edical & Nursing
N E: E T F
USDA
4>EPA
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National Pesticide
Competency Guidelines for
Medical & Nursing Education
A Project of the National Strategies for Health Care Providers:
Pesticides Initiative
January 2003
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 U.S. 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 U.S. EPA.
100% postconsumer recycled, process chlorine free
Extensive resources on pesticides can be found at www.neetf.org/Heatth/Resources/healthcare htm
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Reviewers
This document has been reviewed in draft form by individuals chosen for their unique perspectives
and technical expertise.The purpose of this independent review was to elicit candid and critical
comments that would assist in making this published document as sound and effective as possible.
We thank the following individuals for their review of this document:
John Balbus, MD, MPH George Washington University, School of Medicine
Patricia Bauman The Bauman Foundation
Geoffrey M.Calvert, MD, MPH, FACP National Institute for Occupational Safety & Health
Kerry Hoffman-Richards, PhD Pennsylvania State University, Pesticide Education Program
Ruth Kahn, DNSc Health Resources and Services Administration, Bureau of Health
Professions, Division of Medicine
Philip J. Landrigan, MD, MSc Mount Sinai School of Medicine
Ann Linden CNM, MSN, MPH Liaison for American College of Nurse-Midwives
Paul Locke, JD, DrPH Trust for America's Health
Edward Master, RN, MPH U.S. Environmental Protection Agency, Region 5
Robert K. McLellan, MD, MPH Institute and Center for Human Development and Environmental
Health Service
Ameesha Mehta-Sampath,MPH U.S. Environmental Protection Agency, Region 2
Melissa Melum RN, BSN University of Maryland, School of Nursing, Environmental Health
Education Center
Claudia Miller, MD, MS The University of Texas, Department of Family and Community
Medicine; South Texas Environmental Education & Research
Program
Lillian Mood, RN, MPH, FAAN Retired Public Health Nurse & Community Liaison
Patrick O'Connor-Marer, PhD University of California, IPM Education and Publications
Donna Orti, MS, MPH Agency for Toxic Substances & Disease Registry
Dorothy Powell, EdD, RN, FAAN Howard University, College of Pharmacy, Nursing & Allied Health
Science
Mark Robson, PhD, MPH University of New Jersey, School of Public Health
Elaine Rubin, PhD Center for Interdisciplinary, Community-Based Learning and
Association of Academic Health Centers
Barbara Saltier RN, PhD University of Maryland, School of Nursing
Gina Solomon, MD, MPH Natural Resources Defense Council
David Stevens, MD Association of American Medical Colleges
Michael Stimmann, PhD University of California, Davis, Center for Pest Management
Daniel Sudakin, MD, MPH Oregon State University, Department of Environmental &
Molecular Toxicology
David Wallinga, MD, MPA Institute for Agriculture and Trade Policy
Although the reviewers listed above have provided constructive comments and suggestions, they
were not asked to endorse the content nor did they see the final draft of the document before its
release. Responsibility for the final content rests with the authors and The National Environmental
Education & Training Foundation.
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Authors
Project Coordinators:
Andrea R.Lindell,DNSc
Past President, American Association
of Colleges of Nursing
Dean, College of Nursing
Senior Associate Vice President
University of Cincinnati
Cincinnati, Ohio
George M. Bernier, Jr., MD
Professor of Medicine and Emeritus Dean
University of Texas Medical Branch
Galveston, Texas
Education Team:
Candace Burns, PhD, ARNP
Representative, National Organization of Nurse
Practitioner Faculties
University of South Florida College of Nursing
Tampa, Florida
James R. Roberts, MD, MPH
Assistant Professor, Department of Pediatrics
Medical University of South Carolina
Charleston, South Carolina
The participants gratefully acknowledge the contributions of the staff of the U.S. Environmental
Protection Agency and The National Environmental Education & Training Foundation for their
dedication and support of the project.
Practice Team:
Bonnie Rogers, Dr.PH, COHN-S, LNCC, FAAN
Past President, American Association of
Occupational Health Nurses
University of North Carolina School of Public
Health
Chapel Hill, North Carolina
Cathy Simpson, MD, MPH
Wayne State University School of Medicine
Detroit, Michigan
Pesticide Extension
Representative:
Amy E. Brown, PhD
President, American Association of Pesticide
Safety Educators
Associate Professor, Department of Entomology
University of Maryland
College Park, Maryland
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Table of Contents
Foreword 5
Introduction 6
A Pesticide Primer 11
Pesticide Competency Guidelines for Medical and Nursing Education:
Content, Insertion Points, and Resources for Educational Curricula 18
Competency I: Knowledge and Concepts of Pesticides 21
Competency II: Diagnosis and Assessment 35
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Competency III: Treatment, Intervention, and Referrals 40
n Competency IV: Risk Communication 47
3
Competency V: Reporting Requirements and Regulations 51
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Foreword
Pesticide poisoning in the United States remains under-recognized and under-treated. The lack of
attention to pesticide poisoning exists in spite of the ubiquity of pesticides in our homes, work-
places, and communities, and despite the considerable potential for pesticide-related illness and
injury. Communities expect that their primary care providers will be prepared to deal with
pesticide-related health conditions, as well as other environmental illnesses, but often times they
are not.
This document is part of a national initiative aimed at changing the current situation. The National
Strategies for Health Care Providers: Pesticides Initiative has set forth a strategic direction for the
nation to improve the recognition, management, and prevention of pesticide-related health
conditions.The vision is for all primary health care providers to:
Possess a basic understanding of the health effects associated with pesticide exposures as
well as broader environmental exposures.
Take action to ameliorate such effects through clinical and prevention activities.
Achieving this vision means incorporating some changes in educational institutions related to ฐ
the health professions - medical schools, nursing schools, residency, and practicum programs -
to equip students better to deal with pesticide-related exposures and health conditions.
These guidelines outline the knowledge and skills that students in the health professions need to
have about pesticides. We recognize the challenge that health educational institutions face in
terms of incorporating additional content. Nevertheless, it is important to find room for pesticide
concerns - both in terms of the very real health threats that they pose, and as a first step in
addressing the growing problem of environmental toxins. Medical and nursing schools - and
individual faculty members - will of course wish to make their own choices about how and where
to incorporate this information in their courses. We hope these guidelines help in that task.
Andrea R.Lindell,DNSc
George M. Bernier, Jr., MD
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Introduction
These guidelines form one of two documents that outline the competencies and skills that health
care professionals should have in the pesticides/environmental health area. This document focus-
es on the knowledge base that should be mastered by students as part of medical or nursing
training. The companion document defines the skills and knowledge base that should be mas-
tered and demonstrated by primary care physicians and nurses in the practice arena. The authors
of both documents collaborated to ensure consistency across both documents.
The two documents were developed specifically for everyday, frontline health care professionals,
rather than for specialists and researchers. The Educational Competency guidelines are aimed at
basic and advanced components of educational institutions, rather than specialties such as occu-
pational and environmental medicine. Similarly, the Practice Skills guidelines are aimed at primary
care providers, rather than medical toxicologists or specialists in occupational or environmental
medicine.
As faculty and administrators in medical and nursing schools decide how to incorporate pesticide-
related information, it is hoped that these national guidelines and the larger initiative on pesti-
cides and health care providers will serve as a model for integrating other environmental health
ฐ- issues into health care provider education and training.
Background on Pesticides and Health Care Providers
The need for improvements in environmental health training has been expressed by a number of
health professional groups, academic institutions, as well as government and community organiza-
tions. In 1994, the American Medical Association adopted a resolution urging Congress, govern-
ment 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 a number of studies published in the 1990s, the Institute of Medicine expressed its concern that
health care providers are not prepared to manage this problem, focusing on the issue of environ-
mental health education and the roles of nurses and physicians (IOM 1988, IOM 1991, IOM 1993,
Pope et al, 1995). Each report outlined the deficits in current educational curricula for environmen-
tal medicine, and recommended improvements. At a minimum, primary care physicians and nurses
should be able to identify possible occupationally or environmentally induced conditions and make
appropriate referrals (IOM 1988).The 1993 report offered additional recommendations: eliciting a
detailed environmental history, recognizing signs and symptoms, understanding the relevant toxi-
cology and exposure factors, identifying the available resources for assistance, and understanding
legal and ethical responsibilities.
Extensive resources on pesticides can be found at www.neetf.org/Health/Resources/healthcare.htm
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The National Strategies for Health Care Providers: Pesticides Initiative (http://www.neetf.org/Health/
providers/index.shtm) began in 1998 and is a partnership of the U.S. Environmental Protection
Agency (EPA) and The National Environmental Education &Training Foundation (NEETF), in collab-
oration with the U.S. Department of Health and Human Services (DHHS),the U.S. Department of
Agriculture (USDA), and the U.S. Department of Labor (DOL).
From the outset, this national interagency initiative has been conceived of as a long-term effort.
Working with an expert panel and multiple workgroups, the initiative sought a broad-scale
involvement of stakeholders, including federal agencies, academic institutions, professional organi-
zations, foundations, farmworker and farm groups, industry and trade associations. As part of this
initiative, EPA issued a substantially revised edition of Recognition and Management of Pesticide
Poisonings (Reigart and Roberts, 1999), a landmark handbook used by health care professionals
around the world. In 2002, the Implementation Plan: National Strategies for Health Care Providers:
Pesticides Initiative was published (NEETF, 2002). It outlines a set of strategies to move the initiative
forward in education, practice, and resource development.
Role of Health Care Providers
Primary care providers are on the frontlines of health care. Patients and communities often look to
their primary care providers as important sources of information and guidance on suspected pesti-
cide-related health conditions. Primary care providers can play a key role in identifying and amelio- c
rating potential pesticide poisonings and exposure - but only if they are prepared for this role and ฐ
know where to turn for assistance. Providers must be able to problem solve with patients who
think an exposure has occurred. With the potential effects of pesticide exposure on health so
widespread and consequential, an understanding of the pathophysiology and management of
pesticide exposure and toxicity is important in all areas of health care practice (general and
advanced/specialty), including assessment, diagnosis, planning intervention/treatment, and evalu-
ation (IOM 1993, Pope et al, 1995).
Prevention, health maintenance, and illness and injury management are included in the manage-
ment of pesticide exposure. Essential skills include a basic understanding of the health hazards of
pesticides, prevention and abatement methods, recognition, diagnosis,and treatment of pesticide
exposure, and utilization of resources for referral and assistance at both a patient and community-
based level. In addition to direct patient interventions, health care providers may assume the role
of educator, advocate, and policy planner on behalf of an individual patient or population of
patients.
When pesticide toxicity is discussed, most people usually think of an acute pesticide poisoning
incident in an agricultural setting. However, pesticide exposure regularly occurs in settings outside
agriculture as well, including urban environments, homes, and schools. Pesticides are also of con-
cern because of potential chronic health effects from long-term exposures. This is particularly
important for children, given their developmental risks for pesticide exposure and due to pesticide
residues on food.
Health care providers must be aware of the potential effects of pesticide exposure on high-risk
groups such as infants, children, the elderly, and those with compromised immune systems. The
Extensive resources on pesticides can be found at www.neetf.org/Health/Resources/healthcare.htm
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issue of children's susceptibility prompted Congress to enact the Food Quality Protection Act of
1996, the highlights of which are discussed in Competency I-3 of this document. Epidemiological
studies tend to focus on worker exposure. Since the majority of the pesticide applicator work
force is overwhelmingly male, studies of women exposed to pesticides at work are few. In the
absence of good data, pregnant women should take extra care to avoid exposure to pesticides.
A comprehensive approach to nursing and medical practice requires awareness, recognition, and
treatment of critical factors that affect individual and community health, even if these factors are
not obvious at first to patients or providers.This initiative recognizes the unique role and functions
served by registered nurses and advanced practice nurses. In urban, suburban, and rural settings,
nurses are often the initial, and sometimes only, points of contact for people seeking health care. In
the context of a busy medical practice, physicians often rely on nurses to provide more in-depth
patient education on many preventive issues, and pesticide-related exposures may be included
among these. Community or home health nurses also may visit patients in their homes, work-
places, and local communities, thus gaining firsthand knowledge of potential pesticide exposures
in these settings (Pope et al, 1995). Where possible, the physician should maintain community
contacts as well, as is the case with those with particular expertise in environmental health and
occupational medicine. The opportunity for close interactions when health care providers are
"onsite" provides a better chance of detecting previously unrecognized health problems related to
pesticide exposure.
Finally, health care providers have a role to play in minimizing the unnecessary use of pesticides.
Integrated Pest Management (IPM) is a sustainable approach aimed at providing effective control
of pest populations while minimizing economic, health, and environmental risks. Rather than rely-
ing solely on pesticide applications, IPM employs other tactics as well, including biological control
controls (parasites and predators); cultural controls such as mulching to prevent weeds, varying
planting dates to avoid susceptible windows for pest infestation, etc; and physical controls such as
installation of screens, improved sanitation practices, etc. Based on the identification of pests, mon-
itoring of pest populations, assessment of damage levels, and knowledge of available pest man-
agement strategies, an IPM specialist can provide intelligent advice. Many successful IPM pro-
grams have reduced energy inputs and pesticide use. Health care providers should encourage
patients and communities to contact their local Cooperative Extension offices (see the county list-
ings of the local telephone book) for advice on IPM programs and strategies suitable for their
homes, yards, schools, and communities.
