streThe Maigrant Hemalth News SourcelinVolume 22, e Issue 3 • Fall 2016

Crisis in the Countryside: Addressing the Opioid Epidemic in Rural Washington and Idaho By Claire Hutkins Seda, Writer, Migrant Clinicians Network, Managing Editor, Streamline

he opioid crisis touches all sectors of of MCN’s External Advisory Board. He points capacity.’” Many health clinics around the America’s patient population — espe - out that patients with chronic pain are the country can relate. Once high opioid use Tcially underserved patients like agricul - population that is at high risk for chronic patients are identified, next comes the ardu - tural workers in rural areas. In Washington high opioid use. The goal of the project is to ous and seemingly unprecedented work of and Idaho, six rural health clinics represent - improve safe prescribing of chronic opioid figuring out how to best adjust policy, pro - ing over 20 sites are working through the medication for patients with non-cancer pain cedure, and workflow to serve those patients difficult questions to make sure their policies, at these rural clinics, which are affiliated with and address the crisis head-on. workflow, and clinical visits are all aligned critical access hospitals. But the task is not The project approaches the problem in and implemented to address the crisis that easy, both because the tools are lacking, and part through guided self-assessments and has swept the nation. because the problem is so big. 2shared learning opportunities, during “A lot of the people who live in [these] “Ideally, patients with chronic pain on which the clinics can dive into the project’s rural areas have agricultural and other types opioid medication should be seen every 90 six building blocks for safe, team-based opi - of jobs that are very physically demanding. days, to see where they are, how their pain oid prescribing in primary care. People depends on their ability to do manual is controlled, and how safe their medication work for their livelihood, and as a result a lot use is,” explained Dr. Parchman. “One of Six Building Blocks of their population really do have chronic our clinics said, ‘We did that calculation for Dr. Parchman, in a recent post on the active pain issues,” says Michael Parchman, MD, our population. If we did that, about every blog, Implementing Innovations, described MPH, a lead physician in the Team-Based fourth visit on our schedule would be one of Opioid Management Project and a member these patients, and we just don’t have that continued on page 9 The Social Determinants of Adolescent Health: Q&A with Dr. Tamara Baer

ometimes the contents of the doctor’s medicine bag are just plain insufficient. Innovators in medicine and public health are re-imaging Straditional adolescent care management tools to help providers and systems tackle the significant—and often devastating—effects of social, economic, and environmental conditions on the health and wellbeing of young people. Some call it upstream medicine: treating the root cause rather than the symptom. Three national physician leaders, Tamara Baer, Laura Gottlieb, and Megan Sandel, in an article published in Current Opinion in Pediatrics, made a strong case for an upstream framework to address the influences of poverty and social disadvantage on adolescent health outcomes. 1 The physicians prescribe a model for practice transformation that identifies and remediates non-medical threats to adolescent health. To better equip the adolescent medical home, the authors outline three fundamental strate - gies: 1. Improve triage for social determinants of health need. 2. Develop a comprehensive community resource referral system. 3. Expand the team to include a community resource connector. School-Based Health Alliance President, John Schlitt, spoke with lead author, Dr. Tamara Baer, about the role of social determinants in adoles - cent health and how providers can make practice adaptations to respond more effectively to them. John: You make a compelling case for aligning a public health con - struct with traditional medical practice. And it seems particularly tailor- made for adolescents. Dr. Baer: Adolescents are especially vulnerable to risks commonly asso - ciated with their developmental stage. Add to those risks the context of their social environment, which has a weighty effect on their behaviors – injuries and violence, substance use, sexual activity. If there is nothing to counterbalance the influence of social determinants of health (SDOH) like poverty and unremitting stress, or inadequate access to basic needs like food and shelter, these behaviors can have a cumulative effect with serious life-long health consequences. Research has shown that adolescents with greater social needs are at higher risk for poor health outcomes. John: Your recommendation to include social determinants in screening tools seems rather practical. Dr. Baer: You can’t intervene if you don’t ask the questions. We urge providers to take a critical look at screening tools for adolescent patients: are they inclusive of items like personal safety, food security, income insta - bility, home life, school performance? What about frequency of screening: [Editor’s Note: In this piece, John Schlitt, President of the School- are you asking about basic social needs at every visit? Unfortunately, for Based Health Alliance (SBHA), interviews Dr. Tamara Baer about a too many teens, any of these factors can change from month to month. recent article on adolescent health. Read the full article at SBHA’s John: Have you encountered any specific standardized tools that align website, www.sbh4all.org. Submit abstracts for SBHA’s 2017 National School-Based Health Care Convention at with your framework? https://goo.gl/wyfhfs.] Dr. Baer: There are several that we found in our research. A great example comes from the National Center for Medical-Legal Partnership, which developed a social screening assessment that includes income, housing, education, legal status, literacy and personal safety – the The material presented in this portion of Streamline is sup - mnemonic IHELLP. In addition, The University of Michigan has developed a ported by the Health Resources and Services Administration screening tool called Rapid Assessment for Adolescent Preventive Services (HRSA) of the U.S. Department of Health and Human – Public Health (RAAPS-PH) intended for youth impacted by conditions of Services (HHS) under cooperative agreement number poverty and addresses areas such as hunger and housing. U30CS09742, Technical Assistance to Community and John: Is there any one factor that seems to be correlated with co-occur - Migrant Health Centers and Homeless for $1,094,709.00 ring risk? with 0% of the total NCA project financed with non-federal Dr. Baer: Food insecurity alone can be a valuable way to identify sources. This information or content and conclusions are those of the author and should not be construed as the offi - cial position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government. 1 Baer TE, Gottlieb L, Sandel M. Addressing social determinants of health in the adoles - cent medical home. Curr Opin Pediatr. 2013;25(4):447-53.

2 MCN Streamline hunger as well as risk for other social prob - besides being cost and resource efficient – Dr. Baer: Yes, absolutely. Just this month lems. The American Academy of Pediatrics they may be more effective at eliciting high - Centers for Medicaid and Medicare Services (AAP) now recommends that health care ly sensitive information for adolescents. (CMS) announced a first-ever innovation providers routinely screen children and ado - John: Where do clinics and offices start in model to address SDOH. Health care pay - lescents for food insecurity using two validat - developing a comprehensive community ment reforms are definitely moving in this ed questions that were adapted from the resource referral system? direction. Accountable care organization and U.S. Department of Agriculture (USDA) Dr. Baer: It’s overwhelming and reason - patient-centered medical home models are Household Food Security Scale, and validat - able for a provider to think, “How am I to looking to reward providers to pay more ed by Erin Hager and colleagues: 1) “Within respond to my patients’ complex social attention to social determinants, to get to the past 12 months, we worried whether our issues?” if they believe they’re in it alone. the root cause of disease. When outcomes food would run out before we got money to But they have many potential partners who rather than units of service become valued buy more,” and 2) “Within the past 12 share in their goal of patients’ health and by health payers, we’re going to see much months, the food we bought just didn’t last safety. Community resource guides are quite more innovation in care coordination. and we didn’t have money to get more.” common and available through local public John: Is there anything else you consider Research that I recently published demon - and private child and family service agen - imperative for providers to consider when strated that youth who answered yes to one cies. A great model being used in a number addressing the wellbeing of young people? or both of those questions have significantly of cities is CAP4Kids, a website that links Dr. Baer: All youth should be screened greater likelihood of also experiencing other healthcare providers, social workers, child for social determinants, because these are social problems, including health care advocates and parents and teens with up-to- often ‘hidden’ problems that health care access, housing, education, income insecuri - date information on community resources. providers may not detect and youth will not ty and substance use. John: I imagine most health practices bring up without asking. However, certain John: How do you push back against the aren’t configured for this. How do you con - groups of youth may be particularly vulnera - argument that providers are too constrained vince providers to take on additional staff? ble, such as sexual and gender minority for time to address adolescent SDOH issues? Dr. Baer: Every health care home needs a youth, homeless or runaway youth, youth Dr. Baer: In addition to researching the resource connector of sorts – but it doesn’t who are incarcerated or in the juvenile jus - benefits of short screening tools like the 2- necessarily require advanced degrees or tice system, youth in foster care, and immi - item food insecurity screen, we’ve discov - highly-priced expertise. Some of the most grant youth. It is important for health care ered some online tools that health care prac - creative innovations, in fact, are being led by providers to normalize these questions in tices and clinics could adopt to facilitate self- models using volunteers and paraprofession - their practice, and let youth know that social screening by the patient. It doesn’t take time als. One of the best known examples is determinants matter because they affect out of the clinical interaction. My colleagues Health Leads, which employs college student overall health. Providers should use terminol - at Boston’s Children created a web-based volunteers who are trained to assist families ogy that youth can understand, ask ques - platform called HelpSteps that includes a in filling social prescriptions that meet basic tions in a respectful way that does not con - self-administered needs assessment, which, needs. Community and street outreach vey blame, and let youth know that while upon completion, triggers targeted referrals workers are integrated into health care they may not want to discuss these issues at to community-based resources. It’s been teams to engage in patient advocacy around the current visit, the door is always open. tested to be highly effective with adolescents housing, job training, education and health Finally, providers should identify other team in clinical settings in Massachusetts. care. members whom youth may feel more com - There is another distinct advantage to John: Are these practice reforms fortable turning to, such as social workers, web-based electronic screening instruments sustainable? psychologists, or resource specialists. ■

