DRAFT IMPLEMENTATION PLAN
Pesticides and National Strategies
for Health Care Providers
JULY 2000
svEPA
USDA
U.S. Department ol Labor
N E *E ¦ T ~ F
T5ii National Environmental Education & Training Foundation
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Pesticides and National Strategies
for Health Care Providers:
Draft Implementation Plan
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 8c Ihuning Foundation.
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Acknowledgments
The successful development of this Implementation Plan would not have been possible without
the efforts of a large number of dedicated people and organizations. The Expert Panel members
gave graciously of their time, experience, and energy in developing the broad national strategies.
The members of the Education, Practice, and Resource Workgroups contributed their time, enthusiasm,
and intensive effort during their workshops. Their continued hard work during the review process has
produced this Plan. The workgroups were also expertly guided by their co-chairs, specifically Andrea
Lindell and Ameesha Mehta (Education Workgroup), Karen Pane and Bonnie Rogers (Practice Work
Group), and Mark Robson and Kevin Keaney (Resources Work Group). The Federal Interagency Planning
Committee has contributed many hours of guidance and oversight to the development of the Plan, and
significantly helped to organize the Expert Panel and the three workgroups. The Committee also continues
to guide the entire Pesticides and National Strategies for Health Care Providers initiative.
This Plan was drafted collaboratively by Susan West, Ameesha Mehta, Gilah Langner, and Jennifer Bretsch,
based on the in-depth work of key stakeholders from across the country. The Plan was developed as part
of a larger cooperative agreement for the entire initiative between EPA's Office of Pesticide Programs and
The National Environmental Education 8c Training Foundation (NEETF). Susan West, Senior Director
for Health & Environment Programs at NEETF, has managed this cooperative agreement, including the
planning and facilitation of the Expert Panel and workgroup meetings, the drafting of this Plan, and
setting the overall vision for this initiative in collaboration with Ameesha Mehta at EPA. In addition, a
team of NEETF staff devoted many long hours to this effort, including Jennifer Bretsch, Brynn Ellison,
Leda Huta, Mary Magnini (Meetings Management, Inc.) and Mia Dell.
Gilah Langner (Stretton Associates, Inc.) provided extensive writing and editing support during the
workgroup sessions, drafted the original workgroup proceedings, and managed the drafting, editing,
and graphic design of this Plan.
EPA staff members in the Certification and Worker Protection Branch, Office of Pesticide Programs,
were crucial in ensuring the completion of the Plan. Ameesha Mehta, EPA Project Manager, kept
the Plan's development on track and moving forward. Kevin Keaney, Chief of the Certification and
Worker Protection Branch, gave the Plan priority attention. Delta Valente, EPA Project Manager,
provided support to ensure the completion of the Plan.
Finally, this Plan is the result of successful collaborative leadership among EPA, NEETF, the federal agency
partners and the stakeholders. The team of collaborative partners is pleased to share this Plan with you.
Questions about the content of the Plan can be directed to pesticides@neetf.org.
Photo credits: Photos on pages 13,18, and 41: Steven Delaney, EPA.
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Federal Interagency Planning Committee
U.S. Environmental Protection Agency
Office of Pesticide Programs
Kevin Keaney, MA, MS
Ameesha Mehta, MPH
Delta Valente, MPA
Jerome Blondell, MPH, PhD
Ana Maria Osorio, MD, MPH
Frank Davido
Office of Pollution Prevention and Toxics
Diane Sheridan
Office of Children's Health Protection
Elizabeth Blackburn, RN
Office of Ground Water & Drinking Water
Ron Hoffer, MS
Marjorie C. Jones
Sherri Umansky
U.S. EPA Regional Liaisons
Jane Horton Region 4
Don Baumgartner Region 5
Amy Mysz Region 5
Allan Welch Region 10
U.S. Department of
Health and Human Services
Health Resources & Services Administration
(HRSA) Bureau of Health Professions,
Division of Public Health & Allied Health
Barry Stern, MPH
HRSA Office of Planning, Evaluation & Legislation
Karen Pane, RN, MPSA, CMCN
HRSA Bureau of Health
Professions, Division of Medicine
Barbara Brookmyer, MD, MPH
Ruth Kahn, DNSc
HRSA Bureau of Health
Professions, Division of Nursing
Madeleline Hess, PhD, RN
Joan Weiss, PhD, RN, CRNP
HRSA Bureau of Health Professions, Division of
Interdisciplinary, Community-Based Programs
David D. Hanny, PhD, MPH
HRSA Bureau of Primary Health
Care, Migrant Health Program
Eva Montoya
HRSA Office of Rural Health Policy
Cassandra Lyles
National Institute of Occupational Safety & Health
Geoffrey Calvert, MD, MPH
Rosemary Sokas, MD, MOH
Office of Disease Prevention &
Health Promotion
Dalton Paxman, PhD
Agency for Toxic Substances & Disease Registry
Donna Orti, MS
U.S. Department of Agriculture
Agricultural Marketing Service
Peter S. Wood
Cooperative State Research,
Education, and Extension Service
Larry Olsen, PhD
U.S. Department of Labor
Mike Hancock
Other Organizations
The National Environmental
Education & Training Foundation
Susan T. West, MPH
Jennifer Bretsch, MS
American Association of Pesticide Safety Educators,
University of Maryland-College Park
Amy E. Brown, PhD
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Expert Panel and Workgroup Members
Sheila Brown Arbury, RN, MPH
Association of Occupational and
Environmental Clinics
Colin Austin
Migrant Clinicians Network, and
University of North Carolina-Chapel Hill
Joni Berardino, MS, LSW
National Center for Farmworker Health
Angelina Borbon, RN
Alameda County Lead Poisoning
Prevention Program
Barry Brennan, PhD
American Association of Pesticide Safety
Educators, and Extension Pesticide
Coordinator, University of Hawaii
Amy Brown, PhD
American Association of Pesticide Safety
Educators, and University of
Maryland-College Park
Paul J. Brownson, MD
The Dow Chemical Company
Candace Burns, PhD, ARNP
National Organization of Nurse Practitioner
Faculties, and University of South Florida
College of Nursing
Joan Spyker Cranmer, PhD
University of Arkansas Medical School
Miriam Cruz
Equity Research
Shelley Davis
Farmworker Justice Fund, Inc.
Gerardo de Cosio, MD
U.S.-Mexico Border Health Association
Susannah Donahue, MPH
Children's Environmental Health Network
J. Ward Donovan, Jr., MD, FACEP
American College of Emergency Physicians,
Pennsylvania University Poison Center, and
Milton S. Hershey Medical Center
Gerry Eijkenmans, MD, MPH
Pan American Health Organization
Joe Fedoruk, MD, DABT, CIH
American College of Occupational and
Environmental Medicine
Kesner Flores, EMT
Cortina Indian Rancheria, Wintum
Environmental Protection Agency
Scottie Ford, MA
West Virginia Department of Agriculture
Jose Garcia
Equity Research
Matthew Garabedian, MPH
Texas Department of Health
Jeanne Goshorn, MS
National Library of Medicine
Harold Harlan, PhD
National Pest Control Association
Barbara Hatcher, PhD, MPH, RN
American Public Health Association
Rugh Henderson, MD, MPH
North American Agromedicine Consortium,
Pennsylvania Agromedicine Program, and
Penn State University College of Medicine
Michael Hodgman, MD
National Rural Health Association,
and Bassett Healthcare/NY Center for
Agricultural Medicine and Health
Allen James, MBA, CAE
Elizabeth Lawder, BA (alternate)
Responsible Industry for a Sound Environment
Linda Kanzleiter, M.Ps.Sc.
Celeste Stalk (alternate)
Pennsylvania Area Health Education Center,
Milton S. Hershey Medical Center
Matthew Keifer, MD, MPH
NIOSH Agricultural Health and Safety
Centers, and University of Washington
Kathy Kirkland, MPH
Association of Occupational and
Environmental Clinics
Andrea Lindell, DNSc, RN
American Association of Colleges of Nursing,
and University of Cincinnati College of Nursing
Ann linden, CNM, MSN, MPH
American College of Nurse Midwives
John McCarthy, PhD
American Crop Protection Association
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Claudia Miller, MD
University of Texas Health Science
Center-San Antonio
Mark Miller, MD
American Academy of Pediatrics
Mary Miller, MN, ARNP
American Nurses Association, and Washington
State Department of Labor and Industries
Terry Miller
National Pesticides Telecommunications
Network, and Oregon State University
Rita Monroy
National Alliance for Hispanic Health
(formerly National Coalition of Hispanic
Health and Human Services Organizations)
Karen Mountain, MBA, MSN, RN
Migrant Clinicians Network
Diane Mull
Association of Farmworker
Opportunity Programs
Madaleine Ochinang, MS
Formerly with the Consortium for
Environmental Education in Medicine
Patrick O'Connor-Marer, PhD
American Association of Pesticide Safety
Educators, University of California Statewide
IPM Project, and University of California
Agricultural Health and Safety Center
Marcia Allen Owens, JD
Minority Health Professions Foundation
Dennis Penzell, DO, FACP
Suncoast Community Health Centers, Inc.
Annette Perez, RNC, MSN, CNM, PhD
American College of Nurse Midwives,
and University of Texas-El Paso,
College of Health Sciences
John Pickle, MSEH
Weld County Health Department Greeley, CO
Ana Maria Puente
Bureau of Primary Health Care, Border Health,
Health Resources and Services Administration
Benjamin Ramirez, MD, MPH, FACOEM
DuPont Company
Scott Ratzan, MD, MPA
Academy of Educational Development
Susan Rehm, MBA
American Academy of Family Physicians
J. Routt Reigart, MD
Medical University of South Carolina,
Department of Pediatrics
Mark Robson, MD, MPH
Environmental and Occupational Health
Sciences Institute, and Rutgers University
George C. Rodgers, Jr, MD, PhD
American Association of Poison Control Centers,
and University of Loiusville School of Medicine
Bonnie Rogers, RN, DrPH, COHN-S, FAAN
American Association of Occupational
Health Nurses, and University of North
Carolina-Chapel Hill School of Public Health
Rachel Rosales, MSHP
Texas Department of Health
Elaine R. Rubin, PhD
Association of Academic Health Centers
Barbara Sabol
W. K. Kellogg Foundation
Barbara Sattler, RN, DrPH
University of Maryland School of Nursing
Jackilen Shannon, PhD
Council of State and Territorial Epidemiologists,
and Texas Department of Health
Cathy Simpson, MD
Wayne State University School of Medicine
Gina Solomon, MD, MPH
Natural Resources Defense Council
Elisabeth Spector, MD, MPH
American Academy of Family Physicians
Roger F. Suchyta, MD
Graham Newson (alternate)
Jennifer Stevens (alternate)
American Academy of Pediatrics
Greg P. Thomas, PA-C
American Academy of Physician Assistants
LeonelVela, MD
Migrant Health Advisory Council, and Texas
Tech Health Sciences Center
Sheldon Wagner, MD
National Pesticide Medical Monitoring
Program, and Oregon State University
John Wheat, MD, MPH
North American Agromedicine Consortium,
and University of Alabama
at Birmingham, School of Medicine
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Contents
Executive Summary
Vision, Expected Outcomes, and Evaluation
Making the Case
Target Audience
Framework of the Plan: A Three-Pronged Strategy
Educational Settings
Practice Settings
Resources and Tools
Conclusion
References
Glossary
Appendix A: Expert Panel Proceedings
Appendix B: Summary Proceedings from Workgroups
Appendix C: Federal Interagency Planning Committee
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List of Exhibits
Tables
1 Components of the Implementation Plan
2 Initiative Work Products
3 Pesticides Most Often Implicated in Symptomatic Illnesses, 1996
4 Targets, Populations Served, Practice Settings
5 Stages of Change Model
6 Proposed Competencies for Educational Institutions
7 Proposed Design of Faculty Champions Project
8 Expected Practice Skills Preliminary Outline
Figures
1 Framework of the Implementation Plan
2 Projected Timeline for Accomplishing Implementation Plan
3 Stages of Change and Implementation Plan Components
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Executive Summary
Pesticides are ubiquitous in our society in both agricultural and urban sectors. We use
pesticides in our homes, in our workplaces, and in our communities. Due to the
widespread dissemination of pesticides, and the potential for related illness and injury
(especially among farmworkers and pesticide handlers), health care providers should be
prepared to recognize, manage and prevent pesticide-related health conditions in their patients
and communities. Communities expect that their primary care providers will be prepared to
deal with pesticide-related health conditions, as well as other environmental-related illnesses,
but often times they are not.
This report, an Implementation Plan for the national initiative on Pesticides and National
Strategies for Health Care Providers, sets out a strategic direction for the nation to improve the
recognition, management, and prevention of pesticide-related health conditions. It will lead
to health improvements in both agricultural and urban sectors. The Plan's vision is for all
primary care providers on the front lines of our health care system to:
¦ Possess a basic understanding of the health effects associated with pesticide exposures as
well as broader environmental exposures; and
¦ Take action to ameliorate such effects through clinical and prevention activities.
The Plan sets forth a three-pronged approach to move toward the vision, and includes
both short and long-term components. The Plan will be used to build national consensus
on this issue and to gain funding and resource support to implement and evaluate the
entire initiative.
The initiative, Pesticides and National Strategies for Health Care Providers, was created by
the U.S. Environmental Protection Agency (EPA) in collaboration with the U.S. Department
of Health and Human Services (DHHS), the U.S. Department of Agriculture (USDA), the
U.S. Department of Labor (DOL), and The National Environmental Education & Training
Foundation (NEETF). From the outset, this national interagency initiative has been
conceived of as a long-term effort. Sustained funding will be needed to ensure the success
of the Plan, and multi-stakeholder involvement is necessary from federal agencies, academic
institutions, professional organizations, foundations, farmworker and farm groups, industry
and trade associations.
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This Plan focuses on pesticides as an important model which can easily be expanded to
incorporate other toxic agents and other related initiatives in the field of environmental health.
To avoid duplication of effort, this Plan will be integrated into the broader context of other
national initiatives in educating health providers about occupational and environmental health,
including children's health protection, drinking water, nursing and environmental health,
Healthy People 2010, and NEETF's Wellness and the Environment Initiative. This Plan reflects
the landmark reports from the Institute of Medicine, National Academy of Sciences (1988,
1995) that set forth broad recommendations on environmental health in medicine and nursing,
as well as the extensive efforts that have taken place across the country by key stakeholders to
address this issue. It is hoped that this Plan will pave the way for the strategic next steps
needed to move forward a common national vision for environmental health awareness,
education and training to health care providers.
This Plan, slated for final publication in Fall 2000, and progress on its implementation will be
showcased at a national forum for health care providers scheduled for 2001 in Washington, DC.
The Initiative's Driving Forces
This initiative received its impetus from a number of sources.
The Worker Protection Standard
A primary contributor is EPA's Worker Protection Standard, designed to reduce pesticide
exposure to agricultural workers, mitigate exposures that occur, and inform agricultural
employees of the hazards of pesticides. The regulation, implemented in 1995, mandates that
millions of farmers, pesticide applicators, and farmworkers be educated for such efforts. This
in turn was expected to create additional demand for services from health care providers.
After the first year of full implementation of the Worker Protection Standard, EPA held
nine public meetings to evaluate the progress of implementation and hear the experience
of the people most affected by the regulation. One clear message from the public meetings
was the need to improve the recognition, diagnosis, and management of adverse health
effects from pesticide exposures on the part of all primary care providers of the health
care community.
Although the primary populations affected by pesticides are the 3 to 4.5 million farmworkers
in America and the million or more pesticide applicators, pesticides are widely used in the
urban sector. Urban and suburban exposures to pesticides through lawn care products and
insecticides in the home and workplace are affecting the population at large. Health care
providers in urban settings are even less likely to "think pesticides" in taking patient histories
or diagnosing illnesses.
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Other Forces
In the field of environmental health, the need for improvements in health care provider
training has been expressed by health professional groups, academic institutions, as well as
government and community organizations. In 1994, the American Medical Association
adopted a resolution urging Congress, government agencies, and private organizations to
support improved strategies for the assessment and prevention of pesticide risks. These
strategies included systems for reporting pesticide usage and illness, as well as educational
programs about pesticide risks and benefits. In addition, two Institute of Medicine (IOM)
committees addressed the general issue of environmental health education, focusing on
nurses and physicians, respectively. Both committees recommended an integration of
environmental health issues throughout the various stages of training and clinical practice
for health care providers.
Definition of Environmental Health
A common definition of environmental health has been adopted for purposes of this
initiative. Environmental health is defined as: "freedom from illness or injury related to
exposure to toxic agents and other environmental conditions encountered in the home,
workplace, and community environments that are potentially detrimental to human
health" (adapted from the Institute of Medicine's report, Nursing, Health and the
Environment (Pope et al, 1995)). Pesticide exposures do occur in workplace settings;
therefore, environmental health in the context of this Plan is an overarching category
that includes occupational health.
Building the Initiative - A Collaborative Approach
To ensure that collaboration and integration at the federal level could be incorporated at all
stages of the initiative, EPA established a Federal Interagency Planning Committee in
November 1997 whose initial membership included representatives from DHHS, USDA,
and DOL, as well as EPA. Beginning in February 1998, through a cooperative agreement,
the initiative also involved NEETF as a non-federal collaborative partner. NEETF brings
the expertise of working with a national coalition of health organizations involved in
environmental health through its Wellness & The Environment Initiative, and has played a
major role in coordinating the initiative with EPA and the federal partners. Several other
federal agencies have since joined the initiative and other interested federal partners are
welcome to participate.
Expert Panel and Workgroups
EPA, the Federal Interagency Planning Committee, and NEETF are committed to involving a
wider group of key stakeholders through all stages of this initiative, beginning with the
development of this Plan. In April 1998, an Expert Panel was convened to identify strategies
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for educating health care providers on how to recognize, diagnose, manage, and prevent adverse
health effects from pesticide exposures. This workshop reflected the collaborative nature of
this initiative and the need to involve a wide group of stakeholders in this issue.
An even wider involvement of key stakeholders took place through three workgroup meetings
(Education, Practice, and Resources) held in May and August 1999. (Summaries of the Expert
Panel and workgroup meetings are presented in Appendices A and B, respectively.) Workgroup
members, as liaisons to their organizations, have brought important perspectives to this effort
and have ensured that their organizations are kept abreast of the initiative. These key
stakeholders will play a further role in outreach and consensus building within their
organizations and constituencies to move the overall initiative forward.
Strategic Outreach Meetings to Build Consensus
With the assistance of stakeholders who participated in the Expert Panel and/or the three
workgroups, the Federal Interagency Planning Committee will conduct strategic outreach
meetings with key professional organizations and decision-making bodies to secure official
endorsements. Efforts are currently underway to participate at various national conferences
for the purposes of publicizing the Plan and the upcoming national forum, and to begin
developing support among stakeholders.
Sustained Funding and Support
To ensure that sustained funding is available for the implementation and evaluation of
both short and long-term components of this initiative, funding and resource support must
come from various sources, including federal agencies, professional health organizations,
foundations, academia, industry, trade associations, environmental, farm and farmworker
and community-based organizations. It is this type of resource sharing and collaboration
that will determine the success of this initiative and create a win-win situation of all parties
concerned.
Summary of the Implementation Plan
Objectives
The main purpose of this Plan is to clearly articulate a plan to improve the recognition,
management and prevention of pesticide-related health conditions. This Plan also serves as
a model for broader efforts to educate health care providers about the spectrum of health
conditions associated with environmental problems. The four main objectives of the Plan
are to:
¦ Make the case and raise awareness for why primary health care providers should be
educated about and trained in ways to address health effects from pesticide exposures.
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¦ Identify the target audience for the initiative and explain how strategies are designed to
reach segments of the audience at different stages of their "readiness to change."
¦ Set forth an agenda to build national consensus on this issue and gain funding and resource
support to implement the Plan and evaluate the initiative over a ten-year period from
various sources including federal agencies, academia, professional health organizations,
foundations, farmworker and farm groups, industry, and trade associations.
¦ Articulate a three-pronged strategy and a set of required elements for education settings,
practice settings, and necessary resources and tools.
Strategic Framework
Given that primary care providers are educated and trained in different settings, the Plan
specifically sets out a three-pronged strategy for effectively reaching them in these settings
(see Table 1). The first prong addresses a provider's formal education, such as medical school
or nursing school. The second prong targets the practice setting in which a provider works
and participates in professional development. The final prong articulates the resources and
tools that providers need to effectively deal with pesticide-related health conditions in their
practices and communities. Specifically, the three prongs of the strategy are as follows:
1. Educational Settings: Create significant institutional change in educational settings (e.g.,
medical schools, nursing schools, residency and practicum programs) so that students in
the health professions are prepared to recognize, manage, and prevent pesticide-related
health conditions across the United States.
2. Practice Settings: Change the practice of primary care so that pesticide-related health
conditions are recognized, effectively managed and prevented in practice settings (e.g.,
community clinics, hospitals, work-place clinics) across the United States.
3. Resources and Tools: Create new resources for educational and practice settings that
take into account existing resources, evaluate their quality and suitability for different
audiences, and assure their availability through an informational gateway.
For both the educational and practice settings, the Plan recommends a similar set of component
projects and activities (see Figure 1). These components serve as a framework for the cohesive
implementation of the three-pronged strategy. This Plan intentionally presents the same
conceptual framework for both settings so as to ensure consistency in approach. However, the
Plan distinguishes between the settings because they often involve different decision-makers
and approaches. The components for the settings are:
¦ Make the Case for Change
¦ Define Guidelines for Educational Competencies or Practice Skills
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Table 1: Components of the Implementation Plan
Educational Settings
Component A: Make the case for change in educational
settings Develop an effective case statement to convince
decision makers about the need for environmental health
and pesticide education in medical and nursing educational
institutions.
"Component B: Define competencies and integration
strategies for curricula Produce National Guidelines that
recommend competencies specific to the recognition,
management and prevention of pesticide exposures, for all basic
and advanced training in medicine and nursing; define
accompanying content areas; suggest methods of integration
into curricula; and provide access to relevant resource materials.
'Component C: Assess educational settings Conduct an
assessment of the target audience of educational institutions
to determine (a) amount of existing coursework, (b) faculty
members' current knowledge and comfort level with teaching
pesticide-related topics, and (c) how faculty and educational
institutions will best respond to educational programs and
informational resources. This assessment will be comprised
of a literature review, surveys, and focus groups.
Component D: Secure official endorsements Ensure
the integration of the core competencies oudined in the
National Guidelines into educational institutions by
securing the official endorsements of key professional
organizations and decision making bodies.
Component E: Strengthen and build faculty champions
Create and support faculty champions within medical and
nursing schools to teach environmental health and pesticide
education in the curriculum, and to bring about change
within their institutions.
Component F: Create teaching incentives Influence
the appropriate boards, organizations, and institutions that
create board exams to include several key competencies on
pesticides and environmental health.
* Priority Project
Practice Settings
Component A: Make the case for practitioners - Develop
an effective case statement to convince primary care providers
about the need to incorporate environmental health and
pesticide awareness into their practice settings.
'Component B: Define practice skills and guidelines - Produce
National Guidelines that recommend practice skills and
guidelines for the recognition, management, and prevention of
pesticide exposures for all practicing health care providers; define
accompanying content related to expected behavior; suggest
methods of integration into practice and training settings; and
provide access to relevant resource materials.
"Component C: Assess knowledge and skills of practitioners
Conduct an assessment of the target audience of primary care
providers to determine: (a) providers' current knowledge and (b)
how providers will best respond to educational programs and
informational resources. This assessment will be comprised of a
literature review, surveys, and focus groups.
Component D: Secure official endorsements Ensure the
integration of the expected practice skills into practice settings
by securing the official endorsements of key professional
organizations and decision making bodies.
Component E: Demonstrate model programs Mobilize
practice settings to become population-specific and to
incorporate environmental considerations (specifically
pesticides) into prevention, education, diagnosis, and treatment.
Achieve incremental, site-specific improvements in
identification, early intervention, and prevention, as well as in
measures of practice-specific health outcomes. By 2010, half
of all primary health care practice settings in the United States
should incorporate environmental considerations in
prevention, education, management, and referral.
Component F: Create incentives for change Identify and
promote a number of incentives to incorporate appropriate
prevention, recognition, and management of pesticide-related
health conditions into health care practices.
Resources and Tools
Component A: Inventory existing resources Determine
what educational and informational programs and materials
for health care providers currently exist in education and
practice settings and what gaps should be filled.
"Component B: Establish a national review board
Create a national body to determine assessment criteria and
evaluate existing resources, with the goal of identifying,
selecting, and assessing the ideal resources that primary
health care providers use in both educational and practice
settings for prevention, diagnosis, treatment, and referral
of pesticide-related health conditions.
"Component C: Create an information gateway -
Establish a print, telephone, and Web-based gateway through
which primary health care providers can access information
and educational resources.
Component D: Develop teaching/learning resources for
educational settings Identify and develop new content
resources, tools, and methods for faculty in educational
settings.
Component E: Develop new resources for practice
settings Identify and develop new content resources,
tools, and methods for health care providers in practice
settings.
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Figure 1: Framework of the Implementation Plan
Educational Settings
Practice Settings
Educational institutions
Educational competencies
Institutions and faculty
Key decision-makers
Faculty champions
Exams and requirements
A
- Make the case -
Define guidelines
Assess target audiences
- Secure endorsements -
- Demonstrate success -
- Create incentives
Resources and Tools
Inventory National New
Review Board Resources
Primary care providers
Practice skills
Primary care providers
Key decision-makers
New practice models
Health care requirements
and reporting
i
Information
Gateway
¦ Assess Target Audiences in Each Setting
¦ Secure Key Endorsements
¦ Demonstrate Success Through Faculty Champions and Practice Models
¦ Create Incentives for Change.
The Plan also outlines a process to develop the resources and tools necessary to ensure the
success of the entire initiative:
¦ Inventory Resources
¦ Establish National Review Board and Conduct Evaluation of Resources
¦ Create Internet-based Information Gateway
¦ Create New Resources.
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Table 2 provides a listing of the anticipated work products to be produced in this initiative. The
projects and products can only be accomplished through partnerships among federal and state
agencies, professional health organizations, academia, foundations, industry, farm and farmworker
groups, environmental groups and trade associations. EPA and the Federal Interagency Planning
Committee encourage interested parties to come forward with their ideas for implementation.
