Hawai‘i State Department of Health

Office of Hazard Evaluation and Emergency Response
Pesticide and Heavy Metal Poisoning

Introduction and Background

Due to the seriousness of pesticide and heavy metal poisoning and the lack of understanding of the magnitude of the problem in Hawai‘i, the Department of Health (DOH) has made them reportable conditions.

Physicians and laboratory directors are required to report cases or suspected cases of pesticide or heavy metal poisoning. Many states have already enacted specific laws and regulations for the reporting of environmental illness and injury. However, reporting systems in many states have met with only limited success. DOH recognizes that successful control of environmentally related conditions depends on two factors: recognition and diagnosis of cases by health care workers, and the implementation of surveillance, prevention, and control programs.

In order to meet these needs, the surveillance project will be responsible for:

maintaining statewide surveillance data;
managing the reported cases, including followup studies, if necessary; and
developing and coordinating related surveillance activities including physician education seminars, information dissemination, and technical consultation.

It is expected that this will heighten physician awareness, increase present knowledge, and encourage the reporting of pesticide and heavy metal poisoning.

Reporting Procedures

Health care providers are required to report to the DOH within one day any case of pesticide or heavy metal poisoning as specified in Table 1. For reporting purposes, call 586-4249 on O‘ahu, or 1-800-468-4644 ext 4249 from the Neighbor Islands.

For reporting purposes, pesticide and heavy metal poisoning include acute poisoning or any subacute illness caused by, or believed to be caused by, these toxic agents. Upon receipt of a verbal report, the DOH will send a reporting form to the physician to record relevant information. Reports provided to the DOH about persons diagnosed with an environmentally related illness or injury shall be confidential, as specified in HRS §321-315.

Instructions for Handling of Biological Pesticides and Analysis of Blood/Urine Samples

In addition to any routine medical tests to be performed in the work up of a case, there are several laboratory tests specific for suspected cases of pesticide poisoning.

Blood and urine specimens can be analyzed for the presence of pesticide residue. Confirmation of acute organophosphate exposure is possible by measurement of plasma (pseudo-cholinesterase) and red blood cell (acetylcholinesterase) levels. To be the most reliable, specimens should be collected as soon as possible after exposure and prior to giving any antidotal therapy, if feasible.

Blood

Given the usual uncertainty about the specifics of chemical exposure, it is best to draw several tubes of blood which may be used for analysis, if needed.

Draw one or two (5-10 ml) samples into heparinized (green top) tubes. This sample may be used for cholinesterase testing, if appropriate for the suspected pesticide exposure. Consult with the laboratory performing the analysis for specific instructions, as methods vary.
Draw one sample (5-10 ml) into glass tube (red top), with no heparin or preservative. Remove rubberized stopper and cover it with foil, and replace stopper. Tape down stopper. This sample can then be used for analysis of pesticide residues.

Samples which can be delivered to a lab within 24 hours of drawing should be kept refrigerated. If delivery time will exceed 24 hours, samples should be frozen.

Urine

Samples may be collected in a plastic container unless poisoning by a chlorinated compound is suspected, in which case a glass container is preferable. Do not use any preservative. Samples should be handled and shipped in the same manner as blood.

Other Biological Media (Gavage, Stool, Adipose Tissue)

Use glass containers and freeze samples; ship frozen and package with dry ice or blue ice packs.

Non-Biological Samples

Sometimes it is necessary to analyze a drenched piece of clothing to confirm the identity of a pesticide after an accidental exposure. Samples of material should be double bagged in polyethylene bags and packaged separately from other samples for shipment and analysis. If a sample of a pesticide product is sent for analysis, it should be in a glass container, clearly labeled, and sent separately to avoid cross contamination of biological samples.

Table 1

Acute Health Effects of Reportable Pesticides
and Heavy Metal Poisoning

	Symptoms / Signs	Mechanism of Action	Primary Route of Exposure
Pesticides
Organophosphates	Chest tightness, SOB, pulmonary edema, nausea, vomiting, diarrhea, confusion, pinpoint pupils, blurred vision, muscle twitching, excessive sweating and salivation.	Irreversible cholinesterase inhibitor in vivo, leading to increased amounts of acetylcholine with effects on parasympathetic, sympathetic and CNS.	Skin, gastrointestinal tract and lungs.
Carbamates	Similar effects as organophosphate, but symptoms usually less severe.	Reversible cholinesterase inhibitor in vivo, but with fewer CNS effects due to poor penetration of blood-brain barrier.	Skin, gastrointestinal tract and lungs.
Heavy Metals
Lead	Abdominal pain, vomiting, anorexia, ataxia, anemia, lethargy, encephalopathy, irritability, wrist drop, arthralgias.	Forms complexes with enzyme systems throughout the body with diffuse effects.	Gastrointestinal tract and lungs but absorption through skin possible with heavy exposure.
Cadmium	Vomiting, diarrhea, abdominal pain, pulmonary edema, pleuritic chest pain, conjunctivitis, sore throat, cough, fever.	Mechanisms on acute basis unclear.	Lungs and gastrointestinal tract.
Mercury (Elemental)	Fever, chills, gastrointestinal complaints, pulmonary edema, encephalopathy.	Affinity for SH-groups and other compounds inhibiting wide variety of enzyme and transport mechanisms.	Primarily lungs.
Mercury (Inorganic)	Stomatitis, sore throat, nausea, vomiting, abdominal pain, hematemesis, renal failure, shock.		Gastrointestinal tract, lungs and skin.
Mercury (Organic)	Depending on complex, may mimic inorganic poisoning or possibly dysarthria, visual field deficits and encephalopathy.		Primarily gastrointestinal tract and lungs.
Arsenic	Vomiting, bloody diarrhea, abdominal pain, light-headedness, weakness, hemolysis, renal failure, CHF, cerebral edema.	Inhibition of oxidative phosphorylation with widespread effects.	Primarily gastrointestinal tract and skin, but lungs involved with arsenic gas exposure.

For summary reports on the toxicology of these pesticides and metals, contact HEER at the address listed below.

Office of Hazard Evaluation and Emergency Response
Hawai‘i State Department of Health
919 Ala Moana Boulevard, Room 206
Honolulu, Hawai‘i 96814

Telephone:		(808) 586-4249
From Maui (toll-free):		984-2400 ext 64249
From Hawai‘i (toll-free):		974-4000 ext 64249
From Kaua‘i (toll-free):		274-3141 ext 64249
From Moloka‘i or Lāna‘i (toll-free):		(800) 468-4644 ext 64249
Fax:		(808) 586-7537
E-mail:		heer@doh.hawaii.gov
24-hour Hotline:		(808) 247-2191

Web page maintained by Marsha Mealey Last updated 20 Nov 2007