Risk Management: MCN’s Toolkit Has You Covered Serving migratory and seasonal agricultural but are not limited to, counseling for use non-traditional delivery methods to workers brings a set of risks that other patient mental health issues (e.g., depression, provide health care. This resource dives groups might not present. Migrant Clinicians anxiety) and substance abuse (e.g., alco - into the risk management of care at a site Network’s Risk Management Toolkit gives health hol, recreational drugs). other than a brick-and-mortar clinic. centers guidance on some of the most critical • Care for Undocumented Patients: Unlike • Referrals to Specialty Care: Health centers areas of risk in serving this underserved popula - providers of many other federally-funded can reduce their liability for lawsuits by tion. View the resources at http://www.migrant - services and benefits, health centers are ensuring they are eligible for coverage by clinician.org/toolsource/475/risk-management/ permitted to serve undocumented the Federal Tort Claims Act (FTCA), which index.html. Here is each of the resources, with a patients, and are not required to ask offers protection akin to medical malprac - short introduction to each one. about a patient’s immigration status. tice insurance to federally funded health • Behavioral Health Care for Mobile Health centers need to ensure that their center program grantees. Since health cen - Populations: In recognition of the impor - policies protect patient privacy while com - ters refer patients to medically necessary tance of behavioral health as a compo - plying with applicable laws on collection specialty care services that are not within nent of quality health care delivery, most and disclosure of patient information. their capacity to provide, it is important to health centers provide these services to • Incident Report: The purpose and instruc - be consider the health center’s coverage their patient population. These are servic - tions for such incident reporting accom - and potential exposure in the event that es that are difficult for many migrant panies an example incident report form. problems arise connected to the referral. health centers to provide onsite so they • Off-Site Care: In order to meet the needs These resources are just a few of the hun - may be contracted to outside providers. of special populations such as migratory dreds of tools and resources available on our Behavioral health services may include, agricultural workers, health centers often website, www.migrantclinician.org. ■

MCN Streamline 3 A Clinician’s Guide to Burnout and Balance By Claire Hutkins Seda, Writer, Migrant Clinicians Network, Managing Editor, Streamline

a Federally Qualified Health Center in the northern reaches of the San Joaquin Valley, California. He is seeking to address clinician burnout at his health center. “Some of it has to do with work ethic, where [clinicians] are in life. I think our goals change as we go through life….There’s no set formula.” But there are parameters one can assess. Clinicians can regularly reevaluate their per - sonal work-life balance, which changes as life progresses. Health center administration can take steps to relieve the pressure on cli - nicians while they are at work. And clinicians and administrative officials together can cre - ate a work atmosphere that values balance and strives to help clinicians find it. Changes throughout the stages of life Many clinicians coming out of medical school recognize the stress that is ahead of them. After many years of higher education, they willingly sign up for an often grueling residency. “We’re prepared for residency — you’re prepared to work the long, hard hours,” Dr. Morrison remarked. When a clini - cian finally ends residency, though, “then life starts to happen.” Clinicians may have greater control over work pressures, but urnout, in which a worker is physically result of their patients’ health situation. simultaneously many of these younger clini - and emotionally exhausted from too Agricultural workers – because of their fre - cians begin to have life events that require Bmuch difficult work, is often associated quent mobility, their often tenuous financial greater attention. with the medical field. Almost every clinician situation, and concerns about missing work, When a clinician is pregnant or has a knows someone in the office who has among other barriers – may struggle to get young child at home, or when a personal experienced the serious and debilitating to the clinic. When they do, they may have relationship ends, or when parents need to condition. A 2014 Mayo Clinic survey a backlog of health concerns that cannot all be cared for, daily priorities and motivations uncovered that burnout increased between be addressed in the short window of time shift. “[Modern clinicians] have it correct: 2011 and 2014, with now over 50 percent with the clinician. “We try to adjust treat - We want it all. We don’t mind working of physicians experiencing at least one ment modalities to take into account the hard, but we want to be able to enjoy symptom of burnout. With increasing patient realities of their lives – but it can be very these experiences,” outside of work life, loads, fewer clinicians choosing primary stressful” for clinicians, admitted Karen Dr. Morrison says. care nationwide, and growing demands Mountain, RN, MSN, MBA, Chief Executive Dr. Morrison reminds clinicians to regular - on clinicians like electronic health record Officer for Migrant Clinicians Network. A cli - ly evaluate their work-life balance as both utilization, the increase in burnout is a nician may “know what the patients need, work and life shift. As a clinician enters a concern that can alter a clinician’s life but…be unable to assure that they can get new phase of life, his or her needs and and cause conditions like depression. it,” a frustrating and disheartening experi - responsibilities outside of work may change For patients, it jeopardizes high-quality, ence for many clinicians, said Mountain, yet — and few clinicians account for this in their compassionate health care delivery around another contributor to burnout. work life. Anticipating personal life changes the country. The work-life balance — in which a clini - can help buffer the stress of a big change at Burnt-out physicians feel a high degree of cian ensures enough down-time to decom - work — and vice-versa. cynicism, or “depersonalization” toward press, take care of personal needs, and come their patients, viewing them more like back sufficiently refreshed and ready to work The simple stress of the job objects than human beings; burnout may every morning — is an essential measure to The work-life balance can be difficult for also increase medical errors. Overly stressed prevent or lessen burnout. How does one those who spend their entire careers serving work environments negatively affect others achieve a balance, within work and outside people with significant and overlapping in the office, too, creating a culture of of work, to prevent burnout? health issues, but it may be amplified for cli - burnout. Clinicians serving migrant and sea - “Wellness is about finding balance, but it nicians serving the underserved. sonal agricultural workers and other under - means something different to each person,” Underserved patients often come with sto - served populations may experience greater said Ben Morrison, MD, Chief Medical ries of dire poverty, homelessness, trauma, levels of frustration and hopelessness as a Officer at Community Medical Centers, Inc, and other serious struggles, all of which

4 MCN Streamline affect the health of the patient. A 2012 steps to lessen the blow. Dr. Morrison recommends is assuring that Walter Reed study found that clinicians who Mountain says that when she visits health the executive team is modeling the work-life spent time every week at an on-site comple - centers around the county, she doesn’t see balance that they want to see in the clini - mentary and alternative medicine wellness the burnout — she sees the wreckage. cians. An overworked, burnt-out administra - clinic not only reported feeling more relaxed “When you see people who feel valued, that tion cannot address the burnout issues of after sessions (97.9%) and feeling less just comes across. When you see leaders their staff. “Initially, I thought the harder I stressed (94.5%), and experiencing less pain who are insensitive, who are projecting the work, the more I’m supporting my (78.8%), but, after five or more visits, more needs of the corporation over the needs of providers,” Dr. Morrison noted. “But it sends than half of respondents strongly agreed on the employee… there’s resentment, and the wrong message.” He admits that he their surveys that they experienced increased anger, or just flatness,” among the employ - enjoys his job and isn’t opposed to working compassion with patients. Lead author on ees, Mountain said. “And that just carries long hours, but he has set up his own per - the study, Alaine Duncan, L.Ac, a Maryland- right down to the patients.” sonal barriers that he will not cross, to assure based licensed acupuncturist who focuses on Dr. Morrison recommends that adminis - that he maintains his own work-life balance. trauma in her patients, believes the work-life balance message is clear: self-care is essential in the face of trauma. As a clinician enters a new phase of life, “Clinicians may experience burnout as a sense of overwhelm with the suffering of the his or her needs and responsibilities outside world, and not knowing what to do with it,” Duncan said. Day-in and day-out experi - of work may change — and few clinicians ences with traumatized or suffering patients may weigh heavily on clinicians. Recognizing account for this in their work life. this additional burden and scheduling in time to recuperate and process is essential when dealing regularly with trauma. tration address the work-life balance at the Mountain agrees: “It’s not just the clini - Additionally, a clinician’s reaction to the organizational and individual level. At the cians, it’s everybody” who can experience patient is critical to avoid burnout. “We lose organizational level, “having a provider burnout. She recounts a recent visit with a our witness state,” she said, “and we fall into advocate is important,” Dr. Morrison empha - health center during which the vice presi - their stories.” Duncan encourages clinicians sized, to keep clinician needs at the table dent of operations took the time to help a to seek education on trauma resolution to during executive decision making. A patient navigate a new building. “That to best focus on resiliency of patients and “to provider advocate can guarantee that big me spoke volumes of the values of the lead - treat the patient’s dysregulation — not the decisions aren’t made without the work-life ership — the fact that there’s somebody [patient’s] story.” balance in mind. who is mission-driven and caring. When Equally essential is the support team. you’re burned out, you lose touch with car - Changes in the health world, too “We’re trying to develop our work teams to ing about others — because you haven’t “I don’t think medicine has gotten harder,” better support the provider,” Dr. Morrison been able to care for yourself.” Dr. Morrison states, but the world of medi - noted. Better coordination of the provider’s cine has significantly changed in the last fifty team reduces the burden on the provider Finding compromise years, which presents new challenges to cli - and assures that all clinicians are working at Dr. Morrison cautions that not all rebalanc - nicians. Take the national rollout of the elec - the top of their profession. “We also are ing attempts will be successful. If a clinician tronic health record. While some clinicians reevaluating our compensation models,” Dr. is seeking part-time work only in the middle are relieved to have gotten over the initial Morrison said, looking into how the sched - of the day for a few days a week, health cen - learning curve, others still struggle. Either ule is built, and attempting to find flexibility ter administration may not be able to way, many clinicians were frustrated when in the schedule for those who need it. accommodate that. “We have patient needs new systems disrupted workflows and On the individual level, Dr. Morrison has — we have evening and Saturday clinics — required cumbersome and at times repetitive taken the extra step of reaching out to each so we need to set realistic expectations. But electronic entries. While all clinicians recog - clinician to meet one-on-one. A CMO can - communication is absolutely important,” he nize the many important benefits that not discover what the clinicians need unless stated. “Ultimately, as a provider, we have to patients and health centers will gain as a you directly ask, he says. “I will bring a work very hard. But it doesn’t mean we have result of the EHR, productivity went down provider to lunch, find out what’s going on to suffer because of it, and not have any bal - throughout the country. In recent years, with them. Sometimes everything is going ance. We have to have a team approach — after the initiation of the Affordable Care great and we just talk about their families... because no one can create the balance for Act, a new influx of patients has created but I’m letting the providers know that I you, but you have to have people who are provider shortages. Such system-wide strug - really care about them,” he said. “I want to willing to listen and acknowledge that that gles place undue burden on clinicians and be proactive... What are their needs? Are balance is important.” need to be addressed throughout the coun - there things that we could be doing better Dr. Morrison believes his approach is try. for them?” Additionally, the one-on-one working. A couple of clinicians who left his Just as clinicians can anticipate home life time helps Dr. Morrison get a wider perspec - health center have returned, which he thinks shifts that will change the work-life balance, tive, hearing from busy or quiet clinicians he is a good sign for the work environment he’s health center administrators can account for may otherwise not hear from: “We want set up. But he recognizes it’s an ongoing, new shifts at the workplace. Such big stres - everyone to have a say on things that are lifelong process: “We’re not a perfect sys - sors like clinician shortages and the drop in going on and not implement policies with - tem, but I definitely think we’re heading in efficiency related to the EHR can’t be fixed out getting their input.” the right direction and we’re listening to our easily, but administrators can make concrete One final individual-level adjustment that providers.” ■

