Alanna Bares MD MPH Pesticide Epidemiology Section Office of Environmental Health Hazard Assessment OEHHA California Environmental Protection Agency CalEPA CARHC 14 th Annual Conference ID: 1038468
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1. Pesticide Use and Pesticide-Related Illness in California Alanna Bares, MD, MPHPesticide Epidemiology SectionOffice of Environmental Health Hazard Assessment (OEHHA)California Environmental Protection Agency (CalEPA)CARHC 14th Annual ConferenceFolsom, California July 26-27, 2022
2. AgendaIntroduction to pesticidesPesticides in CAPesticide-related illnessesReporting pesticide-related illnessesPesticide-related illness prevention2
3. MEET THE TEAMPesticide Epidemiology SectionToxicologistResearch ScientistJamesALANNAToxicologistPublic Health Medical OfficerOuahibajingHealth EducatorNANCY3
4. Introduction to PesticidesCommon pestsClassification of pesticides4
5. Common Pests5
6. Classification of PesticidesBy target function:InsecticidesMiticidesHerbicidesFungicidesNematocides Rodenticides FumigantsDisinfectants, sanitizers*Plant growth regulatorsInsect repellentsBy chemical group:OrganophosphatesN-methyl carbamatesPyrethroidsOrganochlorinesNeonicotinoids6
7. Pesticides in California 7Pesticide regulation in CAPesticide use in CAExposure assessment
8. Pesticide Regulation in CaliforniaUS EPARegisters all pesticides sold or distributed in the United StatesEstablishes a maximum permissible level for pesticide residues allowed on food for human consumption and animal feedCalifornia 8
9. DPR’s Pesticide Use Reporting (PUR) ProgramThe most comprehensive in the worldAll “agricultural” use, a broad legal definition:Production agriculture Postharvest treatments of agricultural commoditiesWatersheds, rights-of-way, landscaped areasTreatment in poultry and fish production as well as some livestock applicationException: home-and-garden use, most industrial and institutional uses9
10. Pesticides Used for Production AgricultureAnnual average 191 million lbs. in 2015 - 201910
11. CA Commodities with High Pesticide Use11
12. 12Top 10 Active Ingredients Used for Production Agriculture
13. Pesticides Risk on Human HealthHow toxic is the chemical?How much exposure is there? 13Risk = Toxicity x Exposure
14. Occupational Pesticide Exposure ScenariosPesticide handlers - by direct contactField workers – exposure to residues on plant leaves and produceDrift or off-target movement of applied pesticides through airHandling of pesticide containers that haven’t been de-contaminatedMost occupational pesticide illnesses are due to dermal exposure14
15. California-specific Exposure Assessment Pesticide-related illnessApplication scenarios based on PURRegion, use amount, use acreage, application methodInhalation: air concentrationsIngestion: food intake & residueCommodity Drinking water15
16. Pesticide-Related Illnesses Diagnosis & Pesticide Exposure HistoryCase Scenarios & Treatment 16
17. 17Key Points for Diagnosis
18. Exposure History18What chemicals were you using?How did this happen? How long were you exposed?When did this happen? When did you first notice these symptoms?Do his symptoms match known pesticide effects?
19. Examples of Occupational Screening Questions 19Are you exposed to toxic chemicals at your job? Are you exposed to any other chemicals at work or at home?Do your symptoms seem to be related to anything at work? Do your co-workers have the same or similar symptoms?Please tell me more about your specific job duties. And what about your previous jobs – were you also exposed to chemicals there?
