Practice Skill I: Taking an Environmental History
I-1. Understand the purposes and general principles for taking an environmental history.
- Purposes include:
- Increase awareness of environmental/occupational factors.
- Improve diagnosis.
- Prevent disease and aggravation of conditions.
- Identify potential work-related environmental hazards, and/or environmental hazards in and around the home and community.
- Detect new associations.
- Improve rapport with patient.
- Know the differences in exposure effects on different groups (e.g., children, adults, pregnant and lactating women, elderly).
- Recognize sign/symptoms for pesticides under consideration (see Practice Skill IV below).
- Understand relationships of suspect exposures to health outcomes, including "hallmark" indicators of exposure.
- Recognize timing of suspected exposure to manifested signs and symptoms, including what makes signs/symptoms disappear or get worse.
I-2. Incorporate general environmental screening questions into routine patient histories.
- Adults:
- What kind of work do you do?
- Do you notice the problems you are having while you are at work? at home? in your community? in a specific location?
- What causes symptoms to come and go?
- Have you recently used pesticides, solvents, insecticides, weed killers?
- What kinds of hobbies do you have?
- Has your workplace been treated recently for insects, weeds, or other pest problems?
- Children: (Questions asked of parent or guardian)
- Where does your child go to school, daycare, playgrounds?
- Have any of these places been treated recently (e.g., sprayed) for insects, weeds, or other pest problems?
- Does your child help with gardening activities?
- Sources of food, water (e.g., well water), breast feeding of infant.
I-3. Be able to take a complete environmental exposure/health history for adults and children, covering occupational and nonoccupational exposure factors.
- Adults:
- Type of work, including how long on the job, kinds of work exposures, any specific pesticide or work exposure (e.g., agricultural, extermination), sorting of contaminated clothing, use of personal protective equipment (PPE), hygiene practices of applicators, coworker symptoms.
- Home environment (age of home, characteristics of heating and ventilation system), use of pesticides in gardening or as an insecticide in the home, well water or source of drinking water, storage of chemicals, type of food bought/eaten, anyone else in family sick, hobbies (e.g., pottery, photography, painting, furniture stripping).
- Community exposures, including home location near industry, businesses (e.g., auto repair shops, dry cleaners), landfills, hazardous substance spills.
- Children: (Questions asked of parent or guardian)
- Where child goes to school, daycare, playground, play
- Whether child helps with gardening activities
- Hobbies
- Sources of food, water (e.g., well water), breast feeding of infant
- Parent's occupational exposure
- Developmental issues
- If parents have occupational exposure, is the clothing worn during application stored and washed separately from family clothing?
I-4. Develop network of resources.
- Know local and state experts or specialists who can be consulted for differential questions or exposure questions.
- Review pesticide label, or obtain information on pesticide labels related to health hazards and adverse effects.
- Contact patient's employer about potential work-related pesticide exposures and access to material safety data sheets, for information on health hazards and adverse effects.
- Develop network of resources for assessment tools.
- Compile Web resources for Material Safety Data Sheets (MSDS) and label information.
Practice Skill II: Awareness of Community and Individual Pesticide Risk Factors
II-1. Possess basic awareness of environmental aspects of communities in which patients live.
- Recognize differences in geographic dispersion of population in urban and rural living patterns and relationship to possible pesticide exposure. Recognize that different populations and communities have different exposures to pesticides.
- Use available community assessment data to begin an evaluation of the community (e.g., windshield surveys, citizen surveys, observation, newspaper, Environmental Protection Agency (EPA) Web site zip code search, public library). Consider:
- Location of homes near major industrial complexes or freeways
- Air and water quality
- Demographics of community members
- What populations are at greatest risk (elderly, children, workers, pregnant and lactating women, other)?
- Are there any cultural issues that may be predisposing to certain exposures?
- Where do children play?
- What community resources are available?
- Where are high risk locales (farms, landfills, urban crowding)?
- Which seasonal industries pose the greatest risk of exposure?
- Are some population groups highly mobile or transient?
