N • E a E ¦ T ~ F
The National Environmental Education & Training Foundation
0MAL_
National
Strateg ies for
Health Care
Providers
Pesticides Initiative
June lO-ll, 2003
Washington, DC
Cosponsors
American Academy of Pediatrics, American Association of Colleges of Nursing, American Association of
Occupational Health Nurses, Association of Academic Health Centers, Migrant Clinicians Network,
National Institute of Environmental Health Sciences
Supporting Organizations
American Medical Association, Association of American Medical Colleges
N • E * E ¦ T ~ F
'IT-?? I- >>'" -in i - I' -
US DA
u
v.- .. (tmnv.nt ot un or
AEPA
-------
NATIONAL FORUM PROCEEDINGS
National Strategies for Health Care Providers:
Pesticides Initiative
June 10-11, 2003
Washington, DC
For more information:
The National Environmental Education & Training Foundation
1707 H Street, NW, Suite 900
Washington, DC 20006-3915
Tel: 202-833-2933x535
Fax: 202-261-6464
Email: pesticides@neetf.org
Web: www.neetf.org/health/providers/
Support for this project was made possible through Cooperative Agreement CR 827026-01-0 between
the Office of Pesticide Programs of the US Environmental Protection Agency (US EPA) and The National
Environmental Education & Training Foundation. The conclusions and opinions expressed herein are
those of the authors and do not necessarily represent the view and policies of the US EPA.
-------
ACKNOWLEDGMENTS
The National Forum on the National Strategies for Health Care Providers: Pesticides Initiative was
developed under the leadership of a committee representing environmental, nursing, and medical
institutions, health professional organizations, and government agencies. The National Environmental
Education & Training Foundation (NEETF) gratefully acknowledges the time and effort contributed by
members of the National Forum Planning Committee, as well as conference speakers, workshop co-
chairs and scribes, and the leadership of the Initiative's Federal Interagency Planning Committee.
Funding for the National Forum was provided by the US Environmental Protection Agency
(Offices of Pesticide Programs and Children's Health Protection), the Centers for Disease
Control and Prevention (National Institute for Occupational Safety and Health), and the National
Institute of Environmental Health Sciences.
Several organizations partnered with NEETF by formally sponsoring and/or supporting the
National Forum. Co-sponsors were the American Academy of Pediatrics, American Association of
Colleges of Nursing, American Association of Occupational Health Nurses, Association of Academic
Health Centers, Migrant Clinicians Network, and National Institute of Environmental Health Sciences.
Supporting organizations for the National Forum were the American Medical Association and the
Association of American Medical Colleges.
The National Strategies for Health Care Providers: Pesticides Initiative is a partnership of NEETF
and the US Environmental Protection Agency, in collaboration with the US Department of Health and
Human Services, the US Department of Agriculture, the US Department of Labor, and a wide range of
stakeholders.
About NEETF
Chartered by Congress in 1990, The National Environmental Education & Training Foundation (NEETF) is a
private non-profit organization dedicated to advancing environmental education in its many forms. NEETF is a
leader in the development of new policies, grant-making approaches, and direct programming to advance
environmental literacy in America. NEETF's environmental education efforts are linked to many of society's core
goals, including better health, improved education, environmentally sound and profitable business, and increased
volunteerism in local communities.
-------
TABLE OF CONTENTS
Introduction 1
I. Overview of the Initiative 3
II. National Forum Proceedings 6
A. Forum Overview 6
B. Selected Plenary Session Summaries 7
• Initiative Priority Projects 7
- National Guidelines for Competencies and Practice Skills 7
- Audience Assessment Pilot Project 8
- Pesticide Resources, Tools, and Information Gateway 10
• Action Agenda for Incorporating Environmental Health
in Pediatric Medical and Pediatric Nursing Education Standards 11
C. Keynote Address: Genetics, Environment, and Disease 13
D. Workshop Reports 13
• Educational Settings 13
• Practice Settings 20
• Resources & Tools 26
III. Summary and Recommendations 29
IV. Appendices
A. National Forum Agenda A-1
B. Speaker Presentations B-1
C. Initiative Case Statement: The Need for Pesticide Education
for Health Care Providers C-1
D. National Forum Planning Committee D-1
E. Federal Interagency Planning Committee E-1
F. National Forum Participants F-1
-------
INTRODUCTION
In June 2003, leaders in environmental health, education, nursing, and medicine gathered at a
National Forum to affirm their support for the National Strategies for Health Care Professionals:
Pesticides Initiative, and to determine how best to turn the well-defined, yet broad goals and activities of
the Initiative into reality. As a group, National Forum participants expressed support for the strategy to
view and present the Pesticides Initiative within the broader context of environmental health. The effort
will focus on improving primary health care providers' knowledge of environmental health and toxicants,
which impact Americans in virtually every setting and can cause both chronic disease and acute effects.
The goal of the Pesticides Initiative is to improve the recognition, management, and prevention
of health effects from pesticide exposures. Expert participants brought forth a vast knowledge of the
mechanics of education, practice, research, and public health. The enthusiastic gathering resulted in a
renewed commitment on the part of organizations and individuals to the Initiative as a whole and to
specific action items that will move the project forward.
This volume of Proceedings presents an overview of the plenary presentations at the National
Forum and detailed summaries of discussions at the three interactive workgroup sessions on Education,
Practice, and Resources and Tools. This document is published as a record of the National Forum only
and serves as one piece of a long-term, dynamic project. The information presented here should not be
viewed as independent strategies, plans, or projects. The recommendations and goals articulated by
National Forum participants will provide additional input to Initiative activities already underway and will
help guide the next steps to be undertaken.
The National Forum made clear that two factors will greatly impact the success of the Initiative in
the long term: an emphasis on positioning the Initiative within the broad context of environmental health
- underscored by Dr. Kenneth Olden's characterization of the interplay of genetics, environment, and
lifestyle as the future of clinical medicine; and the involvement of a wider range of opinion leaders
beyond the environmental, occupational, and pesticides experts.
To promote the vision of the Pesticides Initiative in the broader context of environmental health,
National Forum participants strongly recommended developing a NEETF position statement on the need
for environmental education in medicine and nursing. The statement would be presented by EPA and
NEETF to leading public health and primary care organizations, as a way of introducing the products and
activities of the Initiative to opinion leaders and of seeking their organizations' support and/or formal
endorsement of the broad issue. For some organizations, this might represent a renewed commitment to
environmental health, in follow-up to the Institute of Medicine's 1995 recommendations. With the position
statement as a lead, supporting organizations would be requested to become involved in specific
Initiative activities. It is only through this expanded professional involvement that broad environmental
education will become a reality throughout primary care in America.
1
-------
The integration of environmental health and/or pesticides issues in both education and health
care practice will depend on true culture changes within medicine and nursing. Successful
implementation of the Pesticides Initiative within the broader perspective of environmental health should
produce an array of long-term changes in primary care education and practice; heightened interest in
environmental health research; greater numbers of occupational, environmental, and pediatric
environmental specialists; expanded, diversified funding of environmental health projects such as the
Initiative; and, ultimately, improved prevention practices and better health care for Americans.
Finally, through their conference work, the National Forum participants established a foundation
for a national partnership committed to successfully implementing the National Strategies for Health Care
Providers: Pesticides Initiative.
2
-------
OVERVIEW OF THE INITIATIVE
Although environmental health risks are a leading cause of illness, the average health
professional receives minimal environmental education and training on a variety of issues, including
pesticides. Even when environmental factors are identified as a source of a health problem, there is often
little knowledge about how to address or prevent the problem. A study has shown that 75 percent of US
medical schools require only about seven hours of environmental health content over four years.1 In a
survey of nurse practitioner program directors, more than two-thirds of the directors saw a need for
greater emphasis on environmental health in their programs/ In a practice setting, health care providers
may encounter patients suffering acute health effects from pesticides exposure, or seeking answers to
concerns about the risks of cancer, birth defects, reproductive effects, and other conditions from
exposure to low levels of pesticides. A health care community that is more aware of specific concerns
will be better prepared to effectively diagnose, treat, and prevent pesticide-related health conditions.
Pesticides have become ubiquitous in our society, affecting virtually all populations across
America. While agriculture accounts for 76 percent of the conventional
pesticides used each year in the United States, pesticide exposure can
occur in settings outside agriculture, including urban and suburban
environments, homes, and schools. 3 Indoor and outdoor exposures,
prenatal and postnatal exposures in children, and exposure from dietary
intake can lead to acute and/or chronic health effects. Chronic health
effects represent a range of adult and childhood illnesses, such as
cancer and asthma, as well as reproductive and central nervous system
effects. (See Appendix C for the Initiative Case Statement.)
In response to a call for action from organizations such as the American Medical Association4
and the Institute of Medicine,5 6 the National Strategies for Health Care Providers: Pesticides Initiative
was launched in 1998 under the guidance of a Federal Interagency Planning Committee (see Appendix
1 Schenk M. Popp SM Neale AV. et al. Environmental medicine content in medical school curricula. Acad Med.
1996;71(5):27-29.
2 Bellack JP, Musham C, Hainer A, et al. Environmental health competencies: a survey of nurse practitioner
programs. American Association of Occupational Health Nurses Journal. 1997 Jan; 45(1):6
"'US Enviromnental Protection Agency. Pesticides Industry Sales and Usage: 1996 and 1997Market Estimates.
Washington, DC: Office of Prevention Pesticides, and Toxic Substances; 1999. Publication 733-R-99-001.
4 American Medical Association. Report 4 of the Council on Scientific Affairs. Educational and informational
strategies for reducing pesticide risks (Resolutions 403 and 404). 1994.
5 Institute of Medicine. Environmental Medicine: Integrating a Missing Element into Medical Education.
Washington, DC: National Academy Press; 1995.
6 Institute of Medicine, Nursing, Health, & the Environment. Washington, DC: National Academy Press; 1995.
3
-------
E). The Initiative was created to improve health care providers' recognition, management and prevention
of pesticide poisonings and overexposures. Strategies for accomplishing this goal focus on improving
providers' education and practice skills, and increasing resource linkages.
To turn the Initiative into reality, a multidisciplinary team of national experts developed a 10-year
Implementation Plan. The Plan envisions a coordinated effort across the professional fields of
environmental health, pesticides, nursing and medical education, primary care, epidemiology, children's
health, minority health, and agriculture, to effect long-term change in health care provider education and,
ultimately, in the national health care system.
The Implementation Plan presents a three-pronged approach with specific, measurable activities
in education, practice, and resources and tools, through which all target audiences will receive increased
skills.
Educational Settings
Practice Settings
Educational institutions
Educational competencies
Institutions and faculty
Key decision-makers
Faculty champions
Exams and requirements
A
—Make the ease—
¦Define guidelines¦
-Assess target audiences-
—Secure endorsements—
— Demonstrate success—
Create incentives
Resources and Tools
Primary care providers
Practice skills
Primary care providers
Key decision-makers
New practice models
Health care requirements
and reporting
t
IT f
Inventory National
Review Board
New Information
Resources Gateway
Target audiences include primary health care providers (physicians, nurses, nurse practitioners,
physician assistants, and nurse midwives) and decision-making bodies (curriculum committees,
accrediting institutions, administrators, residency review committees, and institutions governing health
care and health practice requirements).
Change will be accomplished through an array of short-term and long-term projects. Examples of
short-term projects detailed in the Initiative's Implementation Plan include:
7
The National Environmental Education & Training Foundation (N'KHTF). National Strategies for Health Care
Providers: Implementation Plan. Washington, DC: NEETF, U.S. EPA, U.S. Dept. of Agriculture, U.S. Dept. of
Health and Human Services, U.S. Dept. of Labor; March 2002.
4
-------
• National Pesticide Competency Guidelines for Education and National Pesticide Practice Skills
Guidelines—Companion documents that present specific educational competencies and practice
skills recommendations
• Audience Assessment of Education Settings and Primary Care Providers—A survey of the
knowledge, attitudes, skills, and preferred learning methods of health care provider faculty and
practitioners
• National Review Board—A panel charged with identifying, selecting, and assessing ideal
pesticides resources for primary care providers in educational and practice settings
• Information Gateway—A multimedia distribution point for print, telephone, and Web-based
resources
• National Forum—A "call to action" conference for executing the recommendations and strategies
of the Initiative's Implementation Plan
The National Strategies for Health Care Providers: Pesticides Initiative is a first step in tackling the
broad challenge of environmental education for health professionals. Based on the supporting body of
scientific knowledge and data, pesticides issues represent an important model through which the health
care community can integrate environmental issues into the education and training of primary health care
professionals.
5
-------
NATIONAL FORUM PROCEEDINGS
A. FORUM OVERVIEW
The National Forum was a planning summit for executing the strategies and recommendations
of the National Strategies for Health Care Providers: Pesticides Initiative's Implementation Plan. (See
Appendix A for the Forum agenda.) The Forum brought together individuals whose expertise reflects the
interdisciplinary efforts critical to implementation of the Initiative. These include representatives of
leading health care provider organizations, credentialing bodies and academic institutions;
representatives from government agencies involved in the education and practice of health care
providers; an array of practicing primary care providers—physicians, nurses, physician assistants, nurse
midwives, community health workers; other opinion leaders; and stakeholders. (See Appendix F for a list
of participants.)
Primary goals of the National Forum were:
¦ To build national consensus on the issue and gain support to implement and evaluate the
Initiative.
¦ To secure specific commitments from participants to influence their professional associations,
decision-making bodies, academic institutions, and practice settings for the integration of
pesticide-related content into health care provider education curriculum and practice.
¦ To create a national partnership of organizations and professionals committed to integrating
environmental health into primary care education and practice.
¦ To build support for replicating the pesticide model for other environmental issues, such as
asthma, and chemical and biological terrorism.
Secondary goals were:
¦ To raise awareness among a large group of health care providers, professional associations,
decision-making bodies, academic institutions, practice settings and other stakeholders about
incorporating environmental health into health care and to gain support for the implementation of
the Initiative.
¦ To increase partnerships among educational settings, practice settings, and communities; and
among health care providers, Cooperative Extension Services, and pesticide-safety educators.
¦ To increase the use of the available pesticide-related resources and tools by health care
providers.
In both the plenary and interactive workshop sessions, the Forum focused on the development of a
strategic, itemized plan of action. Plenary sessions offered details on the Pesticides Initiative's priority
projects and showcased the Initiative as a model for other environmental health issues. Participants in
workshop sessions defined strategies within the Initiative's three focus areas: Education; Practice; and
6
-------
Resources and Tools. Each workshop was co-chaired by individuals involved in the development of the
Initiative's Implementation Plan; discussions centered on core issues raised in the Implementation Plan.
Detailed workshop reports follow, beginning on page 14.
B. SELECTED PLENARY SESSION SUMMARIES
Plenary sessions provided participants with a range of background information and resources.
Presentations on the first day of the conference were intended to help prepare participants for workgroup
assignments, by providing specific background into the health effects of pesticides, the Initiative's priority
projects in progress, and the nursing and medical education and training arenas. On the final day,
plenary sessions focused on various aspects of partnerships, intended to focus participants on the need
for, and value of, expanded collaborative efforts, as they returned to work within their respective
organizations.
This section summarizes selected plenary sessions in which progress was reported for specific
projects. These include the three priority projects of the Initiative - National Guidelines, Audience
Assessment pilot project, and Information Gateway - as well as the Children's Environmental Health
Network Action Agenda. Appendix B includes copies of all presenters' slides.
Initiative Priority Projects
National Guidelines for Competencies and Practice Skills
Development of the National Guidelines was based on a clear vision articulated in the Initiative's
Implementation Plan: that all primary health care providers should possess a basic understanding of the
health effects associated with pesticide exposures as well as broader environmental exposures, and that
providers should take action to ameliorate such effects through clinical and prevention activities. The
Initiative seeks to incorporate changes in educational institutions related to health care; equip students
with skills and competencies to better deal with pesticide exposures and health conditions; recognize
and address real health threats posed by pesticides; and take the first steps in tackling the growing
problem of environmental toxicants.
Two companion documents, National Pesticide Competency Guidelines for Medical & Nursing
Education and National Pesticide Practice Skills Guidelines for Medical & Nursing Practice, were
published in January 2003. The Guidelines were developed by expert clinicians and academicians,
including representatives of the American Association of Colleges of Nursing, American Association of
Occupational Health Nurses, National Organization of Nurse Practitioner Faculties, and American
Association of Pesticide Safety Educators. The authors of the Guidelines were Amy E. Brown, PhD,
Associate Professor, Department of Entomology, University of Maryland; Candace Burns, PhD, ARNP,
University of South Florida College of Nursing; Bonnie Rogers, Dr.PH, COHN-S, LNCC, FAAN,
University of North Carolina School of Public Health; James R. Roberts, MD, MPH, Assistant Professor,
7
-------
Department of Pediatrics, Medical University of South Carolina; and Cathy Simpson, MD, MPH, Wayne
State University School of Medicine. Andrea Lindell DNSc, Dean, College of Nursing, University of
Cincinnati, and George Bernier, Jr., MD, Professor and Dean Emeritus, University of Texas Medical
Branch, served as project coordinators. The Guidelines were externally peer-reviewed. Both documents
contain a brief "primer" on pesticide regulation, use, exposures, and
absorption.
The education competency guidelines outline the pesticide-related
competencies that medical and nursing school students should achieve. Five
specific educational competencies are defined: knowledge and concepts of
pesticides; diagnosis and assessment (including taking an environmental
history); treatment, intervention and referrals; risk communication; and
reporting requirements and regulations. For each competency, the guidelines
suggest possible points of insertion' in medical and nursing school curricula, recognizing that curricula
vary considerably in form and content.
The practice skills guidelines offer opportunities for incorporating
pesticide issues into the ongoing practice of health care and within the context
of providers' continuing education. Highlights include detailed ideas for
incorporating pesticide issues into practice areas; key principles of adult
education; and content for six recommended practice skill areas. The six skill
areas cover: taking an environmental history; knowledge of key health
principles; awareness of community and individual pesticide risk factors;
clinical management of pesticide exposure; reporting pesticide exposure and
supporting surveillance efforts; and providing prevention guidance and education to patients.
National Forum participants were challenged to create dynamic opportunities for engaging
deans, faculty, and practice leaders to transfer content into action—to turn the documents into part of the
reality of nursing and medical education and practice.
National Pesticide Practice Skills Guidelines for
Medical & Nursing
Practice
1MB
S3 <3
Audience Assessment Pilot Project: Attitudes, Beliefs and Practices of Pediatric Health Care
Providers Regarding Continuing Education on Pesticide Toxicity
A pilot audience assessment was conducted to examine the attitudes, beliefs, and practices of
pediatric health care providers regarding continuing education on pesticide toxicity. This study
addresses the Initiative's Practice component, which involves changing knowledge and behaviors of
practicing physicians. The assessment was conducted by John M. Balbus, MD, MPH, Chinonye E.
Umeh, MPH, MT (ASCP), and David F. Goldsmith, PhD, MSPH at the George Washington University
Center for Risk Science and Public Health.
Practicing physicians present three challenges: they are a difficult audience for behavior
change; competing educational priorities limit their interest in and knowledge of environmental health
issues; and very little is known about how practicing physicians view environmental health issues as part
8
-------
of their continuing medical education (CME). The assessment was designed to provide information on
all three issues.
The assessment included practitioner questionnaires—for both nurses and clinicians
(physicians, nurse practitioners, physician assistants)—and focus groups. The focus group instrument
was derived from the questionnaire to gain a deeper understanding of beliefs and motivations of
practitioners regarding CME and the issue of pesticide-related health effects.
Key results of the audience assessment are as follows: Of 160 practitioner questionnaire
responses, 69 percent had never made a diagnosis of pesticide intoxication. Urban (50%) clinicians were
more likely to have considered diagnosis than those in suburban settings (34%), and urban clinicians
(62%) had been asked about pesticides more than suburban clinicians (39%). Fifty-three percent of
clinicians reported feeling very or somewhat uninformed about
pesticides.
