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Bulletin of the World Health Organization, 65 (4): 521-527 (1987)                                        O World Health Organization 1987




Survey of acute pesticide poisoning among
agricultural workers in four Asian countries*
J. JEYARATNAM,' K. C. LUN ,2 & W. 0. PHOON3

                             The study investigated the extent of acute pesticide poisoning in selected agricultural
                        communities in Indonesia, Malaysia, Sri Lanka and Thailand, as well as the contributing
                        factors, because it is believed that this type of poisoning is a major problem in developing
                        countries, but not in the industrialized countries, despite their extensive use of pesticides.
                        The study confirmed the existence ofthis problem, which wasfound to be due to inadequate
                        knowledge of the safe practices in the use of pesticides among users and to the lack of
                        suitable protective clothing for use by agricultural workers in hot and humid climates.




  Agricultural workers who constitute nearly three-                        of acute pesticide poisoning and to identify the factors
quarters of the labour force in the poorest countries                      that should be taken into consideration for
(1) of the world use pesticides to protect their crops,                    prevention.
at least a third of which have been claimed to be
destroyed by pests (2). However, this use of pesti-
cides presents important hazards to human health:                                       MATERIALS AND METHODS
acute poisoning occurs when toxic reactions follow
shortly after exposure, while chronic poisoning
occurs when the reactions appear gradually after                         The selected study areas comprised mainly farmers
prolonged exposure.a It has recently been estimated                    working on their own small holdings, and were not
that about a million cases of unintentional acute                      necessarily typical examples of agricultural practice
pesticide poisoning occur every year worldwide.!                       in other parts of the country. These areas had clearly
  The present study was undertaken among agri-                         defined boundaries and their population numbers
cultural workers in Indonesia, Malaysia, Sri Lanka                     were known from the census. Among the general
and Thailand to determine the extent of the problem                    population, both full-time and part-time agricultural
                                                                       workers were identified by questionnaire. Full-time
    * From the Department of Community, Occupational and               workers were those whose main income was derived
Family Medicine, National University of Singapore, National            from agriculture, while a part-time worker carried
University Hospital, Lower Kent Ridge Road, Singapore 0511,            out regular agricultural work even if this was not his
Singapore.                                                             or her main occupation.
      Associate Professor. Requests for reprints should be sent to       The study was carried out in the four countries
this author.                                                           using a standard questionnaire which identified the
      Senior Lecturer.
      Formerly Professor and Head of the Department; at present,
                                                                       characteristics of the worker's household, the type of
Professor of Occupational Health, University of Sydney, Australia.     agriculture and activities involving pesticide use, the
   a GOULDING, R. Assessment of morbidity and mortality due to         extent of knowledge about the health hazards of
accidental poisoning: data collection and validation, and signifi-     pesticide usage and whether personal protective
cance and magnitude of the problem. Unpublished WHO document,          measures were used, the availability and utilization of
PDS/PP85/W.P.6.                                                        health services, the sources of information on safe use
   h WORLD HEALTH ORGANIZATION. Informal Consultation on               of pesticides, etc. A separate questionnaire identified
Planning Strategy for the Prevention of Pesticide Poisoning.
Unpublished document WHO/VBC/86.926.                                   relevant data from hospital records.
4813                                                                -521
522                                               J. JEYARATNAM ET AL.

  The principal national investigators (all physicians)        agricultural activity was cultivation of paddy,
were    responsible for analysing the hospital case            vegetables, fruit and other cash crops. A total of 4971
records, identifying the cause of the poisoning and the        full-time and part-time agricultural workers were,
type of pesticide, training field investigators, and           identified for the study.
field testing the questionnaire before implementation.
In each country the questionnaire, translated into the
local language, was used to collect data from all              Analysis of hospital records
members of the households in the study areas. This                The clinical records from the local hospital near the
part of the study was completed in 1985 in                     project area were analysed to estimate the number of
approximately one month, but the timing in each                hospital admissions due to acute pesticide poisoning,
country depended on local factors such as the rainy            this group of patients being identified from the
season, convenience of the study team, etc.                    records of all cases of poisoning admitted to the
                                                               hospital between 1 January and 31 December 1983.
Study areas                                                    All the hospital cases classified as poisoning in 1983
                                                               were specially reviewed for the study by the principal
  Indonesia. The study area comprised ten kampongs             national investigator in each country. The class of
(village subunits) in Bangunharjo village, located in          pesticide responsible for the poisoning and the reason
the Bantul Regency of Yogyakarta in Java. Culti-               for the poisoning were obtained from the clinical
vation of paddy and cash crops was the main                    records.
agricultural activity. A total of 1192 full-time and
part-time agricultural workers were identified for the
study.                                                                                 RESULTS

   Malaysia. The study was undertaken in the                     Among the part-time and full-time agricultural
Cameron Highlands, which is approximately 2000                 workers in each of the communities studied, the
metres above sea level in Peninsular Malaysia. This is         proportion handling pesticides was 29.8% in
an area of intensive agricultural activity, largely for        Indonesia, 91.9% in Malaysia, 38.3% in Sri Lanka,
cash crops such as vegetables, flowers and fruit. A            and 41.4% in Thailand (Table 1). In Indonesia there
total of 4351 full-time and part-time agricultural             was no record of pesticide use among part-time
workers were identified for the study.                         agricultural workers; in the other countries, fewer
  Sri Lanka. The project was undertaken in the                 part-time workers were found using pesticides
Anuradhapura district of the North-Central Province.           compared with full-time workers. A minority, parti-
Cultivation of paddy, vegetables and grains was the            cularly among part-time agricultural workers, were
main activity of the farmers in this area. A total of          in the age group of 10-15 years; none of them
3439 full-time and part-time agricultural workers              handled pesticides.
were identified for the study.                                   In the questionnaire survey the agricultural workers
                                                               were asked if they thought they had ever suffered
  7hailand. The study area was in the province of              from acute pesticide poisoning and whether this had
Rayong, about 185 km from Bangkok, on the eastern              occurred during the previous year. Their responses,
seaboard abutting the Gulf of Thailand. The main               reflecting the pesticide users' perception of a




Table 1. Number of pesticide users among full-time and part-time agricultural workers
                                                                         No. of pesticide users among:
                             Total number of
Country                    workers investigated      Full-time workers           Part-time workers             Total

Indonesia                           1192                355   (32.1)                  0   (0)                355   (29.8)
Malaysia                            4351               3893   (97.3)                107   (30.5)            4000   (91.9)
Sri Lanka                           3439               1206   (53.5)                111   (9.4)             1317   (38.3)
Thailand                            4971               1881   (44.4)                179   (27.4)            2060   (41.4)
 "   Figures in parentheses are percentages.
PESTICIDE POISONING IN FOUR ASIAN COUNTRIES                                                 523

Table 2. Percentage of workers with pesticide poisoning among agricultural workers and among pesticide users
                                     Percentage of agricultural workers                               Percentage of pesticide users

                                                                  Poisoned in                                                 Poisoned in
Country                         Ever poisoned                    previous year               Ever poisoned                   previous year

Indonesia                             4.1                            0.08                         13.8                           0.3
Malaysia                             13.3                            6.7                          14.5                           7.3
Sri Lanka                             4.6                            2.7                          11.9                           7.1
Thailand                              8.1                            NAa                          19.4                            NA"
 a NA = data not available.




