pesticide effects: integration into health care provider curricula faculty and student champion...

Pesticide Effects: Integration into Health Care Provider

CurriculaFaculty and Student Champion

Training: Part I

Helen Murphy-FNP/MHSDirector of Outreach

Pacific Northwest Agricultural Safety and Health CenterUniversity of Washington

May 31, 2006

Agenda

Part I: Nurse Murf• Rationale• Exposure Pathways• The Chemicals• Health Effects• Risk

Communication

Part II – Dr. Matt• Environmental/

public health context

• Diagnosis and treatment

• Referrals and Reporting

Did you know? 5 million AG workers at risk for pesticide exposure (U.S.

EPA, 1992)

250-500 physician-diagnosed cases occur per 100,000 agricultural workers (Blondell, 1997).

Migrant and seasonal farmworkers are especially at high risk

84% of American households used pesticides, most commonly insecticides (Whitmore et al, 1992)

Homeowners use 5-10 lbs/ acre/yr on their lawns and gardens, many times greater than farmers apply to corn and soybean fields (Robinson et al, 1994).

Did you know? Widespread pesticide exposure through non -agricultural

sources with use of disinfectants: (e.g., pine oil cleaners, bathroom cleaning products, and cleaning materials for swimming pools).

Non-Ag Sector a concern = pest control, nurseries, greenhouses, and landscaping.

The medical profession uses disinfectants to sanitize and sterilize surfaces and instruments.

Organophosphate and pyrethroid insecticides most implicated for poisonings.

Water chlorination is one of the largest (by tonnage) uses of pesticides.

Where Are Pesticides Used? Forests to control insects and under-

story vegetation.

Landscapes, parks, and recreational areas to control weeds, insects, and disease pests

Rights-of-way along railroads and under electric wires to control vegetation

Houses, schools, and commercial and office buildings to control insects, rodents, and fungi

Boat hulls to control fouling organisms;

Source: 2004 Pesticide Incident Reporting and Tracking (PIRT) Annual Report

67%

Washington State Pesticide Events - 2003

Washington State Source of Case Reports 2002 and 2003 Combined

Source: 2004 Pesticide Incident Reporting and Tracking (PIRT) Annual Report

Poison Control

Workman’s Comp

Dept of AG

Agricultural vs. Non-Agricultural Cases of

Poisonings

Source: 2004 Pesticide Incident Reporting and Tracking (PIRT) Annual Report

19992000

20012002

2003

Agricultural

Non Agricultural

72

90

62

99

111

68

113

58

75

73

0

20

40

60

80

100

120

cases

Occupational versus Non-Occupational Cases of Pesticide Poisoning

Occupational

52%

Non-

Occupational

48%

Source: 2004 Pesticide Incident Reporting and Tracking (PIRT) Annual Report

Proportion of PoisoningsRanked 8th Cause of Poisonings = 102,754 cases in 2005 (4.2%)

Source: Watson WA. 2004 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System

Children Adults

US: Intentional vs. Unintentional

Out of 196,164 suicide fatalities 7

used pesticides

8%

84%Accidental

Suicide

WHO Sentinel Surveillance

Country INDIA NEPAL INDONESIA THAILAND MYANMAR PHILIPPINESTime period 12 mo 6 mo 6 mo 6 mo 12 mo 10 moReporting sites 10 5 8 9 8 38Cases 1531 256 126 130 208 327

Circumstances identified 95% 93% 96% 98% 94% 99%Intentional 89% 92% 43% 62% 86% 87%Accidental 5% 1% 16% 8% 8% 8%Occupational 6% 0% 37% 28% 0% 4%

ROUTES OF EXPOSURE

Source: EPA Protect Yourself from Pesticides-Guide of Agricultural Workers

OP’s are readily absorbed:

Across the SKIN with skin contact

In the lungs with INHALATION of pesticide contaminated air/dust

In the gut by INGESTION of pesticide residue on food/dirt/dust

Where Are Pesticides Used? Aquatic sites

Wood products

Food preparation areas Human skin

Household pets

Livestock

Non Occupational Pesticide Encounters

• Accidental or intentional ingestion

• Food and water residues• Contaminated clothing• Treated wood/structures• Residues on

animals/carpets• Garden residues• Termite control• Hazardous waste sites/spills

Professions Exposed to Pesticides

• Aerial equipment maintenance

• Agronomists• Building maintenance work• Emergency responders• Entomologists• Firefighters• Forestry workers• Formulating end product• Greenhouse- nursery

workers• Hazardous waste workers• Landscapers• Livestock dippers and

veterinarians

• Marina workers• Medical personnel• Park workers• Plant pathologists• Research chemistry• Sewer work• Storage/warehouse work• Structural application• Transporting pesticides• Treating contaminated

workers• Vector control workers• Wood treatment workers• Work on highway or

railroad rights of way

Agriculture Pesticide Applications

aerial

air blast sprayer

enclosed cab

back pack-wand

Boom sprayer

Agriculture Jobs

orchard thinner mixer loader

flagger picker

Agriculture Worker Risk Factors

• Indonesia:– Cocktail mixture of multiple products– Spray frequency– Skin contact > wet clothing– Use of toxic products (1a/Ib, II)

• Washington state: – Baseball caps?– Facial exposure – poor fitting masks?– Contaminated hands: urinating/eating?– Improper decontamination?

Children Are More Vulnerable To Pesticides

• GREATER EXPOSURE– Hand to mouth behaviors– SKIN contact with floors and lawns – Lighter less clothing– Eat and drink more per weight

• GREATER ABSORPTION Breathing rates Heart rates Skin surface/weight

• GREATER SENSITIVITY – Sensitive developing organs – Less ability to detoxify

Children’s Exposure

Children have twice the amount of pesticide by-products in their urine as adults.

What behaviors in young children that would explain this?

Behaviors

Hand to mouth: Taste their environment

Near the ground: Spend more time on the ground

Outdoors: Spend more time outside Diet: consume more per weight

(water and fruits)

Behavior: soil ingestion

2.5 year old Adult

Soil ingestion

Indoor 50mg 20mg

Outdoor 60mg 0.4mg

G. Selevan. EHP 2000;108 Suppl 3:451-455

Diet

•Drinks 2 x more water per their weight than an adult

•Eats 12x more apples per their weight than an adult

Biology: dermal & dietary dose

Newborn Young Child

Older Child Adult

Surface area: body mass ratio (m2/kg)

0.067 0.047 0.033 0.025

< 1 year 1-10 years 11-19 years

20-64 years

Drinking water (tap) mean intake (ml/kg/day)

43.5 35.5 18.2 19.9

< 1 year 3-5 years 12-19 years

40-69 years

Fruit consumption (g/kg/day)

Citrus 1.9 2.6 1.1 0.9

Apples 5.0 3.8 0.4 0.4G. Selevan. EHP 2000;108 Suppl 3:451-455

Pesticides in Urine of 22 ChildrenBefore, During, and After Organic Diet

Intervention

2 12 12 32 32 32 32 32 22 32 32 32 32 12 32 32 0N =

S e q u e n t i a l d a y

1 61 51 41 31 21 11 0987654321

T

C

P

Y

d

a

ily

c

o

n

c

e

n

tr

a

tio

n

(

µ

g

/L

)

2 5

2 0

1 5

1 0

5

0

- 5

Conventional diet

Organicdiet

Conventional diet

Lu et al. 2005 Environ Health Perspect on-line

Children’s Biologic Vulnerability

Maria’s husband is an applicator but his blood test (cholinesterase monitoring program) is normal. She likes to take her baby with her when she picks him up from work but was advised against this. She cannot understand why being around pesticides would be a problem for her baby when her husband who had direct contact is fine.

What is it about a child’s body that would make it more vulnerable than an adult?

Child’s Biological Factors

Higher metabolic rate More skin per body weight

Developing organs

Biology- Higher Dose By:

1. Skin• More permeable: highest at birth• 2.7 x more skin surface/weight than

adults

2. Lungs• Inhales more per day (1.7x) than adult

Biology: inhalation dose

Age (years)

Weight (kg)

Inhalation Rate (m3/day)

“dose”(m3 per kg per day)

<1 7.6 4.5 0.592

1-2 13 6.8 0.523

3-5 18 8.3 0.461

6-8 26 10 0.385

9-11 36 14 0.389

12-14 50 15 0.300

15-17 66 17 0.258

Vulnerability to Health Effects: Organs Still Developing

Nervous System Sex organs Lungs Kidneys

Bones Immune Metabolism Digestive system

“A little kid goes from a single cell to a laughing, sociable, intelligent, friendly human being over the course of two years. That’s dramatic growth and development!”Kenneth Olden, PhD, former Director, National Institute of Environmental Health Sciences

Parent Activities

Ramon and Rosa’s 3 year old has small amounts of OP’s in his urine (he was recruited for a PNASH study). They are asking you how this could occur. The family live 5 miles from the closest orchard.

