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BackgroundA hurried mom presents to your Urgent Care clinic with her two young sons, ages 7 and 3. As she is checking in, you overhear that she was instructed to present to you, following the advice and instructions of a Poison Control Center, the bottle of pesticide. She reports that her older son was spraying the backyard with a mosquito pesticide when her 3-year-old ran face-first into the spray from the pump bottle her older son was using. She immediately removed her 3-year-old’s clothing, and bathed him thoroughly, then called Poison Control.
ExamPyrethrins are a chemical class of pesticides originally derived from chrysanthemum flowers. They function as insecticides by impairing sodium channels in insect neural pathways, causing paralysis and death. Pyrethrins are commonly used commercially and residentially to control mosquitos, fleas, flies, moths, ants, and other insects. They are found in literally thousands of commercial products for use in a myriad of applications, including aerosols (“bug bombs”), dog collars, and lice shampoos. In humans, pyrethrins most commonly cause allergic reactions, including contact dermatitis, conjunctivitis, rhinorrhea, and asthma exacerbations which can be severe and even fatal. Pyrethroids are synthetic versions of pyrethrins and have a similar method of action. Pyrethroids are much more difficult to metabolize, and so are generally more toxic and have longer half-lives than pyrethrins.
Exposure Routes, Symptoms, and TreatmentsOur 3-year-old patient had no apparent injury or toxicity related to his pyrethrin exposure. Mom was assured that there were no acute or likely chronic-related concerns. Clinic staff reiterated advice provided by Poison Control and advised mom to monitor for any change in behavior or with the onset of concerning symptoms, as noted above. This patient was seen in Oregon, and per state law, the pesticide exposure was reported to the Oregon Health Authority.
Clinical PEARLSBond, C.; Buhl, K.; Stone, D. 2014. Pyrethrins General Fact Sheet; National Pesticide Information Center, Oregon State University Extension Services. http://npic.orst.edu/factsheets/pyrethrins.html.
Pesticide Reporting. PERC-med. (n.d.). Retrieved December 12, 2022, from https://pesticideresources.org/med/reporting.html?state=OR
Roberts, J. R., & Reigart, J. R. (2013). Recognition and management of pesticide poisonings. United States Environmental Protection Agency, Office of Pesticide Programs.
Davis, California – The Pesticide Educational Resources Collaborative–Medical (PERC-med) has appointed Steve Kirkhorn, MD, MPH to its Advisory Board. He is currently the Medical Director of the Agrisafe Network. Most recently, Dr. Kirkhorn was the Director/Section Chief of Occupational Health at the Minneapolis Veterans Administration Health Care System; Director of the Occupational and Environmental Medicine Academic Program; Director/Section Chief of Occupational Health; and Assistant Professor at the University of Minnesota.
Dr. Kirkhorn is a Fellow of the American College of Occupational and Environmental Medicine; was the Medical Director of the National Farm Medicine Center and the NIOSH National Children’s Center for Rural and Agricultural Safety and Health; and was the Executive Editor of the Journal of Agromedicine.
Some of his clinical interests are in rural occupational and environmental health, agricultural medicine, and environmental exposures in veterans. Dr. Kirkhorn joins other members of the PERC-med Advisory Board, including:
Davis, California – The Pesticide Educational Resources Collaborative–Medical (PERC-med) would like to recognize Charlotte Halverson, BSN, for her commitment to PERC-med as a member of the Advisory Board. Halverson has been on the PERC-med board since 2019 and is retiring from the Advisory Board and as the Clinical Director at the Agrisafe Network.
“We are grateful to Charlotte for advancing the mission of PERC-med,” said Diana R. Simmes, MPH, PERC-med’s Pesticide Medical Education Director. “She has tirelessly worked at the intersection of educators, researchers, producers, farm and ranch workers, and families. Her contributions in the public health space, in agriculture, and in helping reduce health disparities are profound.”
PERC-med is the Pesticide Educational Resources Collaborative for Medical Professionals, a 5-year cooperative agreement (#X-83935901) between the U.S. EPA's Office of Pesticide Programs and University of California Davis Office of Continuing and Professional Education, in collaboration with Oregon State University. The primary goal of this project is to widely promote and market pesticide-related health resources and education to medical providers across the U.S. to help them prevent, recognize, and treat pesticide-related health conditions.
Pesticide exposure and illness are largely unrecognized or attributed to other more common pathologies in the Urgent Care setting. Over sixty percent of states have mandated reporting for pesticide exposure and illnesses. Reporting is often limited due to patient reluctance to report symptoms and suspected exposure, to clinicians' lack of training/awareness that pesticide-related illness may be present, and the fact that clinicians are not aware of reporting mandates.
