Medical Conditions Commonly Seen in Tobacco Workers

I. Occupational Health Profile Tobacco Workers Tobacco is the nation s ninth highest valued crop and is grown in 16 states. Kentucky and North Carolina produce about 2/3 of all domestic tobacco, although tobacco is also grown further North in places like the Connecticut River Valley to make cigar wrappers. Migrant and seasonal workers help grow, harvest, and prepare the tobacco. There are considerable work-related injuries and illnesses involved in working with tobacco. Injury events, diagnosis, contributing factors...pages 1-2 Tobacco harvesting conditions, varieties..pages 3-4 Irritant injuries... pages 5-6 Intoxication Injuries-Green Tobacco Sickness.pages 7-8 Musculoskeletal injuries...pages 9-10 Chemical illnesses, pesticides pages 11-13 Medical Conditions Commonly Seen in Tobacco Workers Results from a 3 year NEC surveillance study taking place in ME, MA, CT, NY, NJ, PA and MD at federally-funded Migrant Health Centers. Injury and Illness events were documented in patient medical charts and close to 1700 injuries and illnesses were identified in all commodities. Tobacco workers work from bottom to top on the tobacco plants, so they have varied postures throughout the season. Maintaining and harvesting the plants requires fast, repetitive motions and often awkward postures. They work in hot and wet environments daily. 45% 40% 35% 30% 25% 20% 15% 43% Main Injury Events: Tobacco Workers 40% 10% 5% 6% 5% 2.6% 1.7% 1.7% 0% Irritant Strain Other Chemical Cut/Pierced Fell Struck 1

Medical Conditions Commonly Seen in Tobacco Workers Most Common Diagnoses: Tobacco Workers Back Injury Arthritis Other Pain (generalized) Infection Ocular Injury/Inflammation Repetitive Strain Injury Muscle Spasm Trauma Dermatitis Allergies Sprain/Strain 0% 5% 10% 15% 20% 25% Most Common Contributing Factors: Tobacco Workers Crop covered w/natural irritant Using tractor/trailer Repetitive motion Other Chemical exposure Awkward posture Lifting Grasp/pick/pull Carrying object Environmental exposure Inadequate protective gear Weather Conditions Bending/Stooping 0% 5% 10% 15% 20% 25% 30% 2

II. The Tobacco Workplace Working conditions throughout the harvesting season Tobacco maintenance and harvesting conditions: First 2 weeks of July : The flower must be cut off from the top of a growing plant, which is called topping (right). Repetitive reaching: Topping may cause pain/strain. Beginning mid-july and ending mid-september: Picking the tobacco leaves from adult plants, or priming. Wet conditions: Priming begins early in day to avoid heat, but plants are covered with dew and workers become wet in minutes. Sticky secretions: By late morning, heat makes plants produce sticky secretions, which covers the workers clothing and skin. Combination of sweat and raw tobacco juice stings the eyes. Awkward postures: Priming occurs 3-10 times in each field throughout the season, and requires workers to maintain various awkward positions. 1st priming: Must sit or severely bend to reach the leaves. 2 nd and 3 rd primings: Must kneel for long periods of time. Rest of primings: May stand up straight to reach leaves. Repetitive movements: Leaves are snapped in either a quick, upward motion or a traditional quick, downward motion. Leaves are placed underneath the arm (leaves shown aboveright). A gummy layer of juice collects here. General conditions for any work task in a tobacco field: Unavoidable plant contact: Plants are close together, so they brush workers walking through them. Intense heat and humidity: Either working in direct sunlight or under humid tents. Other plant handling: The tobacco leaves are handled many more times throughout the process of their preparation, such as hanging them in drying barns and sewing tobacco leaves. Photographs from http://www.usda.gov/ oc/photo/opc-toba.htm Quandt SA, Arcury TA, Preisser JS, Norton D, Austin C. Migrant farmworkers and green tobacco sickness: new issues for an understudied disease. American Journal of Industrial Medicine 2000; 37:307-315. 3

