Acute Pesticide Illnesses Associated with Off-Target Pesticide Drift from Agricultural Applications: 11 States, 1998–2006

Background: Pesticides are widely used in agriculture, and off-target pesticide drift exposes workers and the public to harmful chemicals

Utilization of Syndromic Surveillance to Identify Naled-Related Illness in Florida

Objective: To describe the use of Florida Poison Information Center Network (FPICN) and Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE-FL) emergency department (ED) chief complaints data to identify acute naled-related illness following aerial spraying in Miami-Dade county, Florida in response to the Zika outbreak.Introduction: Pesticide-related illness and injury is a reportable condition in Florida. In August and September 2016, aerial spraying for mosquito control was conducted in an effort to reduce the population of Aedes aegyptimosquitoes in Miami-Dade County.1 Two areas Wynwood (in August) and Miami Beach (in September) were sprayed with naled. Naled is an organophosphate insecticide registered with the U.S. Environmental Protection Agency (EPA) which is applied via aerial ultra-low volume (ULV) spraying. In addition to routine surveillance using FPICN and reportable disease surveillance data to identify acute naled-related illness, the Florida Department of Health (DOH) also monitored ED chief complaints data to identify any associated increase in ED visits.Methods: In 2016, DOH used three datasets to monitor illness related to naled exposure: FPICN call data, reportable disease (Merlin) data, and ED chief complaints. Product code 2327991 was used to search FPICN data for naled-related exposure calls. FPICN calls with the following medical outcomes were excluded: no health effect, not followed - judged as nontoxic exposure, unrelated effect, and confirmed non-exposure. Individuals who met the reportable disease surveillance case definition for pesticide-related illness and injury2 were entered into Merlin. ESSENCE-FL was monitored to evaluate ED visits in Miami-Dade County for the syndrome categories and free text chief complaints involving eyes (free text queries for eye irritation, eye burning, eye redness, and conjunctivitis), skin (syndrome category for rash), and respiratory (sub-syndrome categories for shortness of breath, wheezing, acute bronchitis, sore throat, and asthma) illnesses.Results: Twenty-two exposure calls were identified through FPICN data in 2016. Seven calls were excluded after DOH review determined that these individuals were not exposed to naled. Fifteen exposure calls were investigated and eight individuals met the surveillance case definition for pesticide-related illness and injury. Among the eight DOH cases, one individual was exposed in August (12.5%), and seven in September (87.5%). Everyone had low severity illness, five (62.5%) were female, and the mean age was 39.6 years (range: 27 to 46 years). Two cases (25%) were work-related. Review of ESSENCE ED chief complaints data for eye, skin, and respiratory illnesses showed a few statistically significant increases in daily patient visits. However, these increases were not attributed to aerial spraying.Conclusions: FPICN data are useful in identifying cases of naled-related illness. Near real-time access to ED chief complaints data along with FPICN and Merlin data has enhanced surveillance capability for DOH and helped address public health concerns related to naled-related illness following aerial spraying in Miami-Dade County

Utilizing Syndromic Surveillance for Hurricane Irma-Related CO Poisonings in Florida