A 54-year-old Hispanic male presents to the Urgent Care Clinic with a 4-day history of a progressively itchy and painful rash affecting bilateral lower extremities--primarily his feet, ankles, and distal legs bilaterally. He reports a history of “athlete's foot” intermittently at varying intervals through the past several years. This rash started similarly to prior episodes of tinea pedis, though it has never been this bad, or extended this far up his legs. The rash is erythematous and affects the entirety of both plantar surfaces, it is itchy and has progressed up his lower legs with “ red dots.” This is accompanied by worse-than-normal foot odor despite efforts to maintain hygiene. He reports that he works on a farm, and in the past 6-7 days has been wearing “muck boots” (waterproof rubber boots that extend to just below the knees) while working in the fields. The rash has not improved with the over-the-counter spray-powder he has used successfully on numerous occasions. He has worked to dry his skin after showers and after work. Additional questioning revealed that this person was working in a low-lying, muddy lettuce field for the duration of his presenting complaint, including onset. He did report a chemical smell in the field and on his boots when they were removed at the end of his workday, repeatedly during this time period. Patient denied headache or special sensorium change, increased salivation, rhinorrhea, respiratory complaint, gastrointestinal discomfort, diarrhea, change in urination, and other review of systems complaints.
Patient is Spanish speaking only, with occasional English nouns, and is seen with the aid of a video interpreter. Provider is English speaking only. Pertinent medical history is limited as patient is not a documented U.S. citizen, has no medical records from his home in Mexico City, Mexico, and reports that he does not avail himself of clinical medicine except for acute circumstances. Medical literacy is considered limited though patient is relatively certain he is not diabetic. He denies other underlying health issues and has no history of symptoms of cardiac disease, hypertension, hyperlipidemia, gout, vasculitis, or other chronic skin conditions. He currently takes no prescription medications and denies that clinicians have prescribed him medications for routine use in Mexico or in the United States. He cannot relate timing or location of his last clinic visit.
Objective findings revealed a prehypertensive and afebrile male, who was pleasant and appropriately interactive. Finger-stick capillary blood glucose reading in the clinic was 124 mg/dL. HEENT exam revealed some dental challenge, no miosis. Lungs were clear on auscultation of all fields and phonation clear, cardiac evaluation revealed S1, S2 and no murmurs. Abdominal exam was without tenderness or mass and with normal bowel sounds. SKIN: Sun related change noted over face/neck/upper chest, as well as over arms and forearms. No obvious concerning lesions noted. Clean and well-fitting shoes and socks were removed to reveal petechiae in sock-like fashion of the skin from just inferior to the knee to the ankle where petechiae became confluent and diffuse; inflammation affected the entirety of both ankles, the dorsum of both feet, and all toes. There was superficial desquamation affecting the entirety of plantar surfaces of both feet, including between all toes, where some macerated tissue was noted. There was no sign of secondary infection, abscess or fluid collection, induration, there was no streaking. Sensorium was intact throughout, capillary refill was brisk in all areas, dorsalis pedis pulses were 2/4 bilaterally. ROM of all toes was full and unlimited. Faint odor was noted despite effort with hygiene. Laboratory services were offered and declined by patient due to cost and no reliable way to contact the patient with results once available.
First-line treatment for cutaneous chemical exposure and injury is to remove the offending agent, clean skin, and consider additional care depending on the nature and severity of injury that has occurred. Thereafter avoidance of additional exposure and injury should be ensured. In this case the patient had accomplished chemical removal and skin cleansing. Patient reported that he was able to take some time away from work (recommended at least 7 days), to limit all occlusive footwear as much as possible, continue his good hygiene, and to clean floors and showers with a 10% bleach solution thereafter. He was instructed to monitor for signs/symptoms of infection and to return to clinic or seek emergent care if they occurred. He was asked to discontinue all other treatments until healed, and was recommended to follow in our clinic in 5-7 days, at which time we would consider resuming care for tinea pedis if it persisted following resolution of inflammatory response.
Clinically, the impression is that of tinea pedis which was greatly aggravated by a chemical dermatitis. The patient refused to reveal his employer. He did not know which pesticides or fertilizers with which he was in contact, though had witnessed application thereof several days prior. The patient was forthright in stating that he would lose his employment, housing, and perhaps risked deportation if he shared more than what history was provided. Of note: patient did not demonstrate classic signs of organophosphate or methylcarbamate poisoning and his symptoms appeared to be limited to the integumentary system. He was provided Spanish language materials on both pesticide poisoning and tinea pedis. In Oregon, where this case was seen, reporting of any suspected or confirmed illness or condition related to pesticides is mandatory. The patient did not consent to allow the name or location of his employer or site of exposure and did not provide a way for other agencies to reach him for follow-up. This clinician looked past the more obvious diagnosis of tinea pedis to determine that other causation was present. This interactive pesticide reporting requirements map, developed by PERC-med, is a useful educational tool for increasing awareness of such requirements by state and territory.
Davis, California – PERC-med has created a Pesticide Coding Resource for Clinicians and Revenue Cycle Professionals that is now featured on the Health Center Resource Clearinghouse and the PERC-med website.
“Coding specifically for pesticide exposure and illness can be arduous,” said Micah Bicker, PA-C, Clinician Peer Educator at PERC-med. “Having this resource at your fingertips will enable the clinicians, coders, and entire billing team to accurately and efficiently code,” he continued.
"We are delighted to partner with NACHC and the Health Center Resource Clearinghouse to offer this resource to as many clinical and revenue cycle professionals as we can," said Diana Simmes, MPH, Pesticide Medical Education Director of PERC-med. "The coding guide augments our collection of pesticide-related resources for clinicians," she added.
