EPIDEMIOLOGICAL STUDIES RELATED TO HEALTH IN ENDOSULFAN AFFECTED AREAS AT KASARGOD DISTRICT, KERALA 2010-11 Department of Community Medicine Government Medical College Calicut a Department of Health & Family Welfare Government of Kerala ‘SAL COLUEGE, CALICUTContents 4 5 1) Introduction Pages 1-2 2) Study 1 a © pages 323 Epidemiological study on the health status of the Population in endosulfan affected areas in Kasargod. District ,Kerala 2010-11 3) Study 2 ages 2445, Epidemiological school based study on the health status of adolescents in areas exposed to endosulfan spraying in Kasargod district of Kerala 2010-11 4) Study 3 Pages 44-54 Esttination of Endosulfan Residues in human blood at Kasargod District , Kerala 2010-11Introduction Kasargod district is situated at the extreme northem end of Kerala, Most of the people of Kasargod are farmers. There are 12 rivers flowing across its terrain and the district has a rainfall of more than 300mm, per year. In the late 1970's Plantation Corporation Kerala started cashew plantations in a large expanse of area in-Kasargod and endosulfan spraying ‘was started against tea mosquito bugs in the plantations. A lot of morbidity and mortality in the area have been reported and associated with endosulfan spraying. As per G.0 No 1550/20/10/H&FW, dated: 09.04.2010 and subsequent meetings ,the Department of Community Medicine , Medical College Calicut as part of petiodic monitoring of endosulfan affected areas in Kasargod, conducted three epidemiological studies on the health status of the population and monitored endosulfan levels in blood samples of a sample poptlation in Kasargod district of Kerala. ‘Work on the project Work commenced in August 2010 after receiving necessary instructions from the authorities .A detailed review of available literature was done end three epidemiological studies were planned as below. In September 2010 a draft protocol was prepared, the field areas of Kasargod were visited and arrangements made with District Medical Officer, Kasargod, local leaders and the community for conduct of these studies. Field work commenced after the election for local self government in Kerala in October 2010. pees sincrngae ‘ile informer er 2 oe aap Simoica 35. cahOUT 14, Community based study Objectives: a) To study the health status in relation to morbidity and mortality among the people living in the endosulfan sprayed areas of Kasargod district ») To analyse the time trend of morbidity and mostatity among the people of various age groups living in the endosulfan sprayed ateas of Kasargod district ©) Tocompare the above variables with an area in Kasargod with no history of local spraying of endosulfan, 2, School based study. Objectives: a) To study the morbidity status among adolescents from schools in areas exposed to endosulfan spraying and in a comparison area. b) To assess the pattem of growth and development among these adolescents, ©) To estimate the related hormone levels in a sub sample of the study groups. Biomonitoring of Endosulfan residues in human blood Objectives a) Estimation of endosulfan residues in human blood from human volunteers from worst affected panchayath areas Work for this study was in coordination with the technical team constituted by the KSCSTE - Govt of Kerala. 2 prot. df, NARAYANAN EV. panna Nese Seiinoe SacerStudy I Report of the Community Based Field Studyr | I Epidemiological study on the health status of the Population in endosulfan affected areas in Kasargod District, Kerala 2010-11 Conducted by Department of Community Medicine, Government Medical College, Calicut, Department of Health & Family Welfare - Government of KeralaInvestigators: Dr. C. Prabhakumari Professor & Head ( Coordinator ) Dept of Community Medicine, Govt.Medical College Calicut Dr. Jayakrishnan. T Assistant Professor Dept of Community Medicine, Govt. Medical College Calicut Dr. Thomas Bina. Professor Dept of Community Medicine, Govt. Medical College CalicutEpidemiological study on the health status of the Population in endosulfan affected areas in Kasargod District, Kerala 2010-11 Objectives: {To study the health status in relation to the morbidity and mortality among the people living in the endosulfan sprayed areas of Kasargod district 2:To analyse the time trend of morbidity and mortality among the people of Various age groups living in the endosulfan sprayed areas of Kasaragod district 3,To compare the above variables with an area in Kasargod with no history of local spraying of endosulfan. Methodology 1 Study Design : Cross sectional descriptive study 2Selection of study areas Stage 1 Area 1. According to the vietims list prepared by the Department of Health, 11 out of 39 Panchayaths were reported to be worst affected by endosulfan spraying.. Out of these 11 panchayaths, one panchayath ~ Muliyar, with large number of victims was selected randomly. This area had cashew estates owned by Plantation Corporation Kerala (PCK Jand also a history of aerial spraying of endosulfan for long years. ‘Area 2aFrom the list of 24 least affected panchayaths, one panchayath ~ Kodombelur was selected by purposive sampling considering the geography ‘and absence of cashew estate owned by PCK in the area. ‘The two study areas are linearly 30 Kms apart, and are at almost the same distance from sea level.