Table 3. Reason given for the pesticide poisoning among hospital admissions in 1983
                                       Accident

Country               Occupational              Non-occupational             Suicide       Homicide           Unstated            Total

Indonesia                2 (1.9)a                   0 (0)                   67 (62.6)       0 (1)             38 (35.5)         107    (100)
Malaysia                 4 (14.3)                   5 (17.9)                19 (67.9)       0 (0)              0 (1)             28    (100)
Sri Lanka               30 (31.9)                  27 (28.7)                34136.2)        3 (3.2)            0 (0)             94    (100)
Thailand                 6 (13.6)                   4 (9.1)                 27 (61.4)       0(1)               7115.9)           44    (100)
 aFigures in parentheses are percentages.




 Table 4. Major classes of chemicals causing pesticide poisoning among hospital admissions
                      Organophosphorus                                                                       Unidentified
 Country                  compounds                  Carbamates             Bipyridyls     Copper             and others              Total
 Indonesia                    19 017.8)a              1 (0.9)                 1 (0.9)     25 (23.4)           61 (57.0)          107 (100)
 Malaysia                     15 (53.6)               3 (10.7)                7 (25)       0(1)                3 (10.7)           28 (100)
 Sri Lanka                    65 (69.1)               0 10)                   010)         0 (1)              29 (30.9)           941100)
 Thailand                     10 (22.7)               7 15.9)               11 125)        0 (0)              16 (36.4)           44(100)
  "
      Figures in parentheses are percentages.




pesticide-related acute illness, showed that in Sri                         Indonesia, 67.9% in Malaysia, 36.2% in Sri Lanka
Lanka and Malaysia 7.1% and 7.3%, respectively,                             and 61.4% in Thailand. Occupation-related acciden-
had suffered an episode of poisoning during the                             tal poisonings were only 1.9% of cases in Indonesia
previous year, compared with only 0.3 % in Indonesia                        and as high as 31.9% in Sri Lanka. Unintentional
(Table 2); there was no result for Thailand as this                         poisonings of non-occupational origin varied from
particular question had by mistake been omitted.                            0% in Indonesia to 28.7% in Sri Lanka. However, in
Table 2 also shows that the proportion of pesticide                         Indonesia 35.5 % of the clinical records did not give a
users ever poisoned was reasonably similar in the                           reason for the poisoning.
four countries (range, 11.9% to 19.4%).                                        The major classes of pesticides responsible for
   The cause of the pesticide poisoning among hospi-                        poisoning among patients admitted to the hospitals
tal admissions was identified in the hospital records                       are shown in Table 4. In Malaysia and Sri Lanka
(Table 3). Suicides accounted for 62.6% of cases in                         organophosphorus compounds were mostly respon-
524                                                            J. JEYARATNAM ET AL.

Table 5. Preferred source of treatment among pesticide users ever poisoned
                       Hospital or
                    western medical            Indigenous                                                Information
Country               practitioners            practitioner         Self-treatment     No treatment     not available       Total
Indonesia               97   (14.3)              1 (2.0)               6 (12.2)           4 (8.2)         31 (63.3)        49   (100)
Malaysia               263   (45.5)              2 (0.3)              24 (4.2)          287 (49.6)         2 (0.3)        578   (99.9)
Sri Lanka               63   (40.1)              3 (1.9)              55 (35.0)          36 (22.9)         0 (0)          157   (99.9)
Thailand                37   (9.2)               4 (1.0)              66 (16.3)         297 (73.5)         0 (0)          404   (100)
 a
     Figures in parentheses are percentages.




sible (53.6% and 69.1 % of cases, respectively). In                         early symptoms of pesticide poisoning were given in
Thailand the bipyridyls were responsible for 25 % of                        Indonesia by only 8.2% compared with 67.5% in
cases, compared with 22.7% due to organophos-                               Malaysia, 47.3 % in Sri Lanka and 70.3 % in Thailand.
phorus compounds. In Indonesia the hospital case                            With regard to the usual route of absorption of
notes often did not indicate the type of pesticide                          pesticides, in all countries the dermal route was
responsible for the poisoning; from the available                           identified as the least important, inhalation as most
information it appears that copper compounds were                           important, and the oral route between the two.
responsible for 23.4 % of cases and organophosphorus                        Protective measures against pesticide poisoning were
compounds for only 17.8 %.                                                  taken by 82.8% of users in Indonesia, the respective
   With regard to treatment after the poisoning, it                         figures for Malaysia, Sri Lanka and Thailand being
appears that the majority either treated themselves or                      95.2 %, 99.5 % and 53.4 %.
took no treatment; in other cases the local hospital                           The activities identified by the pesticide users
or western medical practitioners were preferred                             which resulted in poisoning included spraying using
(Table 5).                                                                  knapsack spray equipment, mixing and diluting of
  Table 6 shows the extent of awareness among                               pesticides, and repairing or cleaning of spray equip-
pesticide users that pesticides were a health hazard                        ment. In all four countries spraying, mixing and
and about the route of absorption into the body. In                         diluting of pesticides were the most frequently
Indonesia, only 3 1.8 % stated that they were aware of                      identified activities associated with poisoning. In
the route of absorption, compared with > 90% in the                         Indonesia, only 5. 1 % of pesticide users used overalls,
other countries. In Indonesia 26.2% stated that they                        9.3 % used a respirator/mask, and 9.3 % used gloves.
were aware that pesticides were a health hazard,                            In Malaysia, 14.7% used overalls, 11.5% used a
compared with 67.2-87.5% in the other countries.                            respirator/mask, and 95 % used gloves. In Sri Lanka,
Positive replies concerning their awareness of the                          26.8% used overalls, 40.8% used a respirator/mask,
                                                                            and 7.1 % used gloves. In Thailand, 67% used
                                                                            overalls, 18% used a respirator/mask, and 5.2% used
                                                                            gloves.
                                                                               With regard to the sources of information available
                                                                            to pesticide users about the safe use of pesticides,
Table 6. Extent of the pesticide users' knowledge about                     it appeared that in Indonesia retail outlets were
the health hazards of pesticides and the need for                           identified more often than information passed on by
protection                                                                  fellow farmers or agricultural officers. In Malaysia
                                                                            the majority of pesticide users stated that no one had
                                         Knew that               Used       specifically told them about the safe use of pesticides,
                Knew the route         pesticides are         protective
Country          of absorption        a health hazard         measures      while some heard of it from retail outlets or from
                                                                            other farmers. In Sri Lanka the agricultural officers
Indonesia          1 13   (31.8) a        93 (26.2)         294    (82.8)   and, to a lesser extent, farmers provided this
Malaysia          3600    (90.0)        3429 (85.7)        3810    (95.2)   information but a good proportion of workers were
Sri Lanka         1195    (90.7)        1017(77.2)         1311    (99.5)   not told by anyone. In Thailand, other farmers and
Thailand          1955    (94.9)        1384 (67.2)        1102    (53.4)
                                                                            retail outlets were identified as the source of
                                                                            information; here also many workers claimed that no
 a
     Figures in parentheses are percentages.                                one provided them with this information.
PESTICIDE POISONING IN FOUR ASIAN COUNTRIES                                     525

