^Environmental; PrdtecliM ;IS dSiji^^jci^ag^ '' '--.-_ " - - ; - ----- - ; - J|^yj^ .".,.!..:.:,!!=.*! {iii^Viil.'-^!^!!,1:' it" r f-,.ii Bint ';:f^^t. [.^' ff''.:, }&. '.'.''i ,*&Vli":: .1 ,i. j;-.. --f«i"i ^ '1 > .... "-. .,:*.;*:.:. ' .-n.lSvi.' .* i.'ui.T.pi' ii1'ii kt",. Til.!' <",. tv PHI >EPA USDA C ------- ------- Pesticides and National Strategies for Health Care Providers Workshop Proceedings April 23-24, 1998 July 1998 ------- Acknowledgments The success of the workshop would not have been possible without the efforts of a large number of dedicated people. We wish to acknowledge the efforts of the members of the Expert Panel who gave graciously of their time, experience, and energy in both attending the workshop and developing a practical product. We are grateful to the three speakers, Augustave Wilson, Mark Robson and Louise Rauckhorst, for their presentations, and to the many observers who came from all over the country to attend the workshop and contribute their experiences. We would like to acknowledge the commitment and enthusiasm of the members of the Federal Interagency Planning Committee who helped organize the event and provide leadership in advancing this historical interagency national initiative. Staff work and planning by EPA personnelincluding Ameesha Mehta, Belen Revilla, Delta Valente, Ana Maria Osorio and Kevin Keaneywere essential in making the workshop a success. A special thankyou to Susan West, with the National Environmental Education and Training Foundation, for her expert assistance in facilitating the workshop and helping to draft these proceedings. We thank Andrea Smith and Mary Davis with the Association of Teachers of Preventive Medicine for their planning and organizational effort, and Gilah Langner of Stretton Associates for editorial and graphics assistance. Additional copies of these proceedings may be obtained by calling EPA at 703-305-7666. Cover photo credits: Left, Alan Pogue; Right, EPA ------- Contents .. r ' i . . , ... ^Executive Summary. > Part I: Setting the Stage 1. Introduction ............................ . ............. ..... . ..... . ......................... , _ 2 , ., , 2. A Collaborative Effort ............... [[[ 7 1 3. « Facts About Pesticides ; ........ ... ....... : ...... ........................ .... 12 4. Practitioner Perspectives: Lessons Learned and Success Stories ............... . ..... ..... 16 Part II: Findings and Recommendations of the Expert Panel 5. Findings [[[ 26 r 6. Preamble to Expert Panel Recommendations ............ .......................................... 29 7. Recommendations of the Expert Panel ............................................... ................. 30 Strategy I: Defining Recommended Competencies ........................................ 30 Strategy II: Impacting Education and Training ............................................. .. 34 Strategy III: Raising Awareness ................................... . ..................... ; .............. 37 Strategy IV: Maintaining and Developing Resources ...................................... 42 8. Recommended Next Steps [[[ 43 Appendices ------- ------- Vybf'ksbpp OW peyeloping National Strategies frililill^^ iHgiUfr 1 Executive Summary In April 1998, EPA and several other federal agencies convened a workshop of experts in the field of health professional education to identify strategies for educating health care providers on how to recognize, diagnose, manage, and prevent adverse health effects from pesticide exposures. The workshop reflected the collaborative nature of EPA's initiative and the need to involve a wide group of stakeholders in this issue. The workshop brought together an expert panel representing associations of health professionals from the medical, nursing, and physician assistant communities; farmworker and community interest groups; academic faculty; and pesticide experts. In addition, an invited group of observers from state and federal agencies, health clinics, community-based programs, farmer and farmworker groups, and other interested organizations participated in question and answer sessions with the expert panel. At the federal level, EPA is coordinating and pooling resources with the Department of Health and Human Services (Health Resources and Services Administration, National Institute for Occupational Safety and Health), the Department of Labor (Occupational Safety and Health Administration, Employment Standards Administration), and the Department of Agriculture (Agricultural Marketing Service and Cooperative State, Research, Education and Extension Service). Among the themes and findings that emerged from the workshop are: The lack of adequate training for health care providers on potential adverse health effects from pesticide exposures; The need for partnerships among the stakeholders involved in this issue; The diversity of peoples and cultures affected by pesticides; The importance of addressing both child and adult pesticide health issues; The importance of addressing both agricultural and non-agricultural (including urban) sectors; The need for multidisciplinary approaches to diagnose, investigate, and prevent adverse health effects from pesticide exposures; ------- Executive,' Si|mmary| The importance of addressing this issue in the context of the larger health care and public health systems; and The need to maintain existing programs and disseminate information about model programs and resources that address pesticide health issues with health care providers. The expert panel decided that the target of this initiative should be primary care providers, defined as physicians, nurses, nurse practitioners, physician assistants, nurse midwives, and community health workers specializing in one of the following areas: family medicine, internal medicine, pediatrics, obstetrics/gynecology, emergency medicine, preventive medicine, or public health. As the "gatekeepers" of our health care system, all primary care providers should possess basic knowledge and skills related to pesticide and other occupational or environmental exposures. The panel outlined desired outcomes in the knowledge and behavior of primary care providers, in general, and for three stages of education: basic education, specialty training, and practice settings/ continuing education. The panel agreed on recommendations for further development in four main areas: Strategy I: Defining Recommended Competencies for primary care providers. The panel made initial recommendations for specific competencies and the appropriate emphasis of training during basic education, specialty training, and in practice settings. Strategy II: Impacting Education and Training to motivate and train students and practitioners on the subject of health effects resulting from pesticide exposures. The panel made initial recommendations for basic education, specialty training, and continuing education/practice settings. Strategy III: Raising Awareness of the broader primary provider constituency through a variety of mechanisms. The panel identified examples such as professional meetings, marketing and outreach efforts, materials and resources development, journal articles, distance learning, and support networks including the Internet. ------- -"Workshop on Developing National Strategics Strategy IV: Maintaining and Developing Resources. The panel recommended exploring the centralization of resources for primary care providers and strengthening links to existing resources. The next steps in the development of a more detailed implementation plan for the strategies are outlined at the end of the workshop proceedings. This initiative is conceived of as a long-term effort. Achieving its goals will depend on the collaboration and involvement of a great many organizations and people. The initiative will be integrated in the broader context of other national initiatives in occupational and environmental health, to avoid duplication of effort. EPA encourages -' ' ' , ' all interested organizations to play a role in the development of the initiative and to stay up-to-date by visiting its Web site at http://www.epa.gov/pesticides/. Feedback on these workshop proceedings and the initial recommended national strategies are welcomed by EPA and its federal partners. Questions and comments can be directed to Ameesha Mehta, EPA, at 703-305-7666. ------- ------- ------- I. Introduction Pesticide poisoning is a commonly under-diagnosed illness in America today. A new initiative of the U.S. Environmental Protection Agency, entitled Pesticides and National Strategies for Health Care Providers, is aimed at ensuring that health care providers become better aware, educated, and trained in pesticide health issues. In April 1998, EPA convened a workshop to develop national strategies to improve the education and awareness of health care providers in dealing with pesticide-related health issues. The workshop brought together an expert panel of key organizations involved in this issue, representing associations of health professionals from the medical, nursing, and physician assistant communities; farmworker and community interest groups; academic faculty; and pesticide experts. In addition, an invited group of observers from government agencies, health clinics, community-based programs, farmer and farmworker groups, and other interested organizations participated in question and answer sessions with the expert panel. jfptisiip^ Hill ;".!". .J"1;,1'1''!!' ; i'ii' ..... "i, : ',. i, ' ' "',,, gfeilS^ " ' ' < ' ' The goals of the workshop were to: Design national strategies on how to effectively educate and train health care providers about potential adverse health effects from pesticide exposures in the agricultural and non-agricultural sectors; Create a cohesive and multidisciplinary team of experts that represents stakeholder groups; Identify possible collaborative efforts between stakeholder organizations and federal agencies to address recommended strategies; and Produce workshop proceedings to be disseminated to stakeholder groups and others. This initiative is a long-term integrated effort. Achieving its goals will depend on the collaboration and involvement of a great many organizations and people. EPA and its counterparts on the Federal Interagency Planning Committee that organized the workshop encourage all interested organizations to play a role in the development of ------- the initiative. Feedback on these workshop proceedings and the initial recommended national strategies are welcomed by EPA and its federal partners. Questions and comments can be directed to Ameesha Mehta, EPA, at 703-305-7666. Background on the Initiative The initiative on pesticides and health care providers received its impetus from a number of sources. A primary contributor is EPA's Worker Protection Standard which is designed to reduce pesticide exposure to agricultural workers, mitigate exposures that occur; and inform agricultural employees of the hazards of pesticides. The regulation, implemented in 1995, mandates that millions of farmers, pesticide applicators, and farmworkers be educated about the health effects of pesticide exposure and the need to get medical treatment for such effects. This in turn is expected to create additional demand for services from health care providers. After the first year of full implementation of the Worker Protection Standard, EPA held nine public meetings to evaluate the progress of implementation and hear the experiences of the people most affected by the regulation. One clear message from the public meetings was the need to improve the recognition, diagnosis, and management of adverse health effects from pesticide exposures on the part of all primary care providers of the health care community. Unfortunately, we have all too few ^.statistics on the rates of pesticide illness, but from the few states that do have sr^reporting on pesticide illnesses, we know '_ ~ihat there are very high rates among [, some occupations... . ~_ ^ i believe that the use of methyl * parathion [in homes] is probably -*r !gT indicative of a broader problem of lack of understanding about pesticide usage in --' our society, and lack of recognition of £ those exposures when they do occur. Dr. Lynn Goldman, EPA Although the primary populations affected by pesticides are the 3 to 4.5 million, farmworkers in America and the million or more pesticide applicators, pesticides have become ubiquitous in our society. Urban and suburban exposures to pesticides through lawn care products and insecticides in the home and workplace are affecting the population at large. Health care providers in urban settings are even less likely to "think pesticides" in taking patient histories or diagnosing illnesses. ------- Workshop on Developing National Strategies Americans look to their health care providers for guidance on health concerns. Increasingly, such concerns include the effects of environmental and occupational hazards such as pesticides on their health. While some progress has been made in introducing environmental health issues into the curriculum of medical and nursing schools, most health professionals still do not have adequate knowledge and tools to address patient and community concerns about pesticides and other environmental hazards. Nor is the recognition and management of pesticide health effects an integrated part of the clinical