PESTICIDE-RELATED ILLNESS AND

INJURY SURVEILLANCE

A How-To Guide for State-Based Programs

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Institute for Occupational Safety and Health
DISCLAIMER

ii

Mention of any company or product does not constitute endorsement by the National Institute

for Occupational Safety and Health (NIOSH). In addition, citations to Web sites do not constitute

NIOSH endorsement of the sponsoring organizations or their programs or products.

Furthermore, NIOSH is not responsible for the content of these Web sites.

ORDERING INFORMATION

To receive documents or other information about occupational safety and health topics, contact NIOSH at

NIOSH

Publications Dissemination

4676 Columbia Parkway

Cincinnati, OH 45226–1998

Telephone: 1–800–35–NIOSH (1–800–356–4674)

Fax: 513–533–8573

E-mail: pubstaft@cdc.gov

or visit the NIOSH Web site at www.cdc.gov/niosh

DHHS (NIOSH) Publication Number 2006–102

October 2005

This document is in the public domain and may be freely copied or reprinted.
Surveillance data can be used to identify new emerging pesticide problems, estimate the magnitude of pesticide poisoning, and evaluate intervention and prevention efforts. Recognizing

this, the National Institute for Occupational Safety and Health (NIOSH) Strategic Surveillance

Plan recommends that States conduct surveillance for acute pesticide-related illness and

injury. 

Since 1987, NIOSH has provided financial and technical support for State-based acute

pesticide poisoning surveillance programs. NIOSH is not the only organization that has recommended improved and/or expanded surveillance in this area. Others include the American

Medical Association, the Council for State and Territorial Epidemiologists, the United States

Government Accountability Office, and the Pew Environmental Health Commission. Despite

these recommendations, most States do not conduct acute pesticide-related illness and

injury surveillance.

Acute pesticide-related illness is a relatively complex disease. Approximately 16,000 pesticide

products are currently registered in the United States. In addition, all organ systems are susceptible to pesticide toxicity. The multitude of pesticide products and associated health effects

may act as a barrier to establishing surveillance programs. NIOSH developed this guide to provide standards and principles that can help to master this complexity.

We expect this document will be useful to agencies that are developing an acute pesticiderelated illness and injury surveillance program or are interested in maintaining and improving

an established surveillance program. The guide provides (1) information about the importance

of pesticide poisoning surveillance; (2) mechanisms to improve reporting of cases to surveillance programs; (3) methods to investigate reported cases; (4) guidance on using the case definition; and (5) additional resources on pesticide toxicology, pesticide usage, governmental

partners, and surveillance. 

To our knowledge, this is the most comprehensive instruction guide for pesticide-related

illness and injury surveillance. The goal of this guide is to assist the efforts of our partners to

identify pesticide poisoning risk factors. Pesticide poisoning prevention can be achieved by

targeting interventions toward these identified risk factors. NIOSH hopes individuals and agencies interested in pesticide poisoning surveillance and prevention (e.g., local, State, and

Federal government agencies, community-based organizations, and international agencies)

will find this guide useful for identifying and preventing pesticide poisoning.

John Howard, M.D.

Director

National Institute for Occupational

Safety and Health

Centers for Disease Control 

and Prevention

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FOREWORD
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Ordering Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ii

Disclaimer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ii

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iii

Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiv

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

1.1 A Guide to the Manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

1.1.1 Goal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

1.1.2 How to Use the Manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

1.1.3 Limits of the Manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

1.2 Introduction to the Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

1.2.1 Problem Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

1.2.1.1 The Changing Patterns of Pesticide Use . . . . . . . . . . . . . . . . . . . . . . . . .4

1.2.1.2 Scope of the Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

1.2.1.3 Susceptibility to Pesticide Poisoning . . . . . . . . . . . . . . . . . . . . . . . . . . .5

1.2.1.4 A Problem That Affects Us All . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

1.2.2 Why Investigate Reports of Pesticide Poisoning? . . . . . . . . . . . . . . . . . . . . . . . .5

1.2.3 Response to the Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

2. First Steps in Surveillance System Design: Objectives, Resources, and the Reporting Rule . .11

2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

2.2 Objectives of Pesticide Poisoning Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

2.3 Program Staffing and Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

2.3.1 Types of Expertise Needed for Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . .12

2.3.2 Ways to Meet Needed Expertise with Minimal Resources and Staffing Levels .12

2.4 Program Funding Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

2.5 Reporting Requirements and Rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

2.5.1 Elements of the Reporting Rule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

2.5.1.1 What Is Reportable? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

2.5.1.2 Who Must Report? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

2.5.1.3 Where to Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

2.5.1.4 When to Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

2.5.1.5 Health Insurance Portability and Accountability Rule and Public 

Health (HIPAA) Privacy Rule and Public Health Surveillance . . . . . .18

2.5.1.6 Confidentiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

2.5.1.7 Interagency Cooperation or Sharing of Information . . . . . . . . . . . . . . .19

2.5.1.8 Authority to Investigate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

2.5.2 Examples of Reporting Laws and Rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

2.5.2.1 New York Reporting Rule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

2.5.2.2 Washington Law . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

2.5.2.3 Texas Reporting Law . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

CONTENTS
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2.6 Surveillance Strategy for States with Limited Resources . . . . . . . . . . . . . . . . . . . . . . . .20

3. Case Ascertainment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

3.2 Poison Control Centers (PCCs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

3.3 Workers’ Compensation Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

3.4 Health Care Professionals (HCPs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

3.5 Referral from Other Agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

3.6 Emergency Department Logs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

3.7 Affected Persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

3.8 Worker Representatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

3.9 Hospital Discharge Data (HDD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

3.10 Laboratories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

4. Data Collection and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

4.2 Data Standardization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

4.3 Documentation of Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

4.4 Data Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38

4.4.1 Standard Variables to Be Collected by Pesticide Poisoning Surveillance 

Program (PPSPs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38

4.4.1.1 Administrative and Demographic Variables . . . . . . . . . . . . . . . . . . . . . .38

4.4.1.2 Occupation and Industry Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39

4.4.1.3 Exposure Descriptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39

4.4.1.4 Chemical Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40

4.4.1.5 Health Effects Descriptors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40

4.4.1.6 Investigation Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40

4.4.1.7 Case Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40

4.4.2 Optional Variables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40

4.4.3 Introduction to the SPIDER Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41

4.5 Data Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42

4.5.1 General Guidelines for Data Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42

4.5.1.1 Confidentiality and Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42

4.5.1.2 System Backups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42

4.5.1.3 Transmitting Data to NIOSH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43

5. Case Intake and Follow-up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47

5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47

5.2 Overview of the Case Investigation Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47

5.3 Initial Report Intake (Complaint Evaluation) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48

5.4 Case Follow-up Interviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50

5.4.1 Affected Persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51

5.4.1.1 Chemically Sensitive Persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53

5.4.2 HCPs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53

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5.4.3 Third Parties-Pesticide Applicators, Landlords, and Employers . . . . . . . . . . . .54

5.5 Notification of the Local Health Department . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55

5.6 Obtaining Pesticide Product Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55

5.6.1 Inert Ingredients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56

5.7 Evaluation and Referral for Site Inspection or Enforcement . . . . . . . . . . . . . . . . . . . . .57

5.8 Overview of Agencies with Jurisdiction of Pesticides . . . . . . . . . . . . . . . . . . . . . . . . . .58

5.8.1 Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA) 

State Designees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58

5.8.2 Occupational Safety and Health Administration (OSHA) . . . . . . . . . . . . . . . . .59

5.8.3 Agencies Responsible for Disease Surveillance and Control . . . . . . . . . . . . . . .59

5.8.4 Other State and Adjunct Agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

5.8.4.1 Vector Control Districts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60

5.8.4.2 Pest Control Boards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60

5.9 State Interagency Coordination of Case Investigations . . . . . . . . . . . . . . . . . . . . . . . . .60

5.9.1 Interagency Agreements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60

5.9.2 Multiagency Coordinating Boards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60

5.9.3 Advisory Committees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61

5.10 NIOSH, National Center for Environmental Health (NCEH), 

and the U.S. Environmental Protection Agency (EPA) . . . . . . . . . . . . . . . . . . . . . . . . . .61

5.11 Federal Agencies That May Have a Role or Be a Resource During Case Investigation 62

5.11.1 United States Department of Agriculture (USDA) . . . . . . . . . . . . . . . . . . . . . . .62

5.11.1.1 Cooperative State Research Education and Extension 

System (CSREES) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62

5.11.1.2 Federal Grain Inspection Service (FGIS) . . . . . . . . . . . . . . . . . . . . . . .62

5.11.1.3 Animal Plant Health Inspection Service (APHIS) . . . . . . . . . . . . . . . .63

5.11.2 Federal Aviation Administration (FAA), National Transportation 

Safety Board . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63

5.11.3 U.S. Fish and Wildlife . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63

5.11.4 Other Federal Agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64

5.11.4.1 Coast Guard . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64

5.11.4.2 Consumer Product Safety Commission (CPSC) . . . . . . . . . . . . . . . . .64

5.11.4.3 Customs Bureau . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64

5.11.4.4 Department of Transportation (DOT) . . . . . . . . . . . . . . . . . . . . . . . . . .64

5.11.4.5 Federal Bureau of Investigation (FBI) . . . . . . . . . . . . . . . . . . . . . . . . .64

5.11.4.6 Federal Railway Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64

5.11.4.7 Food and Drug Administration (FDA) . . . . . . . . . . . . . . . . . . . . . . . . .64

6. Site Inspections by PPSP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67

6.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67

6.2 Getting Started with the Inspection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68

6.3 Site Walk-Around Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69

6.4 Equipment for Site Inspections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69

6.4.1 Camera . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69

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6.4.2 Personal Protective Equipment (PPE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69

6.4.3 Water . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70

6.4.4 Contact Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70

6.5 Sampling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70

6.5.1 Sample Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71

6.5.2 Sample Preparation Custody and Handling . . . . . . . . . . . . . . . . . . . . . . . . . . . .71

7. Case Closure and Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75

7.1 The Case Closure Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75

7.2 Case Definition for Acute Pesticide-Related Illness and Injury Cases . . . . . . . . . . . . .75

7.3 Clinical Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75

7.3.1 Case Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75

7.3.2 Laboratory Criteria for Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76

7.3.3 Case Classification Categories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77

7.4 Communication of Findings and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . .77

8. Data Analysis and Reporting of Aggregated Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81

8.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81

8.2 Routine Descriptive Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81

8.2.1 Person-Based Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81

8.2.1.1 Case Series . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81

8.2.1.2 Bivariate Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81

8.2.1.3 Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .82

8.2.1.4 Time-Based Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83

8.2.1.5 Place-Based Analyses: Mapping of Data . . . . . . . . . . . . . . . . . . . . . . .83

8.2.2 Data Dissemination: Defining What Reports Will Be Useful For 

a Specific Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84

9. Developing Intervention Strategies and Evaluating Surveillance . . . . . . . . . . . . . . . . . . . . . . .87

9.1 Designing Interventions Based on Surveillance Data . . . . . . . . . . . . . . . . . . . . . . . . . . .87

9.1.1 Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87

9.1.1.1 At Home and at Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87

9.1.1.2 Educating the Educators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88

9.1.1.3 Educating the General Public . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88

9.1.2 Engineering Controls, Modifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88

9.1.2.1 Closed Mixing and Loading Systems . . . . . . . . . . . . . . . . . . . . . . . . . .89

9.1.2.2 Creative Formulations and Technologies . . . . . . . . . . . . . . . . . . . . . . .89

9.1.2.3 Enclosed Cabs and Other Protection . . . . . . . . . . . . . . . . . . . . . . . . . .89

9.1.2.4 Application and Equipment Modifications . . . . . . . . . . . . . . . . . . . . . .89

9.1.3 Administrative Controls and Regulatory Changes . . . . . . . . . . . . . . . . . . . . . . .89

9.1.4 Examples of Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90

9.1.4.1 Automatic Insecticide Dispensers . . . . . . . . . . . . . . . . . . . . . . . . . . . .90

9.1.4.2 Mevinphos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90

9.1.4.3 Bis(tributyltin)oxide (TBTO) Paint Additives . . . . . . . . . . . . . . . . . . .91

CONTENTS
viii

9.2 Evaluation of the Surveillance System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .92

9.3 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .97

Appendix A. Listing of Morbidity and Mortality Weekly Report (MMWR) Articles on 

Pesticide-related Illness and Injury; January 1, 1982–September 30, 2004 . . . . . . . . . . . . . . .105

Appendix B. Selected Pesticide Illness Reporting Statutes and Rules . . . . . . . . . . . . . . . . . . . . .111

Appendix C. Sample Forms, Investigation Tools, and Templates for Data Tables . . . . . . . . . . . .115

C.1 Case Tracking Form and Contact Log . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .116

C.2 Main Pesticide Exposure Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .119

C.3 Pesticide Illness and Injury Surveillance Data Collection Form . . . . . . . . . . . . . . . . .141

C.4 Field Investigation Contact Form and Health Safety Checklist for Field Personnel . .161

C.5 Instructions for National Transportation Safety Board (NTSB) Search to Obtain 

Reports of Airplane Accidents Involving Aerial Pesticide Applicators . . . . . . . . . . . .165

C.6 Sample Templates for Tables Presenting Surveillance Data . . . . . . . . . . . . . . . . . . . . .166

C.7 Sample Letters for Case Follow-up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .169

C.8 Instructions for Obtaining Acute Pesticide-related Illness and Injury Reports 

from Poison Control Centers (PCCs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .176

Appendix D. Case Definition for Acute Pesticide-Related Illness and Injury

Cases Reportable to the National Public Health Surveillance System . . . . . . . . . . . . . . . . . . .183

D.1 Clinical Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .183

D.2 Laboratory Criteria for Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .184

D.3 Classification Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .184

D.4 Contacts for Additional Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .187

D.5 Frequently Asked Questions (FAQs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .187

D.6. Characteristic Signs and Symptoms for Several Pesticide Active Ingredients and

Classes of Pesticides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .192

D.7 Glossary of Medical Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .204

Appendix E. Severity Index for Use in State-based Surveillance of Acute

Pesticide-related Illness and Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .209

Appendix F. Pesticide Law and Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .217

F.1 Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA) . . . . . . . . . . . . . . . . . .217

F.2 Federal Food, Drug, and Cosmetic Act (FFDCA) . . . . . . . . . . . . . . . . . . . . . . . . . . . .223

F.3 Food Quality Protection Act (FQPA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .223

F.4 Safe Drinking Water Act (SDWA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .224

F.5 Occupational Safety and Health Act (OSH Act) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .224

Appendix G. Resources for Additional Information Related to Pesticide 

Poisoning Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .229

G.1 General Pesticide Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .229

CONTENTS
ix

G.2 Recognition and Management of Pesticide Poisoning, Including Materials 

for HCPs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .230

G.2.1 Pesticides and Human Health Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .231

G 2.1.1 Telephone Hotlines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .231

G.2.2 Publications for HCPs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .232

G.2.3 Internet Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .235

G.2.4 Additional Resources Related to HCP Training on Recognition and 

Management of Pesticide Poisoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .236

G.2.5 Pesticides and Animal Health Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .237

G.3 Pesticide Toxicology (also see Section G.4 Pesticide Products) . . . . . . . . . . . . . . . . . .237

G.3.1 Publications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .238

G.3.2 Internet Data Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .238

G.4 Pesticide Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .240

G.4.1 Databases on Pesticide Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .240

G.4.2 Pesticide Product Labels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .241

G.4.3 Material Safety Data Sheet (MSDS) Directories . . . . . . . . . . . . . . . . . . . . . . . .241

G.4.4 Pesticide Manufacturers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .242

G.5 Pesticide Usage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .242

G.5.1 Data Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .243

G.5.2 Reviews of Pesticide Use Data Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .244

G.6 Pesticide Safety and Health Information to Assist Workers and Employers . . . . . . . .245

G.7 Farmworker Employment, Demographics, Cultural Issues, and Service 

Organizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .248

G.7.1 Employment Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .248

G.7.2 Child Labor in Agriculture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .248

G.7.3 Farmworker Demographics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .249

G.7.4 Farmworker Cultural Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .250

G.7.5. Farmworker Service Organizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .251

G.8 Nonoccupational Exposure Issues (Homeowner, Schools, Vector Control, etc.) . . . . .252

G.8.1 Public Consumer Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .252

G.8.2 Pesticides in Schools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .252

G.8.3 Vector Control and Pest Eradication Programs . . . . . . . . . . . . . . . . . . . . . . . .254

G.9 State PPSP Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .255

G.10 Federal Agency Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .257

G.10.1 U.S. Department of Agriculture (USDA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .257

G.10.2 U.S. Department of Education-Office of Migrant Education . . . . . . . . . . . . . .258

G.10.3 U.S. Department of Labor (DOL) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .258

G.10.4 U.S. Environmental Protection Agency (EPA) . . . . . . . . . . . . . . . . . . . . . . . . .258

G.10.5 U.S. Department of Health and Human Services–Centers for Disease

Control and Prevention (CDC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .259

G.10.6 U.S. Department of Health and Human Services–Health Resources 

and Services Administration (HRSA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .260

CONTENTS
x

G.10.7 U.S. Food and Drug Administration (FDA) . . . . . . . . . . . . . . . . . . . . . . . . . . .260

G.11 Agricultural Safety and Health (Other Than Pesticides) . . . . . . . . . . . . . . . . . . . . . . . .260

G.11.1 EPA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .260

G.11.2 NIOSH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .260

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .265

CONTENTS
xi

AAPCC American Association of Poison

Control Centers

AFOP Association of Farmworker

Opportunity Programs 

ALT alanine aminotransferase

AMA American Medical Association

ANR Agriculture and Natural Resource

ANSI/ASAE American National Standards

Institute/American Society of

Agricultural Engineers

AOEC Association of Occupational and

Environmental Clinics

APHIS Animal Plant Health Inspection

Service

ASPCA American Society for the

Prevention of Cruelty to Animals

AST aspartate transaminase

ATSDR Agency for Toxic Substances and

Disease Registry

BLS Bureau of Labor Statistics

BOC U.S. Bureau of the Census

BPHC Bureau of Primary Health Care

CCOHS Canadian Center for Occupational

Health and Safety 

CDC Centers for Disease Control and

Prevention

CDPR California Department of Pesticide

Regulation

CFR Code of Federal Regulations

CIRS California Institute for Rural

Studies

CME Continuing medical education

CPS Current Population Survey

CPSC Consumer Product Safety

Commission

CSREES Cooperative State Research

Education and Extension System

CSTE Council of State and Territorial

Epidemiologists

DA Department of Agriculture

DDT dichloro-diphenyl-trichloroethane

DEET N, N-diethyl-m-toluamide 

DHHS U.S. Department of Health and

Human Services

DO doctor of osteopathy

DOL U.S. Department of Labor

DOT U.S. Department of Transportation

EMT emergency medical technician

EPA U.S. Environmental Protection

Agency

EU European Union

EUP experimental use permit

FAA Federal Aviation Administration

FAQ frequently asked questions

FBI Federal Bureau of Investigation

FDA U.S. Food and Drug Administration

FFDCA Federal Food, Drug, and Cosmetics

Act

FGIS Federal Grain Inspection Service 

FIFRA Federal Insecticide, Fungicide, and

Rodenticide Act 

FJF Farmworker Justice Fund 

FQPA Food Quality Protection Act

GAO U.S. Government Accountability

Office (formerly U.S.General

Accounting Office)

GIS geographic information system

HCP health care professional

HDD hospital discharge data

HIPAA Health Insurance Portability and

Accountability Act of 1996

HRSA Health Resources and Services

Administration

ABBREVIATIONS
xii

ABBREVIATIONS

HSDB Hazardous Substances Data Bank

HSEES Hazardous Substances Emergency

Events Surveillance System

IARC International Agency for Research

on Cancer

IATP Institute for Agriculture and Trade

Policy

ICD international classification of disease codes

ICU intensive care unit

ILO International Labor Organization

IPCS International Programme on

Chemical Safety

IPM integrated pest management

IRIS Integrated Risk Information System

LAN local area network

LDH lactate dehydrogenase

LSC Legal Services Corporation

MD medical doctor

MCN Migrant Clinicians Network

MHP Migrant Health Program, Bureau

of Primary Health Care

MMWR Morbidity and Mortality Weekly

Report

MSDS material safety data sheet

MSPA Migrant and Seasonal Agricultural

Worker Protection Act

NAICS North American Industry

Classification System

NAIN National Antimicrobial

Information Network

NAS National Academy of Sciences

NASS National Agricultural Statistics

Service 

NAWS National Agricultural Worker

Survey

NCEH National Center for Environmental

Health

NCFH National Center for Farmworker

Health

NCHS National Center for Health

Statistics

NEETF National Environmental Education

& Training Foundation

NIH National Institutes of Health

NIOSH National Institute for Occupational

Safety and Health

NPHSS National Public Health

Surveillance System

NPIC National Pesticide Information

Center 

NPMMP National Pesticide Medical

Monitoring Program

NSCEP National Service Center for

Environmental Publications

NTP National Toxicology Program

NTSB National Transportation Safety

Board

NUBC National Uniform Billing

Committee

NYDEC New York Department of

Environmental Conservation

ODA Oregon Department of Agriculture

OEHHA Office of Environmental Health

Hazard Assessment 

OHSU Oregon Health Sciences University

OPP U.S. EPA Office of Pesticide

Programs

OSHA Occupational Safety and Health

Administration

OSH Act Occupational Safety and Health

Act

OSU Oregon State University

PA physician’s assistant

PANNA Pesticide Action Network North

America

PAPR powered air purifying respirator
xiii

PARC Pesticide Analytical and Response

Center

PCC poison control center

PHI protected health information

PIRT Pesticide Incident Reporting and

Tracking Review Panel

PISP Pesticide Illness Surveillance

Program

PPE personal protective equipment

PPIS Pesticide Product Information

System

PPSP Pesticide Poisoning Surveillance

Program

PVC polyvinyl chloride

RCW Revised Code of Washington

REDs Reregistration Eligibility Decision

Documents

RN registered nurse

SAS statistical analysis software

SDWA Safe Drinking Water Act

SENSOR Sentinel Event Notification System

for Occupational Risks

SOC standard occupational classification

SPIDER SENSOR Pesticide Incident Data

Entry and Reporting

SPPC SENSOR Pesticide Poisoning

California

TBTO Bis(tributyltin)oxide

TESS Toxic Exposure Surveillance

System

UB uniform bill

UNEP United Nations Environment

Programme

USDA U.S. Department of Agriculture

WHO World Health Organization 

WHS Worker Safety & Health

WSDA Washington State Department of

Agriculture

WSDOH Washington State Department of

Health

WPS Worker Protection Standard

ABBREVIATIONS
xiv

The authors gratefully appreciate the listed

contributors who supplied materials that were

modified for this guide or provided significant

input on the mechanisms of managing a pesticide-related illness and injury surveillance program, including conducting case investigations

and coordinating with partner government and

nongovernmental agencies. The authors appreciate the many other unnamed persons at State

and Federal government agencies and nongovernmental organizations who contributed to

this project by providing information. The

authors also thank Diana L. Ordin, M.D., M.P.H.,

who originally conceived this project and

Lorraine L. Cameron, M.P.H., Ph.D., who provided

guidance in its early stages. The authors also

gratefully acknowledge Jerry Blondell, Gene

Harrington, Amy Liebman, Ray McAllister,

Michael O’Malley, Carol Rubin, Patricia Schnitzer,

and Michael Sprinker who reviewed an earlier

version of this guide. Countless others have

contributed by asking questions over the years,

which we hope are answered by this document.

Finally, creation of this document was made possible by contracts to Strategic Options Consulting,

Inc from both the Oregon Health Division using

funds obtained from the National Institute for

Occupational Safety and Health (NIOSH) under

Cooperative Agreement U60/CCU008161, and

from NIOSH using funding support provided by

the US Environmental Protection Agency.

AUTHORS

Margot Barnett, M.S., Strategic Options

Consulting, Inc.

Geoffrey M. Calvert, M.D., M.P.H., NIOSH,

Centers for Disease Control and Prevention

CONTRIBUTORS

Lynden Baum, Washington State Department

of Health

Michael Heumann, M.P.H., M.A., Oregon

Department of Human Services - Health

Services

Louise N. Mehler, M.D., California

Environmental Protection Agency

Dorilee Peryea Male, New York State

Department of Health

Rachel Rosales, M.S.H.P., formerly with the

Texas Department of Health

Robert Stone, Ph.D., New York State

Department of Health

Patrice Sutton, M.P.H., California Department

of Health Services

Catherine Thomsen, M.P.H., Oregon

Department of Human Services - Health

Services

EDITING

Jane Weber, M.Ed., NIOSH, Centers for

Disease Control and Prevention

George Taylor, Cyrano

DESIGN AND DESKTOP PUBLISHING

Donna Pfirman, AAS, NIOSH, Centers for

Disease Control and Prevention

Vanessa Becks, NIOSH, Centers for Disease

Control and Prevention

PRINTING

Patricia L. Ulakovic, NIOSH, Centers for

Disease Control and Prevention

WEB PRODUCTION

Donna Pfirman, AAS, NIOSH, Centers for

Disease Control and Prevention

David Wall, NIOSH, Centers for Disease

Control and Prevention

ACKNOWLEDGMENTS
xv

ABOUT THE COVER

The cover drawing is titled “Path to Wellness”

and was created by Blake Kidney. His was the

winning entry in a Winter 2002 competition held

at the School of Art, in the College of Design, 

Architecture, Art, and Planning, University of 

Cincinnati. The competition was open to undergraduate and graduate students at the school

who were asked to submit works of art for the

cover of this document. 

ACKNOWLEDGMENTS
1. INTRODUCTION
1.INTRODUCTION

3

1.1 A GUIDE TO THE

MANUAL

1.1.1 GOAL

This manual will help State health

departments develop and maintain

surveillance programs for acute and

subacute health effects from pesticide exposure.

It provides guidelines for program development,

case investigation, data collection, outreach,

and education. A list of resources for further

information is also provided. The manual (which

provides the case classification scheme, severity

index, and sample data collection forms in the

appendices), the standardized variables, and the

SENSOR* pesticide incident data entry and

reporting (SPIDER) computer program software described in the manual are intended to

simplify and streamline the surveillance system

development process. Adoption of these tools

will allow a State to pool data with other Statebased pesticide poisoning surveillance systems.

Many tools and techniques covered in this manual may be generalized for surveillance of other

occupational and environmental illnesses and

injuries.

The manual is designed to address issues of

capturing illnesses and injuries from pesticide

exposures in workplace and nonworkplace settings. Pesticide poisoning is a complex condition for surveillance. It encompasses many

illnesses and injuries created by single or mixed

exposures to pesticide products. Pesticide products are often mixtures composed of pesticides

and other ingredients that may have adverse

human health impacts. The complex nature of

pesticide poisoning and technical resources needed

for case investigation warrants the development

of surveillance programs based predominantly

in State health departments or other State-level

agencies. 

1.1.2 HOW TO USE THE MANUAL

Surveillance of acute pesticide-related illness

and injury requires a multidisciplinary approach

that includes careful planning and implementation. This manual will be most useful when read

in sequence—Chapter 1 through Chapter 9 and

Appendix G—before implementing surveillance. Additional information that will be useful

both in the initial phases of development and the

ongoing implementation of the surveillance system

is provided in the appendices. Readers working

with established pesticide-related illness and

injury surveillance programs can also use the

manual to enhance their surveillance program and

to find additional resources on pesticides.

1.1.3 LIMITS OF THE MANUAL

The surveillance system described here is not

designed to address case and cluster reports of

chronic health effects potentially associated

with pesticide exposure (e.g., cancer, reproductive outcomes, or immunologic and neurologic

effects of chronic exposure). While providing

general guidance about parameters necessary

for an effective pesticide poisoning surveillance

system, it is not intended to cover every situation or to be a complete manual of standard

operating procedures.

________________

*SENSOR is the Sentineal Event Notification System

for Occupational Risk.
1.2 INTRODUCTION TO

THE PROBLEM

1.2.1 PROBLEM OVERVIEW

Over the past 20 years, concern about environmental health issues have increased, particularly

in the area of pesticide exposure. These concerns

have created a growing demand for health and

environmental agencies to provide data on the

impacts of pesticide exposure on human and

environmental health. 

Pesticides are toxic to certain life forms by

design. In addition, they have the potential to

cause adverse health impacts on humans and

other nontarget species. The U.S. Environmental

Protection Agency (EPA) has responsibility for

ensuring that proper pesticide use does not pose

unacceptable risks to humans and the environment. A variety of risk assessment tools are

used to evaluate pesticide products, including

both laboratory tests and field trials. The monitoring of acute illnesses associated with pesticide use is an important additional tool for

identifying potential problems and populations

at high risk, and to develop and evaluate risk

reduction strategies.

1.2.1.1 THE CHANGING PATTERNS OF

PESTICIDE USE

Pesticide use has expanded dramatically since

the discovery of dichloro-diphenyl-trichloroethane (DDT) in 1939. Approximately 16,000

pesticide products are registered with the EPA.

These products are based on approximately 600

active ingredients. Most pesticide products

(approximately 80% by volume) are used by

the agricultural industry [Donaldson et al. 2002].

In addition, a broad range of nonagricultural

pesticide products are formulated for home, garden, structural, veterinary, antimicrobial, and

insect repellent purposes. 

Over time, the use of the most toxic pesticides

has been decreasing as have the numbers of

pesticide-related deaths and more severe poisonings. Advances in technology and the push

for a more ecological approach to pest management will continue to shift the types of pesticides used over time. The current trend is

toward greater use of biopesticides (microorganisms and pheromones) [NAS 2000]. Monitoring any adverse effects of these products on

human and animal population health will be

important. While these products currently represent only a small portion of the market, they are

expected to play a larger role in the future. In

addition, less toxic conventional pesticides will

continue to be used.

1.2.1.2 SCOPE OF THE PROBLEM

From 1993 through 1996, a total of 63,583

symptomatic poisonings from pesticides other

than disinfectants were reported to the Toxic

Exposure Surveillance System (TESS) [Calvert

et al. 2001] and followed to determine a medical

outcome. Of these, 16,258 (25%) were among

children aged 6 and under. Workplace pesticide

exposure accounted for 6,323 cases. According

to TESS, an additional 22,889 poisonings were

attributed to disinfectant exposures. These numbers exclude intentional poisonings such as

malicious use or suicide. Suicides and misuse

represent a relatively low proportion of reported

TESS cases. The data from the TESS system

are an indicator of the size of the problem of

pesticide-related illness and injury in the United

States. During the same time period, however,

3,143 occupationally related cases classified as

definite probable or possible were reported to the

California Department of Pesticide Regulation

(CDPR) [CDPR 2002], suggesting that TESS

may underestimate occupational illnesses by

several fold.

4

CHAPTER 1 INTRODUCTION
5

CHAPTER 1 INTRODUCTION

1.2.1.3 SUSCEPTIBILITY TO PESTICIDE

POISONING

The terms pesticide poisoning and pesticiderelated illness are used interchangeably throughout this manual. These terms refer to acute and

subacute illness or injury resulting from pesticide exposure. Whether pesticide exposure produces health effects in humans depends on the

agent, the exposure scenario, and individual

susceptibility. Agent-specific factors include

the inherent toxicity of the pesticide, the physical characteristics of the formulation, and the

presence of other compounds (e.g., adjuvants,

carriers, emulsifying agents). Relevant exposure scenario factors include the dose (concentration and amount), route of exposure, duration

and frequency of exposure, environment (heat,

humidity, protective equipment), and any concurrent exposure to other substances. Individual susceptibility is influenced by many factors

including age, sex, genetic composition, diet,

and general health (e.g., presence of pre-existing

illness). Health effects may result from acute or

chronic exposure to high or low levels of pesticide products. Pesticide exposure may result in

a wide range of symptoms dependent on the

factors mentioned above. Acute illness may be

mild (e.g., headache, rash, or flu-like

symptoms) or more severe, including serious

systemic illness, third degree burns, neurologic

effects, and, rarely, death.

Some persons may have increased susceptibility

to acute pesticide poisoning. Pesticide poisoning

can affect both children and adults, although

children may be more susceptible because of differences in organ system function and body

composition. In addition, children have behavior

patterns that might increase exposure. Finally,

persons with asthma or other respiratory disease

may also be susceptible to exposure effects

despite proper pesticide application.

Mild illnesses from pesticide exposure are frequently characterized by nonspecific signs and

symptoms, mimicking flu and other common illnesses. Responses to exposure may also be due

to the odor or other irritant properties of the

pesticide products as opposed to actual systemic

intoxication. Health effects may result from

intentional misuse, unintentional exposures, or

use according to the product label.

1.2.1.4 A PROBLEM THAT AFFECTS US ALL

The widespread use of pesticides means that all

sectors of the population are at risk of exposure.

Occupationally exposed persons are at risk

from exposure to more concentrated forms of

pesticide if they are involved in manufacturing,

reformulation, mixing, loading, or applying

pesticide products. Workers who handle pesticides or pesticide-treated products risk illness

arising from either chronic low-level pesticide

exposure or a single acute pesticide exposure.

Persons exposed to pesticides in the residential

environment may have prolonged exposures if a

pesticide product is misapplied to the residence

or its surroundings. Children having repeated

contact with pesticide-treated surfaces and those

who spend large amounts of time in a treated

home environment also may receive a substantial

dose compared with others in the same residence.

In addition, pets may serve as sentinels of exposure in these situations.

1.2.2 WHY INVESTIGATE REPORTS

OF PESTICIDE POISONING?

There are several reasons for addressing reports

of pesticide poisoning. Although pesticide

products go through an extensive battery of

testing before marketing, the testing protocol

does not address all environmental conditions,

mixtures of chemicals, chronic exposure patterns,

and host parameters that can be encountered.
6

CHAPTER 1 INTRODUCTION

Surveillance serves as an early warning system

of any effects not detected by manufacturer testing. It can also identify pesticide problems caused

by noncompliance with pesticide regulations.

Investigation may reveal a pattern of problems

associated with a particular pesticide active

ingredient or a product formulation. An investigation can determine whether a pesticide illness

event arose despite use according to the pesticide label, whether it was because of a violation

of label instructions, or whether the label

instructions were unclear, confusing, or inaccurate. This information can be used to determine

if the product was used inappropriately, or

whether changes are needed in label instructions, product design, or types of personal protective equipment (PPE) necessary to prevent

additional illnesses from occurring. Information

gathered through investigation can be used to

detect whether particular populations are at

greater risk, or whether activities are associated

with exposure and illness that can be modified

to prevent illness.

It would be ideal to have all States conducting

surveillance of pesticide poisoning. In an era of

limited public health resources, however, each

State must determine whether this condition is a

priority for the public it serves. The decision to

implement surveillance may be based on the

types and quantities of pesticides used in the

State for agricultural, urban, or structural pest

control, or in the absence of actual pesticide use

data, the prevalence of crop/agricultural or other activities associated with high pesticide use.

Other local issues may also drive the need to

answer questions about the potential impacts of

pesticides on public health. As another option,

surveillance for pesticide poisoning may be

integrated into a broader poisoning surveillance

system.

1.2.3 RESPONSE TO THE PROBLEM

The Council of State and Territorial Epidemiologist (CSTE) recommends that acute pesticiderelated illness and injury be placed under

surveillance in all States [CSTE 1996]. Additionally, U.S. Government Accountability Office

(GAO) reports from the last 10 years have highlighted the need for standardized surveillance of

human illness associated with pesticide exposure

[GAO 1994, 1999, 2000]. Finally, the American

Medical Association (AMA) supports the need for

improved pesticide poisoning surveillance

[AMA 1997]. Thirty States have rules requiring

some form of physician reporting of pesticide

exposure and illness, although most of these

States do not have a surveillance program to

act on these reports. Nine States (Arizona, California, Florida, Louisiana, Michigan, New York,

Oregon, Texas, and Washington) conduct more

comprehensive case investigation and surveillance activities. States with existing surveillance systems use a variety of systems for

collecting and categorizing data. One objective

of this manual is to raise awareness of the

importance of adopting standardized coding

and categorization systems. This manual will

help States initiate a comprehensive Pesticide

Poisoning Surveillance Program (PPSP).

States considering developing a program may

wish to follow the stepwise approach shown in

Figure 1.1.

The EPA collects information about pesticide

poisonings by a variety of mechanisms. It receives

mandated reports of adverse effects from manufacturers, and periodically reviews both the TESS

data maintained by the American Association of

Poison Control Centers (AAPCC) and aggregated

data from State-based surveillance programs.

Additionally, the EPA receives more timely

reports of significant illnesses and injuries from
7

CHAPTER 1 INTRODUCTION

State surveillance programs, State regulatory

programs, and/or affected persons. State-based

surveillance program reporting of significant

pesticide-related illnesses and injuries to the

EPA is voluntary but is viewed by the participating States as an important part of exchanging information to enhance the understanding

and prevention of pesticide poisonings.

The National Institute for Occupational Safety

and Health (NIOSH) has an interest in developing information about occupational pesticiderelated illness and injury that will lead to

prevention. It has provided funding to States for 

the development and enhancement of pesticiderelated illness and injury surveillance programs.

Most States with PPSPs report aggregated data

to NIOSH that are shared with EPA and the

National Center for Environmental Health (NCEH)

at the Centers for Disease Control and Prevention (CDC). States may also request investigation assistance from NIOSH for particular

types of cases (death, multiple affected persons,

incidents involving new pesticide products,

and incidents that occur despite use according to

the product label). This cooperation helps provide a broader view of the problem of pesticide

poisoning, and participating States benefit from

the knowledge gained from pooled information.
8

CHAPTER 1 INTRODUCTION
2. FIRST STEPS IN SURVEILLANCE SYSTEM

DESIGN: OBJECTIVES, RESOURCES, 

AND THE REPORTING RULE
2.FIRST STEPS IN SURVEILLANCE SYSTEM

DESIGN: OBJECTIVES, RESOURCES, 

AND THE REPORTING RULE

11

2.1 INTRODUCTION

The design of the surveillance system

should be based on the objectives of

the surveillance program, the overall

goals of the program’s parent agency, and the

level of resources available to conduct surveillance. Although this manual assumes that the

surveillance program will be in the State agency

having jurisdiction over health, we recognize that

the surveillance program may be placed in a

Department of Labor (DOL) or an equivalent

agency. This discussion of surveillance system

design is general and cannot address the various configurations that exist in different State

governmental structures. It assumes that the

reader is formally trained with a firm grounding

in epidemiology and the general design of disease

and injury surveillance systems. Many good

resources are available to review the basic principles and practice of surveillance, and the information in those resources is not reproduced

here [Teutsch and Churchill 2000; CDC 2001;

Maizlish 2000]. The surveillance design described

here includes passive case reporting mechanisms

coupled with an active case investigation process.

Many areas discussed are useful for a State that

chooses to develop a surveillance system or to

implement short-term surveillance projects. Some

options are also provided for States without

sufficient resources to conduct full-scale surveillance.

2.2 OBJECTIVES OF

PESTICIDE POISONING

SURVEILLANCE

The primary purposes of pesticide poisoning

surveillance are as follows:

Reduce the incidence of acute pesticide-related

illness/injury.

Identify clusters/outbreaks of pesticide-related

illness/injury.

Identify new pesticide problems and research

needs.

Identify high-risk pesticide active ingredients

and products associated with pesticide-related

illness.

Identify groups at risk for pesticide-related

illness.

Document the distribution of acute pesticiderelated illness.

Target regulatory, enforcement, consultative,

or educational interventions to prevent and

control pesticide-related illness/injury.

Evaluate the effectiveness of prevention

efforts.

Focus public attention on occupational/environmental health problems.

Explore the feasibility of generating useful

rate estimates and trend data.

Generate research hypotheses.

At the individual case report level, the surveillance

program may also assist health care professionals (HCPs) evaluate the patient’s exposure

situation and link the HCP with additional

resources to help determine the patient’s diagnosis.

2.3 PROGRAM STAFFING

AND STRUCTURE

Running an effective PPSP requires a number of

professional skills. The mixture of professionals
who meet the needs of the program varies among

the existing programs. Some programs have sufficient resources to maintain a full-time multimember staff that includes program managers,

data managers, case investigators, and field staff.

Others are staffed more frugally with staff

wearing multiple hats or split between various

program activities, only one of which is pesticide

poisoning surveillance.

2.3.1 TYPES OF EXPERTISE NEEDED

FOR SURVEILLANCE

Surveillance for pesticide-related illness and

injury requires program staff to have knowledge

in a broad range of areas including the following:

Toxicology

Epidemiology

Medicine

Data management

Occupational/environmental health

Industrial hygiene 

Other areas that are important but may be

incorporated into the program by collaboration

with other organizations include integrated pest

management (IPM) and health education. The

most successful PPSPs employ persons with training in epidemiology and environmental or occupational health. Employing or contracting with

persons who are bilingual and bicultural to conduct

interviews and participate in investigations

involving non-English speakers is extremely

important for program effectiveness. In most

regions of the country, this usually means someone who can speak Spanish. In some areas, it

may mean the program needs access to an interviewer who speaks Hmong, Mayan dialects,

Russian, or other languages.

2.3.2 WAYS TO MEET NEEDED

EXPERTISE WITH MINIMAL

RESOURCES AND STAFFING

LEVELS

It would be ideal for a program to have one person in each of the six main disciplines listed in

Section 2.3.1, but most programs acquire this

expertise by developing collaborative relationships with partners from other programs or agencies. Some level of medical expertise is certainly

critical for effective surveillance. Because of the

complexity of pesticide poisoning, a surveillance

program should have access to a clinical toxicologist or a toxicologist and a physician familiar

with the condition to assist with case or outbreak

investigations and case classification. Credibility

of the surveillance program is enhanced if a

physician is either on staff or affiliated with the

program. This may mean the State epidemiologist

takes an active role in the program. If a physician

is not available within the agency to provide

assistance, a contractual arrangement with a clinical toxicologist or emergency physician consultant at a local university or hospital is an alternative solution. The National Pesticide Medical

Monitoring Program (NPMMP) (see Appendix G)

can also provide assistance to PPSPs and reporting physicians. The NPMMP can be contacted

through the National Pesticide Information

Center (NPIC). Over time, as surveillance program

staff become fully trained and familiar with the

toxicology of common pesticide classes, the

day-to-day need for clinical expertise may

decrease, and the consulting physician will be

called on less frequently. The poison control

center (PCC) may serve as a close partner to the

surveillance program, depending on the relationships established by the health department.

The Agricultural Extension Service may also

have toxicologists based at the State land grant

university who are familiar with the toxicology

of pesticides as well as other agriculturally

related toxins.

12

CHAPTER 2 FIRST STEPS IN SURVEILLANCE SYSTEM DESIGN: 

OBJECTIVES, RESOURCES, AND THE REPORTING RULE
13

CHAPTER 2 FIRST STEPS IN SURVEILLANCE SYSTEM DESIGN: 

OBJECTIVES, RESOURCES, AND THE REPORTING RULE

It is not absolutely necessary that staff have

a priori knowledge about pesticides, although

it is certainly helpful. If staff have no knowledge specific to pesticides when hired, they

will need to become familiar with the subject

quickly. New staff should be encouraged to

attend education programs on recognition and

management of pesticide poisoning conducted

by the surveillance program or another source.

Program staff will also need to develop sufficient understanding of pesticide toxicology to

conduct case investigations and participate in

classification of cases. 

If program staff do not have a public health background, an introductory epidemiology course is

useful. The CDC has a tutorial program entitled

Surveillance in a Suitcase [CDC 2000a] that

provides a solid grounding in surveillance. It is

available on the Internet and complements the

book Principles and Practice of Public Health

Surveillance [Teutsch and Churchill 2000].

2.4 PROGRAM FUNDING

OPTIONS

Several funding strategies are used by States with

PPSPs. In California, the surveillance program

managed by CDPR is funded by a tax on pesticide sales. Additional surveillance activities

funded through a cooperative agreement from

NIOSH are conducted by the Occupational

Health Program at the California Department

of Health Services. The surveillance program

in Washington State is funded with State general

funds supplemented by funding from a NIOSH

cooperative agreement. Other States are reliant

on a low level of general fund money combined

with cooperative agreement funds from NIOSH.

At times, States have also received funding from

EPA and NCEH to support PPSP activities.

Programsreliant on Federal funding have limited

budgets and staffing compared with programs

supported by general funds or sales fees.

2.5 REPORTING

REQUIREMENTS

AND RULES

In the United States, State legislatures possess

the authority for requiring disease reporting,

which they exercise by enacting laws and statutes.

In some States, pesticide poisoning and other

conditions are specifically mentioned in a disease-reporting statute. In many States, State and

local agencies are, by statute, delegated the authority to enumerate the reportable health conditions.

In such cases, adding a reportable condition is

most often a rule change rather than a statutory

change. This section discusses elements found

in statutes and rules that are useful for creating

and maintaining a successful PPSP.

Both local and national information about pesticide use and poisonings have been used for

justification when developing the reporting

rule. At least three U.S. Government Accountability Office (GAO) reports discuss pesticide

poisoning [GAO 1994, 1999, 2000]. Many

states have found that GAO reports, annual

reports from existing surveillance programs,

published annual review articles from the

AAPCC, and State workers’ compensation

data are useful resources to support a reporting rule and pesticide poisoning surveillance.

Additional information can be obtained from the

State agency responsible for enforcing pesticide

regulations, which can provide material about

complaint investigations that involve human

health concerns. The series of articles from the

Morbidity and Mortality Weekly Reports

(MMWRs) listed in Appendix A are helpful

examples of the way in which surveillance systems have helped identify particular problems

associated with pesticide use. State-level information about calls received by the NPIC also

provides some useful background information.

The annual reports are available on the NPIC

Web site: http://NPIC.orst.edu/reports.htm. (A
link to an example of a pesticide-related illness

reporting rule and justification appears in

Appendix B.)

States have justified their reporting rule by citing

the number of workers with potential pesticide

exposure. Background information about

migrant and seasonal farmworkers is located in

data from the National Agricultural Workers Survey (NAWS) conducted by the U.S. DOL (data

can be accessed at the following Web site:

http://www.dol.gov/asp/programs/agworker/

naws.htm). State- and county-level census data

on the number of workers by occupation are

available at http://www.census.gov/hhes/www/

occupation.html. These census data can be useful

for determining the number of workers in occupations having potential pesticide exposure (e.g.,

farm workers, pest control occupations). 

The case definition for reporting purposes is

generally broad and does not require a high

degree of clinical diagnostic certainty. This

approach will increase the sensitivity of the surveillance system for capturing cases of acute

pesticide-related illness and injury. Unlike many

other reportable diseases and conditions, pesticide poisoning encompasses a broad range of

exposure agents and related symptomatology.

For most health care providers, the evaluation

of pesticide exposure and illness is a rare event. To

ensure that the HCP or other source of case

reports does not exclude potential cases, often

the language in the reporting rule makes clear

that cases need not be confirmed to be reported.

Many States require that any suspected or confirmed case of pesticide poisoning be reported.

The reporting statutes and/or rules from several

States, including California, Florida, Missouri,

New Jersey, New York, Oregon, Texas, and

Washington, are on the Internet (see Appendix B). 

There are not many major differences across

State rules/statutes. The examples listed in

Appendix B represent those containing the broad

language that is discussed in this chapter. 

All States have significant problems with

underreporting. State statutes/rules differ in

exactly who is required to report. In some States,

it is the licensed physician attending the affected patient; in other States, it is any health care

provider aware of a case or suspected case.