PERC-med is the Pesticide Educational Resources Collaborative for Medical Professionals, a 5-year cooperative agreement (#X-83935901) between the U.S. EPA's Office of Pesticide Programs and University of California Davis Continuing and Professional Education, in collaboration with Oregon State University. The Health Center Resource Clearinghouse is operated by the National Association of Community Health Centers (NACHC) and the project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS).
The Coding Sheet for Pesticide-Related Illnesses can be found online at https://pesticideresources.org/med/resources/pubs.html. For more information on PERC-med, visit https://pesticideresources.org/med/. You can also find us on LinkedIn at https://www.linkedin.com/company/perc-med/ and on Twitter at https://twitter.com/PERCmed
Davis, California – PERC-med has named Micah Bicker, PA-C as its Clinician Peer Educator. Bicker is a certified physician assistant with experience in caring for rural, underserved, farmworker, migrant, and tribal communities. His 20-plus years of experience include working in community-based clinics, family medicine, urgent care, and emergency medicine. PERC-med is the Pesticide Educational Resources Collaborative for Medical Professionals, a 5-year cooperative agreement (#X-83935901) between the U.S. EPA's Office of Pesticide Programs and University of California Davis Continuing and Professional Education, in collaboration with Oregon State University.
“Micah is an ardent patient advocate and incredible clinician educator,” said Diana Simmes, MPH, Pesticide Medical Education Director at UC Davis. “He will create, implement, and execute medical and scientific communications to advance the recognition, management, and prevention of pesticide-related illnesses,” she continued.
“My goal is to improve the health and wellness of communities impacted by pesticide exposure,” said Bicker. “I am vehement about underserved communities and will focus my efforts on working with other frontline clinicians and organizations to enhance educational opportunities,” he added.
Bicker’s role as the Clinician Peer Educator includes serving as a national resource for healthcare providers on pesticide-related health conditions. He will direct, create, and provide clinician-focused educational efforts around pesticide illnesses.
Bicker received his BA in biology from Washburn University and his BS in Physician Assistant Studies from Wichita State University. He is a member of the American Academy of Physician Assistants.
For more information on PERC-med, visit https://pesticideresources.org/med/ and on LinkedIn at https://www.linkedin.com/company/perc-med/.
Vulnerable populations such as impoverished persons, children, and workers including migrant laborers, farmworkers, and hospitality workers are at increased risk of pesticide exposure and poisoning. These workforce groups are less likely to be aware of safety information, protective gear, and specific health risks of using pesticides. Concerns of potential retribution or loss of employment and language barriers can lead them to avoid seeking healthcare or initiating a discussion about exposures when receiving care. Additionally, workers may not recognize that their symptoms could be related to pesticide exposure or know where to find the names of specific products.
Family physicians play a critical role in assessing exposure risks. A national protection standard, the Worker Protection Standard (WPS), is a federal regulation that aims to reduce pesticide poisonings and injuries among agricultural workers and pesticide handlers (Pesticide Educational Resources Collaborative, n.d.). The WPS requires agricultural employers to comply with minimum safety precautions, but this protection is not well known amongst clinicians.
Impoverished persons have increased exposure risks for several reasons. Low-income housing is often located adjacent to areas where pesticides can be found in the water, soil, air, and building materials. These individuals often have fewer healthcare resources and face potential housing loss or other recrimination if exposures are reported. Additionally, they are more likely to experience occupational exposure if they work in the hospitality, janitorial, and food service industries.
Children are the population most profoundly impacted by pesticide poisoning. Pesticides can affect cognitive and physical development and are linked to numerous types of pediatric cancers and chronic diseases. Due to metabolic, behavioral, and physical characteristics, children are much more likely to experience serious effects from toxic exposures at lower doses than adults. Children living in homes with family members who work in high-risk industries are even more vulnerable due to secondhand exposure to chemicals on clothes and equipment. This type of exposure is often not considered in clinical settings. Additional pediatric exposures and mechanisms of injury should be on clinicians’ minds, as the following is considered: “Farm labor can be legally performed by children as young as twelve years of age under the Fair Labor Standards Act, with no minimum age for children working on small farms or family farms. Child labor in agriculture is common, with as many as 500,000 child farmworkers estimated to work in the U.S.” (Children's Health Protection Advisory Committee, 2021, p. 1).
Family medicine clinicians can be vigilant in seeking out possible pesticide exposures while taking histories and performing physicals for high-risk patients. This fact sheet lists related history-gathering tools that will be helpful in this endeavor and recommends networking with community health workers (U.S. Department of Health and Human Services, 2014) who may function as patient advocates, resource coordinators, and patient educators. Recognition and Management of Pesticide Poisoning is a comprehensive, easily digested resource detailing pesticide exposure and treatment that is easy to reference during patient visits (PERC-med, n.d.). This presentation provides clinical guidance on recognizing pesticide poisonings in ambulatory care settings.
Family physicians can help the PERC-med team advocate for increasing awareness and training of clinicians to diagnose and treat excessive and/or prolonged pesticide exposure.