(map of Kasargod ). Socio- demography of the two PAD NARAYANAN BY. 6 ae lermaton Once Vn PL rae ee col LeoR. CATICOTareas were comparable and majority of the natives are permanent residents of the area with limited migration Stage 2 ‘Area 1. From the selected Panchayath, the field area of Muliyar which is the ‘main sub centre (under Muliyar CHC) was selected as the study area. ‘Area 2. From the Kodom belur panchayath, the field area of Banam subeentte (under Ennapara PHC) was selected. ‘The area has no river or streams originating from the up hills or any PCK estate in the near-by area and the chance of drifting insecticides through water may be minimum. Stage3 All the house holds included in the sub centre registers of these two areas were included as study units. Area 1. Muliyar- Total 1200 houses Area 2. Banam -Total 850 houses ‘The areas were visited along with the field co coordinator and the selection ‘was finalized after discussions with the DMO (H),Kasargod.a Fig 1: Map of Kasargod with study areas,3. Data collection: Data collection was done by house hold survey using a pre tested validated proforma by the field workers. Selection of field workers 20 field workers were selected from the field staff of the department of health. They were given one day training at Periya PHC on 6" November 2010, for interview and data collection. Based on geographical land marks, each field area was divided in to blocks with an alphabetical code consisting of about 100 houses. Each block vias allotted to a designated worker ‘To ensure validity they were asked to collect data from maximum of 10 houses per day and were instructed to complete their data collection within 10 days, ‘The data collection period extended from 8" to 20" November 2010 in 2 phases The 1" phase of data collection was for 10 days from 8" to 17" November. The next 3 days were used for revisiting the missed /closed houses. Data collection was done only after getting written informed consent from the head of house hold or informant who was an eldest person in the family. All the house holds except one (Area 2) had given consent for the study and cooperated with the data collection. ‘The socio economic, enviconmental and details on morbidity and mortality of the family members wete collected by the field workers. Where ever available the field workers were accompanied and assisted by local ASHA volunteers. The data collection was monitored frequently by the faculty from the department of Community Medicine by visiting the area. After completion and checking the proformas were collected in sealed packets and brought to the department, 4 Data atfatysis: ‘The data was numerically coded and computer entry was done using Excel data sheet. The entry was cross checked for errors and necessaty corrections were made, Analysis was done using SPSS software SZ Prot Dr NARAYANAN EY ‘Pai lednmstice Otic Va Price Pes toan COLLEGE, CALICUT 95, Results 5.1 Demography: From the area 1, we could collect data from 1156 (96%) house holds out of total 1200 and from 842 (99%) houses out of total 850 house holds. in area 2. Total population covered in area 1 was 6107 and in area 2 was 3742. Average number of members in a house hold was 5.3 and 4.5 in the two areas respectively. - ; | $41.4 Age Composition : ‘The age wise distribution of population is given below. ‘Table 1 Age classification of study population in two areas ‘Areal ‘Area TI ‘Age | Moliyar Bana group | (N=6103) (e3714) No Go No % infants 58. 1.0, 45 12 TS yrs! 961 i527 317 139 10-19 yrs | _1184 19.4 606 163 20-29 yes |_1220 20.0, 684 18.4 30-39 yrs 986 16.2 623 168 40-49 yrs [726 Tis. 86 BL 481 79) 368 oo) 310 31 22 60 121 2.0. 108 29) aL 07, 5 13 5 oF 7 02 ‘The sex ratio of the area 1 was 957 per 1000 males, which is lower than that of Kerala and in area 2 was 1016. Organo-chlorine insecticides are reported to alter sex ratio prothbh NARAYANAN PE o note names en a BERSIGAr Contos. Cats5.1.3 Religion Table 2 Distribution by religion: ‘Raligion [Areal-Mullyar [Areal Banam NO 1% No__1% Hinds (616 [533 387 _*([ 658 Muslim [519 [449 8 __| 150 Christian [2 «(18 1s [52 Total 1136 [700 wat__[ 100 Even though there is a variation in the proportion of distribution by religion in these areas there are no ethnic differences. 5.2 Environment: fy 5.2.1 The source of drinking water: In both areas majority are using dug well water as drinking source, and a very low percentage was using public water supply. In area i (Miuliyar) more people are using bore weils since the soil type is more rocky. Table 3. Source of drinking water Source of drinking | Area T-Moliyar ‘Area Tt Banam Water Nell N=817 No % % Dog well 658 Sal 39 363 Bore well 23 2029 [30 36 Pablie water supply [141 i228 3 8T ‘Others ue To10 [278 Bi 7 5.2.2 Distance from PCK estate. In the area 1 - 52% of the house holds were situated within 1 km distance from the PCK estate and 17% were within 100 metres of the estate, iLIn the area 2 all house holds were > 10 Km away from any of the PCK estates which were situated in the neighbouring panchayaths, ‘There afe no rivers or streams which are originating from the up hills flowing through land of atea 2. ‘Working in PCK estates: 39 (0.6%) had present or past history of occupation in PCK estates in the area Land in the area 2 it was 9 (0.2%). 