This grant supported two independent but related efforts within the NYS Department of Health. The first of these was the improvement of case ascertainment, follow-up and investigation of pesticide poisonings. The second was the development of computer software to store, analyze and report case information. Findings in each area are discussed separately below. Pesticide poisonings are a reportable condition in NYS, under Part 22 of the State Sanitary Code (Appendix). Reporting entities are "physicians, clinical laboratories and health care facilities". Reporting by clinical laboratories is upon completion of an analysis of a blood cholinesterase test that is below the normal range (an effect of the so-called cholinesterase inhibiting pesticides in the organophosphate and carbamate chemical classes), or tissue analysis for pesticide residues. In practice, there are few laboratories performing, and few physicians ordering, actual tissue analysis for pesticides. This is due the high cost of such tests, and the limited diagnostic value of such tests. Cholinesterase tests are valuable in case ascertainment, but efforts in obtaining these reports must be targeted. While depressed blood cholinesterase levels are a well known effect of some pesticide classes, they are also caused by other medical conditions, including pregnancy, stroke, ALS, and electroshock therapy. In addition, a small percentage of the population has a blood cholinesterase level in the 'below normal' range. Reports received from commercial clinical laboratories largely reflect medical tests that are requested as part of normal health care related to these conditions, as well as for pre-surgical screening by anesthesiologists. Unfortunately, such clinical results include only the name of the patient and the provider; in order to determine if these tests are due to a pesticide exposure, follow-up with the health care provider is required. The number of pesticide related cases is minimal, and the effort to make the case ascertainment is not productive. Valuable reports are received from employers who operate their own laboratory, and screen their employees who handle or apply pesticides as part of routine health and safety practices. Such employer-operated laboratories are cost effective for the employer, are certified by NYS and provide a reliable source of pesticide-related cholinesterase reports. Typically, these employers are commercial lawn care services providers and pesticide manufacturers, formulators or re-packagers. In the last few years, employer-based labs have been supplanted by the use of commercial labs. In some cases it is possible to identify employer-sponsored tests in the stream of clinical reports; the employer, or employer's physician, is identified as the source of the sample. Physician and health care facility reporting is a dependable source of pesticide poisoning reports. While under-reporting is likely, these cases involve a physician's assessment of the patient, and include an array of signs and symptoms whose presence and time of appearance can be correlated with the known effects of pesticides. This is important for case evaluation and the case classification scheme incorporated into the software described below. In addition to the required reporting sources, physicians, health facilities and clinical laboratories, NYS has also pursued reporting by poison control centers. This has met with mixed success. A close relationship with the New York City Department of Health and Mental Hygiene allows the PPR to obtain a monthly upload of PCC data. This upload is performed using a secure file transfer utility in a secure network maintained by NYSDOH and in which both PPR and NYCDHMH have accounts. The Finger Lakes PCC also transmits pesticide poisoning reports quarterly using PDF files and a secure file transfer system. Unfortunately, no other PCC is able to send reports this way. They have an ability to send reports as e-mail attachments, but this violates DOH security policy; e-mail messages are not secure and may pass through many internet servers in route. In this aspect of the grant, the funds enabled NYS to 'combat' under-reporting by targeting specific provider populations and exploring new sources of reports. NYS implemented its pesticide reporting regulations in 1991. Software was developed to document reports and effort, however the initial software architecture was 'na´ve'; pesticide reports turned out to be more complicated than its flat-file structure anticipated. When more than one person was affected by a pesticide application, details of the event narrative had to be entered in every record. Although this was fairly easy to do using 'cut & paste', it resulted in duplicate data that was difficult to maintain changes to the narrative were made. In addition there was no unique identifier for each person; persons with multiple exposures could not be easily matched (this is common for seasonally exposed lawn care workers). In 1997, NYS began redesigning its software to accommodate multiple persons in the same event, and persons with multiple events. At the same time, NIOSH was developing a consistent set of core variables to be used by states receiving funding to report pesticide poisonings to a national database under the SENSOR program. NYS included compliance with the standard variables as part of the redesign. In 1999, NYS was asked to make the software available to other states, and the application was 'delocalized' and distributed through NIOSH. At that time the software received a new name, SPIDER, an acronym for SENSOR Pesticide Incident Data Entry and Reporting. SPIDER is a network ready, multi-user data entry application written in Microsoft Visual FoxPro, a fully relational database development environment. Data is validated against the NIOSH Standard variables definitions through both look-up tables and field validation procedures. It includes an export routine that removes identifiers before data is aggregated at NIOSH. Through the SENSOR grant, NYS has updated the software annually with new pesticide products registered by EPA, and to accommodate new variables and changed core definitions. In 2005, SPIDER was upgraded to Microsoft Visual FoxPro 9.0.
New York State Department of Health, Bureau of Occupational Health, Flanigan Square - Room 230 547 River Street, Troy, NY 12180