                     DISCUSSION                            and non-occupational, are mostly preventable, even in
                                                           developing countries; this problem in the industrial-
  The present study is an attempt to estimate the          ized countries, despite the extensive use of pesticides,
extent of acute pesticide poisoning among agri-            has been controlled by appropriate safeguards.'
cultural workers who use pesticides. Previous studies         While the organophosphorus compounds were fre-
in the same countries had depended on hospital             quently responsible for the poisoning, it is discon-
records (3, 4) without particular reference to a base-     certing that in Indonesia, Sri Lanka and Thailand the
line population.                                           class of pesticide responsible for the poisoning was
   Pesticide users among agricultural workers in the       often not identified. Whatever the reasons for this, it
countries studied ranged from 29.8% in Indonesia to        must create problems in the treatment and manage-
91.9% in Malaysia. The extent of pesticide usage           ment of patients and increase the case fatality. In a
among agricultural workers is probably influenced by       previous study in Sri Lanka, a high case fatality rate
the nature of the crops and agricultural practices. For    (28.5%) was noted among patients where no infor-
instance, in Indonesia these workers were mostly           mation was available on the class of pesticides (3).
cultivating paddy while in Malaysia they were                 The instances of acute poisoning reported by the
engaged in the cultivation of cash crops that require      pesticide users could not be related to the hospital
more frequent use of pesticides. A similar variation in    admissions for acute poisoning because the study
the extent of pesticide usage depending on the nature      periods were not the same -in 1984 and 1983,
of the crop may be seen in a study in the Netherlands      respectively. While a large majority of the episodes of
(5), where pesticides were identified as a problem by      acute poisoning recorded by the users must have been
76% of workers in arable farms, 85 % of workers in         very mild because they improved with either no treat-
glass-house nurseries, 83 % of workers in outdoor          ment or self-treatment, it must be recognized that each
horticulture, and 92 % of workers in mushroom              one represents a failure of prevention and could have
farming.                                                   been serious.
   Although the approach of questioning pesticide             The study demonstrates that in all four countries
users as to whether, in their opinion, they had ever       occupation-related acute pesticide poisoning presents
suffered from acute pesticide poisoning is not fool-       a major problem in the communities studied. Specific
proof, the results showed that illness, presumably due     attention should therefore be focused on the
to acute pesticide poisoning, was directly related to      prevention of such poisoning; some of the factors
the workers' immediately previous use and exposure         contributing to this problem are discussed below.
to pesticides. The problem in the four countries              Because spraying and the mixing or diluting of
studied appears to be reasonably similar, 10-20% of        pesticides were the two most frequently associated
pesticide users considering themselves to have suf-        occupational activities resulting in poisoning, special
fered an episode of pesticide poisoning at some time       attention has to be paid to them, a view endorsed by
during their working life (Table 2). Each episode          Copplestone who states, "we are more likely to be
reflects a failure in the prevention of poisoning among    effective in preventing accidentAl poisoning by pesti-
pesticide users. Further, in Malaysia and Sri Lanka it     cides if we concentrate our activities in relevant terms
was observed that 2-7 % of pesticide users stated that     on those areas where hazard is really high than by
this illness occurred in the previous year (Table 2),      trying to give blanket coverage to all pesticide users"
which is an unacceptably high level for an occupa-         (7). One of the important factors contributing to acci-
tional hazard. The low result from Indonesia (0.08 %)      dental acute pesticide poisoning was malfunctioning
for poisoning in the preceding year is atypical,           spray equipment which resulted in contamination of
compared with the previous years, and is probably the      the workers' skin surface with pesticides (8). It is in
result of an interview error.                              this context that the extent of the pesticide users'
   Among the patients admitted to hospital, suicide        knowledge on safe use of pesticides was examined.
was the leading cause of acute pesticide poisoning         But although a large proportion of users, except in
in all the countries (Table 3), a feature reported         Indonesia, were ofthe opinion that they knew the route
previously (3, 6). Except in Indonesia, unintentional      of absorption of pesticides and the early symptoms of
poisonings of occupational and non-occupational            acute poisoning, it was evident that the content of their
origin were responsible for 9-32 % of cases of             knowledge was inadequate to prevent pesticide
poisoning. The relatively low figures for unintentional    poisoning. For instance, in all the countries the users
poisoning in Indonesia and Thailand are probably due       considered inhalation to be the most important route
to the fact that for 35.5 % of patients in Indonesia and   while pesticide absorption through the skin was less
15.9% in Thailand the case records did not indicate the    important. In fact, there is substantial evidence to
immediate circumstances of the poisoning. Such
unintentional pesticide poisonings, both occupational          See footnote b.
526                                                J. JEYARATNAM ET AL.


