anticholinesterase pesticides (metabolism, neurotoxicity, and epidemiology) || epidemiological...

27EPIDEMIOLOGICAL STUDIES OFANTICHOLINESTERASE PESTICIDEPOISONING IN EGYPT

SAMEEH A. MANSOUR

Environmental Toxicology Research Unit (ETRU), Pesticide Chemistry Department, National Research Centre,Tahir Str., Dokki, Cairo, Egypt

27.1 Introduction 379

27.2 Pesticide Epidemiology 380

27.3 An Overview of the Pesticide Market in Egypt 380

27.4 Problems Associated with Pesticide Use in Egypt 38127.4.1 Incidental Toxicity to Humans

and Health Effects 38227.4.2 Data on Acute Poisoning in Egypt 38427.4.3 Incidental Toxicity to Farm Animals 39127.4.4 Spill of Methyl Parathion into the

Mediterranean Sea 39127.4.5 Pest Resistance 39127.4.6 Indoor Use of Pesticides 392

27.5 Occurrence of Pesticide Residues in EnvironmentalMatrices 392

27.5.1 Contamination of Aquatic Ecosystems 39227.5.2 Food Contamination 39227.5.3 Contamination of Vegetables and Fruits 39227.5.4 Pesticide Contamination Pattern

in Vegetables and Fruits 39427.5.5 Contamination of Medicinal

and Aromatic Plants 395

27.6 Factors Contributing to Pesticide Hazards 39627.6.1 General Factors 39627.6.2 Specific Factors 396

27.7 Conclusions and Recommendations 398

Acknowledgments 398

References 398

27.1 INTRODUCTION

Egypt is the most populous country in the Arab world, and thesecond-most populous in Africa after Nigeria. Egyptians liveon 7.4 million acres and this area must feed �80 millioncitizens. Modest calculations indicate that by the year 2018,the country’s population may reach 100 million (Mansour,2004). Egypt is an arid country comprising 97% desert byarea and is dependent on the Nile River for its existence.Agricultural activities account for 28% of the total nationalincome and nearly 50% of the country’s work force is depen-dent on the agricultural sub-sector. Because of the intensiveirrigation needed to support the desert landscape, Egypt hasdeveloped a host of environmentally related problems.These problems have been aggravated by high populationdensity, which places a further strain upon resources. In

addition, the chemical industry in Egypt is by far the mainsource of hazardous waste release in developed regions.Frequent problems have been encountered by these industriesin disposing of the hazardous waste they generate. In additionto the foregoing pollution, water pollution is exacerbatedfrom agricultural pesticides, raw sewage, and urban andindustrial effluents (Barakat, 2004).

Approximately 25% of Egypt’s population is very poorand another 25% are near the poverty line (Assaad andRoushdy, 1998). Another source suggests that almost one-third of Egypt’s population lives below the poverty line, def-ined as a total income below $US30.0 per month (UNDPEgypt, 1999). Thus, Egypt has the challenge of maximizingits limited resources to deal with an array of problems. Thetension between population increase and production ofenough food is one of the most important and challenging

Anticholinesterase Pesticides: Metabolism, Neurotoxicity, and Epidemiology. Edited by Tetsuo Satoh and Ramesh C. GuptaCopyright # 2010 John Wiley & Sons, Inc.

379

problems currently facing Egypt. Therefore, agriculturalproductivity is crucial to Egypt, and the use of pest controlagents (e.g., pesticides) to secure productivity will remainan essential contributing component for the foreseeablefuture. Globally, the use of pesticides has assisted in solvingmany human health and food production problems and hasprovided social, economic, and environmental benefits formankind (Cooper and Dobson, 2007). However, such usagehas also occasionally been accompanied by hazards to manand the environment.

The objective of this chapter is to provide a comprehen-sive assessment of the threats posed to humans due toexposure to pesticide intoxication, either directly or throughresidues in the environment, and to identify priorities anddata gaps and make recommendations for appropriate futureinterventions to control or reduce pesticide contamination inEgypt. A further aim is to improve understanding of the epi-demiologic status of pesticides at the present time. Specialattention will be given to the pesticides characterized ascholinesterase inhibitors.

27.2 PESTICIDE EPIDEMIOLOGY

At present, �1500 active ingredients have been registeredas pesticides, and formulators mix these compounds withone or more of some 900 “inert” ingredients to create the�50,000 commercial pesticides registered for use. Roughly,85% of the pesticides currently used in the world are devotedto the agricultural sector, almost 10% are directed at sanitarymeasures against vectors in public health programs, and therest are applied in specific sites such as buildings, transportmedia, and residential areas (WHO, 1993). Acute human pes-ticide poisoning represents a significant cause of morbidityand mortality in underdeveloped and developing countries.The World Health Organization (WHO) has estimatedthat there are �3 million cases of acute pesticide poisoningannually, with 220,000 deaths. On the basis of a surveyof self-reported minor poisoning carried out in the Asianregion, it is estimated that there could be as many as 25 millionagricultural workers in the developing world suffering an epi-sode of poisoning each year (Jeyaratnam, 1990). About 95%of fatal pesticide poisoning occurs in less developed countries(Ellenhorns et al., 1997). Organophosphorus (OP) and carba-mate (CM) pesticides are believed to cause tens of thousandsof deaths and many more clinical poisonings every year. Theprincipal mechanism of their action, namely inhibition of thecholinesterase group of enzymes, is also responsible fornumerous and differing toxic effects that are mediated byother mechanisms (e.g., inflammation, immunotoxicity, myo-pathy, genetic toxicity, oncogenicity, and developmentaland reproductive toxicity) (Ballantyne and Marrs, 1992;Peiris-John and Wickremasinghe, 2008). Moreover, repeateduse of certain OP and CM pesticides has been associated with

an increased incidence of non-Hodgkin’s lymphoma (NHL)(Dreiher and Kordysh, 2006; Zheng et al., 2001).

Epidemiological investigations increasingly addresspesticides and their potential association with human dis-eases. This increased concern for human toxicity potentialaddresses various levels of exposure (high, medium, low,absent) through various routes of exposure, either directlyor indirectly (e.g., food, air, water, soil). Therefore, the avail-ability of data on pesticide consumption and use patterns,levels of pesticide residues in different environmental com-ponents, health risks associated with occupational exposureto pesticides in workplaces, and hospital discharge data ofpesticide poisoning incidents are essential.

27.3 AN OVERVIEW OF THE PESTICIDEMARKET IN EGYPT

Cotton is still the most important crop in Egypt and comprisesa main part in Egypt’s national economy. Pests infestingcotton affect crop quality and yield. Pesticides are consideredone of the major weapons in protecting cotton production.Insecticides are annually applied to an area ranging between0.7 and 0.8 million acres, using high-pressure ground spray-ers. Applications are made to this area 3–5 times perseason to control certain insect pests of potential economicimportance (e.g., the cotton leafworm, Spodoptera littoralis;the pink bollworm, Pectinophera gossypiella; and the spinybollworm, Erias insulana). Other crops are also treatedwith pesticides, including corn, rice, sugarcane, and manydifferent varieties of vegetable and fruit crops.

Before 1950, only limited Egyptian cotton acreage wastreated with insecticides. Thereafter, the treated area expandedrapidly. During the period 1950–1955, scattered cotton fieldswere treated using insecticidal dusts (10% DDT þ 25%BHC þ 40% sulfur) (El-Sebae and Soliman, 1982). Up to1960, the pesticide market in Egypt was limited mainly toorganochlorine insecticides (OC). Thereafter, the CM insec-ticide carbaryl and the OP insecticide trichlorfon were usedtogether with other OC compounds. Subsequently, thenumber of OC compounds decreased while the number ofOP and CM pesticides increased. Table 27.1 presents thetypes and amounts of insecticides used on cotton in theperiod 1952–1990 (El-Sebae et al., 1993). As shown bythese data, toxaphene was the most abundantly used insecti-cide during the period 1955–1961. The continuous shiftfrom one insecticide to another was mainly caused by thedevelopment of resistance by the cotton leafworm. Accordingto the data presented in Table 27.1, the total quantity of insec-ticides applied to cotton fields during the period 1952–1990accounted for 218,300 Mt, of which �50% were estimated tobe OP and CM insecticides.

The average annual consumption of pesticides during the1970s, 1980s, and 1990s, by decade, amounted to 26,029,

380 EPIDEMIOLOGICAL STUDIES OF ANTICHOLINESTERASE PESTICIDE POISONING IN EGYPT

24,369, and 17,000 Mt, respectively (Mansour, 1993, 2004).Recently (2000–2007), consumption of pesticides has gradu-ally declined, reaching about 12,000 Mt annually. However,pesticide importation prices jumped from US$100 millionannually during the 1990s to about US$300 million annuallyduring the past few years. The local pesticide market obtainsthe pesticides it needs through two main sources: public andprivate. The Ministry of Finance (public source) imports pes-ticides to meet needs set by the Ministry of Agriculture(MOA). The private sector finances pesticide importation tomeet its marketing or use needs using its own resources. Bythe end of 1989, the private sector share accounted for 26%of total amount of pesticides consumed in Egypt. Pesticidesformulated locally represented 48.5% of the total quantityconsumed in the country (Mansour, 1993). In the pastdecade, the local formulating plants have greatly increasedtheir share of the Egyptian pesticide market.

The distribution pattern by class of pesticides used in the1980/1981 growing season comprised 42.8% insecticides,25.9% fungicides, 21.7% herbicides, 4.2% acaricides, 3.0%nematicides, and 2.4% rodenticides of total number of pesti-cides (166 active ingredients, a.i.). OP and CM compoundsrepresented 45.1% of total insecticides. In the 1990/1991growing season, the pesticide classes represented 32.1%,

31.2%, 24.0%, 3.6%, 2.3%, and 6.8%, respectively of thetotal number of pesticides (221 a.i.). OP and CM compoundsaccounted for 52.1% of total insecticides. For the growingseason of 2000/2001, such pesticide classes accounted for33.7%, 34.3%, 20.6%, 5.7%, 2.3%, and 3.4%, respectively,of the total number of pesticides (175 a.i.). The OP and CMcompounds represented 49.2% of the total insecticides. Inthe season 2006/2007, the total number of pesticide classessubject to registration accounted for 171 a.i. compoundscomprising 32.2% insecticides, 39.2% fungicides, 18.1%herbicides, 6.4% acaricides, 2.3% nematicides, and 1.8%rodenticides. OP and CM compounds represented 43.6% oftotal insecticides. This may give an indication of the dynamicpattern of pesticide use in the country, which changes accord-ing to priorities determined by which pests take control atdifferent times. For a long time, the anticholinesterase OPand CM compounds represented the major classes of insecti-cides used in Egypt. Information on some such pesticidesused for a long time in Egyptian agriculture are presentedin Table 27.2. Information about certain pesticides classifiedas “extremely and highly hazardous, probable and possiblehuman carcinogenic” that are registered for use in the countryare available in the literature (Mansour, 2004, 2008).

The use of pesticides in Egypt is governed by two laws:Act No. 53, 1966, issued by the Minister of Agriculture foragricultural-use pesticides, and a separate law, Act No. 127,1955, for household pesticides, issued by the Minister ofHealth. Subsequent amendments have been added to bothlaws according to need. The main provisions of the Agricul-tural Pesticides Act and its regulations have already beenreviewed by many authors (see Mansour, 1993). Briefly,the registration scheme for pesticides in this Act is consonantwith the FAO Guidelines on the Registration and Control ofPesticides.