5.2.3 Any health events among domestic animal, ‘The informants were asked: whether they have uoticed any of the health events like death, abortion or congenital anomaly among the domestic animals (Cow, goat etc) in their home during the previous years. In the area 1, 41(3.5%) of the informants had noticed any one of the, health events in their domestic animals and in area 2 it was only 4 (0.5%) (P< 0001), 3 Morbidity 53.1 Hospitalization. One of the proxy indicators of health status of an area is hospitalization, Since the state has increased health awareness and uniform distribution of hospitals, most of the perceived morbidity will be reported to hospitals and. those with severe illnesses may get admitted. So hospitalization can reflect, the severe morbidity in an area, Table 4 Hospitalization in last one year Health events { Areal -Mullyar_[AreaT-Banam [OR [95% [P-value NO % NOT % a ‘Hospjfalization 293, 48 110 29 1.67 | 1.33- | <0.0001 | <1year 2.08 History of hospitalization during the last one year period was elicited. Hospitalization was 1.67 times higher in area 1 ( Mialiyar) as compared to area 2. Prot. DE. Ni ‘nate Sasoicee, 25.3.2 Prevalence of reported diseases, For collecting the information about the diseases, 31 diseases/birth anomalies which were reported to be attributed to “pesticide use” were listed, The informants were asked whether any member in the family was presently having any of these diseases, If the diseased family member was present during the time of survey, the diagnosis was verified by examination. In others the available records wer cross checked. Since the data was collected by the field workers and ASHA’s who are natives of the area many of the chronic diseased were already known to them. Table 5 Prevalence of selected diseases Disease ‘Areal -Muliyar. [Area -Banam N= 6107 1N=3742, No | Prevalence |No ] Prevalence Per 1000 Per 1000. i. Seimure #7 [sii00~ [39_{ 10/1000 2, Psychiatrie problems [21 [4/1000 (17. {5/1000 3. Behaviour problems [28 [3/1000 [4 [1/1000 [4 Mental retardation | 12_ | 2/1000 7_| 21000 5. Skin disease 110 | 78/1000 [82 | 2171000 6.Asihma Tos [18/1000 113 [30/1000 7, Any Cancer * 10_{ 2/1000 tt _ [271000 8 Kidney disease 33_[ 5/1000, 8 [2/1000 9. History of infertility [44 [7/1000 9__| 21000 10.Liver disease 3 [os/ioo [0 {0/1000 1.Weakness '35_| 9/1000 27 _| 7000 ‘22, Tremor ‘9 [2000 6 [2/000 * In each area there were 3 cases of breast cancer. The gpove table shows that except for the prevatence of kidney & liver diseases, infertility and behavioural problems in area I,most of the other diseases have slightly higher or equal prevalence in area 2. fb Prof. Dr. NARAYANAN 135.33 Prevalence of Congenital anomalies Table 6 Congenital anomalies ‘Disease ‘Area I-Muliyar | Area Tf- Banam N=6107 N=3742 No | Preval-‘tce | No | Prevalence [Any organ anomaly 4 7000 25 | 7/1000 (Limbs + organ) : > 2. Congenital heart disease | 23 | 5/1000. 19. | 5/1000 3. Cleft Lip /Palate 6 | 1/1000 0 | a/1000 4, Undeseended testis. 3_]osnood —|2 [171000 S$. Hernia 25 [4/1000 12 [3/1000 Congenital anomalies are seen in both areas. People with severe anomalies may not survive and the elicited data may be an underestimate, 7 5:34 Physical disability. ‘The physical disability in those below the age of 20 years was elicited Most were duc to congenital causes and majority are movement disability due to brain or limb anomalies. The details are given below. Table7 Physical disability in population below 20 years Physical OR [95% |P value Age group | aisabiity C3 Area I -Muliyar | Area YI- Banam No [% No [% Health check-up and medical care programmes for the diseased should be ongoing. >} Sereening programmes among antenatal women for early detection of congenital anomalies should be arranged . | Rehabilitation and. support measures for the chronically disabled should be ongoing. 5 ; } Periodic field monitoring of the morbidity and mortality in the district to elicit time trends is recommended. > Environmental monitoring of the soil and water samples for insecticide residues in the area should be done periodically.STUDY 1 ~ENDOSULFAN HOUSE HOLD STUDY Name of Field workers [oe PE ‘ADDRESS pk aaa Junior Health inspector, PHC Belloor TB Hoy MP, Leader Tuniox Health Inspector, PHC Mogral puthuz. 30 [| Salith. T Tunior Health inspector, FWC Mangalpady TD] Gopakaarnae. N ‘Junior Heaith inspector, PHC Ennappara STE [Krishna kumar. P| Junior Health Inspector, PHC Uduma S| F__| Sundaran, P Junior Health Inspector, PHC Anandashrant 7 | G__{ Roshan Lal. S “Junior Health Inspector, PHC Perla Vaninagar | H[Baba VK ‘onior Health Inspector, CHC Bedaidka ‘OTL | Pankajekshan, KP | Tunior Health faspector, CHC Bediadka 10-11 | Omana, P 3e, PHN, CHC Panaihsd ik [Selin Thomas IPHN, PHC, Chengala 2 {C_ | Thankamme, S Je. PHN, PHC Mulleria 13 [Mt _[indlwiekaN JPEN, PHC, Chengaia Ta [N | Radha. KV “Junior Health Inspector, PHC Eanappara 15[O | Komalavall PT [Je PHN, PHC Purathoor Fi 16 [P| Jessykutty Dominic. | Jr. PHN, PHC Ennappara, TQ TV. sobha ‘Jr. PN, PAC Mogral pothar tg [R | Sujatha. Je. PHN, PHC Mogral pathur 39 [8 [Geetha M. Js. PHN, PHC Chengala 20__['F | Thamban Adukkathif | Health Inspector, CHC Periya Field Work Coordination Dr. Jose G D'eruze. DMO tH), Kasargod District ‘Mr. Madhavan Nambiar. Coordinator Endosulfan Victim Remedial Celt Mr. Joy. JHI, PHC Mogral Puthur ‘Mrs Jessykutty Dominic. JPHN, PHC Ennapara L 2. 3 4 Field Monitoring Assistance = Dr Jayakrishnan, Dr Bij george, Dr Bhaskar Rao : Mr Berkumon feltc. ‘Data Analysis : Dr Jayakrishnan, Dr Biju george Acknwledgement: Dr Jose G D'cruze. DMO (Bt). Kasargod Dr Gopinath RCH Officer. KasargodStudy I Report On School Based StudyEpidemiological school based study on the Health Status of Adolescents in Areas Exposed to Endosulfan Spraying in Kasargod district of Kerala 2010-11 Conducted by Department of Community Medicine, Government Medical College Calicut. * Department of Health & Family Welfare Government of Kerala.Tnvestigators: Dr C Prabhakumari Professor & Head (Coordinator) Dept of Community Medicine, Govt. Medical College Calicut Dr Jayakrishnan T Assistant Professor . Dept of Community Medicine, Govt. Medical College Calicut Dr Thomas Bina Professor Dept of Community Medicine, Govt. Medical College Calicut 26Epidemiological schoo! based study on the health status of adolescents in areas exposed to endosulfan spraying in Kasargod district of Kerala 2010-11 Objectives: 1) To study the morbidity status among adolescents from schools in areas exposed to endosulfen spraying and ina comparison area. 2)"To assess the pattern of growth and development among these adolescents. 