20. 20Routes of ExposureInhalation FastestIngestion Frequently used in self-harm attemptsMost common route for childrenDermal absorptionSlowerSymptoms may not appear for 6-12 hours after exposureMost common route for occupational exposures
21. Case ScenariosSoil Fumigation and Off-Site DriftField Workers Poisoned by Pesticide Residues21
22. 22Case Study 1 Vapors from a soil fumigation make the neighbors sick (Arvin, CA)
23. Symptoms Observed in ResidentsO’Malley et al, (2005)23
24. Case Study 2 Pesticide residues put 16 farm workers in the hospital24
25. Signs and Symptoms of OP/Carbamate PoisoningSLUDGE/BBB SalivationLacrimationUrinationDefecationGastrointestinal painEmesis Bradycardia, Bronchorrhea, Bronchospasm25Primary cause of death is Respiratory Failure
26. Differential DiagnosisMild casesAcute viral syndromes (flu-like illness)GastroenteritisRespiratory infectionsAsthmaPsychological dysfunctionAllergic dermatitisSevere CasesAcute cerebrovascular accidentHeat strokeHeat exhaustionEpilepsyInfectionsMeningitisEncephalitisPneumoniaPsychosis26
27. Management of Seriously Poisoned Patients (Hospital Setting)Medications Anticholinergic medication is mainstay of treatmentAtropine sulfate, administered IV, or IM (if IV not available) Cholinesterase reactivatorPralidoxime (2-PAM, Protopam)Adults and children >12 years: by IV infusion27Supportive CareEndotracheal intubation and mechanical ventilation for oxygenation and to prevent aspirationDecontamination concurrentlyClothes removed and bagged (dispose of shoes)Completely wash patient (skin, skin folds, scalp, under fingernails) with water and soap or an alkaline detergent (flush eyes if indicated)Roberts & Reigart (2013). Recognition and Management of Pesticide Poisonings, 6th Ed
28. Reporting Pesticide-Related Illnesses in CAHow to reportDataLimitations28
29. Pesticide-illness Reporting in CaliforniaKnown or suspected pesticide-related illness or injury is a “reportable disease” (Title 17 of the California Code of Regulations). Just like communicable disease reporting, health care providers play a key role in pesticide-related illness reporting to state and local authorities. 29
30. 30Who must reportPhysicians and surgeonsWhat to report Any known or suspected case of pesticide-related illness or injury
31. To Whom31Local Health OfficerWithin 24 HoursWhen
32. How?California Poison Control CenterCalREDIE California Reportable Disease Information Exchange Local Health Officer or DesigneeConfidential Morbidity Report32
33. Reporting a Work-Related Pesticide IllnessDoctor’s First Report of Occupational Illness or Injury5 Days7 DaysorEmployerInsurerLocal Health Officer33
34. 34Does Reporting Reduce Excessive Exposure?3 “A Guide to Pesticide Regulation in California” (DPR, 2017)
35. Some Causes of Underreporting Non-specific symptoms that resemble other diseasesPhysicians who are unfamiliar with pesticide effectsInvestigations that fail to identify the pesticide Difficulty in identifying and tracking chronic effectsProviders that are reluctant or unable to report incidentsLack of a universal, mandatory legal duty to report incidentsLack of a central reporting point for all incidents 35CARecognition and Management of Pesticide Poisonings, 6th ed
36. Illness Prevention36General dos and don’tsThe California Medical Supervision Program
37. General dos and don’ts37
38. 38
39. Why?To protect pesticide handlers who work with the most toxic cholinesterase inhibiting pesticides.How?By monitoring blood cholinesterase activity levels.California Medical Supervision Program39
40. 40
41. Recommendations Based on ChE LevelsWhen must the worker stop handling these pesticides: When can the worker resume handling these pesticides: 41If ≤ 70 % of RBC OR if ≤ 60 % of plasma baseline values *Note: workers can continue working in other capacities If levels return to 80% or more of worker’s baseline for both plasma and RBC
42. OEHHA’s Health Education ResourcesOnline Course Provide CME Credits (Free!) on Recognition, Management and Reporting of Pesticide Illness https://oehha.ca.gov/pesticides/clinician-trainings Health Education Materialshttps://oehha.ca.gov/pesticides/health-education-resources 42
43. The EndContact InformationEmail: Alanna.Bares@oehha.ca.govPhone: 916-323-8808
44. On-Line Sources of InformationRecognition and Management of Pesticide Poisonings, 6th Edition (J.R. Roberts and J.R. Reigart, 2013)https://www.epa.gov/pesticide-worker-safety/recognition-and-management-pesticide-poisonings5th edition available in Spanishhttps://espanol.epa.gov/seguridad-laboral-al-usar-pesticidas/reconocimiento-y-manejo-de-los-envenenamientos-por-pesticidasNational Pesticide Information CenterPhone: (800) 858-7378http://npic.orst.eduCalifornia Department of Pesticide Regulation, Pesticides and Human Health Informationhttp://www.cdpr.ca.gov/docs/dept/quicklinks/humanhea.htm44
45. 45California Government Sources of Information Department of Pesticide RegulationWorker Health and Safety Branch: 916-445-4222www.cdpr.ca.gov/docs/whs/whs_homepage.htm Department of Public Health, Occupational Health BranchOccupational Pesticide Illness Prevention Program: 800-970-6680https://www.epa.gov/pesticide-worker-safety/recognition-and-management-pesticide-poisonings Office of Environmental Health Hazard Assessment Pesticide and Environmental Toxicology Branch: 510-622-3170www.oehha.ca.gov/pesticidesCalifornia Medical Supervision Program Calculator https://oehha.ca.gov/pesticides/general-info/medical-supervisor-calculator