Pesticides Initiative · National Strategies for Health Care Providers: Pesticides Initiative Support for this project was made possible through Cooperative Agreement CR 827026-01-0

I M P L E M E N T A T I O N P L A N

National Strategies for Health Care Providers:Pesticides InitiativeM A R C H 2 0 0 2

National Strategies for HealthCare Providers: Pesticides Initiative

Support for this project was made possible through Cooperative Agreement CR 827026-01-0 between

the Office of Pesticide Programs of the US Environmental Protection Agency and The National Environmental

Education & Training Foundation. The conclusions and opinions expressed herein are

those of the authors and do not necessarily represent the views and policies of the US EPA.

IMPLEMENTATION PLAN

MARCH 2002

For more information:

Tel: 202-833-2933 x535

Fax: 202-261-6464

Email: [email protected]

Web: www.neetf.org/health/providers/index.shtm

The National Environmental Education & Training Foundation

1707 H Street, NW, Suite 900

Washington, DC 20006-3915

National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan iii

Acknowledgments

The successful development of this Implementation Plan would not have been possiblewithout the efforts of a large number of dedicated people and organizations. The ExpertPanel members gave graciously of their time, experience, and energy in developing the

broad national strategies. The members of the Education, Practice, and Resource Workgroups,expertly guided by their co-chairs, contributed their time, enthusiasm, and intensive effortduring their workshops. Their hard work has produced this Plan. The Federal InteragencyPlanning Committee has contributed many hours of guidance and oversight to thedevelopment of the Implementation Plan, and significantly helped to organize the ExpertPanel and the three workgroups. The Committee also continues to guide the entire NationalStrategies for Health Care Providers: Pesticides Initiative.

The Implementation Plan was developed as part of a cooperative agreement between TheNational Environmental Education & Training Foundation (NEETF) and EPA’s Office ofPesticide Programs. Overall, this Plan is the result of successful collaborative leadership amongNEETF, EPA, the federal agency partners and the stakeholders. The team of collaborativepartners is pleased to share this Implementation Plan with you. Questions about the contentcan be directed to [email protected]

Photo credits: Photos on pages 13, 19, and 45: Steven Delaney, EPA.

iv National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan

Federal Interagency Planning CommitteeUS Environmental Protection AgencyOffice of Pesticide Programs

Kevin Keaney, MA, MS

Sara Ager

Jerome Blondell, MPH, PhD

Ana Maria Osorio, MD, MPH

Frank Davido

Office of Children’s Health Protection

Elizabeth Blackburn, RN

Office of Ground Water & Drinking Water

Ron Hoffer, MS

Sherri Umansky

Office of Environmental Justice

Delta Valente, MPA

US EPA Regional LiaisonsAdrian Enache, PhD, MPH — Region 2

Don Baumgartner — Region 5

Edward Master, RN, MPH — Region 5

Allan Welch — Region 10

US Department ofHealth and Human ServicesHealth Resources & Services Administration

(HRSA) Bureau of Health Professions, Center

for Public Health

Barry Stern, MPH

Sarat Seneviratne, MS, RS, CHMM, CCHP

HRSA Office of Planning, Evaluation & Legislation

Karen Pane, RN, MPA, CMCN

HRSA Bureau of Health Professions,

Division of Medicine and Dentistry

Ruth Kahn, DNSc

HRSA Bureau of Health Professions, Division of

Interdisciplinary, Community-Based Programs

David D. Hanny, PhD, MPH

Joan Weiss, PhD, RN, CRNP

HRSA Bureau of Primary Health

Care, Migrant Health Program

Eva Montoya

HRSA Office of Rural Health Policy

Cassandra Lyles

National Institute for Occupational Safety & Health

Geoffrey Calvert, MD, MPH

Rosemary Sokas, MD, MOH

Office of Disease Prevention &

Health Promotion

Dalton Paxman, PhD

Agency for Toxic Substances & Disease Registry

Donna Orti, MS, MPH

US Department of AgricultureAgricultural Marketing Service

Peter S. Wood, MS

Cooperative State Research,

Education, and Extension Service

Monte Johnson, PhD

US Department of LaborJohn Leben

Other OrganizationsThe National Environmental

Education & Training Foundation

Leyla Erk McCurdy, MPhil

Jennifer Bretsch, MS

American Association of Pesticide Safety Educators,

University of Maryland-College Park

Amy E. Brown, PhD

National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan v

Expert Panel and Workgroups*Education Workgroup Co-ChairsAndrea Lindell, DNSc, RN

American Association of Colleges of Nursing,

and University of Cincinnati, College of Nursing

Ameesha Mehta, MPH

Office of Pesticide Programs

US Environmental Protection Agency

Practice Workgroup Co-ChairsBonnie Rogers, RN, DrPH, COHN-S, FAAN

American Association of Occupational Health

Nurses, and

University of North Carolina-Chapel Hill,

School of Public Health

Karen Pane, RN, MPA, CMCN

Health Resources & Services Administration

US Department of Health and Human Services

Resources Workgroup Co-ChairsMark Robson, PhD, MPH

Environmental and Occupational Health

Sciences Institute, and Rutgers University

Kevin Keaney, MA, MS



Workgroup MembersSheila Brown Arbury, RN, MPH

Association of Occupational and

Environmental Clinics

Colin Austin

Migrant Clinicians Network, and

University of North Carolina-Chapel Hill

Joni Berardino, MS, LSW

National Center for Farmworker Health

Former Federal InteragencyPlanning Committee MembersUS Environmental Protection Agency,

Office of Pollution

Prevention and Toxics

Diane Sheridan

US Environmental Protection Agency,


Ameesha Mehta-Sampath, MPH

US Environmental Protection Agency,

Office of Ground Water

and Drinking Water

Marjorie C. Jones

US EPA Regional Liaisons

Jane Horton — Region 4

Amy Mysz — Region 5

HRSA Bureau of Health Professions,

Division of Medicine and Dentistry

Barbara Brookmyer, MD, MPH

HRSA Bureau of Health

Professions, Division of Nursing

Madeleine Hess, PhD, RN

US Department of Agriculture, Cooperative State

Research, Education, and Extension Service

Larry Olsen, PhD

US Department of Labor

Mike Hancock

The National Environmental

Education & Training Foundation

Susan T. West, MPH

* As of July 2000

vi National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan

Angelina Borbon, RN

Alameda County Lead Poisoning

Prevention Program

Barry Brennan, PhD

American Association of Pesticide Safety

Educators, and Extension Pesticide

Coordinator, University of Hawaii

Amy Brown, PhD


Educators, and University of

Maryland-College Park

Paul J. Brownson, MD

The Dow Chemical Company

Candace Burns, PhD, ARNP

National Organization of Nurse Practitioner

Faculties, and University of South Florida

College of Nursing

Joan Spyker Cranmer, PhD

University of Arkansas Medical School

Miriam Cruz

Equity Research

Shelley Davis

Farmworker Justice Fund, Inc.

Gerardo de Cosio, MD

US-Mexico Border Health Association

Susannah Donahue, MPH

Children’s Environmental Health Network

J. Ward Donovan, Jr., MD, FACEP

American College of Emergency Physicians,

Pennsylvania University Poison Center, and

Milton S. Hershey Medical Center

Gerry Eijkenmans, MD, MPH

Pan American Health Organization

Joe Fedoruk, MD, DABT, CIH

American College of Occupational and

Environmental Medicine

Kesner Flores, EMT

Cortina Indian Rancheria,

Wintum Environmental Protection Agency

Scottie Ford, MA

North American Agromedicine Consortium

West Virginia Agromedicine Program

West Virginia Department of Agriculture

Jose Garcia

Equity Research

Matthew Garabedian, MPH

Texas Department of Health

Jeanne Goshorn, MS

National Library of Medicine

Harold Harlan, PhD

National Pest Control Association

Barbara Hatcher, PhD, MPH, RN

American Public Health Association

Rugh Henderson, MD, MPH

North American Agromedicine Consortium,

Pennsylvania Agromedicine Program, and

Penn State University College of Medicine

Michael Hodgman, MD

National Rural Health Association,

and Bassett Healthcare/NY Center for

Agricultural Medicine and Health

Allen James, MBA, CAE

Elizabeth Lawder, BA (alternate)

Responsible Industry for a Sound Environment

Linda Kanzleiter, MPsSc

Celeste Stalk (alternate)

Pennsylvania Area Health Education Center,

Milton S. Hershey Medical Center

Matthew Keifer, MD, MPH

NIOSH Agricultural Health and Safety

Centers, and University of Washington

Kathy Kirkland, MPH

Association of Occupational and

Environmental Clinics

Ann Linden, CNM, MSN, MPH

American College of Nurse Midwives

John McCarthy, PhD

American Crop Protection Association

Claudia Miller, MD

University of Texas Health Science

Center–San Antonio

Mark Miller, MD

American Academy of Pediatrics

National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan vii

Mary Miller, MN, ARNP

American Nurses Association, and Washington

State Department of Labor and Industries

Terry Miller

National Pesticides Telecommunications

Network, and Oregon State University

Rita Monroy

National Alliance for Hispanic Health

(formerly National Coalition of Hispanic

Health and Human Services Organizations)

Karen Mountain, MBA, MSN, RN

Migrant Clinicians Network

Diane Mull

Association of Farmworker

Opportunity Programs

Madaleine Ochinang, MS

Formerly with the Consortium for

Environmental Education in Medicine

Patrick O’Connor-Marer, PhD


Educators, University of California Statewide

IPM Project, and University of California

Agricultural Health and Safety Center

Marcia Allen Owens, JD

Minority Health Professions Foundation

Dennis Penzell, DO, FACP

Suncoast Community Health Centers, Inc.

Annette Perez, RNC, MSN, CNM, PhD

American College of Nurse Midwives,

and University of Texas-El Paso,

College of Health Sciences

John Pickle, MSEH

Weld County Health Department, Greeley, CO

Ana Maria Puente

Bureau of Primary Health Care, Border Health,

Health Resources and Services Administration

Benjamin Ramirez, MD, MPH, FACOEM

DuPont Company

Scott Ratzan, MD, MPA

Academy of Educational Development

Susan Rehm, MBA

American Academy of Family Physicians

J. Routt Reigart, MD

Medical University of South Carolina,

Department of Pediatrics

George C. Rodgers, Jr, MD, PhD

American Association of Poison Control Centers,

and University of Loiusville School of Medicine

Rachel Rosales, MSHP

Texas Department of Health

Elaine R. Rubin, PhD

Association of Academic Health Centers

Barbara Sabol

W. K. Kellogg Foundation

Barbara Sattler, RN, DrPH

University of Maryland School of Nursing

Jackilen Shannon, PhD

Council of State and Territorial Epidemiologists,

and Texas Department of Health

Cathy Simpson, MD

Wayne State University School of Medicine

Gina Solomon, MD, MPH

Natural Resources Defense Council

Elisabeth Spector, MD, MPH

American Academy of Family Physicians

Roger F. Suchyta, MD

Graham Newson (alternate)

Jennifer Stevens (alternate)


Greg P. Thomas, PA-C

American Academy of Physician Assistants

Leonel Vela, MD

Migrant Health Advisory Council, and

Texas Tech Health Sciences Center

Sheldon Wagner, MD

National Pesticide Medical Monitoring

Program, and Oregon State University

John Wheat, MD, MPH

North American Agromedicine Consortium,

and University of Alabama

at Birmingham, School of Medicine

ContentsExecutive Summary ................................................................................................................... 1

Vision, Expected Outcomes, and Evaluation ......................................................................... 11

Making the Case ...................................................................................................................... 15

Target Audience ....................................................................................................................... 33

Framework of the Plan: A Three-Pronged Strategy ............................................................... 37

Educational Settings ............................................................................................................... 39

Practice Settings ....................................................................................................................... 65

Resources and Tools ................................................................................................................. 89

Conclusion ............................................................................................................................. 103

References............................................................................................................................... 105

Glossary .................................................................................................................................. 111

Appendix A: Expert Panel Proceedings ............................................................................ 113

Appendix B: Summary Proceedings from Workgroups .................................................. 117

Appendix C: Response to Public Comments ................................................................... 135

Appendix D: Federal Interagency Planning Committee ................................................. 139

List of Exhibits

Tables

1 Components of the Implementation Plan....................................................................... 6

2 Initiative Work Products ................................................................................................... 8

3 Occupational and Non-Occupational Sources of Pesticide Exposure ......................... 21

4 Pesticides Most Often Implicated in Symptomatic Illnesses, 1998 .............................. 22

5 Targets, Populations Served, Practice Settings ............................................................... 33

6 Stages of Change Model ................................................................................................. 34

7 Competencies for Educational Institutions ................................................................... 47

8 Proposed Design of Faculty Champions Project ........................................................... 60

9 Expected Practice Skills .................................................................................................. 72

Figures

1 Framework of the Implementation Plan ......................................................................... 7

2 Projected Timeline for Implementation Plan Activities ................................................. 9

3 Stages of Change and Implementation Plan Components ........................................... 35

National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan 1

Executive Summary

P esticides are ubiquitous in our society in both agricultural and urban environments.We use pesticides in our homes, schools, in our workplaces, and in our communities.Due to the widespread dissemination of pesticides, and the potential for related illness

and injury (especially among farmworkers and pesticide handlers), health care providers shouldbe prepared to recognize, manage and prevent pesticide-related health conditions in theirpatients and communities. Communities expect that their primary care providers will beprepared to deal with pesticide-related health conditions, as well as other environmental-related illnesses, but often times they are not.

This report, an Implementation Plan for the National Strategies for Health Care Providers:Pesticides Initiative, sets out a strategic direction for the nation to improve the recognition,management, and prevention of pesticide-related health conditions. It will lead to healthimprovements in both agricultural and urban sectors. The Implementation Plan’s vision isfor all primary care providers on the front lines of our health care system to:

� Possess a basic understanding of the health effects associated with pesticide exposures aswell as broader environmental exposures; and

� Take action to ameliorate such effects through clinical and prevention activities.

The Implementation Plan sets forth a three-pronged approach to move toward the vision,and includes both short and long-term components. The Implementation Plan will beused to build national consensus on this issue and to gain funding and resource supportto implement and evaluate the entire initiative.

This Initiative — the National Strategies for Health Care Providers: Pesticides Initiative — beganin 1998 and is a partnership between the US Environmental Protection Agency (EPA) andThe National Environmental Education & Training Foundation (NEETF), in collaborationwith the US Department of Health and Human Services (DHHS), the US Department ofAgriculture (USDA), and the US Department of Labor (DOL). From the outset, this nationalinteragency initiative has been conceived of as a long-term effort. Sustained funding will beneeded to ensure the success of the Implementation Plan, and multi-stakeholder involvementis necessary from federal agencies, academic institutions, professional organizations,foundations, farmworker and farm groups, industry and trade associations.

2 National Strategies for Health Care Providers: Pesticides Initiative Implementation Plan

Pesticides Education: A Model for Environmental Health IssuesThis Implementation Plan focuses on pesticides as an important model which can easily beexpanded to incorporate other toxic agents and other related initiatives in the field ofenvironmental health. To avoid duplication of effort, this Implementation Plan will beintegrated into the broader context of other national efforts to educate health care providersabout occupational and environmental health, including children’s health protection,drinking water, nursing and environmental health, Healthy People 2010, and NEETF’s Health& the Environment Programs. This Implementation Plan reflects the landmark reportsfrom the Institute of Medicine, National Academy of Sciences (1988, 1995) that set broadrecommendations on environmental health in medicine and nursing, as well as the extensiveefforts by key stakeholders across the country to address this issue. It is hoped that thisImplementation Plan will pave the way for the strategic next steps needed to move forwarda common national vision for environmental health awareness, education and training tohealth care providers.

The Initiative’s Driving ForcesThis Initiative received its impetus from a number of sources.

The Worker Protection StandardA primary contributor is EPA’s Worker Protection Standard, designed to reduce pesticideexposure to agricultural workers, mitigate exposures that occur, and inform agriculturalemployees of the hazards of pesticides. The regulation, implemented in 1995, mandates thatmillions of farmers, pesticide applicators, and farmworkers be educated. This in turn wasexpected to create additional demand for services from health care providers.

After the first year of full implementation of the Worker Protection Standard, EPA held ninepublic meetings to evaluate the progress of implementation and hear the experience of thepeople most affected by the regulation. One clear message from the public meetings was theneed to improve the recognition, diagnosis, and management of adverse health effects frompesticide exposures by all primary health care providers.

Although the primary populations affected by pesticides are the 3 to 4.5 million farmworkersin America and the million or more pesticide applicators, pesticides are widely used in theurban sector, and rural populations not directly involved in farming also may be at risk forexposure to pesticides. Urban and suburban exposures to insecticides, fungicides, rodenticidesand other pesticides in the home and workplace are affecting the population at large. Healthcare providers in urban settings are even less likely to “think pesticides” in taking patienthistories or diagnosing illnesses.


Other ForcesIn the field of environmental health, the need for improvements in health care provider traininghas been expressed by health professional groups, academic institutions, government andcommunity organizations. In 1994, the American Medical Association adopted a resolutionurging Congress, government agencies, and private organizations to support improvedstrategies for the assessment and prevention of pesticide risks. These strategies included systemsfor reporting pesticide usage and illness, as well as educational programs about pesticide risksand benefits. In addition, two Institute of Medicine (IOM) committees addressed the generalissue of environmental health education, focusing on nurses and physicians, respectively. Bothcommittees recommended an integration of environmental health issues throughout trainingand clinical practice for health care providers. Also, in 1999 an IOM committee onenvironmental justice recommended enhancing health professionals’ knowledge ofenvironmental health as well as environmental justice issues.

Definition of Environmental HealthA common definition of environmental health has been adopted for the purposes of this Initiative.Environmental health is defined as: “Freedom from illness or injury related to exposure to toxicagents and other environmental conditions encountered in the home, workplace, and communityenvironments that are potentially detrimental to human health” (adapted from the Institute ofMedicine’s report, Nursing, Health and the Environment (Pope et al, 1995)). Pesticide exposuresdo occur in workplace settings, so environmental health in the context of this ImplementationPlan is an overarching category that includes occupational health exposures.

Building the Initiative – A Collaborative ApproachTo ensure that collaboration and integration at the federal level could be incorporated at allstages of the Initiative, EPA established a Federal Interagency Planning Committee inNovember 1997 whose initial membership included representatives from DHHS, USDA,and DOL, as well as EPA. Beginning in February 1998, through a cooperative agreement,the Initiative also involved NEETF as a non-federal collaborative partner. NEETF bringsthe expertise of working with a national coalition of health organizations involved inenvironmental health through its Health & The Environment Programs, and has played amajor role in coordinating the Initiative with EPA and the federal partners. Several otherfederal agencies have since joined the Initiative and other interested federal partners arewelcome to participate.

Expert Panel and WorkgroupsEPA, the Federal Interagency Planning Committee, and NEETF are committed to involving awider group of key stakeholders through all stages of this Initiative. This commitment beganwith the development of this Implementation Plan. In April 1998, an Expert Panel was


convened to identify strategies for educating health care providers on how to recognize,diagnose, manage, and prevent adverse health effects from pesticide exposures. This workshopreflected the collaborative nature of this Initiative and the need to involve a wide group ofstakeholders in this issue (US EPA, 1998).

An even wider involvement of key stakeholders took place through three workgroup meetings(Education, Practice, and Resources) held in May and August 1999 (summaries of the ExpertPanel and workgroup meetings are presented in Appendices A and B, respectively). Workgroupmembers, as liaisons to their organizations, have brought important perspectives to this effortand have ensured that their organizations are kept abreast of the Initiative. These keystakeholders will play a further role in outreach and consensus building within theirorganizations and constituencies to move the overall Initiative forward.

Strategic Outreach Meetings to Build ConsensusWith the assistance of stakeholders who participated in the Expert Panel and/or the threeworkgroups, the Federal Interagency Planning Committee will conduct strategic outreachmeetings with key professional organizations and decision-making bodies to secure officialendorsements. Efforts are currently underway to participate at various national conferencesfor the purposes of publicizing the Implementation Plan and the upcoming national forum(see page 10), and to begin developing support among stakeholders.

Sustained Funding and SupportTo ensure that sustained funding is available for the implementation and evaluation of bothshort and long-term components of this Initiative, funding and resource support must comefrom various sources, including federal agencies, professional health organizations,foundations, academia, industry, trade associations, environmental, farm and farmworkerand community-based organizations. It is this type of resource sharing and collaborationthat will determine the success of this Initiative and create a win-win situation for all parties.

Summary of the Implementation PlanObjectivesThe main purpose of this Implementation Plan is to clearly articulate a plan to improve therecognition, management and prevention of pesticide-related health conditions. ThisImplementation Plan also serves as a model for broader efforts to educate health care providersabout the spectrum of health conditions associated with environmental problems. The fourmain objectives of the Implementation Plan are to:

� Raise awareness of the arguments why primary health care providers should be educatedabout and trained in ways to address health effects from pesticide exposures.

� Identify the target audience for the Initiative and explain how strategies are designed toreach segments of the audience at different stages of their “readiness to change.”


� Set forth an agenda to build national consensus on this issue and gain funding and resourcesupport to implement the Plan and evaluate the Initiative over a ten-year period fromvarious sources including federal agencies, academia, professional health organizations,foundations, farmworker and farm groups, industry, and trade associations.

� Articulate a three-pronged strategy and a set of required elements for educational settings,practice settings, and necessary resources and tools.

Strategic FrameworkGiven that primary care providers are educated and trained in different settings, theImplementation Plan specifically sets out a three-pronged strategy for effectively reachingthem in these settings (see Table 1). The first prong addresses a provider’s formal education,such as medical school or nursing school. The second prong targets the practice setting inwhich a provider works and participates in professional development. The final prongarticulates the resources and tools that providers need to deal effectively with pesticide-related health conditions in their practices and communities. Specifically, the three prongsof the strategy are as follows:

1. Educational Settings: Create significant institutional change in educational settings (e.g.,medical schools, nursing schools, residency and practicum programs) so that students inthe health professions are prepared to recognize, manage, and prevent pesticide-relatedhealth conditions across the United States.

2. Practice Settings: Change the practice of primary care so that pesticide-related healthconditions are recognized, effectively managed and prevented in practice settings (e.g.,community clinics, hospitals, workplace clinics) across the United States.

3. Resources and Tools: Create new resources for educational and practice settings thattake into account existing resources, evaluate their quality and suitability for differentaudiences, and assure their availability through an information gateway.

For both the educational and practice settings, the Implementation Plan recommends a similarset of component projects and activities (see Figure 1). These components serve as a frameworkfor the cohesive implementation of the three-pronged strategy. This Implementation Planintentionally presents the same conceptual framework for both settings so as to ensureconsistency in approach. However, the Implementation Plan distinguishes between the settingsbecause they often involve different decision-makers and approaches. The components forthe settings are:

� Make the case for change

� Define guidelines for educational competencies or practice skills

� Assess target audiences in each setting

6

Com

pone

nt A

: Mak

e th

e ca

se fo

r cha

nge

in e

duca

tion

alse

ttin

gs —

Dev

elop

an

effe

ctiv

e ca

se st

atem

ent t

o co

nvin

cede

cisi

on m

aker

s ab

out

the

need

for

env

ironm

enta

l hea

lth

and

pest

icid

e ed

ucat

ion

in m

edic

al a

nd n

ursi

ng e

duca

tion

alin

stit

utio

ns.

*Com

pone

nt B

: De

fine

com

pete

ncie

s an

d in

tegr

atio

nst

rate

gies

for

cur

ricul

a —

Pro

duce

Nat

iona

l Gui

delin

es t

hat

reco

mm

end

com

pete

ncie

s sp

ecif

ic t

o th

e r e

cogn

itio

n,m

anag

emen

t and

pre

vent

ion

of p

estic

ide

expo

sure

s, fo

r all

basic

and

adva

nced

tra

inin

g in

med

icin

e an

d nu

rsin

g; d

efin

eac

com

pany

ing

cont

ent a

reas

; sug

gest

met

hods

of i

nteg

ratio

nin

to cu

rric

ula;

and

pro

vide

acc

ess t

o re

leva

nt re

sour

ce m

ater

ials.

*Com

pone

nt C

: Ass

ess e

duca

tiona

l set

ting

s —

Con

duct

an

asse

ssm

ent o

f the

tar g

et a

udie

nce

of e

duca

tiona

l ins

titut

ions

to d

eter

min

e (a

) am

ount

of

exist

ing

cour

sew

ork,

(b) f

acul

tym

embe

rs’ c

urre

nt k

now

ledg

e an

d co

mfo

rt le

vel w

ith te

achi

ngpe

stic

ide-

rela

ted

topi

cs, a

nd (c

) how

facu

lty a

nd e

duca

tiona

lin

stitu

tions

will

bes

t re

spon

d to

edu

catio

nal p

rogr

ams

and

info

rmat

ion

reso

urce

s. Th

is a

sses

smen

t will

be

com

pris

ed o

fa

liter

atur

e re

view

and

a ra

nge

of n

eeds

ass

essm

ent a

naly

ses .

Com

pone

nt D

: Se

cure

off

icia

l en

dors

emen

ts —

En

sure

the

inte

grat

ion

of t

he c

ore

com

pete

ncie

s ou

tlin

ed i

n th

eN

atio

nal G

uide

lines

into

edu

catio

nal i

nstit

utio

ns b

y se

curin

gth

e of

fici

al e

ndor

sem

ents

of k

ey p

rofe

ssio

nal o

rgan

izat

ions

and

deci

sion

-mak

ing

bodi

es.

Com

pone

nt E

: St

reng

then

and

bui

ld f

acul

ty c

ham

pion

s—

Cre

ate

and

supp

ort f

acul

ty c

ham

pion

s with

in m

edic

al a

ndnu

rsin

g sc

hool

s to

teac

h en

viro

nmen

tal h

ealth

and

pes

ticid

eed

ucat

ion

in th

e cu

rric

ulum

, and

to b

ring

abou

t cha

nge

with

inth

eir i

nstit

utio

ns.

Com

pone

nt F

: Cr

eate

tea

chin

g in

cent

ives

— I

nflu

ence

the

appr

opria

te b

oard

s, or

gani

zati

ons,

and

inst

itut

ions

that

crea

te b

oard

exa

ms t

o in

clud

e se

vera

l key

com

pete

ncie

s on

pest

icid

es a

nd e

nviro

nmen

tal h

ealt

h.

* Prio

rity

Proj

ect

Tabl

e 1:

Com

pone

nts

of t

he Im

plem

enta

tion

Pla

n

Educ

atio

nal S

etti

ngs

Prac

tice

Set

ting

sRe

sour

ces

and

Tool

s

Com

pone

nt A

: M

ake

the

case

for

pra

ctit

ione

rs —

Dev

elop

an e

ffec

tive

cas

e st

atem

ent t

o co

nvin

ce p

rimar

y ca

re p

rovi

ders

abou

t th

e ne

ed t

o in

corp

orat

e en

viro

nmen

tal

heal

th a

ndpe

stic

ide

awar

enes

s in

to t

heir

prac

tice

set

ting

s.

*Com

pone

nt B

: Def

ine

prac

tice

skill

s and

gui

delin

es —

Pro

duce

Nat

iona

l Gui

delin

es th

at re

com

men

d pr

actic

e sk

ills a

nd g

uide

lines

for

the

reco

gniti

on, m

anag

emen

t, an

d pr

even

tion

of p

estic

ide

expo

sure

s fo

r al

l pr

acti

cing

hea

lth

care

pro

vide

rs;

defi

neac

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Information Gateway

Educational Settings

Educational institutions

Educational competencies

Institutions and faculty

Key decision-makers

Faculty champions

Exams and requirements

Make the case

Define guidelines

Assess target audiences

Secure endorsements

Demonstrate success

Create incentives

Practice Settings

Primary care providers

Practice skills

Primary care providers

Key decision-makers

New practice models

Health care requirements

and reporting

Resources and Tools

Inventory National Review Board

New Resources

Figure 1: Framework of the Implementation Plan

� Secure key endorsements

� Demonstrate success through faculty champions and practice models

� Create incentives for change.