MCN Streamline 5 Promotores as Needs Assessment Champions By Claire Hutkins Seda, Writer, Migrant Clinicians Network, Managing Editor, Streamline

eeds assessments are a unique oppor - tunity to gain insight into the commu - Nnities a health center serves — and a great way to assure a health center is on the right track with its programs and services. So, engaging and relying on the health center’s outreach team is a natural fit. At Moses Lake/Quincy Community Health Center, halfway between Yakima and Spokane in central Washington, Mary Jo Ybarra-Vega, MS, LMHC, and Maria Blancas have been steering each step of their health center’s needs assessment process as an integral part of their daily work as promotoras, communi - ty health workers serving the migratory agri - cultural worker community. “When you talk about needs assessments, promotoras are doing needs assessments all the time,” Ybarra-Vega, Outreach/Behavioral Health Coordinator, said. “They are the ones who Mary Jo Ybarra-Vega heads up a community meeting that ranks health priorities using “bolitas.” go get the data,” but they can also lead the process. Partnering with the health center’s promotores, Ybarra-Vega says, is the most have been an important resource for Moses but it’s a good way to find out [what’s really efficient and effective way to best ensure that Lake/Quincy, Ybarra-Vega said. needed], and then maybe you can make a the health center’s services are truly meeting For many health centers, the needs assess - good case for funding or change your servic - the needs of the community. What’s more, ment is a yearlong or multi-year process, es to adapt to the need,” Spurgeon noted. the healthy, long-term relationships that pro - replete with surveys and extra funding and motores have with the community can help staff meetings. For Quincy Community Ongoing work the health center maintain ongoing support Health, part of Moses Lake/Quincy, it’s an At Moses Lake/Quincy, the process starts with and flexibility as the community’s needs shift ongoing and integral part of the day-to-day the promotores . “Our [process] is very organic,” — and to prioritize funding to make sure that operations. “Health centers should always be Ybarra-Vega admits. But she believes it works. level of support is possible. doing something to assure that they are Every year, they use their “bolita method,” responding to the needs of their population says Blancas, Outreach Coordinator and long- What is a needs assessment? because needs change — and health centers time volunteer promotora at Moses Lake. With A needs assessment is just as it sounds: a need to keep that in mind, to make sure that the bolitas, (Spanish for “little dots”), the out - process under which a health center evaluates they’re checking in with their communities, to reach team hosts meetings throughout the and re-evaluates program effectiveness, to make sure that their services are appropriate,” service area in which “everyone gets three determine if it is reaching out to the full com - Spurgeon explained. “If they find out that little round stickers,” she said, where “they get munity in its service area and serving the their needs are something else, [they need to] to pick the three most important issues.” The needs that the community has. Each health figure out how to adapt to those needs.” method helps guide the process and also center program grantee under Section 330 There isn’t one correct way to completing provides a low-literacy format to encourage must undertake a needs assessment, and each a needs assessment, Spurgeon noted, but greater participation. The outreach team health center approaches it differently. “It is a HOP does offer a comprehensive needs collects and tallies the votes. Then, the team requirement — but it’s also the principle of assessment toolkit that encompasses the basic meets one-on-one with providers to ask what being a health center that is serving the processes. (Learn more about the toolkit in issues and concerns they have been hearing, underserved; you want to make sure that “Needs Assessments, Step-By-Step with and what they’d like to see the health center you’re being responsive,” Liam Spurgeon, Health Outreach Partners” in the autumn focus on in the coming year. Finally, the out - Associate Project Manager at Health Outreach 2015 issue of Streamline .) The first step is reach team meets as a group to discuss its Partners (HOP) said. “It’s a big undertaking.” defining specifically what the health center own perspectives, and to develop its plans in HOP provides training, technical assistance, wishes to obtain from the process. After defin - response to the assessments. When the out - and information services to health centers, ing the key steps and goals, the health center reach team renews its meetings the next year, primary care associations, and other commu - plans how to roll out the assessment. The it provides a summary of the previous year’s nity-based organizations around the country. third step, developing data collection tools, is concerns and how the health center respond - A National Cooperative Agreement through followed by the actual collection and analyza - ed. This format provides the base of the health the Health Resources and Services tion of data. Finally, the health center and its center’s formal needs assessment. In this way, Administration (HRSA), HOP’s goal is to build team share the results and use the findings to Moses Lake/Quincy has integrated its needs strong and sustainable grassroots health mod - adjust its programs and services and to priori - assessment process into a cornerstone of its els to increase access for underserved popula - tize and develop new actions to better outreach team’s work. tions. They have been key in many health address the needs of the community. “Maybe centers’ needs assessments processes, and your health center doesn’t have the resources, continued on page 7

6 MCN Streamline Newly Updated Clinician’s Guides: How Policy Affects the Health of Agricultural Workers

[Editor’s Note: This article first appeared that clinicians understand the regulatory nation supplies, and emergency medical as a blog post on Migrant Clinicians protections.” assistance. It also provides more information Network’s active blog, Clinician to Clinician. The Clinician’s Guide to OSHA’s Field on additional requirements and protections Please visit our blog to read up on timely Sanitation Standard dives into the Occupational at the state level. migrant health news, current events analysis, Safety and Health Administration’s 30-year- Finally, the Clinician’s Guide to FIFRA and profiles of clinicians, and updates from the old requirements to assure workers access to FQPA covers the requirements placed on the field: http://www.migrantclinician.org/ toilets, potable drinking water, and hand use and sale of pesticides. The Federal community/blog.html.] washing facilities. The guide covers the Insecticide, Fungicide, and Rodenticide Act illnesses and injuries related to field sanitation, (FIFRA) requires the registration of all pesti - igrant Clinicians Network (MCN) including agricultural workers’ very high risk cides on the market, if proven to not “gener - and Farmworker Justice have jointly of heat stroke and other heat-related illnesses, ally cause unreasonable adverse effects on the Mreleased three updated field guides which can be lessened if workers have access environment.” The Food Quality Protection for clinicians serving agricultural workers, to to clean water to drink and are encouraged Act (FQPA) amended the FIFRA to require that best equip them with knowledge and to take breaks to drink it. pesticides used on food undergo a health- resources on federal policies that are critical The Clinician’s Guide to the EPA’s Worker based assessment before EPA approval. The to the health and well-being of this particu - Protection Standard reflects the guide outlines the importance of clinician larly vulnerable population. Environmental Protection Agency’s recent engagement in identifying and reporting pes - The Clinician’s Guide to OSHA’s Field revisions to the Worker Protection Standard ticide exposure in agricultural worker patients, Sanitation Standard , The Clinician’s Guide to (WPS), which are set to go into effect in which can affect EPA decision making on a the EPA’s Worker Protection Standard , and the January 2017, and, in the case of pesticide pesticide’s ongoing licensure. Clinician’s Guide to FIFRA and FQPA lay down safety training changes, in January 2018. All three guides are supported by the in simple and nontechnical terms how the The WPS provides critical protections to agri - Health Resources and Services Administration federal policies work, and what clinicians cultural workers who work with pesticides, (HRSA) in recognition of the import of these need to know to best support their patients. including required safety training and readily federal policies on the health risks faced by “Workers in agriculture are one of the available information on the chemicals used. the patient population at health centers most vulnerable worker populations in the The five-page guide also covers WPS protec - across the US. country,” noted Amy K. Liebman, MPA, tions regarding medical assistance due to They are available at http://www.migrant - Director of Environmental and Occupational pesticide exposure, protections and restric - clinician.org/toolsource/resource/clinician- Health at MCN. “Water and sanitation stan - tions during and after pesticide application, guides-farmworker-health-and-safety-regula - dards are a basic need — and it’s important personal protective equipment, decontami - tions.html. ■

