Accidental Occupational Exposure to Phytosanitary ...

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Accidental Occupational Exposure to Phytosanitary Products: Experience of the Poison Control Center in Marseille From 2008 to 2010 a

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Myriam Aras MD , Corinne Schmitt PharmD , Mathieu Glaizal PharmD , Morgane a

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Kervégant PharmD , Lucia Tichadou MD & Luc de Haro MD PhD a

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Centre in Marseille, St Marguerite Hospital, Marseille, France

To cite this article: Myriam Aras MD , Corinne Schmitt PharmD , Mathieu Glaizal PharmD , Morgane Kervégant PharmD , Lucia Tichadou MD & Luc de Haro MD PhD (2013): Accidental Occupational Exposure to Phytosanitary Products: Experience of the Poison Control Center in Marseille From 2008 to 2010, Journal of Agromedicine, 18:2, 117-121 To link to this article: http://dx.doi.org/10.1080/1059924X.2013.766144

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Journal of Agromedicine, 18:117–121, 2013 Copyright © Taylor & Francis Group, LLC ISSN: 1059-924X print/1545-0813 online DOI: 10.1080/1059924X.2013.766144

Downloaded by [Hopital Sainte-Marguerite], [Corinne Schmitt] at 00:49 02 April 2013

Accidental Occupational Exposure to Phytosanitary Products: Experience of the Poison Control Center in Marseille From 2008 to 2010 Myriam Aras, MD Corinne Schmitt, PharmD Mathieu Glaizal, PharmD Morgane Kervégant, PharmD Lucia Tichadou, MD Luc de Haro, MD, PhD

ABSTRACT. To gain better insight into the problem of accidental occupational exposure to phytosanitary products, a retrospective study of experience at the Poison Control Center in Marseille, France, was conducted for the period between January 1, 2008, and December 31, 2010. A 129-case series was compiled. The study population was overwhelmingly male (83%), and the most common cause was insecticides (56.6% with a half pyrethrin and 21% organophosphate) and herbicides (26%). Although various exposure routes were observed, the most common were inhalation (43%) and skin contact (34%). The symptoms were mainly neurologic, digestive, and/or cutaneous. The severity of poisoning was generally mild, with no deaths or sequels. Only 5% of cases required hospitalization. KEYWORDS. Farm worker, occupational exposure, pesticide, phytosanitary products

INTRODUCTION Poison Control Center (PCC) hotlines (telemedicine) are confronted with accidents involving various toxic products. Cases involving phytosanitary products are recorded on an almost daily basis in many settings, including gardening accidents, suicide attempts, and environmental contamination.1,2 Farm workers are obviously at particularly high risk for exposure to phytosanitary products that can have devastating effects on health. Given the extremely high risk associated with handling these substances,

personal protective equipment is mandatory. However, since zero risk is impossible, accidental exposure is always possible. The purpose of this report is to describe the results of a study undertaken at the PCC in Marseille, France, to assess the accidental occupational exposure to phytosanitary products over a 3-year period.

METHODS Data recorded at the PCC in Marseille is stored in the French PCC data system (French

Myriam Aras, Corinne Schmitt, Mathieu Glaizal, Morgane Kervégant, Lucia Tichadou, and Luc de Haro are affiliated with Poison Control Centre in Marseille, St Marguerite Hospital, Marseille, France. Address correspondence to: Corinne Schmitt, Pharm D, Poison Control Center in Marseille, St Marguerite Hospital, 270 boulevard St Marguerite, 13009 Marseille, France (E-mail: [email protected]). 117


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acronym SICAP). The SICAP comprises two nationwide databases, i.e., one for cases of poisoning (French acronym BNCI) and one for the products and formulations involved (French acronym BNPC). For the purpose of this study, the BNCI was searched using the following inclusion criteria: date between January 1, 2008, and December 31, 2010, acute or subacute (less than 2 weeks) occupational exposure, symptomatic or asymptomatic presentation, and involvement of one of the substances listed in the phytosanitary product category of the BNPC. The following data were collected: sociodemographic characteristics (sex and age), location and date of accident, route(s) of exposure, clinical findings, and management recommendations. Evaluation of severity was based on symptoms and management recommendations in accordance with the SICAP classification. Based on these criteria, severity was graded on a 5-point scale, i.e., no treatment, first-aid treatment only (usually decontamination at home or workplace), nonemergency medical attention (for persistent or worsening symptoms), emergency medical attention (in doctor’s office or emergency room), and hospitalization. If firstaid treatment would have sufficed, information requests addressed to the PCC by physicians consulted by patients in emergency were classified severity level 1.

RESULTS The PCC in Marseille, France, recorded a total of 174 cases of accidental occupational exposure to phytosanitary products between January 1, 2008, and December 31, 2010. Twenty of these cases were excluded from study because these telephone consultations concerned long-term professional exposures or chronic illnesses. Concerning the 154 remaining patients, from a clinical standpoint, 13 cases were asymptomatic and involvement of phytosanitary products was ruled out in 12. Thus, study was carried out on a series of 129 cases clearly resulting from

