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Bossou YM, Côté J, Morin É, Dumais É, Bianchi C, Bouchard M. Assessing the impact of coexposure on the measurement of biomarkers of exposure to the pyrethroid lambda-cyhalothrin in agricultural workers. Int J Hyg Environ Health 2023; 251:114194. [PMID: 37290330 DOI: 10.1016/j.ijheh.2023.114194] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/26/2023] [Accepted: 05/24/2023] [Indexed: 06/10/2023]
Abstract
There are few published data on the impact of combined exposure to multiple pesticides (coexposure) on levels of biomarkers of exposure in workers, which may alter their toxicokinetics and thus the interpretation of biomonitoring data. This study aimed to assess the impact of coexposure to two pesticides with shared metabolism pathways on levels of biomarkers of exposure to pyrethroid pesticides in agricultural workers. The pyrethroid lambda-cyhalothrin (LCT) and the fungicide captan were used as sentinel pesticides, since they are widely sprayed concomitantly in agricultural crops. Eighty-seven (87) workers assigned to different tasks (application, weeding, picking) were recruited. The recruited workers provided two-consecutive 24-h urine collections following an episode of lambda-cyhalothrin application alone or in combination with captan or following tasks in the treated fields, as well as a control collection. Concentrations of lambda-cyhalothrin metabolites - 3-(2-chloro-3,3,3-trifluoroprop-1-en-1-yl)-2,2-dimethyl-cyclopropanecarboxylic acid (CFMP) and 3-phenoxybenzoic acid (3-PBA) - were measured in the samples. Potential determinants of exposure established in a previous study, including the task performed and personal factors were documented by questionnaire. Multivariate analyses showed that coexposure did not have a statistically significant effect on the observed urinary levels of 3-PBA (Exp(β) (95% confidence interval (95% CI)): 0.94 (0.78-1.13)) and CFMP (1.10 (0.93-1.30). The repeated biological measurements ("time variable") - defined as the within-subjects variable - was a significant predictor of observed biological levels of 3-PBA and CFMP; the within-subjects variance (Exp(β) (95% (95% CI)) for 3-PBA and CFMP was 1.11 (1.09-3.49) and 1.25 (1.20-1.31). Only the main occupational task was associated with urinary levels of 3-PBA and CFMP. Compared to the weeding or picking task, the pesticide application task was associated with higher urinary 3-PBA and CFMP concentrations. In sum, coexposure to agricultural pesticides in the strawberry fields did not increase pyrethroid biomarker concentrations at the exposure levels observed in the studied workers. The study also confirmed previous data suggesting that applicators were more exposed than workers assigned to field tasks such as weeding and picking.
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Affiliation(s)
- Yélian Marc Bossou
- Department of Environmental and Occupational Health, Chair in Toxicological Risk Assessment and Management, and Public Health Research Center (CReSP), University of Montreal, Roger-Gaudry Building, U436, P.O. Box 6128, Main Station, Montreal, Quebec, H3C 3J7, Canada
| | - Jonathan Côté
- Department of Environmental and Occupational Health, Chair in Toxicological Risk Assessment and Management, and Public Health Research Center (CReSP), University of Montreal, Roger-Gaudry Building, U436, P.O. Box 6128, Main Station, Montreal, Quebec, H3C 3J7, Canada
| | - Éloïse Morin
- Department of Environmental and Occupational Health, Chair in Toxicological Risk Assessment and Management, and Public Health Research Center (CReSP), University of Montreal, Roger-Gaudry Building, U436, P.O. Box 6128, Main Station, Montreal, Quebec, H3C 3J7, Canada
| | - Étienne Dumais
- Department of Environmental and Occupational Health, Chair in Toxicological Risk Assessment and Management, and Public Health Research Center (CReSP), University of Montreal, Roger-Gaudry Building, U436, P.O. Box 6128, Main Station, Montreal, Quebec, H3C 3J7, Canada
| | - Clara Bianchi
- Department of Environmental and Occupational Health, Chair in Toxicological Risk Assessment and Management, and Public Health Research Center (CReSP), University of Montreal, Roger-Gaudry Building, U436, P.O. Box 6128, Main Station, Montreal, Quebec, H3C 3J7, Canada
| | - Michèle Bouchard
- Department of Environmental and Occupational Health, Chair in Toxicological Risk Assessment and Management, and Public Health Research Center (CReSP), University of Montreal, Roger-Gaudry Building, U436, P.O. Box 6128, Main Station, Montreal, Quebec, H3C 3J7, Canada.
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Antonangeli LM, Kenzhebekova S, Colosio C. Neurobehavioral Effects of Low-Dose Chronic Exposure to Insecticides: A Review. TOXICS 2023; 11:192. [PMID: 36851066 PMCID: PMC9963921 DOI: 10.3390/toxics11020192] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 02/15/2023] [Accepted: 02/17/2023] [Indexed: 06/18/2023]
Abstract
The modes of action of insecticides frequently involve a neurotoxic effect; therefore, the study of neurotoxic effects caused by long-term and low-dose insecticide exposure is of particular interest. This study looks at whether or not new studies conducted after 2009 and up to 2021 have provided new evidence for a better understanding of the actual neurobehavioral risk associated with long-term insecticide exposure. We selected and reviewed studies carried out on the neurobehavioral effects of neurotoxic insecticides (organophosphates and/or carbamates, pyrethroids, multiple or undefined insecticides, and organochlorines) considering occupational and non-occupational exposures. The articles were also scored and ranked based on seven parameters. Eighty-six studies were chosen for a final review process from among the 950 scientific papers identified. Twenty-six addressed occupational exposure and six environmental exposure. Among the latter group of studies, 17 focused on rural residents, to be assumed exposed because of living in rural areas, and 43 on the general population. Pending doubts have not been resolved in the last ten years due to the presence of contradictory and hardly comparable results and the fact that in most of the studies showing an evident neurobehavioral impairment the frequent presence of a previous episode of poisoning and hospitalization, with severe brain hypoxia, impaired the possibility of confirming the presence of a causal association with insecticide exposure. Interestingly, the most severely exposed groups, such as applicators who did not wear personal protective equipment, performed worse on neurobehavioral tests. As for residential exposure, there is sufficient evidence to suggest that prenatal OP exposure may increase the risk of ADHD in children.