3)"To estimate the related hormone levels in 2 sub sample of the study groups. Methodology. Study design : Cross sectional descriptive comparative study. ‘The study population included 642 adolescents from 2 randomly selected schools in Kasargod district Area 1: BAR High School Bovikanum (aided school) ‘The school is located it Muliyar Panchayath where aerial spraying of Endosulfan was reported till 2002 for 20 years in the Plantation Corporation Kerala (PCK) estates of the area. ‘The students of this school were included as STUDY GROUP. Area 2: Government High school Kalichandukam. The school is located in Kodom Belur Panchayat with no history of aerial spraying of endosulfan and no PCK estate in the area. ‘The students of this school constituted the COMPARISON GROUP. Inathese areas the school enrolment rate was almost 100%, Most of the children were students of corresponding field areas and were representative of respective areas. Being from the same district, the ethnicity and socioeconomic status of theic parenits were also comparable.As per order 1550/2010 H&FW dt 9-4-2010 of Government of Kerala permission for conduct of the study, were obtained from the District Medical officer of Health Kasargod, Deputy Director Education, Kanhangad, respective school head masters, staff, PTA and parents, One week before the study, letters were sent to the parents explaining about the study and inviting their presence on scheduled dates to ensure maximum validity of the data collected. Subject selection. All the children enrolled in the school register in classes 8, 9, 10, willing to participate and who attended the screening camps were selected as subjects in the respective study and comparison groups. Study Period Areal BARHS Bovikanum : Data was collected over 3 days from November 29th to December 1* 2010. Area 2: Government High school Kalichanadukam., Data was collected over 3 days from December 6" to 8" -2010 for 3 days, Data Collection : Data was collected by a field team consisting of 3 child specialists, 2 medical officers, 1 lab technician and 1 paramedical worker. ‘A validated proforma was used and data collected by various methods: - 1) Direct interview: Relevant demographic, morbidity related and details on health status of the subject and family were collected by history taking and from past records. 2) Anthropometric and clinical examination: ‘The anthropometric measurements were done by using validated instruments and standardized procedures. The pulse and Blood pressure was recorded by electronic BP apparatus ( Omron), Prot Dr. NARAYANAN FM B‘The boys and girls were examined separately by male and female doctors including sexual maturity,ensuring full privacy in closed rooms. 3) Collection of blood samples for hormone assessment From selected sub sample population of 100 each from each group the blood samples were collected by venepuncture from antecubital vein using 6 ml vacutainer syringes following all aseptic precautions by the lab technician. It was then centrifuged for 30 minutes (5000 RPM) and the plasma was separated and collected in tightly capped glass tubes and kept in ILR pelow 4 degree centigrade The transportation was done in a fully sealed carrier with ice packs below 4 degree centigrade to the laboratory at Calicut Medical College and kept at -20 degree centigrade till taken for estimation., 4)) Laboratory assessment + Hormone studies were done by the Department of Nuclear Medicine Government Medical College Calicut Kerala. The method used was enzyme immonoassay using robotics reader and paired serums. ‘The following hormones were estimated, ‘Thyroid hormones : ‘13,T4,7SH. Sex hormones; Leutinising hormones (LH). Follicular stimulating hormones.(FSH) estradiol ‘Testosterone. Data Analysis ‘The collected data was crosschecked for reliability and completeness at the end of each day and suitable corrections were made. The variables were numerically coded and the entered data was analysed using SPSS software. Se GEGResults: In this study, 642 students from 2 schools were included as follows: LBARHS Bovikanum 386 students ( Study group) 2.GHS Kalichanadukam ——_-259 students (Comparison Group) Demographic details Table 1 Class wise distribution of student groups Class Study group ‘Comparison group BARHS Bovikanum GHS Kalichandukam N=386 N=259 No % No % vim [it 287 u ma x 150 389 5 367 x 135 zs 3 205 ‘Total 386 100 259 160 Table2 Age distribution of the students Age in [Study group ‘Comparison group n=259 years | n=383 No % No. To a 9 23 9 35 13 B 19.4 6 236 14 145, 376, 70 z is 35 246 os MT 16 ah Ad 10.9 38 147 AT a7 44 17 6.5. Mean: 14.384 1.19 14.45 4 1.32 age ‘The mean age of both groups were comparable. NARAYANAN PY‘Table 3 Study population by gender Gender | STUDY GROUP" COMPARISON GROUP BARBS Bovikanum. GHS Kalichandukam, No: % No % ‘Male 182 aS 140 341 Female 201 525, 119 59 Total 383) 100. 