training program of health care providers. The need for improvements in health care provider training has been expressed by health provider groups as well as government and community organizations. In 1994, the American Medical Association adopted a resolution urging Congress, government agencies, and private organizations to support improved strategies for the assessment and prevention of pesticide risks. These strategies included systems for reporting pesticide usage and illness, as well as educational programs about pesticide risks and benefits. In addition, two Institute of Medicine (IOM) committees have dealt with the general issue of environmental health education, focusing on nurses and physicians, respectively. Both committees recommended an integration of environmental health issues throughout the various stages of training and clinical practice for health care providers. The expert panel convened under the current initiative discussed the lOM's reports at length and chose to adopt a revised IOM statement as a preamble to the expert panel's recommendations (see section 6). Over the years, states, universities, and federal agencies have conducted a number of successful programs aimed at increasing awareness and training. However, few efforts have been sustainable overtime and national in scope. In pursuing this issue further, EPA realized the importance of bringing together federal agencies working in this area and as many stakeholder groups as possible. Moreover, to capture all pesticide-related health issues, the scope of the effort must be geared toward both agricultural and non-agricultural sectors. A Federal Interagency Planning Committee was created in Fall 1997. Its first goal was to conduct a workshop that would develop national strategies for health care providers. ------- Introduction Convening the Workshop The workshop held on April 23-24, 1998 in Arlington, Virginia was sponsored and planned by EPA in collaboration with the Department of Health and Human Services, Department of Agriculture, and Department of Labor. The Association of Teachers of Preventive Medicine and the National Environmental Education and Training Foundation worked with these federal agencies to organize the initiative (see list of Federal Interagency Planning Committee members in Appendix A). In an effort to advance the initiative, the planning committee convened an expert panel with representatives of 16 health organizations involved in this issue. The workshop was conceived of as a deliberative session of the expert panel, open to the public, with comments and questions taken from the audience of observers, who often were experts themselves in the issues raised. The expert panel included representatives from the following organizations: American Academy of Family Physicians; American Academy of Pediatrics; American Academy of Physician Assistants; American Association of Colleges of Nursing; American Association of Poison Control Centers; American College of Emergency Physicians; American College of Occupational and Environmental Medicine; American Nurses Association; Council of State and Territorial Epidemiologists; Migrant Clinicians Network; National Center for Farmworker Health; National Organization of Nurse Practitioner Faculties; National Pesticide Telecommunications Network; National Rural Health Association; Pennsylvania State University/National Agromedicine Consortium; and Suncoast Community Health Centers, Inc. The list of expert panel members can be found in Appendix A. ------- These workshop proceedings are intended as a working document to raise awareness, spark discussion and debate, and involve a still wider group of organizations. The remainder of Part I of the proceedings presents background information, including a brief outline of the federal agencies and other groups collaborating on the initiative (Section 2); facts about pesticides and pesticide-related health concerns (Section 3); and the perspectives of practitioners in the field (Section 4). Part II of the proceedings contains the findings and recommendations of the expert panel. The panel identified its target audience as primary care providers, defined its overall goals for the initiative (Section 5); adopted a preamble (Section 6); and developed four strategies for primary care providers (Section 7). Section 8 outlines the next steps for the initiative. Two appendices to the proceedings identify selected resources in the field and list contacts for the Federal Interagency Planning Committee, the expert panel, and observers at the workshop. EPA and the members of the planning committee welcome the involvement in this initiative of all groups interested in pesticides and health care issues. Please contact members listed in the appendix for more information, or visit our future Web site on the Internet at http://www.epa.gov/pesticides/. The Web site will provide up-to-date information on the status of the initiative, as well as more detailed information about the stakeholders involved, workshop proceedings, and documents produced during the course of the initiative. ------- 2. A Collaborative Effort Getting an initiative of this magnitude underway requires the collaborative efforts of a large number of agencies, organizations, and decision-making bodies. The success of this initiative will depend on the extent to which it can reach and involve the hundreds of groups and organizations whose missions are directly relevant to this effort. EPA is coordinating and pooling resources with the Health Resources and Services Administration and the National Institute for Occupational Safety and Health of the Department of Health and Human Services; the Occupational Safety and Health Administration and the Employment Standards Administration of the Department of Labor; and the Agricultural Marketing Service and the Extension Service of the U.S. Department of Agriculture. State and local governments will also play a vital role, working both with federal agencies and directly with organizations dealing with pesticide exposures. Community-based organizations, agricultural and migrant worker groups, universities, and associations of health professionals are important front-line providers of information and health care to people affected by pesticides. Community and migrant health centers tending to migrant, rural, and farmworker populations understand the health care needs and cultures of individuals who are most likely to seek care for pesticide exposures. Academic faculty (e.g., from agromedicine, environmental and occupational health, pediatrics, and family practice) and medical, nursing, and physician assistant associations provide vital information on the skills that health care providers must possess to diagnose and treat pesticide exposures. The organizations participating in this initial meeting are listed in Appendix A. As the initiative develops, other organizations will be involved in drafting and finalizing the strategies and implementation plan. Federal Agency Collaboration A fundamental approach and unique feature of this initiative is that it brings together a number of federal agencies with pesticide-related mandates in a cooperative and interactive working arrangement that avoids duplication of effort. Following is a short description of the mandates of each of the federal agencies involved in the initiative, along with a brief quote from the remarks of the official representing the agency at the workshop. ------- Workshop on Developing National Strategies U.S. Environmental Protection Agency (EPA) EPA regulates the use of pesticides through its pesticide registration program. In addition, EPA works in partnership with state and tribal agencies to implement two field programs the certification andtrainingprogram forpesticide applicators and the agricultural worker protection standard to protect workers and handlers from pesticide exposures. EPA sets national standards for certification of over 1 million private and commercial pesticide applicators. The Worker Protection Standard represents a major strengthening of national efforts to safeguard agricultural workers. The goal of the regulation is to: inform employees about the use and hazards of pesticides; eliminate or reduce exposure to pesticides; and mitigate the effects of exposures that occur. The regulation contains requirements for worker pesticide safety training, worker notification of pesticide application, use of personal protective equipment, restricted entry intervals after pesticide application, decontamination supplies, and emergency medical assistance. "Due to high pesticide use in both the urban and agricultural sectors there is even a greater need for health care providers to be able to identify possible pesticide-related conditions and make the appropriate treatment. The incorporation of environmental health concepts, and particularly pesticide issues, into professional education is critical for minimizing the occurrence and the severity of pesticide-related illness and injury." Dr. Lynn Goldman, Assistant Administrator, Office of Pesticides, Pollution Prevention, and Toxics, EPA Health Resources and Services Administration (HRSA), Department of Health and Human Services HRSA works to improve the nation's health by assuring equitable access to comprehensive health care. HRSA's efforts are directed at special needs, underserved, and vulnerable populations. Among its offices and bureaus are the Office of Rural Health Policy, the leading federal advocate for better rural health care services; the Bureau of Primary Health Care, whose mission is to increase access for the underserved to comprehensive primary and preventive health care; and the Bureau of Health Professions, which provides national leadership in assuring a workforce of health professionals that meets the health care needs of the public. ------- "I would like to make sure that we stay interdisciplinary, which is a ., critical aspect; that we stay consumer oriented; and that we deliver to the American people a quality product that we hope we'll be able to move ahead on your advice." Neil H. Sampson, Acting Associate Administrator for Health Professions, HRSA National Institute for Occupational Safety and Health (NIOSH), Department of Health and Human Services NIOSH is the federal agency responsible for conducting research on occupational disease and injury. NIOSH may investigate potentially hazardous working conditions upon request, makes recommendations on preventing workplace disease and injury, and provides training to occupational safety and health professionals. "Pesticide-induced issues are found in priority categories within all three of the main areas in NIOSH. These include disease and injury, work environment and the workplace, and in research tools and approaches." Dr. Stephen A. Olenchock, Senior Scientist for Agricultural Research, NIOSH Cooperative State, Research, Education and Extension Service (CSREES), U.S. Department of Agriculture CSREES, more commonly known as the Extension Service, works with its university partners, the state land-grant system, to provide farmers and ranchers information to reduce and prevent agricultural-related work incidents. The Pesticide Applicator Training program trains applicators in the safe use of pesticides and coordinates pesticide-related safety training programs. The Extension Toxicology Network, EXTOXNET, provides science-based information about pesticides to health care providers treating pesticide- related health concerns. ------- Workshop an Developing National Strategies "Training and education can have positive impacts on reducing pesticide-related illnesses. We all have an important role in that trend." Barry M. Brennan, Associate National Program Leader, Pesticide Applicator Training, CSREES Agricultural Marketing Sendee (AMS), U.S. Department of Agriculture AMS administers the pesticide recordkeeping program under which certified pesticide applicators are required to maintain records on restricted-use pesticides. These records must be made available to licensed health care professionals treating patients who may have been exposed to restricted-use pesticides. AMS supports an outreach project to educate health care professionals about the availability of this information. Wage and Standards Division, Employment Standards Administration (ESA), U.S. Department of Labor The Wage and Standards Division administers the wage, hour, and child labor provisions of the Fair Labor Standards Act, as well as several other programs covering prevailing wages for government contracts and farm labor, family and medical leave, immigration, and polygraph testing. "Since early in 1997, the Wage and Hour Division has been the primary federal enforcement agency for enforcing the field sanitation standards developed by OSHA ten years ago...Perhaps the single most important protection from pesticide hazards aside from preventing exposure at all is the availability of handwashing facilities to remove pesticide residues that could otherwise be absorbed through skin or transferred and consumed." Corlis L. Sellers, National Program Administrator, Wage and Hour Division, ESA ------- Occupational Safety and Health Administration (OSHA), U.S. Department of Labor OSHA's mission is to protect lives, prevent injury, and protect the health of America's workers. More than 100 million workers