Regarding CME issues, 40 percent of respondents thought it
was important to receive CME on pesticides; 21 percent thought it was
unimportant; and 90 percent were unaware of educational
opportunities for pesticides. Forty-one percent of respondents reported
being willing to spend a half-day or less to receive CME on pesticides,
39 percent would be willing to spend one hour or less, and 14 percent
would spend one full day.
Nurses were less likely than clinicians to have made a diagnosis of pesticide toxicity (12%) or to
have been asked by patients (37%) about pesticide toxicity. Only 28 percent of nurses felt pesticide
training was important, and 30 percent felt it unimportant. Regarding CME on pesticides, 30 percent said
they would be willing to spend one hour or less; 42 percent would spend a half day or less; and 23
percent would spend one full day.
Six focus groups involved 29 clinicians (27 physicians, 2 nurse practitioners). Using a fairly
broad interpretation of pesticides, nearly all recalled questions about DEET, repellants, food residues,
and lawn residues. Most practitioners were more familiar with acute syndromes but unsure about
recognition and significance of chronic effects. Regarding CME, clinicians participating in focus groups
were split in their preferences between large CME conferences and one-hour grand rounds or local mini-
seminars. On the topic of the importance of pesticides as a CME topic, however, opinions covered
providers' uncertainty over chronic effects, their need for information to be clinically relevant, and an
unwillingness to devote an entire conference to pesticide issues; most said they would welcome one
hour mixed in with other topics.
While the pilot study is limited in geographic area (mid-Atlantic region only) and by its use of
non-random sampling, its results offer useful insights for reaching practicing clinicians on environmental
health topics. The assessment clearly confirmed the need to improve clinicians' knowledge of pesticides.
53 percent of clinicians
reported feeling very or
somewhat uninformed
about pesticides...
Only 28 percent of nurses
felt pesticide training was
important...
9
-------
Pesticide Resources. Tools, and Information Gateway
This project fulfills three of the five components of the Initiative's Implementation Plan strategy for
resources and tools: specifically, to inventory existing resources; establish a National Review Board to
evaluate resources; and create an Information Gateway.
The project team was led by Mark G. Robson, Ph.D, MPH, ATS, University of Medicine and
Dentistry of New Jersey - School of Public Health. The team identified more than 500 online and hard
copy resources for health care providers at all levels. Items were categorized by course provider (private,
government, academic, industrial) and entered into a database. Entries included Web links when
available and short comments on bias, intended audience, level of information, and ease of accessibility.
Upon review by several health care providers and pesticide education specialists, approximately half of
the entries were deemed outdated, hard to use, not relevant, or misleading, and were eliminated. The
remaining 283 sources (as of June 2003) will serve as the beginning of the Initiative's resource base.
While this inventory is just a small part of the Information Gateway being developed, it is a
critical base of resources for health care providers.
Based on anecdotal evidence, health care providers appear to prefer a Web-based approach for
a resources database, which allows them to modify queries, dig more deeply, or return for more
information if time allows. Sites in the database link back to or are adapted from 12 major sites, the
primary being the EPA, US Food and Drug Administration (FDA), and several of the nation's largest
academic institutions. The next steps are to continue gathering resources and to undertake a careful
evaluation of existing and incoming sources by the National Review Board. The resource inventory has
also identified some areas where there are few or no resources; these areas will be presented to state
and federal agencies in an effort to develop new resources to fill these gaps.
The Initiative's Information Gateway is being developed by Clicklmpact; when live, the Web site
address will be PesticideHealthcare.com. The Gateway is being designed as a highly intuitive, fast-
loading Web site. (See sample Web site pages in Appendix B.) It will be information-dense and will
provide easy access to a significant number of articles, tools, databases, and other content modules for
health care professionals.
Site features include the following:
• Document Database—Primary source of content, will contain original documents, document
references, and abstracts
• Reference Desk—Including medical reference, prevention, and pesticide profiles; content will
include a headline, short text description and a link to access all related tools and resources
• Pesticide Profiles/Pesticide Database—Includes "Gateway pages" for all major substances listed
by commercial name (cross-referenced to substance name)
• Directories—Web site guide, organization directory, and key contacts
• Educational Resources—Training modules, training programs, publications lists
• Upcoming Events—List of upcoming events linked to event details
• About Us—Information about the Pesticide Initiative, staff, partners, and Federal Interagency
Planning Committee, and a link to NEETF's Health & Environment page,
10
-------
http://www.neetf.org/Health/providers/index.shtm, including the major items highlighted on that
page
Documents included in the Document Database will focus on a range of diagnostic, treatment,
and prevention topics to assist health care providers in working with pesticide exposure. Basic document
types in the database are articles, reports, case studies, abstracts and external references, and tools
(practical resources such as downloadable forms, diagnostic checklists, and interactive features).
The Pesticide Profiles/Pesticide Database will offer search and browse options as well as
relevant links for various items (e.g., Web sites, environmental data below, environmental case history
form, etc.). Each profile includes a short description of the substance (from the National Pesticides
Information Center), manufacturer's emergency contact information, and at least one link to the most
relevant page on another site with information about that substance (e.g., a link to an EPA database).
Action Agenda for Incorporating Environmental Health in
Pediatric Medical and Pediatric Nursing Education Standards
The Action Agenda for Incorporating Environmental Health into Pediatric Medical and Pediatric
Nursing Education was a study designed to assess the current medical and nursing education structures
and identify key leverage points for curricular change. A partnership between NEETF and CEHN, the
project is funded under a grant from the National Institute for Environmental Health Sciences. Findings of
how various elements of education and licensing/accrediting influence both education and practice
content are critical to the National Strategies for Health Care Providers: Pesticides Initiative's approach
to incorporate environmental health into health care provider education and practice. The leverage points
identified will be used to incorporate, as a pilot project, the National Pesticide Practice Skills Guidelines
for Medical & Nursing Practice and the National Pesticide Competency Guidelines for Medical & Nursing
Education into pediatric medical and nursing education.
The assessment involved a medical and a nursing work group consisting of health professionals
with expertise in one or more of the following areas: environmental health education or medical or
nursing education in general; accreditation programs and systems; and curriculum development.
Workgroups identified phases of medical and nursing education, organizations involved with medical
accreditation and licensing, and those involved with academic or legislated programs to assure quality of
practice. Once these phases were identified, workgroup members recommended potential leverage
points for incorporating environmental health.
Medical Education: Potential Leverage Points Identified
The assessment identified leverage points at the medical school, residency, fellowship, and
practice levels within medical education. In medical schools, several potential leverage points exist:
medical students and medical-student organizations, the creation of designated faculty leaders within
schools of medicine, AAMC, LCME, and NBME. Faculty leaders who have an interest in teaching
environmental health perform essential roles: integrating environmental health content into the
curriculum, providing case material that can be used in courses taught by others, and coordinating
11
-------
environmental health activities at their school. These faculty champions can provide the impetus for
change throughout a program and can influence the career choices of students by setting examples and
providing direct counseling.
At the residency training level, leverage points include program directors, chief residents,
residency review committees, and the guidelines for primary care pediatric education. Within each
residency training program, chief residents have influence over the scheduling of specific conferences
and other educational activities. The Pediatric Residency Review Committee operating under the
auspices of the ACGME approves the content of pediatric residency training, and could require that
some content regarding children's environmental health be included in pediatric residency education.
The Ambulatory Pediatric Association has developed a set of guidelines for primary care
pediatric education at the residency level. Future iterations of these guidelines could include teaching
about children's environmental health. At the specialty level, the American Board of Pediatrics and/or the
American Board of Preventive Medicine could seek permission from the ABMS to develop a Sub Board
in pediatric environmental health.
Additional leverage points include: providing continuing medical education credits in conjunction
with training on pediatric environmental health; including pediatric environmental health education in the
United States Medical Licensing Examination, which is taken by medical students to become licensed
physicians; and increasing student interest in pediatric environmental health through their contact with
clinicians. Other possible leverage points would be to encourage insurance companies to reimburse
environmentally related health care services provided to children, and to insert environmental health
material in accreditation, certification, and licensure processes.
Nursing Education: Potential Leverage Points Identified
The assessment identified nursing education leverage points at the undergraduate and
advanced training level, and in the licensure process. In undergraduate education, leverage points
include: nursing students and nursing-student organizations, the National League for Nursing Accrediting
Commission (NLNAC) and the Commission on Collegiate Nursing Education (CCNE). In advanced
nursing training, the National Organization of Nurse Practitioner Faculties (NONPF) and the Association
of Faculties of Pediatric Nurse Practitioner Programs (AFPNPP) could use their influence on the curricula
and standards for education and competencies to increase the content in children's environmental health
in the programs for advanced practice nurses.
Other leverage points include publishing on pediatric environmental health in leading nursing
publications; providing continuing education credits in conjunction with training on pediatric
environmental health; and the coverage of pediatric environmental health information on the National
Licensure Examination.
12
-------
C. Keynote Address: Genetics, Environment, and Disease
Dr. Kenneth Olden, Director of the National Institute of Environmental Health Sciences and the
National Toxicology Program, gave the keynote address at the Forum. Dr. Olden's presentation focused
on making the case for environmental medicine in the prevention, diagnosis, and treatment of human
illness. He noted that in developed countries the major causes of morbidity and mortality are not easily
treated or cured, making prevention a more attractive avenue for management of chronic diseases.
Most chronic diseases arise from a complex array of factors, such as intrinsic genetic
susceptibility, environmental exposures, behavior, age, and stage of development. There are numerous
examples of exposure to environmental pollutants leading to disease: lung diseases and air pollutants,
impaired intelligence and lead exposure, and cardiovascular disease and air pollutants. The definition of
environment also includes industrial and agricultural
chemicals, foods and nutrients, and physical and biological
agents. The three-pronged approach to preventing human
illness involves identifying risk factors, developing prevention
strategies, and translating knowledge into practice. A trained
cadre of physicians and health professionals, as well as social
and political will, are necessary to achieving the prevention of
human illness due to environmental exposure.
For the past 25 years, there has been a focus on genetic causes of disease, however, even with
the completion of the human genome project, there are few genes that have been identified as the cause
of major diseases. Genetics loads the gun, but environment pulls the trigger, in the words of UC Davis
scientist Dr. Judith Stern. One can inherit a predisposition to have a disease, but never have the disease
unless exposed to the environmental trigger. There is a documented lack of environmental health
education in medical and nursing schools, thus the majority of health practitioners are not well equipped
to diagnose and manage environmentally-related diseases. In 1995, the Institute of Medicine
recommended specific competence-based environmental health training programs for all graduating
medical students. Therefore, NIEHS has undertaken efforts to enhance physician and nurse knowledge
of environmental medicine, and supported children's environmental health research.
Dr. Olden noted that the study of the "Gordian knot" of complex diseases - the interaction of
environment, genetics, behavior, age, and poverty - represents the future of clinical medicine.
D. WORKSHOP REPORTS
Educational Settings
Summary
Advancing environmental health and pesticides education within medical and nursing schools
will depend on a multi-pronged approach that draws upon grass-roots program champions' involvement,
13
"The vast majority of patients are
seen by physicians who have no
training in occupational or
environmental medicine. We can't
prevent disease unless we deal with
the issue of the environment."
—Dr. Kenneth Olden, Director,
National Institute of Environmental
Health Sciences
-------
endorsement by national organizations, strategies to impact accrediting, and promotion and accessibility
of existing resources. Strategies will differ somewhat for nursing and medicine.
Workshop participants detailed issues related to development and training of program
champions networked at targeted institutions nationwide. National endorsements are particularly
influential within nursing. Workshop participants identified the need for a position statement by NEETF or
jointly with EPA on the need for medical and nursing environmental education positioned within the
context of Healthy People 2010. This paper and/or the National Guidelines could be submitted to various
professional organizations for endorsement.
In addition to the National Guidelines, many resources for medical and nursing education exist in
various formats; however, a system does not currently exist for effectively promoting, sharing, and
accessing materials. Workshop participants identified several opportunities for expanding access to
materials, which will dovetail with the Resources & Tools component of the Initiative.
Finally, participants suggested that a promotional strategy be developed to coordinate the
various efforts needed to advance medical and nursing environmental health education.
Discussion
Workshop participants centered their conversation on specific questions, which are presented below,
with particular strategies and relevant issues discussed by the group.
1. What strategies can be utilized to convince decision-makers about the need for environmental
health and pesticide education in medical and nursing educational institutions?
Reaching decision-makers will depend, in part, on the Initiative's taking a customer-product
approach to environmental health and pesticide education. The 'product' is high-level environmental
education; it should encompass more specific pesticide-related 'products' as well. A more general
approach may be more conducive to funding and implementation by medical and nursing programs and
should highlight the universal aspects of competencies. This approach
must be science-based and recognize the complexity of pesticide-
related health conditions, much as the National Institute of
Environmental Health Sciences' model of complex diseases reflects
interactions among genetics, environment, and lifestyle.
Incorporating environmental education into nursing and
medical education will not be a linear process. It will develop over time
as more people are trained in environmental health, take positions in
educational institutions, and begin to educate and train new cohorts of medical and nursing students. .
Faculty with a special interest in environmental health and/or pesticide education already serve as
program champions for these issues. Overtime, a critical mass of clinicians interested and educated in
pesticides issues and environmental health will be involved in a "culture change" within the disciplines.
Participants recommended that NEETF develop a position statement on the need for
environmental education in medicine and nursing. EPA and NEETF would present the statement to
Over time, a critical
mass of clinicians
interested and educated
in pesticides issues and
environmental health
will be involved in a
"culture change" within
the disciplines.
14
-------
leading public health and primary care organizations, seeking their support and/or formal endorsement of
the statement. For some organizations, this may represent a renewed commitment to environmental
health, a follow up to the Institute of Medicine's 1995 recommendations. The position statement would
also introduce existing products and activities of the Pesticides Initiative to opinion leaders, and
encourage their involvement in specific Initiative activities. It is only through such an expanded
professional involvement that broad environmental education can become a reality in primary care.
Participants discussed the types of issues facing decision-makers in medical and nursing
programs, as well as the influence of accrediting bodies. Medical deans' decisions on curriculum are
often influenced by a specific recommendation from an accreditation board, and by questions included
on board exams. Medical board exam questions are written by committees that are convened by the
National Board of Medical Examiners. An important strategy for the Initiative, then, may be to begin
conversations with individuals involved in the question-writing committees. Board exams include
specialty exams, and exam development is different for nursing and for medicine. Nursing board exams
are based on current practices; questions are developed using the results of a survey of practicing
nurses conducted every five years.
Funding is an important motivator for institutions; the availability of funds for this effort can help
garner support at high levels and persuade faculty to take an interest in environmental health and
pesticide education. The availability of grants from federal agencies such as EPA and the US
Department of Health & Human Services, as well as private funders, will also help generate interest and
fuel excellence by spurring competition for funds. Having faculty champions advocate for environmental,
occupational, and pediatric environmental research is critical to receiving funding. For example, NIH R01
grants require a board of advisors—typically, senior education leaders; faculty champions must work to
educate that leadership about the value and need for environmental, occupational, and children's
environmental health research. In turn, high-level faculty may become advocates for environmental
health.
2. What other assessments of educational settings are needed?
Participants agreed there is no need for further assessment of the need for information and
awareness; however, the Initiative should assess issues related to effective delivery of environmental
health information within educational settings. This assessment could be achieved through a thesis
project. The assessment should include the Epidemic Intelligence Service and it should determine how
occupational and medical residents became interested in their specialty areas. This could help identify
strategies for stimulating interest among students and other professionals.
Conducting new surveys is not necessarily feasible, given medical and nursing schools' time and
resource constraints; however, existing surveys of educational settings, including Institute of Medicine
studies, pediatrician resident studies, and medical student studies, could provide valuable information.
Additionally, the Association of American Medical College's Curriculum Management & Information Tool
(CurrMIT©) can be used to assess educational needs; a report can identify schools with the best
environmental curriculum; and faculty at these schools could become mentors for others.
15
-------
3. How can the National Guidelines be integrated into nursing and medical curricula?
Participants discussed a two-pronged approach in which students are educated in the classroom
and clinic, while relevant exam questions are integrated at the board level, which in turn spurs greater
interest in the classroom. Discussion also focused on umbrella issues related to faculty's use of existing
resources, and opportunities to integrate general environmental messages rather than only pesticide-
specific topics.
One idea is for NEETF to develop a document on environmental education and obtain
endorsements from national organizations; this type of document could influence schools and major
organizations to endorse the National Guidelines. The paper should present pesticides as part of
environmental health, and environmental health as an important part of the future of clinical medicine—a
crucial component for understanding how genetics interacts with the environment and impacts chronic
disease.
Working from the National Guidelines
documents and tapping into other existing resources,
faculty can use existing courses to integrate pesticide
issues (e.g., integrate toxicology issues into
pharmacology courses). Faculty champions should
have access to specific, credible resources and
teaching materials in addition to the National
Guidelines; course content should be readily available
online and include PowerPoint modules. Course plug-
ins and packaged courses should be targeted by discipline and would provide faculty with a comfort level
in a new topic area (environmental health and pesticides). Existing lectures by faculty throughout the
country could be shared and/or further developed into packaged modules. Models to examine are the
Centers for Disease Control and Prevention's (CDC) bioterrorism slide and PowerPoint presentations,
and the Association of Occupational and Environmental Clinics' (AOEC) occupational asthma slide
program (all available online). Issues to consider include size of files to download and ongoing costs of
Web site memory. Participants discussed the potential for developing partnerships with these
organizations and suggested the AOEC occupational asthma program as a possible CME offering.
Wthin medical education, the Initiative should consider chief resident training as a prime
opportunity for integration. A team approach should be used that targets the clerkship director,
residency director, and chief residents.
Case-based learning opportunities should be developed as creative tools for incorporating
environmental and pesticide-specific issues into medical and nursing programs. Many programs will use
case materials if they are readily available. While nursing needs a better archive of literature to use for
case-based learning, medicine has well-archived literature available as teaching tools. Beyond archived
literature, workgroup participants can develop case studies by documenting cases from their own
The National Guidelines were based on a
clear vision: that all primary health care
providers should possess a basic
understanding of the health effects
associated with pesticide exposures as
well as broader environmental exposures,
and that they take action to ameliorate
such effects through clinical and
prevention activities.
—Andrea Lindell, DNSc, RN, Past President,
American Association of Colleges of Nursing
16
-------
experience; the Agency for Toxic Substances and Disease Registry (ATSDR) also publishes case
studies that are used by medical schools.
While materials should be easy to obtain, participants discussed the impracticality of having a
single repository for case studies, as many are discipline-specific; rather, materials should be sorted by
both discipline and training levels and linked to a central access point. Users should be introduced to the
resources from discipline-specific sites. Packaged presentations on specific topics, including medico-
legal and ethical issues, are a gap in nursing education.
Textbooks represent another opportunity to integrate environmental health and pesticides topics
into medical and nursing curricula; workgroup members recommend working with textbook publishers to
diffuse environmental health into books in development and/or as they are updated.
4. What strategies should be used to secure endorsement of the National Guidelines by leading
professional associations?
Nursing endorsements should be sought from academic and professional organizations, as well
as accrediting bodies. The American Association of Colleges of Nursing's Board of Directors endorses
specific programs and documents, and participants will submit the National Guidelines for endorsements.
NEETF and EPA should seek endorsement from four important nursing organizations: National League
for Nursing Accrediting Commission, Commission on Collegiate Nursing Education, National
Organization of Nurse Practitioner Faculties, and Association of Community Health Nursing Educators.
Additional nursing organizations from which NEETF should seek endorsements are:
• Community Health Nursing section of American Public Health Association
• Tri-Council (Note: This endorsement can have a major impact on nursing education.)
• National League for Nursing
• American Organization of Nursing Executives
• American Nurses'Association
• American Association of Occupational Health Nurses
• American College of Nurse Mid-Wives
• National Black Nurses Association
• National Association of Hispanic Nurses
• National Association of School Nurses
Endorsement does not impact curriculum in medical programs in the same way as in nursing.
The Association of American Medical Colleges (AAMC) does not endorse curricular materials, although
some technical organizations may review and endorse documents. In general, an endorsement would be
useful only as an intermediate step within medicine. For any new topic area, medicine must first identify
the need for change, which begins at the grassroots level. The role of champion is critical in medicine; a
champion's introduction of a topic into the classroom is the impetus for change throughout a program.
