From 1998 through 2004, a total of 325 cases of acute pesticide poisoning associated with pesticide exposure at retail establishments were identified (). Of these cases, 287 (88%) were retail employees and 38 (12%) were customers. One hundred sixty-seven cases (51%) were obtained from SENSOR-Pesticides and 158 (49%) from CDPR. (Three cases were identified by both SENSOR and CDPR and were excluded from the CDPR total.) The median age was 33 years (range: 2–64 years), 171 cases (53%) were female, and 181 (56%) were from California.
Demographic data, pesticide toxicity, and functional class for 325 cases of acute pesticide poisoning in retail settings by severity category, 1998–2004
and display the pesticides and active ingredients involved in the pesticide-related illnesses. The pesticide functional classes responsible for the largest proportions of cases were insecticides alone or combined with other pesticides (n
=140; 44%), and disinfectants (n
=136; 43%). Organophosphorous compounds were responsible for the largest proportion of insecticide cases (n
=54; 37%), and the most commonly observed organophosphorous active ingredients were diazinon (n
=28) and malathion (n
=18). Other commonly involved insecticide chemical classes were pyrethroids (n
=28; 19%), pyrethrins (n
=26; 18%), N-methyl carbamates (n
=13; 9%), and organochlorine compounds (n
=5; 4%). All five of the organochlorine cases were associated with one event involving chlordane. Although all approved uses of chlordane in the U.S. were cancelled in 1988,12
these five cases occurred in 1999 at a charity thrift store during the cleanup of a donated bottle of chlordane that broke while workers sorted through donations. The most frequently reported disinfectant active ingredients were sodium hypochlorite (n
=69), and quaternary ammonia (n
List of the 15 pesticide active ingredients most commonly associated with acute pesticide poisoning among retail workers and customers, by severity category, 1998–2004
Illness severity is presented in . Overall, severity was low for 283 (87%) of the cases and moderate for 41 (13%). One death was also identified. The distribution of low and moderate severity did not differ by case definition category (p=0.49), age (p=0.47), sex (p=0.83), year (p=0.78), work-related category (p=0.67), pesticide toxicity category (p=0.65), or pesticide functional class (p=0.61).
The fatal case was a 35-year-old man with a history of asthma who worked as a tire shop service manager. This worker turned on the air conditioner in the tire shop and was exposed to Ditrac® rodenticide (toxicity category = III, chemical class = indandiones, and active ingredient = diphacinone) and Drione® insecticide (toxicity category = III, chemical class = multiple ingredients, and active ingredients = silica gel, piperonyl butoxide, and pyrethrins). These chemicals had been applied the previous night to treat a rat infestation and had leaked into the establishment's ventilation system. The man inhaled the chemicals, and approximately 10–15 minutes later he was coughing, had chest tightness, difficulty breathing, watery eyes, and turned red. He was taken to the hospital and then discharged the same day. This exposure exacerbated a pre-existing asthma condition and required management with large doses of steroidal anti-inflammatory agents. After nearly one month, the steroidal treatment led to a bleeding duodenal ulcer complication with extensive blood loss. Death ensued after the gastrointestinal hemorrhage could not be controlled, despite massive transfusions and surgical intervention.
Signs and symptoms observed among the cases were related to the eye (n=147; 45%), nervous system (n=145; 45%), respiratory system (n=123; 38%), gastrointestinal system (n=80; 25%), and skin (n=74; 23%) (). Specific health effects most commonly experienced by the cases included the following: eye pain/irritation/inflammation (n=125; 38%), headache (n=74; 23%), nausea (n=70; 22%), upper respiratory pain/irritation (n=68; 21%), dizziness (n=64; 20%), and dyspnea (n=57; 18%).
Clinical signs and symptoms of acute pesticide poisoning among retail workers and customers, 1998–2004 (N=325)
and display the incidence rates for the retail and non-agricultural, non-retail workers from 1998 through 2004. For retail workers, the rates demonstrated a quadratic trend, monotonically decreasing from 1998 (when they were the highest at 11.36/million FTEs) through 2000 and monotonically increasing from 2000 to 2003. The rates appear to have leveled off in 2003 and 2004. A similar trend was observed for non-agricultural, non-retail workers. For each year, the incidence rates were significantly reduced among the retail workers compared with workers employed in non-agricultural, non-retail industries. Incidence rates were also calculated by U.S. region (West, South, and East) (). The western region had the highest incidence rate (13.32/million FTEs), and retail workers in each of the regions had a lower incidence rate compared with workers in non-agricultural, non-retail industries.
