735R02900
National Strategies for Health Care Providers:
Pesticides Initiative
MARCH 2002
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IMPLEMENTATION PLAN
National Strategies for Health
Care Providers: Pesticides Initiative
MARCH 2002
U.S. Environmental Protection Agency
Region 5, Library (PL-12J)
77 West Jackson Boulevard, 12th Flo*
Chicago, IL 60604-3590
For more information:
Tel: 202-833-2933 x535
Fax:202-261-6464
Email: pesticides@neetf.org
Web: www.neetf.org/health/providers/index.shtm
The National Environmental Education & Training Foundation
1707 H Street, NW, Suite 900
Washington, DC 20006-3915
Support for this project was made possible through Cooperative Agreement CR 827026-01-0 between
the Office of Pesticide Programs of the US Environmental Protection Agency and The National Environmental
Education & Training Foundation. The conclusions and opinions expressed herein are
those of the authors and do not necessarily represent the views and policies of the US EPA.
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Ackno
The successful development of this Implementation Plan would not have been possible
without the efforts of a large number of dedicated people and organizations. The Expert
Panel members gave graciously of their time, experience, and energy in developing the
broad national strategies. The members of the Education, Practice, and Resource Workgroups,
expertly guided by their co-chairs, contributed their time, enthusiasm, and intensive effort
during their workshops. Their hard work has produced this Plan. The Federal Interagency
Planning Committee has contributed many hours of guidance and oversight to the
development of the Implementation Plan, and significantly helped to organize the Expert
Panel and the three workgroups. The Committee also continues to guide the entire National
Strategies for Health Care Providers: Pesticides Initiative.
The Implementation Plan was developed as part of a cooperative agreement between The
National Environmental Education & Training Foundation (NEETF) and EPA's Office of
Pesticide Programs. Overall, this Plan is the result of successful collaborative leadership among
NEETF, EPA, the federal agency partners and the stakeholders. The team of collaborative
partners is pleased to share this Implementation Plan with you. Questions about the content
can be directed to pesticides@neetf.org
Photo credits: Photos on pages 13, 19, and 45: Steven Delaney, hPA
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan iii
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Federal Interagency Planning Committee
US Environmental Protection Agency
Office of Pesticide Programs
Kevin Keaney, MA, MS
Sara Ager
Jerome Blondell, MPH, PhD
Ana Maria Osorio, MD, MPH
Frank Davido
Office of Children's Health Protection
Elizabeth Blackburn, RN
Office of Ground Water d» Drinking Water
Ron Hoffer, MS
Sherri Umansky
Office of Environmental Justice
Delta Valente.M PA
US EPA Regional Liaisons
Adrian Enache, PhD, MPH Region 2
Don Baumgartner Region 5
Edward Master, RN, MPH Region 5
Allan Welch Region 10
US Department of
Health and Human Services
Health Resources 6- Services Administration
(HRSA) Bureau of Health Professions, Center
for Public Health
Barry Stern, MPH
Sarat Seneviratne, MS, RS, CHMM, CCHP
HRSA Office of Planning, Evaluation 6- Legislation
Karen Pane, RN, MPA, CMCN
HRSA Bureau of Health Professions,
Division of Medicine and Dentistry
Ruth Kahn, DNSc
HRSA Bureau of Health Professions, Division of
Interdisciplinary, Community-Based Programs
David D. Hanny, PhD, MPH
Joan Weiss, PhD, RN, CRNP
HRSA Bureau of Primary Health
Care, Migrant Health Program
Eva Montoya
HRSA Office of Rural Health Policy
Cassandra Lyles
National Institute for Occupational Safety & Health
Geoffrey Calvert, MD, MPH
Rosemary Sokas, MD, MOH
Office of Disease Prevention &
Health Promotion
Dalton Paxman, PhD
Agency for Toxic Substances & Disease Registry
Donna Orti, MS, MPH
US Department of Agriculture
Agricultural Marketing Service
Peter S. Wood, MS
Cooperative State Research,
Education, and Extension Service
Monte Johnson, PhD
US Department of Labor
John Leben
Other Organizations
The National Environmental
Education 6- Training Foundation
Leyla Erk McCurdy, MPhil
Jennifer Bretsch, MS
American Association of Pesticide Safety Educators,
University of Maryland-College Park
Amy E. Brown, PhD
IV
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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Former Federal Interagency
Planning Committee Members
US Environmental Protection Agency,
Office of Pollution
Prevention and Toxics
Diane Sheridan
US Environmental Protection Agency,
Office of Pesticide Programs
Ameesha Mehta-Sampath, MPH
US Environmental Protection Agency,
Office of Ground Water
and Drinking Water
Marjorie C. Jones
US EPA Regional Liaisons
lane Horton Region 4
Amy Mysz Region 5
HRSA Bureau of Health Professions,
Division of Medicine and Dentistry
Barbara Brookmyer, MD, MPH
HRSA Bureau of Health
Professions, Division of Nursing
Madeleine Hess, PhD, RN
US Department of Agriculture, Cooperative State
Research, Education, and Extension Service
Larry Olsen, PhD
US Department of Labor
Mike Hancock
The National Environmental
Education 6- Training Foundation
Susan T. West, MPH
Expert Panel and Workgroups'
Education Workgroup Co-Chairs
Andrea Lindell, DNSc, RN
American Association of Colleges of Nursing,
and University of Cincinnati, College of Nursing
Ameesha Mehta, MPH
Office of Pesticide Programs
US Environmental Protection Agency
Practice Workgroup Co-Chairs
Bonnie Rogers, RN, DrPH, COHN-S, FAAN
American Association of Occupational Health
Nurses, and
University of North Carolina-Chapel Hill,
School of Public Health
Karen Pane, RN, MPA, CMCN
Health Resources & Services Administration
US Department of Health and Human Services
Resources Workgroup Co-Chairs
Mark Robson, PhD, MPH
Environmental and Occupational Health
Sciences Institute, and Rutgers University
Kevin Keaney, MA, MS
Office of Pesticide Programs
US Environmental Protection Agency
Workgroup Members
Sheila Brown Arbury, RN, MPH
Association of Occupational and
Environmental Clinics
Colin Austin
Migrant Clinicians Network, and
University of North Carolina-Chapel Hill
Joni Berardino, MS, LSW
National Center for Farmworker Health
* As of July 2000
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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Angelina Borbon, RN
Alameda County Lead Poisoning
Prevention Program
Barry Brennan, PhD
American Association of Pesticide Safety
Educators, and Extension Pesticide
Coordinator, University of Hawaii
Amy Brown, PhD
American Association of Pesticide Safety
Educators, and University of
Maryland-College Park
Paul J. Brownson, MD
The Dow Chemical Company
Candace Burns, PhD, ARNP
National Organization of Nurse Practitioner
Faculties, and University of South Florida
College of Nursing
Joan Spyker Cranmer, PhD
University of Arkansas Medical School
Miriam Cruz
Equity Research
Shelley Davis
Farmworker Justice Fund, Inc.
Gerardo de Cosio, MD
US-Mexico Border Health Association
Susannah Donahue, MPH
Children's Environmental Health Network
J. Ward Donovan, Jr., MD, FACEP
American College of Emergency Physicians,
Pennsylvania University Poison Center, and
Milton S. Hershey Medical Center
Gerry Eijkenmans, MD, MPH
Pan American Health Organization
Joe Fedoruk, MD, DABT, CIH
American College of Occupational and
Environmental Medicine
Kesner Flores, EMT
Cortina Indian Rancheria,
Wintum Environmental Protection Agency
Scottie Ford, MA
North American Agromedicine Consortium
West Virginia Agromedicine Program
West Virginia Department of Agriculture
Jose Garcia
Equity Research
Matthew Garabedian, MPH
Texas Department of Health
Jeanne Goshorn, MS
National Library of Medicine
Harold Harlan, PhD
National Pest Control Association
Barbara Hatcher, PhD, MPH, RN
American Public Health Association
Rugh Henderson, MD, MPH
North American Agromedicine Consortium,
Pennsylvania Agromedicine Program, and
Penn State University College of Medicine
Michael Hodgman, MD
National Rural Health Association,
and Bassett Healthcare/NY Center for
Agricultural Medicine and Health
Allen James, MBA, CAE
Elizabeth Lawder, BA (alternate)
Responsible Industry for a Sound Environment
Linda Kanzleiter, MPsSc
Celeste Stalk (alternate)
Pennsylvania Area Health Education Center,
Milton S. Hershey Medical Center
Matthew Keifer, MD, MPH
NIOSH Agricultural Health and Safety
Centers, and University of Washington
KathyKirkland.MPH
Association of Occupational and
Environmental Clinics
Ann Linden, CNM, MSN, MPH
American College of Nurse Midwives
John McCarthy, PhD
American Crop Protection Association
Claudia Miller, MD
University of Texas Health Science
Center-San Antonio
Mark Miller, MD
American Academy of Pediatrics
VI
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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Mary Miller, MN, ARNP
American Nurses Association, and Washington
State Department of Labor and Industries
Terry Miller
National Pesticides Telecommunications
Network, and Oregon State University
Rita Monroy
National Alliance for Hispanic Health
(formerly National Coalition of Hispanic
Health and Human Services Organizations)
Karen Mountain, MBA, MSN, RN
Migrant Clinicians Network
Diane Mull
Association of Farmworker
Opportunity Programs
Madaleine Ochinang, MS
Formerly with the Consortium for
Environmental Education in Medicine
Patrick O'Connor-Marer, PhD
American Association of Pesticide Safety
Educators, University of California Statewide
IPM Project, and University of California
Agricultural Health and Safety Center
Marcia Allen Owens, JD
Minority Health Professions Foundation
Dennis Penzell, DO, FACP
Suncoast Community Health Centers, Inc.
Annette Perez, RNC, MSN, CNM, PhD
American College of Nurse Midwives,
and University of Texas-El Paso,
College of Health Sciences
John Pickle, MSEH
Weld County Health Department, Greeley, CO
Ana Maria Puente
Bureau of Primary Health Care, Border Health,
Health Resources and Services Administration
Benjamin Ramirez, MD, MPH, FACOEM
DuPont Company
Scott Ratzan, MD, MPA
Academy of Educational Development
Susan Rehm, MBA
American Academy of Family Physicians
J. Routt Reigart, MD
Medical University of South Carolina,
Department of Pediatrics
George C. Rodgers, Jr, MD, PhD
American Association of Poison Control Centers,
and University of Loiusville School of Medicine
Rachel Resales, MSHP
Texas Department of Health
Elaine R. Rubin, PhD
Association of Academic Health Centers
Barbara Sabol
W. K. Kellogg Foundation
Barbara Sattler, RN, DrPH
University of Maryland School of Nursing
Jackilen Shannon, PhD
Council of State and Territorial Epidemiologists,
and Texas Department of Health
Cathy Simpson, MD
Wayne State University School of Medicine
Gina Solomon, MD, MPH
Natural Resources Defense Council
Elisabeth Spector, MD, MPH
American Academy of Family Physicians
Roger F. Suchyta, MD
Graham Newson (alternate)
Jennifer Stevens (alternate)
American Academy of Pediatrics
Greg P. Thomas, PA-C
American Academy of Physician Assistants
LeonelVela,MD
Migrant Health Advisory Council, and
Texas Tech Health Sciences Center
Sheldon Wagner, MD
National Pesticide Medical Monitoring
Program, and Oregon State University
John Wheat, MD, MPH
North American Agromedicine Consortium,
and University of Alabama
at Birmingham, School of Medicine
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
VII
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Contents
Executive Summary 1
Vision, Expected Outcomes, and Evaluation 11
Making the Case 15
Target Audience 33
Framework of the Plan: A Three-Pronged Strategy 37
Educational Settings 39
Practice Settings 65
Resources and Tools 89
Conclusion 103
References 105
Glossary 111
Appendix A: Expert Panel Proceedings 113
Appendix B: Summary Proceedings from Workgroups 117
Appendix C: Response to Public Comments 135
Appendix D: Federal Interagency Planning Committee 139
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List of Exhibits
Tables
1 Components of the Implementation Plan 6
2 Initiative Work Products 8
3 Occupational and Non-Occupational Sources of Pesticide Exposure 21
4 Pesticides Most Often Implicated in Symptomatic Illnesses, 1998 22
5 Targets, Populations Served, Practice Settings 33
6 Stages of Change Model 34
7 Competencies for Educational Institutions 47
8 Proposed Design of Faculty Champions Project 60
9 Expected Practice Skills 72
Figures
1 Framework of the Implementation Plan 7
2 Projected Timeline for Implementation Plan Activities 9
3 Stages of Change and Implementation Plan Components 35
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mmary
Pesticides are ubiquitous in our society in both agricultural and urban environments.
We use pesticides in our homes, schools, in our workplaces, and in our communities.
Due to the widespread dissemination of pesticides, and the potential for related illness
and injury (especially among farmworkers and pesticide handlers), health care providers should
be prepared to recognize, manage and prevent pesticide-related health conditions in their
patients and communities. Communities expect that their primary care providers will be
prepared to deal with pesticide-related health conditions, as well as other environmental-
related illnesses, but often times they are not.
This report, an Implementation Plan for the National Strategies for Health Care Providers:
Pesticides Initiative, sets out a strategic direction for the nation to improve the recognition,
management, and prevention of pesticide-related health conditions. It will lead to health
improvements in both agricultural and urban sectors. The Implementation Plan's vision is
for all primary care providers on the front lines of our health care system to:
Possess a basic understanding of the health effects associated with pesticide exposures as
well as broader environmental exposures; and
Take action to ameliorate such effects through clinical and prevention activities.
The Implementation Plan sets forth a three-pronged approach to move toward the vision,
and includes both short and long-term components. The Implementation Plan will be
used to build national consensus on this issue and to gain funding and resource support
to implement and evaluate the entire initiative.
This Initiative the National Strategies for Health Care Providers: Pesticides Initiative began
in 1998 and is a partnership between the US Environmental Protection Agency (EPA) and
The National Environmental Education & Training Foundation (NEETF), in collaboration
with the US Department of Health and Human Services (DHHS), the US Department of
Agriculture (USDA), and the US Department of Labor (DOL). From the outset, this national
interagency initiative has been conceived of as a long-term effort. Sustained funding will be
needed to ensure the success of the Implementation Plan, and multi-stakeholder involvement
is necessary from federal agencies, academic institutions, professional organizations,
foundations, farmworker and farm groups, industry and trade associations.
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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Pesticides Education: A Model for Environmental Health Issues
This Implementation Plan focuses on pesticides as an important model which can easily be
expanded to incorporate other toxic agents and other related initiatives in the field of
environmental health. To avoid duplication of effort, this Implementation Plan will be
integrated into the broader context of other national efforts to educate health care providers
about occupational and environmental health, including children's health protection,
drinking water, nursing and environmental health, Healthy People 2010, and NEETF's Health
& the Environment Programs. This Implementation Plan reflects the landmark reports
from the Institute of Medicine, National Academy of Sciences (1988, 1995) that set broad
recommendations on environmental health in medicine and nursing, as well as the extensive
efforts by key stakeholders across the country to address this issue. It is hoped that this
Implementation Plan will pave the way for the strategic next steps needed to move forward
a common national vision for environmental health awareness, education and training to
health care providers.
The Initiative's Driving Forces
This Initiative received its impetus from a number of sources.
The Worker Protection Standard
A primary contributor is EPA's Worker Protection Standard, 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. This in turn was
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 experience 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 by all primary health care providers.
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 are widely used in the
urban sector, and rural populations not directly involved in farming also may be at risk for
exposure to pesticides. Urban and suburban exposures to insecticides, fungicides, rodenticides
and other pesticides 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.
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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Other Forces
In the field of environmental health, the need for improvements in health care provider training
has been expressed by health professional groups, academic institutions, 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 addressed the general
issue of environmental health education, focusing on nurses and physicians, respectively. Both
committees recommended an integration of environmental health issues throughout training
and clinical practice for health care providers. Also, in 1999 an IOM committee on
environmental justice recommended enhancing health professionals' knowledge of
environmental health as well as environmental justice issues.
Definition of Environmental Health
A common definition of environmental health has been adopted for the purposes of this Initiative.
Environmental health is defined as: "Freedom from illness or injury related to exposure to toxic
agents and other environmental conditions encountered in the home, workplace, and community
environments that are potentially detrimental to human health" (adapted from the Institute of
Medicine's report, Nursing, Health and the Environment (Pope et al, 1995)). Pesticide exposures
do occur in workplace settings, so environmental health in the context of this Implementation
Plan is an overarching category that includes occupational health exposures.
Building the Initiative - A Collaborative Approach
To ensure that collaboration and integration at the federal level could be incorporated at all
stages of the Initiative, EPA established a Federal Interagency Planning Committee in
November 1997 whose initial membership included representatives from DHHS, USDA,
and DOL, as well as EPA. Beginning in February 1998, through a cooperative agreement,
the Initiative also involved NEETF as a non-federal collaborative partner. NEETF brings
the expertise of working with a national coalition of health organizations involved in
environmental health through its Health & The Environment Programs, and has played a
major role in coordinating the Initiative with EPA and the federal partners. Several other
federal agencies have since joined the Initiative and other interested federal partners are
welcome to participate.
Expert Panel and Workgroups
EPA, the Federal Interagency Planning Committee, and NEETF are committed to involving a
wider group of key stakeholders through all stages of this Initiative. This commitment began
with the development of this Implementation Plan. In April 1998, an Expert Panel was
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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convened to identify strategies for educating health care providers on how to recognize,
diagnose, manage, and prevent adverse health effects from pesticide exposures. This workshop
reflected the collaborative nature of this Initiative and the need to involve a wide group of
stakeholders in this issue (US EPA, 1998).
An even wider involvement of key stakeholders took place through three workgroup meetings
(Education, Practice, and Resources) held in May and August 1999 (summaries of the Expert
Panel and workgroup meetings are presented in Appendices A and B, respectively). Workgroup
members, as liaisons to their organizations, have brought important perspectives to this effort
and have ensured that their organizations are kept abreast of the Initiative. These key
stakeholders will play a further role in outreach and consensus building within their
organizations and constituencies to move the overall Initiative forward.
Strategic Outreach Meetings to Build Consensus
With the assistance of stakeholders who participated in the Expert Panel and/or the three
workgroups, the Federal Interagency Planning Committee will conduct strategic outreach
meetings with key professional organizations and decision-making bodies to secure official
endorsements. Efforts are currently underway to participate at various national conferences
for the purposes of publicizing the Implementation Plan and the upcoming national forum
(see page 10), and to begin developing support among stakeholders.
Sustained Funding and Support
To ensure that sustained funding is available for the implementation and evaluation of both
short and long-term components of this Initiative, funding and resource support must come
from various sources, including federal agencies, professional health organizations,
foundations, academia, industry, trade associations, environmental, farm and farmworker
and community-based organizations. It is this type of resource sharing and collaboration
that will determine the success of this Initiative and create a win-win situation for all parties.
Summary of the Implementation Plan
Objectives
The main purpose of this Implementation Plan is to clearly articulate a plan to improve the
recognition, management and prevention of pesticide-related health conditions. This
Implementation Plan also serves as a model for broader efforts to educate health care providers
about the spectrum of health conditions associated with environmental problems. The four
main objectives of the Implementation Plan are to:
Raise awareness of the arguments why primary health care providers should be educated
about and trained in ways to address health effects from pesticide exposures.
Identify the target audience for the Initiative and explain how strategies are designed to
reach segments of the audience at different stages of their "readiness to change."
[ National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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Set forth an agenda to build national consensus on this issue and gain funding and resource
support to implement the Plan and evaluate the Initiative over a ten-year period from
various sources including federal agencies, academia, professional health organizations,
foundations, farmworker and farm groups, industry, and trade associations.
Articulate a three-pronged strategy and a set of required elements for educational settings,
practice settings, and necessary resources and tools.
Strategic Framework
Given that primary care providers are educated and trained in different settings, the
Implementation Plan specifically sets out a three-pronged strategy for effectively reaching
them in these settings (see Table 1). The first prong addresses a provider's formal education,
such as medical school or nursing school. The second prong targets the practice setting in
which a provider works and participates in professional development. The final prong
articulates the resources and tools that providers need to deal effectively with pesticide-
related health conditions in their practices and communities. Specifically, the three prongs
of the strategy are as follows:
1. Educational Settings: Create significant institutional change in educational settings (e.g.,
medical schools, nursing schools, residency and practicum programs) so that students in
the health professions are prepared to recognize, manage, and prevent pesticide-related
health conditions across the United States.
2. Practice Settings: Change the practice of primary care so that pesticide-related health
conditions are recognized, effectively managed and prevented in practice settings (e.g.,
community clinics, hospitals, workplace clinics) across the United States.
3. Resources and Tools: Create new resources for educational and practice settings that
take into account existing resources, evaluate their quality and suitability for different
audiences, and assure their availability through an information gateway.
For both the educational and practice settings, the Implementation Plan recommends a similar
set of component projects and activities (see Figure ]). These components serve as a framework
for the cohesive implementation of the three-pronged strategy. This Implementation Plan
intentionally presents the same conceptual framework for both settings so as to ensure
consistency in approach. However, the Implementation Plan distinguishes between the settings
because they often involve different decision-makers and approaches. The components for
the settings are:
Make the case for change
Define guidelines for educational competencies or practice skills
Assess target audiences in each setting
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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Resources and Tools
Component A: Inventory existing resources Determine
what educational and information programs and materials
for health care providers exist in educational and practice
settings and what gaps should be filled.
"Component B: Establish a national review board
Create a national body to determine assessment criteria
and to evaluate existing resources, with the goal of
Ian
Practice Settings
Component A: Make the case for practitioners Develop
an effective case statement to convince primary care providers
about the need to incorporate environmental health and
pesticide awareness into their practice settings.
"Component B: Define practice skills and guidelines Produce
National Guidelines that recommend practice skills and guidelines
for the recognition, management, and prevention of pesticide
Q_
Table 1 : Components of the Implementation
Educational Settings
Component A: Make the case for change in educational
settings Develop an effective case statement to convince
decision makers about the need for environmental health
and pesticide education in medical and nursing educational
institutions.
"Component B: Define competencies and integration
strategies for curricula - Produce National Guidelines that
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exposures for all practicing health care providers; define
recommend competencies specific to the recognition,
primary health care providers use in both educational and
practice settings for prevention, diagnosis, treatment, and
accompanying content related to expected behavior; suggest
methods of integration into practice and training settings; and
management and prevention of pesticide exposures, for all basic
and advanced training in medicine and nursing; define
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accompanying content areas; suggest methods of integration
"Component C: Create an information gateway
Establish a print, telephone, and web-based gateway through
"Component C: Assess knowledge and skills of practitioners -
Conduct an assessment of the target audience of primary care
into curricula ; and provide access to relevant resource materials.
"Component C: Assess educational settings - Conduct an
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Figure 1: Framework of the Implementation Plan
Educational Settings
iEdueat«wal institutions
Educational competencies
Institutions and faculty
Key decision-makers
Faculty champions
Exams and requirements
Make the case
Define guidelines
Assess target audiences
- Secure endorsements -
- Demonstrate success -
Create incentives
Resources and Tools
f
Inventory National New
Review Board Resources
Practice Settings
Primary care providers
Key decision-makers
New practice models
Health care requirements
and reporting
t
Information
Gateway
Secure key endorsements
Demonstrate success through faculty champions and practice models
Create incentives for change.
The Implementation Plan also outlines a process to develop the resources and tools necessary
to ensure the success of the entire initiative:
Inventory resources
Establish a national review board and conduct evaluation of resources
Create an internet-based information gateway
Create new resources.
Table 2 provides a listing of the anticipated work products to be produced in this Initiative.
The projects and products can only be attained through partnerships among federal and
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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state agencies, professional health organizations, academia, foundations, industry, farm
and farmworker groups, environmental groups and trade associations. The Federal
Interagency Planning Committee encourages interested parties to come forward with
their ideas for implementation.
Table 2: Initiative Work Products
Case Statement for Educational Settings (p. 41)
Case Statement for Practice Settings (p. 67)
National Pesticide Competency Guidelines for Education (p. 44)
National Pesticide Practice Skill Guidelines (p. 70)
Report on Knowledge, Attitudes, and Skills of Educators and Practitioners (pp. 52, 74)
Organizational Position Papers Endorsing The Plan (pp. 55, 77)
Request for Applications/Proposals to Support Faculty Champions (p. 58)
Request for Applications/Proposals to Support Practice Models (p. 80)
Network of Successful Faculty Champions (p. 59)
Network of Successful Practice Models (p. 80)
Sample Questions for Educational Examinations (p. 61)
New Monetary, Legal, Community-Based, and Peer-Professional Incentives (p. 83)
Inventory of Resources (p. 90)
National Review Board for Resource Materials (p. 92)
Recommended List of Resources (p. 92)
Gateway of Resources (print, telephone, internet) (p. 94)
New Resources and Materials (pp. 97, 99)
Timeline and Priority Projects
A timeline for implementation of the Implementation Plan is provided in Figure 2. As the
timeline shows, several projects have already been initiated, and four component areas will
receive priority attention. They are:
National Pesticide Competency Guidelines for Education, and National Pesticide
Practice Skill Guidelines: These two model documents will recommend competencies
for students and practice skills for practitioners to achieve, respectively, the recognition
and management of pesticide-related health conditions and exposures. Work on the
National Guidelines was initiated in February 2000.