show that dermal absorption is by far the most                    Lanka were agricultural officers identified as a
important, and that absorption by inhalation is                   frequent source of information. The implication of this
relatively unimportant (9, 10). This misconception                finding is that in these countries most of the infor-
among pesticide users must be corrected through                   mation available to pesticide users is not provided on
educational programmes on the safe use of pesticides.             an officially organized basis. None of the countries
  Similarly, a large proportion of pesticide users                had any legislative controls requiring pesticide users
thought that adequate protective measures were being              to be formally trained in safe work practices, which
taken when actually, except for Thailand, these                   contrasts sharply with the situation in the
measures were not extensively used or their efficacy              industrialized world (11). As an interim measure, all
was questionable. This is evident in the observations             countries without formal training requirements may
of the principal national investigator for Sri Lanka              consider enforcing these requirements, at least in
who wrote that the protective clothing worn was                   order to control and train the users of pesticides
inadequate for prevention of pesticide absorption: a              grouped under classes lA and lB of the WHO classi-
handkerchief or shawl was used as a mask, polythene               fication by hazards.d
bags were tied round the hands or feet, open slippers or            The large problem of acute pesticide poisoning in
old shoes, and a turban or old cotton hat on the head;            the four countries studied requires to be controlled. In
the forearms, face and head were usually exposed. Al-             the first instance, education and a training programme
though cotton overalls do provide adequate protection             on the safe use of pesticides for occupationally
provided they are washed daily, this was not the                  exposed workers will have to be instituted; govern-
practice in Sri Lanka.                                            ments should recognize this problem and make every
  With regard to the available sources of information             effort to contain it. The primary health care approach
on the safe use of pesticides, in all four countries a            appears to be most suitable to overcome the problem
significant proportion of pesticide users could not               (12).
identify a specific source of information. When                     d 7he WHO recommended classification ofpesticides by hazard
information was available, it often came from other               and guidelines to classification. Unpublished WHO document,
farmers and retail outlets; only in Malaysia and Sri              VBC/84.2.




                                                ACKNOWLEDGEMENTS
  This study was undertaken on behalf of the Asian Association on Occupational Health and was funded by the International
Development Research Centre (IDRC) of Canada. We are very grateful to Dr Dae-Woo Han, the regional representative in
health sciences, Asia Regional Office, IDRC, for his help and support throughout the study. We also thank the principal
national investigators, Dr P. K. Suma'mur (Indonesia), Dr R. Mahathevan (Malaysia), Dr M. Rajendra (Sri Lanka) and
Professor Malinee Wongphanich (Thailand), for the valuable work in their countries and Miss P. C. Lim for secretarial help.




                                                          RESUME

                            ENQUETE SUR. L'INTOXICATION AIGUE PAR LES PESTICIDES
                          CHEZ LES TRAVAILLEURS AGRICOLES DANS QUATRE PAYS D'ASIE

  Cette etude a ete entreprise pour evaluer I'ampleur de          repandue parmi les utilisateurs de pesticides que parmi les
l'intoxication aigue par les pesticides ainsi que les facteurs    autres travailleurs agricoles.
qui y contribuent dans plusieurs communautes agricoles              L'analyse des registres des hopitaux a montre que dans les
d'Indonesie, de Malaisie, de Sri Lanka et de Thailande.           quatre pays, la tentative de suicide etait la cause la plus
L'etude a porte sur 1192 travailleurs agricoles en Indondsie,     frequente d'intoxication aigue par les pesticides. L'intoxi-
4351 en Malaisie, 3439 a Sri Lanka et 4971 en Thaflande.          cation accidentelle, tant professionelle que non profession-
La proportion des travailleurs agricoles qui ont d6clare qu'a     nelle, etait a l'origine d'une proportion notable des hospi-
leur avis ils ont souffert d'un 6pisode d'intoxication aigue au   talisations sauf en Indonesie ou elle n'intervenait que pour
cours de leur vie professionnelle etait de 4,1 % en Indonesie,    1,9% des admissions; elle etait a l'origine de 32,2% des cas
13,3 % en Malaisie, 4,6 % a Sri Lanka et 8,1 % en Thalilande.     en Malaisie, 60,6% des cas a Sri Lanka et 22,7% des cas en
On a egalement observe que l'intoxication dtait plus              Thadlande. En Malaisie et a Sti Lanka, les pesticides le plus
PESTICIDE POISONING IN FOUR ASIAN COUNTRIES                                            527

souvent incrimin6s etaient les organophosphores, alors       n6cessaires pour eviter une intoxication. Toutefois, un
qu'en Thallande, les bipyridyles etaient responsables de     interrogatoire plus approfondi a montre que ces connais-
25,0% des intoxications, suivis par les organophosphores     sances etaient souvent erronees. De plus, sauf a Sri Lanka
(22,7%). En ce qui concerne l'Indonesie, les donnees         oii les fonctionnaires des services agricoles etaient souvent
disponibles montrent par contre que les composes a base de   mentionnes comme dispensateurs d'information au sujet de
cuivre occupaient la premiere place avec 23,4% des cas,      la securite d'emploi des pesticides, les travailleurs agricoles
contre seulement 17,8% pour les organophosphor6s.            ont d6signe comme source principale d'information les
  Sauf en Indon6sie, une forte proportion d'utilisateurs     agriculteurs ou les detaillants.
de pesticides estimaient qu'ils avaient les connaissances


                                                   REFERENCES

 1. THE WORLD BANK. World development report 1980.                 pesticide application. Amsterdam, Elsevier, 1982, pp.
    New York, Oxford University Press, 1980.                       59-64.
 2. Steering Committee on Pest Control Under the              8.   JEYARATNAM, J. Health hazards awareness of pesticide
    Conditions of Small Farmer Food Crop Production in             applicators about pesticides. In: Education and safe
    Developing Countries. Report. Paris, OECD, 1977.               handling in pesticide application. Amsterdam,
 3. JEYARATNAM, J. ET AL. Survey of pesticide poisoning            Elsevier, 1982, pp. 23-30.
    in Sri Lanka. Bulletin of the World Health                9.   KOLMODIN-HEDMAN, B. ET AL. Studies in phenoxy acid
    Organization, 60: 615-619 (1982).                              herbicides in agriculture. Archives of toxicology, 54:
 4. BULL, D. A growing problem. Pesticides and the 7hird           257-265 (1983).
    World poor. Oxford, Oxfam, 1982.                         10.   AKERBLOM, M. ET AL. Studies of occupational
 5. BIERSTEKER, K. ET AL. A postal survey of health and            exposure to phenoxy acid herbicides. In: IUPACpesti-
    working conditions of Dutch farmers. In: Proceedings           cide chemistry -human welfare and the environment.
    of the 9th International Congress of Agricultural              Oxford, Pergamon, 1983, pp. 227-232.
    Medicine and Rural Health, Christchurch, New             11.   FRANKLIN, C. A. & MUIR, N. I. Education and
    Zealand. Vol. 1, 10-14 September 1984.                         licensing procedures for pesticide applicators and
 6. AMARASINGHAM, R. D. & Ti, T. H. A review of                    vendors in Canada. In: van Heemstra, E. A. H. &
    poisoning cases examined by the Department of Chem-            Tordoir, W. F., ed. Education and safe handling in
    istry, Government of Malaysia, Malaysia, from 1968 to          pesticide application. Amsterdam, Elsevier, 1982,
    1972. Medical journal of Malaysia, 30: 185-193                 pp. 89-104.
    (1976).                                                  12.   JEYARATNAM, J. Editorial: Health problems of
 7. COPPLESTONE, J. F. Problems in education on the safe           pesticide usage in the Third World. British journal of
    handling of pesticides. In: van Heemstra, E. A. H. &           industrial medicine, 42: 505-506 (1985).
    Tordoir, W. F., ed. Education and safe handling in