II. The Tobacco Workplace Plant varieties and related working conditions There are two types of tobacco plants: Virginia (VT): Used to make cigarettes. Contains 1/4 to 1/3 the amount of nicotine as NVT. Non-Virginia (NVT): Used for other products. Shade tobacco: Grown in the Connecticut River Valley. Varieties: 1) Connecticut Valley Shade Grown (cigar wrappers) 2) Connecticut Broadleaf/ Connecticut Havana Seed (cigar binders) Fields are covered with gauze or nets to shield tobacco plants from direct sunlight. Plants grow up to 7 feet tall with leaves up to 2 feet in length. Methods used to cultivate and harvest this tobacco differ significantly with methods used to cultivate and harvest cigarette tobacco: -Less wet conditions: Shade tobacco leaves cannot be blemished. They blemish easier when the plants are wet, so workers rarely harvest wet tobacco leaves. -Less dermal contact: After leaves are picked, they are balanced briefly on the forearm, and then transferred to a conveyor (not held under arm). Shade tobacco and green tobacco sickness in Connecticut. The Journal of Occupational and Environmental Medicine June 2003; 45(6):656-661. Burley tobacco: Primarily grown in Kentucky and Tennessee. Contains 13% more nicotine than flue-cured tobacco. Harvested by the stalk - The entire stalk is cut off at the bottom of the plant. -Less dermal contact: Stalk is briefly held by hand or on forearm (not held under arm). Flue-cured tobacco: Primarily grown in North Carolina, South Carolina, Virginia, and Georgia. Harvested by individual leaves - Workers pick leaves in groups of 3 throughout the season, starting from the bottom of the plant. -More dermal contact: Leaves stored under arm. Burley and Flue-cured tobacco account for 9 of all tobacco grown in the US. McBride JS, Altman DG, Klein M, White W. Green tobacco sickness. Tobacco Control 1998; 7:294-298. Photos from http://www.usda.gov/oc/ photo/opc-toba.htm 4

Irritant Injuries Diagnoses and contributing factors Make up 43% of work-related injuries of tobacco workers Most Common Irritant Diagnoses: Unknown Ocular 2% Injury/Inflammation 10% Burn 2% Dehydration 2% Sprain/Strain 2% Infection 6% Allergies 28% Trauma 18% Dermatitis 30% Part of Body with Irritant Diagnoses: Back 5% Hand 5% Throat 5% Head 5% Eye 26% Chest 8% Arm - 10% Nose 15% Skin - general 21% Contributing Factors of Irritant Injuries: Grasp/pick/pull Crop covered w/poison ivy/oak/sumac Using tractor/trailer Bending/Stooping Repetitive motion Carrying object Environmental exposure - 15% Inadequate protective gear - 29% Weather Conditions 32% 5

Irritant Injuries - Dermatitis 30% of diagnoses for irritant injuries 90% of most cases of occupational dermatitis are contact dermatitis. Contact dermatitis is the most common occupational illness in the US. Irritant Contact Dermatitis: Most prevalent form of contact dermatitis. Occurs when a compound comes into direct contact with the skin, often more than once. Caused by contact with acids, alkaline materials, solvents, or other chemicals. Working around moisture, dirt, detergents, and chemicals increases risk. With enough exposure to the chemical, anyone can develop a reaction. Characterized by erythema and unilocular bullae, resulting from epithelial necrosis. Reaction usually resembles a burn. May result in irritant conjuctivitis Allergic Contact Dermatitis: Less prevalent. Requires a sensitized immune system. Most common plant causing this reaction is poison oak/ivy. Immune system must be sensitized to a chemical or material prior to reacting (not everyone reacts to certain chemicals). Skin reaction usually takes over 24 hours to develop and can last for a few weeks. Acute allergic contact dermatitis is characterized by microvesicles. Skin inflammation varies from mild irritation and redness to open sores. Common cause of allergic contact dermatitis: Poison Ivy/Oak/Sumac Photographs from http://www.dernmnet.com Urushiol is the chemical in the sap of poison ivy and oak plants that causes a rash, blisters, and an itch. Growers often spray herbicides beneath plants to keep undergrowth closely cropped. Poison ivy is immune to many of these chemicals, so competition from other plants is eliminated and poison ivy can spread freely. Treatment: Immediately cleanse exposed skin with rubbing alcohol (alcohol removes the skin s protection along with the urushiol). Wash skin with water. Take a shower with soap and warm water. Do not use soap before this point because it will pick up some urushiol from the surface of the skin and spread it around. Any tools, clothes, shoes, or other items that came into contact with the urushiol should be wiped off with alcohol and water. Adams, RM. Occupational Skin Disease, 2nd Ed. Philadelphia: W.B Sauders Company, 1990. Stehlin, Isadora. Poison Ivy Treatment Guide. FDA Consumer Magazine. Available online at: http://pediatrics.about.com/cs/conditions/a/poison_ivy.htm 6