Considering the problems with underreporting,

the broader wording is most effective for capturing the largest number of reports. 

The PCC serving the State is a critical reporting

entity to include in the surveillance program.

PCCs often are specifically mentioned in the

reporting rule, either by using generalized wording that they can interpret as including them or

by developing a memorandum of understanding between the PCC and the PPSP. Similarly,

workers’ compensation data (both accepted and

denied claims) are an important source of data

on occupational pesticide poisoning, and kindred

efforts should be considered for gaining access

to them.

When developing pesticide poisoning reporting

rules, consider the following important questions discussed in this chapter:

Who is required to report, since the range of

reporters will affect the completeness of

reporting and the complexity of the surveillance system?

Does the health department have authority

to investigate and conduct site inspections of

occupational exposure cases? 

Should the rule include a penalty for failure

to report?

14

CHAPTER 2 FIRST STEPS IN SURVEILLANCE SYSTEM DESIGN: 

OBJECTIVES, RESOURCES, AND THE REPORTING RULE
Do the agency’s existing confidentiality

rules provide adequate protections to affected

persons?

Do enforcement agencies that receive referrals have the same confidentiality rules to

protect medical information and/or the identity

of the affected person? If not, is there an alternative referral approach that can be used?

How will clinicians, the general public,

workers, employers, and other stakeholders

be informed of the rule change? How will

they be given tools for recognizing, managing,

reporting, and preventing pesticide poisoning?

2.5.1 ELEMENTS OF THE REPORTING

RULE

This section provides information about the

elements contained in an effective reporting

rule. Each State has different requirements for

these rules and must make decisions and use

wording based on their specific needs.

2.5.1.1 WHAT IS REPORTABLE?

Pesticide poisoning is a term easily recognized

by clinicians, but it may cause them to limit

their thinking to frank acute poisonings, no

matter how it is defined in a rule. The term

acute pesticide-related illness and injury is a

more accurate description of what should be

reported. In the rule, States specify whether the

program is aimed at capturing only acute or

both acute and chronic illness and injury. All of

the information in this manual is limited to the

surveillance of acute pesticide-related illness

and injury, but some States may have reasons

for wishing to capture both. Indicating that both

clinically suspected or confirmed cases should

be reported encourages health care providers to

report even if they are not sure of the diagnosis.

Pesticide poisoning or pesticide-related illness

and injury, whichever term is used, should be

defined. The definition can make it clear that

acute systemic, opthalmologic, or dermatologic

illness or injury resulting from inhalation, ingestion, dermal exposure, or ocular contact with a

pesticide is reportable. It is also helpful to use

and define the terms case, suspected case, and

pesticide. The definition for pesticide is generally the legal definition used by the State program taken from the State pesticide use laws.

States may choose to make it clear that effects

include those caused by both active and inert

ingredients, and may choose to include adjuvants (see Section 2.5.3). (Adjuvants are materials that are added to a pesticide formulation to

improve or change properties such as deposition, persistence, or mixing ability. These materials, which may be added by the pesticide applicator before a pesticide product is applied,

include wetting agents, spreaders, emulsifiers,

foam suppressants, and dispersing agents.) Since

clinicians and the public often equate pesticides

only with insecticides, confusion can be prevented by adding a statement such as: “Pesticides

include but are not limited to herbicides, insecticides, rodenticides, repellents, fumigants, fungicides, and wood treatment products.” It is important that educational materials for reporters and

the public include information about classes of

pesticides that may not be perceived as pesticides

(e.g., herbicides, disinfectants, and wood preservatives). This definition is also where the surveillance program should indicate whether it is

including or excluding illness and injury resulting

from exposure to disinfectants. 

In the spirit of having a reporting rule with

broad wording, States consider whether to

specifically include disinfectants, which are

considered pesticides and produce a similar

number of poisoning cases as are produced by

conventional pesticides. Some programs, especially those with limited resources, may not be

able to track disinfectant-related cases. However,

including disinfectants in a reporting rule will

15

CHAPTER 2 FIRST STEPS IN SURVEILLANCE SYSTEM DESIGN: 

OBJECTIVES, RESOURCES, AND THE REPORTING RULE
facilitate their surveillance when additional

resources are secured.

Ideally, making the full spectrum of pesticiderelated illness and injury reportable is preferable to limiting reporting to occupational or

nonoccupational cases. If jurisdictional or other

limitations on resources exist, limiting reporting

to occupationally related cases may be useful.

Occupational exposures are more likely to be

ongoing and have the potential to involve more

toxic chemicals. However, having a broad

reporting rule often makes it easier to build

bridges with the agricultural community and

to gain its support for the surveillance program.

When surveillance is limited to occupational

cases only, it must be made clear to the agricultural

community that this surveillance also includes

nonagricultural occupationally related cases.

An example of broad wording to define what is

reportable is “Report cases or suspected cases

of acute pesticide-related illness and injury

when there is a history of exposure and a

temporally-related illness or injury (laboratory

confirmation is not required). For reporting

purposes, pesticide poisoning includes acute

poisoning as well as any subacute illness or

condition (dermatologic, ophthalmologic, or systemic) caused by, or suspected of being caused

by, pesticide exposure.”

The statute/rule either specifies what must be

reported in detail (e.g., a listing of name, address,

phone number, social security number, sex, date

of birth, diagnosis, etc.), or specifies that all

information requested on an agency reporting

form must be supplied to the health department.

If the statute or rule does not clearly describe

the agency’s access to additional medical information or medical records, requests for medical

information may be denied by the HCP or

health institution where the affected person was

seen. Likewise, the parent agency of the surveillance program should determine whether it has

authority to gather information from third parties

(e.g., employers and pesticide applicators) during an investigation. Some States have secured

this authority through a change of the statute or

rule for reporting of pesticide poisoning.

It may be useful to consider requirements for

pesticide use reporting at the same time that the

illness reporting rule is being developed and the

PPSP is being designed. (see Appendix G for

information about pesticide use reporting rules

and data.) This is considered hazard surveillance, as opposed to disease surveillance. Pesticide

use reporting can provide information about

when and where hazardous pesticides are used,

which can guide intervention efforts. In addition, pesticide use reporting can provide useful

denominator data. For each pesticide or pesticide class, rates of pesticide poisoning cases per

pound used of the pesticide can be calculated.

These analyses would allow the identification

of pesticides that poison the largest number of

people per pound used. The disadvantages of

pesticide use reporting are the time and financial burdens placed on pesticide users who

must report this data, and on the State agency

responsible for enforcing the rule and processing

the data. 

2.5.1.2 WHO MUST REPORT?

Reporting rules are typically aimed at licensed

health care providers or physicians and, in

some States, laboratories. A broad statement

that is inclusive of a wide range of reporters is

desirable, if no legal reasons for limiting the

language exist. Some States require reporting

by school nurses or school administrators for

schools without a nurse. This may be a useful

requirement if a State is including nonoccupational poisonings in the surveillance system. It

16

CHAPTER 2 FIRST STEPS IN SURVEILLANCE SYSTEM DESIGN: 

OBJECTIVES, RESOURCES, AND THE REPORTING RULE
would not be advisable if the system is interested in capturing occupational cases only. Surveillance systems that capture only occupational

cases may confront difficulties when responding

to school-based pesticide exposure events. Such

surveillance programs can address the concerns

of teachers and clerical and maintenance staff

who may be ill from a school-based exposure

event. However, the program’s inability to

address the public health concerns of students

and their parents will create significant policy

problems. 

The PCC may be mentioned specifically as a

reporting entity, or PCC staff may consider

themselves to be health care providers under a

broadly stated rule. This issue should be discussed directly with the PCC(s) in the State

before developing language for a proposed

rule. Similarly, workers’ compensation data are

an important source of cases, and kindred

efforts should be considered for gaining access

to it.

If reporting is mandatory, the State may choose

to attach penalties for failure to report. This

particular issue is often not directly addressed

but should be considered. The disadvantage of

penalties is that they may set a hostile tone. A

clearly stated penalty may create a negative relationship with potential reporters when the State

attempts to establish the reporting rule. The

Washington statute includes a statement that no

action shall result from the failure to report as

required by the law, although it does allow the

department of health to submit information

about nonreporting primary care providers to the

applicable disciplining authority [RCW

70.104.055(5)–(6)]†. The California law contains a penalty clause that has been used very

rarely to address a health care provider’s failure

to report. Washington originally proposed a

similar clause in their law but changed it to the

current wording after representatives of the

State medical association made it clear they

would not support penalties for failure to report

[Baum 2001a]. 

2.5.1.3 WHERE TO REPORT

The reporting process is usually standardized

for all reportable conditions in a State with the

report going to either the State or local health

agency. It is easier and will prevent delays if

reports go to the agency that will be conducting

the investigation rather than to an agency that

will only act as a filter or referral center. If

reports go directly by the local health department, clear guidelines are needed to ensure

reports are transferred to the State PPSP in a

timely manner.

Some States stipulate that reporting may be to the

Department of Agriculture (DA), the Department

of Environment, or some other agency. For

example, in Louisiana, reports go to the DA and

the Department of Forestry. If reports go to an

agency other than a local or State health department, it is critical that laws and rules ensure the

appropriate level of medical confidentiality for

reports and the portions of investigations that

include medical information. (Note: Reporting

rules requiring health care providers to report to

a DA have not routinely resulted in health care

provider reports. Most reports received by

these systems come from affected persons complaining about pesticide applications made by

another person.)

2.5.1.4 WHEN TO REPORT

Prompt reporting is critical if the surveillance

program is designed to conduct timely investigations. A rapid reporting and response system

permits information to be captured that might

otherwise be lost, especially data available

from environmental or biological specimens.

17

CHAPTER 2 FIRST STEPS IN SURVEILLANCE SYSTEM DESIGN: 

OBJECTIVES, RESOURCES, AND THE REPORTING RULE

_________________

†Revised Code of Washington. See RCW in references.
By receiving reports promptly, the public health

system can act to prevent additional exposures

and illnesses. The range of reporting times in

existing rules is from 24 hours to 30 days.

Most States encourage telephone or faxed

reports to ensure prompt reporting. Some States

are moving toward electronic reporting: transmitting data in flat file ASCII or another standardized format has significant advantages in

that it can be automated. Data are usually

encrypted for security. This is particularly useful

for reporters who have large numbers of reports

or who provide batched periodic reports of data

(e.g., laboratories, PCCs, or workers’ compensation departments).

2.5.1.5 HEALTH INSURANCE PORTABILITY

AND ACCOUNTABILITY RULE AND

PUBLIC HEALTH (HIPAA) 

PRIVACY RULE AND PUBLIC

HEALTH SURVEILLANCE

The information in this section was adapted

from the CDC publication entitled HIPAA Privacy

Rule and Public Health: Guidance from CDC and

the U.S. Department of Health and Human

Services [CDC 2003]. This document is available on the Internet at http://www.cdc.gov/mmwr/

preview/ mmwrhtml/su5201a1.htm. 

New health information privacy standards have

been issued by the U.S. Department of Health

and Human Services (DHHS), pursuant to the

HIPPAAct of 1996. The new regulations provide

protection for the privacy of certain individually

identifiable health data, referred to as protected

health information (PHI). Balancing the protection of individual health information with the

need to protect public health, the Privacy Rule

expressly permits disclosures without individual

authorization to public health authorities authorized by law to collect or receive the information

for the purpose of preventing or controlling disease, injury, or disability, including but not limited to public health surveillance, investigation,

and intervention [45 CFR 164.512(b)]. This

includes the reporting of disease and injury for

public health surveillance. A public health

authority is broadly defined as including agencies

or authorities of the United States, States

(including public health departments and divisions), territories, American Indian tribes, or a

person or entity acting under a grant of authority

from such agencies and responsible for public

health matters as part of an official mandate.

A public health authority at the Federal, tribal,

State, or local level does not need disease or

condition-specific laws before collection of PHI

is authorized. On the contrary, public health

authorities operate under broad mandates to

protect the health of their constituent population, and they are authorized to receive PHI for

the purpose of controlling disease, injury, or

disability. A covered entity (that is, a health

plan, health care clearinghouse, or health care

provider who transmits any health information

in electronic form in connection with a transaction [45 CFR 164.103] ) may disclose the minimum necessary information to accomplish the

intended public health purpose of the disclosure. The covered entity may rely on the public

health authority’s representation that the information is the minimum necessary to accomplish

the intended public health purpose of the disclosure [45 CFR 164.512(b)].

To receive PHI for public health purposes, public

health authorities should be prepared to verify

their status and identity as public health authorities under the Privacy Rule. To verify its identity,

an agency could provide any one of the following:

If the request is made in person, the requestor

presents an agency identification badge, other

official credentials, or other proof of government status. 

If the request is in writing, the request is on

the appropriate government letterhead.

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CHAPTER 2 FIRST STEPS IN SURVEILLANCE SYSTEM DESIGN: 

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If the disclosure is to a person acting on

behalf of a public health authority, a written

statement that the person is acting under the

government’s authority is on appropriate

government letterhead [45 CFR 164.514(h)(2)].

Public health authorities receiving information

from covered entities as required or authorized by

law [45 CFR 164.512(a) and 45 CFR 164.512(b)]

are not business associates of the covered entities

and therefore are not required to enter into business

associate agreements. Public health authorities that

are not covered entities are also not required to

enter into business associate agreements with

their public health partners and contractors. Also,

after PHI is disclosed to a public health authority

pursuant to the Privacy Rule, the public health

authority (if it is not a covered entity) may

maintain, use, and disclose the data consistent

with the laws, regulations, and policies applicable

to the public health authority.

Additional information about this topic appears

in the CDC publication entitled HIPAA Privacy

Rule and Public Health: Guidance from CDC

and the U.S. Department of Health and Human

Services [CDC 2003]. CDC recommends that

public health authorities share the information in

this document with health care providers and

other covered entities and to work closely with

those entities to ensure implementation of the

rule consistent with its intent to protect privacy

while permitting authorized public health activities to continue. Comprehensive DHHS guidance

is located at the HIPAAWeb site of the Office for

Civil Rights http://www.hhs.gov/ocr/ hipaa/).

2.5.1.6 CONFIDENTIALITY

It is assumed in this discussion that the State

already has existing rules governing the confidentiality of personally identifiable medical

information collected as part of disease reporting and special studies. This is an area that must

be reviewed carefully if reporting is made to an

agency other than the one that usually houses

information about reportable conditions. For

example, departments of labor, business services,

or agriculture may not have adequate policies

to protect confidential medical information.

These issues may be addressed by carefully

crafted regulatory language or a memorandum

of understanding developed in consultation with

the agency’s legal counsel.

2.5.1.7 INTERAGENCY COOPERATION OR

SHARING OF INFORMATION

The mechanisms of interagency cooperation on

investigations are discussed in Chapter 5. Some

States have included statements about interagency

cooperation in their laws or rules governing the

reporting and investigation of pesticide poisoning

(these statements may apply only to pesticide

poisoning or apply to all reportable conditions

or reportable occupational conditions). Several

States have statutes and rules that specify the

establishment of interagency boards related to

the investigation of human illness associated

with pesticide use. Oregon and Washington are

two such States.

2.5.1.8 AUTHORITY TO INVESTIGATE

In some States, the health department does not

have clearly authorized access to workplaces

unless they are establishments that are accessible to the broader public (e.g., retail establishments, schools, etc.). This is something that

should at least be reviewed and considered when

developing a statute and associated rules for surveillance of pesticide poisoning. To our knowledge, no pesticide poisoning rules exist that

address the authority to conduct investigations.

In contrast, some States have laws that address

the authority to conduct investigations. Often,

State health departments without a clear authority

to investigate workplaces can gain access through

voluntary cooperation. Employers are aware that

failure to cooperate with an investigation will

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CHAPTER 2 FIRST STEPS IN SURVEILLANCE SYSTEM DESIGN: 

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usually result in referral to an enforcement agency

that has authority to investigate. (See Section

2.5.2.3 for further discussion of this issue.) 

2.5.2 EXAMPLES OF REPORTING

LAWS AND RULES

This section includes excerpts from laws and

rules from the following States: New York, Texas,

and Washington. These examples were selected

for inclusion as they each contain elements that

warrant some consideration for a State considering adding pesticide poisoning as a reportable

condition. 

2.5.2.1 NEW YORK REPORTING RULE

This State’s reporting rule (Visual 2.1) provides

for reporting from health care providers and

laboratories. It has clear statements about the

reporting of cholinesterase analyses and other

clinical laboratory testing for pesticides in human

tissue. The wording is broad, requiring reports of

confirmed and suspected cases. The requirement

for laboratory reporting of cholinesterase results

does contribute a significant number of reports

that are unrelated to pesticide exposure. This is

due to the routine evaluation of cholinesterase

levels before administration of certain muscle

relaxants used in surgery.

2.5.2.2 WASHINGTON LAW

The Washington law [RCW 70.104 Pesticides—

Health Hazards 2002] describing pesticide

poisoning surveillance is more detailed than

laws in most States. The definition of pesticide

is very broad, specifically including spray adjuvants

and agents intended to be used with pesticides.

The statute includes language that empowers

the Department of Health to “investigate all suspected human cases of pesticide poisoning and

such cases of suspected pesticide poisoning of

animals that may relate to human illness.” The

law also gives the Department of Health authority to take samples including human or animal

tissue specimens for diagnostic purposes with the

consent of the exposed person. This statutory

provision permitting the department to obtain

specimens appears in several other State laws. It is

useful since it is very explicit and allows the

specimens to be collected as part of the investigation to confirm the diagnosis. Without this

explicit statement, States may find it more difficult to collect and analyze such specimens

without a more research-oriented protocol; such a

protocol may require institutional review board

clearance and detailed informed consent. Note

that in Texas, unlike Washington State, the statute

empowers the health department to collect both

biological and environmental specimens.

2.5.2.3 TEXAS REPORTING LAW

The Texas law contains a section (see Visual 2.2)

on investigations that has a clearly stated right

of entry authority for occupational cases, as

well as the right to collect and analyze environmental and biological specimens. This wording

provides access to the information needed to

conduct complete investigations. Subsection (b)

of the law might not permit inclusion of farm

labor housing as part of an investigation. There

may be interagency or constituency reasons

why a State might choose not to include similar

language in its law or statute. These issues

should be explored before proposing language

of this type.

2.6 SURVEILLANCE

STRATEGY FOR STATES

WITH LIMITED

RESOURCES

States with limited resources should consider

adopting a completely passive system that uses

existing PCC(s) data to report occupational

pesticide-related injury and illness incidence as

defined in Visual 2.3. This strategy does not

require any active case follow-up or management

of confidential information since data can be

20

CHAPTER 2 FIRST STEPS IN SURVEILLANCE SYSTEM DESIGN: 

OBJECTIVES, RESOURCES, AND THE REPORTING RULE
obtained without identifiers. Similarly, rates for

nonoccupational pesticide-related illness and

injury can be constructed by changing the demographic group and denominator. This surveillance approach does not require case follow-up,

investigation, or a rule change. Other resourcesparing approaches discussed in this chapter

include the following:

Limiting the case definition to collect occupationally related cases

21

CHAPTER 2 FIRST STEPS IN SURVEILLANCE SYSTEM DESIGN: 

OBJECTIVES, RESOURCES, AND THE REPORTING RULE

Visual 2.1. NYCRR Title 10, Volume A, PART 22

Environmental Diseases

(Statutory Authority: Public Health Law, 

§§ 225[5][t], 206[l][j])

22.11 REPORTING OF PESTICIDE POISONING. Every physician, health facility, and clinical laboratory in attendance on a person with confirmed or suspected pesticide poisoning or with and of the

clinical laboratory results described in section 22.132 of this Part, shall report such occurrence

to the State Commissioner of Health within 48 hours. This report shall be on such forms or in

such manner as prescribed by the State Commissioner of Health. 

_______________

Historical note

Sec. Filed August14, 1990, effective August 29, 1990.

22.12 REPORTABLE LABORATORY TESTS FOR PESTICIDE POISONING. For the purposes of section

22.11, of this Part the following laboratory tests are reportable to the State Commissioner of

Health:

(a) Blood cholinesterase levels that are below the normal range established by the clinical laboratory performing the test in accordance with quality assurance requirements established

by the permit-issuing agency.

(b) Levels of pesticides in human tissue samples that exceed the normal range established in

accordance with quality assurance requirements established by the permit-issuing agency.

_______________

Historical note

Sec. Filed August 14, 1990, effective August 29, 1990.

Following up only on a subset of reports

(e.g., severe illness, incidents involving

multiple persons)

While these resource-sparing approaches provide an incomplete view of the problem of pesticide poisoning within a State, they do provide

options for getting some sense of the scope of

the problem, while using fewer resources than

a more comprehensive surveillance program.
CHAPTER 2 FIRST STEPS IN SURVEILLANCE SYSTEM DESIGN: 

OBJECTIVES, RESOURCES, AND THE REPORTING RULE

22

Visual 2.2. Texas Reporting Law 

Communicable Disease Prevention and Control Act, Health

and Safety Code, Chapter 84, The Occupational Condition

Reporting Act

(§ 84.007. Investigations)

(a) The department shall investigate the causes of occupational conditions and methods of prevention.

(b) In performing the commissioner's duty to prevent an occupational condition, the commissioner or the commissioner's designee may enter at reasonable times and inspect within reasonable limits all or any part of an area, structure, or conveyance, regardless of ownership,

which is not used for private residential purposes.

(c) Persons authorized to conduct investigations under this section may take samples of materials present on the premises, including samples of soil, water, air, unprocessed or processed

foodstuffs, manufactured items of clothing, and household goods. If samples are taken, a

corresponding sample shall be offered to the person in control of the premises for independent analysis.

(d) Persons securing the required samples may reimburse or offer to reimburse the owner for the

materials taken, but the reimbursement may not exceed the actual monetary loss sustained

by the owner.

_________________

Acts 1989, 71st Leg., ch. 678, § 1, eff. Sept. 1, 1989.

Amended by Acts 1997, 75th Leg., ch. 245, § 6, eff. May 23, 1997.
Visual 2.3. Minimum Data Collection for Occupational 

Pesticide-Related 

Illness and Injury Surveillance 

Below are guidelines for minimum data collection for occupational pesticide poisoning surveillance. Data should be obtained from poison control centers (PCCs) serving the State. Collecting

these data will provide a State health agency with information about this condition that is comparable across States.

Data Resources Poison Control Center data (numerator)

BLS Current Population Survey Data (denominator)

available at http://www.bls.gov/opub/gp/laugp.htm

Demographic Group Employed persons aged 16 and older 

Numerator Reported cases of work-related pesticide poisoning defined as:

1. Exposure to an agent included in one of the pesticide 

generic categories (that is, fungicides, fumigants, 

herbicides, insecticides, repellents, or rodenticides), AND 

2. Reason=occupational OR Exposure Site=workplace, AND

3. Medical Outcome is one of the following: minor effect; 

moderate effect; major effect; death; not followed, 

minimal clinical effects possible; or unable to follow, 

judged as a potentially toxic exposure. 

Denominator Employed persons aged 16 and older for the same calendar year

Measures of Frequency Annual number of incident cases

Annual incidence rate per 100,000 employed persons aged 

16 or older

Time Period Calendar year

Limitations of Indicator Some States may not have a PCC. In addition, there may be

rare circumstances in which a State health agency is unable

to obtain data from their State-based PCC; however, under

such circumstances it may be possible to obtain less timely

PCC data from NIOSH at http://www.cdc.gov/niosh/pestsurv/. 

Other Data to Collect Age, sex, pesticide active ingredient, signs/symptoms arising 

from PCCs from the pesticide exposures, illness severity, and whether hospitalization/intensive care unit (ICU) treatment was provided.

Additional Guidance Additional guidance on obtaining the numerator and 

denominator data are available from NIOSH

(http://www.cdc.gov/niosh/topics/pesticides/) or from the

Council of State and Territorial Epidemiologists

(http://www.cste.org/pdffiles/Revised%20Indicators3.4.04.pdf ).

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CHAPTER 2 FIRST STEPS IN SURVEILLANCE SYSTEM DESIGN: 

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3. CASE ASCERTAINMENT
27

3.CASE ASCERTAINMENT

3.1 INTRODUCTION

Several possible sources for pesticide

poisoning case reports exist. Ideally,

all of these sources should be used

for timely identification of cases. However, if

resources are limited, a single type of case

ascertainment method may be chosen, supplemented by a periodic survey to review data

from other sources.

3.2 POISON CONTROL

CENTERS (PCCS)

PCCs may function at a regional or statewide

level. They receive calls from HCPs and the

general public. The main function of PCCs is to

provide toxicologic and case management

information. Calls may be purely informational, but they commonly involve guidance on

management of an acute ingestion or other

acute exposure. PCCs often follow up cases

until there is a final outcome, especially when

there is a possibility that a person is at risk of

more than minor adverse health effects. This

follow-up information is used to determine the

severity of the health effect. PCCs collect a

variety of information including demographic

data, the route of exposure, whether exposures

were intentional, the site of exposure, case

management, the therapy received, clinical

effects by organ system, and medical outcome.

PCCs are an important source of case reports,

especially for nonoccupational pesticide poisonings. As mentioned in Section 2.5.1.2, it

may be helpful to list them specifically as

reporters in the reporting statute or rules. The

mechanisms and requirements for reporting

should be discussed with the PCC prior to proposing language. Prompt reporting of cases by

the PCC allows the surveillance program to act

quickly to prevent additional exposures and illnesses from occurring. 

The reporting guidelines shown in Visual 3.1

are useful according to State surveillance programs working with PCCs. Two data management software programs (Dotlab and TOXICALL®

) commonly used by PCCs have

developed customized reporting capabilities to

facilitate reporting to PPSPs. These modifications include the capacity for real-time reporting to PPSPs. See Appendix C for instructions

on obtaining case reports from PCCs, including

a listing of the pesticide substance codes used

by PCCs and information about search strategies for PCC data. PCCs can also assist reporting by physicians who call for advice on diagnosis and management of acute pesticide

poisoning. The PCC can inform the HCP about

the State reporting requirement and the PCC

can offer to report the case. If the HCP agrees,

the PCC may need to obtain additional patient

information to satisfy the data reporting

requirements (e.g., patient name and contact

information).

Many PCCs have often struggled to maintain

the funding required to remain open. In many

States, PCCs receive financial support from the

State department of health, which should facilitate the creation and maintenance of a reporting

arrangement between the PPSP and the PCC. In

States in which the department of health does

not provide funding support to the PCC, the

PPSP should consider making financial

arrangements with the PCC. This will foster a
28

CHAPTER 3 CASE ASCERTAINMENT

stronger collaboration between the two agencies and will allow both agencies to better meet

their obligations.

PCC data, stripped of individual identifying

information, are aggregated into a national

database by the AAPCC. This database (TESS)

contains information about millions of poison

exposures reported to certified PCCs in the

United States. An annual report is published in

the September issue of the American Journal of

the Emergency Medicine. The annual report

includes information about all toxic agents, not

just pesticides. Additional AAPCC contact

information appears in Appendix G. PCCs do

not systematically collect detailed information

about occupational cases (e.g., information is

not collected on the worker’s industry, occupation, or factors that led to the worker’s

exposure). Work-related information may be

embedded in the narrative but is difficult to

extract and is inconsistent when present.

Visual 3.1. Useful Reporting Guidelines 

for Poison Control Centers (PCCs)

(Adapted from criteria used by Florida Department of Health)

PCCs should report systemic pesticide poisonings (classic toxicosis) and those involving local

responses (dermatitis, ocular effects, etc.) as well as reactions due to unpleasant pesticide formulation odors, pesticide product explosions, and allergic reactions. If an event consists of multiple cases, be sure to report information about each case. If Pesticide Poisoning Surveillance Program (PPSP) resources are limited, it may want to restrict PCC reports to the following cases

involving pesticide exposures: 

1. All occupational cases (that is, anyone with illness or injury associated with exposure to pesticides while he/she was at work):

Including farmworkers, farmers, and pesticide handlers/applicators (pest control operators,

golf course superintendents/technicians, pesticide manufacturing workers, etc. even when selfemployed);

Including office workers, teachers, construction workers, or persons employed in residential settings (home offices, residential service workers, etc.).

2. All serious cases, such as those resulting in death, hospitalization, or physician diagnosis of

a poisoning (this includes attempted suicides).

3. All cases involving HCP-initiated calls in which the HCP describes clinical signs, or situations when callers are advised to seek medical attention. (Clinical signs can be systemic or

local, including miosis, rash, conjunctivitis, dyspnea, etc.)

4. All cases, of any type, involving more than one person. This is intended to capture reports

of mass poisonings in residential neighborhoods, schools, etc., where many people are

reporting exposure-related illnesses due to a common source.

5. All cases involving exposure to public spraying of pesticides (e.g., medfly spraying, mosquito spraying, etc.), where the patient is symptomatic (even if there is only a suspicion that

symptoms are related to the exposure).

6. Any other situation not covered here but considered eligible for a report by the PCC Director/

Assistant Director.
3.3 WORKERS’ 

COMPENSATION DATA

Workers’ compensation claims can be a valuable source of information about occupational

pesticide poisoning cases. States vary in coverage of agricultural workers by workers’ compensation regulations (see Appendix G). In

addition, thresholds for claim acceptance (that

is, the level of documentation required, or type

of illness/exposure) vary among the State

workers’ compensation systems.

The data collected by State workers’ compensation programs vary widely, as does the accessibility of the data. States interpret the confidentiality of this information somewhat differently;

therefore, access may be as simple as requesting a routine data transmission of the desired

subset of variables, or may require development of a formal interagency agreement. If a

surveillance program wishes to use workers’

compensation data as a primary source of cases,

this may require developing a formal agreement

that allows the surveillance program early access

to submitted claims data, including prompt

access to hard copy or electronic physician

reports. Including language in the reporting

rule to permit access to the workers’ compensation submitted claims data may be useful. Evaluation of these data on a monthly, quarterly, or

annual basis will also permit a surveillance program to evaluate the completeness of reporting

for occupational cases from other reporting

sources. It may also provide information about

a particular industry, demographic group, or

type of exposure that is not reported through

other sources.

It is preferable to obtain submitted claims data

for both medical-only (these claims seek reimbursement of medical expenses only) and losttime cases (claims that seek reimbursement for

medical expenses and to recover lost wages).

There are important reasons for gaining access

to submitted claims versus accepted claims.

The first reason involves timeliness. Workers’

compensation claims are often submitted within hours or days of a pesticide exposure. However, it may be several weeks or months before

the claim is accepted. Another issue is sensitivity. Although many submitted claims may be

rejected, these rejected claims may meet the

surveillance program’s case definition for acute

pesticide-related illness or injury. Access to

submitted claims will allow the surveillance

program to identify a larger proportion of the

total universe of cases. One disadvantage is that

some rejected claims are truly not cases of

acute pesticide-related illness or injury. The

surveillance program will expend some resources

on following up on these claims that ultimately

fail to meet the case definition. Visual 3.2 lists

search strategies that some States have found

useful when reviewing workers’ compensation

data. Additional approaches using nature of

injury codes and international classification of

disease codes (ICD) (e.g., ICD9 and ICD10

codes) may also be used, although this type of

strategy is more useful when examining accepted

claims data, due to the timing of when these

codes are entered in the system. ICD9 and

ICD10 codes that are useful for identifying pesticide poisoning cases are listed in Table 3.1.

3.4 HEALTH CARE

PROFESSIONALS

(HCPS)

Physician (or, more broadly, HCP) reporting is

the most common source of cases mentioned in

reporting rules/statutes. While this method has

been the mainstay of many communicable disease and notifiable condition reporting systems,

it is not necessarily the most effective method

for surveillance of pesticide poisoning. The

nonspecific nature of symptoms arising from

many pesticide exposures, difficulties of diagnosis, rare occurrence within an individual

29

CHAPTER 3 CASE ASCERTAINMENT
30

CHAPTER 3 CASE ASCERTAINMENT
practice, lack of timely laboratory testing,

selection of inappropriate tests, and reluctance

to report cases make HCP reporting less reliable for this condition. Despite broadly worded

reporting guidelines, HCPs are often reluctant

to report cases for one or more reasons, including discomfort with reporting clinically unconfirmed cases, concern that an affected worker

may experience job loss, perceptions that pesticide exposures are unlikely to cause illness,

ignorance about the reporting requirement, and

concern that reporting a case might disrupt any

personal relationships with the employer. 

All States with HCP-based reporting systems

have conducted at least some level of HCP education to enhance reporting. Educational presentations on pesticide poisoning recognition

and management provide HCPs with tools for

recognizing the condition and understanding

the reporting and case investigation process.

Educational modalities include written case

reporting guidelines, periodic case presentations in a health department or medical society

publication, continuing medical education (CME)

seminars (whole- or half-day), grand rounds

presentations, tapes, videos, teleconferences,

and Internet educational tools. As a mechanism

for maintaining ongoing awareness that pesticide-related illness is a reportable condition,

case vignettes and program updates can be

included in a regular epidemiology publication

sent to HCPs. Some combination of these different modalities can help maintain HCP

awareness of the reporting requirements and

astuteness in diagnosing potential cases. Any

gains in HCP reporting associated with the

implementation of these educational outreach

efforts will be maintained only if the efforts are

ongoing. Evaluation of educational programs

can help a program fine tune their efforts. Evaluation tools include pre- and post-testing and

examining whether attendees report cases within 1 year of training. Another approach is to

compare the number of reports within a 3- or 6-

month period after a large scale educational

program, compared with the number of reports

during the same time period in the previous

year (comparing similar months will help

account for seasonal variation in reporting).

31

CHAPTER 3 CASE ASCERTAINMENT

Visual 3.2 Useful Search Strategies to Identify Pesticide Poisoning

Cases from Workers’ Compensation Data

In some States, the narrative portion (injured worker and/or physician statement[s]) of workers’

compensation claim data may be searched using a computer; in others, the narrative is not

entered into the data system.

For electronic searches, the following terms have been found useful: *cide, spray*, fumig*. 

If physician narratives are screened, adding the terms organophosphate, *cholinesterase, 2-

PAM, or atropine may yield additional cases.

If the data are being reviewed manually, additional search parameters include pesticide product

names and all chemical exposures to agricultural workers, landscapers, maintenance workers,

structural pest control operators, workers in pesticide and agricultural chemical manufacturing, and swimming pool service workers (this last occupation only if disinfectants are included

in the surveillance system). Reports describing an agricultural worker with systemic or respiratory symptoms or a nonmechanically caused eye or skin injury should also be reviewed.
32

CHAPTER 3 CASE ASCERTAINMENT

Close linkages to a variety of expert resources

are an additional enticement for HCP reporting.

Providing contacts with clinical toxicologic

expertise (e.g., through the local poison center,

a university, the EPA, etc.), laboratory resources,

or on-site sampling to help in the differential

diagnosis can serve as an added incentive for

reporting.

Selection of sentinel HCPs for more active

reporting is a labor intensive process, yet may

yield a number of cases that may not be identified through other reporting sources. The types

of HCPs that are likely to yield the greatest

number of cases include migrant health clinics,

county health clinics, dermatologists, and

emergency departments serving rural areas.

Pesticide manufacturing or reformulation facilities may have contract medical staff who can

also be contacted. Sentinel HCPs can be contacted to ascertain cases on a weekly or monthly basis, either in writing or via telephone.

3.5 REFERRAL FROM OTHER

AGENCIES

Other government agencies receive reports of

pesticide-related illness and can be valuable

sources for case finding. The obvious agencies

include the following departments: agriculture,

forestry, environmental quality, and the State

Occupational Safety and Health Administration

(OSHA) program. The number of case reports

and validity of cases from these sources varies.

Setting up good working relationships with the

agencies and clearly defining the situations that

warrant referral to the surveillance program are

beneficial. A centralized emergency response

program within the State, if there is one, can

also be a source of case referrals. The regional

EPA office sometimes receives complaints from

the public, making it helpful to provide regional EPA staff with a description of the PPSP and

guidelines for the types of reports that should

be referred. Similar information can be provided to other Federal agencies with local jurisdiction that may be willing to refer cases, such as

OSHA, the Department of Transportation, the

Federal Railway Administration, and the Coast

Guard. 

Within the State health department, other programs with overlapping responsibilities for

investigation may exist. Programs that are

responsible for surveillance of hazardous substance spill or release events will usually also

collect information about pesticide-related

events. Drinking water and well testing programs, as well as indoor air quality programs,

may receive complaints of human illness associated with pesticide exposure. It is important

to develop mechanisms to coordinate with

these programs.

3.6 EMERGENCY

DEPARTMENT LOGS

Data are not recorded in any standardized fashion across hospital emergency departments and

review of log information can be labor intensive. Despite their limitations, these data can be

useful tools in developing or evaluating a pesticide poisoning surveillance system. Particular

regional emergency departments may be useful

as sentinel reporting sites. Periodic reviews of

selected emergency departments’ log data within a State, or smaller geographic area can be

used to supplement surveillance data obtained

from other case ascertainment methods. If

emergency department records are available in

electronic format, it may be useful to search

these for the ICD9 and ICD10 codes provided

in Table 3.1.

3.7 AFFECTED PERSONS

More than half of the existing PPSPs accept initial reports from affected persons. The surveil-
33

CHAPTER 3 CASE ASCERTAINMENT

lance program often encourages these persons

to seek medical attention. In some situations,

the person may have already seen an HCP, but

the HCP chose not to report. If this situation

arises, the PPSP may choose to send a letter to

the HCP with a reminder that pesticide-related

illness and injury is a reportable condition.

Appendix C contains a sample letter to address

this situation. 

3.8 WORKER

REPRESENTATIVES

Unions and legal services may function as

referral organizations for persons, especially

when the affected persons have concerns about

confidentiality and potential retaliation from an

employer or landlord. At times, contacts from

these organizations may not provide sufficient

identifying information for the health agency to

conduct an investigation.

3.9 HOSPITAL DISCHARGE

DATA (HDD)

A set of extensive demographic, clinical, and

financial information about every hospital inpatient is received by the hospital association,

department of health, health care cost containment

organization, insurance commission, or an equivalent organization in most States. This information is taken from the Uniform Bill 92 (UB–92), a

document developed for use by third party payers

and hospitals. The UB–92 Form (HCFA 1450)

can be obtained from the Centers for Medicare

and Medicaid Services’ Web site http://cms.hhs.

gov/forms/. Data elements are determined by

the National Uniform Billing Committee (NUBC)

convened by the American Hospital Association. This committee maintains the UB–92 data

specification manual that provides detailed

information about coding for the form. More

information can be obtained directly from NUBC

at http://www.nubc.org. The number of UB–92

data elements collected and used to create the

HDD varies from State to State. Access to HDD

is usually restricted by legislation. Agreements

exist within each State about what elements of

HDD are passed to State agencies involved in

health policy and public health. The UB–92

includes a unique patient identifier for a person

that can be used to track re-admission to the

same or different hospitals over time to determine the course and outcome of injury. Unfortunately, there is frequently strict language in a

statute or a memorandum of understanding that

prohibits release of patient identifiers in the

HDD abstract prepared for agencies.

The HDD abstract is usually made available on

a quarterly or annual basis, which limits its use

for timely case investigation. Health departments may have to pay for access to this data

set. However, the HDD can be useful for determining whether the surveillance system is

capturing the most severe cases of pesticide

poisoning (that is, those requiring inpatient

hospital care). Some States receive more timely

HDD reports. For example, a revision to the

New Jersey code for surveillance of hospitalized

occupational and environmental conditions

specifically requires reporting of notifiable

occupational and environmental diseases and

poisonings by hospitals using electronic HDD

within 30 days of discharge. The rule also

allows the program to request additional information in writing [New Jersey Department of

Health 2000]. The same search strategy that is

used for emergency logs or workers’ compensation data, using ICD9 and ICD10 codes, can

be used for HDD.

3.10 LABORATORIES

Clinical laboratories may collect specimens

and conduct analyses for pesticides and metabolites in a variety of human or animal biologic
34

CHAPTER 3 CASE ASCERTAINMENT

media. The most common laboratory tests related

to pesticide exposure are measurement of plasma

pseudocholinesterase or red blood cell acetylcholinesterase levels, which are tests of

cholinesterase inhibition. These tests may be

conducted by hospital laboratories, local clinical laboratories, or referral laboratories. Other

less frequently conducted tests include detection of pesticides (e.g., organophosphates) or

their metabolites in blood or urine. In most cases, these other tests are conducted only by

referral laboratories. Reporting rules vary by

State about whether reporting is required from

the physician ordering the test, the laboratory

responsible for sample collection, or the laboratory conducting the test.

There are many complexities to interpretation

of cholinesterase inhibition. A review of this

topic appears in California’s guidelines for

monitoring workers exposed to cholinesteraseinhibiting pesticides [California EPA 2002],

which are available at the following URL:

http://www.oehha.org/pesticides/programs/Help

docs1.html. Among the complexities is the

wide normal range. Therefore, someone with a

high normal baseline can have substantial

cholinesterase inhibition and still have a level

within the normal range. In addition, there are

several different methods for conducting the

tests, and all are subject to variability between

and within laboratories. Cholinesterase tests

may also be ordered to determine how a patient

will respond to certain muscle relaxants used in

surgery. This means that a depressed cholinesterase may be totally unrelated to pesticide

exposure. One option, discussed by several States

but not yet implemented, is requesting laboratories to indicate on the laboratory request form

whether pesticide exposure is the reason for the

test. This information would help surveillance

programs and laboratories target resources

toward pesticide-related laboratory test results.

The establishment of mandatory medical monitoring for workers exposed to cholinesteraseinhibiting pesticides coupled with a requirement for laboratory reporting is another

approach that can be used. California and

Washington are the only States that have

mandatory requirements for such medical monitoring. The California Administrative Code,

Title 3, Section 6728, requires medical supervision by a licensed physician for agricultural

workers exposed to acute toxicity category 1 or

2 cholinesterase-inhibiting pesticides for 7 or

more days in any 30-day period. Included with

the code requirements is an extensive set of

guidelines for physicians conducting medical

supervision of these workers [California EPA

2002]. Washington State adopted a regulation

effective in February 2004 that requires cholinesterase testing for some workers [Washington

State Department of Labor and Industries 2003].

States considering laboratory reporting and/or

requirements for medical monitoring of workers

exposed to cholinesterase-inhibiting pesticides

should review the findings of the California program [Ames et al. 1989]. An examination of

this issue was conducted by an advisory committee in Washington [Washington State

Department of Labor and Industries 1995].
4. DATA COLLECTION AND MANAGEMENT
4.DATA COLLECTION AND MANAGEMENT

37

4.1 INTRODUCTION

This chapter addresses some specifics

of documenting PPSP procedures,

including data collection and data

management. Developing case investigation

procedures, forms, and a data management system

are important aspects of surveillance system

design. (Case investigation procedures are covered

in Chapters 5, 6, and 7.) If the appropriate

information is not routinely collected, keyed,

analyzed, interpreted, and disseminated, the

goals of surveillance will not be realized. To

some extent, the level of resources available to

the program will dictate the amount of information that is routinely collected. 

4.2 DATA STANDARDIZATION

At the outset, we cannot overemphasize the

importance of using the standardized variables

and the standardized case definition. Applying

a standardized format for data collection makes

aggregation of data across States feasible. The

ability to aggregate data is valuable both at the

State and Federal level. Potential users of the

aggregated data include regulatory agencies,

public health policy makers, researchers, programs conducting worker education, the public,

and the medical community. 

The large number of pesticide products on the

market and difficulties in obtaining case reports

makes the pooling of all available data particularly desirable. The ability to evaluate pesticide

poisoning by product, crops, and geographic

location greatly enhances the ability of States to

evaluate whether limited case reports in their

jurisdictions are reflecting larger problems

linked to the specific uses of a pesticide product. Applications for this type of surveillance

data at the national level cover a broad range of

functions. Regulatory agencies can use the

aggregated pesticide poisoning data to guide

the development and amendment of regulations, target enforcement efforts, and evaluate

the effectiveness of current control mechanisms.

Pesticide users, commercial and agricultural

pesticide applicators, and users of consumer

pesticide products would all benefit from additional information that increases the understanding of risks associated with pesticide use.

4.3 DOCUMENTATION OF

PROCEDURES

The processes used to investigate cases, classify

cases, enter and analyze data, provide feedback

to reporters, and disseminate information are

integral to a successful surveillance program.

Documenting these procedures is often relegated

to the bottom of the list of program management tasks. While programs can function without

written documentation, it is certainly not advisable. Documentation provides guidance to all

staff for a consistent approach to program objectives. Written policies and procedures make it

easier to justify various decisions, including

whether a particular pesticide exposure event

will be investigated. As program procedures

and policies change over time, written documentation facilitates the identification of those

changes that might influence data analysis findings. Newly developed surveillance programs are

often dependent on only one or two staff people
who are working on many fronts. It is common

for procedures to be developed and passed

along verbally. Regrettably, if these staff leave

the program, the procedures are often lost and

must be recreated by new staff. For some procedures, a simple, bulleted list will suffice for documentation; for others, more complete instructions are desirable. The program should also

maintain an orientation checklist for new staff

to ensure that critical issues are covered in

training. Topics of particular concern that

should be documented include confidentiality,

and safeguards to ensure employee safety and

health when performing investigations.

Procedures should be developed for the following activities:

1. Case report management (intake, investigation, closure, classification, and feedback to

reporters) 

2. Data entry, quality assurance, and control

3. Data analysis

4. Data dissemination

Written policies and procedures should be

developed for protecting the confidentiality of

case report information at all stages of intake,

investigation, and analysis. Examples of PPSP

procedure documentation may be available

through requests to established PPSPs. (Links

to State program offices are in Appendix G

under State PPSP Contact Information.) At later stages, policies and procedures for archiving

data should also be implemented. These issues

and the use of data to target activities and

develop intervention strategies will be discussed in Chapters 5 and 6. 

4.4 DATA COLLECTION

The PPSP collects data on each poisoning case,

and these data are organized using variables.

For all variables that are collected, States are

encouraged to use standardized formats.

Recommended formats are listed in Standardized

Variables for State Surveillance of Pesticiderelated Illness and Injury. (Copies of this document can be obtained from the NIOSH Web

site, http://www.cdc.gov/niosh/topics/pesticides/,

or by calling 1–800–365–4674.) The standardized

variable format includes variable names, definitions, variable types, widths, and clarifying

comments for variables that are considered

desirable for all States to collect. Core variables

that are critical for States to collect and transmit

to CDC are indicated by asterisks. The variables are divided into general subject areas.

Within any given subject area, variables are

available that allow States to provide a brief

narrative description about the data. Some

additional discussion and clarification of the

variables are provided below. The nature of the

data collected for this condition usually dictates

that States use a relational file structure and not

a flat file structure. 

4.4.1 STANDARD VARIABLES TO BE

COLLECTED BY PPSPS

4.4.1.1 ADMINISTRATIVE AND

DEMOGRAPHIC VARIABLES

The variables in this category include information about the source(s) of the report, relevant

dates, event identifiers, county and State of

exposure and residence, sex, age, Hispanic ethnicity, and race. These variables are used to

describe the demographic characteristics of

cases, track the geographic distribution of cases,

and ensure that cases and events are linked

without duplications. Not all of the variables

needed at the State level are included in the

standardized variable document (e.g., personal

identifiers and addresses of the cases). However,

these and other identifying and tracking variables are captured in the SPIDER database pro38

CHAPTER 4 DATA COLLECTION AND MANAGEMENT
gram. Note that race is not captured in the standard format currently recommended by CDC,

since the CDC recommended format makes collection and analysis of race information more

complex for persons who are multiracial. The

race variable found in the standardized variable

document is structured according to the CDC

standard in effect at the time the document was

initially developed and is considered easier to

use by participating States. 

