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Public health surveillance is a systematic approach for acquiring information needed for disease and injury prevention in a community or population. Using gathered data, health investigators can analyze the prevalence of specific diseases or injuries, identify epidemics or clusters of diseases and injuries, evaluate the effectiveness of intervention efforts such as enforcement and regulatory acts, and target new problems and research needs. In this manner, public health surveillance can serve as an excellent tool for assessing the needs of a given community or population and mustering resources to meet those needs.
In determining the most important health and safety concerns of hired farm workers, the work group considered data from critical sources such as the NAWS, Workers' Compensation Insurance, and the Hispanic Health and Nutrition Examination Survey (Hispanic HANES). In doing so, the committee members discussed what is known about the health status of farm workers, what is known about the hazards of the agricultural workplace, and what information gaps exist with respect to these two areas. The group concluded its analysis of surveillance system priorities by looking at interventions and which types of interventions can be measured for their effectiveness in improving the health and safety conditions of hired farm workers.
The ten priorities selected as the focus areas for future surveillance systems were developed from a polling process of the work group members. The priorities as well as their subcategories were ranked in order of importance. The decision for the ranking was largely based on current data taken from previous occupational health surveillance projects. The individual subcategories of the ten priorities were then organized into three sub-topics, which were determined by the work group's responses. Accordingly, the priorities for surveillance consist of ten areas ranked by importance each accompanied by a set of subcategories and sub-topics. In certain instances, ideas or comments that did not fall into one of the subcategories were placed at the end of each topic under the heading "further comments." For a complete breakdown of the priorities for surveillance, refer to Appendix B.
The rigorous nature of farm work exposes workers to a number of risk factors that have been associated with musculoskeletal injuries. Heavy lifting, working in awkward positions for a prolonged period of time, and poorly designed tools and implements take an unforgiving toll on the bodies of hired farm workers and make musculoskeletal conditions the most commonly reported health problem. For these reasons, the work group chose this topic as the most important priority for surveillance.
Among musculoskeletal conditions, back problems and upper body injuries are the most prominent. In examining the various back conditions that affect hired farm workers, surveillance needs to accomplish three tasks. First, it must determine the prevalence of such injuries among working hired farm workers. Then, it should explore and implement ergonomic intervention programs including preseason training, better tool design, and a reorganization of work tasks to decrease repetitiveness and awkward postures. Lastly, it is essential that surveillance assess chronic conditions and long-term health outcomes. This can be achieved by investigating the prevalence of back conditions among disabled and retired farm workers.
As for other upper body extremities, surveillance needs to establish the origin of specific health problems. For example, tendonitis among pruners is one relationship that requires further analysis. To solidify these findings, it will be necessary for future hired farm worker health projects to extrapolate comparative data from other non-agricultural industries.
The third notable area concerns the effectiveness of interventions already in place. In this category, physical conditioning, and its usefulness as a preventive measure for preventing early season injuries, ranks the highest. A second issue deals with Workers' Compensation Insurance and changing the system to recognize non-acute health conditions such as Cumulative Trauma Syndrome. This can be done by improving the definitions of health outcomes and educating claims reviewers on the validity of injuries such as tendonitis, Carpal Tunnel Syndrome, and lower back pain. Likewise, clinicians and migrant health practitioners should be given access to published materials that discuss the biological plausibility of farm work-related injuries and illnesses. The other aspect of the Workers' Compensation system that requires review involves the time lag of payments and its effect on the well-being of an injured or ill hired farm worker and his or her family.
The remaining aspects of ergonomics and musculoskeletal conditions focus on specialized themes. These consist of Carpal Tunnel Syndrome, handweeding, poorly designed ergonomic tools like the short-handled hoe, child safety, reproductive outcomes and their relationship with musculoskeletal injuries, early season injuries, and Workers' Compensation Insurance denial of claims for non-acute injuries. In each instance, surveillance needs to assess prevalence and determine the relationship between a specific work exposure and a subsequent set of possible health outcomes. For example, surveillance must first examine handweeding and its association with back injuries and bodily stress and then determine the prevalence of these types of injuries among workers who perform this task. For reproductive outcomes such as miscarriages and premature deliveries, researchers will need to develop new methodology in order to assess their relationship with musculoskeletal injuries and disorders.
In looking at the health risks associated with pesticides, the work group concluded that the three most important areas for investigation and surveillance are exposures, poisonings, and effectiveness of interventions. Regarding exposures and poisonings, the principle objectives are to gather more data on the actual number and type of incidents involving farm workers and to ascertain the level of underreporting. Other significant issues in the surveillance of exposures and poisonings involve pesticide drift and workers training on this type of exposure, child poisonings from contaminated materials brought into the home, exposures from working with high foliage crops, and the clinical characteristics of over-exposure.