The Implementation Plan also outlines a process to develop the resources and tools necessaryto ensure the success of the entire initiative:

� Inventory resources

� Establish a national review board and conduct evaluation of resources

� Create an internet-based information gateway

� Create new resources.

Table 2 provides a listing of the anticipated work products to be produced in this Initiative.The projects and products can only be attained through partnerships among federal and


state agencies, professional health organizations, academia, foundations, industry, farmand farmworker groups, environmental groups and trade associations. The FederalInteragency Planning Committee encourages interested parties to come forward withtheir ideas for implementation.

Timeline and Priority ProjectsA timeline for implementation of the Implementation Plan is provided in Figure 2. As thetimeline shows, several projects have already been initiated, and four component areas willreceive priority attention. They are:

� National Pesticide Competency Guidelines for Education, and National PesticidePractice Skill Guidelines: These two model documents will recommend competenciesfor students and practice skills for practitioners to achieve, respectively, the recognitionand management of pesticide-related health conditions and exposures. Work on theNational Guidelines was initiated in February 2000.

� Case Statement for Educational Settings (p. 41)

� Case Statement for Practice Settings (p. 67)

� National Pesticide Competency Guidelines for Education (p. 44)

� National Pesticide Practice Skill Guidelines (p. 70)

� Report on Knowledge, Attitudes, and Skills of Educators and Practitioners (pp. 52, 74)

� Organizational Position Papers Endorsing The Plan (pp. 55, 77)

� Request for Applications/Proposals to Support Faculty Champions (p. 58)

� Request for Applications/Proposals to Support Practice Models (p. 80)

� Network of Successful Faculty Champions (p. 59)

� Network of Successful Practice Models (p. 80)

� Sample Questions for Educational Examinations (p. 61)

� New Monetary, Legal, Community-Based, and Peer-Professional Incentives (p. 83)

� Inventory of Resources (p. 90)

� National Review Board for Resource Materials (p. 92)

� Recommended List of Resources (p. 92)

� Gateway of Resources (print, telephone, internet) (p. 94)

� New Resources and Materials (pp. 97, 99)

Table 2: Initiative Work Products

9

Educ

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2010


� National Review Board: The National Review Board will determine assessment criteriaand evaluate existing resources, with the goal of identifying, selecting, and assessing theideal resources that primary care providers use in both the educational and practice settings.

� Information Gateway: The information gateway will be a print, telephone, and web-based resource through which primary care providers can easily access information andeducational resources about pesticides.

� Audience Assessment of Educational Settings and Primary Care Providers: Theassessment report will document the knowledge, attitudes and skills of health care providerfaculty and practitioners on pesticides and environmental health.

Request for Participation and Public CommentThis Implementation Plan is a working document and will be widely shared and disseminatedamong stakeholders in professional associations, health organizations, educational institutions,government agencies and other groups. To gather as much input as possible, the FederalInteragency Planning Committee in 2000 distributed widely more than 4,500 copies of the draftImplementation Plan to stakeholders for public comment. This final Implementation Plan reflectsthose public comments. A summary of issues raised via public comment and the responses bythe Federal Interagency Planning Committee is included (see Appendix C). Further questionsabout the Implementation Plan can be directed to NEETF at [email protected]

National Forum 2002The Implementation Plan will be the subject of a national forum scheduled for 2002 inWashington, DC. The national forum will be held over two days with an audience of 150-200health care providers and stakeholders, including key decision-makers from various agenciesand organizations. The forum will launch this national Implementation Plan, showcasingpesticides as a model for other environmental health issues. Progress on the priority projectsinitiated at the time of the event — the National Guidelines, audience assessment, informationgateway, and national review board — will be featured at the forum, in addition to a broadrange of educational models, practice models, and resources.

The forum will provide an opportunity to secure endorsement from key stakeholders, pavethe way for the strategic next steps needed to move a common national vision forward forenvironmental health outreach to health care providers, and build a nationwide network ofhealth care providers committed to incorporating environmental health into primary careeducation and practice.


Vision, ExpectedOutcomes, and Evaluation

Vision

The goal of the National Strategies for Health Care Providers: Pesticides Initiative is toimprove the recognition, management, and prevention of health effects from pesticidepoisonings and exposures. In addition, all primary health care providers should consider

the impact of pesticide overexposures on human health as they treat patients and prevent disease.All physicians, nurses, and other health care providers are expected to possess a basic knowledgeof health effects related to pesticide exposures and an ability to take action to ameliorate sucheffects through clinical and preventive activities. This will be achieved through training andeducation of health professionals, faculty, and students, and the identification, development,dissemination, and use of appropriate resources and tools, in clinical and public health settings.

The Initiative is set in the broader context of environmental health and holds as its preamblethe following recommendations, adopted from the Institute of Medicine (Pope and Rall, 1995):

� Environmental health concepts will be reflected in all levels of education of primarycare providers, specifically defined as physicians, nurse practitioners, physician assistants,nurses, nurse midwives, and community health workers in the disciplines of familypractice, pediatrics, internal medicine, emergency medicine, obstetrics/gynecology,preventive medicine, and public health.

� Interdisciplinary approaches will be used when educating primary health care providersso as to draw upon the expertise from various environmental health disciplines.

� Environmental health content will be an integral part of lifelong learning and continuingeducation of primary care providers.

� Professional associations, public agencies and private organizations will provide more resourcesand educational opportunities to enhance environmental health in primary care practice.

Expected OutcomesBy 2010, the following expected outcomes of the Initiative will have occurred:

1. Professional associations, decision-making bodies, academic institutions, and practicesettings will have endorsed the need to address health conditions associated with pesticidepoisonings and overexposures.


2. The need for educating health care providers about the health effects of pesticide exposureswill be an accepted part of primary health care education and practice.

3. Education and practice settings will have integrated an endorsed set of educationalcompetencies and practice skills for primary health care providers on pesticide exposures.

4. Evaluated tools and resources will be used by health care providers to recognize, manage,and prevent health effects from pesticide exposures.

5. A faculty champion on this issue will be positioned and funded in over 100 academiceducational institutions, including academic health centers and accompanying nursingschools nationwide.

6. Certification, licensing, and accreditation requirements will include attention to therecognition, management, and prevention of health effects related to pesticide poisoningsand exposures.

7. Over 100 pilot primary care practices will serve as models for effectively integratingattention to health effects from pesticides in clinical, educational, and/or preventive ways.

8. Primary care providers will be integrating attention to the health effects of pesticides inclinical, educational, and/or preventive ways.

9. An internet gateway will effectively guide health care providers and professionalorganizations to information resources and educational materials on the issue.

10. Incentives in the health care system will have increased the attention that primary careproviders pay to the recognition, management, and prevention of health effects frompesticide poisonings and exposures.

11. Resource materials on pesticide poisonings will be easily located in the leading sources ofinformation for the health care community (e.g., professional journals, newsletters, centralinternet sites, professional meetings).

Evaluation of Expected OutcomesThis Initiative has a long-term perspective and ultimately its success will depend on how wellit leads to changes and improved health care in this country. Evaluating its progress along theway and its long-term success will be important, both for making mid-course corrections asneeded, and for learning from its achievements and failures. An evaluation team will becontracted to design and implement the evaluation. The evaluation will begin early on in theInitiative to ensure that measurement indicators are clearly built into all aspects ofimplementation. The evaluation will be both formative and summative in nature so as totrack both process and outcome measures. The following set of indicators will be used toevaluate the components of the Plan.


Professional Endorsement

� The major professional associations andorganizations involved with theInitiative’s target audiences endorseand/or adopt a position papersupporting this Implementation Plan.

� Professional journals increase thenumber of peer-reviewed articles andcommentaries making the case forrecognizing, managing, and preventinghealth effects from pesticide poisoningsand exposures.

Educational Institutions

� Over 40 percent of educationalinstitutions take steps towards integrating pesticide education into their settings (e.g.,adopt components into their curriculum from the National Guidelines, hire a facultychampion, hold periodic Grand Round lectures on the topic, create practice-basedinternships that address the issue).

� Over 100 educational institutions have a “faculty champion” on faculty who integrates apesticide perspective into the education of health professional students.

� Certification and licensing requirements include a component related to pesticides andaddress the broader understanding of environmental health so that students are tested onat least a portion of the endorsed competencies.

Practice Settings

� Over half of practice settings have taken steps towards building a “model practice” thataddresses health effects related to pesticides (i.e., patient education, history taking,community outreach, use of tools and resources, access to internet gateway).

� Model practice settings document improvements based on changes in recognizing,managing, and preventing pesticide exposures. Specific models are tracked in high-impactareas (e.g., migrant farmworker communities, urban settings).

� Re-certification and continuing education requirements include a component related topesticides, or address the broader understanding of environmental health so thatpractitioners are evaluated on at least a portion of endorsed practice skills.

� Incentives are in place in the health care system to reward health care providers whorecognize, manage, and prevent pesticide-related health conditions.

“If you make itrelevant to

teachers, they’llfind a way to teach

their students.”— Marcia Owens, JD

Minority HealthProfessions Foundation


Utilization of Tools and Resources

� Tools and resources are being used at an increased rate by health care providers as trackedthrough sales, requests, downloading off the internet, and distribution at conferences.

� An endorsed list of resources is available to health care providers online and through thekey dissemination mechanisms.

Increased Reporting and Surveillance

� More health care providers are reporting suspected pesticide poisoning and exposures tostate and federal agencies.

� States with existing surveillance systems have improved outreach to health care providersstatewide to report suspected cases.

� More states implement pesticide surveillance systems with effective outreach andinvolvement of health care providers.

Improvements Recognized by Communities/General Public

� Community organizations report improved communication and activities by local healthcare providers and clinics.


Making the Case

P esticides are ubiquitous in our society. We use them in our homes, schools, workplacesand communities. Due to the widespread dissemination of pesticides and the potentialfor related illness and injury, especially among farmworkers and pesticide handlers,

primary care providers should be prepared to recognize, manage, and prevent the pesticide-related health conditions affecting patients and communities.

When pesticide toxicity is discussed, most people usually think of an acute pesticide poisoningincident in an agricultural setting. However, pesticides are also of concern because of potentialchronic health effects from long-term and cumulative exposures. In addition, pesticideexposure can occur in a number of settings outside agriculture, including urban environments,homes, and schools as well as through multiple routes. For example, diet is a major route ofexposure of children (Etzel et al, 1999). A report published by the National Research Councilconcluded that prenatal and postnatal developmental toxic effects and the unique consumptionpatterns of children needed to be taken into account in establishing standards for pesticideson food (NRC, 1993). Rural populations not directly involved in farming also may be at riskfor exposure to pesticides. Several objectives in Healthy People 2010 aimed at improving humanhealth relate to pesticides. These include reducing pesticides exposures indoors and outdoors,as well from dietary intake; monitoring exposures by measuring urine and blood samples;and increasing the number of jurisdictions that are monitoring for pesticide poisonings.

Patients and communities look to their primary care providers as important sources ofinformation and guidance on suspected pesticide-related health conditions. These providersare not always able to respond effectively.

Primary care providers are on the frontline of health care and can play a key role in identifying andameliorating potential pesticide poisonings and exposure. However, more needs to be done toensure that health professionals are prepared for this role and that they know where to turn forassistance. This includes ensuring that providers can “problem solve” with patients who think anexposure has occurred, readily diagnose if appropriate, provide timely treatment for pesticide-related illnesses, provide prevention education, and, where appropriate, consult with localauthorities. This Implementation Plan offers a way for health care professionals to be effectivelyprepared through their education and training, and to maintain this knowledge while in practice.

This Implementation Plan is based on the premise that addressing pesticide-related healthconditions can be a part of routine primary care and does not require extensive expertise on the


part of the provider. This Initiative recognizes that primary care providers are faced with a numberof competing public health concerns. The goal of the Initiative is to build on existing skills intoxicology, pharmacology, history-taking, and risk communication to provide tools that the busypractitioner can use when the need arises. Primary care providers working with high risk populationsmay need to attain a more detailed knowledge of pesticide-related health conditions.

More research is still needed on the health effects of pesticide exposures. Such research effortsshould involve primary care providers. Research should focus on what conditions primarycare providers see in their practices, specifically with regard to chronic exposures. As thisInitiative evolves, it is recommended that epidemiologic research be developed using a registryof primary care offices to identify conditions requiring further research and documentation.

Following are a number of reasons, accompanied by supporting data, why pesticide-relatedhealth conditions are relevant to the practice of primary care today:

� Patient and community concerns

� Recent public pesticide issues

� Potential for acute exposures and health effects

� Potential for chronic exposures and health effects

� Clinical case examples

� Current provider training and education in environmental health.

Patient and Community ConcernsPatients and communities often ask for advice about a suspected pesticide exposure or askthe provider to investigate a potential health condition to see if it might be related to pesticides.Public concern about pesticides has been documented and often shows up in the questionsasked by patients. By helping patients problem solve and evaluate risks from pesticides, primarycare providers can help patients reduce risk to exposure and prevent future exposures. Inaddition, an alert clinician will also be able to identify a potential exposure when it occurs.

In some instances, providers serve populations that are more actively engaged with pesticides,such as the farmworker community. There are 3 to 4.5 million farmworkers in the United Statesand a million or more pesticide applicators who are often at greater risk for pesticide exposurebecause of mixing or applying pesticides or working in fields where pesticides are applied. Aprovider community that is more aware of the specific concerns of this population will be betterprepared to effectively diagnose and treat health conditions, and prevent exposures.

The public has expressed concern about the risks of cancer, birth defects, reproductive effects,and other conditions from exposure to pesticides and other chemicals. For example, from a


list of 30 potentially hazardous activities, use of pesticides was perceived to rank in the top 10most risky activities, higher in “riskiness” than surgery, electric power, swimming, largeconstruction, x-rays, or bicycles (Slovic et al, 1980). In a 2000 survey of registered voters (n =1,565), nearly all (90 percent) indicated that environmental factors like pollution, waste andchemicals are at least somewhat important contributors to diseases. More than half (53 percent)said these factors are very important in causing diseases (Health-Track, 2000). Voters linkedthe role of environmental factors in causing illnesses such as sinus and allergy problems,asthma in children, birth defects and cancer. Health care providers have an important role inhelping their patients evaluate the relative risks from different types of environmentalexposures, including pesticides. Health care providers need to be able to counsel patientsabout realistic risks, and avoid unwarranted trivialization or exaggeration of the risks.

In large measure, this Initiative is intended to help prepare the primary care provider with theinformation, skills, and resources to begin problem solving with patients. The questions inthe shaded box above are only a sampling of the concerns presented to practitioners everyday.This Initiative will help primary care providers carry out their responsibilities to help patientsevaluate the risks and determine whether further steps are required.

Providers are often asked basic questions by their patients. Here is a samplingof pesticide-related questions and concerns that patients bring to their visitswith providers:

(1) I received a report from my water utility that said the water contains 0.5 ppbof dibromochloropropane. What is this chemical, what does it mean for myhealth, and what should I do?

(2) I just read in the newspaper that schools in my state are spraying theirbuildings with toxic pesticides. I’m worried because my child has asthmaand sometimes feels worse at school. Could it be the pesticides?

(3) I have a six-month-old child and the cat has fleas. Is it safe to have theexterminator in to flea-bomb the house? The exterminator says it’s safe ifwe stay out for a few hours and open the windows afterwards.

(4) My husband and I are having trouble conceiving a child. We own a farmand he sprays pesticides. I want to know if the pesticides may be causinga problem.

(5) I get a headache and have difficulty concentrating at the office. I think itmay be because the janitor sprays pesticides at night.

(6) I am a farmworker and was picking celery in the fields. Today I have a rashon my hands and arms. Is it from the chemicals?FR

EQU

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Y AS

KED

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F PR

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Recent Public Pesticide IssuesMisuse of Pesticides – Methyl Parathion — Case Studies of MisdiagnosisUnder the Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA), EPA regulates anorganophosphate insecticide called methyl parathion for use on specific crops. In the 1980sand 1990s, methyl parathion was widely used illegally in indoor environments by unlicensedapplicators. One published report describes methyl parathion-related illness among sevensiblings, two of whom died (CDC, 1984). Approximately two days before these childrenwere correctly diagnosed, five of them were seen by their local physician and sent back totheir contaminated home with a mistaken diagnosis of viral gastroenteritis. Since 1984, atleast five different states have reported illegal use of methyl parathion inside homes andbusinesses. Some people exposed to methyl parathion in their homes experienced mildsymptoms of organophosphate poisoning (e.g., nausea, headache, difficulty breathing,blurred vision) and some of them complained to their health care professionals. A reportsummarizing the 1995 investigations in Ohio (where at least 500 homes were treated illegally)found that 20 percent or more of respondents reported symptoms during the two weeksfollowing methyl parathion application (NCEH, 1996). Unfortunately, corrective actionwas not enacted until 1994. More than 1,500 individuals were relocated from their homes.The estimated clean-up cost for these incidents was more than $90 million (EnvironmentalHealth Perspectives, 1997).

Misdiagnosis of organophosphate poisoning can be a severe problem. Zweiner and Ginsburg(1988) reviewed a case series of 37 infants and children poisoned by organophosphates andcarbamates. Of 20 cases transferred to Children’s Medical Center in Dallas, 16 (80 percent)had an incorrect transfer diagnosis ranging from encephalopathy and seizure disorder topneumonia and pertussis.

Each of these cases of misdiagnosis or delayed diagnosis demonstrates the potential for acuteexposures, public concern, and expenses related to the widespread use (and sometimes misuse)of pesticides in our country. The primary care provider can play a vital role in helpingindividuals deal with these exposures. Furthermore, alert providers aware of potential healthconditions related to pesticide exposure can become a key link in limiting the spread of“pesticide epidemics” by identifying sentinel cases and bringing them to the attention ofappropriate public health officials responsible for pesticide-related illness surveillance.

Control of Exotic Pests – Increase in Potential Pesticide Exposures to the PublicA growing number of exotic and public health pests are besieging the United States. Control ofthese pests increases the potential for pesticide exposure to large segments of the public. Aerialapplications of insecticides over residential neighborhoods involving millions of people havebeen conducted in New Jersey for control of malaria-carrying mosquitoes, in New York City forcontrol of mosquitoes carrying the West Nile virus, and in several Florida counties for controlof the Mediterranean fruit fly (Medfly) (CDC, 2001). Surveillance conducted during the Florida


Medfly Eradication Program identified123 individuals with illness potentiallyrelated to pesticides used in the program(CDC, 1999b). In 1999, when pesticideswere used against mosquitoes in New Yorkduring the outbreak of West Nile Virus,Poison Control Centers receivedapproximately 3,500 inquiries concerningsprayings. Approximately 250 of theseinquiries involved unconfirmedcomplaints of adverse health effects, nearlyall of which were classified as “minoreffects” (e.g., patients exhibited somesymptoms as a result of exposure, but theywere minimally bothersome). Other caseswere classified as “not followed, minimalclinical effects possible,” e.g., patient wasnot followed because, in the clinicaljudgment, the exposure was likely to resultin only minimal toxicity of a trivial nature(Matthew P. Mauer, 2001). Continued useof pesticides against emerging publichealth and agricultural threats is likely to lead to increased health concerns and reports to healthcare providers of illness. During surveillance to detect human illness (e.g. West Nile virus) andpesticide spraying campaigns to control exotic pests, health care providers are called upon toprovide sound preventive advice, and to recognize, manage, and report pesticide-related and/orinsect borne viral illnesses (CDC, 2001). Careful documentation and reporting of suspectedcases are needed to protect those who may be unusually susceptible.

Potential for Acute Exposures and Health EffectsHealth care providers may be faced with patients who have experienced acute pesticidepoisonings. A pesticide poisoning is considered acute when the onset of symptoms occurshortly after the time of pesticide exposure. Acute pesticide poisonings can differ in theirdegree of severity.

While providers may not see very many acutely poisoned patients, they should possess a basicunderstanding of signs and symptoms, and an ability to diagnose so that appropriatemanagement can be instituted. Oftentimes it is the primary care provider who identifiespossible sentinel cases that signify the presence of previously unrecognized pesticide hazardsin the community. By notifying the proper authorities of real or potential poisonings, healthcare providers can play a critical role in pesticide-related illness surveillance.

“Even though I know it is very important to diagnose

and treat this problem, we have to start by preventing

the problem in the very first place. That is when we are

going to start seeing some changes in the long run.”— Gerardo de Cosio, MD

US-Mexico Border Health Association


The EPA manual Recognition and Management of Pesticide Poisonings provides healthprofessionals with information on the health hazards of pesticides currently in use. It dealsprimarily with acute effects and provides consensus recommendations for management ofpoisonings and injuries caused by current pesticides (US EPA, 1999a).

Health Care Providers Poisoned While Providing TreatmentFrom 1982 through 1998, malathion, an organophosphate with relatively low toxicity, wasassociated with 467 cases in California, where it was considered primarily responsible forreported symptoms (mostly minor and often related to the odor). One surprising finding wasthat 31 (7 percent) of these cases were emergency or medical personnel responding to ninecases of ingestion (Blondell et al, 2000). In 2000, eleven more police officers, firefighters, andparamedics sought medical care for symptoms such as burning eyes and throat irritationafter their exposure to a suicide case who ingested and doused himself with malathion (Das,2000). In another incident, several clinic staff became ill within one year of this incident whiletreating 24 vineyard workers exposed to drift from chlorpyrifos and propargite (Das, 2000).Three additional reports came from Georgia, where emergency department staff became illwhile caring for patients contaminated with organophosphate insecticides (Geller et al, 2001).These reports illustrate the personal stake that all health care providers—particularly firstresponders—have to understand the risks of pesticide exposure.

Agricultural ExposuresAgriculture accounts for 76 percent of the conventional pesticides used annually(approximately 944 million pounds, not including disinfectants, wood preservatives, or watertreatment chemicals) (US EPA, 1999b). Pesticide handlers and agricultural workers appear tobe at greatest risk for acute pesticide poisoning. Based on states with required reporting ofpesticide-related health concerns, EPA estimates there are approximately 250-500 physician-diagnosed cases per 100,000 agricultural workers (including pesticide handlers) (Blondell,1997). Migrant and seasonal farmworkers are especially at high risk since they often work andlive in areas where pesticide exposures can be significant.

Non-Agricultural ExposuresUrban and suburban uses of pesticides can be as high as in some agricultural areas. A 1990EPA survey estimated that 84 percent of American households used pesticides, mostcommonly insecticides (Whitmore et al, 1992). Each year, homeowners on average use 5-10 pounds of pesticide per acre on their lawns and gardens, many times the concentrationapplied by farmers to corn and soybean fields (Robinson et al, 1994). They also use pesticidesin the form of disinfectants, including pine oil cleaners, bathroom cleaning products, andcleaning materials for swimming pools. Occupational exposures occur in many, not alwaysobvious, workplace settings, including structural pest control, construction work, work innurseries, greenhouses and landscaping, the application of fumigants and sprays in ships’holds, aircraft and other transport settings, and in the use of engineering and air-conditioning biocides.


Table 3 below lists numerous occupations that increase the chance for pesticide exposure,as well as some occupational and non-occupational sources that present an opportunityfor pesticide exposure.

Table 3: Occupational and Non-Occupational Sources of Pesticide Exposure

NONOCCUPATIONAL OCCUPATIONAL

Source: McConnell R. Chapter 37: Pesticides and Related Compounds. In: Rosenstock L, Cullen MR, eds. Textbook of ClinicalOccupational and Environmental Medicine. Philadelphia, PA: W.B. Saunders Company; 1994.

Agricultural application

Agronomists

Building maintenance work

Crop duster maintenance

Emergency responders

Entomologists

Farm work

Firefighters

Flaggers

Forestry workers

Formulating end product

Greenhouse, nursery, mushroomhouse work

Hazardous waste workers

Landscapers

Livestock dippers and veterinarians

Manufacturing active ingredient

Accident or Intentionalingestion/suicide attempt

Food residues

Hazardous waste sites

Industrial spills

Residues from treated structures(houses, schools, office buildings)

Residues on treatedlawns and landscapes

Termite control

Water residues

Marina workers

Medical personnel

Mixing and loading pesticides

Park workers

Pesticide applicators

Plant pathologists

Research chemistry

Sewer work

Storage/warehouse work

Structural application

Transportation

Transporting pesticides

Treating contaminated workers

Vector control workers

Wood treatment workers

Work on highway orrailroad rights of way

A substantial number of people in the US are at risk of acute pesticide poisoning from non-agricultural uses. One of the major sources of data on acute pesticide poisoning is the ToxicExposure Surveillance System (TESS) maintained by the American Association of PoisonControl Centers (AAPCC). Data collected from Poison Control Centers showed that in 1996,over 40,000 adults were sufficiently exposed to various types of pesticides to warrant a call totheir local Poison Control Center. These calls were from individuals who had a concern aboutoverexposure and were not requests for information. It is estimated that as many as 60 percentof these individuals developed symptoms of pesticide poisoning. These figures are thought torepresent less than 30 percent of the incident cases of acute pesticide-related illness in the US(Litovitz et al, 1997; Chafee-Bahamon et al, 1983; Harchelroad et al, 1990; Veltri et al, 1987).

Pesticide exposures among children also warrant concern. Children may be more susceptiblethan adults to environmental health risks because of their physiology and behavior. They canbe more heavily exposed to environmental toxins than adults because children eat more food,drink more fluids, and breathe more air in proportion to their body weight than adults. They


also play close to the ground and they put objects in their mouths. They may be more susceptibleto toxins because their neurological, immunological, digestive, and other bodily systems arestill developing, and they may be less able than adults to metabolize and excrete the pollutants(Landrigan, 1997).

In the agricultural setting, children may be exposed to pesticides in a number of ways; throughprenatal exposure, from being in the fields where their parents work, contact with pesticideresidues on parents’ clothing, living in migrant camps next to camps being treated and workingin the fields themselves (US Congress, Office of Technology Assessment, 1990). A report bythe General Accounting Office (GAO, 2000) found that improvements were needed to ensurethe safety of farmworkers’ children.

In addition to the agricultural settings, children may be exposed to pesticides in urban andsuburban settings, e.g. in their houses, yards, day care settings and schools. In 1996, PoisonControl Centers were notified about approximately 80,000 children (age 0-19) being exposedto common household pesticides in the United States. It is estimated that one quarter ofthose children developed symptoms of pesticide poisoning. In a study of unintentionalexposures to pesticides (excluding disinfectants), EPA found that 78,500 such exposures werereported annually to Poison Control Centers in 1985-92, with 92 percent of them occurringat residences (AAPCC, 1994). Children ages five and younger accounted for 63 percent of the

Table 4: Pesticides Most Often Implicated in Symptomatic Illnesses, 1998*

Rank Pesticide or Pesticide Class Child Adults and Total*< 6 years 6-19 yrs.

1 Pyrethrins/pyrethroids 947 3369 4333

2 Organophoshate insecticides 429 2865 3307

3 Hypochlorite disinfectants 963 1425 2394

4 Other insecticides 601 1551 2167

5 Herbicides 314 1748 2078

6 Pine oil disinfectants 1182 844 2029

7 Insect repellents 959 748 1712

8 Phenol disinfectants 591 391 987

9 Carbamate insecticides 165 762 932

10 Other disinfectants 323 460 785

All other pesticides 456 1237 1750

TOTAL 6930 15,400 22,474

* Includes only unintentional illnesses. Intentional (e.g., suicide attempts) cases excluded.** Column totals include 144 cases of unknown age.Note: Poison Control Center Specialists categorized 86 percent of these cases as minor medical outcome, and 31 percent ofthe total were seen in a health care facility.Source: American Association of Poison Control Centers, Toxic Exposure Surveillance System, 1998 data.


cases. Additionally, GAO documented over 2,300 reported pesticides poisonings in schoolsbetween 1993 and 1996 (GAO, 1999).

The majority of pesticide poisonings (85 percent of symptomatic cases reported to PoisonControl Centers) have a minor outcome (often treatable at home), 14 percent have a moderateoutcome (typically requiring treatment in a health care facility) and 1 percent experience amajor or fatal outcome (Litovitz et al, 1997). In 1992-98, there were an estimated 24,000emergency department visits annually resulting from pesticide exposure, of which 61 percentof the cases involved children younger than five years (McCaig, 2000; McCaig and Burt, 1999).These figures are likely under-estimates and may represent only a fraction of the incidentcases of acute pesticide-related illness among children.