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Affiliation(s)
| | - Saniya Kenzhebekova
- Department of Health Sciences, University of Milan, International Centre for Rural Health of the Santi Paolo e Carlo ASST of Milan, 20142 Milano, Italy
| | - Claudio Colosio
- Department of Health Sciences, University of Milan, International Centre for Rural Health of the Santi Paolo e Carlo ASST of Milan, 20142 Milano, Italy
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Eadeh HM, Ismail AA, Abdel Rasoul GM, Hendy OM, Olson JR, Wang K, Bonner MR, Rohlman DS. Evaluation of occupational pesticide exposure on Egyptian male adolescent cognitive and motor functioning. ENVIRONMENTAL RESEARCH 2021; 197:111137. [PMID: 33839119 PMCID: PMC8187303 DOI: 10.1016/j.envres.2021.111137] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 03/15/2021] [Accepted: 04/03/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Chronic low-level exposure to organophosphorus pesticides is associated with adverse health effects, including a decline in neurological functioning and long-term impairment. These negative effects may be more detrimental in children and adolescents due to their critical stage in development. Little work has investigated the effects of chronic exposure to pesticides, specifically chlorpyrifos (CPF) during the adolescent period. OBJECTIVES To examine effects of CPF exposure over a year-long period within a group of male adolescents in Egypt (N = 242, mean age = 17.36), including both pesticide applicators and non-applicators. METHODS Associations between average CPF exposure (measured via urinary metabolite levels of 3,5,6-trichloro-2-pyridinol [TCPy]) and neurobehavioral functioning were examined in a 1-year longitudinal study. Given previous literature, higher levels of TCPy were expected to be associated with worse neurobehavioral functioning. RESULTS Using mixed effects linear regression, average TCPy exposure predicted deficits in more complex neurobehavioral tasks (Benton visual retention, digit span reverse, match to sample, serial digit learning, and alternating tapping) with estimates of effects ranging from -0.049 to 0.031. Age (effects ranging from 0.033 to 0.090) and field station (effects ranging from -1.266 to -0.278) were significantly predictive of neurobehavioral functioning over time. An interaction effect was found for field station and TCPy across several neurobehavioral domains. DISCUSSION Results show that occupational exposure to pesticides may have particularly deleterious effects on complex neurobehavioral domains. Additionally, differences across field stations and the age at which individuals are exposed may be important factors to investigate in future research.
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Affiliation(s)
- Hana-May Eadeh
- Department of Psychological and Brain Sciences, University of Iowa, Iowa City, IA, USA.
| | - Ahmed A Ismail
- Department of Occupational and Environmental Health, University of Iowa, Iowa City, IA, USA; Community, Environmental, and Occupational Medicine Department, Faculty of Medicine, Menoufia University, Shebin Elkom, Egypt
| | - Gaafar M Abdel Rasoul
- Community, Environmental, and Occupational Medicine Department, Faculty of Medicine, Menoufia University, Shebin Elkom, Egypt
| | - Olfat M Hendy
- Department of Clinical Pathology, National Liver Institute, Menoufia University, Shebin Elkom, Egypt
| | - James R Olson
- Department of Pharmacology and Toxicology, State University of New York at Buffalo, Buffalo, NY, USA; Department of Epidemiology and Environmental Health, State University of New York at Buffalo, Buffalo, NY, USA
| | - Kai Wang
- Department of Biostatistics, University of Iowa, Iowa City, IA, USA
| | - Matthew R Bonner
- Department of Epidemiology and Environmental Health, State University of New York at Buffalo, Buffalo, NY, USA
| | - Diane S Rohlman
- Department of Occupational and Environmental Health, University of Iowa, Iowa City, IA, USA
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Scott NB, Pocock NS. The Health Impacts of Hazardous Chemical Exposures among Child Labourers in Low- and Middle-Income Countries. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:5496. [PMID: 34065553 PMCID: PMC8160821 DOI: 10.3390/ijerph18105496] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/30/2021] [Accepted: 05/05/2021] [Indexed: 12/21/2022]
Abstract
Of 218 million working children worldwide, many are suspected to be exposed to hazardous chemicals. This review aims to synthesize reported evidence over the last two decades on chemical exposure and adverse health consequences in children labourers in low- and middle-income Countries (LMIC). Included studies investigated health outcomes related to chemical exposures among child labourers aged 5-18 in LMIC. Twenty-three papers were selected for review, focusing on pesticides (n = 5), solvents (n = 3), metals (n = 13) and persistent organic pollutants (POPs) (n = 2). Adverse health effects identified among child labourers included abnormal biomarkers, for example elevated blood and urine chemical concentrations, neurobehavioural deficits and neurological symptoms, mental health issues, oxidative stress and DNA damage, poor growth, asthma, and hypothyroidism. Workplace exposure to chemicals has pernicious health effects on child labourers. Large research gaps exist, in particular for long-term health impacts through chronic conditions and diseases with long latencies. A sizeable disease burden in later life is likely to be directly attributable to chemicals exposures. We urge national and international agencies concerned with child labour and occupational health, to prioritize research and interventions aiming to reduce noxious chemical exposures in workplaces where children are likely to be present.
