PARAQUAT EXPOSURE AMONG FARMERS IN Agusan del Sur

Engr. Ana Trinidad F. Rivera

Supervising Health Program Officer

Occupational Disease Division

Disease Prevention and Control Bureau

Department of Health

Commonly encountered toxicants,

UP-NPMCC, 2008 (N=3,931)

21%

15%

14%13%

9%

7%

6%6% 5% 4%

Alkali Kerosene Silver jewelry cleaner

Paracetamol Ethanol(beverage) Mixed pesticide

Alcohol(household) Acid Iron

Salicylates

Commonly encountered toxicants among

children, UP-NPMCC 2008 (N=1,927)

26%

15%

14%8%8%

8%

5%

5% 4% 4% 3%

Kerosene Alkali Silver jewelry cleaner

Pyrethroids Alcohol(household) Paracetamol

Elemental mercury Salicylates Button batteries

Iron Jathropa

EAMC Poison Center, Poisoning Cases* CY 2007

• Number of patients seen – 417(1.14 patient/day)

• Number of patients admitted – 364

• Number of deaths – 7 (1.7%)

• Top 10 poisoning agents

• Cleaning agents (22.3%) industrial products (6.2%)

• Pharmaceuticals (19.9%) others (5.3%)

• Hydrocarbons (16.7%) personal care (2.1%)

• Pesticides (12.9%) mixed (2.1%)

• Food (10.6%) plant (1.7%)

No. of clinical toxicologist =1

Poison Control and Information Centers, Philippines

UP-NPMCC

Rizal Medical

Center

Zamboanga

Regional

Hospital and

Medical

Center

East

Avenue

Medical

Center

Batangas

Regional

Medical

Center

Eastern Visayas

Regional Medical

Center

Western

Visayas

Medical

Center

Northern Mindanao

Regional Medical

Center

Incidence rates of pesticide poisoning

SOURCE YEAR NUMBER OF PESTICIDE POISONING

INCIDENCE RATE (per 100,000)

Department of Health

(12 regions)

1982-1985

1,704 3.27

NPCIS

National Capital Region

1986-1990

221 2.6

NPCIS

Region XI

1986-1990

166 4.08

Department of Health

(10 regions)

1991-1995

333 1.08

Pesticide poisoning in selected hospitals in four regions in the Philippines

Region # of Pesticide Poisoning Cases Reported (%)

Populations (in millions)

CAR 41 (12.58%) 1.35

Region II 118 (36.2%) 2.76

Region VI 35 (10.74%) 6.15

Region XI 132 (40.49%) 5.12

TOTAL 326 (100%)

Paraquat • Non selective contact herbicide

• Belongs to the bipyridil group of pesticides (quarternary nitrogen herbicide) for broadleaf weed control

• Philippines, use is allowed only in big plantations because of its toxicity

• Crisquat, Cyclone, Dextrone, Dexuron, Gramoxone Extra, Herbaxone, Ortho Weed and Spot Killer, and Sweep

• LD50 values of 110 to 150 mg/kg in rats

• moderately toxic to birds and aquatic organisms

• highly persistent in soil, with reported field half-lives > 1000 days

• liquid formulations (emulsifiable concentrate and soluble concentrate) containing paraquat dichloride at or above 276 g/l, corresponding to paraquat ion at or above 200 g/l, RC Secretariat EXTOXNET

Paraquat

• Acute as well as chronic effects

• Dermal damage- erythema, abrasion, blistering, ulceration, fingernail changes

• Mucosal membranes - Eye pain, redness, tearing, oral ulceration, dryness

• Pulmonary - pulmonary edema leading to fibrosis

Health Assessment of Agusan del Sur Farmers (December 2008)

• 15 farmers exposed to paraquat: 9 directly exposed

5 indirectly exposed

• Various ailments involving the eyes, skin and lungs reported

• Abnormal laboratory findings consisted of low hemoglobin, reticulocytosis, eosinophilia, abnormal Chest X-ray, abnormal simple spirometry studies, (+) KOH stain

• Disease in 3 individuals can be attributed to paraquat exposure.