Table 2: Initiative Work Products
¦ Case Statement for Educational Settings (p. 38)
¦ Case Statement for Practice Settings (p. 64)
¦ National Pesticide Competency Guidelines for Education (p. 41)
¦ National Pesticide Practice Skill Guidelines (p. 67)
¦ Report on Knowledge, Attitudes, and Skills of Educators and Practitioners (pp. 49, 71)
¦ Organizational Position Papers Endorsing The Plan (pp. 52, 74)
¦ Request for Applications/Proposals to Support Faculty Champions (p. 55)
¦ Request for Applications/Proposals to Support Practice Models (p. 77)
¦ Network of Successful Faculty Champions (p. 56)
¦ Network of Successful Practice Models (p. 77)
¦ Sample Questions for Educational Examinations (p. 58)
¦ New Monetary, Legal, Community-Based, and Peer-Professional Incentives (p. 80)
¦ Inventory of Resources (p. 87)
¦ National Review Board for Resource Materials (p. 89)
¦ Recommended List of Resources (p. 89)
¦ Gateway of Resources (print, telephone, Internet) (p. 91)
¦ New Resources and Materials (pp. 94, 96)
Timeline and Priority Projects
A projected timeline identifying the time frame for implementation of the Plan's components
is provided in Figure 2. As the timeline shows, several projects have already been initiated,
and four component areas will receive priority attention in 2000. They are:
¦ National Pesticide Competency Guidelines for Education, and National Pesticide
Practice Skill Guidelines: These two model documents will recommend competencies
for students and practice skills for practitioners to achieve, respectively, the recognition
and management of pesticide-related health conditions and exposures. Work on the
National Guidelines was initiated in February 2000.
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Figure 2: Projected Timeline for Accomplishing Implementation Plan (based on funding availability)
Education:
Make the case for change in
educational settings
Define competencies and integration
strategies for curricula*
Assess educational settings
Secure official endorsements
Strengthen and build faculty champions
Create teaching incentives
Practice:
Make the case for change for practitioners
Define practice skills and guidelines*
Assess knowledge and skill of practitioners
Secure official endorsements
Demonstrate model programs
Create incentives for change
Resources:
Inventory existing resources
Establish national review board
Create information gateway
Develop teaching/learning resources
for educational settings
Develop new resources for practice settings
Convene National Forum
Project Evaluation
"Initiated Feb. 2000
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
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¦ Audience Assessment of Educational Settings and Primary Care Providers: The
assessment report will document the knowledge, attitudes and skills of health care provider
faculty and practitioners on pesticides and environmental health. Work on the audience
assessments will be initiated in 2000.
¦ Information Gateway: The Gateway will be a print, telephone, and Web-based resource
through which primary care providers can easily access information and educational
resources in one place about pesticides. This effort will get underway in 2000.
¦ National Review Board: The National Review Board will determine assessment criteria
and evaluate existing resources, with the goal of identifying, selecting, and assessing the
ideal resources that primary care providers use in both the educational and practice settings.
This effort will get underway in 2000.
Request for Participation and Public Comment
This draft plan is a working document and will be widely shared and disseminated among
stakeholders in professional associations, health organizations, educational institutions,
government agencies and other groups. The Federal Interagency Planning Committee for
this initiative welcomes the widest possible input. The draft Plan will be available for
public comment through the Federal Register. Questions about the Plan or initiative can be
directed to NEETF at pesticides@neetf.org. Once comments have been reviewed and
incorporated, the final Plan is slated to be published in Fall 2000.
National Forum 2001
The Plan, and progress on implementation of the initiative, will be the subject of a national
forum for health care providers scheduled for 2001 in Washington, DC. The national forum will
be held over two days with an audience of 150-200 health care providers and stakeholders,
including key decision-makers from various agencies and organizations. The forum will launch
this national Implementation Plan, showcasing pesticides as a model for other environmental
health issues. Progress on the priority projects initiated this year the National Guidelines,
Audience Assessment, Information Gateway, and National Review Board will be featured at
the forum, in addition to a broad range of educational models, practice models, and resources.
The forum will provide an opportunity to secure endorsement from key stakeholders; build a
network of health care providers nationwide; announce an RFP to fund components of the
Implementation Plan, and hold training workshops for health care providers. EPA and the
Federal Interagency Planning Committee members invite interested organizations and
initiatives to participate in the sponsorship, planning, and organization of the national forum.
10
DRAFT
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Vision, Expected
Outcomes, and Fvaluation
Vision
The goal of the Pesticides and National Strategies for Health Care Providers initiative is
to improve the recognition, management, and prevention of health effects from pesticide
poisonings and exposures. In addition, all primary health care providers should consider
the impact of pesticide overexposures on human health as they treat patients and prevent disease.
All physicians, nurses, and other health care providers are expected to possess a basic knowledge
of health effects related to pesticide exposures and an ability to take action to ameliorate such
effects through clinical and preventive activities. This will be achieved through training and
education of health professionals, faculty, and students, and the identification, development,
dissemination, and use of appropriate resources and tools, in clinical and public health settings.
The initiative is set in the broader context of environmental health and holds as its preamble the
following recommendations, adopted from the Institute of Medicine (Pope and Rail, 1995):
¦ Environmental health concepts will be reflected in all levels of education of primary care
providers, specifically defined as physicians, nurse practitioners, physician assistants, nurses,
nurse midwives, and community health workers in the disciplines of family practice, pediatrics,
internal medicine, emergency, obstetrics/gynecology, preventive medicine, and public health.
¦ Interdisciplinary approaches will be used when educating primary health care providers
so as to draw upon the expertise from various environmental health disciplines.
¦ Environmental health content will be an integral part of lifelong learning and continuing
education of primary care providers.
¦ Professional associations, public agencies and private organizations will provide more
resources and educational opportunities to enhance environmental health in primary
care practice.
Expected Outcomes
By 2010, the following expected outcomes of the initiative should have occurred:
1. Professional associations, decision-making bodies, academic institutions, and practice
settings have endorsed the need to address health conditions associated with pesticide
poisonings and overexposures.
DRAFT
11
-------
2. The need for educating health care providers about the health effects of pesticide exposures
is an accepted part of primary health care education and practice.
3. Education and practice settings have integrated an endorsed set of educational
competencies and practice skills for primary health care providers on pesticide exposures.
4. Evaluated tools and resources are being used by health care providers to recognize, manage,
and prevent health effects from pesticide exposures.
5. A faculty champion on this issue is positioned and funded in over 100 academic
educational institutions, including academic health centers and accompanying nursing
schools nationwide.
6. Certification, licensing, and accreditation requirements include attention to the
recognition, management, and prevention of health effects related to pesticide poisonings
and exposures.
7. Over 100 pilot primary care practices serve as models for effectively integrating attention
to health effects from pesticides in clinical, educational, and/or preventive ways.
8. Primary care providers are integrating attention to the health effects of pesticides in clinical,
educational, and/or preventive ways.
9. An Internet gateway effectively guides health care providers and professional organizations
to informational resources and educational materials on the issue.
10. Incentives in the health care system have increased the attention that primary care providers
pay to the recognition, management, and prevention of health effects from pesticide
poisonings and exposures.
11. Resource materials on pesticide poisonings are easily located in the leading sources of
information for the health care community (e.g., professional journals, newsletters, central
Internet sites, professional meetings).
Evaluation of Expected Outcomes
This initiative has a long-term perspective and ultimately its success will depend on how well
it leads to changes and improved health care in this country. Evaluating its progress along the
way and its long-term success will be important, both for making mid-course corrections as
needed, and for learning from its achievements and failures. An evaluation team will be
contracted to design and implement the evaluation. The evaluation will begin early on in the
initiative to ensure that measurement indicators are clearly built into all aspects of
implementation. The evaluation will be both formative and summative in nature so as to
track both process and outcome measures. The following set of indicators will be used to
evaluate the components of the plan.
12
DRAFT
-------
Professional Endorsement
¦ The maj or professional associations and
organizations involved with the
initiative's target audiences endorse and/
or adopt a position paper supporting
this Implementation Plan.
¦ Professional journals increase the
number of peer-reviewed articles and
commentaries making the case for
recognizing, managing, and preventing
health effects from pesticide poisonings
and exposures.
Educational Institutions
¦ Over 40 percent of educational
institutions take steps towards integrating pesticide education into their settings (e.g.,
adopt components into their curriculum from the National Guidelines, hire a faculty
champion, hold Grand Round lectures on the topic, create practice-based internships
that address the issue).
¦ Over 100 educational institutions have a "faculty champion" on faculty who integrates a
pesticide perspective into the education of health professional students.
¦ Certification and licensing requirements include a component related to pesticides, or
address the broader understanding of environmental health so that students are tested on
at least a portion of the endorsed competencies.
Practice Settings
¦ Over half of practice settings have taken steps towards building a "model practice" that
addresses health effects related to pesticides (i.e., patient education, history taking,
community outreach, use of tools and resources, access to Internet gateway).
¦ Model practice settings document improvements based on changes in recognizing,
managing, and preventing pesticide exposures. Specific models are tracked in high-impact
areas (e.g., migrant farmworker communities, urban settings).
¦ Re-certification and continuing education requirements include a component related to
pesticides, or address the broader understanding of environmental health so that
practitioners are evaluated on at least a portion of endorsed practice skills.
¦ Incentives are in place in the health care system to reward health care providers who
recognize, manage, and prevent pesticide-related health conditions.
"If you make it
relevant to
teachers, they'll
find a way to teach
their students."
- Marcia Owens, JD
Minority Health
Professions Foundation
DRAFT
13
-------
Utilization of Tools and Resources
¦ Tools and resources are being used at an increased rate by health care providers as tracked
through sales, requests, downloading off the Internet, and distribution at conferences.
¦ An endorsed list of resources is available to health care providers online and through the
key dissemination mechanisms.
Increased Reporting and Surveillance
¦ More health care providers are reporting suspected pesticide poisoning and exposures to
state and federal agencies.
¦ States with existing surveillance systems have improved outreach to health care providers
statewide to report suspected cases.
¦ More states implement pesticide surveillance systems with effective outreach and
involvement of health care providers.
Improvements Recognized by Communities/General Public
¦ Community organizations report improved communication and activities by local health
care providers and clinics.
14
DRAFT
-------
Making thp Casp
Pesticides are ubiquitous in our society. We use them in our homes, workplaces and
communities. Due to the widespread dissemination of pesticides, and the potential for
related illness and injury (especially among farmworkers and pesticide handlers),
primary care providers should be prepared to recognize, manage, and prevent pesticide-related
health conditions with their patients and communities.
When pesticide toxicity is discussed, most people usually think of an acute pesticide poisoning
incident in an agricultural setting. However, pesticides are also of concern because of potential
chronic health effects from long-term exposures. In addition, pesticide exposure can occur in
a number of settings outside agriculture, including urban environments, homes, and schools.
For these reasons, patients and communities often look to their primary care providers as
important sources of information and guidance on suspected pesticide-related health
conditions. All too often, however, providers are not able to respond effectively.
Primary care providers are on the front lines of health care and therefore can play a key role in
identifying and ameliorating potential pesticide poisonings and exposure. However, more
needs to be done to ensure that health professionals are prepared for this role and that they
know where to turn for assistance. This includes ensuring that providers can "problem solve"
with patients who think an exposure has occurred, readily diagnose if appropriate, provide
timely treatment for pesticide-related illnesses, provide prevention education, and, where
appropriate, consult with local authorities. This Plan offers a way for health care professionals
to be effectively prepared through their education and training, and to maintain this knowledge
while in practice.
This Plan is based on the premise that addressing pesticide-related health conditions can be a
part of routine primary care and does not require extensive expertise on the part of the provider.
This initiative recognizes that primary care providers are faced with a number of competing
public health concerns. The goal of the initiative is to build on existing skills in toxicology,
pharmacology, history-taking, and risk communication to provide tools that the busy practitioner
can use when the need arises. Primary care providers working with high risk populations may
need to attain a more detailed knowledge of pesticide-related health conditions.
More research is still needed on the health effects of pesticide exposures. Such research efforts
should involve primary care providers. Research should focus on what conditions primary
care providers see in their practices, specifically with regard to chronic exposures. As this
DRAFT
15
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initiative evolves, it is recommended that epidemiologic research be developed using a registry
of primary care offices to identify conditions requiring further research and documentation.
Following are a number of reasons, accompanied by supporting data, why pesticide-related
health conditions are relevant to the practice of primary care today:
¦ Patient and Community Concerns
¦ Recent Public Pesticide Issues
¦ Potential for Acute Exposures and Effects
¦ Potential for Chronic Exposures and Effects
¦ Clinical Case Examples
¦ Current Provider Training and Education in Environmental Health
Patient and Community Concerns
Primary care providers are on the front lines of providing health care. Patients and communities
often ask for advice about a suspected pesticide exposure or ask the provider to investigate a
potential health condition to see if it might be related to pesticides. Public concern about
pesticides has been documented and often shows up in the questions asked by patients of
their personal primary care providers. By helping patients problem solve and evaluate risks
from pesticides, primary care providers can help patients reduce risk to exposure and prevent
future exposures. In addition, an alert clinician will also be able to identify a potential exposure
when it occurs.
In some instances, providers serve populations that are more actively engaged with pesticides,
such as the farmworker community. There are 3 to 4.5 million farmworkers in this country
and a million or more pesticide applicators who are often at greater risk for pesticide exposure
because of mixing or applying pesticides or working in fields where pesticides are applied. A
provider community that is more aware of the specific concerns of this population will be
better prepared to effectively diagnose and treat health conditions, and prevent exposures.
Many members of the public have expressed concern about the risks of cancer, birth defects,
reproductive effects, and other conditions from exposure to pesticides. For example, from a
list of 30 potentially hazardous activities, use of pesticides was perceived to rank in the top 10
most risky activities, higher in "riskiness" than surgery, electric power, swimming, large
construction, x-rays, or bicycles (Slovic et al, 1980). Health care providers have an important
role in helping their patients evaluate the relative risks from different types of environmental
exposures, including pesticides. Health care providers need to be able to counsel patients
about realistic risks, and avoid unwarranted trivialization or exaggeration of the risks.
16
DRAFT
-------
Providers are often asked basic questions by their patients. Here is a sampling
of pesticide-related questions and concerns that patients bring to their visits
with providers:
(1) I received a report from my water utility that said the water contains 0.5 ppb
of dibromochloropropane. What is this chemical, what does it mean for my
health, and what should I do?
(2)1 just read in the newspaper that schools in my state are spraying their
buildings with toxic pesticides. I'm worried because my child has asthma
and sometimes feels worse at school. Could it be the pesticides?
(3) I have a six-month-old child and the cat has fleas. Is it safe to have the
exterminator in to flea-bomb the house? The exterminator says it's safe if
we stay out for a few hours and open the windows afterwards.
(4) My husband and I are having trouble conceiving a child. We own a farm and
he sprays pesticides. I want to know if the pesticides may be causing a problem.
(5) I get a headache and have difficulty concentrating at the office. I think it
may be because the janitor sprays pesticides at night.
(6) I am a farmworker and was picking celery in the fields. Today 1 have a rash
on my hands and arms. Is it from the chemicals?
In large measure, this initiative is intended to help prepare the primary care provider with the
information, skills, and resources to begin problem solving with patients. The questions in
the shaded box above are only a sampling of the concerns presented to practitioners everyday.
This initiative will help primary care providers carry out their responsibilities to help patients
evaluate the risks and determine whether further steps are required.
Recent Public Pesticide Issues
Misuse of Pesticides - Methyl Parathioti Case Studies of Misdiagnosis
Under the Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA), EPA regulates an
organophosphate insecticide called methyl parathion for use on specific crops. In the 1980s
and 1990s, methyl parathion was widely used illegally in indoor environments by unlicensed
applicators. One published report describes methyl parathion-related illness among seven
siblings, two of whom had a fatal outcome (CDC, 1984). Approximately two days before
these children were correctly diagnosed, five of them were seen by their local physician and
sent back to their contaminated home with a mistaken diagnosis of viral gastroenteritis. Since
1984, at least five different states have reported illegal use of methyl parathion inside homes
DRAFT 17
-------
and businesses. Some people exposed to
methyl parathion in their homes
experienced mild symptoms of
organophosphate poisoning (e.g., nausea,
headache, difficulty breathing, blurred
vision) and some of them complained to
their health care professionals. A report
summarizing the 1995 investigations in
Ohio (where at least 500 homes were
treated illegally) found that 20% or more
of respondents reported symptoms
during the two weeks following methyl
parathion application (NCEH, 1996).
Unfortunately, corrective action was not
enacted until 1994. More than 1,500
individuals were relocated from their
home. The estimated clean-up cost for
these incidents is more than $90 million
(Environews, 1997).
Misdiagnosis of organophosphate
poisoning can be a severe problem.
Zweiner and Ginsburg (1988) reviewed a case series of 37 infants and children poisoned by
organophosphates and carbamates. Of 20 cases transferred to Children's Medical Center in
Dallas, 16 (80%) had an incorrect transfer diagnosis ranging form encephalopathy and seizure
disorder to pneumonia and pertussis.
Each of these cases of misdiagnosis or delayed diagnosis demonstrates the potential for acute
exposures, public concern, and expenses related to the widespread use (and often misuse) of
pesticides in our country. The primary care provider can play a vital role in helping individuals
deal with these exposures. Furthermore, alert providers aware of potential health conditions
related to pesticide exposure can become a key link in limiting the spread of "pesticide
epidemics" by identifying sentinel cases and bringing them to the attention of appropriate
public health officials responsible for pesticide-related illness surveillance.
Control of Exotic Pests - Increase in Potential Pesticide Exposures to the Public
A growing number of exotic and public health pests are besieging the United States. Control
of these pests increases the potential for pesticide exposure to large segments of the public.
Aerial application of insecticides over residential neighborhoods involving millions of people
has recently been conducted in New Jersey for control of malaria-carrying mosquitoes, in
New York City for control of mosquitoes carrying the West Nile virus, and in several Florida
counties for control of the Mediterranean fruit fly (Medfly). Surveillance conducted during
KEEP OUT OF REACH
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"Even though / know it is very important to diagnose
and treat this problem, we have to start by preventing
the problem in the very first place. That is when we are
going to start seeing some changes in the long run "
Gerardo de Cosio, MD
U.S.-Mexico Border Health Association
18
DRAFT
-------
the recent Florida Medfly Eradication Program identified 123 individuals with illness
potentially related to pesticides used in the program (CDC, 1999b). During pesticide spraying
campaigns to control exotic pests, health care providers are often called upon to provide
sound preventive advice, and to recognize and manage any pesticide-associated illnesses.
Careful documentation and reporting of suspected cases are needed to protect those who
may be unusually susceptible to low-level exposures.
Potential for Acute Exposures and Effects
Health care providers may be faced with patients who have experienced acute pesticide
poisonings. A pesticide poisoning is considered acute when the onset of symptoms occur
shortly after the time of pesticide exposure. Acute pesticide poisonings can differ in their
degree of severity.
While providers may not see very many acutely poisoned patients, they should possess a basic
understanding of signs and symptoms, and an ability to diagnose and refer. Oftentimes it is
the primary care provider who identifies possible sentinel cases that signify the presence of
previously unrecognized pesticide hazards in the community. By notifying the proper
authorities of real or potential poisonings, health care providers can play a critical role in
pesticide-related illness surveillance.
Agricultural Exposures
Agriculture accounts for 76 percent of the conventional pesticides used annually
{approximately 944 million pounds, not including disinfectants, wood preservatives, or
water treatment chemicals) (U.S. EPA, 1999). Pesticide handlers and agricultural workers
appear to be at greatest risk for acute pesticide poisoning. Based on states with required
reporting of pesticide-related health concerns, EPA estimates there are approximately 250-
500 physician-diagnosed cases occur per 100,000 agricultural workers (including pesticide
handlers) (Blondell, 1997). Migrant and seasonal farmworkers are especially at high risk
since they often work and live in poor occupational environments where pesticide exposures
can be significant.
Non-Agricultural Exposures
Urban and suburban uses of pesticides can be as high as in some agricultural areas. A 1990
EPA survey estimated that 84% of American households used pesticides, most commonly
insecticides (Whitmore et al, 1992). Homeowners annually use 5-10 pounds of pesticide
per acre on their lawns and gardens, many times the amount applied by farmers to corn
and soybean fields (Robinson et al, 1994). They also use pesticides in the form of
disinfectants, including pine oil cleaners, bathroom cleaning products, and cleaning materials
for swimming pools. In addition, work-related exposures for structural pest control operators
and workers in nurseries, greenhouses, and landscaping are also of concern in the non-
agricultural sector.
DRAFT
19
-------
A substantial number of people in the US are at risk of acute pesticide poisoning from non-
agricultural uses. One of the major sources of data on acute pesticide poisoning is the Toxic
Exposure Surveillance System (TESS) maintained by the American Association of Poison
Control Centers (AAPCC). Data collected from poison control centers found that in 1996,
over 40,000 adults were sufficiently exposed to various types of pesticides to warrant a call to
their local poison control center. All 40,000 calls were from individuals who had a concern
about overexposure, not requests for information. It is estimated that as many as 60% of
these individuals developed symptoms of pesticide poisoning. These figures are thought to
represent less than 30% of the incident cases of acute pesticide-related illness in the U.S.
(Litovitz et al, 1997; Chafee-Bahamon et al, 1983; Harchelroad et al, 1990; Veltri et al, 1987).
Pesticide exposures among children also warrant concern. In 1996, poison control centers
were notified about approximately 80,000 children (age 0-19) being exposed to common
household pesticides in the United States. It is estimated that one quarter of those children
developed symptoms of pesticide poisoning. In a study of unintentional exposures to pesticides
(excluding disinfectants), EPA found that 78,500 such exposures were reported annually to
poison control centers in 1985-92, with 92% of them occurring at residences (AAPCC, 1994).
Children ages 5 and younger accounted for 63% of the cases.
The majority of pesticide poisonings (85% of symptomatic cases reported to poison control
centers) have a minor outcome (often treatable at home), 14% have a moderate outcome
(typically requiring treatment in a health care facility) and 1% experience a major or fatal
Table 3: Pesticides Most Often Implicated in Symptomatic Illnesses, 1996
Rank Pesticide or Pesticide Class Child Adults and Total*
< 6 years 6-19 yrs.
1
Organophosphates
700
3274
4002
2
Pyrethrins and pyrethroids**
1100
2850
3950
3
Pine oil disinfectants
1336
903
2246
4
Hypochlorite disinfectants
808
1291
2109
5
Insect repellents
1081
997
2086
6
Phenol disinfectants
630
405
1040
7
Carbamate insecticides
202
817
1030
8
Organochlorine insecticides
229
454
685
9
Phenoxy herbicides
63
387
453
10
Anticoagulant rodenticides
176
33
209
All other pesticides
6331
11,417
4614
Total all pesticides/ disinfectants
7279
15,015
22,433
* Total includes a small number of cases with unknown age.
** Rough estimate: includes some veterinary products not classified by chemical type.
Source: Reigart and Roberts, 1999.
20
DRAFT
-------
outcome (Litovitz et al, 1997). In 1992-98, there were an estimated 24,000 emergency
department visits annually resulting from pesticide exposure, of which 61% of the cases
involved children younger than 5 (McCaig, 2000; McCaig and Burt, 1999). These figures are
likely under-estimates and may represent only a fraction of the incident cases of acute pesticide-
related illness among children.
Pesticides Most Often Associated with Pesticide-Related Health Conditions
Organophosphate and pyrethroid insecticides are the categories of pesticides most often
implicated in acute pesticide-related illnesses reported to poison control centers. Table 3 on the
previous page ranks the class of pesticides most often linked to symptoms in patients, based on
data from TESS. This table includes only unintentional exposures to single pesticide products.
Potential for Chronic Exposures and Effects
Patients and others in the community may also come to providers with concerns about the
chronic health effects of both short and long-term exposure to pesticides. While current
scientific evidence does not offer definitive conclusions about the health effects associated
with chronic exposures to pesticides, early scientific findings lend support to the hypothesis
that overexposures or significant exposures to some pesticides may be associated with the
onset of cancer, neurodevelopmental effects, and reproductive effects. A well-informed health
care provider who possesses a basic understanding of the latest scientific evidence is better
prepared to talk with and counsel patients who are understandably concerned about pesticide
exposures and uncertain about the risk of future adverse health effects.
Risk communication is a critical aspect of the therapeutic encounter, and requires active
listening to identify patients' concerns and fears. It also requires appropriate risk assessment,
including an assessment of the pesticide involved, the actual source and route of exposure,
whether absorption occurred (and, if so, how much), and an honest appraisal of the state of
knowledge about long-term outcomes. Clinicians face the daunting challenge of providing
appropriate reassurance where needed, while being careful not to dismiss a patient's concerns
without investigating them. Under certain circumstances, the most effective course of action
may be to refer the patient to an occupational/environmental specialist, and the list of resources
for that referral should be readily available in every clinical practice. On the other hand, the
primary care clinician may wish to provide this information directly, and information sources
are available to help.
Cancer Studies
With regard to the relationship between chronic pesticide exposure and cancer, EPA has
received and reviewed the required studies for predicting cancer effects for numerous active
ingredients. Over 60 of these active ingredients have been classified as probable human
carcinogens by EPA or the International Agency for Research on Cancer (www.epa.gov/
pesticides/carlist/table.htm). Although most of these pesticides are no longer on the market
DRAFT
21
-------
or have had their uses severely restricted, their potential to cause cancer in persons previously
exposed is still a concern. A review by the National Cancer Institute (NCI) lists 15 pesticides
for which there is evidence of cancer in human epidemiologic studies (Zahm et al, 1997). A
large prospective study of commercial pesticide applicators and their spouses is underway in
Iowa and North Carolina, funded jointly by the National Cancer Institute and EPA, to try to
determine just which pesticides may pose a risk of cancer in humans (Alavanja et al, 1996).
Non-Hodgkin's lymphoma has been associated with frequent use of 2,4-D, and is also
associated with farming (Hoar et al, 1986; Wigle et al, 1990; Zahm et al, 1990). Concerns have
also been raised about the relationship between organochlorine compounds and breast cancer
and endometrial cancer, although studies to date have yielded mixed results (Adami et al,
1995; Ahlborg et al, 1995; Davis, 1993; and Eubanks, 1997).
