COMPETENCIES COMPETENCIES The Raw Material National Pesticide Competency Guidelines for Medical & Nursing Education A Project of the National Strategies for Health Care Providers: Pesticides Initiative January 2003

Your Tasks Understand the Competencies Identify Insertion points in your curricula Help mold the presentation to be consistent with your curricular format Help student champion help us organize the training package Help us insert and assess the insertion process Help spread the word –Professional associations Give us general advice as to content and packages

Timeline

A Kaleidoscope of Options The Competencies are a huge group of skills and knowledge areas If we can bring pesticides-occupational and environmental health into the curriculum we will be achieving our goals The Competencies are a huge group of skills and knowledge areas If we can bring pesticides-occupational and environmental health into the curriculum we will be achieving our goals

Today Content of Competencies –General content of the competencies –Follow along with your competencies –Ponder….. –Which ones should I choose? –How will this fit into my curricula? –What style of presentation should this take?

COMPETENCY I COMPETENCY I Knowledge & Concepts of Pesticides Principles of Environmental & Occupational Health Related to Pesticides

Knowledge & Concepts of Pesticides Basics of Environmental & Occupational Health (MK) Broad Spectrum of Pesticidal Chemicals (HM) Mechanisms and Pathways for Exposure (HM) Temporal Relationship: Exposure - Illness (HM) Advanced Toxicity of Pesticides (MK)

How the Health of our Environment Affects our Health Basics of Environmental Health I-1a Environmental media through which pesticides might affect us: Air WaterFoodSoil

Most pesticides have local effects –Pesticide drift in communities located near farming operations or chemical plants Example: Metam-sodium chemigation, Aircraft applications, Airblast applications Example: Bhopal incident from Union Carbide Chemical plant –Pesticide exposures due to domestic use and residual air contamination indoors or outdoors Example: flea bombs, herbicide applications –Some have general effects or are carried well beyond targets and may have far reaching effects Example: Fumigants and others in California Valley air, Methyl Bromide in oxone Depletion Air

Pesticides in the Air Chemigation Aircraft applications Airblast applications Domestic application Smog Methyl bromide

Direct application or accidental Spillage may pollute water –Example: Carbamate application for Ghost shrimp control, Washington State –Example: Metam-Sodium Spill in Sacramento River Pesticide migration contaminates ground water –Example: Ground water testing results 265 pesticides detected in 45 states in 16,606 wells Water, Purdue

Residual pesticides may contaminate soil for years –Lead Arsenate, Past heavy use results in soil contamination –Other less persistent chemicals are also important Soil

Soil Contamination Orchard sprayer Ag chemical transport (train wreck) Abandoned storage units

Food may contain pesticide residues beyond safe levels –Studies of children show that pesticide levels in urine of children correlate strongly with certain foods eaten –Consequence of these exposures is uncertain –Organic diets eliminate pesticide metabolite excretion Food

Likely Household Exposures Pesticide use in the Home –EPA estimates that 74 Million pounds of pesticide active ingredients are used annually in US homes and gardens –85% of households have some pesticides Banned and old pesticides are present in many homes –Misuse of agricultural pesticides may lead to severe toxicity in the home Example: Parathion used in Mississippi, Arkansas, Louisiana, Alabama –Misapplication of domestic pesticides may lead to toxicity as well. Example: Washington state flea bomb use –Pesticides used in the garden and lawn may find their way into the bodies of children and adult residents of the home. U.S. EPA, Pesticides Industry Sales and Usage: 1994 and 1995 Market Estimates, Table 3. U.S. EPA, National Home and Garden Pesticide Use Survey, March 1992, p. 6.

Issues that Affect Children, Vulnerable Populations & the Elderly Children are more susceptible: –Dose and body weight –Metabolic rate –Respiratory rate per body weight –Surface area per body weight –Developing systems –Immature enzyme systems and immune systems –Behavior: Picca and lack of knowledge and caution

Other Vulnerable Populations Asthmatics/COPD, more susceptible to minor irritation Older adults may be less mobile and may be on medications which alter metabolism or suffer from reduced excretory ability Children of farm working families are at risk both as a function of being children and being close to highly toxic pesticides

Occupations at Risk Pesticide applicators –Structural applicators and agricultural applicators Farm workers –They may enter treated fields Longshoremen –May handle treated grain, wood, and other imported products Health care workers –Disinfectants and sterilizants for medical equipment Municipal water workers –Chlorine is a pesticide