Incorporation into the Curriculum
Although some progress has been made in introducing environmental health issues into the cur-
riculum of medical and nursing schools, more remains to be done. And yet, it is hard to find space
in the already crowded curricula of medical and nursing schools for new topics and subject areas.
To facilitate integration, this document notes possible "Points of Insertion" for each competency.
We strongly recommend that pesticide content be integrated into existing adult health, pediatric,
research, ethical/legal units of instruction and community health nursing courses, both didactic
and clinical. This can be done, for example, by using pesticides to enhance existing case studies, or
as exemplars.
Extensive resources on pesticides can be found at www.neetf.org/Health/Resources/healthcare.htm
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The changing worlds of medical and nursing education present a challenge in identifying where in
the curriculum a particular pesticide topic would be most appropriate. Curricula are highly variable
in the form and substance of topics. Some schools of nursing and particularly some schools of
medicine have adopted Problem Based Learning or other case-based methods or organ system
approaches to all or most of their curricula. Many schools continue to use a traditional curriculum
and maintain a traditional governance structure based on departmental control of curriculum
structure. A topic such as pesticides may be adapted by faculties with either style of curriculum,
but the vehicle used may require modification of the teaching method and style.
In suggesting points of insertion into the curriculum, we have included such components as envi-
ronmental or preventive medicine electives, public sector medicine courses, etc. These serve only as
examples; many schools will have other courses or departments that the material could fit into
equally well. Schools that do not have such courses in place are certainly encouraged to consider
adding them.
The competencies proposed in this document recommend integration of content into medical
and nursing curricula at all levels. Competency I, Knowledge and Concepts of Pesticides, is consid-
ered the most important and basic level that should be incorporated into all curricula as a top pri-
ority. Content items marked with an asterisk (*) are considered appropriate for the more
advanced health care student (i.e., residents or nurse practitioner students), in addition to the
other content items.
c
The role of faculty development in advancing a pesticide-related curriculum cannot be over- ฐ
emphasized. If one or more faculty members are identified as having a special interest or ability in
Environmental Health/Toxicology, those members may serve as a resource for other faculty mem-
bers, especially when the small group clinical case scenario method is used.
The next section of this document contains a brief "primer" on pesticides, with background materi-
al on pesticide regulation, uses, exposures, and absorption. The remainder of the document out-
lines the five educational competencies - the information content, suggested points of insertion,
and a sampling of relevant resources. Readers are encouraged to consult the extensive resources
available on the Internet. Useful starting points include: the National Pesticide Information Center
(http://npic.orst.edu), and NEETF's Online Pesticide Resources Library
(www.neetf.org/Health/Resources/healthcare.htm).
References
Institute of Medicine (IOM). Role of the Primary Care Physician in Occupational and Environmental
Medicine. IOM Report, Division of Health Promotion and Disease Prevention, Washington, DC:
National Academy Press; 1988.
Institute of Medicine. Addressing the Physician Shortage in Occupational and Environmental
Medicine. Washington, DC: National Academy Press; 1991.
Institute of Medicine. Environmental Medicine and the Medical School Curriculum. Washington, DC:
National Academy Press; 1993.
Extensive resources on pesticides can be found at www.neetf.org/Health/Resources/healthcare.htm
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The National Environmental Education & Training Foundation (NEETF). Implementation Plan:
National Strategies for Health Care Providers: Pesticides Initiative. Washington, DC: NEETF, U.S. EPA,
U.S. Dept. of Agriculture, U.S. Dept. of Health and Human Services, U.S. Dept. of Labor; March 2002.
Pope AM, Snyder M, Mood L, for Committee on Enhancing Environmental Health Content in
Practice, Institute of Medicine. Nursing, Health, and the Environment: Strengthening the Relationship
to Improve the Public's Health. Washington, DC: National Academy Press; 1995.
Reigart JR, Roberts JR. Recognition and Management of Pesticide Poisonings, 5th ed. Washington, DC:
U.S. Environmental Protection Agency; 1999. EPA#735-R-98-003.
o
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Extensive resources on pesticides can be found at www.neetf.org/Health/Resources/healthcare.htm
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A Pesticide Primer
A pesticide is defined as any substance that is used to kill or otherwise control a pest.The term "pesti-
cide" includes insecticides, herbicides,fumigants, fungicides, repellents, rodenticides, and disinfectants.
About 940 million pounds of pesticidal active ingredients are applied yearly to agricultural land to
control insects, weeds,fungi, nematodes, bacteria, and other crop pests (Aspelin and Grube, 1999). This
figure accounts for about three-quarters of the total used, with the remainder split about evenly
between applications by homeowners and professional pest control applicators (Aspelin and Grube,
1999). However, it should be noted that on a per-acre basis, homeowners use many times more pesti-
cide on their lawns and gardens than the amounts applied on agricultural land (Robinson et al, 1994).
Pesticides in use in the U.S. today differ in significant ways from the pesticides relied on from the
1940's through the 1970's. DDT and several other organochlorine insecticides have long since
been banned from use in this country. Although these older products tended to have low acute
toxicity to humans, they had very long half-lives. Their persistence in the environment, coupled
with their tendency to be stored in fat, allowed them to accumulate in living organisms and to bio-
concentrate in the food chain.
By contrast, the newer pesticides tend to have shorter half-lives and to be water-soluble, so that
they are excreted (primarily in urine) and are less persistent in the environment. However, the acute
toxicity of some of the newer products (notably organophosphate and carbamate insecticides) is
much higher than the older products, making them more hazardous for users to handle. In addi-
tion, their increased water solubility raises the likelihood of contamination of ground water as a <
result of improper application, poor well construction, improper disposal, or leaching. Whereas earli-
er pesticides were aimed at controlling a broad spectrum of pests, many pesticides today are far
more specific in their action. Also, today's pesticides are effective at much smaller concentrations
than in the past. Together, the latter two factors mean that a larger variety of different products are
in use, but in a far smaller volume (ounces per acre, rather than pounds per acre) than in the past.
Nevertheless, overall pesticide use (Ibs/yr) has steadily increased over the years. 11
By volume, herbicides account for the majority of applications to agricultural crops. Other uses of
pesticides include applications to:
forests to control insects and understory vegetation;
rights-of-way along railroads and under electric wires to control vegetation;
boat hulls to control fouling organisms;
houses, schools, and commercial and office buildings to control insects, rodents, and fungi;
landscapes, parks, and recreational areas to control weeds, insects, and disease pests;
aquatic sites to control mosquitoes and weeds;
wood products to control wood-destroying organisms;
food preparation areas to control insects and rodents;
human skin to kill or repel insects;
household pets to control fleas and ticks; and
livestock to control insects and other pests.
Extensive resources on pesticides can be found at www.neetf.org/Health/Resources/healthcare.htm
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When used properly, pesticides can benefit humans and the environment. Pesticides control
important crop pests, ensuring a plentiful and diverse food supply. They prevent disease in
humans and animals, and control pests that infest homes, schools, hospitals, food warehouses, and
other buildings.
The remainder of this section provides an overview of the regulation of pesticides, effects of pesti-
cidal formulations on potential absorption into the body, and patterns of exposure to pesticides.
Regulatory Context
In the United States, the Environmental Protection Agency (EPA) is responsible for regulation of
pesticides. Pesticides may only be sold in the U.S. if EPA has reviewed and approved the manufac-
turer's application for registration, and determined that use of the product will not present an
unreasonable risk to humans or the environment. A pesticide that passes EPA's scrutiny will be
registered for use on specific crops or sites, and must be sold with specific label directions for how
the product is to be used.
Nearly 900 active ingredients and more than 20,000 pesticide products are registered for use in
the U.S. (Aspelin and Grube, 1999). Each pesticide product consists of one or more active ingredi-
ents (the substance that kills or controls the pest) and may have one or more inert ingredients
(substances for which no pest control claim is made). Inert ingredients are added for a number of
reasons, such as to make the product safer or easier to apply, or to increase the efficacy of the
active ingredient by making it last longer in the range of the target pest. Inert ingredients may
Q.
n> also cause adverse effects in people and/or the environment. As of the writing of this document,
inert ingredients are not required to be identified on the pesticide label, although their percentage
must be indicated. EPA is considering changes that would require some or all inert ingredients to
be identified on the label.
A single active ingredient may be registered for different uses - such as several different crops,
a yard, and a food warehouse - and the concentration, application method, and application
rate may differ for each use. Also, products with the same active ingredient may include differ-
ent inert ingredients. For most applications, such as crops, pets, and livestock, pesticide usage
12 ) patterns are seasonal. For other uses, such as structural pest control and greenhouse situa-
tions, pesticide applications may continue throughout the year. Pesticides may be applied as
sprays, dusts, granules, baits, fumigants, injection systems, roll-on applications, shampoos or
animal dips, and other methods.
Each active ingredient intended for use on food must have a food tolerance established. The tol-
erance is the legal amount of residue that may remain in or on the food at harvest. EPA sets a spe-
cific tolerance for each pesticide/crop, pesticide/meat, or pesticide/meat byproduct combination.
Pesticides used on food or feed crops often have a pre-harvest interval (PHI) established by EPA
that appears on the product label. The PHI is the amount of time that must pass before a treated
crop can be harvested. The PHI is important in allowing time for the pesticide to degrade to a level
at or below the legal tolerance.
In setting a tolerance, EPA considers the relative proportion of each food in the diet, as well as the
acute and chronic toxicity of the active ingredient. Differences in the foods most relied on for
infants and children's diets are also considered. Under the Food Quality Protection Act of 1996,
Extensive resources on pesticides can be found at www.neetf org/Health/Resources/healthcare htm
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EPA was charged with reviewing all tolerances for existing pesticides within ten years to determine
that they pose a "reasonable certainty of no harm"from aggregate and cumulative exposures.
Aggregate exposure refers to exposures from all sources, including residues in food and drinking
water, occupational exposures, and incidental exposures. Cumulative exposure refers to exposure
to different pesticides that share a common mechanism of action.
Pesticides that may cause unreasonable adverse effects on humans and/or the environment even
when used according to label directions are classified by EPA as restricted use pesticides (RUP).
These products may be purchased and used only by certified applicators, or by someone under
the supervision of a certified applicator. In order to become certified, applicators must receive
instruction in the proper use of RUPs and, in most states, pass a written examination. By federal
law, all pesticides not classified as RUP are available for sale to, and use by, anyone without a
requirement for special training. However, many states have stricter pesticide laws requiring train-
ing and/or certification for anyone who applies pesticides to someone else's property, regardless of
whether the product used is classified as RUP.
mates that approximately 250-500
tural workers (including pซซ
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About three-fourths of U.S. households use pesticides (Aspelin and Grube, 1999). Few homeown-
ers who use pesticides themselves have received any training. Because products can be purchased
at grocery stores, hardware stores, and pharmacies, consumers may assume that the products they
use themselves do not pose potential hazards to health or the environment. In fact, most products
marketed for the homeowner contain the same active and inert ingredients as those for commer-
cial markets, although usually at lower concentrations.
Pesticides are designed to be toxic to the pests they control, but they may also pose risks to
humans and wildlife. Therefore, it is extremely important that pesticides be used only in strict
accordance with the label. A pesticide should never be used on a crop, plant, or site for which it is
not labeled, and should never be applied more frequently or at a higher rate than the label allows.
Potential risks can be minimized by choosing alternative measures when feasible and by using
pesticides sparingly. When applying pesticides, care should be given to wearing the proper pro-
tective gear (as indicated on the label), and applying, storing, and disposing of pesticides properly.
Consideration should also be given to the presence of children in the area. Children are more apt
to have extended contact with ground level surfaces and may have extended contact with pets.
Spot treatments, directed or crack and crevice sprays, baits, gels, and pastes pose less potential for
exposure than broadcast treatments.
Exposure and Absorption
There are three main routes of exposure: oral, inhalation, and dermal. (Eye exposure is considered a
special type of dermal exposure.) Most pesticide active ingredients can be absorbed to some extent
by all three routes, but the formulation of a product has a large effect on potential absorption:
Emulsifiable concentrates (liquid active ingredient with one or more petroleum-based solvents
and an agent that allows the product to form an emulsion when mixed with water) and ultra-
low-volume concentrates (products that may approach 100% active ingredient and are
designed to be used as is or diluted with only very small quantities of water) are easily absorbed
through the skin.
Wettable powders (dry, finely ground formulations designed to be mixed with water) are less
14 ) easily absorbed than emulsifiable concentrates and other liquid pesticide formulations, but
the powder may be inhaled during the mixing/loading process.
