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    Heat Stress and Cardiac Strain in French Vineyard Workers 2021

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    Sergio Duarte

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    Annals of Work Exposures and Health, 2021, 380-396 oi: 10.1088/annweh/wxaat 1S BC ‘Advance Access publication 26 December 2020 4 Original Article ah Ferecion OXFORD Original Article Heat Stress and Cardiac Strain in French Vineyard Workers Sonia Grimbuhler"* and Jean-Francois Viel?” ‘TAP, University of Montpellier, INRAE, Institut Agro, F-34000 Montpellier, France; “Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, F-35000 Rennes, France * Author to whom correspondence should be addressed. e-mail: sonia grimbuler@inrae.fr ‘Submit 1 June 220; revised 20 October 202; edtrial decison 26 Ceteber 2020; revised version accepted 2 November 2020, Abstract Agricultural workers often produce considerable excess heat due to the physically demanding na- ture of their activities, increasing their risk of thermal stress in even moderately warm conditions. Few studies have examined the physiological responses to heat load in agriculture. We aimed to as- sess the heat strain experienced by vineyard workers during canopy management in dry field con tions, and to disentangle the effects of the heat produced by the body and the thermal environment. Thirty workers from five Bordeaux vineyards of southern France were monitored during vine-lifting and trellising (June 2012). The mean heart rate, net cardiac cost, relative cardiac cost, and cardiac workload score were assessed during field activity. As the workers were nested within vineyards, multilevel linear regression models were used for correct inference. Skin temperature increased by an average of 1.0°C. Cardiac indices showed marked differences between individuals. The workload was evaluated as ‘heavy’ or ‘very heavy’ for more than one-third of the workers, of whom one ex- perienced heat exhaustion. Above some individual characteristics, we highlighted a contextual effect (air temperature) for the mean heart rate (P = 0.03), the relative cardiac cost (P= 0.01) and, to a lesser extent, a cardiac workload score (P = 0.07). Canopy management by hand in vineyards causes con- siderable cardiac and thermoregulatory strain. Appropriate instruments should be developed to sim- ultaneously evaluate work intensity, work quality, and productivity at the vineyard level to raise the awareness of both managers and employees about taking preventive measures. Keywords: agriculture; cardiac strain; heat stress; vineyard workers Introduction physically demanding nature of their activities, agricul tural workers often produce considerable excess heat, increasing their risk of thermal stress in even moder- ately warm conditions. Moreover, many activities in this Heat exposute is common among workers in the agricul- cure sector because most tasks are performed outdoors, where the climate cannot be controlled. Because of the ‘© The Authr(s 200, Published by Oxford Un i Presson behalf ofthe British Occupatonal Hygiene Society. jo|wiapeDey/:sdyy Woy pepeolUMOG ee puetbug men Jo Le0z Aew o€ wo 10% Annals of Work Exposures and Health, 2021, Vol. 65, No. 4 391 What's important about this paper Agricultural workers can produce excess heat because of the physical demands of their work, putting them at risk of thermal stress even in moderately warm conditions. Among vineyard workers, cardiac strain during canopy management tasks varied widely between individuals, with more than one-third of workers studied experiencing heavy or very heavy workload. Dry-bulb temperature and task duration were associated with cardiac strain. Hoat strass can be prevented among vinoyard and other agricultural workers, sector (especially pesticide spraying) require personal protective equipment (PPE), reducing the body's ability to dissipate heat by hampering the exchange of heat with the environment (Staal Wasterlund, 2018), Changes in the body's core temperature can alter the absorption, distribution, metabolism, and excretion of chemicals. Heat stress, with or without exercise, ac tivates thermo-effectors (e.g. skin blood flow, sweating, respiration), which, in turn, lead to more efficient trans- cutaneous absorption of pesticides im humans (Gordon and Leon, 2005). Increases in respiration can lead to fuether toxicant exposure through inhalation, as high temperatures accelerate dispersion and increase the con: centration of airborne particles (Gordon, 2003; Leon, 2008). Many heat-stress indices, such as the wet-bulb globe temperature (WBGT) index and predicted heat strain (PHS), have been developed to establish work conditions that reduce the risk of heat-related illnesses. However, the