Lindane: An Organochlorine Pesticide

1. Lindane:An Organochlorine Pesticide Pesticide Health Effects Medical Education Database (PHEMED 2010)

2. About Organochlorine Pesticides Organochlorines … • Are chlorinated synthetic organic molecules which may contain sulfur as well • Tend to be fat soluble • Are readily absorbed from the gastrointestinal tract and to a lesser degree, through the skin • Have a wide range of acute & chronic health effects • Are categorized as Persistent Organic Pollutants (POPs) meaning they persist in the environment and accumulate in tissues of living organisms

3. A little history … • Most organochlorines have been banned in the United States because of their long half lives. • The most notorious organochlorine, DDT, was banned in the US 1972. • Others that have been banned since then include: aldrin, dieldrin, heptachlor, toxaphene and chlordane. • Organochlorines still in use include lindane, dicofol, methoxychlor, and pentachorophenol; endosulfan will be in use until current supplies are exhausted.

4. Lindane is used to … • Protect crop seeds from insects • Control pests and ticks in forests, on pets and livestock • Control ants and other household pests • Control lice and scabies in humans

5. Lindane Regulations In the US … • The Environmental Protection Agency (EPA) banned Lindane for agricultural uses in 2006. • The Food and Drug Administration allowed Lindane in pharmaceutical products (such as shampoos and lotions) by prescription • EPA approved the cancellation of Lindane effective Oct 1 2009 • Lindane is likely to be found in homes for a few years Globally… • In May 2009, the Stockholm Convention on Persistent Organic Pollutants issued a provision that included Lindane in a list of pollutants to be phased out.

6. Symptoms of Lindane Toxicity Pesticide Health Effects Medical Education Database (PHEMED)

7. Toxicology of Organochlorines • Exposure occurs through ingestion, inhalation and dermal absorption. • Gastrointestinal and dermal absorption is enhanced by the presence of fats. • Organochlorines tend to be stored in fat tissue, Lindane to a lesser extent than others. • Excretion: • The chief route of excretion is biliary • Nearly all organochlorines yield urinary metabolites • The primary toxic action occurs on the central nervous system causing hyperexcitability

8. Array of Symptoms Associated with Lindane Poisoning • Convulsions • Cough • Dizziness • Headache • Nausea and vomiting • Tremors • Ataxia • Muscular weakness • Paraesthesias of face, tongue and extremities May also cause eye, ear, nose, throat or dermal irritation and severe respiratory problems such as respiratory depression

9. Typical Order of Symptom Occurrence: Organochlorine Poisoning • Symptoms begin to appear about 20 minutes to one hour after exposure • The progression of symptoms depends on dose and susceptibility of affected person • Nausea • Vomiting • Restlessness • Tremor • Apprehension • Convulsions • Coma • Respiratory Failure • Death Source: Carl Zenz, Occupational Medicine, 3rd. Ed.., St. Louis: Mosby 1994

10. A Few Facts About Lindane Poisoning with Lindane … • Most probable route is ingestion … though Lindane is efficiently absorbed through the skin, especially abraded skin. • Should not be used by … • pregnant or nursing women • infants • persons with excoriated skin • persons with seizure disorders

11. Diagnosing Lindane Poisoning Pesticide Health Effects Medical Education Database (PHEMED)

12. Diagnosing Lindane Poisoning Blood, tissue and urine determinations of organochlorine pesticides are available from a limited number of laboratories; however, this testing is rarely useful for Lindane because of its rapid Metabolism.

13. Diagnosing Lindane Poisoning: Health History • The health and exposure history is the primary means to identify Lindane (and other pesticides) as the cause of symptoms. • The history should determine: • The name of the pesticide product used (for Lindane – lotion, cream or shampoo) • Route of exposure (oral, skin, inhaled, eye) • The amount of the substance ingested, inhaled or absorbed • Circumstance of exposure – intentional or accidental • How did it happen? • What actions have been taken (e.g., home remedies)?

14. Lindane Poisoning:A Differential Diagnosis Laboratory studies to rule out other causes of symptoms may include: Electrolytes, Renal panel Liver function tests Arterial blood gas Urinalysis Imaging studies may include: Chest or abdominal radiography CT scan Lumbar puncture Other tests Electroencephalogram The common symptoms of Lindane poisoning may be confused with many other conditions such as: • Brain infections • Meningitis • Viral infections • Food poisoning • And many more….