27.4 PROBLEMS ASSOCIATED WITHPESTICIDE USE IN EGYPT

As previously mentioned, a huge quantity of organochlorinepesticides (OCP) was used in Egypt between 1950 and 1981to protect crops from insects, disease, and weeds, to removeunwanted vegetation, and to control indoor insects to whichthe general public was exposed. Over time, these persistentcompounds were replaced by other chemical classes ofshorter persistence and higher acute toxicity such as OP,CM, and pyrethroid pesticides.

Pesticides move through air, soil, and water and find theirway into living tissues, where they can bio-accumulatethrough the food chain, eventually entering the human diet.Approximately 85–90% of applied agricultural pesticidesnever reach target organisms, but disperse through the air,soil, and water (Moses et al., 1993). Persistent pesticidescan remain for decades; the half-life of toxaphene in soil,

TABLE 27.1 Total Quantities of Active Ingredient (a.i.)Insecticides Used on Cotton in Egyptian Agriculture from1952 to 1990a

CompoundTotal MetricTons (Mt)b

Years ofConsumption

DDT 13,500 1952–1971Lindane 11,300 1952–1978Toxaphene 54,000 1955–1961Trichlorfon 6500 1961–1970Carbaryl 21,000 1961–1978Endrin 10,500 1961–1981Phosfolan 5500 1963–1983Monocrotophos 8300 1967–1978Leptophos 5500 1968–1978Mephosfolan 7000 1968–1983Chlorpyrifos 13,500 1969–1990Methamidophos/

azinphos–methyl7500 1970–1990

Methomyl 9500 1975–1990Fenvalerate 8500 1976–1990Cypermethrin 6300 1976–1990Deltamethrin 5400 1976–1990Triazophos 8500 1977–1990Profenofos 8000 1977–1990Cyanophos 3000 1984–1990Thiodicarb 5000 1984–1990

Total 218,300

aFrom Mansour (2008), with kind permission of Springer Science andBusiness Media.bMt, Metric tons.

27.4 PROBLEMS ASSOCIATED WITH PESTICIDE USE IN EGYPT 381

for example, is up to 29 years (PAN, 1993). Pesticides that arenot bound in soils or taken up into plants and animals can runoff into rivers and lakes and move into the aquatic food chain,inducing severe damage to aquatic life. Such environmentalmobility can cause contamination of several environmentalcompartments. Pesticides therefore augment other sourcesof environmental pollution in Egypt, including manufactur-ing processes of several industries (Barakat, 2003). In thisrespect, a number of problems related to the use of pesticidesin Egypt are given below.

27.4.1 Incidental Toxicity to Humansand Health Effects

A large number of workers, laborers, and overseers partici-pate in pesticide applications to cotton fields, 3–5 timeseach season. Pesticides are typically applied to cotton fromMay to September (approximately 120 days each year), andabout 12,000 workers countrywide participate in the fieldapplication of pesticides under severe climatic conditions(high temperature and humidity). Safety practices are gener-ally inadequate and workers typically lack proper training

in the safe handling of these chemicals (Amr and Halim,1997). Moreover, workers are often not equipped with protec-tive clothing or face masks. Thousands of children, who dailycollect egg masses of the cotton leafworm over a period ofabout 40 days each season, are exposed to insecticide residueson cotton leaves. Exposure to pesticides and other agrochem-icals constitutes a major occupational risk, accounting insome countries for as much as 14% of all occupational inju-ries in the agricultural sector and 10% of all fatal injuries(ILO, 1996).

There are also issues with the large numbers of workersinvolved in formulating pesticides and handling them ingreenhouses. As mentioned above, OP and CM compoundsrepresent �50% of the total insecticides used in Egypt,especially in cotton fields and orchards. Most of these com-pounds are classified as extremely and highly hazardouspesticides (WHO class categories 1A and 1B), with the prob-ability of poisoning increasing as a result of lack of protectivemeasures. This may well give rise to the impression thathuman exposure to pesticides is high in Egypt, particularlyfrom ground application of rather toxic insecticides incotton fields.

TABLE 27.2 Information on Some Anticholinesterase Pesticides Long Used in Egyptian

PesticideChemical

TypeaMainUseb

LD50 (mg/kg,dermal)c

LD50 (mg/kg,oral)d Classe

Aldicarb C I, Ac, N 0.93 0.93 IACarbaryl C I 300 264–500 IICarbofuran C I, N 8 8 IBCarbosulfan C I 250 185–250 IIChlorpyrifos OP I 135 135–163 IIChlorpyrifos–methyl OP I .3000 .3000 UDiazinon OP I, Ac 1000 1250 IIDimethoate OP I, Ac 150 387 IIFenitrothion OP I 503 1700–1720 IIFenthion OP I, L 586 250 IIMalathion OP I 2100 1375–5500 IIIMethamidophos OP I, Ac 30 13–16 IBMethomyl C I 17 30–34 IBNaled OP I, Ac 430 430 IIOmetoate OP I, Ac 50 25 IBPhenthoate OP I, Ac 400 249–270 IIPhosalone OP I, Ac 120 120 IIPirimicarb C AP 147 142 IIPirimiphos–methyl OP I 2018 1414 IIIProfenofos OP I, Ac 358 358 IIThiodicarb C I, M 66 66–120 IITriazophos OP I, Ac, N 82 57–59 IB

aChemical type: OP, organophosphorus compound; C, carbamate compound.bMain use: I, insecticide; L, larvicide; Ac, acaricide; AP, aphicide; N, nematicide; M, molluscicide.cWHO (2005).dTomlin (2004).eClass categories: IA, extremely hazardous; IB, highly hazardous; II, moderately hazardous; III, slightly hazardous; U, unlikely to presentacute hazard in normal use.


Official reports of pesticide poisoning in Egypt are lack-ing except for certain dramatic cases released to the publicand a few reports published by scientists. El-Gamal (1983)reported cases of poisoning and numbers of fatalities annu-ally from 1966 to 1982 and found a total of 20,300 poisonedpersons and 591 deaths. The highest rate of poisoning (2671persons) occurred in 1977 with 69 deaths. The author statedthat, after 1977, incidents of acute intoxication decreased dueto the introduction of preventive measures. He added thatmore than 60% of workers engaged in pesticide applicationssuffer from chronic toxicity. Starting from the 1990s, data onpoisoning, generally, were being recorded by the newly estab-lished poison control centers in the country.

A number of studies on workers occupationally exposed topesticides in Egypt were carried out by many investigators.The hazard of exposure to the OP insecticide phosfolan wasestimated in terms of the amount of insecticide retained onworkers’ body pads during field spraying and AChE inhi-bition in the red blood cells (Soliman et al., 1979). Theauthors found that the toxic dose received for every sprayingday for each worker varied with the type of job. The body ofa mixer received the maximum exposure, reaching 10- to 12-fold that of assistants. The highly exposed group of workerssuffered from 31 to 44% RBC AChE inhibition. About halfof the inhibited enzyme activity recovered after 48 hours,and then took more than 3–4 weeks to reach completerecovery.

Two spray men occupationally working in public healthin Alexandria city, Egypt, experienced acute toxicity fromexposure to diazinon [60% emulsifiable concentrate (EC)].ChE activity showed a marked reduction up to 18 days afterexposure, and then recovered 20–28 days after the poisoningincident. The diazinon, which was stored in tin-plated sheetsteel containers, was found to be completely converted intothe diazinon transformation products sulfotepp and mono-thiono-TEPP, which are much more toxic than diazinon(Soliman et al., 1982).

A study was conducted to evaluate the impact on the healthof workers exposed to pesticides (mostly OP and CM insec-ticides) in large- and small-scale Egyptian formulation plants(Amr, 1990). Dermatitis and neuropsychiatry manifestationswere the most prevalent health effects in this exposed popu-lation, compared to controls, particularly for workers with alonger duration of employment. Other manifestations ofexposure in this population included topical eye changes,gastrointestinal and genitourinary effects, as well as hepato-megaly and ventilatory function changes. A significantlyhigher frequency of polyneuropathy, sensory hypothesia, andabnormal deep reflexes were also observed among exposedworkers. The levels of serum gonadotrophins (LH and FSH)and testosterone were significantly higher in those exposedthan in the control group, particularly for LH. Also, serumlevels of ChE, glutamic pyruvic transaminase (SGPT), alka-line phosphatase (ALP), and proteins were estimated among

100 OP spray men and compared with 60 controls (Kamalet al., 1990). The duration of exposure (3–15 years) to OPpesticides was significantly correlated with levels of ChE,SGPT, and ALP, but not with serum proteins. Compared toother parameters, SGPT seemed to be a good indicator of thehepatic effect of long-term exposure to OP pesticides. ChElevels of spray men who were smokers were significantlylower than those of non-smokers. Bilharzial infectiondid not modify the effect of OP pesticides on the above-mentioned parameters. According to Anwar (1994), a groupof Egyptian agricultural workers exposed to pesticides (e.g.,OPs) showed an increased incidence of chromosomal aberra-tions and sister chromatid exchanges.

In a study at Sharkeya Governorate, a total of 150 workersoccupationally exposed to pesticides and 50 control subjectswere given clinical and dermatological examinations, patchtests, tests of liver and renal function, complete bloodcount, blood sugar, and urine analysis. Activity of the antiox-idant enzymes superoxide dismutase, glutathione peroxidase,and glutathione reductase was also evaluated (Amer et al.,2002). Dermatological findings were positive in 78%, 76%,and 54% of workers exposed to OP, pyrethroid and CM pes-ticides, respectively. The patch test was positive in 70% ofworkers exposed to pyrethroids and in 64% exposed to CMpesticides. Liver enzyme levels were generally increased inworkers and antioxidant enzyme activity was significantlydecreased in all workers compared with controls. In anotherstudy at Kafr El-Sheikh Governorate, Egypt, involving240 individuals, a reduction in semen quality in pesticideapplicators (PAs) was observed when compared with non-farm workers (NFWs). Also, biochemical markers (e.g.,uric acid, urea, creatinine, and AST) in PAs were near theupper limit values of the normal range (Attia, 2005).

Ezzat et al. (2005) studied the association betweenexposure to pesticides and hepatocellular carcinoma (HCC)among 236 subjects from urban and rural regions. Theauthors also obtained information on the rate of exposure topesticides in the home or in agricultural fields. Exposure topesticides in homes in urban or rural regions accounted for62.0% of the surveyed group. However, exposure to rodenti-cides (in the home and in the field) and other pesticides inagricultural fields was higher among the rural population.In rural males (n ¼ 113), 54.9% were exposed to CM pesti-cides and 63.7% were exposed to OP compounds. Almostone-third of workers (29.2%) were exposed to dithiocarba-mate fungicides. These data clearly reveal the multidimen-sional nature of worker exposure to different pesticide classes.