Competency I-1e Toxicology of Pesticides Organophosphates & Carbamates –Inhibition of cholinesterase –Organophosphates are like unwelcome guests: they come to stay –Carbamates are like money: here today, gone tomorrow

Action of Acetylcholine & Cholinesterase

- acetylcholine - cholinesterase - acetate - choline - organophosphate - 2-PAM nerve cell muscle Normal Electrical Nerve Impulse Transmission

Nausea Vomiting & Headache

Changes to the Eye, Pupil Constriction & Blurry Vision

gland Glandular Over-stimulation

Pralidoxime Treatment It Differs for Ops & Carbamates

Metabolism of Parathion

Several Factors Modify Toxicity Genetics –Activity of PON1 An enzyme that hydrolyzes paroxon Behavior –Long sleeve shirts, may be barriers, may be enhancers –Hygiene. Washing hands before eating etc. Nutrition –Certain dietary constituents may turn on or turn off metabolizing enzymes.

Pyrethroids: A Derivative of a Natural Pesticide Pyrethrins, derived from the chrysanthemum flower Modified chemically for greater environmental durability to pyrethroids. Two classes: Type I and Type II Pyrethroids with a cyano group tend to be in type II. Toxicity Differs.

Pyrethroids Type IType II Parasthesias Fine tremorCoarse Tremor Increased StartleChoreoathetosis Seizures Salivation Coma

Metabolism of Pyrethroids Homeothermic animals tend to metabolize pyrethroids quickly Poikilothermics tend to be much slower metabolizers Infants metabolize pyrethroids slowly and may by more susceptible.

Competency I-2e Moral, Ethical and Legal Implications for Patients of Reporting and Referral

Mandatory reporting in Some States WA, OR are the two northwest states with mandatory reporting (more on this later). Health care providers are the front line against epidemics Our responsibility goes beyond a single patient to the family, the workplace and society

Workers Refuse Workers may fear retaliation –Loss of job –Loss of respect from supervisor This may create a very difficult conundrum for providers –Must report –Must respect patient’s wishes –Must protect worker from reexposure

Worker May be an Index Case Exposures at schools, daycare centers, businesses may present with a single case Reporting these cases may embroil the provider in a legal maelstrom Prevention of more illness must feature prominently in the clinicians mind

Competency I-3: Population Based Knowledge & Skills The Laws About Pesticides –Food Quality Protection Act Single Health Based Standard Re-evaluation of registered pesticides Ten Fold safety factor Reasonable Certainty of “no harm” Cumulative Effects from all sources must be considered Right to Know provisions for consumers

Impacts of Pesticide Overexposure Might be On Whole Communities or Whole Workforces Contamination of an entire neighborhood may occur –Example: Bhopal Contamination of a common resource may occur –Example: A contaminated water system Drift or soil contamination may affect large tracts of land or soil –Example: Lead Arsenic in Soil in Wenatchee

Dealing with Populations Public Health Approach Primary prevention –Prevent exposure In the workplace by controlling or substituting, or protecting the worker In the environment but substituting, administratively reducing use (IPM) Education of the consumer/worker to prevent overexposure

Public Health Approach Secondary prevention –Preclinical diagnosis Cholinesterase monitoring is the best example to date This may motivate primary prevention through economic means in workplaces Urinary metabolite monitoring is yet to be applicable

Public Health Approach Tertiary Prevention Diagnosis-treatment and rehabilitation to prevent chronic sequelae –Tertiary prevention means treatment and removal from further exposure

Use Of Epidemiological Data for Worker Compensation Cases Relative risk of 2 = greater than 50% certainty of association –Epidemiologic data showing associations between purported exposure and the patient’s disorder should be used to justify a claim –“More probable than not” –“But for the exposure, the patient would not be sick” –These is 50% certainty language

Epidemiological Data for Cause & Effect Cancer and pesticide exposure –Case-control studies have supported a cause-effect relationship between cancer and pesticides –Cohort studies have been less supportive –Newer cohort studies, with more meaningful exposure estimates have begun to bear out the cancer hypothesis

Case-Control vs. Cohort Studies Case-control –Looking back at controls from the diagnosis of disease Cohort studies –Looking forward from exposure toward the development of disease

Competency I-3b Socio-economic Implications Impacts of Pesticide Related Illness For the day laborer, a day lost is an economic burden –Pesticide Diagnosis is complex, Worker compensation systems are set up for injuries, not disease For Employers: –The loss of a well trained worker is a hardship Pesticide contamination of a water supply can be economically devastating for a small community Society suffers from contamination through loss of resources both economic and esthetic - Cross-subsidy of occupational illness

