1. Pesticide Illness Part I: Background, Epidemiology, Recognition, Diagnosis, Management Prepared by: Rupali Das, MD, MPH, California Department of Health Services, Michael O’Malley, MD, MPH, University of California, Davis, Laura Styles, MPH, Public Health Institute

2. 2 Pesticide Toxicology  Many toxin categories  Affect various organs  Varied health effects Diagram illustrating various pesticide-related health effects.

3. 3 Definition of Pesticide “Any substance or mixture of substances intended for preventing, destroying, repelling, or mitigating any insects, rodents, nematodes, fungi, or weeds, or any other forms of life declared to be pests; any substance or mixture of substances intended for use as a plant regulator, defoliant, or desiccant.” -- Federal Insecticide, Fungicide, and Rodenticide Act (US EPA, 1947)

4. 4 US Pesticide Use  4.5 billion pounds chemicals per year –890 active ingredients, 30,000 formulations –Uses  75% agricultural  25% home, garden, structural

5. 5 Agricultural Pesticide Use  High volume: –Hand labor (Western states)  Vineyards  Orchard, row vegetables, nursery  Low volume: –Mechanized (Midwest states)  Livestock insecticide dipping  Grain agriculture

6. 6 Pesticide Exposure: Occupational Settings  Multiple industries –Agriculture –Emergency response –Maintenance –Transportation  Variety of workers –Applicators, fieldworkers –Firefighters –Medical personnel –Flight attendants NEETF 2002

7. 7 Pesticide Exposure: Environmental-Occupational Interface  Drift –Off-target physical movement of pesticide through air  Take-home –Contaminated clothing –Pesticide containers brought home

8. 8 Pesticide Exposure: Environmental Settings  Use in schools  Lawn, garden use  Household cleaning  Home pesticide use  Residues in food

9. 9 Human Exposure to Pesticides  Second National Report on Human Exposure to Environmental Chemicals –http://www.cdc.gov/exposurereport/ http://www.cdc.gov/exposurereport/  Pesticides or metabolites detected in general population, 1999-2000 –Organophosphates –Organochlorines –Carbamates –Herbicides –Pest Repellents & Disinfectants

10. 10 Pesticide Exposure: Accidental Ingestion  Improper storage or mislabeling of containers  Prescription pesticides resembling oral medications Photo: John P. Lamb, Pharm D., California Poison Control Center Source: EPA Australia

11. 11 Pesticide Exposure: Suicide/Homicide  Unknown substance  Secondary exposure

12. 12 Unintentional Pesticide Illness, USA Toxic Exposure Surveillance System 1993-1996

13. 13 Surveillance of Pesticide Illness  States with ongoing surveillance –Arizona, California, Florida, Louisiana, New York, Oregon, Texas, Washington  States with previous pilot or periodic surveillance programs –Iowa, South Carolina, Wisconsin

14. 14 Methods, Results of Surveillance Surveillance-based illness detection:  Emergency department treatment of organophospate toxicity  Automatic insecticide dispenser units  Occupational use of flea-control products Reporting required Reporting not required

15. 15 Pesticide Illness Rates Vary by Occupation Source: HS-1688, Cal EPA Organophosphate pesticide poisoning rates by agricultural sector California, 1982--1990

16. 16 Pesticide Illness Around the World Annual rates of intentional and unintentional pesticide- related fatalities and hospitalizations in several countries

17. 17 US EPA Toxicity Classification (Systemic toxicity, eye irritation, skin irritation)  Class I: “Danger” –Fatal if ingested; corneal opacity; corrosive to skin  Class II: “Warning” –May be fatal if ingested; reversible corneal opacity; severe skin irritation  Class III: “Caution” –Harmful if ingested; no corneal opacity; moderate skin irritation  Class IV: “Caution” –May be harmful if ingested; no eye irritation; mild/no skin irritation