and 6.5 million employers are covered under the Occupational Safety and Health Act. OSHA and its state partners have approximately 2100 inspectors, plus investigators, standards writers, educators, physicians, nurses, and other staff in over 200 offices across the country. OSHA sets protective workplace standards, enforces the standards, and reaches out to employers and employees through technical assistance and consultation programs. "If your front line clinicians are seeing migrant farmers, typically there will be a labor camp in place, and so typically OSHA will have some' ; jurisdiction. What I want to ask you to think about is figuring out a way to help us effectively convey to your front line clinicians that if they have bad stuff that is obvious, if they have heat stroke, if they have a patient who has lost a limb, had an amputation, had a major accident, or who has even... the chronic effects of lifting with back injuries, shoulder injuries, that sort of thing, as well as clinical pesticide poisoning, that it is worth a phone call to the local OSHA. You can ' - look them up in the blue pages of the phone book." Dr. Rosemary Sokas, Director, Office of Occupational Medicine, OSHA ------- 3. Facts About Pesticides Pesticides Currently in the U.S., there are over 17,000 registered pesticide products and over 800 related active ingredients. Seventy-six percent of the pesticides used annually (approximately 950 million pounds) are used in the agricultural industry. Twenty- three percent of the pesticides used annually (approximately 294 million pounds) are used in the urban sector (U.S. EPA, 1997). EPA regulates the use of pesticides in the United States under the authority of the Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA) and the Federal Food, Drug and Cosmetic Act. Pesticides differ from other substances regulated by EPA because they are intentionally applied to crops and targets, rather than representing by-products of industry or other human activity. Pesticides are likely to be found in nearly every home and business in the United States, in the form of insecticides, weed killers, flea controls, disinfectants, and swimming pool chemicals. They are also used in schools, parks, and other public places. EPA is responsible under FIFRA for registering, re-registering and de-registering pesticides to ensure that, when used according to label directions, they will not pose unreasonable risks to human health or the environment. This involves: 30 major pesticide producers; 100 smaller producers; 3,300 formulators; 29,000 distributors; 40,000 commercial pest control firms; approximately 1 million farms; several million industry and government users; and approximately 90 million households (U.S. EPA, 1998). Pesticide Poisoning Agricultural workers and pesticide handlers appear to be at greatest risk for acute pesticide poisoning. Based on states with required reporting of pesticide poisonings, ^^- :...: : :: iiig ------- EPA estimates approximately 250-500 physician-diagnosed cases occur per 100,000 agricultural workers (including pesticide handlers). It is believed that the number of actual cases would be twice as high if undiagnosed and unreported cases were included (Blondell, 1997). A substantial number of people in the U.S. are also at risk of pesticide poisoning from non- agricultural uses. Data collected from the American Association of Poison Control Centers found that in 1996, almost 80,000 children were exposed to common household pesticides in the United States. It is estimated that one quarter of those children developed symptoms of pesticide poisoning. Over 34,000 adults were exposed to various types of pesticides and an estimated 72% of them developed symptoms of pesticide poisoning (Litovitz et al, 1997). We are looking more and more at ^suburban pesticide use. One of the things concerns us is the number of people * "that are using pesticides in the house at >ur and five times the rate, the mindset being that if one teaspoon is going to kill bug, darn, five teaspoons are really 5> * going to Ml the bug. So we repeatedly ^'"tsee people in our clinic that have just been exposed because they applied it six and seven limes instead of once like the iis:, label says. Dr. Mark Robson, Environmental and Occupational Health Sciences Institute In addition to accidental poisonings, since 1994, EPA has responded to several pesticide misuse incidents occurring in Midwestern and Southern ^ ~ ~ states. Those incidents involved people who had illegally sprayed homes and other buildings with methyl parathion, a highly toxic agricultural pesticide registered for outdoor use only. Investigators found high levels of methyl parathion residues in homes. Based on urinalysis of residents, about 3,400 people were relocated from their residences. The widespread misuse of methyl parathion is a real public health threat, especially to infants and children. Public agencies have spent well over $72 million to date responding to this emergency (U.S. EPA, 1998). Training of Health Care Providers For many years, health care providers were not trained in environmental issues related to human health. In 1985, only 50% of U.S. medical schools included occupational and environmental health in their curricula, with an average of only four hours of ------- instruction over four years (Levy, 1985). By 1992, 66% of schools required about six hours of study in occupational and environmental health (Burstein and Levy, 1994). A survey of 89 departments of internal medicine at U.S. medical schools found that only 22% offered occupational medicine experiences, almost all of which were elective (Cullen and Rosenstock, 1988). In 1988, an Institute of Medicine (IOM) committee on the role of the primary care physician in occupational and environmental medicine recommended that all primary care physicians be able to identify possible occupationally or environmentally induced conditions and make appropriate referrals for follow-up (IOM, 1988). In 1992, the IOM convened a Committee on Curriculum Development in Environmental Medicine which culminated in the report, Environmental Medicine: Integrating A Missing Element into Medical Education (Pope and Rail, 1995). In 1993, the Institute of Medicine convened the Committee on Enhancing Environmental Health Content in Nursing Practice. The committee's report, Nursing, Health and the Environment, recommended that environmental health concepts be incorporated into all levels of nursing education as well as nursing licensure and certification examinations (Pope et al., 1995). Also in 1994, the American Medical Association adopted a resolution urging Congress, government agencies, and private organizations to support improved strategies for the assessment and prevention of pesticide risks (AMA, 1994). References American Medical Association. Report 4 of the Council on Scientific Affairs, Educational and Informational Strategies for Reducing Pesticide Risks (Resolutions 403 and 404), December, 1994. Blondell, J. "Epidemiology of pesticide poisonings in the U.S., with special reference to occupational cases." Occupational Medicine: State of the Art Reviews, Vol. 12.2. April-June, 1997. Burstein, J.M. and B.S. Levy. "The teaching of occupational health in US medical schools: little improvement in nine years." American Journal of Public Health, 84(5):846-849, 1994. Cullen, M.R. and L. Rosenstock. "The challenge of teaching occupational and environmental medicine in internal medicine residencies." Archives of Internal Medicine, 148(110):2401-2404, 1988. ------- Institute of Medicine. Role of the Primary Care Physician in Occupational and. Environmental Medicine, IOM Report, 1988. Levy, B.S. "The teaching of occupational health in US medical schools: five-year follow-up of an initial survey." American Journal of Public Health, 75:79-80, 1985. Litovitz, T.L., M. Smilkstein, L. Felberg, W. Klein-Schwartz, R. Berlin, and J. Morgan, 1996 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. American Journal of Emergency Medicine, 15:447-500, 1997. Pope, A.M. and D.P. Rail, eds. Environmental Medicine: Integrating a Missing Element into Medical Education. Committee on Curriculum Development in Environmental Medicine, Institute of Medicine, National Academy Press, Washington, DC, 1995. Pope, A.M., M.A. Snyder arid L.H. Mood, eds. Nursing, Health and the Environment: Strengthening the Relationship to Improve the Public's Health. Committee on Enhancing Environmental Health Content in Nursing Practice, Institute of Medicine, National Academy Press, Washington, DC, 1995. U.S. EPA. Pesticides Industry Sales and Usage: 1994 and 1995 Market Estimates. Office of Pesticides, Prevention,,and Toxic Substances, EPA #735-R-97-002, pp. 12-13, August, 1997. U.S. EPA. Office of Pesticide Programs Annual Report for FY1997. Office of Pesticides, Prevention, and Toxic Substances, EPA #735-R-97-003, January, 1998. m ------- 4. Practitioner Perspectives: Lessons Learned and Success Stories Three practitioners were invited to make presentations at the workshop. They offered the perspectives of a migrant worker, a university-affiliated pesticide specialist, and a nurse practitioner, respectively. Their presentations are summarized in this section, followed by a discussion of themes that emerged during the course of the workshop and a sampling of comments from workshop participants. Three Perspectives Wilson Augustave, Case Manager, Finger Lakes Migrant Health Care Project, Rushville, New York. Mr. Augustave has been a migrant farmworker for most of his life and has had extensive exposure to pesticides himself. He has spent the last three years training migrants regarding the dangers of pesticides and how best to protect themselves. He is a member of DHHS' National Advisory Council on Migrant Health. Mr. Augustave offered the perspective of farmworkers who by and large are living "a life of immediacy" at poverty levels and are dependent on their jobs to support themselves and their families. Voicing an opinion on pesticide exposures could cost a worker his or her job, "so some things you keep your mouth quiet about, and just hope that it doesn't hurt you severely or soon." Typically, Mr. Augustave noted, when farmworkers go into health centers for pesticide-related concerns, they are given pills and told to come back in a few weeks. Rarely do providers discuss pesticides or are pesticides seen as a problem for the larger community. Nevertheless, he noted, there are plenty of opportunities for broader pesticide exposures. For example, workers use laundry machines in town to wash their clothes which contain pesticide residues. Mr. Augustave related a case of pesticide poisoning that he encountered at a migrant labor camp. Eight men had gashes on their arms which looked "as if they had just had ------- Practitiofier Perspectives MJSt!*'(!."' a tangle with a flesh-eating disease." The contractor was applying a bottle of solution to some of the worst cases, and telling the workers that it was poison ivy. Mr. Augustave brought in the public health officials, who sent the workers to an emergency room. A day later, though, when he received a call from public health, the workers had all moved on and follow-up was no longer possible. Mr. Augustave stressed the need tp find some way for migrant farmworkers to have continuity of health care. Dr. Mark Robson, Executive Director, Environmental and Occupational Health Sciences Institute, Piscataway, New Jersey. Dr. Robson has worked in the area of pesticides for 20 years, having served as the Extension pesticide specialist at Rutgers University, and later working in the New Jersey Department of Environmental Protection. He serves on numerous pesticide-related committees including recently chairing the peer review committee for the EPA portion of the agricultural health study. Dr. Robson is currently involved in a National Institutes of Health environmental justice grant looking at pesticide issues on the Texas-Mexico border. f One afternoon a physician called "I have this terrible ^problem right now, I need some advice. Yesterday a woman s'pushing a baby carriage down the street. A lawn care fellow was coming the other way spraying a herbicide on the lawn. As he came to the comer, so did mom. Mom and baby all got sprayed with 2-4-D. We sent them right away to the hospital, but I want some advice. I immediately asked for a ~ ^ ^ ~~ j- Cholinesterase test, but it didn't show anything." , - I said, "It is not going to identify anything; 'cholinesterase tests are for organophosphorus insecticides. Had you found something, we could have published together!" He said, "You know, the only thing I remember from my medical training was 'Pesticides equal ''cholinesterase test.'" - - ; ' ^ Dr. Mark Rojt>sonv Dr. Robson presented a case study from his clinic in which pesticide exposure and health problems were solved through the cooperation of the growers and local Extension Service. Two New Jersey farmers in their fifties who had farmed all their lives were experiencing blurred vision, lack of concentration, and other health problems. A closer investigation diagnosed chronic organophosphate intoxication. The two farmers grew only one crop some 550 acres of lima beans and did most of the work themselves. That meant that every week from May through July, the farmers did successive planting of ' lima