4.4.1.2 OCCUPATION AND INDUSTRY DATA

Coding of the occupation and industry of an

affected individual can be accomplished by

using one of several different standard coding

systems. Codes for occupation can be based

either on U.S. Bureau of Census (BOC) codes

[NCHS 2003] or the 2000 Standard Occupational

Classification (SOC) codes [OMB 2000].

Codes for industry can be based upon BOC

codes [NCHS 2003] or North American

Industry Classification System (NAICS) codes

[OMB 1997]. Note that industry and occupation codes are periodically updated, with the

BOC codes being revised every 10 years for

use with the decennial census. The current

BOC codes were used on the 2000 U.S. Census

occupation and industry data, and these codes

are referred to as the 2000 BOC codes. The

2000 BOC occupation and industry codes are

based on, but are not identical to, the 2000 SOC

and NAICS codes [OMB 2000], respectively.

BOC codes are always 3-digit codes and therefore cannot provide the detailed industry coding

provided by NAICS (which can code to 6 digits)

nor the detailed occupation coding provided by

SOC (which can also code to 6 digits). The

NIOSH SENSOR-Pesticides Program recommends using the BOC codes for occupation and

industry. This is because the number of workers in each of the BOC industry and occupation

codes is available from Current Population

Survey (CPS) data. CPS data can be used as

the denominator to calculate rates of illness by

industry and occupation. Although having all

States use the same industry and occupation

codes will facilitate the aggregation of data

across States, States should choose the coding

system that best suits their needs. Whichever

coding system is chosen, States should use that

system's most up-to-date codes. 

Crosswalks are available to convert the NAICS

codes into 2000 BOC industry codes, and to

convert 2000 SOC codes into the 2000 BOC

occupation codes. In order to convert industry

and occupation data that may have been coded

using older coding schemes, crosswalks are

available to convert the 1990 BOC industry

codes into the 2000 BOC codes and NAICS

codes, and to convert the 1990 BOC occupation codes into the 2000 SOC codes and 2000

BOC occupation codes. All can be accessed at

http://www.census.gov/hhes/www/ioindex.html. 

Training on how to code occupation and industry is available periodically through the National

Center for Health Statistics. This training usually

covers all of the major occupation and industry

coding systems. 

4.4.1.3 EXPOSURE DESCRIPTIONS

The variables in this subject area help characterize the exposure. They describe the type of

exposure (drift, direct spray, indoor air, contact,

etc.), route(s) of exposure, whether the exposure

was intentional, the person’s activity at the time

of exposure, and PPE worn by the exposed person. They also capture information about the

equipment used to apply the pesticide, what the

intended target of the application was, where

the pesticide was being applied, and where the

person was located when exposed (e.g., farm,

nursery, home, school, manufacturing facility, etc.).

CHAPTER 4 DATA COLLECTION AND MANAGEMENT

39
40

CHAPTER 4 DATA COLLECTION AND MANAGEMENT

4.4.1.4 CHEMICAL INFORMATION

This section records information about the

pesticide products associated with the exposed

person’s illness or injury. The system is not

designed to capture information about nonpesticidal products such as fertilizers and adjuvants. Pesticide product information provided in

SPIDER is adapted from the EPA Pesticide

Product Information System (PPIS). This

system can be accessed from the web at http://

www.epa.gov/opppmsd1/PPISdata/index.htm.

It is available in a searchable format on the Web

site maintained by CDPR at http://www.cdpr.ca.gov. 

States are strongly urged to collect sufficient

data to permit full identification of the pesticide

product whenever possible. However, at a minimum, pesticide functional class and product

chemical class must be collected. This is in

recognition that sometimes only minimal exposure information is available.

4.4.1.5 HEALTH EFFECTS DESCRIPTORS

This set of variables captures information

about biological monitoring, medical diagnosis, pre-existing conditions, whether the person

died, signs and symptoms, type of care

received, and whether the person lost time

from work or regular activities.

4.4.1.6 INVESTIGATION FINDINGS

These variables include enforcement agency

findings, plus case investigation findings from

the agency managing the surveillance program.

Some variables are also specifically related to

the Worker Protection Standard (WPS). The

WPS variables address whether

the incident involved re-entry into an area,

field, or greenhouse treated with pesticide

the worker had been informed of the re-entry

interval for the treated area

(See Section 5.8.1 for more information

about WPS.) In addition, a variable captures

information about whether the product label

was followed.

4.4.1.7 CASE CLASSIFICATION

These variables collect information about the

components of the final case classification

using the Case Definition for Acute PesticideRelated Illness and Injury Cases Reportable to

the National Public Health Surveillance System

(NPHSS) described in Chapter 7 and provided

in full in Appendix D. There is also a variable to

record a separate case classification using either

a separate State classification matrix, or to

override the NIOSH classification matrix. For

cases meeting the definition for reporting to the

NPHSS, an additional component of case

classification is a severity score of the illness/

injury. 

4.4.2 OPTIONAL VARIABLES

The variables in the standardized variable list

that are not marked as core variables are all

considered important, but are ones that some

States may choose not to collect because of

resource limitations. States are urged to collect

as many standardized variables as possible. As

already mentioned, the standardized variables

include only those variables needed for national aggregation of data. Additional variables are

needed for States to track and manage cases.

Examples of some of these variables include

personal identifiers; address and telephone

number of the exposed person; name, address,

and telephone number of HCP(s); laboratory

sample tracking and results information for

environmental and biological specimens; and

information about animals (pets, livestock, and

wildlife) affected by pesticide exposure. PPSP

may want additional flags for particular types

of cases that are of interest or concern at the
State level. Some but not all of these variables

are captured in the SPIDER database.

The SPIDER system does not provide a tracking system to determine what information has

been sent to or received from providers, individuals, and partner agencies. Developing a

generic tracking system that would meet all

States’ needs is not feasible since the investigation and regulatory process is so different within each State. It is important for each PPSP to

develop its own system for tracking cases. A

tracking system can help to ensure that investigations are timely, that all necessary case information and medical or confidential information

releases are obtained, that regulatory agency

referrals and reports are received, and that

appropriate feedback is given to relevant individuals, HCPs, employers, contract pesticide

applicators, and partner agencies.

4.4.3 INTRODUCTION TO THE SPIDER

PROGRAM

The SPIDER program is a data manager for

collecting, managing, and reporting pesticide

illness and injury data. Designed for NIOSH by

the New York State Department of Health, the

Program prepares data in the proper format for

transmittal to NIOSH, and provides some preprogrammed reports used by PPSPs and

NIOSH. The software was created using

Microsoft Visual FoxPro, Version 5.0c, and Visual

ProMatrix 5.0c. You do not need to purchase

these products to run SPIDER [New York State

Department of Health 1997]. Although additional reports can be created within SPIDER,

more complex data analysis will require statistical analysis software (SAS).

System requirements for running SPIDER:

Any IBM®

-compatible computer with an

80486DX processor or higher.

32 MB RAM; 64 MB RAM recommended.

A hard disk with 150 megabytes of free

space. This will grow as cases are added.

A 3 1⁄2" floppy drive and a CD-ROM drive.

VGA or higher resolution monitor running

at 256 colors or more. SVGA (600 x 800) or

XGA 1024 x 768) recommended.

Microsoft Windows 95. (This is a minimum

requirement. SPIDER also runs on more

current systems, e.g., Windows 2000, NT4,

and XP.)

Installed Windows fonts: Arial, Courier

New, and Times New Roman.

A mouse is very helpful but not required.

This system can be installed on a local area network (LAN) for multiuser access. SPIDER

is not equipped to upload cases reported

electronically.

OTHER OPTIONS FOR A SURVEILLANCE

DATABASE

Some States have chosen not to use SPIDER,

and have developed their own data systems for

collecting information about pesticide-related

illness and injury. If a State decides to develop

its own database system and wants the ability to

easily compare data with other States, and to

contribute to national data, it is important to

follow the standardized variable formats. It is

equally important to contact NIOSH when

developing a surveillance database to ensure

that your system will readily transmit the necessary data in the desired format, and that you

have the current version of the standardized

variables. Some States have experienced problems incorporating chemical information into

their databases in a way that will permit aggregation with data from other States. NIOSH may

be able to provide assistance to ensure that

41

CHAPTER 4 DATA COLLECTION AND MANAGEMENT
chemical product data are collected and transmitted in a standardized fashion.

If a system other than SPIDER is used, the system

should include documentation that describes

the database, including a data dictionary, file

structure, and table relationships. There should

be written procedures for installation, operation, and maintenance of the system including

how to backup the system.

4.5 DATA MANAGEMENT

This section provides a brief overview of the

elements needed for data management. It is

provided as a reminder to new PPSPs that these

are issues and elements that must be included in

any data gathering program. For in-depth information about data quality assurance, data quality

control staff should refer to the broad range of

published literature and training programs

available on this topic. 

4.5.1 GENERAL GUIDELINES FOR

DATA MANAGEMENT

The importance of documenting surveillance

procedures has already been emphasized.

Procedures for entering reports into the data

system, mechanisms to prevent duplicate

entries, and management of discrepancies in

information when a report is received from

multiple sources should all be documented.

Having protocols for case triage and management, along with routine daily or weekly

review of open cases will help ensure that data

collection is complete and timely. Staff must be

trained to have a clear understanding of the procedures and to strive for complete and accurate

data. A clear procedure (e.g., a written protocol

or an assigned coding administrator) should be

in place to ensure that narrative data coding,

interpretation of medical information, and pesticide product identification are performed in a

consistent manner. There should be a system to

monitor the quality of data entry to ensure the

results comply with acceptable error rates. Staff

should receive feedback on their data entry performance.

The SPIDER system contains many automated

edit checks, as well as an audit trail, error

reports, and missing data reports. If an alternative

system is used, it should contain edits for missing data and errors (e.g., the program should

identify codes that are outside acceptable

ranges and illogical date sequences). Checks

for duplicate records, blank records, orphaned

data, and other anomalies created by changes in

relationally linked data should also be part of

the system. 

4.5.1.1 CONFIDENTIALITY AND SECURITY

The PPSP must develop systems for maintaining the confidentiality of hard copy and electronic records. Confidentiality procedures should

be in writing to ensure that staff are clear about

these procedures. Staff must understand the

procedures and follow them routinely. Staff

must also know whom to contact with questions. Records containing confidential information should be kept in locked file cabinets.

Electronic systems should have passwords, and

access to the system should be controlled.

4.5.1.2 SYSTEM BACKUPS

The administrator of the data program should

establish written protocols for data system

backup. Typically, there is a daily backup of

data entered or edited during that working day;

there should be a routine weekly or monthly

backup as well. Safeguards for virus protections should be in place and routinely updated.

42

CHAPTER 4 DATA COLLECTION AND MANAGEMENT
4.5.1.3 TRANSMITTING DATA TO NIOSH

Annually, NIOSH assembles an aggregated

database using data provided by participating

PPSPs in the United States. In the past, NIOSH

has requested that these data be provided by

May 1. This gives the States a 4-month lag

period from the end of the calender year to

close out cases reported during the previous

year. Grants and cooperative agreements

awarded by NIOSH to fund PPSPs usually

require this data sharing. PPSPs that receive no

funding from CDC share their data voluntarily.

For SPIDER-using States, transmittal of data is

relatively simple. These States need to ensure

that their data are complete and then use the

Export to NIOSH file command to prepare a

zipped data file that can be transmitted to

NIOSH. States not using SPIDER should contact NIOSH during development of their database system to discuss data transmittal issues.

(Call 1–800–356–4674 or see http://www.cdc.gov/

niosh/pestsurv/default.html.) All personal identifiers are stripped from the data before transmission to NIOSH.

Pooling surveillance data to create an aggregated

database permits the creation of knowledge to

prevent and control acute pesticide-related illness and injury. The aggregated database is

shared with contributing PPSPs, NCEH, and

EPA. Once data are checked for quality, accuracy,

and absence of personal identifiers, it is made

available for public access.

43

CHAPTER 4 DATA COLLECTION AND MANAGEMENT
5. CASE INTAKE AND FOLLOW-UP
47

5.CASE INTAKE AND FOLLOW-UP

5.1 INTRODUCTION

This chapter pertains to surveillance

systems whose case ascertainment

relies on reports from HCPs, workers’

compensation records, PCCs, referral agencies,

affected persons, and laboratories. It describes

some of the processes and issues associated

with case report intake and follow-up. Investigative procedures for cases may differ slightly if long delays exist between time of exposure

and receipt of the report, as is often the situation with cases identified via review of workers’ compensation data. Timeliness of reports

and the PPSP’s response can impact the availability of persons for interviews, exposure site

conditions, and the feasibility of sampling or

collecting physical evidence. Extensive travel

time for PPSP or enforcement agency staff to

reach an exposure site can also have an impact

on the amount of information that is available

and therefore the outcome of a site investigation. 

The guidelines provided in this chapter are

designed for PPSPs without enforcement jurisdiction over pesticide manufacture, use, or

disposal. In most States, another agency (e.g.,

agriculture) is charged with enforcement. These

enforcement agencies have guidelines for identifying violations of pesticide statutes or rules.

The inspection procedures and manuals used by

these agencies are valuable references for nonenforcement investigators. Surveillance program

staff are encouraged to use these manuals as

reference guides. It is also helpful for surveillance program staff to accompany enforcement

program staff on one or two inspections as an

observer to gain a better understanding of the

agency’s inspection process. Any State initiating a PPSP is highly recommended to visit a

State with an existing program, and to accompany the host State’s staff on a site

investigation, if possible.

5.2 OVERVIEW OF THE CASE

INVESTIGATION

PROCESS

The case investigation process includes all caserelated activities beginning with case intake and

ending with the case being prepared for case closure. The main goals of the case investigation

process are as follows:

Obtain sufficient follow-up information to

determine whether the reported illness/

injury meets the case definition of pesticiderelated illness and injury.

Provide information to the affected persons

and/or their HCPs for case management and

prevention.

Provide prevention information and recommendations to the worksite (employer/workers) where

the exposure event occurred.

Determine if aspects of the exposure scenario

require additional broader public health

intervention.

Disseminate information about the hazard

and relevant prevention measures.

The level of action taken on each goal will

depend on the chosen expertise and emphasis of

the PPSP. Case follow-up includes the following
Initial screening and triage of reports to

determine whether they meet criteria for

inclusion in the surveillance system

Interviews with the affected person(s)

Review of medical records, if available, and

interview of HCPs, if needed

Interviews with the applicator, employer,

and/or owner

Obtaining additional pesticide chemical

information, as needed

Identification of other exposed and affected

persons

Notification to the local health department,

if necessary or required

Notification to NIOSH and EPA, if necessary

Referrals and interagency coordination for

additional follow-up and investigation

Final case review for completeness of data

and collection of any additional missing

data, if feasible

The initial case follow-up may be all that is

needed to investigate a particular report. Other

times, a report will meet the program’s criteria

for a site inspection by PPSP staff or a cooperating agency. Elements of the site inspection

can include

Environmental pesticide sampling

Site evaluation

Contacts with pesticide product manufacturers

or equipment manufacturers

Additional interviews

Referrals and interagency coordination for

additional follow-up and investigation

Final case review for completeness of data

and collection of any additional missing

data, if feasible

Regulatory action, if warranted, and/or recommendations for prevention

Case closure and classification involve:

Evaluating whether information about the

case is complete

Assigning the case a classification category

based on the standardized case definition

Feedback to the reporter, HCP(s), affected

person(s), and the worksite if appropriate

Determining if the case warrants further

efforts in terms of preventive intervention

and dissemination of information

Note: Closure and classification may be provisional if a long time lag is expected for the final

regulatory disposition of the investigation.

This chapter covers the case follow-up process.

Site inspection, case closure, and classification

are covered in subsequent chapters. The exact

order of these steps may vary according to

program protocols and the availability of information. A flow diagram of the case investigation process, similar to the example shown in

Figure 5.1, can be helpful for program staff,

and for explaining the process to partner agencies and the public.

5.3 INITIAL REPORT INTAKE

(COMPLAINT

EVALUATION)

This step in report management includes the

collection of basic information about the affected

person to determine whether the report meets

criteria for additional investigation. This stage

48

CHAPTER 5 CASE INTAKE FOLLOW-UP
49

CHAPTER 5 CASE INTAKE FOLLOW-UP
may include follow-up with the informant to

determine if a pesticide exposure occurred and

if temporally-related health effects developed.

Depending on the source of the report, basic

demographic and exposure information may be

received in writing, by telephone, or in electronic format. Initial screening and intake may

be conducted by support staff as long as a structured format is followed. The program administrator needs to determine if the program should

log and track informational calls and/or reports

that are screened out as unrelated to pesticide

exposure. Collection of this information requires

more work, but it provides a good measure of

both service provided to the public and program workload. The step-wise procedures for

logging in and assigning cases should be documented in a procedure manual. (A sample

tracking form is included in Appendix C.) If

multiple staff members are involved in case

investigations, it is helpful for these staff to

meet daily to ensure that individual reports that

are part of a large exposure event are not being

evaluated as separate events. Also, a weekly

meeting to thoroughly review ongoing investigations will help provide structure to investigations, develop consistent program procedures,

and prioritize investigations.

Simple questions asked during an initial report

intake will help determine whether the person

may have been exposed to a pesticide as

defined by PPSP. These questions may seem so

obvious that there is a risk they will not be

asked for fear of insulting the person reporting

the potential case. For example, early screening

may exclude case reports by asking if symptoms began before the exposure of concern.

The temporal relationship between pesticide

exposure and symptom onset is critical.

Rapid identification of the chemical involved will

allow staff to determine whether the chemicals

fall within those covered by the PPSP. For

example, a report may involve exposure to a

disinfectant and these exposures might be

excluded from the particular surveillance system. (Note: If a State does not collect these cases,

the person can still be referred to the EPA product manager for the particular product. See

Appendix G for information about databases

that include product information and EPA contacts.) Other exposures that may be excluded

from the PPSP are fertilizers, fire retardants,

cleaning agents, and other nonpesticides.

It is always important to ask where the person

was relative to the site of the suspect application about which they are concerned (e.g., did

they actually see the plane or helicopter spraying versus just hear it in the area). This type of

information may allow rapid screening of the

call to determine what level of investigation is

needed. For example, it is often possible to

determine whether an aerial application was

being conducted in the vicinity by making a

few telephone calls, and if so, where it was

done and what chemical was applied.

5.4 CASE FOLLOW-UP

INTERVIEWS

Interviews of affected persons should be as

structured as possible to ensure that all pertinent information is collected in an efficient and

consistent manner. Interviews may be done by

telephone or in person. PPSPs should use a

structured questionnaire or data collection form

for all cases. Appendix C contains examples.

Interviews of affected persons can be timeconsuming. Staff should be trained to allow

persons some time to voice concerns about

their exposure but to control the interview and

obtain the information needed to evaluate the

exposure and illness. The interview should conclude with the interviewer summarizing the key

50

CHAPTER 5 CASE INTAKE FOLLOW-UP
51

CHAPTER 5 CASE INTAKE FOLLOW-UP

data elements with the interviewee to be sure

the interviewer has an accurate understanding

of the events surrounding the exposure.

The person, HCP, or agency reporting illness

should always be asked if there are additional

affected persons. The PPSP may ask the index

case or sentinel provider for contact information about other affected persons, or ask to have

them contact the PPSP directly. This is important to ensure that all exposed ill persons are

decontaminated and obtain needed medical

care, as well as to ascertain the magnitude of

the exposure incident. Cases may also be identified retrospectively and linked to a single

exposure event by searching some of the data

sources described earlier in Chapter 3. The procedures for following up on other affected persons may be governed by State rules about

medical confidentiality. The level of effort

expended to find additional cases must be

weighed against the severity of illness, the likelihood of ongoing exposure, and the measures

required to protect the confidentiality of the

index case. Events that occur either in an unstable work environment (e.g., farmworker crew

exposures) or involve a combination of public

and worker exposures (e.g., retail establishments) require a prompt site evaluation to efficiently obtain information about additional

cases beyond the index case. More stable workplaces can be followed up through telephone

interviews.

5.4.1 AFFECTED PERSONS

The affected person should be interviewed,

whenever possible. The only exceptions are

when the exposure is reported to be an intentional self-exposure (these interviews can be

sensitive and are likely to produce little useful

information) or the person is a minor. Interviews

of minors should be conducted only with the

permission of the parent or guardian. 

The main purposes of these interviews are to

Elicit information about the pesticide exposure and resulting illness or injury.

Determine what factors caused the exposure.

Provide information to help prevent ongoing

or future exposures.

Obtain HCP contact information if care was

sought and this is a self-report.

Ascertain if others are at risk.

PPSP staff should be aware that some nonoccupational case reports might involve pesticides

exposures resulting from child neglect or

abuse. The program should have guidelines for

evaluating these situations and ensuring that

appropriate agency referrals are made and

properly documented.

It is important that PPSP staff be sensitive to

concerns affected persons may have about possible repercussions from an investigation of

their exposure. Renters may fear loss of housing if there is an investigation of a pesticide

application made by a property owner. All

occupational exposures may bring concerns

about job loss. Immigrant workers may have

additional concerns about immigration status

and language difficulties understanding the

investigation process.

Follow-up can be difficult if affected persons

cannot be contacted by telephone. In-person

interviews with such affected persons may be

reasonable if the PPSP has regionally located

field staff trained to investigate cases (affiliated

with the State or local health department), or

has a contractual relationship with locally

based interviewers.

Note: If biological specimens are collected as

part of the case investigation process, care must
52

be taken to fully inform the affected persons

what the specimens will be tested for and who

will receive the results. This is particularly

important since persons may be concerned that

blood or urine specimens might be tested for

drugs and alcohol, and that results could be given to employers or police.

When interviewing migrant workers, keep in

mind that they might not remain in the area for

an extended period. Those who are ill or injured

may choose to leave the area and return to their

stable home base for medical treatment; indeed,

they are sometimes encouraged to leave by

their employer or coworkers. It is helpful to get

a permanent address for the migrant worker in

order to inform them of the investigation

results. Interviews involving occupational exposures should include evaluating the potential for

take-home exposures (e.g., ask if the exposed

person removes contaminated clothes and washes

contaminated skin before returning home). 

When interviewers are trained, it is important

to emphasize issues of cultural sensitivity as

well as proper techniques to avoid introducing

bias into the interview process. These issues

should also be considered when developing

questionnaires. Many social science texts are

available that contain guidance on interviewing

techniques. One such text with an in-depth

discussion of interviewing and the use of questionnaires from an anthropologic/ethnographic

perspective is Research Methods in Anthropology:

Qualitative and Quantitative Approaches, 3rd

edition [Bernard 1995], particularly Chapter 9

“Unstructured and Semistructured Interviewing”

and Chapter 10 “Structured Interviewing: Questionnaires.” For a brief overview of epidemiologic issues associated with interviewing, see

Hartge and Cahill [1998]. Appendix B of the

Federal Insecticide Fungicide and Rodenticide

Act (FIFRA) Inspection Manual also contains

useful guidance on interviewing techniques

[EPA 2002]. Since migrant farmworkers may

feel more vulnerable because of concerns about

job loss and deportation, resources on applicable cultural issues (including a link to a bibliography on farmworker living and working

conditions) are provided in Appendix G.

When investigating a cluster of illnesses at a

fixed worksite, school, residential institution, or

a situation involving an exposed group of agricultural field workers, interview as many of the

exposed persons as feasible. This will help to

determine the range of symptoms, circumstances associated with symptoms, and circumstances that may have protected asymptomatic

persons. If exposed persons received emergency decontamination or were transported to

an emergency care facility, the investigator

should also determine whether any of the emergency care providers were exposed and became

symptomatic. If so, these persons should be

included in case follow-up.

Be aware that some reports of pesticide-related

illness may involve exposures and illnesses

among large groups where the illnesses are

ongoing and the source of exposure is unclear.

(For example, a non-agricultrual workplace

receives routine pesticide applications, is located near an agricultural operation, and a group

of persons report ongoing or sporadic illnesses

that are not associated with a specific pesticide

application.) The investigative approach may

be similar to that used in other noninfectious

disease clusters. For instance, protocols for

evaluation of indoor air complaints are particularly useful for these types of investigations

[EPA/NIOSH 1991]. Staff should also be familiar with literature on epidemic psychogenic illness and ensure that the investigation process

does not negatively influence the dynamic

among the exposed persons [Alexander and

Fedoruk 1986; Guidotti et al. 1987; Cole et al.

1990]. In some situations, it is useful to examine the incidence of symptoms in a control popCHAPTER 5 CASE INTAKE FOLLOW-UP
53

CHAPTER 5 CASE INTAKE FOLLOW-UP

ulation of similar demographics. This approach

has been used when investigating illness in

school children and staff [Heumann 2000].

Particular care must be taken to accurately

record identifying information when investigating clusters of illness among farmworkers or

school children. Hyphenated last names and

multiple names found in some cultures may

result in duplicate cases, especially when the

names are presented in differing orders. Also

note that with hyphenated names, sometimes

only one name will be recorded. Careful collection of name, age, date of birth, and addresses

will help to avoid duplicate entry of cases

reported from multiple sources.

5.4.1.1 CHEMICALLY SENSITIVE PERSONS

Chemically sensitive persons may ask the

PPSP for recommendations to prevent pesticide

exposure. In some States (e.g., Florida,

Louisiana, and Washington), the DA maintains

a registry of residents who require notification

before pesticide applications are made near

their homes. To be placed on the registry in

Florida, a person must provide a note from his

or her physician and must pay an initial registration fee and an annual renewal fee. Those on

the registry are notified at least 24 hours before

any relevant pesticide application in the vicinity of their property. Notification can be made by

telephone, mail, hand delivery, or in person. The

Florida statute appears at: http://www.flsenate.

gov/welcome/index.cfm (see Title XXXII,

Chapter 482, Section 2267). Given that these

registries can help chemically sensitive persons

avoid potential pesticide exposures, it is recommended that the PPSP determine if their State

has such a registry. In States without a registry,

some chemically sensitive persons have established

pre-notification agreements. Pre-notification

agreements are informal and involve a request

to neighbors to provide sufficient notification

before application of any relevant pesticides.

PPSPs will occasionally receive reports from

chemically sensitive persons who claim they

were poisoned by pesticides. If such a claim is

for a substantial exposure, the person’s complaint to the State DA may result in an investigation. These investigations often include

sample collection to determine the presence of

residual pesticide, which if detected may cause

the DA to take action against the pesticide

applicator (e.g., verbal or written warning for a

first violation). Involvement of the DA can help

to favorably change the behavior of the pesticide applicator, whether a neighbor or commercial

operation. 

5.4.2 HCPS

A telephone report received from an HCP’s

office can provide more information than a

written or electronic report. However, a telephone report may be incomplete if the person is

still symptomatic or undergoing testing and/or

treatment. If the patient is still present at a clinician’s office when the report is made, you have

an excellent opportunity to provide assistance

to the HCP, such as tracking down information

about the pesticide product. 

For reports received after the person’s symptoms have resolved, follow-up interviews with

HCPs should generally be made only when a

review of medical records does not provide

critical information needed to classify a case.

During HCP follow-up interviews, provide

opportunities for the clinician to ask questions

or to provide insight into the patient’s exposure.

These interviews should be kept as brief as possible and be organized so repeated contacts will

not be needed. follow-up calls can be irritating

in a busy clinical setting, especially if they are
caused by disorganized data collection. Before

conducting a follow-up interview, be sure to

highlight all questions with missing information on the data collection form (or questionnaire) to help ensure that you obtain all of the

information needed. PPSP staff responsible for

contacting HCPs should be trained in medical

terminology and have access to reference materials on standard diagnostic tests.

Migrant and seasonal farmworkers are mobile

and may not be easily accessible by telephone

for follow-up. Clinics that serve this patient

population should therefore be encouraged to

report suspected cases while the patient is still

in the office. It is equally important to have

bilingual/bicultural staff or to contract with

interviewers familiar with the worker populations in your area.

Most programs routinely obtain medical

records of reported cases. Some States have

indicated that having the medical record

request signed by a health department physician is more likely to yield medical records

than when letters are signed by staff who are

not physicians. To protect patient confidentiality, information obtained from a medical record

review must be carefully guarded to ensure it is

not released to other agencies cooperating on

an incident investigation. 

5.4.3 THIRD PARTIES-PESTICIDE

APPLICATORS, LANDLORDS, AND EMPLOYERS

Interviews with or written requests to third parties for information are commonly part of the

case follow-up process. Third parties can

include employers, pesticide applicators, and

landlords, especially in the event of agricultural exposures involving drift or spray from aerial applications. An exposure scenario might

involve several employers; for example, the

employer of the pesticide applicator, another

employer who contracted for a pesticide application, a third employer whose workers in a

nearby field were subjected to drift, and possibly a labor contractor who is the actual employer of the exposed workers. Although third

parties may not be legally required to cooperate

with an investigation, they usually do.

Third-party interviews are often critical in

determining exactly what pesticide the affected

person was exposed to as well as additional factors that may have influenced the exposure. The

employer or applicator can supply information

about anything unusual about the application.

The applicator should also be able to supply

information about application equipment and

methods, product dilution, mixtures of products, and any adjuvants added. When investigating illness in a crew of field workers or a

stationary workplace, the employer should also

be able to supply names and contact information

of the exposed or potentially exposed workers.

If staff conducting interviews and site inspections have limited first-hand knowledge of particular types of pesticide applications, training

them for interviewing pesticide applicators can

be helpful. This could include simulated interviews of volunteer applicators using an unscripted case scenario to familiarize the interviewer

with important information–namely, correct terminology, what the application equipment looks

like, and what might go wrong with an application. It is helpful to ask these volunteer applicators about past problems they experienced or

observed. Their responses and “war stories” can

provide some clues for areas to home in on during an investigation. It is best if the interview is

conducted at a site where the applicator has

access to equipment and record-keeping forms

to help familiarize the interviewer with these

items. Members of the PPSP advisory committee

(see Section 5.9.3) representing various sectors

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CHAPTER 5 CASE INTAKE FOLLOW-UP
of the pesticide industry may be able to assist

with identification of volunteer applicators for

this interview process.

It is important for staff to be carefully trained to

protect the confidentiality of affected persons to

the extent possible. There are clearly times

when complete anonymity of the affected person is not possible, especially when dealing

with a small workplace or investigation of an

application to a residence. If a person is suffering from mild illness and is likely to be easily

identified if questions are asked (e.g., he is the

only pesticide handler at the workplace), the

PPSP must determine if obtaining the third-party information is critical. In these situations, it

is important to gain the permission of the ill

worker before contacting the employer. Staff

should be familiar with protections against discharge and employment discrimination provided

to workers by provisions of the Occupational

Safety and Health Act [29 CFR‡ 1903.11c]

(OSH Act) and other State regulations.

5.5 NOTIFICATION OF THE

LOCAL HEALTH

DEPARTMENT

The relationship between the agency housing

PPSP and the local health departments varies

by State. In general, the minimum level of notification is that all cases received at the State

level are reported within 24 hours to the local

health department, and a brief final summary is

provided when the investigation is complete. If

reports involve multiple persons or a broader

public exposure, the contact should usually be

more in-depth.

In a number of States, local health department

staff are trained to conduct pesticide illness

investigations and may take the lead in some

case investigations. Local health departments

may become involved in investigations involving large numbers of exposed persons, and

clusters where the cause of an illness cluster is

unclear after a preliminary investigation. Even

if local health department staff do not conduct

full investigations (interviewing clinicians,

exposed persons, etc.), they can be valuable

members of the investigation team by collecting and transporting samples. 

5.6 OBTAINING PESTICIDE

PRODUCT INFORMATION

Ideally, the exposed person, treating HCP, or

another informant will be able to give the PPSP

a product name and EPA registration number.

More commonly, substantial sleuthing may be

required to obtain this information. It is important to try to get both the product name and EPA

registration number since some products with

the same or very similar names have very different formulations. Each product has a unique

EPA registration number, and this can be used

to differentiate products with the same name. If

the exposed person is not the person who

applied the pesticide, the pesticide applicator

will need to be contacted by the PPSP or a partner agency depending on the program protocols

to obtain pesticide product information. 

The SPIDER database, POISINDEX®

, EPA

PPIS database, and the PANNA Web sites are

all good starting points to find information

about a pesticide product’s active ingredients.

Links to some of these sites, and commercial

sites for product labels and material safety data

sheets (MSDSs) are provided in Appendix G.

Note that these databases generally only contain information about active ingredients in the

pesticide formulation (that is, those chemicals

added for the purpose of their pesticidal activity)

and not about inert ingredients. 

55

CHAPTER 5 CASE INTAKE FOLLOW-UP

__________________

‡Code of Federal Regulations. See CFR in references.
5.6.1 INERT INGREDIENTS

Pesticide products may contain ingredients that

are considered inert as defined by FIFRA. Inert

ingredients are not included in the formulation

for their pesticidal properties (although they

may possess such activity). In 1987, the EPA

developed a policy to “reduce the potential for

adverse effects from the use of pesticide products containing toxic inert ingredients” [52

CFR 13305]. As part of this policy, inert ingredients were categorized into four lists based on

hazard and priority for testing. All of the inerts

on List 1 (categorized as chemicals of toxicological concern) must be listed on the product

label (see Table 5.1). This categorization is

based on carcinogenicity, neurologic effects,

developmental and reproductive effects, or

adverse ecological effects. Some pesticide

products voluntarily indicate on the product

label the identity of inerts or other ingredients

not on List 1. The use of the term inert is accepted, although EPA now encourages registrants to

use the term other ingredient rather than inert

[EPA 1997]. This policy change is a result of

EPA’s efforts to make the language on pesticide

product labels clearer for consumers. (See

http://www.epa.gov/opptintr/labeling/ for information about the Consumer Labeling Initiative.) 

List 2 provides the 95 chemicals currently used

in pesticide products that are considered potentially toxic. These ingredients are undergoing

review to determine whether they should be

moved to List 1 or List 4, described below. This

determination will be based on an assessment

of carcinogenicity, neurologic effects, developmental and reproductive effects, or adverse

ecological effects.

List 3 contains inert ingredient chemicals of

unknown toxicity that are undergoing assessment. List 4 is composed of two lists: List 4A

are minimal risk inert ingredients and List 4B

are those inert ingredients that the EPA has

determined to pose no adverse risks to the environment or public health when used in pesticide

products. Note: Lists 2, 3, and 4 are not included here because of their length and more frequent

updating compared with List 1. New inert

ingredients are occasionally added to the lists,

and the EPA issues periodic notices of reclassification for chemicals that have undergone

review. Lists 2, 3, and 4 and additional information about inert ingredients appear at http://

www.epa.gov/opprd001/inerts/. This Web site

also has links to Federal Register notices that

list inert ingredients removed from all lists but

which may be found in older products associated with exposure incidents.

Regrettably, product-specific information about

inert ingredients is not readily available to the

public or public health professionals in any

database. Several lawsuits have been filed in an

attempt to require disclosure of inert ingredients on the product label, but the disclosure is

currently voluntary except for inerts on EPA’s

List 1. The inert ingredients are considered

Confidential Business Information protected

under the trade secrecy provision of FIFRA.

Product MSDSs may contain some information

about inert ingredients. If a PPSP suspects that

56

CHAPTER 5 CASE INTAKE FOLLOW-UP
The inert solvents and propellents in aerosol

products can be hazardous. Liquid formulations (emulsifiable concentrates, soluble concentrates, liquids, ultralow-volume concentrates,

and solutions) are of greatest concern. The inert

ingredients can include oils, solvents, or alcohols, and concentrated (as opposed to ready-touse) formulations may contain high levels of

active ingredients. Some liquid formulations

may contain antifreeze to prevent freezing in

storage.

Pesticide dusts are composed of finely ground

pesticide mixed with a dry inert such as ground

clay, talc, or chalk, which functions as a carrier.

These products pose an inhalation hazard, but

the inert ingredients are usually less hazardous.

The inert of greatest concern here is usually silica.

Granular and pellet formulations typically contain

lower amounts of active ingredient bound to a

larger particulate inert carrier such as ground

vegetable material (e.g., corn cob, nut shell),

sand, or clay.

5.7 EVALUATION AND

REFERRAL FOR SITE

INSPECTION OR

ENFORCEMENT

The enforcement agency that receives inspection referrals varies across States and circumstances. Most often it is the DA; less often the

State occupational health agency, department

of forestry, or department of environmental

protection. In most instances, the PPSP cannot

conduct an investigation or evaluation without

having some contact with enforcement agencies. Each PPSP must make its own decisions

about referral protocols for investigation by

these agencies. The PPSP should consider several issues including confidentiality concerns,

whether other persons are at risk, whether the

exposure is ongoing, the severity of the illness

57

CHAPTER 5 CASE INTAKE FOLLOW-UP

an inert ingredient may be implicated in an illness or injury, the product manufacturer or the

local PCC should be contacted to obtain information about that ingredient. Contacting the

manufacturer or the local PCC is usually faster

than trying to obtain the information from the

EPA. Always ask to speak with a manufacturer’s

toxicologist or physician when requesting this

information. You may need to submit a request

via fax to confirm the public health need for the

information. Registrants are required to provide

information about inert ingredients to HCPs

involved in the evaluation of an exposed person. For links to manufacturer and MSDS Web

sites, see Appendix G. Keep in mind that additional carriers or adjuvants that might have

adverse toxicologic effects may be added by

the pesticide applicator. These carriers and

adjuvants are not registered as pesticides,

although they are designed to be mixed with

pesticide products. Information about carriers

and adjuvants is available from some of the

sources listed in Appendix G. The NPIC Web

site (http://npic.orst.edu/manuf.htm) is an additional good source of contact information for

manufacturers.

In the event that inert ingredient information is

not available from either the manufacturer or

the local PCC, this information can be provided by the EPA [40 CFR 2.307]. Currently, this

requires the health department to place a

request on its letterhead (or the letterhead of

another government agency with responsibilities for protecting public health) and fax it to

the Assistant Administrator of EPA’s Office of

Prevention, Pesticides, and Toxic Substances.

The fax number is 202-564-0801.

Inert ingredients are more of an exposure concern for particular product formulation types.

Use of aerosol products can result in exposure

to active and inert ingredients due to the small

droplets dispensed by the pressurized product.
or injury, and whether circumstances suggest

possible rule violations. There should be a system for documenting and tracking referrals to

determine the outcome of investigations by the

partner agencies, and to ensure that findings are

disseminated to the appropriate persons and

agencies. It is helpful to have written protocols

that describe the priority system and process for

referral.

When the PPSP makes a referral, a person’s

name is not usually released unless the person

has agreed to the release or agrees to contact the

enforcement agency him- or herself. Case

intake forms should have a place to indicate if

verbal permission has been given to release sufficient information for a referral, and whether

this includes permission to release the person’s

name. PPSP must develop guidelines on when a

written release is required. This issue is usually

of greatest concern for occupational exposures

where workers are concerned about loss of

employment, and nonoccupational exposures

where tenants are concerned about loss of housing. 

The PPSP must decide under what circumstances a referral is made to an enforcement

agency without the permission of the affected

person. Exposed workers may be reluctant to

have the PPSP contact their employer or make

a referral to an enforcement agency. When

deciding how to proceed in these situations, the

PPSP must take into account whether others are

at risk, the nature of the exposure, and the

severity of the illness or injury. Affected persons

should be informed both of their rights about

confidentiality, and that some enforcement

agencies may be less able to protect confidential information compared with the PPSP. 

5.8 OVERVIEW OF AGENCIES

WITH JURISDICTION OF

PESTICIDES

This section outlines the principal agencies typically involved in regulating pesticide manufacturing,

distribution, use, and disposal at the State level.

As the many entries suggest, a great deal of

variability exists in how individual States manage oversight of pesticide use. There is no uniform way that Federal rules are incorporated into

State laws/rules, nor is there consistency in the

State agencies designated to implement or

enforce these laws/rules. (Appendix F provides

an overview of the main Federal rules that

relate to pesticide use and potential exposures.)

5.8.1 FIFRA STATE DESIGNEES

The key agency for enforcing most of the rules

mandated by FIFRA varies from State to State.

In most States, the DA functions as the EPA

designee for enforcement of FIFRA. In others,

the department of environmental conservation,

or other similar agency holds that responsibility.

The areas covered by FIFRA include the registration of pesticide products, product labeling,

licensing of pesticide applicators, the sale and

distribution of pesticides, and proper work

practices for handling pesticides. Rules on the

disposal of pesticides are usually enforced by

the State environmental agency, which will also

be involved in responding to spill events or

events involving pesticide contamination of

bodies of water. 

The part of FIFRA governing proper agricultural work practices is WPS, the provisions of

which are usually enforced by the same State

58

CHAPTER 5 CASE INTAKE FOLLOW-UP
agency that enforces FIFRA. Formal agreements designate the primary State agency

responsible for WPS enforcement. Oregon is

currently the only State to delegate WPS

enforcement to a State OSHA program, by

agreement with the Oregon DA. In Washington

State, both the DA and the Department of Labor

and Industries simultaneously adopted identical

WPS rules based on EPA standards. A detailed

description of FIFRA is included in Appendix F.

5.8.2 OSHA

Twenty-six States/territories operate their own

OSHA program. In most of them, the OSHA

program is a part of the DOL, but in others it

may be part of the insurance division, health

department, or other section of the State government. The groups of workers covered varies

among the different State and territorial programs.

For more information about State programs,

see http://www.osha.gov/fso/osp/index.html. In

States without their own OSHA program, the

Federal OSHA is responsible for regulating

occupational safety and health. Federal OSHA

maintains one or more regional offices in these

other States.

The Federal Occupational Safety and Health

Act contains provisions that relate to pesticide

exposure, including hazard communication,

farm labor housing, field sanitation, agriculture,

fumigants, first aid and emergency services,

and general duty clauses about provision of a

safe and healthy workplace. OSHA also has

responsibility for workers involved in manufacturing and formulating pesticides.

State level OSHA programs may have broader

jurisdiction over occupational health issues

related to pesticides. PPSP staff should seek

training and information from OSHA staff in

their State about State rules and agency jurisdiction in this area. 

5.8.3 AGENCIES RESPONSIBLE

FOR DISEASE SURVEILLANCE

AND CONTROL

Responsibility for surveillance of both environmental and occupational pesticide-related illness and injury may be in the same office within

an agency, or they may be scattered in different

State agencies and offices. The simplest situation is one in which they occupy a single office

within an agency. This allows development of

protocols that encompass occupational and

nonoccupational exposures. In addition, single

exposure events that involve occupational and

nonoccupational cases can be managed by the

same staff. If the two types of cases (that is,

occupational and nonoccupational) are managed in different offices within the same

agency, a central point of contact for all cases is

usually easiest for reporters. This central contact should have well-structured referral and

follow-up procedures. 

Many States participate in a centralized system

established for reporting chemical spills and

releases, called the Hazardous Substances

Emergency Events Surveillance (HSEES) system. Funding to develop and maintain HSEES

is provided by the Agency for Toxic Substances

and Disease Registry (ATSDR). The PPSP

should make sure it is linked to any HSEES

activities in its State, and receives reports of

events involving human exposures to pesticides. 

5.8.4 OTHER STATE AND ADJUNCT

AGENCIES

Other agencies that may be involved in case

investigations include the State agencies

responsible for the following:

Environmental regulation (that is, the PPSP

is usually involved with these agencies

when an event includes issues related to dis59

CHAPTER 5 CASE INTAKE FOLLOW-UP
posal, transport, spills, or other significant

environmental contamination, or releases

into bodies of water, air, or soil),

Forestry (that is, when an event involves

applications to State forest lands), and

Fish and wildlife (that is, when an event

includes harm to fish or wildlife).

5.8.4.1 VECTOR CONTROL DISTRICTS

Vector control districts are responsible for control of disease vectors at the county or regional

level. They provide public education to help

control breeding of rodents, mosquitoes, flies,

and ticks. They also conduct pesticide applications to control disease vectors and nuisance

problems caused by the vectors. It is helpful to

have a list of the local districts and information

about what pesticide products they are using.

This will allow the PPSP to contact the appropriate district upon receipt of illness reports that

are associated with vector control activities.

The American Mosquito Control Association’s

Web site (www.mosquito.org) has links to affiliated mosquito and vector control associations.

5.8.4.2 PEST CONTROL BOARDS

Some States have governing bodies involved in

the regulation of nonagricultural commercial

pesticide applications, such as applications by

structural pest control operators. These bodies

can be helpful in case reporting, investigating,

and developing intervention strategies. 

5.9 STATE INTERAGENCY

COORDINATION OF CASE

INVESTIGATIONS

Outlining the most effective structure for interagency coordination is extremely difficult

because the level of cooperation, available

resources, and expertise across State agencies

is not standard. This section discusses several

of the different approaches used to address

interagency coordination. At a minimum, it is

important to know which agencies in the State

have responsibility for the various issues associated with pesticide incidents and to have a list

of the appropriate contacts in each of those

agencies.

5.9.1 INTERAGENCY AGREEMENTS

Washington and Texas PPSPs each maintain a

memorandum of understanding between State

agencies for investigation of pesticide poisoning

cases. The agreements set forth formal arrangements among State agencies about communication,

responsibilities, and jurisdiction for investigation of pesticide-related health complaints. Formal

interagency agreements can be time-consuming

to negotiate and may end up with rigid clauses

that do not provide sufficient flexibility to

address all situations that may occur. Nevertheless, they are helpful in clearly stating roles and

responsibilities of agencies and setting a clear

structure for cooperation. The existence of

formal agreements also sets a precedent for

documented cooperation that is easier to maintain over time as agency management and

personnel change. 

5.9.2 MULTIAGENCY COORDINATING

BOARDS

Two States (Oregon and Washington) have created

multiagency boards to establish mechanisms

for coordinating investigations, evaluating data

from investigations, and developing action

plans for pesticide poisoning prevention. These

boards are designed specifically to address

adverse human and environmental impacts from pesticide use and are briefly described below. Web site

addresses for the statutory language establishing

60

CHAPTER 5 CASE INTAKE FOLLOW-UP
the two programs are provided in Appendix B.

States interested in pursuing development of

similar boards are advised to contact the Oregon

Pesticide Analytical and Response Center (PARC)

and Washington Pesticide Incident Reporting

and Tracking Review Panel (PIRT) to obtain

annual reports and other information about

these programs.

PARC was established in the early 1970s in

response to public concerns about the health

effects from herbicide spraying conducted by

the forestry industry. The board is composed of

representatives from seven State agencies with

jurisdiction over pesticides or health, a representative from the Oregon Poison Center, and

one citizen appointed by the governor. Various

toxicologists within the State university system

are included as consultants to the board. PARC

is designed to centralize reporting of actual or

alleged health and environmental incidents

involving pesticides. It is also designed to

mobilize the expertise needed to investigate

pesticide incidents in a timely manner. The

board examines data to identify trends and

problems, and may make recommendations for

actions to member agencies. The budget for

PARC was eliminated in 2003, but agency

members continue to meet on a regular basis to

discuss investigations and review cases. The

Washington PIRT panel was modeled on the

PARC board but has somewhat broader mandates.