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Affiliation(s)
| | - Nicola S. Pocock
- Lumos Foundation, London EC3R 8NB, UK;
- Gender Violence & Health Centre, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
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Chetty-Mhlanga S, Fuhrimann S, Basera W, Eeftens M, Röösli M, Dalvie MA. Association of activities related to pesticide exposure on headache severity and neurodevelopment of school-children in the rural agricultural farmlands of the Western Cape of South Africa. ENVIRONMENT INTERNATIONAL 2021; 146:106237. [PMID: 33171379 DOI: 10.1016/j.envint.2020.106237] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 10/10/2020] [Accepted: 10/22/2020] [Indexed: 05/27/2023]
Abstract
OBJECTIVE Children and adolescents living in agricultural areas are likely to be exposed to mixtures of pesticides during their daily activities, which may impair their neurodevelopment. We investigated various such activities in relation to headache severity and neurodevelopment of school-children living in rural agricultural areas in the Western Cape of South Africa. METHOD We used baseline date from 1001 school-children of the Child Health Agricultural Pesticide Cohort Study in South Africa (CapSA) aged 9-16 from seven schools and three agriculture areas in the Western Cape. Questionnaires were administrated to assess activities related to pesticide exposure and health symptoms addressing four types of activities: 1) child farm activities related to pesticide handling, 2) eating crops directly from the field, 3) contact with surface water around the field, and 4) seen and smelt pesticide spraying activities. Neurocognitive performance across three domains of attention, memory and processing speed were assessed by means of an iPad-based cognitive assessment tool, Cambridge Automated NeuroPsychological Battery (CANTAB). Headache severity was enquired using a standard Headache Impact Test (HIT-6) tool. Cross-sectional regression analysis was performed. RESULTS About 50% of the cohort report to have ever been engaged in activities related to pesticide exposure including farm activities, eating crops directly from the field and leisure activities. Headache severity score was consistently increased in relation to pesticide-related farm activities (score increase of 1.99; 95% CI: 0.86, 3.12), eating crops (1.52; 0.41, 2.67) and leisure activities of playing, swimming or bathing in nearby water (1.25; 0.18, 2.33). For neurocognitive outcomes, an overall negative trend with pesticide exposure-related activities was observed. Among others, involvement in pesticide-related farm activities was associated with a lower multi-tasking accuracy score (-2.74; -5.19, -0.29), while lower strategy in spatial working memory (-0.29; -0.56; -0.03) and lower paired associated learning (-0.88; -1.60, -0.17) was observed for those who pick crops off the field compared to those who do not pick crops off the field. Eating fruits directly from the vineyard or orchard was associated with a lower motor screening speed (-0.06; -0.11, -0.01) and lower rapid visual processing accuracy score (-0.02; -0.03, 0.00). CONCLUSIONS Children who indicate activities related to pesticide exposure may be at higher risk for developing headaches and lower cognitive performance in the domains of attention, memory and processing speed. However, self-reported data and cross-sectional design are a limitation. Future research in CapSA will consider pesticide exposure estimations via urinary biomarkers and longitudinal assessment of cognitive functions.
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Affiliation(s)
- Shala Chetty-Mhlanga
- Centre for Environment and Occupational Health Research, School of Public Health and Family Medicine, University of Cape Town, South Africa; Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Switzerland.
| | - Samuel Fuhrimann
- Institute for Risk Assessment Sciences (IRAS), Utrecht University, 3584 Utrecht, Netherlands.
| | - Wisdom Basera
- Centre for Environment and Occupational Health Research, School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - Marloes Eeftens
- Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Switzerland.
| | - Martin Röösli
- Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Switzerland.
| | - Mohamed Aqiel Dalvie
- Centre for Environment and Occupational Health Research, School of Public Health and Family Medicine, University of Cape Town, South Africa.
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Sears L, Sears CG, Myers JV, Brock GN, Zierold KM. Associations of the Behavioral Assessment and Research System (BARS) neurobehavioral outcomes with attention problems in children living near coal ash storage sites. Neurotoxicology 2020; 81:11-17. [PMID: 32810513 DOI: 10.1016/j.neuro.2020.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 07/26/2020] [Accepted: 08/10/2020] [Indexed: 10/23/2022]
Abstract
Environmental exposures have been linked to childhood problems with overactivity, attention, and impulse control, and an increased risk of attention deficit hyperactivity disorder (ADHD) diagnosis. Two approaches to identify these types of exposure-related neurobehavioral problems include the use of computerized tests, such as the Behavioral Assessment and Research System (BARS), as well as the use of behavior rating scales. To assess comparability of these two types of measures, we analyzed data from 281 children aged 6 to 14 years enrolled in a 5-year research study investigating coal ash exposure and neurobehavioral health. All children lived in proximity of coal ash storage sites. We administered six computer tests from the BARS and obtained behavior measures from the parent-completed Child Behavior Checklist (CBCL) ADHD DSM oriented scale. BARS test performance was associated with age indicating that the tests could be used to evaluate neurodevelopmental changes over time or across a wide age range. Tests within the BARS including Continuous Performance (CPT) false alarm (standardized estimate 1.57, 95% confidence interval (CI) (0.67, 2.48), adjusted p = 0.006), Selective Attention (SAT) wrong count (standardized estimate 2.8, 95% CI (1.17, 4.44), adjusted p = 0.006), and SAT proportion correct (standardized estimate -2.45, 95% CI (-4.01, -0.88), adjusted p = 0.01) were associated with attention and impulse control problems on the CBCL after adjustment for multiple comparisons. Findings support that the BARS can contribute to research on environmental exposures by assessing subclinical behaviors related to ADHD such as sustained attention, impulse control, response inhibition, associative learning, and short-term memory. Future research can examine relationships of these BARS measures with biomarkers of neurotoxic exposures related to living near coal ash storage sites to better identify the potential risk for ADHD-related behaviors among children living near coal ash storage sites.
