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action.” Substantial public health ef- among persons aged Ն18 years from Tobacco Use— forts to reduce the prevalence of to- 42.4% in 1965 to 24.7% in 1997, with bacco use began shortly after the risk was the rate for men (27.6%) higher than United States, described in 1964. With the subse- for women (22.1%). The percentage of 1900-1999 quent decline in smoking, the inci- adults who never smoked increased dence of smoking-related cancers (in- from 44% in the mid-1960s to 55% in MMWR. 1999;48:986-993 cluding cancers of the lung, oral cavity, 1997. In 1998, tobacco use varied and pharynx) have also declined (with within and among racial/ethnic groups. 4 figures, 1 photo omitted the exception of lung cancer among The prevalence of smoking was high- SMOKING—ONCE A SOCIALLY AC- women).4 In addition, age-adjusted est among American Indians/Alaska Na- cepted behavior—is the leading pre- death rates per 100,000 persons (stan- tives, and second highest among black ventable cause of death and disability dardized to the 1940 population) for and Southeast Asian men. The preva- in the United States. During the first de- heart disease (i.e., coronary heart dis- lence was lowest among Asian Ameri- cades of the 20th century, lung cancer ease) have decreased from 307.4 in 1950 can and Hispanic women.12 Smoke- was rare; however, as cigarette smok- to 134.6 in 1996.4 During 1964-1992, less tobacco use has changed little since ing became increasingly popular, first approximately 1.6 million deaths caused 1970, with a 5% prevalence in 1970 among men and later among women, by smoking were prevented.5 and a 6% prevalence in 1991 among the incidence of lung cancer became men, and 2% and 1%, respectively, for epidemic. In 1930, the lung cancer Smoking Trends women. The prevalence of smokeless death rate for men was 4.9 per 100,000; During the Century tobacco use is highest among high in 1990, the rate had increased to 75.6 Early in the 20th century, several events school males, with prevalence being per 100,000.1 Other diseases and con- coincided that contributed to increases 20% among white males, 6% among ditions now known to be caused by to- in annual per capita consumption, in- Hispanics males, and 4% among black bacco use include heart disease, ath- cluding the introduction of blends and males. Prevalence of use tends to be erosclerotic peripheral vascular disease, curing processes that allowed the inha- lower in the northeastern region and laryngeal cancer, oral cancer, esopha- lation of tobacco, the invention of the higher in the southern region of the geal cancer, chronic obstructive pul- safety match, improvements in mass pro- United States. Total consumption of ci- monary disease, intrauterine growth reduction, transportation that permitted gars decreased from 8 million in 1970 tardation, and low birthweight. During widespread distribution of cigarettes, and to 2 million in 1993 but increased 68% the latter part of the 20th century, the use of mass media advertising to pro- to 3.6 million in 1997.13 adverse health effects from exposure to mote cigarettes.6,7 Cigarette smoking Reductions in smoking result from environmental tobacco smoke also were among women began to increase in the many factors, including scientific evi- documented. These include lung can- 1920s when targeted industry market- dence of the relation among disease, to- cer, asthma, respiratory infections, and ing and social changes reflecting the lib- bacco use, and environmental expo- decreased pulmonary function.2 eralization of women’s roles and behav- sure to tobacco; dissemination of this Large epidemiologic studies con- ior led to the increasing acceptability information to the public; surveillance ducted by Ernst Wynder (see box) and of smoking among women.8,9 Annual and evaluation of prevention and others in the 1940s and 1950s linked per capita cigarette consumption in- cessation programs; campaigns by ad- cigarette smoking and lung cancer. In creased from 54 cigarettes in 1900 to vocates for nonsmokers’ rights; re- 1964, on the basis of approximately 7000 4345 cigarettes in 1963 and then de- strictions on cigarette advertising; coun- articles relating to smoking and dis- creased to 2261 in 1998.10,11 Some de- teradvertising; policy changes (i.e., ease, the Advisory Committee to the U.S. creases correlate with events, such as the enforcement of minors’ access laws, leg- Surgeon General concluded that ciga- first research suggesting a link be- islation restricting smoking in public rette smoking is a cause of lung and la- tween smoking and cancer in the 1950s, places, and increased taxation); improve- ryngeal cancer in men, a probable cause the 1964 Surgeon General’s report, the ments in treatment and prevention pro- of lung cancer in women, and the most 1968 Fairness Doctrine, and increased grams; and an increased understand- important cause of chronic bronchitis in tobacco taxation and industry price in- ing of the economic costs of tobacco. both sexes.3 The committee stated that creases during the 1980s. The cigarette itself has changed. “Cigarette smoking is a health hazard of An important accomplishment of the When cigarettes were first associated sufficient importance in the United second half of the 20th century has been with lung cancer in the early 1950s, States to warrant appropriate remedial the reduction of smoking prevalence most U.S. smokers smoked unfiltered

