Genital 1.1 (0.6-2.0) * 1.3 (0.8-2.2) Urinary 0.8 (0.2-3.2) * 0.7 (0.2-3.0) Lymphatic/Hemato 1.3 (0.7-2.3) 1.6 (0.5-5.2) 1.3 (0.8-2.2)

32. ResultsFarmersvsPesticide Applicators Age Adjusted RR (95% CI) Disease Male Female Total Overall Mortality 0.8 (0.6-1.0) 1.0 (0.5-2.1) 0.8 (0.6-1.0) Infectious 0.3 (0.1-1.2) * 0.3 (0.1-1.2) Heart 1.0 (0.7-1.5) 0.6 (0.2-2.1) 0.9 (0.6-1.4) Respiratory 1.6 (0.3-8.7) * 2.1 (0.4-11.1) Nervous System 0.2 (0.0-3.9) * 0.3 (0.0-4.5) MVA/Accidents 0.8 (0.4-1.9) 2.9 (0.3-31.4) 1.0 (0.5-2.2)

33. Results FarmersvsPesticide Applicators Age Adjusted RR (95% CI) Disease Male Female Total Overall Cancer 0.7 (0.5-1.2) 1.7 (0.5-5.7) 0.8 (0.5-1.2) Nervous 0.9 (0.1-11.4) * 1.5 (0.2-11.3) Digestive 0.8 (0.3-2.1) * 0.9 (0.4-2.3) Respiratory 0.7 (0.3-1.6) * 0.7 (0.3-1.6) Breast * * * Prostate 0.4 (0.1-1.1) -- -- Genital 0.4 (0.1-1.1) * 0.4 (0.1-1.1) Urinary * * * Lymphatic/Hemato 0.9 (0.3-3.5) 1.8 (0.2-14.6) 1.1 (0.3-3.4)

35. Limitations • Healthy worker effect • Lack of individual exposure measures • Confounding • Pesticide exposure • Relatively small numbers of deaths However, use of the US worker pop. as the major comparison population is appropriate for issues of the healthy worker effect and other biases

36. Conclusions NHIS population-based sample of US workers • Farmers & Pesticide Applicators vs Other Workers •  Cardiovascular disease •  Tobacco-related diseases •  Infectious diseases •  Motor vehicles & accidents • FarmersvsPesticide Applicators •  Aging Farmers

37. Conclusions All Pesticide Exposed Workers • Men •  Motor vehicles & accidents •  Lymphocytic/Hematopoietic Cancer • Women •  Motor vehicles & accidents •  Lymphocytic/Hematopoietic Cancer •  Nervous system

38. Conclusions Farmers vs Pesticide Applicators • Age adjustment • Pesticide applicators •  Infectious & Nervous system diseases disease •  Respiratory, Male genital, Prostate cancer mortality • Farmers •  Respiratory disease •  Nervous system cancer mortality • Women Farmers •  Motor vehicles & accidents •  Lymphocytic/Hematopoietic Cancer

40. Recommendations National Health Interview Survey (NHIS):Research Potential • Probability sampling of the US Population • Mortality Follow Up • Pesticide-exposed worker Example • Aggregate Morbidity Data • Supplemental surveys

41. 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 Deep South Agricultural Center (University of South Florida)