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Affiliation(s)
- Lonnie Sears
- Department of Pediatrics, University of Louisville, Louisville, Kentucky, USA.
| | - Clara G Sears
- Department of Epidemiology, Brown University, Providence, Rhode Island, USA.
| | - John V Myers
- Department of Biomedical Informatics and Center for Biostatistics, The Ohio State University, Columbus, Ohio, USA.
| | - Guy N Brock
- Department of Biomedical Informatics and Center for Biostatistics, The Ohio State University, Columbus, Ohio, USA.
| | - Kristina M Zierold
- Department of Environmental Health Sciences, University of Alabama at Birmingham, Birmingham, Alabama, USA.
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Ramírez-Santana M, Zúñiga-Venegas L, Corral S, Roeleveld N, Groenewoud H, van der Velden K, Scheepers PTJ, Pancetti F. Association between cholinesterase's inhibition and cognitive impairment: A basis for prevention policies of environmental pollution by organophosphate and carbamate pesticides in Chile. ENVIRONMENTAL RESEARCH 2020; 186:109539. [PMID: 32361078 DOI: 10.1016/j.envres.2020.109539] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 03/18/2020] [Accepted: 04/14/2020] [Indexed: 05/28/2023]
Abstract
BACKGROUND In Chile organophosphate pesticides are widely used in the production of fruits. Pesticides use is regulated for professional practice but there is no regulation regarding exposure to the general population. OBJECTIVE To relate exposure to cholinesterase's inhibitor pesticides during the spray season with neuropsychological impairment in occupationally exposed (OE) and environmentally exposed (EE) groups of people. METHODS Exposure was assessed through inhibition of acetylcholinesterase (AChE) and butyrylcholinesterase (BChE) activity and neuropsychological outcomes were evaluated through a large battery of tests covering general mental status, language, memory, attention, executive function, praxis and psychomotricity. Evaluations were carried out firstly in a period of no/low organophosphate pesticide use and subsequently during the spray season. All parameters were calculated as the relative change from baseline to spray season. RESULTS For this study in total 156 participants were recruited divided equally over participants with environmental exposures (EE) and participants with occupational exposure (OE). In the EE, BChE's enzyme activity inhibition ≥30% showed significant association with 10% or more decreased performance in several tests evaluating six of the eight cognitive areas (excepting psychomotricity and mood status); besides, for AChE inhibition in EE, the association was significant in three tests evaluating attention and one of executive function. Whereas, in OE, the inhibition of the BChE ≥30% was associated with a low performance of one attention test and for AChE the exceedance of the standard was associated with diminished performance in one test of memory and attention, respectively. The association between biomarkers of biological effect and cognitive impairment persisted among the EE group after removing confounders. No association was found between biomarkers of biological acute effect and decreased cognitive performance in the OE group. CONCLUSIONS Increased exposure to pesticides was confirmed by increased inhibition of cholinesterase's in both exposure groups; which was associated with a diminished neuropsychological performance, mainly in the environmentally exposed study group. [310 words].
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Affiliation(s)
- Muriel Ramírez-Santana
- Department of Public Health, Faculty of Medicine, Universidad Católica del Norte, Coquimbo, Chile. PhD Student Radboud University Medical Center, Nijmegen, the Netherlands; Radboud Institute for Health Sciences, Radboud University Medical Center, Radboudumc, Nijmegen, the Netherlands.
| | - Liliana Zúñiga-Venegas
- Laboratory of Biomedical Investigations, Faculty of Medicine, Universidad Católica del Maule, Talca, Chile; Neuropsychology and Cognitive Neurosciences Research Center (CINPSI Neurocog).Universidad Católica del Maule, Talca, Chile
| | - Sebastián Corral
- Laboratory of Translational Psychiatry, Department of Psychiatry and Mental Health. Faculty of Medicine, Universidad de Chile, Santiago, Chile; Facultad de Psicología, Universidad San Sebastián, Santiago, Chile
| | - Nel Roeleveld
- Radboud Institute for Health Sciences, Radboud University Medical Center, Radboudumc, Nijmegen, the Netherlands
| | - Hans Groenewoud
- Radboud Institute for Health Sciences, Radboud University Medical Center, Radboudumc, Nijmegen, the Netherlands
| | - Koos van der Velden
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Paul T J Scheepers
- Radboud Institute for Health Sciences, Radboud University Medical Center, Radboudumc, Nijmegen, the Netherlands
| | - Floria Pancetti
- Laboratory of Environmental Neurotoxicology, Faculty of Medicine, Universidad Católica del Norte, Coquimbo, Chile
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Rohlman DS, Davis JW, Ismail A, Abdel Rasoul GM, Hendy O, Olson JR, Bonner MR. Risk perception and behavior in Egyptian adolescent pesticide applicators: an intervention study. BMC Public Health 2020; 20:679. [PMID: 32404149 PMCID: PMC7222587 DOI: 10.1186/s12889-020-08801-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 04/28/2020] [Indexed: 11/22/2022] Open
Abstract
Background Adolescents are engaged in agricultural work, including pesticide application, around the world. Adolescent pesticide applicators are more likely to be exposed to pesticides than their adult counterparts because of their application practice and hygiene habits surrounding pesticide use. There is a need for low-cost interventions to reduce pesticide exposure. We evaluated a theoretically-based educational intervention to change perceptions about the risk of pesticide use and hygiene habits during and after pesticide application for adolescent and young adult pesticide applicators in Egypt. Methods Young adult and adolescent male pesticide applicators were given a one-hour educational intervention to inform them about the risk of pesticide use and how to reduce pesticide exposure. The median age of participants was 18 years old. Changes in perceived susceptibility and effectiveness were measured with a survey pre and post-intervention (n = 119) on the same day. The same survey (n = 95) was given 8-months post-intervention to identify sustained effects. Observational checklists of pesticide application practice were also completed during application seasons before and after the intervention. Results There was an increase in the proportion of individuals who viewed pesticides as being a long-term health risk (74.7% pre-intervention to 97.9% post-intervention, McNemar test p < 0.001). This change remained significant when surveyed at the 8-month follow-up (90.5%, p < 0.001). There was also a sustained improvement regarding participants’ views of proper hygiene practice surrounding pesticide application. Applicators were observed wearing goggles, shoes, and masks more frequently post-intervention. Conclusion This theoretically-based intervention is an example of a low-cost solution that can improve adolescents’ and young adults’ practices regarding pesticide application and personal hygiene practices during and after pesticide application. The intervention can be applied in other countries with similar safety culture surrounding pesticide application.