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Resources:
Agriculture is known as one of the most dangerous industries for farm owners, workers, and their families, who live, work, and play in the same spaces. “Those working in the agricultural industry producing food, fiber, and fuel experience one of the highest risks factors among all occupations for injury, illness, and death” (Donham, 2016). The U.S. Department of Labor, Occupational Safety and Health Administration states that farmworkers are exposed to numerous safety, health, environmental, biological, and respiratory hazards (OSHA, n.d.). The United States is one of four significant producers of agriculture globally, and in 2016, a reported 1.2 billion pounds of pesticides were used in the United States, ranking America second to China in pesticide usage (Donley, 2019). Furthermore, the U.S. Environmental Protection Agency (EPA) estimates that almost 75% of U.S. households use pesticides (U.S. EPA, n.d.). Pesticides are used in agriculture to control weeds and other unwanted vegetation, insects, rodents, bacteria, fungi, and diseases.
The USDA Census of Agriculture data shows that the number of women in agriculture is increasing, with women accounting for 36% (1.2 million) of the country’s producers (USDA, 2017). Pregnancy and fertility are often not considered when women assume farm tasks. The EPA states, “Women who are pregnant or planning a pregnancy, especially those currently performing farm work, should be informed of the implications of [pesticide] exposure before, during, and after pregnancy and assisted in making appropriate decisions for their work and home situations” (U.S. EPA, 2013).
Populations at significant risk of pesticide poisonings and adverse effects include pregnant women and children who reside in agricultural communities. Incidents of pesticide poisonings often go unnoticed without proper education, including prevention, and this leads to adverse effects such as neural tube defects, neurodevelopmental harm, spontaneous abortion, and cancer.
In a published PLOS One study focused on environmental exposure screenings by OB/GYNs, fewer than half of the physicians surveyed screened for occupational exposures, including pesticide use (Grindler et al., 2018). In addition, 85% of respondents reported that they did not feel comfortable obtaining an environmental history, and 58% of respondents said that they performed no regular screening of environmental exposures. Family physicians have a critical role in serving as the first line of defense for pregnant women working and living in agricultural communities. Occupational and environmental medicine recommend routine screening for environmental and occupational exposures to identify, monitor, and reduce prenatal exposures. Considerations for routine patient screening include:
Family physicians are uniquely positioned to serve as the first line of defense for pregnant women, infants, and children exposed to pesticides. Please visit Pesticide Educational Resources Collaborative-Medical (PERC-med) for more population-specific resources.
References:
Davis, California — PERC-med is hiring a Clinician Peer Educator, who will be responsible for creating, implementing, and executing internal and external medical and scientific communications to advance PERC-med’s educational objectives. As a pesticide subject matter expert, the Clinician Peer Educator will execute PERC-med’s scientific communication and clinical education dissemination strategies. This role will serve as a national resource for healthcare providers about pesticides as well as direct, create, and provide clinician-focused educational and collaboration efforts to clinician peers to increase the national reach of PERC-med resources. This role is tasked with co-creating high-quality and impactful resources as well as amplifying stakeholder engagement opportunities to communicate the mission of PERC-med. The PERC-med program works closely with cross-functional partners such as marketing, an external advisory board, national healthcare provider organizations, subject matter experts, and program administrators to inform the pesticide-specific resource dissemination and provider education strategies. This individual must be a licensed clinician such as an MD, DO, PA, NP, PharmD, etc.
PERC-med is the Pesticide Educational Resources Collaborative for Medical Professionals, a 5-year cooperative agreement (#X-83935901) between the U.S. EPA's Office of Pesticide Programs and the University of California Davis Division of Continuing and Professional Education, in collaboration with Oregon State University. The primary goal of this project is to widely promote and market pesticide-related health resources to medical providers across the U.S. to help them prevent, recognize and treat pesticide-related health conditions.
For more information on this position, visit https://recruit.ucdavis.edu/JPF04707.
PERC-med is online at /med and on LinkedIn at https://www.linkedin.com/company/perc-med/.
Davis, California -- PERC-med has appointed Aidan Black to its Advisory Board. Black is an Environmental Protection Specialist for the United States Environmental Protection Agency (U.S. EPA) and the Delegate Project Officer for PERC-med. PERC-med is the Pesticide Educational Resources Collaborative for Medical Professionals, a 5-year cooperative agreement (#X-83935901) between the U.S. EPA's Office of Pesticide Programs and the University of California Davis Division of Continuing and Professional Education, in collaboration with Oregon State University. The primary goal of this project is to widely promote and market pesticide-related health resources to medical providers across the U.S. to help them prevent, recognize and treat pesticide-related health conditions.
Kaci Buhl, PERC-med’s Deputy Director said, “Aidan’s understanding of and contribution to the pesticide environment is essential. His dedication to protecting and empowering people to work safely with and around pesticides aligns perfectly with PERC-med’s goals.” She added, “Aidan facilitated the Farmworker and Clinician Training workgroup for the Pesticide Program Dialogue Committee. He promoted collaboration among the constituents, enabling successful work group outcomes.”
Black commented, “My work at the EPA includes supporting and training on the Worker Protection Standards and ensuring that federal standards are met. That experience, along with my interest in regulation, policy, outreach and education, will enable me to advance the mission of PERC-med.” He added, “the health advocates on the team are inspiring.”
