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

Outline

• Background

• Objectives

• Methods

• Results

• Conclusions

• Recommendations

Background: Pesticides & Health

• Pesticides & Human Health– Acute Disease– Chronic Disease??

• Occupational Exposed Groups– Manufacturers– Farmers– Pesticide Applicators

Background: Mortality Risks

Farmers & Pesticide Applicators Mortality Tobacco & Ethanol Diseases

– Cardiovascular disease– COPD

Accidents Neurologic Diseases Respiratory & Infectious Diseases

Background: Cancer Risk

Farmers• Skin• Stomach• Brain• Prostate• Multiple Myeloma• Leukemia

Pesticide Applicators• Skin• Stomach• Brain• Testicular • Soft Tissue Sarcoma• Non Hodgkins Lymphoma

Background: Methodologic Issues

Farmers & Pesticide Applicators

• Healthy Worker Effect

• Small sample sizes

• Variable populations by geography

• Inadequate exposure assessment

• Variable exposures

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

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

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

Objectives

Use the NHIS Mortality Follow Up to Assess Overall & Cause-Specific Mortality

• Farmers & Pesticide Applicators vs Other US Workers

• Farmers vs Pesticide Applicators

MethodsNational 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

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

V ariablesIden tification:• N CHS Pe rsonal iden ti fier• B asi c (statistical) we ightD emograph ics:• Gen de r• M on th/Ye ar of B irth• M ain racial back groun d• Hispan ic OriginL ocation:• Geograph ic Re gion• T ype of Res idence (Urb an/ru ral)S ocio-Econ omic• E du cation years com pleted• Fam ily In com eHealth :• Heal th status• Height• We igh t• A ctivity lim itation• Re stri cte d activity• B e d days• D octor vi s its• Hospital s tays• A cute an d Ch ronic con dition s (associated wi th disabil ity days, doctor vi s its an d/or hospitali zation s)Occu pation :• E m ploym ent status in p ast 2 week s• C lass of work er• Occu pation (with recode s)• W ork-loss days in p ast 2 week s• A t work at time of accident/injuryVi tal S tatus:• Pe rsonal Iden tifier for lin kage• Qu ality of m atchin g score• Assum ed Al ive/Dead• M on th/year of death• Un de rlyin g cau se of death• Oth er con ditions

Analytic sample size of employed adults by Ethnicity/Race, Gender and Age Group - NHIS 1986-94

EthnicityStudy Year

FemalesAge Group

MalesAge Group

Total

Total MortalityFollow-up18-44 45-64 65+ Total 18-44 45-64 65+ Total

African-American1986198719881989199019911992199319941986-1994

158631493019276329282770279424912505

24005

544107411291001104310501032908

10008781

53119118118114

87116115105945

218343424266388240853907364235143610

33431

137026182478230923722181231920182054

19719

471927969871885873821746810

7373

6896

10587

114115

857265

671

190936413552326733713169322528362929

27899

409279837818714974567076716763506539

61630

400478187650696473016884692361666353

60063Aleut/Native Amer

1986198719881989199019911992199319941986-1994

87101134111122129147129154

1114

202541483839533756

357

153544535

35

108131178164164172205169215

1506

89132149125153162157139164

1270

344347493948724148

421

423342643

31

127177199177196212235184215

1722

235308377341360384440353430

3228

230300371331352371428345415

3143Cuban-American

1986198719881989199019911992199319941986-1994

559089727879966779

705

112935454739643634

340

165447

1032

42

67125129121129125170106115

1087

599593897771

1338185

783

335452406146

1052635

452

688

1137976

65

98157153140141124247114126

1300

165282282261270249417220241

2387

165278279254266242409210238

2341

Analytic sample size of employed adults by Ethnicity/Race, Gender and Age Group - NHIS 1986-94

EthnicityStudy Year

FemalesAge Group

MalesAge Group

Total

Total MortalityFollow-up18-44 45-64 65+ Total 18-44 45-64 65+ Total

African-American1986198719881989199019911992199319941986-1994

158631493019276329282770279424912505

24005

544107411291001104310501032908

10008781

53119118118114

87116115105945

218343424266388240853907364235143610

33431

137026182478230923722181231920182054

19719

471927969871885873821746810

7373

6896

10587

114115

857265

671

190936413552326733713169322528362929

27899

409279837818714974567076716763506539

61630

400478187650696473016884692361666353

60063Aleut/Native Amer

1986198719881989199019911992199319941986-1994

87101134111122129147129154

1114

202541483839533756

357

153544535

35

108131178164164172205169215

1506

89132149125153162157139164

1270

344347493948724148

421

423342643

31

127177199177196212235184215

1722

235308377341360384440353430

3228

230300371331352371428345415

3143Cuban-American

1986198719881989199019911992199319941986-1994

559089727879966779

705

112935454739643634

340

165447

1032

42

67125129121129125170106115

1087

599593897771

1338185

783

335452406146

1052635

452

688

1137976

65

98157153140141124247114126

1300

165282282261270249417220241

2387

165278279254266242409210238

2341

Number of Deaths and Person-Years Among Employed Adults by Ethnicity/Race/Gender - NHIS 1986-94