5.9.3 ADVISORY COMMITTEES

If a PPSP does not develop formal interagency

agreements and there is no statutorily mandated

multiagency oversight committee (or board) to

address pesticide use, the program might benefit from developing an advisory committee.

Members of the advisory committee can

include representatives from other partner

agencies, public interest groups (e.g., environmental and public health organizations), agricultural employers, worker advocacy groups,

PCCs, HCP associations, pesticide manufacturers or reformulators with facilities in the State,

and the pest control industry. The committee

should meet two to four times per year. The

meetings are often a source of valuable ideas to

the program. They also provide the PPSP an

opportunity to maintain contact with various

constituencies, apprize them of findings, develop

joint programs for outreach and intervention,

and discuss mechanisms for improving reporting

and investigation. 

5.10 NIOSH, NCEH, AND

EPA

Prompt notification of NIOSH, NCEH (for

nonoccupational cases only), and EPA may

allow those agencies to work with the State

PPSP to prevent additional cases. Guidelines

used to trigger NIOSH/NCEH/EPA reporting

are case reports that involve any of the following:

hospitalization or death from unintentional

pesticide exposure, or

events that involve 4 or more ill persons, or

events that occur despite use according to

the pesticide label, or

events that indicate the presence of a recurrent problem at a particular workplace and/or

with a particular employer’s worksites.

Prompt sharing of information with Federal

partner agencies alerts them to possible emerging

problems and may trigger additional investigative

action and assistance to the PPSP. NIOSH may be

notified by contacting the Surveillance Branch,

Division of Surveillance, Hazard Evaluations and

Field Studies at 1-800-356-4674. NCEH may be

notified by contacting the Health Studies

Branch at 404-498-1340. Notification of EPA

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CHAPTER 5 CASE INTAKE FOLLOW-UP
can include contacting both the EPA Regional

Office (see Appendix G) and the Health Effects

Division of EPA in Washington, D.C. (703-

305-7576 or 703-305-5336 ). Ideally, notification between the EPA Regional Office and the

PPSP should be reciprocal (that is, the PPSP

should be notified by EPA when EPA learns of

events within the PPSP’s area of jurisdiction).

The EPA Regional Office typically will refer

complaints or reports to the State designee (that

is, the State agriculture department). Establishing routine contact between programs will

make reciprocal notification more likely.

NIOSH and EPA may also assist in mobilizing

the resources of other agencies as needed (e.g.,

to investigate the illegal residential use of methyl

parathion in several States, the EPA regional

offices solicited assistance from NCEH and

ATSDR [EPA 1996]).

5.11 FEDERAL AGENCIES

THAT MAY HAVE A

ROLE OR BE A

RESOURCE DURING

CASE INVESTIGATION

This section describes those Federal agencies

with which the PPSP will likely have the greatest contact. 

5.11.1 UNITED STATES

DEPARTMENT OF

AGRICULTURE (USDA)

Several USDA programs can serve as useful

information resources or as partners in educational programs. The primary programs pertinent to

pesticide illness surveillance are as follows:

Cooperative State Research Education and

Extension System 

Federal Grain Inspection Service

Animal Plant Health Inspection Service (APHIS)

5.11.1.1 COOPERATIVE STATE RESEARCH

EDUCATION AND EXTENSION

SYSTEM (CSREES)

CSREES is a national system based in the land

grant universities and county administrative

units. This system is well recognized in rural

communities, and increasingly in urban areas,

as a source of information and practical classes.

The system maintains agricultural experiment

stations that work with university researchers,

including toxicologists. Programs include

(1) IPM, (2) sustainable agriculture, (3) food

safety, (5) family health, (6) 4-H clubs, and

(7) environmental and water quality programs.

The EXTOXNET system is a resource on pesticide and environmental toxicology sponsored

through CSREES. Local extension agents provide information about crops, seasonal pesticide use, and particular pest problems in local

areas. They can be valuable resources in understanding local agricultural issues. The extension agents usually specialize in particular

crops and may be a valuable resource in determining what products are typically used and

can identify the local aerial applicators. The

extension service works with EPA and State

designees to conduct pesticide applicator training programs. The extension service also offers

programs aimed at youth (e.g., 4-H), farm families, and suburban gardeners. These established training programs can be ideal avenues

to disseminate pesticide safety information

from the PPSP. The extension programs also

can be ideal partners for developing and testing

interventions. (More information about extension programs appears in Appendix G.)

5.11.1.2 FEDERAL GRAIN INSPECTION

SERVICE (FGIS)

FGIS is part of USDA Grain Inspection, Packers, and Stockyards Administration. It establishes the methods and standards used to

describe grain quality. FGIS or delegated State

62

CHAPTER 5 CASE INTAKE FOLLOW-UP
63

CHAPTER 5 CASE INTAKE FOLLOW-UP

agencies conduct mandatory export grain

inspections and other nonmandatory programs

for domestic grain commerce. PPSPs will usually not have much contact with this branch of

USDA unless addressing fumigant exposures to

FGIS grain inspectors, or to the public from

treated grain or vehicles (railcars, barges, etc.,

used to transport grain). 

5.11.1.3 ANIMAL PLANT HEALTH

INSPECTION SERVICE (APHIS)

APHIS is responsible for conducting activities

aimed at protecting agriculture in the United

States. These activities include securing the

U.S. borders against foreign agricultural pests

and diseases, as well as facilitating exports of

agricultural products. It is also involved with

preventing damage to agriculture from wildlife

(including through the use of pesticides). Additionally, APHIS is involved in ensuring the

safety of genetically engineered plants and other agricultural biotechnology products. At the

State level, APHIS works with State departments of agriculture and health when planning

emergency actions associated with elimination

of foreign pests. Recent examples of these

types of activities include programs to eradicate medfly and citrus canker in Florida, medfly in California, and Asian or European Gypsy

Moth in many States. It is important that PPSP

programs work closely with DA and APHIS

contacts on these types of eradication programs. These eradication programs may require

significant levels of public education and outreach activities aimed at HCPs and the public

prior to a pest control operation taking place. It

is extremely important for the various agencies

involved in emergency actions to present the

same risk communication message since differing messages can weaken public trust and

understanding. If the infestation is a regional

problem, activities may be coordinated with

other States in the region.

When addressing these eradication programs,

the PPSP may choose to add a more active

component to its routine passive surveillance.

There also may be reasons for conducting a

more structured epidemiologic study to address

particular concerns. This might include controlled studies of applicators, or monitoring

emergency room reports for particular illnesses

of concern and comparing illness rates with

background levels [Green et al. 1990; Pearce et

al. 2002]. The volume of calls can increase significantly surrounding these types of spray programs, resulting in a considerable increase in

workload. During these events, PPSPs frequently set up hotline operations to deal with

complaints and questions. In addition, agency

Web sites can serve as valuable sources of

information for the public. Fact sheets and upto-date spray schedules and maps can be posted

and updated as frequently as needed in

response to changing conditions (for an example, see the New York State Department of

Health Web page on West Nile Virus at 

http://www.health.state.ny.us/nysdoh/westnile/index.htm).

5.11.2 FEDERAL AVIATION

ADMINISTRATION (FAA), NATIONAL TRANSPORTATION

SAFETY BOARD

The agency that investigates airplane accidents

can provide information about airplane accidents involving aerial pesticide applications.

Reports on investigations are available on the

agency Web site (see Appendix C for the address

and instructions on conducting a search).

5.11.3 U.S. FISH AND WILDLIFE

This agency has responsibilities for protection

of wildlife and may be involved in investigations of wildlife poisoning. They and their State

partner agencies may work with the PPSP on

analyses to determine whether pesticides are
implicated in wildlife deaths that may also

involve potential human exposures. The agency

is also active in issues associated with pesticide

use and the Endangered Species Act.

5.11.4 OTHER FEDERAL AGENCIES

A number of other Federal agencies, along with

their State counterparts, can be helpful during

some investigations. These agencies will be

discussed briefly because PPSPs will only periodically collaborate with them.

5.11.4.1 COAST GUARD

The Coast Guard will play a role in addressing

exposure incidents involving spills in navigable

waterways.

5.11.4.2 CONSUMER PRODUCT SAFETY

COMMISSION (CPSC)

The CPSC may be a useful partner when

addressing issues associated with imported

products, such as insecticidal chalk.

5.11.4.3 CUSTOMS BUREAU

The Customs Bureau should be notified when

information is obtained about importation of

illegal pesticides (that is, pesticides not registered for use in the United States).

5.11.4.4 DEPARTMENT OF

TRANSPORTATION (DOT)

DOT plays a role in the regulation of interstate

shipping of pesticides and may be a useful contact for exposure incidents involving a shipping

accident or spill.

5.11.4.5 FEDERAL BUREAU OF

INVESTIGATION (FBI)

The FBI should be consulted when PPSP

suspects malicious use of pesticides, and the

malicious use has potential community or

broad public impact.

5.11.4.6 FEDERAL RAILWAY

ADMINISTRATION

The Federal Railway Administration may be

involved in situations involving rolling stock

(that is, rail cars anywhere other than in rail

yards or depots that are under OSHA jurisdiction). They will also have a role in addressing

releases of pesticides being transported by rail.

5.11.4.7 FOOD AND DRUG

ADMINISTRATION (FDA)

The FDA may be involved with investigations

involving veterinary or pharmaceutical uses of

pesticides, and genetically modified crops with

pesticidal properties.

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CHAPTER 5 CASE INTAKE FOLLOW-UP
6. SITE INSPECTIONS BY PPSP
67

6.1 INTRODUCTION

Most poisoning events can be investigated simply through a telephone interview with the poisoned

subject, combined with additional information

gleaned from medical records and investigation

reports from enforcement agencies. In some

instances, however, a site inspection by the

PPSP may be necessary. The process for initiating an inspection depends on the agency’s

authority to access the type of site involved.

Section 2.5.1.9 Authority to Investigate discusses

this in more detail. It’s worth remembering that

site inspections are very resource intensive.

In most States with established PPSPs, investigations are conducted by program staff based in

the centralized State office. The geographic

location of these surveillance programs can

present a significant drawback when conducting

site inspections, since travel can take a significant amount of time. In contrast, the Washington

State program has sufficient staff to base investigators in several areas of the State.

Each PPSP must set its own criteria for what

triggers a site inspection, bearing in mind that

specific mandates may need to be followed.

These mandates may be established by a funding source, the demands of special projects, or

general requirements of the disease reporting

rules in the State. Criteria used to trigger a site

inspection may include the following:

All deaths from nonintentional exposure

All hospitalizations from nonintentional exposure

Four or more ill persons associated with a

single exposure event

An unusual temporal clustering of three or

more reports associated with a particular

pesticide product (especially those newly on

the market), ingestion of pesticide-treated

food, a pesticide device, or a particular

workplace/employer

Incidents involving a pesticide, class of pesticide, type of application, or industry selected

by the surveillance program for special

emphasis

Obtaining the cooperation of the affected persons and the employer or owner of the exposure

site is critical if an inspection is conducted. The

surveillance program must develop protocols

covering whether employers will receive

advance notice prior to inspections. This decision is usually based on whether the agency has

a clearly mandated enforcement responsibility

for any facet of the State’s implementation of

the Occupational Safety and Health Act (OSH

Act) or FIFRA. If the surveillance program

functions outside those acts, the program investigators may decide to offer inspections as a

form of free consultative service to the employer, business owner, or home owner. In these

cases, an advance phone call may help establish

the foundation for a cooperative relationship. If

the primary purpose of the inspection is to

obtain a completely unbiased view of the operation, it may be more useful to perform unannounced site visits. This may not be feasible,

however, unless conducted jointly with an

enforcement agency.

If the program does not have a formalized

authority to investigate, a pre-established plan

of action should be in place to handle inspection refusals. The carrot-and-stick approach is

6.SITE INSPECTIONS BY PPSP
often effective. The agency can discuss the benefits of allowing an inspection on a cooperative

basis, namely that the investigator will provide

information and assistance in preventing exposures. The owner or employer may avoid a formal referral to an enforcement agency by

agreeing to correct the hazards identified during

the inspection. Care should be taken to ensure

that the employer understands the voluntary

nature of the inspection, and what actions will

be taken if an imminent danger situation is

identified. Other items that should be explained

include the following:

The scope of the inspection

An explanation of what information will be

held confidential, if any

What types of actions will be taken when

problems are identified 

Inability of the inspection to identify all hazards or violations of good practice

An explanation that cooperating with the

inspection and/or following recommendations made in the inspection report will not

exempt the employer or worksite from an

enforcement inspection or complying with

relevant regulations

The information that will be provided at the

end of the inspection and to whom it will be

provided

It is a good idea to develop standard language

covering these elements and to provide it in

writing both at the beginning of the inspection

and in the final report.

In some situations, PPSP staff may choose to

conduct site inspections simultaneously with

the enforcement agency, depending on the relationship between agencies. Employers can feel

besieged when multiple agencies conduct separate inspections at different times since these

activities disrupt normal work activities.

Alternatively, the PPSP may prefer to keep its

inspections separate to prevent confusion with

another agency’s mandates, or to maintain a

different relationship with the owner of the

establishment and the exposed persons. In these

cases, the investigator must be able to explain

why the PPSP inspection is different, what is

being evaluated, and what type of information

will be provided to the employer and employees

at its conclusion. (Site inspections of nonoccupational exposures involve similar issues with

landlords, public buildings, neighboring property

owners, and retail establishments.)

PPSP staff may be contacted during emergency

response events, such as spills or fires involving

pesticides. Programs should have policies to

address staff roles in these circumstances. Any

on-site work during these events requires that

staff have the proper level of safety and health

training and PPE.

6.2 GETTING STARTED WITH

THE INSPECTION

Attire for site inspections should be appropriate

for the type of establishment. Failure to dress

accordingly will hinder the investigator’s ability to establish a credible working relationship

with all of the persons involved in an exposure

event.

The investigator should begin by introducing

him- or herself by name, title, and organization,

and presenting appropriate credentials. The

purpose for the visit should be provided next.

The investigator should meet with company

and worker representatives to discuss the

timetable and purpose of the visit and to obtain

information about the exposure event. 

68

CHAPTER 6 SITE INSPECTIONS BY PPSP
6.3 SITE WALK-AROUND

EVALUATION

The purpose of the walk-around inspection is to

gather information to

Evaluate the relationship between the reported

illness and the pesticide exposure

Identify potential safety and health hazards

related to pesticide use in the home or workplace 

Document the exposure

Observe the activities of affected and other

potentially exposed persons

Identify changes in policies or procedures

that will help prevent the recurrence of a

similar exposure event.

It is useful to diagram the site where the exposure occurred and indicate the location of any

windows and ventilation ducts. Another helpful

step is to review relevant written policies, training program materials and records, and the

injury and illness log. Finally, investigators

should obtain multiple perspectives for why the

exposure event occurred. In occupational exposures, that includes the exposed worker(s) and

either their employer or supervisor.

Some programs conduct only limited worker

interviews during a site inspection. Others conduct those interviews only at the worker’s

home, by telephone, or at a neutral place outside of work hours. In most situations, in-depth

worker interviews are most effective when conducted away from the workplace. At the workplace, time spent talking with investigators may

compromise the confidentiality of the exposed

worker, decrease the worker’s earnings (especially in agricultural settings), or make it difficult for the worker to provide as much information as might be possible away from work.

6.4 EQUIPMENT FOR SITE

INSPECTIONS

6.4.1 CAMERA

A camera is indispensable for quick documentation of the site layout, but photos need to be

augmented by notes, diagrams, and measurements. Photographs can help document the

state of repair of application equipment, PPE,

or pesticide product storage. Photographs are

also useful in documenting sampling sites.

(Sampling equipment is described in Section 6.5.)

When photographing workers, consider how

the photographs will be used. Formal consent

should be obtained if the worker will be identifiable. As a courtesy, explain to workers how

the photographs will be used even if the workers

will not be identifiable.

6.4.2 PPE

The information provided here is general and is

designed to serve as a reminder to State programs that they need to address issues of staff

safety and health. It is extremely important that

staff conducting inspections are equipped with

appropriate PPE for the types of situations they

will be evaluating. If there is any doubt about

the safety of entering a particular area with the

level of PPE available, the inspection should be

terminated until appropriate PPE is obtained.

All staff evaluating pesticide illnesses must be

in compliance with all safety and health rules

for their own protection and to protect the credibility of the program. Guidelines for appropriate PPE should be reviewed by the agency’s

safety and health officer or other appropriate

staff to ensure compliance with occupational

safety and health laws. Staff should be properly

fit-tested for respiratory protection devices.

(Guidelines for fit-testing and medical evaluation for use of respiratory protection are included

in the OSHA Respiratory Protection Standard

[29 CFR 1910.134] ).

69

CHAPTER 6 SITE INSPECTIONS BY PPSP
The minimum equipment that should be available for inspections is as follows:

Chemical resistant boots (polyvinyl chloride

[PVC], nitrile, or similar material)

Half-face cartridge respirator or powered air

purifying respirator (PAPR) equipped with

cartridges appropriate for the hazard (usually

a combination organic vapor cartridge with a

dust filter) 

Unlined gloves of nitrile or butyl rubber

Steel-toed rubber boots 

Plastic bags for transporting PPE that may

be contaminated during an inspection

Any necessary sampling equipment and containers for transporting samples

6.4.3 WATER

Staff should carry sufficient water to ensure

proper hydration if working in a hot environment. Water should also be available for decontamination when staff members are observing

pesticide mixing, loading, or application activities.

6.4.4 CONTACT FORM

Since inspections are frequently conducted in

remote areas, it is helpful to have staff complete

a simple contact form prior to leaving the

office. The form should identify the location of

the inspection site, the staff departure time, the

expected return date and time, and a checklist

of PPE to be taken to the inspection site (see

Appendix C).

6.5 SAMPLING

This manual provides general information

about sampling. Sources for more detailed

instructions on sampling and laboratory pesticide analyses are described in this section.

Several types of sampling are appropriate for

ascertaining whether exposure occurred or was

probable, whether pesticide was absorbed, and

whether changes in biologic function took

place as a result of exposure. In most situations,

PPSPs do not have adequate funding and staff

to conduct routine environmental or biological

sampling. Sampling is most often conducted as

part of enforcement inspections by agencies

that have jurisdiction over pesticides or occupational health. The sampling carried out by

these agencies is typically aimed at determining whether a code violation occurred. This

may be different from the sampling desired by a

public health agency aimed at ascertaining

whether a person was exposed to sufficient pesticide to suffer health problems, or whether use

of a product according to the label may cause

adverse health effects.

State enforcement agencies may maintain sampling guides or manuals. PPSPs should review

these if they plan to conduct their own site

sampling or use sampling results from the State

enforcement program. NIOSH, OSHA, and

EPA maintain manuals of analytic methods for

a broad range of chemicals including pesticides

[NIOSH 1994; OSHA 2000; EPA 2000a].

Chapter 13 and Appendix A of the FIFRA

Inspection Manual [EPA 2002] also contain

procedures for collecting residue and environmental samples. 

Pesticide manufacturers can be a useful source

of information about sampling methodologies

for their products. Their industrial hygienists

can provide useful information about sampling

methods and data from the company’s exposure

analyses. They are also a good source for information about decontamination procedures following significant spills or misapplications of

their products.

With the exception of equipment for surface

wipe sampling, most sampling protocols require

an investment in equipment for sampling and

70

CHAPTER 6 SITE INSPECTIONS BY PPSP
71

CHAPTER 6 SITE INSPECTIONS BY PPSP

calibration. It is possible to rent or develop a

system for borrowing equipment that will not

be used frequently. If sampling is not conducted regularly by experienced staff, sampling

measurements may be inaccurate due to various sampling errors. PPSPs that do not conduct

regular sampling may choose to arrange for it

to be conducted by a sister agency (e.g., an

enforcement agency) through an interagency

agreement.

6.5.1 SAMPLE COLLECTION

The sample collection strategy is dictated by

the purposes for obtaining the samples and the

circumstances of the exposure. The date, time,

and environmental conditions of sampling must

be carefully recorded. Storage and handling of

the sample must be documented.

Residue samples are typically the most common types of samples encountered in health

inspections. These involve obtaining samples

of plant material, animal tissues, water, soil,

wipes of hard surfaces, or samples of contaminated fabric, air, runoff water, etc. At times,

samples may be taken to determine whether the

tank mix and/or dilution of pesticide was

appropriate according to the product label or to

identify an unknown pesticide product. 

In the case of drift exposures, it is useful to take

residue samples on the actual site where the

application was intended. The area from the site

of the application to the site where affected persons were exposed should be divided into grids.

A series of samples is then taken in each grid,

moving from the site of application to the site

of exposure. Samples of soil or foliage are most

commonly used to document drift. Wipe samples taken from vehicles or building structures

may also be useful for documenting drift exposures. Contaminated clothing may be collected,

although analysis is often more difficult. 

Sampling pumps must be carefully calibrated

before and after any air sampling. Indoor air

samples must address issues of potential interference from other indoor air contaminants. In

residential exposure situations, samples should

be taken under the same conditions that existed

at the time the person was exposed (e.g., with

respect to heat and ventilation). In addition,

samples should be taken under a worst-case

scenario with heat on or air conditioning off to

determine any ongoing hazard from exposure

in the residence. 

If biological specimens such as blood or urine are

collected, it is critical that the analytical laboratory be contacted ahead of time. The laboratories’

instructions about sample collection media,

preservatives, storage conditions for transport,

and shipping must be carefully followed.

6.5.2 SAMPLE PREPARATION

CUSTODY AND HANDLING

The investigator should carry clean sampling

materials, container seals, and preservatives as

needed. Proper care of the sample during transport is critical for sample integrity. Chain of

custody should be documented using a standard

form. The manuals described earlier have

examples, as do State enforcement agencies.

The laboratory that will be receiving the sample

may require a chain of custody form.
7. CASE CLOSURE AND CLASSIFICATION
75

7.CASE CLOSURE AND CLASSIFICATION

7.1 THE CASE CLOSURE

PROCESS

Once interviews have been completed,

medical information obtained, and

any sampling or site inspection

conducted, the investigator should evaluate the

case for completeness. It may also be helpful to

have each case reviewed for completeness by

an additional investigator. A list of any additional

information needed should then be developed

and additional follow-up conducted. After all

pertinent information has been collected, the

report should go through a formal evaluation

and classification. There is often an extremely

long delay in obtaining reports from enforcement agencies, so the PPSP may choose to

develop a provisional case closure protocol,

with final case closure occurring after receipt of

the enforcement investigation report. 

Case classification is often performed as a

group process to help ensure objective and consistent evaluation of all cases within the surveillance program. Some PPSPs have a panel

of persons who individually review and classify

each case. Afterwards, all panel members’ classifications are reviewed, and the panel meets to

discuss any differences. Other programs assign

two persons who classify cases as a team, with

a designated third party to consult when the

pair disagree on the interpretation of available

case data. 

Case information should be reviewed using

the matrix in the Case Definition for Acute

Pesticide-Related Illness and Injury Cases

Reportable to the National Public Health Surveillance System [NIOSH 2004]. The reviewers

may sometimes feel there are circumstances with

a case that should result in a classification that is

different from that obtained by using the

matrix. They should record the classification

they think is correct and note the reasons for

any differences with the matrix classification. If

the PPSP is using a separate State classification

system in addition to the national case definition, this classification should also be applied at

the time of case closure.

7.2 CASE DEFINITION FOR

ACUTE PESTICIDE- RELATED ILLNESS AND

INJURY CASES

REPORTABLE TO THE

NPHSS

The case definition described here was developed by a consensus process involving Federal

and State agency partners and was adopted by

CSTE [1999]. The full text of the case definition

and its appendices are included in Appendix D.

Portions are provided here for discussion. The

case definition provides a consistent, objective

approach for assessing information gained

about each report. Using this definition to evaluate and classify cases allows an aggregation of

data from all States and a comparison of data

between States. 

7.3 CLINICAL DESCRIPTION

7.3.1 CASE DEFINITION

This surveillance case definition refers to any

acute adverse health effect resulting from exposure to a pesticide product (defined under
FIFRA, except that disinfectants are often

excluded§) including health effects due to an

unpleasant odor, injury from explosion of a

product, inhalation of smoke from a burning

product, and allergic reaction. Because public

health agencies seek to identify and prevent all

adverse effects from regulated pesticides, notification is needed even when the responsible

ingredient is not the active ingredient.

A case is characterized by an acute onset of

symptoms that are dependent on the formulation of the pesticide product and involve one or

more of the following:

Systemic signs or symptoms (including respiratory, gastrointestinal, allergic, and neurological signs/symptoms)

Dermatologic lesions

Ocular lesion

This case definition and classification system is

designed to be flexible in permitting classification of pesticide-related illnesses from all classes

of pesticides. Consensus case definitions for

classes of chemicals may be developed in the

future.

A case will be classified as occupational if the

person is exposed while at work (this includes

working for compensation; working in a family

business, including a family farm; working for

pay at home; and working as a volunteer emergency medical technician [EMT], firefighter, or

law enforcement officer). All other cases will be

classified as nonoccupational. All cases involving suicide or attempted suicide should be classified as nonoccupational.

A case is reportable to the national surveillance

system when the following criteria are met:

Documentation of two or more new adverse

health effects that are temporally related to a

documented pesticide exposure, combined

with

a. consistent evidence of a causal relationship between the pesticide and the health

effects based on the known toxicology of

the pesticide from commonly available

toxicology texts, government publications, information supplied by the manufacturer, or two or more case series or

positive epidemiologic investigations, or 

b. insufficient toxicologic information is

available to determine whether a casual

relationship exists between the pesticide

exposure and the health effects.

7.3.2 LABORATORY CRITERIA FOR

DIAGNOSIS

If available, the following laboratory data may

confirm the diagnosis of acute pesticide-related

illness or injury:

Biological tests for the presence of, or toxic

response to the pesticide and/or its metabolite (in blood, urine, etc.)

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CHAPTER 7 CASE CLOSURE AND CLASSIFICATION

_______________________

§ Pesticides are defined under the Federal Insecticide

Fungicide and Rodenticide Act (FIFRA) as any substance

or mixture of substances intended to prevent, destroy,

repel, or mitigate insects, rodents, nematodes, fungi,

weeds, microorganisms, or any other form of life declared

to be a pest by the Administrator of the U.S. EPA and any

substance or mixture of substances intended for use as a

plant regulator, defoliant, or desiccant. Pesticides include

herbicides, insecticides, rodenticides, fungicides, disinfectants, wood treatment products, growth regulators,

insect repellents, etc.

Please note that adverse health effects resulting from

exposure to disinfectant products are not reportable in

many States because the volume of reports could overwhelm the State’s surveillance system; therefore, these

cases will not be routinely reported to the national surveillance system. Certain States may collect data on

health effects resulting from a few selected disinfectants

(e.g., glutaraldehyde). If resources are available, States

are encouraged to do surveillance on acute disinfectantrelated illness.
77

CHAPTER 7 CASE CLOSURE AND CLASSIFICATION

- Measurement of the pesticide and/or its

metabolite(s) in the biological specimen

- Measurement of a biochemical response

to the pesticide in a biological specimen

(e.g., cholinesterase levels)

Environmental tests for the pesticide (e.g.,

foliage residue, analysis of suspect liquid)

Pesticide detection on clothing or equipment

used by the case subject

7.3.3 CASE CLASSIFICATION

CATEGORIES

The case classification matrix is used to rank

the evidence linking the illness/injury to the

pesticide exposure. Only reports meeting case

classifications of Definite, Probable, Possible,

and Suspicious are reportable to NPHSS. Additional classification categories are provided for

States that choose to track reports that do not fit

the national reporting criteria.

CLASSIFICATION CATEGORIES: 

Definite: Objective evidence confirms the exposure and illness, and the temporally related illness is consistent with the known toxicology of

the pesticide.

Probable: Objective evidence of either the pesticide exposure or the health effects is available,

and the temporally related illness is consistent

with the known toxicology of the pesticide.

Possible: Only subjective evidence of exposure

and illness is available, and the temporally related symptoms are consistent with the known toxicology of the pesticide.

Suspicious: Insufficient toxicological information is available to determine whether a causal

relationship exists between the pesticide exposure and the health effects.

Unlikely: The relationship between the reported exposure and illness is not consistent with

the known toxicology of the pesticide.

Insufficient Information: Insufficient documentation was obtained about the exposure or health

effects to determine whether the health effects

were related to a pesticide exposure. 

Not a case: A person was reported to a State

surveillance system due to an alleged exposure,

but was asymptomatic, or it was determined

that health effects were due to a condition other

than a pesticide exposure. States may choose to

create a subset of the not a case category to track

asymptomatic persons exposed to pesticides.

Once a case has been classified, a determination

of illness/injury severity can be performed using

the severity index provided in Appendix E. Severity is assigned only to cases reported to NPHSS.

7.4 COMMUNICATION OF

FINDINGS AND

RECOMMENDATIONS

PPSPs should aggregate individual case data to

describe the magnitude and distribution of pesticide illness and injury, develop and target prevention messages, and develop policy. However,

more immediate feedback to reporters (that is,

to HCPs and other sources of case reports) is

critical for maintaining reporting to the surveillance program and ensuring that this very

teachable moment is used to deliver prevention

information. Some programs send a routine letter

to providers to thank them for reporting. In the

case of nonreporting providers, the PPSP can

send notification to the provider indicating that

the PPSP is investigating a poisoning report

involving the provider’s patient. Several PPSPs

send a letter to providers when a case is closed,

providing a brief summary of findings and the

epidemiologic case classification. Another useful
gesture is to provide a copy of Recognition and

Management of Pesticide Poisonings [Reigart

and Roberts 1999].

All site inspections should result in a written

report of findings provided to the affected person(s), and the employer or third party responsible for the pesticide application. In the case of

worksite inspections, a brief summary report

may be provided to all interviewed workers.

This report should clearly communicate any recommendations, including those for IPM, product substitution, use of PPE, and training or

engineering controls. In some situations, worker

representatives (e.g., union or advocacy organizations) are involved. These worker representatives should be given a copy of the written

report, as they can serve as another venue for

making sure workers receive and understand

inspection findings. Care should be taken to make

sure confidential information is excluded from

reports sent to affected persons, workers, employers, and other third parties. Follow-up to determine whether recommendations are adopted

should be conducted after an appropriate time

interval. Follow-up may be conducted by mail,

telephone, or a site visit, especially if recommendations included engineering controls.

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CHAPTER 7 CASE CLOSURE AND CLASSIFICATION
8. DATA ANALYSIS AND REPORTING

OF AGGREGATED DATA
8.1 INTRODUCTION

Data analysis is an important component of surveillance. Data analysis is required to decipher the message

that the surveillance data are trying to provide.

As such, it will assist in identifying the most

problematic pesticides, the risk factors associated with acute pesticide-related illness, and

emerging data trends. This chapter will briefly

discuss analysis of pesticide poisoning surveillance data. A more detailed review appears in

standard epidemiological and surveillance textbooks [Teutsch and Churchill 2000; Rothman and

Greenland 1998]. 

Data dissemination is another important function of PPSPs. The control and prevention of

acute pesticide-related illness depends on the

dissemination of surveillance data to ensure

that educational, consultative, and regulatory

interventions can be effectively targeted. In

addition, surveillance partners (that is, HCPs,

other government agencies, and labor and

industry groups) welcome reports on surveillance findings and their impact. Keeping partners informed can promote visibility and

support for PPSP. Additional details on the content and audience for PPSP surveillance reports

are provided in this chapter.

8.2 ROUTINE DESCRIPTIVE

ANALYSIS

The pesticide poisoning data compiled by

PPSPs can be analyzed in terms of person,

place, and time. These analyses are useful for

identifying variations that may be amenable to

intervention. 

8.2.1 PERSON-BASED ANALYSES

8.2.1.1 CASE SERIES

The case series focuses on persons and is the

most basic level of data analysis and presentation. It serves as a useful tool for raising attention about emerging pesticide problems if they

involve a particular pesticide or a particular

type of pesticide usage (e.g., mosquito control

or pesticide use in schools). A case series provides a narrative of the cases, including a

description of the circumstances that led to

exposures, and recommendations for preventing similar events. It also presents a distribution

of case characteristics that can include disease

classification, severity category, occupational

versus nonoccupational, occupation, age, sex,

and other characteristics that highlight the subgroups accounting for the greatest (and perhaps

least) number or percent of cases. Reports of

new and novel emerging problems that are

reported in a timely manner should be considered for publication in the MMWR or another

peer-reviewed publication. Examples of case

series reports that were published in the

MMWR appear in Appendix A.

8.2.1.2 BIVARIATE ANALYSES

Bivariate analyses involve examining the association between two variables. For example, an

analysis of pesticide active ingredients and

severity categories can assist in identifying the

most problematic pesticides. Bivariate analyses

can provide clues about risk factors that will

allow the PPSP to target particular populations for

outreach, education, or further study. Additional

bivariate analyses can examine pesticide chemical

81

8.DATA ANALYSIS AND REPORTING OF

AGGREGATED DATA
class or functional class by risk factors such as

demographic characteristics, occupation, industry,

type of exposure (e.g., drift, spray, or contact

with pesticide residue), or activity of the person

at the time of exposure. The clustering of cases

in particular worksites or across an industry can

be used to determine whether a worksite or

industrial group meets program criteria for targeted on-site investigations.

8.2.1.3 RATES

Ideally, risk factor data should be expressed as

rates. The general form of a rate is:

where the numerator represents the number of

cases meeting the specified criteria (e.g., males

or farmworkers with acute pesticide-related illness), the denominator represents the size of

the population during the specified time period

(e.g., 1 year), and the size of n generally ranges

from 2 to 6 depending on the size of the numerator (that is, n determines if the rate will be as

low as per 100 population or as high as per million population). 

The pesticide poisoning data collected by

PPSPs is placed in the numerator. The denominator data must usually be sought elsewhere.

When calculating county-wide or State-wide

rates, an important source of denominator data

for population estimates is the U.S. Census.

When calculating rates among working populations, the denominator data can be obtained

from the CPS, which is conducted by the

Bureau of Labor Statistics (BLS) and is a useful

source of employment population estimates.

Note that the denominator data involve limitations. Because the numerator and denominator

data are often obtained from different sources,

it is important to ensure that similar criteria are

used for deriving the numerator and denominator. That is, the denominator should represent

that portion of the population at risk for the

exposure of interest. For example, when calculating rates of occupational pesticide poisoning, the denominator should consist of the

number of employed workers, and not the total

workforce or the total population, because the

total workforce includes the unemployed who

are not at risk of occupational pesticide poisoning. Similarly, when the denominator is the

State population, the numerator should contain

only residents of that State, because nonresidents who were poisoned in the State will not

be included in the denominator. It is also important that the numerator and denominator are

from the same time period (e.g., from the same

calendar year).

Many factors influence the reliability of

denominator (population) estimates, especially

among agricultural workers. For example,

migratory patterns and difficulties with tracking

undocumented workers make it difficult to reliably count the total number of farmworkers.

Another way of approaching the issue of

denominators is to utilize the amount of pesticide used or sold in the geographic area in question. This is feasible only in States that routinely

collect this type of data (e.g., California and New

York). Even in these States, pesticide use information is very limited, as data collection is often

confined to restricted-use products or products

applied by licensed applicators.

Despite the limitations, the calculation of rates

is very important. In contrast to simple counts,

a rate allows a more informed comparison

across groups (e.g., occupations, industries, age

categories, sex, race, counties, States, etc.).

Simple counts may erroneously suggest that a

problem exists within a demographic group

that accounts for a high proportion of the total

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CHAPTER 8 DATA ANALYSIS AND REPORTING OF AGGREGATED DATA

 
population. By calculating rates, it may be

found that the number poisoned per 100,000

persons does not vary across demographic

groups. Examples of the use of rates appear in

some SENSOR-pesticides publications [Calvert

et al. 2003, 2004].

8.2.1.4 TIME-BASED ANALYSES

Data can also be analyzed to determine whether

trends occur over time. Data comparing the

number of cases reported in different years can

indicate whether there were sudden shifts in the

pattern of occurrence versus a stable number of

reports. Although such data can be presented in

tables, use of graphs can greatly facilitate the

identification of trends and aberrations. Graphs

can also provide visual clues on the impact of

changes in case definition, program outreach

efforts, introduction of a new pesticide product,

or regulations restricting the use of a product. If

the size of the population changes over time, it

is more appropriate to examine time trends by

graphing rates and not counts.

When constructing graphs, it is preferable to

keep them simple. A simple, straightforward

graph is much easier to interpret than a complex, cluttered graph. The graph should be able

to stand alone. This requires having the title,

axes, legend, and data source clearly and concisely labeled. Any data exclusions should be

noted.

8.2.1.5 PLACE-BASED ANALYSES: 

MAPPING OF DATA

Mapping of data to show the geographic distribution of cases can be a useful tool for presenting information and for examining the spatial

relationship between cases and sources of

exposure. Many States with a PPSP provide a

map indicating the number of cases by county.

States currently involved in surveillance can

geocode data and thereby produce detailed

mapping using geographic information system

(GIS) software. Geocoding involves including

some way of recording the location of exposure

that will permit geographic identification. This

is not always feasible since descriptions of

locations are not always clear (e.g., when workers do not know the address where they were

working, pinpointing the exposure location is

very difficult). The current version of SPIDER

does not capture location data in a format needed for detailed geocoding (that is, location

accuracy in SPIDER does not extend beyond

address or Zip Code). It is anticipated that a

future release of the SPIDER program will

include fields (e.g., longitude and latitude) to

record more precise exposure locations. 

GIS mapping enables illness and injury data to

be overlaid with information about crop distribution, location of waterways, roads, schools,

etc. If the State has a system that records pesticide application data, this could also be

mapped. Mapping can be useful to examine

issues of large-scale vector control programs by

mapping pest habitat areas, treatment areas,

distribution of the disease of concern in animals

or humans, and complaints and illness associated

with pesticide use. Mapping can also be useful

for identifying agricultural fields that abut residential, commercial, or school property, as these

areas may be at risk for off-target pesticide drift.

This approach can be useful for generating

hypotheses about risk factors that influence

exposure, which can be further explored through

epidemiologic studies. Data mapping may provide

additional clues about geographic clustering of

particular uses of pesticides or the prevalence

of problems on the urban-rural interface. This

information may be useful in developing interventions or providing information to policy

makers responsible for land use or pesticide use

regulations. The State of Washington is currently

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CHAPTER 8 DATA ANALYSIS AND REPORTING OF AGGREGATED DATA
piloting a GIS approach for examining their

data on agricultural pesticide-related illness

and injury [Baum 2001b].

Any mapping of data must take into account

confidentiality. A number of techniques are

available to manipulate data to prevent identification of locations. Intentional errors (random

shifts within a range) can be introduced into

maps that contain street-level detail, making it

difficult to determine exact locations. Maps

with such introduced error must be annotated to

make it clear that points are not exact locations.

Simply presenting maps that do not provide

street-level detail may also protect confidentiality. However, data presented on a regional level

can still identify persons if they include age or

race information. Other techniques to protect

confidentiality include suppression for small

numbers in detailed area maps or use of large

symbols that interfere with the ability to precisely locate points [Spinello 2001].

8.2.2 DATA DISSEMINATION:

DEFINING WHAT REPORTS

WILL BE USEFUL FOR A

SPECIFIC PROGRAM

Reports can be comprehensive or short and

concise. Each PPSP must evaluate its own needs

for different types of reports. It is important to

determine the intended audience along with the

purpose of the report, as the presentation of

data will need to be constructed accordingly. A

comprehensive summary report can provide an

overview of the surveillance program, including

tables and graphs on the overall magnitude of

the problem, interpretation of the findings, and

a description of recent program accomplishments. These reports are often required by Federal funding agencies and are also produced for

multiagency coordinating boards. An annual

report to legislatures must sometimes address

statutory requirements (e.g., the need to

demonstrate how the PPSP is meeting requirements for timeliness of response). There may

also be a State interest in presenting data

describing agricultural versus nonagricultural

applications, illnesses affecting school students, or other issues. PPSPs with multiagency

boards typically present data showing referrals

from, or cases investigated by, partner agencies.

Reports prepared for the public or for HCPs

should be brief–the content limited to one or a

few issues. A case vignette or case series presented with some additional descriptive statistics may be useful for communicating a risk or

prevention message to the public or engaging

HCPs’ interest in case identification, treatment,

and reporting.

Reviewing reports produced by other PPSPs

may provide other helpful ideas. In addition,

the SPIDER program provides some standard

descriptive tables that surveillance programs

may find useful to include in their reports. See

Appendix C for sample tables found in SPIDER. Finally, a recent article that provides

national findings from the SENSOR-Pesticides

Program may provide helpful ideas for report

content [Calvert et al. 2004].

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CHAPTER 8 DATA ANALYSIS AND REPORTING OF AGGREGATED DATA
9. DEVELOPING INTERVENTION STRATEGIES AND

EVALUATING SURVEILLANCE
87

9.DEVELOPING INTERVENTION STRATEGIES

AND EVALUATING SURVEILLANCE

9.1 DESIGNING

INTERVENTIONS BASED

ON SURVEILLANCE DATA

There are many types of interventions–

education, adoption of engineering or

administrative controls to mitigate

exposure, implementation of more protective

regulations, among others. The scope of these

interventions may vary, with targets ranging

from a single exposed person to the entire population, or from a single worksite to an entire

industry. Interventions may involve a combination of techniques since adoption of even the

simplest engineering control requires that some

level of education and behavioral change also

be adopted. Analysis of data to examine risk

factors and identify areas for further investigation should be a routine activity of the surveillance program. Indeed, the expectation is that

surveillance data will be used to develop intervention and prevention programs. Unfortunately,

many PPSPs devote few resources toward such

efforts.

When PPSPs implement intervention and prevention programs, they often do so without

incorporating a careful strategy for evaluating

efficacy. While this approach is expedient and

less resource-intensive, it also makes it difficult

to measure the impacts of program activities.

Evaluation issues should be discussed and

examined before embarking on any intervention activity. It is often advantageous, for example,

to conduct a pilot intervention program that

contains a component to demonstrate impact

before implementing the intervention on a broader scale. To achieve this, PPSPs with limited

resources may need to seek supplemental funding sources and collaboration with university or

research institute partners. 

9.1.1 EDUCATION

9.1.1.1 AT HOME AND AT WORK

Interventions that involve education of the

affected persons, their HCPs, and sometimes

their employer are a common part of case investigation protocols. An example of one approach

comes from an Oregon Health Division PPSP

investigation of a food storage warehouse

where a group of workers became ill following

a pyrethrin fogging. The PPSP’s site investigation identified 12 symptomatic workers, 6 of

whom had sought medical care. The investigation also revealed that the warehouse had been

posted indicating when reentry would be safe,

but the posting failed to communicate that the

warehouse should be ventilated for at least 1

hour before entry. That information had been

verbally communicated by the applicator to at

least one worker at the warehouse. As a result

of its investigation, the PPSP provided several

recommendations. It advised the employer, for

instance, to develop routine procedures for

mechanical ventilation after fogging treatments,

and to require that the pesticide applicator provide

written instructions for the timing of building

opening and ventilation. Additional issues about

managing possible exposures were also discussed. These recommendations were provided

to the employer in writing, with a request for a

response by a specific date. In his response, the

employer indicated that the procedures had been

implemented. This was confirmed by follow-up
contact with employees. Ideally, additional

follow-up should be conducted approximately

1 year later to confirm that the changes were still

in place. This type of intervention and follow-up

should be a routine part of all PPSP case investigation activities.

9.1.1.2 EDUCATING THE EDUCATORS

In 1993, the Oregon Health Division PPSP noted an annual pattern of multiple incidents of

pesticide-related illness associated with pesticide applications in school buildings and/or

school grounds. Three such incidents occurred

in 1993, including one that resulted in at least

13 symptomatic persons and temporary school

closure. The PARC multiagency board sent a

mailing to all school district superintendents in

the State containing suggested guidelines on

pesticide use in schools, a checklist, and additional printed information [PARC 1993]. This

letter was sent annually from 1993 to 1995, and

then every other year. The mailing now incorporates additional information from the EPA on

IPM in schools. This intervention has not been

formally evaluated to determine whether the

superintendents have adopted the guidelines or

passed the information along to appropriate

staff. However, illness incidents associated with

applications on school property have declined to

one per year since 1993 [Thomsen 2001a].

9.1.1.3 EDUCATING THE GENERAL PUBLIC

Some PPSPs conduct broad public education

campaigns, especially when involved with surveillance of nonoccupational pesticide-related

illness and injury. These programs may be created by PPSPs on their own, but are more commonly developed as cooperative activities with

partner agencies and organizations. Campaign

elements include dissemination of written

materials (some formatted as fotonovelas) and

use of multilingual radio programs and videos. 

In addition to distributing these materials directly,

PPSPs often partner with other programs to integrate pesticide safety information into diverse

public health or educational efforts. Examples

include child safety programs through migrant

education and outreach programs for women

on environmental health. Mexican consulates

with Cultural Center programs have initiated

traveling outreach campaigns to Mexican

nationals, providing them with information

about legal and social programs in the United

States and Mexico. These efforts have integrated

information about pesticide-related illness prevention and reporting and other occupational

health issues. 

Some States have distributed educational information about proper pesticide mixing and

application through retail outlets that serve residential users. The Master Environmentalist

program, promoted through the American Lung

Association in the Northwest, addresses pesticide exposure prevention in information about

household environmental hazards [Leung et al.

1997; American Lung Association of Washington 2001; EPA 2001]. Whenever possible,

materials developed for individual educational

presentations should be preserved in a form that

allows them to be used with other audiences

(e.g., PowerPoint presentations).

9.1.2 ENGINEERING CONTROLS, MODIFICATIONS

Many types of engineering controls can be used

as interventions to prevent or mitigate exposures, some of which are briefly described here.

These controls can be voluntary or part of a regulatory intervention. All of these approaches

are methods of reducing exposure through

some form of mechanical change in the mixing,

loading, or application process. Like all mechanical systems, they are effective only if properly

maintained and the operators are trained in their

proper use and maintenance. 

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CHAPTER 9 DEVELOPING INTERVENTION STRATEGIES AND

EVALUATING SURVEILLANCE
9.1.2.1 CLOSED MIXING AND LOADING

SYSTEMS

These are effective in reducing contact between

the pesticide handler and the concentrated pesticide product. Closed systems for liquid formulations feature a probe inserted into the

pesticide container which prevents fluid from

spilling when transferring material to a spray

tank or when connecting the pesticide container to the spray application system. Another

component of closed systems are dry disconnects, which are fittings that prevent pesticide

leakage when pipes or hoses accidentally

become disconnected.

9.1.2.2 CREATIVE FORMULATIONS AND

TECHNOLOGIES

Wettable powder formulations that come in dissolvable packets can significantly reduce the

risk of pesticide exposure during the mixing

and loading process. Newer technologies

include the development of gel packs for liquid formulations. (Gel packs are water soluble

packets of a liquid pesticide that has been converted to a gel material.) Other packaging and

package opening systems combined with

application equipment are available for some

granular products. 