- What are common problems related to pest infestation (rodents, mosquitoes, ants, cockroaches)?
- Recognize potential environmental sources of exposure:
- Recreational areas and fields
- Yards
- Golf courses
- Schools and daycare facilities
II-2. Recognize high-risk occupations for pesticide exposure.
The likelihood of pesticide poisoning depends in part on whether or not an individual is present in environments where pesticide exposure is likely to occur, such as:
- Farming, agriculture, migrant work, structural application
- Groundskeeping, schools, gardening (pesticide application): structural, agriculture, greenhouse, nurseries, golf courses, freeways, forestry, residential, schools
- Extermination services
Table 1 in the original guideline document lists numerous occupations that increase the chance for pesticide exposure, as well as some nonoccupational sources that present an opportunity for pesticide exposure.
II-3. Develop community resource list.
The resource listing shown in Table 2 in the original guideline document summarizes in one place the various people and organizations that might be consulted in the event of a pesticide-related incident. They include:
- Basic hospital/emergency care
- Poison control/toxicology assistance
- Health care professional specialists
- University/public agency supports
- Resources specific to locale
Practice Skill III: Knowledge of Key Health Principles
III-1. Demonstrate key principles of environmental/occupational health, epidemiology, and population-based health.
- Understand determinants of persons, location, and time related to exposures:
- Humans differ markedly in their responses dependent on genetics, metabolism, age, gender, size, coexposure, behavior factors, routes of exposure (dermal, inhalation, ingestion).
- Location of exposure includes workplace, home, community, and recreational sites.
- Understand sources of exposure, routes of exposure, clusters of cases.
- Know the relationship of time, duration, and frequency of exposure to health outcomes, change in symptoms during the workday, week, weekends, vacation, etc.
- Recognize that the effects of environmental exposures vary with a number of factors, including rate, type, concentration, and frequency of exposure.
- Be aware of sentinel health events that are unusual patterns of illnesses occurring in persons or community groups that can also act as a "red flag" for wider environmental health problems, such as pesticide poisoning.
- Recognize that many environmental diseases are related to a number of causes interacting together:
- Understand the type and nature of exposure.
- Acquire information about possible interactions including tobacco and alcohol.
- Consider other health conditions that could be aggravated, such as asthma.
- Know exposure hazards (biological, chemical, enviromechanical, physical, psychosocial):
- Biological/infectious hazards are caused by infectious/biological agents, such as bacteria, viruses, fungi, or parasites that may be transmitted via contact with infected patients or contaminated body secretions/fluids, contamination of drinking water supplies (improper sewage treatment and solid waste disposal), and through the air (enhanced by improperly cleaned heating and cooling systems).
- Chemical hazards are various forms of chemicals that are potentially toxic or irritating to the body system, including medications, solutions, and gases. They include pesticides, (herbicides, fungicides, insecticides, etc.) and other household and industrial chemicals. Insecticides and herbicides used in large scale agriculture as well as in households, yards, and gardens, bring about numerous health effects ranging from nausea to long term neurological problems. Not only are many insecticides and herbicides acutely toxic, but some are highly suspect carcinogens.
- Enviromechanical hazards are factors encountered in the work environment that cause or potentiate accidents, injuries, strain, or discomfort (e.g., poor equipment or lifting devices, slippery floors).
- Physical hazards are agents within the work environment, such as radiation, electricity, extreme temperatures, and noise that can cause tissue trauma.
- Psychosocial hazards are factors and situations encountered or associated with one's job or work environment and personal life experiences that create or potentiate stress, emotional stress, and/or interpersonal problems.
- Consider the impact of hazardous substances on reproductive events (preconception, fetal), lactation, and developmental milestones in children (newborn, infant/toddler, and school age).
- Recognize that others may be ill (work, family) and get timeline of health problems for these or consult public health authorities for help in evaluating exposures.
III-2. Understand the dose-response relationship.
- Assess recent and past exposures to toxic agents.