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cigarettes. With a growing awareness of the danger of smoking came the first filter, which was designed to reduce the Ernst L. Wynder, MD tar inhaled in the smoke. Later, low tar Although cigarettes were considered a research. During the next decade, hun- cigarettes were marketed; however, symbol of popularity and social accept- dreds of reports were published linking many smokers compensated by smok- ability from the opening of the 20th cen- cancer and smoking, including large pro- ing more intensely and by blocking the tury, critics warned of the dangers of what spective studies, pathologic, and animal in- 13 they called “coffin nails,” or “little white vestigations. A second effect was to con- filter’s ventilation holes. Adenocarci- slavers.” They implicated cigarettes in can- vince doctors that the health risks of noma has replaced squamous cell car- cer, heart disease, and other serious health smoking were serious. Many gave up the cinoma as the leading cause of lung can- problems; however, opposition to the ciga- habit, including Graham, who quit smok- cer-related death in the United States. rette would gain little ground until com- ing in 1952. Too late, it would seem, as This increase in adenocarcinoma par- pelling scientific evidence linked smoking he wrote to Wynder in 1957, weeks be- allels the changes in cigarette design and and disease. Researcher, educator, and ac- fore the surgeon died from lung cancer. smoking behavior.13 tivist Ernst Wynder, M.D. (April 30, 1922- Wynder devoted his career to the study Changes in the social norms sur- July 14, 1999), dedicated his career to pro- and prevention of cancer and chronic dis- rounding smoking can be docu- ducing this evidence. ease, writing hundreds of scientific pa- Ernst Wynder was born in Herford, Ger- pers advocating further research and pub- mented by examining changes in pub- many. His family emigrated to New Jer- lic education. Through the 1950s and lic policy, including availability of sey in 1938 to escape Nazi persecution. 1960s he worked at the Sloan-Kettering Fairness Doctrine counteradvertising He attended medical school at Washing- Institute for Cancer Research; in 1969, he messages on television and radio and ton University, St. Louis, Missouri, and re- founded the American Health Founda- increased restrictions on tobacco ad- ceived both a bachelor of science and a tion, serving as its medical director. In 1972, vertising beginning with the ban on medical degree in 1950. Wynder began the foundation launched Preventive Medi- broadcast advertising in 1971. Ciga- his lung cancer investigations when he cine, with Wynder as editor. In 1999, the rette advertising no longer appears on was a medical student. While attending a foundation employed approximately 200 summer internship at New York Univer- researchers representing medicine, public television or billboards, and efforts to sity, his curiosity was piqued during the au- health, biology, chemistry, nutrition, and restrict sales and marketing to adoles- topsy of a two-pack-a-day smoker who behavior science. Wynder endured years cents have increased. Indoor air poli- had died from lung cancer. Wynder be- of criticism from the tobacco industry and cies switched from favoring smokers to gan collecting case histories of lung can- skepticism from many researchers, but he favoring nonsmokers. Smoking is no cer victims, first in New York City and then remained determined. longer permitted on airplanes, and in St. Louis. His research brought him to many people, including 12.5% of adult thoracic surgeon Evarts Graham, who, de- Bibliography smokers with children, do not smoke spite initial skepticism about Wynder’s Brandt A. The cigarette, risk, and Ameri- at home.14 Now 42 states have restric- premise (Graham was a heavy smoker), can culture. Daedalus 1990;119:155-76. granted access to his extensive case rec- Kluger R. Ashes to Ashes: America’s tions on smoking at government work ords, and agreed to sponsor the medical Hundred-Year Cigarette War, the Public sites and 20 states have restrictions at student. Health, and the Unabashed Triumph of private work sites. In 1950, the Journal of the American Philip Morris. New York: Knopf, 1996. One of the most effective means of Medical Association published Wynder Steinfeld JL. Smoking and lung cancer: reducing the prevalence of tobacco use and Graham’s “Tobacco Smoking as a Pos- a milestone in awareness. JAMA 1985; is by increasing federal and state ex- sible Etiologic Factor in Bronchiogenic Car- 263:2995-7. cise tax rates. A 10% increase in the cinoma: A Study of 684 Proven Cases.” Wynder EL. A corner of history: micro- price of cigarettes can lead to a 4% re- Wynder and