beans. The spray schedule began when they started to till the soil and continued m ------- "until they harvested the last lima bean." Every eight passes in the field, they would dump in the fine granular insecticide (Diazinon 14-G) and get "a face full of it." Moreover, the pesticides were kept in the shop, not in a separate storage area, as required by law. So the farmers were literally exposed to some amount of pesticides 12 months of the year. Dr. Robson explained how the team of Extension staff and health care providers encouraged the farmers to put up a separate storage area, put up a separate washing facility, launder their work clothes each day and change into fresh coveralls, and start using personal protective equipment. The team also made simple design changes to the farmers' equipment to reduce pesticide exposure. The outcome was that "they looked and felt better than they had in years. It was like a miracle cure," said one of the farmers. Dr. Robson attributed the success to the one-on-one assistance, the farmers' cooperation with everything the doctors asked them to do, and the cooperative working relationship of grower, Extension staff, and health care providers. Dr. Louise Rauckhorst, Professor, Philip Y. Hahn School of Nursing, University of San Diego, San Diego, California. Since 1990, Dr. Rauckhorst has served as the nurse practitioner track coordinator at the School of Nursing. Her faculty experience in schools of nursing spans over 15 years, including conducting research and teaching and advising nursing students. Dr. Rauckhorst serves as project director on programs to improve the preparation of nurses in gerontology and migrant health, and to meet the challenges of health care in the next century. , ,;;.. ...... i.p .. , ;, , . , ., ., , ..... . Dr. Rauckhorst reported on a recent survey of 57 clinics in several California counties conducted by the pesticide management department at the University of California at Davis. Each clinic reported seeing only one or two identified pesticide poisoning cases a year, which makes it understandable why it is difficult to keep providers' attention on pesticide poisoning. Primary care providers reported being largely unaware of reporting requirements, especially the requirement to report by telephone within 24 hours to the local county health officer. Cases were only picked up if a doctor's first report or an occupational illness report was filed, which would delay any investigation of the situation. ------- n Primary care providers in the survey also reported being unaware of contact people and resources for pesticide-related cases. They also reported being reluctant to report a case unless they were 100 percent certain of the diagnosis, even though California law mandates reporting if a clinician suspects pesticide exposure to be the cause of a patient's health problems. Dr. Rauckhorst presented a likely scenario of a pesticide poisoning incident in San Diego County, and concluded with a discussion of gaps in coverage: Limited enforcement of federal and state laws regarding adequate training of workers, and provision and maintenance of required safety equipment and supplies. The need to focus training on local issues specific to local farmworker populations, the types of crops planted, the types of pesticides used. The need to tie these efforts with workshops, CME or CEU granting, written materials, Internet programs, staffed telephone support networks and consultation resources, to give providers ongoing access to pesticide information and referrals. Opportunities to provide health profession students with field trips, especially if they intend to practice in rural areas, to give them first-hand knowledge of occupational risks. Emerging Themes Several themes emerged from the presentations and question and answer sessions among the expert panel, presenters, and observers. They include: Partnerships the importance of developing a sense of partnership at multiple levels among federal and state agencies, stakeholders, industry, community-based organizations, and professional associations; among growers, health care providers, Extension Service, and public health departments; between health care provider and patient, etc. Dr. Lynn Goldman of EPA noted that various agromedicine programs including the ones in Pennsylvania, North Carolina, South Carolina, and West Virginia, provide examples of successful partnerships and cooperation between key stakeholders. Dr. Roger F. Suchyta (American Academy of Pediatrics) noted the need ------- Workshop zm Developing National Strategies to consider how to bring industry into partnership on this issue. Teresa Niedda spoke to the interest and expertise of community organizations as partners. Diversity the diversity of sectors affected by pesticides and the complex web of interests, cultures, and populations involved (agricultural, non-agricultural, rural and urban, family farms, migrant workers, children's exposures to residues, etc.). Dr. Mark Robson (Environmental and Occupational Health Sciences Institute) noted that very- little research has been conducted on women farmworkers, even though more than half the work force are women. Rita Monroy (National Coalition of Hispanic Health and Human Services Organizations) noted the need for sensitivity towards culture, including language, beliefs, and values particular to the Hispanic community, or to other communities with which health care professionals will be dealing. Chip Petrea (University of Illinois/AshNet) noted that even from one Illinois county to the next, dairy farmers would likely have a different frame of reference than grain farmers. In addition, it is important to consider the literacy levels of all the sectors. Multidisciplinary teamwork the need to approach the issue from a multi- disciplinary framework which includes a variety of medical professions, departments of agriculture, OSHA, departments of environmental quality, and Extension. Dr. Sheldon Wagner (National Pesticide Telecommunications Network) noted that in a case of pesticide-related illness, it's not just a matter of a doctor analyzing the case and making a diagnosis. Delbert Shelton (DuPont) pointed out that physicians need follow-up support from others who will take on case investigations. He noted that this type of multidisciplinary approach is used effectively in some of the agromedicine programs. Incentives the importance of examining the incentives that influence health care providers to address pesticide exposures in the larger context of the health care system in which providers operate. Among the issues raised were the usefulness of state reporting requirements in encouraging reporting of pesticide incidents, the high turnover of primary care providers in rural areas, and the impact of managed care. Dr. Rugh Henderson (Penn. State University/National Agromedicine Consortium) pointed out that there are advantages to managed care which might enable reaching and sensitizing health care providers to this issue; on the other hand, the time pressures in managed care make it less likely that a health care provider could pursue pesticide-related health concerns. Joni Berardino (National Center for Farmworker ------- Health) noted that even if managed care were available in rural areas, farmworkers are generally not eligible to participate in such systems because they are uninsured. Other Voices A wide range of other subjects were touched on during the course of the workshop. Following is a sampling of comments from participants gleaned from the question and answer session during the first day of the workshop. Surveillance programs: "Within the [Texas] Department of Health, part of our responsibility of being a surveillance program is to be available to take case reports from physicians when they call in. We follow-up in as much of a multidisciplinary way as we can, at least in Texas. That includes bringing in the Texas Department of Agriculture... They can use their regulatory power to fine growers if necessary, if there has been an inappropriate use of a pesticide. We use the skills that we have to look at health effects, and to follow up on a person after they have seen their physician. . We look at them two and three days later, a week later, two months later. We complete full interviews with these people, looking at what they were exposed to, how they were exposed, what their occupation is. The majority of our reports do not come from primary care physicians, they come from secondary sources, but the system is there." (Dr. Jackilen Shannon, Council of State and Territorial Epidemiologists) Regional resources: "How can we regionalize expertise in a specialized area like pesticide health and safely? In the Northwest we have a multi-state region that is served by the University of Washington Medical School. So we have what is called a medcon or medical consult that feeds calls from anywhere in Idaho, Montana, Alaska, and Washington. Anyone can call into the University of Washington, and then they get directed to specialists. It has been done out of necessity in the region with only , one medical school, and I think it's a model that could also be used elsewhere." (Mary Miller, American Nurses Association) Color coding of charts: "When a provider has an opportunity to come face-to-face with a farmworker, they have to utilize that opportunity to its fullest advantage. Color coding of charts is a simple tool that one of the health centers that we work with uses. The health centers are in an area where there are a lot of farmworkers so ------- Workshop on Developing National Strategies they simply changed the color of the chart for every farmworker. When they knew that that patient did farm work, that patient got a red chart, so that it reminded the provider to ask those important questions when they had the farmworker in front of them." (Joni Berardino, National Center for Farmworker Health) Movable health records: "How about developing a system for keeping records of individuals' exposures that will move with them as they move from one site to another? Just as we have talked about in the migrant populationthat there should be school records, health records, etc., that can move with thempesticide exposures could be an important part of that movable health record." (Dr. Louise Rauckhorst, University of San Diego) "We have been working on trying to put together a comprehensive tracking database for farmworkers... in the area of some very specific disease entities; for instance, we have a binational tuberculosis tracking initiative. We find that there is a willingness in those instances where they know there is going to be high mobility, and where there is absolutely critical information that needs to be exchanged." (Karen Mountain, Migrant Clinicians Network) "The Association for Farmworker Programs has a series of service centers all over the country. They have set up a program where they could link the computers between all these service centers to see if it works as a way of tracking exposures to farmworkers throughout the country." (Corlis Sellers, U.S. Department of Labor) Grower Involvement: "The growers that I have dealt with historically in Hillsborough County [Florida] have been very reluctant to issue any notice of job injury to farm- workers who want to come and see us with a possible pesticide exposure. I'm talking about something that is not life threatening. It may be dermatologic or ophthalmologic or something along those lines. Most of our conversations with the growers are very unyielding and unfruitful in terms of making them believe that something could have happened that really is related to a pesticide exposure, unless the person is actually carried into us. I have had growers say to me things like, well, everybody in my family has the flu now. Or, they must have picked it up from something in their house." (Dr. Dennis Penzell, Suncoast Community Health Centers) ------- Practitioner; Perspectives I Need for Analytic Methods: "Of the thousands of pesticides that are out there, there are only a minority in which there is an analytical method in which you can go ahead and look and see what the patient was exposed to. There is a real need for that to be developed, or to get some way of finding out really what a patient was exposed to more than just bringing in a label." (Dr. Sheldon Wagner, National Pesticide Telecommunications Network) Patient Involvement: "If we think we're going to solve this problem very easily by doing primary education through medical school or nursing school or residency training programs, I think we are deluding ourselves. One of the ways that probably in the long run may have the best success in this area is educating the potential patient. If the patient comes into the doctor's office and says, look doctor, I'm exposed to pesticides on the farmland that stuff blew in my face yesterday, and now I've got this collection of symptoms, it is going to raise a flag for most physicians. But if they come in with nondescript symptoms like many mild to moderate OP poisonings are, and don't identify themselves as a farmworker or an agricultural worker, don't identify themselves that their apartment was sprayed with something the day before, the chances that that diagnosis is going to be made are minuscule. There isn't any laboratory test that most physicians can do that is quick and rapid and will make the diagnosis. It is based on symptomatology, which is non-specific, and it just isn't going to happen." (Dr. George C. Rodgers, American Association of Poison Control Centers) ------- ------- v^ ' x-,..'