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OBJECTIVE: We sought to test whether a 2-week Total Worker Health (TWH) training mapped to TWH education competencies could be administered to a Mexican audience of occupational safety and health professionals and could lead to positive changes to knowledge and behaviors. METHODS: This study used robust program evaluation methods collected before and after each of the nine training days and at the end of the course. RESULTS: Overall course quality received a mean score of 4.6 (SD = 0.6) and 98.8% of participants agreed that their TWH knowledge increased. All participants intended to make at least one change to their professional practice, most frequently helping companies assess their organizational culture to support health, safety, and well-being. CONCLUSIONS: This TWH training was well received and led to positive self-reported increase in knowledge and abilities to influence workers' health, safety, and well-being.

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OBJECTIVE: Agricultural workers worldwide exposed to heat stress could be at the risk of kidney injury, which could lead to chronic kidney disease of an unknown origin (CKDu). Hydration has been promoted as a key measure to reduce kidney injury. In the presence of a hydration intervention, the incidence of acute kidney injury (AKI) was calculated in a sugarcane worker population in Guatemala and several risk factors were evaluated. METHODS: We measured kidney function at the beginning and end of the work shift at three time points in 517 sugarcane workers. We defined AKI as an increase in serum creatinine of 26.5 µmol/L or 50% or more from the pre-shift value. Associations between AKI and risk factors were examined, including interactions with hydration status. RESULTS: The prevalence of dehydration post-shift (> 1.020 specific gravity) was 11% in February, 9% in March, and 6% in April. Cumulative incidence of AKI was 53% in February, 54% in March, and 51% in April. AKI was associated with increasing post-shift specific gravity, a dehydration marker, (OR 1.24, 95% CI 1.02-1.52) and with lower electrolyte solution intake (OR 0.94, 95% CI 0.89-0.99). CONCLUSIONS: Dehydration and insufficient electrolyte consumption are risk factors for AKI. However even well-hydrated sugarcane workers routinely experience AKI. While hydration is important and protective, there is a need to understand other contributors to risk of AKI and identify prevention strategies with these workers.

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OBJECTIVE: Identify early biomarkers and mechanisms of acute kidney injury in workers at risk of developing chronic kidney disease of unknown origin (CKDu). METHODS: We assessed cross-shift changes in kidney function and biomarkers of injury in 105 healthy sugarcane workers. We obtained pre-harvest clinical data as well as daily environmental, clinical, and productivity data for each worker. RESULTS: The average percent decline in cross-shift estimated glomerular filtration rate (eGFR) was 21.8% (standard deviation [SD] 13.6%). Increasing wet bulb globe temperature (WBGT), high uric acid, decreased urine pH, urinary leukocyte esterase, and serum hyperosmolality were risk factors for decline in kidney function. CONCLUSIONS: Sugarcane workers with normal kidney function experience recurrent subclinical kidney injury, associated with elevations in biomarkers of injury that suggest exposure to high temperatures and extreme physical demands.

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BACKGROUND: Climate change has implications for human health and productivity. Models suggest that heat extremes affect worker health, reduce labor capacity, and commodity supply. Chronic health conditions are on the rise internationally. However there is a paucity of direct empirical evidence relating increasing temperatures to both agricultural worker health and productivity. METHODS AND FINDINGS: We evaluated the relationship between temperature exposure, kidney function, and two measures of productivity-tons of commodity produced and job attrition, of 4,095 Guatemalan sugarcane cutters over a 6-month harvest. We used distributed lag non-linear models to evaluate associations between wet bulb globe temperature (WBGT) and productivity of workers with normal or impaired kidney function. The cumulative effect of exposure to a max WBGT of 34°C was 1.16 tons (95% CI: -2.87, 0.54) less sugarcane cut over the next five days by workers with impaired kidney function, compared to exposure to 29°C. Impaired kidney function was associated with premature workforce attrition. Workers starting the harvest season with impaired kidney function were more than twice as likely to leave employment (HR: 2.92, 95% CI: 1.88, 4.32). CONCLUSIONS: Heat extremes may be associated with loss of agricultural worker productivity and employment, especially among those with impaired kidney function. Agricultural workers who develop health conditions, such as kidney disease, are particularly vulnerable in the face of climate change and increasing heat extremes. The resultant loss of employment and productivity has significant implications for global commodity supplies.

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OBJECTIVE: Acute kidney injury (AKI) occurs at high rates among agricultural workers (12-33%) in tropical environments. Because of the remote locations affected, traditional laboratory services are often unavailable. In this study we compare point of care (POC) creatinine values to standardized laboratory values, and examine the effect of POC testing on the interpretation of AKI rates under tropical field conditions. METHODS: Blood samples were collected from 104 sugarcane workers from two time points in January 2018 as a derivation cohort, and from 105 workers from February to April 2017 as a validation cohort. Finger stick and venipuncture samples were drawn at the end of a worker's shift to measure creatinine. Laboratory samples were tested in Guatemala City, Guatemala, in duplicate using the Jaffe Generation 2 method. An adjustment factor to improve agreement with serum creatinine was statistically derived and validated, and then used to determine impact on observed rates of acute kidney injury based on across shift changes in creatinine. RESULTS: POC creatinine and serum creatinine measures showed that POC consistently overestimated the creatinine by an average of 22% (95% CI: 19.8%, 24.7%) and the disagreement appeared greater at higher values of serum creatinine. An adjustment factor of 0.7775 was applied, which led to significantly greater agreement between the two measures. Rates of AKI in the two combined groups fell from 72% before adjustment to 57% afterwards. CONCLUSIONS: POC testing under tropical field conditions routinely overestimates creatinine compared to laboratory testing, which leads to overestimation of rates of acute kidney injury. The application of an adjustment factor significantly improved the accuracy of the POC value.

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OBJECTIVES: To characterize kidney function of sugarcane workers in Guatemala over the 6-month harvest and identify risk factors associated with changes in kidney function. METHODS: Demographic and biological data were collected for 330 sugarcane cutters at the beginning and end of the harvest. Multivariable regression analyses were used to assess factors related to kidney function. RESULTS: A decline in kidney function across the harvest was observed in 36% of the participants. Risk factors associated with this decline included working at a particular plantation mill, local area workers compared with highland workers, and current smokers. CONCLUSION: Results showed both occupational and behavioral factors play significant roles in declines in kidney function. These results underline the need for a comprehensive approach to the epidemic as well as further investigation of risk factors to guide research and interventions.

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