WBGT index and the PITS method were both de- veloped to determine the risk of heat stress in places where people work for extended periods in normal work clothing (Parsons, 2013). These indices cannot, there fore, be used in work situations in which the person is required to wear protective clothing, the thermal con: ditions rapidly change, or people who are not phy ically fit perform the work (Staal Wasterlund, 2018). Under such circumstances, physiological measurements (such as mean skin temperature and/or heart rate [FIR]} (1509886, 2004) provide very good insight into the ex- tent of heat strain experienced by a subject (NIOSH, 2016). Although ergonomic and physiological studies have long investigated the risks associated with activities con- ducted in hot environments (Parsons, 2000; Crandall and Gonzilez-Alonso, 2010), few studies have examined the physiological responses to the heat load in agricul- ture (Costa et al, 1989; Nigg et al., 1992; Singh et al., 2011; Sahu et al., 2013; Mitchell et al., 2017, 2018; Wagoner et al., 2020). Even less is known about the physiological cost in vineyard farming activities. We re- cently compared the physiological burden of vineyard workers wearing three different types of PPE in humid field conditions (Grimbubler and Viel, 2018). Here, we took advantage of this experience to further assess heat strain experienced by vineyard workers during canopy management in dry field conditions, and to disentangle the effects of the heat produced by the body and the thermal environment. Methods Study area and population The study population has been fully described clse~ where (Grimbubler and Viel, 2018). Briefly, the stady took place during the 2012 pesticide treatment season (19 June to 27 June) in seven Bordeaux vineyards of southern France, A total of 42 workers (six per vineyard) accepted to participate and provided written informed consent. Canopy management consisted of lifting (raising the fruit-bearing shoots from the ground and at taching them vertically to wires running above the vine) and trellising (separating the shoots from each other and stapling them to overhead wires), Trellis height ranged. from 1.50 to 2.10 m, depending on the vineyard. Each worker's practice was observed throughout hisfher task by a field staff member. Sociodemographic characteristics, potential determinants of physiological strain, and task-related factors were collected using a structured questionnaire. Subjects also provided sub- jective evaluations. Participants and environmental conditions Vineyard workers were paid by salary rather than by the line of work completed in the field. On arrival at the vineyard, pairs of workers were assigned a number of rows by the supervisor, depending on the wea. ther conditions, the trellising system, the vine vigor, etc, Partners worked each side of the vines, keeping pace with each other, one slightly ahead to make trellising easier, and reduce the risk of injury. At the end of the row, the quickest pairs looked down the rows and helped the slowest pairs get the job done. This group cohesiveness fostered homogencous work speed. Depending on how long the rows were, workers fepuoo-dno'quiopeoe /'sdiy Woy pepeouMog, 1202 AeW of uo s0sn puelBua MON Jo AysrOAUN fq ¥sZ0S0sI06E%H! 392 Annals of Work Exposures and Health, 2021, Vol. 65, No. 4 Table 1. General conditions of the vine-tifting task in dry conditions (Bordeaux vineyards, southern France, June 2012} (extended from Grimbuhler and Viel, 2018), Estate 1 Entate2 Enate 3 Enate 4 Estate 5 Vine-growing area Entre-deux-Mers Entre-deux-Mers ‘Medoe Graves Blayais Date June 20 Jone 21 June 22 June 25 June 27 Starting time (bhsmm) 1340 1420 B33 1428 1030 “Task duration (ma) 46 wa 88 38 100 Dary-bull emperatuce (°C) 312 263, 282 304 30.5 Relative humidity (%) 32 48 39 2 5 Wind speed (mvs 1330 1259 18-47 00-09 6-18 usually took a one/two-minute break for hydration be- fore moving on to another row. Participants were first observed working during hhumid conditions (corresponding to dewy or damp con- ditions or even a short episode of rainfall). After this re-entry task, which lasted between 71 and 120 min, depending on the vineyard, they took a snack break or had lunch. Upon retusa from the break, the researchers and workers decided consensually whether the envi- ‘onmental conditions had changed from humid to dey, based on canopy appearance and field relative humidity (<60%). As a result, a dry context was acknowledged for five of the seven vineyards, eaving 30 of the 42 ini tial workers for consideration in the present study (12 workers from the other 2 vineyards being removed be- cause of on-going humid conditions. According to the guidance document from European Food Safety Authority (EESA) on the as- sessment of