The case for pesticides education must be presented within the broader issue of environmental health
under the clinical basis of gene-environment-lifestyle interaction.
5. How can we move forward in building faculty champions?
17
-------
Successful identification of faculty champions will depend, in part, on positioning of
environmental and pesticides education as part of established objectives such as Healthy People 2010.
A corps of faculty champions should be drawn from a range of specialties: children's environmental
health, occupational medicine and nursing, and environmental medicine and nursing. Targeted schools
would include those with existing expertise and those with agricultural bases. Specifically, medical and
nursing schools with an identifiable expert in pesticide exposure, including pediatric and occupational
health, are a source of faculty champions. The involvement of pediatricians and faculty with expertise in
children's environmental health will be critical, as children may be more susceptible than adults to
environmental health risks because of their physiology and behavior.
Faculty champions could also be recruited by targeting schools in regions with a heavy use of
pesticides, with large agricultural bases, and/or with a large number of reported pesticide exposures. In
addition, working from a regional perspective, the Initiative could target regional meetings of AAMC's
Group on Educational Affairs for small group workshops on environmental health and pesticides.
A closely related issue is how faculty champions can best draw interested students into training
programs. Two concerns arise: training opportunities must be available and promoted to students, and
organizations must work to interest students in the programs. For example, existing NIOSH training
positions for occupational medicine are often unfilled because students are not interested.
Short-Term Goals
Workshop participants identified the following short-term goals for integrating environmental health
and pesticides education in medical and nursing education:
• Identify faculty champions in each medical and nursing school.
• Identify where content should be inserted/incorporated into existing courses.
• Develop additional environmental and occupational modules, including pediatric environmental
modules.
• Create, identify, and promote a better repository of case studies, archives of literature,
independent studies, and modules (such as the Independent Study Modules developed by
University of Maryland School of Nursing).
• Incorporate educational workshops into regional and national workshops and meetings.
• Offer workshops for faculty champions. (Note: Travel budget for nurses would be needed.)
• Create and submit a course redesign paper to specific publications to focus on points of insertion
of the National Guidelines.
• Develop position statement from NEETF on environmental education. Refer to recommendations
outlined in "Nursing and Environmental Health Roundtable Final Report" (2002).
• Develop marketing tools.
• Identify and secure funding for activities.
• Link residency and fellowship opportunities to careers associated with this type of training.
18
-------
Long-Term Goals
Workshop participants identified the following long-term goals for integrating environmental health
and pesticides education in medical and nursing education:
• Secure occupational and environmental curriculum in every nursing and medical school, and
ensure that students are equipped with competencies.
• Ensure that every nursing and medical graduate will have the competency to take an
environmental history.
• Conduct a public relations campaign.
Commitments
Participants made specific follow-up commitments of individual activities that support short-term and
long-term goals. Priority activities will include:
• Create position statement on environmental education in medicine and nursing.
• Approach various professional organizations' boards of directors with position statement and/or
National Guidelines documents for endorsement or documented support.
• Identify medical programs with existing environmental health courses and interested faculty.
• Update professional organizations' Web sites with National Guidelines and Pesticides Initiative
information and materials.
Education Setting Workshop Participants
Co-Chairs: Candace Burns, PhD, ARNP and Geoffrey Calvert, MD, MPH
Scribe: Artensie Flowers, PhD, MPH
Walter A. Alarcon, MD, MSc
Jim T, Criswell, PhD
Deborah Danoff, MD
Allie M. Fields
Daniel A. Goldstein, MD
Michael R. Grey, MD, MPH
David Jefferson, MS
Katherine Kirkland, MPH
Andrea R, Lindell, RN, DNSc
Rita J. Lourie, RN, MSN, MPH
Lee Orr
Jerome Paulson, MD
Maria Elena Leal Perez, MD
Barbara J. Polivka, PhD, RN
Kerry Hoffman-Richards, PhD
James R. Roberts, MD, MPH
Christine Rosheim, DDS, MPH
Rosemary Sokas, MD, MOH
Joan Stanley, PhD, CRNP
Nsedu Obot Witherspoon, MPH
19
-------
Practice Settings
Summary
Health care providers need not be experts in environmental health, but they do need to
understand the importance of targeted environmental history questions, be able to identify "red flags" in a
patient's history and differential diagnosis, and know how and where to refer cases.
Ways of reaching practicing clinicians include: self-assessment tools, key environmental history
questions, customized materials (for providers and patients), role-modeling with environmental and
occupational health specialists and children's environmental health experts, presentations and exhibits at
national and regional conferences, and access to databases with credible, peer-reviewed resources.
Workshop participants discussed promotion and delivery issues, ranging from medical and consumer
media opportunities, to partnerships with professional organizations.
Beyond the content presented in the National Guidelines documents, health care providers also
need information on prevention of pesticide poisonings, use minimization, safe storage, and resources
and contacts that can explain alternatives to pesticides. Further assessments are needed of provider
groups to determine how best to reach, motivate, and communicate new content to different types of
primary care providers. Participants identified the standards for a model practice setting in which health
care providers are aware of local pesticide usage and potential exposures, and are able to refer their
patients and communicate with them appropriately on pesticide issues.
Discussion
Workshop participants centered their conversation on five specific questions presented below.
1. What strategies can be utilized to convince primary care providers of the need to incorporate
occupational and environmental health and pesticide awareness into their practice settings?
While time constraints and staff turn-over were identified as obstacles to working with practicing
clinicians, several agromedicine programs and Pediatric Environmental Health Specialty Units (PEHSUs)
provide expert consultation and resources to primary health care providers. Agromedicine programs
(members of the North American Agromedicine Consortium) provide outreach and training and are
resources for the Initiative's outreach to practicing physicians and nurses. Specific programs include:
• University of Maryland (one-on-one physician and nurse training on pesticides)
• Medical University of South Carolina (community-based physician training as part of primary
education setting-based training)
• Pennsylvania State University College of Medicine
• University of California at Davis (tribal health care provider training)
• Cornell University (Breast Cancer Environmental Research Foundation) and
• North Carolina Agromedicine Institute (a consortium of universities and cooperators
providing education and training for health care providers).
20
-------
Expert staff at regional PEHSUs provide outreach and training to health care providers. Services include
medical consultation with children's environmental health specialists; referral to health agencies with an
interest in pediatric environmental health; and children's environmental health-focused education and
outreach to the medical community.
When working with clinicians, presenting the scientific data is essential to "making the case."
Participants perceived that providers tend to be overwhelmed by environmental health, leaving them
uncertain about issues related to diagnosis and treatment. Scientific facts should be presented first,
followed by the uncertainties over cause-and-effect that require further research. Clinicians need
protocols that can be incorporated into daily practice, integrated by an environmental health primer.
Various subsets of clinicians will have specific needs. Providers treating farm workers, for
example, need further education about the long-term effects of pesticide exposure, so that their "radar"
would be activated when treating an acute effect such as a rash. Community health educators, nurse
practitioners, and physician assistants will have other needs.
Clinicians must become more aware of their regulatory reporting responsibilities (e.g.,
occupational health registries). All clinicians should operate from the perspective that they don't have to
be environmental health experts to report a suspected illness; rather, they need to know what questions
to ask, how to identify "red flags" in the patient's history and
differential diagnosis, and how and where to refer cases. To
increase their knowledge, the Initiative should bring in outside
experts with state-specific expertise. Because history-taking is
taught in medical school rather than residency, this issue must be
addressed in Education strategies as well.
Since environmental problems do not usually appear to be high on the list of severe and
complex illnesses seen, health care providers are not asking key questions during their history-taking.
Providing resources for providers may increase the likelihood that they will ask specific environmental
questions. Participants suggested that patients could complete a written environmental exposure
questionnaire during time spent in the waiting room. Additionally, health care providers need accurate
information to relate to patients, who may be asking questions about environmental health issues.
2. How can the National Guidelines be integrated into practice and training settings?
Participants identified opportunities for integrating the National Guidelines into existing protocols
and benchmarks; examples include well-child visits for pediatricians and similar opportunities by nurses
and family physicians, and visiting nurses' patient visits to newborns and new mothers. Pesticides
information, including exposure prevention, use minimization, safe storage, and availability of
alternatives to pesticides, should be integrated into these visits. Participants highlighted the need to
include seniors as an important patient group, and pointed out possible partnership opportunities with the
American Association of Retired Persons (AARP). Seniors may be primary users of pesticides but may
have "learned" pesticide use that is not acceptable today. They may require reeducation for their
personal safety, as well as that of grandchildren, for whom they may be caregivers.
Patients could complete
a written environmental
exposure questionnaire
during time spent in the
waiting room.
21
-------
Clinicians need different levels of information drawn from the National Guidelines, in a
condensed form. Ongoing exposure to the issues will increase their awareness and build their
knowledge base. Specific tools discussed include a template newsletter that would serve as a
dependable resource for physicians, and a companion continuing education tape or CD that a clinician
can listen to in the car. An additional idea discussed links with the Practice Setting: provide assistant
professors a way of teaching residency in a Socratic method, using teaching rounds to teach
environmental health concepts.
Participants raised the question of whether additional information is needed within the National
Guidelines. For example:
• Do the National Guidelines include enough information on prevention of chronic effects? The
document focuses on preventing acute exposure and handling of pesticides; less data is
available to discuss chronic effects. Expert faculty and faculty champions should add more
information as the data evolve.
• Why does the prevention skill set not include specific information about alternatives to
pesticides? Authors of the National Guidelines responded that this area was avoided because it
involved a whole other knowledge base; instead, the documents include references to other
resources on alternatives to pesticides.
3. How can we provide access to relevant resource materials?
The peer-reviewed PesticideHealthcare Web site is anticipated as a critical resource. Additional
access issues discussed by participants are:
• Need for a list of credible sources of information that is regionally customized. Materials also
should be customized by season, community (urban vs. rural), and by state. AOEC will soon
release a new pesticide curriculum for physicians available on CD; the curriculum includes a
list of credible sources of information.
• Need for materials to be user-friendly.
• Need for proven delivery methods such as nursing in-services, traditional print materials, and
role-modeling (primary care provider spending one day per month in a clinic to serve as a
resource). Workgroup members pointed out that school nurses have an average of 5,000
students, so they have limited time available; parent groups, however, influence school
pesticide policy and may be an important audience. Participants also noted role-modeling
programs in Eastern Washington that could be replicated.
• Need for a variety of formats, such as PDA-accessible, CDs, and patient handouts.
Repeated delivery will help keep the issue at the forefront of providers' attention.
4. What more needs to be done to assess the target audience of primary care providers?
Participants felt that it would be useful to understand what primary care providers perceive as
their needs within pesticide and environmental education. This information could be gathered as part of
provider orientation by agencies' administrations.
22
-------
Opinion leaders and spokespeople could present packaged modules at meetings and
conferences. Ideally, the modules would be audience-specific; cover the range of acute and chronic
health effects, explain how to integrate environmental health into one's daily practice; and carry the
"stamp of approval" of key agencies. Priority providers and the most relevant groups, such as migrant
clinicians, pediatricians and residents, should be targeted first. Additional assessment could identify
ongoing regional training programs that need content, which could be customized to reach specific
audiences' needs.
5. What strategies should be used to secure endorsement of the National Guidelines by key
professional organizations and decision-making bodies, specific to practice?
Two opportunities for seeking endorsements are intermediary organizations, and environmental
health and pesticides articles published in medical journals. For intermediary organizations, tasks
include:
• Securing support of organizational opinion leaders and recruiting an active member
advocate to influence organizations to adopt and promote the National Guidelines.
• Getting information to states and territories through nursing organizations (American Public
Health Association/Public Health Nursing Section, National Organization of Specialty
Nursing Organizations). Publicizing information in national newsletters and other member
communications.
• Working with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
to promote the Guidelines and environmental competency, much the same way it promotes
multi-cultural competency, for example.
• Promoting the Guidelines at professional organizations' annual conferences, by having a
session and/or traveling exhibition and printed information at conference booths. Initiative
participants could submit abstracts and propose sessions for their own organizations'
conferences.
Ideas for promotion through medical and consumer media included the following:
• Submitting articles to professional journals, which publish few environmental health articles.
Make an argument to editors for an issue dedicated to pesticides and health. Consider
journals for primary care providers, pediatricians, nurse-midwives.
• Publishing articles in major medical journals such as the Journal of the American Medical
Association and New England Journal of Medicine would spark both health care provider
and public attention. Articles published in smaller journals would reach providers first, but the
consumer side of the article could then be pitched to consumer media (e.g., parenting and
health magazines). This could lead to parents and/or patients asking more direct questions
of their primary care providers, who would then need to educate themselves to respond to
patient questions.
6. What would a model practice setting that incorporates environmental health look like?
23
-------
Participants identified the following baseline criteria for a model practice setting:
• Health care providers know what pesticides are used, and where, in the communities they
treat. To achieve this baseline standard, providers need access to region-specific
information, such as specially-developed leaflets with local information about pesticide use,
manufacturing plants, businesses, etc
• Pediatricians and pediatric nurse practitioners know specific possible sites of children's
potential exposure, including day care, home, and school setting. They know what pesticides
are used, and where, within their communities and that children are more susceptible than
adults to environmental health risks because of their physiology and behavior.
• Providers incorporate key environmental exposure questions in taking histories. To achieve
this baseline standard, providers need a list of questions appropriate to their local
community.
• Specialties teach Best Management practices for pesticides. For example: don't store
pesticides in the house or where children can have access. To achieve this baseline
standard, teachable moments must be identified and assessed for each specialty.
• Providers have established linkages with referral sources and with credible local experts,
who can help interpret information on what pesticides are used, identify potential local
exposure scenarios, etc. To achieve this baseline standard, linkages must be made among
providers, PEHSUs, land-grant university specialists, Cooperative Extension, and state
pesticide regulatory agencies.
• Providers keep prevention messages simple and provide take-home patient literature.
Prevention messages encourage adoption of recommended practices and behaviors.
Communications with patients are sensitive to literacy and language needs of the patient
population.
Short-Term Goals
• Identify opinion leaders in various groups and recruit them into Initiative activities and strategies.
• Raise awareness of health care providers through sound, science-based arguments.
• Identify teachable moments in the various specialties to avoid missed opportunities.
• Arrive at consensus on key exposure history questions.
• Create tools through which the practice setting can perform a self-assessment on staff
knowledge of diagnosis, treatment, education and prevention strategies related to pesticides.
Long-Term Goals
• Raise awareness of health care providers through sound, science-based arguments.
• Educate current health care providers.
• Educate incoming health care providers.
• Ensure that practicing health care providers perform quick self-assessment on knowledge of
diagnosis, treatment, education and prevention strategies related to pesticides.
24
-------
• Ensure that health care providers perform environmental histories.
• Establish pesticides and environmental health as part of standards of practice and competence
• Look at confounders in terms of practice setting (example: Complications for alternative
medicine treatments).
• Educate patients about potential acute and chronic effects of pesticides as related to exposure.
• Relay information on pathways and sources of exposure, and proper preventive and avoidance
measures to patients.
• Encourage increased implementation of integrated pest management (IPM).
• Encourage minimization of pesticide exposure to patient population—through direct patient
education and by using good judgment with regard to pesticide use in the community.
Commitments
Participants made specific follow-up commitments of individual activities that support short-term
and long-term goals. Priority activities will include:
• Approaching various professional organizations' boards of directors with National Guidelines
documents for support and/or endorsement.
• Integrating sessions on the National Guidelines and Pesticides Initiative into regional and
national meetings of professional organizations.
• Developing self-assessment and environmental health patient screening tools for clinicians.
• Developing award strategies for raising the standard of excellence within health departments.
Practice Setting Workshop Participants
Co-Chairs: Amy E. Brown, PhD and Bonnie Rogers, DrPH, COHN-S, LNCC, FAAN
Scribe: Edward Master, RN, MPH
Sophie J. Balk, MD
Rupali Das, MD, MPH
Shelley Davis
Judy Fitzgerald, BSN, RN
Shira Flax
Gonzalo Garcia-Vargas, PhD
Cheryl Hanks
Siobahn McNally, MD
Lill Mood, RN, MPH, FAAN
Teresa Niedda
Susan Randolph, MSN, RN, COHN-S, FAAOHN
Nancy Rothman, EdD, RN
Kathy Seikel
Maria Valenti
Charles Yarborough, MD, MPH
Edward L. Zuroweste, MD
25
-------
Resources & Tools
Summary
Participants in the Resources & Tools workshop considered the issues of information
distribution, funding for the Gateway and interim repository, and development of materials to fill the gaps
defined by the resources inventory. A large quantity of available resources are not currently distributed
to, or accessed by, primary care providers.
While the "PesticideHealthcare.com" Web site will ultimately address issues related to data
collection and online access, other distribution issues must be addressed and other formats considered
in the meantime. Until the Web site is live, materials should be centralized in a high-profile spot.
Issues and goals identified by workshop participants must be overlaid with those defined by the
Education and Practice workshops, as Resources & Tools impact all areas of the Initiative. Priority tasks
defined by the group are:
• Review the Resource Inventory and develop a plan to fill identified resource gaps.
• Incorporate the Resource Inventory into a high profile Web site, such as Medline or
Medscape.
• Work with existing Web sites (e.g., National Library of Medicine) to house the Initiative's
Information Gateway. Optimally, the Gateway data would be housed on Medline or
Medscape. This approach would reduce curb some of the costs inherent in the launch and
maintenance of a new Web site and would increase provider traffic to high-profile sites.
• Develop an online, state-by-state guide for health care providers, presenting the scope of
their responsibilities on pesticide exposures.
Discussion
Workshop participants concentrated on specific gaps in resources and tools, and access and
distribution issues. Participants stressed that a full assessment of resource gaps must be preceded by a
thorough assessment of the Resource Inventory, which will be undertaken by the National Review
Board. Workshop participants also identified several resource needs and concepts beyond the
immediate scope of this particular workshop; those items are listed in Additional Resource Needs below.
While materials geared towards patients and consumers are also needed, providers must first
understand the issues and materials available for patient education.
Gaps in Distribution—Key problems include:
• Information is not reaching health care providers. We need a better understanding of how
information reaches health care clinics.
• Health care providers are not aware of information currently available online (e.g., EPA materials
on children's health).
• Low-literacy materials are not reaching the intended audience.
26
-------
• The public does not have ready access to information about chronic health effects of pesticide
exposure.
Gaps in Traditional Resources—Gaps encompass several issues, including:
• Existing materials are not perceived as health care provider-friendly and are not reaching target
groups within the public and patient population.
• More resources detailing chronic health effects are needed for health care professionals.
• Case studies for health care providers are needed. (Note: Several uncatalogued resources such
as thesis papers may be available through university-based environmental, occupational, or
pediatric environmental health programs.)
Opportunities for New Media Formats:
• Computer-based tools—Tools needed range from computerized differential diagnosis modules
to PDA-formatted resources.
• CD-ROM modules—Recast existing pesticide modules for primary health care providers.
• PowerPoint lectures and modules—Identify and create pathways for sharing existing
presentations.
Additional Resource Needs:
• Low-literacy patient and family materials (videos, brochures, comic books, etc.)
• Quick reference on pesticides for health care providers
• Fact sheet series: hot pesticide and environmental topics in health care settings
• "Case-of-the-week" e-news or listserv
Short-Term Goals
• Confirm resource and materials gaps; revisit the Resource Inventory.
• Define costs for filling defined gaps, including long-term maintenance of gateway.
• Find an immediate, high-profile home for materials.
• Explore partnerships with existing online services (i.e., National Library of Medicine/Medline,
National Pesticide Information Center) to leverage resources.
• Add existing materials to existing Web sites.
• Explore subscription-based Web sites for health care providers. Although workshop participants
acknowledge inherent issues in working with such sites, it is critical to review all options, given
funding issues with the Initiative's Gateway.
• Identify existing pesticide databases, products, and active ingredients.
Long-Term Goals
• Maintain the Initiative Gateway as a credible, dynamic Web site.
27
-------
• Explore relationships with existing commercial products to develop computer-based products for
health care providers.