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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National Review Board: The National Review Board will determine assessment criteria
and evaluate existing resources, with the goal of identifying, selecting, and assessing the
ideal resources that primary care providers use in both the educational and practice settings.
Information Gateway: The information gateway will be a print, telephone, and web-
based resource through which primary care providers can easily access information and
educational resources about pesticides.
Audience Assessment of Educational Settings and Primary Care Providers: The
assessment report will document the knowledge, attitudes and skills of health care provider
faculty and practitioners on pesticides and environmental health.
Request for Participation and Public Comment
This Implementation Plan is a working document and will be widely shared and disseminated
among stakeholders in professional associations, health organizations, educational institutions,
government agencies and other groups. To gather as much input as possible, the Federal
Interagency Planning Committee in 2000 distributed widely more than 4,500 copies of the draft
Implementation Plan to stakeholders for public comment. This final Implementation Plan reflects
those public comments. A summary of issues raised via public comment and the responses by
the Federal Interagency Planning Committee is included (see Appendix C). Further questions
about the Implementation Plan can be directed to NEETF at pesticides@neetf.org
National Forum 2002
The Implementation Plan will be the subject of a national forum scheduled for 2002 in
Washington, DC. The national forum will be held over two days with an audience of 150-200
health care providers and stakeholders, including key decision-makers from various agencies
and organizations. The forum will launch this national Implementation Plan, showcasing
pesticides as a model for other environmental health issues. Progress on the priority projects
initiated at the time of the event the National Guidelines, audience assessment, information
gateway, and national review board will be featured at the forum, in addition to a broad
range of educational models, practice models, and resources.
The forum will provide an opportunity to secure endorsement from key stakeholders, pave
the way for the strategic next steps needed to move a common national vision forward for
environmental health outreach to health care providers, and build a nationwide network of
health care providers committed to incorporating environmental health into primary care
education and practice.
10 National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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Vision, Expected
Outcomes, and Evaluation
Vision
The goal of the National Strategies for Health Care Providers: Pesticides Initiative is to
improve the recognition, management, and prevention of health effects from pesticide
poisonings and exposures. In addition, all primary health care providers should consider
the impact of pesticide overexposures on human health as they treat patients and prevent disease.
All physicians, nurses, and other health care providers are expected to possess a basic knowledge
of health effects related to pesticide exposures and an ability to take action to ameliorate such
effects through clinical and preventive activities. This will be achieved through training and
education of health professionals, faculty, and students, and the identification, development,
dissemination, and use of appropriate resources and tools, in clinical and public health settings.
The Initiative is set in the broader context of environmental health and holds as its preamble
the following recommendations, adopted from the Institute of Medicine (Pope and Rail, 1995):
Environmental health concepts will be reflected in all levels of education of primary
care providers, specifically defined as physicians, nurse practitioners, physician assistants,
nurses, nurse midwives, and community health workers in the disciplines of family
practice, pediatrics, internal medicine, emergency medicine, obstetrics/gynecology,
preventive medicine, and public health.
Interdisciplinary approaches will be used when educating primary health care providers
so as to draw upon the expertise from various environmental health disciplines.
Environmental health content will be an integral part of lifelong learning and continuing
education of primary care providers.
Professional associations, public agencies and private organizations will provide more resources
and educational opportunities to enhance environmental health in primary care practice.
Expected Outcomes
By 2010, the following expected outcomes of the Initiative will have occurred:
1. Professional associations, decision-making bodies, academic institutions, and practice
settings will have endorsed the need to address health conditions associated with pesticide
poisonings and overexposures.
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan 11
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2. The need for educating health care providers about the health effects of pesticide exposures
will be an accepted part of primary health care education and practice.
3. Education and practice settings will have integrated an endorsed set of educational
competencies and practice skills for primary health care providers on pesticide exposures.
4. Evaluated tools and resources will be used by health care providers to recognize, manage,
and prevent health effects from pesticide exposures.
5. A faculty champion on this issue will be positioned and funded in over 100 academic
educational institutions, including academic health centers and accompanying nursing
schools nationwide.
6. Certification, licensing, and accreditation requirements will include attention to the
recognition, management, and prevention of health effects related to pesticide poisonings
and exposures.
7. Over 100 pilot primary care practices will serve as models for effectively integrating
attention to health effects from pesticides in clinical, educational, and/or preventive ways.
8. Primary care providers will be integrating attention to the health effects of pesticides in
clinical, educational, and/or preventive ways.
9. An internet gateway will effectively guide health care providers and professional
organizations to information resources and educational materials on the issue.
10. Incentives in the health care system will have increased the attention that primary care
providers pay to the recognition, management, and prevention of health effects from
pesticide poisonings and exposures.
11. Resource materials on pesticide poisonings will be easily located in the leading sources of
information for the health care community (e.g., professional journals, newsletters, central
internet sites, professional meetings).
Evaluation of Expected Outcomes
This Initiative has a long-term perspective and ultimately its success will depend on how well
it leads to changes and improved health care in this country. Evaluating its progress along the
way and its long-term success will be important, both for making mid-course corrections as
needed, and for learning from its achievements and failures. An evaluation team will be
contracted to design and implement the evaluation. The evaluation will begin early on in the
Initiative to ensure that measurement indicators are clearly built into all aspects of
implementation. The evaluation will be both formative and summative in nature so as to
track both process and outcome measures. The following set of indicators will be used to
evaluate the components of the Plan.
12 National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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'If you make it
relevant to
, they'll
Professional Endorsement
The major professional associations and
organizations involved with the
Initiative's target audiences endorse
and/or adopt a position paper
supporting this Implementation Plan.
Professional journals increase the
number of peer-reviewed articles and
commentaries making the case for
recognizing, managing, and preventing
health effects from pesticide poisonings
and exposures.
Educational Institutions
Over 40 percent of educational
institutions take steps towards integrating pesticide education into their settings (e.g.,
adopt components into their curriculum from the National Guidelines, hire a faculty
champion, hold periodic Grand Round lectures on the topic, create practice-based
internships that address the issue).
Over 100 educational institutions have a "faculty champion" on faculty who integrates a
pesticide perspective into the education of health professional students.
Certification and licensing requirements include a component related to pesticides and
address the broader understanding of environmental health so that students are tested on
at least a portion of the endorsed competencies.
Practice Settings
Over half of practice settings have taken steps towards building a "model practice" that
addresses health effects related to pesticides (i.e., patient education, history taking,
community outreach, use of tools and resources, access to internet gateway).
Model practice settings document improvements based on changes in recognizing,
managing, and preventing pesticide exposures. Specific models are tracked in high-impact
areas (e.g., migrant farmworker communities, urban settings).
Re-certification and continuing education requirements include a component related to
pesticides, or address the broader understanding of environmental health so that
practitioners are evaluated on at least a portion of endorsed practice skills.
Incentives are in place in the health care system to reward health care providers who
recognize, manage, and prevent pesticide-related health conditions.
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
13
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Utilization of Tools and Resources
Tools and resources are being used at an increased rate by health care providers as tracked
through sales, requests, downloading off the internet, and distribution at conferences.
An endorsed list of resources is available to health care providers online and through the
key dissemination mechanisms.
Increased Reporting and Surveillance
More health care providers are reporting suspected pesticide poisoning and exposures to
state and federal agencies.
States with existing surveillance systems have improved outreach to health care providers
statewide to report suspected cases.
More states implement pesticide surveillance systems with effective outreach and
involvement of health care providers.
Improvements Recognized by Communities/General Public
Community organizations report improved communication and activities by local health
care providers and clinics.
14 National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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Making the
Pesticides are ubiquitous in our society. We use them in our homes, schools, workplaces
and communities. Due to the widespread dissemination of pesticides and the potential
for related illness and injury, especially among farmworkers and pesticide handlers,
primary care providers should be prepared to recognize, manage, and prevent the pesticide-
related health conditions affecting patients and communities.
When pesticide toxicity is discussed, most people usually think of an acute pesticide poisoning
incident in an agricultural setting. However, pesticides are also of concern because of potential
chronic health effects from long-term and cumulative exposures. In addition, pesticide
exposure can occur in a number of settings outside agriculture, including urban environments,
homes, and schools as well as through multiple routes. For example, diet is a major route of
exposure of children (Etzel et al, 1999). A report published by the National Research Council
concluded that prenatal and postnatal developmental toxic effects and the unique consumption
patterns of children needed to be taken into account in establishing standards for pesticides
on food (NRC, 1993). Rural populations not directly involved in farming also may be at risk
for exposure to pesticides. Several objectives in Healthy People 2010 aimed at improving human
health relate to pesticides. These include reducing pesticides exposures indoors and outdoors,
as well from dietary intake; monitoring exposures by measuring urine and blood samples;
and increasing the number of jurisdictions that are monitoring for pesticide poisonings.
Patients and communities look to their primary care providers as important sources of
information and guidance on suspected pesticide-related health conditions. These providers
are not always able to respond effectively.
Primary care providers are on the frontline of health care and can play a key role in identifying and
ameliorating potential pesticide poisonings and exposure. However, more needs to be done to
ensure that health professionals are prepared for this role and that they know where to turn for
assistance. This includes ensuring that providers can "problem solve" with patients who think an
exposure has occurred, readily diagnose if appropriate, provide timely treatment for pesticide-
related illnesses, provide prevention education, and, where appropriate, consult with local
authorities. This Implementation Plan offers a way for health care professionals to be effectively
prepared through their education and training, and to maintain this knowledge while in practice.
This Implementation Plan is based on the premise that addressing pesticide-related health
conditions can be a part of routine primary care and does not require extensive expertise on the
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan 15
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part of the provider. This Initiative recognizes that primary care providers are faced with a number
of competing public health concerns. The goal of the Initiative is to build on existing skills in
toxicology, pharmacology, history-taking, and risk communication to provide tools that the busy
practitioner can use when the need arises. Primary care providers working with high risk populations
may need to attain a more detailed knowledge of pesticide-related health conditions.
More research is still needed on the health effects of pesticide exposures. Such research efforts
should involve primary care providers. Research should focus on what conditions primary
care providers see in their practices, specifically with regard to chronic exposures. As this
Initiative evolves, it is recommended that epidemiologic research be developed using a registry
of primary care offices to identify conditions requiring further research and documentation.
Following are a number of reasons, accompanied by supporting data, why pesticide-related
health conditions are relevant to the practice of primary care today:
Patient and community concerns
Recent public pesticide issues
Potential for acute exposures and health effects
Potential for chronic exposures and health effects
Clinical case examples
Current provider training and education in environmental health.
Patient and Community Concerns
Patients and communities often ask for advice about a suspected pesticide exposure or ask
the provider to investigate a potential health condition to see if it might be related to pesticides.
Public concern about pesticides has been documented and often shows up in the questions
asked by patients. By helping patients problem solve and evaluate risks from pesticides, primary
care providers can help patients reduce risk to exposure and prevent future exposures. In
addition, an alert clinician will also be able to identify a potential exposure when it occurs.
In some instances, providers serve populations that are more actively engaged with pesticides,
such as the farmworker community. There are 3 to 4.5 million farmworkers in the United States
and a million or more pesticide applicators who are often at greater risk for pesticide exposure
because of mixing or applying pesticides or working in fields where pesticides are applied. A
provider community that is more aware of the specific concerns of this population will be better
prepared to effectively diagnose and treat health conditions, and prevent exposures.
The public has expressed concern about the risks of cancer, birth defects, reproductive effects,
and other conditions from exposure to pesticides and other chemicals. For example, from a
16 National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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Providers are often asked basic questions by their patients. Here is a sampling
of pesticide-related questions and concerns that patients bring to their visits
with providers:
(1)1 received a report from my water utility that said the water contains 0.5 ppb
of dibromochloropropane. What is this chemical, what does it mean for my
health, and what should I do?
(2) I just read in the newspaper that schools in my state are spraying their
buildings with toxic pesticides. I'm worried because my child has asthma
and sometimes feels worse at school. Could it be the pesticides?
(3) I have a six-month-old child and the cat has fleas. Is it safe to have the
exterminator in to flea-bomb the house? The exterminator says it's safe if
we stay out for a few hours and open the windows afterwards.
(4) My husband and I are having trouble conceiving a child. We own a farm
and he sprays pesticides. I want to know if the pesticides may be causing
a problem.
(5) I get a headache and have difficulty concentrating at the office. I think it
may be because the janitor sprays pesticides at night.
(6) I am a farmworker and was picking celery in the fields. Today I have a rash
on my hands and arms. Is it from the chemicals?
list of 30 potentially hazardous activities, use of pesticides was perceived to rank in the top 10
most risky activities, higher in "riskiness" than surgery, electric power, swimming, large
construction, x-rays, or bicycles (Slovic et al, 1980). In a 2000 survey of registered voters (n =
1,565), nearly all (90 percent) indicated that environmental factors like pollution, waste and
chemicals are at least somewhat important contributors to diseases. More than half (53 percent)
said these factors are very important in causing diseases (Health-Track, 2000). Voters linked
the role of environmental factors in causing illnesses such as sinus and allergy problems,
asthma in children, birth defects and cancer. Health care providers have an important role in
helping their patients evaluate the relative risks from different types of environmental
exposures, including pesticides. Health care providers need to be able to counsel patients
about realistic risks, and avoid unwarranted trivialization or exaggeration of the risks.
In large measure, this Initiative is intended to help prepare the primary care provider with the
information, skills, and resources to begin problem solving with patients. The questions in
the shaded box above are only a sampling of the concerns presented to practitioners everyday.
This Initiative will help primary care providers carry out their responsibilities to help patients
evaluate the risks and determine whether further steps are required.
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan 1 7
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Recent Public Pesticide Issues
Misuse of Pesticides - Methyl Parathion Case Studies of Misdiagnosis
Under the Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA), EPA regulates an
organophosphate insecticide called methyl parathion for use on specific crops. In the 1980s
and 1990s, methyl parathion was widely used illegally in indoor environments by unlicensed
applicators. One published report describes methyl parathion-related illness among seven
siblings, two of whom died (CDC, 1984). Approximately two days before these children
were correctly diagnosed, five of them were seen by their local physician and sent back to
their contaminated home with a mistaken diagnosis of viral gastroenteritis. Since 1984, at
least five different states have reported illegal use of methyl parathion inside homes and
businesses. Some people exposed to methyl parathion in their homes experienced mild
symptoms of organophosphate poisoning (e.g., nausea, headache, difficulty breathing,
blurred vision) and some of them complained to their health care professionals. A report
summarizing the 1995 investigations in Ohio (where at least 500 homes were treated illegally)
found that 20 percent or more of respondents reported symptoms during the two weeks
following methyl parathion application (NCEH, 1996). Unfortunately, corrective action
was not enacted until 1994. More than 1,500 individuals were relocated from their homes.
The estimated clean-up cost for these incidents was more than $90 million (Environmental
Health Perspectives, 1997).
Misdiagnosis of organophosphate poisoning can be a severe problem. Zweiner and Ginsburg
(1988) reviewed a case series of 37 infants and children poisoned by organophosphates and
carbamates. Of 20 cases transferred to Children's Medical Center in Dallas, 16 (80 percent)
had an incorrect transfer diagnosis ranging from encephalopathy and seizure disorder to
pneumonia and pertussis.
Each of these cases of misdiagnosis or delayed diagnosis demonstrates the potential for acute
exposures, public concern, and expenses related to the widespread use (and sometimes misuse)
of pesticides in our country. The primary care provider can play a vital role in helping
individuals deal with these exposures. Furthermore, alert providers aware of potential health
conditions related to pesticide exposure can become a key link in limiting the spread of
"pesticide epidemics" by identifying sentinel cases and bringing them to the attention of
appropriate public health officials responsible for pesticide-related illness surveillance.
Control of Exotic Pests - Increase in Potential Pesticide Exposures to the Public
A growing number of exotic and public health pests are besieging the United States. Control of
these pests increases the potential for pesticide exposure to large segments of the public. Aerial
applications of insecticides over residential neighborhoods involving millions of people have
been conducted in New Jersey for control of malaria-carrying mosquitoes, in New York City for
control of mosquitoes carrying the West Nile virus, and in several Florida counties for control
of the Mediterranean fruit fly (Medfly) (CDC, 2001). Surveillance conducted during the Florida
1 8 National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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GfCHILDBE*
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w POISON*
RESTRICTED USE
PESTICIDE
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Medfly Eradication Program identified
123 individuals with illness potentially
related to pesticides used in the program
(CDC, 1999b). In 1999, when pesticides
were used against mosquitoes in New York
during the outbreak of West Nile Virus,
Poison Control Centers received
approximately 3,500 inquiries concerning
sprayings. Approximately 250 of these
inquiries involved unconfirmed
complaints of adverse health effects, nearly
all of which were classified as "minor
effects" (e.g., patients exhibited some
symptoms as a result of exposure, but they
were minimally bothersome). Other cases
were classified as "not followed, minimal
clinical effects possible," e.g., patient was
not followed because, in the clinical
judgment, the exposure was likely to result
in only minimal toxicity of a trivial nature
(Matthew P. Mauer, 2001). Continued use
of pesticides against emerging public
health and agricultural threats is likely to lead to increased health concerns and reports to health
care providers of illness. During surveillance to detect human illness (e.g. West Nile virus) and
pesticide spraying campaigns to control exotic pests, health care providers are called upon to
provide sound preventive advice, and to recognize, manage, and report pesticide-related and/or
insect borne viral illnesses (CDC, 2001). Careful documentation and reporting of suspected
cases are needed to protect those who may be unusually susceptible.
Potential for Acute Exposures and Health Effects
Health care providers may be faced with patients who have experienced acute pesticide
poisonings. A pesticide poisoning is considered acute when the onset of symptoms occur
shortly after the time of pesticide exposure. Acute pesticide poisonings can differ in their
degree of severity.
While providers may not see very many acutely poisoned patients, they should possess a basic
understanding of signs and symptoms, and an ability to diagnose so that appropriate
management can be instituted. Oftentimes it is the primary care provider who identifies
possible sentinel cases that signify the presence of previously unrecognized pesticide hazards
in the community. By notifying the proper authorities of real or potential poisonings, health
care providers can play a critical role in pesticide-related illness surveillance.
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
19
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The EPA manual Recognition and Management of Pesticide Poisonings provides health
professionals with information on the health hazards of pesticides currently in use. It deals
primarily with acute effects and provides consensus recommendations for management of
poisonings and injuries caused by current pesticides (US EPA, 1999a).
Health Care Providers Poisoned While Providing Treatment
From 1982 through 1998, malathion, an organophosphate with relatively low toxicity, was
associated with 467 cases in California, where it was considered primarily responsible for
reported symptoms (mostly minor and often related to the odor). One surprising finding was
that 31 (7 percent) of these cases were emergency or medical personnel responding to nine
cases of ingestion (Blondell et al, 2000). In 2000, eleven more police officers, firefighters, and
paramedics sought medical care for symptoms such as burning eyes and throat irritation
after their exposure to a suicide case who ingested and doused himself with malathion (Das,
2000). In another incident, several clinic staff became ill within one year of this incident while
treating 24 vineyard workers exposed to drift from chlorpyrifos and propargite (Das, 2000).
Three additional reports came from Georgia, where emergency department staff became ill
while caring for patients contaminated with organophosphate insecticides (Geller et al, 2001).
These reports illustrate the personal stake that all health care providersparticularly first
respondershave to understand the risks of pesticide exposure.
Agricultural Exposures
Agriculture accounts for 76 percent of the conventional pesticides used annually
(approximately 944 million pounds, not including disinfectants, wood preservatives, or water
treatment chemicals) (US EPA, 1999b). Pesticide handlers and agricultural workers appear to
be at greatest risk for acute pesticide poisoning. Based on states with required reporting of
pesticide-related health concerns, EPA estimates there are approximately 250-500 physician-
diagnosed cases per 100,000 agricultural workers (including pesticide handlers) (Blondell,
1997). Migrant and seasonal farmworkers are especially at high risk since they often work and
live in areas where pesticide exposures can be significant.
Non-Agricultural Exposures
Urban and suburban uses of pesticides can be as high as in some agricultural areas. A 1990
EPA survey estimated that 84 percent of American households used pesticides, most
commonly insecticides (Whitmore et al, 1992). Each year, homeowners on average use 5-
10 pounds of pesticide per acre on their lawns and gardens, many times the concentration
applied by farmers to corn and soybean fields (Robinson et al, 1994). They also use pesticides
in the form of disinfectants, including pine oil cleaners, bathroom cleaning products, and
cleaning materials for swimming pools. Occupational exposures occur in many, not always
obvious, workplace settings, including structural pest control, construction work, work in
nurseries, greenhouses and landscaping, the application of fumigants and sprays in ships'
holds, aircraft and other transport settings, and in the use of engineering and air-
conditioning biocides.
20 National Strategics for Health Care Providers: Pesticides Initiative Implementation Plan
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Table 3 below lists numerous occupations that increase the chance for pesticide exposure,
as well as some occupational and non-occupational sources that present an opportunity
for pesticide exposure.
Table 3: Occupational and Non-Occupational Sources of Pesticide Exposure
NONOCCUPATIONAL
OCCUPATIONAL
Accident or Intentional
mgestion/suicide attempt
Food residues
Hazardous waste sites
Industrial spills
Residues from treated structures
(houses, schools, office buildings)
Residues on treated
lawns and landscapes
Termite control
Water residues
Agricultural application
Agronomists
Building maintenance work
Crop duster maintenance
Emergency responders
Entomologists
Farm work
Firefighters
Flaggers
Forestry workers
Formulating end product
Greenhouse, nursery, mushroom
house work
Hazardous waste workers
Landscapers
Livestock dippers and veterinarians
Manufacturing active ingredient
Marina workers
Medical personnel
Mixing and loading pesticides
Park workers
Pesticide applicators
Plant pathologists
Research chemistry
Sewer work
Storage/warehouse work
Structural application
Transportation
Transporting pesticides
Treating contaminated workers
Vector control workers
Wood treatment workers
Work on highway or
railroad rights of way
Source: McConnell R. Chapter 37: Pesticides and Related Compounds. In: Rosenstock L, Cullen MR, eds. Textbook <>/ (.J
Occupational and Environmental Medicine. Philadelphia, PA: W.B. Saunders Company; 1994.
A substantial number of people in the US are at risk of acute pesticide poisoning from non-
agricultural uses. One of the major sources of data on acute pesticide poisoning is the Toxic
Exposure Surveillance System (TESS) maintained by the American Association of Poison
Control Centers (AAPCC). Data collected from Poison Control Centers showed that in 1996,
over 40,000 adults were sufficiently exposed to various types of pesticides to warrant a call to
their local Poison Control Center. These calls were from individuals who had a concern about
overexposure and were not requests for information. It is estimated that as many as 60 percent
of these individuals developed symptoms of pesticide poisoning. These figures are thought to
represent less than 30 percent of the incident cases of acute pesticide-related illness in the US
(Litovitz et al, 1997; Chafee-Bahamon et al, 1983; Harchelroad et al, 1990; Veltri et al, 1987).
Pesticide exposures among children also warrant concern. Children may be more susceptible
than adults to environmental health risks because of their physiology and behavior. They can
be more heavily exposed to environmental toxins than adults because children eat more food,
drink more fluids, and breathe more air in proportion to their body weight than adults. They
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
21
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also play close to the ground and they put objects in their mouths. They maybe more susceptible
to toxins because their neurological, immunological, digestive, and other bodily systems are
still developing, and they maybe less able than adults to metabolize and excrete the pollutants
(Landrigan, 1997).
In the agricultural setting, children maybe exposed to pesticides in a number of ways; through
prenatal exposure, from being in the fields where their parents work, contact with pesticide
residues on parents' clothing, living in migrant camps next to camps being treated and working
in the fields themselves (US Congress, Office of Technology Assessment, 1990). A report by
the General Accounting Office (GAO, 2000) found that improvements were needed to ensure
the safety of farmworkers' children.
In addition to the agricultural settings, children may be exposed to pesticides in urban and
suburban settings, e.g. in their houses, yards, day care settings and schools. In 1996, Poison
Control Centers were notified about approximately 80,000 children (age 0-19) being exposed
to common household pesticides in the United States. It is estimated that one quarter of
those children developed symptoms of pesticide poisoning. In a study of unintentional
exposures to pesticides (excluding disinfectants), EPA found that 78,500 such exposures were
reported annually to Poison Control Centers in 1985-92, with 92 percent of them occurring
at residences (AAPCC, 1994). Children ages five and younger accounted for 63 percent of the
Table 4: Pesticides Most Often Implicated in Symptomatic Illnesses, 1998*
Rank Pesticide or Pesticide Class Child Adults and Total*
1
2
3
4
5
6
7
8
9
10
Pyrethrms/pyrethroids
Organophoshate insecticides
Hypochlonte disinfectants
Other insecticides
Herbicides
Pine oil disinfectants
Insect repellents
Phenol disinfectants
Carbamate insecticides
Other disinfectants
All other pesticides
TOTAL
< 6 years
947
429
963
601
314
1182
959
591
165
323
456
6930
6-19 yrs.