15. Chronic Problems Associated with Lindane and other Organochlorines Studies that have explored possible correlations include: • Various types of cancer (Xu X et al., 2010; Chiu BC et al., 2009; Purdue M, 2007) • Neurological damage (several organochlorines are known neurotoxins) (Kamel F et al., 2005; Mladenovic D et al., 2010) • Parkinson's disease (Corrigan, FM, 2000; Hammond DB et al. 2008) • Respiratory illness (Valcin M. et al., 2007) • Birth defects (Fernandez, MF et al., 2007; Matsuura, I, 2005; Pierik, FH et al., 2007) • Abnormal immune system function (Farr SL et al., 2004)

16. Other Facts about Lindane* • Lindane has been a second line treatment for scabies and lice. Alternatives include pyrethrins & permethrins. • Available products should be limited and will become more scarce as time goes on. • Most serious adverse events are related to misuse of prescription Lindane. *http://www.fda.gov/Drugs/DrugSafety/PublicHealthAdvisories/UCM052201

17. Treatment of Organocholorine Poisoning Pesticide Health Effects Medical Education Database (PHEMED)

18. First Aid Measures • Ingestion: • Rinse Mouth • Do not induce vomiting (patient may aspirate) • Give plenty of water to drink • Dermal exposure: • Remove any contaminated clothing; • Wash skin • Refer for medical attention

19. Treatment for Lindane (and other organochlorine) Poisoning • If the pesticide has been ingested … • Gastric lavage with 2 to 4 liters of tap water • follow with saline purgative (30 gram sodium sulfate in 250 mL water) • To control restlessness and/or convulsions … • Barbiturate or diazepam IM or IV in appropriate dosage • Make sure patient is physically safe • Mechanical respiratory assistance with oxygen if needed

20. Treatment (continued) • If severely poisoned, monitor cardiac status and pulmonary ventilation • DO NOT GIVE epinephrine or other adrenergic amines. The heart is also hyperexcitable. • DO NOT GIVE vegetable oils or fats by mouth (enhanced GI absorption)

21. Follow-up Considerations • After 6 hours of observation, determine if patient needs to be admitted or sent home. • Survey for on-going home, school or work exposure • Instruct patient and/or family regarding safe storage of pesticides • Provide verbal and written information about pesticide poisoning

22. References • Chiu, BC & Blair, A (2009). Pesticides, chromosomal aberrations, and non-Hodgkins lymphoma. Journal of Agromedicine, 14(2)250-255. • Corrigan, FM et al. (2000). Organochlorine pesticides in substantia nigra in Parkinson’s disease. Journal of Toxicology and Environmental Health, 59(4):229-234 • Farr SL et al. (2004). Pesticide use and menstrual cycle characteristics among premenopausal women in the Agricultural Health Study. American Journal of Epidemiology, 160(12):1194-204.) • Fernandez, MF et al. (2004). Human exposure to endocrine-disrupting chemicals and prenatal risk factors for cryptorchidism and hypospadias: a nested case-control study. Environmental Health Perspectives, 15 Suppl 1:8-14. • Hammond DB et al. (2008). Pesticide exposure and risk of Parkinson's disease: a family-based case-control study. BMC Neurology 8:6 . • Kamel F, et al. (2005). Neurologic Symptoms in Licensed Private Pesticide Applicators in the Agricultural Health Study. Environmental Health Perspectives 113:877–882. • Matsuura, I et al., (2005). Evaluation of a two-generation reproduction toxicity study adding endpoints to detect endocrine-disrupting activity using lindane. Journal of Toxicology Science, 30 Spec No.:135-161.

23. References (continued)… • Mladenovic, D et al., (2010) The correlation between lipid peroxidationin different brain regions and the severity of lindane-induced seizures in rats. Molecular Cellular Biochemistry, 333(1-2):243-50. • Pierik FH et al Maternal pregnancy serum level of heptachlor epoxide, hexachlorobenzene, and beta-hexachlorocyclohexane and risk of cryptorchidism in offspring. (2007). Environmental Research, 105(3):364-9. • Purdue M. (2007). Occupational exposure to organochlorine insecticides and cancer incidence in the Agricultural Health Study. International Journal of Cancer. 1;120(3):642-9. • Valcin M, et al. (2007). Chronic bronchitis among nonsmoking farm women in the agricultural health study. Journal of Occupational Environmental Medicine, 49(5):574-83.] • Xu, X,et al. (2010). Association of serum concentrations of organochlorine pesticides with breast cancer and prostate cancer in U.S. adults. Environmental Health Perspectives, 118(1):60-66