■ Promotores as Needs Assessment Champions continued from page 6 Blancas and Ybarra-Vega point out that emergency kits and the two-page sheets. At a ments, which further informs their programs their ongoing process is especially adept at national Stream Forum sponsored by North and services. responding to new and changing community West Primary Care Association in San Diego, a Ybarra-Vega is proud of the “level of per - needs. In recent years, massive and unprece - panel presentation was held to get the com - sonal commitment” that her team of out - dented wildfires have raged through the com - munity in on the conversation, and to inform reach workers has demonstrated, time and munity. During one fire, mandatory evacua - state and federal authorities of the issue. Visits time again, and she encourages other health tions were in place — but the local migratory to the migrant camps continue and now the centers to give the outreach team the lead in agricultural worker community was not kept promotores also distribute the new materials to developing and executing needs assessments. informed. “We started to hear about it from ensure that migratory agricultural workers “They have the heart, they know how impor - another promotora,” Ybarra-Vega recalled. won’t be left behind in the next big emergency. tant it is to ask the community, to get them “One of the waitresses [that she knew] knew While the process checked off the needs involved, to get the youth involved… We’ve a worker at a labor camp,” who said that assessment box for the health center, it also become a change agent in town. I think our when the sheriff came to announce a level proactively addressed serious and new con - community [has been] transformed,” Ybarra- three evacuation, the farm manager gathered cerns in the health center’s patient popula - Vega said. “We are always getting better and his family and left — without informing the tion. Should the issue no longer be of con - trying to improve… but we feel honored to farm crew. The promotores began to recog - cern among the patients, providers, and out - do the work that we do, with the population nize a gap in emergency preparedness. reach team, the health center will adjust its that we work with.” ■ “What happened is as we started doing our tactics to better reflect newer concerns as needs assessments with the bolitas, these they come. An added bonus is a better pulse Resources issues came up [there], too,” Ybarra-Vega on the community at large. When Ybarra- Health Outreach Partners is at www.outreach-part - said. In response, a volunteer promotora/pre- Vega grew up in Quincy, she says only a ners.org. They offer short “coffee break” webinars, including the recent “Three Key Lessons Learned From med student, Emma Zavala-Suarez, devel - handful of Latinos lived in the region. By the Needs Assessments” oped a two-page Spanish emergency pre - time Blancas joined in, “it was about 50/50” Contact Liam Spurgeon at HOP to request a copy of paredness informational sheet working with between Latinos and non-Latinos. Now, she HOP’s Needs Assessment Toolkit, at liam@outreach- the Grant County Sherriff Department and says, a vast majority of the population in the partners.org. their existing document. Partnering with community are Latino — and that, too, Visit Moses Lake/Quincy’s website at Molina Health Care, the team assembled comes out as they do their needs assess - https://www.mlchc.org/.

MCN Streamline 7 Making the Biggest Impact with Dr. Selwyn Rogers By Claire Hutkins Seda, Writer, Migrant Clinicians Network, Managing Editor, Streamline

[Editor’s note: This article is part of a series on at Harvard Medical School. He then became the lives of members of Migrant Clinicians chief surgeon and department chair at Network’s External Advisory Board. Learn more Temple University in 2012, in North about the board at http://www.migrantclini - Philadelphia, an economically depressed com - cian.org/about/external-advisory-board.html.] munity that he says is tormented with “burned-out homes, burned-out lives, and elwyn Rogers, Jr., MD, MPH, FACS, severe poverty.” “People present to Temple began his career as a trauma surgeon. University with advanced stages of disease SDuring a fellowship at Brigham and that you would say, ‘we are still in 1920,’” Women’s Hospital, which is associated with despite proximity to the hospital, he stated. his alma mater, Harvard University, he His work in Philadelphia demonstrated the noticed a trend among his patients. impact of poverty on health — and shaped “It was clear to me that trauma, especially his perspectives on the health system at large. intentional trauma, was not random. In the “Transparency [in health care] is what I’m city of Boston, disproportionately the people the most enthusiastic about,” he said. He getting shot or stabbed were people of color,” recognizes that some inequities in the US Dr. Rogers recalled. The realization brought health system still exist, despite efforts to him back to why he studied medicine in the alleviate some of the lack of access. Some first place: to use his skills to help as many patients are able to navigate the system; people as he could. He began to question others cannot. “It’s a system that’s porous,” whether he could do more to serve others, Selwyn Rogers, Jr., MD, MPH, FACS he says, that leaves behind populations with - before they were victims of trauma. “I can do out power — like the poor, minorities, a lot of laparotomies, open people’s bellies an inherent distrust of the health care women, unemployed men, immigrants lack - and sew up holes, but what was I doing about system.” Additionally, Dr. Rogers has ing authorization to work — and “those who upstream determinants of disease? What did I brought to the EAB a willingness to trans - just don’t have the social support and net - understand about processes of care and their late his expertise in urban violence to the work that my kids are blessed to have,” just link to outcomes? What did I understand largely mobile immigrant population that by the social circumstances under which about variations? About epidemiology, about MCN serves. they were born, he said. “How just is that?” statistics? The answer, after almost a decade of Now, he continues to push for the rights training: absolutely nothing.” Early Life and Education of the underserved as Vice President and With a wife and two young children in Dr. Rogers’ life intentions to serve as many Chief Medical Officer for University of Texas, tow, and while on call as a trauma sur - people as possible were developed early, Medical Branch Health System in Galveston, geon, Dr. Rogers went back to school to while growing up without much on St. Croix Texas. His recent move to Texas was once receive a Master’s in Public Health at in the United States Virgin Islands. “Early on, again predicated on a desire to increase his Vanderbilt University. When he returned to my mom did a lot with a little,” Dr. Rogers impact, believing that the “greater context” Boston, Dr. Rogers developed a violence said. His mother put a strong emphasis on of the huge service area along the US- intervention and interruption program to education as a pathway out of poverty and a Mexico border offered an opportunity for his stop the retaliatory cycle of violence after a gateway to service. He did exceptionally well leadership to positively affect the lives of gang-related shooting, through targeted academically, and early mentors encouraged even more patients in need: “What greater community health worker engagement — him to go into medicine. When it was time impact can you make than as the Chief an unusual step for a surgeon. He devel - to apply to universities, young Selwyn pulled Medical Officer of a health system in oped a population-based perspective of the down the Encyclopedia Britannica to deter - Galveston, that covers a landmass of patients social factors that influence community mine what medical schools to apply to. “The that’s half of New England?” violence or prevent people from accessing only things under [the entry for] ‘Medical Given the turmoil of intentional violence health care when they need it — the types Schools’ were Johns Hopkins and Harvard,” and alarming health disparities in one of of social determinants of health that influ - he laughed. He was accepted to both. After America’s great cities, Chicago, Dr. Rogers enced his work ever after, including now, a short stint at Johns Hopkins on a full ride will push forward with a new challenge in as he serves on Migrant Clinicians scholarship, he called up the Dean at 2017. Dr. Rogers will serve as the founding Network’s External Advisory Board. He is Harvard to confess that he had made a mis - Director of the Trauma Center and Executive the only surgeon on the Board. “We picked take and wished to transfer. The Dean got Vice President of Community Health Dr. Rogers because he brings his perspec - him in, and assured he got the financial Engagement at The University of Chicago. tive as a clinician who has worked to assistance he needed. He graduated from “In these roles, I will lead strategic initiatives address community violence, an issue that Harvard Medical School in 1991. to address social determinants of disease and has a profound impact on agricultural population health on the South Side of workers,” explained Karen Mountain, RN, Searching for the Greatest Impact Chicago,” he said. MSN, MBA, Chief Executive Officer for After receiving his MPH, Dr. Rogers began a Migrant Clinicians Network, adding that he series of positions where he continually strove Lessons along the way has a “in-depth understanding of special to make the biggest impact in his day-to-day Dr. Rogers, like many health professionals, populations who, like agricultural workers, work, starting as a trauma surgeon at face social isolation and who may have Brigham and Women’s Hospital and professor continued on page 9