9.1.2.3 ENCLOSED CABS AND OTHER

PROTECTION

The use of enclosed cabs for application or for

workers responsible for flagging during aerial

applications can serve as protection against dermal exposure. Cabs that are equipped with a

ventilation system that includes a filtration

device meeting ANSI/ASAE Standard 525-2

[ANSI/ASAE 1998] can be used to protect

against inhalation exposure. This standard is

referenced in the California Code of Regulations definition of an “Enclosed cab acceptable

for respiratory protection” [California Code of

Regulations 2002]. Specific performance criteria

for ventilation systems in enclosed cabs appear

in the EPA WPS [40 CFR Part 170.240(d)(5)].

Use of splash guards on mixing tanks may also

reduce the potential for exposures. 

9.1.2.4 APPLICATION AND EQUIPMENT

MODIFICATIONS

Switching from hand application methods such

as backpack or hand-held sprayer to powered

spray equipment may reduce exposures. So

may other modifications to material handling

equipment, workstations, and ventilation in nurseries, packing sheds, greenhouses, and enclosed

operations. Pesticide manufacturing and reformulation activities are also well suited to engineering controls to reduce worker exposure.

9.1.3 ADMINISTRATIVE CONTROLS

AND REGULATORY CHANGES

The most desirable control is to substitute an

equally effective but nontoxic control mechanism. Regrettably these are often not available.

Collaboration with partners who are specialists

in IPM may identify approaches that allow use

of a less toxic compound or less frequent use of

a more toxic compound. Additionally, workers

can be rotated to reduce exposure to toxic

chemicals that must be used. 

Surveillance data may indicate that reentry

intervals are inadequate for a particular pesticide in relation to a certain crop or other local

conditions. Further evaluation may then lead to

changes in reentry intervals. Periodic biological

monitoring of workers is another method to help

ensure that they are not overexposed to pesticides. The effectiveness of this intervention in

reducing exposures and illness has not been

well studied, however [Keifer 2000; Fillmore

and Lessenger 1993]. It is not required in most

States, the main exceptions being California

and Washington State where cholinesterase

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CHAPTER 9 DEVELOPING INTERVENTION STRATEGIES AND

EVALUATING SURVEILLANCE
monitoring is required for some agricultural

workers.

9.1.4 EXAMPLES OF

INTERVENTIONS

Following are examples of interventions that

were developed by PPSPs to resolve emerging

pesticide problems.

9.1.4.1 AUTOMATIC INSECTICIDE

DISPENSERS

In May 1999, the Florida Pesticide Illness Surveillance Program (PISP) identified an exposure event resulting from a restaurant’s

improperly placed automatic insecticide dispenser. Three persons developed illness associated with exposure to pyrethrin and piperonyl

butoxide. Restaurants and other businesses use

the dispensers to control indoor flying insects,

usually placing them near entrances where they

periodically spray pyrethrins or pyrethroids.

After the PISP investigated the exposure incident, they contacted CDC/NIOSH, where surveillance data were reviewed to determine

whether additional cases of illnesses were associated with automatic insecticide dispensers.

Data were supplied by the Toxic Exposure Surveillance System of AAPCC, the Montana DA,

the National Pesticide Telecommunication Network (now NPIC), the CDPR-PISP, and the

Washington Department of Health PPSP.**

The review identified 97 cases of pesticiderelated illness associated with these devices

from 1986 through 1999. Three cases involved

exposure to resmethrin; the rest involved the

combination of pyrethrin and piperonyl butoxide.

Fifty-five (57%) cases were work-related.

Exposures were associated with dispensers

placed too close to patron and workstation

areas, dispensers placed in areas where pesticides were entrained in room air flow, and dispensers serviced by persons unfamiliar with

them [CDC 2000]. 

This marked the first time pesticide-related illnesses attributable to automatic insecticide dispensing devices had been documented, and it

brought the issue to the attention of public

health officials, consumer groups, and the EPA.

The report recommended nonchemical alternatives to control flying insects plus recommendations for proper installation and warning

stickers whenever automatic insecticide dispensers are used. EPA has requested that the

registrants of these products respond to CDC

recommendations for use modification and

warning labels. 

9.1.4.2 MEVINPHOS

Mevinphos is a highly toxic organophosphate

insecticide that is readily absorbed through the

skin [Formoli et al. 1994]. Its high volatility at

normal farm field temperatures also makes it a

respiratory hazard. Events that occurred in California, Washington, and Florida contributed to

the voluntary cancellation of this pesticide in

1995. In 1978, California instituted requirements for closed mixing and loading systems

for mevinphos. Despite these requirements,

between 1982 and 1989, there were 112 cases

associated with mevinphos alone, plus another

466 cases associated with tank mixes that

included mevinphos. Sixty-eight (12.6%) of the

578 cases were hospitalized. Health officials

determined that a potential of exposure from

small spills and inhalation still existed even

with the use of closed mixing and loading systems [Formoli et al. 1994]. There were additional

concerns that using PPE in hot environments

could lead to heat-related illness, and even shortterm removal of a respirator between loading

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CHAPTER 9 DEVELOPING INTERVENTION STRATEGIES AND

EVALUATING SURVEILLANCE

_______________

**Data from the first three sources were supplied

through the EPA.
operations could result in exposures when

working with this highly volatile compound. 

In 1993, mevinphos was used in Washington

State to address an infestation of aphids in

apple and pear orchards. Phosphamidon, the

chemical once commonly used to manage this

pest, had been discontinued by the manufacturers. The Washington State DA (WSDA) issued

emergency rules on the use of mevinphos with

restrictions based on input from the manufacturer. These emergency rules included requirements for a 96-hour restricted entry period

(increased from 48 hours), limits on the temperature at time of application, prohibition of

hand application, and requirements for an

observer during mixing and loading operations.

As an additional requirement, the registrant

was to make available training on safe use of

the pesticide. 

Despite these precautions, 26 poisonings were

reported to the surveillance program within a

3-month period of use. Twenty-three of the

cases (88%) were involved with mixing and

loading of mevinphos, and seven of the 26

(27%) workers were hospitalized. Washington

State Department of Health (WSDOH) PPSP’s

analysis of cases revealed that 22% of cases

occurred despite compliance with all of the

safety requirements. On August 19, 1993,

WSDA required that only licensed applicators

could mix, load, or apply mevinphos, and on

August 30, 1993, they issued an emergency

order to suspend the use of Phosdrin® (mevinphos) on fruit trees. It is interesting to note that

although orchards in Oregon were also suffering from infestations of the same pest, no

reports of mevinphos poisoning were reported

during that period. Review of information from

agricultural representatives indicated that Oregon growers in the affected areas had decided

not to use mevinphos due to concerns about

toxicity and the potential for drift from ground

applications in the orchards.

The EPA had begun a data call-in to evaluate

risk reduction measures needed to protect workers

from mevinphos and four other organophosphate

insecticides. In June 1994, the EPA considered

suspending all mevinphos registrations but

received a voluntary request from the only registrant to cancel all US registrations. The cancellation was granted and effective July 1, 1994, and

later amended to extend the date to November 30,

1995 [EPA 2000b].

In this example, surveillance data were used to

develop a regulation-mandated engineering control combined with administrative controls

requiring protective equipment and procedures.

Despite these changes, serious poisonings continued to occur. Prompt regulatory action prevented many additional cases. Data from California,

additional information from Washington, and a

report of field worker poisonings in Florida

[Baer and Penzell 1993] all contributed to

EPA’s understanding of the hazards posed by

this chemical. This information was taken into

account as the chemical went through the reregistration process resulting in its voluntary cancellation in the United States. Mevinphos continues

to be used in other countries.

9.1.4.3 BIS(TRIBUTYLTIN)OXIDE (TBTO)

PAINT ADDITIVES

This final example describes the circumstances

that led to cancellation of some uses of TBTO

because of concerns about nonoccupational

exposures. TBTO is a fungicide commonly

used as a paint additive to prevent mildew

growth. Health problems from the indoor use of

paints containing this pesticide have occurred

in Oregon [Thomsen 1997], Washington, and

Wisconsin [CDC l991]. In all three States,

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CHAPTER 9 DEVELOPING INTERVENTION STRATEGIES AND

EVALUATING SURVEILLANCE
investigations consisted of measurement and

detection of this fungicide in the indoor environment. These findings raised concerns about

acute and chronic effects of exposure and

resulted in extensive efforts to remove wall

materials or seal wall surfaces where the paint

product was used.

WSDOH investigated an unpublished case

series of six exposure incidents involving nine

symptomatic persons from 1987 through 1991

[State of Washington 1987a,b,c, 1988a,b,c,d,e,

1991]. In 1988, the WSDOH issued a health

warning about the use of the paint additive on

interior surfaces. The manufacturer of the product involved in all of the Washington cases initiated a label change in 1987 specifying that the

product should be used only for exterior applications. In July 1988, the WSDA enacted rules

that prohibited both the use of paint additives,

paints, and stains that contain tributyltin in

inhabited structures, and the registration of

products that do not clearly warn on the label

that they are not for use on interior surfaces.

With the exception of one case in 1991, no

additional cases have occurred in Washington

State. In 1992, based on the Washington investigations and a series of investigations in Oregon, the Oregon DA agreed to cancel or deny

registration of TBTO paint additive products

with labels that listed interior use, or did not

state for exterior use only, and to issue stop-sale

orders for those found to be in the channels of

commerce. There have been no reported cases

in Oregon involving use of TBTO paint additives in interior paints since 1993 [PARC 1992;

Thomsen 2001b]. 

9.2 EVALUATION OF THE

SURVEILLANCE SYSTEM

All systems should be reviewed periodically to

determine whether they are effectively meeting

objectives and carrying out activities efficiently.

Complete guidelines for evaluating surveillance

systems appear in several excellent references

[CDC 2001; Romaguera et al. 2000]. Since

these guidelines are readily available, this manual will not describe them in detail but will only

touch on a few pertinent areas. Going through a

formal evaluation of the program can highlight

areas of strengths and weaknesses in the surveillance program. This information is useful

for developing strategies for improvement.

PPSPs are urged to schedule periodic evaluations of their programs.

The evaluation process involves a structured

approach for clearly stating the goals of surveillance and determining if they are being met. If

one goal of the system is to provide an estimate

of the magnitude of pesticide-related illness

and injury, the evaluation should determine if

this goal is being met. The ability of the system

to identify new emerging problems and populations at risk and to define areas for further

research and studies are all PPSP functions that

can be examined.

Evaluating the operational aspects of the system is a helpful tool to ensure that the system is

running effectively. Operational evaluation

should examine the roles of surveillance program staff, information flow, protocols for data

collection and management, dissemination of

findings, feedback to reporting providers and

cases, and the effectiveness of interventions.

Other attributes of the surveillance system that

should be evaluated include simplicity, flexibility, data quality, acceptability, sensitivity, predictive value positive, representativeness,

timeliness, and stability. Because some attributes can conflict with other attributes (that is,

excelling in one attribute may hamper the ability to satisfy another attribute), it is important to

identify and strengthen those attributes that are

most important to a particular surveillance system. It should be recognized that it may not be

possible to fully achieve the less important

92

CHAPTER 9 DEVELOPING INTERVENTION STRATEGIES AND

EVALUATING SURVEILLANCE
attributes. Recommended approaches on how to

assess these attributes are available [CDC 2001]. 

The productivity of the surveillance system

should also be assessed. This includes determining (1) the number of investigative reports

that are issued, (2) the number of case reports

received and followed up, (3) the number of

interviews conducted, (4) the number of site

inspections performed, (5) the number of phone

consultations performed, and (6) the frequency

of summary surveillance reports. A summary of

outreach activities to stakeholders should also

be prepared (e.g., number of newsletter articles

published and the number of presentations

delivered). Having an electronic tracking system can facilitate the collection and evaluation

of this information.

Conclusions and recommendations should be

provided when evaluating a surveillance system. An assessment should be made about

whether the surveillance system should be continued (that is, can justification be made for the

resources applied to it?). If the answer is yes,

the need for any modifications to the system

should be identified. Finally, when making recommendations for modifications, it is prudent

to recall that the costs and attributes of the system are interdependent (e.g., improvements in

one attribute may increase costs or affect the

performance of another attribute). Therefore,

these consequences should be considered when

recommending modifications. An evaluation

should examine whether recommendations

made by the PPSP to prevent pesticide poisoning were implemented, or if other actions were

taken as a result of surveillance data (e.g., are

data used for generating research or interventions?). If the PPSP has an advisory committee

(see Section 5.9.3), this committee can often

contribute to the evaluation process.

9.3 CONCLUSION

The strategies and examples described in this

chapter demonstrate how surveillance data can

be used to identify new emerging pesticide

problems, and thus estimate the magnitude of

pesticide poisoning. 

Throughout this instruction guide, our goal has

been to provide tools that NIOSH partners can

use to identify pesticide poisoning risk factors

and target interventions toward them. Those

tools include

Information about the importance of pesticide poisoning surveillance 

Mechanisms to improve reporting of cases

to surveillance programs

Methods to investigate reported cases 

Guidance on using the case definition, and

Additional resources relevant to pesticide

poisoning surveillance.

They are based on the experience of public

health professionals who are directly involved

in the field. Developed over many years, these

tools can provide a strong base for any State or

local entity initiating a pesticide surveillance

program. 

It is our hope that others will continue to build

on this body of knowledge and expand on the

surveillance activities being performed today.

In particular, we look forward to a repository of

successful intervention and prevention strategies and an examination of their ability to

reduce the occurrence of pesticide related-illness

and injury. Much remains to be done in assessing the effectiveness of IPM techniques, administrative controls, and the use of low-toxicity

pesticides when nontoxic methods are impractical

or unsuccessful.

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EVALUATING SURVEILLANCE
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APPENDIX A

LISTING OF MORBIDITY AND MORTALITY WEEKLY

REPORT (MMWR) ARTICLES ON

PESTICIDE-RELATED ILLNESS AND INJURY

JANUARY 1, 1982–SEPTEMBER 30, 2004
LISTING OF MORBIDITY AND MORTALITY WEEKLY REPORT

(MMWR) ARTICLES ON PESTICIDE-RELATED ILLNESS AND

INJURY JANUARY 1, 1982–SEPTEMBER 30, 2004

Note: This listing may be incomplete; efforts were made to include all articles that addressed this

topic, but some may have been missed by the search strategy used. The list is chronological with

most recent articles listed first. Relevant Surveillance Summaries and Recommendations and

Reports are listed separately.

Illness associated with drift of chloropicrin soil fumigant into a residential area – Kern County,

California, 2003. Vol. 53, No. 32: 740–742, 8/20/2004.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5332a4.htm

Surveillance for acute insecticide-related illness associated with mosquito-control efforts—Nine

states, 1999–2002. Vol. 52, No. 27:629–634, 07/11/2003.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5227a1.htm

Nicotine poisoning after ingestion of contaminated ground beef—Michigan, 2003. Vol. 52, No.

18:413–416, 05/09/2003. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5218a3.htm

Poisoning by an illegally imported Chinese rodenticide containing tetramethylenedisulfotetramine—

New York City, 2002. Vol. 52, No. 10:199–201, 03/14/2003.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5210a4.htm

Pesticide-related illnesses associated with the use of a plant growth regulator—Italy, 2001. Vol. 50,

No. 39:845–847, 10/05/2001. http://www.cdc.gov/mmwr/PDF/wk/mm5039.pdf

Nosocomial poisoning associated with emergency department treatment of organophosphate

toxicity—Georgia, 2000. Vol. 49, No. 51:1156–1158, 01/05/2001.

http://www.cdc.gov/mmwr/PDF/wk/mm4951.pdf

Occupational fatalities associated with 2,4-Dichlorophenol (2,4-DCP) exposure, 1980–1998.

Vol. 49, No. 23:516–518, 06/16/2000. http://www.cdc.gov/mmwr/PDF/wk/mm4923.pdf

Illnesses associated with use of automatic insecticide dispenser units—selected States and United

States, 1986–1999. Vol. 49, No. 22:492–495, 6/09/2000.

http://www.cdc.gov/mmwr/PDF/wk/mm4922.pdf

Surveillance for acute pesticide-related illness during the Medfly Eradication Program—Florida,

1998. Vol. 48, No. 44:1015–1018, 1027, 11/12/1999.

http://www.cdc.gov/mmwr/PDF/wk/mm4844.pdf

105

APPENDIX A 
Illnesses associated with occupational use of flea-control products—California, Texas, and

Washington, 1989–1997. Vol. 48, No. 21:443–447, 06/04/1999.

http://www.cdc.gov/mmwr/PDF/wk/mm4821.pdf

Aldicarb as a cause of food poisoning—Louisiana, 1998. Vol. 48, No. 13:269–271, 04/09/1999.

http://www.cdc.gov/mmwr/PDF/wk/mm4813.pdf

Outbreaks of gastrointestinal illness of unknown etiology associated with eating burritos— United

States, October 1997–October 1998. Vol. 48, No. 10:210–213, 03/19/1999.

http://www.cdc.gov/mmwr/PDF/wk/mm4810.pdf

Farmworker illness following exposure to carbofuran and other pesticides. Vol. 48, No. 06:113–116,

02/19/1999. http://www.cdc.gov/mmwr/PDF/wk/mm4806.pdf

Monitoring environmental disease—United States, 1997. Vol. 47, No. 25:522–525, 07/03/1998.

http://www.cdc.gov/mmwr/PDF/wk/mm4725.pdf

Poisonings associated with illegal use of aldicarb as a rodenticide—New York City, 1994–1997.

Vol. 46, No. 41:961–963, 10/17/1997. http://www.cdc.gov/mmwr/PDF/wk/mm4641.pdf

Acute pesticide poisoning associated with use of a sulfotepp fumigant. Vol. 45, No. 36:780–782,

09/13/1996. http://www.cdc.gov/mmwr/PDF/wk/mm4536.pdf

Pentachlorophenol poisoning in newborn infants—St. Louis, Missouri, April-August 1967. Vol. 45, 

No. 25:545–549, 06/28/1996. http://www.cdc.gov/mmwr/PDF/wk/mm4525.pdf

Eye injuries to agricultural workers—Minnesota, 1992–1993. Vol. 44, No. 18:364–366, 05/12/1995.

Deaths associated with exposure to fumigants in railroad cars—United States. Vol. 43, No.

27:489–491, 07/15/1994. http://www.cdc.gov/mmwr/PDF/wk/mm4327.pdf.

Occupational pesticide poisoning in apple orchards—Washington, 1993. Vol. 42, No. 51:993–995,

01/07/1994. http://www.cdc.gov/mmwr/PDF/wk/mm4251.pdf

Acute effect of indoor exposure to paint containing bis(tributyltin)oxide—Wisconsin, 1991. Vol. 40,

No. 17:280–281, 05/ 03/1991.

Unintentional methyl bromide gas release—Florida, 1988. Vol. 38, No. 51:880-882, 01/05/1990.

Mercury exposure from interior latex paint—Michigan. Vol. 39, No. 8:125–126, 03/02/1990.

Endrin poisoning associated with taquito ingestion—California. Vol. 38, No. 19:345–347,

05/19/1989.

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APPENDIX A 

Organophosphate toxicity associated with flea-dip products—California. Vol. 37, No. 21:329–330,

335–336, 06/03/1988.

Serum 2,3,7,8-Tetrachlorodibenzo-p-dioxin levels in air force health study participants—

Preliminary Report. Vol. 37, No. 20:309–311, 05/27/1988.

Fatalities resulting from sulfuryl fluoride exposure after home fumigation—Virginia. Vol. 36, No.

36:602–604, 609–611, 09/18/1987. 

Serum dioxin in Vietnam-Era Veterans—Preliminary Report. Vol. 36, No. 28:470–475, 07/24/1987. 

Current trends postservice mortality among Vietnam Veterans. Vol. 36, No. 05:61–64, 02/13/1987. 

Aldicarb food poisoning from contaminated watermelons—California. Vol. 35, No. 16:254–258,

04/25/1986. 

Acute poisoning following exposure to an agricultural insecticide—California. Vol. 34, No.

30:464–466, 471, 08/02/1985.

Neurologic findings among workers exposed to fenthion in a veterinary hospital—Georgia. Vol. 34,

No. 26:402–403, 07/05/1985.

Vietnam Veterans’ risks for fathering babies with birth defects. Vol. 33, No. 32:457–459, 08/17/1984.

Organophosphate insecticide poisoning among siblings—Mississippi. Vol. 33, No. 42:592–594,

10/26/1984. 

DDT exposures in a natural history museum—Colorado. Vol. 32, No. 34:443–444, 09/02/1983. 

Arsenic contamination in an abandoned building—Ohio. Vol. 31, No. 39:531–532, 10/08/1982. 

Surveillance Summaries

Surveillance for emergency events involving hazardous substances—U.S., 1990–1992. Vol. 43, 

No. SS-2, 07/22/1994. http://www.cdc.gov/mmwr/PDF/SS/SS4302.pdf

Surveillance for occupational asthma—Michigan and New Jersey, 1988–1992. Vol. 43, 

No. SS-1:9-16, 06/10/1994. http://www.cdc.gov/mmwr/PDF/SS/SS4301.pdf

Recommendations and Reports

Diagnosis and management of foodborne illnesses a primer for physicians. Vol. 50, No. RR-2,

01/26/2001.

107
Biological and chemical terrorism: strategic plan for preparedness and response. Vol. 49, No. RR-4,

04/21/2000. http://www.cdc.gov/mmwr/PDF/RR/RR4904.pdf

Recommended framework for presenting injury mortality data. Vol. 46, No. RR-14:1, 08/29/1997.

http://www.cdc.gov/mmwr/PDF/RR/RR4614.pdf

Mandatory reporting of occupational diseases by clinicians. Vol. 39, No. RR-9:019, 06/22/1990. 

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APPENDIX B

SELECTED PESTICIDE ILLNESS REPORTING

STATUTES AND RULES
SELECTED PESTICIDE ILLNESS REPORTING STATUTES AND

RULES

Note: This list was current as of September 30, 2004. The list is not a comprehensive list of all applicable State reporting rule links but is intended to supply links to a rule or statute that may be of particular interest. 

ARIZONA

http://www.azhs.gov. This page has a link to the reporting statute and rule.

CALIFORNIA

http://www.leginfo.ca.gov/cgi-bin/calawquery?codesection=hsc.

Sections 105200–105225 of the health and safety code relate to pesticide illness reporting.

MICHIGAN

http://www.legislature.mi.gov/mileg.asp?page=getObject&objName=mcl-368-1978-5-56&highlight.

MISSOURI

http://www.sos.mo.gov/adrules/csr/current/19csr/19c20-20.pdf. 

NEW MEXICO

http://www.nmcpr.state.nm.us/nmac/_title07/T07C004.htm.

Browse to Control of disease and conditions of public health significance.

NEW JERSEY

http://www.state.nj.us/health/eoh/survweb/.

Browse to occupational disease reporting requirements.

NEW YORK

http://www.health.state.ny.us/nysdoh/environ/pest/appenda.htm.

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OREGON

http://www.leg.state.or.us/ors/433.html.

Browse to Chapter 433.004.

TEXAS

http://lamb.sos.state.tx.us/tac/index.html.

This is a link to the Texas administrative code. Enter the TAC Viewer and select Title 25—Health

Services, Part 1, Chapter 99—Occupational Diseases.

http://www.capitol.state.tx.us/statutes/statutes.html.

This link connects you with the Texas statutes. Select Health and Safety Code; search for Chapter 84—

Reporting of Occupational Conditions.

WASHINGTON

http://search.leg.wa.gov/pub/textsearch/default.asp.

The Washington law establishing the Pesticide Incident Response and Tracking (PIRT) Board is at

this site. Seach for RCW 70.104, after checking the RCW & Depositions box.

The current reporting rules can be found by searching for WAC 246 after checking the WAC box.

Pesticide poisoning is listed as one of the notifiable conditions in Chapter 246-101.

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APPENDIX C

SAMPLE FORMS, INVESTIGATION TOOLS, AND

TEMPLATES FOR DATA TABLES
SAMPLE FORMS, INVESTIGATION TOOLS, AND TEMPLATES FOR

DATA TABLES

CONTENTS

C.1 Case Tracking Form and Contact Log

C.2 Main Pesticide Exposure Questionnaire

C.3 Pesticide Illness and Injury Surveillance Data Collection Form

C.4 Field Investigation Contact Form and Health Safety Checklist for Field Personnel

C.5 Instructions for National Transportation Safety Board (NTSB) Search to Obtain Reports of

Airplane Accidents Involving Aerial Pesticide Applicators

C.6 Sample Templates for Tables Presenting Surveillance Data

C.7 Sample Letters for PPSP Case Follow-up

C.8 Instructions for Obtaining Acute Pesticide-Related Illnesses and Injuries data from Poison

Control Centers (PCC)

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C.1 CASE TRACKING FORM AND CONTACT LOG

These two forms are examples of mechanisms that PPSPs can use to track the case follow-up process

to ensure that all needed information is collected and that appropriate referrals and agency contacts are

made. As noted in Chapter 5, the program should determine if it wants to log and track informational

calls and/or reports that are screened out as unrelated to pesticide exposure. The tracking checklist

form included here does not include informational calls but could be adapted to do so. The procedures

used for any tracking system should be documented in a procedure manual. The contact log is a tool

for recording names of individuals and the dates they were contacted as part of the follow-up investigation process. The comments should be supplemented with additional records of conversation pertinent to the investigation. The forms can be useful tools to review timeliness and completeness of the

investigation process.

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PESTICIDE EXPOSURE QUESTIONNAIRE

C.2 MAIN PESTICIDE EXPOSURE QUESTIONNAIRE

INSTRUCTIONS

This is a sample questionnaire for use by an acute pesticide-related illness and injury surveillance program. It includes questions that satisfy the data requirements for all of the core variables needed by the

National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and

Prevention (CDC). Additional questions for administrative report management at the State level, as

well as optional suggested questions, are included. Optional questions are indicated on the form by

framing with a dashed border. The order of the questions is designed to provide ease of data collection

as well as data entry using the SENSOR Pesticide Incident Data Entry and Reporting (SPIDER) data

management software. Shading on pages 1-17 indicates data to be completed by the interviewer and

not asked during the actual interview. Pages 18-21 are to be completed following the initial interview as

additional medical information is collected and case closure is completed. States will need to customize

this questionnaire for their specific needs. Some States may choose to develop separate questionnaires

for agricultural, occupational, nonoccupational, physician, or non-English speaker interviews. The

design presented here is not appropriate for interviewing non-English speaking farmworkers. An example of a Spanish language questionnaire specific to agriculture situations can be obtained from the

California DHS SENSOR Pesticide Poisoning California (SPPC) Program (510-620-5757 or

http://www.dhs.ca.gov/ohb/AgInjury/).
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DATA COLLECTION FORM

C.3 PESTICIDE ILLNESS AND INJURY SURVEILLANCE

DATA COLLECTION FORM

INSTRUCTIONS

This is a sample data collection form for use by an acute pesticide-related illness and injury surveillance program. This form is for States that choose not to use a standard questionnaire but collect data

via an open-ended interview. The form includes fields that satisfy data requirements for all of the core

variables needed by the National Institute for Occupational Safety and Health (NIOSH), Centers for

Disease Control and Prevention (CDC). Fields needed for administrative report management at the

State level, as well as optional suggested variables are also included. Optional items are indicated on

the form by framing with a dotted-line border. The order of the fields is designed to provide ease of

data collection as well as data entry using the SENSOR Pesticide Incident Data Entry and Reporting

(SPIDER) data management software. Shading indicates items that are to be completed by the interviewer and not asked during the actual exposed individual or attending health care professional (HCP)

interview. The form contains fields for information that may be collected from the exposed individual,

and additional medical and pesticide product information collected from record reviews or additional

interviews. States will need to customize this data collection form for their specific needs.
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c

Rev. 8/10/04 

Activity of case at time of exposure (Enter code)

01 Applying pesticide 

02 Mixing/loading pesticide 

03 Transport or disposal of pesticide 

04 Repair or maintenance of pesticide application equipment 

05 Any combination of activities 01–04 

06 Involved in manufacture or formulation of pesticide 

07 Emergency response 

08 Routine work activity not involved with pesti ide application (includes exposure to field residue) 

09 Routine indoor living activities not involved with pesticide application 

10 Routine outdoor living activities not involved with pesticide application 

98 Not applicable 

99 Unknown 

Others exposed 

Were other persons possibly exposed? Yes No Unknown 

If Yes, How many? ___________ 

Did any seek medical care? Yes No Unknown 

Use a separate sheet of paper to record names and contact information if appropriate. 

Exposure address (That is, subject’s location at time of exposure. This may be the same as 

the case address or the event address.) 

Address 1 _________________________________________________________

Address 2 _________________________________________________________

City _________________________________________________________

State __ __ ZIP __ __ __ __ __

FIPS __ __ __ County __ __ __

County name ____________________________________ 

Note: For cases reported multiple times, you can use the shortcut buttons in SPIDER to either copy the existing 

address from the case table, or if this is a new address, move this address to the case table. 

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C.4 FIELD INVESTIGATION CONTACT FORM AND

HEALTH SAFETY CHECKLIST FOR FIELD PERSONNEL

The following checklist is designed to remind field staff about equipment and safety precautions they

need to take when embarking on a field investigation or any form of on-site follow-up. It also ensures

that supervisory staff have appropriate contact information for field staff. In addition, PPSPs may

decide to use this form when staff are accompanying partner enforcement agency staff. The checklist

is to be completed by PPSP personnel BEFORE going out into the field. For team visits, only the team

leader is required to complete the form. Team leaders are responsible for ensuring that all team members meet the required checklist items stated below. As with all of the sample forms, this form should

be modified to meet the specific needs of the PPSP.

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C.5 INSTRUCTIONS FOR NATIONAL TRANSPORTATION SAFETY

BOARD (NTSB) SEARCH TO OBTAIN REPORTS OF

AIRPLANE ACCIDENTS INVOLVING AERIAL PESTICIDE

APPLICATORS

NTSB maintains data on aviation accidents. The Aviation Synopses can be searched for information

about aviation accidents involving aerial agricultural applications. These applications are covered by

14 CFR Part 137. The synopses may be reviewed by searching monthly lists of accidents or performing a query. Make sure your browser is set to accept cookies. 

Go to the NTSB website http://www.ntsb.gov/NTSB/query.asp.

The first item on the list is a Database Query. First, look at the general instructions for searching, then

select the Database Query form. Complete the various fields. This includes entering the date range

you are interested in, selecting your State, severity, and a specific category of aircraft (if you are

searching for a particular accident or type of accident). You can leave the Operation category as All.

In the area labeled Enter your word string below, type 137. Choose Sort by Date Ascending unless you

want to sort on an option other than date. Click on Submit Query. This search strategy should catch all

of the agricultural accidents (since applications are regulated by 14 CFR Part 137).
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C.6 SAMPLE TEMPLATES FOR TABLES PRESENTING

SURVEILLANCE DATA
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C.7 SAMPLE LETTERS FOR PPSP CASE FOLLOW-UP

The following sample letters are provided as templates that PPSPs can modify to meet their specific

needs and legal requirements.

• Thank-you letter to an HCP who reports a case

• A request for cooperation to an HCP who failed to report a case

• A request to an HCP for medical records

• A letter to an employer regarding an upcoming site inspection
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THANK-YOU LETTER TO HCP WHO REPORTED CASE

[Agency Letterhead]

DATE

INSIDE ADDRESS

Re: [case number]

Dear [insert HCP name]:

Thank you for the information you recently provided regarding the illness and possible pesticide exposure of [insert patient name]. Your report helps us to identify pesticide products and practices that

may affect public health, as well as provide exposure prevention information to affected individuals.

If you would like further information about this case, the [insert agency name] [insert surveillance

program name], or other State agency resources, please call me at [insert phone number].

[Option—include a copy of the EPA Recognition and Management of Pesticide Poisonings]

Sincerely,
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APPENDIX C SECTION 7

REQUEST FOR COOPERATION LETTER TO HCP WHO FAILED TO REPORT CASE

[Agency Letterhead]

DATE

INSIDE ADDRESS

Re: [patient] Case number:

Dear [insert HCP name]:

The [insert agency name] is currently investigating a reported pesticide-related illness of your abovenamed patient. (We have been in touch with a member of your staff regarding the observable signs,

diagnosis, and treatment of the individual.) The [surveillance program name] routinely identifies and

investigates illnesses and injuries associated with pesticide exposure.

Suspected pesticide poisoning is a reportable condition in the [insert State name]. Health care

providers are required by [insert rule reference] to report acute or subacute conditions that are caused

by, or suspected of being caused by, pesticide exposure. All medical details and the person’s identity

are kept confidential. Resources and referrals are available to the reporting provider and the patient,

including exposure prevention information.

Your report helps us identify pesticide products or practices that may affect public health. Your cooperation in reporting any future pesticide-related illnesses is appreciated. If you would like further

information about the program, please contact us at [insert phone number]. [Option—include a

copy of the EPA Recognition and Management of Pesticide Poisonings.]

Sincerely,
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APPENDIX C SECTION 7

MEDICAL RECORDS REQUEST LETTER

[Agency Letterhead]

DATE

INSIDE ADDRESS

Re: [case number]

Dear [insert HCP name]:

This letter is sent by [agency name (agency abbreviation)] to request medical records relevant to illness investigations conducted by the [agency abbrev.]. The [agency] collects medical records in

accordance with State law. Copies of relevant sections of State code are attached for your convenience.

The [agency] has received a notice of pesticide-related illness involving the patient listed below and

requests copies of any medical information (including chart notes and laboratory test results) that you

might have.

[First name Last name, SSN, DOB; injured on: date; seen on: date]

Please also check your records for any information you have on other patients seen on the same date,

or within several days before or after, who may have a pesticide-related illness or injury associated

with the same exposure incident. Please provide copies of any such records to the [agency].

Please mail or fax these records to the return address indicated above. If you have any questions, please call

me at [insert phone number]. Thank you for your cooperation in providing the requested information.

Note that the [agency name] is an agency of [parent authority, e.g., the State of _____ ] and is conducting pesticide poisoning surveillance in its capacity as a public health authority as defined by the

Health Insurance Portability and Accountability Act (HIPAA), Standards for Privacy of Individually

Identifiable Health Information; Final Rule (Privacy Rule) [45 CFR 164.501]. Persuant to 45 CFR

164.512(b) of the Privacy Rule, covered entities such as your organization may disclose, without individual authorization, protected health information to public health authorities “. . .authorized by law to

collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, including, but not limited to, the reporting of disease, injury, vital events such as birth or death,

and the conduct of public health surveillance, public health investigations, and public health interventions . . .” The information being requested represents the minimum necessary to carry out the public

health purposes of pesticide poisoning surveillance pursuant to 45 CFR 164.514(d) of the Privacy Rule.

Sincerely, 
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APPENDIX C SECTION 7

LETTER TO EMPLOYER REGARDING AN UPCOMING SITE INSPECTION

[Agency Letterhead]

DATE

INSIDE ADDRESS

Re: Site inspection scheduled for [date] 

Dear [name]:

Thank you for your cooperation with the [agency name] investigation of illness reports among

employees at [company name]. We are writing to confirm our meeting and to provide you with logistical and other information about our investigation. The meeting will take place at [insert location]. 

Based on phone conversations with [person’s name (date)], it is our understanding that the following

persons will be present at the meeting: [names and titles]. In addition to ourselves, [list any additional names and titles] working with [agency and program name] on pesticide illness tracking will also

attend our meeting.

Background: [agency] is mandated to investigate the causes of morbidity and mortality from workinduced diseases and develop recommendations for improved control of work-induced diseases [code

reference] [Modify sentence as needed to reflect agencies’ authority]. In contrast to [State] -

OSHA, [program name] is not an enforcement agency, and we do not issue citations. [agency] initiated this investigation in response to physician reports of illness among [worker types] potentially

exposed to pesticides as a result of [work activity or task]. Between [dates], [agency] received

[insert number] incident reports involving a total of [insert number] workers. [Give reason there is

concern about the reports.]

Purpose: The purpose of our on-site field investigation on [date] is to gather information and make

observations about [activity] practices at [company name].

Process: The process for the [date] site visit will be an opening conference for introductions, a review

of the purpose, scope, and methodology of our investigation, and an opportunity for company and

worker representatives to ask us questions. We will then conduct an on-site observation of [process,

site, or activity]. We will walk through the [facility type], at which time we will ask [company name]

representatives to provide a detailed explanation of the pesticide application process including local

ventilation conditions at the time of the application. We will ask worker representatives for their

knowledge of the process as well. We will take photographs. The site visit will end with a closing conference at which time we will summarize our progress in the investigation and answer any additional

questions you may have. We anticipate that the site visit will take about four hours (assuming that we

will have received much of the information/documentation about the application from [company

name] prior to the site visit).
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APPENDIX C SECTION 7

Scope: The scope of [agency] investigation is limited to [describe scope]. The limited nature of

[agency name’s] investigation does not imply there are, or are not, other safety and health issues at the

workplace. 

Methodology: [agency name] will evaluate and classify [worker or specific worker job type] illness

reports according to criteria established by the National Institute for Occupational Safety and Health

(NIOSH). Enclosed is a copy of these criteria. They are also available at http://www.cdc.gov/niosh

/pestsurv/pdfs/pest-casdef2000.pdf. Worker exposure to pesticides will be assessed utilizing data from

(1) interviews with employees, employee representatives, and employer representatives; (2) work-site

observations and interviews with company and employee representatives regarding the work process,

tasks, and exposure control measures; (3) review of medical records, policy and procedures, and other

written materials; and (4) a review of the relevant scientific literature. [Agency] will attempt to conduct

a voluntary interview with all workers with a reported illness at the worker’s home by phone.

Employer interviews will be conducted at the work-site and by phone as needed.

Exposure control measures will be evaluated according to the presence, use, and efficacy of standard

industrial hygiene hierarchy of controls (i.e., engineering, administration, and personal protection).

Recommendations to prevent illness will be based on a public health approach; i.e., primary, secondary, and tertiary measures. To the extent possible, it is normal practice for [agency] to direct each of

our recommendations to the persons or groups that have the authority to implement change. 

Our investigation will be conducted independently of regulatory agencies. However, if while at a

workplace, we observe a condition that could reasonably be expected to cause death or serious physical harm immediately (that is, an imminent hazard), we are obliged to notify the employer and affected

workers of the hazard and to notify [State name]-OSHA and/or other appropriate agencies. In practice, circumstances that would require a referral to an enforcement agency have almost never been

encountered by [agency] investigators. The investigation may not identify all hazards or violations of

good practice within the scope of the practices reviewed Allowing [agency] to conduct the investigation and/or following recommendations made in the investigation report will not exempt [company

name] or the worksite from an enforcement inspection or regulatory compliance.

At a minimum, all of [agency’s] findings and recommendations to prevent illness will be reported in

writing in a timely manner to the incident cases, reporting physicians, employee representatives, and

[company name]. Publications may also be disseminated to other interested parties, such as health

and safety professionals, industry-based organizations, government agencies, and labor unions. Our

report will not contain any personal-identifying information about individual workers. Although not

confidential information, our publications for general distribution do not usually specify the name of

the employer. 

Specific information we are seeking from [company name]: In order to make the best use of your time

during our site visit, we are providing you with a list of the questions and information we will request

from [company]. We will also have additional questions based on what we learn from you. All of the

information requested below relates to the time period covered by the scope of this investigation

([date range]), except where otherwise indicated.
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APPENDIX C SECTION 7

[list questions]

We have tried to compile a comprehensive list of questions and sources of information that are relevant to this investigation. However, it is likely that we have omitted something. Please do not hesitate

to provide any other data that you are aware of that may be useful in understanding the work process

of [process, site, or activity being investigated]. Also, please note if certain data are not available, as

it is important for us to understand where there may be gaps in data. 

We appreciate your time and participation in the [agency] investigation. It is our goal that the information collected will contribute to our ability to determine the severity and extent of the potential problem and identify possible causes and solutions. Please contact [name] by e-mail ([e-mail address]) or

phone ( [phone number] ) if you have any questions. We look forward to meeting you on [date].

Sincerely,

cc:

Enclosures
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APPENDIX C SECTION 8

C.8 INSTRUCTIONS FOR OBTAINING ACUTE PESTICIDE- RELATED ILLNESS AND INJURY REPORTS FROM POISON

CONTROL CENTERS (PCCS)

A. Obtaining the annual number of incident cases 

1. Contact your local PCC. Contact information can be obtained from the American 

Association of Poison Control Centers at http://www.aapcc.org/director2.htm. Some States 

have more than one PCC.

2. Include in-State residents and those of unknown residence.

3. Determine if the PCC uses the Toxicall® data system. 

a. If YES, go to step A.4.

b. If NO, go to step A.5.

4. If the PCC uses Toxicall®, ask the PCC to run Report 57.

a. To obtain occupational cases only: Cases should either have reason for the call 

(ExpReason) = 3 (occupational) OR exposure site (ExpSite) = 3 (workplace). 

b. To obtain all acute pesticide-related illnesses and injuries: Neither ExpReason nor 

ExpSite need to be specified.

c. To calculate incidence rates, go to B. Estimating the Total Population at Risk 

(denominator).

5. If the PCC does not use Toxicall® or if it cannot generate Report 57, determine if the 

PCC will provide a data set of all received calls.

a. If YES, go to Step A.6.

b. If NO, go to Step A.7.

6. If the PCC can provide a data set of all received calls, query the data set to identify cases 

that meet the following criteria: 

a. Exposure to an agent included in one of the pesticide generic categories 

(SubGenricCode) =

Disinfectants

0201008 disinfectant industrial cleaner

0201055 bromine water/shock treatment

0201056 chlorine water/shock treatment

0042281 hypochlorite disinfectant: hypochlorite, non-bleach product

0040280 phenol disinfectant: phenol (e.g., Lysol)

0039282 pine oil disinfectant 

0077286 other/unknown disinfectant:
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APPENDIX C SECTION 8

Fungicides (nonmedicinal)

0243566 carbamate fungicide

0201033 copper compound fungicide

0077564 mercurial fungicide

0077565 non-mercurial (inactive) fungicide 

0253000 phthalimide fungicide

0254371 wood preservative

0077566 other/unknown (inactive) nonmedicinal fungicide

0201034 other nonmedicinal fungicide

0201035 unknown nonmedicinal fungicide

Fumigants

0201036 aluminum phosphide fumigant

0201037 metam sodium (fumigant, fungicide, or herbicide)

0201038 methyl bromide (fumigant, fungicide, or herbicide)

0201039 sulfuryl fluoride fumigant

0201040 other fumigant

0201041 unknown fumigant

Herbicides (includes algicides, defoliants, dessicants, plant growth regulators)

0201054 algicide

0254370 anti-algae paint

0243561 carbamate herbicide

0017000 2,4-d or 2,4,5-t (inactive)

0201042 chlorophenoxy herbicide

0049562 diquat

0201043 glyphosate 

0049000 paraquat

0049561 paraquat/diquat combination

0077121 plant hormone

0213000 triazine herbicide

0215000 urea herbicide

0077561 other herbicide

0077567 unknown herbicide

Insecticides (includes insect growth regulators, molluscicides, nematicides)

0004562 arsenic pesticide

0062562 borate/boric acid pesticide

0070000 carbamate only (alone)

0070560 carbamate with other insecticide 

0050000 chlorinated hydrocarbon only (alone)

0050560 chlorinated hydrocarbon with other insecticide

0201044 insect growth regulator
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APPENDIX C SECTION 8

0172000 metaldehyde (molluscicide)

0208562 nicotine (excluding tobacco products)

0038000 organophosphate

0038560 organophosphate/carbamate combined

0038561 organophosphate/chlorinated hydrocarbon (inactive)

0038562 organophosphate/other insecticide 

0038563 organophosphate/carbamate/chlorinated hydrocarbon (inactive)

0176000 piperonyl butoxide only (inactive)

0144000 piperonyl butoxide/pyrethrin (inactive) (without carbamate or o.p.)

0144001 pyrethrins only (inactive) 

0201045 pyrethrin

0201046 pyrethroid

0145000 rotenone

0077568 veterinary insecticide (inactive) (for pets—flea collars, etc.)

0077562 other insecticide

0077569 unknown insecticide

Repellents

0201047 bird, dog, deer, or other mammal repellent

0201048 insect repellent with DEET

0201049 insect repellent without DEET

0218000 insect repellent: unknown (inactive) 

0033000 naphthalene moth repellent

0050430 paradichlorobenzene moth repellent

0077431 other mothball or moth repellent

0077430 unknown mothball or moth repellent

Rodenticides

0174000 antu

0048563 anticoagulant: warfarin-type anticoagulant rodenticide

0048564 anticoagulant: long-acting, superwarfarin anticoagulant rodenticide

0244577 barium carbonate barium carbonate containing rodenticides

0201050 bromethalin

0201051 cholecalciferol rodenticide

0012563 cyanide rodenticide (excluding industrial or misc. chemical)

0162000 monofluoroacetate 1080/monofluoroacetate/smfa

0043000 strychnine rodenticide

0197000 vacor/pnu

0201052 zinc phosphide

0217000 thallium

0077563 other rodenticide

0077577 unknown rodenticide
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APPENDIX C SECTION 8

b. Medical outcome (MedicalOutcome) is coded into one of the following values: 

201=minor effect 

202=moderate effect 

203=major effect 

204=death

206=not followed, minimal clinical effects possible 

207=unable to follow, judged as a potentially toxic exposure 

c. Request specific values for ExpReason and ExpSite, if needed.

(1) To obtain occupational cases only: Cases should either have reason for the call 

(ExpReason) = 3 (occupational) OR exposure site (ExpSite) = 3 (workplace).

(2) To obtain all acute pesticide-related illnesses and injuries: Neither ExpReason nor 

ExpSite need to be specified.

7. Using the case number, delete any duplicate cases.

8. Tally the total number of cases that meet the criteria.

9. If interested in calculating an incidence rate, go to B. Estimating the Total Population at 

Risk (denominator). 

10. If the PCC will not provide a data set:

a. Ask the PCC to tally the number of cases that meet the criteria in A.6.a through A.6.d.

b. If interested in calculating a rate, go to “B. Estimating the Total Population at Risk 

(denominator).”

B. Estimating the Total Population at Risk (denominator for rate calculations) 

1. Determine whether the rate is for acute occupational pesticide-related illness and injury, or 

for all acute pesticide-related illness and injury.

a. If for acute occupational pesticide-related illness and injury, go to B.2.

b. If for all acute pesticide-related illnesses and injuries, go to B.3.

2. To obtain the denominator for an occupational case rate:

a. Go to Current Population Statistics: http://www.bls.gov/opub/gp/laugp.htm.

b. Select Section II: Estimate for States.

c. Select Table 12. Employment status of the civilian noninstitutional population by sex,

age, race, and Hispanic origin.

d. Find your State from the first column.

e. Read the Total row for your State and the 4th column—Employment Number. This 

is the Number of Employer Persons 16 years of age or older (in thousands). 

Multiply by 1000.

f. Go to C. Calculating the annual incidence rate.
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APPENDIX C SECTION 8

3. To obtain the denominator for the total population case rate:

a. Use the US Census standard population. The most recent figures can be found 

at http://quickfacts.census.gov/qfd/index.html.

b. After selecting your State, total population estimates will be provided. 

c. Go to C. Calculating the annual incidence rate.