In a field study, farm workers occupationally exposed toOP pesticides (e.g., curacrun, chlorpyrifos, methamidophos,thimet, profenofos, triazophos, phorate) and CM compounds(e.g., carbaryl, larvin, thiodicarb) through application of theproducts to cotton fields in Menofeya Governorate, Egypt,were subjected to neurobehavioral tests and serological analy-sis for serum AChE (Farahat et al., 2007). The results


indicated that exposed workers exhibited significantly lowerperformance than non-exposed controls on six neurologicaltests (similarities, digital symbol, trail making part A andB, letter cancellation, digital span, and Benton visual reten-tion). Serum (ACh) was significantly lower in exposed(87.34 U/ml) than in control (108.25 U/ml) participants,and a longer period of work with pesticides was associatedwith a lower AChE level. Such a drop in AChE level(�19.3%) may, however, be considered as a slight to moderateinhibition compared to that recorded for public health workersexposed to fenitrothion application in Sudan (Fakhri, 1993).

27.4.2 Data on Acute Poisoning in Egypt

Official data on poisoning in Egypt are difficult to obtain fromthe scientific literature. Hospitals concerned with receivingand treating poisoning patients include the public hospitalsof the Ministry of Health and Population, which are spreadall over the country, as well as poison control centers of edu-cational hospitals in some medical colleges in Cairo,Alexandria, Al-Mansoura, Al-Menofeya, and El-Menya.There are also some private clinics that may receive a fewcases. We have obtained some data by means of personal com-munication with colleagues at some poisoning centers; theyhave kindly provided locally published articles and/or unpub-lished reports. The data presented here will not thereforereflect the overall poisoning figures for Egypt, but may dem-onstrate the pattern of poisoning based on the available data.

The working number of poison control centers in Egypt atthe present time is six: two in Cairo and one in each ofAlexandria, Al-Mansoura, Al-Menofeya, and El-Menyagovernorates. All have nearly the same tasks and roles, butmay differ in technical services according to their capacity.Generally, they are responsible for providing emergency toxi-cological services (both information and treatment) regardingacute poisoning of humans. The oldest ones in Alexandriaand Ain-Shams have the following sectors:

† an Emergency Department,† an Observation and In-Patient Department,† an ICU, and† a Laboratory for Services (e.g., toxicological and bio-

chemical assays for in-patients, drug-abuse screening,and drug monitoring for out-patients).

Their strategies are built on

† the treatment of poisoned patients,† providing a 24-h information services about poisoning

and the management of cases for all healthcareproviders and public,

† using different media to raise the awareness of the com-munity regarding poisoning and how to avoid it,

† providing educational programs through seminars,workshops, and training courses for the specialists andhealthcare providers,

† conducting research programs in the fields of clinicaltoxicology in collaboration with national and inter-national institutes.

27.4.2.1 Alexandria Poison Center (APC) (The datapresented here were kindly provided by Prof. Dr. Laila A.Abdelmegid, Professor of Forensic Medicine & ClinicalToxicology, Faculty of Medicine, Alexandria University,Alexandria, Egypt and founder of APC, in the form oflocally published articles.) The APC was the first poisoncenter established in Egypt, in June 1979, and is located inthe Alexandria main university hospital (teaching hospital).It services the population of Alexandria and its surroundings.The center is an institutional member of the EuropeanAssociation of Poison Control Centers (EAPCC), and theWorld Federation of Associations of Clinical Toxicologyand Poison Control Centers (WFACTPCC). A brief accountof the findings of research conducted at the APC is givenbelow.

A total of 3754 acutely poisoned patients were admitted tothe APC during 1989. Of these, 305 cases (8.1%) were poi-soned by AChE insecticides (Abdel-Megid and Salem,1993). The majority of poisonings occurred during August(12.8%) and September (10.5%), followed by May (9.5%)and October (9.5%), while April and January recorded thelowest number of admitted cases (3.6% and 5.9%, respect-ively). Poisoning occurred slightly more often in females(51.0%) than in males (49.0%). The majority of insecticidepoisoning events were intentional (81.0%), with accidentaloccupational poisoning or accidental ingestion comprisingjust 19.0% of cases. In a studied sample of patients withacute insecticide poisoning (n ¼ 30), OP insecticides (e.g.,diazinon, methamidophos, and dimethoate) represented 63.3%of cases, and CM insecticides (e.g., aldicarb and methomyl)were responsible for the remaining 36.7% of cases.

Abdel-Megid and Salem (1996) surveyed 5913 patientsadmitted to the APC during 1994. Patients 15–35 years oldrepresented 52.3% of admissions, followed by those lessthan 5 years of age (19.4%). Slightly fewer than one-quarterof patients (24.7%) suffered food poisoning. Poisoning byhousehold agents (e.g., Clorox, kerosene, potash, phenol, tan-ning chemicals, benzene, sulfuric acid, and antiseptics) con-stituted 21.2% of admissions, followed by those poisonedwith drugs and pesticides (18.2% and 14.3%, respectively).The total number of poisoning cases by pesticides accountedfor 846 individuals, with more females than males, and mostwere between the ages of 15 and 25 years. Generally, thehighest number of poisoning cases was recorded during themonths from July to September.

A study was carried out on 50 consecutive patients admit-ted to the APC with acute intoxication by AChE insecticides


and compared with 15 healthy subjects (Abdel-Megid et al.,2002). The study revealed that 92% of patients were poisonedby CM insecticides and only 8% by OP insecticides.Poisoning was attributed to accidents (54%) and attemptedsuicides (46%). Of the latter, 68.8% and 5.6% occurred,respectively, in female and male subjects. The severity of poi-soning was estimated to be mild (12%), moderate (64%), orsevere (24%). The mean serum ChE level in poisonedpatients was 562 U/L, compared to 2813 U/L in controls.The degree of ChE activity reached 45.8%, 20.1%, and6.8% in mild, moderate, and severe cases, respectively.Hyperglycemia occurred in 94% of patients. Serum transam-inases (AST and ALT) and trypsin were significantly higherin the control group. ECG findings revealed manifestationscorrelated to poisoning severity. With the exception of onepatient, all (n ¼ 49) survived throughout the course of clini-cal and therapeutic treatments.

Abdel-Megid and colleagues (2003) investigated the pat-tern of acute poisoning by household products in 546 personsadmitted to the APC during a five-month period in 2000. Thehighest percentage of patients were children less than 5 yearsof age (37.9%), followed by the age groups 50260 years(13.0%), 5210 years (11.5%), and 60270 years (6.6%).Approximately 66% of the poisonous agents were kept in thekitchen. Pesticides (insecticides and rodenticides) accountedfor 33.1% of total poisonings. Recovery occurred in 74.7%of patients, while those who developed complications anddied accounted for 24.2% and 1.1%, respectively.

In another study, Abdel-Megid and colleagues (2004)investigated the pattern and severity grading of acute poison-ing among children (,15 years; n ¼ 1072) admitted to theAPC over a six-month period (July to December 2000).

Accidental poisoning accounted for the majority of cases(81.5%), and all were less than 5 years old. Attempted suiciderepresented 17.9% of cases, and overdose from addictivedrugs comprised 0.6%. Different kinds of poisoning agentswere attributed to non-drugs (74.3%), drugs (17.5%), CO(6.7%), animal poisons (1.2%), and plant poisons (0.3%).Of a total of 797 child cases attributed to non-drug poisoning,183 (23.0%) were attributed to ChE inhibitor pesticides.According to the Multicenter Study of Poisoning in Children(MSPC) score, those with score 0 (asymptomatic) represented26.2%, scores 1 and 2 (mild and moderate) constituted 37.0%and 32.0%, respectively, and scores 3 and 4 (severe and verysevere poisoning) accounted for 3.9% and 0.07%,respectively.

27.4.2.2 Poison Control Center of Ain Shams University(PCCA) Hospitals (The data presented here were kindlyprovided by Prof. Dr. Hany Gamalludin, Head of ForensicMedicine & Clinical Toxicology Department, Faculty ofMedicine, Ain Shams University, Cairo, Egypt, and Directorof PCCA.) The PCCA is the largest poison center in Egypt,established in December 1981 to receive and treat poisonedcases predominantly from Greater Cairo (Cairo, Giza, andKalyobeya Governorates) as well as complicated cases thatcannot be served at the public hospitals.

Just after announcing the opening of the PCCA in 1981,the center began to receive patients from different locationsin Egypt. The number of acute poisoning cases received atthe PCCA during its first year of work (1982) totalled 996cases, jumped to 2348 cases in 1983, and then increased dra-matically a year later. Figure 27.1 shows that the total num-bers of patients received yearly over the period 2003–2007

25,31525,555

23,664

21,80521,469

19,000

20,000

21,000

22,000

23,000

24,000

25,000

26,000

Nu

mb

ers

2003 2004 2005 2006 2007

Year

Figure 27.1 Total number/year of poisoning patients received at the Poison Control Center of Ain Shams University Hospitals (PCCA)during the period 2003–2007. Data for 2003–2006 from Mansour, 2008, with kind permission of Springer Science and Business Media.


ranged between 21,469 and 25,555 cases/year. The highestnumber occurred in 2004 (25,555 cases). The gradual declinein the number of cases may reflect patients moving toother recently established poison control centers (e.g., Al-Mansoura, El-Menya, Al-Menofeya, and Cairo University).The majority of poisoning cases were from Greater Cairo(Cairo, Kalyobeya, and Giza), accounting for �97.5% and98.5% of cases, respectively, for 2006 and 2007 (Table 27.3).

Based on the data for 2007, the poisoning incidentsoccurred more frequently during hot summer months (Mayto August) and decreased during cold winter months(November to January), as shown in Figure 27.2. Table 27.4shows that accidental and intentional poisoning occurred

with nearly equal frequency during 2006 and 2007. Poisoningrelated to addiction overdoses accounted for 459 and 703cases, respectively, in 2006 and 2007.

About 50% of accidental poisoning occurred in childrenless than 7 years of age (Table 27.5). Intentional (or suicidal)poisoning prevailed among persons aged 15 to ,25 years.The number in this group accounted for 6779 and 6450cases during 2006 and 2007, respectively (Table 27.6).Cases of intentionally poisoned elders (.40 years old) rep-resented about 5.2% of total suicidal cases. Addiction over-dose causing acute intoxication also predominated amongages ranging between 15 and 40 years (Table 27.7).

The data presented in Table 27.8 show the route for poi-soning, and reveal that in the majority of cases the poisonwas administered orally. Bites/stings and inhalation werethe routes of the second order of magnitude. Acute intoxica-tion was generally caused either by drug or non-drug agents,in addition to unknown causatives. In 2006, drugs causedpoisoning in 8141 cases (37.33%), compared to 8910 cases(41.50%) in 2007, and non-drug agents accounted for11,614 (53.26%) and 10,659 cases (49.65%), respectively(Table 27.9).

More than 15 types of drug substances (e.g., analgesics,addictions, antibiotics, BDZ, theophylline, carbamazepine,etc.) were involved in 1796 cases (22.06%) and 2100 cases(23.57%) during 2006 and 2007, respectively (Table 27.10).Non-drug poisoning occurred due to intoxication with certainchemicals, foods, gases, animal venoms (snakes and scor-pion), metals, and others. A total of 6952 (59.86%) and5043 cases (47.31%) were, respectively, recorded as a resultof chemical poisoning for the two years. Food poisoning

TABLE 27.3 Geographical Distribution of Poisoning CasesAdmitted to the PCCA During 2006 and 2007

Governorate

2006 2007

No. % No. %

Cairo 18,377 84.28 17,518 81.60Kalyobeya 1953 8.96 2385 11.11Giza 915 4.20 1221 5.69Fayoum 139 0.64 64 0.30Menofeya 60 0.28 45 0.21Gharbia 8 0.03 41 0.19Sharkeya 62 0.28 28 0.13Beni Suef 82 0.38 25 0.12Other governorates 209 0.95 142 0.65

Total 21,805 100.00 21,469 100.00

PCCA, Poison Control Center of Ain Shams University Hospitals.