ObjectiveThis study describes how Florida Poison Information Center Network (FPICN) and emergency department (ED) data accessed through Florida’s syndromic surveillance system were used to conduct near real-time carbon monoxide (CO) poisoning surveillance and active case finding in response to Hurricane Irma in Florida.IntroductionOn September 10, 2017, Hurricane Irma made landfall in Florida. Over 90% of Florida counties reported power outages as of September 11. During power outages, CO poisonings often occur due to indoor use of fuel combustion sources (e.g., cooking, heating) or generators for electricity.CO poisoning is a reportable condition in Florida; health care providers and laboratories are required to report suspected cases to the Florida Department of Health (FDOH). In Florida, approximately 202 cases of CO poisoning are reported each year (three-year average from 2014 to 2016). In addition to passive surveillance, FDOH uses the Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE-FL) to find cases of CO poisoning. ESSENCE-FL provides access to ED data from 98% (255 out of 260) of EDs in Florida and all statewide FPICN call data (includes three poison control centers). ESSENCE-FL provides near real-time access to these data sets, as ED data are uploaded every 2 hours or once a day (depending on the hospital system) and FPICN data are uploaded every 10 minutes. The statewide FPICN database includes information about substance, signs and symptoms, exposure scenario, and patient identification information provided by the individual caller or clinician from a health care facility.MethodsIn addition to receipt of health care provider reports through traditional disease reporting, active case finding was conducted using ESSENCE-FL during Hurricane Irma. Exposure calls to the FPICN indicating CO exposure were extracted from the statewide database. Calls coded with the following medical outcomes were excluded: no health effect, not followed – judged as nontoxic exposure, not followed – minimal clinical effects possible, unrelated effect – the exposure was probably not responsible for the effect(s), and confirmed non-exposure. To query ESSENCE-FL ED data, a free-text query was created and executed against the concatenated chief complaint and discharge diagnosis (CCDD) field: (^carbon^,andnot,(,^retention^ ,or,^narcosis^,),),or,^monox^,or,(,^generator^,and, (,^fumes^,or,^expos^,or,^nausea^, or,^headach^,or,^exhaust^,or,^garage^,or,^inhale^,),) . Results of these queries were analyzed and sent to county and regional epidemiologists daily for investigation.Reports of CO poisoning exposures were investigated by collecting medical records and conducting interviews using an expanded risk factor questionnaire.1 Cases were classified using Florida’s reportable disease case definition2 and documented in the electronic reportable disease surveillance system, Merlin (see process flow chart). Descriptive analysis of Hurricane Irma-related CO poisoning cases reported in Merlin was conducted to characterize morbidity, mortality, and exposure scenarios.ResultsIn September 2017, FDOH investigated 666 reports of CO poisoning and identified 529 people (79.4%) who met the case definition for CO poisoning. Among 529 cases, 56.3% were reported by ED data, 5.7% by FPICN data, 29.1% from both data sets, and the remaining 8.9% by other sources (e.g., self-report, media). About 60.1% of cases were only reported by FPICN and ED data, 33.1% by health care providers and laboratories, and 6.8% by other sources. Among 15 deaths, 20% were identified through active case finding using ED and FPICN data. CO poisoning cases peaked on September 12 (within two days of hurricane landfall) and decreased by September 16, as power was restored. About 95% of cases reported CO exposures within the first week of hurricane landfall.Merlin data analysis of 529 cases identified some notable findings related to Hurricane Irma. CO poisoning rates were highest among those aged 5–14 years (4.8 per 100,000 population), and the mean age was 33.2 years (median: 31 years, range: 3 months – 89 years). Most cases were in females (55.6%), non-Hispanics (58.3%), and whites (73%). CO exposures were predominantly caused by generator use (97.5%). Among 516 generator-related exposures, 15.7% of people had a CO detector, 62.8% did not have CO detector, and it was unknown for 21.5%. Among 516 residential exposures due to generator use, 31.3% of people reported generator use inside the home, attached garage, or other attached structures, and 66% reported generator use outside the home, including covered decks and carports. Among 340 people who reported generator use outside the home, 63.5% reported having a generator within 20 feet of windows, doors, air conditioners, or air intake vents.ConclusionsEven though CO poisoning is a reportable condition in Florida, use of active surveillance was key in the public health response to Hurricane Irma-related CO poisonings. FDOH would not have identified 60% of these hurricane-related CO poisoning cases without access to FPICN and ED data. During Hurricane Irma, active case finding complemented routine disease surveillance not only in early detection of CO poisonings but also in guiding rapid public health response. Similarly, in the 2005 hurricane season, FDOH monitored FPICN data and identified an increase in CO poisonings.3 Based on near-real-time CO poisoning surveillance, FDOH produced daily situation reports, sent out a press release about the dangers of CO poisoning from generator use, prepared a YouTube video, and conducted educational outreach through social media and text alert. Other jurisdictions may benefit from use of near real-time ED and poison control center data to better understand the magnitude and characteristics of CO poisonings during power outages in their areas. Public education messages need to emphasize outdoor use of generators (at least 20 feet away from doors, windows, and air conditioners) and use of CO detectors.References1. Florida Department of Health. Carbon monoxide poisoning enhanced case report form; October 2017. Available at: www.floridahealth.gov/diseases-and-conditions/disease-reporting-and-management/disease-reporting-and-surveillance/_documents/crf-co-hurricane-irma-enhanced-surveillance.pdf2. Florida Department of Health. Carbon monoxide poisoning case definition; 2018. Available at: www.floridahealth.gov/diseases-and-conditions/disease-reporting-and-management/disease-reporting-and-surveillance/_documents/cd-carbon-monoxide.pdf3. Monitoring Poison Control Center Data to Detect Health Hazards During Hurricane Season—Florida, 2003-2005. JAMA. 2006;295(21):2469–2470.