C. Calculating the annual incidence rate

1. Divide the numerator (A) by the denominator (B).

2. Multiply this result by 100,000 to get the annual rate per 100,000 persons.
APPENDIX D

CASE DEFINITION FOR ACUTE PESTICIDE-RELATED

ILLNESS AND INJURY CASES

REPORTABLE TO THE NATIONAL PUBLIC HEALTH

SURVEILLANCE SYSTEM
CASE DEFINITION FOR ACUTE PESTICIDE-RELATED ILLNESS

AND INJURY CASES REPORTABLE TO THE NATIONAL PUBLIC

HEALTH SURVEILLANCE SYSTEM

Contents:

D.1 Clinical Description

D.2 Laboratory Criteria for Diagnosis

D.3 Classification Criteria

D.4 Contacts for Additional Information

D.5 Frequently Asked Questions (FAQs)

D.6 Characteristic Signs and Symptoms for Several Pesticide Active Ingredients and Classes of

Pesticides

D.7 Glossary of Terms

D.1 CLINICAL DESCRIPTION

This surveillance case definition refers to any acute adverse health effects resulting from exposure to

a pesticide product (defined under the Federal Insecticide Fungicide and Rodenticide Act [FIFRA] )

including health effects due to an unpleasant odor, injury from explosion of a product, inhalation of

smoke from a burning product, and allergic reaction. Because public health agencies seek to limit all

adverse effects from regulated pesticides, notification is needed even when the responsible ingredient

is not the active ingredient.

A case is characterized by an acute onset of symptoms that are dependent on the formulation of the

pesticide product and involve one or more of the following:

Systemic signs or symptoms (including respiratory, gastrointestinal, allergic, and neurological

signs/symptoms)

Dermatologic lesions

Ocular lesions

This case definition and classification system is designed to be flexible permitting classification of

pesticide-related illnesses from all classes of pesticides. Consensus case definitions for specific classes of chemicals may be developed in the future.

A case will be classified as occupational if exposure occurs while at work (this includes working for

compensation; in a family business, including a family farm; for pay at home; and as a volunteer emer183

APPENDIX D 
gency medical technician [EMT], firefighter, or law enforcement officer). All other cases will be

classified as nonoccupational. All cases involving suicide or attempted suicide should be classified

as nonoccupational.

A case is reportable to the national surveillance system when there is:

Documentation of new adverse health effects that are temporally related to a documented pesticide

exposure, and

Consistent evidence of a causal relationship between the pesticide and the health effects based on

the known toxicology of the pesticide from commonly available toxicology texts, government publications, information supplied by the manufacturer, or two or more case series or positive epidemiologic investigations, or

Insufficient toxicologic information available to determine whether a causal relationship exists

between the pesticide exposure and the health effects.

See the Classification Criteria section for a more detailed description of these criteria.

D.2 LABORATORY CRITERIA FOR DIAGNOSIS

If available, the following laboratory data can confirm exposure to a pesticide:

Biological tests for the presence of, or toxic response to, the pesticide and/or its metabolite (in

blood, urine, etc.)

— Measurement of the pesticide and/or its metabolite(s) in the biological specimen

— Measurement of a biochemical response to the pesticide in a biological specimen (e.g.,

cholinesterase levels)

Environmental tests for the pesticide (e.g., foliage residue, analysis of suspect liquid)

Pesticide detection on clothing or equipment used by the case subject

D.3 CLASSIFICATION CRITERIA

Reports received and investigated by State programs are scored on the three criteria provided below

(criteria A, B, and C). Scores are either 1, 2, 3, or 4 and are assigned based on all available evidence.

The classification matrix (Table D-1) provides the case classification categories and the criteria scores

needed to place the case into a specific category. Definite, probable, possible, and suspicious cases

(see the classification matrix) are reportable to the national surveillance system. Additional classification categories are provided for States that choose to track reports that do not fit the criteria for national reporting. (Frequently asked questions [FAQs] that provide additional clarification on the classification criteria and use of the classification matrix are provided in Section D.5. Section D.6 lists the

characteristic signs and symptoms for several pesticide active ingredients and classes of pesticides.)

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APPENDIX D 
APPENDIX D 

A. DOCUMENTATION OF PESTICIDE EXPOSURE

1. Laboratory, clinical, or environmental evidence corroborates exposure (at least one of the following

must be satisfied to receive a score of 1):

a. Analytical results from foliage residue, clothing residue, air, soil, water, or biologic samples.

b. Observation of residue and/or contamination (including damage to plant material from herbicides) by a trained professional. (Note: a trained professional may be a plant pathologist, agricultural inspector, agricultural extension agent, industrial hygienist, or any other licensed or

academically trained specialist with expertise in plant pathology and/or environmental effects

of pesticides. A licensed pesticide applicator not directly involved with the application may

also be considered a trained professional.)

c. Biologic evidence of exposure (e.g., response to administration of an antidote such as 2-PAM,

Vitamin K1, or repeated doses of atropine).

d. Documentation by a licensed health care professional (HCP) of a characteristic eye injury or

dermatologic effects at the site of direct exposure to a pesticide product known to produce

such effects (these findings must be sufficient to satisfy criteria B.1 under “Documentation of

Adverse Health Effect”).

e. Clinical description by a licensed HCP of two or more post-exposure health effects (at least

one of which is a sign) characteristic for the pesticide as provided in Section D.6.

2. Evidence of exposure based solely on written or verbal report (at least one of the following must be

satisfied to receive a score of 2):

a. Report by case

b. Report by witness

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APPENDIX D 

c. Written records of application

d. Observation of residue and/or contamination (including damage to plant material from herbicides) by other than a trained professional

e. Other evidence suggesting that an exposure occurred

3. Strong evidence that no pesticide exposure occurred.

4. Insufficient data.

B. DOCUMENTATION OF ADVERSE HEALTH EFFECT

1. Two or more new post-exposure abnormal signs and/or test/laboratory findings reported by a

licensed HCP.

2. Two or more new post-exposure abnormal symptoms reported. When new post-exposure signs and

test/laboratory findings are insufficient to satisfy a B1 score, they can be used in lieu of symptoms

toward satisfying a B2 score.

3. No new post-exposure abnormal signs, symptoms, or test/laboratory findings reported.

4. Insufficient data (includes having only one new post-exposure abnormal sign, symptom, or test/laboratory finding).

C. EVIDENCE SUPPORTING A CAUSAL RELATIONSHIP BETWEEN PESTICIDE EXPOSURE AND

HEALTH EFFECTS

1. Where the findings documented under the Health Effects criteria (criteria B) are:

a. characteristic for the pesticide as provided in Section D.6, and the temporal relationship

between exposure and health effects are plausible (the pesticide refers to the one classified

under criteria A), and/or

b. consistent with an exposure-health effect relationship based on the known toxicology (that is,

exposure dose, symptoms, and temporal relationship) of the putative agent (that is, the agent

classified under criteria A) from commonly available toxicology texts, government publications, information supplied by the manufacturer, or two or more case series or positive epidemiologic studies published in the peer-reviewed literature.

2. Evidence of exposure-health effect relationship is not present. This may be because the exposure

dose was insufficient to produce the observed health effects. Alternatively, a temporal relationship

does not exist (that is, health effects preceded the exposure or occurred too long after exposure).

Finally, it may be because the constellation of health effects are not consistent based on the known

toxicology of the putative agent from information in commonly available toxicology texts, government publications, information supplied by the manufacturer, or the peer-reviewed literature.

3. Definite evidence of nonpesticide causal agent.

186
187

APPENDIX D 

4. Insufficient toxicologic information is available to determine causal relationship between exposure

and health effects. (This includes circumstances where minimal human health effects data are available, or where there are less than two published case series or positive epidemiologic studies linking health effects to the particular pesticide product/ingredient or class of pesticides.)

D.4 CONTACTS FOR ADDITIONAL INFORMATION

For information regarding acute occupational pesticide-related illness and injury, contact NIOSH at

1–800–35–NIOSH. For information about acute nonoccupational pesticide-related illness and injury,

contact the National Center for Environmental Health (NCEH) at 404–639–2530. For information

concerning regulation and use of pesticides, contact the US EPA, Office of Pesticide Programs, at

703–305–5336. The National Pesticide Information Center (NPIC) (1–800–858–7378) provides information about pesticides, acute pesticide-related illness and injury, and the toxicology and environmental chemistry of pesticides.

For more information about this case definition contact Geoffrey M. Calvert, M.D., M.P.H., at NIOSH

(513–841–4448, e-mail jac6@cdc.gov).

Revised 11/29/04

D.5 FREQUENTLY ASKED QUESTIONS (FAQS)

Question 1. The terms signs and symptoms are used throughout the case definition. What is the difference

between the two?

Answer 1. Signs are objective findings that can be observed and described by a licensed HCP.

Typically, this is the information found in the physical exam or physical findings section of a medical

record or acute poisoning reporting form. These findings do not rely on the subjective reporting of sensations by the affected person. An objective, knowledgeable observer includes all licensed HCPs (e.g.,

medical doctor [MD], doctor of osteopathy [DO], physician’s assistant [PA], registered nurse [RN],

EMT, etc.).

Symptoms are any subjective evidence of a disease or a condition as perceived and reported by the

patient. This includes reported changes from normal function, sensation, or appearance. This information is the History section of a medical record.

Question 2. How should we classify the exposure when an affected person, their coworker, or family

member indicates that they were “drenched” by pesticide spray?

Answer 2. If no other corroborating evidence presented by an objective observer exists, the information meets criteria A2. If there is documentation by medical personnel, emergency responders (police,

EMT, etc.), an employer, agency representative, or investigators that the person was observed to be

drenched at the scene or treatment facility, this would be classified as meeting criteria A1b. However,

it must be remembered that these observers must be objective and independent, and therefore they cannot be the affected person. 
Question 3. How should an exposure be classified when a person has a dermal exposure that is difficult to document as a direct exposure? For example, a person handles an object contaminated with

pesticides, then touches another part of the body with their possibly contaminated hand. The person

then develops a dermal response at the site of hand contact.

Answer 3. If the person is confident that contact with the pesticide product definitely occurred, and the

hand-to-body part contact occurred shortly afterward, and the dermal response is documented by a

licensed HCP, code the exposure as A1d (documentation by a licensed HCP of a characteristic eye

injury or dermatologic effects at the site of direct exposure to a pesticide product known to produce

such effects). Code as A2 (evidence of exposure based solely on written or verbal report) if the dermal

response is not documented by a licensed HCP. If the history is vague, or if contact may have been with

a plant or product other than a pesticide, code as A4 (insufficient data).

Question 4. How do we interpret cholinesterase results when performing case classification?

Answer 4. Each State may choose to develop its own internal guidelines. The following very cursory

discussion is provided to assist States in this process. Cholinesterase depression is defined as one or

more of the following:

a. 30% depression from baseline (pre-exposure or 60 to 90 days post-exposure) red blood count

cholinesterase level

b. 40% depression from baseline plasma cholinesterase level

c. Cholinesterase level below laboratory normal range

The level of depression may be determined by serial post-exposure testing if a baseline test is not

available. (For example, testing 2 weeks and 4 weeks post exposure show a gradual increase in

cholinesterase by percentages in 1 and 2 above, over the levels at initial testing.) A test that shows significant depression as described above should be considered evidence of exposure and ranked as meeting criteria A1c. It should also be considered evidence for a new post-exposure health effect and helps

to meet the criteria for B1 (an additional post-exposure sign or test/laboratory finding would be needed to fully meet the criteria for B1). A test result that does not indicate depression should not be considered an indication that substantial exposure has not occurred. The timing of testing, laboratory variation, the wide normal range, and administration of praloxidime chloride (2PAM) prior to testing can

all lead to negative results.

Question 5. Can the applicator who is directly affected by exposure or who has performed the application that is associated with health effects supply information that can be considered “evaluation by

a trained professional” specified in criteria A1b?

Answer 5. No. Persons who are considered professional observers should be objective. An applicator

who is the case cannot be considered an objective observer. Nor can an applicator be an objective

observer when allegations or observations suggest a misapplication may have occurred. A trained,

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APPENDIX D 
189

APPENDIX D 

licensed applicator not directly involved with the case could be an observer under A1b. For example,

a second applicator is called in to help evaluate damage to plants on the property, or to help alleviate

odors in an office from an application by another applicator. This second person’s observation can

meet the requirements of a trained professional observer as specified in A1b.

Question 6. What is the definition of antidote that should be used to evaluate exposure (A1c)?

Answer 6. By antidote, we mean an agent that counteracts the effects of the pesticide. Two types of

antidotes satisfy this definition: pharmacological antidotes and specific antidotes. Pharmacological

antidotes counteract the pharmacological effects of the absorbed pesticide. Often, persons poisoned

with pesticides have a high tolerance to repeated doses of pharmacological antidotes. For example,

those poisoned with anticholinesterase pesticides have a high tolerance to atropine. As such, very high

doses of atropine are often required to treat persons poisoned with anticholinesterase pesticides.

Another pharmacological antidote is phenobarbital.

Specific antidotes interact directly with absorbed pesticide or some product of it to block the biochemical effect of the pesticide. Examples include pralidoxime chloride (2-PAM), vitamin K, and pesticidespecific monoclonal antibodies that are under development.

Antidotes are not the same as adjunct treatment that may help relieve symptoms or effects of the exposure in a less direct manner. This also does not include agents that prevent absorption of the ingested

pesticide (e.g., activated charcoal).

Question 7. How can we end up with a classification that is different from the clinical diagnosis in the

medical record? Isn’t that second guessing the physician’s evaluation of the patient?

Answer 7. The case classification scheme and the clinical diagnosis serve different purposes. The purpose of the case classification scheme is to serve surveillance and epidemiologic-related functions.

The classification scheme provides objective guidelines for assessing the certainty of the evidence

regarding exposure and health effects. In contrast, the purpose of the clinical diagnosis is to guide the

immediate treatment course for the person. In addition, the clinician may use more intuitive and subjective criteria when making a diagnosis. Therefore, it is possible that the classification category may

differ from the clinical diagnosis.

Question 8. The classification scheme seems too stringent. By excluding persons who report only one

symptom, we may be missing important cases. For example, a child with seizures after N, N-diethl-mtoluamide (DEET) exposure would be excluded. How can we address this?

Answer 8. The classification scheme requires the presence of at least two post-exposure symptoms for

a report to be considered a case. This may result in the exclusion of a very small number of actual pesticide-related illnesses or injuries. Most concerns about excluding cases due to this criterion can be

alleviated by using structured protocols for obtaining medical histories from the person and/or HCP. If

a single sign or symptom is reported, requesting more details will usually elicit additional signs or

symptoms. Asking about commonly related symptoms as part of an interview is an acceptable practice.
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APPENDIX D 

For example, it is appropriate to ask about symptoms of nausea if a person reports vomiting, stomach

cramping if diarrhea is reported, or loss of consciousness with seizure. This approach should help

resolve concerns about the classification system resulting in false negatives.

Question 9. How do we assess signs and symptoms when a person has a pre-existing condition that

may influence their physiologic response to an exposure?

Answer 9. Few studies have examined the effect of pre-existing disease on the toxicity of pesticides. We

are not aware of any studies that found differences in signs and symptoms among pesticide-poisoned

persons with pre-existing conditions. Therefore, if someone presents with an atypical set of symptoms

for a particular pesticide, a score of C2 should be strongly considered under “evidence supporting a

causal relationship between pesticide exposure and health effects.”

However, it is possible that those with some pre-existing conditions will have reduced physiologic

reserve. Therefore, these persons may manifest symptoms at a lower pesticide dose compared with a

young, healthy person. Nonetheless, in these persons, the signs and symptoms should be characteristic of the particular pesticide, and the temporal relationship should be appropriate. 

It is possible that pesticide exposure may exacerbate a pre-existing condition (e.g., organophosphate

exposure can cause increased shortness of breath in exposed persons, including persons with chronic

lung disease). However, the signs and symptoms that are present should be consistent with poisoning

from the pesticide in question. 

Question 10. How do we address a situation when the underlying condition may create a set of symptoms that are similar to the symptoms caused by the pesticide?

Answer 10. As has been stated previously, pesticide exposure may exacerbate a pre-existing condition.

However, keep in mind that the signs and symptoms that are present should be consistent with poisoning

from the pesticide in question. In addition, there should be an appropriate temporal relationship (that

is, exposure preceded the health effect and the latency between exposure and effect is appropriate), and

the pesticide exposure should be of sufficient dose.

Question 11. How do we determine whether the evidence for an exposure-health effect relationship is

insufficient versus inconsistent?

Answer 11. When there is little literature on the health effects associated with a particular pesticide and

none of it describes the health effects of interest, then the evidence for an exposure-health effect relationship is considered insufficient and a score of C4 is appropriate. However, if there are many references on the health effects associated with a particular pesticide, and none describe the health effects

of interest, then the evidence for an exposure-health effect relationship is considered inconsistent and

a score of C2 is appropriate.

Question 12. The term exposure dose is used in Section C: “Evidence Supporting a Causal

Relationship Between Pesticide Exposure and Health Effects.” Often little information is available on

dose. How should we interpret dose?
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APPENDIX D 

Answer 12. The use of this term refers to whether the dose was sufficient to produce the observed

health effects. Unfortunately, there is a paucity of data available on the minimum dose of a pesticide

needed to produce health effects in humans. In addition, reaction to a pesticide exposure can vary

across persons. It should be remembered that some persons may be much more sensitive to a pesticide

and manifest health effects at a much lower dose compared with other persons. Other factors such as

duration of exposure, use of protective equipment, amount of time between exposure and collection of

the environmental sample, and the effect of intervening weather conditions on environmental samples

and observations must be factored in when evaluating the actual exposure dose likely experienced by

the person. When available, the peer-reviewed literature should be examined for guidance. The judgment of colleagues in the State Department of Agriculture may also be helpful. 

When dealing with self-reports, qualitative information about exposure dose can be obtained. For

example, information can be obtained about proximity to the source of exposure, duration of exposure,

did health effects manifest in others who were exposed, etc. Assessing this information may require

experience and the assistance of other knowledgeable colleagues. 

Question 13. Often we learn that a person was exposed to a particular functional class of pesticides

(e.g., insecticide, herbicide, etc.), but we cannot determine the name of the product or the active ingredient. Should an exposure score of A2=written or verbal report or A4=insufficient data be assigned?

Answer 13. When only the pesticide class is known, a score of A4=insufficient data must be assigned.

This is because the pesticides within a particular class can vary widely in toxicity. Therefore, it would

be impossible to determine if any observed health effects are consistent and/or characteristic with the

pesticide exposure. However, if the chemical class of the pesticide is known (e.g., organophosphate or

carbamate), but the specific pesticide product or active ingredient is unknown, a score of A1 or A2 can

be considered. This is because pesticides within a specific chemical class can produce similar health

effects (see Section D.6).

Question 14. Can documentation or a clinical description “by a licensed HCP” as specified in criteria

A1d, A1e, and B1 be provided by the licensed HCP who is directly affected by exposure (please note

that this is similar to question Question 5)?

Answer 14. No. Persons who are considered professional observers should be objective. An HCP who

is the case cannot be considered an objective observer. A licensed HCP not directly involved in the

exposure event would meet the criteria under A1d, A1e, and B1.
D.6. CHARACTERISTIC SIGNS AND SYMPTOMS FOR SEVERAL PESTICIDE ACTIVE

INGREDIENTS AND CLASSES OF PESTICIDES

Pesticide Signs and Symptoms

Acrolein Conjunctivitis (irritation of mucous membranes, tearing) 

Skin irritation, rash, blistering, or erosion (without sensitization)

Pulmonary edema

Tearing

Upper respiratory tract irritation: rhinitis, scratchy throat, cough

Acrylonitrile Seizures/convulsions (tonic-clonic), sometimes leading to coma

Upper respiratory tract irritation: rhinitis, scratchy throat, cough

Aminopyridine Behavioral-mood disturbances (confusion, excitement, mania, 

disorientation, emotional lability)

Salivation

Sweating (diaphoresis)

Thirst

ANTU Dyspnea

Upper respiratory tract irritation: rhinitis, scratchy throat, cough

Arsenicals (inorganic) Anemia

Abdominal pain

Behavioral-mood disturbances (confusion, excitement, mania, 

disorientation, emotional lability)

Bloody diarrhea

Keratoses, brown discoloration

Kidney (proteinuria, hematuria, sometimes leading to oliguria, acute

renal failure with azotemia

Leukopenia, thrombocytopenia

Metallic taste in mouth

Paralysis, paresis (muscle weakness)

Paresthesia of extremities

Runny nose

Stomatitis

Thirst

Arsine Anemia

Chills

Hemoglobinuria

Hemolysis

Hyperkalemia

Kidney (proteinuria, hematuria, sometimes leading to oliguria, acute

renal failure with azotemia)

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APPENDIX D 
Pesticide Signs and Symptoms

Borate Abdominal pain

Beefy red palms, soles

Diarrhea

Hypotension, shock

Kidney (proteinuria, hematuria, sometimes leading to oliguria, acute

renal failure with azotemia)

Nervous system depression (stupor, coma, respiratory failure, often 

without seizures/convulsions)

Tremor

Cadmium compounds Abdominal pain

Conjunctivitis (irritation of mucous membranes, tearing)

Cyanosis

Diarrhea

Dyspnea

Pulmonary consolidation

Pulmonary edema

Salivation

Skin irritation, rash, blistering, or erosion (without sensitization)

Upper respiratory tract irritation: rhinitis, scratchy throat, cough

Carbamate insecticides Abdominal pain

Anorexia

Bradycardia (sometimes to asystole)

Diarrhea

Diplopia

Dyspnea

Incoordination (including ataxia)

Miosis

Muscle twitching

Nervous system depression (stupor, coma, respiratory failure, often 

without seizures/convulsions)

Paralysis, paresis (muscle weakness)

Runny nose

Salivation

Sweating (diaphoresis)

Tearing

Tremor

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APPENDIX D 
Pesticide Signs and Symptoms

Carbon disulfide Behavioral-mood disturbances (confusion, excitement, mania, 

disorientation, emotional lability)

Breath odor of rotten cabbage

Incoordination (including ataxia)

Paresthesia of extremities

Seizures/convulsions (tonic-clonic), sometimes leading to coma

Carbon tetrachloride Jaundice

Liver enlargement

Liver enzymes elevated (lactate dehydrogenase [LDH], alanine 

amiotransferase [ALT], aspartate transaminase [AST], alkaline phosphatase) 

Cationic detergents Skin irritation, rash, blistering, or erosion (without sensitization)

Pulmonary edema

Chlordimeform Anorexia

Hot sensations

Kidney (dysuria, hematuria, pyuria)

Skin irritation, rash, blistering, or erosion (without sensitization)

Sweet taste in mouth

Chlorhexidine Contact dermatitis

Urticaria

Chloroform Jaundice

Liver enlargement

Liver enzymes elevated (LDH, ALT, AST, alkaline phosphatase)

Chloropicrin Conjunctivitis (irritation of mucous membranes, tearing)

Dyspnea

Tearing

Upper respiratory tract irritation: rhinitis, scratchy throat, cough

Cholecalciferol Anorexia

Hypercalcemia

Polyuria

Thirst

Copper compounds Abdominal pain

Conjunctivitis (irritation of mucous membranes, tearing)

Hypotension, shock

Kidney (proteinuria, hematuria, sometimes leading to oliguria, acute

renal failure with azotemia)

194

APPENDIX D 
Pesticide Signs and Symptoms

Copper compounds Liver enlargement

(continued) Skin irritation, rash, blistering, or erosion (without sensitization)

Stomatitis

Coumarins Bloody diarrhea

Ecchymoses

Hypoprothrombinemia

Creosote Contact dermatitis

Hypothermia

Methemoglobinemia

Pallor

Pulmonary edema

Seizures/convulsions (tonic-clonic), sometimes leading to coma

Smoky urine

Crimidine Cyanosis

Seizures/convulsions (tonic-clonic), sometimes leading to coma

Cyanamide Dyspnea

Hypotension, shock

Skin flushing

Tachycardia

Cyanide Behavioral-mood disturbances (confusion, excitement, mania, 

disorientation, emotional lability)

Bradycardia (sometimes to asystole)

Breath odor of bitter almonds

Dilated pupils

Salivation

Seizures/convulsions (tonic-clonic), sometimes leading to coma

Unreactive pupils

DEET Contact dermatitis

Seizures/convulsions (tonic-clonic), sometimes leading to coma

Urticaria

Dibromochloropropane Low sperm count

Skin irritation, rash, blistering, or erosion (without sensitization)

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APPENDIX D 
Pesticide Signs and Symptoms

Diquat Abdominal pain

Behavioral-mood disturbances (confusion, excitement, mania, 

disorientation, emotional lability)

Bloody diarrhea

Conjunctivitis (irritation of mucous membranes, tearing)

Ileus

Kidney (proteinuria, hematuria, sometimes leading to oliguria, acute

renal failure with azotemia)

Nervous system depression (stupor, coma, respiratory failure, often 

without seizures/convulsions)

Skin irritation, rash, blistering, or erosion (without sensitization)

Stomatitis

Endothall Bloody diarrhea

Conjunctivitis (irritation of mucous membranes, tearing)

Hypotension, shock

Seizures/convulsions (tonic-clonic), sometimes leading to coma

Skin irritation, rash, blistering, or erosion (without sensitization)

Ethylene dibromide Kidney (proteinuria, hematuria, sometimes leading to oliguria, acute

renal failure with azotemia)

Skin irritation, rash, blistering, or erosion (without sensitization)

Pulmonary edema

Upper respiratory tract irritation: rhinitis, scratchy throat, cough

Ethylene oxide Cardiac arrhythmias

Conjunctivitis (irritation of mucous membranes, tearing)

Dermal sensitization

Pulmonary edema

Skin irritation, rash, blistering, or erosion (without sensitization)

Fluoride Abdominal pain

Bloody diarrhea

Dilated pupils

Hypocalcemia

Seizures/convulsions (tonic-clonic), sometimes leading to coma

Tetany, carpopedal spasms

Formaldehyde Conjunctivitis (irritation of mucous membranes, tearing)

Skin irritation, rash, blistering, or erosion (without sensitization)

Upper respiratory tract irritation: rhinitis, scratchy throat, cough

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APPENDIX D 
Pesticide Signs and Symptoms

Fumigants (halocarbon) Cardiac arrhythmias

Incoordination (including ataxia)

Hexachlorobenzene Anorexia

Porphyrinuria (wine-red urine)

Hexachlorophene Contact dermatitis

Seizures/convulsions (tonic-clonic), sometimes leading to coma

Skin irritation, rash, blistering, or erosion (without sensitization)

Indandiones Bloody diarrhea

Ecchymoses

Hypoprothrombinemia

Mercury (organic) Behavioral-mood disturbances (confusion, excitement, mania, 

disorientation, emotional lability)

Constricted eye fields

Hearing loss

Metallic taste in mouth

Paresthesia of extremities

Tremor

Metaldehyde Abdominal pain

Seizures/convulsions (tonic-clonic), sometimes leading to coma

Tremor

Metam sodium Conjunctivitis (irritation of mucous membranes, tearing)

Skin irritation, rash, blistering, or erosion (without sensitization)

Methyl bromide Behavioral-mood disturbances (confusion, excitement, mania, 

disorientation, emotional lability)

Dyspnea

Conjunctivitis (irritation of mucous membranes, tearing)

Pulmonary consolidation

Pulmonary edema

Skin irritation, rash, blistering, or erosion (without sensitization)

Naphthalene Anemia

Conjunctivitis (irritation of mucous membranes, tearing)

Hemoglobinuria

Hemolysis

Hyperkalemia

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APPENDIX D 
Pesticide Signs and Symptoms

Naphthalene Kidney (proteinuria, hematuria, sometimes leading to oliguria, acute

renal failure with azotemia)

Sweating (diaphoresis)

Upper respiratory tract irritation: rhinitis, scratchy throat, cough

Nicotine Abdominal pain

Anorexia

Behavioral-mood disturbances (confusion, excitement, mania, 

disorientation, emotional lability)

Cardiac arrhythmias

Diarrhea

Cyanosis

Diplopia

Dyspnea

Hypertension (early in poisoning)

Incoordination (including ataxia)

Muscle twitching

Paralysis, paresis (muscle weakness)

Salivation

Seizures/convulsions (tonic-clonic), sometimes leading to coma

Sweating (diaphoresis)

Tremor

Nitrophenols Behavioral-mood disturbances (confusion, excitement, mania, 

disorientation, emotional lability)

Fever

Hot sensations

Kidney (proteinuria, hematuria, sometimes leading to oliguria, acute

renal failure with azotemia)

Skin flushing

Sweating (diaphoresis)

Tachycardia

Thirst

Yellow stain on skin

Yellow sclera

Organochlorines Cyanosis

Pallor

Paresthesia (chiefly facial, transitory)

Seizures/convulsions (tonic-clonic), sometimes leading to coma

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APPENDIX D 

(continued)
Pesticide Signs and Symptoms

Organophosphates Abdominal pain

Acetylcholinesterase depression (RBC and/or plasma)

Anorexia

Bradycardia (sometimes to asystole)

Diarrhea

Diplopia

Dyspnea

Incoordination (including ataxia)

Miosis

Muscle twitching

Nervous system depression (stupor, coma, respiratory failure, often 

without seizures/convulsions)

Paralysis, paresis (muscle weakness)

Paresthesia (chiefly facial, transitory)

Runny nose

Salivation

Sweating (diaphoresis)

Tearing

Tremor

Organotin compounds Abdominal pain

Behavioral-mood disturbances (confusion, excitement, mania, 

disorientation, emotional lability)

Conjunctivitis (irritation of mucous membranes, tearing)

Skin irritation, rash, blistering, or erosion (without sensitization)

Paraquat Abdominal pain

Bloody diarrhea

Conjunctivitis (irritation of mucous membranes, tearing)

Contact dermatitis

Cyanosis

Dyspnea

Jaundice

Keratitis

Kidney (proteinuria, hematuria, sometimes leading to oliguria, acute

renal failure with azotemia)

Myalgia

Pulmonary consolidation

Skin irritation, rash, blistering, or erosion (without sensitization)

Stomatitis

Upper respiratory tract irritation: rhinitis, scratchy throat, cough

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APPENDIX D 
Pesticide Signs and Symptoms

Pentachlorophenol Anorexia

Contact dermatitis

Dyspnea

Fever

Kidney (proteinuria, hematuria, sometimes leading to oliguria, acute

renal failure with azotemia)

Sweating (diaphoresis)

Tachycardia

Thirst

Urticaria

Phosphorus Abdominal pain

Breath odor of garlic

Hypotension, shock

Jaundice

Pulmonary edema

Skin irritation, rash, blistering, or erosion (without sensitization)

Tetany, carpopedal spasms

Thirst

Phosphides Abdominal pain

Breath odor of garlic

Hypotension, shock

Jaundice

Paresthesia (chiefly facial, transitory)

Pulmonary edema

Tetany, carpopedal spasms

Thirst

Phosphine Breath odor of garlic

Chills

Hypotension, shock

Jaundice

Liver enlargement

Liver enzymes elevated (LDH, ALT, AST, alkaline phosphatase)

Pulmonary edema

Seizures/convulsions (tonic-clonic), sometimes leading to coma

Thirst

Povidone-iodine Cardiac arrhythmias

Seizures/convulsions (tonic-clonic), sometimes leading to coma

200

APPENDIX D 
Pesticide Signs and Symptoms

Propargite Dermal sensitization

Skin irritation, rash, blistering, or erosion (without sensitization)

Pyriminil Behavioral-mood disturbances (confusion, excitement, mania, 

disorientation, emotional lability)

Breath odor of peanuts

Cardiac arrhythmias

Constipation

Glucosuria

Hyperglycemia (elevated serum glucose)

Ketoacidosis

Ketonuria

Paresthesia of extremities

Urinary retention

Pyrethrins Contact dermatitis

Runny nose

Pyrethroids Diarrhea

Pulmonary edema

Sabadilla Cardiac arrhythmias

Sneezing

Sodium chlorate Anemia

Cardiac arrhythmias

Cyanosis

Hemoglobinuria

Hemolysis

Hyperkalemia

Hypotension, shock

Jaundice

Kidney (proteinuria, hematuria, sometimes leading to oliguria, acute

renal failure with azotemia))

Liver enlargement

Methemoglobinemia

Seizures/convulsions (tonic-clonic), sometimes leading to coma

Skin irritation, rash, blistering, or erosion (without sensitization)

201

APPENDIX D 
Pesticide Signs and Symptoms

Sodium fluoride Cardiac arrhythmias

Hypotension, shock

Kidney (proteinuria, hematuria, sometimes leading to oliguria, acute

renal failure with azotemia)

Pallor

Nervous system depression (stupor, coma, respiratory failure, often 

without seizures/convulsions)

Salivation

Salty, soapy taste in mouth

Thirst

Sodium fluoroacetate Behavioral-mood disturbances (confusion, excitement, mania, 

disorientation, emotional lability)

Cardiac arrhythmias

Cyanosis

Paresthesia of extremities

Seizures/convulsions (tonic-clonic), sometimes leading to coma

Strychnine Cyanosis

Seizures/convulsions (tonic-clonic), sometimes leading to coma

Sulfur Breath odor of rotten eggs

Diarrhea

Skin irritation, rash, blistering, or erosion (without sensitization)

Sulfur dioxide Conjunctivitis (irritation of mucous membranes, tearing)

Dyspnea

Pulmonary edema

Upper respiratory tract irritation: rhinitis, scratchy throat, cough

Sulfuryl fluoride Dyspnea

Kidney (proteinuria, hematuria, sometimes leading to oliguria, acute

renal failure with azotemia)

Muscle twitching

Upper respiratory tract irritation: rhinitis, scratchy throat, cough

Thallium Abdominal pain

Behavioral-mood disturbances (confusion, excitement, mania, 

disorientation, emotional lability)

Bloody diarrhea

Cardiac arrhythmias (ventricular)

Hypertension (early in poisoning)

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APPENDIX D 
Pesticide Signs and Symptoms

Thallium Hypotension, shock

Ileus

Incoordination (including ataxia)

Loss of hair

Paresthesia of extremities

Ptosis

Seizures/Convulsions (tonic-clonic), sometimes leading to coma

Tremor

Thiram Alcohol intolerance

Contact dermatitis

Diarrhea

Skin irritation, rash, blistering, or erosion (without sensitization)

Veratrum alkaloid (See sabadilla)

(Adapted from Morgan DP. Recognition and management of pesticide poisonings. 4th ed. Washington, DC: U.S.

EPA; 1989; and Reigart JR, Roberts JR. Recognition and management of pesticide poisonings. 5th ed. Washington,

DC: U.S. EPA; 1999.)

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APPENDIX D 
D.7 GLOSSARY OF MEDICAL TERMS

Anorexia diminished appetite 

Bradycardia slow heart rate (generally less than 60 beats per minute)

Carpopedal spasms spasm of the hands and/or feet

Conjunctivitis inflammation of the conjunctiva (the mucous membrane covering the 

surface of the eye)

Cyanosis a dark blueish or purplish coloration of the skin and mucous membranes

Diaphoresis sweating, perspiration

Dyspnea shortness of breath

Ecchymoses bruises of the skin larger than 3mm in diameter

Glucosuria presence of glucose in the urine

Hemoglobinuria presence of hemoglobin in the urine

Hemolysis destruction of red blood cells

Hypercalcemia increased calcium in the blood

Hyperkalemia increased potassium in the blood

Hypertension increased blood pressure

Hypoprothrombinemia low levels of prothrombin in the blood

Hypothermia decreased body temperature (significantly below 98.6 F)

Ileus obstruction of the bowel

Keratoses a hard, thick circumscribed skin lesion (characterized by overgrowth of 

the horny layer) 

Ketoacidosis an increase in the pH of the blood caused by the enhanced production of

ketones

Ketouria presence of ketones in the urine

Leukopenia decreased number of white blood cells in the blood

Methemoglobinemia the presence of methemoglobin in the blood

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APPENDIX D 
Miosis pinpoint pupils

Myalgia muscular pain

Paresis muscle weakness

Paresthesia an abnormal sensation such as of burning, pricking, tingling or tickling

Polyuria increased production of urine resulting in increased frequency of urination

Porphyrinuria increased porphyrins in the urine manifesting as wine-red urine

Ptosis a sinking down of the eyelid

Pulmonary consolidation an infiltrate in the lung observed on a chest x-ray

Rhinitis inflammation of the nasal mucous membranes

Stomatitis inflammation of the mucous membranes of the mouth

Tachycardia rapid heart rate (generally greater than 100 beats per minute)

Tetany a clinical neurological syndrome characterized by muscle twitches, 

cramps, carpopedal spasm, and when severe, laryngospasm and 

seizures

Thrombocytopenia decreased number of platelets in the blood

(January 31, 2000)

205

APPENDIX D 
APPENDIX E

SEVERITY INDEX FOR USE IN STATE-BASED

SURVEILLANCE OF ACUTE PESTICIDE-RELATED

ILLNESS AND INJURY
SEVERITY INDEX FOR USE IN STATE-BASED SURVEILLANCE OF

ACUTE PESTICIDE-RELATED ILLNESS AND INJURY

PURPOSE

The purpose of the severity index is to provide simple, standardized criteria for assigning severity to

cases of acute pesticide-related illness and injury.

RATIONALE

It is important to assign a severity category to each case of acute pesticide-related illness and injury.

An understanding of illness severity will be useful to evaluate the morbidity of acute pesticide-related

illness and injury, to assess its impact on society, and to assist the targeting of limited intervention/prevention resources toward the most pressing pesticide problems. 

DESCRIPTION

This severity index is based upon existing systems for ranking severity of poisonings, including pesticide illness [AAPCC 1992; Washington Department of Health 1999; EPA 1998; Persson et al. 1998].

It takes into account the following: signs and symptoms, whether medical care was sought, whether

the individual was hospitalized, and whether lost time from work or usual activities occurred. Severity

should be assigned only to acute pesticide-related illnesses or injuries classified as definite, probable,

possible, or suspicious. As such, this severity index should be used in conjunction with the Case

Definition for Acute Pesticide-Related Illness and Injury Cases Reportable to the National Public

Health Surveillance System [NIOSH 2004].

Figure 1 is the flow diagram that should be used as a guide for assigning severity. The figure often

refers to “the Table.” This is Table 1, a listing of signs and symptoms that correspond to the different

severity categories. Many of the signs and symptoms in the table are included in Standardized

Variables for Pesticide Poisoning Surveillance [NIOSH 2000]. When using the table, only signs and

symptoms related to the pertinent acute pesticide-related illness or injury should be considered (that is,

only consider those signs and symptoms used to classify the acute pesticide-related illness and injury

as definite, probable, possible, or suspicious). 

The list of signs and symptoms provided in the table is not comprehensive, but instead provides examples to assist in assessing severity. In addition, a given health effect may appear in more than one of

the table’s severity columns. In such instances, the health effect observed as a sign (that is, a health

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APPENDIX E 
effect observed and described by a licensed HCP) will be considered as having greater severity compared to the health effect reported as a symptom (that is, a health effect perceived and reported by the

patient but not observed by a licensed HCP).

This severity index provides standardized criteria to ensure inter-rater uniformity in assigning severity.

However, we recognize that this severity index cannot address all conceivable clinical situations.

Therefore, it is not realistic to insist on strict adherence to these criteria. The user must be flexible

when using this severity index, given that the user will not infrequently need to employ judgment and

experience when assigning severity. 

A brief description of each of the four severity categories follows.

S-1 DEATH

This category describes a human fatality resulting from exposure to one or more pesticides.

S-2 HIGH SEVERITY ILLNESS OR INJURY

The illness or injury is severe enough to be considered life threatening and typically requires treatment. This level of effect commonly involves hospitalization to prevent death. Signs and symptoms

include, but are not limited to, coma, cardiac arrest, renal failure, and/or respiratory depression. The

individual sustains substantial loss of time (> 5 days) from regular work (this can include assignment

to limited/light work duties) or normal activities (if not employed). This level of severity might include

the need for continued health care following the exposure event, prolonged time off work, and limitations or modification of work or normal activities. The individual may sustain permanent functional

impairment.

S-3 MODERATE SEVERITY ILLNESS OR INJURY

This category includes cases of less severe illness or injury often involving systemic manifestations.

Generally, treatment was provided. The individual is able to return to normal functioning without any

residual disability. Usually, less time is lost from work or normal activities (3 to 5 days), compared

with those with severe illness or injury. No residual impairment is present (although effects may be

persistent).

S-4 LOW SEVERITY ILLNESS OR INJURY

This is the category of lowest severity. It is often manifested by skin, eye, or upper respiratory irritation and may also include fever, headache, fatigue, or dizziness. Typically the illness or injury resolves

without treatment. There is minimal lost time (< 3 days) from work or normal activities. 

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APPENDIX E 
REFERENCES

AAPCC [1992]. Toxic Exposure Surveillance System (TESS) Manual. Washington, DC: American

Association of Poison Control Centers.

EPA [1998]. Expanded explanation for the new FIFRA 6(a)(2)159.814 (5)(i)(A-E) and (5)(ii)(A E)

exposure severity categories. Washington, DC: U.S. Environmental Protection Agency.

NIOSH [2004]. Case definition for acute pesticide-related illness and injury cases reportable to the

national public health surveillance system. Cincinnati, OH: U.S. Department of Health and Human

Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and

Health, 2000. [http://www.cdc.gov/niosh/topics/pesticides/]

NIOSH [2000]. Standardized variables for state surveillance of pesticide-related illness and injury.

Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control and

Prevention, National Institute for Occupational Safety and Health, 2000. Unpublished.

Persson HE, Sjoberg GK, Haines JA, de Garbino JP [1998]. Poisoning severity score. Grading of acute

poisoning. Clin Toxicol 36:205B213.

WSDOH [1999]. 1998 Annual Report, Pesticide Incident Reporting and Tracking Review Panel.

Olympia, WA: Washington State Department of Health (WSDOH), Office of Environmental Health

and Safety. 

211

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APPENDIX E 

212
213

APPENDIX E 
APPENDIX E 

214

 

 

 

 

 

 
APPENDIX F

PESTICIDE LAW AND DEFINITIONS
PESTICIDE LAW AND DEFINITIONS

This appendix briefly outlines some of the Federal laws that regulate pesticides in the United States. It

does not include every law that pertains to pesticides but touches on those most pertinent for surveillance of acute human illness and injury. The U.S. Environmental Protection Agency (EPA) is responsible for the regulation of pesticide products marketed in the United States. Each State will have its

own set of statutes and administrative rules that address pesticides and reflect these Federal laws.

Contents:

F.1 Federal Insecticide Fungicide and Rodenticide Act (FIFRA)

F.2 Federal Food, Drugs, and Cosmetic Act (FFDCA)

F.3 Food Quality Protection Act (FQPA)

F.4 Safe Drinking Water Act (SDWA)

F.5 Occupational Safety and Health Act (OSH Act)

F.1 FEDERAL INSECTICIDE, FUNGICIDE, AND RODENTICIDE ACT (FIFRA) 

FIFRA was first passed in 1947. It was primarily a consumer protection law aimed at protecting pesticide users from products that did not contain active ingredients or sufficient active ingredients to be

effective. FIFRA underwent extensive amendments by Congress in 1972 that required comprehensive

testing of both old and new products. This required the review of 600 active ingredients and 50,000

registered pesticide products. These amendments shifted the emphasis of FIFRA to protecting human

health and the environment from unreasonable adverse risks associated with the use of pesticides. This

was intended by Congress to include protections for farmers, farmworkers, and others who were in

contact with pesticides. The regulatory approach required an evaluation of risks and benefits from the

use of pesticide products. The data requirements issued in 1975 were quite extensive. They required

manufacturers to provide information about general chemistry, environmental fate, short- and longterm toxicity, ecological effects, and crop residues. In 1982, the EPA proposed additional changes to

the data requirements, and in 1983, published technical guidelines for carrying out the required studies for registration. Registration review is based on an assessment of the potential effects of a product

on human health and the environment when it is used according to the label. Because the labels are

considered to have the force of law, use not in accordance with the label may result in civil or criminal penalties.

The 1988 amendments to FIFRA required that reregistration of products be completed more rapidly

and imposed timelines for portions of the pesticide registration process. These amendments also made

changes in EPA’s funding, authorized fee collection for some new activities, and significantly altered

217

APPENDIX F 
responsibilities relating to suspended and canceled pesticides. These changes removed the requirement that EPA accept and dispose of canceled and suspended pesticides at EPA expense and eliminated certain clauses requiring EPA to provide compensation for the storage and disposal of suspended or

canceled pesticides.

Other more recent amendments to FIFRA are discussed under the specific sections of the statute and

will reference the associated codified regulations. The pesticide regulations are found in the Code of

Federal Regulations, Title 40, Protection of the Environment, Chapter 1, Environmental Protection

Agency, Parts 150 to 189 (40 CFR 150–189). In addition to the provisions already mentioned, FIFRA

requires EPA and the States to establish programs to provide training to and certification of applicators, and to protect workers. It is important for surveillance program staff to have a basic understanding of FIFRA and the regulations that codify it. This will aid interagency cooperation since section

numbers of FIFRA are often used in referring to types of enforcement inspections and pesticide product registrations. This section provides a brief summary of the sections of FIFRA pertinent to surveillance for pesticide-related illness.

SECTIONS 1 AND 2: DEFINITIONS

FIFRA Sections 1 and 2 are a table of contents and definitions. Selected definitions that are particularly important for surveillance are as follows:

“PEST—The term pest means (1) any insect, rodent, nematode, fungus, weed or (2) any other form of

terrestrial or aquatic plant or animal life or virus, bacteria, or other micro-organism (except viruses,

bacteria, or other micro-organisms on or in living man or other living animals) which the

Administrator declares to be a pest under Section 25(c)(l).”

Note that the definition of pest is based only on humans deciding that a particular organism is deleterious or undesirable. An organism may be a pest to an individual or locale and may be considered a

desirable part of the ecosystem in another location. This is particularly true for plant species where

what is considered a weed in one area may be grown as a crop in another area. 

“Pesticide—The term pesticide means (1) any substance or mixture of substances intended for preventing, destroying, repelling, or mitigating any pest and (2) any substance or mixture of substances

intended for use as a plant regulator, defoliant, or desiccant, . . .”

Although the majority of the public tends to think of pesticides primarily as chemicals that kill pests,

it is important to note that this definition in FIFRA also includes products that repel, prevent, and mitigate pests.

“To Use Any Registered Pesticide in a Manner Inconsistent with its Labeling—The term to use any

registered pesticide in a manner inconsistent with its labeling means to use any registered pesticide in

a manner not permitted by the labeling, except that the term shall not include (1) applying a pesticide

at any dosage, concentration, or frequency less than that specified on the labeling unless the label

218

APPENDIX F 
specifically prohibits deviation from the specified dosage, concentration, or frequency, (2) applying a

pesticide against any target pest not specified on the labeling if the application is to the crop, animal,

or site specified on the labeling, unless the Administrator has required that the labeling specifically

state that the pesticide may be used only for the pests specified on the labeling after the Administrator

has determined that the use of the pesticide against other pests would cause an unreasonable adverse

effect on the environment, (3) employing any method of application not prohibited by the labeling

unless the labeling specifically states that the product may be applied only by the methods specified on

the labeling, (4) mixing a pesticide or pesticides with a fertilizer when such mixture is not prohibited

by the labeling, (5) any use of a pesticide in conformance with Section 5, 18, or 24 of this Act, or (6)

any use of a pesticide in a manner that the Administrator determines to be consistent with the purposes of this Act. After March 31, 1979, the term shall not include the use of a pesticide for agricultural or

forestry purposes at a dilution less than label dosage unless before or after that date the Administrator

issues a regulation or advisory opinion consistent with the study provided for in Section 27(b) of the

Federal Pesticide Act of 1978, which regulation or advisory opinion specifically requires the use of

definite amounts of dilution.”