Studies on Central Nervous System Effects
Many insecticides and fumigants are designed specifically to target the nervous system of the
pest they are intended to control (referred to as neurotoxins). There is increasing human
evidence in the form of case reports and epidemiologic studies that suggests that humans
may experience chronic neurologic or neurobehavioral effects following high levels of exposure
to certain types of pesticides (Keifer and Mahurin, 1997). Several reports have also found
chronic neurological sequelae (reduced neurobehavioral function) after acute
organophosphate (OP) poisoning (Savage et al, 1988; Rosenstock et al, 1991; Steenland et al,
1994; Stephans et al, 1995). EPA has concluded that some subset of OP-poisoned subjects
probably experience persistent neurobehavioral effects as a result of their exposure. In
November 1999, the Committee on Toxicity of Chemicals in Food, Consumer Products and
the Environment (1999) of the Department of Health in the United Kingdom concluded:
The balance of evidence supports the view that neuropsychological abnormalities can
occur as a long-term complication of acute OP poisoning, particularly if the poisoning
is severe. Such abnormalities have been most evident in neuropsychological tests involving
sustained attention and speeded flexible cognitive processing ("mental agility").
Studies on Reproductive Effects
Many pesticides have been identified as developmental or reproductive toxicants based on animal
studies. "There is increasing evidence for reproductive effects associated with exposure of males
to occupational agents. Some of the best known examples are reductions in fertility and sperm
counts in men who were occupationally exposed to dibromochloropropane" (Sever et al, 1997).
Dibromochloropropane (DBCP), a nematocide that was banned by EPA in 1979, produced
azo-spermia and oligospermia among exposed workers (Whorton et al, 1979). Sever et al (1997)
concluded "there is increasing evidence for reproductive and developmental effects of both
maternal and paternal pesticide exposures. Areas of particular concern include infertility and
time to pregnancy, spontaneous abortion, neural tube defects, and limb reduction defects."
22
DRAFT
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Studies on Other Health Effects/Specific Populations
Hypotheses related to pesticide effects on respiratory, cardiovascular, endocrine, and other
body systems have also been suggested and are currently being studied. The impact of pesticides
on child development is also a growing area of research and investigation.
While studies have indicated associations between pesticide exposures and chronic health
effects, there still remains insufficient evidence to document a causal relationship between
frequently used pesticides and long term health effects, except in a few cases such as arsenic-
associated cancer, male infertility due to exposure to dibromochloropropane, and neurologic
sequelae following severe poisonings with neurotoxic pesticides. Studies that suggest
associations between pesticide exposures and long-term health effects require support from
studies with stronger research designs before causal relationships can be accepted. Health
care providers must be taught how to interpret the current state of knowledge in order to
assist patients and others in the community who are concerned about long term health effects.
The concern for potential future adverse effects of non-acutely toxic pesticide exposures
represents a special challenge to health care providers. The nature of scientific inquiry yields
associations between pesticide exposures and health effects long before causal relationships
can be reasonably concluded. These associations and the publicity they generate can be enough
to raise concerns among patients and the community. Providers should be sensitive to the
level of concern and the need to provide reassurance, as well as the possibility that a referral to
an occupational and environmental medicine specialist may be indicated.
Evaluation of patient concerns about toxic exposures can be complicated by time constraints
and the need to engage in non-clinical efforts. For example, site visits and industrial hygiene
consultations are expensive and not generally part of a private patient's insurance coverage.
Again, primary care providers need to recognize when these efforts are needed and know how
to obtain an appropriate referral.
Clinical Case Examples: The Challenge of Diagnosing Pesticide Exposures
For many pesticides, the short-term and many of the long-term health effects associated with
exposure can easily be mistaken for other agents or health conditions. The ability to recognize
a potential pesticide exposure will improve a professional's ability to make the correct diagnosis.
To make a timely and accurate diagnosis, primary care providers need to be familiar with the
settings that predispose patients to pesticide exposure, the symptoms associated with these
exposures, and appropriate diagnostic methods.
Case Study 1 - Chronic Health Conditions
At the Environmental and Occupational Health Sciences Institute (EOHSI) at the University
of Medicine and Dentistry of New Jersey, two farmers were referred to the occupational
medicine clinic for problems associated with the use of pesticides. Initially, the concern was
DRAFT
23
-------
the possibility of drug interaction and pesticide use. Both farmers had worked in a large lima
bean operation, and extensively used organophosphate compounds from early in the season
until the harvest. The initial evaluation, along with an industrial hygenist's evaluation of the
farm, led the health scientists and physicians to conclude that both men were chronically
exposed to a series of OP compounds. A careful and rigorous evaluation of all activities led to
putting in place the use of personal protective equipment, installation of an on-site shower
for washing, and a laundry for pesticide-contaminated clothing. Over a period of 12 months,
considerable improvement was noticed. Both men felt better and no longer reported symptoms
of blurred vision, lack of concentration, headaches, etc.
A coordinated effort of the Cooperative Extension faculty, as well as the clinical faculty at
EOHSI, led to the diagnosis and a very positive outcome. An earlier evaluation by the local
physician did not connect pesticide exposure to the health problems; in fact, the farmers were
told that there were no real problems and they should just continue what they were doing.
The wife of one of the farmers pursued the problem aggressively for four years, first going to
the Extension Service and then to the specialists at the university.
Case Study 2 - Aldicarb Exposure
The following case study, reported in the Morbidity and Mortality Weekly Report (CDC,
1999a), describes a foodborne outbreak of aldicarb poisoning that occurred when improperly
stored and labeled aldicarb was mistakenly used in food preparation.
On July 19,1998,20 employees attended a company lunch prepared from homemade foods.
Shortly after eating, several persons developed neurologic and gastrointestinal symptoms.
Ten visited a hospital emergency department, and two were hospitalized. On July 20, a hospital
infection-control nurse reported the incident to the Louisiana Office of Public Health, which
then investigated the outbreak. The lunch consisted of pork roast, boiled rice, cabbage salad,
biscuits, and soft drinks. Only the cabbage salad was associated with illness. Of the 16 persons
who ate the cabbage salad, 14 became ill (attack rate: 88%); the four persons who had not
eaten the cabbage salad did not develop symptoms.
The employee who prepared the cabbage salad reported mixing precut, prepackaged cabbage
in a bowl with vinegar and ground black pepper. The black pepper came from a can labeled
"black pepper" that he had found 6 weeks before the lunch in the truck of a deceased relative.
This black pepper had not been used by the employee for food preparation before the company
lunch. The contents of the black pepper container were tested for organophosphate and
carbamate pesticides. Testing showed the granules in the pepper container as 13.7% aldicarb.
A 6-gram portion of cabbage salad contained 272.6 parts per million of aldicarb, a level which
can produce illness in humans. The deceased owner of the pepper can had been a crawfish
farmer, and it is believed that he used aldicarb on bait to prevent destruction of his crawfish
nets, ponds, and levees by wild dogs and raccoons.
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Cholinesterase-inhibiting pesticides (i.e., organic phosphates and carbamates), which are
widely used in agriculture, can cause illness if they contaminate food or drinking water.
Aldicarb, a regulated carbamate pesticide, is highly toxic. Health care providers and public
health officials should keep in mind that food poisoning might result from pesticide or other
chemical contamination as well as from infectious organisms.
Case Study 3 - Organophosphate Exposure
A couple in their sixties entered their vacation condominium in Hawaii and were immediately
aware of a strong odor. Three days later they discovered that the odor emanated from a leaking
five-gallon can of liquid Metasystox-R-2, an organophosphate insecticide which was being
stored in a room adjoining the condominium. The chemical container had leaked and saturated
the floor boards and the adjoining wall, as well as leaking under the condominium.
The Poison Control Center advised them to see a doctor, which they did, complaining of
continuing and increasingly severe headaches, blurred vision, and shortness of breath (i.e.,
symptoms compatible with organophosphate intoxication). Pulmonary function tests were
performed and unexpectedly revealed mild obstructive pulmonary disease with the test
improving following use of a bronchodilator. No other testing was performed. The physician
treated the couple for a mild reactive airway disease and told them to return for further care
only if symptoms persisted. When they inquired about the need to investigate continuing or
residual effects from exposure to the pesticide, the physician did not know how to answer.
When symptoms persisted, the couple called the National Pesticide Telecommunication
Network (NTPN) and were advised to return immediately to the physician and request a
cholinesterase enzyme assay analysis. The results for the male were minimally above the lower
normal range (i.e., consistent with either an acute or resolving intoxication). NPTN advised
the couple to vacate the condominium and contact the Hawaii Department of Agriculture,
which helped identify a commercial laboratory that confirmed the contamination, and
provided clean up. The couple's symptoms resolved approximately two weeks later.
Case Study 4 Arsenic Exposures
A clinician examined a rural family of eight with a number of signs and symptoms. Family
members had conjunctivitis, bronchitis, pneumonia, sensory hyperthesia of the arms and
legs, muscle cramps, dermatitis over the arms, legs and soles of the feet, nosebleeds, ear
infections, blackouts and seizures, gastrointestinal disturbances, and severe alopecia. Symptoms
became most severe during the winter months and tended to remit in summer (Peters et al,
1983). These conditions were initially attributed to stress, poor diet, hypochondria, and even
child abuse. Only when a toxicologist heard about the case from the news media and performed
appropriate laboratory tests on environmental samples was the source of the problem
identified, three years later. The problem was found to be burning arsenic-copper-chromated
treated wood (outdoor grade plywood) in the family's wood stove.
DRAFT
25
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These case studies point to the preventable human suffering and death that can be associated
with delayed or missed diagnoses of pesticide poisoning. Since the use and presence of
pesticides are so ubiquitous in our society, there is a strong argument for sensitizing all primary
care physicians to develop a high index of suspicion and diagnostic acumen, including
consultation when needed, to respond promptly to patients whose presentations may represent
pesticide poisoning. While it is anticipated that providers working with high-risk populations
such as in agricultural areas, emergency departments, and pediatrics will be most sensitive
to this proposition, these cases show the potential for such severe health consequences that all
primary care providers are advised to be vigilant.
Current Provider Training and Education in Environmental Health
Health care providers are the primary audience for this Plan because the public looks to them
for guidance on health concerns. While some progress has been made in introducing
environmental health issues into curricula at medical and nursing schools, most health
providers still do not have adequate knowledge and tools to address patient and community
concerns. Key studies by recognized medical institutions and committees convened by federal
agencies and national scientific bodies have addressed this concern:
¦ In 1985, only 50% of medical schools addressed occupational and environmental health in
their curricula, with an average of only four hours being taught over four years. By 1992,66%
percent of medical schools required an average of about six hours of study in occupational
and environmental health over four years (Schenk et al, 1996). (See box on next page).
¦ In 1988, an Institute of Medicine (IOM) committee on the role of the primary care
physician in occupational and environmental medicine recommended that all primary
care physicians be able to identify possible occupational or environmentally induced
conditions and make appropriate referrals (IOM, 1988).
¦ In December 1994, the American Medical Association adopted a resolution urging
Congress, government agencies, and private organizations to support improved strategies
for the assessment and prevention of pesticide risks (AMA, 1994).
¦ Specific recommendations to change medical/nursing education and practice were made
by two IOM committees on medicine and nursing, in 1994 and 1995, respectively. In
1995, the Institute of Medicine produced two landmark reportsEnvironmental Medicine:
Integrating a Missing Element into Medical Education and Nursing, Health and the
Environmentthat called for more effective environmental health education and training
of medical and nursing professionals.
Health care providers can be extremely effective in addressing pesticide exposures in the lives
of their patients and in their communities. However, they do not need to become experts in
order to fill an important and crucial role. Some of the important knowledge and skills that
they should possess include:
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DRAFT
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CO
cc
o
cc
A1994 survey of environmental medicine content in U.S. medical schools found that:
¦ Ninety US medical schools (76%) reported requiring environmental medicine
content in the curriculum. Only two schools (2%) had a dedicated course.
¦ Eighty-nine schools (75%) indicated that environmental medicine was
taught as part of a required course. Forty-six schools (39%) offered it as an
elective course.
>
O
cc
a. ¦ Fifty schools (42%) reported no instruction in taking an exposure history.
LU
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>-
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¦ Among schools with required environmental medicine instruction, the
average time in the curriculum was seven hours over the four years of medical
education. An average of three hours of environmental medicine instruction
was provided in preclinical courses and four hours in clinical courses.
¦ Eighty-one schools (68%) reported some faculty with environmental and
occupational medicine expertise, most often in departments of internal
medicine (42%), community/preventive medicine or public health (37%),
O and family medicine (28%).
¦ Nineteen schools indicated innovative or unusual approaches to teaching
environmental medicine, including small group case discussions, community-
< based clerkships, and site visits. These schools reported an average of five faculty
members with occupational/environmental medicine expertise, compared with
an average of four faculty members for all other schools.
Note: Of the 126 schools surveyed, 119 (94%) responded.
Source: Schenk et al, 1996.
¦ Recognizing possible signs and symptoms of pesticide exposure
¦ Taking a brief and relevant environmental and occupational history
¦ Diagnosing possible associated health conditions, including those of sensitive populations
such as children and the elderly
¦ Calling upon an appropriate specialist or expert to assist them
¦ Having ready access to a recommended referral list of resources and contacts
¦ Providing basic preventive guidance for patients
¦ Recognizing when to report exposure incidents to the proper health authorities
¦ Possessing a basic awareness of environments in which patients live, work, and play
¦ Identifying possible sentinel cases
¦ Participating in surveillance systems.
DRAFT
27
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This initiative emphasizes the provider's ability to recognize a potential pesticide exposure, to
communicate effectively, and to access and work with pesticide/environmental health experts
and resources. In an educational setting, this may mean working with an occupational and
environmental medicine specialist to design and integrate a pesticides module into a toxicology
course for medical students. In a practice setting, this may involve incorporating an
environmental history into primary care practice and referring patients to appropriate experts
in the event of a suspected poisoning. User-friendly teaching materials exist for faculty to use,
along with user-friendly guides for faculty and curriculum maps indicating where pesticide
topics could be inserted into the curriculum.
Clearly, the issue of pesticide-related health conditions is one that requires the participation
of health care providers. The rationale given in this section serves as the underpinning of the
three-pronged strategy in this Plan.
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Target Audience
For the purpose of this initiative, the target audience is the primary care provider. Primary
care providers work at the front lines of our health care system and therefore need to be
able to identify a possible pesticide exposure. For this reason, it is recommended that
all primary care providers possess basic knowledge and skills related to pesticide exposures. A
primary care provider, for the purpose of this initiative, is defined as:
a physician, nurse, nurse practitioner, physician assistant, nurse midwife, or community
health worker specializing in one of the following areas: family medicine, internal medicine,
pediatrics, obstetrics/gynecology, emergency medicine, preventive medicine, or public health.
Specialists in occupational and environmental medicine serve as excellent resources both for
purposes of this initiative and for primary providers. However, because they already have a
higher awareness of pesticide issues, specialists in occupational and environmental medicine
are not the primary target of this initiative. They are seen as resource professionals for the primary
care providers, as are another major group of physician specialists, medical toxicologists.
Primary care providers work in a variety of settings. Table 4 summarizes the target audience,
types of populations served, and the range of practice settings commonly encountered. In
addition to these primary care providers, the target audience also includes key decision-making
bodies in the health profession. A decision-making body, for purposes of this Plan, refers to any
Table 4: Targets, Populations Served, Practice Settings
Targets
Populations Served
Practice Settings
Nurses
susceptible populations
hospitals and emergency
Nurse Practitioners
(elderly, frail elderly, kids)
departments
Physicians
urban
community clinics
Physician Assistants
non-urban
medical centers
Nurse midwives
tribal communities
independent practices
Community health workers
agricultural
industry, workplaces
Student training
migrant farmworkers
alternative points of care
Emergency medical technicians
underserved populations
(environmental justice)
public health departments
poison control centers
pesticide handlers
schools
DRAFT
29
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organization, institution, or individual leader that is vested with decision-making authority for the
education and practice of health care in the United States. This includes, but is not limited to,
curriculum committees, residency review committees, exam development bodies, accrediting
institutions, organizations representing academic institutions, faculty, and administrators, and
institutions governing health care practice and requirements. The engagement of, and endorsement
by, such bodies is the only way to ensure success of this Plan and the larger initiative.
Understanding the Target Audience
Consulting the available literature on how health professionals learn is an important first step
in determining the most effective approaches to use. One of the models explored in the
development of this Plan is the Stages of Change model (Prochaska et al, 1995) that looks at
behavior change as a process rather than an event, and describes varying levels of motivation,
or readiness to change. Reaching primary care providers who are at different stages of change
requires different types of interventions and resources. The model outlines a continuum of
behavior change that can be used to help understand where the target audience is on the
continuum, and to effectively reach the audience (through targeted messages, strategies, and
programs) to ensure behavior change. Table 5 outlines the model.
Table 5: Stages of Change Model
Concept Definition Application
Pre-contemplation
Unaware of problem;
has not thought through behavior
Increase awareness of need for
change, personalize information
and risks and benefits
Contemplation
Thinking about change in the
near future
Motivate, encourage to make
specific plans
Decision/Determination
Making a plan to change
Assist in developing concrete
action plans, setting gradual goals
Action
Implementation of
specific action plans
Assist with feedback, problem
solving, social support,
reinforcement
Maintenance
Continuation of desirable
actions, or repeating periodic
recommended step(s)
Assist in coping, reminders,
finding alternatives, avoiding
steps/relapses (as applies)
Source: Prochaska et al, 1995.
Applying the stages of change model to the current initiative, the concepts can be consolidated
into three categories or stages of change:
¦ Stage 1: Building awareness and motivation At this stage, the goal is to increase awareness
and motivation by making an effective case, and increasing the motivation to change.
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¦ Stage 2: Readiness to make changes - To turn readiness into actual change, the goal at
this stage should be to build on knowledge and skills, for example, by creating new resources
and disseminating them effectively.
¦ Stage 3: Maintenance, "champions" For those who have already made a change, the
goal is to maintain support for the change activity and nurture "champions" who will
advocate for change.
When it comes to understanding and dealing with pesticide-related health conditions, many
primary care providers may currently fall in the first category (Stage 1), particularly those working
in urban areas. Nevertheless, resources should still be created and made available for all three
categories, allowing primary care providers to "self-select" into whichever category fits their needs.
Figure 3 shows how the components of this Implementation Plan cover all three stages of change
in the target audience.
Figure 3: Stages of Change and Implementation Plan Components
STAGE 1:
Awareness and
Motivation-Building
Create Incentives
Secure Endorsements
New Resources
STAGE 2:
Knowledge and
Skill Building
Define Competencies
Models of Change
Faculty Champions
Information Gateway
New Resources
STAGE 3:
Maintenance and
Champion-Building
Faculty Champions
Information Gateway
New Resources
DRAFT
31
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Framework of the Plan:
A Three-Pronged Strategy
This Implementation Plan sets forth a three-pronged strategy to reach the goal of
improving the recognition, management and prevention of health effects from pesticide
poisoning and exposure.
Given that primary care providers are educated and trained in different settings, the Plan sets
out a three-pronged strategy for effectively reaching them. The first prong addresses a provider's
"in-service" or formal education, such as in medical school or nursing school. The second
prong targets the practice setting in which a provider works and participates in professional
development. The final prong articulates the resources and tools that providers need to
effectively deal with pesticide-related health conditions in their practices and communities.
The three prongs of the strategy are:
1. Education Settings: Create significant institutional change in educational settings (e.g.,
medical schools, nursing schools, residency, and practicum programs) so that students in
the health professions are prepared to recognize, manage, and prevent pesticide poisoning
and exposures across the United States.
2. Practice Settings: Change the practice of primary care so that pesticide-related health
conditions are recognized, effectively managed, and prevented in practice settings (e.g.,
community clinics, hospitals, work-place clinics) across the United States.
3. Resources and Tools: Create new resources for educational and practice settings that
take into account existing resources, evaluate their quality and suitability for different
audiences, and assure their availability through an information gateway.
For each setting, the Plan recommends a set of components. These components serve as a
framework for the cohesive implementation of the three-pronged strategy. In some cases, the
components for both settings are quite similar; in other cases they are significantly different.
This Plan intentionally presents the same set of components for both settings so as to ensure
consistency in approach. However, the Plan distinguishes between the settings because they
often involve different decision-makers and approaches. The components for each setting are:
¦ Make the Case for Change
¦ Define Guidelines for Educational Competencies or Practice Skills
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¦ Assess Target Audiences in Each Setting
¦ Secure Key Endorsements
¦ Demonstrate Success Through Faculty Champions and Practice Models
¦ Create Incentives for Change.
The Plan also outlines a process to develop the resources and tools necessary to ensure the
success of the entire initiative:
¦ Inventory Resources
¦ Establish National Review Board and Conduct Evaluation of Resources
¦ Create Internet-based Information Gateway
¦ Create New Resources.
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Educational Settings
The first prong of the strategy is directed at the educational setting. Educational settings,
for purposes of this initiative, are defined as medical schools, nursing schools, academic
health centers, training programs for all levels of nursing education, and medical
residency programs. While the components target the educational setting, they also involve
the professional associations and decision-making bodies that represent and/or influence the
educational setting. These include, for example, the Association of American Medical Colleges,
the American Association of Colleges of Nursing, the Association of Academic Health Centers,
and the Accreditation Council for Graduate Medical Education, to name a few. The following
components cut across the continuum of systemic change from raising awareness and
assessment, to development of core competencies, to the support of faculty champions and
model programs.
Component A: Make the case for change in educational settings Develop an effective
case statement to convince decision-makers about the need for environmental health and
pesticide education in medical and nursing educational institutions.
Component B: Define competencies and integration strategies for curricula - Produce
National Guidelines that recommend competencies specific to the recognition, management
and prevention of pesticide exposures, for all basic and advanced training in medicine and
nursing; defines accompanying content areas; suggests methods of integration into curricula;
and provides access to relevant resource materials.
Component C: Assess educational settings Conduct an assessment of the target audience
of educational institutions to determine (a) amount of existing coursework, (b) faculty
members' current knowledge and comfort level with teaching pesticide-related topics, and
(c) how faculty and educational institutions will best respond to educational programs and
informational resources. This assessment will be comprised of a literature review, surveys,
and focus groups.
Component D: Secure official endorsements - Ensure the integration of the core
competencies outlined in the National Guidelines into educational institutions by securing
the official endorsements of key professional organizations and decision-making bodies.
DRAFT
35
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Component E: Strengthen and build faculty champions Create and support faculty
champions within medical and nursing schools to teach environmental health and pesticide
education in the curriculum, and to bring about change within their institutions.
Component F: Create teaching incentives Influence the appropriate boards, organizations,
and institutions that create board exams to include several key competencies on pesticides
and environmental health.
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FnilPATION COMPONFNT A:
Make the Case for Change
in Educational Settings
Statement
Develop an effective case statement to convince administrators, faculty, and students about
the need for environmental health and pesticide education in medical and nursing education.
Expected Outcomes
¦ A written case statement that documents the key reasons why faculty members and
administrators of academic institutions should be aware of pesticide-related health
conditions, using persuasive data and documentation of the scientific literature, and
stressing the importance of teaching pesticides content in their educational curriculum.
¦ Endorsement by leading national professional associations, national bodies, deans, and
faculty committees.
Target Audience
Awareness and Motivation: This component is targeted at educational institutions and key
strategic organizations that need to be convinced that the issue of pesticides and the need to educate
health care providers about this issue are relevant to the educational settings of health care providers.
Proposed Activities
Activity #1
Research and develop a case statement, solicit peer review, and finalize with the input of key
stakeholder groups in the field. The target audiences for the case statement are educational
settings and the organizations that work with them.
Points to be covered in the case statement:
¦ Specific importance of environmental health education and the breadth of the problem
of pesticide-related health conditions.
¦ Convincing arguments for why pesticides should be in the curriculum, with cited scientific
data, along with relevance to faculty and students.
DRAFT
37
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Compelling arguments to gain the attention of health care students and faculty despite the
fact that their time and attention are in high demand elsewhere.
Emphasis that faculty do not need to become experts, and reassurance that experts exist
in the field who can work with them on coursework and teaching.
Emphasis on practical learning for students in settings where pesticide exposures may occur.
Reassurance that user-friendly teaching materials are available for faculty to use, along
with user-friendly guides, and curriculum maps indicating where pesticide topics could
be inserted into the curriculum.
Recommended amount of time to dedicate to pesticides in the curriculum that is
reasonable given the other demands on academic institutions.
Activity #2
Promote the case statement through effective dissemination mechanisms to administrators,
faculty, and curriculum committees, including print and Internet information sources.
Activity #3
Publish journal or newsletter articles on "making the case" for the academic setting in
professional journals and publications.
Activity #4
Hold strategic meetings with bodies that accredit health educational institutions and set curricular
requirements, and with national leaders to seek their endorsement of the case statement. This
includes identifying a subset of decision-makers who can be influenced by the case statement.
Stakeholders
¦ Professional associations
¦ Key accrediting bodies
¦ Curriculum committees
¦ Deans/Department chairs
Evaluation of Outcomes/Indicators of Success
¦ Complete case statement.
¦ Published articles in professional journals and newsletters.
¦ Position papers developed and adopted by professional associations.
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Background
This component was crafted based on the recognition that we need to raise awareness about
why educating health care providers about pesticide-related health conditions and exposures is
so important. Many key decision-makers may still be unconvinced that this is an issue of concern.
Although the supporting documentation is there, there is a need to pull the information together
in a succinct case statement that clearly shows the relevance of this issue to academic institutions.
The document will be used in outreach on the Implementation Plan, and will assist the entire
field in "making the case" for the education of health care providers on this topic. The case
statement will complement a similar statement to be created for practice settings.
DRAFT
39
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I. X
FDIirATIDN COMPONFNT R:
Define Competencies and
Integration Strategies for Curricula
Statement
Produce National Guidelines that recommend competencies specific to the recognition,
management and prevention of pesticide exposures, for all basic and advanced training in
medicine and nursing; define accompanying content areas; suggest methods of integration
into curricula; and provide access to relevant resource materials.
Expected Outcomes
¦ National Pesticide Competency Guidelines for Education which recommend competencies,
content, insertion points into curricula, and resources. The Guidelines will be completed
in mid-2000.
¦ Endorsement of National Guidelines by leading national professional associations.
Target Audience
Readiness to Change: This component is targeted at administrators and faculty in educational
institutions. The guidelines are to assist faculty in integrating the recommended core
competencies into curricula. This component assumes that administrators and faculty
members have been convinced that this is an important topic for their curricula and that they
are ready to change their curricula.
Proposed Activities
Activity #1
Define the core competencies for educational institutions to teach about pesticides in basic
and advanced curricula (See Table 6).1
The intent of Table 6 is to define competencies that could be integrated into existing curricula.
The table will link with a complementary document being created for practice settings.