._ . ,., -"y* . i----T?--- Recom ' _^ ' - xpert Panel 1^ - " ^ E, - ------- Workshop on Developing National Strategies 5. Findings The Broader Context This initiative is set in the context of efforts taking place at the local, state, and federal levels, including activities to educate health care providers, pesticide-related activities, and environmental/occupational health activities. The panel recognizes the importance of building upon efforts in the field to learn from other experiences and link resources together in the initiative. Specifically, the panel recognized the groundbreaking efforts by the Institute of Medicine, in its landmark reports, Environmental Medicine: Integrating A Missing Element into Medical Education and Nursing, Health and the Environment: Strengthening the Relationship to Improve the Public's Health. The panel chose to adopt (with slight revision) several overarching recommendations of the Institute of Medicine committees that developed these two publications. Over the course of the workshop, panelists identified national and regional resources, such as the National Pesticide Telecommunications Network, poison control centers, agromedicine programs, NIOSH agricultural health centers, and the Association of Occupational Clinics, that are vital to the initiative's success. Based upon the recommendation of the expert panel, the next stage of the initiative will include a thorough compilation of existing activities, resources, organizations, and materials aimed at educating primary care providers about pesticide exposures. An initial list of resources, including those suggested by the expert panel, is included in Appendix B. This list is not intended to be a comprehensive list, but rather a sampling of activity. A more complete listing will be carefully designed with participation from the expert panel. Targeting Primary Care Providers For purposes of this initiative, the panel agrees that the target audience is the primary care provider. A primary care provider is defined as a physician, nurse, nurse practitioner, physician assistant, nurse midwife, or community health worker specializing in one of the following areas: family medicine, internal medicine, pediatrics, obstetrics/gynecology, emergency medicine, preventive medicine, or public health. ------- Themes,arid Findings* As the "gatekeepers" of our health care system, primary care providers need to be able to identify a possible pesticide exposure. For this reason, the panel recommends that all primary care providers possess basic knowledge and skills related to pesticide exposures. The panel also recognized the need to ensure that sufficient specialists are trained and available to primary care providers. Health care providers with specialized training in occupational and environmental medicine serve as excellent resources both for purposes of this initiative and for primary providers. However, because such specialists already have a higher awareness of pesticide issues, the majority of the panel agreed that occupational and environmental health providers are not the initial target of this initiative. A minority opinion was expressed at the meeting that occupational medicine should be considered a part of primary care and therefore be part of the initial implementation of this initiative. Current Training of Primary Care Providers The panel agreed that primary care providers are not sufficiently trained at any stage of their education about pesticide exposure, and as a consequence, adverse health effects from pesticide exposures are often underreported. The panel recognizes, however, that the lack of training reflects a larger gap in education on environmental and occupational health. The panel briefly summarized the main concerns about provider knowledge of pesticide exposures: Providers do not receive training on recognition, diagnosis, and management of pesticide-related exposures during their formal education. Pesticide exposures and associated health conditions are difficult topics to teach because they require additional knowledge of toxicology and other topics often not included in the curriculum of health professional education. Providers do not often see acute pesticide poisonings and do not possess enough knowledge to recognize chronic cases. Health conditions associated with pesticide exposures are often misdiagnosed. Providers often do not know how and where to report pesticide exposures; sometimes the reporting is considered burdensome given their demanding work environments. Providers often do not know to whom patients can be referred. ------- VfeislKilp pr'pl||lppmjfRational Strategies Expected Outcomes for Primary Care Providers The panel discussed at length the general goals that should be expected of all targeted primary care providers. Agreement was reached that all primary care providers should: Demonstrate knowledge about pesticides and recognize health effects from pesticide exposures as a health concern; Diagnose and treat pesticide exposures at the earliest possible time and complete the appropriate follow-up and referral (exposure management); Take preventive measures in both the clinical and community settings, including anticipatory guidance and community education (prevention management); Report exposures and health outcomes of patients or communities to appropriate public health or regulatory agencies; and Access the appropriate resources/specialists (local, regional, and national). Three Stages of Education The panel agreed that to achieve these expected outcomes, competencies should be articulated for three stages in the education of primary care providers: Basic Education for purposes of this initiative, defined as education received in medical schools and associate or baccalaureate nursing schools (education leading to Associate Degree Nurses, Bachelor of Science Nurses). Specialty Training for purposes of this initiative, defined as education/training received in residency (variable by specialty), graduate nursing education for advanced practice nursing (e.g., clinical nurse specialist, nurse practitioner, nurse midwife), and physician assistant training. Practice/Continuing Education for purposes of this initiative, defined as the education practitioners receive as part of continuing education or in their practice/ professional settings. This stage also includes community health worker training. The settings in which primary care providers practice include but are not limited to: emergency departments, community clinics, workplace settings, private offices, urgent care facilities, schools, patient's homes, hospital clinics, and managed care settings. ------- 6. Preamble to Expert Panel Recommendations The expert panel agreed to adopt, as a preamble to its own recommendations, the themes and overarching, recommendations made by the Institute of Medicine's Committee on Enhancing Environmental Health Content in Nursing Practice and published in Nursing, Health and the Environment (National Academy Press, 1995). The panel revised the recommendations to more broadly reflect primary care providers. The preamble to the Expert Panel's recommendations is as follows: 1. Environmental health concepts should be incorporated into all levels of primary care provider education, specifically defined for purposes of this initiative as physicians, nurses, nurse practitioners, physician assistants, nurse midwives, and community health workers, and office staff in the disciplines of family practice, pediatrics, internal medicine, emergency, obstetrics/gynecology, preventive medicine and public health. 2. Environmental health content should be included in licensure and certification exams. 3. Expertise in various environmental health disciplines should be included in the education of primary care providers. 4. Environmental health content should be an integral part of lifelong learning and continuing education of primary care providers. 5 . Professional associations, public agencies, and private organizations should provide more resources and educational opportunities to enhance environmental health in primary care practice. ------- Workshop on Developing National Strategies 7. Recommendations of the Expert Panel The expert panel developed four national strategies to reach the expected outcomes defined in Section 5. For each of the strategies, the panel has specific recommendations that will form the basis for a future implementation plan. STRATEGY I: DEFINING RECOMMENDED COMPETENCIES Essential Competencies Recommended for All Primary Care Providers The expert panel recommends that primary care providers be able to demonstrate specific competencies upon completion of their basic education and specialty training, and that practitioners demonstrate specific competencies in their practice settings. The following are the recommended essential competencies of providers: Epidemiology Sentinel Cases: Providers should understand that diagnosis of a pesticide overexposure in one individual may be a sentinel case and often indicates that other individuals may have been exposed. Identification is the first step towards preventive action. Surveillance: Providers should understand the importance of surveillance and should be able to access and report data for local/regional/national surveillance programs. Basic Symptomatology Providers should be able to recognize the signs and symptoms of pesticide exposures (both acute and chronic). Providers should be able to take a basic environmental history to determine if a temporal relationship exists between exposure and symptoms. Management of Pesticide Exposure Providers should be able to effectively diagnose (through appropriate testing) and treat health conditions associated with pesticide exposure, refer patients to appropriate specialists and resources, and follow-up appropriately. ------- Recommendations of the Expert Panel Patient Counseling/Anticipatory Guidance: Providers should ask specific environmentally-related questions in patient histories and provide guidance to patients on how to prevent pesticide exposures. The remedial guidance to patients should be conveyed in a sensitive and appropriate manner. Community Environment of Patients: Providers should possess a basic awareness of environments in which patients live, work, and play in order to anticipate possible encounters with exposure to pesticides. Recommended Competencies Specific to Basic Education The panel recommends that training during basic education emphasize: Raising awareness about the connection between pesticide exposures and health outcomes; Medical/nursing principles relevant to environmental/occupational medicine (including toxicology and epidemiology); and The importance of interdisciplinary effortswithin medicine, agriculture, and environmental sciencesto address complex health issues such as those involving pesticides, and the network of resources available to the primary care provider. Students who complete their basic training should be able to: Identify and recognize a pesticide, with a basic understanding of toxicology (e.g., integrate into pharmacology course); Recognize signs and symptoms of health effects associated with pesticide exposures (e.g., integrate into pathophysiology course); Demonstrate an understanding of principles of environmental/occupational health; Identify risk factors (e.g., occupation, location of home, susceptible populations such as children); Demonstrate an understanding of concepts of epidemiology and population-based health; ------- Workshdp On Peveldpfng Natidn^l Strategies Ask patients 2-3 screening questions that would elicit possible exposure to a number of environmental factors (including but not limited to pesticides); and Advise patients and provide basic education about pesticide exposure. Recommended Competencies Specific to Specialty Training The panel recommends that training at this stage emphasize: Specific pesticide exposures and associated health conditions; Clinical experiences dealing with pesticide exposures; and Environmental history taking. : ; ibf suspicion and people go back j .IIIIBi I thfij. they aon't immediately "^sSjrf poking up cases and go, (hen. you lose that. It is jack of your head. If you don't ......... !T!T" ,"r-l, ', ..... ' 'i'*v *tf?f\ ]">;:" ".'..' ...... ; ..... I fe- ............................. ' s$ II "fn 'a year, ' "it is""out"tiie door. 1" ..... : ....... :" ....... : ............ SfKT^^ ..... g>: ...... ~ ..... srarT^"^ ..... :!;! ...... 