Number of acute pesticide poisoning cases among retail and non-agricultural, non-retail workers 15–64 years of age, full-time equivalent estimates, incidence rates, and incidence rate ratios, by year, 1998–2004 (N=287)
Incidence rates for acute pesticide poisoning among U.S. retail (N=287) and non-agricultural, non-retail workers (N=4,209), 15–64 years, 1998–2004
Number of acute pesticide poisoning cases among retail workers 15–64 years of age, full-time equivalent estimates, incidence rates, and incidence rate ratios, by state, 1998–2004 (N=287)
Four occupations in the retail industry were found to have a significantly elevated acute pesticide poisoning incidence rate compared with workers employed in non-agricultural, non-retail industries: janitors (n=16, incidence rate = 53.33/million FTEs; stock handlers/baggers (n=87, incidence rate = 39.19/million FTEs); bakery/deli clerks (n=18, incidence rate = 29.51/million FTEs); and, shipping/receiving handlers (n=12, incidence rate = 26.09/million FTEs) (). Sales workers (n=63) and clerks/cashiers (n=49) also accounted for a large number of cases; however, their incidence rate of acute pesticide poisoning was not elevated.
Number of acute pesticide poisoning cases among retail workiers 15–64 years of age, full-time equivalent estimates, incidence rates, and incidence rate ratios, by occupation, 1998–2004 (N=287)
The retail industry sectors with the highest acute pesticide poisoning incidence rates were farm supply stores (n=10; incidence rate = 35.71/million FTEs), hardware stores (n=14; incidence rate = 29.79/million FTEs), and nurseries and garden stores (n=9; incidence rate = 24.32/million FTEs) (). Two of these sectors had significantly elevated incidence rates: farm supply stores and hardware stores. Grocery stores (n=99) and department and other general merchandise stores (n=61) accounted for a large number of cases; however, the incidence rates in these sectors (14.12/million FTEs and 10.95/million FTEs, respectively) were equivalent to the rate among workers employed in non-agricultural, non-retail industries. Department and other general merchandise stores includes superstores, warehouse clubs, and other department stores that sell a wide range of new products with no one merchandise line predominating.
Number of acute pesticide poisoning cases among retail workers 15–64 years of age, full-time equivalent estimates, incidence rates, and incidence rate ratios, by industry, 1998–2004 (N=287)
We identified the activities of the 287 retail workers that resulted in pesticide exposure. The majority of workers were exposed while performing routine work activities that did not involve mixing, loading, applying, or disposing of pesticides (n=195; 68%). These routine work activities included: direct contact with spills and/or splashes caused by damaged or dropped pesticide containers (n=44; 23%); bystander exposure involving inhalation from a pesticide application within the retail establishment (n=32; 16%); direct pesticide contact while stocking shelves (n=25; 13%); exposure during checkout (e.g., dropping bottles while scanning or bagging products) (n=22; 11%); and cleaning incidents (i.e., direct contact or splash from disinfecting agents among bakery and deli clerks while cleaning dishes or work surfaces) (n=18; 10%). The remaining occupational activities associated with exposure included: applying pesticides (n=57; 20%); mixing/loading pesticides (n=18; 6%); and transportation/disposal of pesticides (n=15; 5%).
Among the 212 cases with personal protection equipment (PPE) usage information, only 28 individuals (13%) wore PPE. Of these 28 cases, 25 (89%) used disposable or chemical resistant gloves (seven of these 25 individuals reported dermatologic effects), five (18%) used goggles (only one of these five had eye symptoms), four (14%) used chemical resistant clothing (e.g., chemical resistant apron), and three (11%) used cloth/leather gloves.
Non-occupational cases accounted for only 12% of the total cases (n=38). The median age for customers was 28 years (range: 2–64 years) and 53% were female. Insecticides accounted for 21 cases (55%), insect repellents for eight (21%), disinfectants for four (11%), herbicides for three (8%), and other pesticides for two (7%). Exposure scenarios among customers included: direct contact from spills and/or splashes caused by damaged or dropped pesticide containers (n=13; 34%), children spraying themselves in the face with a pesticide (n=11; 29%), bystander exposure following a nearby insecticide application (n=5; 13%), and adults inadvertently spraying themselves in the face with a pesticide (n=3; 8%). Incidence rates for pesticide poisoning among retail customers were not calculated.
Two occupational cases and one customer case are described below to illustrate the types of exposures that were detected.
A 20-year-old female stock handler at a retail garden store was stocking shelves above her head; the cap of an insecticide container was loose and the liquid (active ingredient = diazinon, toxicity category III) splashed into her eyes. She sought medical attention at an emergency room, where she was diagnosed with lacrimation and chemical conjunctivitis, which resulted in her missing one day from work. The case definition category was definite, severity was low, and PPE use was unknown.
A 50-year-old male, working as a janitor at a retail produce store, was assisting with the unloading of pesticide boxes; a box was open and insecticide dust (active ingredient = acephate, toxicity category III) fell all over his shirt. The janitor washed himself, began to feel ill, and reported muscle weakness, abdominal pain and cramping, nausea, and diarrhea. The man was admitted to the hospital where he stayed for three days and lost one day from work. The case definition category was possible, severity was moderate, and PPE use was unknown.
In 2004, while shopping at a large department store with one of her parents, a 2-year-old girl grabbed a squirt bottle of DEET (toxicity category III) that was on display in the checkout line. The girl then proceeded to spray herself in the eyes. She immediately developed eye pain, irritation, and lacrimation bilaterally. The parent called poison control for management advice. The case definition category was possible and severity was low.