1. Maternal Occupational Pesticide Exposure during Pregnancy and Three Babies Born with Birth Defects Perinatal Health Committee Raleigh, North Carolina January 29, 2007

3. Southern Coastal Plains Region Tobacco was dominant crop up until the last decade. After federal tobacco buyout, growers began looking for crop alternatives to preserve land and stay in farming. Offers ideal climate and soils for vegetable and fruit production (blueberry, strawberry, tomato).

4. Regional Tomato Production NC ranks 9 th nationally in tomato production. Two of NC’s top tomato producing counties are within this region (Bladen, Columbus). Mainly family-owned farms. Difficult to represent statistically since the crop is fairly new and there is no county-specific data on type and volume.

5. The Region’s Migrant Labor Force Growth in the region’s migrant workforce in the last five years is consistent with increasing acreage in tomatoes and blueberries. County20002005 % change Bladen8501400+64% Brunswick300600+100% Columbus6501300+100% Pender500900+80%

6. Ag-Mart in North Carolina Previously grew tomatoes in western NC. In 2002, planted 1,100 acres of tomatoes in Brunswick, Pender and Columbus counties. Relies on a crew of 500 migrant workers to stake, plant and pick tomatoes in NC, FL, NJ. Operates within a crewleader structure.

7. Ag-Mart Workforce 500 migrant workers employed, housed and transported by labor contractors. Tend to be families but single men are present. Some migrate to NC in April to prepare land and stakes, with the bulk arriving in July to plant and harvest crop through November. Highly mobile, very poor, and young.

8. Ag-Mart Workforce Many originating from the southern Mexican states of Oaxaca, Chiapas or Guatemala. Frequently speak Spanish as a second language, and a native dialect as a first language. Live and work in remote locations. Few have transportation.

13. Ag-Mart & Housing Violations In 2003, the NC Department of Labor (NCDOL) found hundreds of Ag-Mart workers living in an abandoned hotel that didn’t meet state migrant housing standards. NCDOL was unable to fine the company according to NC Migrant Housing Act. Three labors contractors were fined $20,000.

14. Ag-Mart & Pesticide Violations In 2003, the NCDOL fined Ag-Mart $12,600 for failing to properly train employees using pesticides and for not providing personal protective equipment.

15. Carlos On December 17, 2004, Francisca Herrera, 19, gave birth to a baby boy, Carlos, who had no arms and legs.

16. Jesus On February 4, 2005, Sostenes Meceda, 30, gave birth to a fourth child, Jesus, who had Pierre Robin’s syndrome.

17. Violeta On February 6, 2005, Maria Meza, 21, gave birth to an infant with a missing ear and nose, and no visible sex organs. The baby died three days later.

18. Babies Born with Birth Defects Women lived in the same labor camp in FL where they became pregnant and during their pregnancies, worked in Ag-Mart fields in FL and NC. None received prenatal care prior to the second trimester of pregnancy. Outreach workers at Guadelupe Social Services brought the babies to the attention of the local media. 2 of 3 families served by ECMHSP in Long Creek Center.

19. A Two-State Pesticide Investigation A two-state pesticide investigation was initiated—Florida and North Carolina. FL Department of Agriculture & Consumer Services investigated and fined Ag-Mart $111,200 for 88 violations. NC Department of Agriculture & Consumer Services investigated and fined Ag-Mart $184,500 for 369 violations—the largest fine in state history.

20. A Two-State Exposure Assessment In 2005, FL and NC Departments of Health initiated epidemiologic exposure assessments to determine the possible link between the pesticide exposures and birth defects. The multi-agency Florida investigation did not support or establish a causal association between the birth defects and the potential pesticide exposure in Florida.

21. Assessment of Maternal Occupational Pesticide Exposures, North Carolina

22. Methods NC Division of Public Health (DPH) began investigation in August 2005. Agencies involved: NCDPH, NCDA&CS, East Coast Migrant Head Start Project, NC Birth Defects Registry DPH report was completed and posted on website May 2006.