Agusan Farmers Exposed to Paraquat

• They were not wearing personal protective equipment while exposed to paraquat.

• There is no existing occupational safety and health program in the plantation.

Paraquat Poisoning Cases

• 29 yo/female, non-intentional patient at Batangas Medical Center with swelling of mucosa, CXR (+) infiltrates, right middle lobe, with esophagitis

• Patient was managed symptomatically

• Dr. Norma Pacalso of the Benguet Provincial Health Office said there is an increase in monitored cases of poisoning in the province. She said from 39 cases in 2011, it rose to 48 in 2012. This year (2013), 21 cases have already been recorded – (http://bulatlat.com/main/2013/10/07/nationwide-ban-on-herbicide-gramoxone-sought/#sthash.vZJcVcms.dpuf)

Health and Environmental assessment for paraquat exposure

Patin-Ay, Prosperidad, Agusan del Sur

Demography of Farmers Examined

• Total farmers - 56 (45 males, 11 females)

• Mean age - 36.9 years old (19-69 years old)

• Majority reached high school level of education

• Patients examined were accredited pesticide applicators except one

Demography of Farmers Examined

• Residence of farmers

• Most (60%) have resided in the current residence for over 20 yrs

• Most (58.9%) residences were within 5 km of the plantation

Barangay Number

Lapinigan 13

Tagbayagan 10

Cabanatuan 9

Bayuga 8

Maligaya 6

Mate 6

Others 4

Total 56

Medical History • Common illnesses reported

• Among family members, HPN was most common, followed by DM, PTB, renal disease and allergy