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Pesticide Poisoning Killing Asian Farm Workers

  • 1. Bulletin of the World Health Organization, 65 (4): 521-527 (1987) O World Health Organization 1987 Survey of acute pesticide poisoning among agricultural workers in four Asian countries* J. JEYARATNAM,' K. C. LUN ,2 & W. 0. PHOON3 The study investigated the extent of acute pesticide poisoning in selected agricultural communities in Indonesia, Malaysia, Sri Lanka and Thailand, as well as the contributing factors, because it is believed that this type of poisoning is a major problem in developing countries, but not in the industrialized countries, despite their extensive use of pesticides. The study confirmed the existence ofthis problem, which wasfound to be due to inadequate knowledge of the safe practices in the use of pesticides among users and to the lack of suitable protective clothing for use by agricultural workers in hot and humid climates. Agricultural workers who constitute nearly three- of acute pesticide poisoning and to identify the factors quarters of the labour force in the poorest countries that should be taken into consideration for (1) of the world use pesticides to protect their crops, prevention. at least a third of which have been claimed to be destroyed by pests (2). However, this use of pesti- cides presents important hazards to human health: MATERIALS AND METHODS acute poisoning occurs when toxic reactions follow shortly after exposure, while chronic poisoning occurs when the reactions appear gradually after The selected study areas comprised mainly farmers prolonged exposure.a It has recently been estimated working on their own small holdings, and were not that about a million cases of unintentional acute necessarily typical examples of agricultural practice pesticide poisoning occur every year worldwide.! in other parts of the country. These areas had clearly The present study was undertaken among agri- defined boundaries and their population numbers cultural workers in Indonesia, Malaysia, Sri Lanka were known from the census. Among the general and Thailand to determine the extent of the problem population, both full-time and part-time agricultural workers were identified by questionnaire. Full-time * From the Department of Community, Occupational and workers were those whose main income was derived Family Medicine, National University of Singapore, National from agriculture, while a part-time worker carried University Hospital, Lower Kent Ridge Road, Singapore 0511, out regular agricultural work even if this was not his Singapore. or her main occupation. Associate Professor. Requests for reprints should be sent to The study was carried out in the four countries this author. using a standard questionnaire which identified the Senior Lecturer. Formerly Professor and Head of the Department; at present, characteristics of the worker's household, the type of Professor of Occupational Health, University of Sydney, Australia. agriculture and activities involving pesticide use, the a GOULDING, R. Assessment of morbidity and mortality due to extent of knowledge about the health hazards of accidental poisoning: data collection and validation, and signifi- pesticide usage and whether personal protective cance and magnitude of the problem. Unpublished WHO document, measures were used, the availability and utilization of PDS/PP85/W.P.6. health services, the sources of information on safe use h WORLD HEALTH ORGANIZATION. Informal Consultation on of pesticides, etc. A separate questionnaire identified Planning Strategy for the Prevention of Pesticide Poisoning. Unpublished document WHO/VBC/86.926. relevant data from hospital records. 4813 -521
  • 2. 522 J. JEYARATNAM ET AL. The principal national investigators (all physicians) agricultural activity was cultivation of paddy, were responsible for analysing the hospital case vegetables, fruit and other cash crops. A total of 4971 records, identifying the cause of the poisoning and the full-time and part-time agricultural workers were, type of pesticide, training field investigators, and identified for the study. field testing the questionnaire before implementation. In each country the questionnaire, translated into the local language, was used to collect data from all Analysis of hospital records members of the households in the study areas. This The clinical records from the local hospital near the part of the study was completed in 1985 in project area were analysed to estimate the number of approximately one month, but the timing in each hospital admissions due to acute pesticide poisoning, country depended on local factors such as the rainy this group of patients being identified from the season, convenience of the study team, etc. records of all cases of poisoning admitted to the hospital between 1 January and 31 December 1983. Study areas All the hospital cases classified as poisoning in 1983 were specially reviewed for the study by the principal Indonesia. The study area comprised ten kampongs national investigator in each country. The class of (village subunits) in Bangunharjo village, located in pesticide responsible for the poisoning and the reason the Bantul Regency of Yogyakarta in Java. Culti- for the poisoning were obtained from the clinical vation of paddy and cash crops was the main records. agricultural activity. A total of 1192 full-time and part-time agricultural workers were identified for the study. RESULTS Malaysia. The study was undertaken in the Among the part-time and full-time agricultural Cameron Highlands, which is approximately 2000 workers in each of the communities studied, the metres above sea level in Peninsular Malaysia. This is proportion handling pesticides was 29.8% in an area of intensive agricultural activity, largely for Indonesia, 91.9% in Malaysia, 38.3% in Sri Lanka, cash crops such as vegetables, flowers and fruit. A and 41.4% in Thailand (Table 1). In Indonesia there total of 4351 full-time and part-time agricultural was no record of pesticide use among part-time workers were identified for the study. agricultural workers; in the other countries, fewer Sri Lanka. The project was undertaken in the part-time workers were found using pesticides Anuradhapura district of the North-Central Province. compared with full-time workers. A minority, parti- Cultivation of paddy, vegetables and grains was the cularly among part-time agricultural workers, were main activity of the farmers in this area. A total of in the age group of 10-15 years; none of them 3439 full-time and part-time agricultural workers handled pesticides. were identified for the study. In the questionnaire survey the agricultural workers were asked if they thought they had ever suffered 7hailand. The study area was in the province of from acute pesticide poisoning and whether this had Rayong, about 185 km from Bangkok, on the eastern occurred during the previous year. Their responses, seaboard abutting the Gulf of Thailand. The main reflecting the pesticide users' perception of a Table 1. Number of pesticide users among full-time and part-time agricultural workers No. of pesticide users among: Total number of Country workers investigated Full-time workers Part-time workers Total Indonesia 1192 355 (32.1) 0 (0) 355 (29.8) Malaysia 4351 3893 (97.3) 107 (30.5) 4000 (91.9) Sri Lanka 3439 1206 (53.5) 111 (9.4) 1317 (38.3) Thailand 4971 1881 (44.4) 179 (27.4) 2060 (41.4) " Figures in parentheses are percentages.
