COMPETENCIES The Raw Material

1. COMPETENCIESThe Raw Material National Pesticide Competency Guidelines for Medical & Nursing Education A Project of the National Strategies for Health Care Providers: Pesticides InitiativeJanuary 2003

2. Your Tasks • Understand the Competencies • Identify Insertion points in your curricula • Help mold the presentation to be consistent with your curricular format • Help student champion help us organize the training package • Help us insert and assess the insertion process • Help spread the word • Professional associations • Give us general advice as to content and packages

3. Timeline

4. A Kaleidoscope of Options • The Competencies are a huge group of skills and knowledge areas • If we can bring pesticides-occupational and environmental health into the curriculum we will be achieving our goals

5. Today • Content of Competencies • General content of the competencies • Follow along with your competencies • Ponder….. • Which ones should I choose? • How will this fit into my curricula? • What style of presentation should this take?

6. COMPETENCY IKnowledge & Concepts of Pesticides Principles of Environmental & Occupational Health Related to Pesticides

7. Knowledge & Concepts of Pesticides • Basics of Environmental & Occupational Health (MK) • Broad Spectrum of Pesticidal Chemicals (HM) • Mechanisms and Pathways for Exposure (HM) • Temporal Relationship: Exposure - Illness (HM) • Advanced Toxicity of Pesticides (MK)

8. How the Health of our Environment Affects our HealthBasics of Environmental Health I-1a • Environmental media through which pesticides might affect us: Water Food Soil Air

9. Air • Most pesticides have local effects • Pesticide drift in communities located near farming operations or chemical plants • Example: Metam-sodium chemigation, Aircraft applications, Airblast applications • Example: Bhopal incident from Union Carbide Chemical plant • Pesticide exposures due to domestic use and residual air contamination indoors or outdoors • Example: flea bombs, herbicide applications • Some have general effects or are carried well beyond targets and may have far reaching effects • Example: Fumigants and others in California Valley air, Methyl Bromide in oxone Depletion

11. Pesticides in the Air Aircraft applications Airblast applications Chemigation • Domestic application Methyl bromide Smog

12. , Purdue Water • Direct application or accidental Spillage may pollute water • Example: Carbamate application for Ghost shrimp control, Washington State • Example: Metam-Sodium Spill in Sacramento River • Pesticide migration contaminates ground water • Example: Ground water testing results • 265 pesticides detected in 45 states in 16,606 wells

13. Soil • Residual pesticides may contaminate soil for years • Lead Arsenate, Past heavy use results in soil contamination • Other less persistent chemicals are also important

14. Soil Contamination Ag chemical transport (train wreck) Orchard sprayer Abandoned storage units

15. Food • Food may contain pesticide residues beyond safe levels • Studies of children show that pesticide levels in urine of children correlate strongly with certain foods eaten • Consequence of these exposures is uncertain • Organic diets eliminate pesticide metabolite excretion

16. Likely Household Exposures • Pesticide use in the Home • EPA estimates that 74 Million pounds of pesticide active ingredients are used annually in US homes and gardens • 85% of households have some pesticides • Banned and old pesticides are present in many homes • Misuse of agricultural pesticides may lead to severe toxicity in the home • Example: Parathion used in Mississippi, Arkansas, Louisiana, Alabama • Misapplication of domestic pesticides may lead to toxicity as well. • Example: Washington state flea bomb use • Pesticides used in the garden and lawn may find their way into the bodies of children and adult residents of the home. U.S. EPA, Pesticides Industry Sales and Usage: 1994 and 1995 Market Estimates, Table 3. U.S. EPA, National Home and Garden Pesticide Use Survey, March 1992, p. 6.

17. Issues that Affect Children, Vulnerable Populations & the Elderly • Children are more susceptible: • Dose and body weight • Metabolic rate • Respiratory rate per body weight • Surface area per body weight • Developing systems • Immature enzyme systems and immune systems • Behavior: • Picca and lack of knowledge and caution

18. Other Vulnerable Populations • Asthmatics/COPD, more susceptible to minor irritation • Older adults may be less mobile and may be on medications which alter metabolism or suffer from reduced excretory ability • Children of farm working families are at risk both as a function of being children and being close to highly toxic pesticides

19. Occupations at Risk • Pesticide applicators • Structural applicators and agricultural applicators • Farm workers • They may enter treated fields • Longshoremen • May handle treated grain, wood, and other imported products • Health care workers • Disinfectants and sterilizants for medical equipment • Municipal water workers • Chlorine is a pesticide

20. Competency I-1eToxicology of Pesticides • Organophosphates & Carbamates • Inhibition of cholinesterase • Organophosphates are like unwelcome guests: they come to stay • Carbamates are like money: here today, gone tomorrow

21. Action of Acetylcholine & Cholinesterase

22. Normal Electrical Nerve Impulse Transmission nerve cell • - acetylcholine • - cholinesterase • - acetate • choline • - organophosphate • - 2-PAM muscle

23. Nausea Vomiting & Headache

24. Changes to the Eye,Pupil Constriction & Blurry Vision

25. Glandular Over-stimulation gland

26. Pralidoxime TreatmentIt Differs for Ops & Carbamates

27. Metabolism of Parathion

28. Several Factors Modify Toxicity • Genetics • Activity of PON1 • An enzyme that hydrolyzes paroxon • Behavior • Long sleeve shirts, may be barriers, may be enhancers • Hygiene. Washing hands before eating etc. • Nutrition • Certain dietary constituents may turn on or turn off metabolizing enzymes.

29. Pyrethroids: A Derivative of a Natural Pesticide • Pyrethrins, derived from the chrysanthemum flower • Modified chemically for greater environmental durability to pyrethroids. • Two classes: Type I and Type II Pyrethroids with a cyano group tend to be in type II. Toxicity Differs.