259) 100 Anthropometric measurements ° ‘Table 4 Age wise height of male students ‘Age’ BOYS Heightin oms ( Mean & SD) Pyalue Study group ‘Comparison 57) 140204653 146.7534.35, O14 3 146.3046.53 149,2249.82 O17 6 153.2028.86 156.9038.87 0.064 B 162.2547.24 163.5348.49 047 16 1648126.13 166.5547.59 038F iT 167.2336.82 167.7348.96 oa7L as # Prof. Dr 1 20-2. adAN BV, aie cena ae ep Mebicat Contes, CALICUT 3hTable 5 Age wise height of female students Age GRIS Height in cms( Mean& SD) Pyalue Study group Comparison up _ - i WITS 152007638 035 B TOU 656 1508065 035 4 152.634.5.81 152.894 6.18 0.82 15, 153.804 6.89 154.714 6.07 0.56 16 TSH 88E SIT T2594 528 ney a7 115g 1079 | 155.30E 507 059 Ts § Age wise weight of mate students Age BOYS Weight in Kg (Mean & SD) P value ‘Study group Comparison 1p _ 12 31.8044.09 34.8041.48 0.16 B 36.0949.25 35.6616.57 083 a ASOT RS STAB AA ‘al7 is aa WaaLIOA ous % BRT SHOEI 030 37 SOIESAS 38008870 005 a De MAR AYANN pute axle ten Be FL | DIRDICAL COLLEGE, CALICUT‘Table7 Age wise weight of female students Age GIRLS Weight in Ke( mean &SD) | Pvalue ‘Study group ‘Comparison, ivy 38.7524.19 OST oz) B 3654556 WISE BB O00 4 F250ET10 FTTE6ST O6r 5 465921059 6.182765 80 6 SECS SB67LT AR ‘Oil >IT 44.0029.4T 506021.82 on Age wise the mean of heights and weights of the children in the study group were lower than that of the comparison group, but were not statistically significant. Mean Blood Pressure & Pulse Recordings Table 8 Mean BP & Pulse (riean & SD Study group Comparison group Systotion TS3TE 13.1 [118.79 + 1675 BP(mm Hg) Diastolie 68.10 TOM 7132 H13.35 BP(mm Hg) PulseRate [9295 4 37.19 95.44 4 leas st Prof, Dy. NARAYANAN nv. Fabio lereation Oar Vice cpl MEDICAL COLLEGE. CALICUT x 33Scholastic performance Scholastic performance was measured by average marks and retention rate in any class. Data on average marks/grades were unreliable as most of the students are not aware of theit grades ‘The retention rate in any class was lower in the study group 91(23.8%) at Bovikanum and 73(28.2%) in the Comparison group but was not statistically significant. These may be due to difference in eniteria for promotion in both schools. Morbidity details: ‘The past history of seizure, asthmatic attacks and jaundice were collected by recall or by verifying past records, Skin disease and eye/vision problems were assessed by presenting complaints and clinical examination by doctors. . Pesticide use are known to be associated with seizures, asthma, skin diseases, congenital anomalies and to alter liver enzymes. Morbidity ineluded any of these reported illnesses. - ‘Table 9 Morbidity profile of the adolescent population ‘Morbidity | Study group | Comparison Risk [95% CIP BARHS group Odds value Bovikanum | GHS ratio Kalichandukam No [% No 1% Tay eunent [96 [256 }20 | 86 365 Lis 10.000" itiness ** 6.07 ‘Seizures 2 jar [4 15 163 [0.587- [0257 468, “Astana a jor fis fas 136 [626 ~ | 6281 295 Skin disease /76 [198 29 | iia 194 [1.23 =} 0.00" 3.08, Vision problem (70 [180 [iT [66 Bis pat [Oooo 550 ‘Canrent morbidiey** x. NARAYANAN 2Current morbidity was perceived mozbidity during the survey and history of current medication. They mainly consisted of minor illness like head ache, respiratory tract illness, eye strain, asthma and skin problems. The study group ( BARHS Bovikanum ) had 4 higher prevalence of any current reported morbidity of 25.6% , Vs 8.6 % in the comparison. group, the odds of reported morbidity being 3.65 times higher in this group (OR 3.65 , P=<0,0001) which was statistically significant, Skin diseases and eye problems were also significantly higher in the study group. Seizures: Jn the study group, 12 students gave a history of seizures in the past of which 3 reported current episodes while in the comparison school only 4 had seigures in the past with one having current episodes, Asthma: In the study group ,25'(9.7%)students reported asthma of which only 5 (1.3%) had an attack during the Iast 1 year. In the comparison school 18(4.8%) reported asthma of which, 3 (1.2%) had an attack during the last one year, -Skin disease: All current skin problems were enlisted by the doctors Allergic/contact dermatitis and eczematous lesions were considered. The odds of a skin problem in the study group was 1.94 times higher as compated to the comparison group which was significant.(OR=1.96 ,CI 1.23 to 3.08,p<0.003) Eye problems; The eye problems were refractory errors, eye strain,reading difficulties, increased watering, pain etc. The study group had a 3.15 times significantly higher odds of eye: problems also (OR= 3.15 , Cl. 1.81-5.50,p <0.000). History of jaundice: This was similar in both groups being 10(2.6%) at Bovikanuiff and 6 (2.3%) in the comparison area. Hypersensitivity disorders: The ratio of the presence of any hypersensitivity disorder ( Allergic dermatitis, Eczema, Bronchial asthma ) was 101 : 47 in the study group vs the comparison group. Prot. De meet NARAYANAN py. 35 asem sureDetails of congenital anomalies Congenital anomalies were assessed by clinical examination by pediatricians. Children with severe anomalies and disabilities may not attend the schools and may be at home or enrolled in special schools for challenged children, So the anomalies recorded may not reflect the true. picture of disabilities prevalent in the community. ‘Table 10 Congenital anomalies among study population ‘Study group. ‘Comparison group Anomaly BARHS Bovikanum | GHS Kalichendukera N=383 N=259 No_|ver1000. _[No__| Per 1000. T. Limb anomaly 3 (78 1 139 22. Any organ anomaly 3207 2 [97 ‘3. Congenital Heart disease 1317.8 1_[39 4, Undescended testis 126 1139 5. Cerebral Palsy 2 [52 0 {00 6.Congental Talipes equinovarus| 1 |2.6 [39 71. Poly dactyly 1 [26 1 (39 8, Marfans syndrome 1 [26 1 (39 '9. Cong: adrenal hyper plasia [1 [2.6 a) 10, Short stature 10 [255 a) *The native place of the mother was in bovikanum Any organ, anomaly and Congenital heart disease were higher in the Bovinakunt schoo}. Congenital heart disease was diagnosed either from old records or by detailed clinical examination and history, Ten Children with short stature were recorded from Bovikanum and also had delayed mile stones of puberty Z Dr, NARAYANAN BV. 36‘Table 11 Any congenital anomaly Study group ‘Comparison ‘Risk we TP | BARHS group value Bovikanam GHS N=383 Kolichandukam | Odds e259 tio No [% [No 1% Ray 0 [2243 Tn congecital 61t anomaly Odds of any congenital anomaly was significantly higher at Bovikenum . Death among the siblings Table 12 : Sibling deaths Details ‘Study group | Comparison group | Risk | 95% Ci Prvalue , BARHS GHS ) Bovikanum Kalichandukam, N=386, N=259 Odds ’ No [% No % ratio a | History of.