Graham’s retrospective study epidemiology. Prev Med 1973;2:465-71. duction in the demand for cigarettes. was not the first to link smoking and can- Wynder EL, Graham E. Tobacco smok- cer, but its sophisticated design, impres- ing as a possible etiologic factor in bron- This reduction is the result of people sive population size, and unambiguous chiogenic carcinoma: a study of 684 proven smoking fewer cigarettes or quitting al- findings demanded attention and further cases. JAMA 1950;143:329-36. together.15 Studies show that low- income, adolescent, Hispanic, and non- Hispanic black smokers are more likely 46 states. This agreement settled law- effective tobacco education programs than others to stop smoking in re- suits totaling $206 billion; however, the based on scientific research. sponse to a price increase.17 agreement did not require that any of the The November 1998 Master Settle- state money be spent for tobacco use pre- Future Challenges ment Agreement marks the end of the vention and control. The American Despite the achievements of the 20th 20th century with an unprecedented Legacy Foundation was established as century, approximately 48 million U.S. event. Although admitting no wrong- a result of a provision in the Master adults smoke cigarettes; half of those doing, the tobacco companies signed an Settlement Agreement that called for a who continue to smoke will die from agreement with the attorneys general of foundation with a mandate to conduct a smoking-related disease. Tobacco use

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is responsible for approximately rebrovascular disease also reflect the dis- boundaries and will necessitate politi- 430,000 deaths each year—one of ev- parity in health outcomes, with the rate cal action; mobilization of resources; ery five. Parallel to the health burden being 53.1 per 100,000 among black and implementation of national, re- is the economic burden of tobacco use, men and 26.3 among white men.12 No gional, and global strategies. which amounts to at least $50 billion single factor determines the patterns of Much remains to be done despite the in medical expenditures and $50 bil- tobacco use among racial/ethnic groups; public health achievements in reduc- lion in indirect costs. If trends con- these patterns result from complex in- ing tobacco use in the 20th century. The tinue, approximately 5 million chil- teractions among multiple factors such American Cancer Society has set goals dren living today will die prematurely as socioeconomic status, cultural char- for 2015 of a 25% reduction in cancer because as adolescents they started acteristics, acculturation, stress, bio- incidence and a 50% reduction in can- smoking cigarettes.16 Advances have logic elements, targeted advertising, cer mortality rates.23 Approximately been made in knowledge of tobacco use price of tobacco products, and varying 50% of that goal can be achieved with and its effect on health; intervention capacities of communities to mount a 40%-50% reduction in smoking preva- strategies to reduce these effects re- effective tobacco-control initiatives. lence by 2005. Commensurate with the main serious challenges. These disparities in use and adverse cost of the harm caused by tobacco, re- First, trends from the 1975-1998 health outcomes based on race/eth- sources must be expended, including Monitoring the Future surveys18 indi- nicity and socioeconomic status need to programs preventing adolescents from cate that the 30-day prevalence of to- be addressed. starting to smoke, getting adults and bacco use (smoking on Ն1 of the 30 Fourth, exposure to environmental young people to quit smoking, and days before the survey) among high tobacco smoke (ETS) at home and at eliminating exposure to ETS and dis- school seniors decreased from the late work is a substantial problem. One parities among population groups. 1970s to the mid-1980s, and preva- study found that 87.9% of children and Reported by: Office on Smoking and Health, Na- lence was approximately 30%; how- adult nonusers of tobacco had detect- tional Center for Chronic Disease Prevention and Health ever, during 1991-1997 smoking preva- able levels of serum cotinine.20 The dis- Promotion, CDC. lence increased to 36.5%. Prevalence tribution of serum cotinine levels is bi- REFERENCES among high school seniors today is modal: one peak for nonsmokers 23 available highest among whites and lowest exposed to ETS and a higher one for among blacks.18 The recent increases in smokers. Both the number of smokers prevalence highlight the need for a na- in the household and the hours ex- Surveillance for Acute tionwide comprehensive prevention posed at work were associated with in- program focused on this age group. creased serum cotinine levels among Pesticide-Related Second, decreasing prevalence among nonsmokers. Illness During the adults since the mid-1960s has not con- Fifth, research is needed to deter- tinued. Since 1990, prevalence among mine whether new “highly engi- Medfly Eradication both men and women has remained neered” products can reduce the harm- constant (approximately 28.0% for men ful effects of tobacco or whether the Program—Florida, and approximately 22.5% for women). mistakes associated with low tar and 1998 The stagnation emphasizes the need for nicotine cigarettes will be repeated.21 policy changes that encourage quit- Several novel tobacco products, (e.g., MMWR. 1999;48:1015-1027 ting and for improved access to proven bidis from India) appear to be increas- 1 table omitted treatment interventions (e.g., Food and ing in popularity, but little is known Drug Administration-approved phar- about long-term health effects or about THE MEDITERRANEAN FRUIT FLY (MED- macotherapy and behavior counseling). social and other factors associated with fly) (Ceratitis capitata, Wiedemann) is Third, large differences in tobacco use their use.22 an exotic insect that can damage ap- exist in the United States. For example, Sixth, a dramatic increase in to- proximately 250 fruit and vegetable plant in 1997, smoking prevalence was 37.9% bacco use has occurred worldwide. Be- species and is a serious threat to domes- among American Indian/Alaska Native cause of the increase, the World Health tic agriculture. During the spring and men, 32.1% among black men, and Organization (WHO) established the summer of 1998, pesticides were used 27.6% among white men.19 There are Tobacco Free Initiative, and the World by federal and state agriculture authori- marked differences in deaths from ma- Health Assembly unanimously ap- ties to eradicate Medfly infestations that lignant diseases of the respiratory sys- proved the development of a Frame- had been detected in portions of five tem; the age-adjusted death rates per work Convention on Tobacco Con- Florida counties. This report summa- 100,000 U.S. residents in 1995 were 80.5 trol. This WHO effort will promote rizes surveillance data, describes prob- among black men and 53.7 among white global cooperation on aspects of to- able and possible cases of illness asso- men.12 Age-adjusted death rates for ce- bacco control that transcend national ciated with the eradication effort, and

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provides recommendations for future The 123 probable or possible cases rep- faces. He had covered his pool in accor- Medfly-eradication programs. resent a crude rate of nine cases per dance with recommendations and was The Medfly Eradication Program be- 10,000 residents in the exposed areas. Of exposed to malathion/bait while remov- gan on April 4, 1998, with ground ap- the 123, 89 (72%) occurred in females; ing the cover, which he had folded and plications of malathion/bait* and dia- the median age was 46.5 years (range: 6 carried under his right arm. He was not zinon, followed by aerial malathion/ months-82 years). Eight reports (7%) in- wearing a shirt, and the rash developed bait application that began on April 30. volved children aged Յ5 years, and 20 at those points where the pool cover had All insecticide applications were com- (16%) involved persons aged Ն65 years. contacted his arm and torso. His phy- pleted on September 6. The respective Four reports (3%) described persons sician diagnosed allergic dermatitis. county health departments estimated whose illnesses were considered work- Case 4. A 32-year-old woman with that 132,000 persons resided in the ar- related (i.e., Medfly Eradication Pro- a history of asthma complained of mul- eas treated with these pesticides. gram pesticide applicator, lawn-care tiple symptoms in reaction to ground ap- worker, health department hotline plications of malathion/bait and diazi- Surveillance for Illness worker, and hotel worker). non in her neighborhood. Symptoms Reports of potential adverse health ef- Among the 123 cases, signs and included nausea, diarrhea, abdominal fects attributed to the Medfly Eradica- symptoms for 87 (71%) were respira- cramping, cough, upper respiratory ir- tion Program pesticide applications tory (e.g., dyspnea, wheezing, cough- ritation, dyspnea, wheezing, headache, were solicited by state health and ag- ing, and upper respiratory tract pain/ and fatigue. Her physician diagnosed riculture authorities and collected irritation); 77 (63%) involved the acute aggravation of asthma secondary through telephone hotlines main- gastrointestinal system (e.g., nausea, to pesticide exposure from the Medfly tained by the Florida Poison Informa- vomiting, diarrhea, melena, and ab- Eradication Program. tion Network and county health de- dominal cramping); 74 (60%) in- partments. The public was advised of volved the neurologic system (e.g., Reported by: O Shafey, PhD, HJ Sekereke, Jr, PhD, the pesticide use and the hotline num- headache, vertigo, ataxia, peripheral BJ Hughes, PhD, S Heber, DrPH, RG Hunter, PhD, RG Brooks, MD, Florida Dept of Health. Health Studies ber through public meetings hosted by paresthesia, disorientation, and confu- Br, Div of Environmental Hazards and Health Effects, federal and state agriculture depart- sion); 28 (23%) involved the skin (e.g., National Center for Environmental Health; Surveil- ment officials, news articles, and radio erythema [with or