Case Examples of Worker Poisonings Acute, intense pesticide poisoning with OP in an applicator –Persistent neuropsychological effects Depression, agitation, memory loss, lower function Poisonings in a farm working crew –Group concern about long-term effects lead to anxiety and depression Pesticide allergy –Rare but depilating to a pesticide applicator

Advocacy in Occupational & Environmental Health A workplace illness is totally avoidable The cost of workplace illness should be born by the employer, not the worker Pesticide poisonings too often go unrecognized and workers bear the cost of care and time loss due to illness The savvy clinician is the sick workers best friend –Well trained in the WC system –Willing to fight for the workers right to cure and maintenance –Willing to point out the workplace hazard to proper authorities

Competency 1-3c Barriers to Optimal Care of Vulnerable Populations Undocumented workers may not effectively defend their own interest –Migrant workers may be unaware of worker compensation, or afraid to use it. In WA, documentation status does not affect Worker Comp Eligibility –Earning while sick may be preferable to not earning healing. – Blackballing is a reality and is greatly feared

Obligations of Healthcare Providers If you suspect a workplace illness, you are obliged to file a claim, unless the worker refuses If you suspect a pesticide as a cause of illness, you are obliged to report it in Washington State

Competency I-3d Prevention and Benefits of Pesticide Alternatives Provide guidance –Caution against overuse of DEET, Flea bombs, garden pesticides –Suggest alternatives Pyrethrins saturated clothing, screening, larvicides such as BT, safer soap, BT for caterpillar control –Master Home Environmentalist referral –County Extension and Washington State University

Health People 2010 A goal for the Near Future Reduce pesticide exposures that result in visits to a health care facility. Target: 13,500 visits per year. Baseline: 27,156 visits to health care facilities were due to pesticides in (129,592 pesticide exposures were documented in 1997.) Target setting method: 50 percent improvement. Data source: Toxic Exposure Surveillance System (TESS), American Association of Poison Control Centers. Pesticide exposures include those involving disinfectants, fungicides, herbicides, insecticides, moth repellants, and rodenticides, as defined by EPA. The American Association of Poison Control Centers surveillance covers approximately 93 percent of the U.S. population.”

Competency II-1 Environmental and Occupational History

Competency II-2 Pesticide Poisonings Differential Diagnosis Many Toxins Many Toxidromes

The Great Deceivers Syphilis Lupus AIDS Pesticide Poisonings

Sometimes Easy-Sometimes Hard General Bad Feeling –Nausea, weakness, fatigue, lightheadedness, headache, nausea DD –Viral illness –Early onset diabetes –Incipient malaria –Dehydration –Pesticide poisonings

Other Manifestations Seizures –Organochlorine pesticides may cause isolated grand mal seizures –Late stage organophosphates –Fipronil –DEET Metabolic Acidosis –Boric Acid ingestion (scalded baby syndrome) –Herbicides (glyphosate) Cardiac Arrythmias –Organophosphates and Torsade de pontes and bradycardia Bloody diarrhea- –arsenic-thallium Pulmonary edema- –organophosphates and carbamates Altered mental status –Several pesticides Hypermetabilism –Dinoseb –Pentachlorophenol

Unique (or almost) Signs-Symptoms Miosis Mydriasis Acral and perioral Parasthesias Yellow skin color Hair loss Peripheral Neuropathy Methemoglobinemia (blue baby) Skin burn

Specific Tests Urinary metabolites –If urine captured soon enough Cholinesterase Maybe in OP poisonings History and workplace information is the key Grab the clothes, freeze the urine, cut and save the hair

Competency III Treatment, Intervention and Referrals

The Basics A B C’s and D. D is for Decontaminate –Carefully to avoid health care worker poisonings –Decontamination may need to happen at home Oxygen Before atropine, to avoid arrythmias Contraindicated in early paraquat and diquat Antidotes –Atropine for Ops and Carbamates –2-pam for Ops –Cyanide antidote kit –Chelation for metals –BAL for arsenic then succimer –Succimer for mercury –Vit K for rodenticides

Chronic Health Effects Cancer –Ag health study will help –Lymphoma, leukemia, brain tumors Birth Defects –Dinoseb –Some association with farming Neurological Disease –Several suspects –Parkinsons –Post poisoning neurobehavioral deficits Endocrine disruption –True in animals –Not confirmed in humans