operator, worker, resident, and bystander exposure, PPE is required for re-entry tasks (such as canopy management) (EFSA, 2014). So, the 30 re- maining workers donned a Costal aluminum gar- ment (Brisa®), composed of a shirt and long pants {ovith aluminized leggings) made of poly-cotton blend (35%/65%). Additional gear items were a cotton cap, Mapa Ultrane 553 protective gloves (composed of poly: amide and seamless textile liner with palm and fingers covered with nitrile), and rubber boots. For undergar- ments, al subjects wore identical disposable two-piece Jong johns (100% cotton). The work was self-paced, al- owing workers to adapt their workload to the body's production of heat and its capacity to exchange heat with the surroundings. The outdoor dry-bulb temperature ranged from 26.3 co 31.2°C and relative humidity ranged from 39 10 54% across field sites (Table 1). In two estates (n°2 and 5), changes in wind speed (up to 5.9 and 4.7 mis, respectively) were observed, which are typical during this season, Assessment of physiological cost Skin temperature was measured with a Proges Plus® 22L thermo-button (with an accuracy of 20.1°C) placed against the skin of the tibia (just above the ankle) of each worker. Measurements were recorded once per minute throughout the task, The skin temperature was assessed, at rest before starting vine-lfting and the mean skin tem- perature was calculated during work. All workers were fitted with a Polar® RS800 HR. 1 before putting on their poly-cotton garment. I included an adjustable chest strap equipped with a heartbeat detector and a wrist receiver that displayed and recorded the HR transmitted at 5-s intervals Resting HR (HR,,,) was estimated through the first per- centile value of the HR recording (i.e. when vineyard workers resumed work after their snack or lunch break} (Malchaite et al, 1986). The net cardiac cost (NCC) rep: resented the difference between the mean HR (HR,__.) and HR,.,. The theoretical maximum HR (TMHR) was defined by the Gellish formula (207 ~ 0.7 x age) (Gellish ‘ef al., 2007). Heart rate reserve (HIRR} was the differ- cence between the TMHIR and HR,,,. The relative cardiac cost (RCC) expressed the NCC as a percentage of the HRR (NCCIHRR). A cardiac workload score was ealeu- lated according to Meunier et al, (1994). This summed composite index is based on the HR,,.,, RCC, and 99th, percentile of the HR (HR99) and ranges from 1 to 15. ‘This quantitative score was then transformed into a five level classification of work intensity (1-3: light; 4-6: moderate; 7-9: rather heavys 10-12: heavys 13-15: very heavy} (Meunier et al, 1994) Statistical analyses The following data were considered at the worker-level age (yeas), gender (male/female), body mass index (BMI, kg/m), experience in vine-lifting years), hand. edness (left-handed, right-handed), skin temperature at rest (°C), mean skin temperature during work (°C), and cardiac strain indices (mean HR, bpm; NCC, bpm; fepuoo-dno'quiopeoe /'sdiy Woy pepeouMog, 1202 AeW of uo s0sn puelBua MON Jo AysrOAUN fq ¥sZ0S0sI06E%H! Annals of Work Exposures and Health, 2021, Vol. 65, No. 4 393 Rt worker lost her thermos-button, the missing tempera- ture values were replaced by the modal values from remaining participants. Additional information was col- lected at the vineyard-level: task duration, air tempera~ ture, and relative humidity ‘When considering heat-stress, two dimensions must be taken into consideration: the amount of heat pro- duced (depending on the individual physiological char acteristics and workload) and the thermal environment of the worker (which determines the possibilities for heat dissipation). In an attempt to disentangle the effects of these two dimensions, we drew upon the hierarchical structure of the data for analysis as the workers were 6; cardiac workload score, unitless). Because one nested within vineyards, Associations between various physiological indices (dependent variables) and various risk factors (defined at either the worker or vineyard- level) were examined using multilevel linear regres sion models. After carefal review of the literature, four individual-level covariates (age, gender, BMI, and experi- cence in vine-lifting) were forced into the models, as well as the task duration and the air temperature (vineyard- level covariates). The remaining covariates were intro- duced into the models provided they were associated with the physiological index under study (P < 0.20) Al analyses were performed using MLwiN software version 2.24 (Centre for Multilevel Modelling, Bristol University, UK) Results Description of the population Ages ranged from 21 to 59 years with a median of 39 years. Most of the workers involved in the study were female (19 of 30 workers) (Table 2). According to their BMI, 33% of