Deaths Person-Years*

EthnicityStudy Year

Females Males Total Females Males Total

African-American1986198719881989199019911992199319941986-1994

76125101

806838321614

550

138221167123129

77562912

952

214346268203197115884526

1502

19907357293097024351217541687313201

85075247

176539

1727829523254782032617860135591083767904246

145897

3718665252564474467739614304322403915298

9493322437

Aleut/Eskimo/Native Amer1986198719881989199019911992199319941986-1994

565230022

25

6137555232

48

111912785254

73

990106712931024875716698405306

7374

11561429144110921044

871803450314

8598

2146249727342116191915861501855619

15972Cuban-American

1986198719881989199019911992199319941986-1994

2021111109

688620702

39

88

10731812

48

6291045954750686256572249165

5305

90512851107

874762227831266180

6436

15342329206116241448483

1403515345

11741

Total Number of Employed Adults, Deaths and Person-Years by Occupation and Gender - NHIS 1986-94

Number Deaths Person-Years*

Occupation Female Male Total Female Male Total Female Male TotalExecutive, Administrative and Managerial 26408 37135 63543 264 854 1118 132231 191749 323981

Professional Specialty 35187 30930 66117 301 539 840 176917 157699 334615

Technicians and Related Support 8138 8109 16247 59 122 181 41250 40706 81956

Sales 26913 26386 53299 293 660 953 139308 134321 273629

Administrative Support, Including Clerical 58277 14735 73012 630 356 986 305104 75432 380536

Private Household 3347 157 3504 112 7 119 18134 860 18994

Protective Service 1299 6602 7901 15 173 188 6416 33323 39738

Service , Except Protective and Household 34343 16879 51222 542 483 1025 177430 85632 263062

Farming, Forestry and Fishing 2406 11399 13805 43 455 498 12691 59325 72016

Precision Production, Craft and Repair 4993 47968 52960 61 1039 1100 26322 252676 278997

Machine Operators, Assemblers and Inspectors 13982 19595 33577 201 419 620 75702 102775 178477

Transportation and Material Moving 1989 18154 20143 26 512 538 10156 94403 104559

Handlers, Equipment Cleaners, Helpers and Laborers 3693 14279 17972 41 315 356 19198 74530 93727

Unknown (includes New Workers) 6696 6627 13323 152 170 322 26169 23713 49882

Military 23 107 130 0 1 1 138 635 772

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

S a m p le S ize o f Pesticide Applicators, d e a th s a n d p e rso n-y e a rs , b y G en d e r a n d S tu d y Y e ar - N H IS 1 9 86 -9 4

N um be r D e a ths P e rso n-Ye a rs *

S tu dyYe a r

F e m a le s M a le s T o ta l F e m a le s M a le s T o ta l F e m a le s M a le s T o ta l

P e s tic ideA p p lic a tio n

1 9 8 61 9 8 71 9 8 81 9 8 91 9 9 01 9 9 11 9 9 21 9 9 31 9 9 41 9 8 6-1 9 94

1 3 82 6 22 5 62 1 82 1 02 0 32 5 61 9 11 9 2

1 9 2 6

6 091 1 0 41 0 8 21 0 1 69 399 12

1 0 4 47 538 18

8 2 7 7

7 4 71 3 661 3 381 2 341 1 491 1 151 3 009 4 41 0 101 0 20 3

657464300

3 5

5 19 15 34 23 73 33 81 2

43 6 1

5 79 66 04 64 33 74 11 2

43 9 6

1 2 712 1 361 8 571 4 041 1 21

8 748 764 682 74

10 2 81

5 39 08 87 37 79 06 36 45 01 03 96 33 55 71 84 41 20 9

4 4 00 1

66 6 01 10 0 996 4 777 6 961 3 148 3 744 3 423 1 214 8 3

5 42 8 2

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)

Results

All Workers

• 450,540 persons > 18 yrs

• 8304 deaths

• 209,908 (46.6%) women

• Mean age+SD = 38.9+12.9 years.

Results

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

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

Results Cancer -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

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)

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)

ResultsFarmers vs Pesticide 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)

Results Farmers vs Pesticide 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)

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

Conclusions

NHIS population-based sample of US workers

• Farmers & Pesticide Applicators vs Other Workers Cardiovascular disease Tobacco-related diseases Infectious diseases Motor vehicles & accidents

• Farmers vs Pesticide Applicators Aging Farmers

Conclusions

All Pesticide Exposed Workers

• Men Motor vehicles & accidents Lymphocytic/Hematopoietic Cancer

• Women Motor vehicles & accidents Lymphocytic/Hematopoietic Cancer Nervous system

ConclusionsFarmers 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

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

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)