Studies by Chafee-Bahamon et al. (1983), Harchelroad et al. (1990), and Veltri et al. (1981)found that Poison Control Centers captured between 24 percent and 33 percent of all poisoningcases seen in hospitals as inpatients and/or outpatients. Since this does not include cases seenby health care providers who are not in a hospital setting, it is likely that the actual number ofpesticide cases seen annually is several times the figures reported in the table 4 (previouspage) or around 100,000 per year.

Pesticides Most Often Associated with Pesticide-Related Health ConditionsOrganophosphate and pyrethroid insecticides are the categories of pesticides most oftenimplicated in acute pesticide-related illnesses reported to Poison Control Centers. Table 4 onthe previous page ranks the class of pesticides most often linked to symptoms in patients, basedon data from TESS. This table includes only unintentional exposures to single pesticide products.

Potential for Chronic Exposures and Health EffectsPatients and others in the community may come to providers with concerns about the chronichealth effects of both short- and long-term exposure to pesticides. There is a growing body ofscientific literature detailing these effects. For example, in a 1999 CDC study (National Health andNutrition Examination Survey, NHANES), levels of metabolites of organophosphate pesticideswere measured in urine from a subsample of NHANES participants six through 59 years of agewho were selected to be representative of the US population. Whether the levels of metabolitesreported in the study are a cause for concern is not yet known. The urine metabolite data canprovide health care providers with a reference range so that they can determine whether peoplehave been exposed to higher levels of organophosphate pesticides than those experienced in thegeneral population (NCEH 2001). A well-informed health care provider who possesses a basicunderstanding of the latest scientific evidence is better prepared to talk with and counsel patientswho are concerned about pesticide exposures and the risk of future adverse health effects.

Risk communication is also a critical aspect of the therapeutic encounter, and requires activelistening to identify patients’ concerns and fears. It requires appropriate risk assessment,


including an assessment of the pesticide involved, the actual source and route of exposure,whether absorption occurred (and, if so, how much), and an honest appraisal of the state ofknowledge about long-term outcomes. Clinicians face the daunting challenge of providingappropriate reassurance where needed, while being careful not to dismiss a patient’s concernswithout investigating them. Under certain circumstances, the most effective course of actionmay be to refer the patient to an occupational/environmental specialist, and the list of resourcesfor that referral should be readily available in every clinical practice. On the other hand, theprimary care clinician may wish to provide this information directly, and information sourcesare available to help.

Cancer StudiesWith regard to the relationship between chronic pesticide exposure and cancer, EPA has receivedand reviewed the required studies for predicting cancer effects for numerous active ingredients.Over 60 of these active ingredients have been classified as probable human carcinogens by EPAor the International Agency for Research on Cancer. Although most of these pesticides are nolonger on the market or have had their uses severely restricted, their potential to cause cancer inpersons previously exposed is still a concern. A review by the National Cancer Institute (NCI)lists 15 pesticides for which there is evidence of cancer in human epidemiologic studies (Zahmet al, 1997). A large prospective study of commercial pesticide applicators and their spouses isunderway in Iowa and North Carolina, funded jointly by NCI, EPA and the National Institute ofEnvironmental Health Sciences, to try to determine which pesticides may pose a risk of cancerin humans (Alavanja et al, 1996). This study began enrolling subjects in 1994-1997 and includes57,000 applicators and 32,000 spouses. Analyses of the possible associations of pesticides withprostate, breast, non-Hodgkin’s lymphoma, colon and lung cancer are planned within the nextthree years. Many other disease endpoints will also be studied, including asthma, neurologicsymptoms, Parkinson’s disease, visual dysfunction, adverse reproductive effects, and respiratorydiseases (see http://www.aghealth.org/analyses.html for updates).

Non-Hodgkin’s lymphoma has been associated with frequent use of herbicides (e.g., 2,4-D)and is associated with farming (Hoar et al, 1986; Wigle et al, 1990, Zahm et al, 1990). As a resultof the widespread concern, the Lymphoma Foundation of America prepared a research summary,“Do Pesticides Cause Lymphoma?” (Osburn 2001), which reports abstracts from 79 studies and35 letters/commentaries concerning pesticides and lymphoma. The report did not concludepesticides were a cause of lymphoma but noted “there is some evidence that links pesticideswith non-Hodgkin’s lymphoma”; therefore, “it makes sense for us to reduce our exposure topesticides.” In the face of mounting concern from the public, physicians need to know where togo to obtain objective information about pesticides and their potential for carcinogenicity.

Studies on Central Nervous System EffectsMany insecticides and fumigants are designed specifically to target the nervous system of thepest they are intended to control (referred to as neurotoxins). There is increasing humanevidence in the form of case reports and epidemiologic studies that suggests that humans


may experience chronic neurologic or neurobehavioral effects following high levels of exposureto certain types of pesticides (Keifer and Mahurin, 1997). Several reports have also foundchronic neurological sequelae (reduced neurobehavioral function) after acuteorganophosphate poisoning (Savage et al, 1988; Rosenstock et al, 1991; Steenland et al, 1994;Stephans et al, 1995). EPA has concluded that some subset of organophosphate-poisonedsubjects probably experience persistent neurobehavioral effects as a result of their exposure.In November 1999, the Committee on Toxicity of Chemicals in Food, Consumer Productsand the Environment (1999) of the Department of Health in the United Kingdom concluded:

The balance of evidence supports the view that neuropsychological abnormalitiescan occur as a long-term complication of acute organophosphate poisoning,particularly if the poisoning is severe. Such abnormalities have been most evident inneuropsychological tests involving sustained attention and speeded flexible cognitiveprocessing (“mental agility”).

This report did not find evidence that exposure absent poisoning was a risk factor forneurotoxicity and noted the need for high quality research to better determine the extent andtype of risks that might be associated with long-term and cumulative exposures.

Studies on Reproductive EffectsMany pesticides have been identified as developmental or reproductive toxicants. “There isincreasing evidence for reproductive effects associated with exposure of males to occupationalagents. Some of the best known examples are reductions in fertility and sperm counts in menwho were occupationally exposed to dibromochloropropane” (Sever et al, 1997).Dibromochloropropane (DBCP), a nematocide that was banned by EPA in 1979, producedazospermia and oligospermia among exposed workers (Whorton et al, 1979). Sever et al (1997)concluded “there is increasing evidence for reproductive and developmental effects of bothmaternal and paternal pesticide exposures. Areas of particular concern include infertility andtime to pregnancy, spontaneous abortion, neural tube defects, and limb reduction defects.” Astudy based on the US Collaborative Perinatal Project (Longnecker et al, 2001) strongly suggeststhat DDT use increases preterm births, which is a significant indicator of infant mortality. Theconcentration of DDE, a metabolite of the pesticide DDT, was measured in the mothers’ serumsamples stored during pregnancy (n = 2,380) for children born between 1959 and 1966. Ofthese women’s births, 361 were born preterm, and 221 were small for gestational age. Mothersof these affected infants had higher levels of DDE in their blood, indicating higher DDT exposure.

Asthma and PesticidesIn 1998, asthma affected an estimated 17,299,000 persons in the United States and cost anestimated $12.7 billion for medical care (CDC, 1998a; Weiss et al, 2001). Self-reported prevalenceof asthma increased 75 percent from 1980 to 1994 (CDC, 1998b). From 1975 to 1993-95, officevisits for asthma doubled to over 10 million per year. Around the 1994 time period there were1.8 million emergency room visits, 466,000 hospitalizations, and over 5,000 deaths.


Pests, such as dust mites, cockroaches, and mice, are thought to be important triggers and,perhaps, initiators of asthma (Huss, 2001; Phipatanakul et al, 2000a; Phipatanakul et al, 2000b).Prevalence of these pests may partially explain the increased risk for asthma and asthma-relateddeaths among blacks and especially among the urban poor. The use of pesticides, therefore,could be an important tool in a comprehensive asthma management program. At the sametime, some pesticides may pose additional risks to those with asthma (Wagner, 1994; Wagner,2000; Wax et al, 1994); in fact, deaths due to asthma have been reported to be associated withexposure to pesticides (Wagner, 2000; Wax et al, 1994). In January 2000, a product designed tocontrol dust mites had to be pulled off the market because of hundreds of reports of adversereactions among users including, primarily, asthma and respiratory reactions.

An Institute of Medicine report (IOM, 2000) concluded that although there is evidencesuggesting that high level exposures to some pesticides may elicit persistent asthma, there isinadequate or insufficient evidence whether or not an association exists between pesticideexposures at the levels typically encountered in nonoccupational or residential settings andthe development or exacerbation of asthma. The report suggested that proper use of pesticidesas part of an exposure control program may yield benefits for asthmatics through eliminationof or reduction of allergen sources.

Studies on Other Health Effects/Specific PopulationsHypotheses related to pesticide effects on respiratory, cardiovascular, endocrine, and otherbody systems have also been suggested and are currently being studied. The impact of pesticideson child development is also a growing area of research and investigation.

While studies have indicated associations between pesticide exposures and chronic healtheffects, there still remains insufficient evidence to document a causal relationship betweenfrequently used pesticides and long-term health effects, except in a few cases such as arsenic-associated cancer, male infertility due to exposure to dibromochloropropane, and neurologicsequelae following severe poisonings with neurotoxic pesticides. Health care providers needan awareness of the current state of knowledge on pesticides to assist patients and others inthe community who are concerned about long-term health effects.

The concern about potential future adverse effects of non-acutely toxic pesticide exposuresrepresents a special challenge to health care providers. The nature of scientific inquiry yieldsassociations between pesticide exposures and health effects long before causal relationshipscan be reasonably concluded. These associations and the publicity they generate can be enoughto raise concerns among patients and the community. Providers should be sensitive to thelevel of concern and the need to provide reassurance, as well as the possibility that a referral toan occupational and environmental medicine specialist may be indicated.

Evaluation of patient concerns about toxic exposures can be complicated by time constraintsand the need to engage assistance from non-clinical disciplines. For example, site visits and


industrial hygiene consultations are expensive and not generally part of a private patient’sinsurance coverage. Again, primary care providers need to recognize when these specialtiesare needed and know how to obtain an appropriate referral.

Clinical Case Examples: The Challenge of Diagnosing Pesticide ExposuresFor many pesticides, the short-term and many of the long-term health effects associated withexposure can easily be mistaken for other agents or health conditions. Determining if a patienthas been exposed to pesticides will improve a professional’s ability to make the correct diagnosis.To make a timely and accurate diagnosis, primary care providers need to be familiar with thesettings in which a pesticide exposure may occur, the symptoms associated with these exposures,and the appropriate diagnostic methods.

Case Study 1 – Chronic Health ConditionsAt the Environmental and Occupational Health Sciences Institute (EOHSI) at the Universityof Medicine and Dentistry of New Jersey, two farmers were referred to the occupationalmedicine clinic for problems associated with the use of pesticides. Initially, the concern wasthe possibility of drug interaction and pesticide use. Both farmers had worked in a large limabean operation, and used organophosphate compounds extensively from early in the seasonuntil the harvest. The initial evaluation, along with an industrial hygienist’s evaluation of thefarm, led the health scientists and physicians to conclude that both men had experiencedlong-term exposure to a series of organophosphate compounds. A rigorous evaluation led tothe use of personal protective equipment, installation of an on-site shower, and a laundry forpesticide-contaminated clothing. Over a period of 12 months, considerable improvementwas noticed. Both men felt better and no longer reported symptoms of blurred vision, lack ofconcentration, headaches, etc.

A coordinated effort of the Cooperative Extension faculty, as well as the clinical faculty atEOHSI, led to the diagnosis and a very positive preventive outcome. An earlier evaluation bythe local physician did not connect pesticide exposure to the health problems; in fact, thefarmers were told that there were no real problems and they should just continue what theywere doing. The wife of one of the farmers pursued the problem aggressively for four years,first going to the Extension Service and then to the specialists at the university.

Case Study 2 – Aldicarb ExposureThe following case study, reported in the Morbidity and Mortality Weekly Report (CDC, 1999a),describes a foodborne outbreak of aldicarb poisoning that occurred when improperly storedand labeled aldicarb was mistakenly used in food preparation.

On July 19, 1998, 20 employees attended a company lunch prepared from homemade foods.Shortly after eating, several persons developed neurologic and gastrointestinal symptoms.Ten visited a hospital emergency department, and two were hospitalized. On July 20, a hospital


infection-control nurse reported the incident to the Louisiana Office of Public Health, whichthen investigated the outbreak. The lunch consisted of pork roast, boiled rice, cabbage salad,biscuits, and soft drinks. Only the cabbage salad was associated with illness. Of the 16 personswho ate the cabbage salad, 14 became ill (attack rate: 88 percent); the four persons who hadnot eaten the cabbage salad did not develop symptoms.

The employee who prepared the cabbage salad reported mixing precut, prepackaged cabbagein a bowl with vinegar and ground black pepper. The black pepper came from a can labeled“black pepper” that he had found 6 weeks before the lunch in the truck of a deceased relative.This black pepper had not been used by the employee for food preparation before the companylunch. The contents of the black pepper container were tested for organophosphate andcarbamate pesticides. Testing showed the granules in the pepper container as 13.7 percentaldicarb. A six gram portion of cabbage salad contained 272.6 parts per million of aldicarb, alevel which can produce illness in humans. The deceased owner of the pepper can had been acrawfish farmer, and it is believed that he used aldicarb on bait to prevent destruction of hiscrawfish nets, ponds, and levees by wild dogs and raccoons.

Cholinesterase-inhibiting pesticides (i.e., organophosphates and carbamates), which are widelyused in agriculture and urban pest control, can cause illness if they contaminate food ordrinking water. Aldicarb, a regulated carbamate pesticide, is highly toxic. Health care providersand public health officials should keep in mind that food poisoning might result from pesticideor other chemical contamination as well as from infectious organisms.

Case Study 3 – Organophosphate ExposureA couple in their sixties entered their vacation condominium in Hawaii and were immediatelyaware of a strong odor. Three days later they discovered that the odor emanated from a leakingfive-gallon can of liquid Metasystox-R-2, an organophosphate insecticide which was beingstored in a room adjoining the condominium. The chemical container had leaked and saturatedthe floorboards and the adjoining wall, as well as leaking under the condominium.

The Poison Control Center advised them to see a doctor, which they did, complaining ofcontinuing and increasingly severe headaches, blurred vision, and shortness of breath (i.e.,symptoms compatible with organophosphate intoxication). Pulmonary function tests wereperformed and unexpectedly revealed mild obstructive pulmonary disease that improvedfollowing bronchodilator use. No other testing was performed. The physician treated the couplefor a mild reactive airway disease and told them to return for further care only if symptomspersisted. When they inquired about the need to investigate continuing or residual effectsfrom exposure to the pesticide, the physician did not know how to answer.

When symptoms persisted, the couple called the National Pesticide Information Center (NPIC)and were advised to return immediately to the physician and request a cholinesterase enzymeassay analysis. The results for the male were minimally above the lower normal range (i.e.,


consistent with either an acute or resolving intoxication). NPIC advised the couple to vacatethe condominium and contact the Hawaii Department of Agriculture, which helped identifya commercial laboratory that confirmed the contamination, and provided clean up. Thecouple’s symptoms resolved approximately two weeks later.

Case Study 4 — Arsenic ExposuresA clinician examined a rural family of eight with a number of signs and symptoms. Familymembers had conjunctivitis, bronchitis, pneumonia, sensory hyperthesia of the arms andlegs, muscle cramps, dermatitis over the arms, legs and soles of the feet, nosebleeds, earinfections, blackouts and seizures, gastrointestinal disturbances, and severe alopecia. Symptomsbecame most severe during the winter months and tended to remit in summer (Peters et al,1983). These conditions were initially attributed to stress, poor diet, hypochondria, and evenchild abuse. Only when a toxicologist heard about the case from the news media and performedappropriate laboratory tests on environmental samples was the source of the problemidentified, three years later. The problem was found to be burning copper-chrome-arsenictreated wood (outdoor grade plywood) in the family’s wood stove.

These case studies point to the preventable human suffering that can be associated withdelayed or missed diagnoses of pesticide poisoning. Since the use and presence of pesticidesare ubiquitous, there is a strong argument for sensitizing all primary care providers to developa high index of suspicion, diagnostic acumen, and awareness of available resources, torespond promptly to patients whose presentations may represent pesticide poisoning. Whileit is anticipated that providers working with high-risk populations — such as in agriculturalareas, emergency departments, and pediatrics — will be most sensitive to this proposition,these cases show the potential for such severe health consequences that all primary careproviders are advised to be vigilant.

Current Provider Training and Education in Environmental HealthHealth care providers are the primary audience for this Plan because the public looks to themfor guidance on health concerns. While some progress has been made in introducingenvironmental health issues into curricula at medical and nursing schools, most healthproviders still do not have adequate knowledge and tools to address patient and communityconcerns. Key studies by recognized medical institutions and committees convened by federalagencies and national scientific bodies have addressed this concern:

� In 1985, only 50% of medical schools addressed occupational and environmental healthin their curricula, with an average of only four hours being taught over four years. By1992, 66% percent of medical schools required an average of about six hours of studyin occupational and environmental health over four years (Schenk et al, 1996). (See boxon next page).


� In 1988, an Institute of Medicine (IOM) committee on the role of the primary carephysician in occupational and environmental medicine recommended that all primarycare physicians be able to identify possible occupational or environmentally inducedconditions and make appropriate referrals (IOM, 1988).

� In December 1994, the American Medical Association adopted a resolution urgingCongress, government agencies, and private organizations to support improved strategiesfor the assessment and prevention of pesticide risks (AMA, 1994).

� Specific recommendations to change medical/nursing education and practice were madeby two IOM committees on medicine and nursing, in 1994 and 1995, respectively. In1995, the Institute of Medicine produced two landmark reports — Environmental Medicine:Integrating a Missing Element into Medical Education (Pope and Rall, 1995) and Nursing,

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A 1994 survey of environmental medicine content in US medical schoolsfound that:

� Ninety US medical schools (76 percent) reported requiring environmentalmedicine content in the curriculum. Only two schools (2 percent) had adedicated course. Eighty-nine schools (75 percent) indicated thatenvironmental medicine was taught as part of a required course. Forty-sixschools (39 percent) offered it as an elective course.

� Fifty schools (42 percent) reported no instruction in taking an exposure history.

� Among schools with required environmental medicine instruction, theaverage time in the curriculum was seven hours over the four years of medicaleducation. An average of three hours of environmental medicine instructionwas provided in pre-clinical courses and four hours in clinical courses.

� Eighty-one schools (68 percent) reported some faculty with environmentaland occupational medicine expertise, most often in departments of internalmedicine (42 percent), community/preventive medicine or public health(37 percent), and family medicine (28 percent).

� Nineteen schools indicated innovative or unusual approaches to teachingenvironmental medicine, including small group case discussions, community-based clerkships, and site visits. These schools reported an average of fivefaculty members with occupational/environmental medicine expertise,compared with an average of four faculty members for all other schools.

Note: Of the 126 schools surveyed, 119 (94 percent) responded.Source: Schenk et al, 1996.


Health and the Environment (Pope et al, 1995) — that called for more effectiveenvironmental health education and training of medical and nursing professionals.

� In Toward Environmental Justice, Research, Education, and Health Policy Needs (IOM, 1999)an IOM committee on environmental justice recommended enhancing healthprofessionals’ knowledge of environmental health as well as environmental justice issues.

Health care providers can be extremely effective in addressing pesticide exposures and otherenvironmental health conditions in the lives of their patients and in their communities.However, they do not need to become experts in order to fill an important and crucial role.Some of the important knowledge and skills that they should possess include:

� Recognizing possible signs and symptoms of pesticide exposure

� Taking a brief and relevant environmental and occupational history

� Diagnosing possible associated health conditions, including those of sensitive populationssuch as children and the elderly

� Calling upon an appropriate specialist or expert to assist them

� Having ready access to a recommended referral list of resources and contacts

� Providing basic preventive guidance for patients

� Recognizing when to report exposure incidents to the proper health authorities

� Possessing a basic awareness of environments in which patients live, work, and play

� Identifying possible sentinel cases

� Participating in surveillance systems.

Training of Primary Care ProvidersThis Initiative emphasizes the provider’s ability to recognize a potential pesticide exposure, tocommunicate effectively, and to access and work with pesticide/environmental health expertsand resources. In an educational setting, this may mean working with an occupational andenvironmental medicine specialist to design and integrate a pesticides module into a toxicologycourse for medical students. In a practice setting, this may involve incorporating anoccupational and environmental history into primary care practice and referring patients toappropriate experts in the event of a suspected poisoning. User-friendly teaching materialsexist for faculty to use, along with user-friendly guides and curriculum maps indicating wherepesticide topics could be inserted into the curriculum.

The issue of pesticide-related health conditions is one that requires the participation of healthcare providers. The rationale given in this section serves as the underpinning of the three-pronged strategy in this Implementation Plan.


Target Audience

F or the purpose of this Initiative, the target audience is the primary care provider. Primarycare providers work at the frontline of our health care system and need to beable to identify a possible pesticide exposure. It is recommended that all primary care

providers possess basic knowledge and skills related to pesticide exposures. A primary careprovider, for the purpose of this Initiative, is defined as:

A physician, nurse, nurse practitioner, physician assistant, nurse midwife, or communityhealth worker specializing in one of the following areas: family medicine, internal medicine,pediatrics, obstetrics/gynecology, emergency medicine, preventive medicine, or public health.

Specialists in occupational and environmental medicine, and medical toxicology are notthe primary target of this Initiative. They are seen as resource professionals for the primarycare providers.

Emergency medical technicians (EMTs) can play a vital role in assessing and immediatelytreating patients with pesticide-related conditions, particularly in the case of extreme poisoning.Their education and training, however, is out of the purview of this Implementation Planand varies significantly from those of the target audiences in the Implementation Plan. BothEMTs and other emergency response professionals must be addressed separately.

Primary care providers work in a variety of settings. Table 5 summarizes the target audience,types of populations served, and the range of practice settings commonly encountered. In

Table 5: Targets, Populations Served, Practice Settings

Targets Populations Served Practice Settings

Nurses

Nurse Practitioners

Physicians

Physician Assistants

Nurse Midwives

Community Health Workers

susceptible populations(elderly, frail elderly, kids)

urban

non-urban

tribal communities

agricultural

migrant farmworkers

underserved populations(environmental justice)

pesticide handlers

hospitals and emergencydepartments

community clinics

medical centers

independent practices

industry, workplaces

alternative points of care

public health departments

poison control centers

schools


addition to these primary care providers, the target audience also includes key decision-makingbodies in the health professions. A decision-making body, for purposes of this ImplementationPlan, refers to any organization, institution, or individual leader that is vested with decision-making authority for the education and practice of health care providers in the United States.This includes, but is not limited to, curriculum committees, residency review committees,exam development bodies, accrediting institutions, organizations representing academicinstitutions, faculty, and administrators, and institutions governing health care practice andrequirements. The engagement of, and endorsement by, such bodies is the only way to ensuresuccess of this Implementation Plan and the larger Initiative.

Understanding the Target AudienceConsulting the available literature on how health professionals learn is an important first stepin determining the most effective approaches. One of the models explored in the developmentof this Implementation Plan is the “Stages of Change model” (Prochaska et al, 1995) thatlooks at behavior change as a process rather than an event, and describes varying levels ofmotivation, or readiness to change. Reaching primary care providers who are at differentstages of change requires different types of interventions and resources. The model outlines acontinuum of behavior change that can be used to help understand where the target audienceis on the continuum, and to effectively reach the audience (through targeted messages,strategies, and programs) to ensure behavior change. Table 6 outlines the model.

Table 6: Stages of Change Model

Concept Definition Application

Pre-contemplation Unaware of problem; Increase awareness of need forhas not thought through behavior change, personalize information

and risks and benefits

Contemplation Thinking about change in the Motivate, encourage to makenear future specific plans

Decision/Determination Making a plan to change Assist in developing concreteaction plans, setting gradual goals

Action Implementation of Assist with feedback, problemspecific action plans solving, social support,

reinforcement

Maintenance Continuation of desirable Assist in coping, reminders,actions, or repeating periodic finding alternatives, avoidingrecommended step(s) steps/relapses (as applies)

Source: Prochaska et al, 1995.


Applying the stages of change model to the current Initiative, the concepts can be consolidatedinto three categories or stages of change:

� Stage 1: Building awareness and motivation — At this stage, the goal is to increase awarenessand motivation by making an effective case, and increasing the motivation to change.

� Stage 2: Readiness to make changes — To turn readiness into actual change, the goal atthis stage should be to build on knowledge and skills, for example, by creating new resourcesand disseminating them effectively.

� Stage 3: Maintenance, “champions” — For those who have already made a change, thegoal is to maintain support for the change activity and nurture “champions” who willadvocate for change.

When it comes to understanding and dealing with pesticide-related health conditions, manyprimary care providers may fall currently in the first category (Stage 1), particularly thoseworking in urban areas. Nevertheless, resources should still be created and made available forall three categories, allowing primary care providers to “self-select” into whichever categoryfits their needs. Figure 3 shows how the components of this Implementation Plan cover allthree stages of change in the target audience.

Figure 3: Stages of Change and Implementation Plan Components

Make the Case

Create Incentives

Secure Endorsements

New Resources

STAGE 1:Awareness and Motivation-Building

Define Competencies

Models of Change

Faculty Champions

Information Gateway

New Resources

STAGE 2:Knowledge and Skill Building

Faculty Champions

Information Gateway

New Resources

STAGE 3:Maintenance and Champion-Building


Framework of the Plan:A Three-Pronged Strategy

T his Implementation Plan sets forth a three-pronged strategy to reach the goal ofimproving the recognition, management and prevention of health effects from pesticidepoisoning and exposure.

The Implementation Plan recognizes that primary care providers are educated in differentsettings. The first prong of the strategy addresses a provider’s “in-service” or formal education,such as in medical school or nursing school. The second prong targets the practice setting inwhich a provider works and participates in professional development. The final prongarticulates the resources and tools that providers need to effectively deal with pesticide-relatedhealth conditions in their practices and communities. The three prongs of the strategy are:

1. Educational Settings: Create significant institutional change in educational settings(e.g., medical schools, nursing schools, residency, and practicum programs) so that studentsin the health professions are prepared to recognize, manage, and prevent pesticidepoisoning and exposures across the United States.

2. Practice Settings: Change the practice of primary care so that pesticide-related healthconditions are recognized, effectively managed, and prevented in practice settings (e.g.,community clinics, hospitals, workplace clinics) across the United States.

3. Resources and Tools: Create new resources for educational and practice settings thattake into account existing resources, evaluate their quality and suitability for differentaudiences, and assure their availability through an information gateway.

For each setting, the Implementation Plan recommends a set of components. These componentsserve as a framework for the cohesive implementation of the three-pronged strategy. In somecases, the components for both settings are quite similar; in other cases they are significantlydifferent. This Implementation Plan intentionally presents the same set of components for bothsettings so as to ensure consistency in approach. However, the Implementation Plan distinguishesbetween the settings because they often involve different decision-makers and approaches. Thecomponents for each setting are to:

� Make the case for change

� Define guidelines for educational competencies or practice skills


� Assess target audiences in each setting

� Secure key endorsements

� Demonstrate success through faculty champions and practice models

� Create incentives for change.

The Implementation Plan also outlines a process to develop the resources and tools necessaryto ensure the success of the entire initiative:

� Inventory resources

� Establish a national review board and conduct evaluation of resources

� Create an internet-based information gateway

� Create new resources.

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Educational Settings

The first prong of the strategy is directed at the educational setting. Educational settings,for purposes of this Initiative, are defined as medical schools, nursing schools, academichealth centers, training programs for all levels of nursing education, and medical

residency programs. While the components target the educational setting, they also involvethe professional associations and decision-making bodies that represent and/or influencethe educational setting. These include, for example, the Association of American MedicalColleges, the American Association of Colleges of Nursing, the Association of AcademicHealth Centers, and the Accreditation Council for Graduate Medical Education. Thefollowing components come from across the continuum of systemic change — from raisingawareness and assessment, to development of core competencies, to the support of facultychampions and model programs.