1 [[[ ' Igrant (Clinicians NetworK In addition to the competencies achieved in basic education, residents, advance practice nurses (e.g., nurse practitioners, dinical nurse specialists, and nurse midwives) and physician assistants who complete their basic training should be able to: H Diagnose pesticide-related illness using appropriate testing procedures and treat pesticide overexposures; Identify environmental factors that may possibly be linked to patient illness to ensure that chronic pesticide exposures are addressed; Take an environmental health history with questions regarding where the patient lives, works, and plays; Understand temporal relationship between exposure and symptoms; Demonstrate the use of epidemiology and population-based health principles; Provide patients with education and guidance regarding prevention of pesticide exposures; ------- Access and utilize resources at a local, regional, and national level; and Demonstrate an understanding of case reporting requirements for pesticide exposures. Recommended Competencies Specific to Practice Settings The panel recommends that training at this stage emphasize: Specific pesticide-related issues in the practice area or region; Links to important resources relevant to the provider's specific environment; and Reporting requirements and recommendations. In addition to the competencies demonstrated after basic and specialty education, practicing providers should be able to: Demonstrate knowledge about the environment in which they practice, with specific understanding of communities that may be at-risk for pesticide exposures; Identify exposures related to pesticides used in the region; Recognize possible sentinel cases; Demonstrate an understanding of the legal responsibilities of providers and ethical implications of activities related to pesticide exposures; Utilize the local and regional resources available, such as: local or state public health department, poison control center, occupational/environmental clinic, department of agriculture, department of environmental quality, agriculture extension, and occupational health and safety agency; and Report concerns about pesticide exposures to the appropriate authorities, such as local or state public health departments, OSHA or state department of labor, or department of agriculture. ------- Workshop on Developing National Strategies STRATEGY II: IMPACTING EDUCATION AND TRAINING A key recommendation by the expert panel is to make the issue of pesticide exposures and environmental/occupational health relevant and interesting to students. Wherever possible, material should be integrated into the existing curriculum. Given the differences in the three stages of education, the panel recommends the following strategies for each stage: Basic Education The panel recommends that in basic education (medical school, associate/baccalaureate nursing) students receive the key building blocks necessary to understand the role of environmental and occupational factors on health. Specific recommendations are to: Integrate overviews of environmental/occupation health information into general courses in order to place the concept on the radar screen of students; emphasize the cutting edge issues in the field for students; Identify key courses into which environmental/ occupational concepts can be integrated (i.e., physiology, pharmacology). The panel recommends that a subgroup of the expert panel develop the implementation plan for this recommendation; Ensure that clinical experiences include opportunities to work with pesticide exposures and environmental health by partnering with local resource organizations (e.g., area health education centers, poison control centers, clinics, occupational health and safety agencies); Develop appropriately-tailored case studies to be used in coursework as part of the trend towards problem-based learning; :ing mat go outsit i",,. ii HHii'i!'!::!!!1" 'i'liji niiiniiiKiiiiuw;,rfc,, m nt 'iimii;; '!|!''i!i'»!|!'«p s;1!!!'!!^ "ISII'I "l|!" "" IIT'FIPW! W IT I1 'I "I ' f f'" ' ents thai I know, if you give them a i m is^^^^^ !i m ', m si \ M.'- . it up aha read Ire anxious to have something : that is 'outside. 'They are enthusiastic S !::: !!S!!~ : 11! g*SH iiS *£ !' * t:= '". curriculum wici we are eorge C. Rodgers ------- Recornmendations of the Expert, Panel Integrate environmental/occupational health components into distance learning and telecommunication technologies (on-line materials, CD-ROM educational materials, video training conferences); Develop mechanisms to teach topics with interdisciplinary faculty teams; and Identify the decision-making bodies that influence curricular changes at the institution, state and national levels. Specialty Training The panel recommends that in specialty training (i.e., residencies; graduate nursing training such as education leading to clinical nurse specialists, nurse practitioners, and nurse midwives; and physician assistant training) residents/students focus on more specific aspects of pesticides and address cases of pesticide exposures with patients and in communities. Specific recommendations are to: Integrate questions and educational objectives into Board certification and licensure exams; Develop case studies for appropriate specialty areas that demonstrate a team approach by the providers, emphasizing the interdisciplinary nature of the field and the increasing use of problem-based learning techniques; Research and assess the appropriateness to primary care of curricular materials already developed in occupational/environmental health; Design rotation experiences in environmental/occupational health that build upon ' the lessons learned from other specialties; Include pesticide exposure scenarios and cases in residency/student seminar discussion topics; Identify ambulatory settings where pesticide exposure issues occur, and which could provide appropriate experiences for residents/students; Invite experts, including primary care providers, to give Grand Rounds to residents or similar teaching lectures for nurse practitioner or physician assistant students; Develop effective distance learning and telecommunication materials and programs; ------- Workshop OH Developing National Strategies Link pesticides/environmental health conditions to research courses taken by students; Ensure that pesticide exposures and other environmental hazards are part of differential diagnosis and history taking; and Create opportunities for "teachable moments" - opportunities for faculty to demonstrate real cases of pesticide exposures, or to simulate cases. Practice Settings The panel recommends that practitioners be reached through continuing education, in- service training, professional meetings, and the Internet. The key to success is the communication of a dear and coordinated message to practicing primary care providers. Specific recommendations include: Assess, develop, and evaluate distance learning and telecommunications approaches; Disseminate a dear message through a number of different modes, induding journals and professional newsletters (see Raising Awareness); Build effective linkages between primary care providers and resource people (e.g., poison centers, emergency departments, AOEC clinics, NIOSH agricultural centers, NPTN); Design optional continuing education courses or components to be integrated into required continuing education courses with evaluation mechanisms; Involve specific stakeholders and populations in outreach efforts (e.g., industry, farmworkers, agricultural extension, etc.); Build environmental health/pesticide knowledge into recertification of primary care providers as an incentive for them to educate themselves about the issue; and Identify and make available to practitioners references to ready resources for support/ treatment guidance. ------- RecommendatfoilS of the: Expert Papef STRATEGY III: RAISING AWARENESS The expert panel recognizes that this initiative needs to raise the awareness and attention of professionals in the health care arena about pesticide-related health conditions as well as other occupational and environmental health conditions. A primary component of this strategy is to give primary care providers a clear message about the importance of knowing a patient's occupational and environmental background. The message could be conceived of as "Think Pesticides" or more broadly, "Think Environmental/ Occupational Connection." Another element of the strategy is to raise the visibility of the issue by developing a strong marketing effort, complete with "attention grabbers." To catch the attention of primary care providers, marketing efforts must be relevant, include statistics, be keyed to major events, and convey a message appropriately targeted to the audience. The panel generated a set of ideas for raising awareness, from which more specific plans can be developed. Professional Meetings Develop a portable exhibit for national/regional meetings of targeted professionals; Develop educational sessions for same targeted meetings with the organizations represented by the expert panel and other stakeholders; Target the residency or student sections of professional associations at their national meetings; and Involve residents and students in developing papers/posters. Marketing/Outreach Develop briefing materials that reflect sound science principles and clearly articulate the issues from the perspective of primary care providers; Effectively market and package messages and materials that are clearly designed for the target audiences. Make them newsworthy! m ------- Identify ways to build coverage in the media and television arenas (quick response to newsworthy events, media advocacy projects, influencing television shows, seasonal public service announcements). Materials and Resources for Providers m Design effective and appropriate patient brochures (or revise what already exists) for providers to give to their patients; Develop informational/teaching communication tools (CD-ROM, audio tapes, etc.) for providers; and Utilize effective distance learning and tele-communications tools. Ul* have to remember to target our message to the audiences we are trying to reach. Ordinarily I am sitting in a primary care office not waiting for a imijor event to happen and hoping that it in iii "Hill III li! Journal Articles Design a mechanism to strategically place journal/newsletter articles on pesticides and on the initiative. Several strategies are recommended: Publish peer-reviewed journal article with scientific data (e.g., results from surveillance data in Texas that document the incidence and case reports); Publish professional piece on the initiative to be published in a multitude of journals (commentaries); Publish supplement/monograph on the topic with series of articles, for example, a joint effort on primary care provider/ epidemiology perspectives; Publish a series of articles throughout the year so as to ensure repetition and consistent message. Target a wide list of appropriate journals. An initial list of targeted journals developed by the expert panel will be supplemented with additional research. The initial list includes: American Association of Occupational Health Nurses Journal American Journal of Emergency Medicine .,,,- isn t going to happen...If you want to get 11 I me to modify my day-to-day behavior in the office, you are going to have to focus message to the reality of my clinical n iiiiliii iiiiiii i in i null i ill 11 iiiiiiiH iiiiiiini 1I1I11I1111 iiiiiil iiiiiiiiiiiiii iiiiliii iiiiliii mi in i in i in i in 11 III ;ce. Dr. Hugh Henderson, National Agromedicine Consortium ------- American Journal of Nursing American Journal of Public Health Annals of Emergency Medicine Annals of Internal Medicine Archives of Internal Medicine Contemporary Pediatrics (general issue) Family Practice Journal Graduate Medicine Journal of American Medical Association Journal of Emergency Nursing Journal of Family Practice Journal of Nursing Education Journal of the American Academy of Nurse Practitioners Journal of the Board of American Family Practice New England Journal of Medicine Nurse Midwife Journal Nurse Practitioner Forum Nurse Practitioner World PA Journal Patient Care Pediatrics Public Health Nursing State journals The Nurse Practitioner Build Partnerships/Gather Models Gather models of how specific health care disciplines or localities have raised awareness on pesticides (the expert panel is an important source of models); Learn from and collaborate with the successes and lessons learned in the agromedicine and agricultural health and safety field; Involve additional partners in the initiative, including industry, departments of , agriculture, departments of labor, and cooperative extension service at the local and state levels; Research other effective outreach models (e.g., "Models that Work" - an effort by the Bureau of Primary Health Care at HRSA); ------- Workshop Oil Developing National Strategies Explore possible ways to integrate environmental medicine requirements into national requirements of primary care providers (e.g., through a possible effort at the Health Care Financing Administration); and Collaborate with professional associations and societies to develop position papers. Support Network Establish peer networks and support group for providers by locality or region; Establish consultation and referral resources; Develop Internet site for initiative that includes linkages from/to/between sites; Educate the general public and providers about the necessity and value to them of surveillance systems; and Establish and design a clear mission and purpose of a "listserve"; link with other listserves that already are resources for providers (e.g., OEM Duke List-serv). Evaluate Provider/Faculty Awareness Survey both faculty and providers on their knowledge, skills, and attitudes on pesticide exposures and environmental health issues. Disseminate Proceedings The expert panel generated a list of organizations, professional associations, and credentialing bodies that should be informed of this initiative. This is an initial list; the subgroup on resources will develop a more complete list and dissemination plan. The distribution list includes: Accreditation Council for Continuing Medical Education and equivalents for nursing and physician assistants Accreditation Council for Graduate Medical Education and equivalents for nursing and physician assistants Alliance for Continuing Medical Education (CME) American Association for Colleges of Nursing American Association of Occupational Health Nurses American Board of Occupational Health Nurses American Chemical Society American Nurses Association ------- Recommendations, of tKe:l:kjpert?