This definition is a critical one for determining whether pesticides are used correctly, and it is frequently used at the State level when regulatory actions are taken.

SECTIONS 3, 4, AND 24(C): PESTICIDE REGISTRATION AND REREGISTRATION

The registration of pesticide products is covered under Sections 3 and 4 of FIFRA. The specific

requirements for product registration are covered in 40 CFR Parts 152 to 167. As already mentioned

this includes the review and “reregistration” of all pesticides. This also includes the review of pesticide product labels to ensure that they meet product labeling requirements codified in Part 156.

Products must be registered if they meet the definition of a pesticide under 40 CFR, Section 152.15;

and the product label or other materials indicate claims of pesticidal activity; or the product is represented in a manner that results in its being used as a pesticide. Requirements relating to worker protection are codified in 40 CFR 170; these will be discussed separately.

Products that are not considered pesticides and are exempt from FIFRA include those designed to control fungi, bacteria, viruses, microorganisms, or internal parasites/nematodes in living man or animals

and are labeled for that purpose (e.g., pharmaceuticals). Other nonpesticides are plant nutrients, soil

amendments, fertilizers, and disinfectants (including deodorizers and bleaching or cleaning agents)

that do not make pesticidal claims. 

Some additional products meet the definition of pesticides but are exempt from registration. These

include pesticides regulated by another Federal agency, such as certain biological control agents and

certain human drugs. Other exempted products with specific criteria are described in CFR 40 Section

152.25 and include treated articles or substances such as fabrics or paints where a registered pesticide

is used to preserve the product itself; pheromones and pheromone traps meeting particular labeling criteria; preservatives for biological specimens and foods; natural cedar (not including oils, extracts, or

mixtures); and minimum risk pesticides. Certain conditions allow pesticides to be transferred, sold, or

distributed without registration as specified in CFR 40 Section 152.30.

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APPENDIX F 
Six registration types are provided for in FIFRA: new, amended, supplemental, reregistration, renewal,

and Section 24(c) registrations. The requirements for submitting an application for registration are covered

in CFR 40 Sections 152.40 through 152.175. The new registration is strictly that (that is, registration for a

new pesticide product). An amended registration must be submitted if there is a proposed change in a

product’s composition, label, or packaging.

Reregistration and renewal refer to the processes for updating and reviewing previously approved uses

on the basis of new data and standards. Section 4 of FIFRA covers the complex process established for

reregistration. 

Supplemental registrations allow distributors to assign their own brand name to a product that is registered by the producer. The product must be the same composition and be produced, labeled, and

packaged in a registered establishment of the same producer. The supplemental product label must

make the same claims as the primary product (some claims may be deleted), the product must be in the

producer’s container, and the registration number must have the distributor’s company number added

as a suffix.

Section 24(c) registrations are also referred to as special local needs registrations. These are issued

when a State assigns an additional use for a federally registered product based on a local need. The

State gives the product a special local need registration number and informs the EPA of this action

within 10 days. The EPA then publishes the registration change in the Federal Register.

SECTION 5: EXPERIMENTAL USE PERMITS (EUPS)

EUPs are issued by the EPA to allow applicants to develop data needed to submit an application under

FIFRA Section 3. These permits have specific terms, conditions, and time limitations and may be

revoked at any time. A State with an approved State plan may issue EUPs.

SECTION 6: ADMINISTRATIVE REVIEW; SUSPENSION

This section provides the EPA with the authority to cancel and/or suspend a pesticide registration. A

registration must be canceled after 5 years if the registrant or an interested party does not request

renewal of the registration before the end of the 5 years. The registrant is also required to submit additional information about adverse effects that is obtained after the registration (Section 6[a] [2]). The

actual reporting requirements under this part of FIFRA were codified in 1997 by the addition of Part

159 to 40 CFR. The specific information that must be reported on toxic or adverse effect incident

reports are addressed in Section 159.184. For more information about the 6(a)(2) regulations and

reporting requirements, refer to http://www.epa.gov/pesticides/fifra6a2.htm.

The EPA may also issue a Notice of Intent to Cancel if there is information indicating that a pesticide,

its label, or other required material does not comply with FIFRA. A hearing process and additional

consultations are required as part of this process to cancel or reclassify a pesticide. Canceled pesticides

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APPENDIX F 
that are already in the channels of trade may be sold or used after cancellation unless this is specifically prohibited in the cancellation order. 

A suspension order may be issued after notifying the registrant and if EPA determines that there is an

“imminent hazard” to human health posed by the continued use of a pesticide during the time necessary for cancellation. (Note: There may also be hearings as part of a suspension order.) Typically, the

distribution, sale, or use is prohibited when a pesticide is suspended, although there are some circumstances when the sale or use of existing stocks is allowed.

SECTION 7: REGISTRATION OF ESTABLISHMENTS

This section requires that producers register establishments engaged in producing pesticide products

or active ingredients used in these products. EPA assigns an establishment number that is associated

with the name and address of the establishment. The types of records that must be maintained by establishments are described here. Specific annual reporting requirements exist for establishments and

descriptions of what portion of required information is considered confidential.

SECTION 11: USE OF RESTRICTED USE PESTICIDES; APPLICATORS

The certification of applicators by EPA or State designees is described in this section. It includes

requirements for making instruction on integrated pest management techniques available upon

request. It establishes that there should be separate standards for commercial and private applicators. 

SECTION 12: UNLAWFUL ACTS

A wide range of unlawful acts involving the sale, shipment, adulteration, registration, use, and testing

of pesticides are described in this section. The FIFRA amendments of 1972 added the following language that designates the label as a legal document: “to use any registered pesticide in a manner inconsistent with its labeling.”

SECTION 13: STOP SALE, USE, REMOVAL, AND SEIZURE

EPA or State designees are given the authority to issue stop sale, use, or removal orders if a pesticide

or device is in violation of any portion of FIFRA. This includes pesticides that have been canceled by

final order or suspended. The seizure of pesticides or devices through district court is prescribed for as

described below:

Pesticides that are adulterated or misbranded, not registered, improperly labeled, not colored, or

discolored as required by FIFRA

Product claims or directions for use are not those made in connection with its registration

Misbranded devices

A pesticide or device, when used in accordance with the requirements imposed by FIFRA and

according to the label, still causes unreasonable adverse effects on the environment

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APPENDIX F 
Disposition of seized pesticides or devices, associated costs, and court costs are also covered in this

section.

SECTION 18: EXEMPTION OF FEDERAL AND STATE AGENCIES

The EPA may exempt Federal or State agencies from any provision of FIFRA if it is determined that

there are emergency conditions that require such an exemption. A Federal or State agency may request

the determination from EPA that an emergency exists. EPA must consult with the U.S. Secretary of

Agriculture and the governor of the concerned State when making the determination.

SECTIONS 22, 23, 26, AND 27: DELEGATION AND COOPERATION

Section 22 allows the Administrator to delegate authority to employees and directs the Administrator

to cooperate with the U.S. Department of Agriculture (USDA) and appropriate State or political subdivisions to carry out the act and secure uniform regulations. Section 23 of FIFRA describes the

authority for cooperative agreements between EPA and States. Under Sections 26 and 27, when information of an alleged violation of FIFRA or complaints are received by EPA, these will be referred to

the State, and only “significant” complaints are tracked and followed by EPA. These sections authorize States to conduct inspections using Federal authority when such inspections are not authorized by

State statutes. Funding of cooperative programs is shared by EPA and the State participants. The state

may refer cases to EPA for Federal, civil, or criminal enforcement action. 

Worker Protection Standard (WPS)

Under the 1972 revisions to FIFRA, changes required new wording on labels to increase worker safety, and in 1974, rules were promulgated that specifically addressed worker protection in 40 CFR 170.

The 1974 changes were the addition of four basic requirements that pertained to hand laborers and

included the following: workers should not be directly sprayed with pesticides; re-entry into treated

areas was prohibited until dust was settled or spray dry with longer re-entry intervals for 12 specific pesticides; protective equipment was required for early re-entry; and “appropriate and timely warnings”

regarding pesticide applications. The rules exempted many operations that use pesticides and did not

include pesticide handlers. Reports of worker poisonings and concerns about the vagueness of the rules

caused EPA to review these standards in 1983. An extensive process led to proposed revisions released

in 1988. The final proposed rule was promulgated in 1992 and made changes to 40 CFR Part 170 and

40 CFR Part 156. These became fully effective in January of 1995.

Provisions of WPS include changes in labeling, an expanded scope of coverage to cover more workers and operations, prohibition of employer retaliation for attempting to comply with the standard, and

requirements for

warnings about pesticide applications

use of personal protective equipment (PPE)

restriction on re-entry into treated areas

222

APPENDIX F 
decontamination

emergency assistance

maintaining contact with handlers of highly toxic pesticides

pesticide safety training

Following WPS enactment, EPA initiated a process to evaluate the impact of the standard. More information about WPS, compliance guides, training materials, and a Field Inspection Pocket Guide can be

obtained from the EPA. (See Appendix G or go to http://www.epa.gov/pesticides/safety/workers/

amendmnt.htm.) This Web site also contains information about EPA’s ongoing assessment of WPS.

F.2 FEDERAL FOOD, DRUG, AND COSMETIC ACT (FFDCA)

This act requires the establishment of tolerances for the maximum amount of pesticide residues

allowed in or on human food and animal feed products. It is jointly administered by EPA and the Food

and Drug Administration (FDA).

F.3 FOOD QUALITY PROTECTION ACT (FQPA)

This law is a 1996 amendment to FIFRA and FFDCA, which changes the way standards are set for tolerances. It requires a health-based standard for assessing the risks of pesticide residues in food and

feed. This standard differs significantly from past approaches in that it requires evaluating aggregated

risk from dietary exposure as well as other nonoccupational sources of exposure such as drinking

water and residential pesticide use. It also emphasizes the risks to infants and children. Additionally,

EPA must consider cumulative exposure by evaluating the combined effects of different pesticides that

may act in similar ways on the human body. The law also established a new standard for evaluating

food-use pesticides: “reasonable certainty of no harm.” This is in contrast to the previous standard of

“no unreasonable adverse effects” that required a risk-benefit assessment. FQPA also requires reevaluation of all existing tolerances within 10 years. FQPA also

includes authority to require testing for endocrine effects

allows FDA to impose civil violations

requires that a brochure on the health effects of pesticides be placed in grocery stores and allows

States to require warnings or specific labeling of food that has been treated with pesticides

prevents States from setting tolerances that are different from the Federal levels (Note: There is a

process for exceptions)

sets a 15-year cycle for pesticide reregistration renewal and provides additional funding for EPA

processing of reregistration applications

provides a faster registration process for new, safer pesticides

establishes a minor use program to address EPA and USDA management of pesticides that have

minor uses

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APPENDIX F 
establishes new requirements for antimicrobial pesticides and clarifies jurisdiction 

establishes definitions and registration requirements for public health pesticides

establishes definitions and regulation of two new categories of pesticide applicators: (1) maintenance applicators and (2) service technicians

Appendix G contains references for more information about FQPA.

F.4 SAFE DRINKING WATER ACT (SDWA)

SDWA was enacted to protect the quality of surface and below-ground sources of drinking water. It

authorizes EPA to set standards for contaminants in drinking water including pesticides. As amended

in 1996, it includes establishment for screening and testing programs for a variety of chemicals and

pesticides, including endocrine effects of these chemicals.

F.5 OCCUPATIONAL SAFETY AND HEALTH ACT (OSH ACT)

The OSH Act was originally passed in 1970 and has undergone extensive amendments over the last 30

years. It provides for a safe and healthful working environment by giving authority to OSHA or its

State partners to develop standards and enforce them. The act allows civil and criminal penalties to be

issued for violations. There are 26 states with authorized State plans with standards that are at least as

strict as Federal standards codified in 29 CFR Parts 1900–2400. State programs are based in a variety

of State agencies depending upon the structure of State government; frequently the State OSH Act program is in the State bureau of labor or the State department of business and consumer affairs or equivalent. The State plans in Connecticut and New York cover only State and local government employees.

Federal OSHA maintains offices in the non-State plan States to enforce provisions of the OSH Act. 

At the Federal level, the interpretation of jurisdiction is that enforcement of issues associated with

labeled pesticide products are within the purview of the EPA. State plans may have stricter interpretations and separate agreements with EPA or the State agency EPA designee responsible for enforcing

FIFRA.

Responsibility for enforcing issues associated with the manufacture of pesticides prior to the placement

of a FIFRA registered label on a container would fall under OSHA. The general industry-relevant portions

of 29 CFR 1910 related to pesticide exposure are contained in

Subpart G—Occupational Health and Environmental Control (1910.94 to 1910.98)

Subpart H—Hazardous Materials (1910.101 to 1910.126) 

Subpart I—Personal Protective Equipment (1910.132 to 1910.139) 

Subpart J—General Environmental Controls (1910.141 to 1910.147 Appendix A) 

Subpart K—Medical and First Aid (1910.151 to 1910.152) 

224

APPENDIX F 
Subpart Z—Toxic and Hazardous Substances (1910.1000 to 1910.1450 and Appendices), which

includes air contaminants and hazard communication

A variety of other Federal regulations that involve pesticides are not highlighted in this manual since

they may not be relevant to pesticide poisoning surveillance. These include, but are not limited to, the

Resource Conservation and Recovery Act, the Clean Air Act, and the Endangered Species Act.

Surveillance programs may need to become familiar with these acts or State laws related to them to

address issues raised during particular case investigations. Other issues related to interagency coordination and overlapping jurisdictions are addressed in Chapters 5 and 6.

225

APPENDIX F 
APPENDIX G

RESOURCES FOR ADDITIONAL

INFORMATION RELATED TO

PESTICIDE POISONING

SURVEILLANCE
RESOURCES FOR ADDITIONAL INFORMATION RELATED TO

PESTICIDE POISONING SURVEILLANCE

Contents

G.1 General Pesticide Resources

G.2 Recognition and Management of Pesticide Poisoning, Including Materials for HCPs

G.3 Pesticide Toxicology

G.4 Pesticide Products

G.5 Pesticide Usage

G.6 Pesticide Safety and Health Information to Assist Workers and Employers 

G.7 Farmworker Employment, Demographics, Cultural Issues, and Service Organizations

G.8 Nonoccupational Exposure Issues (Homeowner, Schools, Vector Control, etc.)

G.9 State PPSP Contact Information

G.10 Federal Agency Contact Information

G.11 Agricultural Safety and Health (Other Than Pesticides)

This chapter serves as a starting point for any new PPSP to develop their own list of resources. Any

compendium of this nature is always incomplete and becomes outdated. Efforts have been made to

select references and resources that should remain available and are updated periodically. It includes

resources that existing PPSPs find particularly useful. Listings and links are not an endorsement or

guarantee of the accuracy of any Web site, publication, or other resource material. Also, any mention

of specific products or laboratory resources are not an endorsement and are provided purely for informational purposes. 

G.1 GENERAL PESTICIDE RESOURCES

Several Internet Web sites are particularly useful when looking for information about any aspect of

pesticides including regulation, toxicology, safety and health, and medical management. Links to most

of the resources listed in this chapter can also be found at these sites.

California Department of Pesticide Regulation (CDPR)

http://www.cdpr.ca.gov/docs/dprdocs/docsmenu.htm

This site provides links to publications from the different CDPR programs. Subject areas include

enforcement and worker safety (note that searches for publications including useful research reports

may be done from a link in this section) and environmental monitoring. 

229

APPENDIX G 
Canadian Center for Occupational Health and Safety (CCOHS) Health and Safety

Internet Directory

http://www.ccohs.ca/resources/hshome.html

This site has links to a large number of sites that address a broad range of occupational safety and

health issues. It is divided into subject areas and also has a section on recently added links.

Duke Occupational and Environmental Medicine

http://gilligan.duhs.duke.edu/oem/default.htm

This site provides many resources in the area of occupational and environmental medicine. A link connects to the National Library of Medicine to conduct literature searches. This page provides links to a

moderated e-mail list that is used by many health care and public health professionals to exchange

information and pose questions related to practice. Also at this site is a link to Duke’s OEM WWW

resource list that contains links to many of the sites referenced in this chapter. 

Pesticide Management Resource Guide

http://www.epa.gov/oppfead1/pmreg/

This EPA electronic resource compendium likely contains a link that can help you find what you need.

The guide can be searched by subject, title, source, or full text. The general subject areas include alternative pest control methods (including IPM), bibliographic information, chemical and physical properties, chemical identification, environmental effects and fate, pesticide exposure in food, occupational pesticide exposure, formulation, information exchange, regulatory issue topics, training to develop

pesticide regulatory staff, and worker safety. All listings contain summary information, how to access

the resource, whether there is a cost, and some additional information about the resource when available (e.g., intended audience, language, updates, etc.).

University of Nebraska

http://pested.unl.edu/

This Web site contains a broad range of links related to pesticides. The links are categorized as follows:

IPM, Education, Health and Safety, Databases, Laws and Regulation, Newsletters, Environmental

Protection, Organizations, and Product Manufacturers. It also provides access to electronic versions

of training materials from the Nebraska Agricultural Extension Service.

G.2 RECOGNITION AND MANAGEMENT OF PESTICIDE POISONING, INCLUDING

MATERIALS FOR HCPS

This section provides information about resources related to the clinical recognition and management

of pesticide poisoning. Resources Section G.3 Pesticide Toxicology also contain clinically relevant

information.

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APPENDIX G
G.2.1 PESTICIDES AND HUMAN HEALTH CONCERNS

G.2.1.1 Telephone Hotlines

Local and Regional Poison Control Centers (PCCs)

Local and regional PCCs provide case management information to HCPs who contact them. They provide assistance in identifying products and the constituent ingredients involved in poisonings. Poison

centers also answer inquiries from the public, providing immediate first-aid information and referring

individuals to seek medical consultation as needed. Poison centers also conduct public education campaigns to prevent poisonings. Some poison centers have additional functions including contractual

relationships with certain manufacturers to provide information on product safety and health, and case

management. In 2002, the American Association of Poison Control Centers (AAPCC) established a

toll-free number (1-800-222-1222) that routes a caller to the PCC closest to them. Many PPSPs have

found PCCs to be an important source of case reports. An up-to-date list of PCCs is available at

http://www.aapcc.org/.

National Pesticide Information Center (NPIC) 

http://npic.orst.edu/index.html 

NPIC is an EPA-funded resource available to the general public and HCPs. This is a toll-free telephone

service that provides information about pesticide toxicology, environmental chemistry, and other productspecific information as well as recognition and management of pesticide poisoning. NPIC staff will

refer callers to other resources as needed. NPIC’s Web site provides ready access to EXTOXNET

(the Agriculture Extension Service’s library of information about pesticide toxicology) and to public

consumer-oriented EPA publications. Telephone, Internet, electronic and mail access to fact sheets,

brochures, and NPIC’s annual reports are available from this resource.

Oregon State University

333 Weniger Hall; Corvallis, OR 97331-6502

E-mail: npic@ace.orst.edu

Telephone: 1-800-858-7378

Fax: 541-737-0761

Hours: 6:30 am-4:30 pm Pacific time, daily, except holidays.

The National Antimicrobial Network (NAIN) was the companion program addressing concerns about

antimicrobial products (disinfectants, sterilants, and sanitizers), but it was discontinued March 31,

2002. For further information or assistance regarding antimicrobial products, contact the

Antimicrobial Division in the EPA Office of Pesticide Programs by calling 703-308-0127, sending a

fax to 703-308-6467, or e-mailing Info_Antimicrobial@epa.gov.

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APPENDIX G
National Pesticide Medical Monitoring Program (NPMMP)

http://oregonstate.edu/npmmp/

NPMMP provides informational assistance in the assessment of human exposure to pesticides.

NPMMP has a close relationship with NPIC. Both programs are based at the same location at OSU.

Most of the inquiries received by NPMMP are referred from NPIC. When HCPs or others call NPIC

in need of immediate medical information, they can usually be directly transferred from NPIC to the

NPMMP. NPMMP also receives information requests from the general public and Federal and State

agencies. NPMMP maintains a large paper and electronic library of information that is available upon

request. Finally, NPMMP has limited funds to support the environmental investigation of suspected

exposures using laboratory analyses.

G.2.2 PUBLICATIONS FOR HCPS

Recognition and Management of Pesticide Poisoning, 5th ed. 1999

http://www.epa.gov/oppfead1/safety/healthcare/handbook/handbook.htm

JR Reigart, JR Roberts, eds. Publication No. EPA 735BRB98B003

Environmental Protection Agency; Office of Prevention, Pesticides and Toxic Substances

Ariel Rios Building, 1200 Pennsylvania Avenue, N.W., Washington, DC 20460

Cost: Free. (This publication is also available in Spanish.) To order 1 to 5 copies, call 703-305-7666

(Fax: 703-308-2962); for 6 or more copies, use the following:

U.S. EPA, National Service Center for Environmental Publications

PO Box 42419, Cincinnati, OH 45242-0419

Telephone: 800-490-9198

Fax: 513-489-8695

Internet: http://www.epa.gov/ncepihom

Case Studies in Environmental Medicine

Department of Health and Human Services, Public Health Service, Agency for Toxic Substances and

Disease Registry (ATSDR)

Self-instruction for primary HCPs. Continuing medical education (CME) credits are available through

ATSDR. Pertinent case studies include the following:

Arsenic

Chlordane

Cholinesterase inhibiting pesticides

Pentachlorophenol

Reproductive/developmental hazards

232

APPENDIX G 
Skin lesions

Taking an exposure history (with an additional erratum document)

Cost: Free–There is a charge for CME. Some case studies can be downloaded in PDF format. An

order form for case studies in print format can be downloaded from ATSDR at http://www.atsdr.cdc.gov/

HEC/CSEM/status.html 

To request copies of ATSDR Case Studies, call 404-498-0265, or contact:

Continuing Education Coordinator, ATSDR

Division of Health Education and Promotion, EB33

1600 Clifton Road, NE; Atlanta Georgia 30333

Environmental Health in Family Medicine

This is a set of self-teaching modules on aspects of environmental health pertinent to family medicine

and primary care, which includes a pesticide training module with pediatric, adult, and geriatric cases.

The curriculum can be downloaded from the International Joint Commission at http://www.ijc.org/rel/

boards/hptf/modules/content.html. 

Guidelines for Physicians Who Supervise Workers Exposed to CholinesteraseInhibiting Pesticides, 4th ed., 2002

Pesticide and Environmental Toxicology Section, Office of Environmental Health Hazard Assessment

(OEHHA), California Environmental Protection Agency, Oakland, CA. 

Office of Environmental Health Hazard Assessment

Pesticide and Environmental Toxicology Section

1515 Clay Street, 16th Floor; Oakland, CA 94612

Telephone: 510-622-3170

Cost: Free–PDF version available at http://www.oehha.ca.gov/pesticides/programs/Helpdocs1.html

Handbook of Pediatric Environmental Health, 2nd ed., 2003

RA Etzel, SJ Balk, eds.; American Academy of Pediatrics, Elk Grove Village, IL

This book is designed for pediatric HCPs and contains a chapter on pesticides.

American Academy of Pediatrics; PO Box 927,

141 Northwest Point Boulevard; Elk Grove Village, Il 60009-0927

Cost: $44.95. This book can be ordered online from the bookstore at http://www.aap.org/

Occupational Skin Disease, 3rd ed., 1999

RM Adams, J Fletcher, eds. W B Saunders, Philadelphia, PA.

This is a useful reference that covers contact dermatitis, contact urticaria, systemic toxicity arising

from percutaneous absorption, and other relevant topics.

233

APPENDIX G
Pesticide Exposure and the Health Care Professional’s Access to Pesticide

Application Record Information

http://www.ams.usda.gov/science/sdpr.htm

This brochure describes licensed HCPs’ legal right of access to pesticide application records from certain pesticide applicators when the records may help in diagnosis and treatment of an exposed person.

To obtain copies of this brochure or to request permission to customize the brochure with State-specific

information, contact: 

Pesticide Recordkeeping Program Staff

USDA Agricultural Marketing Service

Science and Technology, Pesticide Records Branch

87000 Centerville Road, Suite 202; Manassas, VA 20110

Telephone: 703-330-7826

E-mail: amspesticide.records@usda.gov

Pesticide Poisoning Symptoms and First Aid, 2002

http://muextension.missouri.edu/xplor/agguides/agengin/g01915.htm

F Fishel, P Andre. MU Extension, University of Missouri-Columbia. Publication G 1915.

Electronic and PDF versions are available.

Cost: $.75-To order hard copies, call 1-800-292-0969.

Pesticide Dermatoses, 2001

H Penagos, M O’Malley, H Maibach. CRC Press, Boca Raton, FL. 

This is a comprehensive reference on skin reactions to pesticides, which includes diagnosis, treatment,

and testing methods with case studies. 

Pesticides and Epidemiology, 2003

http://www.btny.purdue.edu/Pubs/PPP/PPP-43.pdf

F Whitford, J Acquavella, C. Burns. Purdue Pesticide Programs, Purdue University Cooperative

Extension Service, West Lafayette, IN. Publication PPPB43.

A brief primer on pesticide epidemiology useful for explaining pesticide epidemiology to a wide variety of audiences.

234

APPENDIX G 
G.2.3 INTERNET RESOURCES

The following case study modules and clinical resources are available on the Internet.

Association of Occupational and Environmental Clinics (AOEC)

http://www.aoec.org/LLDIR.htm#Peer-reviewed%20Module

This association represents a network of clinics and occupational/environmental health specialists.

Resources include a lending library of educational materials, environmental health-related course syllabi, and bibliographic references for HCPs. A helpful series of PowerPoint presentations on pesticide

illness is available. 

AOEC; 1010 Vermont Avenue NW, Suite 513

Washington, DC 20005

Telephone: 202-347-4976

Children’s Environmental Health Case Study Series 

http://www.uic.edu/sph/glakes/kids/case1/about.htm 

This is from a project funded by AOEC, ATSDR, and EPA. A pediatric environmental health case

study is included.

EnviroDx

http:/medlib.med.utah.edu/envirodx.

This is a multimedia computer-based learning program on environmental-related disease. It is a casefocused system described as a virtual clinic. The reader views video clips that provide the clinical history. Physical exam and test findings are provided. The reader is then provided an opportunity to

select the diagnosis from a multiple choice list. A video clip of the prevention counseling provided to

the patient is also available.

EnvirRn

http://envirn.umaryland.edu/

This Web site offers a broad spectrum of information about environmental health from a nursing perspective and includes educational and resource links. A pesticide case study is on this Web site

(http://envirn.umaryland.edu/interventions/pestcase.htm).

235

APPENDIX G
Pesticide Poisoning Diagnostic Tool (Poisoning Database)

http://www.pesticideinfo.org/Search_Poisoning.jsp

This tool, developed by PANNA, is designed to help HCPs and others recognize, diagnose, and report

pesticide-related illnesses. The database currently provides symptom, first aid, and treatment-related

information for approximately 1,900 pesticides. It can be searched for possible pesticide poisoning

agents by entering as little or as much relevant information as is available. Searches by chemical or

product name, pesticide use type, geographic location, and/or crop or application site are possible. In

addition, a HCP (or other user) can search by observed signs and symptoms. This online resource also

provides reporting information (legal requirements, reporting instructions, and official reporting contacts) for all 50 States. The database lists specific county-level reporting information for California and

Florida.

Pesticide Use on Airlines

http://ostpxweb.dot.gov/policy/Safety%20Energy%20Env/disinsection.htm

There is concern about pesticide exposures of workers and passengers in the air transportation industry. Some countries require arriving international flights to undergo disinsection. Disinsection involves

either spraying aerosol insecticide in the cabin with airline passengers present, or applying a residual

insecticide to the cabin when passengers are not present. The Web site provides more information on

this topic, including a list of airline contacts and a list of countries that require disinsection.

Specific Medical Tests Published in the Literature for OSHA Regulated Substances

http://www.cdc.gov/niosh/nmed/medstart.html 

This resource on medical tests for particular chemicals is on the NIOSH Web site. This site provides

information about specific medical tests that have been published for OSHA regulated substances, and

includes some pesticides. 

G.2.4 ADDITIONAL RESOURCES RELATED TO HCP TRAINING ON RECOGNITION

AND MANAGEMENT OF PESTICIDE POISONING

This section includes background material related to curricula for health provider training programs.

NIOSH Agricultural Health and Safety Centers

The NIOSH Agricultural Health and Safety Centers offer seminars (usually jointly sponsored with other partners) on pesticide medicine. They can provide information about the curriculum used for those

seminars. See Section G.11 Agriculture Safety and Health for contact information. 

236

APPENDIX G 
Pesticides and National Strategies for HCPS

http://www.neetf.org/Health/providers/index.shtm

There is an ongoing national initiative for increasing HCP education and training to improve recognition, management, and prevention of pesticide-related health conditions. This is a long-term, collaborative process created by the EPA, U.S. Department of Health and Human Services (DHHS), U.S.

Department of Agriculture, and the National Environmental Education and Training Foundation

(NEETF). The initiative advocates the education of health professionals while they are in school as

well as developing model programs and practice guidelines to incorporate pesticide poisoning recognition, management, and prevention into the health care setting. The development and dissemination

of training curricula and other resources targeted at practicing HCPs have also been proposed. To

obtain Pesticides and National Strategies for HCPs: Pesticides Initiative, National Pesticide

Competency Guidelines for Medical & Nursing Education, or National Pesticide Practice Skills

Guidelines for Medical and Nursing Practice and other publications as they become available, contact

NEETF.

National Environmental Education & Training Foundation

1707 H Street, NW; Suite 900; Washington, DC 20006

Telephone: 202-261-6481

http://www.neetf.org 

The NEETF Pesticides Resource Library Web site is

http://www.neetf.org/Health/Pestlibrary.shtm 

G.2.5 PESTICIDES AND ANIMAL HEALTH CONCERNS

National Animal Poison Control Center

http://www.aspca.org/site/PageServer?pagename’apcc

This is a nonprofit PCC that addresses concerns and provides veterinary diagnostic and treatment

information for poisoned animals. It requires a fee-for-service, which is paid by the animal owner, veterinarian, or a product manufacturer.

ASPCA National Animal Poison Control Center (member of AAPCC)

1717 South Philo Road; Suite 36 Urbana, IL 61802 

Emergency Telephone: 888-426-4435

G.3 PESTICIDE TOXICOLOGY (ALSO SEE SECTION G.4 PESTICIDE PRODUCTS)

This section lists toxicological resources that provide information about pesticides. The listed

resources include a few books that the PPSP may choose to include in a basic library. The Internetbased data resources can be accessed free of charge. Many other proprietary Internet-based data systems

are not listed here.

237

APPENDIX G 
G.3.1 PUBLICATIONS

Casaret and Doull’s Toxicology: The Basic Science of Poisons, 6th ed., 2001

CD Klaassen, ed. McGraw-Hill, Medical Publishing Division, New York, NY.

This is a standard toxicology text that includes chapters on pesticide toxicology and occupational toxicology, in addition to sections on principles of toxicology and other aspects of toxicology.

Clinical Environmental Health and Toxic Exposures, 2nd ed., 2001

JB Sullivan, GR Krieger, eds. Lippincott Williams & Wilkins, Philadelphia, PA. 

This clinical reference on environmental toxicology has sections on workplace and emergency responses

to hazardous material exposures and information about specific exposures including pesticides.

Handbook of Pesticide Toxicology, 2nd ed., 2001

RI Krieger, ed. Academic Press, San Diego, CA

This is a two-volume set that covers a wide variety of topics and includes toxicology reviews on many

classes of pesticides.

The Pest Book, 5th ed., 2000

GW Ware. Thomson Publications, Fresno, CA

This reference covers chemistry, mode of action, and issues related to handling of pesticides.

Toxicology of the Eye: Effects on the Eyes and Visual System from Chemicals,

Drugs, Metals and Minerals, Plants, Toxins, and Venoms, 4th ed., 1999

WM Grant, JS Schuman. Charles C. Thomas Pub., Ltd., Springfield, IL.

This reference on toxicology of the eye includes information about some pesticides and some chemicals used as inerts and carriers in pesticide products.

G.3.2 INTERNET DATA RESOURCES

The sites listed here contain toxicological data on pesticides. While many other sources are available,

those listed provide links to other sources and are a good starting point.

EPA Reregistration Eligibility Decision Documents (REDs) 

The REDS can be a useful source of toxicology information since they contain regulatory reviews of pesticides that were first registered before November 1, 1984. FIFRA requires that these active ingredients be

238

APPENDIX G 
reviewed to determine if they can be reregistered (that is, they must not cause unreasonable risks to people or the environment when used in accordance with the approved label). These documents can be

accessed from the EPA Office of Pesticide Programs home page at http://www.epa.gov/pesticides, or be

ordered from the National Service Center for Environmental Publications (NSCEP).

EXTOXNET

http://ace.ace.orst.edu/info/extoxnet/

EXTOXNET–The EXtension TOXicology NETwork–is a useful source of toxicology-related information about pesticides. The toxicological information in this data system is developed cooperatively

by the University of California-Davis, Oregon State University, Michigan State University, Cornell

University, and the University of Idaho.

Hazardous Substances Data Bank (HSDB)

http://toxnet.nlm.nih.gov

The HSDB is one of the toxicology data files in the National Library of Medicine’s Toxicology Data

Network (TOXNET7). It includes information about human exposure, industrial hygiene, emergency

handling procedures, environmental fate, and regulatory requirements. The sections on treatment

include much of the information that is found in the POSINDEX7 data system used by PCCs.

INCHEM

http://www.inchem.org/ 

This site is produced by the International Programme on Chemical Safety (IPCS), which is a cooperative program of the World Health Organization (WHO), International Labor Organization (ILO), and

the United Nations Environment Programme (UNEP). It provides access to several series of documents produced by WHO and its partners. The information sources that will likely be of greatest use

to PPSPs are described below. Additionally, this Web site has International Agency for Research on

Cancer (IARC) summaries, evaluations of the toxicity of pesticide residues in foods, and information

on non-pesticide chemicals and pesticidal inert ingredients.

Environmental Health Criteria Monographs

This is a series of monograph publications from the WHO. Many of these monographs describe

the characteristics and effects of pesticides on humans and animals. Each monograph on a class

of compounds covers physical properties and analytical methods, sources of exposure, information about environmental transport and fate, review of human and animal health effects, and risks.

Health and Safety Guides 

A more simply worded general use series on a range of chemicals that includes risks of exposure,

summary information about effects, and medical and administrative issues related to exposure.

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APPENDIX G 
Pesticide Data Sheets

These are peer-reviewed fact sheets that give basic toxicologic information about pesticides in

broad worldwide use, as well as those that have been found to be particularly hazardous. There is

some duplication with fact sheets available from the EXTOXNET site. It also includes information about products registered for use outside of the United States. 

Poison Information Monographs 

This peer-reviewed series emphasizes the health effects related to exposure from a variety of pesticides and other toxins. It includes information about patient evaluation and management.

Integrated Risk Information System (IRIS)

http://www.epa.gov/iriswebp/iris/index.html or http://toxnet.nlm.nih.gov

IRIS is a database on the human health effects that may arise from environmental chemical exposure.

It provides specific hazard and dose response information. It is designed for users with knowledge

about toxicology and life sciences. This system also provides information to aid users in accessing and

understanding IRIS data.

PAN Pesticide Database

http://www.pesticideinfo.org/Index.html

This database has been compiled by PANNA and includes peer-reviewed scientific information about

pesticide products and ingredients. Information about acute and chronic health effects, and ecotoxicity is summarized from a number of sources including the EPA, IRIS, National Toxicology Program,

International WHO, National Toxicology Program (NTP), National Institutes of Health (NIH),

International Agency for Research on Cancer (IARC), the European Union (EU), and the State of

California. 

G.4 PESTICIDE PRODUCTS

G.4.1 DATABASES ON PESTICIDE PRODUCTS

These data systems provide the PPSP with the ability to search and identify pesticide products, formulations, ingredients, and regulatory status. 

The California Pesticide Databases––USEPA/OPP Pesticide-Related Database Queries 

http://www.cdpr.ca.gov/docs/epa/epamenu.htm

The California Department of Pesticide Regulation (CDPR) has developed a query system using data

from the US EPA Office of Pesticide Programs (OPP) pesticide product information system (PPIS).

(The PPIS system is also used to develop the pesticide ingredient and product information used in the

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APPENDIX G 
SPIDER surveillance database system.) The databases found at this site include a pesticide product

database, a chemical ingredient database, and a pesticide manufacturer database. In addition, links are

provided to pesticide label images located at EPA.

PAN Pesticide Database

http://www.pesticideinfo.org/Index.html

This database has been compiled by the PANNA and includes peer-reviewed scientific information

about pesticide products and ingredients. The system can be searched by pesticide product name or

registration number. A variety of advanced searches can be performed (e.g., a search for all products

containing a particular active ingredient). Information about acute, chronic and ecotoxicity is summarized from a number of sources including the EPA, IRIS, National Toxicology Program, WHO,

National Toxicology Program (NTP), National Institutes of Health (NIH), International Agency for

Research on Cancer (IARC), the European Union (EU), and the State of California.

G.4.2 PESTICIDE PRODUCT LABELS

There are several Internet sources for obtaining pesticide product labels. In addition to these sources,

the label as registered in each State is available from the State department of agriculture (or other

designee responsible for registration).

EPA pesticide product label system

http://www.epa.gov/pesticides/pestlabels/

The EPA pesticide product label system is a collection of images of product labels that have been

approved by OPP. (Labels are in TIFF format.) Apart from the label, additional correspondence and

amended labels are included in the system. Because the system is indexed by the product registration

number, you will first need to enter this number. The CDPR site is a useful source of registration numbers,

and it can be searched for all federally registered products (and their corresponding registration number)

by active ingredient, product name or company name (http://www.cdpr.ca.gov/docs/epa/epamenu.htm).

Greenbook

http://www.greenbook.net 

The Greenbook is produced by the Chemical and Pharmaceutical Press. Labels, supplemental labels,

and MSDSs are obtained from the pesticide companies and compiled into a variety of formats (book,

CD-ROM, Internet access).

G.4.3 MATERIAL SAFETY DATA SHEET (MSDS) DIRECTORIES

In addition to the Greenbook site described above, several other sites contain pesticide product

MSDSs. Some entries in Section G.1 also contain links to MSDS directories. PPSPs have found the

following sites to be useful:

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APPENDIX G 
CDMS Label / MSDS Information

http://www.cdms.net/manuf/manuf.asp

Vermont SIRI MSDS Collection

http://www.siri.org/msds/links.html

Where to find MSDS on the Internet

http://www.ilpi.com/msds/index.html

There is no directory of Spanish language MSDSs for pesticide products registered in the United

States. Some manufacturers have MSDSs in Spanish for particular products that are available on

request. These MSDSs are not posted on Web sites, and therefore require a telephone or written request

to the manufacturer. See the following link for further information about this issue:

http://www.ilpi.com/msds/faq/parte.html#foreign.

G.4.4 PESTICIDE MANUFACTURERS

The following sites contain links to pesticide manufacturers:

Croplife America 

http://www.croplifeamerica.org

This is a nonprofit trade organization for the crop protection, pest control, and biotechnology industries. Their Web site has links to many pesticide manufacturers. 

NPIC

http://npic.orst.edu/manuf.htm

PestWeb 

http://www.pestweb.com/ 

This is a pest control industry Web site that contains links to many manufacturers.

University of Nebraska

http://pested.unl.edu/

G.5 PESTICIDE USAGE

Information about pesticide use can be helpful during the process of developing a PPSP and in analyzing and evaluating PPSP data. There is no comprehensive source of pesticide use information. Some

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APPENDIX G 
systems collect data on a segment of pesticide applications while others conduct periodic surveys to

obtain data and create estimates of pesticide usage. Six States mandate some form of pesticide use

reporting: Arizona, California, New Hampshire, New York, New Jersey, and Oregon. Not all of these

State systems provide data in a readily accessible format. Other States are in varying stages of developing or exploring the development of pesticide use reporting systems. This section will briefly

describe some sources of available data and reviews of data. Other sources of data not described here

include Federal and State systems that monitor pesticide residues in food.

G.5.1 DATA SOURCES

California Environmental Protection Agency, CDPR

http://www.cdpr.ca.gov/docs/dprdocs/docsmenu.htm

CDPR within the California Environmental Protection Agency has maintained a database since 1970,

which includes use of restricted use pesticides by farmers and all applications by pest control operators. In 1990, the system changed to require that all agricultural pesticide use be reported on a monthly basis. Agricultural use is broadly defined within this system and includes right-of-way, park, and

golf course applications. An overview of this pesticide use reporting system and reports are under the

topic heading of Pesticide Sales and Use. This data is also accessible at the PANNA site

(http://www.pesticideinfo.org/Search_Use.jsp).

EPA

http://www.epa.gov/oppbead1/pestsales/

EPA has conducted surveys to obtain information about homeowner and commercial pesticide use.

This data and USDA agricultural pesticide-use data have been combined to produce estimates of pesticide use in agricultural and nonagricultural sectors. The most recent sales and usage reports are available from the NSCEP or on the web as a PDF file. 

New York Department of Environmental Conservation (NYDEC)

http://www.dec.state.ny.us/website/dshm/pesticid/prl.htm

This State enacted pesticide reporting legislation in 1996. The NYDEC initiated data collection February

1, 1997. The system collects information about pesticide use by commercial pesticide applicators, sales

of restricted-use pesticides to farmers, and sales of restricted-use pesticides to commercial applicators

and dealers. A description of the program and a link to data reports is available at their Web site.

243

APPENDIX G 
United States Geologic Survey, National Water Quality Assessment Program

http://water.usgs.gov/nawqa/

This program started in 1991 and assesses trends in water quality. Pesticides are considered an important issue in this program. Data and maps describing pesticides in streams, groundwater, and sediments, along with methodology, are available.

USDA

National Agricultural Statistics Service (NASS) 

http://www.usda.gov/nass/offices.htm

The NASS conducts a variety of surveys on the use of pesticides and fertilizers on farms and ranches.

Annual reports are available from this system that list chemical application rates and acres treated for

major crops. Information about some fruit and vegetable crops is reported in alternate years. The

NASS has 45 local field offices that work with State agencies and organizations to collect survey data.

State reports are released on a periodic basis. A listing of State NASS offices and access to reports is

available at the NASS Web site. 

Census of Agriculture

http://www.nass.usda.gov/census

Originally conducted by the Census Bureau, the Census of Agriculture collects data on agricultural

production and provides data down to the county level. It has been conducted in some form since 1840,

initially every 10 years. It has been conducted every 5 years since 1925, currently on a schedule of

years ending in 2 and 7. The survey collects information about land use, ownership, acreage, production, economic information, number of hired farmworkers, injuries and deaths, and chemical, fertilizer and machinery use. Available reports include an atlas of maps prepared from these data.

Other USDA Reports

http://usda.mannlib.cornell.edu/ess_entry.html

Other relevant agricultural reports can be obtained from the USDA Economics and Statistics System,

which incorporates a variety of USDA datasets.

G.5.2 REVIEWS OF PESTICIDE USE DATA SOURCES

Two documents have reviewed the availability of pesticide use data in the last few years. These

reviews were done for different purposes. Each describes available data and gaps in data.

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APPENDIX G 
Oregon Pesticide Use Reporting System: Analytical Review. May 2000

The information presented in this report was gathered and formatted by staff of the Oregon Health

Sciences University (OHSU) and Oregon State University (OSU), under contract with the Oregon

Department of Agriculture (ODA). The report provides information to be considered by ODA in the

development and implementation of the Oregon Pesticide Use Reporting System and can be obtained

from ODA or downloaded from http://oda.state.or.us/purs/history/anreview/index.html.

Oregon Department of Agriculture, Pesticides Division

635 Capitol Street N.E.; Salem, OR 97301-2532

Telephone: 503-986-4635

The Toxic Treadmill. Pesticide Use and Sales in New York State, 1997–1998 

Audrey Thier, Environmental Advocates, and New York Public Interest Research Group. October,

2000 (Revised 3/29/01). This report reviews and critiques pesticide use reporting in New York State

and is available at http://www.eany.org/.

G.6 PESTICIDE SAFETY AND HEALTH INFORMATION TO ASSIST WORKERS AND

EMPLOYERS

A large body of information is available on this subject. This section highlights some of the core publications, electronic documents, and electronic listings of training materials and other resources.

American Association of Pesticide Safety Educators

http://aapse.ext.vt.edu/aapse.html

This is an association of persons and organizations involved in providing education on pesticide safety.

The Web site provides links to State resources, a speakers bureau, EPA regulations, newsletters, and

journals. It has tools for developing and presenting training programs and also provides access to

materials for evaluating pesticide applicator training programs.

Association of Farmworker Opportunity Programs (AFOP)

http://www.afop.org

Radio Pesticida. Set of six cassettes with a guide, includes five mini-dramas and five accompanying

talk shows addressing drift, exposure, and safety at home and work. 

Cost: $50.00. Tapes are in Spanish, and the training manual is in English and Spanish.

Radio Pesticide, Haitian Creole version: $25.00

Telephone: 703-528-4141

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APPENDIX G 
Bibliography for Trainers of Farmworkers Under the Worker Protection

Standard, 2000

Melissa Frisk, Institute for Agriculture and Trade Policy. 

This document is an annotated listing of more than 75 resources for training farmworkers in pesticide

safety. Contact information for ordering resources is included. (45 pages)

Cost: $3.00 (including postage). Available online as a PDF document.

Contact: Candace Falk, Institute for Agriculture and Trade Policy (IATP)

2105 First Avenue South; Minneapolis, MN 55404

Telephone: 612-870-3453

Fax: 612-870-4846

E-mail: cfalk@iatp.org

Web site: http://www.iatp.org/labels/ (Click on the Resources button on the left, then click on the

library tab near the top and select the pull-down selector for by IATP staff to locate the document.)

California Department of Pesticide Regulation (CDPR)

The CDPR Worker Health and Safety Branch produce the Pesticide Safety Information series to assist

employers to comply with regulatory training requirements. The series is available in English and

Spanish and covers both crop and noncrop settings. All of the documents are available in PDF format

from http://www.cdpr.ca.gov/docs/whs/psisenglish.

The Worker Health and Safety Reports are an additional series of publications that address other worker health and safety issues. A search for these reports can be made using a keyword or publication number at http://www.cdpr.ca.gov/docs/whs/whsrep.htm.

Croplife America 

www.croplifeamerica.org 

A crop protection, pest control, and biotechnology industry nonprofit trade organization site that contains worker safety and health information under its Stewardship and Publication links. Topics include

safe work practice information in English and Spanish and storage and disposal information. Guidance

documents designed as tips for pesticide users are also available. A list is available of things a grower

should be aware of when working with aerial applicators, including the need to provide advance notification to neighbors and workers.