Fumigants (pesticides that form poisonous gases when applied) are highly toxic to humans
and all other living organisms. Some active ingredients are liquids when packaged under high
pressure but change to gases when released. Others are volatile liquids when enclosed in an
ordinary container and so are not formulated under pressure. Still others are solids that
release gases when applied under conditions of high humidity or in the presence of water
vapor. Fumigants can injure workers severely through inhalation and dermal exposure even in
a short period of exposure. They require the use of specialized protective equipment, includ-
ing respirators.
Aerosols (typically, low percentage of active ingredient sprayed out as a fine mist or fog) are
difficult to contain on site and are easily inhaled.
CL
rt>
Extensive resources on pesticides can be found at www.neetf.org/Health/Resources/healthcare.htm
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Dusts (typically, a low percentage of active ingredient plus a very fine, dry, inert carrier made
from talc, chalk, clay, nut hulls, or volcanic ash) are applied as dry material. Dusts are less easily
absorbed through the skin but are easily inhaled. Some dusts, such as sulfur, contain high lev-
els of active ingredient. Sulfur is one of the most heavily used pesticides in California and has
been responsible for the highest number of pesticide-related illnesses/injuries there.
Granules (low percentage of active ingredient with larger, heavier absorptive materials such
as clay, corn cobs, or walnut shells forming the carrier) are also applied dry but pose less risk of
inhalation.
Baits (low percentage of active ingredient mixed with food or another pest-attractive substance)
may pose an ingestion hazard if they are placed where children or pets can access them.
Patterns of Exposure
Three types of exposure patterns are considered here: occupational, incidental, and intentional exposures.
Occupational Exposures
People who work in manufacturing or distribution plants for pesticide products have the most
potential exposure to pesticides, but they often have relatively low actual exposure as a result of the
installation of engineering controls at the facilities and use of personal protective equipment
(PPE). Wettable powders and most liquid pesticide products, except those specifically designed for
use by homeowners, require dilution with water, oil, or other solvent prior to application.Those who
mix and load the concentrates into the application equipment also have a high potential for expo-
sure, especially if they do not wear the PPE designated on the product label. Farm workers, migrant
laborers, and others who must reenter treated areas to perform tasks such as cultivation, harvest,
irrigation, and equipment maintenance, may be exposed to pesticide residues remaining on the
plants, but their jobs may require them to spend more time in treated areas than the applicator.
Since the majority of the pesticide applicator work force is overwhelmingly male, there are few
studies of women exposed to pesticides at work. Women who work with pesticides may want to
consider switching to other tasks, if possible, at least during the first trimester of pregnancy, or
should maximize their use of personal protective clothing. 15
EPA's Worker Protection Standard is the federal regulation that applies to agricultural pesticide
handlers and field workers. It includes requirements for: posted warnings about pesticide applica-
tions, use of personal protective equipment (PPE), restrictions on re-entry into treated areas,
decontamination, emergency medical assistance, and pesticide safety training.
To keep exposures at safe levels, the pesticide product label specifies whether PPE must be worn; the
length of time that workers must wait after treatment before reentering a treated area without PPE
(called the restricted entry interval or REI);and whether training is required for workers and pesti-
cide handlers on farms, forests, greenhouses, and nurseries. As of the writing of this document, the
REI applies only to workers, not to the general public. EPA is currently considering instituting sepa-
rate REIs for others, including, for example, consumers who enter treated "pick-your-own" operations.
The rationale is that workers may be in the field eight hours per day for many days, while a consumer
would only be in the field for a short period of time. Thus, the exposure potential for workers is much
greater than for consumers, and the REI established for each type of reentry might differ.
Extensive resources on pesticides can be found at www neetf.org/Health/Resources/healthcare.htm
-------
The type of equipment used in applying pesticides provides different opportunities for exposure.
The selection of equipment varies with the crop or site, the formulation of the product, the pest
being targeted, the pesticide chosen, and the economic situation of the applicator or business.
Airplanes and helicopters, tractor-mounted sprayers, backpack sprayers, canister sprayers (com-
monly referred to as B&G type), granular spreaders, and other equipment may be used. Some
application equipment, such as closed cab systems where the operator is separated from the sur-
rounding environment, provides very good protection from exposure. Sometimes pesticides can
be loaded through closed systems, where there is very little opportunity for exposure of the
mixer/loader. Many structural applications of liquid pesticides call for crack and crevice treatment,
i.e., a stream of pesticide is directed into the angles formed where floors and walls meet or other
such corners along which pests run, rather than a broadcast or space spray. Homeowners typically
have the least specialized application equipment, but they usually apply dilute materials.
Many types of personal protective equipment are available, and label directions specify what
equipment must be worn when performing specific tasks, such as mixing and loading, applying, or
reentering treated areas. In general, the hands and forearms receive the most exposure.
Depending on the application equipment, splashback may occur to the lower legs, drift may fall on
the head and ears, or a vortex effect may be generated, resulting in contamination of the back of
the neck. A full protective suit, gloves, respirator, hood, and boots, while providing excellent pesti-
cide protection, constitutes a very hot outfit and may present a heat stress hazard. Applicators
may also be overexposed if equipment is not properly maintained, e.g., when respirator filters are
not changed often enough.
Incidental Exposures
Outside of occupational exposures, people may be exposed to pesticides through residues in foods
and water; in and around their apartment buildings, homes, and yards; in their office buildings,
schools, and public buildings; and at recreational areas. National attention is focusing interest on
integrated pest management (IPM) strategies rather than relying solely on conventional pesticide
treatments in and around schools and public buildings. Long utilized in many agricultural systems,
IPM combines physical, cultural, biological, and other means of pest control as well as the use of
pesticides to minimize the potential adverse effects on human health and the environment. IPM
considers aspects such as pest detection, quantification of threshold levels for treatment, placement
16 of pesticide, and timing of applications in the interests of maximizing crop yield, aesthetic benefits,
J and public health. Pesticides may be needed, for instance, to control cockroaches and rodents in
school cafeterias, but they may be applied as baits contained in bait stations, with little opportunity
for exposure of children and staff. Herbicides are frequently needed to control weeds on athletic
fields to prevent potential injuries associated with uneven playing surfaces, but they may be
applied as spot treatments rather than broadcast applications.
Many homeowners have herbicides and fungicides applied to their lawns throughout the growing
season either by themselves or by commercial firms. Consumers also use insecticides, herbicides,
and fungicides on their own fruit and vegetable gardens and inside their homes and apartments.
Because members of the general public do not have special training or knowledge about the
proper use of pesticides, they may be more likely to misuse pesticides than trained commercial
applicators. They may use a pesticide at a higher rate or more often than the label allows, or not
use PPE to minimize exposure.
Another problem is use of a pesticide on a site for which the product is not registered, e.g., applica-
tion of pesticides labeled for use on ornamentals to vegetable and fruit gardens, or use of a pesti-
Extensive resources on pesticides can be found at www.neetf.org/Health/Resources/healthcare.htm
-------
cide labeled for outdoor application only to areas inside homes or apartments. Some products are
not registered for additional sites only because there has been no particular need for them (for
instance, if more effective products already exist for such use), but in other cases, the product is
not registered for a particular site because it would present a hazard. A common source of acci-
dental exposure in the home is improper storage of household pesticides, in areas accessible to
children. Children and others have also been injured when empty pesticide containers have been
re-used for other purposes, as residues remain in the containers.
Infants, children, the elderly, and those with compromised immune systems are at special risk if
overexposed to pesticides. Children incur more risk than adults due to the immature nature of
their immune system, larger surface area to body weight ration, higher metabolic rate, different
diet patterns and activities, different exposure profiles, and hormonal changes at puberty.
Intentional Exposures
Suicide attempts, primarily through ingestion, have accounted for deaths and serious injuries. A
total of 808 cases of suicide attempts involving pesticides were reported to Poison Control Centers
in 1 995 (Litovitz et al, 1 996). Pesticides used in suicide attempts are often those commonly found
in homes or on farms.
Pesticides are thought to be a possible choice for terrorists. Even products not considered to be
highly acutely toxic could disrupt the infrastructure and/or cause panic if introduced into water
sources, sprayed over populated areas, or otherwise misused.
References
Aspelin AUGrube AH. Pesticide Industry Sales and Usage: 1996and 1 997 Market Estimates.
Washington, DC: U.S. EPA, Office of Pesticide Programs, 1 999.
Blondell J. Epidemiology of pesticide poisonings in the U.S., with special reference to occupational
cases. Occupational Medicine: State of the Art Reviews, vol. 1 2.2, April-June, 1 997.
Institute of Medicine. Environmental Medicine and the Medical School Curriculum. Washington, DC:
National Academy Press; 1 993.
Litovitz TL, Felberg L, White S, KleinSchwartz W. 7995 Annual Report of the American Association of
Poison Control Centers Toxic Exposure Surveillance System. American Journal of Emergency Medicine
14(5):487-537.1996.
Pope AM, Snyder M, Mood L, for Committee on Enhancing Environmental Health Content in
Practice, Institute of Medicine. Nursing, Health, and the Environment: Strengthening the Relationship
to Improve the Public's Health. Washington, DC: National Academy Press; 1 995.
Robinson JC, Pease WS, Albright DS, Morello-Frosch RA. Pesticides in the Home and Community:
Health Risks and Policy Alternatives. CPS Report. Berkeley, CA: California Policy Seminar, 1994.
U.S. EPA, Regulatory Impact of Worker Protection Standard for Agricultural Pesticides. 1 992.
Whitmore RW, Kelly JE, Reading PL. National Home and Garden Pesticide Survey: Final Report, Volume
1, 1992. Research Triangle Park, NC: Research Triangle Institute, RTI/5 100.1 21 F, 1992.
Extensive resources on pesticides can be found at www.neetf.org/Health/Resources/healthcare.htm
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Pesticide Competency Guidelines for
Medical and Nursing Education
Content, Insertion Points, and Resources for Educational Curricula
The Pesticide Education Competencies outlined in this document are intended to apply to medical
and nursing schools as guidelines in training students to recognize, manage, and prevent pesti-
cide-related illness. The guidelines laid out below are intended as an accompaniment to the
Recognition and Management of Pesticide Poisonings (U.S. EPA, 1999) handbook for health profes-
sionals.
The five competencies (see list on next page) were developed as part of the Draft Implementation
Plan (NEETF, 2000) of the National Strategies for Health Care Providers: Pesticides Initiative. An initial
start at defining competencies was carried out by a subgroup of the Education Workgroup in May
1999, and was further elaborated in July 1999 by a small committee. This set of five competencies
was accepted by the full Education Workgroup. They are derived from a combination of recom-
mendations from the Institute of Medicine for incorporating environmental health into medicine
o
3 and nursing curricula. Competency I, Knowledge and Concepts of Pesticides, is considered the
most important and basic level that should be incorporated into all curricula as a top priority.
For each competency area, we specify the content of the information to be learned, identify points
in the curriculum where this information might be inserted, and suggest resources to consult. An
asterisk (*) denotes material for residents and nurse practitioner students over and above that of
the undergraduate.
We strongly recommend that pesticide content be integrated into existing adult health, pediatric,
research, ethical/legal units of instruction and community health nursing courses, both didactic
and clinical. This can be done, for example, by using pesticides to enhance existing case studies, or
18 ) as exemplars. In suggesting points of insertion into the curriculum, we have included such compo-
nents as environmental or preventive medicine electives, public sector medicine courses, etc.
These serve only as examples; many schools will have other courses or departments that the mate-
rial could fit into equally well, such as Problem-Based Learning.
A more complete resource library with links to sources of information is available online at
http://www.neetf.org/Health/Resources/healthcare.htm.
Extensive resources on pesticides can be found at www neetf.org/Health/Resources/healthcare.htm
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Five Educational Competencies
Competency I: Knowledge and Concepts of Pesticides
1-1. Principles of Environmental and Occupational Health Related to Pesticides
a. Understand the basics of environmental and occupational health
b. Understand the broad spectrum of chemicals classified as pesticides and their areas of use
c. Understand mechanisms and pathways of exposure
d.*Understand temporal relationship between exposure and symptom
e. Understand advanced toxicology, specifically related to organophosphates, carbamates, and
pyrethroids
1-2. Individual Patient Knowledge and Skills
a. Relate the environment in which the patient (and family) lives, works, and plays to potential hazards
and exposures
b. Identify risk factors for occupational pesticide exposures
c. Identify risk factors for pesticide exposures at home
d. Recognize that other family members may be ill from pesticide exposure in addition to index patient
-D
e. Understand potential moral, ethical, and legal implications for patients of reporting and referral -
1-3. Population-Based Health Knowledge and Skills
* An asterisk denotes material for residents and nurse practitioner students over and above that of the undergraduate.
Extensive resources on pesticides can be found at www neetf.org/Health/Resources/healthcare.htm
a. Understand the concept of population-based health as it pertains to pesticide exposure o.
b. Recognize socioeconomic impacts of pesticide-related illness
c. Understand potential moral, ethical, and legal implications for the community of reporting and referral
d. Possess a basic awareness of the role of prevention, and general awareness of benefits of alternatives
to conventional pest control.
