1. 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

2. 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]

3. 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)

4. 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

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

6. 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

7. 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

8. 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

9. California Pesticide Illness Surveillance Program, 1997-99

10. California Pesticide Illness Surveillance Program, 1997-99

11. 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

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

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

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

15. 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

16. Medical Outcome by Pesticide Type (N = 55,722 with 581 in Other Pesticide category not shown; Years ; 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

17. 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

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

19. Steps in the
investigation
of a pesticide
intoxication
outbreak

20. 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.

21. 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

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

23. 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