3369
2865
1425
1551
1748
844
748
391
762
460
1237
15,400
4333
3307
2394
2167
2078
2029
1712
987
932
785
1750
22,474
* Includes only unintentional illnesses. Intentional (e.g., suicide attempts) cases excluded.
** Column totals include 144 cases of unknown age.
Note: Poison Control ("enter Specialists categon/ed 86 percent of these cases as minoi medical outcome, and 31 percent of
the total were seen in a health care facility.
Source: American Association of Poison Control (.enters, loxic hxposure Surveillance System, 1998 data.
22
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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cases. Additionally, GAO documented over 2,300 reported pesticides poisonings in schools
between 1993 and 1996 (GAO, 1999).
The majority of pesticide poisonings (85 percent of symptomatic cases reported to Poison
Control Centers) have a minor outcome (often treatable at home), 14 percent have a moderate
outcome (typically requiring treatment in a health care facility) and 1 percent experience a
major or fatal outcome (Litovitz et al, 1997). In 1992-98, there were an estimated 24,000
emergency department visits annually resulting from pesticide exposure, of which 61 percent
of the cases involved children younger than five years (McCaig, 2000; McCaig and Burt, 1999).
These figures are likely under-estimates and may represent only a fraction of the incident
cases of acute pesticide-related illness among children.
Studies by Chafee-Bahamon et al. (1983), Harchelroad et al. (1990), and Veltri et al. (1981)
found that Poison Control Centers captured between 24 percent and 33 percent of all poisoning
cases seen in hospitals as inpatients and/or outpatients. Since this does not include cases seen
by health care providers who are not in a hospital setting, it is likely that the actual number of
pesticide cases seen annually is several times the figures reported in the table 4 (previous
page) or around 100,000 per year.
Pesticides Most Often Associated with Pesticide-Related Health Conditions
Organophosphate and pyrethroid insecticides are the categories of pesticides most often
implicated in acute pesticide-related illnesses reported to Poison Control Centers. Table 4 on
the previous page ranks the class of pesticides most often linked to symptoms in patients, based
on data from TESS. This table includes only unintentional exposures to single pesticide products.
Potential for Chronic Exposures and Health Effects
Patients and others in the community may come to providers with concerns about the chronic
health effects of both short- and long-term exposure to pesticides. There is a growing body of
scientific literature detailing these effects. For example, in a 1999 CDC study (National Health and
Nutrition Examination Survey, NHANES), levels of metabolites of organophosphate pesticides
were measured in urine from a subsample of NHANES participants six through 59 years of age
who were selected to be representative of the US population. Whether the levels of metabolites
reported in the study are a cause for concern is not yet known. The urine metabolite data can
provide health care providers with a reference range so that they can determine whether people
have been exposed to higher levels of organophosphate pesticides than those experienced in the
general population (NCEH 2001). A well-informed health care provider who possesses a basic
understanding of the latest scientific evidence is better prepared to talk with and counsel patients
who are concerned about pesticide exposures and the risk of future adverse health effects.
Risk communication is also a critical aspect of the therapeutic encounter, and requires active
listening to identify patients' concerns and fears. It requires appropriate risk assessment,
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan 23
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including an assessment of the pesticide involved, the actual source and route of exposure,
whether absorption occurred (and, if so, how much), and an honest appraisal of the state of
knowledge about long-term outcomes. Clinicians face the daunting challenge of providing
appropriate reassurance where needed, while being careful not to dismiss a patient's concerns
without investigating them. Under certain circumstances, the most effective course of action
may be to refer the patient to an occupational/environmental specialist, and the list of resources
for that referral should be readily available in every clinical practice. On the other hand, the
primary care clinician may wish to provide this information directly, and information sources
are available to help.
Cancer Studies
With regard to the relationship between chronic pesticide exposure and cancer, EPA has received
and reviewed the required studies for predicting cancer effects for numerous active ingredients.
Over 60 of these active ingredients have been classified as probable human carcinogens by EPA
or the International Agency for Research on Cancer. Although most of these pesticides are no
longer on the market or have had their uses severely restricted, their potential to cause cancer in
persons previously exposed is still a concern. A review by the National Cancer Institute (NCI)
lists 15 pesticides for which there is evidence of cancer in human epidemiologic studies (Zahm
et al, 1997). A large prospective study of commercial pesticide applicators and their spouses is
underway in Iowa and North Carolina, funded jointly by NCI, EPA and the National Institute of
Environmental Health Sciences, to try to determine which pesticides may pose a risk of cancer
in humans (Alavanja et al, 1996). This study began enrolling subjects in 1994-1997 and includes
57,000 applicators and 32,000 spouses. Analyses of the possible associations of pesticides with
prostate, breast, non-Hodgkin's lymphoma, colon and lung cancer are planned within the next
three years. Many other disease endpoints will also be studied, including asthma, neurologic
symptoms, Parkinson's disease, visual dysfunction, adverse reproductive effects, and respiratory
diseases (see http://www.aghealth.org/analyses.html for updates).
Non-Hodgkin's lymphoma has been associated with frequent use of herbicides (e.g., 2,4-D)
and is associated with farming (Hoar et al, 1986; Wigle et al, 1990, Zahm et al, 1990). As a result
of the widespread concern, the Lymphoma Foundation of America prepared a research summary,
"Do Pesticides Cause Lymphoma?" (Osburn 2001), which reports abstracts from 79 studies and
35 letters/commentaries concerning pesticides and lymphoma. The report did not conclude
pesticides were a cause of lymphoma but noted "there is some evidence that links pesticides
with non-Hodgkin's lymphoma"; therefore, "it makes sense for us to reduce our exposure to
pesticides." In the face of mounting concern from the public, physicians need to know where to
go to obtain objective information about pesticides and their potential for carcinogenicity.
Studies on Central Nervous System Effects
Many insecticides and fumigants are designed specifically to target the nervous system of the
pest they are intended to control (referred to as neurotoxins). There is increasing human
evidence in the form of case reports and epidemiologic studies that suggests that humans
24 National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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may experience chronic neurologic or neurobehavioral effects following high levels of exposure
to certain types of pesticides (Keifer and Mahurin, 1997). Several reports have also found
chronic neurological sequelae (reduced neurobehavioral function) after acute
organophosphate poisoning (Savage et al, 1988; Rosenstock et al, 1991; Steenland et al, 1994;
Stephans et al, 1995). EPA has concluded that some subset of organophosphate-poisoned
subjects probably experience persistent neurobehavioral effects as a result of their exposure.
In November 1999, the Committee on Toxicity of Chemicals in Food, Consumer Products
and the Environment (1999) of the Department of Health in the United Kingdom concluded:
The balance of evidence supports the view that neuropsychological abnormalities
can occur as a long-term complication of acute organophosphate poisoning,
particularly if the poisoning is severe. Such abnormalities have been most evident in
neuropsychological tests involving sustained attention and speeded flexible cognitive
processing ("mental agility").
This report did not find evidence that exposure absent poisoning was a risk factor for
neurotoxicity and noted the need for high quality research to better determine the extent and
type of risks that might be associated with long-term and cumulative exposures.
Studies on Reproductive Effects
Many pesticides have been identified as developmental or reproductive toxicants. "There is
increasing evidence for reproductive effects associated with exposure of males to occupational
agents. Some of the best known examples are reductions in fertility and sperm counts in men
who were occupationally exposed to dibromochloropropane" (Sever et al, 1997).
Dibromochloropropane (DBCP), a nematocide that was banned by EPA in 1979, produced
azospermia and oligospermia among exposed workers (Whorton et al, 1979). Sever et al (1997)
concluded "there is increasing evidence for reproductive and developmental effects of both
maternal and paternal pesticide exposures. Areas of particular concern include infertility and
time to pregnancy, spontaneous abortion, neural tube defects, and limb reduction defects." A
study based on the US Collaborative Perinatal Project (Longnecker et al,2001) strongly suggests
that DDT use increases preterm births, which is a significant indicator of infant mortality. The
concentration of DDE, a metabolite of the pesticide DDT, was measured in the mothers' serum
samples stored during pregnancy (n = 2,380) for children born between 1959 and 1966. Of
these women's births, 361 were born preterm, and 221 were small for gestational age. Mothers
of these affected infants had higher levels of DDE in their blood, indicating higher DDT exposure.
Asthma and Pesticides
In 1998, asthma affected an estimated 17,299,000 persons in the United States and cost an
estimated $12.7 billion for medical care (CDC, 1998a; Weiss et al,2001). Self-reported prevalence
of asthma increased 75 percent from 1980 to 1994 (CDC, 1998b). From 1975 to 1993-95, office
visits for asthma doubled to over 10 million per year. Around the 1994 time period there were
1.8 million emergency room visits, 466,000 hospitalizations, and over 5,000 deaths.
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan 25
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Pests, such as dust mites, cockroaches, and mice, are thought to be important triggers and,
perhaps, initiators of asthma (Huss, 2001; Phipatanakul et al, 2000a; Phipatanakul et al, 2000b).
Prevalence of these pests may partially explain the increased risk for asthma and asthma-related
deaths among blacks and especially among the urban poor. The use of pesticides, therefore,
could be an important tool in a comprehensive asthma management program. At the same
time, some pesticides may pose additional risks to those with asthma (Wagner, 1994; Wagner,
2000; Wax et al, 1994); in fact, deaths due to asthma have been reported to be associated with
exposure to pesticides (Wagner, 2000; Wax et al, 1994). In January 2000, a product designed to
control dust mites had to be pulled off the market because of hundreds of reports of adverse
reactions among users including, primarily, asthma and respiratory reactions.
An Institute of Medicine report (IOM, 2000) concluded that although there is evidence
suggesting that high level exposures to some pesticides may elicit persistent asthma, there is
inadequate or insufficient evidence whether or not an association exists between pesticide
exposures at the levels typically encountered in nonoccupational or residential settings and
the development or exacerbation of asthma. The report suggested that proper use of pesticides
as part of an exposure control program may yield benefits for asthmatics through elimination
of or reduction of allergen sources.
Studies on Other Health Effects/Specific Populations
Hypotheses related to pesticide effects on respiratory, cardiovascular, endocrine, and other
body systems have also been suggested and are currently being studied. The impact of pesticides
on child development is also a growing area of research and investigation.
While studies have indicated associations between pesticide exposures and chronic health
effects, there still remains insufficient evidence to document a causal relationship between
frequently used pesticides and long-term health effects, except in a few cases such as arsenic-
associated cancer, male infertility due to exposure to dibromochloropropane, and neurologic
sequelae following severe poisonings with neurotoxic pesticides. Health care providers need
an awareness of the current state of knowledge on pesticides to assist patients and others in
the community who are concerned about long-term health effects.
The concern about potential future adverse effects of non-acutely toxic pesticide exposures
represents a special challenge to health care providers. The nature of scientific inquiry yields
associations between pesticide exposures and health effects long before causal relationships
can be reasonably concluded. These associations and the publicity they generate can be enough
to raise concerns among patients and the community. Providers should be sensitive to the
level of concern and the need to provide reassurance, as well as the possibility that a referral to
an occupational and environmental medicine specialist may be indicated.
Evaluation of patient concerns about toxic exposures can be complicated by time constraints
and the need to engage assistance from non-clinical disciplines. For example, site visits and
26 National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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industrial hygiene consultations are expensive and not generally part of a private patient's
insurance coverage. Again, primary care providers need to recognize when these specialties
are needed and know how to obtain an appropriate referral.
Clinical Case Examples: The Challenge of Diagnosing Pesticide Exposures
For many pesticides, the short-term and many of the long-term health effects associated with
exposure can easily be mistaken for other agents or health conditions. Determining if a patient
has been exposed to pesticides will improve a professional's ability to make the correct diagnosis.
To make a timely and accurate diagnosis, primary care providers need to be familiar with the
settings in which a pesticide exposure may occur, the symptoms associated with these exposures,
and the appropriate diagnostic methods.
Case Study 1 - Chronic Health Conditions
At the Environmental and Occupational Health Sciences Institute (EOHSI) at the University
of Medicine and Dentistry of New Jersey, two farmers were referred to the occupational
medicine clinic for problems associated with the use of pesticides. Initially, the concern was
the possibility of drug interaction and pesticide use. Both farmers had worked in a large lima
bean operation, and used organophosphate compounds extensively from early in the season
until the harvest. The initial evaluation, along with an industrial hygienist's evaluation of the
farm, led the health scientists and physicians to conclude that both men had experienced
long-term exposure to a series of organophosphate compounds. A rigorous evaluation led to
the use of personal protective equipment, installation of an on-site shower, and a laundry for
pesticide-contaminated clothing. Over a period of 12 months, considerable improvement
was noticed. Both men felt better and no longer reported symptoms of blurred vision, lack of
concentration, headaches, etc.
A coordinated effort of the Cooperative Extension faculty, as well as the clinical faculty at
EOHSI, led to the diagnosis and a very positive preventive outcome. An earlier evaluation by
the local physician did not connect pesticide exposure to the health problems; in fact, the
farmers were told that there were no real problems and they should just continue what they
were doing. The wife of one of the farmers pursued the problem aggressively for four years,
first going to the Extension Service and then to the specialists at the university.
Case Study 2 - Aldicarb Exposure
The following case study, reported in the Morbidity and Mortality Weekly Report (CDC, 1999a),
describes a foodborne outbreak of aldicarb poisoning that occurred when improperly stored
and labeled aldicarb was mistakenly used in food preparation.
On July 19, 1998, 20 employees attended a company lunch prepared from homemade foods.
Shortly after eating, several persons developed neurologic and gastrointestinal symptoms.
Ten visited a hospital emergency department, and two were hospitalized. On July 20, a hospital
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan 27
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infection-control nurse reported the incident to the Louisiana Office of Public Health, which
then investigated the outbreak. The lunch consisted of pork roast, boiled rice, cabbage salad,
biscuits, and soft drinks. Only the cabbage salad was associated with illness. Of the 16 persons
who ate the cabbage salad, 14 became ill (attack rate: 88 percent); the four persons who had
not eaten the cabbage salad did not develop symptoms.
The employee who prepared the cabbage salad reported mixing precut, prepackaged cabbage
in a bowl with vinegar and ground black pepper. The black pepper came from a can labeled
"black pepper" that he had found 6 weeks before the lunch in the truck of a deceased relative.
This black pepper had not been used by the employee for food preparation before the company
lunch. The contents of the black pepper container were tested for organophosphate and
carbamate pesticides. Testing showed the granules in the pepper container as 13.7 percent
aldicarb. A six gram portion of cabbage salad contained 272.6 parts per million of aldicarb, a
level which can produce illness in humans. The deceased owner of the pepper can had been a
crawfish farmer, and it is believed that he used aldicarb on bait to prevent destruction of his
crawfish nets, ponds, and levees by wild dogs and raccoons.
Cholinesterase-inhibiting pesticides (i.e., organophosphates and carbamates), which are widely
used in agriculture and urban pest control, can cause illness if they contaminate food or
drinking water. Aldicarb, a regulated carbamate pesticide, is highly toxic. Health care providers
and public health officials should keep in mind that food poisoning might result from pesticide
or other chemical contamination as well as from infectious organisms.
Case Study 3 - Organophosphate Exposure
A couple in their sixties entered their vacation condominium in Hawaii and were immediately
aware of a strong odor. Three days later they discovered that the odor emanated from a leaking
five-gallon can of liquid Metasystox-R-2, an organophosphate insecticide which was being
stored in a room adjoining the condominium. The chemical container had leaked and saturated
the floorboards and the adjoining wall, as well as leaking under the condominium.
The Poison Control Center advised them to see a doctor, which they did, complaining of
continuing and increasingly severe headaches, blurred vision, and shortness of breath (i.e.,
symptoms compatible with organophosphate intoxication). Pulmonary function tests were
performed and unexpectedly revealed mild obstructive pulmonary disease that improved
following bronchodilator use. No other testing was performed. The physician treated the couple
for a mild reactive airway disease and told them to return for further care only if symptoms
persisted. When they inquired about the need to investigate continuing or residual effects
from exposure to the pesticide, the physician did not know how to answer.
When symptoms persisted, the couple called the National Pesticide Information Center (NPIC)
and were advised to return immediately to the physician and request a cholinesterase enzyme
assay analysis. The results for the male were minimally above the lower normal range (i.e.,
28 National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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consistent with either an acute or resolving intoxication). NPIC advised the couple to vacate
the condominium and contact the Hawaii Department of Agriculture, which helped identify
a commercial laboratory that confirmed the contamination, and provided clean up. The
couple's symptoms resolved approximately two weeks later.
Case Study 4 Arsenic Exposures
A clinician examined a rural family of eight with a number of signs and symptoms. Family
members had conjunctivitis, bronchitis, pneumonia, sensory hyperthesia of the arms and
legs, muscle cramps, dermatitis over the arms, legs and soles of the feet, nosebleeds, ear
infections, blackouts and seizures, gastrointestinal disturbances, and severe alopecia. Symptoms
became most severe during the winter months and tended to remit in summer (Peters et al,
1983). These conditions were initially attributed to stress, poor diet, hypochondria, and even
child abuse. Only when a toxicologist heard about the case from the news media and performed
appropriate laboratory tests on environmental samples was the source of the problem
identified, three years later. The problem was found to be burning copper-chrome-arsenic
treated wood (outdoor grade plywood) in the family's wood stove.
These case studies point to the preventable human suffering that can be associated with
delayed or missed diagnoses of pesticide poisoning. Since the use and presence of pesticides
are ubiquitous, there is a strong argument for sensitizing all primary care providers to develop
a high index of suspicion, diagnostic acumen, and awareness of available resources, to
respond promptly to patients whose presentations may represent pesticide poisoning. While
it is anticipated that providers working with high-risk populations such as in agricultural
areas, emergency departments, and pediatrics will be most sensitive to this proposition,
these cases show the potential for such severe health consequences that all primary care
providers are advised to be vigilant.
Current Provider Training and Education in Environmental Health
Health care providers are the primary audience for this Plan because the public looks to them
for guidance on health concerns. While some progress has been made in introducing
environmental health issues into curricula at medical and nursing schools, most health
providers still do not have adequate knowledge and tools to address patient and community
concerns. Key studies by recognized medical institutions and committees convened by federal
agencies and national scientific bodies have addressed this concern:
*t>
In 1985, only 50% of medical schools addressed occupational and environmental health
in their curricula, with an average of only four hours being taught over four years. By
1992, 66% percent of medical schools required an average of about six hours of study
in occupational and environmental health over four years (Schenk et al, 1996). (See box
on next page).
National Strategics for Health Care Providers: Pesticides Initiative Implementation Plan 29
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A 1994 survey of environmental medicine content in US medical schools
found that:
Ninety US medical schools (76 percent) reported requiring environmental
medicine content in the curriculum. Only two schools (2 percent) had a
dedicated course. Eighty-nine schools (75 percent) indicated that
environmental medicine was taught as part of a required course. Forty-six
schools (39 percent) offered it as an elective course.
Fifty schools (42 percent) reported no instruction in taking an exposure history.
Among schools with required environmental medicine instruction, the
average time in the curriculum was seven hours over the four years of medical
education. An average of three hours of environmental medicine instruction
was provided in pre-clinical courses and four hours in clinical courses.
Eighty-one schools (68 percent) reported some faculty with environmental
and occupational medicine expertise, most often in departments of internal
medicine (42 percent), community/preventive medicine or public health
(37 percent), and family medicine (28 percent).
Nineteen schools indicated innovative or unusual approaches to teaching
environmental medicine, including small group case discussions, community-
based clerkships, and site visits. These schools reported an average of five
faculty members with occupational/environmental medicine expertise,
compared with an average of four faculty members for all other schools.
Note: Of the 126 schools surveyed, 119 (94 percent) responded.
Source: Schenk et al, 1996.
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 occupational or environmentally induced
conditions and make appropriate referrals (IOM, 1988).
In December 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).
Specific recommendations to change medical/nursing education and practice were made
by two IOM committees on medicine and nursing, in 1994 and 1995, respectively. In
1995, the I nstitute of Medicine produced two landmark reports Environmental Medicine:
Integrating a Missing Element into Medical Education (Pope and Rail, 1995) and Nursing,
30 National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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Health and the Environment (Pope et a], 1995) that called for more effective
environmental health education and training of medical and nursing professionals.
In Toward Environmental Justice, Research, Education, and Health Policy Needs (IOM, 1999)
an IOM committee on environmental justice recommended enhancing health
professionals' knowledge of environmental health as well as environmental justice issues.
Health care providers can be extremely effective in addressing pesticide exposures and other
environmental health conditions in the lives of their patients and in their communities.
However, they do not need to become experts in order to fill an important and crucial role.
Some of the important knowledge and skills that they should possess include:
Recognizing possible signs and symptoms of pesticide exposure
Taking a brief and relevant environmental and occupational history
Diagnosing possible associated health conditions, including those of sensitive populations
such as children and the elderly
Calling upon an appropriate specialist or expert to assist them
Having ready access to a recommended referral list of resources and contacts
Providing basic preventive guidance for patients
Recognizing when to report exposure incidents to the proper health authorities
Possessing a basic awareness of environments in which patients live, work, and play
Identifying possible sentinel cases
Participating in surveillance systems.
Training of Primary Care Providers
This Initiative emphasizes the provider's ability to recognize a potential pesticide exposure, to
communicate effectively, and to access and work with pesticide/environmental health experts
and resources. In an educational setting, this may mean working with an occupational and
environmental medicine specialist to design and integrate a pesticides module into a toxicology
course for medical students. In a practice setting, this may involve incorporating an
occupational and environmental history into primary care practice and referring patients to
appropriate experts in the event of a suspected poisoning. User-friendly teaching materials
exist for faculty to use, along with user-friendly guides and curriculum maps indicating where
pesticide topics could be inserted into the curriculum.
The issue of pesticide-related health conditions is one that requires the participation of health
care providers. The rationale given in this section serves as the underpinning of the three-
pronged strategy in this Implementation Plan.
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan 31
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Target Audience
For the purpose of this Initiative, the target audience is the primary care provider. Primary
care providers work at the frontline of our health care system and need to be
able to identify a possible pesticide exposure. It is recommended that all primary care
providers possess basic knowledge and skills related to pesticide exposures. A primary care
provider, for the purpose of this Initiative, 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.
Specialists in occupational and environmental medicine, and medical toxicology are not
the primary target of this Initiative. They are seen as resource professionals for the primary
care providers.
Emergency medical technicians (EMTs) can play a vital role in assessing and immediately
treating patients with pesticide-related conditions, particularly in the case of extreme poisoning.
Their education and training, however, is out of the purview of this Implementation Plan
and varies significantly from those of the target audiences in the Implementation Plan. Both
EMTs and other emergency response professionals must be addressed separately.
Primary care providers work in a variety of settings. Table 5 summarizes the target audience,
types of populations served, and the range of practice settings commonly encountered. In
Table 5: Targets, Populations Served, Practice Settings
Targets Populations Served
Nurses
Nurse Practitioners
Physicians
Physician Assistants
Nurse Midwives
Community Health Workers
susceptible populations
(elderly, frail elderly, kids)
urban
non-urban
tribal communities
agricultural
migrant farmworkers
underserved populations
(environmental justice)
pesticide handlers
Practice Settings
hospitals and emergency
departments
community clinics
medical centers
independent practices
industry, workplaces
alternative points of care
public health departments
poison control centers
schools
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
33
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addition to these primary care providers, the target audience also includes key decision-making
bodies in the health professions. A decision-making body, for purposes of this Implementation
Plan, refers to any organization, institution, or individual leader that is vested with decision-
making authority for the education and practice of health care providers in the United States.
This includes, but is not limited to, curriculum committees, residency review committees,
exam development bodies, accrediting institutions, organizations representing academic
institutions, faculty, and administrators, and institutions governing health care practice and
requirements. The engagement of, and endorsement by, such bodies is the only way to ensure
success of this Implementation Plan and the larger Initiative.
Understanding the Target Audience
Consulting the available literature on how health professionals learn is an important first step
in determining the most effective approaches. One of the models explored in the development
of this Implementation Plan is the "Stages of Change model" (Prochaska et al, 1995) that
looks at behavior change as a process rather than an event, and describes varying levels of
motivation, or readiness to change. Reaching primary care providers who are at different
stages of change requires different types of interventions and resources. The model outlines a
continuum of behavior change that can be used to help understand where the target audience
is on the continuum, and to effectively reach the audience (through targeted messages,
strategies, and programs) to ensure behavior change. Table 6 outlines the model.