Prior to his role at the EPA, Black served as a community gardening and agroforestry facilitator for the U.S. Peace Corps in The Gambia; and was involved in forest conservation in Northern New England. He completed his Bachelor of Arts in Environmental Policy at Colby College in Waterville, Maine.
Originally from Maine, Black now lives in Washington, DC. He joins other members of the PERC-med Advisory Board, including:
Greenville, NC -- The Brody School of Medicine at East Carolina University, North Carolina Agromedicine Institute, and Eastern Area Health Education Center, supported by PERC-med (Pesticide Educational Resources Collaborative for Medical Professionals) and the Pesticide Environmental Trust Fund (PETF) have collaborated to provide free education and training continuing medical education (CMEs) for clinicians. This program, titled Farm Toxicology for Primary Care: Recognition and Management of Pesticide Poisonings, is a three part course on pesticide illnesses, diagnosis, treatment, long term effects, and clinical preparedness and surveillance. It contains medical information on the recognition of symptoms and medical management of pesticide poisoning and presents information on how to diagnose and treat pesticide illnesses, including those due to cholinesterase inhibiting pesticides. This course is designed for health care providers, including physicians, residents, physician assistants, community clinic staff, medical students, nurse practitioners, registered nurses and first responders. The course can be accessed through the PERC-med website.
William J. Meggs, MD, PhD, Professor, Division of Toxicology at the Brody School of Medicine at East Carolina University said, “Healthcare providers must be prepared to diagnose and treat every patient that comes their way. Practitioners in rural areas need to consider toxicants found on the farm in their differential diagnosis of acute and chronic illnesses. Farm Toxicology for Primary Care is an online education course that gives providers the tools needed to effectively recognize and manage farm-related pesticide exposures.”
The Eastern AHEC (Area Health Education Center) program provides and supports educational activities and services with a focus on primary care in rural communities and those with less access to resources to recruit, train, and retain the workforce needed to create a healthy North Carolina.
PERC-med is the Pesticide Educational Resources Collaborative for Medical Professionals, a 5-year cooperative agreement (#X-83935901) between the U.S. EPA's Office of Pesticide Programs and University of California Davis Extension, in collaboration with Oregon State University. PERC-med is an interdisciplinary team with a strong culture of collaboration. The project’s Advisory Board includes scholars in toxicology, nursing, public health, agricultural education, as well as practicing medical providers. The primary goal of this project is to widely promote and market pesticide-related health resources to medical providers across the U.S. to help them prevent, recognize and treat pesticide-related health conditions.
The North Carolina Agromedicine Institute is a University of North Carolina inter-institutional institute whose partners are East Carolina University, North Carolina State University, and North Carolina Agricultural and Technical State University. In addition to the university partners, the Institute relies heavily on its collaborative partnerships with the agricultural community, other universities, businesses, health care organizations, governmental agencies, and non-governmental organizations who are dedicated to identifying and addressing the health and safety risks of farmers, foresters, fishermen, their families and communities in North Carolina. The goal of the program is to reduce injury and illness by conducting research that leads to practical solutions and developing effective educational approaches that can be of benefit daily to the end user. Ultimately, the partnership wants farming, logging and fishing workplaces to be safe and healthy for all.
In 1993, the North Carolina General Assembly enacted legislation creating the Pesticide Environmental Trust Fund (PETF). The predominant purpose of the fund is for those pesticide-related environmental programs administered by North Carolina Department of Agriculture & Consumer Services (NCDA&CS). The authority to use this funding is "...as directed by the Board...", therefore, the NCDA&CS may utilize these funds for Departmental environmental programs, with oversight from the North Carolina Pesticide Board.
For more information or media inquiries, connect with PERC-med at:
pesticideresources.org/med
amos@amosANDadvisors.com
215.287.7879
Pesticide Education Programs
UC Davis Continuing and Professional Education
1333 Research Park Drive
Davis, CA 95618
Family medicine practitioners play a key role in preventing and mitigating the health effects of pesticide exposures. The COVID-19 pandemic has been accompanied by a sharp increase in the use of antimicrobial pesticides—disinfectants—as infection control measures surge.1,2 This upward trend highlighted the lack of consumer knowledge around common pesticide exposures and the potentially hazardous effects of such products deployed for disinfection purposes. It’s important that family medicine physicians are equipped to not only recognize signs of pesticide poisoning but also to help patients understand when and how they may be exposed to pesticides in everyday settings.
Pesticides are substances that are used to prevent, kill, and/or mitigate pests and are most often used to prevent illness in humans or damage to crops.3,4 There are hundreds of pesticide active ingredients incorporated into an enormous number of readily available products. Pesticides include insecticides, herbicides, fungicides, rodenticides, molluscicides, nematicides, and others.5 While pesticides are effective because they disrupt biological processes in the targeted pests, they can lack high selectivity, making them potentially hazardous for humans.3,4
Pesticides can pose health risks to humans through mechanisms of impairing biochemical targets. Targets include enzymes such as acetylcholinesterase (AChE) and cytochrome c reductase, ion channels, and receptors.3 For instance, organophosphorus pesticides are often neurotoxic because of their inhibition of AChE in neuromuscular junctions and other areas of the central nervous system.6,7 Similarly, organochlorine pesticides are toxic because of enzyme inhibition and effects on metabolism and transcription.8 Pesticide type; exposure amount, route, and duration; and the susceptibility of the exposed individual affect health outcomes.7
Given the non-specific symptoms associated with pesticide poisoning, it is important physicians have accurate patient information to assess relevant risk. A pesticide exposure scenario can occur at home, at work, or through hobbies. Recognition and Management of Pesticide Poisonings provides a comprehensive guide to aid clinicians. Family medicine clinicians may consider advising patients who spend time around pesticides—such as gardeners or golfers—how to reduce exposure. Similarly, clinicians in areas known to have higher pesticide usage rates may consider incorporating pesticide exposure prevention education into routine clinical care.