1 An initial start at defining competencies for the three levels of learning was done by a subgroup of the Education Workgroup
in May 1999, and was further elaborated in July 1999 by a small committee. Subcommittee members included Andrea Lindell,
Candace Burns, James Roberts, Matthew Kiefer, Annie Perez, Joan Weiss, Cleora Wittl, Ameesha Mehta, and Susan West.
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Activity #2
Produce National Pesticide Competency Guidelines
for Education to educate students about the
recognition and management of pesticide-related
health conditions and exposures. A complementary
document will focus on the practice settings in
which primary care providers work.
An accompaniment to the Recognition and
Management of Pesticide Poisonings handbook,
the National Guidelines will be designed as a user-
friendly guide on how to integrate pesticides
content into curricula. The Guidelines will be
drafted by a team of experts and will contain the
following components:
¦ Recommended competencies.
¦ Relevant content for each competency area.
¦ Suggested points of insertion into curricula (expected to vary between medical and nursing
schools as well as for basic or advanced training).
¦ Suggested resources to teach content specific to each competency in educational settings.
The team will be responsible for meeting the following objectives:
1) Analyze existing content in the basic, advanced, and specialty curricula in both nursing
and medical institutions, and identify relevance to pesticide competencies.
2) Identify new content to be added to the curriculum for each competency.
3) Determine windows of opportunity for inserting content into existing curricula (both
for traditional educational programs and problem-based learning programs), for medicine
and nursing. Develop a curriculum map i.e., an outline of what courses are taught
during each year highlighting potential points of insertion for pesticide-related content.
4) Identify and provide a list of resources to teach content specific to each competency that
can be added to a computerized database of curricular content.
5) Develop recommendations for designing and implementing teaching/learning strategies
with course directors, faculty (including deans), and students.
6) Develop strategies/methods to evaluate student competencies.
7) Participate in coordination of content development and windows of opportunity between
medicine and nursing in a timely fashion.
7 see us planting seeds at various lev el
Matthew Keifer, MD, MPH
University of Washington
41
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8) Coordinate with the team designing the complementary practice document.
The National Guidelines will not contain actual teaching modules or resources, but rather provide
a listing of relevant resources and how to locate them. The document will be published by EPA;
the team of experts will be recognized as the primary authors. A peer review process will be set
up for reviewers to comment on and make proposed changes to the National Guidelines.
Activity #3
Promote the National Guidelines with key stakeholders. Solicit official endorsements and
organizational support of report, including dissemination to their members.
Stakeholders
¦ Academic institutions
¦ National professional associations for academic institutions
¦ Faculty members who have already developed curricula
Evaluation of Outcomes/Indicators of Success
¦ National Guidelines completed and peer reviewed by at least 10 key individuals and
organizations.
¦ Endorsement by key stakeholder organizations.
Background
In defining "competencies" in pesticides and environmental health, several key recommendations
have helped to frame this component.
¦ Build upon existing documents: The competencies must relate to the Institute of Medicine
competencies for medical and nursing education, so that no duplication of effort occurs.
¦ Balance between pesticides and environmental health: One of the most difficult
questions is the relative balance between environmental health topics in general and
pesticides in particular. Having the competencies deal specifically with pesticides avoids
any charges of duplication, and might even be seen as a useful model for developing other
competencies in specific areas.
¦ Focus on basic and advanced levels: Although Table 6 presents competencies for three
levels of learning (basic, advanced, specialty), the focus of the initiative will be on basic
and advanced, which are most relevant for training primary care providers. Other
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organizations, including the American College of Occupational and Environmental
Medicine, American College of Medical Toxicology, and the American Association of
Occupational Health Nurses, are focusing on specialty training.
Categorize the competencies: The six categories of competencies shown in Table 6 were
derived from a combination of the Institute of Medicine's medicine and nursing
recommendations. They are meant to apply to medical, nursing, and allied health school
curricula. The six categories are:
Basic Knowledge and Concepts of Pesticides
Diagnosis/Assessment
Treatment/Intervention/Referrals/Follow-up
Risk Communication, Advocacy, and Ethics
Reporting
Legislative and Regulatory Knowledge.
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Table 6: Proposed Competencies for Educational Institutions
Competency I:
Basic Knowledge and
Concepts of Pesticides
Basic: 4-year medical school,
undergraduate nursing, undergraduate
allied health professional education
1. Principles of Environmental
and Occupational Health
la. Understand principles of environmental and
occupational health
lb. Understand broad spectrum of chemicals classified as
pesticides and areas of use (should be aware of various
types of pesticides)
lc. Understand mechanisms and pathways of exposure
2. Individual and Patient
Knowledge and Skills
2a. Be aware of the environment in which the patient (and
family) lives, works, and plays (understanding of the
hazards and potential exposures in different settings)
2b. Identify risk factors for pesticide exposure (e.g.,
occupation, location of home, vulnerable populations)
2c. Recognize that other family members may be ill as well
(Possibly due to exposure in the home)
2d. Recognize socio-economic impacts on the patient of
pesticide-related illness
2e. Understand potential moral, ethical and legal
implications for patients of reporting and referral
3. Population-Based Health
Knowledge and Skills
3a. Understand population-based health, including
epidemiology
3b. Recognize socio-economic impacts of pesticide-
related illness
3c Understand potential moral, ethical and legal
implications for the community of reporting and referral
3d. Possess a basic awareness of the role of prevention,
general awareness of benefits of alternatives to
conventional pest control
Advanced: Medical residents, advanced
practice nursing students, physician
assistant students, other advanced degree
programs (Faculty in primary care would
need to be at this level to teach)
la. Strengthen skills from Basic competencies
lb. Understand temporal relationship between
exposure and symptoms (Medicine)
lc Understand advanced toxicology, specifically related
to organophosphates, carbamates, and pyrethroids
(most commonly reported pesticides implicated
in symptomatic illness)
Specialty: Fellows and advanced
students specializing in
occupational and environmental
health/medicine/nursing
la. Apply validated epidemiologic and
biostatistica] principles and techniques to
analyze injury/illness data in defined
populations
lb. Understand temporal relationship between
exposure and symptoms (Nursing)
lc. Understand and apply advanced
courses in toxicology
2a. Strengthen skills from Basic competencies
2b. Understand at a basic level the health effects of
organophosphates and carbamates
2c. Identify risks to patients served (i.e., special
vulnerabilities of children, the elderly)
2a. Apply individual patient interventions to
prevent or mitigate exposure and/or
resultant health effects
3a. Strengthen skills from Basic competencies
3b. Develop more in-depth knowledge of the
environment in which they are learning and
practicing
3c. Develop specific understanding of communities
and populations at risk for pesticide exposure
3d. Understand advanced epidemiology, specifically
related to pesticide-related poisonings
3a. Develop, implement, evaluate and
refine screening programs for groups
to identify risks for disease or injury
and opportunities to promote wellness
3b. Apply community-based interventions
to prevent or mitigate exposure and/
or resultant health effects
-------
Table 6 (continued)
4. Information and Resources
4a.
Identify and access information on pesticides
4a. Strengthen skills from Basic competencies
4a. Use appropriate written and
4b.
4c.
Be aware of importance of information on pesticide labels
Be able to locate resources including Web-based
4b. Demonstrate ability to locate leading
informational resources and experts for health
care providers
computerized databases (e.g. MSDS,
Registry of Toxic Effects of Chemical
Substances [RTECS]) to identify
information, print materials, Material Safety Data
hazardous ingredients of chemical
Sheets (MSDS), and poison control centers
agents
Competency II: Diagnosis
and Assessment
Basic
Advanced Specialty
History Taking
Differential Diagnosis
Diagnosis
la. Be able to take environmental history
lb. Be aware that signs and symptoms of pesticide exposure
may be non-specific (there is nothing pathognomonic
about most pesticide symptoms)
lc. Be able to consider pesticides in differential diagnosis
(pesticide exposures may result in health effects
common to similar diseases)
lc. Recognize signs and symptoms of pesticide
overexposure, with priority given to widely-used
pesticides with identifiable symptoms, such as
cholinesterase-inhibitors and pyrethroids
Id. Perform a complete and focused physical examination
as indicated (ACOEM)
la. Strengthen skills from Basic competencies
lb. Ask patients 2-3 screening questions (students
need to know how to take a full environmental
history before they are able to ask screening
questions)
lc Identify signs and symptoms of overexposure
to a wider range of pesticides
Id. Be able to diagnose pesticide-related illnesses
related to organophosphates and pyrethroids
le. Properly utilize cholinesterase testing
la. Determine the nature and extent of
potential pesticide poisoning or
overexposure considering routes of
exposure and routes of absorption
1 b. Detect, in so far as possible, pre-clinical
or clinical effect s arising from chemical
exposure
1 c. Be able to order/ interpret appropriate
diagnostic tests
Id. Effectively diagnose pesticide-related
illnesses
le. Provide consultation on diagnosis
If. Identify at risk populations, including
children
lg. Collaborate with other disciplines such
as industrial hygiene, sanitarians,
Cooperative Extension
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Table 6 (continued)
Competency III:
Treatment/Intervention/
Referrals/Follow-up
Basic
Advanced
Specialty
1. Treatment
la. Effectively treat health conditions related to pesticide
exposures (Medicine)
la. Strengthen skills from Basic competencies
lb. Effectively treat health conditions (Nursing)
la. Be able to effectively treat specific
pesticide-related health conditions
2. Intervention
2a. Advise patients on how to decontaminate patient and
environment following exposure
2a. Strengthen skills from Basic competencies
2b. Provide specific guidance on how to
decontaminate patient and environment
following overexposure
2a. Identify and prescribe appropriate
personal protective equipment and
engineering controls for specific
pesticides
2b. Develop and manage a comprehensive
occupational health program
3. Referrals
3a. Refer to appropriate specialist (i.e. occupational
medicine/nursing, industrial hygenist, environmental
health specialist, Cooperative Extension) (Medicine)
3a. Strengthen skills from Basic competencies
3b. Make appropriate referrals for medical
diagnosis (Nursing)
3a. Provide consultation on treatment,
intervention, and referrals
4. Follow-up
4a. Arrange appropriate follow-up (Medicine)
4a. Strengthen skills from Basic competencies
4b. Arrange appropriate follow-up (Nursing)
4a. Provide consultation on follow-up
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Table 6 (continued)
Competency IV: Risk
Communication,
Advocacy, ft Ethics
Basic
Advanced
Specialty
1. Risk Communication
la. Provide guidance and education to patients on how to
minimize exposures to pesticides, and about the basic
routes of exposure and absorption
lb. Advise patients to read pesticide label
lc. Refer patients to appropriate resources
la. Strengthen skills from Basic competencies
lb. Communicate on issues of risks and public
health protection to the general public
lc. Publish research and intervention findings in
the professional literature
la. Communicate with media, the public,
and policy makers on issues of
scientific uncertainty
lb. Provide expert testimony on behalf of
patients and communities
lc. Publish research and intervention
findings in the professional literature
2. Advocacy
2a. Advocate on behalf of patients
la. Communicate with media, the public,
and policy makers on issues of
scientific uncertainty
lb. Provide expert testimony on behalf of
patients and communities
3. Ethics (under development)
Competency V: Reporting
Basic
Advanced
Specialty
Reporting
la. Understand importance of surveillance and incident
reporting
lb. Understand case reporting requirements for pesticide
exposures
lc. Report concerns about pesticide exposure situations to
appropriate authorities
la. Strengthen skills from Basic competencies
la. Interact with worker compensation
system efficiently and effectively
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Table 6 (continued)
Competency VI:
Legislative and Regulatory
Basic
Knowledge
Legislative and Regulatory
la. Understand that several pieces of federal law require
Knowledge
health care providers to address pesticide poisonings
lb. Understand that 15 states have mandatory surveillance
systems, and that 31 states have some form of reporting
requirements
Specialty
la. Know the specific components of FIFRA,
OSHA, TOSCA and WPS that reference health
care providers
la. Influence policy regarding pesticides
and public health
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FnilCATION COMPONENT C:
Assess Educational Settings
Statement
Conduct an assessment of the target audience of educational institutions to determine: (a)
amount of existing coursework, (b) faculty members' current knowledge and skill levels, and
comfort with teaching pesticide-related topics, and (c) how faculty and educational institutions
will best respond to educational programs and informational resources. This assessment will
be comprised of a literature review, surveys, and focus groups.
Expected Outcomes
Baseline data indicating the level of education currently taking place in academic institutions,
current curricular content and emphasis on pesticides/environmental health, current
knowledge of teaching faculty, and best mechanisms to reach and train faculty to teach.
Target Audience
Awareness and Motivation: This component targets academic institutions to determine
their level of awareness; their level of interest in this topic; their knowledge and skills base;
and the most effective ways to reach them through educational interventions, model programs,
and resources.
Proposed Activities
Activity #1
Conduct a literature review to locate survey data and evidence of level of training in
educational institutions.
Activity #2
Where literature review is lacking in data, conduct a combination of audience assessment
activities, including focus groups and interviews, to effectively collect baseline data and draw
conclusions on the following questions:
¦ To what extent are the recognition and management of pesticide-related health conditions
taught in the targeted academic institutions?
¦ What is the extent of the knowledge, attitude, and skill base of faculty members with
regard to pesticide issues? Are they at the stage of needing to raise awareness, improve
their knowledge and skills, or provide them with resources?
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49
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¦ What is the extent of faculty comfort level with teaching this topic area? What do faculty
need to feel more comfortable about teaching this topic?
¦ What resources, and in what format (e.g., traditional lecture material, teaching modules,
Web-based, audio cassette, CD, videoconference, satellite), do academic institutions most
need to teach about this topic?
Activity #3
Produce a final report with recommendations for use in the development of the initiative.
Stakeholders
¦ Professional associations that represent academic institutions
¦ Academic institutions
¦ Faculty curriculum committees
¦ Faculty members
¦ Students
Evaluation of Outcomes/Indicators of Success
¦ Comprehensive literature search documenting the findings of studies that have surveyed
academic institutions and deans.
¦ Report with baseline data, conclusions, and recommendations.
Background
Any good plan has at its core a strong assessment component to collect baseline data on existing
knowledge and skills, as well as to determine the most effective mechanism for reaching the target
population. The importance of assessing educational institutions to determine what is already in
place, and how best to structure the educational interventions was emphasized by initiative
participants during the development of the Implementation Plan. This component will collect
vital information not only for this initiative, but also for the entire field of health care provider
education. The assessment will also include a chance to determine where the target population
"sits" along the continuum of change described in the section on Target Audience. Do most people
lie at the beginning of the continuum where they will respond best to activities that raise their
awareness and motivate them to care about this issue? Or are they ready to make changes in their
curricula and are in need of tools and educational resources? The assessment will answer these,
and other key questions, to inform the implementation process and subsequent evaluation.
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FDIIPATION rOMPOMFNT 0:
Secure Official Endorsements
Statement
Ensure the integration of the core competencies outlined in the National Guidelines into
educational institutions by securing the official endorsements and support of key professional
organizations and decision-making bodies.
LU
H-
Expected Outcomes
Professional organizations, licensing and accrediting bodies, administrators, and educators
will agree that these competencies are essential to the education of primary care providers
and will integrate or support their integration into core curricula.
Target Audience
Awareness and Motivation: This component targets key accrediting bodies and associations
for academic institutions, along with academic deans and faculty committee chairs. The
emphasis here is on raising awareness and motivating decision-makers to bring about change
in academic institutions that prepare health care providers.
Maintenance/Sustainability: This component also targets key professional associations to
endorse and support the implementation and outcomes of this initiative over the long-term.
The initiative will only be successful if its expected outcomes are institutionalized into the
educational settings for health care provider training.
Proposed Activities
Activity #1
Promote competencies with professional and decision-making organizations and academic
institutions (along with the case statement) through strategic meetings and outreach. Highlight
the specific recommendations in the National Guidelines on competencies, along with specific
examples of how an educational institution could integrate the content into curricula.
Activity #2
Publish editorials in nationally recognized journals promoting the idea of integrating specific
strategies from the National Guidelines into curricula.
DRAFT 51
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Activity #3
Develop a position paper on the need for competencies to be posted on the Internet, and for
use in meeting with decision-making bodies.
Activity #4
Identify and promote incentives for faculty to teach core competencies, including financial incentives
in the form of grants, faculty development, curriculum development, and research, instructional
teaching and training aids, expert consultants, clinical access, release time for faculty development,
curricula development, and establishing appropriate clinical sites and teaching venues.
Stakeholders
¦ Professional specialty organizations, licensing boards, accreditation/certification bodies
¦ National professional associations
Evaluation of Outcomes/Indicators of Success
¦ New position papers by targeted organizations that support the integration of
recommended pesticide content into curriculum.
¦ New requirements by professional decision-making bodies that require institutions to
teach about health effects from pesticides.
¦ Published journal articles in professional newsletters and peer-reviewed journals.
Background
The success and sustainability of this initiative will only be achieved if the institutions themselves
find ways to integrate pesticide-related content into health professional education. The best
mechanism to reach such organizations is for individuals involved in this initiative to meet one-
on-one with key leaders and offer them simple and easy ways that they can endorse and/or adopt
this Implementation Plan.
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FnilPATION fOMPONFNT F:
Strengthen and Build Faculty Champions
Statement
Create and support faculty champions within medical and nursing schools to teach
environmental health and pesticide education in the curriculum, and to bring about change
within their institutions. A champion, for purposes of this initiative, is defined as a faculty
member who takes a leadership role in integrating environmental health and pesticides into
his/her institution in a sustainable fashion. This component is designed to ensure that a
strong cadre of faculty champions is developed across the country who will lend expertise
and support for this effort in their institutions and surrounding communities.
Expected Outcomes
¦ Funding of 146 faculty champions, including one faculty champion in all 126 academic
health centers1 in the United States, plus an additional 20 faculty champions in 20 other
higher education institutions to ensure a balance of medicine and nursing faculty as well
as representation from diverse institutions.
¦ Additional support for 10 of the academic health centers to serve as regional technical
assistance centers.
Target Audience
Champion Building: This component targets faculty members who are ready to become a
part of a cadre of faculty from across the country who will teach courses, integrate
competencies into curriculum, and serve as a model for how to integrate environmental
health and pesticides into health professional education. The target audience is convinced of
the importance of this issue and has enhanced its knowledge and skill level.
Proposed Activities
Activity #i
Identify and select several model academic setting programs based on the existing work of
faculty across the country, with specific focus on primary care faculty members. Hold a small
1 While the organization and structure of academic health centers vary, every center comprises an allopathic and osteopathic school
of medicine, at least one other health professional school or program, and one or more owned or affiliated teaching hospitals.
DRAFT
53
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invitational workshop of model programs and develop several models on which to base the
funding for all 146 academic institutions.
Activity #2
Develop key required elements for a model faculty champion program including the following:
¦ Faculty member with 25% time availability.
¦ Faculty member trained in primary care (defined as pediatrics, family practice, internal
medicine, obstetric/gynecology, emergency medicine, or preventive medicine/public health).
¦ Commitment of staff time (part time health educator and administrative support).
¦ Existing and proposed partnerships within the academic health center to ensure that the
faculty champion's work reaches all schools within the institution.
¦ Teaching and curriculum development component, including baseline analysis of student
knowledge and skills.
¦ Institutional change component with specific strategies articulated for changing
institutions to support teaching environmental health/pesticides.
¦ Community-based sites for student practicum, internships, residencies.
¦ Advisory Committee, inclusive of environmental health expertise, curriculum committee
members, community members.
¦ Opportunities to link teaching with research activities.
¦ Plan of action for 5-year integration.
¦ Evaluation component.
Activity #3
Establish a coordinating body to manage the grant-making process, to convene the grantees,
and to provide technical assistance to the faculty nationwide. Among the tasks of the national
coordinating office are to:
¦ Develop the RFA with the federal agencies; manage the application and grant-making processes.
¦ Produce a faculty guidebook with model programs on which faculty are asked to base
their activities.
¦ Convene faculty for a working session to introduce model programs and work with project
design. Annual meetings will be held in subsequent years.
¦ Set up ongoing technical assistance and evaluation effort with faculty members to be
available for the length of the project.
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¦ Establish regular forms of communication
among faculty members, including regional
meetings, Web-based interactive activities,
online submission of teaching modules or
other curricular pieces, and formative and
summative evaluation.
¦ Present ongoing findings at national
conferences and assist on national issues as they
may arise.
¦ Coordinate entire evaluation effort.
Activity #4
¦ Release RFA to academic institutions for a 5-
year grant funded effort. Ensure diversity in
faculty and disciplines selected. Publicize RFA
process. Select 146 faculty champions.
Applications must include all items listed in
Activity #2 along with a timeline for completion.
¦ Incorporate a capacity-building mechanism into the grant-making process by creating
10 regional networks of faculty members where the exchange of technical assistance can
take place. To achieve this, one academic center in each region would be granted additional
funding (through a competitive process) to provide technical support to new faculty
champions in that region. In this way, the program will help transfer knowledge and
expertise from existing champions to new faculty members, while also supporting the
additional time spent by existing champions.
Activity #5
Launch initiative with the announcement of the 146 faculty champions and 10 regional centers
receiving additional funding. Faculty efforts will last 5 years with specific increments identified
for evaluation, workshops, submission of work, and activities via the Websites, and quarterly/
annual reviews. Throughout the entire process, the national coordinating organization will
build the cadre of faculty nationwide. (See Table 7).
Stakeholders
¦ Collaborating federal agencies
¦ Key association for health professional schools
¦ National coordinating body
'If we're going to make this successful, we
have to grow our own [champions], and
that takes sotrte time."
Candace Burns, PhD, ARNP
National Organization of Nurse Practitioners
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55
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Table 7: Proposed Design of Faculty Champions Project
Institution Funded
Activities Funded
Individuals Funded
Length of Funding
National
Coordinating
Organization
Overall coordination
and management
of project and
administrative staff
Project Director,
(100% FTE), Coordinator
(100% FTE), Webmaster
6 years (design,
implementation
and evaluation)
10 regional centers
(one per EPA region,
chosen from academic
health centers)
Existing faculty
champion support plus
technical assistance
support for faculty
in the region
Faculty Champion (50% FTE),
Regional Coordinator
(50% FTE),
administrative staff
5 year grant period
146 academic sites
(126 academic health
health centers + 20
representing diverse
populations and
nursing schools)
Implementation of
one of several models
in academic institutions,
including inclusion
in curriculum, and
institutional change
Faculty champion (25% FTE),
administrative support
5 year grant period
Evaluation Team*
Formative and
summative evaluation
Evaluation staff
Portions of all 6 years
'may be subcontracted by the national coordinating organization.
Evaluation of Outcomes/Indicators of Success
The entire component will be evaluated based on the following indicators:
Project Outcomes (1-5 year funded project)
¦ 146 institutions with documented integration of pesticides/environmental health into
curriculum.
¦ 146 institutions with increase in students' basic knowledge and skills in pesticide/
environmental health.
¦ 146 institutions with increased FTE time devoted to environmental health.
¦ Increase in number of practice/field experiences in environmental health sites
¦ Increase in environmental health research activities.
Project Outcomes (post 5-year project)
¦ Increase in new researchers investigating environmental health.
¦ Increase in number of primary care providers out of the pipeline who address environmental
health in practice and research.
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Sustainable institutional change in majority of 146 institutions.
Changes in the way health professionals address environmental health (measure of overall
effectiveness).
Background
This component proposes a significant investment of funding to build a strong cadre of faculty
champions. The funding would pay for part of a designated faculty FTE, plus a half-time
position for administrative and content support at 146 institutions. The funding would also
support 10 regional centers headed by an existing faculty champion and designed to provide
technical assistance and support to new faculty members in the region. The champion would
use a variety of educational methodologies (required courses, integration within existing
courses, field experience, and links with community members and organizations), and would
link with other schools, departments, and organizations as part of a national network of
champions. In particular, it is recommended that faculty champions coordinate with model
practice sites (see Practice Component E, p. 75). The intent is for the faculty champion to
base his/her activities on selected model programs that have already undergone evaluation.
The idea of creating and strengthening "champions" of pesticide/environmental health
education came out of the Education Workgroup's discussion of how important a role
individuals can play at an institution. A threshold level of funding and security of funding is
needed to encourage institutions to hire and/or nuture pesticide/environmental health
champions. A multi-year commitment is also necessary to make it worthwhile both for the
institution and the champion. Much of the champion's time should be spent institutionalizing
the pesticide/environmental health component by developing faculty interest/knowledge and
integrating it into curriculum, both in medicine and nursing disciplines. Otherwise, when
the grant funding ends, the environmental health/pesticide component is likely to be viewed
as "nice but not necessary" and may disappear at the next curriculum change cycle. The proposal
developed is for five year funding, with funding possibly decreasing in years 3-5.
It is recommended that all academic health centers receive funding at the same time. It is
important to make the funding equal across academic health centers. This component will
fund 126 academic health centers and an additional 20 institutions to ensure a balance between
medicine and nursing, and the inclusion of diverse institutions. Faculty champions will be
selected equally from the disciplines of medicine and nursing. Faculty champions will also be
selected from primary care. Given that some institutions already have faculty champions, the
project will include an opportunity for such institutions to compete for regional center grants.
The regional centers will be required to provide technical assistance and support to new faculty
champions in the region. The entire project will build upon other faculty champion models
that have been created for other subject areas nationwide.
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57
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FDIICATION COMPONENT F.
Create Teaching Incentives
Strategy
Influence the appropriate boards, organizations, and institutions that create Board exams
and set curriculum requirements to include several key competencies on pesticides and
environmental health.
Expected Outcomes
¦ Questions on Board exams
¦ Changes in curriculum requirements
Target Audience
Awareness and Motivation: This component targets decision-making organizations that
set curriculum requirements, entities that write Board and certification examinations,
and faculty who teach based on requirements and exams. This component is designed to
motivate and convince these decision-makers to integrate into their requirements and
exams small components that address the health effects from pesticide exposures. This
component will also provide "ready-made" language on requirements and/or exam
objectives and questions.
Proposed Activities
Activity#i
Conduct an initial assessment to determine number of questions related to pesticides/
environmental health on examinations. Identify or develop sample examination questions.
The assessment will also list timeframes for changes in requirements/Board exam questions
by key decision-making bodies.
Activity #2
Develop a succinct strategy for approaching the organizations/decision-making bodies that
develop Board and other examinations, including specific recommendations for educational
objectives, questions and language changes. Action items include:
¦ Convene a working group of high level external partners and key federal agencies to develop
strategy/position paper. This group should be drawn from the Association of American
Medical Colleges, the American Association of Colleges of Nursing, the American
58
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Association of Occupational Health Nurses, the American College of Occupational and
Environmental Medicine, the American Medical Association, the American Nurses
Association, the American Association of Physical Assistants, and American College of
Nurse Midwives. In addition, federal agencies could include National Institute of
Environmental Health Sciences, National Institute of Occupational Safety and Health,
EPA, and Health Resources and Services Administration.