Table 6: Stages of Change Model
Concept Definition
Pre-contemplation
Contemplation
Decision/Determination
Action
Maintenance
Unaware of problem;
has not thought through behavior
Thinking about change in the
near future
Making a plan to change
Implementation of
specific action plans
Continuation of desirable
actions, or repeating periodic
recommended step(s)
Application
Increase awareness of need for
change, personalize information
and risks and benefits
Motivate, encourage to make
specific plans
Assist in developing concrete
action plans, setting gradual goals
Assist with feedback, problem
solving, social support,
reinforcement
Assist in coping, reminders,
finding alternatives, avoiding
steps/relapses (as applies)
Source: Procha.ska et al, 1995.
34
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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Applying the stages of change model to the current Initiative, the concepts can be consolidated
into three categories or stages of change:
Stage 1: Building awareness and motivation At this stage, the goal is to increase awareness
and motivation by making an effective case, and increasing the motivation to change.
Stage 2: Readiness to make changes To turn readiness into actual change, the goal at
this stage should be to build on knowledge and skills, for example, by creating new resources
and disseminating them effectively.
Stage 3: Maintenance, "champions" For those who have already made a change, the
goal is to maintain support for the change activity and nurture "champions" who will
advocate for change.
When it comes to understanding and dealing with pesticide-related health conditions, many
primary care providers may fall currently in the first category (Stage 1), particularly those
working in urban areas. Nevertheless, resources should still be created and made available for
all three categories, allowing primary care providers to "self-select" into whichever category
fits their needs. Figure 3 shows how the components of this Implementation Plan cover all
three stages of change in the target audience.
Figure 3: Stages of Change and Implementation Plan Components
and
ion-Building
edge and
uilding
Make the Case
Create Incentives
Secure Endorsements
New Resources
Define Competencies
Models of Change
Faculty Champions
Information Gateway
New Resources
enance and
ion-Building
am
FacullyXhampions
Information Gateway
New Resources
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
35
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Framework of the Plan:
A Three-Prnnged Strategy
T
his Implementation Plan sets forth a three-pronged strategy to reach the goal of
improving the recognition, management and prevention of health effects from pesticide
poisoning and exposure.
The Implementation Plan recognizes that primary care providers are educated in different
settings. The first prong of the strategy addresses a provider's "in-service" or formal education,
such as in medical school or nursing school. The second prong targets the practice setting in
which a provider works and participates in professional development. The final prong
articulates the resources and tools that providers need to effectively deal with pesticide-related
health conditions in their practices and communities. The three prongs of the strategy are:
1. Educational Settings: Create significant institutional change in educational settings
(e.g., medical schools, nursing schools, residency, and practicum programs) so that students
in the health professions are prepared to recognize, manage, and prevent pesticide
poisoning and exposures across the United States.
2. Practice Settings: Change the practice of primary care so that pesticide-related health
conditions are recognized, effectively managed, and prevented in practice settings (e.g.,
community clinics, hospitals, workplace clinics) across the United States.
3. Resources and Tools: Create new resources for educational and practice settings that
take into account existing resources, evaluate their quality and suitability for different
audiences, and assure their availability through an information gateway.
For each setting, the Implementation Plan recommends a set of components. These components
serve as a framework for the cohesive implementation of the three-pronged strategy. In some
cases, the components for both settings are quite similar; in other cases they are significantly
different. This Implementation Plan intentionally presents the same set of components for both
settings so as to ensure consistency in approach. However, the Implementation Plan distinguishes
between the settings because they often involve different decision-makers and approaches. The
components for each setting are to:
Make the case for change
Define guidelines for educational competencies or practice skills
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan 37
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Assess target audiences in each setting
Secure key endorsements
Demonstrate success through faculty champions and practice models
Create incentives for change.
The Implementation Plan also outlines a process to develop the resources and tools necessary
to ensure the success of the entire initiative:
Inventory resources
Establish a national review board and conduct evaluation of resources
Create an internet-based information gateway
Create new resources.
38 National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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ttings
The first prong of the strategy is directed at the educational setting. Educational settings,
for purposes of this Initiative, are defined as medical schools, nursing schools, academic
health centers, training programs for all levels of nursing education, and medical
residency programs. While the components target the educational setting, they also involve
the professional associations and decision-making bodies that represent and/or influence
the educational setting. These include, for example, the Association of American Medical
Colleges, the American Association of Colleges of Nursing, the Association of Academic
Health Centers, and the Accreditation Council for Graduate Medical Education. The
following components come from across the continuum of systemic change from raising
awareness and assessment, to development of core competencies, to the support of faculty
champions and model programs.
Component A: Make the case for change in educational settings Develop an effective
case statement to convince decision-makers about the need for environmental health and
pesticide education in medical and nursing educational institutions.
Component B: Define competencies and integration strategies for curricula Produce
National Guidelines that recommend competencies specific to the recognition, management
and prevention of pesticide exposures, for all basic and advanced training in medicine and
nursing; defines accompanying content areas; suggests methods of integration into curricula;
and provides access to relevant resource materials.
Component C: Assess educational settings Conduct an assessment of the target audience
of educational institutions to determine (a) amount of existing coursework, (b) faculty
members' current knowledge and comfort level with teaching pesticide-related topics, and
(c) how faculty and educational institutions will best respond to educational programs and
information resources. This assessment will be comprised of a literature review and a range
of needs assessment analyses.
Component D: Secure official endorsements Ensure the integration of the core
competencies outlined in the National Guidelines into educational institutions by securing
the official endorsements of key professional organizations and decision-making bodies.
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan 39
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Component E: Strengthen and build faculty champions Create and support faculty
champions within medical and nursing schools to teach environmental health and pesticide
education in the curriculum, and to bring about change within their institutions.
Component F: Create teaching incentives Influence the appropriate boards, organizations,
and institutions that create board exams to include several key competencies on pesticides
and environmental health.
40 National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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EDUCATION COMPONENT A:
Make the Case for Change
in Educational Settings
Statement
Develop an effective case statement to convince administrators, faculty, and students about
the need for environmental health and pesticide education in medical and nursing education.
Expected Outcomes
A written case statement that documents the key reasons why faculty members and
administrators of academic institutions should be aware of pesticide-related health
conditions, using persuasive data and documentation from the scientific literature, and
stressing the importance of teaching pesticides content in their educational curriculum.
Endorsement by leading national professional associations, national bodies, deans, and
faculty committees.
Target Audience
Awareness and Motivation: This component is targeted at educational institutions and key
strategic organizations that need to be convinced that the issue of pesticides and the need to educate
health care providers about this issue are relevant to the educational settings of health care providers.
Proposed Activities
Activity #1
Research and develop a case statement, solicit peer review, and finalize with the input of key
stakeholder groups in the field. The target audiences for the case statement are educational
settings and the organizations that work with them.
Points to be covered in the case statement:
Specific importance of environmental health education and the breadth of the problem
of pesticide-related health conditions.
Convincing arguments for why pesticides should be in the curriculum, with cited
scientific data.
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan 41
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Compelling arguments to gain the attention of health care students and faculty despite
the fact that their time and attention are in high demand elsewhere.
Emphasis that faculty do not need to become experts, and reassurance that experts exist
in the field who can work with them on coursework and teaching.
Emphasis on practical learning for students in settings where pesticide exposures may occur.
Reassurance that user-friendly teaching materials are available for faculty to use, along
with user-friendly guides, and curriculum maps indicating where pesticide topics could
be inserted into the curriculum.
Recommended amount of time to dedicate to pesticides in the curriculum that is
reasonable given the other demands on academic institutions.
Activity #2
Promote the case statement through effective dissemination mechanisms to administrators,
faculty, and curriculum committees, including print and internet information sources.
Activity #3
Publish journal or newsletter articles on "making the case" for the academic setting in
professional journals and publications.
Activity #4
Hold strategic meetings with bodies that accredit health educational institutions and set curricular
requirements, and with national leaders to seek their endorsement of the case statement. This
includes identifying a subset of decision-makers who can be influenced by the case statement.
Stakeholders
Professional associations
Key accrediting bodies
Curriculum committees
Deans/Department chairs
Collaborating federal agencies
Evaluation of Outcomes/Indicators of Success
Complete case statement.
Published articles in professional journals and newsletters.
42 National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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Position papers developed and adopted by professional associations.
Background
This component was crafted recognizing that we need to raise awareness about why educating
health care providers about pesticide-related health conditions and exposures is so important.
Many key decision-makers may still be unconvinced that this is an issue of concern. Although
the supporting documentation is there, there is a need to pull the information together in a
succinct case statement that shows clearly the relevance of this issue to academic institutions.
The document will be used in outreach on the Implementation Plan, and will assist the entire
field in "making the case" for the education of health care providers on this topic. The case
statement will complement a similar statement to be created for practice settings.
National Strategics for Health Care Providers: Pesticides Initiative Implementation Plan 43
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EDUCATION COMPONENT B:
Define Competencies and
Integration Strategies for Curricula
Statement
Produce National Guidelines that recommend competencies specific to the recognition,
management and prevention of pesticide exposures, for all basic and advanced training in
medicine and nursing; define accompanying content areas; suggest methods of integration
into curricula; and provide access to relevant resource materials.
Expected Outcomes
National Pesticide Competency Guidelines for Education that recommend competencies,
content, insertion points into curricula, and resources.
Endorsement of National Guidelines by leading national professional associations.
Target Audience
Readiness to Change: This component is targeted at administrators and faculty in educational
institutions. The guidelines are to assist faculty in integrating the recommended core
competencies into curricula. This component assumes that administrators and faculty
members have been convinced that this is an important topic for their curricula and that they
are ready to change their curricula.
Proposed Activities
Activity #1
Define the core competencies for educational institutions to teach about pesticides in basic
and advanced curricula (See Table 7).1
The intent of Table 7 is to define competencies that could be integrated into existing curricula.
The table links with a complementary document for practice settings.
1 A start at defining competencies for the thi ee levels of learning was done by a subgroup of the Education Workgroup in May
1999, and was fui ther elaborated in July 1999 by a small committee. Subcommittee members included Andrea Lindell, Candace
Burns, (ames Roberts, Matthew Kiefer, Annie Perez, Joan Weiss, Cleoia Wittl, Ameesha Mehta, and Susan West.
44 National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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Activity #2
Produce National Pesticide Competency
Guidelines for Education to educate students about
the recognition and management of pesticide-
related health conditions and exposures. A
complementary document focuses on the practice
settings where primary care providers work.
An accompaniment to the Recognition and
Management of Pesticide Poisonings handbook,
the National Guidelines are designed as a user-
friendly guide on how to integrate pesticides
content into curricula. The Guidelines contain
the following components:
Recommended competencies.
Relevant content for each competency area.
Suggested points of insertion into curricula (expected to vary between medical and nursing
schools as well as for basic or advanced training).
Suggested resources to teach content specific to each competency in educational settings.
The National Guidelines do not contain actual teaching modules or resources, but rather provide
a listing of relevant resources.
Activity #3
Promote the National Guidelines with key stakeholders. Solicit official endorsements and
organizational support of report, including dissemination to their members.
Stakeholders
Academic institutions
National professional associations for academic institutions
Faculty members who have already developed curricula
Evaluation of Outcomes/Indicators of Success
National Guidelines completed and peer reviewed.
Endorsement by key stakeholder organizations.
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
45
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Background
In defining "competencies" in pesticides and environmental health, several key recommendations
have helped to frame this component.
Build upon existing documents: The competencies must relate to the Institute of Medicine
competencies for medical and nursing education, so that no duplication of effort occurs.
Balance between pesticides and environmental health: One of the most difficult
questions is the relative balance between environmental health topics in general and
pesticides in particular. Having the competencies deal specifically with pesticides avoids
any charges of duplication, and might even be seen as a useful model for developing other
competencies in specific areas.
Focus on basic and advanced levels: Although Table 7 (page 47) presents competencies
for three levels of learning (basic, advanced, specialty), the focus of the Initiative will be
on basic and advanced, which are most relevant for training primary care providers. Other
organizations, including the American College of Occupational and Environmental
Medicine, American College of Medical Toxicology, and the American Association of
Occupational Health Nurses, are focusing on specialty training.
Categorize the competencies: The six categories of competencies shown in Table 7 were
derived from a combination of the Institute of Medicine's medicine and nursing
recommendations. They are meant to apply to medical, nursing, and allied health school
curricula. The six categories are:
Basic knowledge and concepts of pesticides
Diagnosis/assessment
Treatment/intervention/referrals/follow-up
Risk communication, advocacy, and ethics
Reporting
Legislative and regulatory knowledge.
Table 7
Table 7 indicates preliminary competencies formulated in 1999. Further developed competencies
are available in 2002.
46 National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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EDUCATION COMPONENT C-
Assess Educational Settings
Statement
Conduct an assessment of the target audience of educational institutions to determine: (a)
amount of existing coursework, (b) faculty members' current knowledge and skill levels, and
comfort with teaching pesticide-related topics, and (c) how faculty and educational institutions
will best respond to educational programs and information resources. This assessment will
be comprised of a literature review and a range of needs assessment analyses.
Expected Outcomes
Baseline data indicating the level of education currently taking place in academic institutions,
current curricular content and emphasis on pesticides/environmental health, current
knowledge of teaching faculty, and best mechanisms to reach and train faculty to teach.
Target Audience
Awareness and Motivation: This component targets academic institutions to determine
their level of awareness; their level of interest in this topic; their knowledge and skills base;
and the most effective ways to reach them through educational interventions, model programs,
and resources.
Proposed Activities
Activity #1
Conduct a literature review to locate data and evidence of level of training in educational
institutions.
Activity #2
Where literature review is lacking in data, conduct a combination of audience assessment
activities, including focus groups and interviews, to collect baseline data and draw conclusions
on the following questions:
To what extent is the recognition and management of pesticide-related health conditions
taught in the targeted academic institutions?
What is the extent of the knowledge, attitude, and skill base of faculty members with
regard to pesticide issues? Are they at the stage of needing to raise awareness, improve
their knowledge and skills, or provide them with resources?
52 National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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What is the extent of faculty comfort level with teaching this topic area? What do faculty
need to feel more comfortable about teaching this topic?
What resources, and in what format (e.g., traditional lecture material, teaching modules,
web-based, audio cassette, CD, video conference, satellite), do academic institutions most
need to teach about this topic?
Activity #3
Produce a final report with recommendations for use in the development of the Initiative.
Stakeholders
Professional associations that represent academic institutions
Academic institutions
Faculty curriculum committees
Faculty members
Students
Evaluation of Outcomes/Indicators of Success
Comprehensive literature search documenting the findings of studies that have surveyed
academic institutions and deans.
Report with baseline data, conclusions, and recommendations.
Background
Any good plan has at its core a strong assessment component to collect baseline data on
existing knowledge and skills, as well as to determine the most effective mechanism for reaching
the target population. The importance of assessing educational institutions to determine what
is already in place, and how best to structure the educational interventions was emphasized
by participants during the development of the Implementation Plan.
This component will collect vital information not only for this Initiative, but also for the
entire field of health care provider education. The assessment will also include a chance to
determine where the target population "sits" along the continuum of change described in the
section on Target Audience. Do most people lie at the beginning of the continuum where they
will respond best to activities that raise their awareness and motivate them to care about this
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan 53
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issue? Or are they ready to make changes in their curricula and are in need of tools and
educational resources? The assessment will answer these, and other key questions, to inform
the implementation process and subsequent evaluation.
54 National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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EDUCATION COMPONENT D:
Secure Official Endorsements
Statement
Ensure the integration of the core competencies outlined in the National Guidelines into
educational institutions by securing the official endorsements and support of key professional
organizations and decision-making bodies.
Expected Outcomes
Professional organizations, licensing and accrediting bodies, administrators, and educators
will agree that these competencies are essential to the education of primary care providers
and will integrate or support their integration into core curricula.
Target Audience
Awareness and Motivation: This component targets key accrediting bodies and associations
for academic institutions, along with academic deans and faculty committee chairs. The
emphasis here is on raising awareness and motivating decision-makers to bring about change
in academic institutions that prepare health care providers.
Maintenance/Sustainability: This component also targets key professional associations to
endorse and support the implementation and outcomes of this Initiative over the long-term.
The Initiative will only be successful if its expected outcomes are institutionalized into the
educational settings for health care provider training.
Proposed Activities
Activity #1
Promote competencies with professional and decision-making organizations and academic
institutions (along with the case statement) through strategic meetings and outreach. Highlight
the specific recommendations in the National Guidelines on competencies, along with specific
examples of how an educational institution could integrate the content into curricula.
Activity #2
Publish editorials in nationally recognized journals promoting the idea of integrating into
curricula specific strategies from the National Guidelines.
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan 55
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Activity #3
Develop a position paper on the need for competencies to be posted on the internet, and for
use in meeting with decision-making bodies.
Activity #4
Identify and promote incentives for faculty to teach core competencies, including financial incentives
in the form of grants, faculty development, curriculum development, and research, instructional
teaching and training aids, expert consultants, clinical access, release time for faculty development,
curricula development, and establishing appropriate clinical sites and teaching venues.
Stakeholders
Professional specialty organizations, licensing boards, accreditation/certification bodies
National professional associations
Evaluation of Outcomes/Indicators of Success
New position papers by targeted organizations that support the integration of
recommended pesticide content into curriculum.
New requirements by professional decision-making bodies that require institutions to
teach about health effects from pesticides.
Published journal articles in professional newsletters and peer-reviewed journals.
Background
The success and sustainability of this Initiative will only be achieved if the institutions themselves
find ways to integrate pesticide-related content into health professional education. The best
mechanism to reach such organizations is for individuals involved in this Initiative to meet one-
on-one with key leaders and offer them simple and easy ways that they can endorse and/or adopt
this Implementation Plan.
56 National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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EDUCATION COMPONENT E:
Strengthen and Build Faculty Champions
Statement
Create and support faculty champions within medical and nursing schools to teach
environmental health and pesticide education in the curriculum, and to bring about change
within their institutions. A champion, for purposes of this Initiative, is defined as a faculty
member who takes a leadership role in integrating environmental health and pesticides into
his/her institution in a sustainable fashion. This component is designed to ensure that a
strong cadre of faculty champions is developed across the country who will lend expertise
and support for this effort in their institutions and surrounding communities.
Expected Outcomes
Funding of 146 faculty champions, including one faculty champion in all 126 academic
health centers' in the United States, plus an additional 20 faculty champions in 20 other
higher education institutions to ensure a balance of medicine and nursing faculty as well
as representation from diverse institutions.
Additional support for 10 of the academic health centers to serve as regional technical
assistance centers.
Target Audience
Champion Building: This component targets faculty members who are ready to become a
part of a cadre of faculty from across the country who will teach courses, integrate
competencies into curriculum, and serve as a model for how to integrate environmental
health and pesticides into health professional education. The target audience is convinced of
the importance of this issue and has enhanced its knowledge and skill level.
Proposed Activities
Activity #1
Identify and select several model academic setting programs based on the existing work of
faculty across the country, with specific focus on primary care faculty members. Hold a small
While the organization and stiucture of academic health centers vary, every center comprises an allopathic and osteopathic school
of medicine, at least one other health professional school or program, and one or more owned 01 affiliated teaching hospitals.
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan 57
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invitational workshop of model programs and develop several models on which to base the
funding for all 146 academic institutions.
Activity #2
Develop key required elements for a model faculty champion program including the following:
Faculty member with 25 percent time availability.
Faculty member trained in primary care (defined as pediatrics, family practice, internal
medicine, obstetric/gynecology, emergency medicine, or preventive medicine/public health).
Commitment of staff time (part-time health educator and administrative support).
Existing and proposed partnerships within the academic health center to ensure that the
faculty champion's work reaches all schools within the institution.
Teaching and curriculum development component, including baseline analysis of student
knowledge and skills.
Institutional change component with specific strategies articulated for changing
institutions to support teaching environmental health/pesticides.
Community-based sites for student practicum, internships, residencies.
Advisory Committee, inclusive of environmental health expertise, curriculum committee
members, community members.
Opportunities to link teaching with research activities.
Plan of action for five year integration.
Evaluation component.
Activity #3
Establish a coordinating body to manage the grant-making process, to convene the grantees,
and to provide technical assistance to the faculty nationwide. The tasks of the national
coordinating office are to:
Develop the RFA with the federal agencies; manage the application and grant-making processes.
Produce a faculty guidebook with model programs on which faculty are asked to base
their activities.
Convene faculty for a working session to introduce model programs and work with project
design. Annual meetings will be held in subsequent years.
Set up ongoing technical assistance and evaluation effort with faculty members to be
available for the length of the project.
58 National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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Establish regular forms of communication
among faculty members, including regional
meetings, web-based interactive activities,
online submission of teaching modules or
other curricular pieces, and formative and
summative evaluation.
Present ongoing findings at national
conferences and assist on national issues as they
may arise.
Coordinate entire evaluation effort.
Activity #4
Release RFA to academic institutions for a five
year grant funded effort. Ensure diversity in
faculty and disciplines selected. Publicize RFA
process. Select 146 faculty champions.
Applications must include all items listed in
Activity #2 along with a timeline for completion.
Incorporate a capacity-building mechanism into the grant-making process by creating
10 regional networks of faculty members where the exchange of technical assistance can
take place. To achieve this, one academic center in each region would be granted additional
funding (through a competitive process) to provide technical support to new faculty
champions in that region. In this way, the program will help transfer knowledge and
expertise from existing champions to new faculty members, while also supporting the
additional time spent by existing champions.
Activity #5
Launch the effort with the announcement of the 146 faculty champions and ten regional
centers receiving additional funding. Faculty efforts will last five years with specific increments
identified for evaluation, workshops, submission of work, and activities via the websites, and
quarterly/annual reviews. Throughout the entire process, the national coordinating
organization will build the cadre of faculty nationwide (see Table 8).
Stakeholders
Collaborating federal agencies
Key association for health professional schools
National coordinating body
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
59
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Table 8: Proposed Design of Faculty Champions Project
Institution Funded Activities Funded Individuals Funded Length of Funding ,
National
Coordinating
Organization
10 regional centers
(one per EPA region,
chosen from academic
health centers)
146 academic sites
(126 academic
health centers + 20
representing diverse
populations and
nursing schools)
Evaluation Team"
Overall coordination
and management
of project and
administrative staff
Existing faculty
champion support plus
technical assistance
support for faculty
in the region
Implementation of
one of several models
in academic institutions,
including inclusion
in curriculum, and
institutional change
Formative and
summative evaluation
Project Director,
( 100 percent FTP.), Coordinator
( 100 percent FTE), Webmaster
Faculty Champion
(50 percent FTE),
Regional Coordinator
(50 percent FTE),
administrative -staff
Faculty champion (25
percent FTE),
administrative support
Evaluation staff
6 years (design,
implementation
and evaluation)
5 year grant period
5 year grant period
Portions of all 6 years
'May be subcontiacted by the national coordinating organization.
Evaluation of Outcomes/Indicators of Success
The entire component will be evaluated based on the following indicators:
Project Outcomes (1-5 year funded project)
146 institutions with documented integration of pesticides/environmental health into
curriculum.
146 institutions with increase in students' basic knowledge and skills in pesticide/
environmental health.
146 institutions with increased FTE time devoted to environmental health.
Increase in number of practice/field experiences in environmental health sites
Increase in environmental health research activities.
Project Outcomes (post 5-year project)
Increase in new researchers investigating environmental health.
Increase in number of primary care providers out of the pipeline who address environmental
health in practice and research.
60
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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Sustainable institutional change in majority of 146 institutions.
Changes in the way health professionals address environmental health (measure of overall
effectiveness).
Background
This component proposes a significant investment of funding to build a strong cadre of faculty
champions. The funding would pay for part of a designated faculty FTE, plus a half-time
position for administrative and content support at 146 institutions. The funding would also
support ten regional centers headed by an existing faculty champion and designed to provide
technical assistance and support to new faculty members in the region. The champion would
use a variety of educational methodologies (required courses, integration within existing
courses, field experience, and links with community members and organizations), and would
link with other schools, departments, and organizations as part of a national network of
champions. In particular, it is recommended that faculty champions coordinate with model
practice sites (see Practice Component E, p. 79). The intent is for the faculty champion to
base his/her activities on selected model programs that have already undergone evaluation.
The idea of creating and strengthening "champions" of pesticide/environmental health
education came out of the Education Workgroup's discussion of how important a role
individuals can play at an institution. A threshold level of funding and security of funding is
needed to encourage institutions to hire and/or nurture pesticide/environmental health
champions, A multi-year commitment is also necessary to make it worthwhile both for the
institution and the champion. Much of the champion's time should be spent institutionalizing
the pesticide/environmental health component by developing faculty interest/knowledge and
integrating it into curriculum, both in medicine and nursing disciplines. Otherwise, when
the grant funding ends, the environmental health/pesticide component is likely to be viewed
as "nice but not necessary" and may disappear at the next curriculum change cycle. The proposal
developed is for five year funding, with funding possibly decreasing in years 3-5.
