English - Home page

ISS
Istituto Superiore di Sanità
EpiCentro - L'epidemiologia per la sanità pubblica
Istituto Superiore di Sanità - EpiCentro


Surveillance of pesticide-related illnesses and injuries: initial observations from a pilot project of the Istituto Superiore di Sanità

Laura Settimi1, Franca Davanzo2, Giuseppe Miceli3, Terri J. Ballard1, Lorella Faraoni2, Susanna Bascherini1, Maristella Rubbiani4 e Ida Marcello4

1Laboratorio di Igiene Ambientale, ISS - 2Centro Antiveleni, Ospedale Niguarda Cà Granda, Milano - 3Servizio di Medicina del Lavoro, Azienda USL 7, Ragusa - 4Laboratorio di Tossicologia Applicata, ISS

Background

 

The Italian National Institute of Health [Istituto Superiore di Sanità (ISS)] is required  by law to promote and coordinate investigations into possible harmful health effects from exposure to pesticides. ISS is also required to promote preventive measures for identified problem areas. In keeping with this mandate, a research project  was initiated in 1999 that includes  the surveillance of populations exposed to pesticides and related products (project leader: Laura Settimi). Part of this project  was focused on acute pesticide-related illnesses (1), and the development of a national surveillance system was proposed (2). As shown in the figure, the system is based on close collaboration between ISS, Poison Control Center (PCCs), and Departments of Prevention of Local Health Units.

 

To evaluate the proposed surveillance procedures, a pilot project was implemented at the beginning of 2001. This project is currently being conducted in collaboration with the PCC of Milan in Lombardy and  the Occupational Health Service (OHS) of Ragusa in Sicily. The PCC of Milan was selected for the study since it receives 65% of all toxicological consultations originating from other PCCs in the country. The OHS of Ragusa was considered of particular interest since it operates in an agricultural area characterized by an elevated use of pesticides (3).

 

The aim of this article is to present the observations of the first 3 months of the pilot project for the development of a national surveillance system of pesticide-related illnesses.

 

Pilot surveillance project of acute pesticide illnesses- first observations

During January - February 2001, the MPCC identified 11 cases of acute pesticide-related illnesses reported by Emergency Departments in the Ragusa area. These cases fell within the surveillance case definition of at least 2 signs or symptoms related in time to pesticide exposure, as reported by the examining physician. Detection of these cases led to active case-finding efforts at Ragusa-area health care clinics by the Ragusa OHS, which resulted in the identification of 10 additional cases that had not been reported to PCC of Milan. Of the 21 cases of acute illness or injury identified by both entities, 14 were the result of exposure to Dormex ®, a plant growth regulator whose active ingredient is 50% hydrogen cyanamide. The PCC of Milan identified an additional nine cases resulting from exposure the same product (eight in southern Italy outside of the pilot project area and one in Emilia Romagna.).

The number of cases of acute poisoning reported to be due to this product was unexpected based on the findings of the previous five years of activity of both the PCC of Milan and the OHS of Ragusa. However, Dormex was not introduced in Italy until 2000 and is currently the only commercial product on the market containing hydrogen cyanamide.

 

The working group, comprised of the collaborating centers (ISS, PCC  of Milan, and OHS of Ragusa), initiated a detailed examination of the reported cases and of all information available on Dormex.

 

Description of cases with Dormex-related toxicity

All 23 cases resulted from occupational exposure to Dormex, and all occurred in agricultural settings except for one person who accidentally ingested a solution of the product. The signs and symptoms most often reported included dermatological manifestations including macular or papular rash (n=11), erythema/hyperemia (n=9), pruritus (n=2), and caustic burns to the hand (n=2). Two workers reported eye irritation. 