Poison Center Data for Public Health Surveillance: Poison Center and Public Health Perspectives

Since 2008, poisoning became the leading cause of injury-related death in the US. Though most poison center (PC) and public health (PH) officials agree that PCs play an important role in PH practice, collaboration has been hindered by challenges. The Poison Center and Public Health Collaborations Community of Practice was created to share experiences, identify best practices, and facilitate relationships among PH agencies and PCs. This panel discussion aims to describe the use of PC data from the poison center, local, state, and federal public health perspectives and to generate meaningful discussion of how to address the challenges to collaboration

Poison center data for public health surveillance: Poison center and public health perspectives

ObjectiveTo discuss the use of poison center (PC) data for public health (PH) surveillance at the local, state, and federal levels. To generate meaningful discussion on how to facilitate greater PC and PH collaboration.IntroductionSince 2008, poisoning is the leading cause of injury-related death in the United States; since 1980, the poisoning-related fatality rate in the United States (U.S.) has almost tripled1. Many poison-related injuries and deaths are reported to regional PCs which receive about 2.4 million reports of human chemical and poison exposures annually2. Federal, state, and local PH agencies often collaborate with PCs and use PC data for PH surveillance to identify poisoning-related health issues. Many state and local PH agencies have partnerships with regional PCs for direct access to local PC data which help them perform this function. At the national level, the National Center for Environmental Health (NCEH) of the Centers for Disease Control and Prevention (CDC) conducts PH surveillance for exposures and illnesses of PH significance using the National Poison Data System (NPDS), the national PC reporting database and real-time surveillance system.Though most PC and PH officials agree that PC data play an important role in PH practice and surveillance, collaboration between PH agencies and PCs can be hindered by numerous challenges. To address these challenges and bolster collaboration, the PC and PH Collaborations Community of Practice (CoP) has collaborated with members to provide educational webinars; newsletters highlighting the intersection of PH and PC work; and in-person meetings at relevant national and international conferences. The CoP includes over 200 members from state and local PH departments, regional PCs, CDC, the American Association of Poison Control Centers (AAPCC), and the U.S. Environmental Protection Agency (EPA).DescriptionThe panel will consist of 3 presenters and 1 moderator, who are members of the CoP. Each presenter will bring a unique perspective on the use of PC data for PH practice and surveillance. Dr. Prakash Mulay is the surveillance coordinator for chemical related illnesses and injuries in Florida. His primary focus is on carbon monoxide, pesticide, mercury, and arsenic poisoning. He also works as a liaison between the Florida Poison Information Centers and Department of Health. Dr. Mulay has a Medical Degree from India and a Masters of Public Health (MPH) in epidemiology from Florida International University, Miami. For the purpose of the panel discussion, Dr. Mulay will provide PC PH collaboration from the state perspective.Dr. Jay Schauben is the Director of the Florida/United States Virgin Islands Poison Information Center in Jacksonville, the Florida Poison Information Center Network Data Center, and the Clinical Toxicology Fellowship Program at University of Florida Health-Jacksonville Medical Center/University of Florida Health Science Center. He is board-certified in clinical toxicology and is a Fellow of the American Academy of Clinical Toxicology. In 1992, Dr. Schauben implemented the Florida Poison Information Center in Jacksonville and played a major role in crafting the Statewide Florida Poison Information Center Network. On the panel, Dr. Schauben will provide collaboration insight from the PC perspective.Dr. Royal Law is the surveillance and technical lead for the National Chemical and Radiological Surveillance Program, housed within the Health Studies Branch at the CDC. He received his PhD in Public Health from Georgia State University and his MPH at Emory University. Dr. Law will provide insight from the national level including CDC use of PC data for public health surveillance activities.How The Moderator Intends to Engage the AudienceAfter the panel members have been introduced and shared their contributions and experiences with PC PH collaboration the moderator will engage the audience by facilitating discussion of the successes and challenges to using PC data for PH practice and surveillance.Sample questions:What are your current capacities and collaborative activities between your state/local health department and your PC?What non-funding related barriers hinder the collaboration between your state/local health department and PC?If no increase in funding were available, how would you increase the level of interactivity with the PC and state/local health department? What if funding was available?References1Warner M, Chen LH, Makuc DM, Anderson RN, and Minino AM. Drug Poisoning Deaths in the United States, 1980–2008. National Center for Health Statistics Data Brief, December 2011. Accessed 8/29/2012.2Mowry JB, Spyker DA, Brooks DE, Zimmerman A, Schauben JL (2016) 2015 Annual Report of the American Association of Poison Control Centers’ National Poison Data Systems (NPDS): 33rd Annual Report, Clinical Toxicology, 54:10, 924-1109. 