30. Pyrethroids

31. Metabolism of Pyrethroids • Homeothermic animals tend to metabolize pyrethroids quickly • Poikilothermics tend to be much slower metabolizers • Infants metabolize pyrethroids slowly and may by more susceptible.

32. Competency I-2e Moral, Ethical and Legal Implications for Patients of Reporting and Referral

33. Mandatory reporting in Some States • WA, OR are the two northwest states with mandatory reporting (more on this later). • Health care providers are the front line against epidemics • Our responsibility goes beyond a single patient to the family, the workplace and society

34. Workers Refuse • Workers may fear retaliation • Loss of job • Loss of respect from supervisor • This may create a very difficult conundrum for providers • Must report • Must respect patient’s wishes • Must protect worker from reexposure

35. Worker May be an Index Case • Exposures at schools, daycare centers, businesses may present with a single case • Reporting these cases may embroil the provider in a legal maelstrom • Prevention of more illness must feature prominently in the clinicians mind

36. Competency I-3: Population Based Knowledge & Skills • The Laws About Pesticides • Food Quality Protection Act • Single Health Based Standard • Re-evaluation of registered pesticides • Ten Fold safety factor • Reasonable Certainty of “no harm” • Cumulative Effects from all sources must be considered • Right to Know provisions for consumers

37. Impacts of Pesticide Overexposure Might be On Whole Communities or Whole Workforces • Contamination of an entire neighborhood may occur • Example: Bhopal • Contamination of a common resource may occur • Example: A contaminated water system • Drift or soil contamination may affect large tracts of land or soil • Example: Lead Arsenic in Soil in Wenatchee

38. Dealing with PopulationsPublic Health Approach • Primary prevention • Prevent exposure • In the workplace by controlling or substituting, or protecting the worker • In the environment but substituting, administratively reducing use (IPM) • Education of the consumer/worker to prevent overexposure

39. Public Health Approach • Secondary prevention • Preclinical diagnosis • Cholinesterase monitoring is the best example to date • This may motivate primary prevention through economic means in workplaces • Urinary metabolite monitoring is yet to be applicable

40. Public Health ApproachTertiary Prevention • Diagnosis-treatment and rehabilitation to prevent chronic sequelae • Tertiary prevention means treatment and removal from further exposure

41. Use Of Epidemiological Data for Worker Compensation Cases • Relative risk of 2 = greater than 50% certainty of association • Epidemiologic data showing associations between purported exposure and the patient’s disorder should be used to justify a claim • “More probable than not” • “But for the exposure, the patient would not be sick” • These is 50% certainty language

42. Epidemiological Data for Cause & Effect • Cancer and pesticide exposure • Case-control studies have supported a cause-effect relationship between cancer and pesticides • Cohort studies have been less supportive • Newer cohort studies, with more meaningful exposure estimates have begun to bear out the cancer hypothesis

43. Case-Control vs. Cohort Studies • Case-control • Looking back at controls from the diagnosis of disease • Cohort studies • Looking forward from exposure toward the development of disease

44. Competency I-3bSocio-economic Implications Impacts of Pesticide Related Illness • For the day laborer, a day lost is an economic burden • Pesticide Diagnosis is complex, • Worker compensation systems are set up for injuries, not disease • For Employers: • The loss of a well trained worker is a hardship • Pesticide contamination of a water supply can be economically devastating for a small community • Society suffers from contamination through loss of resources both economic and esthetic - Cross-subsidy of occupational illness

45. Case Examples of Worker Poisonings • Acute, intense pesticide poisoning with OP in an applicator • Persistent neuropsychological effects • Depression, agitation, memory loss, lower function • Poisonings in a farm working crew • Group concern about long-term effects lead to anxiety and depression • Pesticide allergy • Rare but depilating to a pesticide applicator

46. Advocacy in Occupational & Environmental Health • A workplace illness is totally avoidable • The cost of workplace illness should be born by the employer, not the worker • Pesticide poisonings too often go unrecognized and workers bear the cost of care and time loss due to illness • The savvy clinician is the sick workers best friend • Well trained in the WC system • Willing to fight for the workers right to cure and maintenance • Willing to point out the workplace hazard to proper authorities

47. Competency 1-3c Barriers to Optimal Care of Vulnerable Populations • Undocumented workers may not effectively defend their own interest • Migrant workers may be unaware of worker compensation, or afraid to use it. • In WA, documentation status does not affect Worker Comp Eligibility • Earning while sick may be preferable to not earning healing. • Blackballing is a reality and is greatly feared

48. Obligations of Healthcare Providers • If you suspect a workplace illness, you are obliged to file a claim, unless the worker refuses • If you suspect a pesticide as a cause of illness, you are obliged to report it in Washington State

49. Competency I-3dPrevention and Benefits of Pesticide Alternatives • Provide guidance • Caution against overuse of DEET, Flea bombs, garden pesticides • Suggest alternatives • Pyrethrins saturated clothing, screening, larvicides such as BT, safer soap, BT for caterpillar control • Master Home Environmentalist referral • County Extension and Washington State University

50. Health People 2010A goal for the Near Future Reduce pesticide exposures that result in visits to a health care facility. Target: 13,500 visits per year. Baseline: 27,156 visits to health care facilities were due to pesticides in 1997. (129,592 pesticide exposures were documented in 1997.) Target setting method: 50 percent improvement. Data source: Toxic Exposure Surveillance System (TESS), American Association of Poison Control Centers. Pesticide exposures include those involving disinfectants, fungicides, herbicides, insecticides, moth repellants, and rodenticides, as defined by EPA. The American Association of Poison Control Centers surveillance covers approximately 93 percent of the U.S. population.”