1592

1544

1833

1887

2226

2154

2230

2010

1534

1686

1375

1398

7.42%

7.19%

8.54%

8.79%

10.37%

10.03%

10.39%

9.36%

7.15%

7.85%

6.40%

6.51%

0 500 1000 1500 2000 2500

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Mo

nth

s

Numbers & Percent

Figure 27.2 Distribution of poisoning cases admitted to the Poison Control Center of Ain Shams University Hospitals (PCCA) during 2007(total number, 21,469).


TABLE 27.4 Types of Poisoning Among Patients Admitted tothe PCCA During 2006 and 2007

Type

2006 2007

No. % No. %

Accidental 10,196 46.76 9910 46.16Intentional 10,090 46.27 9750 45.41Addiction overdose 1060 4.86 1106 5.15Others 459 2.11 703 3.28

Total 21,805 100.00 21,469 100.00


TABLE 27.5 Cases, by Age Groups, of Accidental PoisoningAmong Patients Admitted to the PCCA During 2006 and 2007

Age(years)

2006 2007

No. % No. %

,7 5163 50.64 4828 48.727– ,15 1052 10.32 964 9.7315– ,25 1712 16.79 1880 18.9725–40 1442 14.14 1441 14.54.40 827 8.11 797 8.04

Total 10196 100.00 9910 100.00


TABLE 27.6 Cases, by Age Groups, of Intentional PoisoningAmong Patients Admitted to the PCCA During 2006 and 2007

Age(years)

2006 2007

No. % No. %

,7 0 0.00 0 0.007– ,15 513 5.08 466 4.7815– ,25 6779 67.19 6450 66.1525–40 2274 22.54 2327 23.87.40 524 5.19 507 5.20

Total 10,090 100.00 9750 100.00


TABLE 27.7 Cases, by Age Groups, of Addiction OverdosePoisoning Among Patients Admitted to the PCCA During2006 and 2007

Age(years)

2006 2007

No. % No. %

,7 0 0.00 0 0.007– ,15 8 0.75 8 0.7015– ,25 482 45.47 545 49.3025–40 472 44.53 436 39.40.40 98 9.25 117 10.60

Total 1060 100.00 1106 100.00


TABLE 27.8 Routes of Poisoning Among Patients Admittedto the PCCA in 2006 and 2009

Route

2006 2007

No. % No. %

Oral 20,438 93.73 20,041 93.35Bites/stings 648 2.97 710 3.31Inhalation 610 2.80 634 2.95Injection 85 0.39 49 0.23Skin/scalp 21 0.10 24 0.11Rectal 2 0.01 6 0.03Ocular 1 0.00 5 0.02

Total 21,805 100.00 21,469 100.00


TABLE 27.9 Causes of Poisoning Among Patients Admittedto the PCCA in 2006 and 2007

Type

2006 2007

No. % No. %

Drugs 8141 37.33 8910 41.50Non-drugs 11,614 53.26 10,659 49.65Unknown 2050 9.41 1900 8.85

Total 21,805 100.00 21,469 100.00


TABLE 27.10 Types of Drugs Involved in Poisoning AmongPatients Admitted to the PCCA in 2006 and 2007

Drug

2006 2007

No. % No. %

Analgesics 1796 22.06 2100 23.57Addictive drugs 1060 13.02 1700 19.08Antibiotics 790 9.70 905 10.16BDZ 611 7.52 611 6.86Phenothiazines 317 3.90 310 3.48Carbamazepine 478 5.87 410 4.60Theophylline 599 7.36 630 7.07Hypoglycemic 260 3.19 369 4.14TCA 170 2.16 150 1.68Contraceptives 190 2.33 267 3.00Vitamines 136 1.67 213 2.39Digoxin 96 1.18 96 1.08Muscle relaxants 82 1.01 80 0.90Beta blockers 110 1.35 110 1.23Valproate 59 0.72 110 1.23Others 1381 16.96 849 9.53

Total 8141 100.00 8910 100.00



accounted for 3288 cases (28.31%) and 3548 cases (33.29%)for 2006 and 2007, respectively (Table 27.11).

Based data from 2006 (Table 27.12), chemicals involvedin acute intoxication were characterized as pesticides (e.g.,OP, CM, and zinc phosphide), corrosives (e.g., Clorox,potash, phenol, H2SO4), petroleum distillates (e.g., kerosene,tanner, benzene), and others (e.g., alcohols, cleaners, antisep-tics, iodine, hair oils, dyes). Pesticides accounted for 3564cases, of which OP insecticides represented 75%, CM 5%,and zinc phosphide 20% (Fig. 27.3).

According to the data presented in Table 27.13, OP insec-ticides caused death in 23 cases, giving rise to 0.65% deathsfrom the total number poisoned by pesticides (3564 cases;Table 27.12), or 23.47% of total deaths (98 cases;Table 27.13). Methanol resulted in 16.33% of deaths, com-pared to only 1.02% for ethanol. Zinc phosphide and venomeach accounted for 4.10%. Drug abuse resulted in 20.4% offatalities (Table 27.13).

27.4.2.3 Toxicology Unit in Mansoura EmergencyHospital (TUMEH), Faculty of Medicine, MansouraUniversity (The data presented here were kindly providedby Prof. Dr. Seham A. Gad Elhak, Professor of ForensicMedicine & Clinical Toxicology, Faculty of Medicine,Al-Mansoura University, Egypt.)

The Toxicology Unit in Mansoura Emergency Hospitalwas established in 1995 to diagnose and treat cases of poison-ing. The unit carries out its services 24 hours a day forpatients from the middle Delta of Egypt, a region in whichagriculture is the major activity. Recorded poisoning casesover 13 successive years (1995–2007) ranged between 884in 1995 and 2525 in 1998, with an average of 1821 casesannually (Fig. 27.4). Generally, the majority of poisoning

TABLE 27.12 Types of Chemicals Involved in Poisoningof Patients Admitted to the PCCA in 2006

Type No. % Classification

Pesticides 3564 51.27 OP; carbamates; zincphosphide

Corrosives 1544 22.21 Clorox; potash; phenol;H2SO4; and so on

Petroleumdistillates

893 12.84 Kerosene; tanner;benzene; and so on

Others 951 13.68 Alcohols; cleaners;antiseptics; iodine;hair oils and dyes;and so on

Total 6952 100.00 —


Zinc phosphide722 (20%)

Carbamates186 (5%)

Organophosphates2656 (75%)

Total number = 3564

Figure 27.3 Number and percentage of pesticides involved inpoisoning of patients admitted to the Poison Control Center of AinShams University Hospitals (PCCA) during 2006.

TABLE 27.11 Types of Non-Drugs Involved in PoisoningAmong Patients Admitted to the PCCA in 2006 and 2007

Type

2006 2007

No. % No. %

Chemicals 6952 59.86 5043 47.31Food poisoning 3288 28.31 3548 33.29Gases 583 5.02 1326 12.44Metals 81 0.70 29 0.27Plants 30 0.26 8 0.08Animals (snakes

and scorpion)662 5.70 690 6.47

Others 18 0.15 15 0.14

Total 11,614 100.00 10,659 100.00


TABLE 27.13 Number and Causative of Deaths AmongPoisoned Cases Admitted to Poison Control Center ofAin Shams University Hospitals (PCCA) during 2006

Causative

Year 2006

No. %

OP pesticides 23 23.47Methanol 16 16.33Potash 6 6.10Zinc phosphide 4 4.10CO 3 3.06Opiate 5 5.10Snakes/scorpion 4 4.10Kerosene 1 1.02Ethanol 1 1.02Corrosives 1 1.02Drug abuse 20 20.40Unknown 14 14.28

Total 98 100.00


cases were attributed to drugs, foods, and pesticides.Figure 27.5 demonstrates the numbers of poisoning by differ-ent materials during 2007, as an example. Poisoning bypesticides ranked the second after drugs over the period2003–2007, and was third during 1995–1997 and 1999–2001. Over the 13 years, pesticide poisoning ranged between109 cases in 1995 and 413 cases in 1999, with an averageof 322 cases annually (Fig. 27.4). Relative to total poisoning,pesticide poisoning accounted for 11.6% in 1998 and 21.5%in 2004 (Fig. 27.6). As previously mentioned, pesticides aretypically applied to cotton fields from May to Septembereach year. In addition to the huge quantities of pesticides

applied to cotton fields, additional quantities are used onsummer vegetables and fruits. During the May toSeptember period, poisoning by pesticides contributed tomore than 70% of annual pesticide poisoning cases in1995, 2005, and 2006. The lowest contribution was 49% in2001, and exceeded 52% in other years (Fig. 27.6). Suchfindings reveal an association between pesticide poisoningand the cotton season in the middle Delta region.

27.4.2.4 National Environmental Center for Toxicologi-cal Research (NECTR) (The data presented here werekindly provided by Prof. Dr. Abdel-Rahman M. El-Naggar,

0

500

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

1000

1500

2000

2500

3000

Year

Nu

mb

er

Total no. of poisoning cases No. of pesticide poisoning cases

Figure 27.4 Total number/year of poisoning cases generally and of pesticides in the middle Delta of Egypt in the period 1995–2007, basedon data from the Toxicology Unit in Mansoura Emergency Hospital, Faculty of Medicine, Mansoura University, Egypt.

505

345310

120100

32 36

272

0

100

200

300

400

500

600

Drugs Pesticides Foods Snake bite Householdmaterials

Alcohol CO Miscellaneous

Type of poisoning materials

Nu

mb

er o

f p

ois

on

ing

cas

es

Figure 27.5 Types of poisons taken by patients admitted to the Toxicology Unit Egypt during 2007. Household materials include kerosene,potash, tanner, benzene, and antiseptics. Miscellaneous includes poisonings arising from addictions and plant poisoning. Total number ofrecorded cases ¼ 1720.


Professor of Clinical Pharmacology & Director of NECTR,Faculty of Medicine, Cairo University, Egypt.) NECTRbegan operating in 1992 as a small unit located in the CairoMedical College. In June 2004, the Center transferred to anewly constructed building to meet increasing demand forpoisoning treatment. Over the three years 2005, 2006, and2007, the number of poisoning cases received at NECTRwere 3285, 4092, and 5521, respectively, with a 1 : 1.3male : female ratio. Between 12.4% and 15.8% of the totalnumbers were classified as pesticide poisoning, mainly dueto high exposures to OP, CM, and synthetic pyrethroid insec-ticides. This type of poisoning occurred among farm workerswho apply pesticides in fields, consumers of newly sprayedvegetables and fruits, and females using illegal adulteratedhair lotion containing highly toxic insecticide. The pattern

of intoxication with respect to types of poisoning agents isrepresented in Figure 27.7 for 2007, as an example.