| 35 oS 7 66 Lal | .770-2.37 0.167 Sibling > [death a 15 History of sibling deaths was higher at Bovikenum: > > Death among te siblings were collected by verbal autopsy from the parents -2 and students Most of the deaths were during néonatal period, infancy and og children under $ years of age and were attributed to either preterm deliveries “5 oF congenital anomalies. Most of the recalled congenital anomalies were related (0 the brain or CNS with symptoms of seizures,: Few neonatal 7 deaths among twins were also noticed. ~~ Z Prot. By rane fad fice tae t MEDICA. woLieoR Cae 37 ~History of previous of surgery Previous surgeries recorded in both groups were as below: ‘Table 13 Details of previous surgery Previous Surgery ‘Study group [ Comparison group N=383 ‘Ne=2s9 No [% No 1% [Any previous surgery [16 [41 ]an~ [42 Binh defect 6 (155 0.386 [ Appendicectom 3 jo7 fa O77 ‘Hernia o Jo 2 ‘O72 Fracture 2 [0138 [3 1.158 Brain related 1 [026 —|o 0 (Genitourinay sytem (1 [026 [0 0 Hormone study Goitre was examined by clinical examination and graded according to WHO grading as 0, 1 and 2, Table 14 Goitre in the study population ‘Thyroid grade [Study group | Comparison group N=369 N=243 Grade 0 206 [55.85 [151 [6.14 Gradel [io [27.37 [46 [1893 Grade? @_fi680 [46 [1893 ”. Students in the study area had significantly higher proportion of goitre of 163 (44.17 %) compared to 92 (37.86 %) in the Comparison area (odds ratio 2.09( CI 1.51-2.90) p <.001* ) sARAYANAR EA . PiSexual maturity ‘The mean age of attaining menarche among the girls of the study group 13.20 + 0,80 was higher than in the comparison schoo) of 12.60 + 1,0 {p<0.001*) Comparison of hormone values: Blood froma sub sample of the study Lae of both sexes were taken for hormone studies. Table 15 ‘Thyroid hormones ‘Study group | Comparison group [P valve 1298 0297 ‘Mean | sd. Mean. ‘sd. T3 11.12 | 0.33 [0.97 OAL 0.009 ‘T4__ [75.50 | 23.76 | 66.79 18.95, 0.008 (rswtzia [544 [aie [37 [oso Table 16 Sex hormones Study group | Comparison group | P value N=98 NAOT ‘Mean | SD _j Mean. SD. [Oestrogen | 51.02 | 68.24 | 42.22 [51.38 | 033% FSH 645 [5.64 [13.01 [9.26 — [0.001% TH 3.08 [6.84 [606 | 9.77 [ 0.433 “Fesiosterone | 1.98 [2.94 [199 [2.08 [6.989 a ‘A higher level of oestrogens, and lower FSH (Follicular Stimulating Hormone) and LH (Leutenising Hormones) levels were also noted in the study group. Prof. Ps? Paseiomata Soe Ves MEDICAL COLLEGE, GaLtCI?TLimitations Due to resistance from the local community and activists, it was not possible to collect blood for the estimation of endosulfan residues from the students. Summary and conclusion An epidemiological school based study among adolescents from 2 schools in Kasargod district from an area with history of exposure’ to endosulfan spraying vs a Comparison area was done in’November 2010 to February 2011. ‘Area 1 -BRHS Bovikanom, Moliyar Panchayath -was the Study group, Area 2- Government High school Kalichandukam,, Kodom belur panchayat being the Comparison group. All the children enrolled in the school registers of classes 8,9,10 were selected as subjects. BRHS Bovikanum -----383. students GHS Kalichanadukam 259. students. ‘Total data from 642 students ie..322 boys and 320 girls were collected . The mean age of students from both schools were comparable 14,38,4 1.19 in the study group and 14.45 + 1.32 in the comparison group. The mean heights and weights of students from the study group was lower than in the comparison group . : Curent morbidity was higher in the study group 96(25.6%) vs 20 (8.6%) in the comparison group. Skin diseases (19.8% Ys 11.2%) , vision problems (18% vs 6.6%), asthma (9.7% vs 4.8%) and seizures (3.1% vs.1.5%) were higher in the study group than in the comparison groups. History of gen among the siblings was higher 9.5% vs 6.6% in the comparison ¥roup. Any congenital’ anomaly 2.2% vs 1.6% and Congenital heart disease 7.8% vs 3.9% were higher in the study group than in the comparison group.Cerebral palsy, undescended testis, Congenital Talipes equinovarus, Poly dactyly, Marfans syndrome, Congenital adrenal hyperplasia and short stature ‘were some of the other anomalies noted, Previous surgery for birth defects was higher in the study group.(1.5% vs 0.38%) ‘The mean age at menarche among the girls of the study group 13,20 4.0.80 was higher than in the Comparison school of 12.60 + 1.0 years Students in the study area had a higher proportion of goitre, 163 (44.17 %) compared to 92 (37.86 %) in the Comparison area A higher level of oestrogen and lower level of Follicular Stimulating Hormones ( FSH) and (Leutenising Hormones) LH were found in the study group. ‘Recommendations Monitoring of the health status, growth and development patter and. hormone levels among this population may be done periodically at an interval of at least 3 years Monitoring of endosulfan residues in the blood samples may be done and correlated with the findings. Medical care and rehabilitation services for those with disabilities should be ongoing. * alSTUDY - Field Teams: School 1. BAR HS Bovikanum . Muliyar Panchayath, 1. Dr Jayakrishnan-T Asst professor Community medicine 2.Dr Bijo george . Asst professor Community medicine. 