- Review interpretation of exposure monitoring data done by a professional (e.g., industrial hygienist).
- Recognize that in a dose-response relationship, as the dose increases, the severity of effect increases and could be fatal with pesticides.
- Understand that high dose exposures may manifest signs and symptoms almost immediately, making causal relationships more easily identified.
- Understand that low dose exposures over a period of time may manifest effects over a long latency period, often months or years (e.g., cancer, chemical sensitivity, neuropathy).
III-3. Understand measures of morbidity/mortality and study designs.
- Know incidence rates (i.e., number of new cases of illness/injury in the at-risk population during a defined period) and prevalence rates (i.e., all cases of illness/injury in the population at a point in time) of exposure and morbidity related to the home and community.
- Know the different types of study designs that can be utilized in investigations.
- Support or conduct investigations:
- Differentiate study designs (case-control, cohort, cross-sectional studies) and when each is appropriate to use.
- Understand ethical issues in using experimental designs or clinical trials in research.
- Participate in study efforts as able.
- Be alert to possible clustering of pesticide exposure cases through case identification, examination of dose-response relationships, and population disease rate increases.
- Use epidemiologic data to link exposure and effect.
- Initiate opportunities for investigation of disease outbreaks through collaboration with public health, academic, governmental bodies (Centers for Disease Control and Prevention [CDC], EPA, etc.).
Practice Skill IV: Clinical Management of Pesticide Exposure
IV-1. Recognize the signs and symptoms of pesticide exposures (both acute and chronic).
Basic Clinical Management Techniques
Basic management of acute pesticide poisoning includes eye, skin, and gastrointestinal decontamination, airway protection, and control of seizures. These techniques apply to most pesticide poisonings although there are special concerns for specific pesticides. Basic techniques are outlined below.
Skin and Eye Decontamination
- Shower patient, hair to toe with soap and water to remove chemical.
- Rubber gloves should be worn during decontamination.
- Remember to clean skin folds and under fingernails.
- Flush eyes with lots of clean water for 10 to 15 minutes.
- Contaminated clothing should be removed promptly and bagged.
- Avoid contact with contaminated clothing and body fluids.
Airway Protection
- Ensure clear airway.
- Suction oral secretions.
- Administer oxygen unless not recommended (i.e., in paraquat and diquat poisoning).
Gastrointestinal Decontamination
No technique should be considered as routine management in pesticide poisonings, but can be considered as an option.
- Gastric Lavage:
- Use only with ingestion of potentially life-threatening amount of poison and if it can be done within 60 minutes of ingestion.
- Contraindicated in hydrocarbon ingestion
- Catharsis:
- Should be used as a single dose to reduce harmful effects
- Sorbitol – 1–2 g/kg one time dose or
- Adults: 70% sorbitol, 1–2 mL/kg
- Children: 35% sorbitol, 1.5–2.3 mL/kg
- Contraindications include absent bowel sounds, abdominal trauma or surgery, and intestinal perforation or obstruction. Also contraindicated in volume depletion, hypotension, electrolyte imbalance, and ingestion of a corrosive substance
- Sorbitol is not recommended for poisoning with organophosphate, carbamates, arsenical diquat, or paraquat.
Activated Charcoal:
- Most effective if used within 60 minutes of ingestion
- Dosage:
- Adults 12 years and older: 25–100 g in 300–800 mL of water
- Children under 12 years: 25–50 g
- Infants under 20 kg: 1g/kg
- Contraindications include unprotected airway, non-intact gastrointestinal tract, if there is increased risk for aspiration of a hydrocarbon pesticide
Syrup of Ipecac:
- Check pesticide label to determine if induced vomiting is contraindicated.
- Dosage:
- Adolescents and adults: 15–30 mL followed immediately with 240 mL of water
- Children 1–12 years: 15 mL preceded or followed by 120–240 mL of water
- Infants 6 months to 12 months: 5–10 mL preceded or followed by 120–240 mL of water
- Dose may be repeated if no emesis in 20 to 30 minutes.