Poison Center Data for Public Health Surveillance: Poison Center and Public Health Perspectives

OBJECTIVE: To describe the use of poison center data for public health surveillance from the poison center, local, state, and federal public health perspectives and to generate meaningful discussion on how to address the challenges to collaboration. INTRODUCTION: Since 2008, poisoning has become the leading cause of injury-related death in the United States (US); since 1980, the poisoning-related fatality rate in the US has almost tripled.1 Many poison-related injuries and deaths are reported to regional poison centers (PCs) which receive about 2.4 million reports of human chemical and poison exposures annually.2 Federal, state, and local public health (PH) agencies often collaborate with poison centers and use PC data for public health surveillance of poisoning-related health issues. Many state and local PH agencies have partnerships with regional PCs for direct access to local PC data which help them perform this function. At the national level, CDC conducts public health surveillance for exposures and illnesses of public health significance using the National Poison Data System (NPDS), the national PC reporting database. Though most PC and PH officials agree that PC data play an important role in PH practice and surveillance, collaboration between PH agencies and PCs has been hindered by numerous challenges. To address these challenges and bolster collaboration, the Poison Center and Public Health Collaborations Community of Practice (CoP) was created in 2010 by CDC as a means to share experiences, identify best practices, and facilitate relationships among federal, state and local public health agencies and PCs. To date, the Poison Center and Public Health Collaborations CoP includes over 200 members from state and local public health, regional PCs, CDC, the American Association of Poison Control Centers (AAPCC), and the Environmental Protection Agency (EPA). A leadership team was created with representatives of the many stakeholders of the community to drive its direction and oversee activities. METHODS: The panel will consist of 4 presenters and 1 moderator, who are members of the Poison Center and Public Health Collaborations CoP leadership team. Each presenter will bring a unique perspective of the use of PC data for PH practice and surveillance: CDC, state department of health, a local department of health, and a PC. Royal Law from the CDC National Center for Environmental Health will present on using PC data for identification of exposures and illnesses of public health significance identified from NPDS data collected from all 57 PCs. Dr. Jay Schauben from the Florida/USVI Poison Information Center - Jacksonville will discuss PC participation in surveillance and use of PC data for tracking and mitigation of PH events in Florida. Dr. Prakash Mulay from the Florida Department of Health will discuss utilization of PC data to enhance ESSENCE-based chemical-associated exposure and illness surveillance in Florida. Katherine Wheeler from the New York City (NYC) Department of Health and Mental Hygiene will discuss NYC’s use of PC data in surveillance of potential emerging issues, from energy drinks to synthetic marijuana. Each presenter will discuss the use of PC data for PH practice and surveillance in his or her organization and jurisdiction, the successes of using PC data, and their challenges. RESULTS: The moderator will engage the audience by facilitating discussion of the successes and challenges to using PC data for PH practice and surveillance with the audience. Sample questions: What are your current capacities and collaborative activities between your state/local health department and your poison center? What non-funding related barriers hinder the collaboration between your state/local health department and poison center? If more funding were available, how would you use this funding to increase the level of interactivity with the poison center and state/local health department

Withania somnifera (L.) Dunal whole-plant extracts exhibited anti-sporotrichotic effects by destabilizing peripheral integrity of Sporothrix globosa yeast cells.