  • 3. PESTICIDE POISONING IN FOUR ASIAN COUNTRIES 523 Table 2. Percentage of workers with pesticide poisoning among agricultural workers and among pesticide users Percentage of agricultural workers Percentage of pesticide users Poisoned in Poisoned in Country Ever poisoned previous year Ever poisoned previous year Indonesia 4.1 0.08 13.8 0.3 Malaysia 13.3 6.7 14.5 7.3 Sri Lanka 4.6 2.7 11.9 7.1 Thailand 8.1 NAa 19.4 NA" a NA = data not available. Table 3. Reason given for the pesticide poisoning among hospital admissions in 1983 Accident Country Occupational Non-occupational Suicide Homicide Unstated Total Indonesia 2 (1.9)a 0 (0) 67 (62.6) 0 (1) 38 (35.5) 107 (100) Malaysia 4 (14.3) 5 (17.9) 19 (67.9) 0 (0) 0 (1) 28 (100) Sri Lanka 30 (31.9) 27 (28.7) 34136.2) 3 (3.2) 0 (0) 94 (100) Thailand 6 (13.6) 4 (9.1) 27 (61.4) 0(1) 7115.9) 44 (100) aFigures in parentheses are percentages. Table 4. Major classes of chemicals causing pesticide poisoning among hospital admissions Organophosphorus Unidentified Country compounds Carbamates Bipyridyls Copper and others Total Indonesia 19 017.8)a 1 (0.9) 1 (0.9) 25 (23.4) 61 (57.0) 107 (100) Malaysia 15 (53.6) 3 (10.7) 7 (25) 0(1) 3 (10.7) 28 (100) Sri Lanka 65 (69.1) 0 10) 010) 0 (1) 29 (30.9) 941100) Thailand 10 (22.7) 7 15.9) 11 125) 0 (0) 16 (36.4) 44(100) " Figures in parentheses are percentages. pesticide-related acute illness, showed that in Sri Indonesia, 67.9% in Malaysia, 36.2% in Sri Lanka Lanka and Malaysia 7.1% and 7.3%, respectively, and 61.4% in Thailand. Occupation-related acciden- had suffered an episode of poisoning during the tal poisonings were only 1.9% of cases in Indonesia previous year, compared with only 0.3 % in Indonesia and as high as 31.9% in Sri Lanka. Unintentional (Table 2); there was no result for Thailand as this poisonings of non-occupational origin varied from particular question had by mistake been omitted. 0% in Indonesia to 28.7% in Sri Lanka. However, in Table 2 also shows that the proportion of pesticide Indonesia 35.5 % of the clinical records did not give a users ever poisoned was reasonably similar in the reason for the poisoning. four countries (range, 11.9% to 19.4%). The major classes of pesticides responsible for The cause of the pesticide poisoning among hospi- poisoning among patients admitted to the hospitals tal admissions was identified in the hospital records are shown in Table 4. In Malaysia and Sri Lanka (Table 3). Suicides accounted for 62.6% of cases in organophosphorus compounds were mostly respon-
  • 4. 524 J. JEYARATNAM ET AL. Table 5. Preferred source of treatment among pesticide users ever poisoned Hospital or western medical Indigenous Information Country practitioners practitioner Self-treatment No treatment not available Total Indonesia 97 (14.3) 1 (2.0) 6 (12.2) 4 (8.2) 31 (63.3) 49 (100) Malaysia 263 (45.5) 2 (0.3) 24 (4.2) 287 (49.6) 2 (0.3) 578 (99.9) Sri Lanka 63 (40.1) 3 (1.9) 55 (35.0) 36 (22.9) 0 (0) 157 (99.9) Thailand 37 (9.2) 4 (1.0) 66 (16.3) 297 (73.5) 0 (0) 404 (100) a Figures in parentheses are percentages. sible (53.6% and 69.1 % of cases, respectively). In early symptoms of pesticide poisoning were given in Thailand the bipyridyls were responsible for 25 % of Indonesia by only 8.2% compared with 67.5% in cases, compared with 22.7% due to organophos- Malaysia, 47.3 % in Sri Lanka and 70.3 % in Thailand. phorus compounds. In Indonesia the hospital case With regard to the usual route of absorption of notes often did not indicate the type of pesticide pesticides, in all countries the dermal route was responsible for the poisoning; from the available identified as the least important, inhalation as most information it appears that copper compounds were important, and the oral route between the two. responsible for 23.4 % of cases and organophosphorus Protective measures against pesticide poisoning were compounds for only 17.8 %. taken by 82.8% of users in Indonesia, the respective With regard to treatment after the poisoning, it figures for Malaysia, Sri Lanka and Thailand being appears that the majority either treated themselves or 95.2 %, 99.5 % and 53.4 %. took no treatment; in other cases the local hospital The activities identified by the pesticide users or western medical practitioners were preferred which resulted in poisoning included spraying using (Table 5). knapsack spray equipment, mixing and diluting of Table 6 shows the extent of awareness among pesticides, and repairing or cleaning of spray equip- pesticide users that pesticides were a health hazard ment. In all four countries spraying, mixing and and about the route of absorption into the body. In diluting of pesticides were the most frequently Indonesia, only 3 1.8 % stated that they were aware of identified activities associated with poisoning. In the route of absorption, compared with > 90% in the Indonesia, only 5. 1 % of pesticide users used overalls, other countries. In Indonesia 26.2% stated that they 9.3 % used a respirator/mask, and 9.3 % used gloves. were aware that pesticides were a health hazard, In Malaysia, 14.7% used overalls, 11.5% used a compared with 67.2-87.5% in the other countries. respirator/mask, and 95 % used gloves. In Sri Lanka, Positive replies concerning their awareness of the 26.8% used overalls, 40.8% used a respirator/mask, and 7.1 % used gloves. In Thailand, 67% used overalls, 18% used a respirator/mask, and 5.2% used gloves. With regard to the sources of information available to pesticide users about the safe use of pesticides, Table 6. Extent of the pesticide users' knowledge about it appeared that in Indonesia retail outlets were the health hazards of pesticides and the need for identified more often than information passed on by protection fellow farmers or agricultural officers. In Malaysia the majority of pesticide users stated that no one had Knew that Used specifically told them about the safe use of pesticides, Knew the route pesticides are protective Country of absorption a health hazard measures while some heard of it from retail outlets or from other farmers. In Sri Lanka the agricultural officers Indonesia 1 13 (31.8) a 93 (26.2) 294 (82.8) and, to a lesser extent, farmers provided this Malaysia 3600 (90.0) 3429 (85.7) 3810 (95.2) information but a good proportion of workers were Sri Lanka 1195 (90.7) 1017(77.2) 1311 (99.5) not told by anyone. In Thailand, other farmers and Thailand 1955 (94.9) 1384 (67.2) 1102 (53.4) retail outlets were identified as the source of information; here also many workers claimed that no a Figures in parentheses are percentages. one provided them with this information.
