^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/.
------- |