Competency II: Diagnosis and Assessment
11-1. Environmental History: Be able to take an environmental history 19
11-2. Differential Diagnosis: Be able to consider pesticides in a differential diagnosis of poisoning
and be aware that signs and symptoms of pesticide over-exposure may be non-specific
11-3. Signs and Symptoms: Recognize signs and symptoms of pesticide over-exposure, especially
widely used cholinesterase-inhibitors and pyrethroids insecticides
-------
Competency III: Treatment, Intervention, and Referrals
111-1 .Treatment: Be able to effectively treat health conditions related to pesticide over-exposures
111-2. Intervention: Be able to advise health care providers on decontaminating patients and the
environment following over-exposure
111-3. Referrals: Understand when to make referrals to appropriate occupational/environmental
health specialists
IV-4. Follow-Up: Be able to arrange appropriate patient follow-up
Competency IV: Risk Communication
IV-1. Patient Education: Be able to educate patients about basic routes of exposure and absorp-
tion, and how to minimize exposure to pesticides
IV-2. Labels: Be able to advise patients on how to read pesticide labels
~ Competency V: Reporting Requirements and Regulations
n
o
3 V-1. Surveillance Needs: Understand the importance of surveillance and incident reporting
-a
V-2. Reporting: Know how to participate in mandatory state surveillance systems and reporting
requirements
o
V-3. Regulations: Understand other legal and regulatory provisions that have implications for
health care providers
3
V-4. *Legal Framework: Understand framework of federal laws that address pesticides and pesti-
cide exposures
20 V-5. Ethical, Legal, Advocacy: Understand ethical, legal, and advocacy roles of health care
providers in pesticide exposure incidents
* An asterisk denotes material for residents and nurse practitioner students over and above that of the undergraduate.
Extensive resources on pesticides can be found at www.neetf.org/Health/Resources/healthcare.htm
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Competency I:
Knowledge and Concepts of Pesticides
1-1. Principles of Environmental and Occupational Health Related to
Pesticides.
1-1 a. Understand basics of environmental and occupational health.
Content
The student should know the primary environmental health effects that patients encounter
today, including issues in their local community as well as national and international environ-
mental health problems. ฃ
Points of Insertion
Nursing
I Community Health or Public Health Nursing courses, both didactic courses and clinical
o
Know likely household exposures.
Know the primary issues that are unique to children, vulnerable populations at disproportion-
ate risk, and the elderly. ^
Know the primary occupational health hazards that workers face. Know how to take an
Occupational and Environmental Medicine (OEM) history. 3
o
CU
a
rotations u
I Home Health Nursing courses (didactic and clinical) [ 21
> Adult Health Nursing or Occupational Health Nursing courses
I Units of instruction on health promotion, protection and prevention of illness and injury
I Units of instruction on current trends and issues in nursing practice
Medicine
I 3rd year medical school clerkship in Pediatrics, Family Medicine, and Internal Medicine
may all have components for such clinical and epidemiological information
I A 4th year elective in the medical school curriculum on Environmental Health, Preventive
Health, Epidemiology, or similar subject may be considered or already exist in a school's
curriculum
Extensive resources on pesticides can be found at www.neetf.org/Health/Resources/healthcare.htm
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1-1 b. Understand the broad spectrum of chemicals classified as pesticides and
their areas of use.
Content
The student should be aware of various types of pesticides, especially the following categories and
selected agents within each category. Students should be aware that brand names for pesticide
products change from year to year, therefore the focus should be on active ingredients.
Insecticides
I Agents that inhibit cholinesterase: organophosphates and n-methyl carbamates
I Pyrethrins (ocloresin extract of chrysanthemum) and pyrethroids (the synthetic derivative
of natural pyrethrins. A clinically recognizable example of a pyrethroid is permethrin
(Nixฎ, Elimiteฎ); however, there are many other brand names of permethrin, and many
other pyrethroids.
o I Organochlorines
I DEET
I Boric Acid
I Fluorides
^ I Nicotine (There were still reports of toxicity in the 1990s from old stores of nicotine.)
o I Arsenicals (Rarely used anymore, with the exception of some ant bait stations.)
3
o
g
ft
g Herbicides
TO
Sฐ
i Chlorophenoxy herbicides (2-4D, mecoprop are both widely available)
I Paraquat and diquat
I Pentachlorophenol and dinitrocresol (wood preservatives)
I Copper chromium arsenate (Primary source of wood preservative for decks, fences, and
children's wood playground sets - discontinued in 2003.)
TJ
ft
Fumigants
Q.
ft
I Include: cyanide, 1,3-dichloropropane, metam-sodium, methylbromide, naphthalene,
phosphine gas (from aluminum phosphide)
I Accidental dermal exposure and inhalation, especially after premature re-entry, can cause
severe toxicity. Most fatalities are due to suicidal ingestion, because of the high concen-
tration of exposure.
Rodenticides
I Warfarin-related compounds: warfarin, coumarins, brodifacoum, difenacoum (so-called
"super warfarins")
I Others: thallium, zinc phosphide, sodium fluoroacetate
Fungicides
I Include: hexachlorobenzene, thiram, maneb, methylmercury compounds
Extensive resources on pesticides can be found at www.neetf.org/Health/Resources/healthcare.htm
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Disinfectants
i Agents used for sanitization and sterilization in the home and hospital
i Registered as pesticides by the U.S. EPA
I Examples include alcohols, chlorhexidine, hypochlorites, iodines, phenols, and pine oil.
1-1 c. Understand mechanisms and pathways of exposure.
Content
Know the most common patterns of exposure:
I Unintentional (common exposure pattern in children)
i For acute poisoning, pathway is generally intestinal absorption from unintentional
ingestion.
I Inhalation exposure and dermal from surrounding environment
I Hand to mouth activity in children
I Occupational
I Inhalation is a common pathway. a
I Dermal exposure is important, especially for pesticide applications.
I Ingestion is less common in the occupational setting, but can occur through failure to ฐ
wear protective gloves and following poor hygiene practices.
Dl
a
Intentional (suicide attempt/intentional abuse)
o
I Ingestion is primary pathway.
I Inhalation is another pathway, although primary agents of abuse in this manner are
non-pesticide chemicals (aromatic solvents).
HI
Know the biochemical mechanism of action for organophosphates/ carbamates. a
o
u
I Understand that there are many different pesticides with different methods of action. 23
I Organophosphates and carbamates:
I Mechanism of action: Inhibition of the enzyme acetylcholinesterase (AChase)
I This is accomplished by the binding of the pesticide to the AChase, forming either a
carbamyl-AChase complex or a phosphoryl-AChase complex.
I Result is an accumulation of ACH at synapse site, causing unopposed cholinergic
stimulation.
Know that pyrethroids may sometimes present with similar clinical findings as
cholinesterase inhibitors, but the method of action is entirely different.
Extensive resources on pesticides can be found at www.neetf.org/Health/Resources/healthcare.htm
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*Md. Understand temporal relationship between exposure and symptom.
Content
Know that onset of symptoms of acute poisoning will occur shortly (within 24-48 hours) after
exposure.
Know that some chronic symptoms may follow an acute exposure, such as organophosphate-
induced delayed neuropathy with onset a few weeks after exposure.
Know that in cases of continued but lower level exposure (chronic or subacute exposure),
symptoms may present much later. Examples include possible links to cancer following long-
term pesticide exposure.
*l-1e. Understand advanced toxicology, specifically related to organophosphates,
o carbamates, and pyrethroids.
3
Content
Know that cholinesterase inhibition is readily and spontaneously reversible with carbamate
poisoning. Poisoning due to carbamates therefore does not require the use of pralidoxime.
0 However, cholinesterase inhibition due to organophosphate poisoning is less reversible. The
enzyme can be reactivated by pralidoxime, especially in the first 48 hours following
organophosphate poisoning.
o Know that pyrethroids are rapidly metabolized in the mammalian liver, accounting for their
ฃ relatively lower toxicity than organophosphates.
T3
Know that cyano-pyrethroids are more toxic than other pyrethroids.
Points of Insertion for 1-1 (b-e)
Undergraduate Nursing
24
I Pathophysiology course unit
> Pharmacology course unit
I Community Health or Public Health Nursing courses (didactic and clinical)
Advanced Practice Nursing
I Environmental Health or Occupational Health program course, including a course in
Toxicology and applied in Environmental or Occupational Health Nursing didactic and
clinical courses
Undergraduate Medicine
I Pharmacology class in 2nd year
I Clinical rotations tailored to specific patient encounters during 3rd year
I ER rotation in 4th year
Extensive resources on pesticides can be found at www.neetf.org/Health/Resources/healthcare.htm
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Residency
I Elective in Toxicology or Environmental Medicine, ER rotation, clinical patient case discussions
Resources for Competency 1-1 (a-e)
Online Resources:
I State and Regional Poison Control Centers: http://npic.orst.edu/poison.htm
I National Pesticide Information Center (EPA-funded): http://npic.orst.edu
I EPA's Pesticide Management Resource Guide (PMReG):
www.epa.gov/oppfead1/pmreg/index.html
I NEETF's Pesticides Resource Library: www.neetf.org/Health/Resources/healthcare.htm
Publications:
I Committee on Environmental Health. Handbook ofPediatric Environmental Health.
Washington, DC: American Academy of Pediatrics; 1 995.
I Dorman DC, Beasley VR. Neurotoxicology of pyrethrin and the pyrethroid insecticides. Vet
Hum Toxicol 1989;63:33:238-43.
I Hayes W, Laws E, eds. Handbook of Pesticide Toxicology. San Diego, CA: Academic Press;
1991.
I LaDou J, ed. Occupational and Environmental Medicine, 2nd ed. Stamford, CT: Appleton &
Lange;1997.
-1
i ATSDR Case Studies in Environmental Medicine, Agency for Toxic Substances and Disease
Registry, www.atsdr.cdc.gov/HEC/CSEM
I Marrs TC. Organophosphate poisoning. Pharmac Ther 1 993;58:5 1 -66.
01
T3
01
H
o
I Pope AM, Rail DP, eds. for Committee on Curriculum Development in Environmental
Medicine, Institute of Medicine. Environmental Medicine: Integrating a Missing Element into
Medical Education. Washington, DC: National Academy Press; 1 995.
I Pope AM, Snyder M, Mood L, for Committee on Enhancing Environmental Health Content
in Practice, Institute of Medicine. Nursing, Health and the Environment: Strengthening the ฃ
Relationship to Improve the Public's Health. Washington, DC: National Academy Press; 1 995.
I Reigart JR, Roberts JR. Recognition and Management of Pesticide Poisonings, 5th ed. 25
Washington, DC: U.S. Environmental Protection Agency; 1 999. EPA#735-R-98-003.
I Risher JF, Mink FL, Stara JF. The toxicologic effects of the carbamate insecticide aldicarb in
mammals: A review. Env Health Persp 1987,72:267-81.
I Rosenstock L, Cullen M. Textbook of Clinical Occupational and Environmental Medicine,
Chapter 1. Philadelphia, PA: W.B.Saunders Company; 1994.
I Wang S, Lui L, et al. Clinical manifestations and diagnosis of acute pyrethroid poisoning.
Arch Toxicol 1 989;63:54-8.
I Zahm S,Ward M. Pesticides and childhood cancer. Env Health Persp 1998; 106:893-908.
* An asterisk denotes material for residents and nurse practitioner students over and above that of the undergraduate.
Extensive resources on pesticides can be found at www neetf.org/Health/Resources/healthcare htm
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1-2. Individual Patient Knowledge and Skills.
l-2a. Relate the environment in which the patient (and family) lives, works, and
plays to potential hazards and exposures.
Content
The student should know about the common pesticide hazards associated with major rural
and urban industries, occupations, and avocations, including commercial agriculture, farming,
grounds keeping, plant nursery maintenance, general lawn care, structural pest control / exter-
minators, parks, playgrounds, home or apartment yards, in-house treatments for pests (e.g.,
ants, roaches), home and gardens, schools and day care centers.
Numerous pesticides are used for public health protection, including water purification,
sewage treatment, vector control.
o
~" Be aware that the vast majority (80-90%) of pesticides produced are used for commercial agri-
culture; the remainder are used for structural pest control, horticulture, and consumer home
and garden purposes.
Be aware that health care professionals typically use and are exposed to a large number of
1 registered pesticides on a regular basis.
Understand that children are at risk for greater pesticide exposure from residuals in food than
are adults due to greater consumption per kilogram of body weight, and that prevention of
this excess exposure is addressed by the Food Quality Protection Act of 1996.
Points of Insertion
Community Health and Public Health Nursing courses (didactic and clinical)
Public Sector Medicine rotation
26 4th year medical school elective in Environmental or Preventive Medicine
l-2b. Identify risk factors for occupational pesticide exposures.
Content
Understand that commercial preparations of pesticides may be more concentrated, and there-
fore pose greater risk to someone in an occupational setting (particularly manufacturing) than
the use of a diluted final product.