¦ Create a strategy that recommends specific content (per National Competency Guidelines
in Education Component B) and insertion points into specific Board exams and specialty
requirements. Strategy will also set targets for change.
Activity #3
Contact decision-making bodies and provide with them with specifically tailored position
paper and recommended changes to questions, exams, and requirements. Include the
endorsement of the relevant working group organizations. Identify Boards and schedule using
the following outline of priorities:
Short-term Priorities
Medicine:
¦ United States Medical License Examination (Steps 1,2,3)
¦ Board Examinations in Family Practice, Pediatrics, Internal Medicine, Ob/Gyn,
Emergency Medicine
Nursing:
¦ AANC generalist examinations
¦ Nurse practitioners adult, pediatrics, family, gerontological (ANP, PNP, FNP, GNP)
¦ Nurse midwives American College of Nurse Midwives (ACNM)
¦ Clinical nurse specialists (CNS)
Longer-term Priorities
¦ Physicians Assistants
¦ Pharmacists
¦ Basic Nursing
¦ Genetic Counselors
DRAFT
59
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Stakeholders
¦ Key national decision-making bodies for curriculum changes, requirements, and
examinations
¦ National professional association
¦ Key federal agencies involved with health profession education
¦ Faculty members
Evaluation of Outcomes/Indicators of Success
¦ Increase in the number of questions in the examination pool and on each examination as
compared with the initial assessment.
¦ Changes in requirements for primary care disciplines (pediatrics, family practice, internal
medicine, preventive medicine/public health, emergency medicine and obstetrics and
gynecology) to include pesticides/environmental health.
Background
One way to motivate change in curriculum is to convince the medical and nursing examination
boards of the importance of environmental health in the coming years, and urge them to
incorporate environmental health questions on their exams. This would also be one of the better
ways to institutionalize the subject matter over the long term. Some of the boards are expected
to be receptive to a concerted effort in this area; for example, the Residency Review Committee
for Pediatrics in 1997 adopted two recommendations on children's environmental health.
60
DRAFT
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Practice Settings
The second prong of the strategy is the practice setting. Practice settings, for purposes of
this initiative, are defined as community health centers and clinics; managed care clinics;
hospitals and emergency departments; private practices; urgent care centers; poison control
centers; and work and/or school-based clinics. While the components target the practice setting,
they also involve the professional associations and decision-making bodies that represent and/
or influence the practice setting. These include, for example, the American Nurses Association,
the American Academy of Pediatrics, the American Academy of Family Physicians, and the
Migrant Clinicians Network, to name a few. The following components cut across the continuum
of systemic changefrom raising awareness and assessment, to development of expected practice
skills, to the support of "model practices" and system-wide incentives.
Component A: Make the case for practitioners Develop an effective case statement to convince
primary care providers of the need to incorporate environmental health and pesticide awareness
into their practice settings.
Component B: Define practice skills and guidelines Produce National Guidelines that
recommend practice behaviors and guidelines for the recognition, management, and
prevention of pesticide exposures, for all practicing health care providers; define accompanying
content related to expected behavior; suggest methods of integration into practice and training
settings; and provide access to relevant resource materials.
Component C: Assess knowledge and skills of practitioners Conduct an assessment of
the target audience of primary care providers to determine: (a) providers' current knowledge
and (b) how providers will best respond to educational programs and informational resources.
This assessment will be comprised of a literature review, surveys, and focus groups.
Component D: Secure official endorsements Ensure the integration of the expected practice
skills into practice settings by securing the official endorsements of key professional
organizations and decision-making bodies specific to practice.
Component E: Demonstrate model programs Mobilize practice settings to become
population-specific and to incorporate environmental considerations (specifically pesticides)
into prevention, education, diagnosis, and treatment. Achieve incremental, site-specific
improvements in identification, early intervention, and prevention, as well as in measures of
practice-specific health outcomes. By 2010, half of all primary health care practice settings in
DRAFT
61
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the United States should incorporate environmental considerations in prevention, education,
management, and referral.
Component F: Create incentives for change Identify and promote a number of incentives
to incorporate appropriate prevention, recognition, and management of pesticide-related
health conditions into health care practices. Specifically: (1) provide grant support to practicing
providers for interventions and research related to pesticide poisonings and exposures, (2)
create free, readily available opportunities for continuing medical education involving
pesticides and environmental health, (3) increase providers' awareness of the value of taking
an occupational and environmental history for optimizing Evaluation and Management
(E&M) coding and billing, (4) require knowledge of environmental health issues for
certification and recertification, (5) require pesticide poisoning reporting for worker
compensation reimbursement and automatic worker compensation reimbursement for work-
up of suspected occupational pesticide-related health conditions, and (6) promote
documentation of occupational and environmental history in medical records via
incorporation into quality assurance/quality control mechanisms.
UJ
CJ
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62
DRAFT
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PRAfTICF COMPONENT A:
Make the Case for Practitioners
Statement
Develop an effective case statement to convince primary care providers of the need to
incorporate environmental health and pesticide awareness into their practice settings.
Expected Outcomes
¦ A written case statement that documents the key points of why practicing health care
providers should care about the environments in which their patients live, especially with
regards to potential pesticide poisonings and exposures, along with the accompanying
scientific literature to support the need for well educated health care providers. This
statement will be linked with the case statement for educational settings.
¦ Endorsement of the case statement by leading national professional associations and
national bodies that work with practitioners.
Target Audience
Awareness and Motivation: This component is targeted at decision-makers and key strategic
organizations that need to be convinced that the issue of pesticide poisonings and the need to
educate health care providers about this issue are relevant to the practice settings of health
care providers. This component also targets primary care providers who are not yet convinced
that this is an appropriate subject for a national plan.
Proposed Activities
Activity #1
Research and develop a case statement, solicit peer review, and finalize with the input of key
stakeholder groups in the field. The target audience for the case statement is the practicing
health care providers and the organizations that work with them.
Points to be covered in the case statement:
¦ Importance of environmental health training and the breadth of the problem of pesticide-
related health conditions.
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63
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¦ Convincing arguments for why pesticides should be part of what health care providers
address in their practice settings, with cited scientific data, along with relevance to the
practice of health care and public health.
¦ Compelling arguments to gain the attention of primary care providers despite the fact
that their time and attention are in high demand elsewhere.
¦ Emphasis that practitioners do not need to become experts, and reassurance that experts
are available to work with them on specific clinical cases and/or community concerns.
¦ Reassurance that user-friendly tools exist for practitioners to use, along with user-friendly
guides for teaching pesticide issues to practitioners through continuing education.
¦ Recommended amount of time to dedicate to pesticides in the clinic that is reasonable
given the other demands on practice settings.
Activity #2
Promote case statement through effective dissemination mechanisms, including print and
Internet information sources.
Activity #3
Publish journal or newsletter articles in professional journals and publications.
Activity #4
Hold strategic meetings with professional associations and national leaders to seek their
endorsement of the case statement. This includes identifying a subset of decision-makers
who can be influenced by the case statement.
Stakeholders
¦ Professional associations
¦ Recertification bodies
¦ Continuing education organizations
Evaluation of Outcomes/Indicators of Success
¦ Case statement
¦ Published articles in professional journals and newsletters
¦ Position papers developed and adopted by professional associations
64
DRAFT
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Background
It is recognized that many key decision-makers are still unconvinced that this is an issue of
concern. Although the supporting documentation exists, there is a need to pull the information
together in a succinct case statement directly designed for practitioners.
DRAFT
65
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PRAfTirF COMPONENT R:
Define Practice Skills and Guidelines
Statement
Produce National Guidelines that recommend practice skills and guidelines for the recognition,
management, and prevention of pesticide exposures, for all practicing health care providers;
define accompanying content related to expected behavior; suggest methods of integration into
practice and training settings; and provide access to relevant resource materials.
Expected Outcomes
¦ National Pesticide Practice Skill Guidelines which recommend practice skills, content,
insertion points into practice and training settings, and resources. The Guidelines will be
completed in mid-2000.
¦ Endorsement of National Guidelines by leading national professional associations.
Target Audience
Readiness to Change: This component is targeted at administrators of clinics and health
care delivery systems, providers of professional development, and practitioners. The
component assumes that the administrators and practitioners are convinced of the importance
of this topic and are ready to make changes in their practices.
Proposed Activities
Activity #i
Define the basic practice skills for practice settings to ensure that all practicing primary care providers
are prepared to address pesticide-related health conditions and exposures in their practice.
A preliminary outline of practice skills for practicing health care providers has already been
completed, as shown in Table 8 on page 68. The intent of the table is to define expected
practice skills for all practitioners. This table will link with a complementary document being
created for educational settings.
Activity #2
Produce National Guidelines that will guide practitioners on the recognition and management
of pesticide-related health conditions. A complementary report will focus on the educational
settings where primary care providers receive their training.
66
DRAFT
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The National Guidelines will be drafted by a team of experts and will contain the following
components:
¦ Recommended practice skills.
¦ Relevant content for each practice skill.
¦ Suggested points of insertion into practice settings.
¦ Suggested resources to teach content specific to each competency in practice settings.
The team will be responsible for meeting the following objectives:
1) Define the target population for the practice setting for purposes of this project.
2) Qualitatively analyze the existing content in the practice settings for both physicians and
nurses, and identify relevance to pesticide expected practice skills. (The team is expected
to conduct a literature review, but not to conduct a full survey and/or questionnaire of
existing content.)
3) Identify new content to be added to practice settings for each expected practice skill.
4) Determine windows of opportunity for inserting the content into existing training
programs (including continuing education, distance learning, etc.), for physicians and
nursing. Develop a map of creative delivery mechanisms highlighting potential points of
insertion of pesticide-related content in such training programs.
5) Identify resources specific to each expected practice skill that can be added to a
computerized database of educational resources.
6) Develop recommendations for designing and implementing workshops and educational
opportunities with professional associations and continuing education.
The report will be designed as a user-friendly guide on how to integrate pesticides content
into practice skills. It will serve as a supplementary practitioner guide to the Recognition and
Management of Pesticide Poisonings. The report will not contain actual training modules or
resources, but instead will provide a listing of relevant resources and how to locate them.
Activity #3
Promote the National Guidelines with key stakeholders and solicit official endorsements and
organizational support of report, including dissemination to their members.
Stakeholders
¦ National professional associations for practicing primary care providers
¦ Practicing health care providers who have already developed tools and practice models
DRAFT
67
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Evaluation of Outcomes/Indicators of Success
¦ The National Guidelines will include defined practice behaviors, content areas, insertion
points, examples as necessary, and recommended resources.
¦ Endorsement by key professional organizations for providers.
Background
The preliminary list of "Expected Practice Skills" shown in Table 8 is recommended as a useful
goal for primary care providers seeking to provide the highest quality care to their patients.
This list will form the starting point for future efforts.
Table 8: Expected Practice Skills - Preliminary Outline
1. Take an environmental and occupational health history.
¦ Providers should be able to take a basic environmental and occupational history
to determine if a temporal relationship exists between exposure and symptoms.
¦ Ask patients 2-3 screening questions that would elicit possible exposure to a
number of environmental factors (including but not limited to pesticides).
¦ Take an environmental health history with questions regarding where the patient
lives, works, and plays.
2. Recognize the signs and symptoms of pesticide exposures and appropriately
manage or refer patients.
¦ Recognize the signs and symptoms of pesticide exposures (both acute and chronic).
¦ Providers should be able to treat and manage health conditions associated with
pesticide exposure or refer patients to appropriate specialists and resources, and
follow up appropriately.
¦ Diagnose pesticide-related health conditions using appropriate testing procedures
and treat pesticide exposures.
3. Identify risk factors for pesticide exposure and resulting health effects.
¦ Identify risk factors for pesticide exposure (e.g. occupation, location of home,
susceptible populations such as children).
- continued on the following page
68
DRAFT
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Table 8 (continued)
¦ Identify environmental factors that may possibly be linked to patient illness to
ensure that chronic pesticide exposures are addressed.
4. Demonstrate key principles of environmental/occupational health and
epidemiology and population-based health.
¦ Demonstrate an understanding of principles of environmental and occupational
health, and epidemiology.
¦ Understand the temporal relationship between exposure and symptoms.
¦ Recognize that others may be ill (co-workers, family) and get a timeline of health
problems for these or consult public health authorities for help in evaluating exposures.
5. Take steps to report pesticide exposure and support surveillance efforts.
¦ Understand the importance of surveillance and reporting.
¦ Be able to access and report data for local, regional, and national surveillance programs.
¦ Report cases involving pesticide exposures as required.
¦ Report concerns about pesticide exposures to the appropriate authorities, such as
local and state health departments, NIOSH, OSHA or state departments of labor,
or departments of agriculture.
6. Possess basic awareness of communities in which patients live.
¦ Providers should possess a basic awareness of environments in which patients live,
work, and play in order to anticipate possible encounters with exposure to pesticides.
¦ Demonstrate an understanding of population-based health.
¦ Demonstrate knowledge about the environment in which the practice is situated, with
specific understanding of communities that maybe at-risk for pesticide exposures.
¦ Be aware of, and access, the resources available within the community and in the
state or region, that could assist in pesticide exposures and illness.
7. Provide prevention guidance/education to patients.
¦ Provide guidance to patients on how to prevent pesticide exposures.
¦ Advise patients and provide basic education about pesticide exposure.
¦ Counsel patients about minimizing unnecessary use of pesticides, refer patients
to appropriate experts on integrated pest management.
¦ Address the whole patient in the context of his/her life and/or community (e.g.,
link to social services, etc.).
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DRAFT
69
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PRACTirF POMPONFNT C:
Assess Knowledge and Skills of Practitioners
Statement
Conduct an assessment of the target audience of primary care providers to determine: (a)
providers' current knowledge and (b) how providers will best respond to educational programs
and informational resources. This assessment will be comprised of a literature review, surveys,
and focus groups.
Expected Outcomes
Baseline data indicating the level of training currently taking place in practice settings, current
knowledge of practicing providers, and identification of best mechanisms to reach and train
providers, and to equip them with user-friendly tools.
Target Audience
Awareness and Motivation: This strategy targets health care practitioners to determine
their level of awareness; their motivation, or lack of motivation, for this topic; their knowledge
and skills base; and the most effective ways to reach them through educational interventions,
model programs, and resources.
Proposed Activities
Activity #1
Conduct a literature review to locate survey data and evidence of level of knowledge, attitude
and skills of health care providers related to pesticide-related health conditions.
Activity #2
Where literature review is lacking in data, conduct a combination of audience assessment
activities, including surveys and focus groups, to be able to effectively collect baseline data
and draw conclusions on the following questions:
¦ To what extent are the recognition and management of pesticide- related health conditions
included in the continuing professional development of primary care providers?
¦ What is the extent of the knowledge, attitude, and skill base of practicing primary care
providers with regard to pesticide issues? Are they at the stage of needing to raise awareness,
improve their knowledge and skills, or obtain resources?
70 DRAFT
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¦ What level of comfort do practitioners have with
addressing pesticides with their patients and in
communities? What do practitioners need to feel
more comfortable in addressing pesticides in
their practice settings?
¦ What resources, and in what format (e.g.,
traditional lecture material, teaching modules,
Web-based, audio cassette, CD, videoconference,
satellite), do practitioners need most?
Activity #3
Produce a final report with recommendations for use
in the development of the initiative.
Stakeholders
¦ Professional associations that represent
practitioners
¦ Continuing education programs, organizations
that offer continuing education
¦ Practicing clinics and health care delivery systems
¦ Practicing providers
Evaluation of Outcomes/Indicators of Success
¦ Comprehensive literature search documenting the findings of studies that have surveyed
practicing primary care providers.
¦ Report with baseline data and conclusions/recommendations for implementation of
the Initiative.
Background
Any good plan has at its core a strong assessment component to collect baseline data on
existing knowledge and skills, as well as to determine the most effective mechanism for
reaching the target population. This component will collect vital information not only
for this initiative, but also for the entire field of health care provider education. The
assessment will also include a chance to determine where the target population presents
Office of Pesticide Program*
"It is not clear that we really know
what /resources] health care
providers want and need."
Allen James, MBA, CAE
Responsible Industry for a Sound Environment
DRAFT
71
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itself along the continuum of change described in the section on Target Audience. Do
most people lie at the beginning of the continuum where they will respond best to activities
that raise their awareness and motivate them to care about this issue? Or are they ready to
make changes in their practice and are in need of tools and educational resources? The
assessment will answer these, and other key questions, to inform the implementation
process and subsequent evaluation.
72
DRAFT
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PRACTICF fflMPONFNIT D:
Secure Official Endorsements
Statement
Ensure the integration of the expected practice skills into practice settings by securing the
official endorsements of key professional organizations and decision-making bodies.
Expected Outcomes
Professional organizations, influencing bodies, and practitioners will agree that the expected
practice skills are essential to the ongoing training of primary care providers and will integrate
or support their integration into practice settings.
Target Audience
Awareness and Motivation: This component targets key recertification and continuing
education bodies and professional associations for practitioners. The key emphasis here is on
raising awareness and motivating decision-makers to bring about change in practice that
provide lifelong learning to health care providers.
Maintenance/Sustainability: This component also targets key professional associations to
endorse and support the implementation and outcomes of this initiative over the long-term.
This initiative will only be successful if its expected outcomes are institutionalized into the
practice settings for health care provider training.
Proposed Activities
Activity #1
Promote expected practice skills and case statement with professional organizations to garner
their involvement and support in implementing interventions to improve the knowledge,
attitudes, and skills of practicing health care providers.
Activity #2
Highlight the specific recommendations in the National Guidelines on expected practice skills,
along with specific examples of how practice settings can integrate the content into the ongoing
training of providers.
DRAFT
73
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Activity #3
Publish editorials in nationally recognized journals on specific strategies from the National
Guidelines, along with user-friendly tools for providers.
Activity #4
Develop a position paper on the need for expected practice skills, to be posted on the Internet
and for use in meeting with credentialing bodies and decision-makers.
Activity #5
Identify and promote incentives for professional associations to be involved in the initiative,
including financial incentives in the form of grants, technical assistance for clinics, community-
based interventions and research, instructional teaching and training aids, expert consultants,
clinical access, release time for professional development, and establishing appropriate clinical
sites for additional training.
Stakeholders
¦ Professional specialty organizations
¦ Licensing boards
¦ National professional associations
Evaluation of Outcomes/Indicators of Success
¦ New position papers by targeted organizations that support the integration of
recommended pesticide content into practice settings.
¦ New requirements by professional decision-making bodies that require professional
education to teach about health effects from pesticides.
¦ Published journal articles in professional newsletters and peer-reviewed journals.
74
DRAFT
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PRACTIPF COMPflNFNT F:
Demonstrate Model Programs
Statement
Mobilize practice settings to become population-specific and to incorporate environmental
considerations (specifically pesticides) into prevention, education, diagnosis, and treatment.
Achieve incremental, site-specific improvements in identification, early intervention, and
prevention, as well as in measures of practice-specific health outcomes. By 2010, half of all
primary health care practice settings in the United States should incorporate environmental
considerations in prevention, education, management, and referral of pesticide-related
health conditions.
Expected Outcomes
¦ Demonstration projects (distributed geographically across the United States) that model
practice settings where pesticide-related health conditions are an integrated part of the
provision of care and community outreach.
¦ Evaluation of demonstration models and creation of a "models that work" guide for the
field and other practice settings.
¦ Creation of a tool kit that can be used by other practice settings that want to set up a
model program.
¦ Launching of nationwide effort to redesign 50% of all practice settings.
Target Audience
Maintenance/Demonstration: This component targets specific practice settings that are
ready to become part of a cadre of model practices across the country that will change the
way they practice, specifically addressing potential health effects from pesticide poisonings
and exposures. The target audience in this case has been convinced that this is an important
issue and has increased its knowledge and skills in this area. Model practices may also be
located in areas of higher impact, such as farmworker clinics and urban settings.
Proposed Activities
Activity #1
Mobilize practice settings that currently address environmental health/pesticide issues. Identify current
leaders among practice settings and encourage them to spread the word on what they already do.
DRAFT 75
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Activity #2 (option 1)
Secure funding, create a program description, and develop an RFP to solicit proposals from 5-
10 clinical/community sites to receive financial support over three years to create a practice
model. Ensure that the funded sites represent the range of practice settings and the breadth of
pesticide issues (e.g., urban and rural, agricultural and non-agricultural, diversity of cultures
and literacy rates). Ensure that some programs are located in states with pesticide reporting
requirements.
Activity #2 (option 2)
Secure funding, create a program description, and develop an RFP to solicit small proposals
from 100 clinical/community sites to receive financial support over 1.5 years to create a practice
model. Ensure that the funded sites represent the range of practice settings and the breadth of
pesticide issues (e.g., urban and rural, agricultural and non-agricultural, diversity of cultures
and literacy rates). Ensure that some programs are located in states with pesticide reporting
requirements.
Activity #3
Define the major components of the proposed practice model, allowing for flexibility by the
specific site. Ensure that the models are grounded in theories and experience about how change
actually happens so as to learn from other experiences in practice settings. One model that
has been recommended is the Diabetes Collaborative (see box on page 78).
Activity #4
Establish a coordinating body to manage the project and the creation of the consortium of
pilot sites, and to create the plan of action for the project. Among the tasks of the national
coordinator are:
¦ Create a consortium of the pilot sites that use the proposed model as a guide for developing
their own specific practice intervention plan (including what they want to do, the
intervention, the evaluation and the implementation of the proven change).
¦ Build a technical assistance component that can work with sites in designing the
intervention, piloting the intervention and evaluating its success.
¦ Convene pilot sites on a regular basis by conference call and in-person meetings to share
success stories, challenges, and lessons learned.
¦ Establish an evaluation mechanism for the sites and the national project to determine the
success of the creation of new models. Evaluation would be both formative and summative.
Activity #5
Launch nationwide effort to redesign 50% of practice settings based on findings from the
model sites.
76
DRAFT
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Stakeholders
¦ Professional associations
¦ Practice settings
¦ National coordinating organization
¦ Funding agencies and partners
¦ Organizations that have created practice change models
Evaluation of Outcomes/Indicators of Success
¦ RFP completed and funding secured for pilot program.
¦ Chosen sites underway in developing practice models.
¦ Five to ten practice change models with evaluation components and identified success stories.
¦ Publication of model programs.
¦ Effective dissemination of practice models nationwide.
¦ Enhanced reporting of cases.
Background
The key to changing practice is demonstrating how changes in day-to-day activities actually
make a difference in health outcomes of patients and communities. This strategy was generated
by the Practice Workgroup as a way to model expected changes and to evaluate what practice
changes actually lead to the overall goal of the initiative to increase the recognition,
management and prevention of pesticide poisonings and exposures. There are two recommended
options for this strategies: (1) fund a large number of demonstration practice sites to make
several small practice changes and evaluate the outcome, or (2) fund a small number of
demonstration practice sites to overhaul their practices and bring about substantial change.
Both options offer different rewards and utilize the resources in different ways. In either case,
there are model organizations that have developed such an effort for other health conditions,
such as the Diabetes Collaborative (see box on page 78).
DRAFT
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The Diabetes Collaborative is a multi-year initiative sponsored by the Health Resources
Services Administration and the Bureau of Primary Health Care, in partnership with health
centers, primary care associations, and clinical networks. Its goal is to eliminate health
disparities and ensure access to quality primary care for racial and ethnic minorities and
for underserved populations. Among underserved and minority populations, diabetes is a
virtual epidemic, with 1.2 million patient visits in 1996 alone, and lost resources and human
productivity estimated at over $92 billion annually.
The project aims to redesign diabetes management to effect a measurable change in health
status among the approximately 60,000 diabetic patients at the 92 participating health
centers. The key concept of the partnership is dissemination of the lessons learned through
adapting the learning process developed by the Institute for Healthcare Improvement. The
project was developed as part of the Breakthrough Series Workgroup of the Clinicians
National Forum.
The improvement model is based on three fundamental questions: (1) What are we
trying to accomplish? (2) How will we know that a change is an improvement? and (3)
What changes can we make that will result in an improvement? The national measure
of success for the first phase of the project is meeting the goal of over 90% of the 60,000
diabetic patients in the target population receiving two HbAlc blood tests per year, at
least three months apart. A short-term trial-and-leaming method called PISA (Plan,
Do, Study, Act) provides the framework for implementing changes and learning from
them. An example of PISA in action might be:
¦ Plan: The diabetes team at Rocky Road Health Center predicted that a registry of diabetic
patients would improve the measurement of HbAlc. Setting up this system took 3
weeks. During that time, the center also established protocols for glucose measurements
and ran a trial utilizing patient self-management for home glucose measurements.
¦ Do: The registry was tested for 2 weeks with one volunteer nurse practitioner and
her diabetic patients. After the diabetes flow sheet was revised to reflect the registry
information, the collection went well.
¦ Study: The time spent on completing the flow sheet increased from 1 minute to 2
minutes and it took an additional 3 minutes to enter data into the registry. Waiting
time for diabetic patients increased an average of 8 minutes. Of the patients with
diabetes, only half had appropriate testing of HbAlc; but after the trial, all of the
patients had current values.
¦ Act: After a team meeting with the executive director and finance officer in charge
of the information system, the health center adapted a scannable flow sheet form
they had learned about from the Midwest Clinicians Network. To cut down on
cycle time, the medical records were reviewed the night before to identify gaps and
pre-enter data.
Source: Migrant Clinicians Network
78
DRAFT
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PRACTICE rfllVIPnNFNT F:
Create Incentives for Change
Statement
Identify and promote a number of incentives to incorporate appropriate prevention,
recognition, and management of pesticide-related health conditions into health care practices.
Specifically, (1) provide grant funding to practicing providers for interventions and research
related to pesticide poisonings and exposures, (2) create free and readily available opportunities
for continuing education involving pesticides and environmental health, (3) increase providers'
awareness of the value of taking an occupational and environmental history for optimizing
Evaluation and Management (E&M) coding and billing, (4) require knowledge of
environmental health issues for certification and re-certification, (5) require pesticide
poisoning reporting for worker compensation reimbursement and automatic workers
compensation reimbursement for work-up of suspected occupational pesticide-related health
conditions, and (6) promote documentation of occupational and environmental history in
medical records, via incorporation into quality assurance/quality control mechanisms.