Component A: Make the case for change in educational settings — Develop an effectivecase statement to convince decision-makers about the need for environmental health andpesticide education in medical and nursing educational institutions.

Component B: Define competencies and integration strategies for curricula — ProduceNational Guidelines that recommend competencies specific to the recognition, managementand prevention of pesticide exposures, for all basic and advanced training in medicine andnursing; defines accompanying content areas; suggests methods of integration into curricula;and provides access to relevant resource materials.

Component C: Assess educational settings — Conduct an assessment of the target audienceof educational institutions to determine (a) amount of existing coursework, (b) facultymembers’ current knowledge and comfort level with teaching pesticide-related topics, and(c) how faculty and educational institutions will best respond to educational programs andinformation resources. This assessment will be comprised of a literature review and a rangeof needs assessment analyses.

Component D: Secure official endorsements — Ensure the integration of the corecompetencies outlined in the National Guidelines into educational institutions by securingthe official endorsements of key professional organizations and decision-making bodies.

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Component E: Strengthen and build faculty champions — Create and support facultychampions within medical and nursing schools to teach environmental health and pesticideeducation in the curriculum, and to bring about change within their institutions.

Component F: Create teaching incentives — Influence the appropriate boards, organizations,and institutions that create board exams to include several key competencies on pesticidesand environmental health.

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EDUCATION COMPONENT A:

Make the Case for Changein Educational Settings

StatementDevelop an effective case statement to convince administrators, faculty, and students aboutthe need for environmental health and pesticide education in medical and nursing education.

Expected Outcomes

� A written case statement that documents the key reasons why faculty members andadministrators of academic institutions should be aware of pesticide-related healthconditions, using persuasive data and documentation from the scientific literature, andstressing the importance of teaching pesticides content in their educational curriculum.

� Endorsement by leading national professional associations, national bodies, deans, andfaculty committees.

Target AudienceAwareness and Motivation: This component is targeted at educational institutions and keystrategic organizations that need to be convinced that the issue of pesticides and the need to educatehealth care providers about this issue are relevant to the educational settings of health care providers.

Proposed ActivitiesActivity #1Research and develop a case statement, solicit peer review, and finalize with the input of keystakeholder groups in the field. The target audiences for the case statement are educationalsettings and the organizations that work with them.

Points to be covered in the case statement:

� Specific importance of environmental health education and the breadth of the problemof pesticide-related health conditions.

� Convincing arguments for why pesticides should be in the curriculum, with citedscientific data.

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� Compelling arguments to gain the attention of health care students and faculty despitethe fact that their time and attention are in high demand elsewhere.

� Emphasis that faculty do not need to become experts, and reassurance that experts existin the field who can work with them on coursework and teaching.

� Emphasis on practical learning for students in settings where pesticide exposures may occur.

� Reassurance that user-friendly teaching materials are available for faculty to use, alongwith user-friendly guides, and curriculum maps indicating where pesticide topics couldbe inserted into the curriculum.

� Recommended amount of time to dedicate to pesticides in the curriculum that isreasonable given the other demands on academic institutions.

Activity #2Promote the case statement through effective dissemination mechanisms to administrators,faculty, and curriculum committees, including print and internet information sources.

Activity #3Publish journal or newsletter articles on “making the case” for the academic setting inprofessional journals and publications.

Activity #4Hold strategic meetings with bodies that accredit health educational institutions and set curricularrequirements, and with national leaders to seek their endorsement of the case statement. Thisincludes identifying a subset of decision-makers who can be influenced by the case statement.

Stakeholders

� Professional associations

� Key accrediting bodies

� Curriculum committees

� Deans/Department chairs

� Collaborating federal agencies

Evaluation of Outcomes/Indicators of Success

� Complete case statement.

� Published articles in professional journals and newsletters.

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� Position papers developed and adopted by professional associations.

BackgroundThis component was crafted recognizing that we need to raise awareness about why educatinghealth care providers about pesticide-related health conditions and exposures is so important.Many key decision-makers may still be unconvinced that this is an issue of concern. Althoughthe supporting documentation is there, there is a need to pull the information together in asuccinct case statement that shows clearly the relevance of this issue to academic institutions.The document will be used in outreach on the Implementation Plan, and will assist the entirefield in “making the case” for the education of health care providers on this topic. The casestatement will complement a similar statement to be created for practice settings.

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EDUCATION COMPONENT B:

Define Competencies andIntegration Strategies for Curricula

StatementProduce National Guidelines that recommend competencies specific to the recognition,management and prevention of pesticide exposures, for all basic and advanced training inmedicine and nursing; define accompanying content areas; suggest methods of integrationinto curricula; and provide access to relevant resource materials.

Expected Outcomes

� National Pesticide Competency Guidelines for Education that recommend competencies,content, insertion points into curricula, and resources.

� Endorsement of National Guidelines by leading national professional associations.

Target AudienceReadiness to Change: This component is targeted at administrators and faculty in educationalinstitutions. The guidelines are to assist faculty in integrating the recommended corecompetencies into curricula. This component assumes that administrators and facultymembers have been convinced that this is an important topic for their curricula and that theyare ready to change their curricula.

Proposed ActivitiesActivity #1Define the core competencies for educational institutions to teach about pesticides in basicand advanced curricula (See Table 7).1

The intent of Table 7 is to define competencies that could be integrated into existing curricula.The table links with a complementary document for practice settings.

1 A start at defining competencies for the three levels of learning was done by a subgroup of the Education Workgroup in May1999, and was further elaborated in July 1999 by a small committee. Subcommittee members included Andrea Lindell, CandaceBurns, James Roberts, Matthew Kiefer, Annie Perez, Joan Weiss, Cleora Wittl, Ameesha Mehta, and Susan West.


Activity #2Produce National Pesticide CompetencyGuidelines for Education to educate students aboutthe recognition and management of pesticide-related health conditions and exposures. Acomplementary document focuses on the practicesettings where primary care providers work.

An accompaniment to the Recognition andManagement of Pesticide Poisonings handbook,the National Guidelines are designed as a user-friendly guide on how to integrate pesticidescontent into curricula. The Guidelines containthe following components:

� Recommended competencies.

� Relevant content for each competency area.

� Suggested points of insertion into curricula (expected to vary between medical and nursingschools as well as for basic or advanced training).

� Suggested resources to teach content specific to each competency in educational settings.

The National Guidelines do not contain actual teaching modules or resources, but rather providea listing of relevant resources.

Activity #3Promote the National Guidelines with key stakeholders. Solicit official endorsements andorganizational support of report, including dissemination to their members.

Stakeholders

� Academic institutions

� National professional associations for academic institutions

� Faculty members who have already developed curricula


� National Guidelines completed and peer reviewed.

� Endorsement by key stakeholder organizations.

“I see us planting seeds at various levels...”— Matthew Keifer, MD, MPH

University of Washington

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BackgroundIn defining “competencies” in pesticides and environmental health, several key recommendationshave helped to frame this component.

� Build upon existing documents: The competencies must relate to the Institute of Medicinecompetencies for medical and nursing education, so that no duplication of effort occurs.

� Balance between pesticides and environmental health: One of the most difficultquestions is the relative balance between environmental health topics in general andpesticides in particular. Having the competencies deal specifically with pesticides avoidsany charges of duplication, and might even be seen as a useful model for developing othercompetencies in specific areas.

� Focus on basic and advanced levels: Although Table 7 (page 47) presents competenciesfor three levels of learning (basic, advanced, specialty), the focus of the Initiative will beon basic and advanced, which are most relevant for training primary care providers. Otherorganizations, including the American College of Occupational and EnvironmentalMedicine, American College of Medical Toxicology, and the American Association ofOccupational Health Nurses, are focusing on specialty training.

� Categorize the competencies: The six categories of competencies shown in Table 7 werederived from a combination of the Institute of Medicine’s medicine and nursingrecommendations. They are meant to apply to medical, nursing, and allied health schoolcurricula. The six categories are:

� Basic knowledge and concepts of pesticides

� Diagnosis/assessment

� Treatment/intervention/referrals/follow-up

� Risk communication, advocacy, and ethics

� Reporting

� Legislative and regulatory knowledge.

Table 7Table 7 indicates preliminary competencies formulated in 1999. Further developed competenciesare available in 2002.


1.Pr

inci

ples

of

Envi

ronm

enta

l

and

Occ

upat

iona

l Hea

lth

1a.

Und

erst

and

prin

cipl

es o

f en

vir o

nmen

tal

and

occu

patio

nal

heal

th

1b.

Und

erst

and

broa

d sp

ectr

um o

f ch

emic

als

clas

sifi

ed a

s

pest

icid

es a

nd a

reas

of u

se (s

houl

d be

aw

are

of v

ario

us ty

pes

of p

esti

cide

s)

1c.

Und

erst

and

mec

hani

sms

and

path

way

s of

exp

osur

e

1a.

Stre

ngth

en s

kills

fro

m b

asic

com

pete

ncie

s

1b.

Und

erst

and

tem

pora

l re

lati

onsh

ip b

etw

een

expo

sure

and

sym

ptom

s (M

edic

ine)

1c.

Und

erst

and

adva

nced

tox

icol

ogy,

spe

cifi

cally

rela

ted

to o

rgan

opho

spha

tes,

car

bam

ates

, an

d

pyre

thro

ids

(mos

t co

mm

only

rep

orte

d pe

stic

ides

impl

icat

ed in

sym

ptom

atic

illn

ess)

1a.

App

ly v

alid

ated

epi

dem

iolo

gic

and

bios

tati

stic

al p

rinc

iple

s an

d te

chni

ques

to a

naly

ze in

jury

/illn

ess

data

in d

efin

ed

popu

lati

ons

1b.

Und

erst

and

tem

pora

l rel

atio

nshi

p be

twee

n

expo

sure

and

sym

ptom

s (N

ursin

g)

1c.

Und

erst

and

and

appl

y ad

vanc

ed c

our s

es

in t

oxic

olog

y

2.In

divi

dual

and

Pat

ient

Know

ledg

e an

d Sk

ills

2a.

Be a

war

e of

the

env

ironm

ent

in w

hich

the

pat

ient

(an

d

fam

ily) l

ives

, wor

ks, a

nd p

lays

(und

erst

andi

ng o

f the

haz

ards

and

pote

ntia

l exp

osur

es in

dif

fere

nt s

etti

ngs)

2b.

Iden

tify

risk

fact

ors f

or p

estic

ide

expo

sure

(e.g

., oc

cupa

tion,

loca

tion

of

hom

e, v

ulne

rabl

e po

pula

tion

s)

2c.

Reco

gniz

e ot

her

fam

ily m

embe

r s m

ay a

lso

be il

l (po

ssib

ly

due

to e

x pos

ure

in t

he h

ome ,

or

“par

aoc c

upat

iona

l

expo

sure

s”, e

.g.,

cont

amin

ated

wor

k ov

eral

ls br

ough

t hom

e)

2d.

Reco

gniz

e so

cio-

e con

omic

im

pact

s on

the

pat

ient

of

pest

icid

e-re

late

d ill

ness

2e.

Und

erst

and

pote

ntia

l mor

al, e

thic

al a

nd le

gal i

mpl

icat

ions

for

pati

ents

of

repo

rtin

g an

d re

ferr

al

2a.

Stre

ngth

en s

kills

fro

m b

asic

com

pete

ncie

s

2b.

Und

erst

and

at a

bas

ic le

vel t

he h

ealt

h ef

fect

s of

orga

noph

osph

ates

and

car

bam

ates

2c.

Ide n

tify

ris

k s t

o pa

tie n

ts s

e rv e

d (i

.e.,

spe c

ial

vuln

erab

iliti

es o

f ch

ildre

n, t

he e

lder

ly)

2a.

Appl

y in

divi

dual

pat

ient

inte

rven

tion

s to

pre v

e nt

or m

itig

ate

e xpo

sure

and

/or

resu

ltan

t he

alth

eff

ects

Spec

ialt

y: F

ello

ws

and

adva

nced

stud

ents

spe

cial

izin

g in

occu

pati

onal

and

env

ironm

enta

lhe

alth

/med

icin

e/nu

rsin

g

Com

pete

ncy

I:Ba

sic

Know

ledg

e an

dCo

ncep

ts o

f Pe

stic

ides

Basi

c: 4

-yea

r m

edic

al s

choo

l,un

derg

radu

ate

nurs

ing,

und

ergr

adua

teal

lied

heal

th p

rofe

ssio

nal e

duca

tion

Adva

nced

: M

edic

al re

side

nts,

adva

nced

prac

tice

nur

sing

stu

dent

s, ph

ysic

ian

assi

stan

t st

uden

ts, o

ther

adv

ance

d de

gree

prog

ram

s (F

acul

ty in

prim

ary

care

wou

ldne

ed t

o be

at

this

leve

l to

teac

h)

3.Po

pula

tion

-Bas

e d H

e alt

h

Know

ledg

e an

d Sk

ills

3a.

Und

erst

and

popu

latio

n-ba

sed

heal

th, in

clud

ing

epid

emio

logy

3b.

Reco

gniz

e so

cio-

econ

omic

impa

cts o

f pes

ticid

e-re

late

d ill

ness

3c.

Und

erst

and

pote

ntia

l mor

al, e

thic

al a

nd le

gal i

mpl

icat

ions

for

the

com

mun

ity

of re

port

ing

and

refe

rral

3d.

Poss

ess

a ba

sic

awar

enes

s of

the

rol

e of

pre

vent

ion,

gen

eral

aw

aren

ess

of b

enef

i ts

of a

l ter

nat

i ves

to

conv

enti

onal

pes

t co

ntro

l

3a.

Stre

ngth

en s

kills

fro

m b

asic

com

pete

ncie

s

3b.

De v

e lop

m

ore

in-d

e pth

k n

owle

dge

of

the

envi

ronm

ent i

n w

hich

they

are

lear

ning

and

pra

ctic

ing

3c.

Dev

elop

spe

cifi

c un

ders

tand

ing

of c

omm

unit

ies

and

popu

lati

ons

at r

isk

for

pest

icid

e ex

posu

re

3d.

Und

erst

and

adva

nced

epi

dem

iolo

gy,

spec

ific

ally

rela

ted

to p

esti

cide

-rel

ated

poi

soni

ngs

3a.

Dev

elop

, im

plem

ent,

eval

uate

and

refi

ne

scre

enin

g pr

ogra

ms f

or g

roup

s to

iden

tify

risk

s fo

r di

seas

e or

in

jury

an

d

oppo

rtun

itie

s to

pro

mot

e w

elln

ess

3b.

Appl

y co

mm

unity

-bas

ed in

terv

entio

ns to

prev

ent

or m

itig

ate

expo

sure

and

/ or

resu

ltan

t he

alth

eff

ects

Tabl

e 7:

Pro

pose

d Co

mpe

tenc

ies

for

Educ

atio

nal I

nsti

tuti

ons


4.In

form

atio

n an

d Re

sour

ces

4a.

Iden

tify

and

acc

ess

info

rmat

ion

on p

esti

cide

s

4b.

Be a

war

e of

impo

rtan

ce o

f inf

orm

atio

n on

pes

tici

de la

bels

4c.

Be

able

to

loca

te r

esou

rces

in

clu

din

g w

eb-b

ased

info

rmat

ion,

prin

t m

ater

ials

, Mat

eria

l Saf

ety

Dat

a Sh

eets

(MSD

S), a

nd p

oiso

n co

ntr o

l cen

ters

4a.

Stre

ngth

en s

kills

fro

m b

asic

com

pete

ncie

s

4b.

Dem

onst

rate

abi

lity

to lo

cate

lead

ing

info

rmat

ion

reso

urce

s an

d ex

pert

s fo

r he

alth

car

e pr

ovid

ers

4a.

Use

app

ropr

iate

writ

ten

and

com

pute

rized

data

base

s (e

.g.

MSD

S, R

egis

try

of T

oxic

Effe

cts

of C

hem

ical

Sub

stan

ces

[RTE

CS])

to i

dent

ify

haza

rdou

s in

gred

ient

s of

chem

ical

age

nts

Spec

ialt

yCo

mpe

tenc

y II:

Dia

gnos

isan

d As

sess

men

tBa

sic

Adva

nced

1.H

isto

ry T

akin

g

Dif

fere

ntia

l Dia

gnos

is

1a.

Be a

ble

to t

ake

occu

pati

onal

and

env

ironm

enta

l his

tory

1b.

Be a

war

e th

at s

igns

and

sym

ptom

s of

pes

tici

de e

xpos

ure

may

be

non-

spec

ific

(the

re is

not

hing

pat

hogn

omon

ic a

bout

mos

t pe

stic

ide

sym

ptom

s)

1c.

Be a

ble

to c

onsi

der

pest

icid

e s i

n di

ffe r

e nti

al d

iagn

osis

(pes

tici

de e

xpos

ures

may

resu

lt in

hea

lth

effe

cts

com

mon

to s

imila

r di

seas

es)

1c.

Reco

gniz

e si

gns

and

sym

ptom

s of

pes

tici

de o

vere

xpos

ure,

wit

h pr

iori

ty g

ive n

to

wid

e ly -

use d

pe s

tic i

des

wit

h

iden

tifia

ble

sym

ptom

s, su

ch a

s cho

lines

tera

se-i

nhib

itors

and

pyre

thro

ids

1d.

Perf

orm

a c

ompl

ete

and

focu

sed

phys

ical

exa

min

atio

n as

indi

cate

d (A

COEM

)

1a.

Stre

ngth

en s

kills

fro

m b

asic

com

pete

ncie

s

1b.

Ask

patie

nts 2

-3 sc

reen

ing

ques

tions

(stu

dent

s nee

d

to k

now

how

to

tak e

a f

ull

occu

pati

onal

and

envi

ronm

enta

l his

tory

bef

ore

they

are

abl

e to

ask

scre

enin

g qu

esti

ons)

1c.

Iden

tify

sig

ns a

nd s

ympt

oms

of o

vere

xpos

ure

to a

wid

er ra

nge

of p

esti

cide

s

1d.

Be a

ble

to d

iagn

ose

pest

icid

e -re

late

d ill

ness

e s

rela

ted

to o

rgan

opho

spha

tes

and

pyre

thro

ids

1e.

Prop

erly

uti

lize

chol

ines

tera

se t

esti

ng

1a.

De t

e rm

ine

the

natu

re a

nd e

x te n

t of

pote

nti

al

pest

icid

e po

ison

ing

or

ove r

e xpo

sure

con

side

ring

rou

tes

of

expo

sure

and

rout

es o

f ab

sorp

tion

1b.

Det

ect,

in s

o fa

r as

pos

sibl

e, p

re-c

linic

al

or c

linic

al e

ffec

ts a

risin

g fr

om c

hem

ical

expo

sure

1c.

Be a

ble

to o

rder

/ in

terp

ret

appr

opria

te

diag

nost

ic t

ests

1d.

Effe

ctiv

e ly

diag

nose

pe s

tici

de-r

e lat

e d

illne

sses

1e.

Prov

ide

cons

ulta

tion

on

diag

nosi

s

1f.

Ide n

tify

at

risk

pop

ulat

ions

, in

clud

ing

child

ren

1g.

Colla

bora

te w

ith o

ther

dis

cipl

ines

such

as

indu

stri

al

hy g

ien

e ,

san

itar

ian

s,

Coop

erat

ive

Exte

nsio

n

Tabl

e 7(

cont

inue

d)


1.Tr

eatm

ent

1a.

Effe

ctiv

ely

trea

t he

alth

con

diti

ons

r ela

ted

to p

esti

cide

expo

sure

s (M

edic

ine)

1a.

Stre

ngth

en s

kills

fro

m b

asic

com

pete

ncie

s

1b.

Effe

ctiv

ely

trea

t he

alth

con

diti

ons

(Nur

sing

)

1a.

Be a

ble

to e

ffec

tive

ly t

reat

spe

cifi

c

pest

icid

e-re

late

d he

alth

con

diti

ons

2a.

Adv

ise

pati

ents

on

how

to

deco

ntam

inat

e pa

tien

t an

d

envi

ronm

ent

follo

win

g ex

posu

r e

2a.

Stre

ngth

en s

kills

fro

m b

asic

com

pete

ncie

s

2b.

Prov

ide

spec

ific

guid

ance

on

how

to d

econ

tam

inat

e

pati

ent

and

envi

ronm

ent

follo

win

g ov

erex

posu

re

2a.

Iden

tify

an

d pr

escr

ibe

appr

opri

ate

prev

enti

ve

acti

on,

for

exam

ple

alte

rnat

ives

to p

esti

cide

s, su

bsti

tuti

on o

f

harm

ful w

ith le

ss h

arm

ful p

r odu

cts,

or u

se

of b

ette

r sy

stem

des

ign

, pe

rson

al

prot

e cti

ve e

quip

men

t an

d e n

gine

e rin

g

cont

rols

for

spe

cifi

c pe

stic

ides

2b.

Dev

elop

and

man

age

a co

mpr

ehen

sive

occu

pati

onal

hea

lth

prog

ram

3.Re

ferr

als

3a.

Refe

r to

appr

opria

te sp

ecia

list (

i.e.,

occu

patio

nal m

edic

ine/

nurs

ing,

ind

ustr

ial

hyge

nist

, e n

v iro

nmen

tal

heal

th

spec

ialis

t, Co

oper

ativ

e Ex

tens

ion)

(Med

icin

e)

3a.

Stre

ngth

en s

kills

fro

m b

asic

com

pete

ncie

s

3b.

Mak

e ap

prop

riate

ref

erra

ls f

or m

edic

al d

iagn

osis

(Nur

sing

)

3a.

Prov

ide

c ons

ulta

tion

on

tre a

tme n

t,

inte

rven

tion

, and

refe

rral

s

Spec

ialt

y

Com

pete

ncy

III:

Trea

tmen

t/In

terv

enti

on/

Refe

rral

s/Fo

llow

-up

Basi

cAd

vanc

ed

4.Fo

llow

-up

4a.

Arra

nge

appr

opria

te f

ollo

w-u

p (M

edic

ine)

4a.

Stre

ngth

en s

kills

fro

m b

asic

com

pete

ncie

s

4b.

Arra

nge

appr

opria

te f

ollo

w-u

p (N

ursi

ng)

4a.

Prov

ide

cons

ulta

tion

on

follo

w-u

p

Tabl

e 7(

cont

inue

d)

2.In

terv

enti

on


1.Ri

sk C

omm

unic

atio

n1a

.Pr

ovid

e gu

idan

ce a

nd e

duca

tion

to

pati

ents

on

how

to

min

imiz

e ex

posu

res t

o pe

stic

ides

, and

abo

ut th

e ba

sic r o

utes

of e

xpos

ure

and

abso

rpti

on

1b.

Advi

se p

atie

nts

to r e

ad p

esti

cide

labe

l

1c.

Refe

r pa

tien

ts t

o ap

prop

riate

reso

urce

s

1a.

Stre

ngth

en s

kills

fro

m b

asic

com

pete

ncie

s

1b.

Com

mun

icat

e on

issu

es o

f ris

ks a

nd p

ublic

hea

lth

prot

ecti

on t

o th

e ge

ner a

l pub

lic

1c.

Publ

ish

rese

arch

and

inte

rven

tion

fin

ding

s in

the

prof

essi

onal

lite

ratu

re

1a.

Com

mun

icat

e w

ith m

edia

, the

pub

lic, a

nd

polic

y m

aker

s on

iss

ues

of s

cien

tifi

c

unce

rtai

nty

1b.

Prov

ide

expe

rt t

esti

mon

y on

beh

alf

of

pati

ents

and

com

mun

itie

s

1c.

Publ

ish re

sear

ch a

nd in

terv

entio

n fin

ding

s

in t

he p

rofe

ssio

nal l

iter

atur

e

2.Ad

voca

cy2a

.Ad

voca

te o

n be

half

of

pati

ents

2a.

Com

mun

icat

e w

ith m

edia

, the

pub

lic, a

nd

polic

y m

ake r

s on

iss

ues

of s

c ie n

tifi

c

unce

rtai

nty

2b.

Prov

ide

e xpe

rt t

e sti

mon

y on

beh

alf

of

pati

ents

and

com

mun

itie

s

Spec

ialt

yCo

mpe

tenc

y IV

: Ris

kCo

mm

unic

atio

n,Ad

voca

cy, &

Eth

ics

Basi

cAd

vanc

ed

3. E

thic

s (u

nder

dev

elop

men

t)

Spec

ialt

yCo

mpe

tenc

y V:

Rep

orti

ngBa

sic

Adva

nced

Repo

rtin

g1a

.U

nder

stan

d im

port

ance

of s

urve

illan

ce a

nd in

cide

nt re

port

ing

1b.

Unde

rsta

nd ca

se re

port

ing

requ

irem

ents

for p

estic

ide e

xpos

ures

1c.

Repo

rt c

once

rns

abou

t pe

stic

ide

expo

sur e

sit

uati

ons

to

appr

opria

te a

utho

ritie

s

1a.

Stre

ngth

en s

kills

fro

m b

asic

com

pete

ncie

s1a

.In

tera

ct w

ith

wor

k ers

' co

mpe

nsat

ion

syst

em e

ffic

ient

ly a

nd e

ffec

tive

ly

Tabl

e 7(

cont

inue

d)


Legi

slat

ive

and

Reg

ula

tory

Know

ledg

e

1a.

Und

erst

and

that

seve

ral p

iece

s of f

eder

al la

w re

quire

hea

lth

care

pro

vide

rs t

o ad

dres

s pe

stic

ide

pois

onin

gs

1b.

Und

erst

and

that

15

stat

es h

ave

man

dato

ry s

urve

illan

ce

syst

ems,

and

that

31

stat

es h

ave

som

e fo

rm o

f r e

port

ing

requ

irem

ents

1a.

Know

the

spe

cifi

c co

mpo

nent

s of

FIF

RA,

OSH

A,

TSCA

and

WPS

that

r efe

renc

e he

alth

car

e pr

ovid

ers

1a.

Infl

uenc

e po

licy

rega

rdin

g pe

stic

ides

and

publ

ic h

ealt

hSpec

ialt

y

Com

pete

ncy

VI:

Legi

slat

ive

and

Regu

lato

ryKn

owle

dge

Basi

cAd

vanc

ed

Tabl

e 7(

cont

inue

d)

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EDUCATION COMPONENT C:

Assess Educational Settings

StatementConduct an assessment of the target audience of educational institutions to determine: (a)amount of existing coursework, (b) faculty members’ current knowledge and skill levels, andcomfort with teaching pesticide-related topics, and (c) how faculty and educational institutionswill best respond to educational programs and information resources. This assessment willbe comprised of a literature review and a range of needs assessment analyses.

Expected OutcomesBaseline data indicating the level of education currently taking place in academic institutions,current curricular content and emphasis on pesticides/environmental health, currentknowledge of teaching faculty, and best mechanisms to reach and train faculty to teach.

Target AudienceAwareness and Motivation: This component targets academic institutions to determinetheir level of awareness; their level of interest in this topic; their knowledge and skills base;and the most effective ways to reach them through educational interventions, model programs,and resources.

Proposed ActivitiesActivity #1Conduct a literature review to locate data and evidence of level of training in educationalinstitutions.

Activity #2Where literature review is lacking in data, conduct a combination of audience assessmentactivities, including focus groups and interviews, to collect baseline data and draw conclusionson the following questions:

� To what extent is the recognition and management of pesticide-related health conditionstaught in the targeted academic institutions?

� What is the extent of the knowledge, attitude, and skill base of faculty members withregard to pesticide issues? Are they at the stage of needing to raise awareness, improvetheir knowledge and skills, or provide them with resources?

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� What is the extent of faculty comfort level with teaching this topic area? What do facultyneed to feel more comfortable about teaching this topic?

� What resources, and in what format (e.g., traditional lecture material, teaching modules,web-based, audio cassette, CD, video conference, satellite), do academic institutions mostneed to teach about this topic?

Activity #3Produce a final report with recommendations for use in the development of the Initiative.