without maculo- lance Br, Div of Surveillance, Hazard Evaluations, and Field Studies, National Institute for Occupational Safety and television reports. During April 30- papular rash], pruritis, and burning sen- and Health, CDC. September 30, 1998, 230 reports of sations); and 23 (19%) involved the illness were received from Florida resi- eyes (e.g., lacrimation, conjunctivitis, CDC Editorial Note: The Environmen- dents and physicians and were inves- blepharitis, and blurred vision)‡. tal Protection Agency (EPA) classifies tigated by the Florida Department of malathion as an acute toxicity category Health. Reports were classified accord- Case Reports III compound§, and it is considered safer ing to a standard case classification sys- Case 1. A 49-year-old man experi- than many other organophosphates tem.† Of the 230 reports, 34 (15%) enced dyspnea, upper respiratory irri- because it is rapidly detoxified by the cases were classified as probable pes- tation, and headache after being body. Nevertheless, adverse health effects ticide-related illness based on abnor- exposed to aerial malathion/bait appli- have been reported by persons exposed mal medical signs compatible with cations while working on the roof of his to malathion.1 Self-reported health effects malathion/bait or diazinon toxicity ob- house. His physician diagnosed se- previously associated with aerial spray- served by a licensed health-care pro- vere bronchitis and reported that the ill- ing of malathion/bait include respira- fessional, and 89 (39%) were classi- ness probably resulted from malathion/ tory symptoms (particularly among fied as possible based on symptoms bait exposure. persons with pre-existing respiratory con- compatible with malathion/bait or dia- Case 2. A 31-year-old man re- ditions), gastrointestinal symptoms, neu- zinon toxicity reported to health-care ported a blistering rash over his arms, rologic symptoms, contact dermatitis, providers or a state health authority. Of legs, and neck following an aerial ap- and conjunctivitis.2-4 These effects may the remaining 107 (47%), 24 were ex- plication of malathion/bait. He was ex- represent irritant or allergic responses to cluded because of insufficient informa- posed to malathion/bait while conduct- either component of the malathion/bait tion, 32 were asymptomatic or had ing his lawn maintenance business. He formulation.5,6 Cholinesterase inhibi- symptoms unrelated to exposure, and reported that the rash developed where tion3 or anxiety about aerial malathion/ 51 were classified as unlikely. No re- grass trimmings coated with pesticide bait application2,7 also may be respon- ports were classified as definite cases of stuck to his skin. His physician diag- sible for some symptoms. pesticide-related illness because this cat- nosed allergic contact dermatitis sec- The findings in this report suggest egory requires confirmation by labora- ondary to malathion/bait exposure. that for most persons, aerial applica- tory testing of clinical or environmen- Case 3. A 35-year-old man reported tion of malathion/bait does not pose an tal samples that were not available. a pruritic rash on exposed skin sur- acute risk to health; however, at least

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123 probable or possible pesticide- tion§*. To reduce the risk for illness pesticide label. Supplementary PPE also related cases of illness were associated among persons sensitive to the effects may be indicated. with pesticide exposure. Each case- of malathion/bait applications, federal patient had signs and/or symptoms con- and state agricultural authorities are en- REFERENCES sistent with pesticide exposure, and ill- couraged to pursue and enhance alter- 1. Blondell J. Epidemiology of pesticide poisonings in ness probably resulted from sensitivity native methods for Medfly control. the United States, with special reference to occupational cases. Occup Med 1997;12:209-20. to the irritant/allergic effects of mala- These methods include preventing 2. Kahn E, Berlin M, Deane M, Jackson RJ, Stratton thion/bait. Although ground applica- Medfly importation into the United JW. Assessment of acute health effects from the Med- tion of diazinon, another acute toxic- States, quickly detecting Medfly infes- fly Eradication Project in Santa Clara County, Califor- nia. Arch Environ Health 1992; 47:279-84. ity category III organophosphate, was tations (e.g. through increased senti- 3. Book SA, Jackson RJ, Fan AM, DiBartolomeis MJ, employed in some locations, this agent nel trapping densities), releasing ster- Russell H. Health risk assessment of aerial application of malathion-bait. Berkeley, California: California De- was considered less likely to be respon- ile male Medflies to interrupt the partment of Health Services, 1991. sible for the observed health effects be- reproductive cycle, and identifying and 4. Kreutzer R, Harmon L, Hoshiko S. Citizen illness reports following February-May 1994 aerial malathion cause it was used in only three coun- using safer eradication agents. applications in Corona and Norco, Riverside County, ties, was applied focally (without aerial During aerial malathion applica- California. Emeryville, California: California Depart- application), and was used in minimal tions for mosquito control and Medfly ment of Health Services, 1996. 