Understand that highest risk of exposure is faced by individuals working in agricultural pest
control operations: mixing, loading, applying, and flagging. Mixers and loaders are exposed to
concentrated pesticides and large volumes.
Extensive resources on pesticides can be found at www neetf.org/Health/Resources/healthcare.htm
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Understand strategies for reducing the risk of exposure, including engineering controls, such
as closed systems for loading pesticides into tanks, and correct use of personal protective
clothing and devices.
Know that pesticide handlers and workers on farms, forests, greenhouses, and nurseries are
required to be supplied with appropriate protective gear by their employers.
Understand that pregnant women who work with pesticides are at high risk and should con-
sider switching to other tasks, if possible, at least during the first trimester of pregnancy, or
should maximize their use of personal protective clothing.
Understand that workers are at risk of exposure if insufficient time is allowed before re-entry
to treated fields.
Understand need for proper removal and handling of contaminated clothing and showering
prior to going home to reduce risk of exposure to residuals on clothing and skin.
l-2c. Identify risk factors for pesticide exposures at home.
Content ฐ
Understand that women, especially those who are pregnant, and children of farming families
are vulnerable to pesticide exposure even if they don't work in the fields. Migrant workers
and their families may also suffer from poor living conditions, lack of command of the English
language, and sporadic medical care. ^
tu
T3
Q.
O
u
01
Know that homes located near farmlands may constitute a particular hazard (above the base- ฐ
line risks of personal pesticide application to yards).
Know that children family members on farms are at risk for exposure to concentrated agents
and old supplies of chemicals that are no longer used. Children playing in or near the fields
while their parents work are at risk for exposure to pesticides.
o
l_>
Emphasize to families that care should be taken to reduce exposure to pesticides in areas 27
where food is prepared and consumed, and in children's play areas.
Be aware that pesticides used by consumers for home and garden are often nearly identical in
formulation as those used by professional applicators or differ only in reduced strength of
active ingredient.
Be aware that pesticide residues are implicated in chemical sensitivities reported by patients
who may experience symptoms in multiple systems in response to exposures to chemicals
and environmental agents widely tolerated by a majority of people.
Know that children incur more risk than adults due to the immature nature of their immune
system, larger surface area to body weight ratio, higher metabolic rate, different diet patterns
and activities, different exposure profiles, and hormonal changes at puberty.
Extensive resources on pesticides can be found at www.neetf.org/Health/Resources/healthcare htm
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n
o
3
Q.
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8=
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28
Be aware that children are more apt to have extended contact with ground level surfaces and
may have extended contact with pets. Properly applied spot treatments, directed or crack and
crevice sprays, baits, gels, and pastes pose less potential for exposure than broadcast treat-
ments.
Know that contamination of food, clothing, and other objects can occur through improper
application of pesticides in homes, or if items are not removed or covered prior to treatment
of the area.
Know that improper practices, including use of food or drink containers to store pesticides,
reuse of empty pesticide containers, and failure to lock pesticides away from children, have
resulted in serious illnesses and injuries to children.
Recognize that consumers generally have less education and training on how to properly
apply pesticides than farmers or commercial applicators.
Be aware that residues may be carried into homes on shoes worn across treated surfaces
(lawns) or on clothing worn to apply pesticides.
Points of Insertion
Nursing
Community Health Nursing and Primary Care rotations
Maternal / Child Health Nursing
Medical / Surgical Nursing
Psychiatric / Mental Health Nursing rotation
Unit on Oncology
Medicine
Public Sector Medicine rotation
Primary Care rotations
Psychiatric/Mental Health rotation
Oncology rotation
4th year elective in Environmental or Preventive Medicine
l-2d. Recognize that other family members may be ill from pesticide exposure in
addition to index patient.
Content
Understand that family members, including women and children, of exposed individuals are at
risk for exposure to reproductive and childhood toxicants due to residues "brought home" on
clothing, shoes, etc.
Understand the epidemiological concept of "disease clustering"and that a single exposure
may result in numerous family / household members being sick.
Extensive resources on pesticides can be found at www.neetf.org/Health/Resources/healthcare.htm
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Understand risks of perinatal exposure and implications for pregnancy outcomes, fetal effects,
lactation, and child development / developmental disabilities, elderly, individuals with chemi-
cal sensitivities, and other vulnerable populations.
Understand risks of consuming foods that contain residues of pesticides while working / har-
vesting agricultural products.
Points of Insertion
Nursing
I Community Health or Public Health Nursing rotations
I Maternal / Child Health units of instruction
I Psychiatric / Mental Health units of instruction
Medicine
OJ
I Public Sector Medicine rotations "ฐ
I Pediatric and Obstetrical rotations
I 4th year elective in Environmental or Preventive Medicine
l-2e. Understand potential moral, ethical, and legal implications for patients of
reporting and referral. ฐ
c3
Content o>
T3
Know state-specific reporting requirements for the workers'compensation system or surveil-
lance system. Be able to list which states have mandatory pesticide case reporting and the
process for reporting.
Understand that health care providers are often the first to identify a sentinel health event.
Understand the need to recognize such an event and the process for reporting.
o
u
Understand workers' reluctance to get involved in pesticide case reporting, ranging from fear
of retaliatory actions such as loss of job or pay cuts, to fear of complete closure of an operation \^
with the loss of many jobs. Therefore, consent of the patient should be obtained prior to
reporting.
Understand that pesticide contamination at sites such as schools, daycare centers, and busi-
nesses have additional consequences beyond individual health effects. Such legal and finan-
cial issues may affect willingness to report and disclose.
Be able to describe the health care provider's role in assuring follow-up of patients with pesti-
cide exposure, in order to reduce the risk of re-exposure or return to work sites where re-expo-
sure is likely.
Learn how to access state data on pesticide use and pesticide poisonings, where available.
Extensive resources on pesticides can be found at www.neetf org/Health/Resources/healthcare.htm
-------
Points of Insertion
Nursing
I Community Health or Public Health Nursing rotation
I Units of instruction on ethical/legal issues in nursing; patient advocacy role of the nurse
I Advanced Nursing Practice courses (e.g., graduate midwifery, FNP, PNP) addressing ethical,
legal, public policy issues in health care and role of nursing
Medicine
I Ethical, legal issues of medical practice
I Public Sector Medicine rotation
I 4th year elective in Environmental or Preventive Medicine
I Occupational Medicine
Resources for Competency 1-2:
Code of Ethics for specific disciplines
Websites:
I Occupational Safety and Health Administration (OSHA): www.osha.gov
National Pesticide Information
http://npic.orst.edu/tech.htm
Pesticide Information Databases:
- I National Pesticide Information Center,Technical Pesticide Information:
I Extension Toxicology Network (EXTOXNET): http://ace.ace.orst.edu/info/extoxnet
I Crop Data Management Systems (CDMS) database: www.CDMS.net/pfa/LUpdateMsg.asp
I Integrated Risk Information System (IRIS): www.epa.gov/ngispgm3/iris
An electronic database, maintained by EPA, on human effects that may result from expo-
sure to various chemicals in the environment. Provides hazard assessment and dose-
response assessment information.
30
J Publications:
i ATSDRCase Studies in Environmental Medicine, Agency for Toxic Substances and Disease
Registry, www.atsdr.cdc.gov/HEC/CSEM
I Epidemiologic Notes and Reports Organophosphate Insecticide Poisoning Among
Siblings - Mississippi. MMWR 1984;33(42):592-4.
I Farm Chemicals Handbook. Meister Publishing. Annual.
I Frazier L, Hage M. Reproductive Hazards of the Workplace. Philadelphia, PA: Van Nostrand
Reinhold;1998.
I LaDou J, ed. Occupational and Environmental Medicine, 2nd ed. Stamford, CT: Appleton &
Lange; 1997;Table 32-1, p. 532,Table 32-3, pp. 536-40,Table 32-4, pp. 542-3.
I Mardowitz SB. Poisoning of an urban family due to misapplication of household
organophosphate and carbamate pesticides. J Clin Tox Clin Tox 1992:30:295-303.
I Pope AM, Snyder M, Mood L, for Committee on Enhancing Environmental Health Content
Extensive resources on pesticides can be found at www neetf.org/Health/Resources/healthcare.htm
-------
in Practice, Institute of Medicine. Nursing, Health, and the Environment: Strengthening the
Relationship to Improve the Public's Health. Washington, DC: National Academy Press; 1995;
p. 45, Box 3.1.
I Reigart JR, Roberts JR. Recognition and Management of Pesticide Poisonings, 5th ed.
Washington, DC: U.S. Environmental Protection Agency; 1999. EPA#735-R-98-003.
I Rosenstock L, Cullen M. Textbook of Clinical Occupational and Environmental Medicine,
Chapter 1. Philadelphia, PA:W.B. Saunders Company; 1994.
1-3. Population-Based Health Knowledge and Skills.
l-3a. Understand the concept of population-based health as it pertains to
pesticide exposure.
Content
Understand the key components of the Food Quality Protection Act of 1996 and how it per-
tains to prevention of excessive pesticide exposure to children:
Q-
O
I Establishes a single, health-based standard for all pesticide residues in food.
I Requires a re-evaluation of all tolerances (maximum amount of pesticide allowed on food)
by August 2006. o
i Requires that EPA use an additional 10-fold safety margin when setting standards for pes-
ticides on foods to protect children, and allows EPA to use a different margin of safety
only if, on the basis of reliable data, such a margin will be safe for children.
I Requires that EPA ensure that there is a reasonable certainty that no harm will result to o
infants and children from aggregate exposure to the pesticide residue (including from
other sources such as water, residential, etc.).
I Requires that EPA consider the cumulative effects from all pesticides that share a common
mechanism of action.
i Provides certain right-to-know provisions for consumers.
Q.
E
o
u
Understand the context of community population-based health. Know that the populations of 31
entire neighborhoods and regions can be affected by pesticide contamination of the enviro-
ment.
Understand that issues of public health must be approached from a population-based pri-
mary, secondary, and tertiary prevention perspective.
Understand the use of epidemiologic data to support presumed causal relationships between
an exposure and an outcome.
Points of Insertion
Nursing
I Community Health or Public Health Nursing courses (didactic and clinical)
I Advanced Nursing Practice courses addressing ethical, legal, or public policy issues
Extensive resources on pesticides can be found at www neetf.org/Health/Resources/healthcare.htm
-------
Medicine
I Public Sector Medicine rotation or Evidence-Based Medicine
I 2nd year Introduction to Clinical Medicine
I 4th year elective in Environmental or Preventive Medicine
l-3b. Recognize socioeconomic impacts of pesticide-related illness.
Content
Be aware of socioeconomic implications of pesticide-related illness on each of the following
groups:
I Individual / family (e. g., impact on a head-of-household earning minimum wage)
I Employers and related businesses (e.g., loss of business, employees, customers)
I Community (e.g., well water contamination, drinking water supplies)
o I Society (e.g., contamination of underground water reserves, lakes, waterways)
T3
"" Understand potential economic impacts on workers who cannot return to jobs, temporarily or
permanently, due to pesticide exposure and poisoning. Give at least three specific examples:
migrant farmworker, mixer/loader, and applicator.
| Understand the role of advocacy and justice in environmental and occupational health, and
workers' compensation.
60 Points of Insertion
Nursing
I Community Health or Public Health Nursing courses
I Units of instruction on ethical, legal aspects of nursing
I Units of instruction on health policy and client advocacy in nursing
Medicine
32
/ I Public Sector Medicine rotation
I 4th year elective in Environmental or Preventive Medicine
I Ethical, legal, advocacy issues of medical practice
l-3c. Understand potential moral, ethical and legal implications for the
community of reporting and referral.
Content
Understand barriers and challenges to providing optimal care to migrant farmworkers, other
transient populations, and individuals without U.S. citizenship, green cards, work permits, etc.,
since they are often the most vulnerable populations for exposure.
Understand how economic, workplace issues sometimes outweigh health issues for vulnera-
ble populations.
Extensive resources on pesticides can be found at www neetf.org/Health/Resources/healthcare.htm
-------
Know that health care providers are obligated to report pesticide-related illness in some states.
Be able to describe Healthy People 2010: National Health Promotion and Disease Prevention
Objective 10 relative to reducing the morbidity and mortality of the population due to toxic
exposures.
Points of Insertion
Nursing
I Community Health or Public Health Nursing courses (didactic and clinical)
I Ethical, legal aspects of nursing / medicine
I Health policy courses at both undergraduate and graduate levels
Medicine
> Public Sector Medicine rotation
> 4th year elective in Environmental or Preventive Medicine
l-3d. Possess a basic awareness of the role of prevention and benefits of
alternatives to conventional pest control.
Content ฐ
o3
Be able to provide appropriate anticipatory guidance to individuals and families regarding
appropriate use of pesticides and products. (For example, be able to advise family on appro-
priate concentrations of DEET.) |
Know to advise family to contact local county Cooperative Extension services (check local tele-
phone directory blue pages under county Cooperative Extension) or National Pesticide
Information Center (http://npic.orst.edu) for information regarding integrated pest manage-
ment (IPM) and alternatives to pesticide use for control of insects, weeds, etc.