Why is this? What things are the parents doing that would account for this? What questions will you ask and what things will you look for in the household

Sources – Child-Pesticide Encounters

Dietary

Residentialuse

Drinkingwater

Parental take-home

Farm proximity

Proximity Data from Agricultural Washington State

PNASH Center Research

Proximity

Family type1462 141141235N =

Ref family

≥ 1/4 mile

200 ft - 1/4 mile

50 - 200 ft

≤ 50 ft

Ref family

Ag family

.30

.25

.20

.15

.10

.05

0.00

-.05

Parental Take-Home

Parent Activity Questions Source of food and water Parent occupation? Shower after working before holding children? Work clothes and shoes in the house? Laundry practices ? Use household pesticides ? Garden pesticides ? House and car cleaning ? Pesticide storage? Location of day care? House near fields?

Key Household Safety Points

1. Proximity2. Take home3. Garden4. Animals5. Recycle6. Decant7. Storage8. Disposal9. Child

play/daycare

“ Partly Trained Gorillas Always Run Down Streets Doing Cartwheels”

pesticide

Pesticide

Types of Pesticides

Insecticides Herbicides Fungicides Rodenticides

‘cide = to kill

DisinfectantsFumigants

Pesticide Chemical Families-grouping based on similarities-

1. Similar chemically (similar structure)2. Attacks pests in a similar way (toxicity)3. Common treatment + antidote

OrganophosphateOP

CarbamateC

PyrethroidPY

OrganochlorineOC

Chlorophenoxy Paraquat

Diquat

Pesticide Sample Label

Type of pesticide (used for?)Company nameBrand nameCommon/generic name (active

ingredient)Chemical family (? atropine under 1st

aid)Signal word (hazard level)

Pesticide Classification Table

# Type Company

Name

BrandName

CommonName

Chemical Family

SignalClass

1.

insecticide

Gowen Supracide

methidathion

OPorganophosphate

Danger-PoisonIb

COMPANY BRAND COMMON TYPE FAMILY SIGNAL Who

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

Pesticide Labels

Bayer Temik Aldicarb Insecticide Carbamate Danger-poison la

Verdicon Sevin Carbaryl Insecticide Carbamate Caution ll

UCP Alliance Thiodan Endosulfan Insecticide Organochlorine Warning ll

Bayer Guthion Azinophos methyl Insecticide Organophospate Danger-poison lb

Dow Dursban Chlorpyrifos Insecticide Warning ll

Syngenta Gramoxone Paraquat Herbicide Paraquat Danger-poison ll

Helena Weed Rhap 2, 4-D Herbicide Chlorophenoxy Danger ll

DuPont Asana Esfenverlate Insecticide Pyrethroid Warning lV

Bayer Captan Captan Fungicide Danger-poison

Max Roundup Glyphosate Herbicide Caution U-IV

II

Dow DithaneMancozeb Fungicide

Caution U-IV

Cerexagri-Nisso Ziram Ziram Fungicide Danger III

Exercise: Classifying Pesticides

Organophospate

How toxic is it?

Source: Richards, Kerry Penn State University Extension Service

Source: Richards, Kerry Penn State University Extension Service

LD50

Lethal dose = Amount of chemical it takes to kill 50% of an experimental population

Source: Richards, Kerry Penn State University Extension Service

Adapted from Richards, Kerry Penn State University Extension Service

DANGER/POISON = extremely toxic by ingestion DANGER = extremely toxic high potential for skin and eye irritation

*

*

Source: Richards, Kerry Penn State University Extension Service

Insecticides

• ChE Inhibitors: – Organophosphates – n-methyl carbamates

• Pyrethroids– Pyrethrins (ocloresin extract of chrysanthemum) – Pyrethroids (the synthetic derivative)

• Organochlorines (e.g. DDT)• DEET• Boric Acid• Fluorides• Nicotine • Arsenicals

Herbicides

• Chlorophenoxy herbicides (e.g. 2-4D)

• Paraquat and diquat• Pentachlorophenol and

dinitrocresol (wood preservatives)• Copper chromium arsenate

( decks, fences, and children’s wood playground sets – d/c 2003)