• Create and maintain an inventory of mandatory reporting requirements in each state.
• Develop a state-by-state guide for health care providers, defining their responsibilities on
pesticide exposures: what must be reported and next steps to take (whom to contact, what
clinical steps to take, where and how to refer patient, etc). This should be available online with
links by state.
Commitments
Workgroup participants made specific follow-up commitments of individual activities that support short-
term and long-term goals. Priority activities will include:
• Coordinate development of a state-specific reporting database with the Pesticides Action
Network of North America.
• Research existing online and off-line data bases, as well as commercial products, for additional
resources, potential partnerships and/or as a temporary repository of Initiative's inventory.
• Review Initiative's current inventory and begin research and request of existing case studies,
lectures and other university-based modules.
• Examine distribution issues.
• Define costs for priority activities.
Resources & Tools Workshop Participants:
Co-Chairs: Mark Robson, PhD, MPH and Elizabeth Blackburn, RN
Scribe: Delta Valente, MPA
Jerome Blondell, PhD
Paul J. Brownson, MD
Velma Charles-Shannon, PhD
Rupali Das, MD, MPH
Frank L. Davido
Kathy Davis
Michelle DeVaux
Angelina Duggan
Adrian J. Enache, PhD, MPH
Jeanne Goshorn, MS
Amy Liebman, MPH, MA
Terry Miller, PhD
Kagan Owens
Virginia Ruiz
Daniel L. Sudakin, MD, MPH
Jennifer Weber
28
-------
SUMMARY AND RECOMMENDATIONS
The National Forum gave participants the opportunity to closely examine the progress of the
Initiative and view it within the context of a broader arena of environmental health and the complex
realities of medicine and nursing professions. Participants were able to successfully expand the
implementation approaches outlined in the Pesticides Initiative's Implementation Plan. They concluded
the two-day conference by highlighting major issues to be pursued, noting that the Initiative's success
will depend on the realization of three key objectives:
• Definition of the ultimate 'product' as environmental health education and training, with
pesticides representing one component of the broader issue. Participants supported Dr.
Kenneth Olden's paradigm in which the interaction of genetics and environmental issues
emerges as the crux of clinical medicine in the future.
• Recruitment and active participation of opinion leaders beyond the environmental,
occupational, nursing, medical, and academic specialists who built the base of the
project. Individuals representing primary care organizations, as well as leaders in education, will
be needed to integrate the Initiative's principles throughout medical and nursing primary care.
• Use of a marketing approach. The delivery of individual products and activities must be a
coordinated effort, and must be grounded in the perspective of the clinician or educator whom
the Initiative is trying to reach. This approach will ensure that products are created, promoted,
and reach individuals in a manner that is tailored to them specifically.
Broken into three workgroups, participants identified and analyzed specific activities focused on
the National Guidelines, other Education and Practice issues, and Resources & Tools. Specific
recommendations and priority activities follow.
National Guidelines
The two National Guidelines documents - National Pesticide Competency Guidelines for
Medical & Nursing Education and National Pesticide Practice Skills Guidelines for Medical & Nursing
Practice - are landmark products of the Initiative. Integrating these guidelines into both educational and
practice settings is clearly a priority. National Forum participants identified numerous strategies to
achieve integration, and provided insight into the mechanisms and intangible elements in medical and
nursing education and practice. This knowledge will greatly enhance marketing plans focused on
outreach to the medical and nursing communities.
Several participants made commitments to bring the National Guidelines documents to the
boards of professional organizations for endorsement and/or support (dependent upon each
29
-------
organization's policies). Individuals also will present the Guidelines as workshop topics at regional and
national meetings of professional organizations.
Organizations targeted or represented by participants include: American Association of Colleges
of Nursing, American Public Health Association, American College of Occupational & Environmental
Medicine, Migrant Clinicians Network, American Association of Occupational Health Nurses, Association
of Occupational and Environmental Clinics, American Association of Pesticide Safety Educators, and
American Academy of Pediatrics.
Based on these specific activities and commitments to be pursued by National Forum
participants, NEETF will involve participants in the implementation of its existing outreach strategies to
promote the National Guidelines.
Education
Participants committed to moving the Initiative forward by focusing on the following areas: the
development of faculty champions, creation of a NEETF position statement on environmental education
in medical and nursing education, and development and identification of environmental, occupational,
and pediatric environmental modules.
To implement the faculty champion strategy, NEETF will research existing medical and nursing
courses, identify faculty focused on environmental and/or occupational health and children's
environmental health, and determine available funding sources for grants to faculty champions. The
network of emerging faculty champions will be strengthened through training workshops and ongoing
communications between champions and Initiative leaders.
NEETF will develop a position statement on the need for environmental education in nursing and
medicine, which will help introduce and supplement the National Guidelines within medical and nursing
education. While some professional organizations do not review and/or endorse specific curriculum
and/or documents such as the National Guidelines, a position statement on environmental health can be
presented to governing bodies of organizations, which can formally support these activities and
potentially result in their membership's involvement. The statement will be presented to the American
Association of Colleges of Nursing, American Public Health Association/Public Health Nursing Section,
and Association of Occupational & Environmental Clinics, among others.
Participants defined a strategy to enhance the points of insertion published in the National
Pesticide Competency Guidelines for Medical & Nursing Education: the creation and distribution of
curricula re-design papers, which would further define tactics for integrating pesticides and
environmental issues into already-saturated medical and nursing curricula. Workgroup members also will
create task plans to develop additional environmental, occupational, and pediatric environmental
curriculum modules and to identify and promote a solid repository of existing case studies and other
educational tools.
30
-------
Practice
In addition to activities supporting implementation of the National Practice Skills Guidelines for
Medical & Nursing Practice, priority activities will focus on identifying opinion leaders in key organizations
and recruit them to join the Initiative. All activities targeted toward practicing providers will be
communicated through science-based arguments and will seek to characterize pesticides and
environmental health issues as part of clinicians' standards of practice and competence.
Participants in the Practice workgroup will focus on the development of two key tools for
clinicians:
• Self-assessment tool through which clinicians can measure their knowledge of diagnosis and
treatment of environmental-related illnesses
• Patient screening tool with basic key environmental questions
Together, these projects will encourage health care providers to incorporate environmental histories as a
routine matter.
Individuals representing and/or active in professional organizations will work toward including
sessions on the Initiative, or including the Initiative as part of environmental sessions, at regional and
national conferences. Targeted organizations include Migrant Clinicians Network, American Public
Health Association, American Association of Occupational Health Nurses, and American College of
Occupational & Environmental Medicine.
Gateway/Resources & Tools
Many of the priority issues analyzed by the Resources & Tools workgroup center on the
Gateway project—specifically, securing launch and long-term funding to maintain the Web site as a
credible, dynamic home for the resources that will vastly expand all education and training opportunities
and activities.
Pending the launch and long-term funding of the Gateway, participants will focus on interim
solutions: finding an immediate, high-profile home for the existing inventory of resources, and adding
existing materials to current Web sites. Other activities include potential partnerships with online services
to leverage the Initiative's inventory and exploring subscription-based Web sites to expand outreach.
Beyond the Gateway issues, participants will explore issues and solutions around the major
gaps they identified: the lack of distribution of resources throughout the ladder of organizations and
professionals who ultimately must diagnose, treat, and communicate with patients and families; a
comprehensive, accessible database for physicians on state-specific reporting requirements and
systems; and prevention messages and tools based on data from the literature on exposure and chronic
health effects. As these individual projects are developed, they will be overlaid with activities undertaken
within both Education and Practice to maximize the efforts of all individuals and organizations working
together to implement the Initiative.
31
-------
APPENDIX A
National Forum Agenda
National Strategies for Health Care Providers: Pesticide Initiative
Hamilton Crowne Plaza ¦ Washington, DC ¦ June 10-11,2003
June 10,2003
8:00 am - 8:30 am
Registration & Continental Breakfast
8:30 am - 10:30 am
Plenary Session
Welcome
Jim Jones, Director, Office of Pesticides Programs, U.S. Environmental
Protection Agency
Kevin Coyle, President, National Environmental Education and Training
Foundation
Opening Remarks
Deborah Danoff, MD, Association of American Medical Colleges
Patricia Butterfield, PhD, RN, American Association of Colleges of
Nursing
Initiative Overview
Kevin Keaney, Chief, Certification & Worker Protection Branch, Office
of Pesticides Programs, U.S. Environmental Protection Agency
Goals and Objectives
Leyla Erk McCurdy, Senior Director, National Environmental Education
and Training Foundation
Making the Case: The Need to Improve Health Care Provider
Education and Practice
Daniel Goldstein, MD, Monsanto Company
James Roberts, MD, MPH, Medical University of South Carolina
Project Overviews
National Guidelines for Competencies and Practice Skills
Andrea Lindell, DNSc, RN, College of Nursing, University of Cincinnati
Audience Assessment Pilot Project
David F. Goldsmith, MSPH, PhD, School of Public Health and Health
Services, The George Washington University
10:40 am- 11:00 am
Break
11:00 am - 12:30 pm
Plenary Session (Continued)
A-l
-------
Pesticide Resources, Tools and Information Gateway
Mark Robson, PhD, MPH, School of Public Health, University of Medicine
& Dentistry of New Jersey
Brian West, Clicklmpact
Action Agenda for Incorporating Environmental Health into Pediatric
Medical and Nursing Education Standards
Jerome Paulson, MD, Mid-Atlantic Center for Children's Health and
the Environment, The George Washington University, and Children's
Environmental Health Network
Kenneth Olden PhD, Director, National Institute of Environmental
Health Sciences
Education Settings
Co-Chairs: Candace Burns PhD, ARNP, University of South Florida
College of Nursing, and Geoffrey Calvert, MD, MPH, National Institute
of Environmental Health Sciences
Scribe: Artensie Flowers, PhD, MPH, Office of Pesticides Programs,
U.S. EPA
Practice Settings
Co-Chairs: Amy Brown, PhD, University of Maryland, and Bonnie
Rogers, DrPH, COHN-S, LNCC, FAAN, University of North Carolina
School of Public Health
Scribe: Edward Master, RN, MPH, Region 5, U.S. EPA
Resources and Tools
Co-Chairs: Mark Robson, PhD, MPH, University of Medicine &
Dentistry of New Jersey, and Elizabeth Blackburn, RN, Office of
Children's Health Protection, U.S. EPA
Scribe: Delta Valente, MP A, Office of Environmental Justice, U.S. EPA
12:30 pm -2:00 pm
Lunch & Key Note Address
2:00 pm - 3:30 pm
Concurrent Workshops
3:30 pm - 3:45 pm
Break
3:45 pm - 5:30 pm
Concurrent Workshops Continued
5:30 pm
Adjourn for the Day
6:00 pm - 7:30 pm
Reception
A-2
-------
June 11,2003
8:00 am - 8:30 am Continental Breakfast
8:30 am - 12:00 pm Plenary Session
8:30 am -9:00 am The Initiative and Public/Private Partnerships
Michael A. McGeehin, PhD, MSPH, National Center for Environmental
Health, Centers for Disease Control and Prevention
Bonnie Rogers, DrPH, COHN-S, LNCC, University of North Carolina
School of Public Health
9:00 am - 10:00 am Workshop Reports and Discussion
10:00 am - 10:15 am Break
10:15 am - 12:00 pm Discussion Continued and Wrap Up
12: 00 pm Adjourn
A-3
-------
APPENDIX B
SPEAKER PRESENTATIONS
Opening Remarks
Deborah Danoff, MD
Associate Vice President
American Association of Medical Colleges
Patricia Butterfield, PhD, RN
American Association of Colleges of Nursing
Initiative Overview
Kevin Keaney
Chief, Certification & Worker Protection Branch, Office of Pesticides Programs
US Environmental Protection Agency
Goals and Objectives
Leyla Erk McCurdy, M Phil
Senior Director
The National Environmental Education and Training Foundation
Making the Case: The Need to Improve Health Care Provider Education and Practice
The Issue In Perspective
Daniel Goldstein, MD, F.A.C.M.T.
Senior Science Fellow
Director, Medical Toxicology
Monsanto Company
Children as a Vulnerable Population
James Roberts, MD, MPH
Assistant Professor, Department of Pediatrics
Medical University of South Carolina
Project Overviews
National Guidelines for Competencies and Practice Skills
Andrea Lindell, DNSc, RN
Past President, American Association of Colleges of Nursing
Dean, College of Nursing
Associate Senior Vice President & Vice Provost, Medical Center
University of Cincinnati
Audience Assessment Pilot Project
David F. Goldsmith, NSPH, PhD
Associate Research Professor of Environmental Occupational Health
The George Washington University Medical Center
Pesticide Resources. Tools and Information Gateway
Mark Robson, PhD, MPH, ATS
University of Medicine and Dentistry of New Jersey, School of Public Health
Brian West
Founder and Principal
Clicklmpact
B-l
-------
Action Agenda for Incorporating Environmental Health into Pediatric Medical and Nursing
Education Standards
Jerome Paulson, MD
Mid-Atlantic Center for Children's Health and the Environment
George Washington University Medical Center & the Children's Environmental Health Network
Key Note Address
Kenneth Olden PhD
Director, National Institute of Environmental Health Sciences
National Institutes of Health
The Initiative and Public/Private Partnerships
Michael A. McGeehin, PhD, MSPH
Director, Division of Environmental hazards and Health Effects
National Center for Environmental Health
Centers for Disease Control and Prevention
Bonnie Rogers, DrPH, COHN-S, LNCC, FAAN
Past President, American Association of Occupational Health Nurses
University of North Carolina School of Public Health
B-2
-------
National Forum Agenda
National Strategies for Health Care
Providers: Pesticide Initiative
June 2003
Deborah Danoff MD
Associate Vice President
Association of American Medical Colleges
AAMC
Members:
• LCME accredited medical schools in the
US and Canada (142)
• 400 teaching hospitals
• 90 academic societies
• Medical students
• Residents
• Faculty
AAMC Mission
The improvement of the nation's
health through the advancement
of medical schools and teaching
hospitals
Assist its institutional and individual
members to integrate ongoing
education into the provision of
effective health care
Work with educators across the
continuum of education
Understand and enhance the role of
continuing medical education in
the support of high quality medical
practice
aaIjSc
Enhancing Medical Education
• Inspire, encourage and mentor
• Curriculum review and revision
• Resource materials
• Professional development
Continuum of Medical
Education
• Undergraduate (Medical
School)
• Graduate (Residency and
Fellowship)
• Continuing Medical Education
-------
Medical School Objectives
Project
(MSOP)
Consensus within the medical education
community on the attributes that medical
students should possess at the time of
graduation, and to set forth learning
objectives for the medical school
curriculum derived from those attributes.
General Attributes
• Altruistic
• Knowledgeable
• Skillful
• Dutiful
MSOP
• Knowledge of the various causes
(genetic, developmental, metabolic,
toxic-—)of maladies and the ways that
they operate on the body.
• Physicians must feel obligated to
collaborate with other health
professionals and use systematic
approaches for promoting, maintaining
and improving the health of individuals
and populations.
aaIjSc
• They must be knowledgeable about risk
factors for disease and injury, must
understand how to utilize disease and
injury prevention practices-.
• They must understand the economic,
psychological, occupational, social and
cultural factors that contribute to the
development and/or perpetuation of
conditions that impair health.
Liaison Committee on Medical al
Education
LCME
The Liaison Committee on Medical
Education (LCME) is the nationally
recognized accrediting authority for
medical education programs leading to
the M.D. degree in U.S. and Canadian
medical schools. The LCME is
sponsored by the Association of
American Medical Colleges and the
American Medical Association.
-------
Educational Program
• It must include the contemporary
content of those disciplines that
have been traditionally titled
anatomy, biochemistry, genetics,
physiology, microbiology and
immunology, pathology,
pharmacology and therapeutics,
and preventive medicine.
Current Curriculum
CurrMIT
Schools include teaching about
environmental and occupational
health in curriculum
Various offerings related to
toxicology with some specific
mention of pesticides
Current Curriculum
"We have included discussion and
case analysis of
organophosphorous compounds
as part of our basic pharmacology
course."
"The thrust is more in response to
bioterrorism issues than
environmental issues"
South Carolina
Agromedicine Program
Medical University of South Carolina
Department of Family Medicine
Lectures in the medical school
curriculum
Final year elective
Required residency rotation
aaIjSc
Strategies
Identify a champion
Educate and involve key faculty
Work incrementally
Work with existing curriculum structure,
culture
Engage students
Grants—not just the money, enhance
profile
-------
National Strategies for Health Care
Providers—Pesticides Initiative:
Capitalizing on Nursing Expertise
Patricia Butterfield, PhD, RN
American Association of Colleges of Nursing
K) American Association
||| | of Colleges of Nursing
Nurses working to prevent and reduce
over-exposure to
pesticides
... .Sandy Kuntz, a community
health nursing faculty member at
Montana State University, owns a
cherry orchard on Flathead Lake
... She serves as a resource to local
citizens and health providers
... In her courses Sandi teaches
student nurses to recognize and
refer patients with possible pesticide
poisoning to local health providers
and the Montana Migrant Council
mobile clinic
Nurses—first line in early recognition and
treatment of pesticide over-exposure
¦ "...nurses are often the
initial, and sometimes,
only points of contact
for people seeking
health care." NEETF,
2003
¦ How nurses assess
and document a
patient's symptoms
may determine the type
of health care provided
Valli Stager, FNP, Butte, Montana
Poorly documented symptoms can mean
missed cases and improper health care
¦ "Community and
home health nurses
also may visit patients
in their homes,
workplaces and local
communities, thus
gaining first hand
knowledge of
potential pesticide
exposures in these
settings."
NEETF, January 2003
Teresa Henry, ANP, Missoula, Montana
Overloaded curricula and under-trained
faculty
Most nurses don't learn
about primary or
secondary prevention
of pesticide over-
exposure
Most nursing faculty
have little or no
background in the
recognition of pesticide
poisoning
COOP Nursing Student, MSU
The 21st century nursing curricula: context
and critical thinking
WW «
1 1
b' - j
The Essentials of Master's Education for Advanced
Practice Nursing
The Essentials of Baccalaureate Education for
Professional Nursing Practice
American Association of Colleges of Nursing
-------
I Essentials of Baccalaureate Education
¦ Core knowledge
~ "foster
strategies for
health
promotion, risk
reduction, and
disease
prevention
across the
lifespan."
Community Health Clinic, Dillon, Montana
Essentials of Master's Education
¦ "Course work should provide graduates with the
knowledge and skills to: use epidemiological, social,
and environmental data to draw inferences regarding
the health status of client populations...."
K ) \1—Nursing, Health, & the
Environment
Environmental heath
competencies
addressing:
¦Education
¦Practice
¦Research
•Nursing,
inviromnaffit
IOM Competencies—continued
¦ "Medical/surgery
course work must
include lecture
content on the health
effects of chronic
exposure to chemical ,
physical, and
biological agents on
the job and in the
environment (e.g.,
asbestos,
pesticides) "
National Pesticide Competency Guidelines
¦ Guides faculty to
competencies
and points of
insertion in the
curriculum
National Competency fitiidelmns for
Medical & Nursing
^Education
^ Vi r
HB * « -
National Pesticide Competency Guidelines
for Medical & Nursing Practice
Provides clear and
concise information for
busy practitioners
addressing symptoms
and management
considerations for
different categories of
pesticides
-------
Leading the charge: American Association
of Colleges of Nursing
Stimulates change
by naming
overexposure to
pesticides as a
nursing issue and
articulating
nursing's role in
responding to
health concerns
Why nursing and why now
¦ 2.6 million registered
nurses
¦ In all practice
settings—hospital
units, homes,
schools, industry,
emergency rooms
¦ Assessment,
referral, and case
management are
strengths
Why nursing and why now (continued)
Gallatin City County Health Department, Board of Health
Comfortable with
both an individual
and population focus
on health care
Increasing role in
creation of local and
national health policy
Work from a
framework of
prevention
Conclusion
Nurses in school garden in Mexicali, Mexicc
¦ Nursing is
often an
untapped
resource in
national
public health
initiatives
¦ Applaud the efforts of NEETF, EPA, and other agencies
in identifying nursing as a key stakeholder
Conclusion
¦ Assure that high
risk groups will
be identified
¦ Assure that
clients will be
assessed and
directed to the
most
appropriate type
of health care
Rebecca Spear, RN, Bozeman, Montana
¦Promote optimal treatment
in emergency situations and
hazardous-material spills
Conclusion
¦ Play a pivotal role in assuring that current
and future generations of nurses are well
prepared to recognize and manage persons
with pesticide poisoning
¦ Play an equally important role in primary
prevention efforts in homes, schools, and
communities
¦ Play a role for the judicious use of pesticides
and for science-based decision making
-------
9
National Strategies for
Health Care Providers:
Pesticides Initiative
An Overview
National Forum
June 2003
An EPA initiative through a
cooperative agreement with
the National Environmental
Education & Training
Foundation (NEETF) to
improve the recognition,
management and prevention
of health effects from
pesticide exposure.