It is recommended that all academic health centers receive funding at the same time. It is
important to make the funding equal across academic health centers. This component will
fund 126 academic health centers and an additional 20 institutions to ensure a balance between
medicine and nursing, and the inclusion of diverse institutions. Faculty champions will be
selected equally from the disciplines of medicine and nursing. Faculty champions will also be
selected from primary care. Given that some institutions already have faculty champions, the
project will include an opportunity for such institutions to compete for regional center grants.
The regional centers will be required to provide technical assistance and support to new faculty
champions in the region. The entire project will build upon other faculty champion models
that have been created for other subject areas nationwide.
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan 61
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EDUCATION COMPONENT F:
Create Teaching Incentives
Strategy
Influence the appropriate boards, organizations, and institutions that create Board exams
and set curriculum requirements to include several key competencies on pesticides and
environmental health.
Expected Outcomes
Questions on Board exams
Changes in curriculum requirements
Target Audience
Awareness and Motivation: This component targets decision-making organizations that
set curriculum requirements, entities that write Board and certification examinations,
and faculty who teach the courses. This component is designed to convince these decision-
makers to integrate elements that address the health effects from pesticide exposures.
This component will also provide "ready-made" language on requirements and/or exam
objectives and questions.
Proposed Activities
Activity#l
Conduct an initial assessment to determine number of questions related to pesticides/
environmental health on examinations. Identify or develop sample examination questions.
The assessment will also list timeframes for changes in requirements/Board exam questions
by key decision-making bodies.
Activity #2
Develop a succinct strategy for approaching the organizations/decision-making bodies that
develop Board and other examinations, including specific recommendations for educational
objectives, questions and language changes. Action items include:
Convene a working group of high level external partners and key federal agencies to develop
a strategy/position paper. This group should be drawn from the Association of American
Medical Colleges, the American Association of Colleges of Nursing, the American
Association of Occupational Health Nurses, the American College of Occupational and
62 National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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Environmental Medicine, the American Medical Association, the American Nurses
Association, the American Academy of Physician Assistants, and American College of
Nurse Midwives. In addition, federal agencies could include National Institute of
Environmental Health Sciences, National Institute for Occupational Safety and Health,
EPA, and Health Resources and Services Administration.
Create a strategy that recommends specific content (per National Competency Guidelines
in Education Component B) and insertion points into specific Board exams and specialty
requirements. Strategy will also set targets for change.
Activity #3
Contact decision-making bodies and provide with them with a specifically tailored position
paper and recommended changes to questions, exams, and requirements. Include the
endorsement of the relevant working group organizations. Identify Boards and schedule using
the following outline of priorities:
Short-term Priorities
Medicine
United States Medical License Examination (Steps 1, 2, 3)
Board Examinations in Family Practice, Pediatrics, Internal Medicine, Ob/Gyn,
Emergency Medicine
Nursing
AANC generalist examinations
Nurse practitioners adult, pediatrics, family, gerontological (ANP, PNP, FNP, GNP)
Nurse midwives American College of Nurse Midwives (ACNM)
Clinical nurse specialists (CNS)
Longer-term Priorities
Physician Assistants
Pharmacists
Basic Nursing
Genetic Counselors
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Stakeholders
Key national decision-making bodies for curriculum changes, requirements, and
examinations
National professional association
Key federal agencies involved with health profession education
Faculty members
Evaluation of Outcomes/Indicators of Success
Increase in the number of questions in the examination pool and on each examination as
compared with the initial assessment.
Changes in requirements for primary care disciplines (pediatrics, family practice, internal
medicine, preventive medicine/public health, emergency medicine and obstetrics and
gynecology) to include pesticides/environmental health.
Background
One way to motivate change in curricula is to convince the medical and nursing examination
boards of the importance of environmental health in the coming years, and urge them to
incorporate environmental health questions on their exams. This would also be one of the better
ways to institutionalize the subject matter over the long-term. Some of the boards are expected
to be receptive to a concerted effort in this area; for example, the Residency Review Committee
for Pediatrics in 1997 adopted two recommendations on children's environmental health.
64 National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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Practice Settings
The second prong of the strategy is the practice setting. Practice settings, for purposes of
this Initiative, are defined as community health centers and clinics; managed care clinics;
hospitals and emergency departments; private practices; urgent care centers; poison control
centers; and work and/or school-based clinics. While the components target the practice setting,
they also involve the professional associations and decision-making bodies that represent and/
or influence the practice setting. These include, for example, the American Nurses Association,
the American Academy of Pediatrics, the American Academy of Family Physicians, and the
Migrant Clinicians Network. The following components apply across the continuum of systemic
change from raising awareness and assessment, to development of expected practice skills, to
the support of "model practices" and system-wide incentives.
Component A: Make the case for practitioners Develop an effective case statement to convince
primary care providers of the need to incorporate occupational and environmental health and
pesticide awareness into their practice settings.
Component B: Define practice skills and guidelines Produce National Guidelines that
recommend practice behaviors and guidelines for the recognition, management, and
prevention of pesticide exposures, for all practicing health care providers; define accompanying
content related to expected behavior; suggest methods of integration into practice and training
settings; and provide access to relevant resource materials.
Component C: Assess knowledge and skills of practitioners Conduct an assessment of the
target audience of primary care providers to determine: (a) providers' current knowledge and
(b) how providers will best respond to educational programs and information resources. This
assessment will be comprised of a literature review and a range of needs assessment analyses.
Component D: Secure official endorsements Ensure the integration of the expected practice
skills into practice settings by securing the official endorsements of key professional
organizations and decision-making bodies specific to practice.
Component E: Demonstrate model programs Mobilize practice settings to become
population-specific and to incorporate environmental considerations (specifically pesticides)
into prevention, education, diagnosis, and treatment. Achieve incremental, site-specific
improvements in identification, early intervention, and prevention, as well as in measures of
practice-specific health outcomes. By 2010, half of all primary health care practice settings in
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan 65
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the United States should incorporate environmental considerations in prevention, education,
management, and referral.
Component F: Create incentives for change Identify and promote a number of incentives
to incorporate appropriate prevention, recognition, and management of pesticide-related
health conditions into health care practices. Specifically: (1) provide grant support to practicing
providers for interventions and research related to pesticide poisonings and exposures; (2)
create free, readily available opportunities for continuing medical education involving
pesticides and environmental health; (3) increase providers' awareness of the value of taking
an occupational and environmental history for optimizing Evaluation and Management
(E&M) coding and billing; (4) require knowledge of occupational and environmental health
issues for certification and recertification; (5) require pesticide poisoning reporting for workers'
compensation reimbursement and automatic workers' compensation reimbursement for
work-up of suspected occupational pesticide-related health conditions; and (6) promote
documentation of occupational and environmental history in medical records via
incorporation into quality assurance/quality control mechanisms.
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PRACTICE COMPONENT A:
Make the Case for Practitioners
Statement
Develop an effective case statement to convince primary care providers of the need to incorporate
occupational and environmental health and pesticide awareness into their practice settings.
Expected Outcomes
A written case statement that documents the key points of why practicing health care
providers should care about the environments in which their patients live and work,
especially with regards to potential pesticide poisonings and exposures, along with the
accompanying scientific literature to support the need for well educated health care
providers. This statement will be linked with the case statement for educational settings.
Endorsement of the case statement by leading national professional associations and
national bodies that work with practitioners.
Target Audience
Awareness and Motivation: This component is targeted at decision-makers and key strategic
organizations that need to be convinced that the issue of pesticide poisonings and the need to
educate health care providers about this issue are relevant to the practice settings of health
care providers. This component also targets primary care providers who are not yet convinced
that this is an appropriate subject for a national plan.
Proposed Activities
Activity #1
Research and develop a case statement, solicit peer review, and finalize with the input of key
stakeholder groups in the field. The target audience for the case statement is the practicing
health care providers and the organizations that work with them.
Points to be covered in the case statement:
Importance of occupational and environmental health training and the breadth of the
problem of pesticide-related health conditions.
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Convincing arguments for why pesticides should be part of what health care providers
address in their practice settings, with cited scientific data, along with relevance to the
practice of health care and public health.
Compelling arguments to gain the attention of primary care providers despite the fact
that their time and attention are in high demand elsewhere.
Emphasis that practitioners do not need to become experts, and reassurance that experts
are available to work with them on specific clinical cases and/or community concerns.
Reassurance that user-friendly tools exist for practitioners to use, along with user-friendly
guides for teaching pesticide issues to practitioners through continuing education.
Recommended amount of time to dedicate to pesticides in the clinic that is reasonable
given the other demands on practice settings.
Activity #2
Promote case statement through effective dissemination mechanisms, including print and
internet information sources.
Activity #3
Publish journal or newsletter articles in professional journals and publications.
Activity #4
Hold strategic meetings with professional associations and national leaders to seek their
endorsement of the case statement. This includes identifying a subset of decision-makers
who can be influenced by the case statement.
Stakeholders
Professional associations
Recertification bodies
Continuing education organizations
Collaborating federal agencies
Evaluation of Outcomes/Indicators of Success
Case statement.
Published articles in professional journals and newsletters.
Position papers developed and adopted by professional associations.
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Background
It is recognized that many key decision-makers are still unconvinced that this is an issue of
concern. Although the supporting documentation exists, there is a need to pull the information
together in a succinct case statement directly designed for practitioners.
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PRACTICE COMPONENT R:
Define Practice Skills and Guidelines
Statement
Produce National Guidelines that recommend practice skills and guidelines for the
recognition, management, and prevention of pesticide exposures, for all practicing health
care providers; define accompanying content related to expected behavior; suggest
methods of integration into practice and training settings; and provide access to relevant
resource materials.
Expected Outcomes
National Pesticide Practice Skill Guidelines which recommend practice skills, content,
insertion points into practice and training settings, and resources.
Endorsement of National Guidelines by leading national professional associations.
Target Audience
Readiness to Change: This component is targeted at administrators of clinics and health
care delivery systems, providers of professional development, and practitioners. The
component assumes that the administrators and practitioners are convinced of the importance
of this topic and are ready to make changes in their practices.
Proposed Activities
Activity #1
Define the basic practice skills for practice settings to ensure that all practicing primary
care providers are prepared to address pesticide-related health conditions and exposures in
their practice.
An outline of practice skills for practicing health care providers is shown in Table 9 on page
72. The intent of the table is to define expected practice skills for all practitioners. This table
links with a complementary document for educational settings.
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Activity #2
Produce National Guidelines to guide practitioners on the recognition and management of
pesticide-related health conditions. A complementary report focuses on the educational
settings where primary care providers receive their training.
The National Guidelines contain the following components:
Recommended practice skills.
Relevant content for each practice skill.
Suggested points of insertion into practice settings.
Suggested resources to teach content specific to each competency in practice settings.
The report is designed as a user-friendly guide on how to integrate pesticides content into
practice skills. It serves as a supplementary practitioner guide to the Recognition and
Management of Pesticide Poisonings. The report does not contain actual training modules or
resources, but instead provides a listing of relevant resources.
Activity #3
Promote the National Guidelines with key stakeholders and solicit official endorsements and
organizational support for the report, including dissemination to their members.
Stakeholders
National professional associations for practicing primary care providers
Practicing health care providers who have already developed tools and practice models
Evaluation of Outcomes/Indicators of Success
The National Guidelines will include defined practice behaviors, content areas, insertion
points, examples as necessary, and recommended resources.
Endorsement by key professional organizations for providers.
Table 9
The preliminary list of "Expected Practice Skills" shown in Table 9 (page 72-73) is
recommended as a useful goal for primary care providers seeking to provide the highest quality
care to their patients. Further developed practice skills are available in 2002.
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Table 9: Expected Practice Skills
1. Take an environmental and occupational health history.
Providers should be able to take a basic environmental and occupational history
to determine if a temporal relationship exists between exposure and symptoms.
Ask patients 2-3 screening questions that would elicit possible exposure to a
number of environmental factors (including but not limited to pesticides).
Take an environmental health history with questions regarding where the patient
lives, works, and plays.
2. Recognize the signs and symptoms of pesticide exposures and appropriately
manage or refer patients.
Recognize the signs and symptoms of pesticide exposures (both acute and chronic).
Providers should be able to treat and manage health conditions associated with
pesticide exposure or refer patients to appropriate specialists and resources, and
follow up appropriately.
Diagnose pesticide- related health conditions using appropriate testing procedures
and treat pesticide exposures.
3. Identify risk factors for pesticide exposure and resulting health effects.
Identify risk factors for pesticide exposure (e.g. occupation, location of home,
susceptible populations such as children).
Identify environmental factors that may possibly be linked to patient illness to
ensure that chronic pesticide exposures are addressed.
4. Demonstrate key principles of environmental/occupational health and
epidemiology and population-based health.
Demonstrate an understanding of principles of environmental and occupational
health, and epidemiology.
Understand the temporal relationship between exposure and symptoms.
Recognize that others may be ill (co-workers, family) and get a timeline of health
problems for these or consult public health authorities for help in evaluating exposures.
5. Take steps to report pesticide exposure and support surveillance efforts.
Understand the importance of surveillance and reporting.
- continued on the following page
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Table 9 (continued)
Be able to access and report data for local, regional, and national surveillance programs.
Report cases involving pesticide exposures as required.
Report concerns about pesticide exposures to the appropriate authorities, such as
local and state health departments, EPA, NIOSH, federal OSHA, state OSHA or
state departments of labor, or departments of agriculture.
6. Possess basic awareness of communities in which patients live.
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.
Demonstrate an understanding of population-based health.
Demonstrate knowledge about the environment in which the practice is situated, with
specific understanding of communities that may be at-risk for pesticide exposures.
Be aware of, and access, the resources available within the community and in the
state or region, that could assist in pesticide exposures and illness.
7. Provide prevention guidance/education to patients.
Provide guidance to patients on how to prevent pesticide exposures.
Advise patients and provide basic education about pesticide exposure.
Counsel patients about minimizing unnecessary use of pesticides, refer patients
to appropriate experts on safer work practices including, use of safety substances
or alternative methods of pest control including integrated pest management.
Address the whole patient in the context of his/her life and/or community (e.g.,
link to social services, etc.).
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PRACTICE CDMPONFNT C-
Assess Knowledge and Skills of Practitioners
Statement
Conduct an assessment of the target audience of primary care providers to determine: (a)
providers' current knowledge; and (b) how providers will best respond to educational programs
and information resources. This assessment will be comprised of a literature review and a
range of needs assessment analyses.
Expected Outcomes
Baseline data indicating the level of training currently taking place in practice settings, current
knowledge of practicing providers, and identification of best mechanisms to reach and train
providers, and to equip them with user-friendly tools.
Target Audience
Awareness and Motivation: This strategy targets health care practitioners to determine
their level of awareness; their motivation, or lack of motivation, for this topic; their knowledge
and skills base; and the most effective ways to reach them through educational interventions,
model programs, and resources.
Proposed Activities
Activity #1
Conduct a literature review to locate survey data and evidence of level of knowledge, attitude
and skills of health care providers related to pesticide-related health conditions.
Activity #2
Where literature review is lacking in data, conduct a combination of audience assessment analyses
to be able to effectively collect baseline data and draw conclusions on the following questions:
To what extent are the recognition and management of pesticide-related health conditions
included in the continuing professional development of primary care providers?
What is the extent of the knowledge, attitude, and skill base of practicing primary care
providers with regard to pesticide issues? Are they at the stage of needing to raise awareness,
improve their knowledge and skills, or obtain resources?
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What level of comfort do practitioners have
addressing pesticides with their patients and in
communities? What do practitioners need to feel
more comfortable in addressing pesticides in
their practice settings?
What resources, and in what format (e.g.,
traditional lecture material, teaching modules,
web-based, audio cassette, CD, video conference,
satellite), do practitioners need most?
Activity #3
Produce a final report with recommendations for use
in the development of the Initiative.
Stakeholders
Professional associations that represent
practitioners
Continuing education programs, organizations
that offer continuing education
Practicing clinics and health care delivery systems
Practicing providers
Evaluation of Outcomes/Indicators of Success
Comprehensive literature search documenting the findings of studies that have surveyed
practicing primary care providers.
Report with baseline data and conclusions/recommendations.
Background
Any good plan has at its core a strong assessment component to collect baseline data on
existing knowledge and skills, as well as to determine the most effective mechanism for
reaching the target population. This component will collect vital information not only
for this Initiative, but also for the entire field of health care provider education. The
assessment will also include a chance to determine where the target population presents
itself along the continuum of change described in the section on Target Audience.
National Strategics for Health Care Providers: Pesticides Initiative Implementation Plan
75
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Do most people lie at the beginning of the continuum where they will respond best to
activities that raise their awareness and motivate them to care about this issue? Or are
they ready to make changes in their practice and in need of the necessary tools and
educational resources? The assessment will answer these, and other key questions, to
inform the implementation process and subsequent evaluation.
76 National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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PRACTICE COMPONENT D:
Secure Official Endorsements
Statement
Ensure the integration of the expected practice skills into practice settings by securing the
official endorsements of key professional organizations and decision-making bodies.
Expected Outcomes
Professional organizations, influencing bodies, and practitioners will agree that the expected
practice skills are essential to the ongoing training of primary care providers and will integrate
or support their integration into practice settings.
Target Audience
Awareness and Motivation: This component targets key recertification and continuing
education bodies and professional associations for practitioners. The emphasis is on raising
awareness and motivating decision-makers to bring about change in practice that provides
lifelong learning to health care providers.
Maintenance/Sustainability: This component also targets key professional associations to
endorse and support the implementation and outcomes of this Initiative over the long-term.
This Initiative will only be successful if its expected outcomes are institutionalized into the
practice settings for health care provider training.
Proposed Activities
Activity #1
Promote expected practice skills and case statement with professional organizations to garner
their involvement and support in implementing interventions to improve the knowledge,
attitudes, and skills of practicing health care providers.
Activity #2
Highlight the specific recommendations in the National Guidelines on expected practice skills,
along with specific examples of how practice settings can integrate the content into the ongoing
training of providers.
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan 77
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Activity #3
Publish editorials in nationally recognized journals on specific strategies from the National
Guidelines, along with user-friendly tools for providers.
Activity #4
Develop a position paper on the need for expected practice skills, to be posted on the internet
and for use in meeting with credentialing bodies and decision-makers.
Activity #5
Identify and promote incentives for professional associations to be involved in the Initiative,
including financial incentives in the form of grants, technical assistance for clinics, community-
based interventions and research, instructional teaching and training aids, expert consultants,
clinical access, release time for professional development, and establishing appropriate clinical
sites for additional training.
Stakeholders
Professional specialty organizations
Licensing boards
National professional associations
Evaluation of Outcomes/Indicators of Success
New position papers by targeted organizations that support the integration of
recommended pesticide content into practice settings.
New requirements by professional decision-making bodies that require professional
education to teach about health effects from pesticides.
Published journal articles in professional newsletters and peer-reviewed journals.
78 National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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PRACTICE COMPONENT E:
Demonstrate Model Programs
Statement
Mobilize practice settings to become population-specific and to incorporate environmental
considerations (specifically pesticides) into prevention, education, diagnosis, and treatment.
Achieve incremental, site-specific improvements in identification, early intervention, and
prevention, as well as in measures of practice-specific health outcomes. By 2010, half of all
primary health care practice settings in the United States should incorporate environmental
considerations in their pesticide-related prevention, education and management activities,
and in the referral of pesticide-related health conditions.
Expected Outcomes
Demonstration projects (distributed geographically across the United States) that model
practice settings where pesticide-related health conditions are an integrated part of the
provision of care and community outreach.
Evaluation of demonstration models and creation of a "models that work" guide for the
field and other practice settings.
Creation of a tool kit that can be used by other practice settings that want to set up a
model program.
Launching of nationwide effort to redesign 50 percent of all practice settings.
Target Audience
Maintenance/Demonstration: This component targets specific practice settings that are
ready to become part of a cadre of model practices across the country that will change the
way they practice, specifically addressing potential health effects from pesticide poisonings
and exposures. The target audience in this case has been convinced that this is an important
issue and has increased its knowledge and skills in this area. Model practices may also be
located in areas of higher impact, such as farmworker clinics and urban settings.
Proposed Activities
Activity #1
Mobilize practice settings that currently address environmental health/pesticide issues. Identify current
leaders among practice settings and encourage them to spread the word on what they already do.
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan 79
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Activity #2 (option 1)
Secure funding, create a program description, and develop an RFP to solicit proposals from
5-10 clinical/community sites to receive financial support over three years to create a practice
model. Ensure that the funded sites represent the range of practice settings and the breadth
of pesticide issues (e.g., urban and rural, agricultural and non-agricultural, diversity of
cultures and literacy rates). Ensure that some programs are located in states with pesticide
poisoning surveillance programs.
Activity #2 (option 2)
Secure funding, create a program description, and develop an RFP to solicit small proposals
from 100 clinical/community sites to receive financial support over 1.5 years to create a
practice model. Ensure that the funded sites represent the range of practice settings and the
breadth of pesticide issues (e.g., urban and rural, agricultural and non-agricultural, diversity
of cultures and literacy rates). Ensure that some programs are located in states with pesticide
poisoning surveillance programs.
Activity #3
Define the major components of the proposed practice model, allowing for flexibility by the
specific site. Ensure that the models are grounded in theories and experience about how change
actually happens so as to learn from other experiences in practice settings. One model that
has been recommended is the Diabetes Collaborative (see box on page 82).
Activity #4
Establish a coordinating body to manage the project and the creation of the consortium of
pilot sites, and to create the plan of action for the project. Among the tasks of this body are:
Create a consortium of the pilot sites that use the proposed model as a guide for developing
their own specific practice intervention plan (including what they want to do, the
intervention, the evaluation and the implementation of the proven change).
Build a technical assistance component that can work with sites in designing the
intervention, piloting the intervention and evaluating its success.
Convene pilot sites on a regular basis by conference call and in-person meetings to share
success stories, challenges, and lessons learned.
Establish an evaluation mechanism for the sites and the national project to determine the
success of the creation of new models. Evaluation would be both formative and summative.
Activity #5
Launch nationwide effort to redesign 50 percent of practice settings based on findings from
the model sites.
80 National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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Stakeholders
Professional associations
Practice settings
National coordinating organization
Funding agencies and partners
Organizations that have created practice change models
Evaluation of Outcomes/Indicators of Success
RFP completed and funding secured for pilot program.
Chosen sites underway in developing practice models.
Five to ten practice change models with evaluation components and identified success stories.
Publication of model programs.
Effective dissemination of practice models nationwide.
Enhanced reporting of acute pesticide-related illness cases.
Background
The key to changing practice is demonstrating how changes in day-to-day activities actually
make a difference in health outcomes of patients and communities. This strategy was generated
by the Practice Workgroup as a way to model expected changes and to evaluate what practice
changes actually lead to the overall goal of the Initiative to increase the recognition,
management and prevention of pesticide poisonings and exposures. There are two
recommended options for this strategies: (1) fund a large number of demonstration practice
sites to make several small practice changes and evaluate the outcome, or (2) fund a small
number of demonstration practice sites to overhaul their practices and bring about substantial
change. Both options offer different rewards and utilize the resources in different ways. In
either case, there are model organizations that have developed such an effort for other health
conditions, such as the Diabetes Collaborative (see box on page 82).
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan 81
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The Diabetes Collaborative is a multi-year initiative sponsored by the Health KescJarces
& Services Administration and the Bureau of Primary Health Care, ip partnership:
with health centers, primary care associations, and clinical networks. Itsizgoal is to
eliminate health disparities and ensure access to quality primary ear&for racial and
; ethnic minorities and for underserved popidations.^inongJundeBeffMandraMarity
npoj3ulation3,41abetes is a virtual epidenuc^with 12millidnpatientvisitsSal9SSM6ne^=
iandJost resources andhuman productivity estimated-ahoverj3$92TjiUohinrMally, = ;:
_Tjie:pro;ect aims to redesign diabetesmanagementto effects measurable ebfakige in;
;z health status among the *ppR»dmatelyQ,QQO diabetlcfratients atthe 92^participating5
t (health centers, and 4ises adaptations onearnmg^etfods dffised 3p^^3nstia§Ee;for
- ^Healthcare Improvement. The project was developed as part of the Breakite^gKSeries
Workgroup of theClinicians National Eorofrk f f 4| i =+ %!
_,-- .-".'_5 ^ :\_ - .. - -,"''": ' - -^ -'--' ^'^^^.^--
I3ieiimprovementtnodel is based on ihree fundamental questions* {1^ Whit are wes
-"__ ~J ""-'-->_ -"-_~'r ~ """z: ~-. "-1 -
trying to accomplish? (2) How will we know that a change is an improvement? and (3)
What changes can we make that will result in an improvement? The national measure
of success for the first phase of the project is meeting the goal of over 90 percent of the
60,000 diabetic patients in the target population receiving two HbAlc blood tests per
5 year, at least three months apart. A short-term trial-and-learning method called PISA
(Plan, Do, Study, Act) provides the framework for implementing changes and learning
from them. An example of PISA in action might be:
O Plan: The diabetes team at Rocky Road Health Center predicted that a registry of
diabetic patients would improve the measurement of HbAlc. Setting up this system
took three weeks. During that time, the center also established protocols for glucose
cr measurements and ran a trial utilizing patient self-management for home glucose
measurements.