|pAiii£r American Nurses Credentialing Center American Public Health Association Area Health Education Centers Association of American Medical Colleges Emergency Nurses Association Federation of Associations of Schools of the Health Professions Liaison Council for Medical Education National Association of Emergency Medicine Technicians National Council of State Nursing Boards National League for Nursing (NLN) Nurse Midwifery Osteopathic Medicine Residency Review Committees Society of Toxicology Specialty areas including but not limited to: Occupational Medicine, Pharmacists, Podiatrists State Offices of Rural Health. ------- WbMtshop on STRATEGY IV: MAINTAINING AND DEVELOPING RESOURCES The panel discussed the urgent need to maintain and increase resources which currently are often subject to uncertain funding and viability. The panel concludes that there is a strong need to consider centralizing resources in this area in order to avoid duplication of effort and make information and resources more widely available and publicized to a wider audience. Specific recommendations of the panel include: Centralize the resources available to primary care providers on pesticide-related health concerns. Resources could be centralized nationally or in a network of regional and local centers. Such centers would provide a combination of referral information, specialists, Internet materials, case studies, and surveillance services; and e is a lot ofiflfonnation out ._ : || ; -,.. ,. . Their clinical toxicolosv on -RQli is great, and I think I ||V.nj|| ;: /Jj *;| "jnn iJUj iij i. I'llll'lij1 7 r' i ', '"j,1' i, ' to do is get the ession to now tat " don, Wagner, ! js ;l t ij-= = =|- JNatioriai Pesticide mi ! |j|ji|i|||||||j|||||||||||||||||l lecommunications Network : "1 Strengthen the link of the pesticides and health care initiative with resources already in existence, such as poison centers, agromedicine programs, agricultural health and safety centers, and land grant universities. ------- 8. Recommended Next Steps T I he panel discussed the implementation of these strategies and the challenges that would be encountered by this initiative. Challenges Facing the Initiative The expert panel recognizes that there are significant barriers to changing the awareness and training of primary care providers on pesticide issues. Therefore the expert panel recommends that this initiative be integrated in the broader context of other national initiatives in occupational and environmental health. This integration will also avoid any duplication of effort. A few of the challenges that this initiative will need to grapple with were identified: General Challenges Ensuring an interdisciplinary approach; Coordinating varying definitions of pesticide exposures and environmental health; Developing a consistent and clearly stated message; Increasing the level of importance of this issue among health science faculty; and Assisting faculty in teaching a challenging technical topic. Reaching Primary Care Providers Getting information to practitioners in a digestible and implementable form; Encouraging primary care providers to let go of old habits and learn new ones; / Convincing primary care providers and health science faculty that pesticide exposure is relevant and important; Improving the understanding of the use of diagnostic tests (e.g., cholinesterase testing); and Developing a link between the provider's clinical role and community involvement. ------- Workshop an Developing National Strategies m Institutional Barriers Barriers in curriculum committees and Board exam decisions; Perceived weak link between primary care providers and occupational and environmental specialists and resources; and Tenuous future support for resources and services for primary care providers. Involving All Stakeholders Involving industry in this effort; Determining best role for growers, agricultural extension, and relevant agencies; Involving community-based organizations; and Involving worker representatives. Environmental/Occupational Health Field Lack of data; Limited resources for research and technical assistance. Need for improved reporting procedures; and Need for increased enforcement. Implementation Plan Developing an effective implementation plan for the initiative is the next step for the planning committee and expert panel. The implementation plan is expected to build on the recommendations coming out of the workshop, to specify in more detail the next steps in implementing each of the strategies, and to include timetables, schedules, and responsibilities for each task. To develop this implementation plan, the panel decided to create three subgroups comprised of expert panel members and additional experts. The three subgroups are: Primary Education Content (curriculum specialists) covering Strategy I. ------- Reco rn m en d ed. M§%^'.?tgpS Dissemination to Practicing Primary Care Providers covering Strategies II and III, as well as the marketing/dissemination effort related to Strategy I. Resource Development/Dissemination/Centralization covering Strategy IV. As part of the implementation plan, the subgroups will build on the network of stakeholders involved in this initiative. A key part of the initiative is a strong, effective outreach effort to involve as many stakeholders and target groups as possible at an early stage, and to maintain their interest and participation over time. The subgroups will help launch this outreach effort, compile a complete list of participating organizations, and determine which organizations and agencies will carry out which responsibilities. The implementation plan will also include a comprehensive list of resources related to pesticides and health care, including model programs, scientific research on pesticides, medical journal articles, and Internet sites for state and community-based programs. ------- ------- Appendices ------- Workshop OH Developing National Strategies Appendix A: Who's Who FEDERAL INTERAGENCY PLANNING COMMITTEE U.S. Environmental Protection Agency Kevin Keaney Acting Branch Chief Certification & Worker Protection Branch Field & External Affairs Division U.S. Environmental Protection Agency 401 M Street, SW (7506C) Washington, D.C. 20460 Phone: 703-305-5557 Fax: 703-308-2962 keaney.kevin@epamail.epa.gov Ameesha Mehta, MPH Project Lead Certification & Worker Protection Branch Field & External Affairs Division U.S. Environmental Protection Agency 401 M Street, SW (7506C) Washington, D.C. 20460 Phone: 703-305-6448 Fax: 703-308-2962 mehta.ameesha@epamail.epa.gov Delta Valente, MPA Project Manager for Farmworker Health Certification & Worker Protection Branch Field & External Affairs Division U.S. Environmental Protection Agency 401 M Street, SW (7506C) Washington, D.C. 20460 Phone: 703-305-7164 Fax: 703-308-2962 valente.delta@epamail.epa.gov Belen Revilla Certification & Worker Protection Branch Field & External Affairs Division U.S. Environmental Protection Agency 401 M. Street, SW (7506C) Washington, D.C. 20460 Phone: 703-308-8734 Fax: 703-308-2962 revilla.belen@epamail.epa.gov Ana Maria Osorio, MD, MPH Medical Officer Certification & Worker Protection Branch Field & External Affairs Division U.S. Environmental Protection Agency 401 M Street, SW (7506C) Washington, D.C. 20460 Phone: 703-305-7666 Fax: 703-308:2962 osorio.anamaria@epamail.epa.gov Frank Davido Pesticide Incident Response Officer Public Information & Records Integrity Branch Information Resources & Services Division U.S. Environmental Protection Agency 401 M Street, SW (7502C) Washington, D.C. 20460 Phone: 703-305-7576 Fax: 703-305-4646 davido.frank@epamail.epa.gov Jerome Blondell, PhD Health Effects Division U.S. Environmental Protection Agency 401 M Street, S.W. (7509C) Washington, D.C. 20460 Phone: 703-305-5336 Fax: 703-305-7775 blondell.jerry@epamail.epa.gov U.S. EPA Regional Liaisons Jane Horton U.S. EPA, Region 4 Pesticides Section (4APT-PS) 61 Forsyth St, SW Atlanta, GA 30303 Phone: 404-562-9012 Fax: 404-562-8972 Horton.Jane@epamail.epa.gov ------- Appendices Don Baumgartner U.S. EPA Region 5 Pesticides Program Section (DRT-8J) 77 West Jackson Boulevard Chicago, IL 60604-3590 Phone: 312-886-7835 Fax: 312-353-4788 baumgartner.donald@epamail.epa.gov Allan Welch U.S. EPA Region 10 Pesticides Section (AT-083) 1200 Sixth Avenue Seattle, WA 9 8101 Phone: 206-553-1980 Fax: 206-553-8338 Welch.Allan@epamail.epa.gov U.S. Department of Health and Human Services D.W. Chen, MD, MPH Deputy Director Division of Associated, Dental, and Public Health Professions Bureau of Health Professions Health Resources & Services Administration U.S. Dept. of Health and Human Services 5600 Fishers Lane, Rm-8-101 Rockville, MD 20857 Phone: 301-443-6853 Fax:301-443-1164 dchen@hrsa.dhhs.gov Jack Egan Acting Director Migrant Health Branch Division of Community and Migrant Health Bureau of Primary Health Care Health Resources & Services Administration U.S. Dept. of Health and Human Services 4350 East West Highway Bethesda, MD 20814 Phone: 301-594-4301 Fax: 301-594-4997 jegan@hrsa.dhhs.gov Ruth Kahn, D.N.Sc. Health Professions Education Specialist Office of the Director Division of Medicine Bureau of Health Professions Health Resources & Services Administration U.S. Dept. of Health and Human Services Parklawn Building Room 9A-27 5600 Fishers Lane Rockville, MD 20857 Phone: 301-443-6823 Fax: 301-443-8890 rkahn@hrsa.dhhs.gov Cassandra Lyles Program Analyst Office of Rural Health Policy Health Resources & Services Administration U.S. Dept. of Health and Human Services 5600 Fishers Lane, Rm 9-05 Rockville, MD 20857 Phone: 301-443-7321 Fax: 301-443-2803 slyles@hrsa.dhhs.gov Madeleline Hess, Ph.D, RN Acting Branch Chief Nurse Education and Practice Branch Division of Nursing Bureau of Health Professions Health Resources & Services Administration U.S. Dept. of Health and Human Services 5600 Fishers Lane, Rm 9-35 Rockville, MD 20857 Phone: 301-443-6336 Fax: 301-443-8586 mhess@hrsa.dhhs.gov Mark Nehring, DMD, MPH Senior Program Management Consultant EMC/Maternal and Child Health Bureau Health Resources & Services Administration U.S. Dept. of Health and Human Services 5600 Fishers Lane, Rm 18A-30 Rockville, MD 20857 Phone: 301-443-3449 Fax: 301-443-1296 mnehring@hrsa.dhhs.gov ------- Workshop on Developing National Strategies Karen Pane, RN, MPA Nurse Consultant Nurse Education and Practice Branch Division of Nursing Bureau of Health Professions U.S. Dept. of Health and Human Services 5600 Fishers Lane, Rm 9-36 Rockville, MD 20857 Phone: 301-443-6334 Fax: 301-443-8586 kpane@hrsa.dhhs.gov Sherry Baron, MD Medical Officer National Institute for Occupational Safety and Health U.S. Dept. of Health and Human Services 4676 Columbia Parkway, MS R-10 Cincinnati, OH 45226 Phone: 513-458-7159 Fax: 513-458-7105 slb8@cdc.gov U.S. Department of Agriculture Peter S. Wood USDA-AMS Pesticide Records Branch 8700 Centreville Rd., Suite 202 Manassas, VA 20110 Phone: 703-330-7826 Fax: 703-330-6110 peter_s_wood@usda.gov John Impson National Program Leader USDA CSREES AG Box 2220 Aero Space Building, Room 330M 901 D Street, SW Washington, D.C. 20250-2220 Phone: 202-401-4201 Fax: 202-401-4656 IIMPSON@REEUSDA.GOV U.S. Department of Labor Mike Hancock Leader, Farmworker Labor Team Wage and Hour Division 200 Constitution Ave., NW Rm S-3510 Washington, D.C. 20210 Phone: 202-219-7605 Fax: 202-219-5122 jtc@fenix2.dol-esa.gov Rosemary Sokas, MD, MOH Director of Office of Occupational Medicine OSHA/DOL : RoomN3653 200 Constitution Ave, NW Washington, D.C. 20210 Phone: 202-219-5003 Fax: 202-219-9053 rosemary.sokas@osha-no.osha.gov Association of Teachers of Preventive Medicine Barbara }. Calkins, MA Executive Director ATPM 1660 L St, NW, Suite 208 Washington, D.C. 20036 Phone: 202-463-0550 Fax: 202-463-0555 Mary V. Davis, DrPH Programs Director ATPM 1660LSt, NW, Suite 208 Washington, D.C. 20036 Phone: 202-463-0550 Fax: 202-463-0555 mvd@atpm.org ------- Andrea B. Smith Projects Assistant ATPM 1660 LSt, NW, Suite 208 Washington, D.C. 20036 Phone: 202-463-0550 Fax: 202-463-0555 abs@atpm.org EXPERT PANEL American Academy of Family Physicians Elisabeth Spector, MD, MPH (could not attend); 17 Sherwood Court Flemington, NJ 08822 Phone:908-284-1730 Fax: 908-788-6111 elspecto@umdnj.edu ' American Academy of Pediatrics Roger F. Suchyta, MD Associate Executive Director 141 Northwest Point Blvd. Elk Grove Village, IL 60007 Phone: 847-981-7101 Fax: 847-228-5027 rsuchyta@aap.org American Academy of Physician Assistants Greg P. Thomas, PA-C V-P, Clinical Affairs and Education 950 North Washington St. Alexandria, VA 22314 Phone: 703-836-2272 x3107 Fax: 703-684-1924 greg@aapa.org American Association of Colleges of Nursing Andrea