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