"Do: The registry was tested for two weeks with one volunteer nurse practitioner
and her diabetic patients. After the diabetes flowsheet was revised to reflect the
registry information, the collection went well.
Study: The time spent on completing the flow sheet increased from one minute to
two minutes and it took an additional three minutes to enter data into the registry.
Waiting time for diabetic patients increased an average of eight minutes. Of the
patients with diabetes, only half had appropriate testing of HbAlc; but after the
trial, all of the patients had current values.
" Act: After a team meeting with the executive director and finance officer in charge
of the information system, the health center adapted a scannable flow sheet form
they had learned about from the Midwest Clinicians Network. To cut down on
cycle time, the medical records were reviewed the night before to identify gaps and
pre-enter data.
Source: Migrant Clinicians Network
82 ' National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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PRACTICE COMPONENT F:
Create Incentives for Change
Statement
Identify and promote a number of incentives to incorporate appropriate prevention, recognition,
and management of pesticide-related health conditions into health care practices. Specifically: (1)
provide grant funding to practicing providers for interventions and research related to pesticide
poisonings and exposures; (2) create free and readily available opportunities for continuing
education involving pesticides and environmental health; (3) increase providers' awareness of the
value of taking an occupational and environmental history for optimizing Evaluation and
Management (E&M) coding and billing; (4) require knowledge of environmental health issues
for certification and re-certification; (5) require pesticide poisoning reporting for workers'
compensation reimbursement and automatic workers compensation reimbursement for work-
up of suspected occupational pesticide-related health conditions; and (6) promote documentation
of occupational and environmental history in medical records, via incorporation into quality
assurance/quality control mechanisms.
Expected Outcomes
Increased attention paid by primary care providers to pesticide poisoning and exposures
based on incentives to change practice.
Creation of new or improved incentives in the following areas: monetary incentives;
legal incentives; community-based incentives; and peer/professional incentives.
Target Audience
Awareness and Motivation: This component targets health care system administrators and
funders to create incentives for providers to address pesticide-related health conditions. This
component is designed to motivate and convince decision-makers that specific changes can
and should be made in grant funding, continuing education, E&M codes, re-certification,
workers' compensation, and quality assurance. This component will also provide "ready-
made" language on recommendations for proposed changes.
Proposed Activities
Activity #1
Provide grant support to practicing providers for interventions and research related to pesticide
poisonings and exposures:
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan 83
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Urge federal agencies (CDC, NIH, EPA, HRSA, NIOSH, NIEHS), state agencies, and
private foundations to support intervention and research projects conducted by
practicing primary care providers.
Publicize models developed through grant support.
Create a centralized source of information about grants and grantees.
Activity #2
Create free and readily available opportunities for continuing education involving pesticides
and environmental health:
Connect continuing education (CE) courses on pesticides to major national meetings.
Offer free CE credits in a variety of settings.
Offer CE credits in local settings and support experts to go out to local clinics to provide
pesticide education.
Establish free, web-based continuing education.
Encourage and fund NIOSH Education and Research Centers (ERCs) to hold local
continuing education courses on pesticides.
Address barriers such as competing priorities for providers, cost of hosting continuing
education programs, and lack of provider interest.
Activity #3
Increase providers' awareness of the value of taking an occupational and environmental history
for optimizing Evaluation and Management (E&M) coding and billing. See next page for a
brief summary of how E&M coding could be upgraded.
Activity #4
Require knowledge of environmental health issues for certification and re-certification:
Identify priority professional certifying bodies.
Recruit high-profile supporters from each of the relevant disciplines.
Create sample objectives and questions on environmental health issues.
Approach certifying bodies about including questions.
Coordinate outreach to the certifying bodies.
Address barriers such as institutional inertia, competing priorities, and lack of
perceived problem.
84 National Strategics for Health Care Providers: Pesticides Initiative Implementation Plan
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According to the 1997 Health Care Financing Administration Documentation
Guidelines, in order for a provider to bill for a "comprehensive" visit for a new
outpatient, a new inpatient, or a new consult, the provider must document taking
all of the following; a past medical -history J(PMH), a family history (FH), and a
social history (SH), The social history is defined as an "age-appropriate review of
past and current activities," For follow-up visits and emergency department visits
to be designated as comprehensive, two out of the three ^histories must be
documented. It may be possible tosconvince health care providersthat taking ah
occupational/environmental medicine history wiirhelp them to fulfill the SH
requirement for billing for a "comprehensive" visit, particularly foxnewpatients.
The billing codes affected are:
" New outpatient visit codes 99204 and 99205
New outpatient consults 99244 and 99245
New inpatient consults 99254 and 99255
Initial hospital care 99222 and 99223
Emergency department 99285
These HCFA Documentation Guidelines apply only to Medicare patients;
however, most third-party payers have adopted the same guidelines for their
reimbursement schedules. Considerable research will need to be done to
determine if this approach is viable.
Activity #5
Require pesticide poisoning reporting for workers' compensation reimbursement and
automatic workers' compensation reimbursement for work-up of suspected occupational
pesticide poisoning. See, for example, Washington State's program described on page 86. The
goals are for work-related pesticide health effects to be universally reimbursed, including
relevant diagnostic testing; mandatory reporting of pesticide-related health effects for workers'
compensation reimbursement; and standardized weight-of-evidence for claims reimbursement
for pesticide-related illnesses. Tasks include:
Target high-priority states for change.
Gather information about model state workers' compensation laws (especially California
and Washington).
Win support of professional organizations, advocacy groups, and state agencies.
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan 85
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O
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v; Washington State has moved into the forefront in reporting of occupational diseases.
; Under state law, the Department of Labor and Industries {L&I) and the Department
; of Health (DOH) both have responsibilities for addressing chemically-related Illnesses
u:: (CRI)illnesses known or .suspected to be caused or substantially worsened by
P exposure to chemicals in the workplace or other environments.
lit Twuttrease^fficaencyahd provide more consistent handling of chemically-related
proclaims, LSd established a single CRI unit with responsibility for Tall chemically-
p.iilated claims.* Qaims adjudkatots in the CRI unit receive special training on
f_^clKmically^related "injuries and illnesses, L&I has also contracted with an
iQcctfpatiortalTraedicinephysiciah to provide additional medical reviewofthe more
x claims and'to ensure that appropriate testing and work-ups are done.
£j [. *; L&I averages about 200 claims per month,
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°- 4 ;Some of the key provisions of Washington's workers' compensation system include:
LO
An injury/illness incident is eligible for a claim to be filed whenever medical
treatment is provided.
Tor all claims filed, the costs for diagnostic evaluations to determine if the injury/
illness is work-related are covered. Although the claim may eventually be rejected if
it is determined not to be work-related, die initial visit(s) and testing are paid for.
Individuals with accepted claims are eligible for time loss (wage replacement) if
they lose more than three days of work.
Health care providers are required to file a claim if the worker feels the condition
is work-related.
I
1/5
The CRI unit has recently started to identify clusters of chemically-related illnesses,
particularly involving a single employer with more than one claim for a specific
exposure event. The goals include early intervention to reduce exposures and prevent
future morbidity and mortality. For example, a cluster of carbon monoxide poisonings
was identified, triggering efforts to reduce future exposures in the plant where the
poisonings occurred. CRI staff find this process also improves the adjudication of
claims by grouping together the claims from a particular employer.
Since 1990, DOH has been responsible for investigating pesticide-related illness
incidents and developing a database of pesticide-related problems. L&I provides
detailed reports to DOH to enable DOH to include workers' compensation claims in
their investigations. Some consider the claims process to fulfill their reporting
requirements, although there is a longer delay when L&I reports claims to DOH
than when a health care provider reports directly to DOH at the time a patient is
evaluated. It is not clear if this mechanism is sufficient or could be improved.
Source: Mary Miller, Washington State Department of Labor and Industries
86 National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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Approach state Workers' Compensation Commissions for changes.
Build key leadership supporters including workers' compensation attorneys, labor,
farmworker groups, clinicians, and public health groups.
Address barriers such as lack of leadership, cost, and decentralized state authorities.
Activity #6
Promote documentation of occupational and environmental history in medical records, via
incorporation into quality assurance/quality control mechanisms. Quality assurance/quality
control mechanisms could also be used to promote documentation that providers have given
pesticide information to certain at-risk groups (e.g., parents of toddlers, farmworkers, pregnant
women). Activities include to:
Create consensus on minimum necessary documentation through a committee process.
Research the scope, authority, and current priorities of the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO).
Approach the JCAHO to require documentation of occupational and environmental
medicine (OEM) history and pesticide education.
Approach targeted major managed care organizations to require documentation of OEM
history and pesticide education.
Approach family medicine and Ob/Gyn to include OEM history and pesticide education
in their chart review for certification/recertification.
Determine whether this is a priority activity area, and address barriers such as institutional
inertia, extra burden on hospitals, clinics, and JCAHO, and time pressure.
Stakeholders
Federal agencies and foundations that support research and interventions
Professional associations
NIOSH Educational Resource Centers
Health care centers and hospitals
Community clinics
Worker's compensation partners
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan 87
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Evaluation of Outcomes/Indicators of Success
Increase in number of grants and level of support available to practicing primary
care providers.
Increase in publications of research findings and interventions undertaken by providers.
Report on success stories and lessons learned in the field.
Adoption of models in other settings.
Increase in number of continuing education offerings.
Increase in number of people attending continuing education programs and number of
people completing web-based credits (percentage increase in participation each year).
Short-term and long-term changes in Evaluation and Management coding and
workers' compensation.
Questions added to recertification exams of professionals.
Workers' compensation systems in target states are changed to reimburse for work-up of
suspected pesticide poisoning, and payment is linked to reporting of pesticide exposures
to state registries.
Quality assurance/quality control mechanisms in targeted health care organizations
are changed to incorporate review of documentation of an occupational and
environmental history.
Background
One of the most effective ways to bring about change is to build incentives into existing
requirements and activities of health care plans and practitioners. There are certain key points
of entry into the health care system that require providers to address specific issues in their
practices. For example, by integrating pesticide components into workers' compensation, E&M
coding, and quality assurance, the Initiative can ensure that pesticide issues will become
institutionalized into health care practice.
88 National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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and Tools
Resources of all kinds serve as the "infrastructure" for this Initiative. The five resource
components are designed to identify, create, and disseminate the necessary tools to
support change in both educational and practice settings. Key concerns are to avoid
duplication of existing resources by inventorying the current stock of resources available, and
to ensure the scientific credibility and usefulness of resources by establishing a national review
board to evaluate them.
Component A: Inventory existing resources Determine what educational and information
programs and materials for health care providers exist currently in education and practice
settings and what gaps should be filled.
Component B: Establish a national review board Create a national body to determine
assessment criteria and evaluate existing resources, with the goal of identifying, selecting,
and assessing the ideal resources that primary health care providers use in both educational
and practice settings for prevention, diagnosis, treatment, and referral of pesticide-related
health conditions.
Component C: Create an information gateway Establish a print, telephone, and web-
based gateway through which primary health care providers can access information and
educational resources.
Component D: Develop teaching/learning resources for educational settings Identify and
develop new content resources, tools, and methods for faculty in educational settings.
Component E: Develop new resources for practice settings Identify and develop new
content resources, tools, and methods for health care providers in practice settings.
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan 89
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RESOURCE COMPONENT A:
Inventory Existing Resources
Statement
Determine what educational and information programs and materials for health care providers
exist in education and practice settings and what gaps should be filled.
Expected Outcomes
An inventory of pesticide resources based upon information from health care providers in
education and practice settings.
Target Audience
Readiness for Change: This strategy will target health care providers who have already
developed model tools, resources, and programs so as to create a centralized inventory of
what exists and what gaps need to be filled.
Proposed Activities
Activity #1
Develop and document the inventory methodology to be used in collecting resources,
including documentation for the study instrument and an announcement requesting
resources and materials.
Activity #2
Conduct the resources inventory. Key questions to be asked of organizations include:
What resources do you use to diagnose pesticide exposures?
What resources do you use to treat pesticide exposures?
What resources do you use to refer pesticide-exposed patients?
How useful are current resources?
What "stage of change" is the resource targeting?
For which target discipline is the resource designed?
For what practice settings is the resource designed?
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For what characteristics of patient/community populations are the resources designed?
What resources are needed that are not readily available?
Stakeholders
Federal Interagency Planning Committee for this Initiative
Organization conducting the inventory
Evaluation of Outcomes/Indicators of Success
Inventory completed and available.
Feedback from website users indicating additional resources and/or identifying gaps.
Acknowledgment of a thorough inventory by the national review board.
Background
In order to evaluate the existing resources and to effectively disseminate what is available, an
inventory of available resources needs to be created. Such an inventory is already underway
and will be completed as part of this Initiative. The inventory will be available online.
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan 91
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RESOURCE COMPONENT B:
Establish National Review Board
to Evaluate Resources
Statement
Create a national body to determine assessment criteria and evaluate existing resources, with
the goal of identifying, selecting, and assessing the ideal resources that primary health care
providers use in both educational and practice settings for prevention, diagnosis, treatment,
and referral of pesticide-related health conditions.
Expected Outcomes
An established board available for ongoing consultation and review.
A published document with a list of evaluated and recommended pesticide resources that
primary health care providers can use in both educational and practice settings for
prevention, diagnosis, treatment, and referral of pesticide exposures.
Proposed Activities
Establish selection criteria for national review board membership.
Establish a multidisciplinary national review board to conduct the evaluation of existing
resources.
Refine the list of suggested evaluation criteria:
Pilot tested
Demonstrated level of success
* Regional applicability
Significant number of participants
Cost-effectiveness
Peer review of resources
Significant relevance
Related to at least one competency/practice behavior
Developed by credentialed sources/authors
Accessibility
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Credibility of information/sound science
Convenience
Endorsement by appropriate professional association
Approved programs for CE credits
Built-in incentives to use the resources.
Convene the national review board to evaluate the existing inventory of resources (Resource
Component A) using the evaluation process.
Publish recommended resource document online and in print format.
Assess the usefulness of the resource document to health care providers.
Stakeholders
Federal Interagency Planning Committee
National review board members
Evaluation of Outcomes/Indicators of Success
Published resources document, online and in print format.
Feedback from health care providers on the usefulness of the resource list.
Background
The concept of a national review board came out of the Resources Workgroup's focus on how
pesticide-related resources used in education and practice settings could be evaluated, in the
interests of using the highest quality materials. The national review board will be composed
of leaders in the areas of pesticides and primary health care.
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan 93
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RESOURCE COMPONENT C:
Create an Information Gateway
Statement
Establish a print, telephone, and web-based gateway through which primary health care
providers can access information and educational resources.
Expected Outcomes
A fully functional, interactive, information gateway that provides primary health care providers
with access to readily available and useful pesticide resources.
Target Audience
Readiness to Change, Maintenance: This component targets individuals and organizations
who are looking for models and resources for how to address health effects from pesticides, as
well as individuals and organizations who have become part of the cadre of health care
providers involved in this issue.
Proposed Activities
Activity #1
Build the gateway using resources gathered through the inventory process and evaluated by
the national review board.
Identify existing resource centers that could develop the gateway, under direction of the
Federal Interagency Planning Committee.
Develop or enhance a resource center infrastructure and address logistical issues including
a toll-free number and website.
Assign priority access to primary health care providers.
Link to regional and geographical specific information, coordinated industry websites,
and other resources, universities, associations, etc.
Activity #2
Market the gateway and its information/education resources through dissemination channels
to reach primary health care providers in education and practice settings.
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To build awareness among health care providers: Disseminate persuasive case statements
(see Education Component A, page 41, Practice Component A, page 67, for development
of case statements) through professional associations, journals, and peers that address
the main issues, why primary care providers should be concerned, and how to access
the gateway.
To provide tools/resources to health care providers ready to make changes: Disseminate curricular
packages to educational settings and training packages to practice settings. Packages maybe
defined as lectures, slides, case studies, exercises, assignment/project ideas, ideas on how to
involve experts, access to gateway, etc. Packages would be combined from existing resources
and/or new resources that have undergone peer-review and pilot testing.
To help health care providers learn of the latest resources: Disseminate concise information
on how to access the gateway, especially the network of expertise. Dissemination methods
include posters, flyers at conferences, NPIC clearinghouse, and links on websites.
Convene one or more focus groups to evaluate the effectiveness of the dissemination efforts.
Stakeholders
Federal Interagency Planning Committee
Organization to manage the gateway
Evaluation of Outcomes/Indicators of Success
Number of requests for information.
Number of pageviews and downloads from the website.
Number of calls.
Customer satisfaction feedback on the website.
Feedback from focus groups.
Degree to which the dissemination efforts are nationwide.
Degree to which dissemination efforts and resources address primary health care providers
at varying stages of change.
Background
A centralized gateway to information can be an efficient way to provide comprehensive
access to evaluated, pesticide-related resources. This centralized resource should include
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan 95
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emergency information and contacts, educational materials, and other resources, and be
accessible by a toll-free number and via a website. The gateway must be able to provide real-
time answers to short-term questions as well as larger educational resources. Access must
be multi-pronged; phone, web, print, email, listservs. It should contain geographic linkages
to local providers, researchers, and sources of local information (e.g., local health
departments). The gateway will build on existing resource networks, such as the National
Pesticide Information Center (NPIC see box below) and will require a multi-stakeholder
partnership for effective implementation. The gateway will need extensive marketing in order
to ensure that it is widelv used.
A cooperative effort between Oregon State University and EPA, the National
Pesticide Information Center (NPIC) provides objective,«cience-based, and plain-
language pesticide information to the general public, and medical and veterinary
communities. It handles over 23,000 calls a year on topics ranging from toxicology
to pesticide poisonings. NPIC's staff of pesticide professionals includes
toxicologists and a physician trained to:
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help callers interpret and understand health and environmental information
about pesticides
answer questions about pesticide labels
supply general information on the regulation of pesticides in the United States
access over 300 pesticide resources
direct callers for pesticide incident investigation, emergency human and
animal treatment, safety practices, clean-up and disposal, laboratory analyses
LLJ
°" « confer with private physicians to determine an appropriate treatment plan
in the event of poisonings
provide information regarding safety practices for field/farmworkers and handlers
provide callers with information about anti-microbial pesticides
(1-800-447-6349) (Monday-Friday).
Toll-free tel: 1-800-858-7378 daily, 6:30 a.m. - 4:30 p.m. (Pacific time);
Fax: 541-737-0761; e-mail: npic@ace.orst.edu; website: http://npic.orst.edu
96 National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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RESOURCE COMPONENT D:
Develop Teaching/Learning
Resources for Educational Settings
Statement
Identify and develop new content resources, tools, and methods for faculty to use in
educational settings.
Expected Outcomes
Teaching modules
Network of experts and organizations nationwide
Target Audience
Readiness to Change: This component targets faculty in educational settings who are ready
to integrate the issue into their curriculum.
Proposed Activities
Create teaching modules for faculty that address pesticides/environmental health and that
respond to the National Guidelines, and the assessment of educational institutions.
Review existing teaching modules collected and evaluated by the national review board
and review the assessment of educational institutions to determine the type of teaching
modules still needed by faculty.
Identify key experts and/or organizations to develop teaching modules and create
contractual agreements for the development of specific modules.
Develop pesticide-teaching modules with flexibility for use by different schools,
departments, etc.
Establish a peer review and pilot testing process for the modules developed.
Distribute teaching modules to all academic health centers and nursing schools.
Make modules available online (via gateway and/or published resources document).
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan 97
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Stakeholders
Faculty who have already developed resources
Key professional associations for faculty
Cooperative extension pesticide safety educators
State lead agency pesticide educators
Evaluation of Outcomes/Indicators of Success
New resources are approved and endorsed by the national review board.
Background
Guiding principles for developing new resources include:
Easy to implement
Interdisciplinary
Culturally and geographically relevant
Measurable outcomes
Usable in both urban and rural communities.
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RESOURCE COMPONENT E:
Develop New Resources for Practice Settings
Statement
Identify and develop new content resources, tools, and methods for health care providers in
practice settings.
Expected Outcomes
Increased access to and availability of relevant information and resources including experts
in the field, content materials and available data within communities.
Target Audience
Readiness to Change: This component targets practitioners who are ready to integrate the
issue into their clinical practice and prevention activities.
Proposed Activities
Activity #1
Develop a variety of resources, including:
Training package for a one-day workshop on Health Care Providers and Pesticides.
This package could be used to train health care providers in continuing education, covering
the breadth of topics related to pesticides.
User-friendly materials:
1. Accessible print- and web-based guides for physicians and nurses. Ensure that guides
are dated so that revisions can be made and distributed, and that they contain return
cards for new information and comments.
Guide I: Highlights of symptoms, treatments, and reference.
Guide II: How to take an occupational and environmental history.
2. "ABCs of environmental health" a simple tool, similar to the CAGE screening tool
for alcoholism, that will indicate signs and symptoms for screening purposes.
3. Wall posters on pesticides for health care providers to post in their clinical practices
4. Audio cassettes/CDs to listen to in transport to and from a practice setting.
Outreach: Use of radio to serve patients and primary care providers whose first language
is not English.
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Certification of training: Some type of recognition that a primary care provider has
completed a certain level of training.
Journal articles in the literature: Encourage researchers to produce professional journal
articles on the subject of pesticide-related health concerns.
Internet/web-based materials and training, including video-conferencing, satellite training.
Encourage creation of a centralized industry website on pesticide/health data.
Activity #2
Increase the participation of professional associations in the support, use, and promotion of
educational materials and resources.
Develop model policy statement that can be tailored and adopted by professional associations.
Coordinate with national organizations to develop policy statements on educating health
care providers about pesticides (along the lines of those developed by the American
Academy of Pediatrics).
Encourage development of environmental health committees in professional organizations
and local chapters.
Coordinate with professional associations to secure more continuing education (CE)
opportunities at national and regional meetings.
Build pesticide/environmental health CE into internet-based offerings by professional
associations.
Activity #3
Establish a national network of experts and organizations that can answer questions and
serve as resources to health care providers nationwide.
Identify existing organizations that have the capability to establish and/or expand a database
of individuals and organizations.
Identify areas of expertise to be included.
Identify experienced professionals and define the parameters of their responsibility.
Solicit availability for consultation, teaching, guidance, etc.
Develop a Pesticide Poisoning Orientation Training program to build "practice champions"
or motivate providers to become champions. Training could be web-based, via audio
cassettes, CDs, or in-person. Short courses (half or full day) could be held in conjunction
with other professional conferences, and should be integrated with other disciplines.
100 National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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Stakeholders
Faculty who have already developed resources
Key professional associations for faculty
Cooperative extension pesticide safety educators
State lead agency pesticide educators
Network of pesticide and pest management experts i n land grant colleges and universities
throughout the US.
Evaluation of Outcomes/Indicators of Success
Increased utilization of community resources.
Increased number of customized educational programs/materials.
Increased number of resource collaborations.
Number of RFPs related to new and innovative ways to get information to primary care providers.
Increased number and frequency of pesticide practice related publications.
Increased number of CE courses.
Increased number of presentations in practice settings.
Numbers of policy statements.
Numbers of re-certification exams.
Numbers of questions on exams.
Increased availability of reimbursement mechanisms.
Number of people applying for Certificate of Recognition.
Number of requests made of experienced professionals.
Number of professionals who agree to participate.
Diversity of professional background.
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan 101
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Background
A wide range of credible, convenient, and easy to use materials need to be developed. Examples
include "cheat sheets," cassette tapes or CDs that can be listened to in the car, web-based
instruction (depending on how recently the providers graduated and how comfortable they
are with technology). Providers are overburdened and need quick help either in the form
of checklists or a person at the other end of a line.
To the extent that primary care providers keep up with their professional journal literature
and to the extent that there is a sufficient stream of articles in the literature on pesticide
diagnosis and treatment, it can be expected that providers will encounter pesticide-related
information in the course of their reading. However, there may well be a gap in articles on
pesticide poisoning prevention and diagnosis in the journals that are generally read, a gap
that could be remedied by encouraging researchers to prepare and submit such articles.
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This Implementation Plan is the starting point for a strategic and coordinated effort to
change our national health care system so that it adequately addresses the problems
posed by pesticide poisonings and exposures. The Implementation Plan presents the goal
of the Initiative and the expected outcomes, and sets out the strategic direction to improve the
recognition, management and prevention of pesticide-related health conditions. At the heart of
the Implementation Plan is a three-pronged strategy for accomplishing the necessary change.