  • 5. PESTICIDE POISONING IN FOUR ASIAN COUNTRIES 525 DISCUSSION and non-occupational, are mostly preventable, even in developing countries; this problem in the industrial- The present study is an attempt to estimate the ized countries, despite the extensive use of pesticides, extent of acute pesticide poisoning among agri- has been controlled by appropriate safeguards.' cultural workers who use pesticides. Previous studies While the organophosphorus compounds were fre- in the same countries had depended on hospital quently responsible for the poisoning, it is discon- records (3, 4) without particular reference to a base- certing that in Indonesia, Sri Lanka and Thailand the line population. class of pesticide responsible for the poisoning was Pesticide users among agricultural workers in the often not identified. Whatever the reasons for this, it countries studied ranged from 29.8% in Indonesia to must create problems in the treatment and manage- 91.9% in Malaysia. The extent of pesticide usage ment of patients and increase the case fatality. In a among agricultural workers is probably influenced by previous study in Sri Lanka, a high case fatality rate the nature of the crops and agricultural practices. For (28.5%) was noted among patients where no infor- instance, in Indonesia these workers were mostly mation was available on the class of pesticides (3). cultivating paddy while in Malaysia they were The instances of acute poisoning reported by the engaged in the cultivation of cash crops that require pesticide users could not be related to the hospital more frequent use of pesticides. A similar variation in admissions for acute poisoning because the study the extent of pesticide usage depending on the nature periods were not the same -in 1984 and 1983, of the crop may be seen in a study in the Netherlands respectively. While a large majority of the episodes of (5), where pesticides were identified as a problem by acute poisoning recorded by the users must have been 76% of workers in arable farms, 85 % of workers in very mild because they improved with either no treat- glass-house nurseries, 83 % of workers in outdoor ment or self-treatment, it must be recognized that each horticulture, and 92 % of workers in mushroom one represents a failure of prevention and could have farming. been serious. Although the approach of questioning pesticide The study demonstrates that in all four countries users as to whether, in their opinion, they had ever occupation-related acute pesticide poisoning presents suffered from acute pesticide poisoning is not fool- a major problem in the communities studied. Specific proof, the results showed that illness, presumably due attention should therefore be focused on the to acute pesticide poisoning, was directly related to prevention of such poisoning; some of the factors the workers' immediately previous use and exposure contributing to this problem are discussed below. to pesticides. The problem in the four countries Because spraying and the mixing or diluting of studied appears to be reasonably similar, 10-20% of pesticides were the two most frequently associated pesticide users considering themselves to have suf- occupational activities resulting in poisoning, special fered an episode of pesticide poisoning at some time attention has to be paid to them, a view endorsed by during their working life (Table 2). Each episode Copplestone who states, "we are more likely to be reflects a failure in the prevention of poisoning among effective in preventing accidentAl poisoning by pesti- pesticide users. Further, in Malaysia and Sri Lanka it cides if we concentrate our activities in relevant terms was observed that 2-7 % of pesticide users stated that on those areas where hazard is really high than by this illness occurred in the previous year (Table 2), trying to give blanket coverage to all pesticide users" which is an unacceptably high level for an occupa- (7). One of the important factors contributing to acci- tional hazard. The low result from Indonesia (0.08 %) dental acute pesticide poisoning was malfunctioning for poisoning in the preceding year is atypical, spray equipment which resulted in contamination of compared with the previous years, and is probably the the workers' skin surface with pesticides (8). It is in result of an interview error. this context that the extent of the pesticide users' Among the patients admitted to hospital, suicide knowledge on safe use of pesticides was examined. was the leading cause of acute pesticide poisoning But although a large proportion of users, except in in all the countries (Table 3), a feature reported Indonesia, were ofthe opinion that they knew the route previously (3, 6). Except in Indonesia, unintentional of absorption of pesticides and the early symptoms of poisonings of occupational and non-occupational acute poisoning, it was evident that the content of their origin were responsible for 9-32 % of cases of knowledge was inadequate to prevent pesticide poisoning. The relatively low figures for unintentional poisoning. For instance, in all the countries the users poisoning in Indonesia and Thailand are probably due considered inhalation to be the most important route to the fact that for 35.5 % of patients in Indonesia and while pesticide absorption through the skin was less 15.9% in Thailand the case records did not indicate the important. In fact, there is substantial evidence to immediate circumstances of the poisoning. Such unintentional pesticide poisonings, both occupational See footnote b.