- Contraindications include diminished airway protective reflexes, ingestion of a corrosive material, ingestion of a substance likely to lead to life support within the next hour.
Control of Seizures
- Most patients respond to benzodiazepines.
- Lorazepam for status epilepticus:
- Adults: 2–4 mg/dose given intravenously (IV) over 2–5 minutes. Repeat as necessary to 8 mg in 12 hours
- Adolescents: Same as adult with 4 mg maximum
- Children under 12 years: 0.05–0.10 mg/kg IV over 2–5 minutes. Repeat as necessary 0.05 mg/kg 10–15 minutes after first dose. Maximum of 4 mg
- Diazepam is often used for organochlorine poisonings.
- Adults: 5–10 mg IV, repeat every 5–10 minutes to maximum of 30 mg
- Children: 0.2–0.5 mg/kg IV every 5 minutes to maximum of 10 mg in children over 5 years and 5 mg in children under 5 years
- Phenobarbital may also be used.
- Adults, children, and infants: 15–20 mg/kg IV loading. 5 mg/kg IV every 15–30 minutes for a maximum of 30 mg/kg. Do not push drug faster than 1 mg/kg per minute.
IV-2. Diagnose pesticide-related illness using appropriate testing procedures and treat pesticide exposures.
Symptoms of pesticide poisoning and acute and long-term effects of exposure are outlined in Table 5 in the original guideline document. This type of information should be at the finger-tips of practitioners. The material is organized by pesticide classification (insecticides, herbicides, fungicides, rodenticides, disinfectants, and miscellaneous).
Table 4 in the original guideline document can be used as a cross reference to determine the classification of common pesticides.
IV-3. Treat and manage health conditions associated with pesticide exposure or refer patients to appropriate specialists and resources, and follow up appropriately.
Carcinogenic and Reproductive Effects
The likelihood of pesticide exposure causing cancer is dependent on the frequency, duration, and magnitude or intensity of exposure as well as on latency (the length of time from exposure to onset of disease). The potential for carcinogenicity shown in Table 6 in the original guideline document is based on EPA's classification system.
Adverse Reproductive Outcomes
Table 7 in the original guideline document outlines reproductive outcomes for certain pesticides for which there are either animal or human data. The information in this table is suggestive only and should not be considered conclusive.
IV-4. Rapid Reference Tables for Common Pesticides
Tables 8-14 in the original guideline document can be used as rapid reference tables for signs and symptoms of common exposures, as well as evaluation tips and key points of treatment. Practitioners can identify common pesticides that may explain a patient's symptoms or physical findings and then identify basic evaluation and treatment recommendations. The following points should be kept in mind in using these tables:
- Included are those pesticides most often involved in symptomatic illness, based on 1996 data from the American Association of Poison Control Centers’ Toxic Exposure Surveillance System.
- The symptoms and signs listed are not specific to pesticide poisoning, but can be manifestations of other illness or exposures.
- An individual exposed to a pesticide listed in the tables may present with signs and symptoms not listed in the tables.
- The main purpose of this reference is to provide the practitioner with hints that may indicate additional investigation or prompt referral for further evaluation and treatment.
For further information, refer to EPA's Recognition and Management of Pesticide Poisonings for more in-depth discussion of toxicology, poisoning confirmation, and treatment for these and other pesticides.
Practice Skill V: Reporting Pesticide Exposure and Supporting Surveillance Efforts
V-1. Understand the importance of surveillance and incident reporting.
- Identify illnesses and hazards that are potentially related to pesticide exposure.
- Review available data that allow for trend analysis of pesticide exposures and health effects.
- Monitor a given population for disease occurrence.
- Identify hypersensitive individuals to develop strategies to prevent disease in others.
- Remove individuals from exposure as indicated.
- Provide information to individuals, groups, and committees about efforts (e.g., reporting and tracking exposures) to further the understanding of pesticide-related advanced health outcomes.
- Be able to access and report data for local, regional, and national surveillance programs.
V-2. Know the roles of federal and state regulatory agencies with regard to pesticide exposure control.