the workers could be considered ‘overweight and 10% were obese. Experience in vineyard lifting ranged from zero to more than 40 years. Most workers were right-hand dominant (90%). No worker reported current use of medications that could have con- tributed to the early onset of heat stress. Physiological costs and work intensity Physiological characteristics are reported in Table 3. During canopy management, skin temperature increased by an average of 1.0°C (from 33.9 to 34.9°C). In terms of the average cardiac indices, the mean HR was 113.5 beats per mn (bpm), the mean NCC was 24.1 bpm, the mean RCC was 23.1%, and the mean cardiac workload score was 8.8. When transforming the latter into the five-level classification, the workload associated with canopy Table 2. Characteristics of vineyard workers (n= 30, number [percentage], Bordeaux vineyards, southern France, June 2012) {extended from Grimbuhler and Viel, 2018). ‘Age (years) 30 6 (0.20) 3039 10 0.33) 40-49 540.17) 250 9 (0.30) Gender Female 19 (0.63 Male 11 (0337 Body mass index (kg/m) 2s 70s 25-299 10 (0.33 230 310.10 [Experience inthe vine lifting task (years) Ss 540.17) 53 510.26 10-14 7 (0.3) 15-19 240.07) 20-04 340.10 22s 5 (0.17) Handedness Left-handed 3 (10.0 Right-handed 2719010 ‘management was evaluated as heavy’ ot ‘very heavy’ for more than one-third of the workers (10 of 28). Among. the five individuals facing a very heavy workload, a woman (aged 50, TMHR of 172 bpm, NCC of 63 bpm, RCC of 87%) experienced heat exhaustion. Alerted by apparent weakness and possible giddiness, the field ‘monitor checked her cardiac frequency displayed on the ‘wrist-unit (195 bpm) and immediately interrupted her job (17 min before the other 5 workers of Estate 5). The worker was then moved to a cool environment for rest and provided with fluids to drink. Risk factors for physiological costs Risk factors for physiological strain of workers ap. pear in Table 4. Independent variables were iden- tical whatever the physiological index considered, as, no remaining covariate was associated at P < 0.20. Regarding the worker-level variables, age was not sig- nificant for any outcome, Male gender was associated with the mean skin temperature at rest (P < 10"), as swell as BMI (P = 0.02). Experience in vine-lifting was significantly linked to the mean skin temperature during, work (P = 0.01), and near-significantly with the NC fepuoo-dno'quiopeoe /'sdiy Woy pepeouMog, 1202 AeW of uo s0sn puelBua MON Jo AysrOAUN fq ¥sZ0S0sI06E%H! 394 Annals of Work Exposures and Health, 2021, Vol. 65, No. 4 Table 3. Physiological strain of workers (n= 30, Bordeaux vineyards, Southern France, June 2012). Mean Standard deviation Minimum ‘Maximam ‘Skin temperature at 6st (°C) 338) 7 37 358 ‘Mean skin temperature during work (°C) 34g) Lo 3234 36.1 ‘Mea heart rate (bpm) 13s 173 787 65.3, et eardiae cost (bpm) 241 BB 7 o7 Relative cardiac cost 231 Bs 10.1 872 Cardiac workload score (untless} 38 33 20 150 * casas pa es wee xing for wo wera beet of denon he adit Table 4, Risk factors for physiological strain of workers (n= 30, multilevel regression model, beta coefficient [standard deviation], Bordeaux vineyards, Southern France, June 2012), skin Meanskin -Meanheart ——-Netcardac ‘Relative cardiac Cardin workload temperatre ——temperatere ate open) cont hp) fost (%) score (ani atest’) during work ‘Workerleel variables Age ear) -0.006 0018 ona 0296 0.408 010 (0097,0035) — 0.087,0011) (-0.538..822) (-0.212,0.804) (0.106094) (-0.099.0:159) Gender ale) 0.250 Laer -0.605 asad 37 0570 (0514, 1014) fon2,t972) (1288411674) ISSIT4825) SASL IDI) (2,897,198 Body mas inde kh) one uss “018 -0912 oases “0.136 (0.020,0.208) —(-000300.100) (1. 736,1.412) (21560192) (0.708 L.684) _(-04340.162) Experience in 2.000 038 aos -oare* 0.332 010 ne iting pea) (00430043) — (90090.067 —(-0.6160.792) |-2.001,0049) (-0865,0201) (-0123,0.43 Vineyard-ee viable Tad ration (mn) -0.010 0097 one eas ons (-0.036,0.006) (048.0382) 64.0300) 0.083, 0.405) (-0.081,0.065 Deybulbuemperatre °C) 0.132 4088 2040 3.682 a6 (-0359,0095) (0,100,018) (0482,7.726) 1-0.6794.758) (0.88, 6.416) (-0.046,.534) + Cardiovasc paramere were ming foro workers ects of elancion fhe aroma "P6095, (P = 0.08). Regarding the vineyard-level variables, the task duration was significantly associated with the RCC (P = 0.02), Finally, a significant link was found between the air temperature and both the mean HR (P = 0.03), and the RCC (P = 0.01), while the link with the car- dine workload score was of borderline significance (P =0.07). Discussion ‘This study shows that the cardiac strain recorded during canopy management varied greatly between individ: uals. One-third of vineyard workers were heat-stressed to nearly critical physiological levels (heavy or very heavy workload), with