 

In total, 14 workers had systemic signs and/or symptoms characteristic of adverse effects known to be associated with the active ingredient, hydrogen cyanamide, including tachycardia (n=4), weakness (n=4), palpitations (n=3), headache (n=3), dizziness (n=4), vomiting and/or nausea (n=3), dyspnea (n=3), and hypotension (n=1). In 13 cases, the severity of adverse effects was considered low (i.e. minimally bothersome health effects that generally resolve rapidly), and nine had moderately severe effects (i.e. non-life threatening health effects that are more pronounced, prolonged or of a systemic nature compared with the low severity category). The case of ingestion was a 44-year old man who unintentionally ingested the product which had been placed in a plastic water bottle in the refrigerator. As a consequence, he became seriously ill with shock, coma, miosis, and hepatic necrosis. This case was classified as high severity (i.e. life threatening health effects).

 

The signs and symptoms of the 23 cases reported above are consistent with the toxicological characteristics of hydrogen cyanamide, the active ingredient of Dormex. Adverse health effects from acute contact with hydrogen cyanamide include severe irritation and ulceration of the eyes, skin, and respiratory tract (4). Hydrogen cyanamide also inhibits aldehyde dehydrogenase, and can produce the acetaldehyde syndrome (i.e., flushing, nausea, vomiting, parasympathetic hyperactivity, dyspnea, hyperpnea, hypotension, dizziness, weakness, tachycardia, and confusion) when exposure coincides with alcohol use. (4)

 

Hydrogen cyanamide is classified in the European Union as "toxic" if swallowed, "harmful" in contact with skin, "irritating" to eyes and skin, and capable of producing sensitization after skin contact.

 

In Italy, the product Dormex was classified as "harmful" if swallowed or if there is contact with the skin.  Other indications of danger on the label include irritation for the eyes and skin, risk of serious eye lesions and possible sensitivity to the product.  The toxicity classification and label information were based on acute toxicity data of the formulation containing 50% active ingredient provided by the manufacturer.

 

In the United States, where the product has been sold for more than 20 years and where there have been only 5 cases of acute poisoning since 1981 (5), the product is placed in the acute toxicity category I (danger).

The product labels for Dormex do not contain the same information in Italy and the US, differing with respect not only to the danger symbol that indicates toxicity category, but also with respect to other relevant information. The Italian label, unlike the US label, does not state that death may result if the product is swallowed or is absorbed through the skin, nor does it state that the product is corrosive to the skin. In addition, the Italian label advises the user to protect the face and eyes and to use "appropriate" protective equipment, whereas the US label specifically states the type of protective equipment to be used. Regarding first aid measures after exposure, the Italian label indicates that vomiting should be induced in case of ingestion, whereas the US label indicates the opposite.

 

Comments

Notification of this outbreak was provided by the ISS to the Italian Ministry of Health. After a review of the data on the 23 cases by the Consulting Commission of Agricultural Preparations, it was decided that, as a precautionary measure, that use of the product be temporarily suspended pending further examination of data to be provided by the manufacturer.

 

These initial observations from the first three months of the pilot project demonstrate the usefulness of surveillance for detecting emerging pesticide problems in a timely fashion.

 

The comparison of our experience with other countries, in particular the United States where both state and federal level pesticide-related surveillance activities have been in place for years, is especially useful in the evaluation of the effectiveness of adopted prevention measures, including the classification and labeling of pesticide products.

 

During 2002, the active surveillance of acute pesticide-related illnesses will be extended to other areas of Italy, selected on the basis of the number of cases referred to the PCC of Milan. The procedures adopted during the pilot project will be applied and evaluated in this wider context, which in turn will be instrumental towards the development of a more effective surveillance system to be implement on the regional and national level.

 

References

1. Intossicazioni acute da antiparassitari in Italia: stato delle conoscenze e prospettive di indagine. A cura di Laura Settimi. Ann Ist Super Sanità 2001; 37(2): 125-85.

2.Settimi L, Davanzo F, Miceli G, et al. Ann Ist Super Sanità 2001; 37(2): 181-5.

3. Miceli G, Ravalli P, Settimi L, et al. Ann Ist Super Sanità 2001; 37(2): 141-6.

4. Hathaway GJ, Proctor NH, Hughes JP. Proctor and Hughes' chemical hazards in the workplace. 4th ed. New York: Van Nostrand Reinnold; 1996.

5. CDC. MMWR 2001; 50(39): 845-7.