Stakeholders

� Professional associations that represent academic institutions

� Academic institutions

� Faculty curriculum committees

� Faculty members

� Students


� Comprehensive literature search documenting the findings of studies that have surveyedacademic institutions and deans.

� Report with baseline data, conclusions, and recommendations.

BackgroundAny good plan has at its core a strong assessment component to collect baseline data onexisting knowledge and skills, as well as to determine the most effective mechanism for reachingthe target population. The importance of assessing educational institutions to determine whatis already in place, and how best to structure the educational interventions was emphasizedby participants during the development of the Implementation Plan.

This component will collect vital information not only for this Initiative, but also for theentire field of health care provider education. The assessment will also include a chance todetermine where the target population “sits” along the continuum of change described in thesection on Target Audience. Do most people lie at the beginning of the continuum where theywill respond best to activities that raise their awareness and motivate them to care about this

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issue? Or are they ready to make changes in their curricula and are in need of tools andeducational resources? The assessment will answer these, and other key questions, to informthe implementation process and subsequent evaluation.

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EDUCATION COMPONENT D:

Secure Official Endorsements

StatementEnsure the integration of the core competencies outlined in the National Guidelines intoeducational institutions by securing the official endorsements and support of key professionalorganizations and decision-making bodies.

Expected OutcomesProfessional organizations, licensing and accrediting bodies, administrators, and educatorswill agree that these competencies are essential to the education of primary care providersand will integrate or support their integration into core curricula.

Target AudienceAwareness and Motivation: This component targets key accrediting bodies and associationsfor academic institutions, along with academic deans and faculty committee chairs. Theemphasis here is on raising awareness and motivating decision-makers to bring about changein academic institutions that prepare health care providers.

Maintenance/Sustainability: This component also targets key professional associations toendorse and support the implementation and outcomes of this Initiative over the long-term.The Initiative will only be successful if its expected outcomes are institutionalized into theeducational settings for health care provider training.

Proposed ActivitiesActivity #1Promote competencies with professional and decision-making organizations and academicinstitutions (along with the case statement) through strategic meetings and outreach. Highlightthe specific recommendations in the National Guidelines on competencies, along with specificexamples of how an educational institution could integrate the content into curricula.

Activity #2Publish editorials in nationally recognized journals promoting the idea of integrating intocurricula specific strategies from the National Guidelines.

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Activity #3Develop a position paper on the need for competencies to be posted on the internet, and foruse in meeting with decision-making bodies.

Activity #4Identify and promote incentives for faculty to teach core competencies, including financial incentivesin the form of grants, faculty development, curriculum development, and research, instructionalteaching and training aids, expert consultants, clinical access, release time for faculty development,curricula development, and establishing appropriate clinical sites and teaching venues.

Stakeholders

� Professional specialty organizations, licensing boards, accreditation/certification bodies

� National professional associations


� New position papers by targeted organizations that support the integration ofrecommended pesticide content into curriculum.

� New requirements by professional decision-making bodies that require institutions toteach about health effects from pesticides.

� Published journal articles in professional newsletters and peer-reviewed journals.

BackgroundThe success and sustainability of this Initiative will only be achieved if the institutions themselvesfind ways to integrate pesticide-related content into health professional education. The bestmechanism to reach such organizations is for individuals involved in this Initiative to meet one-on-one with key leaders and offer them simple and easy ways that they can endorse and/or adoptthis Implementation Plan.

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EDUCATION COMPONENT E:

1 While the organization and structure of academic health centers vary, every center comprises an allopathic and osteopathic schoolof medicine, at least one other health professional school or program, and one or more owned or affiliated teaching hospitals.

Strengthen and Build Faculty Champions

StatementCreate and support faculty champions within medical and nursing schools to teachenvironmental health and pesticide education in the curriculum, and to bring about changewithin their institutions. A champion, for purposes of this Initiative, is defined as a facultymember who takes a leadership role in integrating environmental health and pesticides intohis/her institution in a sustainable fashion. This component is designed to ensure that astrong cadre of faculty champions is developed across the country who will lend expertiseand support for this effort in their institutions and surrounding communities.

Expected Outcomes

� Funding of 146 faculty champions, including one faculty champion in all 126 academichealth centers1 in the United States, plus an additional 20 faculty champions in 20 otherhigher education institutions to ensure a balance of medicine and nursing faculty as wellas representation from diverse institutions.

� Additional support for 10 of the academic health centers to serve as regional technicalassistance centers.

Target AudienceChampion Building: This component targets faculty members who are ready to become apart of a cadre of faculty from across the country who will teach courses, integratecompetencies into curriculum, and serve as a model for how to integrate environmentalhealth and pesticides into health professional education. The target audience is convinced ofthe importance of this issue and has enhanced its knowledge and skill level.

Proposed ActivitiesActivity #1Identify and select several model academic setting programs based on the existing work offaculty across the country, with specific focus on primary care faculty members. Hold a small

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invitational workshop of model programs and develop several models on which to base thefunding for all 146 academic institutions.

Activity #2Develop key required elements for a model faculty champion program including the following:

� Faculty member with 25 percent time availability.

� Faculty member trained in primary care (defined as pediatrics, family practice, internalmedicine, obstetric/gynecology, emergency medicine, or preventive medicine/public health).

� Commitment of staff time (part-time health educator and administrative support).

� Existing and proposed partnerships within the academic health center to ensure that thefaculty champion’s work reaches all schools within the institution.

� Teaching and curriculum development component, including baseline analysis of studentknowledge and skills.

� Institutional change component with specific strategies articulated for changinginstitutions to support teaching environmental health/pesticides.

� Community-based sites for student practicum, internships, residencies.

� Advisory Committee, inclusive of environmental health expertise, curriculum committeemembers, community members.

� Opportunities to link teaching with research activities.

� Plan of action for five year integration.

� Evaluation component.

Activity #3Establish a coordinating body to manage the grant-making process, to convene the grantees,and to provide technical assistance to the faculty nationwide. The tasks of the nationalcoordinating office are to:

� Develop the RFA with the federal agencies; manage the application and grant-making processes.

� Produce a faculty guidebook with model programs on which faculty are asked to basetheir activities.

� Convene faculty for a working session to introduce model programs and work with projectdesign. Annual meetings will be held in subsequent years.

� Set up ongoing technical assistance and evaluation effort with faculty members to beavailable for the length of the project.


� Establish regular forms of communicationamong faculty members, including regionalmeetings, web-based interactive activities,online submission of teaching modules orother curricular pieces, and formative andsummative evaluation.

� Present ongoing findings at nationalconferences and assist on national issues as theymay arise.

� Coordinate entire evaluation effort.

Activity #4

� Release RFA to academic institutions for a fiveyear grant funded effort. Ensure diversity infaculty and disciplines selected. Publicize RFAprocess. Select 146 faculty champions.Applications must include all items listed inActivity #2 along with a timeline for completion.

� Incorporate a capacity-building mechanism into the grant-making process by creating10 regional networks of faculty members where the exchange of technical assistance cantake place. To achieve this, one academic center in each region would be granted additionalfunding (through a competitive process) to provide technical support to new facultychampions in that region. In this way, the program will help transfer knowledge andexpertise from existing champions to new faculty members, while also supporting theadditional time spent by existing champions.

Activity #5Launch the effort with the announcement of the 146 faculty champions and ten regionalcenters receiving additional funding. Faculty efforts will last five years with specific incrementsidentified for evaluation, workshops, submission of work, and activities via the websites, andquarterly/annual reviews. Throughout the entire process, the national coordinatingorganization will build the cadre of faculty nationwide (see Table 8).

Stakeholders


� Key association for health professional schools

� National coordinating body

“If we're going to make this successful, we

have to grow our own [champions], and

that takes some time.”— Candace Burns, PhD, ARNP

National Organization of Nurse Practitioners

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Evaluation of Outcomes/Indicators of SuccessThe entire component will be evaluated based on the following indicators:

Project Outcomes (1-5 year funded project)

� 146 institutions with documented integration of pesticides/environmental health intocurriculum.

� 146 institutions with increase in students’ basic knowledge and skills in pesticide/environmental health.

� 146 institutions with increased FTE time devoted to environmental health.

� Increase in number of practice/field experiences in environmental health sites

� Increase in environmental health research activities.

Project Outcomes (post 5-year project)

� Increase in new researchers investigating environmental health.

� Increase in number of primary care providers out of the pipeline who address environmentalhealth in practice and research.

aMay be subcontracted by the national coordinating organization.

Institution Funded Activities Funded Individuals Funded Length of Funding

National Overall coordination Project Director, 6 years (design,Coordinating and management (100 percent FTE), Coordinator implementationOrganization of project and (100 percent FTE), Webmaster and evaluation)

administrative staff

10 regional centers Existing faculty Faculty Champion 5 year grant period(one per EPA region, champion support plus (50 percent FTE),chosen from academic technical assistance Regional Coordinatorhealth centers) support for faculty (50 percent FTE),

in the region administrative staff

146 academic sites Implementation of Faculty champion (25 5 year grant period(126 academic one of several models percent FTE),health centers + 20 in academic institutions, administrative supportrepresenting diverse including inclusionpopulations and in curriculum, andnursing schools) institutional change

Evaluation Teama Formative and Evaluation staff Portions of all 6 yearssummative evaluation

Table 8: Proposed Design of Faculty Champions Project

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� Sustainable institutional change in majority of 146 institutions.

� Changes in the way health professionals address environmental health (measure of overalleffectiveness).

BackgroundThis component proposes a significant investment of funding to build a strong cadre of facultychampions. The funding would pay for part of a designated faculty FTE, plus a half-timeposition for administrative and content support at 146 institutions. The funding would alsosupport ten regional centers headed by an existing faculty champion and designed to providetechnical assistance and support to new faculty members in the region. The champion woulduse a variety of educational methodologies (required courses, integration within existingcourses, field experience, and links with community members and organizations), and wouldlink with other schools, departments, and organizations as part of a national network ofchampions. In particular, it is recommended that faculty champions coordinate with modelpractice sites (see Practice Component E, p. 79). The intent is for the faculty champion tobase his/her activities on selected model programs that have already undergone evaluation.

The idea of creating and strengthening “champions” of pesticide/environmental healtheducation came out of the Education Workgroup’s discussion of how important a roleindividuals can play at an institution. A threshold level of funding and security of funding isneeded to encourage institutions to hire and/or nurture pesticide/environmental healthchampions. A multi-year commitment is also necessary to make it worthwhile both for theinstitution and the champion. Much of the champion’s time should be spent institutionalizingthe pesticide/environmental health component by developing faculty interest/knowledge andintegrating it into curriculum, both in medicine and nursing disciplines. Otherwise, whenthe grant funding ends, the environmental health/pesticide component is likely to be viewedas “nice but not necessary” and may disappear at the next curriculum change cycle. The proposaldeveloped is for five year funding, with funding possibly decreasing in years 3-5.

It is recommended that all academic health centers receive funding at the same time. It isimportant to make the funding equal across academic health centers. This component willfund 126 academic health centers and an additional 20 institutions to ensure a balance betweenmedicine and nursing, and the inclusion of diverse institutions. Faculty champions will beselected equally from the disciplines of medicine and nursing. Faculty champions will also beselected from primary care. Given that some institutions already have faculty champions, theproject will include an opportunity for such institutions to compete for regional center grants.The regional centers will be required to provide technical assistance and support to new facultychampions in the region. The entire project will build upon other faculty champion modelsthat have been created for other subject areas nationwide.

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EDUCATION COMPONENT F:

Create Teaching IncentivesStrategyInfluence the appropriate boards, organizations, and institutions that create Board examsand set curriculum requirements to include several key competencies on pesticides andenvironmental health.

Expected Outcomes

� Questions on Board exams

� Changes in curriculum requirements

Target AudienceAwareness and Motivation: This component targets decision-making organizations thatset curriculum requirements, entities that write Board and certification examinations,and faculty who teach the courses. This component is designed to convince these decision-makers to integrate elements that address the health effects from pesticide exposures.This component will also provide “ready-made” language on requirements and/or examobjectives and questions.

Proposed ActivitiesActivity#1Conduct an initial assessment to determine number of questions related to pesticides/environmental health on examinations. Identify or develop sample examination questions.The assessment will also list timeframes for changes in requirements/Board exam questionsby key decision-making bodies.

Activity #2Develop a succinct strategy for approaching the organizations/decision-making bodies thatdevelop Board and other examinations, including specific recommendations for educationalobjectives, questions and language changes. Action items include:

� Convene a working group of high level external partners and key federal agencies to developa strategy/position paper. This group should be drawn from the Association of AmericanMedical Colleges, the American Association of Colleges of Nursing, the AmericanAssociation of Occupational Health Nurses, the American College of Occupational and

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Environmental Medicine, the American Medical Association, the American NursesAssociation, the American Academy of Physician Assistants, and American College ofNurse Midwives. In addition, federal agencies could include National Institute ofEnvironmental Health Sciences, National Institute for Occupational Safety and Health,EPA, and Health Resources and Services Administration.

� Create a strategy that recommends specific content (per National Competency Guidelinesin Education Component B) and insertion points into specific Board exams and specialtyrequirements. Strategy will also set targets for change.

Activity #3Contact decision-making bodies and provide with them with a specifically tailored positionpaper and recommended changes to questions, exams, and requirements. Include theendorsement of the relevant working group organizations. Identify Boards and schedule usingthe following outline of priorities:

Short-term PrioritiesMedicine

� United States Medical License Examination (Steps 1, 2, 3)

� Board Examinations in Family Practice, Pediatrics, Internal Medicine, Ob/Gyn,Emergency Medicine

Nursing

� AANC generalist examinations

� Nurse practitioners — adult, pediatrics, family, gerontological (ANP, PNP, FNP, GNP)

� Nurse midwives — American College of Nurse Midwives (ACNM)

� Clinical nurse specialists (CNS)

Longer-term Priorities

� Physician Assistants

� Pharmacists

� Basic Nursing

� Genetic Counselors

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Stakeholders� Key national decision-making bodies for curriculum changes, requirements, and

examinations

� National professional association

� Key federal agencies involved with health profession education

� Faculty members


� Increase in the number of questions in the examination pool and on each examination ascompared with the initial assessment.

� Changes in requirements for primary care disciplines (pediatrics, family practice, internalmedicine, preventive medicine/public health, emergency medicine and obstetrics andgynecology) to include pesticides/environmental health.

BackgroundOne way to motivate change in curricula is to convince the medical and nursing examinationboards of the importance of environmental health in the coming years, and urge them toincorporate environmental health questions on their exams. This would also be one of the betterways to institutionalize the subject matter over the long-term. Some of the boards are expectedto be receptive to a concerted effort in this area; for example, the Residency Review Committeefor Pediatrics in 1997 adopted two recommendations on children’s environmental health.

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Practice Settings

The second prong of the strategy is the practice setting. Practice settings, for purposes ofthis Initiative, are defined as community health centers and clinics; managed care clinics;hospitals and emergency departments; private practices; urgent care centers; poison control

centers; and work and/or school-based clinics. While the components target the practice setting,they also involve the professional associations and decision-making bodies that represent and/or influence the practice setting. These include, for example, the American Nurses Association,the American Academy of Pediatrics, the American Academy of Family Physicians, and theMigrant Clinicians Network. The following components apply across the continuum of systemicchange — from raising awareness and assessment, to development of expected practice skills, tothe support of “model practices” and system-wide incentives.

Component A: Make the case for practitioners — Develop an effective case statement to convinceprimary care providers of the need to incorporate occupational and environmental health andpesticide awareness into their practice settings.

Component B: Define practice skills and guidelines — Produce National Guidelines thatrecommend practice behaviors and guidelines for the recognition, management, andprevention of pesticide exposures, for all practicing health care providers; define accompanyingcontent related to expected behavior; suggest methods of integration into practice and trainingsettings; and provide access to relevant resource materials.

Component C: Assess knowledge and skills of practitioners — Conduct an assessment of thetarget audience of primary care providers to determine: (a) providers’ current knowledge and(b) how providers will best respond to educational programs and information resources. Thisassessment will be comprised of a literature review and a range of needs assessment analyses.

Component D: Secure official endorsements — Ensure the integration of the expected practiceskills into practice settings by securing the official endorsements of key professionalorganizations and decision-making bodies specific to practice.

Component E: Demonstrate model programs — Mobilize practice settings to becomepopulation-specific and to incorporate environmental considerations (specifically pesticides)into prevention, education, diagnosis, and treatment. Achieve incremental, site-specificimprovements in identification, early intervention, and prevention, as well as in measures ofpractice-specific health outcomes. By 2010, half of all primary health care practice settings in

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the United States should incorporate environmental considerations in prevention, education,management, and referral.

Component F: Create incentives for change — Identify and promote a number of incentivesto incorporate appropriate prevention, recognition, and management of pesticide-relatedhealth conditions into health care practices. Specifically: (1) provide grant support to practicingproviders for interventions and research related to pesticide poisonings and exposures; (2)create free, readily available opportunities for continuing medical education involvingpesticides and environmental health; (3) increase providers’ awareness of the value of takingan occupational and environmental history for optimizing Evaluation and Management(E&M) coding and billing; (4) require knowledge of occupational and environmental healthissues for certification and recertification; (5) require pesticide poisoning reporting for workers'compensation reimbursement and automatic workers' compensation reimbursement forwork-up of suspected occupational pesticide-related health conditions; and (6) promotedocumentation of occupational and environmental history in medical records viaincorporation into quality assurance/quality control mechanisms.

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PRACTICE COMPONENT A:

Make the Case for Practitioners

StatementDevelop an effective case statement to convince primary care providers of the need to incorporateoccupational and environmental health and pesticide awareness into their practice settings.

Expected Outcomes

� A written case statement that documents the key points of why practicing health careproviders should care about the environments in which their patients live and work,especially with regards to potential pesticide poisonings and exposures, along with theaccompanying scientific literature to support the need for well educated health careproviders. This statement will be linked with the case statement for educational settings.

� Endorsement of the case statement by leading national professional associations andnational bodies that work with practitioners.

Target AudienceAwareness and Motivation: This component is targeted at decision-makers and key strategicorganizations that need to be convinced that the issue of pesticide poisonings and the need toeducate health care providers about this issue are relevant to the practice settings of healthcare providers. This component also targets primary care providers who are not yet convincedthat this is an appropriate subject for a national plan.

Proposed ActivitiesActivity #1Research and develop a case statement, solicit peer review, and finalize with the input of keystakeholder groups in the field. The target audience for the case statement is the practicinghealth care providers and the organizations that work with them.

Points to be covered in the case statement:

� Importance of occupational and environmental health training and the breadth of theproblem of pesticide-related health conditions.

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� Convincing arguments for why pesticides should be part of what health care providersaddress in their practice settings, with cited scientific data, along with relevance to thepractice of health care and public health.

� Compelling arguments to gain the attention of primary care providers despite the factthat their time and attention are in high demand elsewhere.

� Emphasis that practitioners do not need to become experts, and reassurance that expertsare available to work with them on specific clinical cases and/or community concerns.

� Reassurance that user-friendly tools exist for practitioners to use, along with user-friendlyguides for teaching pesticide issues to practitioners through continuing education.

� Recommended amount of time to dedicate to pesticides in the clinic that is reasonablegiven the other demands on practice settings.

Activity #2Promote case statement through effective dissemination mechanisms, including print andinternet information sources.

Activity #3Publish journal or newsletter articles in professional journals and publications.

Activity #4Hold strategic meetings with professional associations and national leaders to seek theirendorsement of the case statement. This includes identifying a subset of decision-makerswho can be influenced by the case statement.

Stakeholders


� Recertification bodies

� Continuing education organizations



� Case statement.

� Published articles in professional journals and newsletters.

� Position papers developed and adopted by professional associations.

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BackgroundIt is recognized that many key decision-makers are still unconvinced that this is an issue ofconcern. Although the supporting documentation exists, there is a need to pull the informationtogether in a succinct case statement directly designed for practitioners.

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PRACTICE COMPONENT B:

Define Practice Skills and Guidelines

StatementProduce National Guidelines that recommend practice skills and guidelines for therecognition, management, and prevention of pesticide exposures, for all practicing healthcare providers; define accompanying content related to expected behavior; suggestmethods of integration into practice and training settings; and provide access to relevantresource materials.

Expected Outcomes

� National Pesticide Practice Skill Guidelines which recommend practice skills, content,insertion points into practice and training settings, and resources.

� Endorsement of National Guidelines by leading national professional associations.

Target AudienceReadiness to Change: This component is targeted at administrators of clinics and healthcare delivery systems, providers of professional development, and practitioners. Thecomponent assumes that the administrators and practitioners are convinced of the importanceof this topic and are ready to make changes in their practices.

Proposed ActivitiesActivity #1Define the basic practice skills for practice settings to ensure that all practicing primarycare providers are prepared to address pesticide-related health conditions and exposures intheir practice.

An outline of practice skills for practicing health care providers is shown in Table 9 on page72. The intent of the table is to define expected practice skills for all practitioners. This tablelinks with a complementary document for educational settings.

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Activity #2Produce National Guidelines to guide practitioners on the recognition and management ofpesticide-related health conditions. A complementary report focuses on the educationalsettings where primary care providers receive their training.

The National Guidelines contain the following components:

� Recommended practice skills.

� Relevant content for each practice skill.

� Suggested points of insertion into practice settings.

� Suggested resources to teach content specific to each competency in practice settings.

The report is designed as a user-friendly guide on how to integrate pesticides content intopractice skills. It serves as a supplementary practitioner guide to the Recognition andManagement of Pesticide Poisonings. The report does not contain actual training modules orresources, but instead provides a listing of relevant resources.

Activity #3Promote the National Guidelines with key stakeholders and solicit official endorsements andorganizational support for the report, including dissemination to their members.

Stakeholders

� National professional associations for practicing primary care providers

� Practicing health care providers who have already developed tools and practice models


� The National Guidelines will include defined practice behaviors, content areas, insertionpoints, examples as necessary, and recommended resources.

� Endorsement by key professional organizations for providers.

Table 9The preliminary list of “Expected Practice Skills” shown in Table 9 (page 72-73) isrecommended as a useful goal for primary care providers seeking to provide the highest qualitycare to their patients. Further developed practice skills are available in 2002.

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1. Take an environmental and occupational health history.

� Providers should be able to take a basic environmental and occupational historyto determine if a temporal relationship exists between exposure and symptoms.

� Ask patients 2-3 screening questions that would elicit possible exposure to anumber of environmental factors (including but not limited to pesticides).

� Take an environmental health history with questions regarding where the patientlives, works, and plays.

2. Recognize the signs and symptoms of pesticide exposures and appropriatelymanage or refer patients.

� Recognize the signs and symptoms of pesticide exposures (both acute and chronic).

� Providers should be able to treat and manage health conditions associated withpesticide exposure or refer patients to appropriate specialists and resources, andfollow up appropriately.

� Diagnose pesticide-related health conditions using appropriate testing proceduresand treat pesticide exposures.

3. Identify risk factors for pesticide exposure and resulting health effects.

� Identify risk factors for pesticide exposure (e.g. occupation, location of home,susceptible populations such as children).

� Identify environmental factors that may possibly be linked to patient illness toensure that chronic pesticide exposures are addressed.

4. Demonstrate key principles of environmental/occupational health andepidemiology and population-based health.

� Demonstrate an understanding of principles of environmental and occupationalhealth, and epidemiology.

� Understand the temporal relationship between exposure and symptoms.

� Recognize that others may be ill (co-workers, family) and get a timeline of healthproblems for these or consult public health authorities for help in evaluating exposures.

5. Take steps to report pesticide exposure and support surveillance efforts.

� Understand the importance of surveillance and reporting.

Table 9: Expected Practice Skills

— continued on the following page

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Table 9 (continued)

� Be able to access and report data for local, regional, and national surveillance programs.

� Report cases involving pesticide exposures as required.

� Report concerns about pesticide exposures to the appropriate authorities, such aslocal and state health departments, EPA, NIOSH, federal OSHA, state OSHA orstate departments of labor, or departments of agriculture.

6. Possess basic awareness of communities in which patients live.

� Providers should possess a basic awareness of environments in which patients live,work, and play in order to anticipate possible encounters with exposure to pesticides.

� Demonstrate an understanding of population-based health.

� Demonstrate knowledge about the environment in which the practice is situated, withspecific understanding of communities that may be at-risk for pesticide exposures.

� Be aware of, and access, the resources available within the community and in thestate or region, that could assist in pesticide exposures and illness.

7. Provide prevention guidance/education to patients.

� Provide guidance to patients on how to prevent pesticide exposures.

� Advise patients and provide basic education about pesticide exposure.

� Counsel patients about minimizing unnecessary use of pesticides, refer patientsto appropriate experts on safer work practices including, use of safety substancesor alternative methods of pest control including integrated pest management.

� Address the whole patient in the context of his/her life and/or community (e.g.,link to social services, etc.).

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PRACTICE COMPONENT C:

Assess Knowledge and Skills of Practitioners

StatementConduct an assessment of the target audience of primary care providers to determine: (a)providers’ current knowledge; and (b) how providers will best respond to educational programsand information resources. This assessment will be comprised of a literature review and arange of needs assessment analyses.

Expected OutcomesBaseline data indicating the level of training currently taking place in practice settings, currentknowledge of practicing providers, and identification of best mechanisms to reach and trainproviders, and to equip them with user-friendly tools.

Target AudienceAwareness and Motivation: This strategy targets health care practitioners to determinetheir level of awareness; their motivation, or lack of motivation, for this topic; their knowledgeand skills base; and the most effective ways to reach them through educational interventions,model programs, and resources.

Proposed ActivitiesActivity #1Conduct a literature review to locate survey data and evidence of level of knowledge, attitudeand skills of health care providers related to pesticide-related health conditions.

Activity #2Where literature review is lacking in data, conduct a combination of audience assessment analysesto be able to effectively collect baseline data and draw conclusions on the following questions:

� To what extent are the recognition and management of pesticide-related health conditionsincluded in the continuing professional development of primary care providers?

� What is the extent of the knowledge, attitude, and skill base of practicing primary careproviders with regard to pesticide issues? Are they at the stage of needing to raise awareness,improve their knowledge and skills, or obtain resources?


“It is not clear that we really know

what [resources] health care

providers want and need.”— Allen James, MBA, CAE

Responsible Industry for a Sound Environment

� What level of comfort do practitioners haveaddressing pesticides with their patients and incommunities? What do practitioners need to feelmore comfortable in addressing pesticides intheir practice settings?

� What resources, and in what format (e.g.,traditional lecture material, teaching modules,web-based, audio cassette, CD, video conference,satellite), do practitioners need most?

Activity #3Produce a final report with recommendations for usein the development of the Initiative.

Stakeholders

� Professional associations that representpractitioners

� Continuing education programs, organizationsthat offer continuing education

� Practicing clinics and health care delivery systems

� Practicing providers


� Comprehensive literature search documenting the findings of studies that have surveyedpracticing primary care providers.

� Report with baseline data and conclusions/recommendations.

BackgroundAny good plan has at its core a strong assessment component to collect baseline data onexisting knowledge and skills, as well as to determine the most effective mechanism forreaching the target population. This component will collect vital information not onlyfor this Initiative, but also for the entire field of health care provider education. Theassessment will also include a chance to determine where the target population presentsitself along the continuum of change described in the section on Target Audience.

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Do most people lie at the beginning of the continuum where they will respond best toactivities that raise their awareness and motivate them to care about this issue? Or arethey ready to make changes in their practice and in need of the necessary tools andeducational resources? The assessment will answer these, and other key questions, toinform the implementation process and subsequent evaluation.

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PRACTICE COMPONENT D:

Secure Official Endorsements

StatementEnsure the integration of the expected practice skills into practice settings by securing theofficial endorsements of key professional organizations and decision-making bodies.

Expected OutcomesProfessional organizations, influencing bodies, and practitioners will agree that the expectedpractice skills are essential to the ongoing training of primary care providers and will integrateor support their integration into practice settings.

Target AudienceAwareness and Motivation: This component targets key recertification and continuingeducation bodies and professional associations for practitioners. The emphasis is on raisingawareness and motivating decision-makers to bring about change in practice that provideslifelong learning to health care providers.