3, Dr Vijaya kumar. Asso professor peadiatrics 4.Dr Sunitha. Resident peadiatrics 5.DrManjusha.Resident peadiatrics ‘6. Mr Berkumon Felix.health educator. 7. Ma Rajan. Muliyar CHC, : 8. Mr Madhavan Nambiar,Co-ordinator.Endosulfan victim remedial Cel 9. Mt Joy JHL School 2 . Government High school Kalichandukam, Kodom belur panchayath. 1. Dr Jayakrishnan. Asst professor Department of Community Medicine, 2. Dr Suchi raj . Lecturer Department of Community Medicine, 3. Dr Rajesh . Asst professor Department of Pediatrics 4, Dr Sunitha Resident Department of Pediatrics 5. Dr Manjusha, Resident Department of Pedictrics 6. Mrs Radha KV THI, 7. MrsCelin Thomas JPRIN 8, Miss Rohini K School JPEN 9. Mr Rajeevan Nileshram CHC 40 Mr Madhavan Nambiar, Co-ordinator. Endosulfan vi Cell remedial Consultation: Dr Vijaya kumar. Asso professor Department of Peadiatrics Hormone estimation. Dr Anila kumari HOD U/C Nuclear Medicine Mr Premehand Scientific officer . Nuclear Medicine Statistical Assistance: Dr Jayekrishnan T ,Dr Biju George. re Prof. Dr, NARAYANAN PV. toring MEDICAL COLLEGE, CALIOUT 42Acknowledgements: ‘Mr CK Padmanabhan, HM. BR HS Bovikanum ‘MrBM AbbobackerPTA president, BR HS Bovikanum ‘Mr Augustine TD HIM , Government High school Kalichandukam Me Vijeyan PTA president Goverment High schotl Kalichandukam Mars Rajanikrishnan. Mother PTA, Government High school Kalichandukam Dr Jose G D’cruze . DMO (H) . Kasaragod district. Dr Gopinath RCH Officer . Kasaragode district, Dr Riyas Professor &HOD Paediatrics. # Prof. Di, NARAVATIAN Pati ifetn Oo ee Pd . MEDICAL COLLEGE, CALICUT >Study Il Report on Biomonitoring of Endosulfan Residues in Human Blood SamplesReport on the Estimation Of Endosulfan Residues In Human Blood At Kasaragod District, Kerala 2010-11 Conducted by Department of Community Medicine Government Medical College, Calicut. Department of Health & Family welfare * Government of Kerala. # ae ae cg eaNaNay Nica Se Prot Be 45Investigators: Dr C Prabhakumari Professor & Head ( Coordinator ) Dept of Community Medicine, Medical College Calicut Dr Jayakrishnan T Assistant Professor Dept of Community Medicine, Medical College Calicut Dr Thomas Bina Professor Dept of Community Medicine, Medical College Calicut ”Report on the estimation of Endosulfan residues in human blood in Kasaragod District, Kerala 2010-11 Introduction With the objective of biomonitoring of endosulfan residues in human blood samples, volunteers were selected from the affected areas. Their health status and that of some family members were assessed. Blood samples were taken and endosulfan residues in the blood samples were estimated. ‘Material and methods Design: Observational Descriptive study Study area: Study areas were selected by purposive sampling and included 11 of the 39 panchayaths in Kasaragod district of Kerala as given below, which are reported to be affected by hazards of endosulfan and with history of aerial spraying endosolfan in the past.( report of previous committees) Wo” [ Name of Grama Block Panchayath Panchayath 1 Badiadka Manjeswar_ 2. Bellur “Manjeswar 3. | Enmakaje “Manjeswar &_ | Kombadaje Manjeswar S| Karadka ‘Kasargod 8 | Maliyar ‘Kasargod Ay 7) Ajanur ‘Kanhangad 8 ‘Kallar Kanhangad 9 | Panathady Kanhangad 16 | Pullur periya Kanhangad Ti | Kayyur- Cheemeni ‘Nileshwaram_ i 1a Oifeer tn Bineipa 41. \Cat, COLLEGE, CALIGUTSubject selection: From each affected panchayath, one geographical area or ward for the study was selected based on the topography and neamess to the Plantation Corporation of Kerala estates. The District Medical Officer of Health, Kasatgod organized the necessary field arrangements. The water and soil samples for testing endosulfan residues were collected from the same areas by the Kerala State Council for Science, Technology and environment( KSCSTE )study team, ‘The investigator along with KSCSTE team members visited these field areas and selection of volunteers were done after discussion with the medical officers and health staff of these areas-during the month of Sept 2010. 1. Selection of Volunteers : In the 11 selected panchayaths, the Local self Government and primary Health Centre authorities were informed and requested to give a list of volunteers from the local community with eligible criteria as below and. willing to participate in the study. Inclusion criteria a) Persons from both sexes in the age group 10 to 40 years. ‘This age group was included as Endosulfan spraying was started in the area since late 1970s and continued till 2002. b) Permanent residents of the area for the last 10 years. ty of exposure to endosulfan from other sources out side the Contra indfeation for drawing blood due to any disease. From the lists given by local health staff, with the help of a field coordinator the volunteers who were willing to co operate with future studies including drawing of blood samples for endosulfan residue analysis were recruited, 48From the listed volunteers finally 3-5 persons belonging to both sexes, who salisly the inclusion criteria, were selected by simple random method. Few endosulfan affected victims were also included, Final sample From each ward, 3-5 subjects were selected and a total of 44 subjects from 1} Panchayats were included. The subjects were enrolled only after getting informed consent to participate in the study for data collection and drawing blood samples for analysis. After enrolment they were asked to report at the data collection centers on 30" October 2010. Data collection centers: 1. Volunteers-from hospital based camps: a) District hospital Kanhangad : For those volunteers belonged to Nileshwaram and Kanhangad blocks. b) General hospital Kasargod. For those volunteers belonged to Manjeswar and Kasaragod blocks. They were accompanied by the field staff of the respective PHC area, ‘Transport facilities to the centre and back home were arranged. The purpose of the study was detailed to the subjects personally and only after getting written informed consent they were enrolled. In case of children below 13 years, the informed consent from their parents were taken. 