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G reen Tobacco Sickness and Salivary Cotinine Levels in Connecticut Shade Tobacco Farmworkers

G reen Tobacco Sickness and Salivary Cotinine Levels in Connecticut Shade Tobacco Farmworkers. Marcia Trapé-Cardoso, MD*; Anne Bracker, CIH, MPH; Michael Grey, MD, MPH; Eddie Sapiain, CTCOSH; Cheryl

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G reen Tobacco Sickness and Salivary Cotinine Levels in Connecticut Shade Tobacco Farmworkers

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  1. Green Tobacco Sickness and Salivary Cotinine Levels in Connecticut Shade Tobacco Farmworkers Marcia Trapé-Cardoso, MD*; Anne Bracker, CIH, MPH; Michael Grey, MD, MPH; Eddie Sapiain, CTCOSH; Cheryl Oncken, MD; Laura Victoria Barrera, MPH; Bruce Gould, MD University of CT Health Center and School of Medicine 131st Annual APHA Meeting – November 17, 2003

  2. Abstract Background: Green Tobacco Sickness (GTS), acute nicotine poisoning, has been reported among workers who harvest tobacco. The objective of this prospective study was to determine whether or not the Connecticut shade tobacco farmworkers who have symptoms consistent with GTS also have a corresponding increase in salivary cotinine. Methods: The study utilized a prospective cohort design to evaluate salivary cotinine concentrations and symptoms of possible GTS in a population of shade tobacco farmworkers compared to a control group of nursery workers. Workers were assessed at two points in time (planting and harvest season). An additional group of exposed workers were recruited during harvest and added to a cross-sectional. A Repeated Measures Analyses of Covariance (ANCOVA) statistical model was used to analyze the data.

  3. Results: There was no statistically significant increase in salivary cotinine over time in this population of shade tobacco farmworkers. During the harvest season there was not a significant difference between the cotinine levels of the tobacco and the nursery workers when the data was controlled for tobacco use. During the harvest season, 4 tobacco workers (8%) and 1 nursery worker (2%) reported symptoms consistent with GTS. Because the 4 tobacco workers were recruited during the cross-sectional phase of the study, they did not have baseline cotinine levels. • Conclusion: Control strategies, specifically the careful techniques used to handle shade tobacco leaves, appear to reduce shade tobacco farmworkers’ dermal nicotine absorption. Limitations of this study and need for further studies are discussed.

  4. Green Tobacco Sickness • Acute nicotine poisoning presumably from the transdermal absorption of nicotine from tobacco leaves. • Case definition: Headache or Dizziness and Nausea or Vomiting after working in tobacco (Arcury, 2001) • Prevalence estimates: 9-41% (Weizenecker, 1970, Gehlbach, 1974, Behlbach, 1975, Ballard, 1995, Quandt, 2000 and Arcury, 2001)

  5. Cotinine: a biomarker of exposure • GTS non-specific constellation of symptoms • Cotinine (metabolite of nicotine with ½ life of 20 hours): a biological marker of exposure • Salivary Cotinine correlates well with serum cotinine • Specimens are easily collected by non-invasive procedure

  6. Do CT Tobacco Farmworkers Report Green Tobacco Sickness? • No cases diagnosed among migrant shade tobacco farm workers seeking care at outreach clinics • Retrospective Review of shade tobacco workers seeking care at a medical clinic (2001) found: • ICD-9 codes – 15 %- primary or secondary diagnosis that could be categorized as possible GTS (no ICD-9 code for GTS) • Chart review for tighter case definition (all nonsmokers) – 4 % • Trapé et al, JOEM 6/2003

  7. Seeds planted in rows Under shade

  8. Stringing

  9. Wrapping and Suckering

  10. Harvesting

  11. Harvesting with Bicycle Powered Conveyor

  12. Methods • Prospective Cohort • Shade tobacco workers (exposed) and Nursery workers (non exposed) • Planting Season (Time 1) and Harvest Season (Time 2) • Questionnaire Interview • Biological Monitoring (salivary cotinine) and • CO in exhaled breath • Statistical analysis • Repeated Measures Analyses of Covariance (ANCOVA)

  13. Results Shade tobacco Workers (exposed) Time 1- 53 Planting Season Time 2- 29 (55%) Harvest Season +24 (added tobacco workers for a cross- sectional survey because many workers left before time 2) Nursery Workers (non exposed) Time 1- 59 Planting Season Time 2- 43 (73%) Harvest Season

  14. Results- Demographic DataShade Tobacco (Exposed) and Nursery Workers (Unexposed)

  15. Results- Demographic Data Shade Tobacco (Exposed) and Nursery Workers (Unexposed)

  16. Salivary Cotinine (ng/dL) in Paired Workers

  17. ANCOVA: Salivary Cotinine (ng/dL) by Time and by Farm Type

  18. Planting Season (time 1 pre-exposure)Workers with Possible GTS

  19. Harvest Season (time 2 during exposure)Workers with Possible GTS

  20. Discussion • No statistically significant increase in salivary cotinine between planting and harvest time among shade tobacco farmworkers • Among all studied farmworkers (nursery and tobacco) there was a statistically significant increase in cotinine levels over time. This effect remains even when controlling for type of farm. There was a trend indicating that tobacco use may have played a role in this increase. • During the harvest season, there was no difference between the cotinine levels of the tobacco farmworkers compared to the control group (nursery workers). • GTS: non-specific case definition • 1 tobacco worker with possible GTS had a salivary cotinine level of 0 ng/dL • Unexposed nursery workers with no occupational exposure to nicotine reported GTS symptoms

  21. Conclusions • Case definition should include documentation of increase in salivary cotinine • When compared to workers that harvest cigarette tobacco, shade tobacco farmworkers appear not to have significant occupational exposure to nicotine or high prevalence rate of possible GTS • Work practices- less dermal exposure among shade tobacco (work practices represent potential interventions that could be introduced during the harvesting of cigarette tobacco) • Small sample size- unable to detect significant effect • Only two time measurements perhaps losing high peak levels in between the two sampling periods

  22. Future work • Repeat study with a larger sample size • Collect data at more frequent intervals throughout the planting and harvest season • Collect data until the end of the harvest season • Enhance tobacco use instrument • Intervention study for cigarette tobacco workers Funding: NEC-NYCAMH, UCHC HCRAC and UCHC GCRC Acknowledgements: to the many volunteers during the data collection process and to the administrative support of Miriam Muniz and Cheryl Steciak

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