Fungicides

• Hexachlorobenzene• Thiram • Maneb• Methylmercury compounds

Fumigants

• Cyanide, • 1, 3-

dichloropropane• Metam sodium• Methyl bromide• Naphthalene• Phosphine gas (from

aluminum phosphide)

Rodenticides

• Warfarin-related compounds: – Warfarin – Coumarins – Brodifacoum – Difenacoum (so-called

“super warfarins”)

• Others: – Thallium– Zinc phosphide– Sodium fluoroacetate

Disinfectants

• Agents used for sanitization and sterilization in the home and hospital

• Registered as pesticides by the U.S. EPA• Examples include

– Alcohols – Chlorhexidine – Hypochlorites – Iodines – Phenols – Pine oil

General central nervous system • Fatigue• Dizziness• Headache• Tremors• Ataxia • Convulsions (uncommon w/carbamate)• LOC (uncommon w/carbamate)• Coma (uncommon w/carbamate)

From muscle over stimulation: • Muscle weakness• Muscle cramps• Muscle fasciculations

From gland over stimulation: • Salivary gland- excessive salivation• Sweat gland- excessive sweating• Lachrymal gland-excessive eye tearing

From organ over-stimulation: • Eyes • Gastrointestinal

• Pulmonary

•Blurred vision (constricted pupils)• Stomach cramps• Nausea• Vomiting• Diarrhea• Chest tightness• Wheezing• Cough• Runny nose

Organophosphates: 30”-240

Carbamates: 15”-30

PyrethroidsPyrethroids: are irritants to the eyes, skin and respiratory tract. The symptoms last from 1-2 hours. Systemic toxicity from inhalation or dermal absorption is low.

Normal use: * Paresthesias (cyno pyrethroids) * Shortness of breath (wheezing)* Mucous membrane irritation (throat nose)* Skin itching

If ingested: • Loss of consciousness/coma • Seizures (cyno-pyrethroids)

High doses: • Vomiting • Diarrhea • Excessive saliva • Muscle fasciculation • Ataxia

• Irritability: to sound ~ touch

Cyno-pyrethroids: fenverlate, flucythrinate, fluvalinate cypermethrine, deltapermethrin,

Organochlorines: 10 - 480

lipophylic

The nerves stimulating glands are not affected so you will NOT see:

• excessive salivation• excessive sweating• excessive eye tearing (or over-stimulation of

small muscles like)• twitching eyelids

CNS Effects• Muscle Weakness• Dizziness• Headache• Numbness • Nausea/vomiting• LOC• Seizures• Tremors• Ataxia • Anxiety/restlessness• Confusion

ParaquatParaquat is very toxic to the skin and mucous membranes. Particles are too large to get deep into the lungs*, but once in the blood it collects in the lungs. If ingested high case fatality rate.

• Skin: • dryness, cracks• erythema • blistering• ulcerations

• Nails: • discoloration• splitting nails• loss of nails

• Respiratory tract: • cough• nosebleeds• sore throat

• Eyes: • conjunctivitis • ulceration, scarring, blindness

• Ingestion: • lung fibrosis (stiff lungs)• multi-system organ failure,

specifically • respiratory failure• kidney failure

DEETDIETHYLTOLUAMIDE

• Few toxic cases - given the widespread use

• Toxic if ingested• Children: toxic encephalopathy w/

heavy use on large surface area on kids (+ ETOH - isopropyl or ethyl)

• Dermal problems: tingling, irritation, desquamination, contact dermatitis, exacerbate pre-existing skin dz

• Kids: use 5-6.5% formulations

Boric AcidAnts, Cockroaches in Residences

“broiled lobster appearance”

Boric Acid Respiratory tract irritant

Moderate skin irritant

Historic antibacterial: poisonings from burn compresses, diaper powder, irrigation solutions

Targets: GI tract, skin, vasculature, brain

Chronic ingestion more toxic than acute (13 ½ life)

Absorption: via gut and abraded skin

Fluorides

• Transformed in stomach to corrosive hydrofluoric acid: thirst, nausea-vomiting,

diarrhea, abdominal pain• Fluoride ion reduces extra-cellular fluid

concentrations of Ca+ and Mg hypocalcemic tetany

• Cardiac arrythmias- shock 2ndary to fluid/electrolyte imbalances, hypokalemia and the fluoride itself

• CNS H.A. muscle weakness, stupor, seizures and coma