R. Lindell, PhD Dean, University of Cincinnati College of Nursing PO Box 210038 Cincinnati, OH 45221 Phone: 513-558-5200 Fax: 513-558-7523 andrea.lindell@uc.edu American College of Emergency Physicians /. Ward Donovan, Jr,, MD, FACEP Director of The Pennsylvania University Poison Center University Hospital-MS Hershey Medical Center 500 University Drive PO Box 850 Hershey, PA 17033-0850 Phone: 717-531-7057 Fax: 717-531-4441 wdonovan@nursing.hmc.psghs.edu American Association of Poison Control Centers George C. Rodgers, Jr, MD, PhD Professor of Pediatrics and Pharmacology/Toxicology Professor of International Pediatrics University of Louisville School of Medicine 4250 Georgetown-Greenville Rd. Georgetown, IN 47122-8816 Phone: 502-852-8630 Fax: 502-852-3998 gcrodgers@pol.net American College of Occupational and Environmental Medicine Joe Fedoruk, MD, DABT, CIH Diplomat of American Board of Toxicology, Certified in Industrial Hygienist (Toxicology Aspects) 333 South Anita Drive, Suite 640 Orange, CA 92868 Phone: 714-456-2124 Fax: 714-456-2143 mjfinc@aol.com American Nurses Association Mary Miller, MN, ARNP Occupational Health Nurse Practitioner Washington State Department of Labor and Industries PO Box 44610 Olympia, WA 98504-4610 Phone: 360-902-5666 Fax: 360-902-5438 mmdr235@lni.wa.gov ------- Workshop on Developing National Strategies Council of State and Territorial Epidemiologists Jackilen Shannon, PhD Epidemiologist, Texas Department of Health 1100 W. 49th St Austin, TX 78756 Phone: 512-458-7269 Fax: 512-458-7699 jackilen.shannon@tdh.state.tx.us Migrant Clinicians Network Karen Mountain, MBA, MSN, RN Executive Director PO Box 164285 Austin, TX 78716 Phone: 512-327-2017 Fax: 512-327-0719 MCN@onr.com National Center for Farmworker Health Joni Berardino, MS, LSW Director of Public Affairs and Resource Development 1515 Capitol of TX Hwy. South, Suite 220 Austin, TX 78746 Phone: 512-328-7682 Fax: 512-328-8559 berardin@ncfh.org National Organization of Nurse Practitioner Faculties Candace M. Bums, PhD, ARNP University of South Florida College of Nursing HSC 22 12901 Bruce B. Downs Blvd. Tampa, FL 33612 Phone: 813-974-9160 Fax: 813-239-3653 cburns@coml.med.usf.edu National Pesticide Telecommunications Network Sheldon Wagner, MD Professor of Clinical Toxicology Oregon State University 1007 Agricultural and Life Sciences Corvallis, OR 97331-7301 Phone: 541-757-5086 Fax: 541-757-5085 wagners@ucs.orst.edu National Rural Health Association Michael Hodgman, MD Bassett Healthcare/NY Center for Agricultural Medicine and Health 1 Atwell Rd Cooperstown, NY 13326 Phone: 607-547-3981 mrunt@aol.com Pennsylvania State University/National Agromedicine Consortium Rugh Henderson, MD Associate Professor College of Medicine Dept. of Family and Community Medicine PO Box 850 Hershey, PA 17033-0850 Phone: 717-531-8753 Fax: 717-531-5024 RHENDERS@family.fcm.hmc.psu.edu Suncoast Community Health Centers, Inc. Dennis Penzell, DO, FACP Medical Director 2814 14th Ave, SE Ruskin, FL 33570 Phone: 813-645-4681 x315 Fax: 813-645-9240 DRSTACI@pol.net ------- SPEAKERS AND FACILITATOR Wilson Augustave Case Manager Finger Lakes Migrant Health Care Project 2 Rubin Drive Rushville, NY 14544 Phone: 716-554-6617 Fax: 716-554-4402 mighealth@aol.com Louise M. Rauckhorst, EdD, MSN Professor, Philip Y. Hahn School of Nursing University of San Diego 19 51 Azure Way Encinitas, CA 92024 Phone: 619-260-4575 Mark G. Robson, Ph.D., MPH Executive Director Environmental and Occupational Health Sciences Institute 681 Frelinghusen Rd. Piscataway, NJ 08854 Phone: 732-445-0201 Fax: 732-445-0131 robson@eohsi.rutgers.edu Susan T. West, Facilitator Senior Director, Health and Environment Programs National Environmental Education and Training Foundation, Inc. 734 15th Street, NW, Suite 420 Washington, D.C. 20005 Phone: 202-628-8200 x20 Fax: 202-628-8204 west@neetf.org LIST OF OBSERVERS Sheila Arbury, RN, MPH Association of Occupational and Environmental Clinics 101 Vermont Avenue, Suite 513 Washington, D.C. 20005 Phone: 202-347-4976 Fax: 202-347-4950 Margarita Benitez( Equity Research Corp 5 Thomas Circle, NW Washington, D.C. 20005 Phone: 202-387-3331 Fax:202-797-1344. Sue Bernstein » HRSA/ORHP 5600 Fishers Lane, Rm 9-05 Rockville, MD 20857 Phone: 301-443-0612 Stephen W. Borron International Poison Center 1215 17th St, NW Washington, D.C. 20036 Phone: 202-588-0620 Fax: 202-478-0444 Barry Brennan, PhD Extension Pesticide Coordinator University of Hawaii 1800 East-West Road Honolulu, HI 96822 Phone: 808-956-9208 Fax: 808-956-9675 barry@hpirs.stiph.hawaii.edu Janet Byron Pesticide and Toxic Chemical News 1435 Auston Way Berkeley, CA 94702 Phone: 510-848-4008 Fax: 510-848-4002 ------- Workshop on Developing National Strategies Lennie Carter Department of Veteran Affairs, NJ Health Care System 385 Tremont Avenue East Orange, NJ Phone: 973-676-1000 ext. 1641 Fax: 973-672-7636 David Crow D.C.LR.S. 1100 New York Avenue, NW, #520E Washington, D.C. Phone: 202-331-8181 Fax: 202-331-8173 Sue Darcey Pesticide Report 3918 Oglethorpe St Hyattesville, MD 20782 Phone: 301-864-3088 Fax: 301-864-3089 Shelly Davis Farmworker Justice Federation 1111 19th St., NW Washington, D.C. Phone: 202-776-1575 Caroline Whitehead Doherty North Carolina Farmworker Health Program 311 Ashe Avenue Raleigh, NC 27606 Phone: 919-715-7210 Fax: 919-733-8300 Linda Durkee U.S. EPA 401 M Street, SW #7101 Washington, D.C. 20460 Phone: 202-260-6873 Fax: 202-260-1847 Florence Feinberg Migrant Legal Action Program Phone: 301-417-7067 Scottie Ford West Virginia Department of Agriculture 1900 Kanawha Blvd. E. Charleston, WV 25313 Phone:304-558-2209 Fax: 304-558-2228 Scott Hirsch Association of Farmworker Opportunity Programs 1611 N Kent Street #910 Arlington, VA 22209 Phone: 703-528-4141 ext 120 Fax: 703-528-4145 Rick Kingston International Poison Center 8009 34th Avenue Suite 1050 Minneapolis, MN 55425 Phone: 612-814-7107 Fax: 612-814-7101 Bryon Little American Farm Bureau 600 Maryland Ave, SW Washington, D.C. 20032 Phone: 202-484-3614 x3604 Paulo Mendonca The Virginia Justice Center PO Box 197 105 4th Street SE Charlottesville, VA 22902 Phone: 804-977-0553 Fax: 804-977-0558 Terry Miller Oregon State University Ag Chemistry Corvallis OR 97331 Phone: 541-737-1811 Rita M. Monroy National Coalition of Hispanic Health and Human Services Organizations 1501 16th St, NW Washington, D.C. 20036 Phone: 202-797-4334 Fax: 202-797-4353 ------- Appendices Teresa Niedda Farmworker Health and Safety Institute PO Box 510 ' Glassboro, NJ 08028, ' . Phone: 609-881-2507 Fax: 609-881-2027 Steve Olenchock NIOSH' ; 1095 Willowdale Road Morgantown, WV 26505 Phone: 304-285-6271 Fax: 304-275-6126 Chip Petrea University of Illinois/Ash.Net 1304 W. Pennsylvania . Urbana, IL 61801 Phone: 217-333-5035 Fax: 217-244-0323 . PatPhibbs Environmental Health Letter 951 Pershing Drive Silver Spring, MD 20910-4464 Phone: 301-587-6300 x3022 Fax:301-587-1081 Telisport Putsaviage Neuberg, Hargrave, Rambiave 1225 Eye St, NW #500 Washington, D.C. 20005 Phone:202-312-2010 Fax:202-289-8781 Maryann Ramos OSHA 200 Constitution Ave, Rm 3457 Washington, D.C. Phone: 202-219-5003 Fax: 202-219-9053 Lori Rectanus GAO 441 Connecticut St NW Washington, D.C: 20548 Phone: 202-512-9847 Fax:202-512-8696 Cindy Lynn Richard Achieva 5570 Sterrett Place Suite 208A Columbia, MD 21044 Phone: 410-964-9900 Fax: 410-964-0008 Robert I. Rose EPA, Office of Pesticide Programs 401 M Street SW (7506C) Washington, D.C. 20460 Phone: 703-305-6708 Fax: 703-305-2962 Roger Rosenthal Migrant Legal Action Agency PO Box 53308 Washington, D.C. 20009 Phone: 202-462-7744 Fax: 202-462-7914 Kyla Sell Sunkist 50 F St NW Suite 1100 Washington, D.C. 20001 Phone: 202-879-0256 Fax: 202-628-8233 , Omar Shafey Pesticide Poisoning Surveillance Florida Department of Health 1317 Wimewood Blvd. Tallahassee, FL 32399 Phone: 850-488-8921 Fax: 850-922-8473 Delbert Shelton DuPont 3750 Banyon Lane Alphareta, GA 30022 Phone: 770-740-1313 Fax: 770-740-1314 ------- Workshop OH Developing National Strategies Judy Smith EPA 401 M Street SW Washington, D.C. 20460 Phone: 703-305-5621 Fax: 703-308-2962 Monica F. Spann EPA, Office of Pesticide Programs 401 M Street SW (7509C) Washington, D.C. 20460 Phone: 703-305-6459 Julia Storm North Carolina State University Toxicology, Box 7633 Raleigh, NC 27695-7633 Phone: 919-515-7961 Fax: 919-515-7169 John Tacelosky Chief, Division of Health and Safety PA Department of Agriculture 2301 N. Cameron St Harrisburg, PA 17110 Phone: 717-772-5217 Fax: 717-783-3275 Dorothy Tibbetts Ag. Chem. Extension Oregon State University Corvallis, OR 97330 Phone: 333-737-6123 Katinka Van der Jagt JSC 1525 Wilson Blvd. Arlington,VA Phone: 703-312-8523 Fax: 703-527-5477 Jennifer Weber University of California at Davis IPM Education and Publications One Sheilds Ave. Davis, CA 95616 Phone: 530-752-5930 Fax: 530-952-9336 Lawrence Worthington Maryland Governor's Commission 311 W. Saratoga St, Baltimore, MD 21201 Phone: 410-767-7631 Fax: 410-333-3980 ------- ApperuHces Appendix B: Selected Resources Please note: The materials listed in this appendix are provided for information purposes only. NATIONAL RESOURCES National Pesticide Telecommunications Network (NPTN): partially funded by EPA and maintained at Oregon State University, this toll-free telephone service (1-800-858- 7378) provides pesticide information to callers in the U.S., Puerto Rico and the Virgin Islands. Web site: http://ace.orst.edu/info/nptn/. EPA Office of Pesticide Programs: 401 M Street SW (7506C) Washington DC 20460 Tel: 703-305-5017 Web site: http://www.epa.gov/pesticides/. NIOSH Agricultural Health Centers High Plain Intermountain Center for Agricultural Health and Safety 154B Environmental Health Bldg Colorado State University Fort Collins, CO 80523 Director: Roy Buchan, DrPH Tel 970-491-6151 Pacific Northwest Agricultural Safety and Health Center Box 357234 University of Washington Seattle, WA 98195 Director: Richard Fenske, PhD, MPH Tel 206-685-8962 University of Texas Health Center at Tyler PO Box 2003 Tyler, TX 75710 Director: Arthur Frank, MD, PhD Tel 903-877-7250 Northeast Center for Agricultural Medicine and Health One Atwell Road Cooperstown, NY 13326 Director: John May, MD Tel 607-547-6023 Southeast Center for Agricultural Health and Safety Prevention Department of Preventive Medicine University of Kentucky 1141 Red Mile Road, Suite 102 Lexington, KY 40504 Director: Robert McKnight, ScD, MPH Tel 606-323-6836 Great Plains Center for Agricultural Health 100 Oakdale Campus, #124 AMRF University of Iowa Iowa City, IA 52242 Director: Stephen Reynolds, PhD, CIH Tel 319-335-4212 National Farm Medicine Center 1000 North Oak Avenue Marshfield, WI 54449 Director: Paul Gunderson, PhD Tel 715-389-3415 UC Agricultural Health and Safety Center at Davis Old Davis Road University of California at Davis Davis,'CA 95616 Director: Marc Schenker, MD,MPH Tel 916-752-5676 Association of Occupational and Environ- mental Clinics: Established in 1987, the As- sociation of Occupational and Environmen- tal Clinics (AOEC) is a non-profit organiza- ------- Workshop OH Developing National S&afelSeS tion committed to improving the practice of occupational and environmental health through information sharing and collabora- tive research. AOEC has grown to a network of 55 clinics and more than 250 individual members, and is funded primarily through cooperative agreements with the Agency for Toxic Substances and Disease Registry (ATSDR) and the National Institute for Occupational Safety and Health (NIOSH). AOEC members develop curriculum materials in occupational and environmental health and provide train- ing programs for primary care practitioners. A lending library of course outlines, handouts, slides and videotapes has been established to assist members in this effort. A quarterly news- letter, an Occupational/ Environmental Medi- cine Listserver and an AOEC web site are part of the overall outreach and training strategy. Executive Director: Katherine Kirkland, MPH, Tel: 202-347-4976. AOEC Web site: http://occ-env- med.mc.duke.edu/oem/aoec.htm/. MATERIALS Environmental Medicine: Integrating A Missing Element into Medical Education (1995) and Nursing, Health and the Environment (1995), Institute of Medicine Case Studies in Environmental Medicine, Agency for Toxic Substances and Disease Registry Pennsylvania State University, Agromedicine Program video and materials. Ag-Med: Rural Practitioner Guide to Agromedicine. American Association of Family Physicians, Health Resources and Services Administration, Medical University of South Carolina, Clemson University Environmental Epidemiology for the Busy Clinician, Medical University of South Carolina Case Studies on Skin Disease and Respiratory Disease, University of California at Davis American College of Occupational and Environmental Medicine materials/trainings. Core Guidelines on Occupational Health and Allergy/Immunology, American Academy of Family Physicians Handbook on Children's Environmental Health (under development), American Academy of Pediatrics Draft Faculty Training Module on Pesticides (under development), Children's Environmental Health Network Recognition and Management of Pesticide Poisonings, Dr. Donald Morgan, MD, PhD, ed. March 1989, EPA 540/9-88-001, available in English and Spanish (new edition coming out soon) Web site with full text: http://gnv.ifas.ulf.edu/~firstweb/text/ pp/19729.html/. ------- |