23. Methods AIM: To determine extent of exposure and relationship to birth defects (NC): Established critical gestation. Matched work records with pesticide application records. Determined pesticides of concern and amounts of exposure (1 & 2). Evaluated teratogenicity of pesticides.

24. Methods Conducted literature review. Examined prevalence of birth defects in Pender and Brunswick Counties. Interviewed mothers (1&2) and obtained medical records (1). Evaluated worksite violations.

25. Regulatory Inspections Label violations: many REI violations Disposal violations Storage requirement violations Worker Protection Standard (WPS) violations NCDACS: 369 alleged pesticide violations Structural Pest Control; no good addresses 2003 NC DOL investigation found violations too

26. Findings Could not prove pesticides caused birth defects. Established plausible association for Case 1 (baby born with no arms and legs). Found unacceptable levels of possible exposure (256/103). Determined work environment likely placed women (1&2) at increased risk. Study limitations.

27. Recommendations Request NIOSH technical visit. Evaluate agency coordination. Establish work group to: -Raise awareness regarding the Worker Protection Standards (WPS). -Raise awareness among women of childbearing age. -Educate medical providers about occupational/ environmental history taking. -Promote awareness among growers.

28. Recommendations Encourage more regulatory oversight. Establish a pesticide surveillance program (January 07’). Add occupational data to Birth Defects Registry. Recommend strengthening of WPS (documentation). Develop state-level task force to address pesticide exposure in the agricultural community (workers and families).

29. Responses and Activities Exposure Assessment, Findings, and Recommendations Physician Reporting Rule and Pesticide Surveillance Project (effective January 1, 2007) Interagency dialogue and collaboration to evaluate current efforts (state agencies and health providers) Pesticide prevention training (farmworkers, growers, providers)

30. Responses and Activities Targeted outreach and health education Enforcement (compliance inspections) Service Expansion in 2007 & 2008 Foster relationships with Ag-Mart and other growers Advocacy

31. Lessons Learned

32. Things to Consider Ag-Mart case is not an anomaly. Need pesticide-related prevention education efforts with tailored messages for health care providers, farmworkers and growers/crewleaders. There are few, if any educational initiatives targeting the nearly 10,000-20,000 migrant farmworker women in NC, most of whom are of childbearing age and at risk of occupational pesticide exposure. More interagency collaboration is needed; state-level task force.

33. Things to Consider Current federal and state laws are not adequately enforced and do not protect workers (bilingual inspectors, complaint system, penalty issuance, training). Pesticide surveillance is a good early detection mechanism but funding-limited. Further research on trends and long-term effects of pesticide exposure is needed.

34. Resources Ag-Mart http://www.procaccibrothers.com/sweets.htm http://www.santasweets.com/home.php Media Coverage in North Carolina http://www.newsobserver.com/100/story/402173.html http://www.newsobserver.com/125/story/410676.html http://www.newsobserver.com/712/story/415292.html http://www.newsobserver.com/689/story/417424.html http://www.newsobserver.com/102/story/419494.html Media Coverage in Florida http://www.palmbeachpost.com/localnews/content/news/special_reports/carlitos/

35. Resources Assessment of Maternal Occupational Pesticide Exposures during Pregnancy and Three Children with Birth Defects: North Carolina, 2004 http://www.epi.state.nc.us/epi/oii.html Examining the Evidence on Pesticide Exposure & Birth Defects in Farmworkers: An Annotated bibliography with resources for lay readers www.PESTed.org www.PESTed.org Pesticide Illness and Injury Surveillance http://www.cdc.gov/niosh/topics/pesticides Federal Pesticide Law, Worker Protection Standard http://www.epa.gov/pesticides/health/worker.htm

36. For More Information Stephanie Triantafillou, MPH Family/Community Partnership Specialist East Coast Migrant Head Start Project (919) 218-0212 striantafillou@ecmhsp.orgstriantafillou@ecmhsp.org Sheila Higgins, RN, MPH, COHN-S State Occupational Health Nurse Consultant NC DHHS, Division of Public Health (919) 707-5940 sheila.higgins@ncmail.netsheila.higgins@ncmail.net