2, Endosulfan Victims The list of victims were available from the Endosulfan victim remedial Celt. The team I visited the houses of 2 endosulfan victims at Periya and the team II visited the houses of 2 endosulfan victims at Muliyar and could collectedlood samples from 2 persons. Data collection: Data collection was done by using a validated proforma developed by the department of Community medicine. Pel caver Pid tuarmanmge aan nM Nobidet eaten teams 49Data on health status: The demographic, morbidity details of the subjects and health status of the family members were collected, Past health records Were verified and documented. Anthropometric measurements were done by using validated instruments and. standardized procedures. Collection of blood samples Blood samples were collected by venepuncture from antecubital vein using vacultainer syzinges following all aseptic precautions by.lab technician. 5 ml blood was drawn and collected in glass tubes and centrifuged, serum was transferred immediately to tightly capped glass tubes in to a fully sealed cartier with ice packs below 4 degree centigrade and brought to the department at -20degreec on the same day. Laboratory work up : ‘The samples were transferred to testing lab in cold chain.Testing of endosulfan residues was done from Eco- toxicology division of Salim Alt Center for Omithology and Natural History (SACON)Coimbatore, Tamil ‘Nadu, under the direct super vision of the scientist who is one of the technical members of the state team. ‘The Endosulfan residues tested were 1. Alpha endo sulfan 2. Beta endo suffan 3. Endo sulfan sulphate. Results: Data was collected. from 43 persons, 39 from hospital based camps and 4 from house visits . Blood samples were collected from 41 subjects. 2 persons from the victim list did not cooperate to take blood samples. 17 persons were apparently healthy and 26 were having some morbidity or Gisability associated with endosuifan use. Details of analysis of the residential areas, age, sex, apparent health status and endosulfan residue levels in blood of the subjects are given in the table below. R 50.Endosulfan Residues (ppb) in human blood plasma. Name of Age, ‘Health status [ Alte We Wadosalfan | Total Panchayth | Gender of Endosulfan | Endosuttan. | Sulphate | Badosultan the Person. 1 [Rater 45M Healy . a 3.83 BDL BDL = 7] Paliur Cancer beat | - Pesiva 35 P Bipised | Hemiplegia, | Blood Sample Not ken 3) Pallur ar ‘Alley tO] Periya ‘kin, Blood Sample Not taken 7 [Pilar TF Tealy 470 BDL BDL. 0 3 [uur a Weay I 450 BDL. sala aa 6] Pallor aM Fplepay Reriya Impired = [13.33 | BDL ¥48s7 Dearing 16190 7 | kayar | 2 “Healy . Cherent 129 BDL. an 30.00, @ [Rayer | FS eat 7 883 BDL. BDL. Pa OP Kayyur | M38 Heaty a 9.0 BDL 40.20 — TO [Ajmer [M36 Heating g 407 ane 40 oe TT [Afar | Fas Cone ‘smomaly x [533 BDL. a9 5283 30. | Ajaoor | FAT ‘eaully —|330 ‘BOL BDL a0 retarded Epilepsy 13 | Panathoa Healy a 408 ‘BDL. ea = 14” Panathaal | F47 ‘Tila Menstral | 5.42 BDL 4073 Jnregularies. 4635 15 | Penathaat | #30 Hesihy 1538 BDL BOL 1838 16 | Kaiar 3 Tealhy mw 1625 BDL nar a 17 | Kalla M2 Twig iPr a 7530 1 [Kala wae ealy 9.40 BDL, 6700 ae 5 [Katie F30 Healy 1295] BDL. 3341 4638 x stSIpbICAL covtzas, CALICUT | Wliyat FS Tower Tb Tit cetomty [1147 | BDL BDL a | Mlivar | AS Cobra palsy Sealy | 99 BDL BDL 939 | Miligar | 1 76 BBE BOE sc | Mayer’ — [aD Healy a3 am BOE 730 Matyar [Ft Helity [238 BDL Bor 2 ws Bear 35 Thyroid 5.94 ‘BDL 40.64 46.58 | Bear Healy [586 BoE Baas 2 | Badlyadake | FIO ‘Asthma, Limb | ae iy 490 BDL BOL 3.90 B Bataan [Fa Talerty ueamment — | 3063 BDL BDL 38 B | Baalvaduia [FH Epilepsy, Valvular tear | 1418 | BDL 5600 | uaa disease, 3 aaa [FA Taferty Taterty Ysa BDL BDL 578 aT [aairaas ‘uring — of = ae 429 BDL BDL 49 | Wadpadala [Fd Visual dee oxy no | ane 313 33 | Karaduiea [FIT Tambress ee |g ag ron joo | aa | Raractca ‘Diabetic a 420 BDL cd 35 | Karsdunka | #25 Hetty [297 BDL 267 | 88 36° [Kacadukia ) F et 37 BDL 2752 3.28 Pansat a7” | Kumnadeje | 32 surgery nao | BDL 1se00 | x7aa0 38) Kumbadeje | Fiz Fealihy aa 308 BDL, Bou 35 [Romina ad 2.66 BDL 4119 3.85" 40 | Enkameja ~ [M41 ‘Epilepsy Intety | 433 BDL BDL, 433 ch ‘Enkameja = | M27 Healthy 22 BDL BDL 2a wy ‘Enkameja | M30 Healthy: 314 BDL 16.24 aoe a Enkameja | F38 Healthy: 19.68 ‘BDL 97.50 ed (br, NARAYANAN PV. sae trata ice ten been) 32BDL* = below Ippb. (Detectable level was Lppb) All the blood samples contained alfa endosulfan and 24 samples (59%) had endosulfan sulfate above detectable levels.None of the samples contained beta endosulfan . Conclusion & Recommendations: E All the blood samples contained alfa endosulfan and 59% samples ' contained endosulfan sulfate . 1 ) The results may be comrelated with the soil; water levels of endosulfan residues monitored by the KSCSTE study team. , } > Periodic monitoring of human blood samples for insecticide residues ’ may be conducted. a i > Environmental monitoring should be done simultaneously. > Medical care and support programmes for those with moxbidity. may be implemented. ml Prot QS YANT pict spa BMEDICAL CoLuoui, CALICUT ee ee ee 2 no