- The Environmental Protection Agency (EPA) is the lead federal agency for regulation of pesticide use under the Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA). FIFRA requires training and certification of pesticide applicators which is enforced through delegated authority to the states. Health care providers can obtain pesticide information and surveillance data from state agencies and EPA.
- The Federal Food, Drug, and Cosmetic Act (FFDCA) is the basic food and drug law in the U.S. and is administered by the Food and Drug Agency (FDA). It establishes the concept of a tolerance (the maximum legally permissible level of residue at harvest) for pesticide residues in or on human food and animal feed. Tolerances are specific to a pesticide/commodity combination. FFDCA requires EPA to establish these residue tolerances for pesticides in or on food, feed, and byproducts.
- Under the Food Quality Protection Act (FQPA) of 1996, EPA is to review all tolerances for existing pesticides within ten years to determine that they meet the new health-based standard – i.e., that they pose a "reasonable certainty of no harm" from aggregate and cumulative exposures. (Aggregate exposure refers to exposures from all sources, including residues in food and drinking water, occupational exposures, and incidental exposures. Cumulative exposure refers to exposure to different pesticides that share a common mechanism of action.) FQPA also provides extra protection for infants and children, by requiring an explicit determination that tolerances are safe for children, including an additional safety factor of up to 10-fold, if necessary, to account for uncertainty in data relative to children; and requiring consideration of children's special sensitivity and potential exposure to pesticides.
- Other federal agencies also have important roles in pesticide exposure control, and offer resources for health care providers.
- The Occupational Safety and Health Administration (OSHA) has authority over work-related exposures (e.g., pesticide manufacturing). OSHA can perform inspections to determine if a hazard is present. Anonymous calls can be made to prompt an investigation. www.osha.gov
- The National Institute for Occupational Safety and Health (NIOSH) conducts research, funds professional occupational safety and health education, and conducts health hazard evaluations. Providers can obtain educational materials and surveillance data from NIOSH related to occupational safety and health. www.cdc.gov/niosh/homepage.html
- The Centers for Disease Control and Prevention (CDC) offer epidemiological data and guidance, surveillance, health statistics reports, and laboratory information. www.cdc.gov
- The Agency for Toxic Substances and Disease Registry (ATSDR) develops case studies in environmental medicine and risk profiles for individual pesticides. www.atsdr.cdc.gov
- EPA's Worker Protection Standard (WPS) is the regulation that applies to agricultural pesticide handlers and field workers. It includes requirements for: warnings about pesticide applications, use of personal protection equipment, restrictions on reentry into treated areas, decontamination, emergency medical assistance, and pesticide safety training.
- State departments of agriculture, health or environment will investigate pesticide exposure incidents. State specific requirements for reporting to Workers’ Compensation may vary.
V-3. Report pesticide exposures as required.
- Know the mandatory reporting requirements in the state in which the provider is practicing (over 25 states have mandatory reporting requirements).
- Report pesticide-related illness to the appropriate authorities, such as local and state health departments.
- Be aware of workers' potential reluctance to get involved in reporting of workplace exposures, due to fears of retaliatory action and economic loss. Consent of the patient should be obtained prior to reporting.
- Report and validate Workers' Compensation claims as indicated in each state.
Practice Skill VI: Providing Prevention Guidance and Education to Patients
VI-1. Engage in primary prevention strategies to promote health and prevent disease among patients.
For Individuals and Families:
- Assess perceived risk of exposure. Provide anticipatory guidance about pesticides to prevent exposures. (For example, advise families on appropriate concentrations of N, N-diethyl-m-toluamide [DEET].)
- Provide anticipatory guidance about signs, symptoms, and recognition of pesticide exposure; and safe use of pesticides including hygiene practices, and protective clothing (pamphlets, slides, etc.). Advise patients to read and follow label directions on protective garb needed when applying pesticides around the home, garden, or yard. Long pants, a long-sleeved shirt, and chemical-resistant gloves are generally recommended as extra protection even when not required by the label.