With respect to interventions, the primary concern is examining the already existing workplace requirements. The Worker Protection Standard, restricted entry intervals, Personal Protective Equipment (PPE), and worker and employer training fall into this category. Additional topics, which were not ranked, include the removal of pesticides from the market, the availability of laundry facilities and the provision of rehabilitation centers.
The remaining pesticide-related topics pertain to pesticide exposures and their effect on reproductive outcomes, heat stress and personal protective equipment, greenhouse hazards, untrained hired farm workers who work with pesticides and chemicals, and unknown health problems with cholinesterase inhibitors. Under reproductive outcomes, the key concerns are birth defects and miscarriages. For the latter, surveillance will need to develop new monitoring and data collection techniques.
A critical aspect in these remaining topics involves improving the training and education of workers and employers. For example, pesticide drift is a common cause of worker exposure; however, many hired farm workers are unaware of this danger. Consequently, surveillance needs to not only determine the extent of certain kinds of pesticide exposures but also measure worker awareness with respect to these types of work hazards. For some issues like cholinesterase inhibitors, health outcomes such as Parkinson's disease, muscular dystrophy, and other neurological disorders will require extensive surveillance and possibly the creation of new assessment methods.
Due to their frequency and their severity, the work group ranked traumatic injuries such as bone fractures, occupational fatalities, and other types of disabling accidents as the third priority. Among serious injuries, motor vehicle accidents involving the transportation of workers to and from the job-site are the most important topic for surveillance. With respect to those injuries directly associated with the workplace, the committee identified farm machinery, electrocutions, and ladder injuries as the most crucial. A key sub-topic involving all four of these categories pertains to incidence on small farms -- those employing eleven or fewer employers -- where the federal Occupational Safety and Health Administration (OSHA) only has jurisdiction under specific circumstances such as a work-related deaths or if the establishment operates a temporary labor camp.
As with the pesticide and musculoskeletal priorities, Workers' Compensation Insurance was given high priority under traumatic injuries. In this case, surveillance needs to compare coverage for acute conditions with coverage for chronic problems, review the level of compensation for disabling health outcomes, and compare those states that grant farm workers coverage against those that do not.
Other priorities include child safety, interventions, disabled workers, reproductive problems associated with traumatic injuries, personal and societal costs of traumatic injuries, and the lack of rehabilitation facilities for hired farm workers. For children, surveillance efforts should be focused on developing preventive methods such as increased daycare services, assessing the prevalence of traumatic injuries, and analyzing issues such as child labor and living conditions.
For interventions, the main objectives pertain to looking at the effectiveness of programs that offer incentives for improving safety in the workplace and in transportation. From this standpoint, surveillance needs to assess programs like California's open rating with its experienced modification factor which allows farm operators and labor contractors who have lower workers' compensation claims to qualify for reduced insurance premiums.
Under the remaining categories, such as disabled workers, surveillance needs to determine the extent of the problem, develop techniques for monitoring the population concerned, for example binational studies, and address the availability of government agencies and health services, which can offer assistance. In the case of reproductive problems such as miscarriages and their relationship with traumatic injuries, new surveillance procedures must be created.
The variety of exposures that confront hired farm workers and their respiratory systems make upper and lower respiratory conditions a high priority for health surveillance. Pollen, dust, molds, pesticides, and other agricultural chemicals represent just some of the substances that can cause allergies and a wide range of other respiratory conditions. In this category, the top two priorities for surveillance are nursery and greenhouse workers and interventions. As with others health outcomes, investigators need to assess the prevalence of respiratory diseases among nursery and greenhouse workers and then institute new programs to educate migrant clinicians about these kinds of occupational health hazards.
In looking at interventions, the first priority is to examine the impact of a change of environment on a worker's respiratory condition. Similarly, surveillance needs to consider rehabilitation and its influence on a worker's respiratory condition. Lastly, with respect to interventions, surveillance must explore avenues for preventing work-related respiratory illnesses.
The remaining areas of concern under upper and lower respiratory conditions deal with specific crops and work activities. For example, surveillance needs to investigate the relationship between certain respiratory problems and pesticides such as cotton defoliants and sulfur dust, which is used on table grapes; determine the prevalence of such health outcomes; and assess clinician training in recognizing these types of conditions.