9 M
Federal Interagency Planning
Committee & Stakeholders
8EPA - HHS - USDA - DoL - NEETF - AAPSE
• Federal Agencies
•Academic Institutions
• Professional Organizations
• Foundations
• Farm Worker and Farm Groups
• Industry and Trade Associations
9
The Need
• Established in WP public hearings.
• Studies indicating +/- 7 hours of required study
in environmental medicine during medical
school.
• Institute of Medicine recommends integrating
environmental health education into medical
and nursing professions.
• American Medical Association urges improved
assessment and prevention of pesticide risks.
9 IB
Initiative History
• 1998 - EPA workshop of experts
• 1999 - Workgroup meetings
• 2000 - Draft Implementation Plan
• 2002 - Implementation Plan
• 2003 - Competency Guidelines for Medical Education &
Nursing Education
• June 10-11, 2003 - National Forum
•:
Target Audience
• Primary HCP's: * Decision-making Bodies, such
s Physicians as:
s Nurses s Professional Associations
n Nurse Practitioners n Curriculum Committees
¦ Physician Assist. ¦ Accrediting Institutions
s Nurse Midwives s Faculty and Administrators
n Community Health a Residency Review Committees
Workers a Institutions Governing Health
Care Practice and Requirements
-------
Strategic Framework
I Educational Settings
Practice Settings
Etiucat onal institutions
Educational competencies
Institutions and faculty
Key decision-makers
Faculty champion*
Primary ca'e providers
Practice skills
Primary care providers
Key decision-makers
New practice models
< Define guidelines ~
< Assess target audiences ~
•4 Secure endorsements ~
A Demonstrate success ~
and reporting
A
1
I
Resources
t +^
Inver tnry National New Information
Review Board Resources Gateway
Competency Guidelines for
Medical & Nursing Education
I. Knowledge and Concepts of Pesticides
II. Diagnosis and Assessment
III. Treatment, Intervention, and Referrals
IV. Risk Communication
V. Reporting Requirements and Regulations
9 H
Practice Skills Guidelines for
Medical & Nursing Practice
I. Taking an Environmental History
II. Knowledge of Key Health Principles
III. Awareness of Community and Individual Pesticide
Risk Factors
IV. Clinical Management of Pesticide Exposure
V. Reporting Pesticide Exposure and Supporting
Surveillance Efforts
VI. Providing Prevention Guidance and Education to
Patients
Assessment of Practitioners
Pediatric Health Care Providers Pilot
Study
Conducted by George Washington University
Assessment of knowledge, skills and preferred
learning styles of urban, suburban and rural
clinicians (pediatricians and pediatric nurse
practitioners) and nurses in the mid-Atlantic.
Assessment of Practitioners
Pilot Study Conclusions
• Uncertain whether pesticides are a problem for their
community.
• Limited time to devote to CE in general, and
pesticide / EH issues specifically.
• Don't feel well prepared to handle pesticide issues.
• Don't inquire about issues with which they are not
comfortable.
• Rely on emergency rooms / poison control centers
to manage pesticide issues.
• Prefer in-person expert methods of training over
self-administered materials.
National Forum
o June 10-11 2003 in Washington, DC
o Health care providers and key decision-
makers from agencies and stakeholder
organizations.
e Priority projects - successful models -
workgroups strategies
• Forum report
• Six-month follow up
-------
•
National Strategies for
Health Care Providers:
Pesticides Initiative
National Forum
Goals and Objectives
Leyla Erk McCurdy
National Environmental Education & Training Foundation
Primary Goals
• Build national consensus and gain support to implement the
Initiative
• Secure commitments to influence professional associations,
decision-making bodies, academic institutions, and practice
settings to integrate pesticide content
• Create national partnership to develop action agenda to
institutionalize integration of environmental health into health
care
• Build support for replicating the pesticide model for other
environmental issues
Secondary Goals
• Raise awareness among large group of stakeholders
• Lead to an increase of partnerships
• Lead to an increase in use of the available resources/tools
9
Structure
• Planning summit for executing the strategies and
recommendations of Initiative's implementation plan
• Interactive workshops:
B Education settings
B Practice settings
¦ Research and Tools
Follow Up
• Forum Report in Fall 2003
• Follow Up Survey in January 2004
-------
Making the Case: The Need to Improve Health
Care Provider Education and Practice
The Issue in Perspective
National Forum Agenda:
National Strategies for Health Care Providers: Pesticide Initiative
June 10-11, 2003 , CROWN PLAZA HOTEL, WASHINGTON DC
Daniel A. Goldstein, M.D., F.A.C.M.T.
Senior Science Fellow
Director, Medical Toxicology
The Monsanto Company
St Louis, Missouri
314-694-6469 daniel.a. goldstein@ST L. monsanto. com
Q ~
® Industry and NEETF
• Industry strongly supports the NEETF
educational effort:
• Environmental health IS under-taught.
• Environmental history often forgotten!!
• Recognition of major acute tox-syndromes
( pesticide and other) is useful.
• Providers need information / resources.
n
n
ffl f"\
B NEETF GOALS *3 g)
~~~ Taking a brief and relevant environmental and occupational history
~ Basic awareness of environments in which patients live/work/play
~ Recognizing possible signs and symptoms of pesticide exposure
~ Identifying possible sentinel cases
~ Diagnosing possible associated health conditions, including those of
sensitive populations- children and elderly (CARE NEEDED !!)
~ Ready access to a recommended referral list
~~~ Calling upon an appropriate specialist or expert to assist them
~ Recognizing when to report exposure incidents to health authorities
~ Participating in surveillance systems
~ Providing basic preventive guidance for patients.
A need for Perspective:
¦ Proper and timely diagnosis requires:
¦ Knowledge
¦ Resources
¦ ACCURATE perspective on the nature & frequency of disease.
¦ Commonly held and promoted beliefs about
pesticide illness are not supported by available data.
¦ Pesticide issues need to be in perspective so that:
¦ Diagnostic practices do not become distorted.
¦ NEETF Program information can be used to optimal benefit.
1®
a.
Outline
• Why is perspective important?
• Acute pesticide poisoning.
• Pesticides & Environmental Health.
• Pesticides & children / at-risk populations.
• Pesticides and chronic disease.
• Where do we go from here?
ffl
The Problem of Rare Diseases
• Medical school is of finite length, physicians have finite
knowledge.
• Most presentations have a LARGE differential diagnosis.
• Most cases are caused bv common causes!
• General physicians:
• Need to know most about common diseases.
• Need to know when to CONSIDER rare disease.
• Initial evaluations CANNOT evaluate all causes:
• Time and cost limitations
• Invasiveness / discomfort
• Risk of diagnostic procedures
-------
Diagnosis - a probabilistic exercise:
• Hypertension i=- pheochromocytoma,
• Distorting conceptions about the
probability of disease results in
mis-diagnosis, mis-treatment,
and mis-allocation of resources.
• Rare diseases SHOULD, on average, be under-diagnosed at
initial presentation relative to common diseases unless:
• HISTORY suggests a rare disease is more likely.
• Characteristic sign, symptom, or syndrome allows for recognition
of a UNIQUE presentation.
"Flu" ^ Leptospirosis
n
p
1.
Pesticide Poisoning- A Rare Disease in
the General Population
• TESS 2001 reports 90,000 Pesticide Exposures:
• Pesticides are 4 % of total (2.3 Million) exposures.
• Many asymptomatic or limited to eye/skin topical
effects. (Ex: 42% Cal-EPA, 2001)
• Severity:
• Major 242
• Moderate 2461
• 17 deaths (1.6% of all deaths)
• Intentional - 15
• Accidental - 2
| • Pediatric deaths - 1 |
Pesticides- vs. Other Fatalities
AGENT
# SEVERE
# FATAL
Pesticides
Alcohols
Cleaning products
242
1803
352
17
108
26
Analgesics
I—~ (Acetaminophen
Antidepressants
Sedative/hypnotic
4295
2017
4398
4692
531
238)
255
266
(TESS, 2001)
Unintentional Injury is the Leading cause of Death- Age 1-17 #
CAUSE
# DEATHS
Motor vehicle
4648
Drowning
1085
Fire / burn
601
Other Land Transport
225
Pedestrian, other
213
Poisoning (unintentional)
198
Pesticide
3- (1
Firearm (unintentional)
149
Fall
108
* (est. from TESS 2001: [pesticide fatality / total fatality] X 198)
# US data, year 2000 from http://webapp.cdc.gov/sasweb/ncipc/leadcaus.html
Q ~
Assessing a symptom complex: GI
• There are 55 MILLION visits in the US for GI tract and
digestive symptoms:
• Assume: All 14,500 OP/Carbamate Exposures (TESS) are
symptomatic:
OP/Carbamate poisoning accounts for 0.03%, or about
ONE IN EVERY 4000 PEOPLE with GI SYMPTOMS
(estimates: CDC, NCHS website, for year 2002)
If we work these up....
• 55 Million cholinesterase at $50 = $2.8 Billion
• 55 M Cholinesterase, 5% randomly below
"normal" = 2.8 Million "false positives"
• 14,500 "true +" (assume all exposures = poisoning) gives
a Positive Predictive Value of 0.5%
• Exaggerated?? Yes! - but if done only 0.1 % of the
time:
• 2.8 Million dollars in testing.
• 2,800 false positives.
-------
ffl
PESTICIDES =£ ENVIRONMENT
• Environmental and occupational health includes:
• Air pollution
• Water quality / pollutants (pesticide/ non-pesticide)
• Infectious agents (SARS, TB, HIV/AIDS, STD's)
• Food poisoning: estimates: 76 M illnesses; 325,000
hospitalizations, and 5,000 deaths
http ://www. cdc .gov/ncidod/ eid/vol5no5/mead.htm
• Radiation
• Physical hazards (automobile, bicycle, drowning,
gunshot, child abuse, neglect)
• Work related exposures
• Pharmaceuticals
Pesticides are DIVERSE!!
• Pesticide poisoning is just as conceptually useful as:
• "Drug poisoning"
• "Chemical poisoning"
• "Infection"
• INCLUDES: Insecticides, fungicides, rodenticides,
antimicrobials and disinfectants, etc...
• Vary WIDELY by mechanism of action, kinetics,
degree of toxicity, use, and presence in the
environment.
Q ~
® Pesticides and Children:
• Children often have a greater weight-adjusted
exposure to pesticides and other agents:
• Higher air and water intake.
• More hand-mouth and exploratory activity.
• More time spent on floors/surfaces/ground.
• Less personal hygiene.
• HOWEVER:
• Beyond 6 months- little difference in kinetics.
• May have increased OR decreased
susceptibility to chemical effects.
1 Populations at Risk:
• Migrant workers and children have:
• More direct exposure to field application
• Higher rate of pesticide intoxication in SOME
geographies (esp. table vegetables)
• Serious unmet health and other needs.
• Farm families:
• More opportunity for acute exposure/accident.
• Do NOT necessarily have uniformly increased
exposure to pesticides (Farm Family Study)
• ENVIRONMENTAL HISTORY helps to identify these
populations!
® Pesticides and Chronic Disease
• Childhood cancer rates are essentially stable.
• There is no clear evidence that pesticide residues
account for any significant portion of childhood cancer.
• Epidemiologic studies of cancer generally lack
validated exposure.
• No evidence for change in the frequency of learning
disabilities, autism, or other developmental disorders.
• No clear evidence that pesticide residues account for
any significant proportion of neuro-developmental
disorders.
ffl
Pesticides and Chronic Disease
• Rates of childhood asthma / asthma deaths are increasing:
• Role of changing diagnosis vs. changing rate??
• Role of medication ??
• Some insecticides may be associated with asthma.
• Some insects ARE associated with asthma.
• There is no clear evidence that pesticides account for
changes in the epidemiology of childhood asthma.
• There is no evidence that pesticide residues account
significantly for adverse reproductive outcomes.
-------
n
p
1 Attribution of Disease
• ACUTE: Identification of a possible exposure does
NOT make a diagnosis.
• CHRONIC: EXTREME difficulty attributing outcome
to exposure(s).
• Offhand attributions have serious consequences:
• Unrealistic blame of self/others.
• Unrealistic expectations of compensation/justice.
• Consumption of energy and financial resources.
• Loss of focus on the patient's needs.
• Unjustified avoidance behaviors
• Generalists probably should REFER most issues of
this type to a specialist (epi., toxicology, etc.)
Where do we go from here?
• Strong support for increased training and
resources - NEETF
• Training should proceed with:
• ACCURATE perspective on pesticide related
illness
• appreciation for the BROAD SCOPE of
Environmental Health.
• A reluctance to assign case-specific causality.
n p
Consistent with Rare Disease:
• Improve teaching of Environmental Health.
• Improve teaching /use of ENVIRONMENTAL
HISTORY!!!
• Help providers to better understand the diversity of
pesticides and other chemicals.
• Encourage recognition of key tax- syndromes.
• Provide reference materials.
• Provide referral resources.
• Connect to surveillance networks.
Great Moments in Natural "History"
-------
Making the Case:
The Need to Improve Health Care
Provider Education and Practice
Children as a Vulnerable Population
James R. Roberts, MD, MPH
Medical University of South Carolina
Objectives
• Children are different from adults and have
unique susceptibilities
• Children's exposure to pesticides
• State of current educational activity for
pesticide exposure and environmental
health
• Why is this Initiative so important?
Cause for Concern
• In my lifetime we've seen
- Increasing rates of asthma, obesity, autism
- Changing exposures to chemicals
- Decreasing age of puberty in girls
• More discussion on Low level exposure vs.
acute poisoning
• Subtle but serious dysfunction particularly
with learning, attention, and IQ
Sites of Pesticide Exposure
• Children of farm workers
• Home and Garden Use
- Insecticides and herbicides
- Flea products on pets
• Water supply, particularly well water
• Food supply
Children Differ from Adults!
More than just physically
Exposure
Quantitative
Qualitative
Critical Windows
Time-Sensitive Toxicity
Metabolism
Disease Processes
Unique to Children
Exposure:
Quantitative Differences
Maintanence Requirements
cal/kg/day ml/kg/day
¦ l
~ 1.0-3.0
~ 4.0-6.0
~ 7.0-10.0
~ 11.0-14
~ 15-18
~ Adults
Age in Years
Harriet Lane, 13th ED
Ershow and Cantor NC11
-------
Exposure:
Qualitative Differences
• Unique Exposures
- (Transplacental)
- Breast Feeding
• Environmental Interaction
- Hand-to-Mouth
- Object-to-Mouth
- Living Zones
• Children do not understand danger
- Preambulatory
- Adolescence "high risk" behaviors
Growth and Maturation
• Physical growth is non-linear
- Weight: doubles 5 mo; triples by 1 year
- Length: 50% increase by 1 year
- Surface area: 200% increase by 1 year
- Growth rate slows until puberty
• Development is a continuous process
• Metabolism differs greatly from infancy
to adulthood
Diseases of Childhood With Marked
Variation in Incidence by Age
• Necrotizing Enterocolitis, Retinopathy of
Prematurity
• Pyloric Stenosis, Colic
• Cow's Milk Allergy
• SIDS
• Intussusception
• Kawasaki's Disease
• Febrile Seizures
• Slipped capito-femoral epiphysis
Of Course Children Are Different
Misdiagnosis: Why this is
important
• 5 of 7 siblings from Mississippi present with
abdominal pain, 1 with fever and diarrhea
• Diagnosis of viral gastroenteritis
• 2 days later, 3 children do not respond to
voice, and all are obviously ill
• Later in afternoon all 7 present to Memphis
ER with signs and symptoms of
organophosphate poisoning
• 1 child died
MMWR 1984;33:592-4
-------
Nosocomial Exposure
• A 40 year old man presented to a local
hospital ED after intentional ingestion of
insecticide containing an phosmet®
• Poison control center was contacted
and recommended decontamination of
patient's skin and gastric contents in a
sealed container
• No decontamination occurred
MMWR 2001;49(51): 1156-8
Nosocomial Exposure
• 3 health care workers developed signs and
symptoms of organophosphate toxicity, one
requiring respiratory support
• Third episode in the year 2000 reported in a
Georgia hospital
• 1987-1998- NIOSH identified 46 health care
workers who acquired pesticide related
illness following medical care
MMWR 2001 ;49(51): 1156-8
Organophosphates and Children
• Present with different clinical picture from adults
- seizures (22%-25%) and mental status
changes (54%-96%) were more common
• 2-3% of adults presented with CNS findings
- Bradycardia, sweating, lacrimation and other
cholinergic signs less common in children
• 80% wrong transfer diagnosis in one study
• 88% of parents initially denied exposure in other
Zweiner RJ. Pediatrics 1988;81:121-6. Sofer S. Pediatr Emer Care 1989;5:222-5.
The Need
75% of medical schools require about 7 hours of
study in environmental medicine over four years
Survey of 109 Chief Residents of pediatric
residency programs
- 72% provide some type of educational material related
to environmental health
- Most common topics were lead poisoning and asthma
• 17% included pesticides
- 2.5 hours or less on environmental health (78%)
- 2 of 109 respondents thought too much time was spent
on environmental health issues
Schenk, M et al. Academic Medicine 1996;71:499-501.
Roberts JR, Gitterman BA. Ambulatory Pediatrics 2003;3;57-59.
Assessment of
Practitioners
Pediatric Health Care Providers
Pilot Study
• David F. Goldsmith, MSPH, PhD will be
presenting the results later today
• Adds additional support for The Need for this
initiative
Survey of 3rd Year Medical Students
History Taking Practices
• Where they live
• Smokers
• Pets
• Occupation for
adult patients
• Parent's Occupation .
for pediatric patients
33%
Always ask
53%
ask at least
3/4
of time
30%
ask at least
3/4
of time
73%
ask at least
3/4
of time
18%
ask at least
3/4
of time
Roberts JR, Reigart JR. Ambulatory Pediatrics 2001;1:108-111.
-------
Students' Practices and Attitudes
• Age of housing
• 82% Never ask
• Water supply
• 76% Never ask
• Chemicals in home
• 79% Never ask
• Environmental history
• 77% Always should
for a well child visit
include
• Environmental history
• 69% Always should
for a sick visit
include
Roberts JR, Reigart JR. Ambulatory Pediatrics 2001;1:108-111.
Environmental Health Education
Does Work
• Modest interventions in pediatric residency
program yielded increase in resident's
history taking for asthma patients
- Bearer CF and Phillips R. Pediatric environmental health training:
Impact on pediatric residents. AJDC 1993;147:682-684.
• Initial success in Undergraduate Medical
Education
- Goldman RH, Rosenwasser S, Armstrong E. Incorporating an
environmental/occupational medicine theme into the medical
school curriculum. J Occup Environ Med 1999;41:47-52.
Why is this Initiative Important?
• # of childhood exposures
• More we don't know than know
• Missed cases of pesticide exposure
- The other MMWR reports
• Important step towards introducing
additional environmental health curriculum
Why is this Initiative Important?
Parents have many pesticide
related questions
It is the Generalist or primary
nurse in the office who
receives these questions
- What is a safe and effective
way of preventing insect
bites/ West Nile virus?
- What should I do about my
wood play structure and
deck treated with arsenic?
-------
NATIONAL PESTICIDE . . .