In summary, the above-mentioned data do not reflect theoverall figure of poisoning for Egypt, because data from theother poison control services are not included because oflack of availability or under-reporting. There are manyreasons for under-reporting. In some areas, people sufferingfrom acute poisoning may lack access to medical care andmay not even report the illness to the medical system(WHO, 2004). The symptoms of pesticide poisoning maybe similar to those of other health problems, such as skinrash or mild gastroenteritis. In addition, the recording ofcauses of poisoning in hospitals and information transferfrom hospitals to the centers of toxicological vigilance, evenwhen mandatory, are not always efficient (Oliveira-Silva and

12.3

19.8

14.8

11.6

4 .

7 1

6 .

6 1

19.3

16.1

21.4

21.5

21.3

19.7

20.1

70.6 66.3 67.6

52.7 53.8 55.2

49.1

56.2

63.6 59.2

73.5 70.1

64.1

0

10

20

30

40

50

60

70

80

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Year

Per

cen

t

%PP/TP %PP1/PP2

Figure 27.6 Pattern of pesticide poisoning in the middle Delta of Egypt in the period 1995–2007, based on data from the Toxicology Unit inMansoura Emergency Hospital, Faculty of Medicine, Mansoura University, Egypt. %PP/TP, ratio of pesticide poisoning to total poisoning;PP1/PP2, ratio of pesticide poisoning over the period May–September to total pesticide poisoning each year.

Snake/Insect bites, 111(2%) Miscellaneous, 419

(8%)Narcotics, 202(4%)

Householdmaterials, 601

(11%)

Pesticides, 687(12%)

Foods, 631(11%)

Drugs, 2870(52%)

Total number = 5521

Figure 27.7 Pattern of pesticide poisoning among patients admitted to the National Environmental Center for Toxicological Research(NECTR), Faculty of Medicine, Cairo University, during 2007. Household materials include kerosene, potash, tanner, benzene, and antiseptics.Miscellaneous includes alcohols, addiction, and gases.


Meyer, 2003). According to Oliveira-Silva and Meyer, foreach reported poisoning by the Brazilian Ministry ofHealth, another 50 were not reported. However, we cansuggest an estimate for the number of total acute intoxicationsin Egypt as at least 48,000 cases annually, which includes�7200 cases (�15%) of pesticide poisoning. This meansthat acute poisoning at the present time accounts for 61persons/100,000 capita. The contribution of acute pesticidepoisoning (APP), mainly by ChE inhibitors, represents�9.2/100,000 in the general population and can be doubledfor the section of the country’s work force that is dependenton the agricultural sub-sector. This can be compared todata from other developing countries; the rate of APPreaches 180/100,000 in Sri Lanka (Eddleston et al., 2006),35/100,000 for the general population in El Salvador andNicaragua (Henao and Arbelaez, 2002), 19.4/100,000inhabitants living in rural areas in Brazil (Recena et al.,2006a), 17.8/100,000 occupationally related APP inThailand (Thai FDA, 2003), and 17.0/100,000 residents inBelize (Osorio et al., 2002). The reason for this variation islikely attributed to inconsistent recording methodologiesand a lack of a standard case definition for APP in developingcountries generally (IPCS/WHO, 2004).

Studies in developed countries have found the annualincidence rate of APP in agricultural workers to be as muchas 18.2/100,000 persons (Calvert et al., 2004). For manyreasons, the incidences are expected to be higher in develop-ing countries.

27.4.3 Incidental Toxicity to Farm Animals

The failure to overcome resistance in the cotton leafworm toseveral insecticides has led to the introduction of newer com-pounds not yet registered in the producing countries (e.g.,phosfolan, mephosfolan, and leptophos). El-Sebae (1977)reported incidents of delayed neurotoxicity in farm animalsfrom large-scale applications of leptophos (Phosvelw) tocotton during the period 1971–1974. In 1971, a mysteriousepidemic of paralysis struck several hundred water buffaloat villages in the middle Delta region, eventually resultingin the death of 1300 animals. Evidence strongly pointed toleptophos as being the agent responsible for this delayedneurotoxic syndrome. Additional similar incidents wererecorded in 1971 in Dakahleya and Sharkeya provinces. In1973 and 1974, other incidents were recorded in Fayoumand El-Menya provinces, respectively, as a result of sprayingof leptophos or ethyl p-nitrophenyl thionobenzenephospho-nate (EPN) blends. Furthermore, some people developedneurotoxic poisoning symptoms, and traces of leptophoswere found in their tissues. Other OP insecticides [e.g., tri-chloronate, salithion, cyanophos, methamidophos, trichlorfon,2,2-dichlorovinyl dimethyl phosphate (DDVP)] were foundto cause delayed neuropathy in man and animals (El-Sebaeet al., 1979, 1981).

In this respect, it may be appropriate to mention that thefirst outbreak of delayed neuropathy occurred in the 1930sin the United States, causing poisoning of 20,000 people asa result of drinking “Jamaica Ginger” that had been fortifiedwith the OP compound triorthocresyl phosphate (TOCP)(Rose et al., 1999).

According to Feinsod and colleagues (1986), epidemicRift Valley fever is generally recognized when a higherthan expected frequency of abortions and hemorrhagesoccurs in sheep and other livestock. Other infectious agentscan cause similar clinical signs. In Egypt, an outbreak ofabortions and hemorrhages in sheep and goats in 1982, how-ever, was traced to intoxication with the rodenticide brodifa-coum. The epidemic lasted for three weeks and resulted in120 deaths. The authors commented that such an outbreakdemonstrates the need for the strict control of the use ofrodenticides and widens the differential diagnosis of epi-demic abortion in sheep and goats.

27.4.4 Spill of Methyl Parathion into theMediterranean Sea

In February 1982, the collision of two ships, the Garnet andMolaventure, took place near the northern entrance to theSuez Canal at Port Said. As a result, Garnet, which wasloaded with 31,000 kg of methyl parathion, slowly sank in shal-low water. More than 10,000 kg of the insecticide found its wayinto the Mediterranean Sea. Estimated concentrations of methylparathion (mid June, 1982) near the area where the ship sankranged from 1.0296.0 mg/L in water, 5.12450.0 mg/kg insediment, and 46.72195.5 mg/kg in fish. Bioaccumulationin fish species followed the order Anguilla . Mugil .

Sardine . Scidena (Badawy et al., 1984).

27.4.5 Pest Resistance

In Egypt, it is well known that most insecticide use is directedat cotton fields. Therefore, the side effects most often exertedby insecticides are from applications on cotton. The use of aninsecticide against a particular pest may cause

† the development of resistance in the pest population,† the destruction of natural enemies of pests (e.g.,

predators and parasites), and† the appearance of new pests.

Toxaphene (60% EC) was first introduced into Egyptin 1955 to combat major cotton insect pests such asSpodoptera littoralis, Pectinophera gossypiella, and Eriasinsulana. In the 1961 season, a disaster occurred when toxa-phene, even at 4 L/acre instead of 2 L/acre, failed to controlthe outbreak of the cotton leafworm, resulting in loss of 50%of the national cotton yield for that season. This failure wascaused by the build-up of resistance to this insecticide. The


total amount of toxaphene a.i. used during six seasons of usewas estimated to be 54,000 Mt. Field trials showed that therewas no reversion of resistance and, on the contrary, cross-resistance to other insecticides took place. After thetoxaphene disaster, many insect resistance problems occurredsubsequently with other insecticides, including OPs and CMs(El-Sebae et al., 1993).

27.4.6 Indoor Use of Pesticides

Indoor use of pesticides for pest control is currently wide-spread in Egypt. Pesticides used for this are mainly OP com-pounds, as well as some synthetic pyrethroids. Accurateinformation concerning local production and consumptionof household pesticides is not available. We estimate thattheir consumption greatly exceeds that of the agriculturalsector, and their use lacks adequate regulation andmanagement.

27.5 OCCURRENCE OF PESTICIDERESIDUES IN ENVIRONMENTAL MATRICES

Over the past three decades in Egypt, a considerable number ofworks concerned with pesticide residues in different environ-mental samples have been published in scientific journals.Part of this work has been directed to monitoring organochlor-ine (OC) pesticides and other persistent organic pollutants(POPs) in aquatic ecosystems, dairy products, human milk,blood, urine, and foodstuffs. Most of this work has beenreviewed recently by Mansour (2008). Our concern here isdirected mainly to works about OP and CM pesticides.

27.5.1 Contamination of Aquatic Ecosystems

The data presented in Table 27.14 demonstrate contaminationof aquatic ecosystems (e.g., water sediment and fish) by anumber of OP and CM pesticides. Water and/or sedimentsamples collected from irrigation canals at El-Haram district,Giza, Egypt, were found to contain detectable residues ofchlorpyrifos, dimethoate, parathion, diazinon, carbosulfan,aldicarb, and carbaryl (El-Kabbany et al., 2000). Some ofthese pesticides, in addition to malathion, chlorpyrifos-methyl, pirimiphos-methyl, and profenofos, were found insamples from different locations (Abbassy, 2000; Abdel-Halim et al., 2006; Mansour, 2006; Mansour and Sidky,2003; Mansour et al., 2001) (Table 27.14). Generally, concen-tration levels of all the above pesticides were reported to be“within safety margins” of their respective permissible limits.

27.5.2 Food Contamination

The main source of non-occupational exposure topesticides is through the diet (Kashyap et al., 1994). In anon-occupational pesticide exposure study (NOPES) carriedout by U.S. EPA, it was concluded that for 14 of the 25

pesticides tested, food appears to be the major contributorto total exposure, whereas air appears to be the dominantfor six of the other eleven compounds (U.S. EPA, 1990). Ina recent study conducted on urban/suburban children livingin Seattle, Washington, USA, Lu and colleagues (2008)demonstrated that dietary intake of OP pesticides representedthe major source of exposure in young children. Food con-tamination by pesticides originates from normal use of agri-cultural pesticides before and/or after crop harvesting,misuse of these chemicals, and unintended environmentalcontamination (Eilrich, 1991).

According to El-Kady et al. (2001), �3.1% of localEgyptian cow meat samples (n ¼ 64) were found to containpirimiphos-methyl (587.6 mg/kg fat), and 1.7% of thesamples contained profenofos (63.3 mg/kg fat). Such con-centration levels exceeded the maximum residue limits(MRLs) set by the Egyptian Organization for Standardizationand Quality Control (EOS, 1991) for pirimiphos-methyl(50.0 mg/kg fat) and profenofos (20.0 mg/kg fat).Malathion was detected at concentrations below the MRLs.On the other hand, imported fish samples of sardine andmackerel were found to contain some pesticides at highfrequency (e.g., dimethoate, p,p0-DDA, lindane, endrin, hep-tachlor, and malathion); however, their mean concentrationswere below the permissible levels proposed by FAO(1983). Total pesticide residues were found to be 0.358 and1.817 ppm in mackerel and sardine, respectively. Of thesecontamination values, OP pesticide residues (e.g., dimetho-ate, malathion, and methyl parathion) represented 59.0%and 33.5%, respectively (Abou-Arab et al., 1996).

Samples of white corn and wheat grains collectedfrom local markets in Cairo were found to contain residuesof some OCs (e.g., aldrin, dieldrin, lindane, HCB, andDDTs) and OPs (e.g., malathion, pirimiphos-methyl, andchlorpyrifos-methyl), with relatively high levels of the lattergroup of compounds. Such high levels of OP insecticideswere linked to probable post-harvest treatments (Salim andZohair, 2004). The total residues of the detected OC pesti-cides equaled 0.75 mg/kg in white corn and 0.74 mg/kg inwheat, compared to 16.3 and 13.1 mg/kg, respectively fortotal concentration of OP insecticides estimated in theanalyzed grain samples.