8 MCN Streamline ■ Addressing the Opioid Epidemic continued from page 1 the six building blocks as “the core compo - Implementing the Building Blocks tions: Is there a good protocol? How do you nents of safe, team-based opioid prescribing The project assigned a clinic coach, some - assess a patient’s willingness to taper off? that we have seen in primary care settings one who stays in touch with the clinics each Does anyone have an opioid tapering tool? across the country.” The project’s website has month to provide technical assistance in When does someone qualify as a chronic its resources aligned with each of these build - implementing each of the building blocks. opioid user? ing blocks, under “Resources and Tools”. During that time, the clinics began review - The project also offers the clinics monthly Here’s a short summary of each of the six from ing their policies and procedures — which webinars with the Director of Chronic Pain the Implementing Innovations blog post. Visit Dr. Parchman says can be a revealing Management at the University of the website at www.improvingopioidcare.org process. Washington, after which each clinic gets the for more on each topic. “A lot of the [clinics] already had some opportunity to present a difficult case for 1. Leadership and consensus: Build organi - kind of patient agreement form, also known discussion. zation-wide consensus to prioritize safe, as a ‘pain contract,’” Dr. Parchman noted, The project is about halfway through its 36- more selective, and more cautious opioid but they often found “their policies weren’t month grant from the Agency for Healthcare prescribing. in agreement with the patient agreement Research and Quality, at the end of which 2. Use a registry to proactively manage form,” and vice versa. Once they aligned they hope to release a package of tools — but patients: Implement pro-active popula - the two, the clinics began to question the the project has created a number of resources tion management before, during, and workflow in the clinic to make sure the that they’ve already released on the website. between clinic visits of all chronic opioid policies are implemented. For most clinics, “We’re releasing tools and resources on the therapy patients to ensure that care is safe this unleashed a barrage of questions: website as fast as we can,” Dr. Parchman and appropriate and to measure results of Where do we get random urine drug tests explained, “Because it’s a crisis.” ■ chronic opioid therapy improvement done? Who’s going to check the state activities. prescription database once or twice a Resources 3. Revise policies and standard work: year? Who’s responsible for checking to The project’s website, www.improvingopioidcare.org, is Revise and implement clinic policies and make sure that the patient agreement has full of useful resources. Here are a few recommended define standard work for health care team been updated and signed in the past year by Dr. Parchman: members to achieve safer opioid prescrib - during the clinic visit? Where does that Get tips on how to navigate the difficult opioid conver - ing and chronic opioid therapy manage - workflow occur? sation with patients by downloading “Opioid Patient Discussion Guidelines,” available on the Planned ment in each clinical contact with chronic An additional challenge is determining Patient-Centered Visits page: https://goo.gl/94nQ78. opioid therapy patients. what measures the clinic will use to track “Revise Policies and Standard Work” features four 4. Planned, patient-centered visits: whether the care patients receive is improv - resources to help health centers adjust their guidelines Through planned visits, conduct proactive ing and that their patients are actually get - and treatment agreements: https://goo.gl/1wcj3Z. population management before, during, ting better. “There are no validated meas - The US Surgeon General has called on clinicians to and between clinic visits of all patients on ures out there, traditional quality measures,” lead against the opioid crisis. Learn more and sign on chronic opioid therapy to ensure that care Dr. Parchman explained. “So now, they’re at www.turnthetiderx.org/join. is safe and appropriate. Support patient- struggling with how to measure success,” Read the Implementing Innovations blog post on the centered, empathic communication for how to determine whether the added work Six Building Blocks at https://goo.gl/qO8IcJ. chronic opioid therapy patient care. that is being factored into the workflow is The Clinician Consultation Center offers free, real- 5. Caring for complex patients: Develop worth the time and effort. time clinician-to-clinician telephone consultation, focusing on substance use evaluation and manage - policies and resources to ensure that In addition to a clinic coach, the clinics ment for primary care clinicians. With special expert - patients who become addicted to opioids, share questions and gain insight through ise in pharmacotherapy options for opioid use, its or who develop complex opioid depend - shared learning opportunities, which include addiction medicine-certified physicians, clinical phar - ence, are identified and provided with monthly phone-in discussions among the macists, and nurses provide advice based on Federal appropriate care, either in the care setting clinics to help them troubleshoot issues and treatment guidelines, up-to-date evidence, and clini - cal best practices. Call 1-855-300-3595, 10:00am – or by outside referral. share resources. During one recent call, the 6:00pm, EST. For more information: 6. Measuring success: Continuously moni - group discussed how to taper someone off http://nccc.ucsf.edu/clinician-consultation/substance- tor progress and improve with experience. of opioids, which sparked a number of ques - use-management/

■ Making the Biggest Impact with Dr. Selwyn Rogers continued from page 8 has struggled with work-life balance. During Burnout and Balance.”) between the patient and provider.” He calls his time at Temple, while battling health Despite the added pressures of the posi - on clinicians to strengthen the sanctity of issues and managing stress, he began to feel tions he’s chosen, Dr. Rogers is adamant that the relationship between clinician and burned out. “That was a hard lesson for recalibrating regularly is essential for clini - provider, by listening, by treating patients me,” he admitted. His genetic makeup, cians — not just to avoid personal burnout, with respect — and to go a step further. mixed with lack of sleep, poor eating habits, but to keep reminding ourselves of the “We still have power that our patients and not enough exercise is “a recipe for importance of our work. “[We] need to may not have, especially those serving death. Who can I help if I’m dead? I can’t remain steadfast to the principles that got patients who have no voice, like migrant help my patients, I can’t help my kids — I’m [us] to make the commitment to hard work workers,” he said. “If you have power as a just another statistic.” So he began to slowly in the first place... to serve others,” he said. physician — the education, the background, adopt a healthier lifestyle. “Emphasizing self- “Somewhere along the line — with the your resilience, your income, your standing care is so important,” among clinicians, he insurance categories, the paperwork, the in society — you should speak to power…. said. (Read more about the work-life balance Affordable Care Act, value-based purchasing Physicians need to stand up more. We’ve in this issue’s article, “A Clinician’s Guide to — there [have been] artificial barriers placed got to be the voice of the patient.” ■

MCN Streamline 9 ENVIRONMENTAL / OCCUPATIONAL HEALTH SECTION Head Lice Now Resistant to Common Treatments, Study Says

he human head louse is now mostly resistant to common insecticide treat - ments, say researchers in a recent arti - T 1 cle in the Journal of Medical Entomology. Pediculus humanus capitis is well known to cause itching and annoyance, particularly for school children around the world, leading it to be one of the most prevalent human par - asitic infestations. Here in the US, widely available over-the-counter topical treatments like Nix or Rid have been relied upon for sev - eral decades to rid human head hair of the small dark colored insect. The active ingredi - ent of most of those OTC insecticides are pyrethrins or synthetic pyrethroids, the latter including permethrin and phenothrin. For this study, volunteer school nurses and professional lice combers collected lice from 138 sites in 48 states between 2013 and 2015. Researchers then extracted and ana - lyzed the DNA of the lice to determine the frequency of knockdown resistance ( kdr )- type mutations. Such a mutation is associat - ed with nerve insensitivity to insecticides like pyrethroids, pyrethrins, and DDT, chemicals that target the nervous system. Kdr -type mutations have already been identified in based insecticides like Nix are no longer percent permethrin and trimethoprim/sul - the common house fly and among the pota - effective as a lice treatment. The study does famethoxazole. Pediatrics . 2001;107:E30. to tuber moth, an agricultural pest. not analyze or recommend alternative treat - 4 Meiking T, Vicaria M, Eyerdam D, Villar M, Reyna While the identification of kdr -type muta - ments nor does it explore the insecticides’ S, Suarez G. Efficacy of a reduced application time of Ovide lotion (0.5% malathion) compared to tions might not necessarily predict the failure impact on human health. Nix creme rinse (1% permethrin) for the treatment of one of these insecticides to kill lice, its The Centers for Disease Control and of head lice. Pediatr Dermatol. 2004;21:670-674. identification seems correlated with reports Prevention continues to recommend FDA- 5 Stough D, Shellabarger S, Quiring J, Gabrielsen A. of product failures, the authors note. And approved OTC treatments containing Efficacy and safety of spinosad and permethrin product failure has been on the rise. pyrethrins or permethrins, or to ask a doctor creme rinses for Pediculosis capitis (head lice). Between 1984 and 1995, studies consistent - for a prescription medication. While some Pediatrics . 2009;124:e389-e395. ly found permethrin to have a 96 to 100 small peer-reviewed studies exist, more 6 Kim C. Biostatistics team leader memorandum. US Department of Health and Human Services. percent effectiveness in killing lice, but by research needs to be conducted into alterna - Center for Drug Evaluation and Research. 2010. 2001, a study reported the effectiveness at tive products. ■ Available online at: http://www.accessdata.fda.gov/ just 80 percent. The researchers describe drugsatfda_docs/nda/2011/022408Orig1s000Stat recent studies that have shown effectiveness References: R.pdf. Accessed 31 October 2016. rates between 28 and 55 percent. 2-6 1 Gellatly KJ, Krim S, Palenchar DJ, et al. Expansion This report’s findings were even graver. of the Knockdown Resistance Frequency Map Resources for Human Head Lice (Phthiraptera: Pediculidae) The CDC’s complete recommendations on head lice The overall mean percent resistance allele in the United States Using Quantitative frequency — meaning, the percentage of are at: http://www.cdc.gov/parasites/lice/head/treat - Sequencing. J Med Entomol . 2016. Available online ment.html. lice with genes that were found with at least at: one kdr-type mutation — was 98.6 percent. http://jme.oxfordjournals.org/content/early/2016/ American Academy of Pediatrics recommendations 03/30/jme.tjw023. Accessed 31 October 2016. are at: http://pediatrics.aappublications.org/ Only one of the 138 sites collected lice with content/pediatrics/early/2015/04/21/peds. 2 Burkhart CG, Burkhart CN. Clinical evidence of lice no mutations. Forty-two of the 48 states 2015-0746.full.pdf resistance to over-the-counter products. J Cutan sampled had a mean resistance of 100 per - Med Surg. 2000;4:199-201. American Academy of Dermatology recommenda - cent. Urban, suburban, and rural lice showed 3 Hipolito R, Mallorca F, Zuniga-Macaraig Z, poli - tions are at: similar levels of resistance. nario P, Wheeler-Sherman J. Head lice infestation: https://www.aad.org/public/diseases/contagious-skin- The study demonstrates that permethrin- single drug versus combination therapy with one diseases/head-lice

[The material presented in this portion of Streamline is supported by a grant from the Environmental Protection Agency, Office of Pesticide Programs, Grant # x8-83487601.]