EPA

http://www.epa.gov/pesticides/health/worker.htm

The EPA has many educational resources available on worker safety and training.

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APPENDIX G 
Pesticide Education–University of Nebraska

http://pested.unl.edu/

This Web site provides links to the Nebraska Agricultural Extension pesticide safety education

resources as well as links to other sites.

Pesticide Safety Teaching Resources, VA Tech List

http://www.vtpp.ext.vt.edu/htmldocs/trainres.html

This Web site contains links to resources for teaching pesticide safety. 

Thomson’s Spanish-English English-Spanish, Illustrated Agricultural Dictionary

RP Rice, Jr. [1993] Thomson Publications, Fresno, CA

An illustrated dictionary of terms used in agriculture, including tools, irrigation, animals, crops, and

plant propagation, with a broader non-illustrated section that includes terms related to pesticides and

pesticide application.

University of California Statewide IPM Program

http://anrcatalog.ucdavis.edu

This program offers a wide range of high quality publications on integrated pest management (IPM)

and safe application of pesticides. A few publications of interest are listed here by title, with year of

publication. The relevant publications are listed under the headings of Pest and Disease Management

and Pest Control Training and DPR Test Materials in the Agriculture and Natural Resource (ANR)

Catalog.

• Establishing IPM Policies and Programs: A Guide for Public Agencies, 2003.

• La seguridad en el manejo de pesticidas, 1999.

• Illustrated Guide to Pesticide Safety, 1999. (Instructor version; worker versions in English,

Spanish, and Punjabi)

• Jorge’s New Job: Getting Tested for Cholinesterase, 2000. (English and Spanish)

• La lotería de los pesticidas, 1992. (Spanish/English pesticide safety training game with trainer’s

manual)

247

APPENDIX G 
University of California; Agriculture and Natural Resources (ANR) Communications Services

6701 San Pablo Avenue; Oakland CA 94608-1239

Telephone: 1-800-994-8849

Fax: 510-643-5470 

G.7 FARMWORKER EMPLOYMENT, DEMOGRAPHICS, CULTURAL ISSUES, AND

SERVICE ORGANIZATIONS

G.7.1 EMPLOYMENT ISSUES

Migrant and Seasonal Agricultural Worker Protection Act (MSPA) 

(29USC', et seq.)

This act provides legal protections for migrant and seasonal agricultural workers in their interactions

with labor contractors, employers, and providers of housing. The act addresses issues of labor contract

registration and disclosure of terms of employment and housing occupancy. A poster lists the rights

and protections of this group of workers. The Wage and Hour Division of the United States

Department of Labor (DOL), along with its State level designees, is responsible for enforcing the

MSPA. More information about the MSPA and the poster are available at 

http://www.dol.gov/esa/whd/mspa/index.htm.

Workers’ Compensation Coverage for Agricultural Workers

State laws vary widely on whether agricultural workers are covered by workers’ compensation. The

two reports listed here provide some background information about this issue.

Legal Background Paper: Protection of Migrant Agricultural Workers in Canada, Mexico, and the

United States. 2002

http://www.naalc.org/english/study4.shtml 

The Secretariat of the Commission for Labor Cooperation. Washington DC. 

Increasing Farmworkers’Access to Workers Compensation Benefits. 

S Davis, Farmworker Justice Fund, Inc., 1999. PC499

Report available from HRSA Contact: 1-800-BASKBHRSA or http://www.ask.hrsa.gov/

G.7.2 CHILD LABOR IN AGRICULTURE

PPSP staff should be familiar with the agricultural exemptions of the Fair Labor Standards Act and

other factors influencing the safety and health of children working in agriculture. The following publications provide a starting point for becoming familiar with the issue.

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APPENDIX G 
Child Labor in Agriculture: Changes Needed to Better Protect Health and Educational Opportunities,

1998. (GAO/HEHSB98B193.) U.S. General Accounting Office, Washington, DC; http://www.gao.gov 

Fingers to the Bone: United States Failure to Protect Child Farmworkers,2000. Human Rights Watch,

Washington, DC. Telephone: 202-612-4321; http://www.hrw.org/

The Ones the Law Forgot: Children Working in Agriculture. Shelley Davis and James B. Leonard,

Farmworker Justice Fund; http://www.fwjustice.org/fjf_reports.htm.

Pesticides: Improvements Needed to Ensure the Safety of Farmworkers and Their Children, 2000.

(GAO/RCEDB00B40.) U. S. General Accounting Office, Washington, DC; http://www.gao.gov.

G.7.3 FARMWORKER DEMOGRAPHICS

Changes in agricultural work, immigration patterns, and government policies all impact the demographics of agricultural workers in the United States. These demographics are important to consider when

developing programs, interventions, and studies. A few sources of information are provided here.

California Institute for Rural Studies (CIRS)

Suffering in Silence: A Report on the Health of California’s Agricultural Workers. Nov 2000.

In 1999, the CIRS conducted the study described in this report. The report provides baseline data on

the health status of California’s agricultural workers. Included is a health status assessment based on a

medical exam with blood chemistry, information about access to health care, occupational injuries,

workers’ compensation coverage, pesticide safety training, and sanitation. The report can be obtained

from CIRS or downloaded from the Internet. Further analysis of these data and follow-up studies will

be available from CIRS. 

California Institute for Rural Studies

P.O. Box 2143, Davis, CA 95616

Telephone: 530-756-6555

Web site: www.cirsinc.org

Enumeration Studies

The Migrant Health Program at the Bureau of Primary Care, Health Resources and Services

Administration, U.S. Department of Health and Human Services (DHHS), has contracted for enumeration studies of migrant seasonal farmworker populations at the county level in ten States (Arkansas,

California, Florida, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, Texas, and

Washington). Profiles may be developed for additional States. The Migrant Health Program definition

of migrant and seasonal farmworker was used for this study. The scope does not include all sectors of

the agricultural industry or year-round nonmigrant agricultural workers. The reports are available from

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APPENDIX G 
their office (see Section G.10 for the address and telephone number), at their Web site

(http://bphc.hrsa.gov/migrant/), or at the Web site of the National Center for Farmworker Health

(http://www.ncfh.org).

National Agricultural Worker Survey (NAWS)

This extensive survey is conducted by the US DOL. It collects information on farmworkers, including

information about household members, detailed demographics on the farmworker, detailed employment

information (e.g., location and work type), wages, working conditions, availability of safety and

health training and equipment, household income, legal status, and use of social services. The questionnaire and periodic reports can be obtained from the DOL at http://www.dol.gov/

asp/programs/agworker/naws.htm or by telephone at 202-219-6197.

G.7.4 FARMWORKER CULTURAL ISSUES

The three resources listed here explore some pertinent cultural issues. Farmworkers come from culturally diverse backgrounds. By understanding the farmworker’s perception of risk, safety behavior, and

use of health care, valuable insight can be gained on the effect of these beliefs on the surveillance of

pesticide-related illness and injury.

Bibliography of Books on Migrant Workers

http://www.fwjustice.org/bibliography.htm

The Farmworkers Justice Fund has developed a selected bibliography of books, both fiction and nonfiction, on migrant agricultural workers. The listing includes current and older works that provide

insight into the historical, social, and cultural aspects of migrant agricultural work.

EthnoMed

http://www.ethnomed.org

This Web site provides information about cultural beliefs and medical issues that relate to health care.

The cultural groups included are recent immigrant groups in the Seattle area since the site is located at

the Harborview Medical Center, University of Washington. PPSP staff may find useful information in

the Cultural Profiles and at some of the related Web site links. 

Migrant Clinicians Network (MCN)

http://www.migrantclinician.org/excellence/cultural/

Dr. Jennie McLuarin has written two pieces on cultural competency for Streamline, the MCN newsletter (March/April 2002 and November/December 2002). The articles and other cultural competency

resources can be accessed from the Web address given above.

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APPENDIX G 
G.7.5. FARMWORKER SERVICE ORGANIZATIONS

Association of Farmworker Opportunity Programs (AFOP)

http://www.afop.org

AFOP is an alliance of organizations serving farmworkers and their families. The services provided by

AFOP include information, education, support, advocacy, and representation at the national level.

Since 1995, AFOP has had a collaborative program with AmeriCorps to support work in rural farmworker service agencies. The US EPA provides these farmworker service agencies with curriculum

materials to promote pesticide safety. AFOP’s national headquarters coordinates the program activities

and provides expert technical assistance and training. By the end of 2000, the program had trained

more than 215,000 farmworkers, provided at least 82,000 community services, and placed some 450

AmeriCorps members in communities throughout the United States. For more information about this

program, contact 703-528-4141. The ASAFE: Serving America’s Farmworkers Everywhere link on the

AFOP Web page provides information about AFOP members who participate in the program in

Arizona, Arkansas, California, Florida, Maine, Maryland, Massachusetts, New Jersey, New York,

North Carolina, Ohio, Oregon, Pennsylvania, Tennessee, Virginia, and Washington. 

Farmworker Justice Fund (FJF)

http://www.fwjustice.org/

FJF is a nonprofit organization that works to improve working and living conditions for migrant and

seasonal farmworkers in the United States. FJF provides training, legal advocacy, and technical assistance. Their Web site provides links to farmworker labor organizations, migrant farmworker labor law

sites, and GAO reports on farmworkers.

Legal Services Corporation (LSC)

http://www.lsc.gov/index2.htm

LSC is a private nonprofit corporation established by Congress in 1974 to provide civil legal assistance to those who are otherwise unable to afford it. A listing of LSC-funded programs and links to

programs with Web sites is available on the homepage listed above. The local legal services offices

were mentioned in Chapter 3 as a source of reports, since farmworkers with concerns about pesticide

exposures and workplace safety may seek legal assistance.

Mexican Consulates

http://www.mexonline.com/consulate.htm

The consulates can be valuable partners for outreach and education activities aimed at Mexican national and immigrant agricultural workers. 

251

APPENDIX G 
National Center for Farmworker Health (NCFH) 

http://www.ncfh.org

This is a nonprofit organization that serves farmworkers and farmworker health service agencies and

organizations. It sponsors four annual conferences that focus on the health issues impacting the different migratory streams traveled by farmworkers in the United States. This organization has a catalogue

of products, many of which are free or low cost. Materials include videos, resources for HCPs, patient

education materials, a bibliography, and some research information. This group also sponsors an electronic discussion group on migrant health research issues. This listserv encourages the exchange of

information, resources, grant opportunities, and original research in the area of migrant health.

Subscriptions to the listserv are available on the organization’s homepage. 

G.8 NONOCCUPATIONAL EXPOSURE ISSUES (HOMEOWNER, SCHOOLS, VECTOR

CONTROL, ETC.)

G.8.1 PUBLIC CONSUMER INFORMATION

A broad body of information is available for the general public on the safe use of pesticides. Most of

the sources have already been mentioned in other sections of this appendix. All of the sites listed in the

General Resources section contain some materials aimed at the general public. NPIC’s Web site provides ready access to EXTOXNET, the Agriculture Extension Service’s library of information about

pesticide toxicology and to consumer-oriented EPA publications (see Section G.3.2). The EPA-OPP

Web site home page has additional consumer resources including fact sheets on drift and pesticides in

the home (www.epa.gov/pesticides). Some topic-specific areas of information for the public are listed

below. 

G.8.2 PESTICIDES IN SCHOOLS

The use of pesticides in and around schools has been an area of public concern in the last few years.

Several States have passed legislation addressing the use of pesticides in schools, including the adoption of parental notification. Links to some recent reports on pesticide use in schools and resources on

IPM in schools are provided below: 

California School Integrated Pest Management Program

http://www.cdpr.ca.gov/cfdocs/apps/schoolipm/main.cfm

This site also has several resources on school IPM. Among them is this report: 

Overview of Pest Management Policies, Programs, and Practices in Selected California Public School

Districts. March 1996. PM 96-01.

Sewell E. Simmons, Timothy E. Tidwell, and Terrell A. Barry, Pest Management Analysis and

Planning Program.

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APPENDIX G 
State of California Environmental Protection Agency; Department of Pesticide Regulation

Division of Enforcement, Environmental Monitoring, and Data Management

Environmental Monitoring and Pest Management Branch

1020 N Street, Sacramento; California 95814-5624.

This report provides findings from a study conducted by CDPR, in cooperation with the California

Department of Education, which examined pest management programs in California’s public school

districts. The report provides an overview of current practices and recommended improvements to

these practices.

EPA–IPM in schools

http://www.epa.gov/pesticides/ipm/

This Web site provides access to EPA and State resources addressing IPM in schools.

Pesticide Use At New York Schools: Reducing the Risk 

http://www.oag.state.ny.us/press/reports/pesticide_school/pesticide_school.html

This document contains a review of the issue and recommendations. Appendix 3 of the document contains a listing of information about IPM in schools. 

Poisoned Schools: Invisible Threats, Visible Actions. March 2001

This report is a combined effort involving member organizations of the Child Proofing Our

Communities: Poisoned School Campaign. This is a locally based, nationally connected campaign to

protect children from exposure to environmental health hazards in schools, homes, and communities.

It is available on the internet at http://www.beyondpesticides.org, or can be ordered from:

Child Proofing Our Communities Campaign

c/o Center for Health, Environment and Justice

P.O. Box 6806; Falls Church, VA 22040

Telephone: 703-237-2249

E-mail: childproofing@chej.org 

The Schooling of State Pesticide Laws–2002 Update: A review of State pesticide

laws regarding schools.

Kagan Owens and Jay Feldman. Pesticides and You, 20:2:16–23, 2000. 

Beyond Pesticides/National Coalition Against the Misuse of Pesticides. (This report updates two earlier reports released in Pesticides and You, 20;2:16-23, 2000 and 18:3:1998.) Available from Beyond

Pesticides at http://www.beyondpesticides.org/

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APPENDIX G 
G.8.3 VECTOR CONTROL AND PEST ERADICATION PROGRAMS

The use of pesticides in the eradication of disease vectors and economic pests raises issues and concerns about potential public exposure. Several publications and resources are provided here. This is an

area with many available sources of information, so this listing is just a starting point.

American Mosquito Control Association 

http://www.mosquito.org/ 

This professional association provides links to educational materials, State and local affiliate organizations, and other relevant resources.

Animal and Plant Health Inspection Service

http://www.usda.gov/ 

Provides information about pest eradication programs.

Department of Defense Pest Management Homepage

http://www.afpmb.org/ 

This site contains access to directive and guidance documents on pest control from the Armed Forces

Pest Management Board. The Contingency Pest Management Guidance document contains information that may be useful for PPSPs involved in the public health aspects of vector control.

Toxicological Profile for Malathion Draft for Public Comment

http://www.atsdr.cdc.gov/toxprofiles/tp154.html 

U.S. Department of Health and Human Resources, Agency for Toxic Substances and Disease Registry,

Atlanta, Georgia, September, 2001.

Emerging Infectious Disease Journal

http://www.cdc.gov/ncidod/EID/index.htm

This journal can be searched for articles on mosquito control and other relevant topics.

EPA and Mosquito Control

http://www.epa.gov/pesticides/factsheets/skeeters.htm

This site has fact sheets related to mosquito control (larvicides, repellents, malathion, naled,

pyrethrins, etc.), a joint EPA/CDC statement on mosquito control, and links to other sites.

254

APPENDIX G 
Human Health Surveillance During the Aerial Spraying for Control of The

American Gypsy Moth on Southern Vancouver Island, British Columbia, 1999

http://www.caphealth.org/btk journals.html

A report to the Administrator, Pesticide Control Act, Ministry of Environment, Lands and Parks,

Province of British Columbia. Prepared by the Capital Health Region, Office of the Medical Health

Officer, Director of Research, December 31, 1999.

West Nile Virus Home Page–CDC Division of Vector Borne Infectious Diseases 

http://www.cdc.gov/ncidod/dvbid/westnile/index.htm

255

APPENDIX G 

Provides much information about West Nile virus infections, including background information, 

entomology, vertebrate ecology, virology, and surveillance.

G.9 STATE PPSP CONTACT INFORMATION

The following list of State contacts is not a comprehensive list of all States that may collect some pesticide-related illness surveillance data. It includes those that routinely produce annual reports and/or who

are partners with EPA and NIOSH in efforts to standardize and enhance pesticide poisoning surveillance. 

ARIZONA

Arizona Department of Health Services

Office of Environmental Health

3815 North Black Canyon Highway 

Phoenix, AZ 85028

Telephone: 602-230-5830 

http://www.hs.state.az.us/phs/oeh/invsurv/

pesticide/index.htm

CALIFORNIA

California Department of Health Services

Occupational Health Branch

1515 Clay Street Suite 1901

Oakland, CA 94612

Telephone: 510-620-5757 Fax: 510-620-5743

http://www.dhs.ca.gov/ohb/AgInjury/Default.htm

California Department of Pesticide Regulation

Pesticide Illness Surveillance Program

1020 North Street, Room 200 

Sacramento, CA 95814

Telephone: 510-540-3547 Fax: 510-540-3472

http://www.cdpr.ca.gov

Program Brochure:

http://www.cdpr.ca.gov/docs/whs/pisp.htm and

click on About the program.

FLORIDA

Florida Department of Health

Bureau of Environmental Epidemiology

4052 Bald Cypress Way Rm. 215L

Tallahassee, FL 32399-1712

Telephone: 850-245-4115 Fax: 850-922-8473

http://www.doh.state.fl.us/

IOWA

Iowa Department of Health

321 E. 12th Street Lucas State Office Bldg.

Des Moines, IA 50319-0075

Telephone: 515-281-6596 Fax: 414-242-6384

http://www.idph.state.ia.us/eh/toxicology_env_

health.asp#pesticide
Lousiana

Louisiana Office of Public Health

Environmental Epidemiology and Toxicology

325 Loyola Avenue Suite 210

New Orleans, LA70112

Telephone: 504-568-8322 Fax: 504-568-5815

http://www.dhh.state.la.us

Michigan

Michigan Department of Community Health

Division of Environmental and Occupational

Epidemiology

3423 N. Martin Luther King, Jr. Blvd.

P.O. Box 30195

Lansing, MI 48909

Telephone: 517-335-8761

http://www.michigan.gov/mdch/

Mississippi

Mississippi State Department of Health

2423 North State Street 

Felix J. Underwood Building

Jackson, MS 39216

Telephone: 601-960-7725

New Mexico

New Mexico Department of Health Services

1190 St. Francis Ave 

Santa Fe, NM 87502

Telephone: 505-476-3583 Fax: 505-476-3589

http://www.health.state.nm.us/Web site.nsf/

frames?ReadForm

Border Health

1170 North Solano Drive Suite L

Las Cruces, NM 88001

Telehone: 505-528-5156 Fax: 505-528-6045

NEW YORK

New York Department of Health

Bureau of Occupational Health

547 River Street Flanigan Square - Rm 230

Troy, NY 12203

Telephone: 518-402-7900 Fax: 518-402-7909

http://www.health.state.ny.us/nysdoh/pest/

pesticid.htm

OREGON

Environmental and Occupational

Epidemiology

Department of Health Services

800 NE Oregon St, # 827

Portland, OR 97232 2162

Telephone: 503 731 4025 Fax: 503 872-5398

http://www.ohd.hr.state.or.us/pesticide/index.cfm

TEXAS

Texas Department of State Health Services

Environmental & Occupational Epidemiology

Program

1100 West 49th Street 

Austin, TX78756

Telephone: 512-458-7111 Fax: 512-458-7699

http://www.dshs.state.tx.us/epitox/pest.shtm

WASHINGTON

Washington State Department of Health

Office of Toxic Substances

7171 Clean Water Lane, Building 4 

Olympia, WA98501

Telephone: 360-236-3361 Fax: 360-586-4499

http://www.doh.wa.gov/ehp/ts/pest.htm

256

APPENDIX G 
G.10 FEDERAL AGENCY CONTACT INFORMATION

G.10.1 U.S. DEPARTMENT OF AGRICULTURE (USDA)

The USDA programs relevant to pesticide illness surveillance were described in Chapter 5, “Case

Intake and Investigation” and in Section G.5. The agency descriptions are not repeated here. USDA

also maintains the National Agricultural Library, which is a national network that provides a wide variety of information about agricultural issues. Information about the USDA services described here are

available at http://www.usda.gov/AgenciesandOffices/.

Animal Plant Health Inspection Service

For telephone contact information, look in your local phone directory, or search using the term state

plant regulatory officials at http://www.aphis.usda.gov/ppq/searchpage.html.

Cooperative State Research Education and Extension System (CSREES)

Local offices of CSREES are available in the Federal or county government listings of your local telephone directory, usually under the heading of Agricultural Extension Service, Extension Service, or

Farm Services. The main State contacts are at land grant universities. A listing of State universities with

land grant university status is available at http://www.nasulgc.org/About_Nasulgc/about_nasulgc.htm. 

Contact: CSREES; USDA; Washington, DC 20250-0900

Telephone: 202-702-3029

Fax: 202-690-0289

Federal Grain Inspection Service (FGIS)

http://www.usda.gov/gipsa/

Federal Grain Inspection Service; Grain Inspection and Stockyards, Administration; STOP 3601

1400 Independence Avenue; Washington, DC 20250-3601

For telephone contact information, look in your local phone directory or search using the term The

Animal Plant Health Inspection Service at http://www.usda.gov/gipsa/.

National Agricultural Statistics Service (NASS)

NASS Hotline 1-800-727-9540

NASS Census Division can be reached by calling 1-800-523-3215 

Listings for NASS State offices are available at http://www.usda.gov/nass/sso-rpts.htm.

257

APPENDIX G 
G.10.2 U.S. DEPARTMENT OF EDUCATION–OFFICE OF MIGRANT EDUCATION

This office supports educational programs for migratory children. The local offices can be partners in

PPSP education and outreach efforts. This program has produced a Directory of Services for Migrant

and Seasonal Farmworkers and Their Families (1999). The directory is now maintained as an online

database that is available at http://www.ael.org/eric/mied/. For more information and access to State

offices, see http://www.ed.gov/about/offices/list/oese/ome/index.html.

G.10.3 U.S. DEPARTMENT OF LABOR (DOL)

OSHA

http://www.osha.gov/

This agency’s Web site provides access to regulations and interpretations, technical documents, and

directories of Federal and State program offices. 

Wage and Hour Division

This division of DOL has responsibilities for enforcement of the Fair Labor Standards Act and the

National Migrant and Seasonal Agricultural Worker Protection Act (MSPA). Information about

Federal rules on labor contractors, wage and hour issues, child labor, the HB2A program, and a listing

of district offices are available at http://www.dol.gov/esa/whd/. To locate a local Wage and Hour

Office or get additional information, call toll-free 1-866-487-9243.

G.10.4 U.S. ENVIRONMENTAL PROTECTION AGENCY (EPA)

EPA/Office of Pesticide Programs 7506 C; Ariel Rios Building

1200 Pennsylvania Ave, NW; Washington, DC 20460

Telephone: 703-305-7666

Fax: 703-308-2962

http://www.epa.gov/pesticides

Regional pesticide contacts are available at this site as well as access to the EPAFIFRArules (FQPA, WPS).

To receive weekly e-mail updates from this office, you can subscribe to the mailing list by visiting

http://www.epa.gov/oppfead1/cb/csb_page/form/form.html. 

An EPA-OPP contact that is useful for PPSPs is provided below. Questions about general pesticide

issues, exposure concerns, and reporting of clusters and unusual illnesses and injuries from pesticides

should be directed to either of the two numbers below.

EPA/ Office of Pesticide Programs; Health Effects Division 7509C

401 M Street SW; Washington DC 20460

Telephone: 703-305-7576 or 703-305-5336

Fax: 703-305-5147

258

APPENDIX G 
G.10.5 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES–CENTERS FOR

DISEASE CONTROL AND PREVENTION (CDC)

National Center for Environmental Health (NCEH), CDC

The Environmental Hazards and Health Effects Section of NCEH conducts investigations that

increase knowledge of the relationship between human health and the environment and uses this

understanding to develop national public policy and programs to prevent disease. NCEH studies ways

to prevent or control health problems associated with exposure to air pollution, nuclear radiation, lead,

and other toxicants, as well as hazards resulting from natural and technologic disasters. NCEH is a

resource for environmental pesticide case surveillance and disease outbreak investigations. For general information about NCEH, see http://www.cdc.gov/nceh/.

The contact office for issues related to surveillance of pesticide-related illness and injury is: 

National Center for Environmental Health; Health Studies Branch

Centers for Disease Control and Prevention

4770 Buford Highway, F46, Atlanta, GA 30341

Telephone: 770-488-3406

Fax: 770-488-3450

National Institute for Occupational Safety and Health (NIOSH), CDC

http://www.cdc.gov/niosh/topics/pesticides/

NIOSH is the Federal agency responsible for conducting research on occupational disease and injury.

NIOSH investigates potentially hazardous working conditions upon request, makes recommendations

on preventing workplace disease and injury, and provides training to occupational safety and health

professionals. NIOSH provides funding and technical support to the Sentinel Event Notification

System for Occupational Risks (SENSOR)-Pesticides program and supported the development of the

SPIDER software for State-based surveillance of pesticide-related illness and injury. NIOSH also supports State-based surveillance of other occupational diseases and injuries. For general information

about NIOSH programs, see http://www.cdc.gov/niosh/homepage.html.

The NIOSH contact for PPSPs is:

Project Officer, SENSOR-Pesticides

NIOSH/ Division of Surveillance, Hazard Evaluations and Field Studies

4676 Columbia Parkway, RB17; Cincinnati, OH 45226

Telephone: 1-800-356-4674

Fax: 513-533-8573

259

APPENDIX G 
G.10.6 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES– HEALTH RESOURCES AND SERVICES ADMINISTRATION (HRSA) 

Migrant Health Program (MHP), Bureau of Primary Health Care (BPHC)

The Migrant Health Act of 1962 was added to the Public Health Services Act. The Migrant Health

Program provides medical and support services to migrant and seasonal farmworkers and their families. The MHP provides grant funds to public agencies and nonprofit organizations in 42 States and

Puerto Rico for the development and operation of medical clinics. More information about the MHP

and links to related resources are available at http://bphc.hrsa.gov/migrant/.

For information contact: 

Division of Community and Migrant Health; Bureau of Primary Health Care

4350 East-West Highway, 7th Floor; Bethesda, MD 20814

Telephone: 301-594-4303

Fax: 301-944997

G.10.7 U.S. FOOD AND DRUG ADMINISTRATION (FDA)

The FDA is responsible for pesticide residue monitoring in foods as mandated by FIFRA and the

Federal Food Drug and Cosmetic Act. Residue monitoring reports and other technical documents are

available at http://www.cfsan.fda.gov/~lrd/pestadd.html.

G.11 AGRICULTURAL SAFETY AND HEALTH (OTHER THAN PESTICIDES)

G.11.1 EPA

EPA and OSHA have collaborated to produce materials on heat stress in agriculture. A training guide,

posters, and a laminated card are available on this topic from EPA or through the Government Printing

Office. The document titles and document numbers are listed here.

A Guide to Heat Stress in Agriculture, 1994, Document No. 055B000B00474B9

Controlling Heat Stress in Agriculture, 1996, Document No. 055B000B00557B5 (Available in

English or Spanish, 8"x4" cards with key items on recognizing and preventing heat stress.) 

Controlling Heat Stress Made Simple/Maneras Sencillas de Controlar la Fatiga Causada por el

Calor. Document No. 055B000B00544B3. Two-sided poster, available in English or Spanish.

G.11.2 NIOSH

NIOSH has many projects related to agricultural safety and health. To obtain information about this

topic, visit: http://www.cdc.gov/niosh/topics/agriculture/. 

260

APPENDIX G 
261

APPENDIX G 

NIOSH Agricultural Health and Safety Centers

NIOSH has funded eight Agricultural Health and Safety Centers throughout the country, which

involve clinicians and other health specialists in the area of pesticide related illness and injury. A listing of the NIOSH supported centers with links to the individual center Web sites is available at

http://www.cdc.gov/niosh/agctrhom.html.
INDEX
265

A

AAPCC, xi, 6, 13, 28, 90, 209, 211, 231, 237

active ingredients, 4, 6, 11, 55, 57, 76, 81,

183-184, 191-203, 217, 221, 238, 241

adjuvants, 5, 15, 20, 40, 54, 57

advisory committee, 54, 61, 93

advisory opinion, 219

affected person, 7, 14-17, 31-33, 39, 47-48,

50-52, 54-55, 58, 67, 71, 78, 87, 170, 174, 187

AFOP, xi, 245, 251

Agricultural Extension Service, 12

agricultural worker, 29, 31, 34, 82, 90, 106-107,

248-251, 258

ALT, xi, 194, 200

AMA, xi, 6, 97

analysis of data, 81-84,87

ANR, xi, 247-248

ANSI /ASAE, xi, 89, 97

AOEC, xi, 235

APHIS, xi, 62-63

Arizona, 6, 111, 243, 251, 255

ASPCA, xi, 237

AST, xi, 194, 200

ATSDR, xi, 59, 62, 232-233, 235, 254

B

biological monitoring, 40, 89, 184

biological sampling, 70

biological specimen, 17, 20, 40, 51, 71, 184, 219

bivariate analyses, 81

BLS, xi, 23, 82

BOC, xi, 39

BPHC, xi, 249-250, 260

C

California, 6, 13-14, 17, 34, 63, 82, 89-91,

97-99, 105-107, 111, 119, 229, 233, 236,

239-241, 243, 246-249, 251-253, 255

case

ascertainment, 27-34, 49

classification, 3, 12, 40, 75-78, 183-205

closure, 38, 47-48, 75-78, 119

definition, iii, 14, 21, 27, 29,37, 40 47-48, 

75-77, 83, 93, 183-205, 209, 211

follow-up, 20, 21, 47-54, 116, 169

intake, 38, 47-50,

investigation, 3, 11-13, 31, 33, 37, 40, 47-

64, 87-88

is reportable, 184

management, 20, 27, 231

report, 3, 11, 14, 27, 32, 37-38, 50-51, 61,

77, 93, 170, 231

series, 76, 81, 84, 92, 184, 186-187

CCOHS, xi, 230

CDC, xi, 7, 11, 13, 18-19, 38-39, 43, 90-93,

97-98, 100, 105-108, 119, 141, 187, 255, 259

CDPR, xi, 4, 13, 40, 90, 98, 229, 240-241,

243, 246, 252-253, 255

CFR, xi, 98

chemical class, 40, 81-82, 191

The following index is provided for readers of the Pesticide-Related Illness and Injury

Surveillance, A How-To Guide for State-Based Programs to locate information by page number.

INDEX
266

INDEX

children, 4-5, 53, 223, 235, 248-249, 253, 258

CIRS, xi, 249

class of pesticide, 67, 183-184, 187, 191-192

clusters, 52-53, 55, 258

CME, xi, 31, 232-233

coding systems, 38-41

(see also industry/occupation codes)

hospital, 32-34

industry, 39

occupation, 14, 28, 31, 39

variable, 38-41

confidential information, 20, 38, 41-42, 58, 68

confidentiality, 15, 17, 19, 29, 33, 38, 42, 51,

54-55, 57-58, 69, 84

CPS, xi, 23, 39, 82

CPSC, xi, 64

CSREES, xi, 62, 257

CSTE, xi, 6, 23, 75, 98

Current Population Survey (see CPS)

D

DA, xi, 17, 53, 57-59, 63, 90-92

data

analysis, 37-38, 41, 81-84, 87

collection, 3, 23, 37-38, 42, 48, 50, 54, 82,

92, 119, 141, 243

dissemination, 38, 81, 84, 

entry, 3, 38, 42, 119, 141

management, 12, 27, 37, 42, 119, 141

optional variables, 40

DDT, xi, 4, 107

death, 5, 7, 23, 28, 61, 64, 67, 106, 172, 174,

179, 210

DEET, xi, 189, 195

demographic, 27, 29, 33, 50, 53, 229, 249-250

denominator data, 16, 21, 23, 82

DHHS, xi, 18-19, 237, 249

diagnosis, 11, 15-16, 20, 27-29, 32, 40, 76,

171, 183-184, 189, 234-235

discrimination, employment, 55

disinfectants, 4, 15, 31, 76, 176, 231

DO, xi, 187

DOL, xi, 11, 14, 59, 248, 250, 258

dose, 5, 186, 190-191, 240

DOT, xi, 64

E

education, 3, 31, 37, 60, 62-63, 81, 87-88,

230-233, 237, 245, 247, 251-253, 257-258

emergency department, 32, 105

emergency response, 68, 187, 238

employee representatives, 174

employment data

rate-based surveillance with, 82

sources of, 39

employment discrimination, 55

EMT, xi, 76, 184, 187

engineering control, 78, 87-89, 91

environment, 4-5, 51, 56, 59-61, 70-71, 88, 90,

92, 217-219, 221, 224, 239, 253, 259

EPA, xi, 4, 6-7, 13, 32, 34, 40, 43, 48, 50, 52,

55-59, 61-62, 70, 76, 88-91, 97-100, 170-171,

187, 203, 211, 217-218, 220-224, 230-232,

235, 237-241, 243, 245-246, 251-255, 258, 260

epidemiology, 31, 234
267

INDEX

EU, xi, 240-241

EUP, xi, 220

evaluation, 31, 87, 92-93

exposure

acute, 5, 61, 75-76, 83, 185, 190-191, 236

chronic, 3, 5

intentional, 39

mixed, 3, 57

nonoccupational, 27, 50-51, 58-59 61, 107,

183-188, 230, 236, 252-255

occupational, 5, 14, 16-17, 21, 23, 28-29,

31, 51-52,54, 58-59, 69, 76 105-107, 

183-188, 236

unintentional, 5, 61, 106

exposure analyses, 70

extension service, 62, 230-231, 247, 252, 257

EXTOXNET 62, 231, 239, 240, 252

F

FAA, xi, 63

FAQ, xi, 187-191

farmworker, 28, 51-54, 82, 97, 99, 106, 119,

217, 229, 244-246, 248-252, 258, 260

FBI, xi, 64

FDA, xi, 64, 223

FFDCA, xi, 223

FGIS, xi, 62, 63, 257

field investigation, 19-20, 22, 67-71, 82, 87,

92, 161-164, 173-175115, 161, 173

FIFRA, xi, 52, 56, 58-59, 67, 70, 76, 183, 211,

217-225, 238, 258, 260

FJF, x, 249, 251

Florida, 6, 14, 28, 53, 63, 90-91, 236, 249,

251, 255, 

follow-up, 47-53, 59, 75, 78, 87-88, 116-118,

161-164

forms, 3, 33, 37, 58, 115-164

FQPA, xi, 223-224, 258

fumigants, 59, 63, 105-106, 177, 197

functional class, 40, 82, 191

funding, 7, 13, 27, 43, 67, 70, 84, 87, 259

G

GAO, iii, xi, 6, 13, 99, 249

gender (see Sex)

GIS, xi, 83, 84

H

HCP, xi, 11, 14, 16, 27-33, 40-41, 47-48, 51,

53-55, 57, 61, 63, 77, 81, 84, 87, 141, 

170- 172, 185-189, 191, 210, 230-237, 252

HDD, xi, 33

health department, 48, 51, 54-55, 57, 59

HIPAA, xi, 18-19, 172

HRSA, xi, 260

HSDB, xii, 239

HSEES, xii, 59

I

IARC, xii, 239-241

IATP, xii, 246

ICD, xii, 29, 32-33

ICD10, 29, 32-33
268

INDEX

ICD9, 29, 32-33

ICU, xii, 23

identifiers, 18-19, 21, 33, 40, 43, 171-172, 174

illegal, 62, 64, 106

ILO, xii, 239

incidence, 11, 20, 23, 52, 176, 179

indicator, 4, 23

industry and occupation codes, 39

inert ingredients, 15, 55-57, 238-239

ingestion, 15, 27, 67, 105-106

injury, pesticide, xiii, 3-7, 18, 29, 31, 75, 183,

185, 188,

insurance data (see workers’ compensation data)

interagency agreement, 29, 60-61, 71

interagency cooperation, 19, 218

interagency coordination, 48, 60-61, 225

intervention, iii, 11, 16, 47-48, 60-62, 87-93,

172, 209, 249

interviews, 12, 47-48, 50-55, 67, 69, 75, 93,

119, 141, 173-175

investigation, case 11, 16-21, 31-33, 37-38,

47-58, 60-64, 87-88, 225

investigation, field, (see field investigation)

IPCS xii, 239

IPM, xii, 12, 62, 78, 88-89, 93, 230, 247, 252-253

IRIS xii, 240-241

L

label, 5-7, 40, 55-56, 58, 61, 70-71, 90, 92,

217-224, 239, 241-242

laboratories, 16, 18, 20, 33-34, 47, 71

LAN, xii, 41

latency, 190

LDH, xii, 194, 200

letters, 54, 169-175

local health department, 48, 51, 55

lost time, 29, 40, 209-210, 214

Louisiana, 6, 17, 53, 108, 249, 256

LSC, xii, 251

M

MD, xii, 187

management

confidential information, 20, 42, 54-55, 58

data, 12, 27, 31, 37, 41-43 119, 141

integrated pest management, (see IPM)

manufacturer, 6, 48, 57, 61, 70, 76, 91-92,

217, 230-231, 237, 241-242

mapping of data, 83-84

maps, 63, 83-84, 244

MCN, xii, 250

medical record, 16, 48, 53-54, 67

MHP, xii, 260

Michigan, 6, 111, 239, 256

Migrant farmworker, 14, 52, 54, 248-252, 258, 260

Migrant Clinicians Network, 250

Migrant Health Program, 249, 260

migrant worker, (see migrant farmworker)

MMWR, xii, 13, 81, 105-108

MSDS xii, 55-57, 241-242

MSPA, xii, 248, 258
269

INDEX

N

NAICS, xii, 39

NAIN, xii, 231

NAS, xii, 100

NASS, xii, 244, 257

NAWS, xii, 14, 250

NCEH, xii, 7, 13, 43, 61-62, 187, 259

NCFH, xii, 250, 252

NCHS, xii, 39, 100

NEETF, xii, 237

New Jersey, 111, 243, 251

New Mexico, 111, 256

New York, 6, 14, 20, 41, 63, 82, 100, 105-106,

112, 224, 243, 245, 251, 253, 256

NIH, xii, 240-241

NIOSH, iii, xii, 7, 13, 23, 38-41, 43, 48, 

61-62, 75, 90, 93, 99-100, 119, 141, 174,

187, 209, 211, 236, 255, 259-261

nonoccupational exposure, (see exposure,

nonoccupational)

notifiable conditions, 29, 33

notification, 48, 53, 55, 61-62, 76-78, 183,

246, 259

local health department, 48, 55

to employer, 77-78

to EPA, 48, 61-62

to manufacturer, 77-78

to NCEH, 61-62, 76-77

to NIOSH, 48, 61-62, 76-77

to physician, 28-29, 31, 34, 76-77

NPHSS, xii, 40, 75, 77, 98

NPIC, xii, 12, 13, 57, 90, 187, 231, 232, 242, 252

NPMMP, xii, 12, 232

NSCEP, xii, 239, 243

NTP, xii, 240-241

NTSB, xii, 165

NUBC, xii, 33

NYDEC, xii, 243

O

objectives, 11, 37, 92

occupational exposures, (see exposure, occupational)

ODA, xii, 59, 92 245

OEHHA, xii, 233

OHSU, xii, 245

OPP, xii, 187, 240-241, 252, 258

Oregon, 6, 14, 19, 59-61, 87-88, 91-92, 

99-101, 112, 231, 239, 243, 245, 251, 256

OSH Act, xi, 55, 67, 224

OSHA, xii, 32, 59, 64, 69-70, 100, 173-174,

224, 236, 258, 260

OSU, xii, 232, 245

outreach, 3, 31, 61, 63, 81, 83, 88, 93, 251, 258

P

PA, xii, 187

PANNA, xii, 55, 236, 240-241, 243

PAPR, xii, 70

PARC, xiii, 61, 88, 92, 100

passive surveillance, 20

patient identifier, 18-19, 21, 33, 40, 43, 

171-172, 174

PCC, xiii, 12, 14, 17-18, 20, 23, 27-28, 47, 57,

61, 176-180, 231, 239
270

INDEX

person, place, and time, 81

personal identifiers, 18-19, 21, 38, 40, 43,

171-172, 174

pesticide application, 5, 17, 83-84, 234, 236,

243-244, 247

pesticide applicator, 15-16, 28, 37, 41, 48, 53-

55, 57-58, 62-63,165, 185, 188-189, 234,

243, 245-246

pesticide manufacturers, (see manufacturer)

pesticide use, 4-7,13, 15, 16, 19

pesticide use reporting, 16, 243-245

PHI, xiii, 18, 19

PIRT, xiii, 61, 112

PISP, xiii, 90

POISINDEX®, 55

Poison Control Centers, (see PCC)

policy, 17, 33, 56, 83, 259

population 23, 82-83, 87, 92 176, 179-180

PPE, xiii, 6, 39, 68, 69-70, 78, 90, 161-164, 222

PPIS, xiii, 40, 55, 240

PPSP, xiii, 6-7, 11-14, 16-17, 27-28, 32-33,

37- 38, 40-43, 47-48, 50-51, 53-64, 67-68,

70-71, 75, 77, 81-84, 87-88, 90-93, 116, 161,

169, 229, 231, 237, 239-242, 248, 250, 254-

255, 258-259

predictive value positive, 92

prevalence, 6, 83

protocol, 20, 42, 48, 52, 55, 57-59, 67, 70, 75,

87, 92, 189

case triage, 42

data system backup, 42

investigation, 87

PVC, xiii, 70

Q

questionnaire, 50, 52, 54, 115, 119-141, 250

R

RN, xiii, 187

rate(s), 11, 16, 21, 23, 39, 42, 63, 82-83, 176,

179-180, 204-205, 244

RCW, xiii, 17, 20,, 112

records, 16, 32, 42, 47, 48, 53, 54, 67, 69, 83,

115-116, 169, 172, 174, 186, 221, 234

duplicate, 42, 179

electronic, 42

emergency department, 32

hard copy, 42

medical, 16, 48, 53, 54, 67, 169, 172, 174,

187, 189

pesticide application, 83, 186, 234, 243

tracking, 38, 40-41, 43, 50, 53, 58, 61, 77,

82, 93, 115-116, 173, 211

REDs, xiii, 238

referral, 15, 17, 20, 32-34, 41, 47-48, 51, 57-59,

62, 68, 84, 116, 171, 231-232

reportable condition, 17, 19, 31, 33, 171

reporting laws, 13, 17-20, 22

reporting rule, 13 -17, 20-21, 27, 29, 33-34,

67, 111-112

reporting statutes, 13-14, 16-17, 19-20, 27,

29,109, 111

reports 3, 5-6, 13-14, 17-18, 20-21, 27-29, 31-32,

34, 37, 41-42, 47-55, 59-63, 67, 75-78, 81,

83-84, 91, 93, 107, 109, 115-116, 161-168,

173-174, 181-185, 188-191, 221, 223, 229,

231, 243-244, 246, 248-253, 255, 260

annual, 13, 61, 81, 83-84, 231, 243-244, 255
271

INDEX

case, 3, 5-6, 14, 17-18, 20-21, 27-29, 31-32,

34, 37, 42, 47-55, 60-62, 97, 75-77, 91, 93,

115-116, 173-174, 184-8, 188, 222, 225, 231

data, 41-42, 81, 83-84, 93, 161-169, 243-244,

249-251

GAO, 6, 13-14, 251

investigation, 75, 78, 93

representativeness, 92

risk factors, iii, 5-6, 81, 82, 83, 87, 89, 93

route of exposure 5, 27, 39

S

samples, 20-22, 40, 53, 55, 70-71, 185, 191

SAS, xiii, 41

schools, 16, 19, 28, 81, 83, 88, 229, 252-253

SDWA, xiii, 224

sensitivity, 14, 29, 52, 92

SENSOR, xiii, 3, 39, 83-84, 97, 119, 141, 259

severity, 3, 23, 27, 40, 51, 57-58, 77, 81, 140,

160, 165, 175, 207, 209-211

sex, 5, 16, 23, 38, 81-82, 179

signs, 5, 23, 28, 40, 76, 171, 134-136, 140,

156-158, 160, 183-184, 186-187, 189-190,

192-203, 209-210, 212-214, 236

site evaluation, 48, 51, 69

site inspection, 48, 54, 57, 65, 67-71, 75, 78,

93, 173

site investigation, 47, 82, 87, 173-175

SOC, xiii, 39

SPIDER, xiii, 3, 38, 40-43, 55, 83-84, 100,

119, 141, 241, 259

SPPC, xiii, 119

staff, 12-13, 32, 37-38, 42, 47-48, 50-55, 59,

67-71, 88, 92, 161, 171, 218, 230-231, 234,

245-246, 248, 250

staffing, 11-13

standardized variables, 3, 37-42, 209

State health departments, 3, 17, 19, 32

suicide, 4, 28, 76, 184

support, iii, 13, 16-17, 19, 27, 50, 81, 232,

251, 259-260

surveillance program, iii, ix, 3, 6-7, 11-14, 

16-17, 21, 27-29, 32, 37, 40, 47-48, 67, 75, 77,

84, 87, 90-93, 119, 141, 170, 171, 217-218,

225, 255-256

surveillance system, 3, 4, 6-8, 11,16-17, 31-33,

37, 40, 47-48, 50, 75-77, 90, 92-93, 181,

183-184

flow diagram, 48

symptoms, 5, 23, 28-29, 31, 40, 50, 52-53, 

76-77, 134-136, 140, 156-158, 160, 183-184,

186-187, 189-190, 192-203, 209-210, 

212-213, 234-237

T

TBTO, xiii, 91-92

TESS, xiii, 4, 6, 28, 90

Texas, xiv, 6, 14, 20, 22, 60, 106, 112, 249, 256

timeliness, 6, 17, 23, 27, 29, 31, 33, 41, 42, 47,

61, 81, 84, 92

toxicology, iii, 12-13, 62, 64, 76-77, 140, 160,

184, 186-187, 229-231, 233, 237-241, 252

tracking, 15, 33, 38, 40-41, 43, 50, 53, 58, 61,

77, 82, 93, 115-116, 173, 184, 222

training, 12, 31, 38-39, 42, 50-52, 54-55, 59,

62, 68, 69, 71, 78, 91, 218, 223, 230, 233,

236-237, 245-247, 249-251, 259-260
272

INDEX

trends, 11, 61, 81, 83, 107, 244

time, 83

U

UB-92, xiii, 33

underreporting, 14

UNEP, xiii, 239

USDA, xiii, 62-63, 222, 223, 234, 243-244, 257

use data, (see pesticide use reporting)

V

variables, 3, 29, 37-42, 81, 119, 141, 209 

standard variables to be collected by PPSPs, 38 

W

Washington State, xiii, 6, 13-14, 17, 19-20, 34,

53, 59-62, 67 83, 88-92, 106,112, 249-251, 256

WHO, xiii, 231, 233, 239-241, 251, 255

WHS, xiii, 246, 

worker representatives, 68, 78, 173

workers’ compensation, 29, 31, 33, 248-249

workers’ compensation data 13-14, 17-18, 29,

30, 31, 33, 47

workers’ compensation records, 47

worksite inspections, 67-71, 78, 173-175

WPS, xiii, 40, 58-59, 89, 222-223, 258

WSDA, xii, 91-92

WSDOH, xiii, 91, 92