27.5.3 Contamination of Vegetables and Fruits

Monitoring of pesticide residues in various kinds of veg-etables and fruits collected from six different governoratesof Egypt between 1995 and 1999 (Dogheim et al., 1999,2001, 2002, 2004) revealed that percentages of contaminatedsamples were 42.1%, 26.5%, 20.5%, and 23.2%, respect-ively, for the above-mentioned years. The authors reportedthat bendiocarb, chlorpyrifos, acephate metabolites, andprofenofos were the most frequently found pesticides.

Monitoring of pesticide residues in 21 different kinds ofvegetables and fruits collected from local markets in


Greater Cairo governorates indicated that HCB, heptachlor-epoxide, DDT and its derivatives, malathion, and dimethoatepredominated in the most analyzed samples (Abou-Arabet al., 1998). According to the authors’ results, concentrationsof malathion and dimethoate were, respectively, 0.941 and0.848 mg/kg in spearmint, 0.864 and 0.961 mg/kg in pota-toes, 0.623 and 0.481 mg/kg in tomatoes, 0.090 and0.711 mg/kg in peach, and 0.057 and 2.131 mg/kg in straw-berry. The concentration levels of the OP compounds werevery high when compared with those of the OC compounds.Similar trends of high contamination with OP pesticides com-pared with that of OCs has been observed previously byDogheim et al. (1996) in their work on citrus and potatoes.They stated that the detected OP compounds included chlor-pyrifos, dimethoate, malathion, pirimiphos-methyl, feni-trothion, parathion-methyl, and profenofos.

From 50 tomato fruit samples collected from differentregions in Greater Cairo governorates, 25% of samples

were found to contain detectable concentrations of someOC and OP pesticides. Fruit contamination with OP com-pounds accounted for 52% of the total contamination, andwas attributed to dimethoate (0.461 mg/kg), profenofos(0.206 mg/kg), and pirimiphos-methyl (0.114 mg/kg).Specifically, dimethoate and profenofos were found to bedistributed in skin, pulp, seeds, and juice of the fruits at con-centrations of 0.588, 0.084, 0.009, and 0.048 mg/kg, respect-ively for dimethoate. For profenofos, the distribution was0.211, 0.066, 0.009, and 0.098 mg/kg, respectively (Abou-Arab, 1999). In potatoes, pesticide residues (OC and OP com-pounds) were found with total mean concentrations of 1.44,4.27, and 1.01 mg/kg in whole tubers, skin, and pulp, respec-tively (Soliman, 1999). Of these contamination levels, the OPpesticides malathion, dimethoate, and pirimiphos-methylrepresented 52.0%, 61.0%, and 55.0%, respectively.

In some vegetables and fruits collected from supermarketsin Alexandria city, Egypt, OC pesticides were not detected

TABLE 27.14 Residues of OP and CM Pesticides in Water, Fish and Sediment Samples from Different Locations in Egypta

Location/PesticideYear of

SamplingConcentration

(ppb) Ref.

El-Haram, Giza Irrigation Canals 1996 Water Fish Sediment El-Kabbanyet al. (2000)Chlorpyrifos 13.4–15.8 — 16.0–23.0

Dimethoate 12.4 — 9.0–32.0Parathion 10.8 — 1.2–26.2Diazinon ND — 14.3–20.8Endosulfan 3.4–290.2 — NDCarbosulfan 12.0–21.0 — 18.8–35.2Aldicarb 8.9–42.4 — 25.0–48.6Carbaryl 19.8–48.3 — 18.6–20.0

North Coast, Mediterranean Sea(drainage water)

1997–1998 Abbassy(2000)

Dimethoate 0.09–0.10 — —Malathion 0.06–0.07 — —Captan 0.08–0.09 — —Ametryne 0.07–0.08 — —

New Damietta (major drainagecanal)

1999–2001 Abdel-Halimet al. (2006)

Chlorpyrifos 24.5–303.8 16.5–31.6 0.9–303.8Chlorpyrifos-Me 21.8 ND 61.3Pirimiphos-Me 23.3 3.1 NDProfenofos 41.0 2.1–12.6 NDMalathion 71.9–466.0 4.9–19–3 2.0–5.12Diazinon 24.6–70.5 21.1–43.0 0.9–279.0

Western Desert Lakes Rayan) 1997–1999 Mansour andSidky(2003)

Malathion ND ND 2.0–3.0Pirimiphos-Me ND 82.0–132.0 NDDiazinon 4.5 ND ND

Western Desert Lakes (Qarun) 1997–1999 Mansour et al.(2001)Malathion 14.1 43.8 ND

Pirimiphos-Me 24.8 50.5 NDProfenofos ND ND ND

aFrom Mansour (2008), with kind permission of Springer Science and Business Media.ND, not detected, no data.

27.5 OCCURRENCE OF PESTICIDE RESIDUES IN ENVIRONMENTAL MATRICES 393

and the estimated concentration levels of OP pesticides didnot violate permitted limits in any of the samples analyzed.Examples of identified OP compounds in the analyzed com-modities were dimethoate and profenofos in tomato andcucumber, profenofos and triazophos in egg plant, feni-trothion and malathion in potato, and dimethoate, profenofos,and malathion in orange (Abbassy, 2001).

Vegetable samples (e.g., eggplant, green pepper, and okra)and fruits (e.g., apple and grape) were randomly collectedfrom Gharbia Governorate, Egypt, and subjected to analysesfor OP pesticide residues. Concentration levels of malathion,dimethoate, pirimiphos-methyl, profenofos, chlorpyrifos,and fenitrothion were frequently detected in some of theanalyzed fruit samples (El-Nabarawy et al., 2001). Some ofthe aforementioned pesticides, in addition to diazinon, weredetected in the analyzed vegetable samples (El-Nabarawyet al., 2002). Generally, the estimated pesticide residues inboth studies were below the MRLs established by Codex(1997).

Finally, it has to be mentioned that pesticide residues infoods reported from most surveys are sufficiently belowMRLs for the respective compounds. However, much of theconcern about residue levels relates to whether current levelsare safe rather than whether they are under the legal tolerancelevel (Gots, 1992). Toxic implications of pesticide residues inhumans are not completely understood, and they may beunsafe even at low daily intake (Dogheim et al., 1990).According to Peiris-John and Wickremasinghe (2008),exposure to OP pesticides at levels currently regarded as safeadversely affect human reproductive function and survival.

27.5.4 Pesticide Contamination Patternin Vegetables and Fruits

A large pesticide residue monitoring program was conductedin 1997 on vegetables and fruits collected from differentlocations in Egypt and was published by Dogheim andcolleagues (2002). All samples (numbering 2318) weresubjected to analysis for 54 targeted pesticide residues.Based on the data obtained, 81.5% of the samples had nodetectable pesticide residues. Of the contaminated samples,18.5% contained detectable residues and �2.0% exceededtheir MRLs. Contamination was mainly attributed to someOP, nitrogen, and OC compounds. Based on the authorsdata, an attempt is made here to analyze the magnitude ofcontamination by OP and CM pesticides in a qualitativeand quantitative manner.

The data presented in Table 27.15 show the OP and CMpesticides found in selected kinds of vegetables and fruits.Of the 12 commodities, the insecticide dimethoate wasfound in 11 (91.7%). The other detected pesticides in theselected commodities had the following frequencies: pro-fenofos (75.0%), malathion (58.3%), chlorpyrifos (41.7%),pirimiphos-methyl (41.7%), omethoate (25.0%), phosalone

(25.0%), carbosulfan (16.7%), chlorpyrifos-methyl (16.7%),pirimicarb (16.7%), triazophos (16.7%), diazinon (8.3%),fenitrothion (8.3%), and methamidophos (8.3%).

The total number of pesticides found in each commodityranged between 6 (in orange and peach) and 17 (in pepper),and the total mean residues of all detected pesticides wereas low as 0.87 mg/kg in cantaloupe and as high as11.52 mg/kg in grapes (Table 27.16). From the data pre-sented in the Table 27.16, the magnitude of contaminationby OP and CM compounds could be estimated and expressedas percentages of total number and total residues of alldetected pesticides. Accordingly, the number of OP andCM pesticides found in cantaloupe, for example, accountedfor 62.5% of the total number found in this commodity,and their residual concentration level accounted for 43.7%of the total estimated residues coming from all detectedpesticides. In this manner, contamination of cantaloupe byAChE pesticides may be estimated qualitatively and quanti-tatively. In a similar manner, the contamination pattern ofthe other selected commodities could be demonstrated.Taking into account the quantitative estimates, the share ofAChE pesticides accounted for 65.9%, 62.6%, and 51.9%(i.e., .50%) of the total residues found in orange, peach,and guava, respectively. In grapes, this value was only19.7% (Table 27.16).

TABLE 27.15 OP and CM Pesticides Found in SomeVegetables and Fruits Collected from Local EgyptianMarkets During 1997a

Commodity Detected pesticides

Cantaloupe Dimethoate, malathion, pirimicarb, profenofos,triaziphos

Cucumber Chlorpyrifos, dimethoate, pirimicarbGreen beans Dimethoate, omethoate, pirimiphos-methylGreen peas Chlorpyrifos, dimethoate, omethoate,

phosalone, pirimiphos-methyl, profenofosPepper Chlorpyrifos, diazinon, dimethoate, malathion,

phosalone, pirimiphos-methyl, profenofos,methamidophos

Tomato Carbosulfan, chlorpyrifos, chlorpyrifos-methyl, malathion, pirimiphos-methyl,profenofos

Apple Carbosulfan, dimethoate, malathion,phosalone, triaziphos

Grape Chlorpyrifos, chlorpyrifos-methyl, dimethoate,malathion, omethoate, pirimiphos-methyl,profenofos

Guava Dimethoate, fenitrothion, malathion,profenofos

Orange Dimethoate, malathion, profenofosPeach Dimethoate, profenofosStrawberry Dimethoate, malathion, profenofos

aAdapted from Dogheim et al. (2002).


Based on the data from the above-mentioned authors(Dogheim et al., 2002; Mansour, 2008) the dietary intakeof pesticides from vegetables and fruits can be estimated andit can be concluded that contamination by dicofol, dimetho-ate, chlorpyrifos, and pirimiphos-methyl may be regardedas being of probable risk to the health of consumers. As men-tioned above, each of the analyzed commodities was found tocontain more than one OP and/or CM pesticide. Accordingto Haley and Kurt (1997) and McCauley (2006), exposure tocombinations of chemicals that inhibit ChE may cause delayedchronic neurotoxic syndromes. Exposure to sub-lethal dosesof pesticide combinations was shown to alter biochemicalparameters in rats in a diverse maner, resulting in differentforms of interaction (e.g., additive, synergistic, and antagon-istic). Fortunately, antagonistic effects were found occurmore commonly than other effects (Mansour and Refaie,2000; Mansour and Heikal, 2001; Mansour et al., 2008).