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Affiliation(s)
- Diane S Rohlman
- Occupational and Environmental Health, University of Iowa, 145 N. Riverside Drive, Iowa City, IA, 52242, USA. .,Oregon Health and Science University, Portland, OR, USA.
| | - Jonathan W Davis
- Occupational and Environmental Health, University of Iowa, 145 N. Riverside Drive, Iowa City, IA, 52242, USA
| | - Ahmed Ismail
- Occupational and Environmental Health, University of Iowa, 145 N. Riverside Drive, Iowa City, IA, 52242, USA.,Faculty of Medicine, Menoufia University, Shebin El-Kom, Egypt
| | | | - Olfat Hendy
- National Liver Institute, Menoufia University, Shebin El-Kom, Egypt
| | - James R Olson
- Department of Epidemiology and Environmental Health, State University of New York Buffalo, Buffalo, NY, USA.,Department of Pharmacology and Toxicology, State University of New York, Buffalo, NY, USA
| | - Matthew R Bonner
- Department of Epidemiology and Environmental Health, State University of New York Buffalo, Buffalo, NY, USA
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9
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Anger WK, Farahat FM, Lein PJ, Lasarev MR, Olson JR, Farahat TM, Rohlman DS. Magnitude of behavioral deficits varies with job-related chlorpyrifos exposure levels among Egyptian pesticide workers. Neurotoxicology 2020; 77:216-230. [PMID: 32006538 DOI: 10.1016/j.neuro.2020.01.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 01/27/2020] [Accepted: 01/27/2020] [Indexed: 01/17/2023]
Abstract
Chronic occupational exposure to organophosphorus pesticides (OPs) is consistently associated with deficits on behavioral tests when compared to unexposed comparison groups. However, a dose-response relationship has yet to be established, leading some to doubt an association between occupational OP exposure and behavioral deficits. Pesticide application teams in Egypt who are primarily exposed to one OP, chlorpyrifos (CPF), were recruited into a field assessment. Trail Making A and the more challenging Trail Making B tests were administered to 54 engineers (who supervise the pesticide application process, usually from the side of the field), 59 technicians (who guide the pesticide applicators in the field), 31 applicators (who mix and apply pesticides using knapsack sprayers), and 150 controls (who did not work in the fields) at two different times during the OP application season as well as immediately after applications had ended and 1.5 months later. All participants were males since only males work on pesticide application teams in Egypt. Urinary levels of 3,5,6-trichloro-2-pyridinol (TCPy), a specific metabolite of CPF, confirmed the pattern of lower to higher CPF exposures from engineers to technicians to applicators, and these were all greater than urinary metabolite levels in controls. A consistent relationship between job title and performance speed on the behavioral task was observed: Controls had the best (fastest) performance on Trail Making A and B tests throughout the application season, and applicators had significantly slower performance than engineers on Trail Making A (p = 0.015) and B (p = 0.003). However, individual urinary TCPy, blood acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE) levels did not predict individual performance. This study identifies a dose-related effect based on job title, which serves as a surrogate for chronic exposure in that differing job titles exhibit varying group exposure levels. The results establish that chronic occupational exposure to chlorpyrifos is neurotoxic and suggest that the classic biomarkers of recent CPF exposure are not predictive of chronic exposure effects.
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Affiliation(s)
- W Kent Anger
- Oregon Health & Science University, Institute of Occupational Health Sciences, Portland, OR 97239, USA.