Be able to describe the goals of Healthy People 2010 relative to the health promotion, health
education, and prevention of illness relative to pesticide exposure.
Be able to teach individuals and families to read labels and follow directions when using prod-
ucts containing pesticides.
Points of Insertion
Nursing
I Ethical, legal aspects of nursing at both undergraduate and graduate levels
> Role courses at both undergraduate and graduate levels
I Community Health or Public Health Nursing courses (didactic and clinical)
o
u
Extensive resources on pesticides can be found at www.neetf org/Health/Resources/healthcare.htm
-------
Medicine
Ethical, legal aspects of medicine at both undergraduate and graduate levels
Public Sector Medicine
4th year elective in Environmental or Preventive Medicine
Occupational Medicine
Agromedicine if available in curriculum
Resources for Competency 1-3:
Online:
I U.S. EPA: Integrated Pest Management: www.epa.gov/oppbppd1/ipm/index.htm. Read
the Label First, www.epa.gov/pesticides/label/ ("Interactive label" shows pop-up text that
explains the basic statements found on pesticide product labels.)
i National Pesticide Information Center, General Pesticide Information:
o http://npic.orst.edu/gen.htmttps.
Publications:
I Department of Health and Human Services. Healthy People 2010: National Health
Promotion and Disease Prevention. Washington, DC: Dept. of Health and Human Services;
ง
Hennekens CH, Buring JE. Chapter 3: Statistical association and cause and effect relation-
m ships. In: Mayrent SL, ed. Epidemiology in Medicine. Boston, MA: Little, Brown and Company;
1987:30-41.
n
i I Hitchcock J, Schubert P,Thomas S. Community Health Nursing. Albany, NY: Delmar
n
n>
"O
Publishers; 1999;15-16.
I Institute of Medicine. Role of the Primary Care Physician in Occupational and Environmental
Medicine. IOM Report, Division of Health Promotion and Disease Prevention, Washington,
DC: National Academy Press;1988.
I Pope AM, Snyder M, Mood L, for Committee on Enhancing Environmental Health Content
in Practice, Institute of Medicine. Nursing, Health, and the Environment: Strengthening the
34 Relationship to Improve the Public's Health. Washington, DC: National Academy Press; 1995;
17-8.
I Rogers B. Occupational Health Nursing Concepts and Practice. Chapter 1,2,5. Philadelphia,
PA: W.B. Saunders Company; 1994.
I Rosenstock L, Cullen M. Textbook of Clinical Occupational and Environmental Medicine,
Chapters 1-2. Philadelphia, PA: W.B. Saunders Company; 1994.
I Reigart JR, Roberts JR. Recognition and Management of Pesticide Poisonings, 5th ed.
Washington, DC: U.S. Environmental Protection Agency; 1999. EPA#735-R-98-003.
I U.S. Environmental Protection Agency. The Worker Protection Standard for Agricultural
Pesticides. Washington, DC: U.S. EPA; 1994.
Extensive resources on pesticides can be found at www.neetf.org/Health/Resources/healthcare.htm
-------
Competency II:
Diagnosis and Assessment
11-1. Environmental History. Be able to take an environmental history.
When considering taking an environmental history related to pesticide exposure, it is useful to
compare it to the chances of finding relatively uncommon diseases in a lifetime of general prac-
tice. Although one may obtain thousands of complete blood counts to find one case of childhood
leukemia, we are taught to include such illnesses in a differential diagnosis. If we don't consider
the uncommon illness in the diagnosis, one day it might be missed. Similarly, if pesticide poison-
ing is not considered in a patient's differential diagnosis, it will surely be missed.
Content
Know sources of additional information relevant to a patient history:
I Pesticide labels: www.CDMS.net/pfa/LUpdateMsg.asp
I Material safety data sheets (MSDS): For a list of sites with MSDS information, go to:
www.phys.ksu.edu/area/jrm/Safety/msds.html
I Agency for Toxic Substances Disease Registry (ATSDR) (www.atsdr.cdc.gov)
I Pesticide manufacturer: Contact information should be on the label, or go to:
http://npic.orst.edu/manuf.htm
Be able to complete a detailed environmental history for the adult patient when indicated, to
include the following elements:
I Occupation, including length of time on job, nature of work, involvement with hazardous
materials, use of protective equipment, habits at worksite (eating, smoking), and prior jobs
I Home environment, including presence of or use of pesticides in house, lawn, garden; use
on pets; storage of pesticides; location of home in relation to industries, dump sites, farms
Source of drinking water
Food sources
Relocation of home due to health problems
Source of heat in home (e.g., wood stove)
New/recent construction or new materials (e.g., carpets)
Medical condition and symptoms, including temporal relationship to any given place or
time, others with similar problems (co-worker or family member)
I Use of tobacco, alcohol, other drugs (illegal, prescription, and over-the-counter), constant
exposure to second-hand smoke
I Recreational activities and hobbies of the patient or family
Be able to complete a detailed environmental history for the pediatric patient, to include the
following elements. (Under most circumstances, similar items in the adult history should be
covered, from the child's perspective.)
Extensive resources on pesticides can be found at www.neetf.org/Health/Resources/healthcare.htm
-a
c
o
u
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Occupation / hobbies of parents and other guardians or individuals living in the home to
a level of detail similar to above. If the child spends time with a sitter or another person's
home, inquire about occupations, hobbies, etc., in those homes as well.
Use of pesticides in home/play areas; child's play activities in relation to areas treated; pro-
tection of toys and surfaces during pesticide application
Proper washing of food (eggs, raw fruits, vegetables)
For infants: if bottle-fed, inquire into source of water for formula; if breast-fed, consider
maternal exposures
Proper storage of dangerous chemicals (i.e., is home properly "child proofed")
Amount of food consumed by child, and relationship between amount of exposure/body
weight for child compared to that of an adult
Be able to do developmental history (e.g., infants crawling on the floor, walking, getting
into objects)
Pesticide use on pets
n
3 I Is there spraying going on while you are in the field?
Know specific questions for agricultural workers and their families:
Is there spraying going on while yoi
I Do you feel sick while in the fields?
I Were the fields wet when you were picking? (Note: Dry fields can be a source of residues
and are potentially hazardous with certain crops such as citrus, grapes.)
I Do your children play in the fields?
0 I Do you have lunch in the fields?
*Be able to complete a brief screening environmental history: (This is reserved for residents,
nurse practitioners, and midwives. All students should first learn to do a complete environ-
mental history before being able to use a screening history to determine whether further
history is necessary based on risk factors.)
I Occupation (or parents'occupation)
I Temporal relationship of patient's symptoms to either home, school, day care or work
environment
I Known exposure of patient to pesticides, solvents, or other chemicals
36
/ Points of Insertion
Nursing
I Assessment courses, both baccalaureate and master's level
I Adult Health Nursing courses (didactic and clinical)
I Community Health or Public Health Nursing courses (didactic and clinical)
I Occupational Health Nursing clinical rotations
Medicine
> Undergraduate Medicine
I 1 st or 2nd year Introduction to Patient Assessment/ Clinical Medicine, etc.
> Material should be reinforced during 3rd year clinical rotations
* An asterisk denotes material for residents and nurse practitioner students over and above that of the undergraduate.
Extensive resources on pesticides can be found at www.neetf.org/Health/Resources/healthcare.htm
-------
11-2. Differential Diagnosis: Be able to consider pesticides in a differ-
ential diagnosis of poisoning.
Content (Medicine and Advanced Practice Nurses)
Know that pesticide exposures may result in health effects similar to other diseases. Signs
and symptoms of pesticide over-exposure may be non-specific. With few exceptions, there are
no pathognomonic signs of pesticide exposure.
*Knowing that many signs and symptoms of pesticide-related illness are non-specific and may
be due to a variety of causes, it is important for the clinician to be able to consider pesticides
in the differential diagnosis. Know agents that cause:
Cardiac arrhythmias
Altered mental status
Seizures
Pulmonary edema
Bloody diarrhea
-------
11-3. Signs and Symptoms: Recognize signs and symptoms of pesti-
cide over-exposure, especially widely used cholinesterase-inhibitors
and pyrethroid insecticides.
Content (Medicine)
Cholinesterase inhibitors (organophosphates and carbamates)
I Acute Poisoning: Know that patient will exhibit signs and symptoms of cholinergic toxici-
ty, including salivation, lacrimation, diarrhea, nausea and vomiting, miosis with blurred
vision, fasciculations, seizures, bradycardia, bronchorrhea, pulmonary edema, bron-
chospasm, dizziness, headache, toxic psychosis.
I Tachycardia and hypertension may initially occur due to ACh stimulation of nicotinic fibers.
I Life-threatening presentation includes a loss of consciousness, incontinence, seizures, and
respiratory depression.
I *Children: Know that children's presentation may be different from adults:
n
o
3 I Children are much more likely to present with lethargy, coma, seizures than adults
"O
n> I Other typical cholinergic signs, especially the hyper-secretory signs, were found less
likely to occur at initial presentation in several case series
*Chronic pesticide toxicity may go unrecognized because of failure to obtain a thorough
exposure history. Some exposures are complex, signs and symptoms are nonspecific, and
may be similar to other chronic illnesses. Consultation with specialists may be indicated
for timely or optimal diagnosis and treatment.
Know what organophosphate-induced delayed neuropathy (OPIDN) is:
3
0.
Chiefly manifested by weakness, paralysis, and paresthesias, especially of lower
extremities
Other symptoms of chronic toxicity to organophosphates may include headache,
ซ> blurred vision, muscle weakness, depression, memory and concentration problems,
irritability, and intolerance to selected chemicals
38 I Pyrethroids
I Know that within the class of pyrethroids, the sub-category of cyano-pyrethroids is more toxic.
I Know that the most severe toxicity is to the central nervous system, but that it occurs less
frequently than other signs and symptoms.
I Seizures and disturbed level of consciousness are the chief signs.
I Know that paresthesias are a common presenting sign.
I Know that sensitization and allergic reactions also have been reported.
I *Know that several additional signs and symptoms may mimic organophosphate toxicity:
I Vomiting and diarrhea
I Salivation and pulmonary edema
I Muscle fasciculations
I *Know that pyrethroid poisoning has been misdiagnosed as organophosphate poisoning
* An asterisk denotes material for residents and nurse practitioner students over and above that of the undergraduate.
Extensive resources on pesticides can be found at www.neetf.org/Health/Resources/healthcare.htm
-------
and that patients have been given very high doses of atropine, unnecessarily resulting in
atropine toxicity.
Points of Insertion
Undergraduate Medicine
I 2nd year Pharmacology and Pathology courses
I 3rd year clinical rotations
I 4th year ER rotations and Environmental Medicine elective (or equivalent)
Residents
I ICU rotations
I ER and inpatient rotations
Nurse Practitioners
Resources for Competency II
ATSDR Case Studies in Environmental Medicine, Agency for Toxic Substances and Disease Registry, ^
www.atsdr.cdc.gov/HEC/CSEM <
He R,Wang S, Lui L, et al. Clinical manifestations and diagnosis of acute pyrethroid poisoning. Arch
7bx/co/1989;63:54-8.
o
c
01
Jamal JA. Neurological syndromes of organophosphoms compounds. Adverse Drug React Toxicol
ReV\ 997 Aug;16(3):133-70. Q
LaDou J,ed. Occupational and Environmental Medidne,2r\d ed. Stamford, CT: Appleton & Lange; 1997.
MarrsTC. Organophosphate poisoning. PharmacTher 1993;58:51-66.
E
o
Osorio AM. Environmental and occupational history. In: Reigart JR, Roberts JR. Recognition and
Management of Pesticide Poisoning, 5th ed. Washington, DC: U.S. Environmental Protection Agency;
1999. EPA#735-R-98-003.
Reigart JR, Roberts JR. Recognition and Management of Pesticide Poisonings, 5th ed. Chapters 3-5,8,
Index of signs and symptoms, pp. 210-22. Washington, DC: U.S. Environmental Protection Agency;
1999. EPA#735-R-98-003. Online: http://npic.orst.edu/rmpp.htm
Rosenstock L, Cullen M. Textbook of Clinical Occupational and Environmental Medicine, Chapter 1.
Philadelphia, PA: W.B. Saunders Company; 1994.
Savage E, Keefe T, Mounce L, et al. Chronic neurological sequelae of acute organophosphate pesti-
cide poisoning. Archives Environmental Health 1988;43:38-45.
Steenland K, Jenkins B, Ames RG, et al. Chronic neurological sequelae to organophosphate poison-
ing. AmerJ Pub Health 1994;84:731-6.
Zwiener RJ,Ginsburg CM. Organophosphate and carbamate poisoning in infants and children.
Ped/africs1988;81:121-126.