Expected Outcomes
¦ Increased attention paid by primary care providers to pesticide poisoning and exposures
based on incentives to change practice.
¦ Creation of new or improved incentives in the following areas: monetary incentives,
legal incentives, community-based incentives, and peer/professional incentives.
Target Audience
Awareness and Motivation: This component targets health care system administrators and
funders to create incentives for providers to address pesticide-related health conditions. This
component is designed to motivate and convince decision-makers that specific changes can
and should be made in grant funding, continuing education, E&M codes, re-certification,
workers compensation, and quality assurance. This component will also provide "ready-made"
language on recommendations for proposed changes.
Proposed Activities
Activity #i
Provide grant support to practicing providers for interventions and research related to pesticide
poisonings and exposures:
DRAFT
79
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¦ Urge federal agencies (CDC, NIH, EPA, HRSA), state agencies, and private foundations
to support intervention and research projects conducted by practicing primary care
providers.
¦ Publicize models developed through grant support.
¦ Create a centralized source of information about grants and grantees.
Activity #2
Create free and readily available opportunities for continuing education involving pesticides
and environmental health:
¦ Connect continuing education (CE) courses on pesticides to major national meetings.
¦ Offer free CE credits in a variety of settings.
¦ Offer CE credits in local settings and support experts to go out to local clinics to provide
pesticide education,
¦ Establish free, Web-based continuing education.
¦ Encourage and fund NIOSH Education and Research Centers (ERCs) to hold local
continuing education courses on pesticides.
¦ Address barriers such as competing priorities for providers, cost of hosting continuing
education programs, and lack of provider interest.
Activity #3
Increase providers' awareness of the value of taking an occupational and environmental history
for optimizing Evaluation and Management (E&M) coding and billing. See next page for a
brief summary of how E&M coding could be upgraded.
Activity #4
Require knowledge of environmental health issues for certification and re-certification:
¦ Identify priority professional certifying bodies.
¦ Recruit high-profile supporters from each of the relevant disciplines.
¦ Create sample objectives and questions on environmental health issues.
¦ Approach certifying bodies about including questions.
¦ Coordinate outreach to the certifying bodies.
¦ Address barriers such as institutional inertia, competing priorities, and lack of
perceived problem.
80
DRAFT
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According to the 1997 Health Care Financing Administration Documentation
Guidelines, in order for a provider to bill for a "comprehensive" visit for a new
<3 outpatient, a new inpatient, or a new consult, the provider must document taking
all of the following: a past medical history (PMH), a family history (FH), and a
< social history (SH). The social history is defined as an "age-appropriate review of
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O past and current activities." For follow-up visits and emergency department visits
to be designated as comprehensive, two out of the three histories must be
documented. It may be possible to convince health care providers that taking an
O occupational/environmental medicine history will help them to fulfill the SH
requirement for billing for a "comprehensive" visit, particularly for new patients.
The billing codes affected are:
< ¦ New outpatient visit codes 99204 and 99205
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¦ New outpatient consults 99244 and 99245
¦ New inpatient consults 99254 and 99255
¦ Initial hospital care 99222 and 99223
¦ Emergency department 99285
These HCFA Documentation Guidelines apply only to Medicare patients;
however, most third-party payers have adopted the same guidelines for their
reimbursement schedules. Considerable research will need to be done to
determine if this approach is viable.
Activity #5
Require pesticide poisoning reporting for worker compensation reimbursement and
automatic worker compensation reimbursement for work-up of suspected occupational
pesticide poisoning. See, for example, Washington State's program described on page 82.
The goals are for work-related pesticide health effects to be universally reimbursed,
including relevant diagnostic testing; mandatory reporting of pesticide-related health
effects for worker compensation reimbursement; and standardized weight-of-evidence
for claims reimbursement for pesticide-related illnesses. Tasks include:
¦ Target high-priority states for change.
¦ Gather information about model state worker compensation laws (especially California
and Washington).
¦ Win support of professional organizations, advocacy groups, and state agencies.
DRAFT
81
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Washington State has moved into the forefront in reporting of occupational diseases.
Under state law, the Department of Labor and Industries (L&I) and the Department
of Health (DOH) both have responsibilities for addressing chemically-related illnesses
(CRI)illnesses known or suspected to be caused or substantially worsened by
exposure to chemicals in the workplace or other environments.
To increase efficiency and provide more consistent handling of chemically-related
claims, L&I established a single CRI unit with responsibility for all chemically-
related claims. Claims adjudicators in the CRI unit receive special training on
chemically-related injuries and illnesses. L&I has also contracted with an
occupational medicine physician to provide additional medical review of the more
complex claims and to ensure that appropriate testing and work-ups are done.
L&I averages about 200 claims per month.
Some of the key provisions of Washington's worker compensation system include:
¦ An injury/illness incident is eligible for a claim to be filed whenever medical
treatment is provided.
¦ For all claims filed, the costs for diagnostic evaluations to determine if the injury/
illness is work-related are covered. Although the claim may eventually be rejected if
it is determined not to be work-related, the initial visit(s) and testing are paid for.
¦ Individuals with accepted claims are eligible for time loss (wage replacement) if
they lose more than 3 days of work.
¦ Health care providers are required to file a claim if the worker feels the condition
is work-related.
The CRI unit has recently started to identify clusters of chemically-related illnesses,
particularly involving a single employer with more than one claim for a specific
exposure event. The goals include early intervention to reduce exposures and prevent
future morbidity and mortality. For example, a cluster of carbon monoxide poisonings
was identified, triggering efforts to reduce future exposures in the plant where the
poisonings occurred. CRI staff find this process also improves the adjudication of
claims by grouping together the claims from a particular employer.
Since 1990, DOH has been responsible for investigating pesticide-related illness
incidents and developing a database of pesticide-related problems. L&I provides
detailed reports to DOH to enable DOH to include worker compensation claims in
their investigations. Some consider the claims process to fulfill their reporting
requirements, although there is a longer delay when L&I reports claims to DOH
than when a health care provider reports directly to DOH at the time a patient is
evaluated. It is not clear if this mechanism is sufficient or could be improved.
Source: Mary Miller, Washington State Department of Labor and Industries
82
DRAFT
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¦ Approach state Workers Compensation Commissions for changes.
¦ Build key leadership supporters including worker compensation attorneys, labor,
farmworker groups, clinicians, and public health groups.
¦ Address barriers such as lack of leadership, cost, and decentralized state authorities.
Activity #6
Promote documentation of occupational and environmental history in medical records, via
incorporation into quality assurance/quality control mechanisms. Quality Assurance/Quality
Control mechanisms could also be used to promote documentation that providers have given
pesticide information to certain at-risk groups (e.g., parents of toddlers, farmworkers, pregnant
women). Activities include:
¦ Create respected consensus on minimum necessary documentation through a committee
process.
¦ Research the scope, authority, and current priorities of the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO).
¦ Approach the JCAHO to require documentation of Occupational and Environmental
Medicine (OEM) history and pesticide education.
¦ Approach targeted major managed care organizations to require documentation of OEM
history and pesticide education.
¦ Approach family medicine and Ob/Gyn to include Occupational and Environmental
Medicine history and pesticide education in their chart-review for certification/
recertification.
¦ Determine whether this is a priority activity area, and address barriers such as institutional
inertia, extra burden on hospitals, clinics, and JCAHO, and time pressure.
Stakeholders
¦ Federal agencies and foundations that support research and interventions
¦ Professional associations
¦ NIOSH Educational Resource Centers
¦ Health care centers and hospitals
¦ Community clinics
DRAFT
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Evaluation of Outcomes/Indicators of Success
¦ Increase in number of grants and level of support available to practicing primary
care providers.
¦ Increase in publications of research findings and interventions undertaken by providers.
¦ Report on success stories and lessons learned in the field.
¦ Adoption of models in other settings.
¦ Increase in number of continuing education offerings.
¦ Increase in number of people attending continuing education programs and number of
people completing Web-based credits (percentage increase in participation each year).
¦ Short-term and long term changes in Evaluation and Management coding and worker
compensation.
¦ Questions added to recertification exams of professionals.
¦ Worker compensation systems in target states are changed to reimburse for work-up of
suspected pesticide poisoning, and payment is linked to reporting of pesticide exposures
to state registries.
¦ Quality Assurance/Quality Control mechanisms in targeted health care organizations are
changed to incorporate review of documentation of an occupational and environmental
history.
Background
One of the most effective ways to bring about change is to build incentives into existing
requirements and activities of health care plans and practitioners. There are certain key points
of entry into the health care system that require providers to address specific issues in their
practices. For example, by integrating pesticide components into worker compensation, E&M
coding, and quality assurance, the initiative can ensure that pesticide issues will become
institutionalized into health care practice.
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Resources and Tools
Resources of all kinds serve as the "infrastructure" for this initiative. The five resource
components are designed to identify, create, and disseminate the necessary tools to
support change in both educational and practice settings. Key concerns are to avoid
duplication of existing resources by inventorying the current stock of resources available, and
to ensure the scientific credibility and usefulness of resources by establishing a national review
board to evaluate them.
Component A: Inventory existing resources Determine what educational and informational
programs and materials for health care providers currently exist in education and practice
settings and what gaps should be filled.
Component B: Establish a national review board Create a national body to determine
assessment criteria and evaluate existing resources, with the goal of identifying, selecting,
and assessing the ideal resources that primary health care providers use in both educational
and practice settings for prevention, diagnosis, treatment, and referral of pesticide-related
health conditions.
Component C: Create an information gateway Establish a print, telephone, and Web-
based gateway through which primary health care providers can access information and
educational resources.
Component D: Develop teaching/learning resources for educational settings Identify and
develop new content resources, tools, and methods for faculty in educational settings.
Component E: Develop new resources for practice settings Identify and develop new
content resources, tools, and methods for health care providers in practice settings.
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RFSOIIRPF COMPONFNT A:
Inventory Existing Resources
Statement
Determine what educational and informational programs and materials for health care
providers exist in education and practice settings and what gaps should be filled.
Expected Outcomes
An inventory of pesticide resources based upon information from health care providers in
education and practice settings.
Target Audience
Readiness for Change: This strategy will target health care providers who have already
developed model tools, resources, and programs so as to create a centralized inventory of
what exists and what gaps need to be filled.
Proposed Activities
Activity #1
Develop and document the inventory methodology to be used in collecting resources,
including documentation for the survey instrument and an announcement requesting
resources and materials, including placing a solicitation in the Federal Register.
Activity #2
Conduct the resources inventory. Key questions to be asked of organizations in the survey
include:
¦ What resources do you use to diagnosis pesticide exposures?
¦ What resources do you use to treat pesticide exposures?
¦ What resources do you use to refer pesticide-exposed patients?
¦ How useful are current resources?
¦ At what "stage of change" is the resource targeting providers?
¦ For which target discipline is the resource designed?
¦ For what practice settings is the resource designed?
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¦ For what characteristics of patient/community populations are the resources designed?
¦ What resources are needed that are not readily available?
Stakeholders
¦ Federal Interagency Planning Committee for this initiative
¦ Organization conducting the inventory
Evaluation of Outcomes/Indicators of Success
¦ Inventory completed and available.
¦ Feedback from Website users indicating additional resources and/or identifying gaps.
¦ Acknowledgment of a thorough inventory by the national review board.
Background
In order to evaluate the existing resources and to effectively disseminate what is available, an
inventory of available resources needs to be created. Such an inventory is already underway
and will be completed as part of this initiative. The inventory will be available online and in
print formats.
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DRAFT
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RFSOIIRrF rOMPONFNT R:
Establish National Review Board
to Evaluate Resources
Statement
Create a national body to determine assessment criteria and evaluate existing resources, with
the goal of identifying, selecting, and assessing the ideal resources that primary health care
providers use in both educational and practice settings for prevention, diagnosis, treatment,
and referral of pesticide-related health conditions.
Expected Outcomes
¦ An established board available for ongoing consultation and review.
¦ A published document with a list of evaluated and recommended pesticide resources that
primary health care providers can use in both educational and practice settings for
prevention, diagnosis, treatment, and referral of pesticide exposures.
Proposed Activities
¦ Establish selection criteria for review board membership.
¦ Establish a multidisciplinary national review board to conduct the evaluation of existing
resources.
¦ Refine the list of suggested evaluation criteria:
Pilot tested
Demonstrated level of success
Regional applicability
Significant number of participants
Cost-effectiveness
Peer review of resources
Significant relevance
Related to at least one competency/practice behavior
Developed by credentialed sources/authors
Accessibility
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DRAFT
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Credibility of information/sound science
Convenience
Endorsement by appropriate professional association
Approved programs for CE credits
Built-in incentives to use the resources.
¦ Convene the national review board to evaluate the existing inventory of resources (Resource
Component A) using the evaluation process.
¦ Publish recommended resource document online and as a paper document.
¦ Assess the usefulness of the resource document to health care providers.
Stakeholders
¦ Federal Interagency Planning Committee
¦ National review board members
Evaluation of Outcomes/Indicators of Success
¦ Published document of resources, online and as a paper document.
¦ Feedback from health care providers on the usefulness of the resource list (via online
mechanism and mail-back card inserted in the paper document).
Background
The concept of a national review board came out of the Resources Workgroup's focus on how
pesticide-related resources used in education and practice settings could be evaluated, in the
interests of using the highest quality materials. The review board would be composed of leaders
in the areas of pesticides and primary health care.
DRAFT
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1
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RESOHRCF COMPONFNT C:
Create an Information Gateway
Statement
Establish a print, telephone, and Web-based gateway through which primary health care
providers can access information and educational resources.
Expected Outcomes
A fully functional, interactive, informational gateway that provides primary health care
providers with access to readily available and useful pesticide resources.
Target Audience
Readiness to Change, Maintenance: This component targets individuals and organizations
who are looking for models and resources for how to address health effects from pesticide
poisonings, as well as individuals and organizations who have become part of the cadre of
health care providers involved in this issue.
Proposed Activities
Activity #1
Build the gateway using resources gathered through the inventory process and evaluated by
review board.
¦ Identify existing resource centers that could develop the gateway, under direction of the
Federal Interagency Planning Committee.
¦ Develop or enhance a resource center infrastructure and address logistical issues including
a toll-free number and Website functioning in real time.
¦ Assign priority access to primary health care providers.
¦ Link to regional and geographical specific information, coordinated industry Websites,
and other resources, universities, associations, etc.
Activity #2
Market the gateway and its information/education resources through dissemination channels
to reach primary health care providers in education and practice settings.
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DRAFT
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¦ To build awareness among health care providers: Disseminate persuasive case statements
(see Education Component A, Practice Component A for development of case statements)
through professional associations, journals, and peers that address the main issues, why
primary care providers should be concerned, and how to access the gateway.
¦ To provide tools/resources to health care providers ready to make changes: Disseminate auricular
packages to educational settings and training packages to practice settings. Packages maybe
defined as lectures, slides, case studies, exercises, assignments/project ideas, ideas on how to
involve experts, access to gateway, etc. Packages would be combined from existing resources
and/or new resources that have undergone peer-review and pilot testing.
¦ To help health care providers learn of the latest resources: Disseminate concise information
on how to access the gateway, especially the network of expertise. Dissemination methods
include posters, flyers at conferences, NPTN clearinghouse, and links on Websites.
¦ Convene one or more focus groups to evaluate the effectiveness of the dissemination efforts.
Stakeholders
¦ Federal Interagency Planning Committee
¦ Organization to manage the gateway
Evaluation of Outcomes/Indicators of Success
¦ Number of requests for information.
¦ Number of hits to the Website.
¦ Number of calls.
¦ 'Customer satisfaction' survey on the Website.
¦ Feedback from focus groups.
¦ Degree to which the dissemination efforts are nationwide.
¦ Degree to which dissemination efforts and resources address primary health care providers
at varying 'stages of change.'
Background
A centralized gateway to the wealth of information available and paths to information can
be an efficient way to provide comprehensive access to evaluated, pesticide-related resources.
This centralized resource should include emergency information and contacts, educational
DRAFT
91
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materials, and other resources, and be accessible by an 800 number and via a Website. The
gateway must be able to provide real-time answers to short-term questions as well as larger
educational resources. Access must be multi-pronged: phone, Web, print, email/listservs. It
should contain geographic linkages to local providers, researchers, and sources of local
information (e.g., local health departments). The gateway will build on existing resource
networks, such as NPTN (see box below) and will require a multi-stakeholder partnership for
effective implementation. Clearly, the gateway itself will need extensive marketing in order
to ensure that it is widely used.
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A cooperative effort between Oregon State University and EPA, NPTN provides
objective, science-based, and plain-language pesticide information to the general
public, and medical and veterinary communities. It handles over 23,000 calls a
year on topics ranging from toxicology to pesticide poisonings. NPTN's staff of
pesticide professionals includes toxicologists and a physician trained to:
¦ help callers interpret and understand health and environmental information
about pesticides
¦ answer questions about pesticide labels
¦ supply general information on the regulation of pesticides in the United States
¦ access over 300 pesticide resources
¦ direct callers for pesticide incident investigation, emergency human and
animal treatment, safety practices, clean-up and disposal, laboratory analyses
¦ confer with private physicians to determine an appropriate treatment plan
in the event of poisonings
¦ provide information regarding safety practices for field/farm workers and handlers
¦ provide callers with information about anti-microbial pesticides (1 -800-447-
6349) (Monday-Friday).
Toll-free tel: 1-800-858-7378 daily, 6:30 a.m. - 4:30 p.m. (Pacific time); Fax: 541 -
737-0761; E-mail: nptn@ace.orst.edu; Website: http://nptn.orst.edu.
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DRAFT
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RFSflllRPF rflMPONFNT D:
Develop Teaching/Learning
Resources for Educational Settings
Statement
Identify and develop new content resources, tools, and methods for faculty to use in
educational settings.
Expected Outcomes
¦ Teaching modules
¦ Network of experts and organizations nationwide
Target Audience
Readiness to Change: This component targets faculty in educational settings who are ready
to integrate the issue into their curriculum.
Proposed Activities
Create teaching modules for faculty that address pesticides/environmental health and that
respond to the recommended competencies, the National Guidelines, and the assessment of
educational institutions.
¦ Review existing teaching modules collected and evaluated by the national review board
and review the assessment of educational institutions to determine the type of teaching
modules still needed by faculty.
¦ Identify key experts and/or organizations to develop teaching modules and create
contractual agreements for the development of specific modules.
¦ Develop pesticide-teaching modules with flexibility for use by different schools,
departments, etc.
¦ Establish a peer review and pilot testing process for the modules developed.
¦ Distribute teaching modules to all academic health centers and nursing schools.
¦ Make modules available online (via gateway and/or published resources document).
DRAFT
93
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Stakeholders
¦ Faculty who have already developed resources
¦ Key professional associations for faculty
¦ Cooperative Extension Pesticide Safety Educators
¦ State Lead Agency Pesticide Educators
Evaluation of Outcomes/Indicators of Success
¦ New resources are approved and endorsed by the national review board.
Background
Guiding principles for developing new resources include:
¦ Easy to implement
¦ Interdisciplinary
¦ Culturally and geographically relevant
¦ Measurable outcomes
¦ Usable in both urban and rural communities.
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DRAFT
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RFSOIIRrF COMPONFNT F:
Develop New Resources for Practice Settings
Statement
Identify and develop new content resources, tools, and methods for health care providers in
practice settings.
Expected Outcomes
Increased access to and availability of relevant information and resources including experts
in the field, content materials and available data within communities.
Target Audience
Readiness to Change: This component targets practitioners who are ready to integrate the
issue into their clinical practice and prevention activities.
Proposed Activities
Activity #1
Develop a variety of resources, including:
¦ Training package for a one-day workshop on Pesticides and Health Care Providers:
This package could be used to train health care providers in continuing education, covering
the breadth of topics related to pesticides.
¦ User-friendly materials:
1. Pocket guides for physicians and nurses, for both print and Web media. Ensure that
guides are dated so that revisions can be made and distributed, and that they contain
return cards for new information and comments.
Guide I: Highlights of symptoms, treatments, and reference (similar to "Highlights"
feature in Recognition and Management of Pesticide Poisoning)
Guide II: How to take an environmental history (could be adapted from
Recognition manual).
2. "ABCs of environmental health" a simple tool, similar to the CAGE screening tool
for alcoholism, that will indicate signs and symptoms for screening purposes.
3. Wall posters on pesticides for health care providers to post in their clinical practices
4. Audio cassettes/CDs to listen to in transport to and from a practice setting.
DRAFT
95
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¦ Outreach: Use of radio for both patients and primary care providers from Central and
Latin American countries.
¦ Certification of training: Some type of recognition that a primary care provider has
completed a certain level of training.
¦ Journal articles in the literature: Encourage researchers to produce professional journal
articles on the subject of pesticide-related health concerns.
¦ Internet/Web-based materials and training, including video-conferencing, satellite training.
¦ Encourage creation of a centralized industry Website on pesticide/health data.
Activity #2
Increase the participation of professional associations in the support, use, and promotion of
educational materials and resources.
¦ Develop model policy statement that can be tailored and adopted by professional associations.
¦ Coordinate with national organizations to develop policy statements on educating health
care providers about pesticides (along the lines of those developed by the American
Academy of Pediatrics).
¦ Encourage development of environmental health committees in professional organizations
and local chapters.
¦ Coordinate with professional associations to secure more continuing medical education
(CME) opportunities at national and regional meetings.
¦ Build pesticide/environmental health CME into Internet-based offerings by professional
associations.
Activity #3
Establish a national network of experts and organizations that can answer questions and
serve as resources to health care providers nationwide.
¦ Identify existing organizations that have the capability to establish and/or expand a database
of individuals and organizations.
¦ Identify areas of expertise to be included.
¦ Identify experienced professionals and define the parameters of their responsibility.
¦ Solicit availability for consultation, teaching, guidance, etc.
¦ Develop a Pesticide Poisoning Orientation Training program to build "practice champions"
or motivate providers to become champions. Training could be Web-based, via audio
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DRAFT
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cassettes, CDs, or in-person. Short courses (half or full day) could be held in conjunction
with other professional conferences, and should be integrated with other disciplines.
Stakeholders
¦ Faculty who have already developed resources
¦ Key professional associations for faculty
¦ Cooperative Extension Pesticide Safety Educators
¦ State Lead Agency Pesticide Educators
¦ Network of pesticide and pest management experts in land grant colleges and universities
throughout the U.S.
Evaluation of Outcomes/Indicators of Success
¦ Increased utilization of community resources.
¦ Increased number of customized educational programs/materials.
¦ Increased number of collaborations among resources.
¦ Number of RFPs related to new and innovative ways to get information to primary care providers.
¦ Increased number and frequency of pesticide-practice related publications.
¦ Increased number of CME courses.
¦ Increased number of presentations in practice settings.
¦ Numbers of policy statements.
¦ Numbers of re-certification exams.
¦ Numbers of questions on exams.
¦ Increased availability of reimbursement mechanisms.
¦ Number of people applying for Certificate of Recognition.
¦ Number of requests made of experienced professionals.
¦ Number of professionals who agree to participate.
¦ Diversity of professional background.
DRAFT
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Background
A wide range of materials needs to be developed that are credible, convenient, and easy to use.
Examples include "cheat sheets," cassette tapes or CDs that can be listened to in the car, Web-
based instruction (depending on how recently the providers graduated and how comfortable
they are with technology). Providers are overburdened and need quick help either in the
form of checklists or a person at the other end of a line.
To the extent that primary care providers keep up with their professional journal literature
and to the extent that there is a sufficient stream of articles in the literature on pesticide
diagnosis and treatment, it can be expected that providers will encounter pesticide-related
information in the course of their reading. However, there may well be a gap in articles on
pesticide poisoning prevention and diagnosis in the journals that are generally read, a gap
that could be remedied by encouraging researchers to prepare and submit such articles.
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Conclusion
This Implementation Plan is the starting point for a strategic and coordinated effort to
change our national health care system so that it adequately addresses the problems
posed by pesticide poisonings and exposures. The Plan presents the goal of the initiative
and the expected outcomes, and sets forth a strategic direction for how to improve the
recognition, management and prevention of pesticide-related health conditions. At the heart
of the Plan is a three-pronged strategy for accomplishing the necessary change. The strategy
is aimed at improving the teaching of pesticides and environmental health in educational
settings of nursing, medical, and other health professional schools, changing the way primary
care providers assess and react to pesticide cases in their practice settings, and creating the
necessary new resources for both educational and practice settings that build upon the existing
knowledge base and respond to the needs of faculty, students, administrators, and practitioners.
The three-pronged strategy and the Plan as a whole are intended to serve as a model for other
toxic exposures and broader efforts to educate health care providers about environmental
health problems. It is hoped that this Plan will pave the way for the strategic next steps needed
to move forward a common national vision for environmental health awareness, education
and training for health care providers.
Work is already underway on a number of components of the Plan including development
of competency guidelines, establishment of a national evaluation panel/review board,
conducting an audience assessment through literature review and focus groups, and creation
of an information gateway. Most of the remaining components will get underway in the next
three years. Evaluation of progress will be an ongoing theme during the course of this initiative.
The next steps in moving this initiative forward will require the support and participation of
a wide spectrum of stakeholders nationwide. This Implementation Plan can be used as a way
of introducing new additional stakeholders and interested parties to the initiative and of
involving them in specific components. The Plan will also form the basis for a National Forum
to be convened in 2001.
As work proceeds, workgroup members and other stakeholders are encouraged to stay active
in the initiative through e-mail and EPA's host Website (www.epa.gov/pesticides/safety/
healthcare) and to bring the initiative to the attention of colleagues and other contacts in the
health care world.
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References
Adami.H.O. et al., 1995."Organochlorine compounds and estrogen-related cancer in women."
Cancer Causes and Control, 6:551-566.
Ahlborg, U.G., L. Lipworth, L. Titus-Ernstoff, et al., 1995. "Organochlorine compounds in
relation to breast cancer, endometrial cancer, and endometriosis: An assessment of the
biological and epidemiological evidence." Critical Reviews in Toxicology, 25:463-531.
Alavanja, M.C.R, D.P. Sandler, S.B. McMaster, et al., 1996. "The Agricultural Health Study."
Environmental Health Perspectives, 104:362-369.
American Association of Poison Control Centers (AAPCC), 1994. Tabulations prepared for
EPA: All Pesticides 1985-1992 Without Concomitant Exposures. Washington, D.C., December.
American Medical Association, 1994. Report 4 of the Council on Scientific Affairs, Educational
and Informational Strategies for Reducing Pesticide Risks (Resolutions 403 and 404), December.