Competency Guidelines
for Medical & Nursing Education
Practice Skills Guidelines for
Medical & Nursing Practice
Andrea R. Lindell
Dean, College of Nursing
Associate Senior Vice Preside]
& Vice Provost, Medical Cent
University of Cincinnati
A Project of the National
Strategies for Healthcare Providers:
Pesticide Initiative
SUPPORT
A cooperative agreement between the Office
of Pesticide Programs of the US Environmental
Protection Agency & the National Environmental
Education and Training Foundation
PROJECT VISION
For all primary healthcare providers to ...
... Possess a basic understanding of the health
effects associated with pesticide exposures as
well as broader environmental exposures.
... Take action to ameliorate such effects through
clinical and prevention activities.
PROJECT VISION (cont.)
To achieve vision:
- incorporate changes in educational
institutions related to healthcare
- equip students with skills and competencies
to better deal with pesticide exposures and
health conditions
- recognize and accept real health threats
posed by pesticides
- take first step in addressing growing
problem of environmental toxins
PROJECT OUTCOMES
Documents
- 2 printed documents
- Outline of competencies and skills needed
by healthcare professionals in pesticides/
environment health
The Importance of the Project
- Developed for frontline healthcare professionals
The What & Who
- Educational competency guidelines for
basic and advanced components of
educational institutions
- Practice skills guidelines for primary
care providers
-------
EDUCATION DOCUMENT ELEMENTS
- Pesticide Primer
- Regulatory Context
- Pesticide Quick Facts
- Exposure & Absorption
- Patterns of Exposure
- References
Pesticide Competency Guidelines for
- Content
- Insertion Points
- Resources for Educational Curricula
Five Educational Competencies
COMPETENCY GUIDELINES for
MEDICAL & NURSING EDUCATION
1. Knowledge & Concepts of Pesticides
2. Diagnosis and Assessment
3. Treatment, Intervention & Referrals
4. Risk Communication
m
y ~
5. Reporting Requirements
& Regulations
PRACTICE DOCUMENT ELEMENTS
- Pesticide Primer
- Regulatory Context
- Pesticide Quick Facts
- Exposure & Absorption
- Patterns of Exposure
- References
• Literature Review
• Incorporating Pesticides into Practice Skills
- Points of Contact for Training/Refreshing Practitioners
- Adult Principles
- Content & Resources for Practice Settings
Six Practice Skills
PRACTICE SKILLS GUIDELINES for
MEDICAL & NURSING PRACTICE
l.
Taking an Environmental History
2.
Knowledge of Key Health Principles
3.
Awareness of Community & Individual
Pesticide Risk Factors
4.
Clinical Management of Pesticide Exposure
5.
Reporting Pesticide Exposure & Supporting
Surveillance Efforts
6.
Providing Prevention Guidance &
Education to Patients
-------
ATTITUDES, BELIEFS AND PRACTICES
OF PEDIATRIC HEALTH CARE
PROVIDERS REGARDING
CONTINUING EDUCATION ON
PESTICIDE TOXICITY
John M. Balbus, MD, MPH
Chinonye E. Umeh, MPH, MT(ASCP)
David F. Goldsmith, PhD, MSPH
The George Washington University
Background
¦ National Strategies for Health Care
Providers: Pesticide Initiative
¦ Collaborative effort between US EPA and National
Environmental Education and Training Foundation
¦ Three-prong effort: educational setting, practice
setting, informational resources and tools
¦ Practice component involves changing knowledge
and behaviors of practicing physicians
The problem
¦ Practicing physicians are a difficult audience for
behavior change
¦ Competing educational priorities limit interest in
and knowledge of environmental health issues
¦ Very little is known about how practicing
physicians view environmental health issues as
they meet their continuing education needs
This study
¦ Conducted by the George Washington
University Center for Risk Science and Public
Health
¦ Pilot study to assess knowledge, attitudes and
practices of practicing pediatric care providers
regarding continuing education on pesticide
toxicity
Methods
¦ Practitioner questionnaire
¦ Two questionnaires designed; one for clinicians
(MD, NP, PA) and one for nurses
¦ Distributed at pediatric grand rounds given in Mid-
Atlantic region and at group practice sites of focus
groups
¦ Content and consent forms approved by
Institutional Review Board of GWU
Methods, cont.
¦ Focus Groups
¦ Focus group instrument derived from questionnaire
to get deeper understanding of beliefs and
motivations of practitioners regarding CME
¦ Focus groups recruited through pediatrician contacts
in Greater Washington, DC
¦ Practices selected for geographic (MD, VA), demographic
(pnvate insurance) vs. medicaid populations, and
urban/rural diversity
-------
Questionnaire results
¦
203 total responses
¦ 160 "clinicians"; 43 "nurses"
¦
74% of clinicians from urban/suburban practices; 83%
self-reported practice area as "pediatrics"
¦ Others mostly pediatnc subspecialties
¦
69% never made diagnosis of pesticide intoxication
¦
Urban/suburban clinicians more likely to have:
¦ considered diagnosis 59% vs. 34%
¦ been asked by patients 62% vs. 39%
¦ 53% of clinicians asked felt very or somewhat uninformed
Questionnaire results, cont.
¦ 40% thought it important to receive CME on
pesticides; 21% thought it was unimportant
¦ 90% unaware of educational opportunities for
pesticides
¦ How much time would clinicians be willing to
spend?
¦ 39% one hour or less
¦ 41% half day or less
¦ 14% one full day
Questionnaire results, nurses
¦ Nurses less likely to have made diagnosis of
pesticide toxicity (12%) or have been asked by
patients (37%)
¦ Only 28% felt pesticide training was important,
30% felt it unimportant
¦ How much time would nurses be willing to
spend?
¦ 30% one hour or less
¦ 42% half day or less
¦ 23% one full day
Focus groups
¦ 29 clinicians (27 MD, 2 NP) participated in
6 focus
groups
¦ 4 located in inner suburbs, 2 in more rural area
¦ With broader interpretation of pesticides, nearly all
recalled questions
¦ DEET, repellants
¦ Food residues, lawn residues
¦ Most practitioners more familiar with acute
syndromes,
unsure about recognition and significance o
f chronic
effects
Focus groups, cont.
¦ Preferences for CME
¦ Split between large CME conferences and one hour grand
rounds or local mini-seminars
¦ Divergence over importance of pesticides as CME
topic
¦ Uncertainty over chronic effects
¦ Expressed need to make information clinically relevant
¦ Most unwilling to devote entire conference to pesticide
issues, but would welcome one hour mixed in with other
topics
Discussion
¦ Pilot offers unique insights based on
questionnaires and in-depth focus groups
¦ Limited by constrained geographic reach and
non-random sampling
¦ Still offers useful insights for reaching practicing
clinicians on environmental health topics
-------
Recommendations
Need to "make the case" first
¦ Point out unrecognized widespread uses, give more
information on chronic effects
¦ AAP newsletter cited as good outlet
Information must be clinically relevant
¦ E.g., address issues of household re-entry, residues
on food, as well as acute poisoning
Embed pesticide CME within mixed content
CME conferences
-------
National Strategies for Health Care
Providers:
Pesticides Resources Project
Mark G. Robson, Ph.D., M.P.H., A.T.S.
UMDNJ — School of Public Health
June 10, 2003
An initiative of The National
Environmental Education &
Training Foundation (NEETF)
and the US EPA's Office of
Pesticide Programs, in
collaboration with other US
EPA offices, the US
Departments of Health and
Human Services (DHHS),
Agriculture (USDA), and Labor
(DOL).
Purpose
• The goal of the Initiative is to improve the recognition,
management and prevention of health effects from
pesticide exposures.
• The Initiative is a long-term effort involving a wide
range of stakeholders.
Stakeholders
•
Federal Agencies
•
Academic Institutions
•
Professional Organizations
•
Foundations
•
Farmworker and Farm Groups
•
Industry and Trade Associations
The Need
• Outcome of nine public hearings for WPS in 1996 established the
need to improve the recognition, diagnosis, and management of
adverse health effects from pesticide exposure by all primary
health care providers.
• 75% of medical schools require only about seven hours of study in
environmental medicine over four years (1994).
• Institute of Medicine issued recommendations to integrate
environmental health education into medical and nursing
professions.
Target Audience
• Primary HCP's: • Decision-making Bodies, such as:
• Physicians • Professional Associations
• Nurses • Curriculum Committees
• Nurse Practitioners • Accrediting Institutions
• Physician Assistants • Faculty and Administrators
• Nurse Midwives • Residency Review Committees
• Community Health • Institutions Governing Health
Workers Care Practice and Requirements
-------
Strategic Framework
I Educational Settings
Practice Settings
Etiucat onal institutions
Educational competencies
Institutions and faculty
Key decision-makers
Faculty champion*
Primary cat providers
Practice skills
Primary care providers
Key decision-makers
New practice models
< Define guidelines ~
< Assess target audiences ~
•4 Secure endorsements ~
A Demonstrate success ~
4
and reporting
*
I
Resources
T7 f +^
Inver tnry National New Information
Review Board Resources Gateway
Implementation Strategies for
Resources and Tools
>
Inventory Existing Resources
>
Establish National Review Board to Evaluate Resources
>
Create an Information Gateway
•
Develop Teaching/Learning Resources for
Educational Settings
•
Develop New Resources for Practice Settings
> Priority project
The Purpose
• We were asked to go through and identify useful
resources for health care providers at all levels.
• The database originally had over 500 resources,
both on line and hard copy.
• The original approach was just web based
information, but there were some requests for
good hard copy references as well.
•
The next step was to coordinate these into a
useful database.
•
Items were entered in the database and
categorized regarding the course: Private,
Government, Academic, or Industrial.
•
A short set of comments on the resource were
noted as well.
•
When there was a web link available,this was
added.
•
If there were some particular issues, such a bias,
that was added too.
•
We also looked at the level of the information
and the ease of accessibility.
•
Some materials are written for clinical folks and
not easily understood by non-clinicians.
•
Others, while useful for clinicians are also fairly
generic and have some utility for the general
public.
• The inventory was then reviewed by myself, my
staff, and some of my students.
• Finally we went out to several health care
providers as well as pesticide education
specialists for a review.
• About half of the entries were deemed out f date,
hard to use, not relevant, or even misleading.
These were eliminated and the database is now
about 283 sources.
-------
• These sources are the BEGINNING of a resource
base. New and better sources are available every
day. Other sources, particular the websites for
the private sector, are no longer active sites,
have new URL's, etc.
• Why is this a useful starting point—for us it was
a good snap shot of the resources available.
• The sites for the most part link back or are
adapted from about 12 major sites, the primary
being EPA, then FDA, several of the larger
academic institutions.
• In talking to our own medical staff as well a s
several providers, they prefer the web based
approach, fast, they can modify the query, go
further, or return for more information if time
allows.
• My own primary physician indicated that he now
spends a significant amount of time on the web,
just on follow up, using the web for particular
journal articles, regulations, or for consultation.
• This inventory is just a small part of the
GATEWAY that Click Impact has developed, but
we feel it is a critical base for the resources for
health care providers at all levels and with a
variety of experience and resources.
• NEXT STEP-we invite our colleagues to share sources
that they have found to be useful, factual, and appropriate.
• We have established a National Review Board that will
carefully evaluate these 280+ sources as well as review
any additions to our resource database.
• We see that this as an continuous project.
4 The resource inventory has also helped us identify some
areas where there are little or no resources, this areas will
be presented to the state and federal agencies in an effort
to develop new resource to fill these gaps.
& ' „£ £ £*
* * * a i)
Stop
£»»»«*. 4 --4 c**. 4
«*. 4 !¦**• 4 4 IWUI 4 f,¦III Mil
School of Public Health
NEETF Pesticide Resource Inventory
LJ=
St***.- Hit', MP H
(nvilMtntaiM
Dtoko ¦< EmvxxMinl mi OccupiMfiai Heife
UMDNJ
\K\m
SCHOOL OF
PUBLIC HEALTH
KOHS1
-------
£ r 3 4 3 !1
A Mlanl IHiuo J - •<«» t4
Sfcftoof <>f Public Health
NEETF Pesticide Resource Inventory
VtmCdBT^te
1 J
Search
Lus*
MatQ fc5twaW.P.H?a
Iwmtn c, m 'w. 4 '4 Csx*»«i ^ Cu
School qf Public Health
NEETF Pesticide Resource Inventory
•lA
A.
Si ACSH D«ci?-hv -It
85 - ...
hi
ISO As;:=fcj.< Fm*£!i Itnrc!£c
|y B«k '>x.St to Peaciirj TV» CSarKSautxriHirjfdi Itp
IKWUfrttgfo
|k
usa. , I*
t* *e» o> t
£ *
3 & a i ^ * a
School o/ PuWt'c Health
NEETF Pesticide Resource Inventory
SttoNtfn* fli^
* Wei. AAfctnijr
P G^WtdPU*-:
P Cotrnwiiy H*aBi
r Ckn.c«(OOOe»
P R«*«r h&r.Km Pw« :»a(»v Si*s S*c
Jwurm ^ ww* ¦< Cjtrar ¦< fi.fc. 'j| PTOH I H Iwmi
"3^
s
ALABAMA PESTICIDE INFORMATION
SlildlMjl.ralOrtr.fwi
» twvtA(fk«n
hto|inl Syxiei CwDxy Mapi
• fetagri SltiW C< iWfBH ,M
HHrlli '¦ iMi
•haafc »•«>«<««
-------
contact | home | search |
PesticideHealthcare
National Strategies for Health Care Providers Pesticides Initiative
Medical Reference
Prevention
Pesticide Profiles
DIRECTORIES
Website Guide
Organization Directory
Key Contacts
EDUCATIONAL RESOURCES
(framing Modules
Training Programs
I Publications Lists
Upcoming Events
The Initiative
Staff
Partners
Advisory Board
about our initiative
The Medical Resource
on Pesticide Exposure
Why Pesticides and Health Care Providers?;. JL
Pesticides have become ubiquitous in our
society, affecting rural, urban and suburbar
populations across America
home, school, workplace and
community
1
EEE3E*
» Implementation Plan
Fact Sheet (PDF)
FAQ
? our partners
S-EPA
Learn more about our
partners
Search pesticide
profiles.
k
Search
symptoms.
Browse detailed information on
s p e f i tl i; p e s 11 c i d e c o rn p o ij n d s:
| Select a Pesticide ( -*• |
View chemical characteristics and
agents associated with common
symptoms of pesticide exposure.
1 S-e¦:> ori.'j.rin -Vy".;
Upcoming Events mors -
Pesticides National Forum
June 2002, Washington D.C.
Key Contacts - more
Mark Robson, PhD, MPH, MS, ATS
Director, ENOH
Sign Up & Keep Up
Our monthly electronic
newsletter delivers the
latest on pesticide
treatment.
SIGN ME UP
3
New National
Guidelines
Organizations - more |-
National Center for Environmental Health (NCEH)
Atlanta, GA
Training Modules more -
Pesticide Heath Care
A comprehensive training course in pesticides safety
Websites 4 more -
US Department of Agriculture
Extensive resources in pesticide safety and treatment
National Pesticide Practice
Skills Guidelines for
Medical & Nursing Practice
outlines the knowledge and
skills that professionals In
the health professions
need to have about
pesticides. More...
about | contact I home
-¦< Aiiii r-'.---ii rdeHenllhi rum **|| rights ie;eiveri i Site developed byClicklmpact
contact | home | search. | j Igq||<>|
PesticideHealthcare
National Strategies for Health Cans Providers. Pesticides Initiative
reference desk 1 Refpren,, , Oesk; Prevention
~ related websites
Pesticide Profiles
DIRECTORIES
Website Guide
Organization Directory
Search Prevention Documents
Find documents and articles related to the prevention
of pesticide exposure.
Browse Prevention Documents by:
» Environmental Clinical
Research Training
Program for Nurses and
Physicians
A comprehensive training
program for nurses and
physicians in
environmental medicine
and health research.
Key Contacts
¦ Prevention Topic | Select a Prevention Topic ||j > .. K>|
EDUCATIONAL RESOURCES
• Symptom | Select a Symptom -"j |go||<>|
.
¦ Exposure | Select an Exposure 1 voe U |co||<>|
~ related organizations
Publications Lists
¦ Pesticide Class | Select a Pesticide Class 3]
» Health Care Without
Harm
An international coalition
in 44 countries working to
transform the health care
industry.
EVENTS
--OR-
Upcoming Events
Search Prevetrtion Database j I go ||<>|
ABOUT us
The Initiative
feature
Staff
Exposure to Pesticides on the
Farm Linked to Depression
and Decreased Sperm Count
Conventional wisdom holds that farms and the surrounding countryside
are healthier than polluted urban environments.
But two new studies call this idea into question, showing that pesticides
and other agricultural chemicals may expose farming communities to
significant health hazards, including lower sperm counts and increased
depression.
| MORE INFO ||cj>|
~ highlights
Partners
Advisory Board
/J\ New National
Y'4 Guidelines
National Pesticide Practice
Skills Guidelines for
Medical & Nursing Practice
outlines the knowledge
and skills that
professionals in the health
professions need to have
about pesticides. More...
about | contact | home
©2002 PesticideHealthcare.com All rights reserved. | Site developed byClicklmpact
-------
contact |home |search [ J [go||ct>l
PesticideHealthcare
National Strategies for Health Care Providers: Pesticides Initiative
REFERENCE DESK
1 Reference Desk: Medical Reference 1
Prevention
Pesticide Profiles
DIRECTORIES
h related websites
Search Symptoms Profiles ?
View chemical characteristics and agents associated C S
with common symptoms of pesticide exposure.
» Environmental Clinical
Research Training
Program for Nurses and
Physicians
A comprehensive training
program for nurses and
physicians in
environmental medicine
and health research.
Website Guide
Organization Directory
Browse Profiles by:
Key Contacts
* Organ System [Select an Organ System |oo|K>|
Training Programs
Publications Lists
EVENTS
Search Document Database
Find documents and articles related to the pesticide
exposure reference information you are seeking.
~ related organizations
» Health Care Without
Harm
An international coalition
in 44 countries working to
transform the health care
industry.
Upcoming Events
Browse Documents by:
ABOUT us
¦ Geography | Select 9 Geographical Rector. -r|
The Initiative
Staff
~ highlights
Partners
¦ Exposure | Select an Exposure Tvoe | go ||cj>|
jj J New National
JrA Guidelines
Advisory Board
¦ Pesticide Class | Select a Pesticide Class H
--OR--
National Pesticide Practice
Skills Guidelines for
Medical 6 Nursing Practice
outlines the knowledge
and skills that
professionals in the health
Search Document Database | |go ||<; |
feature
10 Key Symptoms
of Fungicide Exposure
| W3RE INFO ||cj>|
professions need to have
about pesticides. More...
about | contact | home
2002 PesticideHealthcare.com All rights reserved. I Site developed by Clicklmpact
PesticideHealthcare
National Strategies for Health Care Providers: Pesticides Initiative
contact | home | search
J IMS
REFERENCE DESK
Medical Reference
Pesticide Profiles
DIRECTORIES
EDUCATIONAL RESOURCES
Training Modules
Training Programs
Publications Lists
Upcoming Events
about us
The Initiative
Staff
Partners
Advisory Board
Educational Resources: Tr?
' Modules
^ related websites
Website Guide
Organization Directory
Online Tools that Build Knowledge
A collection of training modules to help you better
understand the recognition, treatment and prevention of
pesticide exposure.
