Pesticide Effects: Integration into Health Care Provider Curricula Faculty and Student Champion Training: Part I Helen Murphy-FNP/MHS Director of Outreach Pacific Northwest Agricultural Safety and Health Center University of Washington May 31, 2006

Agenda Part I: Nurse Murf Part II – Dr. Matt 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;

Washington State Pesticide Events - 2003 67% Source: 2004 Pesticide Incident Reporting and Tracking (PIRT) Annual Report

Washington State Source of Case Reports 2002 and 2003 Combined Workman’s Comp Dept of AG Poison Control Source: 2004 Pesticide Incident Reporting and Tracking (PIRT) Annual Report

Agricultural vs. Non-Agricultural Cases of Poisonings Source: 2004 Pesticide Incident Reporting and Tracking (PIRT) Annual Report

Occupational versus Non-Occupational Cases of Pesticide Poisoning Source: 2004 Pesticide Incident Reporting and Tracking (PIRT) Annual Report

Proportion of Poisonings Ranked 8th Cause of Poisonings = 102,754 cases in 2005 (4.2%) Adults Children Source: Watson WA. 2004 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System

US: Intentional vs. Unintentional Accidental 84% Suicide 8% Out of 196,164 suicide fatalities 7 used pesticides

WHO Sentinel Surveillance

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

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 Boom sprayer enclosed cab back pack-wand air blast 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 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 G. Selevan. EHP 2000;108 Suppl 3:451-455

Pesticides in Urine of 22 Children Before, During, and After Organic Diet Intervention Conventional diet Organic diet 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: Skin More permeable: highest at birth 2.7 x more skin surface/weight than adults 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

Proximity Data from Agricultural Washington State PNASH Center Research

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 “ Partly Trained Gorillas Always Run Down Streets Doing Cartwheels” Proximity Take home Garden Animals Recycle Decant Storage Disposal Child play/daycare pesticide

Pesticide ‘cide = to kill Disinfectants Fumigants

Pesticide Chemical Families -grouping based on similarities- Similar chemically (similar structure) Attacks pests in a similar way (toxicity) Common treatment + antidote Pyrethroid PY Organophosphate OP Carbamate C Organochlorine OC Chlorophenoxy Paraquat Diquat

Pesticide Sample Label Type of pesticide (used for?) Company name Brand name Common/generic name (active ingredient) Chemical family (? atropine under 1st aid) Signal word (hazard level)

Pesticide Classification Table # Type Company Name Brand Common Chemical Family Signal Class 1. insecticide Gowen Supracide methidathion OP organophosphate Danger-Poison Ib

Exercise: Classifying Pesticides Pesticide Labels COMPANY BRAND COMMON TYPE FAMILY SIGNAL Who 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 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 Organophospate 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 II Max Roundup Glyphosate Herbicide Caution U-IV Dow Mancozeb Fungicide Dithane Caution U-IV Cerexagri-Nisso Ziram Ziram Fungicide III Danger

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

* * DANGER/POISON = extremely toxic by ingestion DANGER = extremely toxic high potential for skin and eye irritation Adapted from Richards, Kerry Penn State University Extension Service

Source: Richards, Kerry Penn State University Extension Service

Insecticides ChE Inhibitors: Pyrethroids Organochlorines (e.g. DDT) 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: Others: 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

Organophosphates: 30”-240 Carbamates: 15”-30 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

Pyrethroids Normal use: If ingested: High doses: Pyrethroids: 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 CNS Effects Muscle Weakness Dizziness Headache Numbness Nausea/vomiting LOC Seizures Tremors Ataxia Anxiety/restlessness Confusion 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

Paraquat Paraquat 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

DEET DIETHYLTOLUAMIDE 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 Acid Ants, 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