27.5.5 Contamination of Medicinaland Aromatic Plants

Pesticide residues were also detected in medicinal and aro-matic plants frequently used by infants and adults. Accordingto the data published by Abou-Arab et al. (1999), the OP pes-ticides malathion, dimethoate, and profenofos predominatedin most analyzed samples (peppermint, chamomile, anise,caraway, and tilio), but at concentration levels within thelimits of the EOS. In addition to OP contamination, thesamples were found to contain OCs, and the concentrationof total contaminants amounted to 2.43, 3.18, 3.22, 3.38,and 2.05 ppm in peppermint, chamomile, anise, caraway,

and tilio, respectively. Of the total, OP contaminantsrepresented 48.3%, 56.2%, 23.0%, 25.9%, and 60.1%,respectively, in the analyzed commodities.

In another monitoring study, Abou-Arab and Abou-Donia(2001) reported that some OP and OC pesticides were foundin certain medicinal plants at concentration levels exceedingthe permissible limits of the EOS. The following are examplesfrom their findings. Malathion levels were 0.52 ppm in Jewsmallow; 1.72 ppm in dill; 0.46 ppm in celery; 0.61 ppm intea; 0.36 ppm in caraway; 2019 ppm in chamomile; and0.67 ppm in saffron. Dimethoate was found in caraway andchamomile at concentration levels of 1.76 and 1.78 ppm,respectively. Chamomile also contained some OC pesticidessuch as lindane (0.80 ppm), aldrin (0.17 ppm), dieldrin(0.17 ppm), t-DDT (1.30 ppm), chlordane (0.59 ppm), andendrin (0.14 ppm); concentration levels exceeding theirMRLs.

Dogheim and colleagues (2004), in their studies on con-tamination of certain medicinal plants (e.g., anise, chamo-mile, coriander, and fennel) by non-organochlorinepesticides, reported that malathion, profenofos, dimethoate,and pirimicarb were the most frequently found pesticides.In a previous study carried out by Ahmed and colleagues(2001), anise was found to contain 0.007 mg/kg ofmalathion, compared to 0.40 and 0.027 mg/kg in cuminand cinnamon, respectively. Dimethoate (0.006 mg/kg)was detected in cinnamon only, whereas other analyzed com-modities (anise, caraway, cumin, and ginger) were found tobe free of this insecticide. In addition to malathion, profeno-fos and chlorpyrifos were found in cumin at concentrations of0.37 and 0.01 mg/kg, respectively.

TABLE 27.16 Pesticide Contamination Pattern for Some Vegetables and Fruits Collected from Local Egyptian MarketsDuring 1997a

Commodity

Total No. ofSamplesAnalyzed

% ofContaminated

Samples

Total No. ofPesticidesFound (B)

Total MeanResidues

(mg/kg) (D)

OP & Carbamate Compounds

FoundNo. (A)

Total MeanResidues

(mg/kg) (C)

As % ofTotalNo.b

As % of TotalMean

Residuesc

Cantaloupe 56 26.8 8 0.87 5 0.38 62.5 43.7Cucumber 115 30.4 11 2.18 3 0.63 27.3 28.9Green beans 234 21.4 10 3.83 3 1.17 30.0 30.5Green peas 122 15.6 9 4.68 6 1.75 66.7 37.4Pepper 141 34.8 17 9.57 8 2.24 47.1 23.4Tomato 134 31.3 13 2.57 6 1.20 46.2 46.7Apple 73 30.1 10 1.69 5 0.56 50.0 33.1Grape 61 39.3 14 11.52 7 2.27 50.0 19.7Guava 110 24.5 7 1.04 4 0.54 57.1 51.9Orange 100 44.0 6 1.32 3 0.87 50.0 65.9Peach 35 28.6 6 2.46 2 1.54 33.3 62.6Strawberry 34 70.6 10 3.54 3 0.97 30.0 27.4

aAdapted from Dogheim et al. (2002).b% of total number ¼ A/B.c% of total mean residues ¼ C/D.

27.5 OCCURRENCE OF PESTICIDE RESIDUES IN ENVIRONMENTAL MATRICES 395

27.6 FACTORS CONTRIBUTINGTO PESTICIDE HAZARDS

27.6.1 General Factors

In a previous publication, Mansour (2004) reported threemajor factors that contribute to health risks of pesticides indeveloping countries, generally:

1. Inadequate governmental controls (e.g., lack of aneffective pesticide registration scheme, import ofhighly toxic pesticides or those banned elsewhere,absence of a national plan for monitoring residues infood, lack of adequate occupational safeguards andpoisoning surveillance systems, and tolerating falseadvertising of pesticides in the media);

2. Laxity among pesticide users (e.g., misuse or improperhandling of pesticides, ignoring re-entry and pre-harvest intervals, involvement of children and womenin pesticide farm work, illiteracy, in the context of“Good Agriculture Practices” (GAP), and excessiveuse of household pesticides by the public);

3. Miscellaneous factors (e.g., malnutrition, infectiousand parasitic diseases, multiple exposures to toxicmixtures and poverty).

27.6.2 Specific Factors

As mentioned, in Egypt, safety measures are generally poorlyapplied and workers lack proper knowledge or training in safehandling of pesticides (Amr and Halim, 1997). Unfortu-nately, workers are often not equipped with protective clothes(impermeable) or masks when they use toxic compounds.Moreover, many thousands of children who collect eggmasses of the cotton leafworm day after day for about40 days each season are exposed to insecticide residues oncotton leaves.

The first step in developing pesticide hazard reductionprograms is to establish the extent of the problem byinvestigating farmers’ knowledge, attitudes, and behaviorregarding agricultural pesticides (Koh and Jeyaratnam,1996). Therefore, an attempt was made by Mansour (2008)to investigate the attitudes and behavior of Egyptian ruralfarmers regarding their use of pesticides in one of the largestagricultural areas in Egypt (“Damanhour”, El-BeheiraGovernorate in the middle Delta region). The main purposewas to get answers concerning levels of education, farmers’knowledge of pesticides and the sources they use to obtaininformation about use and risk avoidance, as well as waysin which they dispose of empty containers of pesticides,all in an attempt to identify the best means of communicatingto farmers the risks inherent in the unsafe use of pesticides.The following summarizes results of a questionnaireadministered face-to-face to a total of 203 farmers selected

randomly from villages adjacent to Damanhour center(Mansour, 2008).

The age of the participants ranged from 15 to 83 years, witha mean of 43.7 years, and were classified into four age cat-egories: ,18 years (n¼ 20); 18239 years (n¼ 60); 40260years (n¼99); and .60 years (n¼24). The participants dif-fered greatly in how long they had been employed in farmwork (mainly pesticide applications). Because health hazardsare proportional to the duration of exposure to toxicants, theauthor estimated the ratio “years-of-employment : age” (E/A)for each participant and expressed the product as percentages.The resulted percentage values were used to rate the degree ofoccupational exposure to pesticides among the studied groupinto five categories, as follows:

Category I: “Excessive occupational exposure” for indi-viduals with E/A � 70%

Category II: “Extreme occupational exposure” for individ-uals with E/A ¼ 56–70%

Category III: “High occupational exposure” for individ-uals with E/A ¼ 36–55%

Category IV: “Moderate occupational exposure” for indi-viduals with E/A ¼ 20–35%

Category V: “Low occupational exposure” for individualswith E/A � 20%.

TABLE 27.17 Distribution of Respondents by Years ofInvolvement in Pesticide Field Work Through a SurveyingStudy Conducted on Agricultural Laborers at El-BeheiraGovernorate, Egypt (n 5 203 persons)a

Category (Rating)b Frequency Percent

I. ExcessiveOccupationalExposure(.70%)

31 15.3

II. ExtremeOccupationalExposure(56–70%)

62 30.5

III. High OccupationalExposure(36–55%)

67 33.0

IV. ModerateOccupationalExposure(26–35%)

37 18.2

V. Low OccupationalExposure(,20%)

6 3.0

Total 203 100.0

aFrom Mansour (2008), with kind permission of Springer Science andBusiness Media.bValues in parentheses are expressed as percent of employment period to theage, and categorized into five classes.


Table 27.17 shows the distribution of the studied groupamong the above-mentioned categories.

It was noted that the youngest group (,18 years) includedsome workers of 15–17 years who claimed they had about10 years of involvement in field pesticide applications.This means they were originally employed at the age of5–7 years. According to data presented in Table 27.17,such workers should be grouped within Category II (extremeoccupational exposure). Involvement of young children infarm work, especially those collecting cotton-leafworm eggmasses and carrying the high-pressure rubber hoses ofground sprayers, are common throughout Egypt during thecotton season. The Human Rights Watch Report: “Egypt:Underage and Unprotected” (HRW, 2006) proposes usefulrecommendations regarding the “Use of Child Labor inCotton Pest Management.”

According to Mansour (2008), the answers of the partici-pants to some key questions (Table 27.18) revealed that 37%were uneducated (illiterates) and only 8.7% of the total hadreceived a university education. The remaining participants

had various levels of education. Nearly, half of participants(95 persons, representing 46.8%) declared that they did notwear protective clothes during pesticide application. Suchbehavior poses significant health risks to the farm-workerpopulation. The participants demonstrated varied behaviorregarding disposal of empty pesticide containers. The mostcommon action was to throw the empty containers intocanals (39.4%). Some farmers used such containers to storewater or grain, and ignored the fact that the crops theyhandle could be contaminated with pesticide residues. Thefull questionnaire results are presented in Table 27.18.

In another location, Menya El-Kamh, Sharkeya Governor-ate, Egypt, Ibitayo (2006) has reported results of a question-naire administered to 188 farmers who were involved inpesticide field work. The attitude and behavior of bothgroups is generally similar.

It has long been recognized that the inability of farmersto understand and follow label instructions, due to illiteracy,in addition to unsafe use or misuse of pesticides, lack ofan effective regulation system, and the high costs of

TABLE 27.18 Survey Respondent’s Answers to Key Questions Given to Pesticide Field Workers at El-Beheira Governorate, Egypt(n 5 203 persons)a

Question Response Frequency Percent

Q1: What is your education level? Incomplete elementary/no schooling 75 37.0Elementary 24 11.8Preparatory 46 22.8Secondary 40 19.7Some college 18 8.7

Q2: Do you wear protective clothes? Never 95 46.8Sometimes 65 32.0Always 43 21.2

Q3: What are your ways of disposing of emptypesticide containers?

Used to store water/grains 22 10.8Sell them 14 6.9Give to neighbors/friends 12 5.9Burn or bury them 60 29.6Throw into canals 80 39.4Throw into rubbish 15 7.4

Q4: Do you think a pesticide leaves residues onplants?

Yes 50 24.6No 40 19.7Not sure 113 55.7

Q5: Who taught you about application ofpesticides?

Ministry officials 43 21.2Neighbors/friends 160 78.8

Q6: What is your source for selection ofsuitable pesticides?

Pesticide container label 15 7.4Cooperatives 60 29.6Ministry officials 30 14.8Neighbors/friends 50 24.6Pesticide seller 48 23.6

Q7: What is your action about a fruit you pickedup during work time?

Eat directly without washing 65 32.0Wash in water and eat 100 49.3Keep for break time 38 18.7

Q8: Can we stop using pesticides? Never 191 94.1Possible 12 5.9

aFrom Mansour (2008), with kind permission of Springer Science and Business Media.