10 MCN Streamline ENVIRONMENTAL / OCCUPATIONAL HEALTH SECTION Home Use of a Pyrethroid-Containing Pesticide and Facial Paresthesia in a Toddler: A Case Report

[Editor’s Note: The following has been excerpted from an open-access article published in the International Journal of Environmental Research and Public Health. Please visit the journal’s website for the complete article: http://www.mdpi.com/ journal/ijerph.]

Perkins A, Walters F, Sievert J, Rhodes B, Morrissey B, Karr CJ. Home Use of a Pyrethroid-Containing Pesticide and Facial Paresthesia in a Toddler: A Case Report. Int J Environ Res Public Health. 2016;13(8). DOI: 10.3390/ijerph13080829.

Abstract Paresthesias have previously been reported among adults in occupational and non- occupational settings after dermal contact Low-dose chronic pesticide exposures are odd facial movements. His parents observed with pyrethroid insecticides. In this report, common in the United States and around no other unusual signs or symptoms and we describe a preverbal 13-month-old who the world given widespread use in homes, reported he was otherwise behaving normal - presented to his primary care pediatrician gardens, and agricultural settings. 1 A popula - ly. The pediatrician observed the symptoms with approximately one week of odd tion-based survey of households with young as somewhat tic-like. History taking revealed facial movements consistent with facial children found that over 80% reported the patient’s family had been coincidentally paresthesias. The symptoms coincided applying some type of insecticide in the treating an ant problem in their house (pre - with a period of repeat indoor spraying previous year. 2 Children have been identified vious two weeks) using products they pur - at his home with a commercially available as particularly vulnerable to uptake of chased and applied themselves as instructed insecticide containing two active ingredients pesticides from their environment due to on the label. They also reported hiring a in the pyrethroid class. Consultation by the frequent hand-to-mouth behavior, ingestion licensed pest management professional Northwest Pediatric Environmental Health of soil and dust, mouthing of nonfood items, (PMP) to treat their home (indoors and out - Specialty Unit and follow-up by the increased contact with soil, floors and car - doors) during the same period. The child Washington State Department of Health pets where spray residues settle, and higher was not taking any medications and no included urinary pyrethroid metabolite concentrations of pesticide residues close to unintentional exposure sources to medica - measurements during and after the the floor in their breathing zone. 3-5 In the US, tions or other toxic substances were identi - symptomatic period, counseling on home residential applications have been identified fied. All other household members who cleanup and use of safer pest control as the most important contributor to chil - included his parents and a 32-month old sib - methods. The child’s symptoms resolved dren’s exposure to pyrethroid insecticides. 6 ling were in good health without symptoms soon after home cleanup. A diagnosis of We describe a case of pyrethroid or health complaints. The pediatrician pesticide-related illness due to pyrethroid insecticide toxicity in a toddler resulting requested the label for the home use prod - exposure was made based on the from use of a common household insecticide ucts. Given the rarity of tic disorders in the opportunity for significant exposure product. Symptomatic pediatric pesticide toddler period and the temporal relationship (multiple applications in areas where the poisonings are relatively rarely reported, of the symptoms to pesticide use in the child spent time), supportive biomonitoring especially in countries such as the US, home, the physician consulted the data, and the consistency and temporality where regulatory protections have reduced Northwest Pediatric Environmental Health of symptom findings (paresthesias). This risk. However, it is likely some pesticide- Specialty Unit (NW PEHSU) at the University case underscores the vulnerability of children related toxicity in children goes unrecog - of Washington (Catherine Karr) and a child to uptake pesticides, the role of the primary nized due to the non-specific presentation neurology specialist. The pediatric neurolo - care provider in ascertaining an exposure of these illnesses. gist found no abnormal findings beyond the history to recognize symptomatic illness, facial movements and electroencephalogram and the need for collaborative medical and Case History (EEG) testing was normal. public health efforts to reduce significant A 13-month-old boy with normal develop - The NW PEHSU informed the pediatrician exposures in children. ment and no prior significant medical prob - that the pesticide active ingredients identi - lems presented to his primary care pediatri - Introduction cian with a one-week history of persistent continued on page 12

MCN Streamline 11 ENVIRONMENTAL / OCCUPATIONAL HEALTH SECTION

■ Home Use of a Pyrethroid-Containing Pesticide continued from page 11 fied on the label had known neurotoxicity and further investigation was merited. The family was advised that use of the product should be discontinued immediately. Suspected pesticide-related illness is a reportable condition in Washington State and NW PEHSU alerted the Washington State Department of Health (WDOH). The WDOH Pesticide Illness Monitoring and Prevention staff and NW PEHSU worked together to assess the exposure history by time, location, and active ingredient. The child’s parents were interviewed further, application records were obtained from the PMP, and medical records from the pediatrician were reviewed. The family was counseled to clean treated areas with soap and water, and steam clean carpeting to remove residues in the home based on the pesticide manufacturer recom - mendation. Symptoms resolved sponta - neously in the days following home cleaning. dermal contact with the pyrethroid home boards in the carpeted playroom). The expanded exposure history discerned spray applied to baseboards in the carpeted Follow up urine testing seven weeks later, multiple pesticide types and applications in playroom and other areas of the house. Such in the non-symptomatic period, showed a the home. manifestations had been reported in several significant drop in 3-PBA and trans-DCCA Approximately one week before the case reports of adults following both occu - metabolites to below the 50th percentile symptoms developed, the family purchased pational and non-occupational exposures to range of the reference sample. and applied a product containing active pyrethroid-containing insecticides and their A diagnosis of pesticide-related illness due ingredient D-limonene (5%) but found it volatilized form. 7-9 NW PEHSU requested that to pyrethroid exposure was made based on ineffective. One week later, the licensed PMP the WDOH biomonitoring program provide the opportunity for significant exposure applied fipronil (0.06%) to the foundation analysis of the patient’s urine for pyrethroid (multiple applications in areas where the and applied chlorfenapyr (0.5%) and imida - metabolites. Pyrethroids are metabolized child spent time), supportive biomonitoring cloprid (0.05%) inside as crevice treatment and excreted rapidly in humans and urinary data, and the consistency and temporality of in the kitchen and master bath. An ant bait metabolites provide a measure of recent symptom findings (paresthesias). gel containing sodium tetraborate decahy - exposure. The WDOH program had recently drate (5.0%) was applied to the window sills conducted pyrethroid metabolite biomoni - Discussion of the master bath. Two days after the PMP toring in a general statewide population To our knowledge, this is the first child case application, the parent purchased an sample including a sample of children aged report of pyrethroid pesticide toxicity mani - indoor/outdoor ready-to-use insecticide con - 6–11 years. WDOH agreed to test the festing in facial paresthesias. It illustrates sev - taining pyrethroids bifenthrin (0.05%) and patient’s urine. eral key points including the particular vul - zeta-cypermethrin (0.0125%). This spray A spot urine sample collected from the nerability of young children to commonly product was applied at night to the kitchen, patient on day six of the symptomatic peri - used pest control products including toxicity living room, master bath and along base - od showed urinary metabolite concentra - under use conditions described on the label. boards in the child’s carpeted play room. tions of 2.22 µg/g creatinine (Cr) for 3-PBA Furthermore, the important role of the Onset of the toddler’s facial movements and 3.82 µg/g Cr for trans-DCCA. These lev - health care provider in recognizing potential was noted the day after first use of this els were in the range of the 90th and 95th toxicity and the collaborative public health home spray pyrethroid insecticide. The prod - percentile observed for a representative sam - role in surveillance and prevention are uct was sprayed several more times over the ple of young school age children during the demonstrated. following week coincident with the persist - Washington State survey (age 6–11 years), Pyrethroids are a class of neurotoxic insec - ence of the child’s facial symptoms. The PMP respectively. ticides used widely for agricultural and resi - returned the next week and applied a sec - Exposures to the other pesticides used in dential pest control. Toxicity testing identi - ond pyrethroid product to the foundation of the home have not been associated with fies multiple nervous system targets in mam - the home (bifenthrin 7.9%). Indoors, the paresthesias and applications were done in a malian systems, including voltage-gated PMP applied an insecticide containing manner that would present less opportunity sodium and chloride channels, and gamma- pyrethrins, piperonyl butoxide, and amor - for the child’s exposure (e.g., crack and aminobutyric acid (GABA), nicotinic acetyl - phous silica, as well as the same gel bait crevice treatment, gels, outdoor foundation choline, and peripheral benzodiazepine applied the week before along the window treatments) compared to repeated spray receptors. 8 The pyrethroids used in this sills of the master bath. application of the home-use pyrethroid child’s home, cypermethrin and bifenthrin, NW PEHSU suspected that the symptoms product in areas where the child spent a sig - could represent facial paresthesias caused by nificant amount of time (sprays along base - continued on page 13

