Evaluation of Acute Pesticide Intoxications in Belize Preliminary Findings Rony Maza, BS PAHO/WHO-DANIDA, Belize mazarony@blz.paho.org Ana Maria Osorio, MD, MPH US EPA, Office of Pesticide Programs Washington DC Osorio.AnaMaria@epa.gov Jim Deddins, PhD, NIOSH, Cincinnati, Ohio

Acknowledgements Belize Ministry of Health University of Belize Central Statistical Office Pesticide Control Board Ministry of Agriculture Growers Associations Hospitals/Clinics Colleagues at PAHO, NIOSH and US EPA Belize participants

Survey Objectives Estimate national and district-specific prevalence rates for acute pesticide intoxication (API) Assess degree of underreporting of API cases within Cayo (CY)and Stann Creek (SC) Districts - both agricultural regions

API Survey, Belize, June 2001: Methods (study period for data collection: 17 June 2000 - 16 June 2001) 6 June - All day training Formed 3 teams (7 - 10 persons) North (CZ + OW) Central (CY + BZ) South (SC + TL) Population divided into 3 pesticide exposure risk groups High: ag workers and pesticide applicators, distribution center workers, quarantine officers, and vector control officers Medium: rural residents near ag activities Low: other rural residents, urban residents

Survey Case Definition: All reports need to occur during survey period (17 June 2000 – 16 June 2001) Q Data Source Survey API Case: Person with onset of acute Sx (within 24 hours after exp). Sx can be ocular, dermal and/or systemic. Sx consistent with pesticide type. Possible API Case: Above factors but lacks sufficient detail on pesticide type Hospital Data Source Clinician report of pesticide intoxication API Surveillance Data Source (CY + SC only)

*Refusal rate = 4.8%; Mean time for interviw = 8.1 minutes) Q Survey Participation by District and Exp Risk Group* (N= 1,060 persons, Target = 1024) *Refusal rate = 4.8%; Mean time for interviw = 8.1 minutes)

Q Survey Demographics Gender by District (N = 1060, 47% F & 53% M)

Q Survey Participation by Age Range and District (N = 1017, 43 persons missing info)

Q Survey Demographics Selected Variables (N = 1060 total persons) Distribution N (% missing info) Where born? 72% Belize 16% C.A. 2% Mexico 1031 (3) Ethnicity/culture? 35% Mestizo 20% Latino/Hispanic 16% Creole 10% Mayan 11% Multiple 1044 (2) Language spoken at home? 48% Spanish 17% Creole 6% English 21% Multiple 1053 (1)

Q Survey Demographics - Continued Selected Variables (N = 1060 total persons) Distribution N (% missing info) Read English? 51% Well 10% Somewhat 19% Little 17% Not at all 1030 (3) Crop among Ag workers? 19% Banana 16% Citrus 13% Sugar 6% Corn 1% Rice 230 (14) Among those working with pesticides… 68% Given instructions 16% Symptoms associated with use 83% Load/mix (30% no PPE) 453 (3) 431 (7) 449 (3)

API cases identified from the questionnaire survey (n = 87 events, 63 possible cases, & 36 cases)

Dose-response relationship by risk for API cases from survey (n = 87 events, 63 possible cases, & 36 cases)

Q Survey API Cases (N = 36 cases, 1 lack age and 1 lacks work-related information) CZ OW BZ CY SC TL Total # Cases 5 1 4 7 11 8 36 % Males 80 100 75 86 82 88 83 Mean age, yr 37 23 50 41 33 Age range 21-56 -- 39-75 21-61 18-59 21-72 18-75 # Ag worker 3 19

Q Survey API Cases (N = 36 cases) Most common types of active ingredients associated with cases: 12 Organophosphate 6 Paraquat 4 Carbamate 4 Pyrethroid 3 Pyrethrin 4 Phosphonate

Adjusted estimated prevalence rates by country and district

Medical Record Review API Cases (N = 59 cases, 13 lack age and 14 lack work-related information) CZ OW BZ CY SC TL Total # Cases 2 10 5 16 19 7 59 % Males 80 100 75 86 82 88 83 # Deaths 1 3 Age, yr Mean Range 50 42-58 29 15-45 9 2-22 28 2-75 25 14-31 21 3-35 % Work-related 24 90 37

Medical Record Review API Cases (N = 59 cases) Most common types of active ingredients associated with cases: 23 Organophosphate 21 Paraquat 15 Carbamate 4 2,4 D

API Surveillance, # Cases in SC and CY (21 – 22 per year)

API Surveillance Cases (N = 16 cases) CY SC Total # Cases 8 16 % Males 50 86 69 # Deaths 1 2 Age, yr Mean Range 26 2-75 25 14-31 % Work-related -- 75 38 Most common active ingredients associated with cases: 6 Dipyridyl 5 Organophosphate 5 Carbamate

Prevalence rates by data source (only duplication occurred between med record cases and API cases, 16 identical cases) Region No. of cases Prevalence Belize Q cases Med record cases 4,083 59 170 / 10,000 2.5 / 10,000 CY & SC API cases 1991 35 16 258 / 10,000 4.5 / 10,000 2.1 / 10,000

Underreporting rates for API surveillance system (note: Q cases are derived from adjusted rate estimates) CY & SC # API cases # New cases # Total cases % Under-reporting Q cases 16 1991 2007 99% Med record cases 19 35 54%

Strengths of this study Awareness among stakeholders foster collaboration Quick interview (< 10 minutes) and short time period for data collection Nationwide data collection with good representation First national survey on pesticides and health in country Standardized protocols and forms Three different data sources Favorable response from participants & advisory groups Led to an outbreak investigation among banana workers

Potential study limitations Language & cultural barrier (Mayan, German-Mennonite) Q based case identification difficult Possible misclassification of exposure categories for individuals Some medical sites lacked diagnostic options/expertise regarding pesticide intoxications Some medical sites were not logging in cases Some occupational clinics work for growers and do not report

Conclusions Population at risk for API: Many immigrants from C.A. and Mexico; majority Mestizos, Latinos/Hispanics; many read little or no English; many persons working with pesticides have received no training; and many who load or mix pesticides use no PPE. Q survey: Adjusted prevalence rate estimate = 170/10,000 persons in Belize per year (highest rate for SC with 490/10,000. Dose-response relationship (case by exposure risk) = for possible cases (cases did not show much difference between moderate and low risk groups). Most common pesticides for intox = OP and paraquat 53% of cases are agricultural workers Estimate that 4,142 preventable intoxications occur annually in country

Conclusions (continued) Medical record review: National prevalence rate = 2.5 / 10,000 persons per year Cases are more severe with 3 deaths (paraquat) Most common pesticides = OP and paraquat 37% of cases are occupational There are 59 preventable severe intoxications nationally per year API surveillance: Prevalence rate for CY and SC = 2.1 / 10,000 persons annually All of these cases were also identified by medical record review Most common pesticide = paraquat 38% of cases are occupational Underreporting rate in CY and SC = 99% (in comparison to Q case ascertainment) and 54% (in comparison to medical record review cases)

Recommendations Increase extent of awareness and informational program Review current surveillance protocol for case reporting, data collection and analysis Encourage other institutions/organizations to build on current study findings Consider active surveillance (representative goes out to each hospital and clinic to review medical records) Consider follow-up study of high-risk subgroups Conduct periodic update training of clinicians regarding pesticide intoxication diagnosis, treatment and prevention Implement expansion of surveillance nationwide