Intoxication Injuries Green Tobacco Sickness (GTS) Characteristics, factors The surface of wet tobacco leaves contain nicotine, and dermal contact causes absorption. 2 of tobacco workers have GTS at least once a year. Workers experience about 2 days of illness for every 100 days at risk. Characteristics of GTS GTS usually occurs in the afternoon or evening (several hours after exposure). Dermal absorbtion of nicotine, an alkaloid, may cause the following: Either stimulate or desensitize receptors in the autonomic ganglia and peripheral nerve endings, causing nausea,vomiting, and variable effects on blood pressure and heart rate. Increases release of epinephrine by the adrenal gland, causing increased blood pressure and heart rate. Acts directly on brain causing generalized stimulation, tremor, and activation of emetic hemoreceptor trigger zone, causing vomiting. Generally, GTS is diagnosed if a patient is experiencing nausea or vomiting, AND headache or dizziness, and has worked in tobacco that day or the previous day. Other symptoms may include abdominal cramps, headache, prostration, difficultly breathing, abdominal pain, diarrhea, and fluctuations in blood pressure or heart rate. GTS is normally self-limiting, but a case may be severe enough to result in dehydration. Emergency medical care may be needed. Factors of GTS Task: The graph to the right shows which tasks provide the highest and lowest risk for GTS. Those whose dominant task is priming are most at risk, and may have GTS 4 days per 100. Experience: Those who have worked in tobacco for over 5 years have GTS an average of.87 days per 100, while those who have worked in tobacco for 2 to 4 years have GTS 2.3 days per 100, on average. Young age has been found to increase the risk of GTS. Season time: There is a 10.9% chance of a worker having GTS in the late season versus a 3.6% chance in the early season. Clothing protection: Wearing rubberized nylon rainsuits effectively prevents nicotine absorption in tobacco workers, although they are hot and uncomfortable. Glove protection: Use of rubber gloves provides protection against nicotine absorption among 93% of tobacco workers, while cotton gloves protect 78.5% of tobacco workers. Rubber gloves are less comfortable but more durable than cotton gloves. Working in wet clothes: The chance of having GTS for those wearing wet clothes over 25% of the time is twice as high as it is for those wearing wet clothes less than 25% of the time. Smoking: Nicotine from nonskin sources such as smoking may reduce transdermal nicotine adsorption by regulating vasodilation. Days 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 Days out of 100 with GTS Priming Priming and barning Topping Barning Other activities Arcury TA, Quandt SA, Preisser JS, Norton D. The incidence of green tobacco sickness among Latino farmworkers. The Journal of Occupational and Environmental Medicine July 2001; 43(7):601-609. Quandt SA, Arcury TA, Preisser JS, Norton D, Austin C. Migrant farmworkers and green tobacco sickness: new issues for an understudied disease. American Journal of Industrial Medicine 2000; 37:307-315. 7

Intoxication Injuries Green Tobacco Sickness (GTS) Over half of tobacco workers report taking no precautions to prevent GTS. 96. of those who reported GTS took one or more actions to treat the symptoms. Typical treatments used by farmworkers are shown to the right. The most common prevention methods include smoking, wearing protective gloves/clothing, changing out of wet clothing, drinking lemon juice, and various herbal remedies. Although smoking appears to lower the number of GTS cases, it s inadvisable because of a greater health risk associated with tobacco use. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% One or more treatments Treatments used by farmworkers with GTS Anti-nausea medication Lying down Drinking milk Seeing a Not working health care for a day provider Quandt SA, Arcury TA, Preisser JS, Norton D, Austin C. Migrant farmworkers and green tobacco sickness: new issues for an understudied disease. American Journal of Industrial Medicine 2000; 37:307-315. GTS protection and treatment methods for tobacco farmworkers: If possible, avoid handling wet tobacco. Plastic or rubber protective aprons or rainsuits will reduce dermal nicotine absorption, but watch for signs of heat stress. Chemical resistant gloves, such as those recommended for pesticide mixing, will protect workers hands from nicotine absorption. See glove pictures below. Changing into dry clothes after a worker s clothing becomes completely wet with moisture from the tobacco plants will help reduce nicotine absorption. Over-the-counter medicines may help treat symptoms of GTS, but they should only be taken while not working because their side effects may be dangerous in the workplace. Cleansing the skin with cold water (hot water may hasten the absorption of nicotine) to remove tobacco sap may help alleviate symptoms. F Blosser. NIOSH issues warning to tobacco harvesters. Available online at www.cdc.gov/niosh/93-115.html (June 29, 2004). Left: Gloves before working with tobacco. Right: Gloves after working with tobacco. Generally, medication is perscribed that alleviates nausea and vomiting (antiemetics). Prochlorperazine or dimenhydrinate had previously been recommended for fast relief, but it has been more recently inferred that GTS is due to nicotinic stimulation of ganglionic cholinergic receptors. Therefore, the antihistamine dimenhydrinate (producing anticholinergic effects) or oral diphenhydramine have been thought to be effective in alleviating symptoms. Weizenecker R, Deal WB: Tobacco cropper s sickness. Fla Med Assoc J 1970; 57:13-14. Ives TJ: Use of dimenhydrinate in the treatment of green tobacco sickness. Drug Intell Clin Pharm 1983; 17:548-549. 8