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■ Home Use of a Pyrethroid-Containing Pesticide continued from page 12 have generally low systemic toxicity via der - mal contact and inhalation but moderate to high acute toxicity if ingested. Absorption MCN’s Popular Pesticide Resources across intact skin is low 5,11,12 . Notably, topical contact with pyrethroids is associated with for Clinicians Now Available in Spanish paresthesias, which are believed to result This month, Migrant Clinicians Network released key guidelines, protocols, and forms from local action on sensory neurons in the related to patient pesticide exposure, newly translated into Spanish. Pesticides are heavi - skin. 13 Paresthesias, which manifest as sting - ly used in agricultural settings across the United States, and illnesses resulting from expo - ing, itching, and numbness commonly in sures to pesticides are a significant and common occupational injury for agricultural the face, have been observed in the absence workers and their families. But primary care providers — those who are most likely to see of other pyrethroid toxicity symptoms in an agricultural worker patient suffering from pesticide exposure — often lack the training and resources to diagnose and treat pesticide exposures. Last year, MCN launched occupational case reports. 8,14-16 This prever - important partnerships with Costa Salud and Corporación De Servicios Médicos, two bal child’s odd facial movements were sus - community health centers in Puerto Rico, as part of our Workers and Health pected to represent a response to these well- program. The Workers and Health program includes on-site clinical training, the provision described paresthesias. In general, paresthe - of resources and technical assistance, and peer-to-peer networking between frontline sias dissipate within 24 hours of removal providers and occupational and environmental medicine specialists. To best support the from the exposure source and in this case, health centers’ frontline clinicians, MCN translated its key pesticide resources, which are symptoms resolved in the days following now available to all clinicians on MCN’s online Tools and Resources page. home cleaning to remove remaining “These resources give Spanish-speaking clinicians the basic framework to identify pesti - residues] 8. cide exposure, to better serve agricultural workers and their families,” explained Amy Young children are at higher risk of expo - Liebman, MPA, MA, Director of Environmental and Occupational Health with MCN. sure than adults following use of indoor pes - “This will help clinicians assure agricultural worker health and safety on the job.” ticide sprays. After spray application, pesti - cide residues settle on floors and surfaces, The resources include: which contributes to a higher risk of dermal Acute Pesticide Exposures Clinical Guidelines/ Guías de Manejo de Exposición Aguda a contact for children who crawl and play on Plaguicidas — A six-page instructional guide with sections on crisis response, decontami - the floor. 3 Younger children exhibit the high - nation, data collection from an exposed patient, physical exams, lab tests, treatment, est extent of hand to mouth and mouth to reporting, and documentation, as well as additional resources. object behavior, which can increase exposure Pesticide Exposure Assessment Form/ Evaluación de Exposición a Plaguicida — An easy-to- to residential pesticide residues. 4,17 Children read two-page questionnaire. During the clinical assessment, the clinician reads specific take in more air on a per kilogram basis than questions aloud to the patient and fills out information regarding the exposure and adults, so when air contains volatilized pesti - symptoms. A second page prompts the clinician to gather relevant physical signs, col - cides or dust containing pesticides, they lect materials, execute lab tests, report the incident, and more. receive a higher dose. Spraying of base - Cholinesterase Testing Protocol Algorithm/ Algoritmo del Protocolo de Prueba de boards in the playroom provided a significant Colinesterasa — a one-page dichotomous key for clinicians to quickly and accurately source of exposure for this toddler. determine whether and when to conduct cholinesterase testing. Partly due to their more favorable (less acute) toxicity profiles, pyrethroids have Cholinesterase Protocols for Health Care Providers/ Pruebas de Colinesterasa para Proveedores de Cuidado de la Salud — A short one-pager on baselines, testing, retest for replaced organophosphorus insecticides in return to work, and more. residential pest control products. 18 They are among the most commonly used and stored Access the pesticide resources in English and Spanish at goo.gl/ydR091. class of pesticide in US homes and are Access the Cholinesterase-specific resources in English and Spanish at among the most commonly identified pesti - https://goo.gl/sMgTQX. 19 cide residues on household surfaces. They Learn more about MCN’s Environmental and Occupational Health initiatives at also represent the class associated most fre - http://www.migrantclinician.org/services/initiatives/occupational-health.html. quently with pesticide exposures in children reported to US network of Poison Control Centers. 20 tiveness as well as safety. 21,22 would greatly enhance our understanding of In the case presented, multiple pesticides In this case, state-based public health the magnitude of pesticide-related illnesses were applied in and around the child’s home resources for biomonitoring and investiga - in children. on at least six different days in a two-week tion were helpful but unfortunately are not The ability of health care providers to take period. This case illustrates the need for rais - available to clinicians in every setting. In the an environmental history, to read pesticide ing awareness of the health risks associated US, suspected pesticide-related exposure is a labels, to identify symptoms of poisoning, and with pesticides, especially to children. reportable condition in all but 13 states to provide anticipatory guidance is a critical Greater education is needed for consumers (reporting is optional in six states). 23 Such part of efforts to prevent unnecessary and seeking do-it-yourself pest control. For programs provide useful public health track - potentially harmful exposures. Unfortunately, example, integrated pest management (IPM) ing as well as individual case support. A data suggests that most pediatricians in the methods which prioritize no or low toxicity more comprehensive national or global pes - approaches are recognized for their effec - ticide-related illness surveillance system continued on page 14

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■ Home Use of a Pyrethroid-Containing Pesticide continued from page 13