The strategy is aimed at improving the teaching of pesticides and environmental health in
educational settings of nursing, medical, and other health professional schools, changing the
way primary care providers assess and react to pesticide cases in their practice settings, and
creating the necessary new resources for both educational and practice settings that build
upon the existing knowledge base and respond to the needs of faculty, students, administrators,
and practitioners. The three-pronged strategy and the Implementation Plan as a whole are
intended to serve as a model for other toxic exposures and broader efforts to educate health
care providers about environmental health problems. It is hoped this Implementation Plan
will be a positive step towards a national vision for environmental health awareness, education
and training for health care providers.
Work is already underway on a number of components of the Implementation Plan
including development of competency guidelines, establishment of a national evaluation panel/
review board, conducting an audience assessment through literature review and focus groups,
and creation of an information gateway. The intention is to get the remaining components
underway in the next several years. Evaluation of progress will be an ongoing theme during
the course of this Initiative. The next steps in moving this Initiative forward will require the
support and participation of a wide spectrum of stakeholders nationwide. This Implementation
Plan can be used as a way of introducing new additional stakeholders and interested parties
to the Initiative and of involving them in specific components. The Implementation Plan will
also be a focus of a National Forum, to be convened in 2002.
As work proceeds, workgroup members and other stakeholders are encouraged to stay active in
the Initiative through e-mail, EPA's host website (wvvw.epa.gov/oppfeadl/safety/healthcare/
healthcare.htm) and NEETF's host website (www.neetf.org/health/providers/index.shtm) and
to bring the Initiative to the attention of colleagues and other contacts in the health care world.
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan 103
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Glossary
AAP American Academy of Pediatrics
AACN American Association of Colleges of Nursing
AAFP American Academy of Family Physicians
AAMC Association of American Medical Colleges
ACNM American College of Nurse Midwives
AAOHN American Association of Occupational Health Nurses
ACOEM American College of Occupational and Environmental Medicine
AMA American Medical Association
ANA American Nurses Association
APN Advanced Practice Nurse
ATSDR Agency for Toxic Substances and Disease Registry
CDC Centers for Disease Control and Prevention
CE Continuing education
CME Continuing medical education
CNS Clinical nurse specialist
E&M Evaluation and Management
EPA Environmental Protection Agency
FIFRA Federal Insecticide, Fungicide and Rodenticide Act
FNP Family Nurse Practitioner
GIMP Gerontological Nurse Practitioner
HHS Department of Health and Human Services
HRSA Health Resources and Services Administration
MSDS Material Safety Data Sheet
NEETF The National Environmental Education & Training Foundation
NIEHS National Institute of Environmental Health Sciences
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NIH National Institutes of Health
NIOSH National Institute for Occupational Safety and Health
NLN National League of Nursing
NPIC National Pesticide Information Center
OSHA Occupational Safety and Health Administration or
Occupational Health and Safety Act
PNP Pediatric Nurse Practitioner
RFA Request for Applications
RFP Request for Proposals
TSCA Toxic Substances Control Act
USDA US Department of Agriculture
WPS Worker Protection Standard
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Appendix A:
Expert Panel Proceedings
To launch the National Strategies for Health Care Providers: Pesticides Initiative, EPA and
several other federal agencies convened an expert forum. This forum initiated the
development of national strategies to improve the education and awareness of health
care providers in dealing with pesticide-related health concerns. The April 23-24, 1998
event in Arlington, VA, was sponsored 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 & Training Foundation worked with these federal agencies to organize the
event (see US EPA, 1998).
The expert forum was conceived of as a deliberative session of representatives of 16 health
organizations, open to the public, and with comments and questions from federal agencies
and outside observers. The panel included representatives from: 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.
Concerns About Provider Education and Training
The panel agreed that the principal focus of this Initiative should be on primary care providers.
The panel found that primary care providers are not sufficiently trained at any stage of their
education about pesticide exposure. The panel also recognized that the lack of training is
larger than just pesticides and reflects a serious deficiency in education on environmental and
occupational health. The panel briefly summarized the main concerns in provider knowledge
about pesticide exposures:
Pesticide exposures are often underreported.
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Providers often do not know how and where to report pesticide exposures; sometimes the
reporting is considered burdensome given their demanding work environments.
Health conditions associated with pesticide exposures are often misdiagnosed.
Providers do not often see acute pesticide poisoning, and they do not possess enough
knowledge to recognize chronic cases.
Providers have not received training on pesticide exposures during their years of formal
education.
Pesticide exposures and associated health conditions are difficult topics to teach because
they require additional knowledge on toxicology and other topics which are often not
included in the curriculum of health professional education.
Expected Outcomes for Primary Care Providers
The panel discussed at length what should be expected of primary care providers. Agreement
was reached that all primary care providers should:
Be knowledgeable about pesticides and recognize pesticide exposures as a health concern.
Be able to 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 either patients or communities.
Access the appropriate resources/specialists (local, regional, and national).
Expert Panel's Overarching Strategies
The expert panel generated specific strategies that were consolidated into four general topic areas:
1. Define and recommend basic environmental health (emphasizing pesticides) competencies
for primary care providers.
2. Develop a set of education and training strategies for students and primary care providers
on the subject of pesticide-related health concerns.
3. Raise the awareness of primary care providers on pesticide issues and risk factors through
professional meetings, information mailings by professional associations, and journal articles.
4. Centralize information resources for primary care providers and strengthen their linkage
to existing resources.
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Expert Panel Membership
Joni Berardino, MS, LSW
National Center for Farmworker Health
Candace M. Burns, PhD, ARNP
National Organization of Nurse
Practitioner Faculties, and University of
South Florida College of Nursing
Joe Fedoruk, MD, DABT, CIH
American College of Occupational and
Environmental Medicine
J. Ward Donovan, Jr., MD, FACEP
American College of Emergency
Physicians, and
Pennsylvania University Poison Center,
Milton S. Hershey Medical Center
Rugh Henderson, MD, MPH
North American Agromedicine
Consortium, Pennsylvania
Agromedicine Program, and Penn
State University College of Medicine
Michael Hodgman, MD
National Rural Health Association, and
Bassett Healthcare/NY Center for
Agricultural Medicine and Health
Andrea R. Lindell, DNSc, RN
American Association of Colleges of
Nursing, and University of Cincinnati
College of Nursing
Mary Miller, MN, ARNP
American Nurses Association, and
Washington State Department of Labor
and Industries
Karen Mountain, MBA, MSN, RN
Migrant Clinicians Network
Dennis Penzell, DO, FACP
Suncoast Community Health Centers, Inc.
George C. Rodgers, Jr., MD, PhD
American Association of Poison Control
Centers, and University of Louisville
School of Medicine
Jackilen Shannon, PhD
Council of State and Territorial
Epidemiologists, and Texas Department
of Health
Elisabeth Spector, MD, MPH
American Academy of Family Physicians
Roger F. Suchyta, MD
American Academy of Pediatrics
Greg P. Thomas, PA-C
American Academy of Physician Assistants
Sheldon Wagner, MD
National Pesticide Medical Monitoring
Program, and Oregon State University
Speakers and Facilitator
Wilson Augustave
Finger Lakes Migrant Health Care Project
Louise M. Rauckhorst, EdD, MSN
Philip Y. Hahn School of Nursing,
University of San Diego
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Mark G. Robson, PhD, MPH Susan T. West, MPH, Facilitator
Environmental and Occupational Health The National Environmental Education
Sciences Institute, and Rutgers University & Training Foundation'
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Appendix B: Summary
Proceedings from Workgroups
T
his appendix provides a brief summary of the deliberations of the three workgroups
created under this Initiative and a list of their members. The strategies and plans that
emerged from the workgroup meetings are the subject of this Implementation Plan.
The workgroups discussed competencies and expected outcomes, and devoted some time to
brainstorming sessions on overall strategies and plans of action. Members held small group
discussions for the better part of the second day of each meeting, to flesh out the strategies
and action items. The groups then reviewed the strategies and decided on next steps. Both
short-term (1-3 year timeframe) and longer-term actions (3-5 years) were identified. The
meetings were facilitated by Susan West of The National Environmental Education & Training
Foundation (NEETF).
The Education Workgroup was charged with developing a national strategic plan to enable
undergraduate and graduate formal education and training institutions to prepare primary
care providers to prevent, diagnose, treat, and refer patients exposed to pesticides. The
workgroup was expected to set (and/or select already established) competencies for the
educational setting, and to identify strategies on how to achieve those competencies through
education, training, and raising student awareness.
The Practice Workgroup was charged with developing a national strategic plan for improving
the practice of primary care providers in preventing, diagnosing, treating, and referring patients
exposed to pesticides. This group, too, was expected to set (and/or select already established)
competencies for the practice setting and to identify strategies on how to achieve those
competencies through education, training, and raising awareness.
The Resources Workgroup was charged with developing a national strategic plan which
addresses an effective method of linking, centralizing, and disseminating an array of resources
for the prevention, diagnosis, treatment, and referral of patients exposed to pesticides. This
plan would also evaluate existing assessments of resources, identify gaps, and begin to develop
needed resources for health care providers.
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Key Principles
Key principles and findings emerging from the three 1999 workgroups include:
Pesticides must be seen in the context of environmental and occupational health.
All three workgroups expressed the opinion that pesticides are a useful and important
focus of attention in themselves; however, pesticides must also be seen as a stepping-
stone for the underrecognized and broader issue of environmental and occupational
health as a whole.
Gaining attention and raising awareness are the primary challenges. One of the most
difficult obstacles is gaining the attention of students, faculty, and primary care providers
to the issue-of pesticides and/or environmental health. Curricula are crowded, providers
are busy, and time is at a premium. Nevertheless, sometimes a single case encounter can
have long-lasting effects. Much of the effort of the workgroups was driven by the need to
gain attention and raise awareness. Strategies include developing case statements, creating
monetary and professional incentives, nurturing pesticide/environmental health
"champions" and model practices and convening focus groups to better understand
providers' communication styles.
Occupational and environmental histories are gateways. Few primary care providers
ask patients the questions that would be likely to alert them to the possibility of a
pesticide-related illness. Although it is important for primary care providers to take
occupational and environmental histories, both workgroups recognized that a full
occupational and environmental history can sometimes take up the entire patient visit.
However, getting primary care providers to ask just a few simple questions such as
'Where do you work?' and 'Do you think your problems are related to something that
happened at work or at home?' could go a long way toward uncovering pesticide-
related health conditions and raising awareness about the environment in which patients
live and work.
There is a spectrum of pesticide-related health conditions. Stereotypes of pesticide
illness insecticides, farmworkers, acute poisoning, cholinesterase testing may cover
an important segment of the population, but they by no means cover the entire field.
Students, faculty, and primary care providers must come to understand the wide
spectrum of pesticide-related health concerns: low-dose chronic effects as well as acute,
high-dose poisonings; effects on children, people with chemical sensitivities, other
vulnerable populations; the wide variety of pesticide products on the market; urban,
rural, and suburban settings.
The need is for credible, convenient, and easy-to-use resources. The best way to reach
already overburdened primary care providers is by ensuring that the resources available
to them on pesticide-related illnesses are scientifically credible, easy to access, and provide
quick answers to providers' questions.
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The importance of understanding the audience cannot be overstated. Primary care
providers work in a wide variety of settings and have varying levels of exposure to pesticide-
related health issues. Understanding primary care providers their backgrounds, level of
awareness and knowledge about pesticide issues, and preferred modes of receiving
information is essential to effectively targeting and reaching the audience for this Initiative.
Evaluation plays a key role. There is a strong need for expert evaluation of the resources
available to primary care providers on pesticide topics and for ensuring that new materials
developed through this Initiative meet stringent evaluation criteria.
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Education Workgroup
One of the key issues that workgroup members grappled with over the course of the
meeting was the need to gain the attention of health care students, faculty, and primary
care providers when their time and attention is in high demand elsewhere. Many
members noted that there is little time in the basic undergraduate curriculum for pesticide
and environmental health material. It would be unreasonable to expect more than a total of
30-40 hours over the course of a four-year degree program; a more modest rise to just 10
hours of instruction would stand a better chance of acceptance. The key is to get the education
setting both interested in and comfortable with pesticide issues.
Making the Case
Workgroup members agreed on the need to "make the case" to medical and nursing schools
about the importance of environmental health education and
the extent of the problem of pesticide-related health concerns.
Even the most supportive faculty challenge why environmental
health is important to teach.
/ have been challenged by some
of the most supportive faculty
who say, "You haven't made a
strong enough case" We
haven't effectively made the
case to incorporate
Workgroup members spent considerable time discussing how to
spark the interest of faculty and students. One workgroup member
noted that environmental poisonings are seldom encountered by
medical school students. The best way he has found to motivate
medical students is to have them accompany primary care physicians
in rural area practices so that they can experience the scope of
occupational medicine first-hand. The payoff is that students value
this practical type of learning enormously, and that it has a greater
impact than hearing lecture after lecture on the same topic. It also
combats one of the problems of the practice setting, which is that
primary care providers often do not perceive the agricultural environment as a workplace.
"Make it Easy for Them to Let Us In..."
How will educational institutions allow material on pesticides/environmental health into their
curriculum, and how can the materials be designed to "make it easy for them to let us in?" It
is important to identify where in the curriculum the materials should be inserted. Usually the
schools have a flow of courses/topics and the group could suggest where a given topic in
environmental health would fit. The aim of this Initiative is not to overwhelm medical and
nursing students with a vast amount of information.
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"Teachers Don't Teach What They Don't Know..."
It was noted that "Teachers don't teach what they don't know... If you make it relevant to them,
they'll find a way to teach their students." Several workgroup members raised the issue that many
faculty are not comfortable teaching the full range of subjects involved in pesticides. For example,
pharmacology professors may lack the clinical expertise to teach about pesticides; other medical
faculty may lack the toxicology background. Others agreed that it might be difficult to find enough
faculty with competence in pesticides/environmental health. Workgroup members discussed at
some length whether faculty should be trained to become comfortable with, or expert at, teaching
pesticides/environmental health subjects, or whether it is sufficient for faculty to know of experts
in their local area whom they can tap as needed.
Merely making materials available is not sufficient it is not true that "if you build it, they will
use it." The situations where new material has worked best in medical schools is where there was
an advocate or champion who pushed until the material was included in the curriculum. A
study at Worcester State College reported that the No.l barrier to integrating environmental
health into nursing curriculawhich the deans of nursing schools supported was the absence
of faculty with the knowledge and confidence to carry out that integration.
Several models were discussed, including the 26 NIEHS five-year grants for mid-career funding
of environmental health positions, which provided half of the faculty's salary plus evaluation
components, and the 1990-95 faculty development grant program at the University of South
Florida that supported curriculum development and research in substance abuse. Faculty
spent the first two of the five years becoming experts in their chosen areas through seminars,
courses, networking with other experts, etc.
Workgroup members discussed the "fragile toehold" environmental health courses have in
health care education. There is no additional funding for teaching pesticides/environmental
health courses and environmental health is not a "revenue generator." This may have
particularly problematic implications for undergraduate education. Increasingly, faculty
members need to generate funding to support their own salaries. "Contextual realities" are
important. Of the 126 environmental health science centers around the country, possibly 20
are on the verge of disappearing. The workgroup discussed the possibility of developing
fellowships around pesticides in specialties that are highly valued within medical schools,
since pesticides affect multiple systems in the body. This would require the time of in-house
faculty to incorporate existing resources and information into an institution's curriculum.
Convincing the Examination Boards
One way to motivate change in curriculum, workgroup members agreed, is to convince the
medical and nursing examination boards of the importance of environmental health in the
coming years, and push them to incorporate environmental health questions on their exams.
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This would also be one of the better ways to institutionalize the subject matter over the long-
term. Workgroup members felt that some of the boards would be receptive to a concerted
effort in this area. For example, the Residency Review Committee for Pediatrics in 1996 adopted
two recommendations on children's environmental health.
The workgroup discussed whether public education and K-12 education should also be dealt
with as part of this Initiative. The group noted efforts on environmental education becoming
incorporated into K-12 education, partly through the support of EPA and the National Institute
of Environmental Health Sciences. But while many K-12 schools are teaching ecological effects,
there is relatively little being taught about the human health effects of the environment. This
is a ripe opportunity, and one which would have advantages down the line, with students
entering medical school already having an awareness of pesticides/environmental health issues.
Despite the importance of raising awareness and education in the larger educational sphere,
however, the workgroup decided that it fell outside the scope of this Initiative, which focuses
on educating primary care providers. The group recommended that the issue be addressed in
other initiatives.
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Education Workgroup Membership'
Co-Chairs
Andrea Lindell, DNSc, RN
American Association of Colleges of
Nursing, and University of Cincinnati,
College of Nursing
Ameesha Mehta, MPH
Office of Pesticide Programs
US Environmental Protection Agency
Facilitator
Susan West, MPH
The National Environmental Education
& Training Foundation
Members
Amy Brown, PhD
American Association of Pesticide Safety
Educators, and University of Maryland-
College Park
Candace Burns, PhD, ARNP
National Organization of Nurse
Practitioner Faculties, and University
of South Florida
Joan Spyker Cranmer, PhD
University of Arkansas Medical School
Miriam Cruz
Equity Research
Kesner Flores, EMT
Cortina Indian Rancheria, Wintum
Environmental Protection Agency
Jose Garcia
Equity Research
Rugh Henderson, MD, MPH
North American Agromedicine
Consortium, Pennsylvania Agromedicine
Program, and Penn State University
College of Medicine
Matthew Keifer, MD, MPH
NIOSH Agricultural Health and Safety
Centers, and University of Washington
John McCarthy, PhD
American Crop Protection Association
Claudia Miller, MD
University of Texas Health Science
Center-San Antonio
Madaleine Ochinang, MS
Formerly with the Consortium for
Environmental Education in Medicine
Marcia Allen Owens, JD
Minority Health Professions Foundation
Annette Perez, RNC, MSN, CNM, PhD
American College of Nurse Midwives,
and University of Texas-El Paso, College
of Health Sciences
J. Routt Reigart, MD
Medical University of South Carolina,
Department of Pediatrics
Elaine R. Rubin, PhD
Association of Academic Health Centers
Barbara Sattler, RN, DrPH
University of Maryland, School of Nursing
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Leonel Vela, MD
Migrant Health Advisory Council, and
Texas Tech Health Sciences Center
Federal Agency Representatives
Elizabeth Blackburn, RN
Office of Children's Health
Protection, US EPA
Jerome Blondell, MPH, PhD
Office of Pesticide Programs, US EPA
Barbara Brookmyer, MD, MPH
Bureau of Health Professions, Division
of Medicine and Dentistry, Health
Resources and Services Administration
Ruth Kahn, DNSc
Bureau of Health Professions, Division
of Medicine and Dentistry, Health
Resources and Services Administration
Dalton Paxman, PhD
Office of Disease Prevention and Health
Promotion, US Department of Health
and Human Services
Rosemary Sokas, MD, MOH
National Institute for Occupational
Safety and Health
Delta Valente, MPA
Office of Pesticide Programs, US EPA
Joan Weiss, PhD, RN, CRNP
Bureau of Health Professions, Division
of Nursing, Health Resources and
Services Administration
Peter Wood, MS
Agricultural Marketing Service, US
Department of Agriculture
As of July 2000
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Practice Workgroup
Like the Education Workgroup, the Practice Workgroup spent a great deal of time
discussing how to motivate change. Recognizing that primary care providers are busy
and confront a myriad of public health issues and illnesses, what is the best way to gain
their attention to ensure that they ask the right questions?
One answer is that providers remember what they see in their practice. If primary care providers
do not see enough acute cases of pesticide-related illness, they will not consider it important
enough to pay attention. However, this is a classic Catch-22 situation, because if providers
aren't aware of pesticide poisoning, they won't recognize the cases. The lack of data in this
area makes it hard to convince primary care providers they need to alter their practices. One
way for primary care providers to be sensitized to the possibility of pesticide poisoning is to
become knowledgeable about the local community.
What Should Primary Care Providers Know?
Workgroup members noted that we need to limit the demands; primary care providers
shouldn't be expected to be toxicologists. Instead, it is often
patients who are directing health care providers to focus more
on pesticides and environmental health by the questions they
bring up. Some workgroup members felt that it would be
enough to have primary care providers be aware of the
possibility of pesticide-related health conditions, know what
questions to ask, and know where to go to get additional help.
Others argued that minimum competencies, or practice
changes, are needed. For example, a primary care provider
shouldn't let a patient walk out of the office without
ascertaining the possibility of exposure. The provider shouldn't
just ask when a patient last vomited, but ask if the vomiting
coincided temporally with something that happened at work.
Knowing when to do a cholinesterase test is extremely
important for all primary care providers. Such testing, for
example, is essential to establish that a person has been harmed
for purposes of workers' compensation, so that medical bills are reimbursed.
Two workgroup members pointed out that getting health care providers to ask a few simple
questions would go a long way toward raising awareness of patients' environmental health
issues, without requiring these providers to do additional legwork in the community. Two
How do you know that what
you're seeing is not the flu, it's
really organophosphate
exposure? If you think it's the
flu and you never ask any of
the questions, this guy is going
to walk out of your office and
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
125
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simple questions might be: (1) Where do you work? and (2) Do you think your problems are
related to something that happened at work?
The workgroup devoted an extensive amount of time to the discussion of competencies for
primary care providers (see Practice Component B on page 70 for more details). Many
workgroup members thought that although "competencies" was an appropriate term for an
educational setting, in a practice setting the term implied that primary care providers are
incompetent if they don't remember all of the material. They preferred to use terms such as
"knowledge and skill outcomes," "expected practice skills," or "content."
A Two-Track System?
One important aspect of the question of "what providers should know" is whether primary
care providers in certain communities should know more than providers in other areas. For
example, should there be different levels of knowledge and skills for primary care providers in
agricultural areas compared to providers in urban or suburban settings?
While the issue was not resolved, the consensus appeared to be that all primary care
providers should have a certain minimum content level of knowledge and skill related to
pesticides/environmental health. On the other hand, it may be that primary care providers
in agricultural communities have an added function, going beyond the minimum in
recognition, diagnosis, and management of pesticide-related illness to a larger role in
prevention and education, and advising their patients about such things as heat stress,
prenatal care, and pesticides.
Making Change Happen
How does change actually happen? Workgroup members discussed the difficulties in bringing
about changes in health care. The literature on continuing education shows the need for a
multifaceted approach. Continuing education alone has little impact without additional visits
to clinics, feedback loops, hands-on workshops, etc. Even in Grand Rounds, occupational and
environmental medicine subjects get very poor turnout.
Other Issues
Workgroup members stressed the need for research in a number of areas, including research
on human exposure, biomonitoring, and the extent to which pesticide poisonings are currently
being misdiagnosed in primary care practices.
It is important to look at interconnections between the clinical setting, community setting,
reporting, and the regulatory context, even though primary care providers may not see these
interconnections. For example, it is not clear that primary care providers realize the importance
126 National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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of their role in reporting cases of pesticide illness both for regulating harmful pesticides and
for efforts to make safer pesticides. Upon investigation, some incidents may turn out to have
been a violation of the label restrictions; but in some cases, pesticide poisoning occurs with
no apparent label violation. That information is extremely important, even if it cannot be
proven conclusively.
Another connection that does not generally work well is with workers' compensation systems.
Even in Washington State, which is often pointed to as the model for an integrated reporting/
surveillance/workers' compensation system (see box on page 86), the system is based on "objective
findings." Most pesticide illnesses yield signs and symptoms rather than objective findings, so
patient claims maybe denied. Primary care providers need help understanding what the medical
rules of evidence are so that patient claims won't be rejected. One model might be Colorado's
system of associating occupational categories with subjective symptoms (e.g., carpal tunnel);
something similar could be done for pesticides. Health care providers also need to know how to
write up their findings, about the statute of limitations for repeat injuries, and where to go for
help. Finally, states need to reimburse for relevant diagnostic testing for pesticide illness. At
present, only Washington State reimburses for diagnostic evaluations.
Defining workers' compensation requirements related to pesticide illnesses would attract the
attention of medical associations and their members; physicians would know that they could
get paid for this category of health concern. In the California workers' compensation system,
physicians don't get paid if they don't report; such an incentive would likely encourage reporting
if it were used more widely. Despite the anticipated difficulties of revising workers'
compensation systems, workgroup members agreed on the importance of tackling them. Half
a dozen states are the sole insurers on workers' compensation and in those states, the state
commission would be the only organization to deal with. It was also pointed out that six
states California, Texas, Florida, Oregon, Washington, and North Carolina probably
cover 70 percent of agricultural workers, and might be the natural focus of attention for this
type of effort.
Workgroup members agreed that community health workers are an important part of the health
care team. Caseworkers and community health workers are needed to go out and work with
vulnerable populations. They can be particularly important in conducting follow up with migrant
workers and bringing them back into the health care system. The workgroup raised, but did not
reach a consensus on, whether to widen the scope of the Initiative to involve the family, the role
of the physician in the workplace, or the role of health professionals in the community.