Blondell, J., 1997. "Epidemiology of pesticide poisonings in the U.S., with special reference to
occupational cases." Occupational Medicine: State of the Art Reviews, Vol. 12.2. April-June.
Centers for Disease Control and Prevention (CDC), 1984. "Organophosphate insecticide
poisoning among siblings Mississippi." MMWR. 33:592.
Centers for Disease Control and Prevention, 1999a. "Aldicarb as a cause of food poisoning
Louisiana, 1998." MMWR. 48:269-271.
Centers for Disease Control and Prevention, 1999b. "Surveillance for pesticide-related illness
during the Medfly Eradication Program in Florida, 1998." MMWR. 48:1015-1018,1027.
Chafee-Bahamon, C., D.L. Caplan, and F.H. Lovejoy, 1983. "Patterns in hospital's use of a
regional Poison Information Center "American Journal of Public Health, 73:396-400.
Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment,
1999. Organophosphates. Department of Health, United Kingdom. Crown Copyright: London.
Davis, D.L., H.L. Bradlow , M. Wolff, et al., 1993. "Medical hypothesis: Xenoestrogens as
preventable causes of breast cancer." Environmental Health Perspectives, 101:372-377.
DRAFT
101
-------
Environews, 1997. "Methyl Parathion Comes Inside." Environmental Health Perspectives,
106(7), July.
Eubanks, M.W., 1997. "Hormones and health." Environmental Health Perspectives, 105:482-487.
Harchelroad, F., R.F. Clark, B. Dean, and E.P. Krenzelok, 1990. "Treated vs. reported toxic
exposures: Discrepancies between a Poison Control Center and a member hospital." Veterinary
and Human Toxicology, 32:156-159.
Hoar, S.K., et al., 1986. "Agricultural herbicide use and risk of lymphoma and soft tissue
sarcoma." JAMA, 256:1141-47.
Institute of Medicine, 1988. Role of the Primary Care Physician in Occupational and
Environmental Medicine, IOM Report, Division of Health Promotion and Disease Prevention,
National Academy Press, Washington, D.C.
Keifer, M.C. and R.K. Mahurin, 1997. "Chronic neurologic effects of pesticide overexposure."
Occupational Medicine: State of the Art Reviews, 12(2):291 -304.
Levy, B.S., 1985. "The teaching of occupational health in US medical schools: Five-year follow-
up of an initial survey"American Journal of Public Health, 75:79-80.
Litovitz, T.L., M. Smilkstein, L. Felberg, et al., 1997. "1996 Annual Report of the American
Association of Poison Control Centers Toxic Exposure Surveillance System!'American Journal
of Emergency Medicine, 15:447-500.
McCaig, L.F. and C.W. Burt, 1999. "Poisoning-related visits to emergency departments in the
United States, 1993-1996." Clinical Toxicology, 37:817-826.
McCaig, L.F., 2000. National Center for Health Statistics. Personal communication to Jerome
Blondell, Feb. 7.
National Center for Environment Health (NCEH), 1996. "NCEH Activities during Lorain County
Methyl Parathion Decontamination Project." Centers for Disease Control and Prevention.
Peters, H.A., W.A. Croft, E.A. Woolson, et al., 1983. "Arsenic, chromium, and copper
poisoning from burning treated wood" (Letter to the Editor). New England Journal of
Medicine, 308:1360-1361.
102
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Pope, A.M. and D.P. Rail, eds., 1995. Environmental Medicine: Integrating a Missing Element
into Medical Education. Committee on Curriculum Development in Environmental Medicine,
Institute of Medicine, National Academy Press, Washington, DC.
Pope, A.M., M.A. Snyder, and L.H. Mood, eds., 1995. Nursing, Health, and the Environment.
Committee on Enhancing Environmental Health Content in Practice, Institute of Medicine,
National Academy Press, Washington, D.C.
Prochaska, J.O., J.C. Norcross, and C.C. DiClemente, 1995. Changing for Good: The
Revolutionary Program That Explains the Six Stages of Change and Teaches You How to Free
Yourself from Bad Habits. Avon Books (pb).
Reigart, J.R. and J.R. Roberts, 1999. Recognition and Management of Pesticide Poisonings, fifth
edition. EPA#735-R-98-003, Washington, DC.
Robinson, J.C., W.S. Pease, D.S. Albright, and R.A. Morello-Frosch, 1994. Pesticides in the
Home and Community: Health Risks and Policy Alternatives. CPS Report, California Policy
Seminar, Berkeley, CA.
Rosenstock, L., M. Keifer, W.E. Daniell, et al., 1991. "Chronic central nervous system effects of
acute organophosphate pesticide intoxication." Lancet, 338:223-227.
Savage, E.P., T.J. Keefe, L.M. Mounce, et al., 1988. "Chronic neurological sequelae of acute
organophosphate pesticide poisoning." Archives of Environmental Health, 43:38-45.
Schenk, M., S.M. Popp, A.V. Neale, and R.Y. Demers, 1996. "Environmental medicine content
in medical school curricula." Academic Medicine, Vol. 71, No. 5, May.
Schnitzer, P.G. and J. Shannon, 1999. "Development of a surveillance program for occupational
pesticide poisoning: Lessons learned and future directions." Public Health Report, May-Jun;
114(3):242-8.
Sever, L.E., T.E. Arbuckle, and A. Sweeney, 1997. "Reproductive and developmental effects of
occupational pesticide exposure: The epidemiologic evidence." Occupational Medicine: State
of the Art Reviews, 12(2):305-325.
Slovic, P., B. Fischhoff, and S. Lichtenstein, 1980. "Facts and fears: Understanding perceived
risk." In: Schwing, R.C. and W.A. Albers, Jr. eds., Societal Risk Assessment: How Safe is Safe
Enough? New York, Plenum Press.
DRAFT
103
-------
Steenland, K., B. Jenkins, R.G. Ames, et al., 1994. "Chronic neurological sequelae to
organophosphate pesticide poisoning." American Journal of Public Health, 84:731-36.
Stephens, R., A. Spurgeon, LA. Calvert, et al., 1995. "Neuropsychological effects of long-term
exposure to organophosphates in sheep dip." Lancet, 345:1135-1139.
U.S. EPA, 1998a. Office of Pesticide Programs Annual Report for FY 1997. Office of Prevention,
Pesticides, and Toxic Substances, EPA #735-R-97-003, January.
U.S. EPA, 1998b. Pesticides and National Strategies for Health Care Providers; Workshop
Proceedings. Office of Prevention, Pesticides, and Toxic Substances, EPA #735-R-98-001, July.
U.S. EPA, 1999. Pesticides Industry Sales and Usage: 1996 and 1997 Market Estimates. Office of
Prevention, Pesticides, and Toxic Substances, EPA #733-R-99-001, Washington, D.C.
U.S. General Accounting Office, 1993. Pesticides on Farms: Limited capability exists to monitor
occupational illnesses and injuries. (GAO/PEMB-94-6) Washington, D.C., December.
Veltri, J.C., N.E. McElwee, and M.C. Schumacher, 1987. "Interpretation and uses of data
collected in Poison Control Centers in the United States." Medical Toxicology, 2:389-397.
Whitmore, R.W., J.E. Kelly, and P.L. Reading, 1992. National Home and Garden Pesticide
Survey: Final Report, Volume 1, 1992. Research Triangle Institute NC: RTI\5100.121F,
Research Triangle Park, NC.
Whorton et al., 1979. "Testicular function in DBCP exposed workers." Journal of Occupational
Medicine, 21:161-166.
Wigle, D.T., R.M. Semenciw, K. Wilkins, et al., 1990. "Mortality study of Canadian male farm
operators: Non-Hodgkin's lymphoma mortality and agricultural practices in Saskatchewan."
Journal of National Cancer Institute, 82:575-82.
Zahm, S.H., D.D. Weisenburger, P. Babbitt, et al, 1990. "A case-control study of non-Hodgkin's
lymphoma and the herbicide 2,4-dichlorophenoxyacetic acid (2,4-D) in eastern Nebraska."
Epidemiology, 1:349-356.
Zahm, S.H., M.H. Ward, and A. Blair, 1997. "Pesticides and Cancer." Occupational Medicine:
State of the Art Reviews, 12(2):269-289.
Zweiner, R.J. and C.M. Ginsburg, 1988. "Organophosphate and carbamate poisoning in infants
and children." Pediatrics, 81:121-6.
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Glossary
AAP
American Academy of Pediatrics
AACN
American Association of Colleges of Nursing
AAFP
American Academy of Family Physicians
AAMC
Association of American Medical Colleges
ACNM
American College of Nurse Midwives
AAOHN
American Association of Occupational Health Nurses
ACOEM
American College of Occupational and Environmental Medicine
AMA
American Medical Assocation
ANA
American Nurses Association
APN
Advanced Practice Nurse
ATSDR
Agency for Toxic Substances and Disease Registry
CDC
Centers for Disease Control and Prevention
CE
Continuing education
CME
Continuing medical education
CNS
Clinical nurse specialist
E&M
Evaluation and Management
EPA
Environmental Protection Agency
FNP
Family Nurse Practitioner
GNP
General Nurse Practitioner
HHS
Department of Health and Human Services
HRSA
Health Resources and Services Administration
NEETF
The National Environmental Education & Training Foundation
NIEHS
National Institute for Environmental Health Sciences
NIH
National Institutes of Health
NIOSH
National Institute for Occupational Safety and Health
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NLN National League of Nursing
NPTN National Pesticides Telecommunications Network
OSHA Occupational Safety and Health Administration
PNP Pediatric Nurse Practitioner
RFA Request for Applications
RFP Request for Proposals
USDA U.S. Department of Agriculture
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Appendix A:
Fxpert Panel Proceedings
To launch the Pesticides and National Strategies for Health Care Providers initiative, EPA
and several other federal agencies convened an expert forum to begin the process of
developing national strategies that will improve the education and awareness of health
care providers in dealing with pesticide-related health concerns. The workshop, held on April 23-
24,1998 in Arlington, VA, was sponsored by EPA in collaboration with the Department of Health
and Human Services, Department of Agriculture, and Department of Labor. The Association of
Teachers of Preventive Medicine and The National Environmental Education and Training
Foundation worked with these federal agencies to organize the event. (See U.S. EPA, 1998b. J
The expert forum was conceived of as a deliberative session of representatives of 16 health
organizations, open to the public, and with comments and questions from federal agencies
and outside observers. The panel included representatives from: American Academy of Family
Physicians, American Academy of Pediatrics, American Academy of Physician Assistants,
American Association of Colleges of Nursing, American Association of Poison Control Centers,
American College of Emergency Physicians, American College of Occupational and
Environmental Medicine, American Nurses Association, Council of State and Territorial
Epidemiologists, Migrant Clinicians Network, National Center for Farmworker Health,
National Organization of Nurse Practitioner Faculties, National Pesticide Telecommunications
Network, National Rural Health Association, Pennsylvania State University/National
Agromedicine Consortium, and Suncoast Community Health Centers.
Concerns About Provider Education and Training
The panel agreed that the primary focus of this initiative should be on primary care providers.
The panel found that primary care providers are not sufficiently trained at any stage of
their education about pesticide exposure. The panel also recognized that the lack of training
is larger than just pesticides and reflects a serious deficiency in education on environmental
and occupational health. The panel briefly summarized the main concerns in provider
knowledge about pesticide exposures:
¦ Pesticide exposures are often underreported.
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¦ Providers often do not know how and where to report pesticide exposures; sometimes the
reporting is considered burdensome given their demanding work environments.
¦ Health conditions associated with pesticide exposures are often misdiagnosed.
¦ Providers do not often see acute pesticide poisoning, and they do not possess enough
knowledge to recognize chronic cases.
¦ Providers have not received training on pesticide exposures during their years of formal education.
¦ Pesticide exposures and associated health conditions are difficult topics to teach because
they require additional knowledge on toxicology and other topics which are often not
included in the curriculum of health professional education.
Expected Outcomes for Primary Care Providers
The panel discussed at length what should be expected of primary care providers. Agreement
was reached that all primary care providers should:
¦ Be knowledgeable about pesticides and recognize pesticide exposures as a health concern.
¦ Be able to diagnose and treat pesticide exposures at the earliest possible time and complete
the appropriate follow-up and referral (exposure management).
¦ Take preventive measures in both the clinical and community settings, including
anticipatory guidance and community education (prevention management).
¦ Report exposures and health outcomes of either patients or communities.
¦ Access the appropriate resources/specialists (local, regional, and national).
Expert Panel's Overarching Strategies
The expert panel generated specific strategies that were consolidated into four general topic areas:
1. Define and recommend basic environmental health (emphasizing pesticides) competencies
for primary care providers.
2. Develop a set of education and training strategies for students and primary care providers
on the subject of pesticide-related health concerns.
3. Raise the awareness of primary care providers on pesticide issues and risk factors through
professional meetings, informational mailings by professional associations, and journal articles.
4. Centralize information resources for primary care providers and strengthen their linkage
to existing resources.
The panel recommended that three workgroups be created to develop strategies on education,
practices, and resources.
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Expert Panel Membership
Joni Berardino, MS, LSW
National Center for Farmworker Health
Candace M. Burns, PhD, ARNP
National Organization of Nurse Practitioner Faculties, and
University of South Florida College of Nursing
Joe Fedoruk, MD, DABT, CIH
American College of Occupational and Environmental Medicine
J. Ward Donovan, Jr., MD, FACEP
American College of Emergency Physicians, and
Pennsylvania University Poison Center, Milton S. Hershey Medical Center
Rugh Henderson, MD, MPH
North American Agromedicine Consortium,
Pennsylvania Agromedicine Program, and Penn State University College of Medicine
Michael Hodgman, MD
National Rural Health Association, and
Bassett Healthcare/NY Center for Agricultural Medicine and Health
Andrea R. Lindell, DNSc, RN
American Association of Colleges of Nursing, and
University of Cincinnati College of Nursing
Mary Miller, MN, ARNP
American Nurses Association, and
Washington State Department of Labor and Industries
Karen Mountain, MBA, MSN, RN
Migrant Clinicians Network
Dennis Penzell, DO, FACP
Suncoast Community Health Centers, Inc.
George C. Rodgers, Jr., MD, PhD
American Association of Poison Control Centers, and
University of Louisville School of Medicine
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Jackilen Shannon, PhD
Council of State and Territorial Epidemiologists, and
Texas Department of Health
Elisabeth Spector, MD, MPH
American Academy of Family Physicians
Roger F. Suchyta, MD
American Academy of Pediatrics
Greg P. Thomas, PA-C
American Academy of Physician Assistants
Sheldon Wagner, MD
National Pesticide Telecommunications Network, and
Oregon State University
Speakers and Facilitator
Wilson Augustave
Finger Lakes Migrant Health Care Project
Louise M. Rauckhorst, EdD, MSN
Philip Y. Hahn School of Nursing, University of San Diego
Mark G. Robson, PhD, MPH
Environmental and Occupational Health Sciences Institute, and
Rutgers University
Susan T. West, MPH, Facilitator
The National Environmental Education and Training Foundation, Inc.
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Appendix B: Summary
Proceedings frnm Wnrkgroups
This appendix provides a brief summary of the deliberations of the three workgroups
created under this initiative and a list of their members. The strategies and plans that
emerged from the workgroup meetings are the subject of this Implementation Plan.
The workgroups discussed competencies and expected outcomes, and devoted some time to
brainstorming sessions on overall strategies and plans of action. Members held small group
discussions for the better part of the second day of each meeting, to flesh out the strategies
and action items. The groups then reviewed the strategies and decided on next steps. Both
short-term (1-3 year timeframe) and longer-term actions (3-5 years) were identified. The
meetings were facilitated by Susan West of The National Environmental Education and Training
Foundation (NEETF).
The Education Workgroup was charged with developing a national strategic plan to enable
undergraduate and graduate formal education and training institutions to prepare primary
care providers to prevent, diagnose, treat, and refer patients exposed to pesticides. The
workgroup was expected to set (and/or select already established) competencies for the
educational setting, and to identify strategies on how to achieve those competencies through
education, training, and raising student awareness.
The Practice Workgroup was charged with developing a national strategic plan for improving
the practice of primary care providers in preventing, diagnosing, treating, and referring patients
exposed to pesticides. This group, too, was expected to set (and/or select already established)
competencies for the practice setting and to identify strategies on how to achieve those
competencies through education, training, and raising awareness.
The Resources Workgroup was charged with developing a national strategic plan which
addresses an effective method of linking, centralizing, and/or disseminating an array of
resources for the prevention, diagnosis, treatment, and referral of patients exposed to pesticides.
This plan would also evaluate existing assessments of resources, identify gaps, and begin to
develop needed resources for health care providers.
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Key Principles
Key principles and findings emerging from the three 1999 workgroups include:
¦ Pesticides must be seen in the context of environmental and occupational health.
All three workgroups expressed the opinion that pesticides are a useful and important
focus of attention in themselves; however, pesticides must also be seen as a stepping-
stone for the underrecognized and broader issue of environmental and occupational
health as a whole.
¦ Gaining attention and raising awareness are the primary challenges. One of the most
difficult obstacles is simply gaining the attention of students, faculty, and primary care
providers to the issue of pesticides and/or environmental health. Curricula are crowded,
providers are busy, and time is at a premium. Nevertheless, sometimes a single case
encounter can have long-lasting effects. Much of the effort of the workgroups was driven
by the need to gain attention and raise awareness. Strategies include developing case
statements, creating monetary and professional incentives, nurturing pesticide/
environmental health "champions" and model practices and convening focus groups to
better understand providers' communication styles.
¦ Environmental histories are gateways. Few primary care providers ask patients the
questions that would be likely to alert them to the possibility of a pesticide-related
illness. Although it is important for primary care providers to take environmental
histories, both workgroups recognized that a full environmental history can sometimes
take up the entire patient visit. However, getting primary care providers to ask just a
few simple questions such as 'Where do you work?' and 'Do you think your problems
are related to something that happened at work or at home?' could go a long way
toward uncovering pesticide-related health conditions and raising awareness about the
environment in which patients live.
¦ There is a spectrum of pesticide-related health conditions. Stereotypes of pesticide
illness insecticides, farmworkers, acute poisoning, cholinesterase testing may cover
an important segment of the population, but they by no means cover the entire field.
Students, faculty, and primary care providers must come to understand the wide
spectrum of pesticide-related health concerns: low-dose chronic effects as well as acute,
high-dose poisonings; effects on children, people with chemical sensitivities, other
vulnerable populations; the wide variety of pesticide products on the market; urban,
rural, and suburban settings.
¦ The need is for credible, convenient, and easy-to-use resources. The best way to reach
already overburdened primary care providers is by ensuring that the resources available
to them on pesticide-related illnesses are scientifically credible, easy to access, and provide
quick answers to providers' questions.
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¦ The importance of understanding the audience cannot be overstated. Primary care
providers work in a wide variety of settings and have varying levels of exposure to pesticide-
related health issues. Understanding primary care providers their backgrounds, level of
awareness and knowledge about pesticide issues, and preferred modes of receiving
information is essential to effectively targeting and reaching the audience for this initiative.
¦ Evaluation plays a key role. There is a strong need for expert evaluation of the resources
currently available to primary care providers on pesticide topics and for ensuring that
new materials developed through this initiative meet stringent evaluation criteria.
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Education Workgroup
One of the key issues that workgroup members grappled with over the course of the
meeting is the need to gain the attention of health care students, faculty, and primary
care providers despite the fact that their time and attention are in high demand
elsewhere. Many members noted that there is little time in the basic undergraduate curriculum
for pesticide and environmental health material. It would be unreasonable to expect more
than a total of 30-40 hours over the course of a four-year degree program; a more modest rise
to just 10 hours of instruction would stand a better chance of acceptance. The key is to get the
education setting both interested in and comfortable with pesticide issues.
Making the Case
Workgroup members agreed on the need to "make the case" to medical and nursing schools
about the importance of environmental health education and
the breadth of the problem of pesticide-related health concerns.
Even the most supportive faculty challenge why environmental
health is important to teach.
Workgroup members spent considerable time discussing how to
spark the interest of faculty and students. One workgroup member
noted that environmental poisonings are seldom encountered by
medical school students. The best way he has found to motivate
medical students is to have them accompany primary care physicians
in rural area practices so that they can experience the scope of
occupational medicine first-hand. The payoff is that students value
this practical type of learning enormously, and that it has a greater
impact than hearing lecture after lecture on the same topic. It also
combats one of the problems of the practice setting, which is that
primary care providers often do not perceive the agricultural environment as a workplace.
"Make it Easy for Them to Let Us In..."
How will educational institutions allow material on pesticides/environmental health into their
curriculum, and how can the materials be designed to "make it easy for them to let us in?" It
is important to identify where in the curriculum the materials should be inserted. Usually the
schools have a flow of courses/topics and the group could suggest where a given topic in
environmental health would fit. The aim of this initiative is not to overwhelm medical and
nursing students with a vast amount of information. Developing some tools along the lines of
the successful "10 Steps to Identify Cancer" would be a useful approach.
I have been challenged by some
of the most supportive faculty
who say, "You haven't made a
strong enough case." We
haven't effectively made the
case to incorporate
environmental health in
general... Until we do that, we'll
always be an afterthought.
Madaleine Ochinang, MS
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"Teachers Don't Teach What They Don't Know..."
It was noted that "Teachers don't teach what they don't know... If you make it relevant to them,
they'll find a way to teach their students." Several workgroup members raised the issue that many
faculty are not comfortable teaching the Ml range of subjects involved in pesticides. For example,
pharmacology professors may lack the clinical expertise to teach about pesticides; other medical
faculty may lack the toxicology background. Others agreed that it might be difficult to find enough
faculty with competence in pesticides/environmental health (environmental health). Workgroup
members discussed at some length whether faculty should be trained to become comfortable
with, or expert at, teaching pesticides/environmental health subjects, or whether it is sufficient for
faculty to know of experts in their local area whom they can tap as needed.
Merely making materials available is not sufficient it is not true that "if you build it, they will
use it." The situations where new material has worked best in medical schools is where there was
an advocate or champion who pushed until the material was included in the curriculum. A
study at the Worcester School of Nursing reported that the number one barrier to integrating
environmental health into nursing curricula which the deans of nursing schools supported
was the absence of faculty with the knowledge and confidence to carry out that integration.
Several models were discussed, including the 26 NIEHS five-year grants for mid-career funding
of environmental health positions, which provided half of the faculty's salary plus evaluation
components, and the 1990-95 faculty development grant program at the University of South
Florida that supported curriculum development and research in substance abuse. Faculty
spent the first two of the five years in becoming experts in their chosen areas through
seminars, courses, networking with other experts, etc.
Workgroup members discussed the "fragile toehold" that environmental health courses
currently have in health care education. There is no additional funding for teaching pesticides/
environmental health courses and environmental health is not a "revenue-generator." This
may have particularly problematic implications for undergraduate education. Increasingly,
faculty members need to generate funding to support their own salaries. "Contextual realities"
are important. Of the 126 environmental health science centers around the country, possibly
20 are on the verge of disappearing. The workgroup discussed the possibility of developing
fellowships around pesticides in specialties that are highly valued within medical schools,
since pesticides affect multiple systems in the body. This would require the time of in-house
faculty to incorporate existing resources and information into an institution's curriculum.
Convincing the Examination Boards
One way to motivate change in curriculum, workgroup members agreed, is to convince the
medical and nursing examination boards of the importance of environmental health in the
coming years, and push them to incorporate environmental health questions on their exams.
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This would also be one of the better ways to institutionalize the subject matter over the long
term. Workgroup members felt that some of the boards would be receptive to a concerted
effort in this area. For example, the Residency Review Committee for Pediatrics in 1996 adopted
two recommendations on children's environmental health.
The workgroup discussed whether public education and K-12 education should also be dealt
with as part of this initiative. The group noted efforts on environmental education becoming
incorporated into K-12 education, partly through the support of EPA and the National Institute
of Environmental Health and Sciences. But while many K-12 schools are teaching ecological
effects, there is relatively little being taught about the human health effects of the environment.
This is a ripe opportunity, and one which would have advantages down the line, with students
entering medical school already having an awareness of pesticides/environmental health issues.
Despite the importance of raising awareness and education in the larger educational sphere,
however, the workgroup decided that it fell outside the scope of this initiative, which focuses
on educating primary care providers. The group recommended that the issue be addressed in
other ongoing initiatives.
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Education Workgroup Membership
Co-Chairs
Andrea Lindell, DNSc, RN
American Association of Colleges of Nursing, and
University of Cincinnati, College of Nursing
Ameesha Mehta, MPH
Office of Pesticide Programs
U.S. Environmental Protection Agency
Facilitator
Susan West, MPH
The National Environmental Education and Training Foundation, Inc.
Members
Amy Brown, PhD
American Association of Pesticide Safety Educators, and
University of Maryland-College Park
Candace Burns, PhD, ARNP
National Organization of Nurse Practitioner Faculties, and
University of South Florida
Joan Spyker Cranmer, PhD
University of Arkansas Medical School
Miriam Cruz
Equity Research
Kesner Flores, EMT
Cortina Indian Rancheria, Wintum Environmental Protection Agency
Jose Garcia
Equity Research
Rugh Henderson, MD, MPH
North American Agromedicine Consortium,
Pennsylvania Agromedicine Program, and Penn State University College of Medicine
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Matthew Keifer, MD, MPH
NIOSH Agricultural Health and Safety Centers, and
University of Washington
John McCarthy, PhD
American Crop Protection Association
Claudia Miller, MD
University of Texas Health Science Center-San Antonio
Madaleine Ochinang, MS
Formerly with the Consortium for Environmental Education in Medicine
Marcia Allen Owens, JD
Minority Health Professions Foundation
Annette Perez, RNC, MSN, CNM, PhD
American College of Nurse Midwives, and
University of Texas-El Paso, College of Health Sciences
J. Routt Reigart, MD
Medical University of South Carolina, Department of Pediatrics
Elaine R. Rubin, PhD
Association of Academic Health Centers
Barbara Sattler, RN, DrPH
University of Maryland, School of Nursing
Leonel Vela, MD
Migrant Health Advisory Council, and
Texas Tech Health Sciences Center
Federal Agency Representatives
Elizabeth Blackburn, RN
Office of Children's Health Protection, U.S. EPA
Jerome Blondell, MPH, PhD
Office of Pesticide Programs, U.S. EPA
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Barbara Brookmyer, MD, MPH
Bureau of Health Professions, Division of Medicine
Health Resources and Services Administration
Ruth Kahn, DNSc
Bureau of Health Professions, Division of Medicine
Health Resources and Services Administration
Dalton Paxman, PhD
Office of Disease Prevention and Health Promotion,
U.S. Department of Health and Human Services
Rosemary Sokas, MD, MOH
National Institute of Occupational Safety and Health
Delta Valente, MPA
Office Pesticide Programs, U.S. EPA
Joan Weiss, PhD, RN, CRNP
Bureau of Health Professions, Division of Nursing
Health Resources and Services Administration
Peter Wood
Agricultural Marketing Service, U.S. Department of Agriculture
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Practice Workgroup
Like the Education Workgroup, the Practice Workgroup spent a great deal of time
discussing how to motivate change. Recognizing that primary care providers are busy
and confront a myriad of public health issues and illnesses, what is the best way to gain
their attention to ensure that they ask the right questions?