  • 6. 526 J. JEYARATNAM ET AL. show that dermal absorption is by far the most Lanka were agricultural officers identified as a important, and that absorption by inhalation is frequent source of information. The implication of this relatively unimportant (9, 10). This misconception finding is that in these countries most of the infor- among pesticide users must be corrected through mation available to pesticide users is not provided on educational programmes on the safe use of pesticides. an officially organized basis. None of the countries Similarly, a large proportion of pesticide users had any legislative controls requiring pesticide users thought that adequate protective measures were being to be formally trained in safe work practices, which taken when actually, except for Thailand, these contrasts sharply with the situation in the measures were not extensively used or their efficacy industrialized world (11). As an interim measure, all was questionable. This is evident in the observations countries without formal training requirements may of the principal national investigator for Sri Lanka consider enforcing these requirements, at least in who wrote that the protective clothing worn was order to control and train the users of pesticides inadequate for prevention of pesticide absorption: a grouped under classes lA and lB of the WHO classi- handkerchief or shawl was used as a mask, polythene fication by hazards.d bags were tied round the hands or feet, open slippers or The large problem of acute pesticide poisoning in old shoes, and a turban or old cotton hat on the head; the four countries studied requires to be controlled. In the forearms, face and head were usually exposed. Al- the first instance, education and a training programme though cotton overalls do provide adequate protection on the safe use of pesticides for occupationally provided they are washed daily, this was not the exposed workers will have to be instituted; govern- practice in Sri Lanka. ments should recognize this problem and make every With regard to the available sources of information effort to contain it. The primary health care approach on the safe use of pesticides, in all four countries a appears to be most suitable to overcome the problem significant proportion of pesticide users could not (12). identify a specific source of information. When d 7he WHO recommended classification ofpesticides by hazard information was available, it often came from other and guidelines to classification. Unpublished WHO document, farmers and retail outlets; only in Malaysia and Sri VBC/84.2. ACKNOWLEDGEMENTS This study was undertaken on behalf of the Asian Association on Occupational Health and was funded by the International Development Research Centre (IDRC) of Canada. We are very grateful to Dr Dae-Woo Han, the regional representative in health sciences, Asia Regional Office, IDRC, for his help and support throughout the study. We also thank the principal national investigators, Dr P. K. Suma'mur (Indonesia), Dr R. Mahathevan (Malaysia), Dr M. Rajendra (Sri Lanka) and Professor Malinee Wongphanich (Thailand), for the valuable work in their countries and Miss P. C. Lim for secretarial help. RESUME ENQUETE SUR. L'INTOXICATION AIGUE PAR LES PESTICIDES CHEZ LES TRAVAILLEURS AGRICOLES DANS QUATRE PAYS D'ASIE Cette etude a ete entreprise pour evaluer I'ampleur de repandue parmi les utilisateurs de pesticides que parmi les l'intoxication aigue par les pesticides ainsi que les facteurs autres travailleurs agricoles. qui y contribuent dans plusieurs communautes agricoles L'analyse des registres des hopitaux a montre que dans les d'Indonesie, de Malaisie, de Sri Lanka et de Thailande. quatre pays, la tentative de suicide etait la cause la plus L'etude a porte sur 1192 travailleurs agricoles en Indondsie, frequente d'intoxication aigue par les pesticides. L'intoxi- 4351 en Malaisie, 3439 a Sri Lanka et 4971 en Thaflande. cation accidentelle, tant professionelle que non profession- La proportion des travailleurs agricoles qui ont d6clare qu'a nelle, etait a l'origine d'une proportion notable des hospi- leur avis ils ont souffert d'un 6pisode d'intoxication aigue au talisations sauf en Indonesie ou elle n'intervenait que pour cours de leur vie professionnelle etait de 4,1 % en Indonesie, 1,9% des admissions; elle etait a l'origine de 32,2% des cas 13,3 % en Malaisie, 4,6 % a Sri Lanka et 8,1 % en Thalilande. en Malaisie, 60,6% des cas a Sri Lanka et 22,7% des cas en On a egalement observe que l'intoxication dtait plus Thadlande. En Malaisie et a Sti Lanka, les pesticides le plus
  • 7. PESTICIDE POISONING IN FOUR ASIAN COUNTRIES 527 souvent incrimin6s etaient les organophosphores, alors n6cessaires pour eviter une intoxication. Toutefois, un qu'en Thallande, les bipyridyles etaient responsables de interrogatoire plus approfondi a montre que ces connais- 25,0% des intoxications, suivis par les organophosphores sances etaient souvent erronees. De plus, sauf a Sri Lanka (22,7%). En ce qui concerne l'Indonesie, les donnees oii les fonctionnaires des services agricoles etaient souvent disponibles montrent par contre que les composes a base de mentionnes comme dispensateurs d'information au sujet de cuivre occupaient la premiere place avec 23,4% des cas, la securite d'emploi des pesticides, les travailleurs agricoles contre seulement 17,8% pour les organophosphor6s. ont d6signe comme source principale d'information les Sauf en Indon6sie, une forte proportion d'utilisateurs agriculteurs ou les detaillants. de pesticides estimaient qu'ils avaient les connaissances REFERENCES 1. THE WORLD BANK. World development report 1980. pesticide application. Amsterdam, Elsevier, 1982, pp. New York, Oxford University Press, 1980. 59-64. 2. Steering Committee on Pest Control Under the 8. JEYARATNAM, J. Health hazards awareness of pesticide Conditions of Small Farmer Food Crop Production in applicators about pesticides. In: Education and safe Developing Countries. Report. Paris, OECD, 1977. handling in pesticide application. Amsterdam, 3. JEYARATNAM, J. ET AL. Survey of pesticide poisoning Elsevier, 1982, pp. 23-30. in Sri Lanka. Bulletin of the World Health 9. KOLMODIN-HEDMAN, B. ET AL. Studies in phenoxy acid Organization, 60: 615-619 (1982). herbicides in agriculture. Archives of toxicology, 54: 4. BULL, D. A growing problem. Pesticides and the 7hird 257-265 (1983). World poor. Oxford, Oxfam, 1982. 10. AKERBLOM, M. ET AL. Studies of occupational 5. BIERSTEKER, K. ET AL. A postal survey of health and exposure to phenoxy acid herbicides. In: IUPACpesti- working conditions of Dutch farmers. In: Proceedings cide chemistry -human welfare and the environment. of the 9th International Congress of Agricultural Oxford, Pergamon, 1983, pp. 227-232. Medicine and Rural Health, Christchurch, New 11. FRANKLIN, C. A. & MUIR, N. I. Education and Zealand. Vol. 1, 10-14 September 1984. licensing procedures for pesticide applicators and 6. AMARASINGHAM, R. D. & Ti, T. H. A review of vendors in Canada. In: van Heemstra, E. A. H. & poisoning cases examined by the Department of Chem- Tordoir, W. F., ed. Education and safe handling in istry, Government of Malaysia, Malaysia, from 1968 to pesticide application. Amsterdam, Elsevier, 1982, 1972. Medical journal of Malaysia, 30: 185-193 pp. 89-104. (1976). 12. JEYARATNAM, J. Editorial: Health problems of 7. COPPLESTONE, J. F. Problems in education on the safe pesticide usage in the Third World. British journal of handling of pesticides. In: van Heemstra, E. A. H. & industrial medicine, 42: 505-506 (1985). Tordoir, W. F., ed. Education and safe handling in