- Teach patients to read labels and follow instructions carefully, paying specific attention to precautionary statements and "signal words" that indicate level of toxicity.
- Assess lifestyle factors and medications taken for interactions. Discuss or refer to specialist about use of substitutes.
- Deal appropriately with pesticide-related questions that patients pose – whether by asking additional pertinent questions, by searching out accurate information, by referring patients to specialists, or by preparing oneself to answer certain types of questions (see Examples of frequently asked questions [FAQs]).
- Counsel patients about minimizing unnecessary use of pesticides. Discuss the rationale for integrated pest management. Advise family to contact local county cooperative extension services for information regarding alternatives to pesticide use for control of insects, weeds, etc.
- Discuss potential reproductive toxicity (e.g., teratogenic) effects related to pesticide exposures.
- Caution nursing mothers that pesticides may be excreted into mother’s milk.
- Be aware that there may be specific patient populations with limitations in reading labels (illiterate, non-English speaking only, etc.), and special preventive education may be necessary.
For Workers:
- Assess occupational exposure risk knowledge.
- Provide anticipatory guidance about pesticides to prevent exposures.
- Educate about signs/symptoms of pesticide exposure.
- Discuss and demonstrate use of personal protective equipment and clothing, (gloves, face shields, aprons, boots).Teach patients to read labels and follow instructions carefully. Discuss the dangers of altering mixing and application procedures. Teach patients to pay attention to specific components of a pesticide label, including precautionary statements and "signal words" that indicate level of toxicity.
- Teach patients to be prepared to treat emergencies prior to occurrence, to know what types of first aid are indicated and contraindicated, and to ensure that necessary equipment, supplies, etc., are available and in proper working order.
- Assess lifestyle factors and medications taken for interactions. Discuss or refer to specialist about use of substitutes.
- Discuss use of closed cab systems in mixing and loading pesticides with proper training, closed tractor cabs in application. Carbon-high efficiency particulate air (HEPA) filtration systems are recommended in some cases.
- Discuss use of substitute pesticide formulations that are less toxic.
- Discuss need for washing facilities for decontamination and removal of residues before eating or bathroom use.
- Discuss avoidance of mixing/spraying during windy conditions.
- Discuss need to change contaminated clothing at work, place in a separate bag, and wash separately from other wash.
- Be aware that there may be specific patient populations with limitations in reading labels (illiterate, non-English speaking only, etc.), and special preventive education may be necessary.
VI-2. Work proactively with patients and the community to prevent exposure, ensure early detection, and limit effects of illness.
Individuals/Families:
- Provide information about emergency procedures to be used if contamination occurs.
- Discuss how to report exposures to appropriate authorities.
- Conduct screening tests to detect pesticide-related exposure/illness (e.g., cholinesterase, spirometry), including baseline screening and after exposure.
- Limit disability and rehabilitate or restore to optimal functioning, for example, by providing avenues for vocational rehabilitation, or case management services to restore optimal functioning.
Workers:
- Conduct worker screening tests (e.g., cholinesterase, spirometry) to detect pesticide-related exposure/illness. If possible, conduct baseline screening before and after exposure. Remove worker from exposure if indicated.
- Advise workers to carry water attached to tractors and know emergency procedures for decontamination (need to follow WPS and OSHA regulations about providing basic hygiene requirements).
- Partner with workers to develop peer support groups for disabled workers.
Population-Based:
- Work with local agricultural extension office, agro-universities, local grain/pesticide sellers, health care practitioners, farm bureaus, garden shops, plant nurseries, manufacturers, distributors, etc. in prevention strategy development.
- Develop network for new work opportunities.
- Work with community groups (e.g., schools, parent-teacher associations, churches, daycare, migrant groups, farm worker, farm associations) to identify environmental justice issues, and to discuss and advocate for targeted prevention strategies.
- Discuss need for integrated pest management programs to control pest growth.
- Develop/use pesticide/illness incident reporting system to track patterns of exposure and disease.