5. Schanker HM, Rachelefsky G, Siegel S, et al. Im- quantities. eradication, the public should be ad- mediate and delayed type hypersensitivity to mala- The findings in this report are sub- vised to stay indoors and, when appro- thion. Ann Allergy 1992;69:526-8. 6. Sharma VK, Kaur S. Contact sensitization by pes- ject to at least three limitations. First, priate, persons with exposure-related ticides in farmers. Contact Dermatitis 1990;23: because this was a passive surveil- health concerns should seek medical at- 77-80. 7. Kahn E, Jackson RJ, Lyman DO, Stratton JW. A cri- lance effort, persons may have be- tention. The public also should be pro- sis of community anxiety and mistrust: the Medfly come ill who did not seek medical at- vided with an opportunity to ask ques- eradication project in Santa Clara County, California, 1981-82. Am J Public Health 1990;80:1301-4. tention or were not reported to the tions and receive timely responses about 8. California Environmental Protection Agency. Guide- surveillance system. Second, rates of the the malathion applications (i.e., through lines for physicians who supervise workers exposed health outcomes in the exposed popu- telephone hotlines and community to cholinesterase-inhibiting pesticides. 3rd ed. Berke- ley, California: California Environmental Protection lation could not be compared with those meetings). When malathion/bait appli- Agency, 1995. for the general population because base- cations are used for Medfly eradica- line incidence data for many of the ef- tion, additional precautions are recom- *Malathion (Fyfanonா ULV, Cheminova Inc., Wayne, New Jersey) combined with a corn protein bait, Nu- fects attributed to the malathion/bait ap- mended, including immediately Lureா (Miller Chemical and Fertilizer Co., Hanover, plication are not available. Third, the washing any skin surfaces that come Pennsylvania) was applied at a rate of 2.4 fluid ounces malathion and 9.6 fluid ounces bait per acre per week. role of cholinesterase inhibition was not into contact with malathion/bait- The reportedly nontoxic bait comprises hydrolyzed corn determined because blood cholinester- contaminated surfaces; providing ad- gluten meal and inert ingredients including corn syrup. Backpack sprayers or truck-mounted pressure spray- ase levels were not obtained. vance public notification of spray sched- ers were used for ground applications; UH-1 “Huey” Certain malathion formulations are ules; performing aerial malathion/bait helicopters and DC-3 aircraft conducted the aerial ap- registered by EPA for aerial spraying applications when residents are usu- plications. (Use of trade names and commercial sources is for identification only and does not imply endorse- over urban areas in mosquito-control ally indoors (e.g., at night); directing ment by CDC or the U.S. Department of Health and programs. The use of malathion in these the homeless to shelters; advising highly Human Services.) †CDC’s National Institute for Occupational Safety and programs provides an important pub- sensitive persons to leave the area dur- Health classifies a case of acute pesticide-related ill- lic health benefit by controlling mos- ing spraying; and convening a health ness and injury as being definite, probable, possible, or suspicious as determined by the level of certainty quitoes that transmit human diseases advisory committee, an action that has of exposure, whether health effects were observed by such as encephalitis, dengue fever, and been shown to be useful for mitigat- a health-care provider, and whether sufficient toxi- 7 cologic information supports a causal relation be- malaria. Spraying malathion/bait over ing risk. Medfly Eradication Program tween the exposure and the reported health effects. urban populations for Medfly eradica- workers should be trained in the safe When toxicologic evidence for an exposure-health ef- tion has generated controversy in part handling of pesticides, and consider- fect relation is not present, the case is classified as unlikely. because these applications are di- ation should be given to measuring ‡Total is 289 cases because some persons experi- rected not at preventing human ill- plasma and red blood cell cholinester- enced signs and symptoms in more than one system. §EPA classifies pesticides into one of four acute tox- ness but at eradicating an agricultural ase in these workers before beginning icity categories based on established criteria (40 CFR pest. Federal law does not permit spray- exposure and periodically thereafter.8 Part 156). Pesticides with the greatest toxicity are in toxicity category I and those with the least are in cat- ing malathion/bait over urban areas Workers should wear the personal pro- egory IV. without an emergency EPA exemp- tection equipment (PPE) listed on the §*40 CFR Part 166.

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