Extensive resources on pesticides can be found at www.neetf.org/Health/Resources/healthcare htm
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n
o
3
Competency III:
Treatment, Intervention, and Referrals
111-1. Treatment: Be able to effectively treat health conditions related
to pesticide over-exposures.
Content (Medicine)
Know that supportive therapy is often the mainstay in treating the pesticide-poisoned patient.
Understand the general principles of airway control in managing a pesticide-poisoned patient:
I *Be able to intubate the patient and provide emergency ventilation (residents, selected
advance practice nurses)
I "Understand pesticide-specific instances with regard to 02:
I Organophosphates/Carbamates: adequate oxygenation is essential prior to adminis-
tering atropine.
I Diquat / Paraquat: Oxygen is contraindicated in the early stages due to progressive
oxygen toxicity to lung tissue.
Understand principles of gastrointestinal decontamination:
I Know the uses, indications, and contraindications for each of the following: syrup of
=> ipecac, gastric lavage, catharsis, & activated charcoal.
I Know that ipecac is no longer recommended for routine use in most poisonings.
I *Know proper dosage of activated charcoal.
I *Know that if a second dose of activated charcoal is needed in children, it should be with-
40 out a cathartic to avoid sudden electrolyte shifts.
Understand principles of seizure management:
I Diazepam is used in many of the reported pesticide poisonings including organochlorines
and others.
I Lorazepam is now being recognized as the drug of choice for status epilepticus, although
there are few reports of its use with certain pesticides.
I *Know that with organochlorine poisoning, seizures can be refractory and may require
several medications and possibly pentobarbital coma.
*Be able to provide necessary cardiac life support.
Understand that decontamination, life support, and emergency care may need to be provid-
ed concurrently.
* An asterisk denotes material for residents and nurse practitioner students over and above that of the undergraduate.
Extensive resources on pesticides can be found at www.neetf.org/Health/Resources/healthcare.htm
-------
Know that many signs and symptoms are non-specific and many agents have no specific anti-
dotal treatment.
Understand special treatments required for certain pesticides:
I Organophosphates and Carbamates
I Know that tissue oxygenation must be improved as much as possible prior to giving
atropine.
I *Know required atropine dose and dosing intervals. Be aware that the dose for
cholinesterase-inhibiting insecticides is much higher than that for cardiac resuscitation.
I *Know the indications for pralidoxime.
> *Know that pralidoxime is usually not needed for carbamates because the enzyme-
pesticide complex rapidly dissociates; therefore atropine alone is effective.
I Pyrethroids
I Be able to provide supportive therapy.
OJ
I *Know that Vitamin E oil preparations may prevent or stop paresthesias. cc-
*Arsenicals
I Know that initial chelation is performed using dimercaprol (BAL) as an intramuscular
injection.
I After gastrointestinal tract is free of arsenic, one may consider an oral chelating agent
such as DMSA ("Succimer"), which is available in the U.S. but not labeled for this use.
cu
B
*0rganomercury Compounds (fungicides)
I DMSA ("Succimer") is probably the most effective agent available in the U.S.
*Hydrogen Cyanide and Acrylonitrile (transformed to hydrogen cyanide)
I Amyl nitrite by inhalation 15-30 seconds of every minute.
I Sodium nitrite 3%; 10 ml given I.V. over 5 minutes. ^
I Sodium thiosulfate 50ml of 25 % solution given I.V. over 10 minutes.
I The above antidotes are commercially available as the Lilly Cyanide Antidote Kit.
I *Rodenticides (specifically "superwarfarins" such as brodifacoum)
I For ingestion larger than about 1 mouthful, prothrombin time (PT) is currently recom-
mended at 24 to 48 hours post-ingestion.
I More recent data suggest that if a known quantity (small amount) is unintentionally
ingested, PT measurement may not be necessary.
I Phytonadione (vitamin K1) is given for an elevated PT or signs of bleeding.
I If taken during the preceding 15 days, determine patient's PT and give vitamin K1
intramuscularly if PT is significantly prolonged.
I Intravenous vitamin K1 should be reserved for patients with active bleeding only, due
to potential severe side effects.
* An asterisk denotes material for residents and nurse practitioner students over and above that of the undergraduate.
Extensive resources on pesticides can be found at www.neetf.org/Health/Resources/healthcare.htm
01
Q.
-------
I Be aware that PT prolongation and bleeding are much more likely in cases of inten-
tional ingestion, and that due to a very long half-life of superwarfarins, PT prolonga-
tion may persist for months.
I *Sodium chlorate and cyanide can result in methemoglobinemia.
I Know that methylene blue is indicated when about 25-30% of hemoglobin has con-
verted to methemoglobin.
I The dose is 0.1 ml/kg body weight of 1 % solution over 10 minutes.
I Know that an exchange transfusion may enhance clearance in severe cases.
Chronic effects: Be aware of recent research on chronic effects associated with pesticides,
including the following (non-exhaustive) list:
I Cancer
I Leukemia and brain tumors have been noted in many epidemiological studies to be
3 associated with pesticides.
~o
"> I Epidemiology suggests that DDT and other agents may increase risk for breast and
ovarian cancer.
I Risk factors:
I parental occupation
I family use of pesticides (e.g., pest strips, termite treatment, flea collars for pets)
3
" Birth Defects
I Norwegian farmers - CNS, orofacial clefts, male genitalia, and limb reduction defects
5> > Canadian families near agriculture center - spina bifida and stillbirth
* I Minnesota - higher rates of unspecified birth defects
I Endocrine Disruption
I Emerging concern for pediatricians, but controversy remains.
I Many chemicals in environment bind to endocrine receptors; some are pesticides.
I Organochlorines are the most well known (DDT, chlordane, heptachlor, dieldrin)
I DDT is still highly persistent in environment
42 > Endosulfan, atrazine, & 2,4-D still used in U.S.
I Animal studies confirm in vitro activity:
I Rat exposure to chlordane results in masculinization of female rats
I Other agents have caused feminization of alligators.
I Chronic Neurologic Effects Association with Organophosphates
I Follows acute and subacute exposure
I Headaches, blurred vision, depression, memory loss, irritability, poor concentra-
tion
I Epidemiological studies in adults have supported these observations.
I No controlled studies have been done in children.
* An asterisk denotes material for residents and nurse practitioner students over and above that of the undergraduate.
Extensive resources on pesticides can be found at www.neetf.org/Health/Resources/healthcare.htm
-------
Points of Insertion
Nursing
I Adult Health Nursing courses (didactic and clinical). Undergraduate nursing students
should be able to recognize and provide supportive care to patients with pesticide poi-
soning. Advanced practice nurses, especially primary care nurse practitioners and occupa-
tional health nursing practitioners, should be able to diagnose and treat patients with
pesticide poisoning.
I Community Health, Public Health Nursing, or Pediatric Nursing courses (didactic and clinical)
I Environmental Health Nursing elective
Undergraduate Medicine
I 2nd year Pharmacology and Pathology courses
I 3rd year clinical rotations
I 4th year ER rotations, Environmental Medicine elective
Residents
I ICU rotations =
o
I ER and inpatient rotations
111-2. Intervention: Be able to advise health care providers on decont-
amination of patients and the environment following over-exposure.
Content (Medicine, Advanced Practice Nursing, and Specialty Environmental Health Nursing)
Advise other health care providers on how to decontaminate patients and the environment
following over-exposure.
> Understand principles of skin decontamination, flushing eyes with water. j|
> Understand proper clothing and precautions for emergency personnel, including goggles ฐ
and rubber gloves. 43
I Be aware that pesticide contamination can occur on the insides of boots and gloves.
Understand that site decontamination needs to occur. Examples include:
I Environmental exposure at home or school with excess pesticide residue
I Hospital exposure to personnel resulting in toxicity to health care providers
Points of Insertion
Nursing
I Advanced Adult Health Nursing courses (didactic and clinical)
I Advanced Community Health or Public Health Nursing courses
i Environmental Health Nursing elective
Extensive resources on pesticides can be found at www.neetf.org/Health/Resources/healthcare.htm
-------
Undergraduate Medicine
I 2nd year Pharmacology and Pathology courses
I 3rd year clinical rotations
I 4th year ER rotations, Environmental Medicine elective
Residents
I ICU rotations
I ER and inpatient rotations
Resources for Competencies 111-1 and III-2
ATSDR Case Studies in Environmental Medicine, Agency for Toxic Substances and Disease Registry,
www.atsdr.cdc.gov/HEC/CSEM
o Helmuth RA, McCloskey DW, Doedens DJ, et al. Fatal ingestion of a brodifacoum-containing roden-
ticide. Lab Mea"\ 989:20:25-7.
LaDou J, ed. Occupational and Environmental Medicine, 2nd ed. Stamford, CT: Appleton & Lange;
1997.
Lieske CN, Clark JH, Maxwell DM, et al. Studies of the amplification of carbaryl toxicity by various
oximes. Toxicology Letters 1992;62:127-137.
Lipton RA, Klass EM. Human ingestion of a"superwarfarin"rodenticide resulting in a prolonged
anticoagulant effect. JAMA 1984;252:3004-5.
Muckter H, Liebl B, Beichl FX, et al. Are we ready to replace dimercaprol (BAL) as an arsenic anti-
<
ro
3
ฐ dote? Hum Exp Toxicol 1997;16:460-5.
o>
3
Mullins ME, Brands CL, Daya MR. Unintentional pediatric superwarfarin exposures: Do we really
need a prothrombin time? Pediatrics 2000; 105:402-4.
Reigart JR, Roberts JR. Recognition and Management of Pesticide Poisonings, 5th ed. Washington, DC:
U.S. Environmental Protection Ag
http://npic.orst.edu/rmpp.htm
44 ) U.S. Environmental Protection Agency; 1999. EPA#735-R-98-003. Online:
Rosenstock L, Cullen M. Textbook of Clinical Occupational and Environmental Medicine. Philadelphia,
PA: W.B. Saunders Company; 1994.
Thompson DF,Thompson GD, Greenwood RB,Trammel HL Therapeutic dosing of pralidoxime
chloride. Drug Intelligence and Clinical Pharmacy 1987;21:590-3.
Tucker SB, Flannigan SA, Ross CE. Inhibitions of cutaneous paresthesia resulting from synthetic
pyrethroid exposure. IntJDermatol 1984;! 0:686-9.
Extensive resources on pesticides can be found at www.neetf.org/Health/Resources/healthcare.htm
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111-3. Referrals: Understand when to make referrals to appropriate
occupational / environmental health specialists.
Content
The student should be able to make appropriate judgments of when, where, why, and to
whom the patient should be referred.Treatment of pesticide exposure may be beyond the
scope of practice for the provider. Consultation and referral to a specialist in the field of envi-
ronmental and occupational health can facilitate timely diagnosis and optimal treatment. For
more severe health events that involve numerous individuals, additional assistance can be
obtained from the state health department or a state regulatory agency.
Know how to contact (via national, regional, state, and local professional organizations and
websites), and be able to compare and contrast the role, scope of practice, and setting of, the
following environmental/occupational health specialists:
cooperative extension
environmental health specialist
industrial hygienist
occupational health nurse
occupational health nurse practitioner
occupational medicine physician
111-4. Follow-up: Know how to arrange appropriate patient follow-up.
Content
Understand appropriate follow-up of patients who have had pesticide poisoning.
Know that patients with organophosphate poisoning may need later neurologic follow-up.
HI
Q.
Points of Insertion for 111-3 and 111-4 |
u
Nursing
I Leadership in nursing
I Clinical nursing rotations such as Adult Health, Pediatrics, Maternal-Child Health Nursing
I Community Health or Public Health Nursing courses (didactic and clinical)
I Environmental Health Nursing or Emergency Nursing elective
Medicine
I 3rd year clerkships in Family Medicine, Pediatrics, or Internal Medicine
I 4th year elective in Environmental Medicine or Emergency Medicine
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Extensive resources on pesticides can be found at www neetf.org/Health/Resources/healthcare.htm
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3
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46
Residency
I Primary care
Resources for Competencies 111-3 and 111-4
Hitchcock J, Schubert P,Thomas S. Community Health Nursing. Albany: Delmar Publishers; 1999;
15-16.
Institute of Medicine. Role of the Primary Care Physician in Occupational and Environmental Medicine.
IOM Report, Division of Health Promotion and Disease Prevention, Washington, DC: National
Academy Press;1988.
Pope AM, Snyder M, Mood L, for Committee on Enhancing Environmental Health Content in
Practice, Institute of Medicine. Nursing, Health, and the Environment: Strengthening the Relationship
to Improve the Public's Health, Chapter 3. Washington, DC: National Academy Press; 1995; 17-8.
Rogers B. Occupational Health Nursing Concepts and Practice. Chapter 4. Philadelphia, PA: W.B.
Saunders Company; 1994.
RosenstockL,Cullen M. Textbook of Clinical Occupational and Environmental Medicine, Chapters 1,
10. Philadelphia, PA: W.B. Saunders Company; 1994.
Extensive resources on pesticides can be found at www.neetf.org/Health/Resources/healthcare.htm
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Competency IV:
Risk Communication
IV-1. Patient Education: Be able to educate patients about basic
routes of exposure and absorption, and how to minimize exposure to
pesticides.