| | - Fayssal M Farahat
- Menoufia University, Department of Public Health and Community Medicine, Menoufia, Egypt; King AbdulAziz Medical City, King Saud bin AbdulAziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Pamela J Lein
- Oregon Health & Science University, Institute of Occupational Health Sciences, Portland, OR 97239, USA; Department of Molecular Biosciences, University of California-Davis, School of Veterinary Medicine, Davis, CA 95616, USA
| | - Michael R Lasarev
- Oregon Health & Science University, Institute of Occupational Health Sciences, Portland, OR 97239, USA
| | - James R Olson
- Department of Pharmacology and Toxicology, School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY 14214, USA
| | - Taghreed M Farahat
- Menoufia University, Department of Public Health and Community Medicine, Menoufia, Egypt
| | - Diane S Rohlman
- Oregon Health & Science University, Institute of Occupational Health Sciences, Portland, OR 97239, USA; Occupational and Environmental Health, University of Iowa, Iowa City, IA 52242, USA
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Joubert BR, Mantooth SN, McAllister KA. Environmental Health Research in Africa: Important Progress and Promising Opportunities. Front Genet 2020; 10:1166. [PMID: 32010175 PMCID: PMC6977412 DOI: 10.3389/fgene.2019.01166] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 10/23/2019] [Indexed: 12/16/2022] Open
Abstract
The World Health Organization in 2016 estimated that over 20% of the global disease burden and deaths were attributed to modifiable environmental factors. However, data clearly characterizing the impact of environmental exposures and health endpoints in African populations is limited. To describe recent progress and identify important research gaps, we reviewed literature on environmental health research in African populations over the last decade, as well as research incorporating both genomic and environmental factors. We queried PubMed for peer-reviewed research articles, reviews, or books examining environmental exposures and health outcomes in human populations in Africa. Searches utilized medical subheading (MeSH) terms for environmental exposure categories listed in the March 2018 US National Report on Human Exposure to Environmental Chemicals, which includes chemicals with worldwide distributions. Our search strategy retrieved 540 relevant publications, with studies evaluating health impacts of ambient air pollution (n=105), indoor air pollution (n = 166), heavy metals (n = 130), pesticides (n = 95), dietary mold (n = 61), indoor mold (n = 9), per- and polyfluoroalkyl substances (PFASs, n = 0), electronic waste (n = 9), environmental phenols (n = 4), flame retardants (n = 8), and phthalates (n = 3), where publications could belong to more than one exposure category. Only 23 publications characterized both environmental and genomic risk factors. Cardiovascular and respiratory health endpoints impacted by air pollution were comparable to observations in other countries. Air pollution exposures unique to Africa and some other resource limited settings were dust and specific occupational exposures. Literature describing harmful health effects of metals, pesticides, and dietary mold represented a context unique to Africa. Studies of exposures to phthalates, PFASs, phenols, and flame retardants were very limited. These results underscore the need for further focus on current and emerging environmental and chemical health risks as well as better integration of genomic and environmental factors in African research studies. Environmental exposures with distinct routes of exposure, unique co-exposures and co-morbidities, combined with the extensive genomic diversity in Africa may lead to the identification of novel mechanisms underlying complex disease and promising potential for translation to global public health.
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Affiliation(s)
- Bonnie R Joubert
- National Institute of Environmental Health Sciences, National Institutes of Health, Durham, NC, United States
| | | | - Kimberly A McAllister
- National Institute of Environmental Health Sciences, National Institutes of Health, Durham, NC, United States
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Perez-Fernandez C, Flores P, Sánchez-Santed F. A Systematic Review on the Influences of Neurotoxicological Xenobiotic Compounds on Inhibitory Control. Front Behav Neurosci 2019; 13:139. [PMID: 31333425 PMCID: PMC6620897 DOI: 10.3389/fnbeh.2019.00139] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 06/06/2019] [Indexed: 01/24/2023] Open
Abstract
Background: Impulsive and compulsive traits represent a variety of maladaptive behaviors defined by the difficulties to stop an improper response and the control of a repeated behavioral pattern without sensitivity to changing contingencies, respectively. Otherwise, human beings are continuously exposed to plenty neurotoxicological agents which have been systematically linked to attentional, learning, and memory dysfunctions, both preclinical and clinical studies. Interestingly, the link between both impulsive and compulsive behaviors and the exposure to the most important xenobiotic compounds have been extensively developed; although the information has been rarely summarized. For this, the present systematic review schedule and analyze in depth the most important works relating different subtypes of the above-mentioned behaviors with 4 of the most important xenobiotic compounds: Lead (Pb), Methylmercury (MeHg), Polychlorinated biphenyls (PCB), and Organophosphates (OP) in both preclinical and clinical models. Methods: Systematic search strategy on PubMed databases was developed, and the most important information was structured both in text and in separate tables based on rigorous methodological quality assessment. Results: For Lead, Methylmercury, Polychlorinated biphenyls and organophosphates, a total of 44 (31 preclinical), 34 (21), 38 (23), and 30 (17) studies were accepted for systematic synthesis, respectively. All the compounds showed an important empirical support on their role in the modulation of impulsive and, in lesser degree, compulsive traits, stronger and more solid in animal models with inconclusive results in humans in some cases (i.e., MeHg). However, preclinical and clinical studies have systematically focused on different subtypes of the above-mentioned behaviors, as well as impulsive choice or habit conformations have been rarely studied. Discussion: The strong empirical support in preclinical studies contrasts with the lack of connection between preclinical and clinical models, as well as the different methodologies used. Further research should be focused on dissipate these differences as well as deeply study impulsive choice, decision making, risk taking, and cognitive flexibility, both in experimental animals and humans.
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Affiliation(s)
| | - Pilar Flores
- Department of Psychology and Health Research Center, University of Almería, Almería, Spain
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Rohlman DS, Ismail A, Bonner MR, Abdel Rasoul G, Hendy O, Ortega Dickey L, Wang K, Olson JR. Occupational pesticide exposure and symptoms of attention deficit hyperactivity disorder in adolescent pesticide applicators in Egypt. Neurotoxicology 2019; 74:1-6. [PMID: 31077682 DOI: 10.1016/j.neuro.2019.05.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/03/2019] [Accepted: 05/06/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Exposure to environmental chemicals, including organophosphorus pesticides, is associated with behavioral disorders such as attention deficit hyperactivity disorder (ADHD). However, the impact of occupational pesticide exposure on ADHD development in adolescents has not been examined. OBJECTIVE We examined the association between exposure to chlorpyrifos and ADHD symptoms among adolescents in Egypt. METHODS Adolescent pesticide applicators and non-applicators, 12-21 years old, participated in a 10-month longitudinal study examining health effects from pesticide exposure. Repeated urine and blood samples were collected at various time points during the 10-months to assess biomarkers of chlorpyrifos exposure (urinary trichloro-2-pyridinol or TCPy) and effect (blood acetyl cholinesterase activity and butyryl cholinesterase activity). Parents from a subset of the cohort (N = 64) completed the Short Form of Conners' Parent Rating Scale - Revised. Poisson regressions were used to examine the associations between the number of ADHD symptoms and occupation and biomarkers. RESULTS Pesticide applicators had significantly more symptoms of ADHD than participants in the non-applicator group. Urinary TCPy levels were associated with increased symptoms, demonstrating a dose-response effect. Applicators with ADHD reported applying pesticides for more hours during the application season and had greater cumulative TCPy levels than participants without ADHD. One fourth of all applicators met the criteria for an ADHD diagnosis (having 6 or more reported symptoms). CONCLUSIONS This study provides preliminary evidence of an association between occupational exposure to chlorpyrifos and ADHD symptoms among adolescent pesticide applicators in spite of its limited small sample size. There is a critical need to investigate the susceptibility of children and adolescents to repeated occupational and environmental exposures to pesticides because the developing brain may be uniquely sensitive to the neurotoxic effects of these agents.