Illness Number reporting Illness

Allergy 8

UTI 5

HPN 4

Personal and Social History

• 30 (53.6%) were smokers

• 40/56 drank alcohol--40 males and 6 females

Occupational History Pesticide Number

Paraquat 56

Glyphosate 56

2,4 D 10

Pyrethroids 4

Malathion 2

Others (Butachlor, Endrin,

Endosulfan) 6

Occupational History Job Description Number

Mixing/Loading/Applying 35

Loading/Applying 9

Applying 11

Mixing/Applying 1

Total 56

Occupational History

Number

Use PPE 55

No PPE 1

Type of PPE Number

Gauntlet gloves 53

Face mask 52

Apron 49

Goggles 45

Boots 44

Coverall 25

Face Shield 18

Respirator 14

Occupational History: Work Practices

Re-entry Number

Yes 6

No 40

No Data 10

Total 56

Occupational History: Work Practices

Experienced a

Spill Number

Yes 39

No 17

Total 56

Activity During Spills Number

Back-pack Spraying 35

Loading 17

Mixing 12

Aerial Spraying 22

Total 56

Occupational History: Work Practices

Pesticide Use at

Home Number

Yes 16

No 31

No Data 9

Total 56

Knowledge learned

from Number

Lectures 36

Co-workers 8

Informal Talks 7

Self learning 2

Reading materials 1

No Data 5

Occupational History: Work Practices

Pesticide Storage

at Home Number

Yes* 15

No 36

No Data 5

Total 56

Method of Disposal Number

Bury 8

Return to Company 4

Garbage Can 4

Reuse Container 3

Composting 1

No Data 37

Environmental History: Exposure to Chemicals

Exposed to

Chemicals at

Work or Duting

Leisure

Not Exposed to

Chemicals No Data

Males 4 29 12

Females 6 3 2

Total 10 32 14

Environmental History: Type of Cooking

Cooking

Type Number

Wood/Ch

arcoal 49

Gas 2

Electricity 2

Palm

Seed Oil 2

No data 1

Total 56

Environmental History : Source of Water

Exposure to Pesticides

Sick Number

Yes 17

No 39

Total 56

Exposure to Pesticides

Symptoms Felt Number

General (fever, headache, chills,

weakness) 12

Respiratory ( diff breathing, chest pain,

tightness) 9

Eye (redness, itchiness, blurring, tearing,

dryness) 6

Musculoskeletal ( myalgia, neck/back pain) 6

ENT (cough, nasal congestion,

hoarseness, dry throat) 5

Dermal (dry skin, itchiness) 2

CVS (palpitation) 2

Review of Symptoms

Symptoms Felt Number

General (fever, headache, chills, weakness) 17

Musculoskeletal ( myalgia, neck/back pain) 12

Respiratory ( diff breathing, chest pain,

tightness) 10

ENT (cough, nasal congestion, hoarseness,

dry throat) 8

GIT 8

Eye (redness, itchiness, blurring, tearing,

dryness) 6

Genitourinary 4

Others 6

Physical Exam Findings

• Mean SBP 123.3 (90-160)

• Mean DBP 76.9 (60-100)

• 10 farmers with elevated systolic and/or diastolic BP

• Mean HR 71.6 (48-90)

• 37 normosthenic, 12 underweight, 6 overweight, none obese

Skin Findings

Finding Number

Hypo/hyper pigmented patches 25

Lichenified lesions 8

Itchy, scaly lesions 3

Thickened waxy dorsum of hands 2

Discolored/deformed/thickened nails 24

Yellow brown discoloration of nails 6

Brittle nails 5

Mee's lines 4

Pale nailbeds 3

Cyanotic nailbeds 1

ENT Findings

Finding Number

Carious teeth 28

Nasal congestion 9

Impacted cerumen 8

Tonsillopharyngeal Congestion 5

Cervical lymphadenopathy 5

Others 2

Neurological Findings

Finding Number

Visual Acuity Defects 30

Hearing loss 5

Sensory deficits 2

Weakness in face 1

Postural tremors 1

Other Findings

System Finding

Respiratory Wheezing 2

Harsh breath sounds 2

Ocular

Fleshy scleral growths 4

Eccentric pupil

Corneal Haziness

Reddish conjunctiva

Lens opacity ex

Clinical Diagnosis

Diagnosis Number

Skin

Fungal infection 41

Chronic Irritant Dermatitis 12

Paronychia 13

EENT

EOR 30

Dental Caries 28

Irritant Rhinitis 9

Neuro Hearing Loss 5

Neuropathy 2

Respiratory

Asthma/Asthma like 4

CRLD from PTB 1

Pulmonary Mass 1

Pulmonary Function Test

• Pulse Oximetry Ave 98.4 (95-99)

• Spirometry Results Freq

Normal 39

Abnormal 17

Restrictive Lung 10

Obstructive Lung 4

Both 1

Small Airway Disease 2

Urine Paraquat

Results Freq

Not detected 5

Present 46

< 0.18 ng/ml 20

0.19-200 21

201-500 3

>500 2

•ADI: 0.004 mg/kg/day [12]

•MCL: Not Available

•RfD: 0.0045 mg/kg/day [13]

•PEL: Not Available

•HA: 0.03 mg/L (lifetime) [111]

•TLV: 0.1 mg/m3 (8-hour) (respirable fraction)

•a concentration of 100 g/l at 4 hrs indicates a 70% chance of survival but at 20 hrs indicates less than a 10% chance of survival.

Labs

• Anemia in 2

• Chest X-ray - PTB in 2, pneumonia in 1, atheromatous aorta in 4, cardiomegaly in 1

• Creatinine > 1.2 in 16

• SGOT >49 in 5, SGPT >49 in 5

Summary

• Integumentary changes (chronic irritant dermatitis) that could be compatible with chronic paraquat exposure were seen in 21.4 %; nail changes were seen in 69.6%

• 30.3% had abnormal spirometry findings

• Urine paraquat was detected in 90% of workers, although less than detectable limit in 43%

• Although majority of workers use PPE, the item used may not provide enough protection against paraquat

Recommendations

• Review suitability of PPE

• Review work practices when handling paraquat

• Strengthen OSH programmes at the workplace