Maintenance/Sustainability: This component also targets key professional associations toendorse and support the implementation and outcomes of this Initiative over the long-term.This Initiative will only be successful if its expected outcomes are institutionalized into thepractice settings for health care provider training.

Proposed ActivitiesActivity #1Promote expected practice skills and case statement with professional organizations to garnertheir involvement and support in implementing interventions to improve the knowledge,attitudes, and skills of practicing health care providers.

Activity #2Highlight the specific recommendations in the National Guidelines on expected practice skills,along with specific examples of how practice settings can integrate the content into the ongoingtraining of providers.

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Activity #3Publish editorials in nationally recognized journals on specific strategies from the NationalGuidelines, along with user-friendly tools for providers.

Activity #4Develop a position paper on the need for expected practice skills, to be posted on the internetand for use in meeting with credentialing bodies and decision-makers.

Activity #5Identify and promote incentives for professional associations to be involved in the Initiative,including financial incentives in the form of grants, technical assistance for clinics, community-based interventions and research, instructional teaching and training aids, expert consultants,clinical access, release time for professional development, and establishing appropriate clinicalsites for additional training.

Stakeholders� Professional specialty organizations

� Licensing boards

� National professional associations

Evaluation of Outcomes/Indicators of Success� New position papers by targeted organizations that support the integration of

recommended pesticide content into practice settings.

� New requirements by professional decision-making bodies that require professionaleducation to teach about health effects from pesticides.

� Published journal articles in professional newsletters and peer-reviewed journals.

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PRACTICE COMPONENT E:

Demonstrate Model Programs

StatementMobilize practice settings to become population-specific and to incorporate environmentalconsiderations (specifically pesticides) into prevention, education, diagnosis, and treatment.Achieve incremental, site-specific improvements in identification, early intervention, andprevention, as well as in measures of practice-specific health outcomes. By 2010, half of allprimary health care practice settings in the United States should incorporate environmentalconsiderations in their pesticide-related prevention, education and management activities,and in the referral of pesticide-related health conditions.

Expected Outcomes

� Demonstration projects (distributed geographically across the United States) that modelpractice settings where pesticide-related health conditions are an integrated part of theprovision of care and community outreach.

� Evaluation of demonstration models and creation of a “models that work” guide for thefield and other practice settings.

� Creation of a tool kit that can be used by other practice settings that want to set up amodel program.

� Launching of nationwide effort to redesign 50 percent of all practice settings.

Target AudienceMaintenance/Demonstration: This component targets specific practice settings that areready to become part of a cadre of model practices across the country that will change theway they practice, specifically addressing potential health effects from pesticide poisoningsand exposures. The target audience in this case has been convinced that this is an importantissue and has increased its knowledge and skills in this area. Model practices may also belocated in areas of higher impact, such as farmworker clinics and urban settings.

Proposed ActivitiesActivity #1Mobilize practice settings that currently address environmental health/pesticide issues. Identify currentleaders among practice settings and encourage them to spread the word on what they already do.

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Activity #2 (option 1)Secure funding, create a program description, and develop an RFP to solicit proposals from5-10 clinical/community sites to receive financial support over three years to create a practicemodel. Ensure that the funded sites represent the range of practice settings and the breadthof pesticide issues (e.g., urban and rural, agricultural and non-agricultural, diversity ofcultures and literacy rates). Ensure that some programs are located in states with pesticidepoisoning surveillance programs.

Activity #2 (option 2)Secure funding, create a program description, and develop an RFP to solicit small proposalsfrom 100 clinical/community sites to receive financial support over 1.5 years to create apractice model. Ensure that the funded sites represent the range of practice settings and thebreadth of pesticide issues (e.g., urban and rural, agricultural and non-agricultural, diversityof cultures and literacy rates). Ensure that some programs are located in states with pesticidepoisoning surveillance programs.

Activity #3Define the major components of the proposed practice model, allowing for flexibility by thespecific site. Ensure that the models are grounded in theories and experience about how changeactually happens so as to learn from other experiences in practice settings. One model thathas been recommended is the Diabetes Collaborative (see box on page 82).

Activity #4Establish a coordinating body to manage the project and the creation of the consortium ofpilot sites, and to create the plan of action for the project. Among the tasks of this body are:

� Create a consortium of the pilot sites that use the proposed model as a guide for developingtheir own specific practice intervention plan (including what they want to do, theintervention, the evaluation and the implementation of the proven change).

� Build a technical assistance component that can work with sites in designing theintervention, piloting the intervention and evaluating its success.

� Convene pilot sites on a regular basis by conference call and in-person meetings to sharesuccess stories, challenges, and lessons learned.

� Establish an evaluation mechanism for the sites and the national project to determine thesuccess of the creation of new models. Evaluation would be both formative and summative.

Activity #5Launch nationwide effort to redesign 50 percent of practice settings based on findings fromthe model sites.

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Stakeholders� Professional associations

� Practice settings

� National coordinating organization

� Funding agencies and partners

� Organizations that have created practice change models

Evaluation of Outcomes/Indicators of Success� RFP completed and funding secured for pilot program.

� Chosen sites underway in developing practice models.

� Five to ten practice change models with evaluation components and identified success stories.

� Publication of model programs.

� Effective dissemination of practice models nationwide.

� Enhanced reporting of acute pesticide-related illness cases.

BackgroundThe key to changing practice is demonstrating how changes in day-to-day activities actuallymake a difference in health outcomes of patients and communities. This strategy was generatedby the Practice Workgroup as a way to model expected changes and to evaluate what practicechanges actually lead to the overall goal of the Initiative — to increase the recognition,management and prevention of pesticide poisonings and exposures. There are tworecommended options for this strategies: (1) fund a large number of demonstration practicesites to make several small practice changes and evaluate the outcome, or (2) fund a smallnumber of demonstration practice sites to overhaul their practices and bring about substantialchange. Both options offer different rewards and utilize the resources in different ways. Ineither case, there are model organizations that have developed such an effort for other healthconditions, such as the Diabetes Collaborative (see box on page 82).

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VEThe Diabetes Collaborative is a multi-year initiative sponsored by the Health Resources

& Services Administration and the Bureau of Primary Health Care, in partnership

with health centers, primary care associations, and clinical networks. Its goal is to

eliminate health disparities and ensure access to quality primary care for racial and

ethnic minorities and for underserved populations. Among underserved and minority

populations, diabetes is a virtual epidemic, with 1.2 million patient visits in 1996 alone,

and lost resources and human productivity estimated at over $92 billion annually.

The project aims to redesign diabetes management to effect a measurable change in

health status among the approximately 60,000 diabetic patients at the 92 participating

health centers, and uses adaptations of learning methods devised by the Institute for

Healthcare Improvement. The project was developed as part of the Breakthrough Series

Workgroup of the Clinicians National Forum.

The improvement model is based on three fundamental questions: (1) What are we

trying to accomplish? (2) How will we know that a change is an improvement? and (3)

What changes can we make that will result in an improvement? The national measure

of success for the first phase of the project is meeting the goal of over 90 percent of the

60,000 diabetic patients in the target population receiving two HbA1c blood tests per

year, at least three months apart. A short-term trial-and-learning method called PISA

(Plan, Do, Study, Act) provides the framework for implementing changes and learning

from them. An example of PISA in action might be:

� Plan: The diabetes team at Rocky Road Health Center predicted that a registry of

diabetic patients would improve the measurement of HbA1c. Setting up this system

took three weeks. During that time, the center also established protocols for glucose

measurements and ran a trial utilizing patient self-management for home glucose

measurements.

� Do: The registry was tested for two weeks with one volunteer nurse practitioner

and her diabetic patients. After the diabetes flowsheet was revised to reflect the

registry information, the collection went well.

� Study: The time spent on completing the flow sheet increased from one minute to

two minutes and it took an additional three minutes to enter data into the registry.

Waiting time for diabetic patients increased an average of eight minutes. Of the

patients with diabetes, only half had appropriate testing of HbA1c; but after the

trial, all of the patients had current values.

� Act: After a team meeting with the executive director and finance officer in charge

of the information system, the health center adapted a scannable flow sheet form

they had learned about from the Midwest Clinicians Network. To cut down on

cycle time, the medical records were reviewed the night before to identify gaps and

pre-enter data.

Source: Migrant Clinicians Network

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PRACTICE COMPONENT F:

Create Incentives for Change

StatementIdentify and promote a number of incentives to incorporate appropriate prevention, recognition,and management of pesticide-related health conditions into health care practices. Specifically: (1)provide grant funding to practicing providers for interventions and research related to pesticidepoisonings and exposures; (2) create free and readily available opportunities for continuingeducation involving pesticides and environmental health; (3) increase providers’ awareness of thevalue of taking an occupational and environmental history for optimizing Evaluation andManagement (E&M) coding and billing; (4) require knowledge of environmental health issuesfor certification and re-certification; (5) require pesticide poisoning reporting for workers'compensation reimbursement and automatic workers compensation reimbursement for work-up of suspected occupational pesticide-related health conditions; and (6) promote documentationof occupational and environmental history in medical records, via incorporation into qualityassurance/quality control mechanisms.

Expected Outcomes

� Increased attention paid by primary care providers to pesticide poisoning and exposuresbased on incentives to change practice.

� Creation of new or improved incentives in the following areas: monetary incentives;legal incentives; community-based incentives; and peer/professional incentives.

Target AudienceAwareness and Motivation: This component targets health care system administrators andfunders to create incentives for providers to address pesticide-related health conditions. Thiscomponent is designed to motivate and convince decision-makers that specific changes canand should be made in grant funding, continuing education, E&M codes, re-certification,workers’ compensation, and quality assurance. This component will also provide “ready-made” language on recommendations for proposed changes.

Proposed ActivitiesActivity #1Provide grant support to practicing providers for interventions and research related to pesticidepoisonings and exposures:

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� Urge federal agencies (CDC, NIH, EPA, HRSA, NIOSH, NIEHS), state agencies, andprivate foundations to support intervention and research projects conducted bypracticing primary care providers.

� Publicize models developed through grant support.

� Create a centralized source of information about grants and grantees.

Activity #2Create free and readily available opportunities for continuing education involving pesticidesand environmental health:

� Connect continuing education (CE) courses on pesticides to major national meetings.

� Offer free CE credits in a variety of settings.

� Offer CE credits in local settings and support experts to go out to local clinics to providepesticide education.

� Establish free, web-based continuing education.

� Encourage and fund NIOSH Education and Research Centers (ERCs) to hold localcontinuing education courses on pesticides.

� Address barriers such as competing priorities for providers, cost of hosting continuingeducation programs, and lack of provider interest.

Activity #3Increase providers’ awareness of the value of taking an occupational and environmental historyfor optimizing Evaluation and Management (E&M) coding and billing. See next page for abrief summary of how E&M coding could be upgraded.

Activity #4Require knowledge of environmental health issues for certification and re-certification:

� Identify priority professional certifying bodies.

� Recruit high-profile supporters from each of the relevant disciplines.

� Create sample objectives and questions on environmental health issues.

� Approach certifying bodies about including questions.

� Coordinate outreach to the certifying bodies.

� Address barriers such as institutional inertia, competing priorities, and lack ofperceived problem.

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Activity #5Require pesticide poisoning reporting for workers' compensation reimbursement andautomatic workers' compensation reimbursement for work-up of suspected occupationalpesticide poisoning. See, for example, Washington State’s program described on page 86. Thegoals are for work-related pesticide health effects to be universally reimbursed, includingrelevant diagnostic testing; mandatory reporting of pesticide-related health effects for workers'compensation reimbursement; and standardized weight-of-evidence for claims reimbursementfor pesticide-related illnesses. Tasks include:

� Target high-priority states for change.

� Gather information about model state workers' compensation laws (especially Californiaand Washington).

� Win support of professional organizations, advocacy groups, and state agencies.

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GAccording to the 1997 Health Care Financing Administration DocumentationGuidelines, in order for a provider to bill for a “comprehensive” visit for a newoutpatient, a new inpatient, or a new consult, the provider must document takingall of the following; a past medical history (PMH), a family history (FH), and asocial history (SH). The social history is defined as an “age-appropriate review ofpast and current activities.” For follow-up visits and emergency department visitsto be designated as comprehensive, two out of the three histories must bedocumented. It may be possible to convince health care providers that taking anoccupational/environmental medicine history will help them to fulfill the SHrequirement for billing for a “comprehensive” visit, particularly for new patients.

The billing codes affected are:

� New outpatient visit codes 99204 and 99205

� New outpatient consults 99244 and 99245

� New inpatient consults 99254 and 99255

� Initial hospital care 99222 and 99223

� Emergency department 99285

These HCFA Documentation Guidelines apply only to Medicare patients;however, most third-party payers have adopted the same guidelines for theirreimbursement schedules. Considerable research will need to be done todetermine if this approach is viable.

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Washington State has moved into the forefront in reporting of occupational diseases.Under state law, the Department of Labor and Industries (L&I) and the Departmentof Health (DOH) both have responsibilities for addressing chemically-related illnesses(CRI)—illnesses known or suspected to be caused or substantially worsened byexposure to chemicals in the workplace or other environments.

To increase efficiency and provide more consistent handling of chemically-relatedclaims, L&I established a single CRI unit with responsibility for all chemically-related claims. Claims adjudicators in the CRI unit receive special training onchemically-related injuries and illnesses. L&I has also contracted with anoccupational medicine physician to provide additional medical review of the morecomplex claims and to ensure that appropriate testing and work-ups are done.L&I averages about 200 claims per month.

Some of the key provisions of Washington’s workers' compensation system include:

� An injury/illness incident is eligible for a claim to be filed whenever medicaltreatment is provided.

� For all claims filed, the costs for diagnostic evaluations to determine if the injury/illness is work-related are covered. Although the claim may eventually be rejected ifit is determined not to be work-related, the initial visit(s) and testing are paid for.

� Individuals with accepted claims are eligible for time loss (wage replacement) ifthey lose more than three days of work.

� Health care providers are required to file a claim if the worker feels the conditionis work-related.

The CRI unit has recently started to identify clusters of chemically-related illnesses,particularly involving a single employer with more than one claim for a specificexposure event. The goals include early intervention to reduce exposures and preventfuture morbidity and mortality. For example, a cluster of carbon monoxide poisoningswas identified, triggering efforts to reduce future exposures in the plant where thepoisonings occurred. CRI staff find this process also improves the adjudication ofclaims by grouping together the claims from a particular employer.

Since 1990, DOH has been responsible for investigating pesticide-related illnessincidents and developing a database of pesticide-related problems. L&I providesdetailed reports to DOH to enable DOH to include workers' compensation claims intheir investigations. Some consider the claims process to fulfill their reportingrequirements, although there is a longer delay when L&I reports claims to DOHthan when a health care provider reports directly to DOH at the time a patient isevaluated. It is not clear if this mechanism is sufficient or could be improved.

Source: Mary Miller, Washington State Department of Labor and Industries

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� Approach state Workers’ Compensation Commissions for changes.

� Build key leadership supporters including workers' compensation attorneys, labor,farmworker groups, clinicians, and public health groups.

� Address barriers such as lack of leadership, cost, and decentralized state authorities.

Activity #6Promote documentation of occupational and environmental history in medical records, viaincorporation into quality assurance/quality control mechanisms. Quality assurance/qualitycontrol mechanisms could also be used to promote documentation that providers have givenpesticide information to certain at-risk groups (e.g., parents of toddlers, farmworkers, pregnantwomen). Activities include to:

� Create consensus on minimum necessary documentation through a committee process.

� Research the scope, authority, and current priorities of the Joint Commission onAccreditation of Healthcare Organizations (JCAHO).

� Approach the JCAHO to require documentation of occupational and environmentalmedicine (OEM) history and pesticide education.

� Approach targeted major managed care organizations to require documentation of OEMhistory and pesticide education.

� Approach family medicine and Ob/Gyn to include OEM history and pesticide educationin their chart review for certification/recertification.

� Determine whether this is a priority activity area, and address barriers such as institutionalinertia, extra burden on hospitals, clinics, and JCAHO, and time pressure.

Stakeholders

� Federal agencies and foundations that support research and interventions


� NIOSH Educational Resource Centers

� Health care centers and hospitals

� Community clinics

� Worker’s compensation partners

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� Increase in number of grants and level of support available to practicing primarycare providers.

� Increase in publications of research findings and interventions undertaken by providers.

� Report on success stories and lessons learned in the field.

� Adoption of models in other settings.

� Increase in number of continuing education offerings.

� Increase in number of people attending continuing education programs and number ofpeople completing web-based credits (percentage increase in participation each year).

� Short-term and long-term changes in Evaluation and Management coding andworkers' compensation.

� Questions added to recertification exams of professionals.

� Workers' compensation systems in target states are changed to reimburse for work-up ofsuspected pesticide poisoning, and payment is linked to reporting of pesticide exposuresto state registries.

� Quality assurance/quality control mechanisms in targeted health care organizationsare changed to incorporate review of documentation of an occupational andenvironmental history.

BackgroundOne of the most effective ways to bring about change is to build incentives into existingrequirements and activities of health care plans and practitioners. There are certain key pointsof entry into the health care system that require providers to address specific issues in theirpractices. For example, by integrating pesticide components into workers' compensation, E&Mcoding, and quality assurance, the Initiative can ensure that pesticide issues will becomeinstitutionalized into health care practice.

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Resources and Tools

R esources of all kinds serve as the “infrastructure” for this Initiative. The five resourcecomponents are designed to identify, create, and disseminate the necessary tools tosupport change in both educational and practice settings. Key concerns are to avoid

duplication of existing resources by inventorying the current stock of resources available, andto ensure the scientific credibility and usefulness of resources by establishing a national reviewboard to evaluate them.

Component A: Inventory existing resources — Determine what educational and informationprograms and materials for health care providers exist currently in education and practicesettings and what gaps should be filled.

Component B: Establish a national review board — Create a national body to determineassessment criteria and evaluate existing resources, with the goal of identifying, selecting,and assessing the ideal resources that primary health care providers use in both educationaland practice settings for prevention, diagnosis, treatment, and referral of pesticide-relatedhealth conditions.

Component C: Create an information gateway — Establish a print, telephone, and web-based gateway through which primary health care providers can access information andeducational resources.

Component D: Develop teaching/learning resources for educational settings — Identify anddevelop new content resources, tools, and methods for faculty in educational settings.

Component E: Develop new resources for practice settings — Identify and develop newcontent resources, tools, and methods for health care providers in practice settings.

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RESOURCE COMPONENT A:

Inventory Existing Resources

StatementDetermine what educational and information programs and materials for health care providersexist in education and practice settings and what gaps should be filled.

Expected OutcomesAn inventory of pesticide resources based upon information from health care providers ineducation and practice settings.

Target AudienceReadiness for Change: This strategy will target health care providers who have alreadydeveloped model tools, resources, and programs so as to create a centralized inventory ofwhat exists and what gaps need to be filled.

Proposed ActivitiesActivity #1Develop and document the inventory methodology to be used in collecting resources,including documentation for the study instrument and an announcement requestingresources and materials.

Activity #2Conduct the resources inventory. Key questions to be asked of organizations include:

� What resources do you use to diagnose pesticide exposures?

� What resources do you use to treat pesticide exposures?

� What resources do you use to refer pesticide-exposed patients?

� How useful are current resources?

� What “stage of change” is the resource targeting?

� For which target discipline is the resource designed?

� For what practice settings is the resource designed?

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� For what characteristics of patient/community populations are the resources designed?

� What resources are needed that are not readily available?

Stakeholders

� Federal Interagency Planning Committee for this Initiative

� Organization conducting the inventory


� Inventory completed and available.

� Feedback from website users indicating additional resources and/or identifying gaps.

� Acknowledgment of a thorough inventory by the national review board.

BackgroundIn order to evaluate the existing resources and to effectively disseminate what is available, aninventory of available resources needs to be created. Such an inventory is already underwayand will be completed as part of this Initiative. The inventory will be available online.

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RESOURCE COMPONENT B:

Establish National Review Boardto Evaluate Resources

StatementCreate a national body to determine assessment criteria and evaluate existing resources, withthe goal of identifying, selecting, and assessing the ideal resources that primary health careproviders use in both educational and practice settings for prevention, diagnosis, treatment,and referral of pesticide-related health conditions.

Expected Outcomes

� An established board available for ongoing consultation and review.

� A published document with a list of evaluated and recommended pesticide resources thatprimary health care providers can use in both educational and practice settings forprevention, diagnosis, treatment, and referral of pesticide exposures.

Proposed Activities

� Establish selection criteria for national review board membership.

� Establish a multidisciplinary national review board to conduct the evaluation of existingresources.

� Refine the list of suggested evaluation criteria:

� Pilot tested

� Demonstrated level of success

� Regional applicability

� Significant number of participants

� Cost-effectiveness

� Peer review of resources

� Significant relevance

� Related to at least one competency/practice behavior

� Developed by credentialed sources/authors

� Accessibility

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� Credibility of information/sound science

� Convenience

� Endorsement by appropriate professional association

� Approved programs for CE credits

� Built-in incentives to use the resources.

� Convene the national review board to evaluate the existing inventory of resources (ResourceComponent A) using the evaluation process.

� Publish recommended resource document online and in print format.

� Assess the usefulness of the resource document to health care providers.

Stakeholders

� Federal Interagency Planning Committee

� National review board members


� Published resources document, online and in print format.

� Feedback from health care providers on the usefulness of the resource list.

BackgroundThe concept of a national review board came out of the Resources Workgroup’s focus on howpesticide-related resources used in education and practice settings could be evaluated, in theinterests of using the highest quality materials. The national review board will be composedof leaders in the areas of pesticides and primary health care.

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RESOURCE COMPONENT C:

Create an Information Gateway

StatementEstablish a print, telephone, and web-based gateway through which primary health careproviders can access information and educational resources.

Expected OutcomesA fully functional, interactive, information gateway that provides primary health care providerswith access to readily available and useful pesticide resources.

Target AudienceReadiness to Change, Maintenance: This component targets individuals and organizationswho are looking for models and resources for how to address health effects from pesticides, aswell as individuals and organizations who have become part of the cadre of health careproviders involved in this issue.

Proposed ActivitiesActivity #1Build the gateway using resources gathered through the inventory process and evaluated bythe national review board.

� Identify existing resource centers that could develop the gateway, under direction of theFederal Interagency Planning Committee.

� Develop or enhance a resource center infrastructure and address logistical issues includinga toll-free number and website.

� Assign priority access to primary health care providers.

� Link to regional and geographical specific information, coordinated industry websites,and other resources, universities, associations, etc.

Activity #2Market the gateway and its information/education resources through dissemination channelsto reach primary health care providers in education and practice settings.

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� To build awareness among health care providers: Disseminate persuasive case statements(see Education Component A, page 41, Practice Component A, page 67, for developmentof case statements) through professional associations, journals, and peers that addressthe main issues, why primary care providers should be concerned, and how to accessthe gateway.

� To provide tools/resources to health care providers ready to make changes: Disseminate curricularpackages to educational settings and training packages to practice settings. Packages may bedefined as lectures, slides, case studies, exercises, assignment/project ideas, ideas on how toinvolve experts, access to gateway, etc. Packages would be combined from existing resourcesand/or new resources that have undergone peer-review and pilot testing.

� To help health care providers learn of the latest resources: Disseminate concise informationon how to access the gateway, especially the network of expertise. Dissemination methodsinclude posters, flyers at conferences, NPIC clearinghouse, and links on websites.

� Convene one or more focus groups to evaluate the effectiveness of the dissemination efforts.

Stakeholders

� Federal Interagency Planning Committee

� Organization to manage the gateway


� Number of requests for information.

� Number of pageviews and downloads from the website.

� Number of calls.

� Customer satisfaction feedback on the website.

� Feedback from focus groups.

� Degree to which the dissemination efforts are nationwide.

� Degree to which dissemination efforts and resources address primary health care providersat varying stages of change.

BackgroundA centralized gateway to information can be an efficient way to provide comprehensiveaccess to evaluated, pesticide-related resources. This centralized resource should include

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emergency information and contacts, educational materials, and other resources, and beaccessible by a toll-free number and via a website. The gateway must be able to provide real-time answers to short-term questions as well as larger educational resources. Access mustbe multi-pronged; phone, web, print, email, listservs. It should contain geographic linkagesto local providers, researchers, and sources of local information (e.g., local healthdepartments). The gateway will build on existing resource networks, such as the NationalPesticide Information Center (NPIC — see box below) and will require a multi-stakeholderpartnership for effective implementation. The gateway will need extensive marketing in orderto ensure that it is widely used.

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A cooperative effort between Oregon State University and EPA, the NationalPesticide Information Center (NPIC) provides objective, science-based, and plain-language pesticide information to the general public, and medical and veterinarycommunities. It handles over 23,000 calls a year on topics ranging from toxicologyto pesticide poisonings. NPIC’s staff of pesticide professionals includestoxicologists and a physician trained to:

� help callers interpret and understand health and environmental informationabout pesticides

� answer questions about pesticide labels

� supply general information on the regulation of pesticides in the United States

� access over 300 pesticide resources

� direct callers for pesticide incident investigation, emergency human andanimal treatment, safety practices, clean-up and disposal, laboratory analyses

� confer with private physicians to determine an appropriate treatment planin the event of poisonings

� provide information regarding safety practices for field/farmworkers and handlers

� provide callers with information about anti-microbial pesticides

(1-800-447-6349) (Monday-Friday).

Toll-free tel: 1-800-858-7378 daily, 6:30 a.m. - 4:30 p.m. (Pacific time);Fax: 541-737-0761; e-mail: [email protected]; website: http://npic.orst.edu

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RESOURCE COMPONENT D:

Develop Teaching/LearningResources for Educational Settings

StatementIdentify and develop new content resources, tools, and methods for faculty to use ineducational settings.

Expected Outcomes

� Teaching modules

� Network of experts and organizations nationwide

Target AudienceReadiness to Change: This component targets faculty in educational settings who are readyto integrate the issue into their curriculum.

Proposed ActivitiesCreate teaching modules for faculty that address pesticides/environmental health and thatrespond to the National Guidelines, and the assessment of educational institutions.

� Review existing teaching modules collected and evaluated by the national review boardand review the assessment of educational institutions to determine the type of teachingmodules still needed by faculty.

� Identify key experts and/or organizations to develop teaching modules and createcontractual agreements for the development of specific modules.

� Develop pesticide-teaching modules with flexibility for use by different schools,departments, etc.

� Establish a peer review and pilot testing process for the modules developed.

� Distribute teaching modules to all academic health centers and nursing schools.

� Make modules available online (via gateway and/or published resources document).

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Stakeholders

� Faculty who have already developed resources

� Key professional associations for faculty

� Cooperative extension pesticide safety educators

� State lead agency pesticide educators


� New resources are approved and endorsed by the national review board.

BackgroundGuiding principles for developing new resources include:

� Easy to implement

� Interdisciplinary

� Culturally and geographically relevant

� Measurable outcomes

� Usable in both urban and rural communities.

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RESOURCE COMPONENT E:

Develop New Resources for Practice Settings

StatementIdentify and develop new content resources, tools, and methods for health care providers inpractice settings.

Expected OutcomesIncreased access to and availability of relevant information and resources including expertsin the field, content materials and available data within communities.

Target AudienceReadiness to Change: This component targets practitioners who are ready to integrate theissue into their clinical practice and prevention activities.

Proposed ActivitiesActivity #1Develop a variety of resources, including:

� Training package for a one-day workshop on Health Care Providers and Pesticides.This package could be used to train health care providers in continuing education, coveringthe breadth of topics related to pesticides.

� User-friendly materials:

1. Accessible print- and web-based guides for physicians and nurses. Ensure that guidesare dated so that revisions can be made and distributed, and that they contain returncards for new information and comments.

� Guide I: Highlights of symptoms, treatments, and reference.

� Guide II: How to take an occupational and environmental history.

2. “ABCs of environmental health” — a simple tool, similar to the CAGE screening toolfor alcoholism, that will indicate signs and symptoms for screening purposes.

3. Wall posters on pesticides for health care providers to post in their clinical practices

4. Audio cassettes/CDs to listen to in transport to and from a practice setting.

� Outreach: Use of radio to serve patients and primary care providers whose first languageis not English.