In apple thinning, where workers are in frequent contact with pesticide residues, surveillance must look at the prevalence of respiratory illnesses and assess provider awareness of these health problems. Likewise, hops asthma, which is special respiratory concern, must be looked at for prevalence as well as for clinician familiarity with this particular health outcome. Other important priorities for surveillance include analyzing upper respiratory conditions such as rhinitis and conjunctivitis and their respective symptoms on a crop by crop basis, differentiating between allergic and irritative etiology, and examining lung diseases beyond asthma.
Like back conditions, dermatitis is one of the most commonly reported health problems among hired farm workers. Allergic reactions to plants and contact with pesticide residues make up a significant proportion of the cases seen by migrant clinicians and other health practitioners. In this category, dermatitis caused by pesticides, dermatitis caused by plants, and dermatitis among nursery workers are the three most important priorities. Within these three categories, surveillance must analyze the prevalence of the problem, construct methods for improving clinician knowledge, and ascertain which activities are associated most with exposure.
Other topics that require investigation involve special reactions such as Urticaria (hives), effectiveness of interventions, and dermatitis caused by insects. For hives, surveillance needs to assess their prevalence and educate health care providers on the pervasiveness of this health outcome among hired farm workers. Under interventions, surveillance needs to look at changing restricted entry intervals, explore methods for decreasing plant-related dermatitis such as increasing the availability of field sanitation facilities, and develop techniques for measuring the effectiveness of these interventions. With respect to skin problems associated with insects, surveillance needs to analyze a broad set of exposures ranging from mosquito bites to lice and scabies.
A host of communicable diseases such as dysentery and typhoid fever are spread through contaminated water. Furthermore, ingestion of pesticides or other agricultural chemicals frequently occurs through drinking water. From this standpoint, the work group chose contaminated water as the top surveillance priority under water quality. Within this category, examining contaminated drinking water for fecal coliforms, pesticides, fertilizers, and arsenic, in those areas where lead arsenate is used, should constitute the objectives for future surveillance projects.
Additional topics for surveillance involve field sanitation, urinary tract infections, and effectiveness of interventions. Investigation of field sanitation practices must include assessing employer compliance with the Occupational Safety and Health Act's field sanitation regulations and gathering information on worker use of facilities. Surveillance of this particular topic also needs to account for those farm owners and operators who are exempt from the aforementioned law and determine whether employees at these workplaces experience higher levels of sanitation-related diseases.
In a similar manner, urinary tract infections, common among female hired farm workers, are often related to the absence of sanitation facilities, specifically toilets and potable drinking water. For this particular health issue, surveillance must examine its prevalence and consider key topics such as restroom cleanliness and whether workers receive adequate time to use the facilities.
Under effectiveness of interventions, surveillance needs to consider those workplace situations where sanitation facilities are made available. In doing so, it is essential to look at the quality of these facilities and examine whether farm operators and labor contractors keep them in the appropriate condition as required by law. To obtain this type of information, surveillance must conduct surveys of hired farm workers and gather feedback about their individual work experiences. Moreover, it should also review enforcement procedures and document their ability to promote employer compliance with the statutes.
As previously mentioned, many infectious diseases that affect hired farm workers are associated with poor sanitation, particularly contaminated water. In this category, the first duty for surveillance with respect to these types of illnesses is to look at field sanitation-related health problems. The primary concerns are the unavailability and inaccessibility of facilities, heat stress, and urinary tract infections in women.
Outside of the workplace the other area where hired farm workers are susceptible to infectious diseases is their homes. Overcrowding, the absence of indoor plumbing facilities, and poor hygiene all contribute to the spread of communicable illnesses such as tuberculosis. With respect to tuberculosis, surveillance needs to focus on the aspect of overcrowding both in housing situations and in transportation. As for housing, the majority of hired farm workers have little option in choosing an adequate place to live, and thus it is necessary to view this topic as an occupational hazard. As with other occupational hazards surveillance must determine prevalence and look at means of intervention.
The two other important types of infectious diseases are sexually transmitted diseases (STDs) and zoonoses. Regarding the latter, these are sometimes transmitted at the workplace through human contact with animal waste, but more often, contraction occurs through contact with rodents, which often persist in areas with poor sanitation. Here, the key surveillance issue is analyzing the prevalence of zoonotic diseases among hired farm workers and examining their links with working and living conditions.
As for STDs, surveillance needs examine four specific themes: (1) male-only camps, (2) drug and alcohol abuse, (3) homosexual behavior, and (4) prostitution. In addition to these factors, surveillance needs to determine the prevalence of STDs, especially HIV and conclude to what extent the high-risk behaviors of hired farm workers are associated with these health outcomes.
