Cholinesterase Testing: Reporting Requirements and the Role of the WA State Department of Health (DOH) Cheryl J. Hanks, RNWA State Pesticide Surveillance Program

Objectives:

Describe PIRT and PIMs2 Review reporting pesticide exposures Notifiable Conditions WAC 246-101-105 Duties of the health care provider

1970 WA State legislature required DOH to investigate suspected pesticide poisonings

1990 pesticide exposures became a notifiable condition for public health surveillance purposes

Statewide Surveillance ProgramKNOWN OR SUSPECTED CASES OF PESTICIDE RELATED ILLNESSNOTIFIABLE by licensed health provider hospitalized, fatal, or clusterimmediately; others-within 3 daysRequirement is fulfilled by calling the Poison Control Center 1-888-222-1222

PIRT, the Pesticide Incident Reporting and Tracking Review Panel Includes representatives of 6 state agencies and a public member. The agencies conduct pesticide investigation and collect data in accordance with their respective statutory responsibility.PIRT analyzes the data and makes recommendations made for public health and safety.

PIMS-Pesticide Incident Monitoring System

established by DOH to investigate and track all suspected cases.

DOH Classification of Cases Pesticide related may be Definite, Probable, Possible (DPP) National criteria based on signs and symptoms, findings characteristic for the pesticide, the temporal relationship and/or consistent with exposure health effect relationship for known toxicology

Others classified as Suspicious Insufficient Information Unrelated Unlikely and Asymptomatic

Trends in Pesticide Injuries in Washington State 1995-1999 An analysis of 5 years of occupational illness and injury data

Case Classifications 1995-1999 2, 246 cases over 5 years with 1,011 (45%) classified as Definite 176 Probable 322 Possible 51344% occurred among workers in agricultural settings primarily men 1850 years of age

How did the agricultural exposure occur? (1995-1999)Occupationalyes noApplicator/mixer/loader 173 1 Drift 95 56Residue 74 7Cleaning/fixing 10 0Accident 14 3Other 10 7Total376 74

IncidentsCases

This gives an idea of the volume of cases investigated by our programSomewhere between 300-400 incidents/yr involving 400-500 individuals

5-year Data Summary of DPPs*84% of Ag cases were work-related97% reported mild/moderate symptomsMost common exposures: applying, drift, field residuesMost common location: tree fruit*Cases classified as definitely, probably and possibly related to pesticides, 1995-1999

In Year 2000 DOH responded to 302 incidents involving 388 individuals

In 2000 pesticide related incidents reported to DOH increased by 11% from 271 in 1999 to 302Following investigation of the 388 total cases 203 or (52%) were classified as DPPs Occupational exposures accounted for 115 of the 203 cases, a 25% increase from 1999.

87 of the 115 occupational cases were agriculturalIn 1998 the number of agricultural cases dropped in 1999 to 48In 2000 the number of agricultural cases returned to the 1998 level (88).47 (54%) of the occupational agricultural cases occurred in the tree fruit industry.The remaining cases occurred in vegetable crops, grain crops, hops, nurseries, greenhouses, and livestock industriesAgricultural Occupational Cases

National Data: Insecticide Type Acute occupational pesticide-related illnessesPreliminary data from NIOSH SENSOR states, Jan 2002n = 466

Chart1

15

227

33

42

52

23

71

3

data prodtype

Chemical Class, Insecticides only

PRODCLAS1_NEWFreq%

Organochlorine153.22%

Organophosphate22748.71%

N-methyl carbamate337.08%

Pyrethrin429.01%

Pyrethroid5211.16%

Combination of AChE inhibitors234.94%

Other *7115.24%

Unknown30.64%

total466

Includes avermectin B1 (n = 41), paradichlorbenzene (n = 9)

Chemical Class of Pesticide

PRODCLAS1_NEW_CATFreq%

Organochlorine0.00%

Organophosphate0.00%

N-methyl carbamate0.00%

Pyrethrin0.00%

Pyrethroid0.00%

Dipyridyl0.00%

Inorganic0.00%

Dithiocarb.0.00%

Other0.00%

Unknown0.00%

total0

data prodtype

0

0

0

0

0

0

0

0

Conclusions:Illness due to pesticide poisoning is a serious public health problem.Exposures occur where pesticides are used.PPE is not always reliable.Primary prevention message: education

Recognition and Management of Pesticide Poisonings

The Recognition and Management of Pesticide Poisonings is made an excellent text on pesticides and pesticide treatment. It is made available by the U.S. EPA.

It is available on-line at http://www.epa.gov/oppfead1/safety/healthcare/handbook/handbook.htm

DOH Sources of Pesticide Exposure Reports

Youby calling the Poison Control Center 1-888-222-1222Or directly to us Mon-Fri 1-888-586 9427Department of Agriculture notifies us of human case and provides spray recordsDepartment of Labor and Industry provide us with copes of claims which may involve pesticides

Questions?Washington State Department of Health--Pesticide Surveillance ProgramDorothy Tibbetts, Manager (360) 236-3361Cheryl J. Hanks, RN (360) 236-3365

You may ask, how does the state health dept. know about cases occuring in washingtonREPORTABLE, that means that HCP who sees a patient with symptomatic pesticide exposure has to call it inThis helps us monitor for acute cases of pesticide poisoning. (sx resulting from a specific exposure incident)We do not get all the case reported

STAFF IN YAKIMA, TOXICOLOGIST, I REVIEW CASES FOR ACCURACY AND COMPLETENESSFor the five yrs 95-99 there were 2,246 cases investigatedAbout half of the cases investigated are considered at least possibly related to pesticide exposureAll numbers from here on out will only consider DPP cases Classifications have to do with how well we could document the exposure and how well the symptoms fit with the exposure. If we really received all our cases directly from HCP this number would be much higher. But we get referrals from less reliable sources too so some of these do not end up being related.

Information is obtained from interviewing individuals involved , from witnesses, collects info on exposure, requests the spray records and copies of the medical records and when there is enough information a determination is made.

The confirmed cases are the DPPs. Classifications are based on likelihood that the illness related to the pesticide exposure.

Reasons for not confirming a cases are: case referred to late to obtain enough information, the medical and/or environmental information did not confirm the exposure, or significant uncertainty. More national data, again similar results, OPs dominatingOther includes avermectin B1 (n = 41, 57.8% of other), paradichlorbenzene (n = 9, 12.7% of other)