one worker experiencing heat exhaustion, Above some individual characteristics, we highlighted a contextual effect (air temperature) for three cardiac indices (mean HR, RC extent cardiac workload score) ‘his study had three main strengths. First, the im. pact of heat on people performing routine agricultural activities has been little studied. Work conditions and practices were representative of the conditions typically ‘encountered during hand canopy management in vine yards. Second, temperature and HR monitoring pro- Vided a more objective measurement of the physiological reactions and intensity of the effort of vineyard workers than the use of perceived discomfort (such as the Borg scale of perceived exertion), which is generally deter ‘mined by a combination of physiological, psychological, and physical factors. Third, we used a sound statistical methodology, as the potential correlation of the data jo|wiapeDey/:sdyy Woy pepeolUMOG ee puetbug men Jo Le0z Aew o€ wo 10% Annals of Work Exposures and Health, 2021, Vol. 65, No. 4 395 within vineyards was accounted for by the two-level re- sression models for correct inference, Our study also had a few limitations. First, the sample size (30 workers) was modest, although the stat- istical power was sufficient to highlight a contextual effect (air temperature) above some individual charac teristics. Second, we were well aware of the ISO 9886 4-point method used in hot conditions for estimating mean skin temperature (1809886, 2004). However, only ‘one thermo-button was placed against the skin of the tibia (one of the four recommended sites together with neck, right scapula, and left hand) to ensure worker acceptance and avoid interfering with the demanding canopy management task, Although a distinction has to be made between local skin temperature measured at a specific point on the body surface and mean skin temperature measured over the entire body surface, comparisons across workers were appropriate as skin, temperature was measured at the same anatomical site. ‘Third, environmental heat was only measured as dry bulb temperature and aot WBGT (as no black bloc thermometer was available in the field), although the WEGT is used in many heat-stress alert limits to pro- tect most healthy workers. However, the Outdoor Heat Exposure Rule from the Washington State Department of Labor and Industries can be a useful standard for our study (NIOSH, 2016). It is applicable to employees per forming work in an outdoor environment during sum- rmertime. For those wearing double-layer woven clothes (c.g. coveralls, jackets, and sweatshiets) it applies to tem: peratures at or above 25°C, According to this alert limi, cour study clearly took place under heat-steess conditions However, the absence of a black bloc sensor precluded the measurement of the mean radiant temperature al- though solar radiant load is known to contribute to heat stress. Forth, the hydration status could unfortunately not be measured. We did not monitor the consumption of fluids because our main concern was to minimize the effect of our study on the regular work, most workers reported drinking before coming to work, and task dur- ation (increasing fluid intake) varied between vineyards. Moreover, for cultural and practical reasons, managers were reluctant to facilitate urine collection (to measure specific gravity or osmolality) or weight monitoring (be- fore and after the shift) The difficulty of accurately determining which workers are most at risk of excessive occupational heat exposure is that heat tolerance varies broadly be tween individuals and even within an individual on a day-to-day basis. This is because environmental condi- tions, intensity of the activity, the worker's behavior, and individual physiological factors can shift and modulate the risk of occupational heat exposure (Schlader et al, 2011; Staal Wasterlund, 2018). For example, workers may adjust weit work pace, such as taking short rests berween rows. Cardiac strain can also vary according to other personal criteria, such as physical fitness or physio logical acclimatization to the work conditions In this study, average cardiac estimates were not far below or just above the individual recommended limits (110 bpm, 30 bpm, and 30%, for mean HR, NCC, and. RCC, respectively} (Saha et al, 2008}, revealing environ- mental heat stress and the high physiological demand of the job. It was expected that the vineyard-level variables had no influence on the mean skin temperature at rest (as the vine-lifting had not started at that time}, suggesting internal validity. The experience in vine-ifting was nega- tively linked to the NCC. Being related to the resting HR, this index is considered to more specifically evaluate the workload strictly connected to the job (Costa etal, 1989). This negative association of borderline sig- nificance suggests that the more experienced workers adapted their performance strategies. Conversely, the RCC, whieh takes into consideration the maximal HR of the subjects, provides an evaluation more related to indi- Vidual strain (Costa et al, 1989). This i in line with our results, showing that both heat stress and length of task. deeply influenced this cardiac strain. Unfortunately, our results cannot be easily com pared to those of other studies because very few (if any) field studies in the scientific literature have monitored the cardiac burden of farming activities under identical conditions. Conclusion ur results show that canopy management by hand in vineyards causes considerable cardiac and thermoreguls tory strain. Heat stress management strategies are well known (training about heat illness prevention, imple- mentation of appropriate work-rest schedules, provi sion of shade at the outdoor setting, availability of fluids for hydration, etc.) (Jackson and Rosenberg, 2010). However, it appears necessary to develop appropriate instruments for simultaneously evaluating work inten- sity, work quality, and productivity at the vineyard-level, which could provide an integrative view and raise the awareness of the necessity to take preventive measures among both managers and employees, Acknowledgments We are grateful to the vineyard workers, vineyard managers, anid field monitors who made tht study possible fepuoo-dno'quiopeoe /'sdiy Woy pepeouMog, 1202 AeW of uo s0sn puelBua MON Jo AysrOAUN fq ¥sZ0S0sI06E%H! Annals of Work Exposures and Health, 2021, Vol. 65, No. 4 Funding ‘The Union des Industries de Ia Protection dee Plantes (French Crop Protection Industry Association) funded the National Research Institute of Science and Technology for Envionment and Agriculture for the feld study within the framework of the Safe Use Initiative project. The funder had no roe in the design ‘or canduet of this study, the analysis or interpretation of the data, or the preparation of ths manuscript Conflict of interest “The authors have no conflicts of interest or financial relation shipe to disclose. Ethical approval Subjects included in the study volunteered, gave their written informed consent, and were observed in the course of their normal work activities, Therefore, no approval from an ethice committee was requized by French regulations at the time of the study. References ‘Costa G, Bert F, Betta A. (1989) Physiological cost of apple farming activities. App! Ergon; 20: 281-6. (Crandall CG, Gonzdlez-Alonso J. (2010) Cardiovascular func ‘on in the heat stressed human, Acta Physiol (Oxf; 199: 407-23, European Food Safety Authority (EFSA), (2014) Guidance on the assessment of exposure of operators, workers, residents and bystanders in risk assessment for plant protection prod vets. BESA Jy 12: 3874 Gellish RL, Goslin BR, Olson RE et al, (2007) Longitudinal ‘modeling of che relationship between age and maximal heart rate. Med Sei Sports Exerc; 39: 822-9 Gordon CJ. (2003) Role of environmental stress in the physio: logical response to chemical toxicants. Environ Res; 92: 17. Gordon CJ, Leon LR. (2005) Thermal stress and the physio~ logical response to envizonmental toxicants. Rev Environ Health; 20; 235-63, Grimbubler S, Viel JE (2018) Physiological strain in Freneh vineyard workers wearing protective equipment to conduct re-entry tasks in humid conditions, Ann Work Expo Health 62: 1040-6 1809886. (2004) Frgonomics—evaluation of thermal stain by physiological measurements. 2nd edn. Switzerland, Geneva: International Organization for Standardization, Jackson LL, Rosenberg IIR. (2010) Preventing heat-related illness among agricultural workers, J Agromed; 15: 200-15, Leon LR, (2008) Thermoregulatory responses to environmental toxicants: the interaction of thermal stress and toxicant ex: posure, Toxicol Appl Pharmacol; 238: 146-61. Malchaite J, Rogowsky M, Vanderputten M er al. (1986) Evaluation of physical workload by continuous heart rate recording in the automobile industry. [in French] Trav Hum 49; 75-87. Meunier P, Smolik HJ, Knoché C. (1994) Cas ‘work: which evaluation grid to choose? [in French]. Cahiers Med Interprofi 2: 153-8. Mitchell DC, Castzo J, Armitage TL et af. (2017) Recruitment, methods, and descriptive results of a physiologic assess” ment of Latino farmworkers: the California Heat Hlness Prevention Study (CHIPS). Occup Environ Med; 59: 649-58, Mitchell DG, Castro J, Armitage TL er al. (2018) Physical ac- tivity and common tasks of California farm workers: California Heat Ilness Prevention Seudy (CHIPS). J Occup Environ Hyg; 15: 857-69, [Nigg HN, Stamper JH, Easter E et a, (1992) Feld evaluation of

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