There are an enormous number of pesticide products on the market ranging from pet flea collars and common household disinfectant wipes to garden-ready herbicides and sprays used across agricultural lands. There are inherent health risks associated with such products. Family medicine physicians[KM1] who are knowledgeable about the vast array of products and can identify active ingredients may be able to more readily identify pesticide-related health conditions. Screening for both acute and chronic exposure provides concrete information for reducing health risks. Screenings could include questions about occupation and hobbies, as well as common household products.
With known or suspected exposure, treatment is the clear priority. While pesticide reporting requirements for physicians providers[KM2] vary across the country, reporting is mandatory in over 60% of states. Learn about requirements in your state of practice here.
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Poison Control Center data shows over 35,000 calls related to pesticide exposure concerns for children ≤5 years old in 2018. Most serious acute poisonings occur after unintentional ingestion, although poisoning may also follow inhalational exposure or significant dermal exposure, such as in drift events. Misuse, such as violating label instructions, may also lead to overexposure. It is well recognized that pesticide poisonings are likely to be underreported because of difficulty with diagnosis, incomplete reporting and symptoms not being recognized as a poisoning. High-risk children may include those who:
Pesticides are toxic by design. Insecticides and rodenticides are most commonly associated with acute pediatric poisoning. Warfarin-type rodenticides are also a significant ingestion risk for young children. Many insecticide chemical classes designed to be neurotoxic for insects have been shown to be neurotoxic in humans, such as the cholinesterase-inhibiting organophosphate and carbamate insecticides and the pyrethroids. Toxicity varies by the active ingredient(s) and formulation.
Many signs and symptoms related to acute pesticide exposure are nonspecific and resemble other common childhood illnesses. Diagnosis depends on identifying an exposure and determining that the exposure scenario was likely to lead to significant uptake and the signs and symptoms experienced.
Determine if the child might have been exposed to pesticides in suspected illness events.
Verify:
Determine if the pesticide of concern is associated with the signs and symptoms. The EPA’s Recognition and Management of Pesticide Poisonings offers a comprehensive online Index of Signs and Symptoms organized by pesticide class.
Linkage of signs and symptoms to pesticide exposure, further workup, and poisoning management may require specialist consultation. For poisoning management, contact the Poison Control Center (800-222-1222). The regional Pediatric Environmental Health Specialty Units (PEHSU) programs can provide consultation for subacute concerns, post-acute phase questions, or assistance in determining pesticide active ingredients and potential toxicity.
Cholinesterase testing may be useful for guiding the early treatment of suspected organophosphate and carbamate poisoning. Preserved urine or clothing samples may be useful for future analysis as evidence of exposure or to assist in public health investigations. Samples should be obtained as soon as possible as many pesticides metabolize quickly.
Clinician reporting of suspected pesticide-related illnesses is required by law in many states. Regardless, clinicians should notify the local or state public health department or state pesticide regulatory agency if the exposure source may present a hazard to others or if help is desired in identifying an environmental exposure source. State-specific reporting requirements can be found at PERC-med.
Download Acute Pediatric Pesticide Poisoning Resource
Download Chronic Pediatric Pesticide Poisoning Resource
References
The Pesticide Educational Resources Collaborative – Medical is a cooperative agreement (agreement #X-83935901) between the U.S. EPA's Office of Pesticide Programs and University of California Davis Extension, in collaboration with Oregon State University.
Adapted from material originally supported by the American Academy of Pediatrics (AAP) and funded (in part) by the cooperative agreement award number 5 NU61TS000296-02-00 from the Agency for Toxic Substances and Disease Registry (ATSDR). The U.S. Environmental Protection Agency (EPA) supports the PEHSU by providing partial funding to ATSDR under Inter-Agency Agreement number DW-75-95877701. Neither EPA nor ATSDR endorse the purchase of any commercial products or services mentioned in PEHSU publications.
Davis, California -- A free course to train health professionals to recognize, treat and report pesticide poisoning and illnesses in California has been expanded to provide information on reporting requirements throughout the nation.
The California Office of Environmental Health Hazard Assessment (OEHHA) has joined forces with the Pesticide Educational Resources Collaborative for Medical Professionals (PERC-med) to expand the reach of the 60-minute online course. The continuing medical education (CME) program, titled Recognition, Management and Reporting of Pesticide Illness, provides medical information on the recognition and management of symptoms of pesticide poisoning. It also presents information on how to diagnose and treat pesticide illnesses, including those due to cholinesterase-inhibiting pesticides.
The original course, designed by OEHHA for health care providers in California, contained information on reporting requirements of pesticide illnesses in the state. A national module created by PERC-med has been added to the course.