Competency III-2: Interventions- Decontamination Of the skin –Wash –Beware of clothing Of the gut –Is ipecac in or out –Activated charcoal Of the Blood –Hemodialisis with carbon filter extraction Of the Home

Competency III-3: Referrals Few specialties have a knowledge of pesticide health effects Occupational Medicine has the best intellectual structure for dealing with the question and dealing with worker comp and long term issues Help organize the referral material –Cooperative extension –Industrial hygiene (if available) –Departments of Health may investigate –OSHA may provide worksite investigation

Competency III-4: Follow-up Follow-up is important Worker comp claims management is complex for Illnesses Pesticides are scary and a poisoning event can be frightening Many patients have questions about issues such as birth defects, cancer etc after overexposure Occupational Medicine/nursing may be very helpful here

COMPETENCY V COMPETENCY V Reporting Requirements and Regulations V-1 Surveillance Needs: Understanding the importance of Surveillance and Incident Reporting –Vignette: In 1993 the EPA Registration for phosphamidon on Apple Trees expired. The only available cost effective alternative for aphid control still approved for use on apple was phosdrin.

Phosdrin & Phosphamidon Workers began to use Phosdrin in Washington State, a chemical rarely used in the past. Phosdrin LD 50 mg/kg PosphamidonLD 50 mg/kg Pesticide Poisonings began to roll in.

How did we Know to act? During the course of the summer of 1993 Department of Health received notice of and investigated 26 acute pesticide poisonings with Phosdrin An emergency ban on Phosdrin was initiated by the state Phosdrin was eventually deregistered by the EPA

Surveillance of Pesticide Poisonings: How it can make a Difference California system: 1970s California began surveillance of pesticide poisonings Washington State began pesticide poisoning surveillance in 1991 This event highlights the importance of surveillance of pesticide poisonings which identified an outbreak early on and resulted in a prompt public health intervention MMWR report available:

Surveillance is: The systematic collection and evaluation of all aspects of exposure occurrence and sequelae- useful in controlling exposure. Screening is testing a person or population for the presence of disease or a marker of disease

What to Do With a Sick Farm Worker Mr Gomez reports to clinic with nausea, vomiting, headache, blurry vision, abdominal cramping, weakness. He is sweating, has pinpoint pupils, has fasciculations, bradicardia Your history confirms you suspicion –OP pesticide overexposure –You treat with atropine, 2-pam and hospitalize Who ya gonna call? When you gonna call?

Competency V-2 Surveillance and Worker Compensation In Washington State –Filing a worker compensation claim results in a report but does not satisfy reporting requirements* Reporting a Pesticide Poisoning in Washington –Calling Poison Control –Calling WA DOH Hospitalizations and Deaths must be reported immediately Others- 3 days. Pesticide poisonings-Reports.

Ethical/Legal Requirements To report or not to report –A legal obligation in 30 states. –Investigations in 9 states To report a dangerous workplace –An ethical obligation- you are obliged to act Each employer – (OSHA General Duty Clause) (1) shall furnish to each of his employees employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees; (2) shall comply with occupational safety and health standards promulgated under this Act. Int Code of Ethics for Occ Heatlh Prof AAOHN Code of Ethics ACOEM Code of Ethics

NIOSH Sentinel Event Notification System SENSOR Eight States are funded to provide in depth investigatory information about reported pesticide poisonings Four states provide data unfunded Aggregate data is available for the country Estimates of the national burden can be made from Sensor Data Trends can be seen Outbreaks identified Basis for future epidemiological studies NIOSH Sensor program

Other Pertinent Standards EPA Worker Protection Standard –Training, Notification, Personal Protective Equipment, Decontamination, Medical emergencies –Medical Provider’s “right to know” OSHA Workers “Right to Know” –Employee has access to MSDS. –Information provided to worker and medical provider WPS

Other Standards FIFRA –Defines pesticides and label as law FFDCA –Tolerances FQPA –Health based stadard for pesticides –Ten-fold safety factor –Cumulative exposure concept WPS –Protects field workers and handlers OSHAct –Workplace protection for non ag workplaces TSCA –Inventory of toxic chemicals –Authority to regulate chemicals given to EPA

Competency V-5: Ethical, Legal, Advocacy Who are the at risk, vulnerable populations? What is Environmental Justice and Environmental Injustice Write a Paper?????

Ask Yourself: How will this fit?