symptomatic accidental occupational exposure to phytosanitary products. Most of the occupational exposures to phytosanitary products in this series occurred in male adults (i.e., 83%) of working age, i.e., 48% between the ages of 31 and 50. Most cases (i.e., 93.8%) occurred in mainland France. Other locations included overseas French territories (4.7%) and foreign countries including Morocco (1.6%). The most common phytosanitary substances were products used to control animal pests: 57% (with 99% insecticides) and plant growth: 43% (with 62% herbicides and 38% fungicides). The implicated insecticides were mainly pyrethrins (53%) and organophosphate (21%), whereas herbicide exposures concerned glyphosate in 35% of the case series. Some cases involved two types of phytosanitary products. Analysis according to date of accident showed that the risk of exposure was highest in spring and especially summer, when use of these products is most intensive in temperate climates (Figure 1). These two seasons accounted for nearly one half of exposure by inhalation and skin contact. The symptoms observed in the 129 cases are listed in Table 1. The most frequent manifestations were neurologic including headache and dizziness (51 cases), digestive including nausea and vomiting (50 cases), and cutaneous including irritation (41 cases). Table 2 shows severity levels in the symptomatic cases. In nearly one out of five cases, symptoms were considered as selflimiting and no treatment was recommended. In 29% of cases, first-aid treatment at home or workplace was recommended. In one out of seven cases involving first-aid treatment, patients were advised to seek medical attention in case of persistent or worsening of symptoms. Immediate medical attention was recommended in 38% of cases, mainly to the emergency room. However, hospitalization was required in only 5% of cases principally due to fungicides and insecticides. Symptoms were mainly digestive and neurologic, two patients had severe cutaneous reaction, and one patient had bronchospasm associate with digestive

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FIGURE 1. Chronological distribution of occupational poisonings induced by phytosanitary products between 2008 and 2010, N = 129. 30 25 20 15

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and neurologic symptoms (organophosphate). No deaths or permanent sequels were recorded. TABLE 1. Clinical Features Occurring in Patients (N = 129)

DISCUSSION Symptoms Neurologic Neurologic only Neurologic + digestive Neurologic + other Total Digestive system Digestive only Digestive + neurologic Digestive + other Total Cutaneous Only cutaneous Cutaneous + neurologic Cutaneous + ocular Cutaneous + other Total Ocular Ocular only Ocular + other Total ENT ENT only ENT + other Total Respiratory Respiratory only Respiratory + other Total

No. of cases

14 25 12 51 11 25 14 50 21 7 6 7 41 12 14 26 5 11 16 2 9 11

French PCCs receive many information requests from individuals as well as health care professionals. However, reporting is not mandatory for occupational accidents involving phytosanitary products in France. Thus, this survey is not comprehensive: the series only corresponds to the experience of one clinical toxicology unit and cannot be considered as representative of the French regions involved. This study showed that the incidence of occupational accidents due to phytosanitary products is highest among working-age men. Most victims had been working for at least 10 years at the time of exposure. Schenker et al.3 has previously noted that younger age in working men was associated with better utilization of protective equipment against dust, noise, and pesticides. A possible explanation for this finding is that older farm workers are less aware and trained concerning safe practices and protective measures. Moreover, in Mediterranean regions, many farm employees may shun the use of personal protection equipment because of the discomfort in hot weather.

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TABLE 2. Medical Management of the 129 Symptomatic Cases


Number of cases Percentage (%)

Hospitalization

Emergency room advice

Delayed medical management

Management at home

No treatments

Total

7 5

42 33

18 14

38 29

24 19

129 100

Most of the cases in this series from the PCC in Marseille occurred in three regions in mainland France, i.e., Provence, LanguedocRoussillon, and Corsica, that are located in the responsibility area of PCC in Marseille. All three of these regions are located on the Mediterranean coast where farming requires more intensive use of pesticides. In comparison with the rest of France, farming in Mediterranean areas is concerned less with raising animals (e.g., cows and pigs) and cereal and more with producing wine, olive growing, flowers, fruits, and vegetables. In addition to these mainland regions, the PCC in Marseille also covers French overseas territories in the Indian Ocean and receives requests from physicians in other French regions and foreign countries (e.g., Morocco in one case in this series). With regard to products involved in accidents recorded at the PCC in Marseille, pesticides were the most frequent causes. This finding is directly related to the attitude of farmers and emergency care physicians concerning pesticide exposure that are generally considered as more hazardous than fertilizers or chemical additives. However, the incidence of accidents involving the latter products is probably underestimated based on PCC data. From a clinical standpoint, two findings of this series should be emphasized. The first is that symptoms fell into three main classes, i.e., neurologic,4 digestive, and cutaneous (Table 1). It is notable that neurologic symptoms often involved anticholinesterase insecticides and that digestive symptoms were triggered not only by direct ingestion but also by passive swallowing after inhalation. Cutaneous symptoms were frequently linked to improper use of protective equipment. The second noteworthy clinical finding in this series of 129 patients is the low severity of exposure to phytosanitary products.

Hospitalization was required in only seven cases: very variable clinical features induced by various circumstances and different family products (organophosphate, organochlorate, herbicides, and fungicides). No fatality or sequels were observed. These findings contrast sharply with data recorded in PCCs in other settings. Phytosanitary products cause higher morbidity and mortality in suicide attempts than in occupational accidents. Finally, it is interesting to compare this study with a similar one carried out at the Marseille PCC in 1997–1998. At that time, a total of 192 occupational accidents related to phytosanitary products were compiled.5 Comparison of the two populations taking into account the shorter study period (2 vs. 3 years) indicates a 45% decline in incidence, with no change in the total activity of the PCC. This apparent decrease in the number of cases of exposure to phytosanitary products in southeast France is consistent with reports from other countries including the United States.6 In this regard, it is important to underline that specialists in agricultural medicine have devoted great effort to prevention. A number of preventive strategies have been implemented, including improvement of working conditions and equipment, development of more efficient farming technology requiring less pesticides, and promotion of less toxic products for workers as well as for the environment.7

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