Chronic topical cases of Sporotrichosis, a chronic fungal infection caused by the ubiquitously present cryptic members of the Sporothrix species complex, are treated with oral administrations of itraconazole. However, severe pulmonary or disseminated cases require repeated intra-venous doses of amphotericin B or even surgical debridement of the infected tissue. The unavoidable adverse side-effects of the current treatments, besides the growing drug resistance among Sporothrix genus, demands exploration of alternative therapeutic options. Medicinal herbs, due to their multi-targeting capacity, are gaining popularity amidst the rising antimicrobial recalcitrance. Withania somnifera is a well-known medicinal herb with reported antifungal activities against several pathogenic fungal genera. In this study, the antifungal effect of the whole plant extract of W. somnifera (WSWE) has been explored for the first time, against an itraconazole resistant strain of S. globosa. WSWE treatment inhibited S. globosa yeast form growth in a dose-dependent manner, with IC50 of 1.40 mg/ml. Minimum fungicidal concentration (MFC) was found to be 50 mg/ml. Sorbitol protection and ergosterol binding assays, revealed that anti-sporotrichotic effects of WSWE correlated well with the destabilization of the fungal cell wall and cell membrane. This observation was validated through dose-dependent decrease in overall ergosterol contents in WSWE-treated S. globosa cells. Compositional analysis of WSWE through high performance liquid chromatography (HPLC) exhibited the presence of several anti-microbial phytochemicals like withanone, withaferin A, withanolides A and B, and withanoside IV and V. Withanone and withaferin A, purified from WSWE, were 10-20 folds more potent against S. globosa than WSWE, thus, suggesting to be the major phytocompounds responsible for the observed anti-sporotrichotic activity. In conclusion, this study has demonstrated the anti-sporotrichotic property of the whole plant extract of W. somnifera against S. globosa that could be further explored for the development of a natural antifungal agent against chronic Sporotrichosis

Wild Mushroom Exposures in Florida, 2003-2007

OBJECTIVE: Exposure to wild mushrooms can lead to serious illness and death. However, there is little information on the epidemiology of mushroom exposures nationwide, as there is no specific surveillance for this outcome. We described mushroom exposures in Florida using available data sources. METHODS: We performed a population-based study of mushroom exposure calls to the Florida Poison Information Center Network (FPICN) and cases of mushroom poisoning reported in hospital inpatient and emergency department (ED) data from 2003 through 2007. RESULTS: There were 1,538 unduplicated mushroom exposures reported during this period, including 1,355 exposure calls and 428 poisoning cases. Most exposures reported to FPICN occurred in children ≤6 years of age (45%) and males (64%), and most were unintentional ingestions (60%). Many exposures resulted in no effect (35%), although 21% reported mild symptoms that resolved rapidly, 23% reported prolonged/systemic (moderate) symptoms, and 1% reported life-threatening effects. Most calls occurred when in or en route to a health-care facility (43%). More than 71% of poisonings identified in hospital records were managed in an ED, and most occurred in young adults 16–25 years of age (49%), children ≤6 years of age (21%), adults >25 years of age (21%), and males (70%). No deaths were reported. CONCLUSIONS: Combined, these data were useful for describing mushroom exposures. Most exposures occurred in males and in young children (≤6 years of age) and young adults (16–25 years of age), with 78% resulting in contact with a health-care facility. Education should target parents of young children—especially during summer, when mushrooms are more abundant—and young adults who are likely experimenting with mushrooms for their potential hallucinogenic properties

Magnitude and characteristics of acute paraquat- and diquat-related illnesses in the US: 1998–2013

Background: Paraquat and diquat are among the most commonly used herbicides in the world. Objectives: Determine the magnitude, characteristics, and root causes for acute paraquat- and diquatrelated illnesses in the US Methods: Illnesses associated with paraquat or diquat exposure occurring from 1998 through 2011 were identified from the Sentinel Event Notification System for Occupational Risks (SENSOR)-Pesticides Program, the California Department of Pesticide Regulation (CDPR) Pesticide Illness Surveillance Program (PISP), and the Incident Data System (IDS). Cases identified by the National Poison Data System (NPDS) were reviewed for the years 1998–2003 and 2006–2013. Results: A total of 300 paraquat- and 144 diquat-related acute illnesses were identified by SENSOR, PISP, and IDS. NPDS identified 693 paraquat- and 2128 diquat-related acute illnesses. In SENSOR/PISP/IDS, illnesses were commonly low severity (paraquat=41%; diquat=81%); however, SENSOR/PISP/IDS identified 24 deaths caused by paraquat and 5 deaths associated with diquat. Nineteen paraquat-related deaths were due to ingestion, seven of which were unintentional, often due to improper storage in beverage bottles. In SENSOR/PISP/IDS, paraquat and diquat-related acute illnesses were work-related in 68% (n=203) and 29% (n=42) of cases, respectively. When herbicide application site was known, the vast majority of acute paraquat-related illnesses (81%) arose from agricultural applications. Common root causes of illness were failure to use adequate personal protective equipment (PPE), application equipment failure, and spill/splash of herbicide. Conclusions: Although the magnitude of acute paraquat/diquat-related illnesses was relatively low, several fatalities were identified. Many illnesses could be prevented through stricter compliance with label requirements (e.g. ensuring proper herbicide storage and PPE use), and through enhanced training of certified applicators