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Affiliation(s)
- Diane S Rohlman
- Occupational and Environmental Health, University of Iowa, Iowa City, IA, USA; Oregon Health and Science University, Portland, OR, USA.
| | - Ahmed Ismail
- Occupational and Environmental Health, University of Iowa, Iowa City, IA, USA; Faculty of Medicine, Menoufia University, Shebin El-Kom, Egypt
| | - Matthew R Bonner
- Department of Epidemiology and Environmental Health, State University of New York Buffalo, NY, USA
| | | | - Olfat Hendy
- National Liver Institute, Menoufia University, Shebin El-Kom, Egypt
| | | | - Kai Wang
- Biostatistics, University of Iowa, Iowa City, IA, USA
| | - James R Olson
- Department of Epidemiology and Environmental Health, State University of New York Buffalo, NY, USA; Department of Pharmacology and Toxicology, State University of New York, Buffalo, NY, USA
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Fuhrimann S, Winkler MS, Staudacher P, Weiss FT, Stamm C, Eggen RI, Lindh CH, Menezes-Filho JA, Baker JM, Ramírez-Muñoz F, Gutiérrez-Vargas R, Mora AM. Exposure to Pesticides and Health Effects on Farm Owners and Workers From Conventional and Organic Agricultural Farms in Costa Rica: Protocol for a Cross-Sectional Study. JMIR Res Protoc 2019; 8:e10914. [PMID: 30681969 PMCID: PMC6367668 DOI: 10.2196/10914] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 08/30/2018] [Accepted: 10/10/2018] [Indexed: 12/15/2022] Open
Abstract
Background Pesticide use is increasing in low- and middle-income countries (LMICs) including Costa Rica. This increase poses health risks to farm owners, farm workers, and communities living near agricultural farms. Objective We aimed to examine the health effects associated with occupational pesticide exposure in farm owners and workers from conventional and organic smallholder farms in Costa Rica. Methods We conducted a cross-sectional study involving 300 owners and workers from organic and conventional horticultural smallholder farms in Zarcero County, Costa Rica. During the baseline study visit, we administered a structured, tablet-based questionnaire to collect data on sociodemographic characteristics, pesticide exposure, and health conditions (eg, respiratory and allergic outcomes and acute pesticide intoxication symptoms) and administered a neurobehavioral test battery (eg, Finger Tapping Test and Purdue Pegboard); we measured blood pressure, anthropometry (height, weight, and waist circumference), and erythrocytic acetylcholinesterase activity and also collected urine samples. In addition, a functional neuroimaging assessment using near-infrared spectroscopy was conducted with a subset of 50 study participants. During the follow-up study visit (~2-4 weeks after the baseline), we administered participants a short questionnaire on recent pesticide exposure and farming practices and collected hair, toenail, and urine samples. Urine samples will be analyzed for various pesticide metabolites, whereas toenails and hair will be analyzed for manganese (Mn), a biomarker of exposure to Mn-containing fungicides. Self-reported pesticide exposure data will be used to develop exposure intensity scores using an exposure algorithm. Furthermore, exposure-outcome associations will be examined using linear and logistic mixed-effects regression models. Results Fieldwork for our study was conducted between May 2016 and August 2016. In total, 113 farm owners and 187 workers from 9 organic and 83 conventional horticultural smallholder farms were enrolled. Data analyses are ongoing and expected to be published between 2019 and 2020. Conclusions This study is one of the first to examine differences in health effects due to pesticide exposure between farm owners and workers from organic and conventional smallholder farms in an LMIC. We expect that this study will provide critical data on farming practices, exposure pathways, and how occupational exposure to pesticides may affect farm owners and workers’ health. Finally, we hope that this study will allow us to identify strategies to reduce pesticide exposure in farm owners and workers and will potentially lay the groundwork for a future longitudinal study of health outcomes in farm owners and workers exposed to pesticides. International Registered Report Identifier (IRRID) DERR1-10.2196/10914
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Affiliation(s)
- Samuel Fuhrimann
- School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Mirko S Winkler
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Philipp Staudacher
- Swiss Federal Institute of Aquatic Science and Technology (Eawag), Dübendorf, Switzerland.,Institute of Biogeochemistry and Pollutant Dynamics, Department of Environmental Systems Science, ETH Zürich, Zürich, Switzerland
| | - Frederik T Weiss
- Swiss Federal Institute of Aquatic Science and Technology (Eawag), Dübendorf, Switzerland.,Institute of Biogeochemistry and Pollutant Dynamics, Department of Environmental Systems Science, ETH Zürich, Zürich, Switzerland
| | - Christian Stamm
- Swiss Federal Institute of Aquatic Science and Technology (Eawag), Dübendorf, Switzerland.,Institute of Biogeochemistry and Pollutant Dynamics, Department of Environmental Systems Science, ETH Zürich, Zürich, Switzerland
| | - Rik Il Eggen
- Swiss Federal Institute of Aquatic Science and Technology (Eawag), Dübendorf, Switzerland.,Institute of Biogeochemistry and Pollutant Dynamics, Department of Environmental Systems Science, ETH Zürich, Zürich, Switzerland
| | - Christian H Lindh
- Division of Occupational and Environmental Medicine, Institute of Laboratory Medicine, Lund University, Lund, Sweden
| | - José A Menezes-Filho
- Laboratory of Toxicology, Faculty of Pharmacy, Federal University of Bahia, Bahia, Brazil
| | - Joseph M Baker
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Stanford University, Stanford, CA, United States