*
featured modules 11
Pesticide Exposure Diagnosis Training for Nurses
This module, written for nurses, gives training in the area of
diagnosing pesticides exposure,
more on this module >
Pesticide Exposure Diagnosis Training for Doctors
This module, written for doctors, gives training in the area of
diagnosing pesticides exposure,
more on this module >
Pesticide Exposure Diagnosis Training for Students
This module, written for students, gives training in the area of
diagnosing pesticides exposure,
more on this module >
Pesticide Exposure Diagnosis Training for Professors
This module, written for professors, gives training in the area of
diagnosing pesticides exposure,
more on this module >
View All Training Modules (displayed 4 of 35)
1 VIEvV ALL 1|<>|
» www.website.com
Lorem ipsem dolor siet
amet, consectetuer
adipiscing elit
related organizations
Organization Name
Lorern ipsem dolor sit
amet, consectetuer
adipiscing elit
www.website.com
about | contact | home
© 2002 PesticideHealthcare.com All lights reserved I Site developed by Clicklmpact
-------
Incorporating Environmental
Health in Pediatric Medical
and Pediatric Nursing
Education Standards
Jerome A. Paulson, MD
Nsedu Obot Witherspoon, MPH
Children's Environmental Health Network
Leyla Erk McCurdy, M.Phil
National Environmental Education & Training Foundation
Incorporating Environmental
Health in Pediatric Medical
and Pediatric Nursing
Education Standards
This report has been generated through a
partnership between the National Environmental
Education & Training Foundation (NEETF) and
the Children's Environmental Health Network
(CEHN). Support for this project was made
possible through a grant from National Institute for
Environmental Health Sciences (NIEHS).
Background
• Current education of physicians and nurses in
environmental health is inadequate
• "... as a minimum, all primary care physicians
should be able to identify possible occupationally
or environmentally induced conditions and make
the appropriate referrals for followup."*
• Environmental education should be a part of all
aspects of nursing education - from undergraduate
through continuing education.**
Why this project was undertaken.
• There is an increasing need for individuals
with specific, public-health-focused training
in children's environmental health.
-PEHSUs
- Research Centers
- Government activities at federal and state levels
- NGO activities
The Goal of the Project
•To assess the current medical and nursing
education structures and identify key
leverage points for curricular change.
Methods
• Create a medical and a nursing work group
consisting of individuals with expertise in
one or more of the following areas:
- environmental health education or medical or
nursing education in general;
- accreditation programs and systems;
- curriculum development.
-------
Findings - Medical
• Four Phases of Medical Education
- Undergraduate Medical Education (MD
Curriculum) (Phase I):
- Graduate Medical Education (Residency)
(Phase II):
- Graduate Medical Education (Fellowships)
(Phase III) (Optional):
- Continuing Medical Education (CME) Credits
(Phase III or IV):
Findings - Medical
• Organizations Involved With Medical
Accreditation and Licensing
- Liaison Committee on Medical Education (LCME): (I)
- National Board of Medical Examiners (NBME): (I &
II)
- Accreditation Council for Graduate Medical Education
(ACGME): (II)
• Residency Review Committees (RRC): (Phase II)
- American Board of Medical Specialties (ABMS): (III
or IV)
• Specialty Boards: (III or IV)
- Accreditation Council for Continuing Medical
Education (ACCME): (III or IV)
Findings - Nursing
• Three Phases of Nursing Education
- Undergraduate Nursing Education (Phase I):
(AA or BS)
- Graduate Nursing Education (The Master's and
Doctoral Degree) (Phase II):
- Continuing Nursing Education (Phase III):
Findings - Nursing
• Organizations Involved With Academic or
Legislated Programs to Assure Quality of
Nursing Practice
- Credentialing of Baccalaureate and Graduate
Degree Programs:
• National League for Nursing Accrediting
Commission (NLNAC):
• Commission on Collegiate Nursing Education
(CCNE):
Findings - Nursing
• Organizations Involved With Academic or
Legislated Programs to Assure Quality of
Nursing Practice
- State Boards of Nursing:
• National Council of State Boards of Nursing:
• State Boards of Nursing:
Findings - Nursing
• Organizations Involved With Academic or
Legislated Programs to Assure Quality of
Nursing Practice
- Specialty Boards:
• National Certification Board for Pediatric Nurse Practitioners
(PNP) & Nurses:
• American Nurses' Credentialing Center (ANCC):
• American Academy of Nurse Practitioners (AANP):
• National Certification Council for Obstetrical, Gynecological,
and Neonatal Nurses (NCC):
• American College of Nurse Midwives (ACNM):
-------
Findings - Nursing
• Organizations Involved With Academic or
Legislated Programs to Assure Quality of
Nursing Practice
- Nurse Practitioner Faculty Organizations:
• National Organization of Nurse Practitioner
Faculties (NONPF):
• Association of Faculties of Pediatric Nurse
Practitioner Programs (AFPNPP):
Acknowledgments
• Kenneth Olden,PhD - Director, National
Institute of Environmental Health Sciences
• Allen Dearry, PhD - Associate Director,
Research Coordination Planning &
Translation, NIEHS
Acknowledgments
• Nursing Education Work Group: Robert
Atkins, MSN, CRNP; Cathie Burns, PhD,
RN, CRNP; Hurdis Griffith, PhD, RN;
Barbara Kelley, EdD, MPH, MS; Rita
Lourie, MSN, RN; Leyla Erk McCurdy, M.
Phil.; Grace K. Paranzmo, MS, RN, CHES,
FAAOHN; Dorothy Powell, EdD, RN,
FAAN; Bonnie Rogers, DrPH, COHN-S,
FAAN; Izzat Sbeih, MPH.
Acknowledgments
• Medical Education Work Group: Rob
Amler, MD, MS; Lois Colburn; Susan
Cummins, MD, MPH; Deborah Danoff,
MD; Ruth Etzel, MD, PhD; Leyla Erk
McCurdy, M.Phil; Jerome A. Paulson, MD;
James Roberts, MD, MPH; Chris Rosheim,
DDS, MPH; Bernhard L. Wiedemann, MD.
-------
Environmental
Exposures
Intrinsic
Genetic
sceptdhDiy
Behavior/Age/Stage of Development
t National Institute of Environmental Health Sciences
'•C
iBC
Public^e alth# Environmental
Medicine and Health Care
Kenneth Olden, Ph.D.,. .D.
Sc
Director, National Institute of Environmental
Health Sciences and the National Toxicology
Program, National Institutes of Health,
Department of Health and Human Services
(
I National Institute of Environmental Heatth^j^pces
Center far the Study of Complex Disease
Behavior
Environment
Poverty
^COMPLEX
Life
Genetics
r National Institute of Environmental Health^^pces
V5
-------
Complex Diseases
tnviron^
o-
%
The Gordiaii Knot of
OenetiCs
' _'p
(
National Institute of Environmental Health Sciences
Sfifcl
"Genetics Loads the Gun, but
Environment PuO.Sj.he Trigger"
Judith Stern
Professor of Nutrition and Internal
Medicine
UDiversity of California at Davis
r"-\
I
i National Institute of Environmental Health Sciences
"ENVIRONMENT"^ ncludes:
• industrial^ emicals
• agriculturaL
chemicals
• PhysicaL agents
(e-g.,, at.,
radiation)
• By-products c£
combustion and
industrial ocesses
(e. g. floxin)
i National Institute of Environmental Health Sciences
• foods and nutrients
• prescription drugs
« ifestyLe choices
and substance
abuse
« social and
economic factors
• MdLogical agents
i
V5
t2S
I .ilfes
National Institute of Environmental Health Sciences
THE
HUMAN
GENOME
-------
TWIN STUDIES
Tanner, C. M aL Parkinson's disease in twins: an
etioLogic study. JAMA 281:341-346, 1999.
Powell,j .J. et aL Evidence farthej^oLe cf
environmental ents in the initiatiar^ r progression
cf autoimmune conditions. EHP, 107:667-672, 1999.
Lichtenstein, P. aL. Environments! and heritable
6C~
factors in the causatian cf cancer. NEJM 343:
78-85, 2000.
National Institute of Environmental Health Sciences
iAi
¦W
Efforts To Enhance Physician
Knowledge cf Environmental Medicine:
— Development^ f Children's Environmental Health
Research and Prevention Centers (1998).
— Development cf& Special Section^ n "Grand
Rounds in Environmental Medicine" in
Environmental Health Perspectives (1998).
— Development a^n Ihttamural Clinical Research and
Training Program (1997) .
r National Institute of Environmental Health Sciences
"We are grossly overselling
genetics. I thinly e should really
tempei^ a king genetics the
established religion of our
country."
Dr. Kenneth M. Weiss
N.Y. Times (Science Section)
February 25, 2003
r National Institute of Environmental Health Sciences
<3
Efforts To Enhance Physician fAi
Knowledge cf Environmental Medicine
(Cont'd):
— Development cf n Extramural Physicians Training
OL
Program in^ nvironmental Medicine ( 1991).
— Plan to DeveLop Continuing Medical Educatian
Courses ir^ cOlabaratLcn with Various Medical
Societies
z"
f _
i National Institute of Environmental Health Sciences
-------
Public-Private Partnerships:
A CDC Approach
Michael A. McGeehin, Ph.D., M.S.P.H.
Director
Division of Environmental Hazards and Health Effects
National Center for Environmental Health
Centers for Disease Control and Prevention (CDC)
If
Historic
CDC
X
State Health
jS Departments
Infectious
Diseases
Present
CDC
State Health
r N
Infectious Diseases
Departments
Private Care
Chronic Diseases
Universities,
Providers
Occupational
Environmental
" Research Centers
Third Partvx*
Payers ^
^ Injury J
^Other Federal
and State
NGO's
Agencies
gjjg
Public-Private Partnerships:
Environmental Health
Challenges
! Indirect link
! Time lag
! Developing evidence
! Sub-acute conditions
Public-Private Partnerships:
Asthma State Coalitions
Develop a state/local strategic plan
Patient education
Br ? JP9
Provider education
Wm j- iv1?*'/ v
Community outreach
Case management
. >.
-------
Public-Private Partnerships:
Asthma State Coalitions
! First steps in asthma control
program
! Statewide coalition comprised
of local coalitions
! Advice, guidance, networking
! All interested parties
rgrra
Public-Private Partnerships:
Controlling Asthma in American Cities
! Collaborative effort to improve asthma care and
control in defined urban populations
! City-wide collaboration
! Improve access, quality of care, empowerment, and
education
! Hospitals, foundations, health departments, Medicaid
agencies, physician groups, schools
HB8
Public-Private Partnerships:
Controlling Asthma in American Cities
Minnesota's Health Learners Board
Council of Health Plans and Public School System
Improve in-school asthma care
Better management care
Training of personnel
Primary care provider, family, and school
gjjg
Public-Private Partnerships:
Controlling Asthma in American Cities
Chicago's Mobile Van Project
! Spragg Foundation and Public School System
! Mobile asthma vans
! Primary asthma care
! Training of Primary Care Physicians in asthma
management
rggg
Public-Private Partnerships:
Controlling Asthma in American Cities
St. Louis Community Asthma Program
! Asthma Consortium and Washington University
! Partnership with Healthcare USA
! Work with individual clinics
! Improve procedures and asthma management
rgiTi
Public-Private Partnerships:
Pesticides
! 90,000 PCC reports annually
! Exposure difficult to quantify
! Array of symptoms and
syndromes
! Less familiar than asthma
-------
Public-Private Partnerships:
Summary
Grown dramatically at CDC
Best approach to complicated problems
Many examples - asthma, AIDS, terrorism
Environmental health issues would benefit from this
approach
up
-------
The Initiative and
Public/Private Partnerships
Bonnie Rogers, OPH, COHN-S, LNCC, FAAN
University of North Carolina at Chapel Hill
Why are Partnerships Needed?
~Public Health Concerns
»Sites of exposure
•Targets of exposure
nOutcomes of exposure
~Provider Preparation
Partnerships
Education
Practice
Resources
Partnership Examples
Education
Universities/Colleges
Practica Sites
Practitioners
-------
APPENDIX C
INITIATIVE CASE STATEMENT
The Need for Pesticide Education
for Health Care Providers
Introduction
Pesticides are ubiquitous in American society. We use them in our homes, workplaces, schools
and communities. In fact, Americans are at risk for both acute and chronic health effects from
agricultural and non-agricultural pesticides exposures:
• The US Environmental Protection Agency estimates approximately 250-500 physician-diagnosed
cases occur per 100,000 agricultural workers (Blondell, 1997).
• Data collected from Poison Control Centers found that in 1996, more than 40,000
adults were sufficiently exposed to various types of pesticides to warrant a call to
their local Poison Control Center. These exposures were non-agricultural in nature
and are believed only to representless than 30% of the incident cases of acute
pesticide-related illness in the United States (Litovitz et al, 1997; Chafee-Bahamon
et al, 1983; Harchelroad et al, 1990; Veltrietal, 1987).
• Chronic health effects represent a range of adult and childhood illnesses, such as
cancer and asthma, as well as reproductive and central nervous effects.
Because of the widespread use of pesticides and the potential for related adverse health effects,
primary care providers need to be prepared to recognize, manage, and prevent pesticide-related
health conditions in their patients and communities.
The public expects that their primary care providers are prepared to deal with pesticide-related health
problems, as well as other environmental-related illnesses. But all too often providers are not able to
respond effectively. A survey of environmental medicine content in US medical schools found that 75%
of medical schools require only about seven hours of study in environmental medicine over four years
(Schenk et al, 1996). Furthermore, once in practice, health care providers' awareness and understanding
of pesticide-related illness may or may not ever expand.
The current lack of adequate environmental education for health care providers sounds an alarm for
leaders in the health care community, whose professionals are not prepared to deal with pesticide-related
illnesses as they are presented. Primary care providers are on the frontline of health care and therefore
can play a key role in identifying, treating and preventing potential pesticide poisonings and exposure.
C-l
-------
The National Strategies for Health Care Providers: Pesticides Initiative aims to improve health care by
incorporating environmental issues into education and practice. The Initiative is focused on preparing
primary care providers to recognize, manage and prevent pesticide-related health conditions. It is an
initiative of The National Environmental Education & Training Foundation (NEETF) in partnership with
the US Environmental Protection Agency, and in collaboration with the US Department of Health and
Human Services, the US Department of Agriculture, and the US Department of Labor.
Pesticide education is needed in medical and nursing schools, as well as in practice settings, including
community clinics, hospitals, and work-place clinics. Providers need to be prepared to:
• Take an environmental history and be prepared to "problem solve" with patients who may have
been exposed to pesticides.
• Readily diagnose if appropriate.
• Provide timely treatment for pesticide-related health conditions.
• Provide prevention education.
• Where appropriate, consult with local authorities.
Case Studies: Misdiagnosis of Infants & Children
Although public health experts are challenged to demonstrate successful prevention of pesticide-related
illness, the following cases illustrate that further illness could have been avoided with properly educated
and trained health care providers.
EPA regulates an organophosphate insecticide called methyl parathion for use on specific crops. In
the 1980s and 1990s, methyl parathion was used widely in indoor environments by unlicensed
applicators. One published report describes methyl parathion-related illness among several siblings,
two of whom died (CDC, 1984). Approximately two days before these children were correctly
diagnosed, five of them were seen by their local physician and sent back to their contaminated home
with a mistaken diagnosis of viral gastroenteritis.
In another case of organophosphate poisoning, Zweiner and Ginsburg (1998) 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 from
encephalopathy and seizure disorder to pneumonia and pertussis.
C-2
-------
Why Pesticide-Related Health Conditions Are Relevant to Primary Health Care
Public concern about pesticides can come from a variety of sources. Patients may have heard about
pesticide issues in the national or local news, or read about the health effects of acute or chronic
exposure to pesticides. Concerned patients may turn to their primary care provider for answers about
their own risks of illnesses from exposure to pesticides. They may question providers about acute health
effects, as well as potential chronic effects, such as cancer, birth defects, reproductive effects, or other
conditions from pesticide exposure.
Providers may get questions from patients about the safe use of pesticides in the home, workplace or
school, if their water supply contains harmful chemicals, and whether a skin rash or asthma attack may
be related to a pesticide exposure. By helping patients recognize symptoms of pesticide-related illnesses,
problem-solve and evaluate risks from pesticides, primary care providers can help patients reduce
exposure and prevent future exposures.
Acute Health Effects
While primary care providers may not encounter many patients who have experienced acute pesticide
poisoning, it's important for them to have a basic understanding of signs and symptoms, and an ability to
diagnose and refer. Many times 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, primary care providers can play a critical role in
pesticide-related illness surveillance.
Agricultural Exposures
Agriculture accounts for 76% of the conventional pesticides used each year (US EPA, 1999b).
Pesticide handlers and agricultural workers appear to be at greatest risk for acute pesticide
poisoning. Based on states with required reporting of pesticide-related health concerns, EPA
estimates there are approximately 250-500 physician-diagnosed cases 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 areas where pesticide
exposures can be significant.
Non-agricultural Exposures
A substantial number of people in the United States are at risk of acute pesticide poisoning from non-
agricultural uses. Data collected from Poison Control Centers found that in 1996, more than 40,000
adults were sufficiently exposed to various types of pesticides to warrant a call to their local Poison
Control Center. It is estimated that as many as 60% of these individuals developed symptoms of
pesticide poisoning. These figures are thought only to represent less than 30% of the incident cases of
acute pesticide-related illness in the United States (Litovitz et al, 1997; Chafee-Bahamon et al, 1983;
Harchelroad et al, 1990; Veltri et al, 1987).
An estimated 84% of American households use pesticides, according to a 1990 EPA survey (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, structural pest control operators and workers in
nurseries, greenhouses, and landscaping are also at risk for work-related exposures.
C-3
-------
Children's Pesticide Exposures
Children may be more susceptible than adults to environmental health risks because of their physiology
and behavior. They eat and drink more and breathe more air in proportion to their body weight than
adults. They also play close to the ground and put objects in their mouths. Their bodily systems are still
developing, and they may be less able than adults to metabolize and excrete the pollutants (Landrigan
1997). In the agricultural setting, children may be exposed to pesticides in a number of ways: through
prenatal exposure, from being in the fields where their parents work, contact with pesticide residues on
parents' clothing, living in migrant camps next to camps being treated and working in the fields
themselves (US Congress, Office of Technology Assessment, 1990). A report by the General Accounting
Office (US GAO, 2000) found that improvements were needed to ensure the safety of farmworkers'
children.
In non-agricultural settings, children may be exposed to pesticides in their houses, yards, day cares and
schools. In 1996, Poison Control Centers were notified about approximately 80,000 children who were
exposed to common household pesticides in the United States, one-quarter of whom developed
symptoms of pesticide poisoning. 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 age 5 (McCaig, 2000; McCaig and Burt, 1999). These figures may represent only a fraction of the
incident cases of acute pesticide-related illness in children.
Chronic Health Effects
Patients may also discuss their concerns about the potential danger of chronic exposure to pesticides with
their primary care providers, and providers also must be cognizant that patients may be unaware of
exposures. There is recent evidence that the general U.S. population is exposed to an array of
organophosphate insecticides, the most widely used insecticides available. There is also a growing body
of scientific literature detailing health effects from chronic exposure to pesticides.
Common concerns about chronic exposure to pesticides include:
• Cancer. Over 60 active ingredients for pesticides have been classified as probable human
carcinogens by EPA or the International Agency for Research on Cancer. Although most of
these pesticides are no longer on the market or have had their uses severely restricted, their
potential to cause cancer in persons previously exposed is still a concern. A review by the
National Cancer Institute (NCI) lists 15 pesticides for which there is evidence of cancer in
human epidemiologic studies (Zahm et al, 1997).
• Central nervous system effects. Many insecticides and fiimigants are designed specifically to
target the nervous system of the pest they are intended to control. 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 poisoning
(Savage et al, 1988; Rosenstock et al, 1991; Steenland et al, 1994; Stephens et al, 1995).
• Reproductive effects. Many pesticides have been identified as developmental or reproductive
toxicants based on animal studies. 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."
• Asthma. An Institute of Medicine report (Institute of Medicine, 2000) concluded that although
there is evidence suggesting that high level exposures to some pesticides may elicit persistent
asthma, there is not enough evidence to say whether an association exists between pesticide
exposures at the levels typically encountered in nonoccupational or residential settings and the
development or exacerbation of asthma.
C-4
-------
Challenge of Diagnosing Pesticide Exposure
The short-term and many of the long-term health effects associated with pesticide exposure can easily be
mistaken for other agents or health conditions. Primary care professionals who can recognize a potential
pesticide exposure are more likely to make the correct diagnosis. They need to be familiar with the
settings that predispose patients to pesticide exposure, the symptoms associated with these exposures,
and appropriate diagnostic methods. Yet many health professionals receive little training in pesticide
health issues.
