Surveillance and Informational Resources associated with Pesticide Exposure & Health Ana Maria Osorio, MD, MPH US Public Health Service, on detail to: US Environmental Protection Agency Washington DC Tel 703.305.7666 E-mail Osorio.AnaMaria@epa.gov

Information & Networks: USA examples Text + guidelines Recognition and Management of Pesticide Poisoning, 5th Edition (text + online) Guidelines for Physicians: Medical Supervision of Pesticide Workers, California EPA (AChE inhibitors) - online ATSDR case studies in Environmental Medicine (self-test, web site) Telephone help hotlines National Poison Control Center Tel # National Pesticide Information Center (NPIC) – daytime hours every day except holidays [Web site with hot links]

Information & Networks: USA examples Regional monitoring programs Surveillance systems for pesticide intoxications (local states) Other online sources EPA/California Dept of Pesticide Regulation – web site providing regulatory status of pesticides EPA text NIOSH surveillance system (SENSOR) Environmental/Occupational Case Studies (New Jersey Health Dept/Hahnemann Univ) OEM Listserv (Duke University)

Information & Networks: USA examples Clinical networks Association of Occupational and Environmental Clinics (Canada, Mexico & USA, web site with hot links) Migrant Health Clinics (Migrant Health Clinicians Network) Indian Health Service

Summary Text/guidelines Telephone help hotlines Regional monitoring programs Other online sources Clinical networks

Surveillance Systems for Pesticide Intoxications Definition - ongoing standardized system of data collection, analysis, interpretation, dissemination and, as needed, follow-up intervention for pesticide intoxications Utility – Planning, implementing and evaluating public health intervention and control programs. System itself should be periodically evaluated. Medical monitoring – Periodic assessment of specific population (e.g. ChE testing of pesticide handlers, mixers, loaders and applicators): Q, physical exam, and lab tests usually coupled with environmental sampling

Key Components of Surveillance System Objectives Case definition Pesticide definition Target region and population Time period Advisory Board Criteria for follow-up investigations Timing of periodic evaluations Overall data flow Reporting sources Std reporting form Protocol for data ascertainment, transmission & storage Case definition (Inclusion criteria) Std statistical analysis Periodic report generation Dissemination of information

Assessing relationship between disease and pesticide exposure Physical signs & sx consistent with pesticide being considered Co-workers or others in the environment who are ill Timing of exposure event and disease onset Confirmation of physical exposure to pesticide Record of environmental sampling data Biological monitoring data Biological plausibility Non-pesticide exposures or pre-existing health problems

California Pesticide Illness Surveillance Program, 1997-99

California Pesticide Illness Surveillance Program, 1997-99

Poison Control Center Data TESS Toxic Exposure Surveillance System Poison Control Center reports Years 1993 – 1998 64 – 67 Centers cover approximately 80% of U.S. population Include all pesticide cases < 18 years old Exclude intentional cases and those with exposure to > one product

Mean age: 4.3 yrs. (Male) & 4.7 yrs. (Female) Age Range (in years) by Gender (N = 55,600 with 57% Male; Years 1993-98, 122 cases lacking gender excluded) Mean age: 4.3 yrs. (Male) & 4.7 yrs. (Female)

Age Range (in years) by Exposure Site (N = 55,722; Years 1993-98; 203 cases lack site data)

Note: Insecticides account for 54% of all cases Pesticide Categories among Cases (N = 55,722; Years 1993-98; Age < 18) Note: Insecticides account for 54% of all cases

Definition: Medical Outcome of Case Minor – minimal symptoms/signs with no residual disability Moderate – symptoms/signs more pronounced, prolonged or systemic with no residual disability (usually with treatment indicated) Major – symptoms/signs life-threatening or result in permanent disability or disfigurement Death

Medical Outcome by Pesticide Type (N = 55,722 with 581 in Other Pesticide category not shown; Years 1993-98; Age < 18) Pesticide Minor Effect Moderate Major Death Insecticide 27,497 2,195 208 4 Disinfectant 19,787 1,151 35 1 Herbicide 2,392 200 7 Rodenticide 1,110 172 22 Fungicide 271 20 Fumigant 60 8

Medical Outcome by Insecticide Type (N = 29,904; Years 1993-98; Age < 18) Minor Effect Moderate Major Death Borate/ Boric Acid 417 25 Carbamate 1,893 169 11 1 Organo-chlorine 1,619 190 53 Organo-phosphate 5,114 470 71 3 Pyrethroid/ Pyrethrin 6,580 737 35 Repellent – moth 1,075 80 10 Repellent – other 7,942 301 12 Other 2,857 223 16

Symptoms/Signs by Pesticide Type (N = 55,722 with 581 in Other Pesticide category not shown; Years 1993-98; Age < 18)

Steps in the investigation of a pesticide intoxication outbreak

Example of a case definition used in a recent pesticide intoxication outbreak A case is defined as a farm worker who was present during a recent half-day application of a carbamate pesticide (Temik) at a banana plantation AND who has one or more symptoms consistent with cholinesterase inhibition. For those workers receiving medical attention, reversibility of symptoms after atropine treatment provides confirmation of cholinesterase inhibition.

Worker Age Sx onset Rx 1 27 End of application Atropine, Hospital 2 21 List of subjects in outbreak investigation among banana workers involved in pesticide applications. All exposed workers were Latino men. Backpack application of Temik (a carbamate nematicide) occurred for approximately five hours partly during heavy rains. Worker Age Sx onset Rx 1 27 End of application Atropine, Hospital 2 21 30 min None 3 31 1 hour 4 24 5 Unk ER observation 6 7-15 20-40 None reported Unknown

Epidemic Curve Timing of sx onset following 5 hour Temik application, N = 15 applicators involved in activity

Outbreak Incidence Rate 40% incidence rate using case definition of survey (6 out of 15 workers) 33.3% incidence rate using only physician confirmation of disease (5 out of 15 workers) Potential survivor population bias Important to report cases to proper agency