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan 127
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Practice Workgroup Membership*
Co-Chairs
Bonnie Rogers, RN, DrPH, COHN-S, FAAN
American Association of Occupational
Health Nurses and University of
North Carolina-Chapel Hill, School
of Public Health
Karen Pane, RN, MPA, CMCN
Health Resources and Services
Administration, US Department of
Health and Human Services
Facilitator
Susan West, MPH
The National Environmental Education
& Training Foundation
Members
Sheila Brown Arbury, RN, MPH
Association of Occupational and
Environmental Clinics
Shelley Davis
Farmworker Justice Fund, Inc.
J. Ward Donovan, MD, FACEP
American College of Emergency
Physicians, Pennsylvania University
Poison Center, and Milton S. Hershey
Medical Center
Harold Harlan, PhD
National Pest Control Association
Barbara Hatcher, PhD, MPH, RN
American Public Health Association
Ann Linden, CNM, MSN, MPH
American College of Nurse Midwives
Mark Miller, MD
American Academy of Pediatrics
Mary Miller, MN, ARNP
American Nurses Association, and
Washington State Department of Labor
and Industries
Karen Mountain, MBA, MSN, RN
Migrant Clinicians Network
Diane Mull
Association of Farmworker Opportunity
Programs
Patrick O'Connor-Marer, PhD
American Association of Pesticide
Safety Educators, University of
California Statewide IPM Project,
and University of California
Agricultural Health and Safety Center
John Pickle, RS, MSEH
Weld County Health Department -
Greeley, CO
George C. Rodgers, Jr., MD, PhD
American Association of Poison Control
Centers, and University of Louisville
School of Medicine
Rachel Rosales, MSHP
Texas Department of Health
128
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Cathy Simpson, MD
Wayne State University, School of Medicine
Gina Solomon, MD, MPH
Natural Resources Defense Council
Sheldon Wagner, MD
National Pesticide Medical Monitoring
Program, and Oregon State University
John Wheat, MD, MPH
North American Agromedicine
Consortium, and University of Alabama
at Birmingham, School of Medicine
Federal Agency Representatives
Barbara Brookmyer, MD, MPH
Bureau of Health Professions, Division
of Medicine and Dentistry, Health
Resources and Services Administration
Frank Davido
Office of Pesticide Programs, US EPA
Eva Montoya, MSN, RN
Bureau of Primary Health Care, Migrant
Health Program, Health Resources and
Services Administration
Ana Maria Osorio, MD, MPH
Office of Pesticide Programs, US EPA
Ana Marie Puente
Bureau of Primary Health Care, Border
Health, Health Resources and Services
Administration
Capt. Barry Stern, MPH
Bureau of Health Professions, Health
Resources and Services Administration
* A.s of July 2000
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Resources Workgroup
Building on the ideas of the Education and Practice Workgroups, the Resources
Workgroup began its discussion by examining the types of resources that are used in
educational and practice settings. The workgroup then undertook a more detailed
exploration of key issues relating to resources, including; the credibility of sources of
information, defining and understanding the audience, reaching the target audience with
appropriate resources, and evaluating the effectiveness of resources.
Credible Sources of Information
The Resources Workgroup felt strongly that resources created or promoted through this
Initiative must be credible and scientifically sound. The group explored the sources of
information that health care providers and the public currently use, and the credibility of
different information sources in different communities. One workgroup member suggested
that the public trusts the universities first, the federal government next, state water agencies
after that, and state agriculture departments after that. In
many places, the community health worker plays a key role.
There are 78 different names for community health workers
in the US, and although they are generally considered "non-
professional," they are the most trusted health care workers
and have the highest ability to change behavior. Standards
for community health workers are only starting to be
developed as community colleges get involved in their
training. Unfortunately, environmental health is not
generally taught as part of their training.
When I train residents I tell them:
you'll do a lot better if you don't
assume you're the primary
provider. The primary provider is
often the grandmother or an elder,..
The natural system of health care in
the community is alive and well.
We need to recognize the system,
A related issue that the group considered is sensitivity to
local concerns and parlance.
Reaching the Target Audience
The workgroup's discussions emphasized the importance of
defining and understanding the target audience of primary
care providers. Aware that the universe of health care
providers runs into the millions, the group explored ways of segmenting the universe by
type of provider, population served, and practice setting, or by matching types of providers to
epidemiologic cases of pesticide use or abuse.
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The workgroup devoted considerable time to a discussion of the varying levels of needs of
primary health care providers. One workgroup member stated that "it is not clear that we
really know what health care providers want and need" in the way of educational and
information resources. It will be important to examine the extensive literature on how health
professionals learn in order to determine the most effective approaches.
The workgroup explored in detail the Stages of Change model created by Prochaska and
DiClemente (Prochaska, 1995). The model looks at behavior change as a process rather than
an event, and describes how individuals are at varying levels of motivation, or readiness to
change. The model outlines a continuum of behavior change that can be used to help
understand where the target audience is on the continuum, and to reach the audience (through
targeted messages, strategies, and programs) to ensure behavior change (see Table 6 on page
34 and the discussion of how the model can be adapted to the current initiative).
Workgroup members examined existing resources in an effort to determine "what works"
and identify gaps. Members reviewed the guide, "Preliminary Resources Materials," developed
by The National Environmental Education & Training Foundation, and mentioned additional
materials. Workgroup members discussed all aspects of providing effective resources types
of resource materials, settings in which they are delivered, delivery mechanisms, modes of
dissemination, and motivation for use.
Professional associations could play a big role in reaching member providers. The group
discussed the types of technology that providers are most comfortable with, and acknowledged
that while health care providers lag behind in their use of the internet, they will no doubt
increase their usage over time. Nevertheless, the web can be a "giant disorganized mess of bad
data, good data, and it takes time to learn how to use it." Providers will continue to need
quick and easy ways of accessing information. Some members argued that continuing
education for health care providers has been shown not to be an effective way to change
behavior and that consensus statements of professional associations can take a long time to
develop and to have an impact. It is important, however, to approach the target audiences and
find out where they obtain information.
Evaluating Results
Some type of measurement and evaluation effort is certainly needed for this Initiative. Evaluation
and measurement are relevant for several purposes for assessing the "baseline," i.e., the current
state of awareness and involvement of primary care providers, for evaluating the quality of
existing resources, for helping to design effective new resources and dissemination strategies,
and for determining the success of the Initiative.
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan 131
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Workgroup members noted that a great deal of attention has been given to measuring the degree
to which educating health care providers on nutrition, tobacco, and other issues has led to
measurable changes in practice as well as changes in patient practices. Even with tobacco, "the
whole world is trying to get physicians to counsel their patients who smoke to stop smoking."
Nevertheless, only 30-60 percent of physicians appear to do so, and measuring this activity has
been very difficult. The group agreed that qualitative research, including holding focus groups,
would be an appropriate tool for this Initiative. It was suggested to begin with a summary of the
literature. Several provider associations (clinics, pediatricians, family physicians, etc.) represented
on this workgroup could provide a source for focus group participants.
Other Issues
The role of the public in spurring health care providers' interest was noted. Increasingly, patients
are a big source driving the physicians' interest in pesticides: "Patients instigate by asking a
question that the physician or nurse can't answer." Although primary care providers are often
concerned chiefly with acute health effects, the public is increasingly leading the way in terms of
interest in chronic and behavioral effects of pesticides (e.g., asthma, effects on IQ, etc.).
Workgroup members agreed that pesticides must continue to be seen in the context of
environmental health as a whole. The importance of making primary care providers aware of
preventive information along with diagnosis and treatment was stressed.
Finally, the group discussed support for the Initiative. "There have been too many programs
in government that just go away... If you don't have the money at the time you need it, it fades
away." It is important that workgroup members go back to their organizations and discuss
how the organizations can play a supporting role in implementing the Initiative. The
workgroup recommended that the federal representatives develop a broad outline of resource
needs and federal commitments, as well as remaining needs for which extramural funding
will be sought from industry, professional associations, and possibly environmental
foundations and trusts.
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Resources Workgroup Membership*
Co-Chairs
Mark Robson, PhD, MPH
Environmental and Occupational Health
Sciences Institute, and Rutgers University
Kevin Keaney, MA, MS
Office of Pesticide Programs, US
Environmental Protection Agency
Facilitator
Susan West, MPH
The National Environmental Education
& Training Foundation
Members
Colin Austin
Migrant Clinicians' Network, and
University of North Carolina-Chapel Hill
Angelina Borbon, RN
Alameda County Lead Poisoning
Prevention Program
Barry Brennan, PhD
American Association of Pesticide Safety
Educators, and Extension Pesticide
Coordinator, University of Hawaii
Paul J. Brownson, MD
The Dow Chemical Company
Gerardo de Cosio, MD
US-Mexico Border Health Association
Susannah Donahue, MPH
Children's Environmental Health Network
Gerry Eijkenmans, MD, MPH
Pan American Health Organization
Scottie Ford, MA
West Virginia Department of Agriculture
Matthew Garabedian, MPH
Texas Department of Health
Allen James, MBA, CAE
Elizabeth Lawder, BA (alternate)
Responsible Industry for a Sound
Environment
Linda Kanzleiter, MPsSc
Celeste Stalk (alternate)
Pennsylvania Area Health Education
Center, Milton S. Hershey Medical Center
Kathv Kirkland, MPH
Association of Occupational and
Environmental Clinics
Terry Miller
National Pesticides Telecommunications
Network, and Oregon State University
Rita Monroy
National Alliance for Hispanic Health
(formerly National Coalition of
Hispanic Health and Human Services
Organizations)
Benjamin Ramirez, MD, MPH, FACOEM
DuPont Company
Scott Ratzan, MD, MPA
Academy of Educational Development
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Susan Rehm, MBA
American Academy of Family Physicians
Barbara Sabol
W.K. Kellogg Foundation
Roger F. Suchyta, MD
Graham Newson (alternate)
Jennifer Stevens (alternate)
American Academy of Pediatrics
Federal Agency Representatives
Elizabeth Blackburn, RN
Office of Children's Health Protection,
US EPA
Jerome Blondell, MPH, PhD
Office of Pesticide Programs, US EPA
Frank Davido
Office of Pesticide Programs, US EPA
Jeanne Goshorn, MS
National Library of Medicine
Ron Hoffer, MS
Office of Ground Water and Drinking
Water, US EPA
Ameesha Mehta, MPH
Office of Pesticide Programs, US EPA
Donna Orti, MS
Agency for Toxic Substances and Disease
Registry, US Department of Health and
Human Services
Karen Pane, RN, MPA, CMCN
Health Resources and Services
Administration, US Department of
Health and Human Services
Dalton Paxman, PhD
Office of Disease Prevention and Health
Promotion, US Department of Health
and Human Services
Sherri Umansky
Office of Ground Water and Drinking
Water, US EPA
Peter S. Wood
Agricultural Marketing Service, US
Department of Agriculture
' A.s of July 2000
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Appendix C:
Response tn Public Comments
This Implementation Plan is a working document and will be widely shared and
disseminated among stakeholders in professional associations, health organizations,
education institutions, government agencies and other groups. To gather as much input
as possible, the Federal Interagency Planning Committee widely distributed more than 4,500
copies of the draft Implementation Plan to stakeholders in 2000 for review and public
comment. This final Implementation Plan reflects those public comments received, including
many specific suggestions for text changes and requests for clarification and/or expansion.
While some reviewers submitted specific text changes, as well as ideas for expansion and/or
clarification of Implementation Plan activities, several reviewers focused on broad perspectives
of the National Strategies for Health Care Providers: Pesticides Initiative in general and related
elements of this Implementation Plan. Two major themes emerged:
Why are pesticides the topic of this model initiative?
Will a focus on pesticides result in overdiagnosis of pesticides-related illness by health
care providers?
In addition, reviewers cited changes to a range of issues. For example, one reviewer called
attention to the critical issues of the relationship between chronic pesticide exposure and
various types of cancers, as well as reproductive effects of exposures. These sections have been
edited to reflect current scientific data and the recent emphasis on lymphoma research.
Specifically, the text references the Lymphoma Foundation of America's 2001 report, "Do
Pesticides Cause Lymphoma?," and incorporates additional information about the National
Cancer Institute's prospective study of commercial pesticide applicators and their spouses.
The following is a summary of the Federal Interagency Planning Committee's response to the
two major themes.
Why Pesticides?
Reviewers raised this issue from two perspectives: that of the chemical industry and that of
public health professionals. The chemical industry's concerns focused on the accuracy of some
data presented, the depth of the issues, and a concern that the Implementation Plan will
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan 135
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overemphasize pesticides as a public health issue. The public health professionals' concerns
focused on whether or not pesticides is the most important environmental health issue as the
focus of the model initiative.
Addressing Industry Concerns
Data are well documented through peer-reviewed journals, having been studied by government
and non-government scientific organizations and individual researchers. Published research
includes case studies, epidemiological reports, and clinical research.
Current statistics and clinical data on pesticide poisonings and human health effects may not
accurately reflect what is actually occurring in the US due to misdiagnoses and lack of reporting
and tracking by health care providers and others.
For example, as presented within the Making the Case chapter of this Implementation Plan,
the American Association of Poison Control Centers collects data on acute pesticide poisoning
via its Toxic Exposure Surveillance System. According to this data, in years 1993-1998
approximately 20,000 cases were seen each year in health care facilities in the United States,
and 52 percent of the cases pertained to children less than six years of age. Studies by Chafee-
Bahamon et al. (1983), Harchelroad et al. (1990), and Veltri et al. (1981) found that Poison
Control Centers captured between 24 percent and 33 percent of all poisoning cases seen in
hospitals as inpatients and/or outpatients. Since this does not include cases seen by health
care providers who are not in a hospital setting, it is likely that the actual number of pesticide
cases seen annually is much higher.
Addressing Public Health Concerns
Pesticides as the focus of the Implementation Plan and this Initiative is, indeed, an appropriate
topic as a model for the myriad environmental health issues that can affect the US population.
First, pesticides are ubiquitous. While the principal at-risk group for pesticide exposure is
farmworkers and pesticide applicators, virtually everyone in America is at risk of dangerous
levels of exposure, including individuals living in nonagricultural rural areas, as well as urban
and suburban communities.
Second, a large body of scientific knowledge on pesticides has been built over many years,
allowing the health community to acquire some ability to deal with pesticides in a coordinated
manner. Unfortunately, neither the information about other toxins nor the health community's
ability to deal with them is so advanced. Pesticides can provide a training and education
model for health care workers that can be developed and applied to environmental health
risks overall. This Implementation Plan will become the blueprint for a coordinated approach
to health care provider education and training.
136 National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan
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Fear of Overdiagnosis
As noted above and in the Making the Case section of this Implementation Plan, pesticide-
related health conditions have been misdiagnosed in the United States. The development of a
comprehensive national education and training strategy targeted at health care providers will
bring attention to the current inadequacies in addressing pesticide-related health conditions.
The challenge is that pesticide-related health conditions can share many symptoms with
common conditions like flu or food poisoning, so pesticide poisoning may not be considered
as a possible diagnosis. As a result, not only are patients not given proper care, but also a
public health issue is left inadequately addressed. If a case of pesticide poisoning is not identified
as an index case, other individuals who may be affected are not being cared for.
In the absence of an occupational and environmental health history, health care providers
may be likely to overdiagnose as well as underdiagnose pesticide-related health conditions.
Taking a good health history and understanding how to rule out the likelihood of a pesticide-
caused symptom or illness are critical steps in making the correct diagnosis. And because in
most cases the appropriate health screening questions are not being asked, health care providers
may be making a diagnosis based on what is most probable (e.g. food poisoning), rather than
considering all the options and possible illnesses. Health care providers should consider all
the possibilities, given similar symptoms, and check with a specialist to accurately assess the
source of the poisoning, determine what testing can be done to confirm the diagnosis, and
consult about treatment options.
The vision for this Implementation Plan is for all primary care providers to:
Possess a basic understanding of the health effects associated with pesticide exposures as
well as broader environmental exposures; and
Take action to ameliorate such effects through clinical and prevention activities.
As this national pesticides education and training strategy is implemented, it is unlikely that
pesticide-related health conditions will be overdiagnosed because health care providers will
be taking a complete health history, considering pesticide exposure only as a possibility related
to the presenting illness, and consulting with specialists when additional follow-up is necessary.
National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan 1 37
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Appendix D: Federal
Interagenoy Planning Committee
US Environmental Protection Agency
Frank Davido
Kevin Keaney
Office of Pesticide Programs
US EPA
1200 Pennsylvania Avenue NW (7506C)
Washington, DC 20460
Tel: (703) 305-5557 Fax: (703) 308-2962
E-mail: keaney.kevin@epa.gov
Sara Ager
Office of Pesticide Programs
US EPA
1200 Pennsylvania Avenue NW (7506C)
Washington, DC 20460
Tel: (703) 308-3003 Fax: (703) 308-2962
E-mail: ager.sara@epa.gov
Elizabeth Blackburn, RN
Office of Children's Health Protection
US EPA
1200 Pennsylvania Avenue NW (1107A)
Washington, DC 20460
Tel: (202) 564-2192 Fax: (202) 260-4103
E-mail: blackburn.elizabeth@epa.gov
Jerome Blondell, MPH, PhD
Office of Pesticide Programs
US EPA
1200 Pennsylvania Avenue NW (7509C)
Washington, DC 20460
Tel: (703) 305-5336 Fax: (703) 305-5147
E-mail: blondell.jerry@epa.gov
Office of Pesticide Programs
US EPA
1200 Pennsylvania Avenue NW (7502C)
Washington, DC 20460
Tel: (703) 305-7576 Fax: (703) 305-4646
E-mail: davido.frank@epa.gov
Ron Hoffer
Office of Ground Water and Drinking Water
US EPA
1200 Pennsylvania Avenue NW (4601)
Washington, DC 20460
Tel: (202) 260-7096 Fax: (202) 260-3762
E-mail: hoffer.ron@epa.gov
Ana Maria Osorio, MD, MPH
Office of Pesticide Programs
US EPA
1200 Pennsylvania Avenue NW (7506C)
Washington, DC 20460
Tel: (703) 305-7891 Fax: (703) 308-2962
E-mail: osorio.anamaria@epa.gov
Sherri Umansky
Office of Ground and Drinking Water
US EPA
1200 Pennsylvania Avenue NW (4607)
Washington, DC 20460
Tel: (202) 260-0432 Fax: (202) 401-6135
E-mail: umansky.sherri@epa.gov
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Delta Valente, MPA
Office of Environmental Justice
US EPA
1200 Pennsylvania Avenue NW (2201 A)
Washington, DC 20460
Tel: (202) 564-2594 Fax: (202) 501-1106
E-mail: valente.delta@epa.gov
US EPA Regional Liaisons
Don Baumgartner
Pesticides Section (DRT-8J)
US EPA, Region 5
77 West Jackson Boulevard
Chicago, IL 60604
Tel: (312) 886-7835 Fax: (312) 353-4788
E-mail: baumgartner.donald@epa.gov
Adrian J. Enache, PhD, MPH
Pesticides and Toxic Substance Branch
US EPA, Region 2
2890 Woodbridge Avenue Bldg. 5 (500)
Edison, NJ 08837
Tel: (732) 321-6769 Fax: (732) 321-6771
E-mail: enache.adrian@.epa.gov
Edward Master, RN, MPH
Pesticides and Toxics Branch (DT-8J)
US EPA, Region 5
77 West Jackson Beaulvard
Chicago, IL 60604
Tel: (312) 353-5830 Fax: (312) 353-4788
E-mail: master.edward@epa.gov
Allan Welch
Pesticides Section (AT-083)
US EPA, Region 10
1200 Sixth Avenue
Seattle, WA 98101
Tel: (206) 553-1980 Fax: (206) 553-8338
E-mail: welch.allan@epa.gov
U.S Dept. of Health
and Human Services
Geoffrey Calvert, MD, MPH
National Institute for
Occupational Safety & Health
US Dept. of Health & Human Services
4676 Columbia Parkway (21)
Cincinnati, OH 45226
Tel: (513) 841-4448 Fax: (513) 841-4489
E-mail: jac6@cdc.gov
David Hanny, PhD, MPH
Bureau of Health Professions
Division of Interdisciplinary, Community
Based Programs
Health Resources & Services Administration
US Dept. of Health & Human Services
5600 Fishers Lane (9105)
Rockville, MD 20857
Tel: (301) 443-0024 Fax: (301) 443-0162
E-mail: dhanny@hrsa.gov
Ruth Kahn, DNSc
Bureau of Health Professions
Division of Medicine and Dentistry
Health Resources & Services Administration
US Dept. of Health & Human Services
5600 Fishers Lane (9A-27)
Rockville, MD 20857
Tel: (301) 443-6823 Fax: (301) 443-8890
E-mail: rkahn@hrsa.gov
Cassandra Lyles
Office of Rural Health Policy
Health Resources & Services Administration
US Dept. of Health & Human Services
5600 Fishers Lane (9-05)
Rockville, MD 20857
Tel: (301) 443-7321 Fax: (301) 443-2803
E-mail: slyles@hrsa.gov
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Eva Montoya
Bureau of Primary Health Care
Migrant Health Program
Health Resources & Services Administration
US Dept. of Health & Human Services
4350 East West Highway
Bethesda,MD20814
Tel: (301) 594-4305 Fax: (301) 594-4997
E-mail: emontoya@hrsa.gov
Donna L. Orti, MS, MPH
Agency for Toxic Substances
and Disease Registry
US Dept. of Health & Human Services
1600 Clifton Road (E-33)
Atlanta, GA 30333
Tel: (404) 498-0325 Fax: (404) 498-0062
E-mail: dlo]@cdc.gov
Karen Pane, RN, MPA, CMCN
Office of Planning, Evaluation and Legislation
US Dept. of Health and Human Services
5600 Fishers Lane(14-36)
Rockville, MD 20857
Tel: (301)443-1128 Fax:(301)443-9270
E-mail: kpane@hrsa.gov
Dalton Paxman, PhD
Office of Disease Prevention
and Health Promotion
US Dept. of Health & Human Services
200 Independence Avenue SW (738-G)
Washington, DC 20201
Tel: (202) 205-5829 Fax: (202) 205-9478
E-mail: dpaxman@hrsa.gov
Sarat Seneviratne, MS, RS, CHMM, CCHP
Bureau of Health Professions
Center for Public Health
US Dept. of Health & Human Services
5600 Fishers Lane (8103)
Rockville, MD 20857
Tel: (301) 443-3231 Fax: (301) 443-6411
E-mail: sseneviratne@hrsa.gov
Rosemary Sokas, MD, MOH
National Institute for
Occupational Safety & Health
US Dept.of Health & Human Services
200 Independence Avenue SW (715-H)
Washington, DC 20201
Tel: (202) 401-0721 Fax: (202) 693-1647
E-mail: rrs8@cdc.gov
Barry Stern, MPH
Bureau of Health Professions
Health Resources & Services Adminstration
US Dept. of Health & Human Services
5600 Fishers Lane (8C-09)
Rockville, MD 20857
Tel: (301) 443-6758 (301) 443-0650
E-mail: bstern@hrsa.gov
Joan Weiss, PhD, RN, CRNP
Bureau of Health Professions
Division of Interdisciplinary, Community-
Based Programs
Health Resources & Services Administration
US Dept. of Health & Human Services
5600 Fishers Lane (9-105)
Rockville, Maryland 20857
Tel: (301) 443-0430 Fax: (301) 443-0162
E-Mail: jweiss@hrsa.gov
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US Dept. of Agriculture
Monte P. Johnson, PhD
Plant and Animal Systems
USDA-Cooperative State Research,
Education, and Extension Service
1400 Independence Avenue SW
Waterfront Building 2220
Washington, DC 20250
Tel: (202) 401-1108 Fax: (202) 401-4888
E-mail: Monte.P.Johnson@usda.gov
Peter S. Wood
Pesticide Records Branch
USDA Agricultural Marketing Service
8700 Centreville Road, Suite 202
Manassas,VA20110
Tel: (703) 330-7826 Fax: (703) 330-6110
E-mail: peter.wood@usda.gov
US Dept. of Labor
John Leben
Wage and Hour Division
US Dept. of Labor
200 Constitution Avenue NW (S 3510)
Washington, DC 20210
Tel: (202) 693-0596 Fax: (202) 693-1432
E-mail: jleben@fenix2.dol-esa.gov
Other Organizations
Amy E. Brown, PhD
American Association of
Pesticide Safety Educators
Dept. of Entomology, Univ. of Maryland
College Park, MD 20742
Tel: (301) 405-3928 Fax: (301) 314-9290
E-mail: ab35@umail.umd.edu
Leyla Erk McCurdy, M Phil.
Health & Environment Programs
The National Environmental Education &
Training Foundation
1707 H Street NW, Suite 900
Washington, DC 20006
Tel: (202) 261-6488 Fax: (202) 261-6464
E-mail: mccurdy@neetf.org
Jennifer Bretsch, MS
Health & Environment Programs
The National Environmental Education &
Training Foundation
1707 H Street NW, Suite 900
Washington, DC 20006
Tel: (202) 261-6470 Fax: (202) 261-6464
E-mail: bretsch@neetf.org
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