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� Certification of training: Some type of recognition that a primary care provider hascompleted a certain level of training.

� Journal articles in the literature: Encourage researchers to produce professional journalarticles on the subject of pesticide-related health concerns.

� Internet/web-based materials and training, including video-conferencing, satellite training.

� Encourage creation of a centralized industry website on pesticide/health data.

Activity #2Increase the participation of professional associations in the support, use, and promotion ofeducational materials and resources.

� Develop model policy statement that can be tailored and adopted by professional associations.

� Coordinate with national organizations to develop policy statements on educating healthcare providers about pesticides (along the lines of those developed by the AmericanAcademy of Pediatrics).

� Encourage development of environmental health committees in professional organizationsand local chapters.

� Coordinate with professional associations to secure more continuing education (CE)opportunities at national and regional meetings.

� Build pesticide/environmental health CE into internet-based offerings by professionalassociations.

Activity #3Establish a national network of experts and organizations that can answer questions andserve as resources to health care providers nationwide.

� Identify existing organizations that have the capability to establish and/or expand a databaseof individuals and organizations.

� Identify areas of expertise to be included.

� Identify experienced professionals and define the parameters of their responsibility.

� Solicit availability for consultation, teaching, guidance, etc.

� Develop a Pesticide Poisoning Orientation Training program to build “practice champions”or motivate providers to become champions. Training could be web-based, via audiocassettes, CDs, or in-person. Short courses (half or full day) could be held in conjunctionwith other professional conferences, and should be integrated with other disciplines.

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Stakeholders

� Faculty who have already developed resources

� Key professional associations for faculty

� Cooperative extension pesticide safety educators

� State lead agency pesticide educators

� Network of pesticide and pest management experts in land grant colleges and universitiesthroughout the US.

Evaluation of Outcomes/Indicators of Success� Increased utilization of community resources.

� Increased number of customized educational programs/materials.

� Increased number of resource collaborations.

� Number of RFPs related to new and innovative ways to get information to primary care providers.

� Increased number and frequency of pesticide practice related publications.

� Increased number of CE courses.

� Increased number of presentations in practice settings.

� Numbers of policy statements.

� Numbers of re-certification exams.

� Numbers of questions on exams.

� Increased availability of reimbursement mechanisms.

� Number of people applying for Certificate of Recognition.

� Number of requests made of experienced professionals.

� Number of professionals who agree to participate.

� Diversity of professional background.


BackgroundA wide range of credible, convenient, and easy to use materials need to be developed. Examplesinclude “cheat sheets,” cassette tapes or CDs that can be listened to in the car, web-basedinstruction (depending on how recently the providers graduated and how comfortable theyare with technology). Providers are overburdened and need quick help — either in the formof checklists or a person at the other end of a line.

To the extent that primary care providers keep up with their professional journal literatureand to the extent that there is a sufficient stream of articles in the literature on pesticidediagnosis and treatment, it can be expected that providers will encounter pesticide-relatedinformation in the course of their reading. However, there may well be a gap in articles onpesticide poisoning prevention and diagnosis in the journals that are generally read, a gapthat could be remedied by encouraging researchers to prepare and submit such articles.


Conclusion

This Implementation Plan is the starting point for a strategic and coordinated effort tochange our national health care system so that it adequately addresses the problemsposed by pesticide poisonings and exposures. The Implementation Plan presents the goal

of the Initiative and the expected outcomes, and sets out the strategic direction to improve therecognition, management and prevention of pesticide-related health conditions. At the heart ofthe Implementation Plan is a three-pronged strategy for accomplishing the necessary change.

The strategy is aimed at improving the teaching of pesticides and environmental health ineducational settings of nursing, medical, and other health professional schools, changing theway primary care providers assess and react to pesticide cases in their practice settings, andcreating the necessary new resources for both educational and practice settings that buildupon the existing knowledge base and respond to the needs of faculty, students, administrators,and practitioners. The three-pronged strategy and the Implementation Plan as a whole areintended to serve as a model for other toxic exposures and broader efforts to educate healthcare providers about environmental health problems. It is hoped this Implementation Planwill be a positive step towards a national vision for environmental health awareness, educationand training for health care providers.

Work is already underway on a number of components of the Implementation Plan —including development of competency guidelines, establishment of a national evaluation panel/review board, conducting an audience assessment through literature review and focus groups,and creation of an information gateway. The intention is to get the remaining componentsunderway in the next several years. Evaluation of progress will be an ongoing theme duringthe course of this Initiative. The next steps in moving this Initiative forward will require thesupport and participation of a wide spectrum of stakeholders nationwide. This ImplementationPlan can be used as a way of introducing new additional stakeholders and interested partiesto the Initiative and of involving them in specific components. The Implementation Plan willalso be a focus of a National Forum, to be convened in 2002.

As work proceeds, workgroup members and other stakeholders are encouraged to stay active inthe Initiative through e-mail, EPA’s host website (www.epa.gov/oppfead1/safety/healthcare/healthcare.htm) and NEETF’s host website (www.neetf.org/health/providers/index.shtm) andto bring the Initiative to the attention of colleagues and other contacts in the health care world.


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US General Accounting Office. Pesticides: Use, Effects, and Alternatives to Pesticides in Schools.Washington, DC: US General Accounting Office; 1999. Publication RCED-00-17.

US General Accounting Office. Pesticides: Improvements Needed to Ensure the Safety ofFarmworkers and Children. Washington, DC: US General Accounting Office; 2000. PublicationRCED-00-40.

Veltri JC, McElwee NE, Schumacher MC. Interpretation and uses of data collected in poisoncontrol centers in the United States. Med Toxicol. 1987;2:389-397.

Wagner SL. Allergy from pyrethrin or pyrethroid insecticides. J Agromedicine. 1994;1(1):39-45.

Wagner SL. Fatal asthma in a child after use of an animal shampoo containing pyrethrin(letter to the editor). West J Med. 2000;173:86-87.

Wax PM, Hoffman RS. Fatality associated with inhalation of a pyrethrin shampoo. Clin Toxicol.1994;32:457-460.


Weiss KB, Sullivan, SD. The health economics of asthma and rhinitis: assessing the economicimpact. J Allergy Clin Immunol. 2001;107(1):3-8.

Whitmore RW, Kelly JE, Reading PL. National Home and Garden Pesticide Survey: Final Report,Volume 1, 1992. Research Triangle Park, NC: Research Triangle Institute: RTI\5100.121F; 1992.

Whorton D, Milby TH, Krauss RM, et al. Testicular function in DBCP exposed workers. JOccup Med. 1979;21(3):161-166.

Wigle DT, Semenciw RM, Wilkins K, et al. Mortality study of Canadian male farm operators:Non-Hodgkin’s lymphoma mortality and agricultural practices in Saskatchewan. J Nal CancerInst. 1990;82:575-582.

Zahm SH, Weisenburger DD, Babbitt P, et al. A case-control study of non-Hodgkin’s lymphomaand the herbicide 2,4-dichlorophenoxyacetic acid (2,4-D) in eastern Nebraska. Epidemiology.1990;1:349-356.

Zahm SH, Ward MH, Blair A. Pesticides and cancer. Occ Med: State of the Art Reviews.1997;12(2):269-289.

Zweiner RJ, Ginsburg CM. Organophosphate and carbamate poisoning in infants and children.Pediatrics. 1998;81:121-126.


Glossary

AAP American Academy of Pediatrics

AACN American Association of Colleges of Nursing

AAFP American Academy of Family Physicians

AAMC Association of American Medical Colleges

ACNM American College of Nurse Midwives

AAOHN American Association of Occupational Health Nurses

ACOEM American College of Occupational and Environmental Medicine

AMA American Medical Association

ANA American Nurses Association

APN Advanced Practice Nurse

ATSDR Agency for Toxic Substances and Disease Registry

CDC Centers for Disease Control and Prevention

CE Continuing education

CME Continuing medical education

CNS Clinical nurse specialist

E&M Evaluation and Management

EPA Environmental Protection Agency

FIFRA Federal Insecticide, Fungicide and Rodenticide Act

FNP Family Nurse Practitioner

GNP Gerontological Nurse Practitioner

HHS Department of Health and Human Services

HRSA Health Resources and Services Administration

MSDS Material Safety Data Sheet

NEETF The National Environmental Education & Training Foundation

NIEHS National Institute of Environmental Health Sciences


NIH National Institutes of Health

NIOSH National Institute for Occupational Safety and Health

NLN National League of Nursing

NPIC National Pesticide Information Center

OSHA Occupational Safety and Health Administration orOccupational Health and Safety Act

PNP Pediatric Nurse Practitioner

RFA Request for Applications

RFP Request for Proposals

TSCA Toxic Substances Control Act

USDA US Department of Agriculture

WPS Worker Protection Standard


Appendix A:Expert Panel Proceedings

T o launch the National Strategies for Health Care Providers: Pesticides Initiative, EPA andseveral other federal agencies convened an expert forum. This forum initiated thedevelopment of national strategies to improve the education and awareness of health

care providers in dealing with pesticide-related health concerns. The April 23-24, 1998event in Arlington, VA, was sponsored by EPA in collaboration with the Department ofHealth and Human Services, Department of Agriculture, and Department of Labor. TheAssociation of Teachers of Preventive Medicine and The National EnvironmentalEducation & Training Foundation worked with these federal agencies to organize theevent (see US EPA, 1998).

The expert forum was conceived of as a deliberative session of representatives of 16 healthorganizations, open to the public, and with comments and questions from federal agenciesand outside observers. The panel included representatives from: American Academy of FamilyPhysicians, American Academy of Pediatrics, American Academy of Physician Assistants,American Association of Colleges of Nursing, American Association of Poison Control Centers,American College of Emergency Physicians, American College of Occupational andEnvironmental Medicine, American Nurses Association, Council of State and TerritorialEpidemiologists, Migrant Clinicians Network, National Center for Farmworker Health,National Organization of Nurse Practitioner Faculties, National Pesticide TelecommunicationsNetwork, National Rural Health Association, Pennsylvania State University/NationalAgromedicine Consortium, and Suncoast Community Health Centers.

Concerns About Provider Education and TrainingThe panel agreed that the principal focus of this Initiative should be on primary care providers.The panel found that primary care providers are not sufficiently trained at any stage of theireducation about pesticide exposure. The panel also recognized that the lack of training islarger than just pesticides and reflects a serious deficiency in education on environmental andoccupational health. The panel briefly summarized the main concerns in provider knowledgeabout pesticide exposures:

� Pesticide exposures are often underreported.


� Providers often do not know how and where to report pesticide exposures; sometimes thereporting is considered burdensome given their demanding work environments.

� Health conditions associated with pesticide exposures are often misdiagnosed.

� Providers do not often see acute pesticide poisoning, and they do not possess enoughknowledge to recognize chronic cases.

� Providers have not received training on pesticide exposures during their years of formaleducation.

� Pesticide exposures and associated health conditions are difficult topics to teach becausethey require additional knowledge on toxicology and other topics which are often notincluded in the curriculum of health professional education.

Expected Outcomes for Primary Care ProvidersThe panel discussed at length what should be expected of primary care providers. Agreementwas reached that all primary care providers should:

� Be knowledgeable about pesticides and recognize pesticide exposures as a health concern.

� Be able to diagnose and treat pesticide exposures at the earliest possible time and completethe appropriate follow-up and referral (exposure management).

� Take preventive measures in both the clinical and community settings, includinganticipatory guidance and community education (prevention management).

� Report exposures and health outcomes of either patients or communities.

� Access the appropriate resources/specialists (local, regional, and national).

Expert Panel’s Overarching StrategiesThe expert panel generated specific strategies that were consolidated into four general topic areas:

1. Define and recommend basic environmental health (emphasizing pesticides) competenciesfor primary care providers.

2. Develop a set of education and training strategies for students and primary care providerson the subject of pesticide-related health concerns.

3. Raise the awareness of primary care providers on pesticide issues and risk factors throughprofessional meetings, information mailings by professional associations, and journal articles.

4. Centralize information resources for primary care providers and strengthen their linkageto existing resources.


Expert Panel Membership

Joni Berardino, MS, LSWNational Center for Farmworker Health

Candace M. Burns, PhD, ARNPNational Organization of NursePractitioner Faculties, and University ofSouth Florida College of Nursing

Joe Fedoruk, MD, DABT, CIHAmerican College of Occupational andEnvironmental Medicine

J. Ward Donovan, Jr., MD, FACEPAmerican College of EmergencyPhysicians, andPennsylvania University Poison Center,Milton S. Hershey Medical Center

Rugh Henderson, MD, MPHNorth American AgromedicineConsortium, PennsylvaniaAgromedicine Program, and PennState University College of Medicine

Michael Hodgman, MDNational Rural Health Association, andBassett Healthcare/NY Center forAgricultural Medicine and Health

Andrea R. Lindell, DNSc, RNAmerican Association of Colleges ofNursing, and University of CincinnatiCollege of Nursing

Mary Miller, MN, ARNPAmerican Nurses Association, andWashington State Department of Laborand Industries

Karen Mountain, MBA, MSN, RNMigrant Clinicians Network

Dennis Penzell, DO, FACPSuncoast Community Health Centers, Inc.

George C. Rodgers, Jr., MD, PhDAmerican Association of Poison ControlCenters, and University of LouisvilleSchool of Medicine

Jackilen Shannon, PhDCouncil of State and TerritorialEpidemiologists, and Texas Departmentof Health

Elisabeth Spector, MD, MPHAmerican Academy of Family Physicians

Roger F. Suchyta, MDAmerican Academy of Pediatrics

Greg P. Thomas, PA-CAmerican Academy of Physician Assistants

Sheldon Wagner, MDNational Pesticide Medical MonitoringProgram, and Oregon State University

Speakers and FacilitatorWilson Augustave

Finger Lakes Migrant Health Care Project

Louise M. Rauckhorst, EdD, MSNPhilip Y. Hahn School of Nursing,University of San Diego


Mark G. Robson, PhD, MPHEnvironmental and Occupational HealthSciences Institute, and Rutgers University

Susan T. West, MPH, FacilitatorThe National Environmental Education& Training Foundation


Appendix B: SummaryProceedings from Workgroups

This appendix provides a brief summary of the deliberations of the three workgroupscreated under this Initiative and a list of their members. The strategies and plans thatemerged from the workgroup meetings are the subject of this Implementation Plan.

The workgroups discussed competencies and expected outcomes, and devoted some time tobrainstorming sessions on overall strategies and plans of action. Members held small groupdiscussions for the better part of the second day of each meeting, to flesh out the strategiesand action items. The groups then reviewed the strategies and decided on next steps. Bothshort-term (1-3 year timeframe) and longer-term actions (3-5 years) were identified. Themeetings were facilitated by Susan West of The National Environmental Education & TrainingFoundation (NEETF).

The Education Workgroup was charged with developing a national strategic plan to enableundergraduate and graduate formal education and training institutions to prepare primarycare providers to prevent, diagnose, treat, and refer patients exposed to pesticides. Theworkgroup was expected to set (and/or select already established) competencies for theeducational setting, and to identify strategies on how to achieve those competencies througheducation, training, and raising student awareness.

The Practice Workgroup was charged with developing a national strategic plan for improvingthe practice of primary care providers in preventing, diagnosing, treating, and referring patientsexposed to pesticides. This group, too, was expected to set (and/or select already established)competencies for the practice setting and to identify strategies on how to achieve thosecompetencies through education, training, and raising awareness.

The Resources Workgroup was charged with developing a national strategic plan whichaddresses an effective method of linking, centralizing, and disseminating an array of resourcesfor the prevention, diagnosis, treatment, and referral of patients exposed to pesticides. Thisplan would also evaluate existing assessments of resources, identify gaps, and begin to developneeded resources for health care providers.


Key PrinciplesKey principles and findings emerging from the three 1999 workgroups include:

� Pesticides must be seen in the context of environmental and occupational health.All three workgroups expressed the opinion that pesticides are a useful and importantfocus of attention in themselves; however, pesticides must also be seen as a stepping-stone for the underrecognized and broader issue of environmental and occupationalhealth as a whole.

� Gaining attention and raising awareness are the primary challenges. One of the mostdifficult obstacles is gaining the attention of students, faculty, and primary care providersto the issue of pesticides and/or environmental health. Curricula are crowded, providersare busy, and time is at a premium. Nevertheless, sometimes a single case encounter canhave long-lasting effects. Much of the effort of the workgroups was driven by the need togain attention and raise awareness. Strategies include developing case statements, creatingmonetary and professional incentives, nurturing pesticide/environmental health“champions” and model practices and convening focus groups to better understandproviders’ communication styles.

� Occupational and environmental histories are gateways. Few primary care providersask patients the questions that would be likely to alert them to the possibility of apesticide-related illness. Although it is important for primary care providers to takeoccupational and environmental histories, both workgroups recognized that a fulloccupational and environmental history can sometimes take up the entire patient visit.However, getting primary care providers to ask just a few simple questions — such as‘Where do you work?’ and ‘Do you think your problems are related to something thathappened at work or at home?’ — could go a long way toward uncovering pesticide-related health conditions and raising awareness about the environment in which patientslive and work.

� There is a spectrum of pesticide-related health conditions. Stereotypes of pesticideillness — insecticides, farmworkers, acute poisoning, cholinesterase testing — may coveran important segment of the population, but they by no means cover the entire field.Students, faculty, and primary care providers must come to understand the widespectrum of pesticide-related health concerns: low-dose chronic effects as well as acute,high-dose poisonings; effects on children, people with chemical sensitivities, othervulnerable populations; the wide variety of pesticide products on the market; urban,rural, and suburban settings.

� The need is for credible, convenient, and easy-to-use resources. The best way to reachalready overburdened primary care providers is by ensuring that the resources availableto them on pesticide-related illnesses are scientifically credible, easy to access, and providequick answers to providers’ questions.


� The importance of understanding the audience cannot be overstated. Primary careproviders work in a wide variety of settings and have varying levels of exposure to pesticide-related health issues. Understanding primary care providers — their backgrounds, level ofawareness and knowledge about pesticide issues, and preferred modes of receivinginformation — is essential to effectively targeting and reaching the audience for this Initiative.

� Evaluation plays a key role. There is a strong need for expert evaluation of the resourcesavailable to primary care providers on pesticide topics and for ensuring that new materialsdeveloped through this Initiative meet stringent evaluation criteria.


I have been challenged by some

of the most supportive faculty

who say, “You haven’t made a

strong enough case.” We

haven’t effectively made the

case to incorporate

environmental health in

general... Until we do that, we’ll

always be an afterthought.— Madaleine Ochinang, MS

Education Workgroup

One of the key issues that workgroup members grappled with over the course of themeeting was the need to gain the attention of health care students, faculty, and primarycare providers when their time and attention is in high demand elsewhere. Many

members noted that there is little time in the basic undergraduate curriculum for pesticideand environmental health material. It would be unreasonable to expect more than a total of30-40 hours over the course of a four-year degree program; a more modest rise to just 10hours of instruction would stand a better chance of acceptance. The key is to get the educationsetting both interested in and comfortable with pesticide issues.

Making the CaseWorkgroup members agreed on the need to “make the case” to medical and nursing schools

about the importance of environmental health education andthe extent of the problem of pesticide-related health concerns.Even the most supportive faculty challenge why environmentalhealth is important to teach.

Workgroup members spent considerable time discussing how tospark the interest of faculty and students. One workgroup membernoted that environmental poisonings are seldom encountered bymedical school students. The best way he has found to motivatemedical students is to have them accompany primary care physiciansin rural area practices so that they can experience the scope ofoccupational medicine first-hand. The payoff is that students valuethis practical type of learning enormously, and that it has a greaterimpact than hearing lecture after lecture on the same topic. It alsocombats one of the problems of the practice setting, which is that

primary care providers often do not perceive the agricultural environment as a workplace.

“Make it Easy for Them to Let Us In...”How will educational institutions allow material on pesticides/environmental health into theircurriculum, and how can the materials be designed to “make it easy for them to let us in?” Itis important to identify where in the curriculum the materials should be inserted. Usually theschools have a flow of courses/topics and the group could suggest where a given topic inenvironmental health would fit. The aim of this Initiative is not to overwhelm medical andnursing students with a vast amount of information.


“Teachers Don’t Teach What They Don’t Know...”It was noted that “Teachers don’t teach what they don’t know... If you make it relevant to them,they’ll find a way to teach their students.” Several workgroup members raised the issue that manyfaculty are not comfortable teaching the full range of subjects involved in pesticides. For example,pharmacology professors may lack the clinical expertise to teach about pesticides; other medicalfaculty may lack the toxicology background. Others agreed that it might be difficult to find enoughfaculty with competence in pesticides/environmental health. Workgroup members discussed atsome length whether faculty should be trained to become comfortable with, or expert at, teachingpesticides/environmental health subjects, or whether it is sufficient for faculty to know of expertsin their local area whom they can tap as needed.

Merely making materials available is not sufficient — it is not true that “if you build it, they willuse it.” The situations where new material has worked best in medical schools is where there wasan advocate or champion who pushed until the material was included in the curriculum. Astudy at Worcester State College reported that the No.1 barrier to integrating environmentalhealth into nursing curricula — which the deans of nursing schools supported — was the absenceof faculty with the knowledge and confidence to carry out that integration.

Several models were discussed, including the 26 NIEHS five-year grants for mid-career fundingof environmental health positions, which provided half of the faculty’s salary plus evaluationcomponents, and the 1990-95 faculty development grant program at the University of SouthFlorida that supported curriculum development and research in substance abuse. Facultyspent the first two of the five years becoming experts in their chosen areas — through seminars,courses, networking with other experts, etc.

Workgroup members discussed the “fragile toehold” environmental health courses have inhealth care education. There is no additional funding for teaching pesticides/environmentalhealth courses and environmental health is not a “revenue generator.” This may haveparticularly problematic implications for undergraduate education. Increasingly, facultymembers need to generate funding to support their own salaries. “Contextual realities” areimportant. Of the 126 environmental health science centers around the country, possibly 20are on the verge of disappearing. The workgroup discussed the possibility of developingfellowships around pesticides in specialties that are highly valued within medical schools,since pesticides affect multiple systems in the body. This would require the time of in-housefaculty to incorporate existing resources and information into an institution’s curriculum.

Convincing the Examination BoardsOne way to motivate change in curriculum, workgroup members agreed, is to convince themedical and nursing examination boards of the importance of environmental health in thecoming years, and push them to incorporate environmental health questions on their exams.


This would also be one of the better ways to institutionalize the subject matter over the long-term. Workgroup members felt that some of the boards would be receptive to a concertedeffort in this area. For example, the Residency Review Committee for Pediatrics in 1996 adoptedtwo recommendations on children’s environmental health.

The workgroup discussed whether public education and K-12 education should also be dealtwith as part of this Initiative. The group noted efforts on environmental education becomingincorporated into K-12 education, partly through the support of EPA and the National Instituteof Environmental Health Sciences. But while many K-12 schools are teaching ecological effects,there is relatively little being taught about the human health effects of the environment. Thisis a ripe opportunity, and one which would have advantages down the line, with studentsentering medical school already having an awareness of pesticides/environmental health issues.Despite the importance of raising awareness and education in the larger educational sphere,however, the workgroup decided that it fell outside the scope of this Initiative, which focuseson educating primary care providers. The group recommended that the issue be addressed inother initiatives.


Education Workgroup Membership*Co-ChairsAndrea Lindell, DNSc, RN

American Association of Colleges ofNursing, and University of Cincinnati,College of Nursing

Ameesha Mehta, MPHOffice of Pesticide ProgramsUS Environmental Protection Agency

FacilitatorSusan West, MPH

The National Environmental Education& Training Foundation

MembersAmy Brown, PhD

American Association of Pesticide SafetyEducators, and University of Maryland-College Park

Candace Burns, PhD, ARNPNational Organization of NursePractitioner Faculties, and Universityof South Florida

Joan Spyker Cranmer, PhDUniversity of Arkansas Medical School

Miriam CruzEquity Research

Kesner Flores, EMTCortina Indian Rancheria, WintumEnvironmental Protection Agency

José GarciaEquity Research

Rugh Henderson, MD, MPHNorth American AgromedicineConsortium, Pennsylvania AgromedicineProgram, and Penn State UniversityCollege of Medicine

Matthew Keifer, MD, MPHNIOSH Agricultural Health and SafetyCenters, and University of Washington

John McCarthy, PhDAmerican Crop Protection Association

Claudia Miller, MDUniversity of Texas Health ScienceCenter-San Antonio

Madaleine Ochinang, MSFormerly with the Consortium forEnvironmental Education in Medicine

Marcia Allen Owens, JDMinority Health Professions Foundation

Annette Perez, RNC, MSN, CNM, PhDAmerican College of Nurse Midwives,and University of Texas-El Paso, Collegeof Health Sciences

J. Routt Reigart, MDMedical University of South Carolina,Department of Pediatrics

Elaine R. Rubin, PhDAssociation of Academic Health Centers

Barbara Sattler, RN, DrPHUniversity of Maryland, School of Nursing


* As of July 2000

Leonel Vela, MDMigrant Health Advisory Council, andTexas Tech Health Sciences Center

Federal Agency RepresentativesElizabeth Blackburn, RN

Office of Children’s HealthProtection, US EPA

Jerome Blondell, MPH, PhDOffice of Pesticide Programs, US EPA

Barbara Brookmyer, MD, MPHBureau of Health Professions, Divisionof Medicine and Dentistry, HealthResources and Services Administration

Ruth Kahn, DNScBureau of Health Professions, Divisionof Medicine and Dentistry, HealthResources and Services Administration

Dalton Paxman, PhDOffice of Disease Prevention and HealthPromotion, US Department of Healthand Human Services

Rosemary Sokas, MD, MOHNational Institute for OccupationalSafety and Health

Delta Valente, MPAOffice of Pesticide Programs, US EPA

Joan Weiss, PhD, RN, CRNPBureau of Health Professions, Divisionof Nursing, Health Resources andServices Administration

Peter Wood, MSAgricultural Marketing Service, USDepartment of Agriculture


How do you know that what

you’re seeing is not the flu, it’s

really organophosphate

exposure? If you think it’s the

flu and you never ask any of

the questions, this guy is going

to walk out of your office and

you’re still going to think it’s

the flu.— Shelley Davis

Farmworker Justice Fund, Inc.

Practice Workgroup

L ike the Education Workgroup, the Practice Workgroup spent a great deal of timediscussing how to motivate change. Recognizing that primary care providers are busyand confront a myriad of public health issues and illnesses, what is the best way to gain

their attention to ensure that they ask the right questions?

One answer is that providers remember what they see in their practice. If primary care providersdo not see enough acute cases of pesticide-related illness, they will not consider it importantenough to pay attention. However, this is a classic Catch-22 situation, because if providersaren’t aware of pesticide poisoning, they won’t recognize the cases. The lack of data in thisarea makes it hard to convince primary care providers they need to alter their practices. Oneway for primary care providers to be sensitized to the possibility of pesticide poisoning is tobecome knowledgeable about the local community.

What Should Primary Care Providers Know?Workgroup members noted that we need to limit the demands; primary care providersshouldn’t be expected to be toxicologists. Instead, it is oftenpatients who are directing health care providers to focus moreon pesticides and environmental health by the questions theybring up. Some workgroup members felt that it would beenough to have primary care providers be aware of thepossibility of pesticide-related health conditions, know whatquestions to ask, and know where to go to get additional help.Others argued that minimum competencies, or practicechanges, are needed. For example, a primary care providershouldn’t let a patient walk out of the office withoutascertaining the possibility of exposure. The provider shouldn’tjust ask when a patient last vomited, but ask if the vomitingcoincided temporally with something that happened at work.Knowing when to do a cholinesterase test is extremelyimportant for all primary care providers. Such testing, forexample, is essential to establish that a person has been harmedfor purposes of workers’ compensation, so that medical bills are reimbursed.

Two workgroup members pointed out that getting health care providers to ask a few simplequestions would go a long way toward raising awareness of patients’ environmental healthissues, without requiring these providers to do additional legwork in the community. Two


simple questions might be: (1) Where do you work? and (2) Do you think your problems arerelated to something that happened at work?