Content
Healthy People 2000 / 2010 Objective 11. Environmental Health
Be able to discuss examples of potential exposure, routes of exposure, and absorption in lay
person's terms, and be able to incorporate them into patient teaching that is appropriate to
the patient/family.
Be able to counsel patients about minimizing unnecessary use of pesticides.
Be able to provide anticipatory guidance about signs, symptoms, and recognition of pesticide
exposure, and safe use of pesticides including hygiene practices, reading labels, and protective E
clothing. ฐ
Be able to assess and discuss risks of patient exposure to pesticides and to develop individual-
ized strategies for patient and family for reducing risk of exposure (See Pesticide Safe Use
Checklist on page 49):
I Safeguard homes during pesticide applications
I Mitigating risks to family during and following an application
I For patients who work with pesticides: use of personal protective clothing and equipment,
decontamination procedures, preventing residues from being brought home on clothing.
Be able to counsel patients who are pregnant or planning a pregnancy that some pesticides 47
have adverse reproductive risks, and the desirability of switching to other tasks, if possible, at
least during the first trimester of pregnancy.
Be able to describe the purpose and function of available resources and know when to refer
patients to the following:
Local health department
Cooperative extension services
Primary care provider
Poison Control Center
EMS
Extensive resources on pesticides can be found at www.neetf.org/Health/Resources/healthcare.htm
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Points of Insertion
Nursing
> Adult, Pediatric, Maternal-Child Health Nursing courses (didactic and clinical) at both
undergraduate and graduate levels
> Community Health or Public Health Nursing courses (didactic and clinical)
> Primary Care Management courses (didactic and clinical)
> Elective in Environmental Health Nursing
I Midwifery
Undergraduate Medicine
I 3rd year clerkships in Pediatrics, Internal Medicine, Family Medicine
> 4th year elective in Preventive Medicine
I OB-GYN rotations
Residency
n
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| Content
> Primary Care clinics
I Occupational/Environmental Medicine
IV-2. Labels: Be able to advise patients on how to read pesticide
labels.
Know the components of a pesticide label that patients should look for:
I Pay special attention to the precautionary statements and physical hazards.
I Know what the "signal word" is to determine level of toxicity.
I Know what types of first aid are indicated and contraindicated.
48
-/ Know that it is a violation of the law to use pesticides in a manner other than as stated on the label.
Be able to teach patients to read labels and follow instructions carefully:
I Discuss the dangers of altering mixing and application procedures.
I Discuss the need for wearing appropriate protective clothing, masks, and other personal
protective equipment (PPE),as instructed on product labels.
I Discuss the need to be prepared for emergencies and to ensure that necessary equip-
ment, supplies, etc., are available and in proper working order.
I Teach patients to post telephone numbers nearby for EMS and Poison Control Center.
Be aware that there may be specific patient populations that will have limitations in reading the
label (illiterate, non-English speaking, etc.) and special preventive education will be necessary.
Extensive resources on pesticides can be found at www neetf.org/Health/Resources/healthcare.htm
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Points of Insertion
Nursing
Community Health or Public Health Nursing course (didactic and clinical)
Home Health Nursing courses (didactic and clinical)
Maternal-Child Health Nursing, Obstetric Medicine rotations
Pediatric Nursing courses (didactic and clinical)
Adult Health Nursing courses (didactic and clinical)
Elective course in Environmental Health Nursing
Midwife training courses
Undergraduate Medicine
> 3rd year clerkships in Pediatrics, Internal Medicine, Family Medicine
I 4th year elective in Preventive Medicine
ป OB/GYN rotations
Residency c
o
I Environmental Medicine rotation
> Anticipatory guidance in Primary Care clinics
I Occupational/Environmental Medicine residency
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u
Resources for Competency IV
Online Resources
I U.S. EPA, Read the Label First: www.epa.gov/pesticides/label/
Integrated Pest Management: www.epa.gov/oppbppdl/ipm/index.htm
I National Pesticide Information Center: Public access to pesticide information; supported
by EPA. Tel: (800) 858-7378 (M-F,8 am - 6 pm CST). http://npic.orst.edu/gen.htmttps
I NEETF Pesticides Resource Library: www.neetf.org/Health/Resources/healthcare.htm
Publications
I Hitchcock J, Schubert P,Thomas S. Community Health Nursing. Albany: Delmar Publishers;
1999;15-16.
I Institute of Medicine. Role of the Primary Care Physician in Occupational and Environmental
Medicine. IOM Report, Division of Health Promotion and Disease Prevention, Washington,
DC: National Academy Press;1988.
I Pope AM, Snyder M, Mood L, for Committee on Enhancing Environmental Health Content
in Practice, Institute of Medicine. Nursing, Health, and the Environment: Strengthening the
Relationship to Improve the Public's Health, Chapter 3. Washington, DC: National Academy
Press; 1995; 17-8.
I Rogers B. Occupational Health Nursing Concepts and Practice. Chapter 4. Philadelphia, PA:
W.B.Saunders Company; 1994.
I Rosenstock L, Cullen M. Textbook of Clinical Occupational and Environmental Medicine,
Chapters 1,10. Philadelphia,PA:W.B.Saunders Company; 1994.
Extensive resources on pesticides can be found at www.neetf.org/Health/Resources/healthcare.htm
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'*'ฐ:/./fe^|K.^ -. .'. '
I - , be W theiite or.plartt to which you interi' &ซ&$?& pesticide Is listed on the label;
I see If any special protective ctothing or equipment is necessary;
'
'*'-'::^*^feth^^
I be syreyouafe applying 'the pesticide at the right time
8w only enough: pesticide for pne, or at most, two years. ' Pesticides stored longer may degrade and
-
. . Reftiove pr :cpytrpet:,|xD^ and water dishes and fish tanks,
DURING APPLICATION:
. AI^:^j<^9:y^rsFa Ipng-deewd shirt, socked shoes when' applying any pesticide, Other protective
e^ulpr^ht,^^ extra, protection,
m, .Da not wearleather shoes, fadOts,of gtoves while handling pesticides. Leather absorbs pesticides and can-
toot be(Jecolปtarriir^ed easily, '. . .
.:" ' ... :tafe|\^ซe:%;9^,:;p%tlcicteg corning Into contact with your eyes, mouth/orsMn.
;* : '. ;%ป'ซ'ซ; i^MMyj,-w ซ,iyoM twp, piepK tne'.ia'oeJ tg.sp ^jr;^^ a^'V^:-Wtaa-Mtt..-:.';-,!'..''.:
."'^^^^^^H;:^';^:-^:;. '';:..",;/. '!'.'': : ':',': '- '\^'1'^-^'^'''^- '-^^Mf^S
^iiWI^wflste'iBSidteifes^
Extensive resources on pesticides can be found at www.neetf.org/Health/Resources/healthcare.htm
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Competency V:
Reporting Requirements and Regulations
Content
V-1. Surveillance Needs: Understand the importance of surveillance
and incident reporting.
Understand surveillance as the systematic collection and evaluation of all aspects of exposure
occurrence and sequelae resulting in information that may be useful in the control of the
exposure.To be effective, surveillance should be linked to preventive action.
Be aware of cases of pesticide exposure and monitoring data on trends of exposure.
Be able to describe strategies, both individual patient focused and population-based, that may
result in reduced exposure.
Be able to compare and contrast surveillance versus screening.
Understand the relationship between incident reporting and workers'compensation process,
including when to report and to whom to report.
Understand the ethical / legal requirements of the nurse and physician for reporting pesticide
exposures and be able to cite regulations, OSHA standards, etc.
Understand relevant OSHA standards and the 1994 Worker Protection Standard, as well as
additional requirements for workers in greenhouses and nurseries, and for early-entry workers.
Be able to briefly describe the NIOSH Sentinel Event Notification System for Occupational
Risks (SENSOR) system.
V-2. Reporting: Know how to participate in mandatory state surveil-
lance systems and reporting requirements.
Know that eight states conduct pesticide poisoning surveillance, and that at least 25 have
some form of pesticide poisoning reporting requirements.
Be able to briefly describe the rules and regulations regarding surveillance and reporting in
the student's current state.
Be knowledgeable about local, county, state, and national agencies for reporting of pesticide
exposure, and about how to access state reporting data.
Extensive resources on pesticides can be found at www.neetf.org/Health/Resources/healthcare.htm
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73
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3
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30
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in
Given a scenario, the student should be able to briefly describe his/her responsibilities and the
process for reporting a pesticide exposure, and give a rationale for his/her actions, including
regulatory and ethical considerations.
V-3. Regulations: Understand other legal and regulatory provisions
that have implications for health care providers.
Know that several laws administered by EPA, FDA, and OSHA regulate the use and sale of pes-
ticides to protect human health.
Understand the role and functions of EPA in the regulation of pesticide use under the Federal
Insecticide, Fungicide, and Rodenticide Act.
Understand the role, jurisdiction, and function of the Occupational Safety and Health
Administration (OSHA) relative to workplace pesticide exposures.
Know about EPA's Worker Protection Standard and the two types of workers to whom it
affords protection in the farming, greenhouse, nursery and forest industries: (1) agricultural
pesticide handlers (mixers, loaders, applicators, equipment cleaners or repair persons, and flag-
s' gers) and (2) field workers (cultivators or harvesters).
Understand EPA's role relative to pesticide contamination of water and implications for
migrant farmworkers.
3 V-4. *Legal Framework: Understand framework of federal laws that
address pesticides and pesticide exposures.
(*Advanced nurse practitioner/resident or fellow)
FIFRA: Federal Insecticide, Fungicide, Rodenticide Act (1947)
I Provides definition of pesticide
I Establishes pesticide label as law
I Enables EPA to take action against pesticides considered to present unreasonable risks to
human health
FFDCA: Federal Food, Drug, and Cosmetic Act
> Establishes concept of a tolerance, the maximum level of pesticide residue at harvest, for
pesticide residue on human food and animal feed
I Requires EPA to set tolerance levels
FQPA: Food Quality Protection Act
ป Amends FIFRA and FFDCA
I Establishes health-based standard for all pesticides
I Provides additional ten-fold safety factor for infants and children
Extensive resources on pesticides can be found at www.neetf.org/Health/Resources/healthcare.htm
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I Requires EPA to review pesticide registrations
I Requires consideration of cumulative exposure
> Requires reasonable certainty that pesticides are not causing harm
WPS: Worker Protection Standard
I EPA regulation issued under FIFRA
I Provides protection to pesticide handlers and agricultural workers
I Requires employer to ensure safety for all workers
OSHAct: Occupational Safety and Health Act
I Provides for worker safety in manufacture, formulation, and distribution of pesticides
I Establishes "Right-to-Know" law, whereby employers furnish employees information on
hazardous chemicals they may be exposed to at work
> Administered by Occupational Safety and Health Administration
TSCA: Toxic Substances Control Act
V-5. Ethical, Legal, Advocacy: Understand ethical, legal, and advo-
cacy roles of health care providers in pesticide exposure incidents.
01
I Establishes an inventory of chemical substances a-
I Requires manufacturers of chemicals to submit test results to EPA
I Allows EPA to regulate new and existing commercial chemicals based on their risk to
health or the environment |
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ns
T3
O
ID
33
Q.
33
54
I Leadership in Nursing (undergraduate and graduate levels)
I Role course/unit of instruction or module (undergraduate and graduate levels)
Medicine
i Public Sector Medicine rotation
I 4th year elective and residency elective in Environmental Medicine or Preventive
Medicine
I Occupational/Environmental Medicine or Primary Care residency
Resources
National Pesticide Information Center: http://npic.orst.edu
NEETF Pesticides Resource Library: www.neetf.org/Health/Resources/healthcare.htm
U.S. EPA: Laws and Regulations, http://www.epa.gov/epahome/lawreg.htmwww.epa.gov/pesti-
cides/regleg.htm. Pesticide Management Resource Guide:
www.epa.gov/oppfead1/pmreg/index.html.Worker Protection Standard and Recent Amendments:
www.epa.gov/pesticides/safety/workers/amendmnt.htm
* An asterisk denotes material for residents and nurse practitioner students over and above that of the undergraduate.
Extensive resources on pesticides can be found at www.neetf.org/Health/Resources/healthcare.htm
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The National Environmental Education & Training Foundation
The National Environmental Education & Training Foundation (NEETF) was chartered by Congress
in 1990 as a private non-profit organization that designs and implements innovative programs in
life-long environmental learning. NEETF serves students as well as adults, elected and appointed
officials of local, state, and federal government, and professionals in health, business, education
and the media.
The National Environmental Education & Training Foundation
1707 H Street, NW Suite 900
Washington, DC 20006-3915
Tel: 202-833-2933
Fax:202-261-6464
E-mail: neetf@neetf.org
Website: www.neetf.org
Extensive resources on pesticides can be found at www.neetf.org/Health/Resources/healthcare.htm
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