1. The Health of Farmworkers-Pt. 2 Marc Schenker M.D., M.P.H. Dept. Public Health Sciences, University of California at Davis Director, Western Center for Agricultural Health and Safety

2. Part II **** Acute Injuries and Fatalities of Farmworkers

3. Outline The hazardous passage Occupational fatalities among agricultural workers –Animal –Machine/tractor –Transportation Fatalities of children Pesticides

4. Causes of Death Among Latin Immigrants Crossing US Border During the crossing –Exposure –Drowning –Accidents –Murder After the crossing – Disease – Injury (occupational)

5. U.S.-Mexico Border: The Season of Death “The deaths trickle in over the cooler months. A couple here from a rollover. Four dead there during a cold snap. They begin in earnest once the temperature spikes over 100 degrees sometime in May.” PBS Frontline, June 27, 2006

8. Occupational Fatalities in Agriculture

12. SOURCE: U.S. Bureau of Labor Statistics, U.S. Department of Labor, 2007

13. Occupational fatality rates by age group for farming, 1992-2004* * Excludes New York City. Rates calculated by NIOSH and may differ from BLS.

14. Agriculture Fatality Rate vs. Private Sector, US, 1992 - 2002

21. Children : The Forgotten Farmworkers “Farmers and Labor Contractors say they allow children to perform field work because the grower needs to get the crop in, parents need the money or children would learn the value of working.” Fresno Bee, 12/14/92

25. José (22) and Angelica Alatorre and son Guillermo. Jose died while working in a manure pit at Aguiar-Faria & Sons Dairy, Gustine, CA. February 22, 2001

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

27. 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)

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

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

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

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

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

33. 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

34. Pesticide Exposure: Suicide/Homicide Unknown substance Secondary exposure

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

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

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

38. 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

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

40. 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

41. 41 Commonly-used Acronyms for Cholinesterase Inhibition Syndromes Salivation Lacrimation Urination Diarrhea Urination Miosis Bronchorrhea Emesis Lacrimation Salivation

42. 42 Cholinesterase Inhibitors Clinical Presentations Vary Some signs & symptoms may be absent –Bronchorrhea more likely with high-dose exposures (ingestion) Common presentations –Nausea, vomiting –Miosis –Sweating, urinary frequency –Non-specific constitutional symptoms

43. 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

44. 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

45. 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

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

47. 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.htmlhttp://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.edunpic@ace.orst.edu

48. 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

49. 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

50. Poison Control Centers Toxicity Decontamination Management Reporting

51. 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

52. 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

53. 53 66 year-old male with eye irritation, abdominal pain, nausea, vomiting, headache, dizziness, frequent urination, muscle shaking. Symptoms began after weeding a cotton field for 4 hours. Occasional palpitations but no other symptoms over the past 6 months 33 other crew members complain of similar symptoms Case Farmworker with Multiple Symptoms

54. 54 Farmworker with Multiple Symptoms Exposure History 4:00 am: Aerial application of –Carbofuran (N-methyl carbamate) –Abamectin (macrolytic lactone) –Mepiquat chloride (growth regulator) 6:00 am: Workers entered field 10:00 am: Symptoms

55. 55 Farmworker with Multiple Symptoms Physical Exam Nausea & abdominal pain Conjunctival injection Irregularly irregular pulse; rate 106-155, Lungs clear, no murmurs; neurological exam normal This warning sign was posted after the workers entered the field and became ill.

56. 56 Pyrethroid Insecticides Use increasing Examples of use –Structural & agricultural –Pet flea control –Pediculicide Vector control –West Nile virus –Aircraft “disinsection” Source: CDC

57. 57 Pyrethroids: Health Effects  Skin  Paresthesia, dermatitis  Respiratory  Rhinitis  Systemic  Dizziness, headache  Fasciculations, seizures,  Hormonal disruption in vitro

58. 58 Pyrethrin & Pyrethroid Illness: Treatment Decontamination Vitamin E cream Symptomatic therapy Remove from further exposure if needed

59. 59 Case Woman Exposed to Flea Bomb 35 year-old non-pregnant female with skin burning, itching and chest tightness after putting on clothes from closet. Physical exam –Arms and face bright red –Vital signs normal –Lungs clear

60. 60 Woman Exposed to Flea Bomb Ingredients Label –0.435% permethrin –0.05% pyrethrins –0.4% piperonyl butoxide –99.115% inert ingredients Recommended no entry for 4 hours after fogging

61. 61 Fumigants Halogenated hydrocarbons –Methyl bromide –Ethylene dibromide, DBCP Inorganic compounds –Sulfuryl fluoride Pro-fumigants –Metam sodium Metal phosphides –Aluminum, Zinc, Magnesium US DOT

62. 62 Fumigants Methyl Bromide High vapor pressure Heavier than air Odorless –Chloropicrin added Toxic mechanism –Tissue methylation

63. Pesticide Availability in Mexico

64. Pesticide Illness: Summary Occupational, environmental history Clinical suspicion Tests supplement clinical diagnosis Treatment symptomatic, few exceptions

65. Thank you!