With the addition of this new module, providers across the United States will find information on reporting pesticide illnesses in their specific state. The information is designed to be useful to hospitals, physicians, nurses, physician assistants, health centers, medical students, and first responders.
The course can be accessed through the PERC-med website at pesticideresources.org/med/resources/training.html or through the OEHHA website at oehha.ca.gov/pesticides/education-and-training.
"The addition of the reporting module extends the reach of this course to a national audience," said Dr. Ouahiba Laribi of OEHHA, CalEPA, and the PERC-med Advisory Board. "The national expansion ensures a comprehensive training for health-care providers, with health benefits for all US residents, especially people in agricultural areas."
OEHHA works to protect human health from the toxic effects of pesticides, including:
Visit OEHHA online at oehha.ca.gov/pesticides or on LinkedIn at linkedin.com/company/office-of-environmental-health-hazard-assessment/.
PERC-med's goal is to raise awareness among health care providers by making it easier for them to:
Davis, California -- PERC-med appointed David Vearrier, MD, MPH to its Advisory Board. Dr. Vearrier is Professor of Emergency Medicine and Preventive Medicine at the University of Mississippi Medical Center; Adjunct Associate Professor of Emergency Medicine at the Perelman School of Medicine at the University of Pennsylvania; and Associate Professor of Emergency Medicine, and was Medical Toxicology Associate Fellowship Director at Drexel University College of Medicine. PERC-med is the Pesticide Educational Resources Collaborative for Medical Professionals, a 5-year cooperative agreement (#X-83935901) between the U.S. EPA's Office of Pesticide Programs and University of California Davis Extension, in collaboration with Oregon State University. The primary goal of this project is to widely promote and market pesticide-related health resources to medical providers across the U.S. to help them prevent, recognize and treat pesticide-related health conditions.
Diana Simmes, MPH, Pesticide Medical Education Director at UC Davis said, "Dr. Vearrier's expertise in emergency medicine and medical toxicology positions him to advance healthcare providers' knowledge of pesticide-related conditions. His professional relationships and educational roles, along with his credentials, will ensure that more clinicians are trained on recognizing, treating and preventing these illnesses and injuries," she added.
"Pesticide spans many medical subspecialties -- public health, emergency medicine, preventive medicine, and toxicology," said Dr. Vearrier. "PERC-med's mission and mine are aligned -- teaching clinicians to recognize, treat and prevent pesticide illnesses and injuries."
Dr. Vearrier has published over 70 peer-reviewed publications; led as site principal investigator in several funded grants including those from the National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC), and the Federal Drug Administration (FDA); and has written seven book chapters. He is board certified in medical toxicology, occupational medicine, and emergency medicine. He is Chair of the Occupational and Environmental Toxicology Section of the American Academy of Clinical Toxicology; and is a member of the the American College of Occupational and Environmental Medicine, the American College of Medical Toxicology, and the American Academy of Emergency Medicine.
Dr. Vearrier received his Bachelor of Arts from the University of California Berkeley and his Doctor of Medicine from University of California San Diego. He completed his Residency in Emergency Medicine at Drexel University College of Medicine, his Fellowship in Medical Toxicology in the Department of Emergency Medicine at Drexel University College of Medicine, and completed his Residency in Occupational Medicine from Perelman School of Medicine at the University of Pennsylvania. Dr. Vearrier also received his Master of Public Health from Drexel University.
Dr. Vearrier joins other members of the PERC-med Advisory Board, including:
Davis, California -- PERC-med appointed Michael Yeh, MD to its Advisory Board, effective immediately. Board-certified in both emergency medicine and internal medicine, Dr. Yeh is finishing his medical toxicology fellowship at Emory University and the Centers for Disease Control and Prevention (CDC). PERC-med is the Pesticide Educational Resources Collaborative for Medical Professionals, a 5-year cooperative agreement (#X-83935901) between the U.S. EPA's Office of Pesticide Programs and University of California Davis Extension, in collaboration with Oregon State University. The primary goal of this project is to widely promote and market pesticide-related health resources to medical providers across the U.S. to help them prevent, recognize, and treat pesticide-related health conditions.
Diana Simmes, MPH, Pesticide Medical Education Director at UC Davis said, "Dr. Yeh's focus on medical toxicology and emergency medicine complements PERC-med's work." She continued, "His medical toxicology work with the CDC and Emory enhances our mission to provide clinicians with practical, timely, science-based resources on pesticide-related illnesses."
"The important work that PERC-med is doing coordinates perfectly with my medical toxicology interests," said Dr. Yeh. "Working in the field, researching, and educating clinicians are my passions. Collaborating with PERC-med enables me to further those goals."
Dr. Yeh received his Doctor of Medicine and his Master of Science in Epidemiology degrees from State University of New York at Buffalo; his Master of Science in Journalism from Columbia University; and his Bachelor of Science in Biology from SUNY at Stony Brook. Dr. Yeh completed his emergency medicine/internal medicine residencies at Allegheny General Hospital in Pittsburgh, Pennsylvania.