One answer is that what providers see in their practice is what they remember. If primary care
providers do not see enough acute cases of pesticide-related illness, they will not consider it
important enough to pay attention. However, this is a classic Catch-22 situation, because if
providers aren't aware of pesticide poisoning, they won't recognize the cases. The lack of data
in this area makes it hard to convince primary care providers that they need to alter their
practices. One way for primary care providers to be sensitized to the possibility of pesticide
poisoning is to become knowledgeable about the local community.
What Should Primary Care Providers Know?
Workgroup members noted that we need to keep our demands on physicians limited;
primary care providers shouldn't be expected to be
toxicologists. Instead, it is often patients who are directing
physicians to focus more on pesticides and environmental
health by the questions they bring up. Some workgroup
members felt that it would be enough to have primary care
providers be aware of the possibility of pesticide-related health
conditions, know what questions to ask, and know where to
go to get additional help. Others argued that minimum
competencies, or practice changes, are needed. For example, a
primary care provider shouldn't let a patient walk out of the
office without ascertaining the possibility of exposure. The
provider shouldn't just ask when a patient last vomited, but
ask if the vomiting coincided temporally with something that
happened at work. Knowing when to do a cholinesterase testing
is extremely important for all primary care providers. Such
testing, for example, is essential to establish that a person has
been harmed for purposes of workers' compensation, so that medical bills are reimbursed.
Two workgroup members pointed out that getting health care providers to ask a few simple
questions would go a long way toward raising awareness of patients' environmental health
issues, without requiring these providers to do additional legwork in the community. Two
How do you know that what
you're seeing is not the flu, it's
really organophosphate
exposure? If you think it's the
flu and you never ask any of
the questions, this guy is going
to walk out of your office and
you're still going to think it's
the flu.
- Shelley Davis
Farmworker Justice Fund, Inc.
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simple questions might be: (1) Where do you work? and (2) Do you think your problems are
related to something that happened at work?
The workgroup devoted an extensive amount of time to the discussion of competencies for
primary care providers. (See Practice Component B on page 66 for more details.) Many
workgroup members thought that although "competencies" was an appropriate term for an
educational setting, in a practice setting the term implied that primary care providers are
incompetent if they don't remember all of the material. They preferred to use terms such as
"knowledge and skill outcomes," "expected practice skills," or "content."
A Two-Track System?
One important aspect of the question of "what providers should know" is whether primary
care providers in certain communities should know more than providers in other areas. For
example, should there be different levels of knowledge and skills for primary care providers in
agricultural areas compared to providers in urban or suburban settings?
While the issue was not resolved, the consensus appeared to be that all primary care
providers should have a certain minimum content level of knowledge and skill related to
pesticides/environmental health. On the other hand, it may be that primary care providers
in agricultural communities have an added function, going beyond the minimum in
recognition, diagnosis, and management pesticide-related illness to a larger role in
prevention and education, and advising their patients about such things as heat stress,
prenatal care, pesticides, etc.
Making Change Happen
How does change actually happen? Workgroup members discussed the difficulties in bringing
about changes in health care. The literature on continuing education shows the need for a
multifaceted approach. Continuing education alone has little impact without additional visits
to clinics, feedback loops, hands-on workshops, etc. Even on grand rounds, occupational and
environmental medicine subjects get very poor turnout.
Other Issues
Workgroup members stressed the need for research in a number of areas, including research
on human exposure, biomonitoring, and the extent to which pesticide poisonings are currently
being misdiagnosed in primary care practices.
It is important to look at interconnections between the clinical setting, community setting,
reporting, and the regulatory context, even though primary care providers may not see these
interconnections. For example, it is not clear that primary care providers realize the importance
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of their role in reporting cases of pesticide illness both for regulating harmful pesticides and
for efforts to make safer pesticides. Upon investigation, some incidents may turn out to have
been a violation of the label restrictions; but in some cases, pesticide poisoning occurs with
no apparent label violation. That information is extremely important, even if it cannot be
proven conclusively.
Another connection that does not generally work well is with worker compensation systems.
Even in Washington State, which is often pointed to as the model for an integrated reporting/
surveillance/worker compensation system (see box on page 82), the system is based on "objective
findings." Most pesticide illnesses yield signs and symptoms rather than objective findings, so
patient claims may be denied. Primary care providers need help understanding what the medical
rules of evidence are so that patient claims won't be rejected. One model might be Colorado's
system of associating occupational categories with subjective symptoms (e.g., carpal tunnel);
something similar could be done for pesticides. Physicians also need to know how to write up
their findings, about statutes of limitations for repeat injuries, and where to go for help. Finally,
states need to reimburse for relevant diagnostic testing for pesticide illness. At present, only
Washington State reimburses for diagnostic evaluations.
Defining worker compensation requirements related to pesticide illnesses would attract the
attention of medical associations and their members; physicians would know that they could
get paid for this category of health concern. In the California worker compensation system,
physicians don't get paid if they don't report; such an incentive would likely encourage reporting
if it were used more widely. Despite the anticipated difficulties of affecting worker
compensation systems, workgroup members agreed on the importance of tackling them. Half
a dozen states are the sole insurers on worker compensation and in those states, the state
commission would be the only organization to deal with. It was also pointed out that six
states California, Texas, Florida, Oregon, Washington, and North Carolina probably
cover 70 percent of agricultural workers, and might be the natural focus of attention for this
type of effort.
Workgroup members agreed that community health workers are an important part of the health
care team. Caseworkers and community health workers are needed to go out and work with
vulnerable populations. They can be particularly important in conducting follow up with migrant
workers and bringing them back into the health care system. The workgroup raised, but did not
reach a consensus on, whether to widen the scope of the initiative to involve the family, the role
of the physician in the workplace, or the role of health professionals in the community.
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Practice Workgroup Membership
Co-Chairs
Bonnie Rogers, RN, DrPH, COHN-S, FAAN
American Association of Occupational Health Nurses and
University of North Carolina-Chapel Hill, School of Public Health
Karen Pane, RN, MPA, CMCN
Health Resources and Services Administration
U.S. Department of Health and Human Services
Facilitator
Susan West, MPH
The National Environmental Education and Training Foundation, Inc.
Members
Sheila Brown Arbury, RN, MPH
Association of Occupational and Environmental Clinics
Shelley Davis
Farmworker Justice Fund, Inc.
J. Ward Donovan, MD, FACEP
American College of Emergency Physicians,
Pennsylvania University Poison Center, and Milton S. Hershey Medical Center
Harold Harlan, PhD
National Pest Control Association
Barbara Hatcher, PhD, MPH, RN
American Public Health Association
Ann Linden, CNM, MSN, MPH
American College of Nurse Midwives
Mark Miller, MD
American Academy of Pediatrics
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Mary Miller, MN, ARNP
American Nurses Association, and
Washington State Department of Labor and Industries
Karen Mountain, MBA, MSN, RN
Migrant Clinicians Network
Diane Mull
Association of Farmworker Opportunity Programs
Patrick O'Connor-Marer, PhD
American Association of Pesticide Safety Educators,
University of California Statewide IPM Project, and
University of California Agricultural Health and Safety Center
John Pickle, RS, MSEH
Weld County Health Department - Greeley, CO
George C. Rodgers, Jr., MD, PhD
American Association of Poison Control Centers, and
University of Louisville School of Medicine
Rachel Rosales, MSHP
Texas Department of Health
Cathy Simpson, MD
Wayne State University, School of Medicine
Gina Solomon, MD, MPH
Natural Resources Defense Council
Sheldon Wagner, MD
National Pesticide Medical Monitoring Program, and
Oregon State University
John Wheat, MD, MPH
North American Agromedicine Consortium, and
University of Alabama at Birmingham, School of Medicine
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Federal Agency Representatives
Barbara Brookmyer, MD, MPH
Bureau of Health Professions, Division of Medicine
Health Resources and Services Administration
Frank Davido
Office of Pesticide Programs, U.S. EPA
Eva Montoya, MSN, RN
Bureau of Primary Health Care, Migrant Health Program,
Health Resources and Services Administration
Ana Maria Osorio, MD, MPH
Office of Pesticide Programs, U.S. EPA
Ana Marie Puente
Bureau of Primary Health Care, Border Health,
Health Resources and Services Administration
Capt. Barry Stern, MPH
Bureau of Health Professions, Health Resources and Services Administration
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Resources Workgroup
Building on the ideas of the Education and Practice Workgroups, the Resources
Workgroup began its discussion by examining the types of resources that are used in
educational and practice settings. The workgroup then undertook a more detailed
exploration of key issues relating to resources, including: the credibility of sources of
information, defining and understanding the audience, reaching the target audience with
appropriate resources, and evaluating the effectiveness of resources.
Information
felt strongly that resources created or promoted through this
initiative must be credible and scientifically sound. Credibility
must form the basis for the initiative's efforts. The group
explored the sources of information that health care providers
and the public currently use, and the credibility of different
information sources in different communities. One
workgroup member suggested that the public trusts the
universities first, the federal government next, state water
agencies after that, and state agriculture departments after
that. In many places, the community health worker plays a
key role. There are 78 different names for community health
workers in the U.S., and that although they are generally
considered "non-professional," they are the most trusted
health care workers and have the highest ability to change
behavior. Standards for community health workers are only
starting to be developed as community colleges get involved
in their training. Unfortunately, environmental health is not
generally taught as part of their training.
A related issue that the group considered is sensitivity to local concerns and parlance.
Reaching the Target Audience
The workgroup's discussions emphasized the importance of defining and understanding the
target audience of primary care providers. Aware that the universe of health care providers
runs into the millions, the group explored ways of segmenting the universe by type of
provider, population served, and practice setting, or by matching types of providers to
epidemiologic cases of pesticide use or abuse.
Credible Sources of
The Resources Workgroup
When I train residents I tell them:
you'll do a lot better if you don't
assume you're the primary
provider. The primary provider is
often the grandmother or an elder...
The natural system of health care in
the community is alive and well.
We need to recognize the system,
not try to change it, and partner
with it to be effective.
- Angelina Borbon, RN
Alameda County Lead Poisoning
Prevention Program
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The workgroup devoted considerable time to a discussion of the varying levels of needs of
primary health care providers. One workgroup member stated that "it is not clear that we
really know what health care providers want and need" in the way of educational and
information resources. It will be important to examine the extensive literature on how health
professionals learn in order to determine the most effective approaches.
The workgroup explored in detail the Stages of Change model created by Prochaska and
DiClemente (Prochaska, 1995). The model looks as behavior change as a process rather than
an event, and describes how individuals are at varying levels of motivation, or readiness to
change. The model outlines a continuum of behavior change that can be used to help
understand where the target audience is on the continuum, and to effectively reach the audience
(through targeted messages, strategies, and programs) to ensure behavior change. (See Table
3 on page 20 and discussion of how the model can be adapted to the current initiative.)
Workgroup members examined existing resources in an effort to determine "what works"
and identify gaps. Members reviewed the guide, "Preliminary Resources Materials," developed
by The National Environmental Education and Training Foundation and mentioned additional
materials. Workgroup members discussed all aspects of providing effective resources types
of resource materials, settings in which they are delivered, delivery mechanisms, modes of
dissemination, and motivation for use.
Professional associations could play a big role in reaching member providers. The group
discussed the types of technology that providers are most comfortable with, and acknowledged
that while health care providers lag behind in their use of the Internet, they will no doubt
increase their usage over time. Nevertheless, the Web can be a "giant disorganized mess of bad
data, good data, and it takes time to learn how to use it." Providers will continue to need
quick and easy ways of accessing the information they seek. Some members argued that
continuing medical education has been shown not to be an effective way to change behavior
and that consensus statements of professional associations can take a long time to develop
and to have an impact. It is important, however, to approach the target audiences and find out
where they obtain information.
Evaluating Results
Some type of measurement and evaluation effort is certainly needed for this initiative. Evaluation
and measurement are relevant for several purposesfor assessing the "baseline," i.e., the current
state of awareness and involvement of primary care providers, for evaluating the quality of
existing resources, for helping to design effective new resources and dissemination strategies,
and for determining the success of the initiative.
Workgroup members noted that a great deal of attention has been given to measuring the degree
to which educating health care providers on nutrition, tobacco, and other issues has led to
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measurable changes in practice as well as changes in patient practices. Even with tobacco, "the
whole world is trying to get physicians to counsel their patients who smoke to stop smoking."
Nevertheless, only 30-60 percent of physicians appear to do so, and measuring this activity has
been very difficult. The group agreed that qualitative research, including holding focus groups,
would be an appropriate tool for this initiative. It was suggested to begin with a summary of the
literature in this area. Several provider associations (clinics, pediatricians, family physicians,
etc.) represented on this workgroup could provide a source for focus group participants.
Other Issues
The role of the public in spurring health care providers' interest was duly noted. Increasingly,
patients are a big source driving the physicians' interest in pesticides: "Patients instigate by
asking a question that the physician or nurse can't answer." Although primary care providers
are often chiefly concerned with acute health effects, the public is increasingly leading the way in
terms of interest in chronic and behavioral effects of pesticides (e.g., asthma, effects on IQ, etc.).
Workgroup members also frequently returned to the larger context in which this initiative is
set. The group agreed that pesticides must continue to be seen in the context of environmental
health as a whole. The importance of making primary care providers aware of preventive
information along with diagnosis and treatment was continually stressed.
Finally, the group discussed support for the initiative. "There have been too many programs
in government that just go away... If you don't have the money at the time you need it, it fades
away." It is important that workgroup members go back to their organizations and discuss
how the organizations can play a supporting role in implementing the initiative. The workgroup
recommended that the federal representatives develop a broad outline of resource needs and
federal commitments, as well as remaining needs for which extramural funding will be sought
from industry, professional associations, and possibly environmental foundations and trusts.
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Resources Workgroup Membership
Co-Chairs
Mark Robson, PhD, MPH
Environmental and Occupational Health Sciences Institute, and
Rutgers University
Kevin Keaney, MA, MS
Office of Pesticide Programs, U.S. Environmental Protection Agency
Facilitator
Susan West, MPH
The National Environmental Education and Training Foundation, Inc.
Members
Colin Austin
Migrant Clinicians' Network, and
University of North Carolina-Chapel Hill
Angelina Borbon, RN
Alameda County Lead Poisoning Prevention Program
Barry Brennan, PhD
American Association of Pesticide Safety Educators, and
Extension Pesticide Coordinator, University of Hawaii
Paul J. Brownson, MD
The Dow Chemical Company
Gerardo de Cosio, MD
U.S.-Mexico Border Health Association
Susannah Donahue, MPH
Children's Environmental Health Network
Gerry Eijk^nmans, MD, MPH
Pan American Health Organization
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Scottie Ford, MA
West Virginia Department of Agriculture
Matthew Garabedian, MPH
Texas Department of Health
Allen James, MBA, CAE
Elizabeth Lawder, BA (alternate)
Responsible Industry for a Sound Environment
Linda Kanzleiter, M.Ps.Sc.
Celeste Stalk (alternate)
Pennsylvania Area Health Education Center, Milton S. Hershey Medical Center
Kathy Kirkland, MPH
Association of Occupational and Environmental Clinics
Terry Miller
National Pesticides Telecommunications Network, and
Oregon State University
Rita Monroy
National Alliance for Hispanic Health (formerly National
Coalition of Hispanic Health and Human Services Organizations)
Benjamin Ramirez, MD, MPH, FACOEM
DuPont Company
Scott Ratzan, MD, MPA
Academy of Educational Development
Susan Rehm, MBA
American Academy of Family Physicians
Barbara Sabol
W.K. Kellogg Foundation
Roger F. Suchyta, MD
Graham Newson (alternate)
Jennifer Stevens (alternate)
American Academy of Pediatrics
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Federal Agency Representatives
Elizabeth Blackburn, RN
Office of Children's Health Protection, U.S. EPA
Jerome Blondell, MPH, PhD
Office of Pesticide Programs, U.S. EPA
Frank Davido
Office of Pesticide Programs, U.S. EPA
Jeanne Goshorn, MS
National Library of Medicine
Ron Hoffer, MS
Office of Ground Water and Drinking Water, U.S. EPA
Ameesha Mehta, MPH
Office of Pesticide Programs, U.S. EPA
Donna Orti, MS
Agency for Toxic Substances and Disease Registry
U.S. Department of Health and Human Services
Karen Pane, RN, MPA, CMCN
Health Resources and Services Administration
U.S. Department of Health and Human Services
Dalton Paxman, PhD
Office of Disease Prevention and Health Promotion
U.S. Department of Health and Human Services
Sherri Umansky
Office of Ground Water and Drinking Water, U.S. EPA
Peter S. Wood
Agricultural Marketing Service, U.S. Department of Agriculture
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Appendix C: Federal
Interagency Planning Committee
U.S. Environmental Protection >
Kevin Keaney
Office of Pesticide Programs
U.S. EPA
1200 Pennsylvania Avenue NW (7506C)
Washington, DC 20460
Tel: (703) 305-5557 / Fax: (703) 308-2962
Email: keaney.kevin@epa.gov
Ana Maria Osorio, MD, MPH
Office of Pesticide Programs
U.S. EPA
1200 Pennsylvania Avenue NW (7506C)
Washington, DC 20460
Tel: (703) 305-7891 / Fax: (703)308-2962
Email: osorio.anamaria@epa.gov
Ameesha Mehta, MPH
Office of Pesticide Programs, U.S. EPA
1200 Pennsylvania Avenue NW (7506C)
Washington, DC 20460
Tel: (703) 305-6448 / Fax: (703) 308-2962
Email: mehta.ameesha@epa.gov
Delta Valente, MPA
Office of Pesticide Programs
U.S. EPA
1200 Pennsylvania Avenue NW (7506C)
Washington, DC 20460
Tel: (703) 305-7164/Fax: (703) 308-2962
Email: valente.delta@epa.gov
Jerome Blondell, PhD
Office of Pesticide Programs
U.S. EPA
1200 Pennsylvania Avenue NW (7509C)
Washington, DC 20460
Tel: (703) 305-5336 / Fax: (703) 305-5147
Email: blondell.jerry@epa.gov
Frank Davido
Office of Pesticide Programs
U.S. EPA
1200 Pennsylvania Avenue NW (7502C)
Washington, DC 20460
Tel: (703) 305-7576 / Fax: (703) 305-4646
Email: davido.frank@epa.gov
Diane Sheridan
Office of Pollution Prevention and Toxics
U.S. EPA
1200 Pennsylvania Avenue NW (7407)
Washington, DC 20460
Tel: (202) 260-3435 / Fax: (202) 260-2347
Email: sheridan.diane@epa.gov
Elizabeth Blackburn, RN
Office of Children's Health Protection
U.S. EPA
1200 Pennsylvania Avenue NW (1107)
Washington, DC 20460
Tel: (202) 260-7935 / Fax: (202) 260-4103
Email: blackburn.elizabeth@epa.gov
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Ron Hoffer
Office of Ground Water and Drinking Water
US. EPA
1200 Pennsylvania Avenue NW (4607)
Washington, DC 20460
Tel: (202) 260-7096 / Fax: (202) 260-3762
Email: hoffer.ron@epa.gov
Marjorie C. Jones
Office of Groundwater and Drinking Water
U.S. EPA
1200 Pennsylvania Avenue NW (4601)
Washington, DC 20460
Tel: (202) 260-4152 / Fax: (202) 260-4383
Email: jones.marjorie@epa.gov
Sherri Umansky
Office of Ground Water and Drinking Water
U.S. EPA
1200 Pennsylvania Avenue NW (4607)
Washington, DC 20460
Tel: (202) 260-0432 / Fax: (202)401-6135
Email: umansky.sherri@epa.gov
U.S. EPA Regional Liaisons
Jane Horton
Pesticides Section (4APT-PS)
U.S. EPA, Region 4
61 Forsyth St., SW
Atlanta, GA 30303
Tel: (404) 562-9012 I Fax: (404) 562-8972
Email: horton.jane@epa.gov
Don Baumgartner
Pesticides Section (DRT-8J)
U.S. EPA, Region 5
77 West Jackson Boulevard
Chicago, IL 60604-3590
Tel: (312) 886-7835
Fax: (312) 353-4788
Email: baumgartner.donald@epa.gov
Amy Mysz
U.S. EPA, Region 5
77 W. Jackson Blvd. (DT-8J)
Chicago, IL 60604
Tel: (312) 886-0224/Fax: (312) 353-4788
Email: mysz.amy@epa.gov
Allan Welch
Pesticides Section (AT-083)
U.S. EPA, Region 10
1200 Sixth Avenue
Seattle, WA 98101
Tel: (206) 553-1980/Fax: (206)553-8338
Email: welch.allan@epa.gov
U.S. Department of Health
and Human Services
Barry Stern, MPH
Bureau of Health Professions
Health Resources & Services Administration
5600 Fishers Lane (8C-09)
Rockville, MD 20857
Tel: (301) 443-6758/Fax: (301)443-0650
Email: bstern@hrsa.gov
Karen Pane, RN, MPA, CMCN
Office of Planning, Evaluation and Legislation
Health Resources & Services Administration
5600 Fishers Lane (14-36)
Rockville, MD 20857
Tel: (301) 443-1128/Fax: (301)443-9270
Email: kpane@hrsa.gov
Barbara Brookmyer, MD, MPH
Bureau of Health Professions,
Division of Medicine
Health Resources & Services Administration
5600 Fishers Lane (9A-27)
Rockville, MD 20857
Tel: (301) 443-1468 /Fax: (301)443-8890
Email: bbrookmyer@hrsa.gov
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Ruth Kahn, DNSc
Bureau of Health Professions,
Division of Medicine
Health Resources & Services Administration
5600 Fishers Lane (9A-27)
Rockville, MD 20857
Tel: (301) 443-6823 / Fax: (301) 443-8890
Email: rkahn@hrsa.gov
Madeleline Hess, PhD, RN
Bureau of Health Professions,
Division of Nursing
Health Resources & Services Administration
5600 Fishers Lane (9-35)
Rockville, MD 20857
Tel: (301) 443-6336 / Fax: (301) 443-8586
Email: mhess@hrsa.gov
Joan Weiss, PhD, RN, CRNP
Bureau of Health Professions,
Division of Nursing
Health Resources 8c Services Administration
5600 Fishers Lane (9-36)
Rockville, MD 20857
Tel: (301) 443-5486 / Fax: (301) 443-8586
Email: jweiss@hrsa.gov
David D. Hanny, PhD, MPH
Bureau of Health Professions
Division of Interdisciplinary,
Community-Based Programs
Health Resources & Services Administration
5600 Fishers Lane (9105)
Rockville, MD 20857
Tel: (301) 443-0024/Fax: (301)443-0162
Email: dhanny@hrsa.gov
Eva Montoya
Bureau of Primary Health Care,
Migrant Health Program
Health Resources 8i Services Administration
4350 East West Highway
Bethesda, MD 20814
Tel: (301) 594-4305 /Fax: (301) 594-4997
Email: emontoya@hrsa.gov
Cassandra Lyles
Office of Rural Health Policy
Health Resources & Services Administration
5600 Fishers Lane (9-05)
Rockville, MD 20857
Tel: (301)443-7321 /Fax: (301)443-2803
Email: slyles@hrsa.gov
Geoffrey Calvert, MD, MPH
National Institute of
Occupational Safety & Health
4676 Columbia Parkway, R-21
Cincinnati, OH 45226
Tel: (513) 841-4448 / Fax: (513) 841-4489
Email: jac6@cdc.gov
Rosemary Sokas, MD, MOH
National Institute of
Occupational Safety & Health
200 Independence Avenue SW, Room 715-H
Washington, DC 20201
Tel: (202) 401-0721 /Fax: (202)693-1647
Email: rrs8@cdc.gov
Dalton Paxman, PhD
Office of Disease Prevention
and Health Promotion
Department of Health and Human Services
200 Independence Avenue, SW, Room 738-G
Washington, DC 20201
Tel: (202) 205-5829 / Fax: (202) 205-9478
Email: dpaxman@osophs.dhhs.gov
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Donna Orti, MS
Agency for Toxic Substances & Disease Registry
Department of Health and Human Services
1600 Clifton Road (E-42)
Atlanta, GA 30333
Tel: (404) 639-6217/Fax: (404)639-6208
Email: dlol@cdc.gov
U.S. Department of Agriculture
Peter S. Wood
Pesticide Records Branch
USDA Agricultural Marketing Service
8700 Centreville Road, Suite 202
Manassas, VA 20110
Tel: (703) 330-7826 / Fax: (703) 330-6110
Email: peter.wood@usda.gov
Larry Olsen, PhD
USDA Cooperative State Research,
Education, and Extension Service
Interim National Program Leader PAT
1400 Independence Ave. SW
AG Mail Stop 2220
Washington, DC 20250
Tel: (202) 401-4201 /Fax: (202)401-4888
Email: lolsen@reeusda.gov
U.S. Department of Labor
Mike Hancock
Wage and Hour Division
U.S. Department of Labor
200 Constitution Ave. NW, Room S-3510
Washington, DC 20210
Tel: (202) 219-7605/Fax: (202)219-5122
Email: jtc@fenix2.dol-esa.gov
Other Organizations
Susan T. West, MPH
The National Environmental Education
8c Training Foundation
1707 H Street, NW, Suite 900
Washington, DC 20006
Tel: (202) 261-6473 / Fax: (202)261-6464
Email: west@neetf.org
Jennifer Bretsch, MS
The National Environmental Education
8c Training Foundation
1707 H Street, NW, Suite 900
Washington, DC 20006
Tel: (202) 261-6470/Fax: (202)261-6464
Email: bretsch@neetf.org
Amy E. Brown, PhD
American Association of
Pesticide Safety Educators
Dept. of Entomology, Univ. of Maryland
College Park, MD 20742
Tel: (301) 405-3928/Fax: (301)314-9290
Email: ab35@umail.umd.edu
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