14. Tucker SB, Flannigan SA. Cutaneous effects US are poorly prepared for this. Only 12% of quences (secondary prevention). This case also from occupational exposure to fenvalerate. chief residents in pediatric residencies sur - illustrates the ongoing need for programs and Arch Toxicol. 1983;54(3):195-202. veyed in 2003 reported pesticide content policies to reduce pesticide applications in chil - http://www.ncbi.nlm.nih.gov/pubmed/6661029 was part of their curriculum. 24 A 2006 survey dren’s environments (primary prevention). ■ 15. Tucker SB, Flannigan SA, Ross CE. Inhibition of cuta - neous paresthesia resulting from synthetic pyrethroid of health care providers in a highly produc - exposure. Int J Dermatol. 1984;23(10):686-9. tive agricultural area with high pesticide use References http://www.ncbi.nlm.nih.gov/ pubmed/6526564 revealed that only 30% had training on pes - 1. American Academy of Pediatrics Council on 16. Chen SY, Zhang ZW, He FS, et al. An epidemio - ticides and children’s health. 25 This illustrates Environmental Health. Pesticide exposure in chil - logical study on occupational acute pyrethroid the need for knowledge of pesticides and dren. Pediatrics . 2012;130: e1757–e1763. poisoning in cotton farmers. Br J Ind Med. 1991; their health effects in medical education as 2. Wu XM, Bennett DH, Ritz B, et al. Residential 48(2):77-81. http://www.ncbi.nlm.nih.gov/ insecticide usage in northern California homes pubmed/1998611 well as accessible specialty consultation with young children. J Expo Sci Environ Epidemiol. resources. 26 In North America, the network 17 . Tulve NS, Suggs JC, Mccurdy T, Cohen hubal EA, 2011;21(4):427-36. http://www.ncbi.nlm.nih.gov/ Moya J. Frequency of mouthing behavior in young of academically-based PEHSUs are available pubmed/20588323. children. J Expo Anal Environ Epidemiol. 2002; for consultations on non-emergent manage - 3. Fenske RA, Black KG, Elkner KP, Lee CL, Methner 12(4):259-64. http://www.ncbi.nlm.nih.gov/ ment and questions related to low dose, MM, Soto R. Potential exposure and health risks of pubmed/12087432 chronic environmental exposures while the infants following indoor residential pesticide appli - 18. Williams MK, Rundle A, Holmes D, et al. Changes cations. Am J Public Health. 1990;80(6):689-93. Poison Control Centers remain the primary in pest infestation levels, self-reported pesticide http://www.ncbi.nlm.nih.gov/pubmed/1693041. use, and permethrin exposure during pregnancy source of guidance on acute poisoning man - 4. United States Environmental Protection Agency. 27 after the 2000-2001 U.S. Environmental agement in most settings. Non-dietary ingestion factors. Child-Specific Protection Agency restriction of organophosphates. Pyrethroid biomonitoring was available in Exposures Handbook EPA/600/R-06/096F; US Environ Health Perspect. 2008;116(12):1681-8. this case but its usefulness for case diagnosis Environmental Protection Agency: Washington, http://www.ncbi.nlm.nih.gov/pubmed/19079720 is subject to a few limitations. These urinary DC, USA, 2008;1–31. 5. 19. Trunnelle KJ, Bennett DH, Tulve NS, et al. Urinary metabolites are an indicator of exposure only. 5. Roberts JR, Karr CJ. Pesticide exposure in children. pyrethroid and chlorpyrifos metabolite concentra - There is no established threshold of exposure Pediatrics . 2012;130(6):e1765-88. tions in Northern California families and their rela - http://www.ncbi.nlm.nih.gov/pubmed/23184105. tionship to indoor residential insecticide levels, associated with symptom onset. Elevated bio - 6. Wu XM, Bennett DH, Ritz B, Tancredi DJ, Hertz- part of the Study of Use of Products and Exposure markers may be associated with diverse picciotto I. Temporal variation of residential pesti - Related Behavior (SUPERB). Environ Sci Technol. sources of pyrethroids including: background cide use and comparison of two survey platforms: 2014;48(3):1931-9. http://www.ncbi.nlm.nih.gov/ dietary exposure, lice and scabies treatments, a longitudinal study among households with pubmed/24422434 public mosquito spraying programs, or mos - young children in Northern California. Environ 20. Bronstein AC, Spyker DA, Cantilena LR, Green JL, quito resistant clothing. In the case present - Health. 2013;12:65.http://www.ncbi.nlm.nih.gov/ Rumack BH, Dart RC. 2010 Annual Report of the pubmed/23962276. American Association of Poison Control Centers' ed, dietary exposure could not be ruled out. 7. Walters JK, Boswell LE, Green MK, et al. Pyrethrin National Poison Data System (NPDS): 28th Finally, spot urine measurement of rapidly and pyrethroid illnesses in the Pacific northwest: Annual Report. Clin Toxicol (Phila). 2011; excreted metabolites can be highly variable a five-year review. Public Health Rep. 2009 ; 49(10):910-41. http://www.ncbi.nlm.nih.gov/ throughout a day. While the elevated 3-PBA 124(1):149-59. http://www.ncbi.nlm.nih.gov/ pubmed/22165864 metabolite in this case report is consistent pubmed/19413037. 21. Citizen’s Guide to Pest Control and Pest Safety. with increased exposure, it cannot alone con - 8. Roberts J, Reigart J (Eds.) Pyrethrins and Available online: http://www.epa.gov/oppfead1/ Publications/Cit_Guide/citguide.pdf. Accessed on firm that the child’s symptoms were caused pyrethroids. Recognition and Management of Pesticide Poisonings, 6th ed. National Association 2 February 2015. by the pyrethroid, nor that the pesticides of State Departments of Agriculture Research 22. What Is Integrated Pest Management? Available sprayed in the home were the source of ele - Foundation: Arlington, VA, USA. 2013;38–42. online: http://www.cdc.gov/nceh/ehs/Docs/ vated pyrethroids in the child’s urine. In this 9. Hudson NL, Kasner EJ, Beckman J, et al. Factsheets/ What_Is_Integrated_Pest_ case, the urine tests were supportive but not Characteristics and magnitude of acute pesticide- Management.pdf. Accessed on 2 February 2015. confirmative of the diagnosis. Diagnosis related illnesses and injuries associated with 23. Pesticide Reporting and Workers’ Compensation relied on patient history, presence of a hall - pyrethrin and pyrethroid exposures--11 states, Map. Available online: http://www.migrantclini - 2000-2008. Am J Ind Med. 2014;57(1):15-30. cian.org/ issues/occupational-health/pesticides/ mark sign, supportive urine testing, and the http://www.ncbi.nlm.nih.gov/pubmed/23788228. reporting-illnesses.html. Accessed on 27 January ruling out of other etiologies. 10. Washington Environmental Biomonitoring Survey. 2015. 2011. Available online: http://www.doh.wa.gov/ 24. Roberts JR, Gitterman BA. Pediatric environmen - Conclusions DataandStatisticalReports/EnvironmentalHealth/ tal health education: a survey of US pediatric res - We report a clinically significant exposure to WashingtonTrackingNetworkWTN/Biomonitoring idency programs. Ambul Pediatr. 2003;3(1):57-9. home-use pyrethroid insecticide in a toddler. /76. Accessed 28 June 2016. 25. Karr C, Murphy H, Glew G, Keifer MC, Fenske The case illustrates the unique vulnerability of 11. Reregistration Eligibility Decision for Cypermethrin. RA. Pacific Northwest health professionals survey children to routine pesticide exposure and the Available online: http://www.epa.gov/pesticides/ on pesticides and children. J Agromedicine. reregistration/REDs/cypermethrin_red.pdf. 2006;11(3-4):113-20. frontline role of the pediatric health profes - Accessed 3 February 2015. 26. Balbus JM, Harvey CE, Mccurdy LE. Educational sional in recognizing toxicity through taking 12. Bifenthrin: General Fact Sheet. Available online: needs assessment for pediatric health care an environmental history. Once recognized, http://www.npic.orst.edu/ingred/bifenthrin.html. providers on pesticide toxicity. J Agromedicine. collaborative support of environmental med - Accessed 3 February 2015. 2006;11(1):27-38. ical and public health specialists can support 13. Ray D. Pyrethroid insecticides: Mechanisms of 27. Trasande L, Schapiro ML, Falk R, et al. clinicians in deciphering timely and appropri - toxicity, systemic poisoning syndromes, paresthe - Pediatrician attitudes, clinical activities, and ate diagnosis and thwarting ongoing exposure sia, and therapy. Handbook of Pesticide knowledge of environmental health in Wisconsin. Toxicology, Volume 2: Agents , 2nd ed. Academic WMJ. 2006;105(2):45-9. and potentially more significant health conse - Press: New York, NY, USA. 2001;1289–1303.

14 MCN Streamline ENVIRONMENTAL / OCCUPATIONAL HEALTH SECTION New Release: Comic Book on Zoonotic Diseases

igrant Clinicians Network, in partnership with The Ohio State MUniversity and with support from the United States Department of Agriculture, is excited to announce the release of a new comic book, Working with farm animals: Keeping Yourself, Your Family, and Your Community Healthy . This comic book delves into the causes and symptoms of zoonotic diseases, and depicts ways that workers can protect themselves, their loved ones, and their local community. Workers who work with animals, be it in a milking parlor on a dairy, at poultry plant or at a meat packing facility, are at risk of exposure to disease-causing bacterium such as E. coli, salmonella, and campy - lobacter. These germs not only cause dis - ease in the exposed worker, but can also be carried home unknowingly by workers on their skin, or on soiled boots or cloth - ing. This comic book, offered in both Spanish and English, focuses on hygiene as a key strategy for protecting workers and their family members. MCN has a long history of using comic books as means to educate, because it allows health education messaging to bridge literacy gaps while keep - ing the interest of a diverse audi - ence of readers. This particular comic book was pilot tested with a group of dairy workers to ensure that the images and language used were culturally appropriate for the target audience. This newly released comic book is now available for download at the MCN website at https://goo.gl/ ZpR0kB. MCN also has a limited number of printed copies available free of charge on a first-come, first- serve basis. The order form is on the website on MCN’s Environmental and Occupational Health section. For more information, please contact Juliana Simmons, MSPH, CHES, Environmental and Occupational Health Program Manager for MCN, at [email protected]. ■

MCN Streamline 15 Non Profit Org. U.S. Postage PAID Migrant Clinicians Network PERMIT NO. 2625 P.O. Box 164285 • Austin, TX 78716 Austin, TX

calendar February 17-19, 2017 May 3-6, 2017 30th Annual Camden Conference – 10th Annual National Conference Refugees and Migration: on Health Disparities Acknowledgment: Streamline is published by Humanity’s Crisis JW Marriot Migrant Clinicians Network (MCN). This publi - Camden Opera House New Orleans, LA cation may be reproduced, with credit to MCN. Camden, ME http://www.nationalhealthdisparities.com/2017/ Subscription information and submission of arti - https://www.camdenconference.org/ cles should be directed to: 2017-camden-conference/ May 9, 2017 Migrant Clinicians Network NRHA’s Health Equity Conference P.O. Box 164285 February 22-24, 2017 Sheraton San Diego Hotel & Marina Austin, Texas, 78716 2017 Western Forum for Migrant San Diego, CA Phone: (512) 327-2017 and Community Health http://www.ruralhealthweb.org/mm Fax (512) 327-0719 San Francisco, CA E-mail: [email protected] http://www.nwrpca.org May 22-24, 2017 Rosemary Sokas, MD, MOH 2017 Conference for Chair, MCN Board of Directors March 1-3, 2017 Agricultural Worker Health Karen Mountain, MBA, MSN, RN Migrant Labor and Savannah Marriot Riverfront Chief Executive Officer Global Health Conference Savannah, GA University of California, Davis http://meetings.nachc.com/register/ Jillian Hopewell, MPA, MA http://johnmuir.ucdavis.edu/register-now- farmworker-registration-form/ Director of Education and Professional migrant-labor-and-global-health-conference- march-2017 Development, Editor-in-Chief June 16-18, 2017 Claire Hutkins Seda North American Refugee Writer, Managing Editor April 28-30, 2017 Health Conference 5th Annual National Sheraton Centre Toronto Hotel Editorial Board – Linda Forst, MD, MPH; LGBTQ Health Conference: Toronto, Canada Kathy Kirkland, MPH, DrPH; Kim L. Larson, Bridging Research and Practice http://www.northamericanrefugeehealth.com/ PhD, RN, MPH; Linda McCauley, RN, PhD, Chicago, IL FAAN, FAAOHN; Marie Napolitano, RN, http://isgmh.northwestern.edu/conference/ FNP, PhD.

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