Musculoskeletal Injuries Contributing Factors and Parts of the Body Make up 40% of work-related injuries of tobacco workers Part of Body with Strain/Sprain Diagnoses: Finger Knee Rib Elbow Wrist - 8% Shin Thumb Neck 8% Leg 9% Back 3 Arm - 9% Shoulder 8% Contributing Factors of Strain Injuries: Repetitive motion Cutting weeds 3% Chopping/cutting 3% Reaching 3% 3% Awkward posture 3% Other - 6% Lifting - 9% Bending/Stooping 52% Grasp/pick/pull 9% Carrying object 6% Weather Conditions 3% 9

Musculoskeletal Injuries Awkward postures and repetitive movements During topping season (cutting off tobacco flowers from the tops of plants), workers make repetitive motions. Workers must repeatedly reach for the flowers on top of the plants, causing pain/strain. Repetitive, quick motions are made when cutting off the flower, which may cause repetitive strain injuries. Right: Tobbaco topping During priming season (picking tobacco leaves), harvesters must work in various awkward positions. 1st priming: Must sit or severely bend to reach the leaves (shown right). 2 nd and 3 rd primings: Must kneel or stoop for long periods of time. Rest of primings: Depending on plant height, may have moderate trunk flexion or may stand up straight to reach leaves (shown below). Workers must also make repetitive movements during priming season. Leaves are snapped in either a quick, upward motion or a traditional quick, downward motion causing repetitive strain injuries. http://www.usda.gov/oc/photo/cuba1.htm Severe flexion http://www.lsc.org/tobacco/farming/ Moderate to severe trunk flexion occurs while priming, shown above. Moderate flexion 10

Chemical Injuries Make up 5% of work-related injuries of tobacco workers Most Common Diagnoses of Chemical Injuries: Trauma 17% Pesticide reaction 17% Dermatitis 33% Allergies 33% Part of Body with Chemical Diagnoses: Shoulder 17% Skin - general 17% Neck 17% Eye 17% Arm 32% Contributing Factors of Chemical Injuries: Crop covered w/pesticides 25% Inadequate protective gear 25% Chemical exposure 50% 11