18. 18 Common Components of Pesticide Formulations  Technical grade chemical (active ingredient)  Adjuvants/synergists  “Inert” ingredients –e.g., formaldehyde, sulfuric acid, benzene, toluene, other organic solvents

19. 19 Diagnosis of Pesticide Illness  Exposure history most important –Occupational and environmental history –Duration, dose, route of potential exposure  Symptom review  Physical exam & lab findings  Health effects may be due to any component of pesticide formulations

20. 20 Aspects of History that Suggest Pesticide Illness  Multiple cases –Similar symptoms, exposure history  History of chemical application –Home or office  Accidental ingestion, esp. children  Suicide, homicide attempts

21. 21 Pesticide Illness Nonspecific Symptoms & Signs  Rash  Flu-like symptoms –Dizziness, malaise, respiratory tract irritation  Gastrointestinal symptoms  Seizures  Odor-related effects –Not toxicological effects of active ingredient

22. 22 Pesticide Illness May Mimic Common Medical Conditions  Mild : –Upper respiratory tract infection/influenza –Food-borne illness –Asthma –Plant-induced irritant or allergic dermatitis  Severe : –Cerebrovascular accident –Psychiatric dysfunction –Heat stroke

23. 23  Application records  Label  Material Safety Data Sheet  www.msdsonline.com www.msdsonline.com  http://www.ilpi.com/msds/index.html http://www.ilpi.com/msds/index.html How to Identify Pesticides

24. 24 Sources of Pesticide Information  Internet –EXTOXNET: http://ace.orst.edu/info/extoxnet/ http://ace.orst.edu/info/extoxnet/ –California Department of Pesticide Regulation: http://www.cdpr.ca.gov/docs/label/labelque.htm http://www.cdpr.ca.gov/docs/label/labelque.htm –Pesticide Action Network: http://www/pesticideinfo.org/index.html http://www/pesticideinfo.org/index.html  Textbooks –US EPA. Recognition and Management of Pesticide Poisonings. 1999; 5 th ed. http://www.epa.gov/pesticides/safety/healthcare http://www.epa.gov/pesticides/safety/healthcare –R Krieger (ed). Handbook of Pesticide Toxicology. 2001; 2 nd ed.  Poison Control Centers: 1-800-222-1222  National Pesticide Information Center (NPIC): 1-800-858-7378 or npic@ace.orst.edu 1-800-858-7378 or npic@ace.orst.edu npic@ace.orst.edu

25. 25 Treatment of Pesticide Illness Decontamination  Shower, shampoo –Scrub under fingernails  Contain contaminated clothing, body fluids –Save for residue analysis  Protect treating staff –Body fluid precautions –Personal protective equipment if appropriate

26. 26  Symptomatic treatment –Respiratory distress  Maintain airway, breathing, circulation  Oxygen, bronchodilators if indicated –Ingestion  Gastric lavage, charcoal if indicated  Specific antidotes where applicable Pesticide Illness Medical Treatment

27. 27 Poison Control Centers  Toxicity  Decontamination  Management  Reporting

28. 28 Case Applicator with Gastrointestinal Illness  27 year-old pesticide applicator with dizziness, headache, body ache, nausea and vomiting. Sprayed Carzol yesterday.  Exam: Weak (not flaccid), oriented; orthostatic hypotension; exam otherwise normal.  Cholinesterase normal compared to laboratory reference range

29. 29 Applicator with Gastrointestinal Illness Discussion  Differential etiology of gastroenteritis  Pesticide-related  Food-borne  Viral  Test results confirm clinical suspicions –Normal results do not rule out exposure –Treatment based on symptoms

30. 30 Pesticide Illness: Summary (I)  Varied populations at risk  Environmental, occupational exposure  Keys to reducing illness –Physician diagnosis –Reporting to surveillance system –Advice on preventing exposure

31. 31 Pesticide Illness: Summary (II)  Occupational, environmental history  Clinical suspicion  Tests supplement clinical diagnosis  Treatment symptomatic, few exceptions