A 1994 survey of environmental medicine content in US medical schools (Schenk et al, 1996) found
that:
• Ninety U.S. medical schools (76%) reported requiring environmental medicine content in the
curriculum, but only two schools (2%) had a dedicated course.
• Fifty schools (42%) reported no instruction in taking an exposure history.
• Among schools with required environmental medicine instruction, the average time in the
curriculum was only 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.
Health professional groups, academic institutions, and government and community
organizations have called for improved health care provider training in environmental health.
The American Medical Association, for instance, adopted a resolution urging Congress,
government agencies, and private organizations to support improved strategies for the
assessment and prevention of pesticide risks. In addition, two Institute of Medicine committees
recommended an integration of environmental health issues throughout the various stages of
training and clinical practice for health care providers. (Institute of Medicine, 1995a and 1995b).
A third Institute of Medicine committee on environmental justice recommended enhancing
health professionals' knowledge of environmental health as well as environmental justice issues
(Institute of Medicine, 1999).
Necessary Knowledge and Skills
Primary care providers can be extremely effective in addressing pesticide exposures in their
patients and communities. However, they do not need to become experts in order to fill an
important and critical role. Based upon a recommendation from an Institute of Medicine report
(Institute of Medicine, 1988) "that all primary care physicians should be able to identify
possible occupationally or environmentally induced conditions and make the appropriate
referrals for follow-up," some of the important pesticide knowledge and skills primary care
providers should possess include:
• Taking a brief and relevant environmental and occupational history
• Possessing a basic awareness of environments in which patients live, work, and play
• Recognizing possible signs and symptoms of pesticide exposure
• Identifying possible sentinel cases
• Diagnosing possible associated health conditions, including those of sensitive populations such
as children and the elderly
• Having ready access to a recommended referral list of resources and contacts
• Calling upon an appropriate specialist or expert to assist them
• Recognizing when to report exposure incidents to the proper health authorities
• Participating in surveillance systems
• Providing basic preventive guidance for patients.
C-5
-------
Conclusion
Primary care providers can play a much-needed role in recognizing a potential pesticide
exposure and in working with pesticide/environmental health experts and resources. They can
do this without extensive expertise but must be prepared with increased education and training
to identify exposures and work with experts to manage their patients' pesticides-related
illnesses. In an educational setting, primary care providers can work with occupational and
environmental medicine specialists to design and integrate a pesticides module into a toxicology
course for medical students. Faculty can take advantage of existing user-friendly teaching
materials, along with user-friendly guides and curriculum maps that indicate where pesticide
topics can be inserted.
Two projects that are part of the National Strategies for Health Care Providers: Pesticides Initiative will
be particularly useful. National Pesticide Competency Guidelines for Education and National Pesticide
Practice Skill Guidelines define education competencies and practice skills that will lead practitioners to
effective recognition and management of pesticide-related health conditions and exposures. And the
Initiative's Information Gateway is a print, telephone, and web-based resource through which primary
care providers can easily access information and educational resources about pesticides.
In a practice setting, primary care providers can incorporate an environmental history into their practice
and refer patients to appropriate experts in the event of a suspected poisoning. One resource for primary
care providers is the U.S. Environmental Protection Agency's Recognition and Management of Pesticide
Poisonings, which provides health professionals with information on the health hazards of pesticides
currently in use. It deals primarily with acute effects and provides consensus recommendations for
management of poisonings and injuries caused by current pesticides (U.S. EPA, 1999a). More resources
are under development.
Through effective education and training, health care professionals can build on their existing skills in
toxicology, pharmacology, history-taking, and risk communication to provide much-needed guidance to
patients on pesticide-related health conditions. With that tenet as its cornerstone, the National Strategies
for Health Care Providers: Pesticides Initiative will enable primary care providers to improve the
recognition, management, and prevention of health effects from pesticide poisonings and exposures.
References
Blondell I. Epidemiology of pesticide poisonings in the US with special reference to occupational cases.
Occup Med: State of the Art Reviews. 1997;12.2.
Centers for Disease Control and Prevention. Organophosphate insecticide poisoning among siblings—
Mississippi. MMWR. 1984;33:592.
Chafee-Bahamon C, Caplan DL, Lovejoy FH. Patterns in hospital's use of a regional poison information
center. Am J Public Health. 1983;73:396-400.
Harchelroad F, Clark RF, Dean B, et al. Treated vs. reported toxic exposures: discrepancies between a
poison control center and a member hospital. Vet Hum Toxicol. 1990;32:156-159.
Institute of Medicine. Role of the Primary Care Physician in Occupational and Environmental Medicine,
Institute of Medicine Report. Washington, DC: National Academy Press; 1988.
Institute of Medicine. Environmental Medicine: Integrating a Missing Element into Medical Education.
Washington, DC: National Academy Press; 1995a.
C-6
-------
Institute of Medicine. Nursing, Health, & the Environment. Washington, DC: National Academy Press;
1995b.
Institute of Medicine. Toward Environmental Justice, Research, Education, and Health Policy Needs.
Washington, DC: National Academy Press; 1999.
Institute ofMedicine. Clearing the Air: Asthma and Indoor Air Exposures. Washington, DC: National
Academy Press; 2000.
Keifer MC, Mahurin RK. Chronic neurologic effects of pesticide overexposure. Occ Med: State of the
Art Reviews. 1997;12(2):291-304.
Landrigan PJ. Children's health and the environment ~ the first Herbert L. Needleman award lecture.
Matern Child Health J. 1997; 1:61 -64.
Litovitz TL, Smilkstein M, Felberg L, et al. 1996 annual report of the American Association of Poison
Control Centers toxic exposure surveillance system. Am JEmergMed. 1997;15:447-500.
McCaig LF, Burt CW. Poisoning-related visits to emergency departments in the United States, 1993-
1996. Clin Tox. 1999;37:817-826.
McCaig LF. National Center for Health Statistics. Personal communication with Blondell J, MPH, PhD.
2000.
Robinson JC, Pease WS, Albright DS, et al. Pesticides in the Home and Community: Health Risks and
Policy Alternatives, CPS Report. Berkeley, CA: California Policy Seminar; 1994.
Rosenstock L, Keifer M, Daniell WE, et al. Chronic central nervous system effects of acute
organophosphate pesticide intoxication. Lancet. 1991;338:223-227.
Savage EP, Keefe TJ, Mounce LM, et al. Chronic neurological sequelae of acute organophosphate
pesticide poisoning. Arch Environ Health. 1988;43:38-45.
Schenk M, Popp SM, Neale AV, et al. Environmental medicine content in medical school curricula.
AcadMed. 1996;71(5):27-29.
Sever LE, Arbuckle TE, Sweeney A. Reproductive and developmental effects of occupational pesticide
exposure: the epidemiologic evidence. Occup Med: State of the Art Review s. 1997;12(2):305-325.
Steenland K, Jenkins B, Ames RG, et al. Chronic neurological sequelae to organophosphate pesticide
poisoning. Am J Public Health. 1994;84:731-736.
Stephens R, Spurgeon A, Calvert IA, et al. Neuropsychological effects of long-term exposure to
organophosphates in sheep dip. Lancet. 1995;345:1135-1139.
US Congress, Office of Technology Assessment. Identifying and Controlling Poisons of the Nervous
System. Washington, DC: US Government Printing Office; 1990. Publication OTA-VA-436.
C-7
-------
US Environmental Protection Agency. Recognition and Management of Pesticide Poisonings.
Washington, DC: Office of Prevention, Pesticides, and Toxic Substances; 1999a. Publication 735-R-98-
003.
US Environmental Protection Agency. Pesticides Industry Sales and Usage: 1996 and 1997Market
Estimates. Washington, DC: Office of Prevention, Pesticides, and Toxic Substances; 1999b. Publication
733-R-99-001.
US General Accounting Office (GAO). Pesticides: Improvements Needed to Ensure the Safety of
Farmworkers and Children. Washington, DC: US General Accounting Office; 2000. Publication RCED-
00-40.
Veltri JC, McElwee NE, Schumacher MC. Interpretation and uses of data collected in poison control
centers in the United States. Med Toxicol. 1987;2:389-397.
Whitmore RW, Kelly JE, Reading PL. National Home and Garden Pesticide Survey: Final Report,
Volume 1, 1992. Research Triangle Park, NC: Research Triangle Institute: RTI\5100.121F; 1992.
Zahm SH, Ward MH, Blair A. Pesticides and cancer. Occ Med: State of the Art Reviews.
1997;12(2):269-289.
Zweiner RJ, Ginsburg CM. Organophosphate and carbamate poisoning in infants and children.
Pediatrics. 1998;81:121-126.
C-8
-------
APPENDIX D
NATIONAL FORUM PLANNING COMMITTEE
Elizabeth Blackburn, RN Environmental Protection Agency, Office of Children's Health Protection
Marcia Britt, Ph.D Department of Health and Human Services, Bureau of Health Professions
Amy Brown, Ph.D University of Maryland-College Park and Representative,
American Association of Pesticide Safety Educators
Geoffrey Calvert, MD, MPH National Institute for Occupational Safety & Health
Deborah Danoff, MD Association of American Medical Colleges
Allen Dearry, Ph.D National Institute of Environmental Health Sciences
Adrian J. Enache, Ph.D, MPH Environmental Protection Agency, Region 2
Allie Fields Environmental Protection Agency, Office of Pesticides Programs
Artensie Flowers, Ph.D, MPH Environmental Protection Agency, Office of Pesticides Programs
Thomas Houston, MD American Medical Association
Amy Liebman, MPH, MA Migrant Clinicians Network
Andrea Lindell, DNSc, RN University of Cincinnati and Representative,
American Association of Colleges of Nursing
Edward Master, RN, MPH Environmental Protection Agency, Region 5
Ley la Erk McCurdy, MPhil National Environmental Education & Training Foundation
Eva Montoya, MSN, RN Department of Health and Human Services,
Bureau of Primary Health Care, Migrant Health Program
Donna Orti, MS, MPH Agency for Toxic Substances and Disease Registry
Jerome Paulson, MD Mid-Atlantic Center for Children's Health and the Environment,
George Washington University, and Children's Environmental Health Network
Andrew Pope, Ph.D Institute of Medicine
James Roberts, MD, MPH Medical University of South Carolina and Representative,
American Academy of Pediatrics
Mark Robson, Ph.D, MPH University of New Jersey, School of Public Health
Bonnie Rogers, Dr PH, COHN-S, LNCC University of North Carolina, School of Public Health and Representative,
FAAN American Association of Occupational Health Nurses
Delta Valente, MPA Environmental Protection Agency, Office of Environmental Justice
D-l
-------
APPENDIX E
FEDERAL INTERAGENCY PLANNING COMMITTEE
EPA
Elizabeth Blackburn, RN Office of Children's Health Protection
Jerome Blondell, PhD, MPH Office of Pesticide Programs
Frank Davido Office of Pesticide Programs
Allie Fields Office of Pesticide Programs
Ron Hoffer, MS Office of Ground Water & Drinking Water
Kevin Keaney, MA, MS Office of Pesticide Programs
Artensie Flowers, PhD, MPH Office of Pesticide Programs
Sherri Umansky Office of Ground Water & Drinking Water
Delta Valente, MPA Office of Environmental Justice
EPA Regional Liaisons
Don Baumgartner Region 5
Adrian J. Enache, PhD, MPH Region 2
Edward Master, RN, MPH Region 5
Allan Welch Region 10
HHS
Marcia Britt, PhD HRSA, Bureau of Health Professions
Geoffrey Calvert, MD, MPH National Institute for Occupational Safety & Health
David D. Hanny, PhD, MPH HRSA, Bureau of Health Professions, Division of
Interdisciplinary, Community-Based Programs
Eva Montoya, MSN, RN HRSA, Bureau of Primary Health
Care, Migrant Health Program
Donna Orti, MS, MPH Agency for Toxic Substances & Disease Registry
Karen Pane, RN, MPA, CMCN HRSA, Office of Planning, Evaluation & Legislation
Barry Stern, MPH HRSA, Bureau of Health Professions,
Division of Public Health & Allied Health
Joan Weiss, PhD, RN, CRNP HRSA, Bureau of Health Professions, Division of
Nursing
E- 1
-------
Federal Interagency Planning Committee (Con'd)
USDA
Monte Johnson, PhD Cooperative State Research, Education, & Extension Service
Peter S. Wood, MS Agricultural Marketing Service
Dept of Labor
John Leben Wage and Hour Division
Other Organizations
Amy E. Brown, PhD University of Maryland-College Park and
Representative, American Association of
Pesticide Safety Educators-
Ley la Erk McCurdy, M Phil National Environmental Education & Training Foundation
E-2
-------
APPENDIX F
NATIONAL FORUM PARTICIPANTS
Walter A. Alarcon, MD, MSc
National Institute for Occupational Safety and Health
Sophie J. Balk, MD
Children's Hospital at Montefiore
Elizabeth Blackburn, RN
US Environmental Protection Agency
Office of Children's Health Protection
Jerome Blondell, PhD
US Environmental Protection Agency
Office of Pesticide Programs
Jennifer Bretsch, MS
American College Preventive Medicine
Amy E. Brown, PhD
University of Maryland Pesticide Education & Assessment Program
Representative, American Association of Pesticide Safety Educators
Paul J. Brownson, MD
The Dow Chemical Company
Candace Burns, PhD, ARNP
University of South Florida College of Nursing
Representataive, National Organization of Nurse Practitioner Faculties
Patricia Butterfield, PhD, RN
American Association of Colleges of Nursing
Geoffrey Calvert, MD, MPH
National Institute for Occupational Safety and Health
Centers for Disease Control and Prevention
Velma Charles-Shannon, PhD
US Department of Agriculture
Kevin Coyle
The National Environmental Education and Training Foundation
Jim T. Criswell, PhD
Oklahoma State University
Deborah Danoff, MD
Association of American Medical Colleges
Rupali Das, MD, MPH
California Department of Health Services, Occupational Health Branch
Frank L. Davido
US Environmental Protection Agency
Office of Pesticide Programs
F-l
-------
Kathy Davis
US Environmental Protection Agency
Office of Pesticide Programs
Shelley Davis
Farmworker Justice Fund, Inc.
Allen Dearry, PhD
National Institute of Environmental Health Sciences
National Institutes of Health
Michelle DeVaux
US Environmental Protection Agency
Office of Pesticide Programs
Angelina Duggan
Crop Life America
Donald Eckerman
US Environmental Protection Agency
Office of Pesticide Programs
Adrian J. Enache
US Environmental Protection Agency, Region 2
Allie Fields
US Environmental Protection Agency
Office of Pesticide Programs
Judy Fitzgerald, BSN, RN
InterCare Community Health Network, Inc.
Shira A. Flax
Agency for Toxic Substances & Disease Registry
Centers for Disease Control & Prevention
Artensie Flowers
US Environmental Protection Agency
Office of Pesticide Programs
Gonzalo Garcia-Vargas, PhD
Universidad Juarez de Durango
David F. Goldsmith, MSPH, PhD
The George Washington University Medical Center
Daniel A. Goldstein, MD
Monsanto Company
Jeanne Goshorn, MS
National Library of Medicine
National Institutes of Health
Michael R. Grey, MD, MPH
University of Connecticut School of Medicine
F-2
-------
Cheryl Hanks
Washington State Department of Health
Rugh A. Henderson, MD, MPH
Penn State University College of Medicine
Representative, North American Agromedicine Consortium
Jeanne Heying
US Environmental Protection Agency
Office of Pesticide Programs
Kerry Hoffman-Richards, PhD
Pennsylvania State University Pesticide Education Program
Allen James, MBA, CAE
Responsible Industry for a Sound Environment
David Jefferson, MS
University of the District of Columbia Cooperative Extension Service
Rosa B. Joyner
US Environmental Protection Agency
Office Of Pesticide Programs
Kevin Keaney
US Environmental Protection Agency
Office of Pesticide Programs
Katherine Kirkland, MPH
Association of Occupational and Environmental Clinics
Jenny Levy
Physicians for Social Responsibility
Amy K. Liebman, MPH, MA
Migrant Clinicians Network
Andrea R. Lindell, RN, DNSc
College of Nursing, University of Cincinnati Medical Center
Representative, American Association of Colleges of Nursing
Rita J. Lourie, RN, MSN, MPH
Temple University, Department of Nursing
Susan West Marmagas, MPH
Physicians for Social Responsibility
Edward Master, RN, MPH
US Environmental Protection Agency, Region 5
Ray S. McAllister, PhD
CropLife America
Leyla Erk McCurdy, M Phil
The National Environmental Education & Training Foundation
F-3
-------
Michael McGeehin, PhD, MSPH
National Center for Environmental Health
Centers for Disease Control & Prevention
Siobhan McNally, MD
Sprout-Berkshire Initiative for Children's Environmental Health
Terry L. Miller
Oregon State University Department of Environment and Molecular Toxicology
National Pesticide Information Center
Evangelina Montoya, MSN, RN
Health Resources & Services Administration
Lill Mood, RN, MPH, FAAN
NEETF Health & Environment Advisory Committee
Teresa Nastoff, RN, BSN
Agency for Toxic Substances & Disease Registry
Centers for Disease Control & Prevention
Lisa Neel
George Washington University, School of Public Health Services
Teresa Niedda
Farmworker Health & Safety Institute
Kenneth Olden, PhD
National Institute on Environmental Health Sciences
National Institutes of Health
Larry G. Olsen
Michigan State University
Lee Orr
West Virginia Department of Agriculture
Donna Orti, MS, MPH
Agency for Toxic Substances & Disease Registry
Centers for Disease Control & Prevention
Kagan Owens
Beyond Pesticides
Jerome Paulson, MD
George Washington University Medical Center
Representative, Children's Environmental Health Network
Maria Elena Leal Perez, MD
Escuela de Medicina de la Universidad Au Autonoma de San Luis Potosi
Janice Phillips, PhD, RN
National Institute of Nursing Research
National Institutes of Health
Barbara J. Polivka, PhD, RN
The Ohio State University College of Nursing
F-4
-------
Richard Pont
US Environmental Protection Agency
Office of Pesticide Programs
Certification & Worker Protection Branch
Susan A. Randolph, MSN, RN, COHN-S, FAAOHN
Representative, American Association of Occupational Health Nurses
Rosemary Reiner
Southwest General Health Center
James R. Roberts, MD, MPH
Medical University of South Carolina
Representative, American Academy of Pediatrics
Mark Robson, PhD, MPH
University of Medicine and Dentistry of New Jersey,
School of Public Health
Bonnie Rogers, DrPH, COHN-S, LNCC, FAAN
Occupational Health Nursing Program, University of North Carolina at Chapel Hill
Past President, Representative, American Association of Occupational Health Nurses
Christine Rosheim, DDS, MPH
Agency for Toxic Substances & Disease Registry
Centers for Disease Control & Prevention
Nancy Rothman, EdD, RN
Temple University
Elaine Rubin, PhD
Association of Academic Health Centers
Virginia Ruiz
Farmworker Justice Fund, Inc.
Barbara Sattler, RN, PhD
University of Maryland School of Nursing
Kathy Seikel
US Environmental Protection Agency
Office of Pesticide Programs
Joshua Sharfstein, MD
US House of Representatives
Committee on Government Reform
Martha Shimkin
MShimkin Consulting
Debbie Sliter
The National Environmental Education & Training Foundation
Rosemary Sokas, MD, MOH
University of Illinois at Chicago
F-5
-------
Vera Soltero
US Environmental Protection Agency
Office of Pesticide Programs
Joan Stanley, PhD, CRNP
American Association of Colleges of Nursing
Daniel L. Sudakin, MD, MPH
Oregon State University National Pesticide Medical Monitoring Program
Delta Valente
US Environmental Protection Agency
Office of Environmental Justice
Maria Valenti
Greater Boston Physicians for Social Responsibility
Jennifer Weber
University of California-Davis Pesticide Safety Education Program
Kathy Wilcoxen
US Environmental Protection Agency, Region 9
Nsedu Obot Witherspoon, MPH
Children's Environmental Health Network
Charles Yarborough, MD, MPH
BASF
Edward L. Zuroweste, MD
Migrant Clinicians Network
Entire document printed on 30% post consumer recycled paper. 4L# F-6
------- |