Chemical Injuries Pesticides used on tobacco Crops covered with pesticides account for 25% of the contributing factors of chemical injuries 37 pesticides approved by EPA were commonly used on tobacco in the United States in the 1990s. Over 25 million pounds of pesticides are used in tobacco production in the US. Tobacco ranks 6th in the amount of pesticides applied per acre among all agricultural commodities. EPA has set supposed safe levels of exposure, but if these conditions aren t followed, harmful effects can occur. 17 out of the 37 pesticides commonly used on tobacco belong to three classes that could cause adverse health effects at high doses, including death. These classes are explained below. Right: A pesticide is applided to burley tobacco after topping in order to prevent the growth of suckers. Organochlorines, organophosphates, and carbamates: Chemical classes of harmful pesticides at high doses. Act on the nervous system to prevent normal flow of nerve impulses to muscles controlling both voluntary and involuntary movement. Pesticides in these 3 classes are absorbed at various rates through inhalation, ingestion, and skin contact. Typical symptoms of exposure are fatigue, weakness, dizziness, sweating, headache, nausea, cramps, diarrhea, muscle twitching, confusion, and cramps. Many of the pesticides in these classes are thought to cause cancer and birth defects. For more specific details and symptoms, see the chart on the next page. Pesticides on tobacco - federal activities to assess risks and monitor residues. GAO-03-485, March 2003. Available online at: http://www.gao.gov/new.items/d03485.pdf (August 4, 2004). Treatment of pesticide exposure: Carbamates: Clear patient s airways, give oxygen if necessary. Administer atropine sulfate. Decontaminate skin by removing clothing and washing skin and hair thoroughly with soap and water. Flush eyes with clean water 10-15 minutes. Avoid adrenergic amines unless absolutely necessary. Organophosphates: Clear patients airways, administer oxygen if necessary. Administer atropine sulfate. Glyco-pyrolate can be affective with continuous infusion. Prali-doxime can be administered if organophosphate exposure is known and patient is experiencing a severe poisoning. Decontaminate skin by removing clothing and washing skin and hair thoroughly with soap and water. Flush eyes with clean water 10-15 minutes. Organochlorines: Convulsions should be treated with anticonvulsants and patient should be taken to a trauma center if there is no reduction in seizures. Benzodiazepines therapy is recommended. Administer oxygen, decontaminate skin by removing clothing and washing skin and hair thoroughly with soap and water. Flush eyes with clean water 10-15 minutes. Don t give patients any drugs that would increase myocardial irritability. 12

Pesticide 1,3- dichloropropene Primary Use Pounds used on tobacco (1997) Fungicide, insecticide, herbicide Chloropicrin Fumigant, insecticide Maleic hydrazide Chemical Injuries Pesticides used on tobacco Plant growth regulator, herbicide Chemical Class & Exposure Symptoms Toxicity to mammals 13,279,285 These pesticides, along with many others, represent 12 other chemical classes ranging from mild to severe. 6,761,644 1,790,089 Endosulfan Insecticide 172,766 Organochlorine: Persist in environment and accumulate in body tissue. -Symptoms of exposure include headache, dizziness, tremor, confusion, hyperesthesia & paraesthesia, and convulsions. -Associated with cancer & damage to neurological and reproductive systems. -Largely replaced by organophosphates and carbamates. High Notes Highly toxic when ingested or inhaled. Acephate Insecticide 871,899 Organophosphate: Break down quickly Low May cause cancer. in environment but are much more Chlorpyrifos Insecticide 406,822 Low May cause birth defects at very high lev- acutely toxic. -Exposure can be determined by a els and may harm cholinesterase test. pregnant female. -Symptoms of exposure include nausea, Fenamiphos Insecticide 379,841 headache, dizziness, sweating, High Ethoprop Insecticide 182,321 salivation, tremors, cramps, confusion, blurred vision, tightness in the chest May cause cancer. Diazinon Insecticide (trouble breathing), muscle twitching, Moderate Disulfoton Insecticide 13,495 anxiety, and depression. -Symptoms can develop during use of High Fonofos Insecticide 16 pesticides or minutes to hours later. High Inhalation exposure results in most Malathion Insecticide 15,437 rapid appearance of toxic symptoms. Low Methidathion Insecticde -May cause respiratory failure and decreasing heart rate, progressing to car- Moderate May cause cancer. Trichlorfon Insecticide diac arrest. May cause cancer. Pebulate Mancozeb Aldicarb Carbaryl Herbicide Fungicide Insecticide Insecticide 131,665 356,811 59,719 2,057 Carbamate: Symptoms include fatigue, weakness, dizziness, sweating, headache, nausea, cramps, diarrhea, muscle twitching, and slurred speech. -Symptoms tend to have a shorter duration and are easier to treat. High Low Carbofuran Insecticide -Seizures, coma, and cardiorespiratory High depression can occur with higher Methomyl Insecticide 29,773 doses. High These were the top 3 pesticides used on tobacco in 1997. One out of these six carbamate pesticides and a by-product may cause cancer. One pesticide may cause birth defects. Pesticides on tobacco - federal activities to assess risks and monitor residues. GAO-03-485, March 2003. Available online at: http://www.gao.gov/ new.items/d03485.pdf (August 4, 2004). *This is not an exhaustive list of pesticides. This chart contains only pesticides that tobacco workers are most likely to encounter. To see a more comprehensive list, see this resource: Moore JM. Worker protection standards for agricultural pesticides used in tobacco production. Available online at: www.griffin.peachnet.edu/caes/tobacco/handbook/worker-stand98.html (August 4, 2004). 13