The workgroup devoted an extensive amount of time to the discussion of competencies forprimary care providers (see Practice Component B on page 70 for more details). Manyworkgroup members thought that although “competencies” was an appropriate term for aneducational setting, in a practice setting the term implied that primary care providers areincompetent if they don’t remember all of the material. They preferred to use terms such as“knowledge and skill outcomes,” “expected practice skills,” or “content.”

A Two-Track System?One important aspect of the question of “what providers should know” is whether primarycare providers in certain communities should know more than providers in other areas. Forexample, should there be different levels of knowledge and skills for primary care providers inagricultural areas compared to providers in urban or suburban settings?

While the issue was not resolved, the consensus appeared to be that all primary careproviders should have a certain minimum content level of knowledge and skill related topesticides/environmental health. On the other hand, it may be that primary care providersin agricultural communities have an added function, going beyond the minimum inrecognition, diagnosis, and management of pesticide-related illness to a larger role inprevention and education, and advising their patients about such things as heat stress,prenatal care, and pesticides.

Making Change HappenHow does change actually happen? Workgroup members discussed the difficulties in bringingabout changes in health care. The literature on continuing education shows the need for amultifaceted approach. Continuing education alone has little impact without additional visitsto clinics, feedback loops, hands-on workshops, etc. Even in Grand Rounds, occupational andenvironmental medicine subjects get very poor turnout.

Other IssuesWorkgroup members stressed the need for research in a number of areas, including researchon human exposure, biomonitoring, and the extent to which pesticide poisonings are currentlybeing misdiagnosed in primary care practices.

It is important to look at interconnections between the clinical setting, community setting,reporting, and the regulatory context, even though primary care providers may not see theseinterconnections. For example, it is not clear that primary care providers realize the importance


of their role in reporting cases of pesticide illness both for regulating harmful pesticides andfor efforts to make safer pesticides. Upon investigation, some incidents may turn out to havebeen a violation of the label restrictions; but in some cases, pesticide poisoning occurs withno apparent label violation. That information is extremely important, even if it cannot beproven conclusively.

Another connection that does not generally work well is with workers' compensation systems.Even in Washington State, which is often pointed to as the model for an integrated reporting/surveillance/workers' compensation system (see box on page 86), the system is based on “objectivefindings.” Most pesticide illnesses yield signs and symptoms rather than objective findings, sopatient claims may be denied. Primary care providers need help understanding what the medicalrules of evidence are so that patient claims won’t be rejected. One model might be Colorado’ssystem of associating occupational categories with subjective symptoms (e.g., carpal tunnel);something similar could be done for pesticides. Health care providers also need to know how towrite up their findings, about the statute of limitations for repeat injuries, and where to go forhelp. Finally, states need to reimburse for relevant diagnostic testing for pesticide illness. Atpresent, only Washington State reimburses for diagnostic evaluations.

Defining workers' compensation requirements related to pesticide illnesses would attract theattention of medical associations and their members; physicians would know that they couldget paid for this category of health concern. In the California workers' compensation system,physicians don’t get paid if they don’t report; such an incentive would likely encourage reportingif it were used more widely. Despite the anticipated difficulties of revising workers'compensation systems, workgroup members agreed on the importance of tackling them. Halfa dozen states are the sole insurers on workers' compensation and in those states, the statecommission would be the only organization to deal with. It was also pointed out that sixstates — California, Texas, Florida, Oregon, Washington, and North Carolina — probablycover 70 percent of agricultural workers, and might be the natural focus of attention for thistype of effort.

Workgroup members agreed that community health workers are an important part of the healthcare team. Caseworkers and community health workers are needed to go out and work withvulnerable populations. They can be particularly important in conducting follow up with migrantworkers and bringing them back into the health care system. The workgroup raised, but did notreach a consensus on, whether to widen the scope of the Initiative to involve the family, the roleof the physician in the workplace, or the role of health professionals in the community.


Practice Workgroup Membership*

Co-ChairsBonnie Rogers, RN, DrPH, COHN-S, FAAN

American Association of OccupationalHealth Nurses and University ofNorth Carolina-Chapel Hill, Schoolof Public Health

Karen Pane, RN, MPA, CMCNHealth Resources and ServicesAdministration, US Department ofHealth and Human Services



MembersSheila Brown Arbury, RN, MPH

Association of Occupational andEnvironmental Clinics

Shelley DavisFarmworker Justice Fund, Inc.

J. Ward Donovan, MD, FACEPAmerican College of EmergencyPhysicians, Pennsylvania UniversityPoison Center, and Milton S. HersheyMedical Center

Harold Harlan, PhDNational Pest Control Association

Barbara Hatcher, PhD, MPH, RNAmerican Public Health Association

Ann Linden, CNM, MSN, MPHAmerican College of Nurse Midwives

Mark Miller, MDAmerican Academy of Pediatrics

Mary Miller, MN, ARNPAmerican Nurses Association, andWashington State Department of Laborand Industries

Karen Mountain, MBA, MSN, RNMigrant Clinicians Network

Diane MullAssociation of Farmworker OpportunityPrograms

Patrick O’Connor-Marer, PhDAmerican Association of PesticideSafety Educators, University ofCalifornia Statewide IPM Project,and University of CaliforniaAgricultural Health and Safety Center

John Pickle, RS, MSEHWeld County Health Department -Greeley, CO

George C. Rodgers, Jr., MD, PhDAmerican Association of Poison ControlCenters, and University of LouisvilleSchool of Medicine

Rachel Rosales, MSHPTexas Department of Health


Cathy Simpson, MDWayne State University, School of Medicine

Gina Solomon, MD, MPHNatural Resources Defense Council

Sheldon Wagner, MDNational Pesticide Medical MonitoringProgram, and Oregon State University

John Wheat, MD, MPHNorth American AgromedicineConsortium, and University of Alabamaat Birmingham, School of Medicine

Federal Agency RepresentativesBarbara Brookmyer, MD, MPH

Bureau of Health Professions, Divisionof Medicine and Dentistry, HealthResources and Services Administration

Frank DavidoOffice of Pesticide Programs, US EPA

Eva Montoya, MSN, RNBureau of Primary Health Care, MigrantHealth Program, Health Resources andServices Administration

Ana Maria Osorio, MD, MPHOffice of Pesticide Programs, US EPA

Ana Marie PuenteBureau of Primary Health Care, BorderHealth, Health Resources and ServicesAdministration

Capt. Barry Stern, MPHBureau of Health Professions, HealthResources and Services Administration

* As of July 2000


When I train residents I tell them:

you’ll do a lot better if you don’t

assume you’re the primary

provider. The primary provider is

often the grandmother or an elder...

The natural system of health care in

the community is alive and well.

We need to recognize the system,

not try to change it, and partner

with it to be effective.— Angelina Borbon, RN

Alameda County Lead PoisoningPrevention Program

Resources Workgroup

B uilding on the ideas of the Education and Practice Workgroups, the ResourcesWorkgroup began its discussion by examining the types of resources that are used ineducational and practice settings. The workgroup then undertook a more detailed

exploration of key issues relating to resources, including; the credibility of sources ofinformation, defining and understanding the audience, reaching the target audience withappropriate resources, and evaluating the effectiveness of resources.

Credible Sources of InformationThe Resources Workgroup felt strongly that resources created or promoted through thisInitiative must be credible and scientifically sound. The group explored the sources ofinformation that health care providers and the public currently use, and the credibility ofdifferent information sources in different communities. One workgroup member suggestedthat the public trusts the universities first, the federal government next, state water agencies

after that, and state agriculture departments after that. Inmany places, the community health worker plays a key role.There are 78 different names for community health workersin the US, and although they are generally considered “non-professional,” they are the most trusted health care workersand have the highest ability to change behavior. Standardsfor community health workers are only starting to bedeveloped as community colleges get involved in theirtraining. Unfortunately, environmental health is notgenerally taught as part of their training.

A related issue that the group considered is sensitivity tolocal concerns and parlance.

Reaching the Target AudienceThe workgroup’s discussions emphasized the importance ofdefining and understanding the target audience of primarycare providers. Aware that the universe of health care

providers runs into the millions, the group explored ways of segmenting the universe — bytype of provider, population served, and practice setting, or by matching types of providers toepidemiologic cases of pesticide use or abuse.


The workgroup devoted considerable time to a discussion of the varying levels of needs ofprimary health care providers. One workgroup member stated that “it is not clear that wereally know what health care providers want and need” in the way of educational andinformation resources. It will be important to examine the extensive literature on how healthprofessionals learn in order to determine the most effective approaches.

The workgroup explored in detail the Stages of Change model created by Prochaska andDiClemente (Prochaska, 1995). The model looks at behavior change as a process rather thanan event, and describes how individuals are at varying levels of motivation, or readiness tochange. The model outlines a continuum of behavior change that can be used to helpunderstand where the target audience is on the continuum, and to reach the audience (throughtargeted messages, strategies, and programs) to ensure behavior change (see Table 6 on page34 and the discussion of how the model can be adapted to the current initiative).

Workgroup members examined existing resources in an effort to determine “what works”and identify gaps. Members reviewed the guide, “Preliminary Resources Materials,” developedby The National Environmental Education & Training Foundation, and mentioned additionalmaterials. Workgroup members discussed all aspects of providing effective resources — typesof resource materials, settings in which they are delivered, delivery mechanisms, modes ofdissemination, and motivation for use.

Professional associations could play a big role in reaching member providers. The groupdiscussed the types of technology that providers are most comfortable with, and acknowledgedthat while health care providers lag behind in their use of the internet, they will no doubtincrease their usage over time. Nevertheless, the web can be a “giant disorganized mess of baddata, good data, and it takes time to learn how to use it.” Providers will continue to needquick and easy ways of accessing information. Some members argued that continuingeducation for health care providers has been shown not to be an effective way to changebehavior and that consensus statements of professional associations can take a long time todevelop and to have an impact. It is important, however, to approach the target audiences andfind out where they obtain information.

Evaluating ResultsSome type of measurement and evaluation effort is certainly needed for this Initiative. Evaluationand measurement are relevant for several purposes — for assessing the “baseline,” i.e., the currentstate of awareness and involvement of primary care providers, for evaluating the quality ofexisting resources, for helping to design effective new resources and dissemination strategies,and for determining the success of the Initiative.


Workgroup members noted that a great deal of attention has been given to measuring the degreeto which educating health care providers on nutrition, tobacco, and other issues has led tomeasurable changes in practice as well as changes in patient practices. Even with tobacco, “thewhole world is trying to get physicians to counsel their patients who smoke to stop smoking.”Nevertheless, only 30-60 percent of physicians appear to do so, and measuring this activity hasbeen very difficult. The group agreed that qualitative research, including holding focus groups,would be an appropriate tool for this Initiative. It was suggested to begin with a summary of theliterature. Several provider associations (clinics, pediatricians, family physicians, etc.) representedon this workgroup could provide a source for focus group participants.

Other IssuesThe role of the public in spurring health care providers’ interest was noted. Increasingly, patientsare a big source driving the physicians’ interest in pesticides: “Patients instigate by asking aquestion that the physician or nurse can’t answer.” Although primary care providers are oftenconcerned chiefly with acute health effects, the public is increasingly leading the way in terms ofinterest in chronic and behavioral effects of pesticides (e.g., asthma, effects on IQ, etc.).

Workgroup members agreed that pesticides must continue to be seen in the context ofenvironmental health as a whole. The importance of making primary care providers aware ofpreventive information along with diagnosis and treatment was stressed.

Finally, the group discussed support for the Initiative. “There have been too many programsin government that just go away... If you don’t have the money at the time you need it, it fadesaway.” It is important that workgroup members go back to their organizations and discusshow the organizations can play a supporting role in implementing the Initiative. Theworkgroup recommended that the federal representatives develop a broad outline of resourceneeds and federal commitments, as well as remaining needs for which extramural fundingwill be sought — from industry, professional associations, and possibly environmentalfoundations and trusts.


Resources Workgroup Membership*Co-ChairsMark Robson, PhD, MPH

Environmental and Occupational HealthSciences Institute, and Rutgers University

Kevin Keaney, MA, MSOffice of Pesticide Programs, USEnvironmental Protection Agency



MembersColin Austin

Migrant Clinicians’ Network, andUniversity of North Carolina-Chapel Hill

Angelina Borbon, RNAlameda County Lead PoisoningPrevention Program

Barry Brennan, PhDAmerican Association of Pesticide SafetyEducators, and Extension PesticideCoordinator, University of Hawaii

Paul J. Brownson, MDThe Dow Chemical Company

Gerardo de Cosio, MDUS-Mexico Border Health Association

Susannah Donahue, MPHChildren’s Environmental Health Network

Gerry Eijkenmans, MD, MPHPan American Health Organization

Scottie Ford, MAWest Virginia Department of Agriculture

Matthew Garabedian, MPHTexas Department of Health

Allen James, MBA, CAEElizabeth Lawder, BA (alternate)

Responsible Industry for a SoundEnvironment

Linda Kanzleiter, MPsScCeleste Stalk (alternate)

Pennsylvania Area Health EducationCenter, Milton S. Hershey Medical Center

Kathy Kirkland, MPHAssociation of Occupational andEnvironmental Clinics

Terry MillerNational Pesticides TelecommunicationsNetwork, and Oregon State University

Rita MonroyNational Alliance for Hispanic Health(formerly National Coalition ofHispanic Health and Human ServicesOrganizations)

Benjamin Ramirez, MD, MPH, FACOEMDuPont Company

Scott Ratzan, MD, MPAAcademy of Educational Development


* As of July 2000

Susan Rehm, MBAAmerican Academy of Family Physicians

Barbara SabolW.K. Kellogg Foundation

Roger F. Suchyta, MDGraham Newson (alternate)Jennifer Stevens (alternate)


Federal Agency RepresentativesElizabeth Blackburn, RN

Office of Children’s Health Protection,US EPA

Jerome Blondell, MPH, PhDOffice of Pesticide Programs, US EPA

Frank DavidoOffice of Pesticide Programs, US EPA

Jeanne Goshorn, MSNational Library of Medicine

Ron Hoffer, MSOffice of Ground Water and DrinkingWater, US EPA

Ameesha Mehta, MPHOffice of Pesticide Programs, US EPA

Donna Orti, MSAgency for Toxic Substances and DiseaseRegistry, US Department of Health andHuman Services

Karen Pane, RN, MPA, CMCNHealth Resources and ServicesAdministration, US Department ofHealth and Human Services

Dalton Paxman, PhDOffice of Disease Prevention and HealthPromotion, US Department of Healthand Human Services

Sherri UmanskyOffice of Ground Water and DrinkingWater, US EPA

Peter S. WoodAgricultural Marketing Service, USDepartment of Agriculture


Appendix C:Response to Public Comments

This Implementation Plan is a working document and will be widely shared anddisseminated among stakeholders in professional associations, health organizations,education institutions, government agencies and other groups. To gather as much input

as possible, the Federal Interagency Planning Committee widely distributed more than 4,500copies of the draft Implementation Plan to stakeholders in 2000 for review and publiccomment. This final Implementation Plan reflects those public comments received, includingmany specific suggestions for text changes and requests for clarification and/or expansion.

While some reviewers submitted specific text changes, as well as ideas for expansion and/orclarification of Implementation Plan activities, several reviewers focused on broad perspectivesof the National Strategies for Health Care Providers: Pesticides Initiative in general and relatedelements of this Implementation Plan. Two major themes emerged:

� Why are pesticides the topic of this model initiative?

� Will a focus on pesticides result in overdiagnosis of pesticides-related illness by healthcare providers?

In addition, reviewers cited changes to a range of issues. For example, one reviewer calledattention to the critical issues of the relationship between chronic pesticide exposure andvarious types of cancers, as well as reproductive effects of exposures. These sections have beenedited to reflect current scientific data and the recent emphasis on lymphoma research.Specifically, the text references the Lymphoma Foundation of America’s 2001 report, “DoPesticides Cause Lymphoma?,” and incorporates additional information about the NationalCancer Institute’s prospective study of commercial pesticide applicators and their spouses.

The following is a summary of the Federal Interagency Planning Committee’s response to thetwo major themes.

Why Pesticides?Reviewers raised this issue from two perspectives: that of the chemical industry and that ofpublic health professionals. The chemical industry’s concerns focused on the accuracy of somedata presented, the depth of the issues, and a concern that the Implementation Plan will


overemphasize pesticides as a public health issue. The public health professionals’ concernsfocused on whether or not pesticides is the most important environmental health issue as thefocus of the model initiative.

Addressing Industry ConcernsData are well documented through peer-reviewed journals, having been studied by governmentand non-government scientific organizations and individual researchers. Published researchincludes case studies, epidemiological reports, and clinical research.

Current statistics and clinical data on pesticide poisonings and human health effects may notaccurately reflect what is actually occurring in the US due to misdiagnoses and lack of reportingand tracking by health care providers and others.

For example, as presented within the Making the Case chapter of this Implementation Plan,the American Association of Poison Control Centers collects data on acute pesticide poisoningvia its Toxic Exposure Surveillance System. According to this data, in years 1993-1998approximately 20,000 cases were seen each year in health care facilities in the United States,and 52 percent of the cases pertained to children less than six years of age. Studies by Chafee-Bahamon et al. (1983), Harchelroad et al. (1990), and Veltri et al. (1981) found that PoisonControl Centers captured between 24 percent and 33 percent of all poisoning cases seen inhospitals as inpatients and/or outpatients. Since this does not include cases seen by healthcare providers who are not in a hospital setting, it is likely that the actual number of pesticidecases seen annually is much higher.

Addressing Public Health ConcernsPesticides as the focus of the Implementation Plan and this Initiative is, indeed, an appropriatetopic as a model for the myriad environmental health issues that can affect the US population.First, pesticides are ubiquitous. While the principal at-risk group for pesticide exposure isfarmworkers and pesticide applicators, virtually everyone in America is at risk of dangerouslevels of exposure, including individuals living in nonagricultural rural areas, as well as urbanand suburban communities.

Second, a large body of scientific knowledge on pesticides has been built over many years,allowing the health community to acquire some ability to deal with pesticides in a coordinatedmanner. Unfortunately, neither the information about other toxins nor the health community’sability to deal with them is so advanced. Pesticides can provide a training and educationmodel for health care workers that can be developed and applied to environmental healthrisks overall. This Implementation Plan will become the blueprint for a coordinated approachto health care provider education and training.


Fear of OverdiagnosisAs noted above and in the Making the Case section of this Implementation Plan, pesticide-related health conditions have been misdiagnosed in the United States. The development of acomprehensive national education and training strategy targeted at health care providers willbring attention to the current inadequacies in addressing pesticide-related health conditions.

The challenge is that pesticide-related health conditions can share many symptoms withcommon conditions like flu or food poisoning, so pesticide poisoning may not be consideredas a possible diagnosis. As a result, not only are patients not given proper care, but also apublic health issue is left inadequately addressed. If a case of pesticide poisoning is not identifiedas an index case, other individuals who may be affected are not being cared for.

In the absence of an occupational and environmental health history, health care providersmay be likely to overdiagnose as well as underdiagnose pesticide-related health conditions.Taking a good health history and understanding how to rule out the likelihood of a pesticide-caused symptom or illness are critical steps in making the correct diagnosis. And because inmost cases the appropriate health screening questions are not being asked, health care providersmay be making a diagnosis based on what is most probable (e.g. food poisoning), rather thanconsidering all the options and possible illnesses. Health care providers should consider allthe possibilities, given similar symptoms, and check with a specialist to accurately assess thesource of the poisoning, determine what testing can be done to confirm the diagnosis, andconsult about treatment options.

The vision for this Implementation Plan is for all primary care providers to:

� Possess a basic understanding of the health effects associated with pesticide exposures aswell as broader environmental exposures; and

� Take action to ameliorate such effects through clinical and prevention activities.

As this national pesticides education and training strategy is implemented, it is unlikely thatpesticide-related health conditions will be overdiagnosed because health care providers willbe taking a complete health history, considering pesticide exposure only as a possibility relatedto the presenting illness, and consulting with specialists when additional follow-up is necessary.


Appendix D: FederalInteragency Planning Committee

Kevin KeaneyOffice of Pesticide ProgramsUS EPA1200 Pennsylvania Avenue NW (7506C)Washington, DC 20460Tel: (703) 305-5557 Fax: (703) 308-2962E-mail: [email protected]

Sara AgerOffice of Pesticide ProgramsUS EPA1200 Pennsylvania Avenue NW (7506C)Washington, DC 20460Tel: (703) 308-3003 Fax: (703) 308-2962E-mail: [email protected]

Elizabeth Blackburn, RNOffice of Children’s Health ProtectionUS EPA1200 Pennsylvania Avenue NW (1107A)Washington, DC 20460Tel: (202) 564-2192 Fax: (202) 260-4103E-mail: [email protected]

Jerome Blondell, MPH, PhDOffice of Pesticide ProgramsUS EPA1200 Pennsylvania Avenue NW (7509C)Washington, DC 20460Tel: (703) 305-5336 Fax: (703) 305-5147E-mail: [email protected]

Frank DavidoOffice of Pesticide ProgramsUS EPA1200 Pennsylvania Avenue NW (7502C)Washington, DC 20460Tel: (703) 305-7576 Fax: (703) 305-4646E-mail: [email protected]

Ron HofferOffice of Ground Water and Drinking WaterUS EPA1200 Pennsylvania Avenue NW (4601)Washington, DC 20460Tel: (202) 260-7096 Fax: (202) 260-3762E-mail: [email protected]

Ana Maria Osorio, MD, MPHOffice of Pesticide ProgramsUS EPA1200 Pennsylvania Avenue NW (7506C)Washington, DC 20460Tel: (703) 305-7891 Fax: (703) 308-2962E-mail: [email protected]

Sherri UmanskyOffice of Ground and Drinking WaterUS EPA1200 Pennsylvania Avenue NW (4607)Washington, DC 20460Tel: (202) 260-0432 Fax: (202) 401-6135E-mail: [email protected]



Delta Valente, MPAOffice of Environmental JusticeUS EPA1200 Pennsylvania Avenue NW (2201A)Washington, DC 20460Tel: (202) 564-2594 Fax: (202) 501-1106E-mail: [email protected]

US EPA Regional LiaisonsDon BaumgartnerPesticides Section (DRT-8J)US EPA, Region 577 West Jackson BoulevardChicago, IL 60604Tel: (312) 886-7835 Fax: (312) 353-4788E-mail: [email protected]

Adrian J. Enache, PhD, MPHPesticides and Toxic Substance BranchUS EPA, Region 22890 Woodbridge Avenue Bldg. 5 (500)Edison, NJ 08837Tel: (732) 321-6769 Fax: (732) 321-6771E-mail: [email protected]

Edward Master, RN, MPHPesticides and Toxics Branch (DT-8J)US EPA, Region 577 West Jackson BeaulvardChicago, IL 60604Tel: (312) 353-5830 Fax: (312) 353-4788E-mail: [email protected]

Allan WelchPesticides Section (AT-083)US EPA, Region 101200 Sixth AvenueSeattle, WA 98101Tel: (206) 553-1980 Fax: (206) 553-8338E-mail: [email protected]

U.S Dept. of Healthand Human ServicesGeoffrey Calvert, MD, MPHNational Institute forOccupational Safety & HealthUS Dept. of Health & Human Services4676 Columbia Parkway (21)Cincinnati, OH 45226Tel: (513) 841-4448 Fax: (513) 841-4489E-mail: [email protected]

David Hanny, PhD, MPHBureau of Health ProfessionsDivision of Interdisciplinary, CommunityBased ProgramsHealth Resources & Services AdministrationUS Dept. of Health & Human Services5600 Fishers Lane (9105)Rockville, MD 20857Tel: (301) 443-0024 Fax: (301) 443-0162E-mail: [email protected]

Ruth Kahn, DNScBureau of Health ProfessionsDivision of Medicine and DentistryHealth Resources & Services AdministrationUS Dept. of Health & Human Services5600 Fishers Lane (9A-27)Rockville, MD 20857Tel: (301) 443-6823 Fax: (301) 443-8890E-mail: [email protected]

Cassandra LylesOffice of Rural Health PolicyHealth Resources & Services AdministrationUS Dept. of Health & Human Services5600 Fishers Lane (9-05)Rockville, MD 20857Tel: (301) 443-7321 Fax: (301) 443-2803E-mail: [email protected]


Eva MontoyaBureau of Primary Health CareMigrant Health ProgramHealth Resources & Services AdministrationUS Dept. of Health & Human Services4350 East West HighwayBethesda, MD 20814Tel: (301) 594-4305 Fax: (301) 594-4997E-mail: [email protected]

Donna L. Orti, MS, MPHAgency for Toxic Substancesand Disease RegistryUS Dept. of Health & Human Services1600 Clifton Road (E-33)Atlanta, GA 30333Tel: (404) 498-0325 Fax: (404) 498-0062E-mail: [email protected]

Karen Pane, RN, MPA, CMCNOffice of Planning, Evaluation and LegislationUS Dept. of Health and Human Services5600 Fishers Lane (14-36)Rockville, MD 20857Tel: (301) 443-1128 Fax: (301) 443-9270E-mail: [email protected]

Dalton Paxman, PhDOffice of Disease Preventionand Health PromotionUS Dept. of Health & Human Services200 Independence Avenue SW (738-G)Washington, DC 20201Tel: (202) 205-5829 Fax: (202) 205-9478E-mail: [email protected]

Sarat Seneviratne, MS, RS, CHMM, CCHPBureau of Health ProfessionsCenter for Public HealthUS Dept. of Health & Human Services5600 Fishers Lane (8103)Rockville, MD 20857Tel: (301) 443-3231 Fax: (301) 443-6411E-mail: [email protected]

Rosemary Sokas, MD, MOHNational Institute forOccupational Safety & HealthUS Dept.of Health & Human Services200 Independence Avenue SW (715-H)Washington, DC 20201Tel: (202) 401-0721 Fax: (202) 693-1647E-mail: [email protected]

Barry Stern, MPHBureau of Health ProfessionsHealth Resources & Services AdminstrationUS Dept. of Health & Human Services5600 Fishers Lane (8C-09)Rockville, MD 20857Tel: (301) 443-6758 (301) 443-0650E-mail: [email protected]

Joan Weiss, PhD, RN, CRNPBureau of Health ProfessionsDivision of Interdisciplinary, Community-Based ProgramsHealth Resources & Services AdministrationUS Dept. of Health & Human Services5600 Fishers Lane (9-105)Rockville, Maryland 20857Tel: (301) 443-0430 Fax: (301) 443-0162E-Mail: [email protected]


US Dept. of AgricultureMonte P. Johnson, PhDPlant and Animal SystemsUSDA-Cooperative State Research,Education, and Extension Service1400 Independence Avenue SWWaterfront Building 2220Washington, DC 20250Tel: (202) 401-1108 Fax: (202) 401-4888E-mail: [email protected]

Peter S. WoodPesticide Records BranchUSDA Agricultural Marketing Service8700 Centreville Road, Suite 202Manassas, VA 20110Tel: (703) 330-7826 Fax: (703) 330-6110E-mail: [email protected]

US Dept. of LaborJohn LebenWage and Hour DivisionUS Dept. of Labor200 Constitution Avenue NW (S 3510)Washington, DC 20210Tel: (202) 693-0596 Fax: (202) 693-1432E-mail: [email protected]

Other OrganizationsAmy E. Brown, PhDAmerican Association ofPesticide Safety EducatorsDept. of Entomology, Univ. of MarylandCollege Park, MD 20742Tel: (301) 405-3928 Fax: (301) 314-9290E-mail: [email protected]

Leyla Erk McCurdy, M Phil.Health & Environment ProgramsThe National Environmental Education &Training Foundation1707 H Street NW, Suite 900Washington, DC 20006Tel: (202) 261-6488 Fax: (202) 261-6464E-mail: [email protected]

Jennifer Bretsch, MSHealth & Environment ProgramsThe National Environmental Education &Training Foundation1707 H Street NW, Suite 900Washington, DC 20006Tel: (202) 261-6470 Fax: (202) 261-6464E-mail: [email protected]

Documents

Pesticides Initiative · National Strategies for Health Care Providers: Pesticides Initiative Support for this project was made possible through Cooperative Agreement CR 827026-01-0