Dr. Yeh currently resides in Atlanta, Georgia. He joins other members of the PERC-med Advisory Board, including:
Davis, California -- PERC-med appointed James Russell Roberts, MD, MPH to its Advisory Board. A board-certified pediatrician, Dr. Roberts is a Professor of Pediatrics with Tenure at the Medical University of South Carolina. PERC-med is the Pesticide Educational Resources Collaborative for Medical Professionals, a five-year cooperative agreement (#X-83935901) between the U.S. EPA's Office of Pesticide Programs and University of California Davis Extension, in collaboration with Oregon State University. The primary goal of this project is to widely promote and market pesticide-related health resources to medical providers across the U.S. to help them prevent, recognize and treat pesticide-related health conditions.
Diana Simmes, MPH, Pesticide Medical Education Director at UC Davis said, "Dr. Roberts has significantly contributed to the field as co-author of the most authoritative reference on pesticide poisonings -- Recognition and Management of Pesticide Poisoning." She continued, "His work with the EPA and the Children's Environmental Health Network -- plus his dedication to pediatrics, environmental health and public health -- makes him a great resource for PERC-med and our mission to educate clinicians on pesticide-related illnesses."
"I am honored to join the Advisory Board at PERC-med," said Dr. Roberts. "My passion for educating healthcare practitioners on pesticide-related illnesses aligns perfectly with PERC-med's vision. By working with this diverse group of environmental, healthcare and scientific professionals, I hope to bring awareness to this medical and environmental issue."
Dr. Roberts has published over 50 peer-reviewed publications, received 20 grants, and has written seven chapters and six books. He is a member of the American Academy of Pediatrics, the Academic Pediatric Association and the American Academy of Clinical Toxicology.
Dr. Roberts received his Bachelor of Science in Biology from McMurry College in Abilene, Texas; and his Doctor of Medicine from Texas Tech University Health Sciences Center in Lubbock, Texas. He completed his Pediatric Internship and Residency at the Medical College of Georgia in Augusta, Georgia; and was a General Academic Pediatrics Fellow at the University of Alabama at Birmingham School of Medicine in Birmingham, Alabama. Dr. Roberts also received his Master of Public Health in Maternal and Child Health at the University of Alabama at Birmingham School of Public Health in Birmingham, Alabama.
Dr. Roberts currently resides in Charleston, South Carolina. He joins other members of the PERC-med Advisory Board, including:
A pesticide is any substance or mixture of substances intended for preventing, destroying, or mitigating any pest. Children and pregnant women are uniquely vulnerable to toxic effects from exposure to pesticides. Some of the widely used pesticides of concern in the United States include the herbicide glyphosate, organophosphate insecticides (e.g., chlorpyrifos, malathion), carbamate insecticides (e.g., carbaryl, propoxur), neonicotinoid insecticides (e.g., imidacloprid, thiamethoxam), and pyrethroid insecticides (e.g., permethrin, cypermethrin). Chronic or repeated low-dose exposures are common. There is growing evidence on the relationship between this non-acute pesticide exposure in early life and adverse neurocognitive and neurobehavioral outcomes (ADHD, autism) in children. Additional associated morbidities include cancer (brain tumors, leukemia) and adverse birth outcomes (reduced intrauterine growth, preterm birth, congenital anomalies, fetal death).
Read full article here.
Poison Control Center data shows over 35,000 calls related to pesticide exposure concerns for children ≤ 5 years old (2018). Most serious acute poisonings occur after unintentional ingestion, although poisoning may also follow inhalational exposure (particularly from fumigants) and/or significant dermal exposure, such as in drift events. Misuse, such as violating label instructions, may also lead to overexposure. It is well recognized that pesticide poisonings are likely to be underreported because of difficulty with diagnosis, incomplete reporting and symptoms not being recognized as a poisoning.
Read full article here.
You may be surprised to learn that many infection control products commonly used in healthcare are actually pesticides.
More specifically, they are antimicrobial pesticides. Antimicrobial pesticides are essential public health tools because we use them in hospitals, schools, bathrooms and food preparation areas to prevent the spread of germs that can cause disease. So, what exactly constitutes a pesticide? A pesticide is defined as any substance or mixture of substances intended for preventing, destroying, repelling, or mitigating any pest. Microorganisms, bacteria and viruses are included in the definition of pests. Pesticides help protect our food, water, and health. However, there are always risks related to their use.
Given global challenges with the COVID-19 pandemic, an increasing number of antimicrobial pesticides are being used to help control the spread of the novel coronavirus, SARS-CoV-2, that causes COVID-19. Since the emergence of COVID-19, the demand for antimicrobial pesticides has risen sharply. A recent CDC Morbidity and Mortality Weekly Report, found that U.S. poison centers received an increase in calls (45,550) related to exposure to cleaners (28,158) and disinfectants (17,392) from January–March 2020, compared to January–March 2019 (37,822) and January–March 2018 (39,122). Although this data does not provide a definite link between exposures and COVID-19 related cleaning activity, a clear temporal association can be seen (Chang, 2020).
Read full article here.
To arrange an interview with an expert on pesticides and pesticide-related illnesses, contact us at PERC-MedSupport@ucdavis.edu. Our experts can speak about pesticides, pesticide-related illnesses, toxicology, occupational health, environmental health, pediatrics, agromedicine, and public health.