| | - Fernando Ramírez-Muñoz
- Central American Institute for Studies on Toxic Substances, Universidad Nacional, Heredia, Costa Rica
| | - Randall Gutiérrez-Vargas
- Centro de Investigación y Diagnóstico en Salud y Deporte, Universidad Nacional, Heredia, Costa Rica
| | - Ana M Mora
- Central American Institute for Studies on Toxic Substances, Universidad Nacional, Heredia, Costa Rica
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Comfort N, Re DB. Sex-Specific Neurotoxic Effects of Organophosphate Pesticides Across the Life Course. Curr Environ Health Rep 2018; 4:392-404. [PMID: 29063415 DOI: 10.1007/s40572-017-0171-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW This review discusses the sex-specific effects of exposure to various organophosphate (OP) pesticides throughout the life course and potential reasons for the differential vulnerabilities observed across sexes. RECENT FINDINGS Sex is a crucial factor in the response to toxicants, yet the sex-specific effects of OP exposure, particularly in juveniles and adults, remain unresolved. This is largely due to study design and inconsistencies in exposure and outcome assessments. Exposure to OPs results in multiple adverse outcomes influenced by many factors including sex. Reported sex-specific effects suggest that males are more susceptible to OPs, which reflects the sex-dependent prevalence of various neurodevelopmental and neurodegenerative disorders such as autism and amyotrophic lateral sclerosis (ALS), in which males are at greater risk. Thus, this review proposes that the biological sex-specific effects elicited by OP exposure may in part underlie the dimorphic susceptibilities observed in neurological disorders. Understanding the immediate and long-term effects of OP exposure across sexes will be critical in advancing our understanding of OP-induced neurotoxicity and disease.
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Affiliation(s)
- Nicole Comfort
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, NY, 10032, USA. .,NIEHS Center for Environmental Health Sciences in Northern Manhattan, Columbia University, New York, NY, 10032, USA. .,, 722 W 168th Street, 11th floor, New York, NY, 10032, USA.
| | - Diane B Re
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, NY, 10032, USA. .,NIEHS Center for Environmental Health Sciences in Northern Manhattan, Columbia University, New York, NY, 10032, USA. .,Center for Motor Neuron Biology and Disease, Columbia University, New York, NY, 10032, USA. .,, 722 W 168th Street Suite 1107B, New York, NY, 10032, USA.
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Ismail AA, Wang K, Olson JR, Bonner MR, Hendy O, Rasoul GA, Rohlman DS. The impact of repeated organophosphorus pesticide exposure on biomarkers and neurobehavioral outcomes among adolescent pesticide applicators. JOURNAL OF TOXICOLOGY AND ENVIRONMENTAL HEALTH. PART A 2017; 80:542-555. [PMID: 28880741 PMCID: PMC5648326 DOI: 10.1080/15287394.2017.1362612] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
Egyptian adolescents are hired as seasonal workers to apply pesticides to the cotton crop and may perform this occupation for several years. However, few studies examined the effects of repeated pesticide exposure on health outcomes The goal of this study was to determine the impact of repeated pesticide exposure on neurobehavioral (NB) performance and biomarkers of exposure (urinary metabolite) and effect (cholinesterase activity). Eighty-four adolescents from two field stations in Menoufia, Egypt, were examined four times: before and during pesticide application season in 2010 and again before and during application season in 2011. At each of the four time points, participants completed a questionnaire, performed an NB test battery, and were assessed for urinary levels of the chlorpyrifos metabolite TCPy (3,5,6-trichloro-2-pyridinol) and blood cholinesterase activity. Following the study cohort over two consecutive pesticide application seasons revealed that TCPy levels significantly increased following exposure, and returned to baseline levels following the end of the application season. Blood butyryl cholinesterase activity exhibited a similar pattern. Although NB outcomes displayed learning and practice effects over time, deficits in performance were significantly associated with increased TCPy levels with reduction in the number of NB measures showing improvement over time. Biomarkers of exposure and effect demonstrated changes associated with pesticide application and recovery after application ended. Deficits in NB performance were correlated with elevated pesticide exposure. Data demonstrated that repeated pesticide exposure may exert a long-term adverse impact on human health.
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Affiliation(s)
- Ahmed A. Ismail
- Department of Occupational and Environmental Health, College of Public Health, University of Iowa, Iowa City, IA, USA
- Community Medicine and Public Health Department, Faculty of Medicine, Menoufia University, Shebin El-Kom, Egypt
| | - Kai Wang
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - James R. Olson
- Department of Epidemiology and Environmental Health, State University of New York, Buffalo, NY, USA
- Department of Pharmacology and Toxicology, State University of New York, Buffalo, NY, USA
| | - Matthew R. Bonner
- Department of Epidemiology and Environmental Health, State University of New York, Buffalo, NY, USA
| | - Olfat Hendy
- Department of Clinical Pathology, National Liver Institute, Menoufia University, Shebin El-Kom, Egypt
| | - Gaafar Abdel Rasoul
- Community Medicine and Public Health Department, Faculty of Medicine, Menoufia University, Shebin El-Kom, Egypt
| | - Diane S. Rohlman
- Department of Occupational and Environmental Health, College of Public Health, University of Iowa, Iowa City, IA, USA
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