The last two categories under infectious diseases pertain to effectiveness of interventions and the underreporting of communicable diseases. The key assessments for surveillance with respect to interventions involve employer compliance with state and federal laws and the efficacy of regulatory enforcement. Surveillance should also look at the media and review its ability to improve public and hired farm worker awareness of infectious diseases. As for the underreporting of communicable diseases, it is impossible to create means for intervention without having a better idea of the magnitude of these health outcomes. Thus, surveillance needs to determine the degree of underreporting and then develop methods for correcting the problem.
Unlike other illnesses and injuries, much less is known about the prevalence of cancer among hired farm workers. While previous studies have revealed some links between certain agricultural occupations and specific types of cancer, much of the gathered data is inconclusive.
Among the diseases that fall into this category, breast cancer and leukemia are the top two priorities. In these cases, the primary concerns involve establishing their relationship with farm work hazards, such as pesticides, and measuring their prevalence. For breast cancer, surveillance needs to examine its link with estrogenic pesticides and develop measurable methods of intervention. For leukemia, surveillance should review the work of the National Cancer Institute and its population studies.
Due to their frequent involvement with farm work and their living situations, which are often located near agricultural workplaces, the work group selected children as their third priority under cancer. Earlier studies have pointed to the existence of associations between pesticides and deadly childhood cancers such as leukemia and brain cancer. These studies, however, need to be updated with new surveillance. Similarly, the cancer clusters in agricultural areas, such as McFarland, California, are in need of further observation and analysis.
Other important surveillance priorities in the area of cancer involve creating a national descriptive study and looking at skin cancer. With respect to a national study, surveillance should prioritize epidemiological studies and then investigate and establish occupational linkages between specific work exposures and specific types of cancer. For skin cancer, the two objectives must include measuring prevalence and evaluating interventions.
The multitude of exposures ranging from dust to branches to pesticides makes eye conditions a significant health problem for many hired farm workers. Given the fact that most hired farm workers do not utilize health care services, untreated eye injuries frequently manifest themselves into a serious health problem. For example, repetitive eye irritations can develop into chronic inflammations such as blepharitis or conjunctivitis. From this standpoint, surveillance needs to consider chronic eye conditions as its first priority. Within this category, surveillance needs to assess prevalence, examine migrant clinician awareness of these type of health outcomes, and determine methods for prevention that can then be measured for their efficacy.
The second critical area pertains to Workers' Compensation Insurance and its underestimation of work-related eye problems such as chronic conjunctivitis. While it is hypothesized that chronic conditions are often missed by the Workers' Compensation Insurance claims reviewers, surveillance still needs to evaluate the actual prevalence of this problem. Once this has been determined, surveillance needs to see whether health care providers themselves are cognizant of this underestimation of eye conditions.
The last two topics dealing with eye conditions are Pterygia and measuring the effectiveness of interventions. Pterygia, membranous growths that occur on the eyes, is believed to develop as result of chronic irritation from wind and dust. In some cases, the growths can extend over parts of the cornea and obstruct vision. It is thought that this eye condition is often overlooked and that many health providers discount it as a serious problem. Examining the prevalence and provider awareness constitute the key priorities for surveillance of Pterygia. For effectiveness of interventions, the main objectives entail observing the use of protective equipment such as goggles, ultraviolet sunglasses, and hats and whether they result in fewer reported eye conditions.
The strenuous working and living conditions of hired farm workers often lead to various mental health problems. In addition, several studies have demonstrated that toxic chemical exposures can alter mental function and lead to a host of conditions such as depression and cognitive impairments.
In this category, the four priorities include surveys for prevalence, occupational links, stress and its connection with domestic violence, and effectiveness of interventions. Under surveys for prevalence, surveillance needs to look at conditions like depression and pesticide exposure and measure health care provider awareness of these types of outcomes. For occupational links, the overall objective is to examine the relationship between living and working conditions and mental illness. Issues for surveillance include the link between mental health problems and increased occupational injury, lack of money and food and their relationship with severe mental stress, and drug and alcohol abuse.
With respect to stress and its link to domestic violence, it is necessary to measure the prevalence of domestic violence in the hired farm worker community. This can be accomplished by looking at the work of various farm worker women's groups, such as Lideres Campesinas, which have been conducting research and doing peer education since the early nineties. Lastly, surveillance needs to look at provider awareness of domestic violence and develop methods of prevention.
For effectiveness of interventions, surveillance must focus on clinics and hired farm worker access to mental health services. This should include determining whether clinics and migrant clinicians are adequately trained in the area of mental health, whether providers have sufficient resources for treating these health outcomes, and how to make mental health services culturally appropriate and more accessible for hired farm workers.
This document is in the public domain and may be freely copied or reprinted.
NOTE: This document is provided for historical purposes only.
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