27.6 FACTORS CONTRIBUTING TO PESTICIDE HAZARDS 397

protective equipment are among the major factors contribut-ing to pesticide poisoning in developing countries (WHO,2004). Specifically, the use of personal protective devices(PPD) during pesticide application is not common practicein regions of frequent hot weather (Mansour, 2004; Recenaet al., 2006b). However, the potential for pesticide poisoningin developing countries is not limited to the unsafe useor misuse of pesticides, but also arises from accidental con-tamination. Such contamination or poisoning may resultfrom improper storage of pesticides, improper disposal ofpesticide containers, the use of empty containers for storingfoodstuffs and water, and the repacking of pesticides intosmaller containers and subsequent sale in open-air marketsnext to farm produce or foodstuffs (Al-Saleh, 1994). Othersources of accidental poisoning to farmers and communitymembers include drift from sprayed fields, early re-entry tosprayed farms, and eating crops that have recently beensprayed or treated with pesticides (Clarke et al., 1997).Taking into consideration the large number of workersinvolved in pesticide application in Egypt and their attitudesand behavior on dealing with these chemicals, solutions to theproblem of health risks among those workers must beaddressed.

27.7 CONCLUSIONS AND RECOMMENDATIONS

The use of pesticides in agriculture seems crucial to meetingthe increasing demand for food and fiber in Egypt. The occur-rence of OP and CM pesticides, which have a relatively shortpersistent compared with OC pesticides, in food commoditiesis undeniable, because “pre-harvest safety intervals” are notstrictly applied. However, the presence of multi-pesticideresidue contaminants in a commodity, even within the safetymargins for each compound, may pose risks to human health,because there are insufficient safety data regarding complexmixtures of food contaminants. One of the major factorsaffecting pesticide misuse in Egypt is the behavior of pes-ticide applicators, which requires training programs andregulations for this set of workers. Collaboration betweennational governmental authorities, agrochemical industries,and international agencies, particularly WHO and the Inter-national Labour Organization (ILO), is necessary to supportand improve educational and training programs on safety inthe use of pesticides. Furthermore, occupational and non-occupational epidemiological studies should be carried outwithin national strategic plans in order to better determinethe relation between pesticide exposure and the noticeablespread of some diseases. In this respect, the standardizedcase definition proposed by WHO for acute pesticide poison-ing (APP) (Thundiyil et al., 2008) should be followed tofacilitate the identification and diagnosis of APP, especiallyat the field level, in rural clinics, primary health-care systems,and poison control centers. In achieving the aforementioned

goals, the Egyptian Ministry of Agriculture has to continueeliminating hazardous pesticides, expanding the applicationof biocontrol measures and organic farming, and utilizingIPM programs in order to minimize environmental pesticidecontamination in Egypt.

ACKNOWLEDGMENTS

The data and information provided by Prof. Dr. Hany Gamalludin,Prof. Dr. Laila A. Abdelmegid, Prof. Dr. Seham A. Gad Elhak,and Prof. Dr. Abdel-Rahman El-Naggar enabled us to provide anoverview of some of the current activities in their institutions inthe course of poisoning management in Egypt. The author givesthanks to them.

REFERENCES

Abbassy, M.S. (2000) Pesticides and polychlorinated biphenylsdrained into north coast of the Mediterranean Sea. Egypt. Bull.Environ. Contam. Toxicol. 64: 508–517.

Abbassy, M.S. (2001) Pesticide residues in selected vegetables andfruits in Alexandria City, Egypt, 1997–1998. Bull. Environ.Contam. Toxicol. 67: 225–232.

Abdel-Megid, L.A.M. and Salem, E.M. (1993) Clinical manifes-tation and management of patients with acute poisoning by anti-cholinesterase insecticides (ANTI-ChEI). J. Pest. Cont. Environ.Sci. 5(2): 1–21.

Abdel-Megid, L.A.M. and Salem, E.M. (1996) Trends in the patternof acute poisoning in Alexandria Poison Center in 1994. Proc.3rd Cong. Toxicol. Dev. Count, Cairo, Egypt (19–23November 1995) Vol I: 237–250.

Abdel-Megid, L.A.M., Abd El-Rassoul, M.I., Metwalley, H.E., andEl-Henawy, Y.G. (2002) Acute poisoning by cholinesteraseinhibitor insecticides: Effect on myocardial, hepatic and pancrea-tic functions in humans. Mansoura J. Forensic Med. Clin.Toxicol. X(2): 23–40.

Abdel-Megid, L.A.M., El-Gendy, M.A.F., El-Gohary, A.M., andGouda, S.A. (2003) A study of patients with acute poisoningby household products admitted to the Alexandria PoisonCenter (APC): Strategies for prevention. Mansoura J. ForensicMed. Clin. Toxicol. XI(2): 99–115.

Abdel-Megid, L.A.M., El-Gendy, M.A.F., Hafez, F.M., and Abd El-Aziz, M.A.A. (2004) Assessment of the pattern and severitygrading of acute poisoning in children admitted to AlexandriaPoison Center. Mansoura J. Forensic Med. Clin. Toxicol.XII(2): 63–83.

Abdel-Halim, K.Y., Salama, A.K., El-Khateeb, E.N., and Bakry,N.M. (2006) Organophosphorus pollutants (OPP) in aquaticenvironment at Damietta Governorate, Egypt: Implications formonitoring and biomarker responses. Chemosphere 63:1491–1498.

Abou-Arab, A.A.K. (1999) Behavior of pesticides in tomatoesduring commercial and home preparation. Food Chem. 65:509–514.


Abou-Arab, A.A.K., Soliman, K.M., and Naguib, Kh. (1998)Pesticide residue contents in Egyptian vegetables and fruitsand removal by washing. Bull. Nutr. Inst. Cairo, Egypt 18(1):117–138.

Abou-Arab, A.A.K. and Abou-Donia, M.A. (2001) Pesticide resi-dues in some Egyptian spices and medicinal plants as affectedby processing. Food Chem. 72: 439–445.

Abou-Arab, A.A.K., Ayesh, A.M., Amra, H.A., and Naguib, Kh.(1996) Characteristic levels of some pesticides and heavymetals in imported fish. Food Chem. 57(4): 4872492.

Abou-Arab, A.A.K., Soliman, K.M., El-Tantawy, M.E., Ismail,B.R., and Naguib, Kh. (1999) Quantity estimation of some con-taminants in commonly used medicinal plants in the Egyptianmarket. Food Chem. 67: 357–363.

Ahmed, M.T., Loutfy, N., and Youssof, Y. (2001) Contamination ofmedicinal herbs with organophosphorus insecticides. Bull.Environ. Contam. Toxicol. 66: 421–426.

Al-Saleh, I. (1994) Pesticides: A review article. J. Environ. Pathol.Oncol. 13(3): 1512161.

Amer, M., Metwalli, M., and Abu el-Magd, Y. (2002). Skin diseasesand enzymatic antioxidant activity among workers exposed topesticides. East Mediter. Hlth J. 8(2–3): 363–373.

Amr, M.M. (1990) Health Hazards of Pesticides. Project of PesticideIntoxication—Egypt, Final Report. Fac. Med., Cairo Univ.,Egypt & Int. Dev. Res. Ctr. (IDRC), Canada.

Amr, M.M. and Halim, Z.S. (1997) Psychiatric disorders amongEgyptian pesticide applicators and formulators. Environ. Res.73: 193–199.

Anwar, W.A. (1994) Assessment of cytogenetic changes in humanpopulations at risk in Egypt. Mut. Res. 313: 183–191.

Assaad, R. and Roushdy, M. (1998) Poverty and Poverty AlleviationStrategies in Egypt. A report submitted to the Ford Foundation,Cairo, Egypt.

Attia, A.M. (2005) Risk assessment of occupational exposureto pesticides. In: Linkov, I., Ramadan, A.B. (eds) Comparativerisk assessment and environmental decision making. NATOScience Series, Springer, Netherlands, 38(3): 349–362.

Badawy, M.I., El-Dib, M.A., and Aly, O.A. (1984) Spill of methylparathion in the Mediterranean Sea: a case study at Port-Said,Egypt. Bull. Environ. Contam. Toxicol. 32: 469–477.

Ballantyne, B. and Marrs, T.C. (1992) Overview of the biologicaland clinical aspects of organophosphates and carbamates. In:Ballantyne, B., Marrs, T.C. (eds) Clinical and experimental toxi-cology of organophosphates and carbamates. Butterworth-Heinemann, Oxford, pp 3–14.

Barakat, A.O. (2003) Persistent organic pollutants in smoke particlesemitted during open burning of municipal solid wastes. Bull.Environ. Contam. Toxicol. 70(1): 1742181.

Barakat, A.O. (2004) Assessment of persistent toxic substances inthe environment of Egypt. Environ. Int. 30: 309–322.

Calvert, G.M., Plate, D.K., Das, R., Rosales, R., Shafey, O., andThomsen, C. (2004) Acute occupational pesticide-related illnessin the US, 1998–1999: surveillance findings from the SENSOR-pesticide program. Am. J. Ind. Med. 45: 14–23.

Clarke, E.E.K., Levy, L.S., Spurgeon, A., and Calvert, L.A. (1997)The problems associated with pesticide use by irrigation workersin Ghana. Occup. Med. 47(5): 3012308.

Codex (1997) Codex Alimentarius Commission, Joint FAO/WHOFood Standards Programme. Via delle Terme di Caracalla00100 Rome, Italy.

Cooper, J. and Dobson, H. (2007) The benefits of pesticides to man-kind and the environment. Crop Protec. 26: 1337–1348.

Dogheim, S.M., Gad Alla, S.A., and El-Marsafy, A.M. (1999)Monitoring pesticide residues in Egyptian fruits and vegetablesin 1995. J AOAC Int. 82(4): 948–955.

Dogheim, S.M., Gad Alla, S.A., and El-Marsafy, A.M. (2001)Monitoring of pesticide residues in Egyptian fruits and veg-etables during 1996. J AOAC Int. 84(2): 519–531.

Dogheim, S.M., Nasr, E.N., Almaz, M.M., and El-Tohamy, M.M.(1990) Pesticide residues in milk and fish samples collectedfrom two Egyptian governorates. J. Assoc. Anal. Chem. 73:19–21.

Dogheim, S.M., Gad Alla, S.A., El-Syes, S.M.A., Almaz, M.M., andSalama, E.Y. (1996) Organochlorine and organophosphoruspesticide residues in food from Egyptian local markets.J AOAC Int. 79(4): 949–952.

Dogheim, S.M., El-Marsafy, A.M., Salama, E.Y., Gad Alla, S.A.,and Nabil, Y.M. (2002) Monitoring of pesticide residues inEgyptian fruits and vegetables during 1997. Food Ad. Contam.19(11): 1015–1027.

Dogheim, S.M., El-Marsafy, A.M., Gad Alla, S.A., Khorshid, M.A.,and Fahmy, S.M. (2004) Pesticides and heavy metals levels inEgyptian leafy vegetables and some aromatic medicinal plants.Food Ad. Contam. 21(4): 323–330.

Dreiher, J. and Kordysh, E. (2006) Non-Hodgkin lymphoma andpesticide exposure: 25 years of research. Acta Haematol.116(3): 153–164.

Eddleston, M., Sudarshan, K., Senthilkumaran, M., Reginald, K.,Karalliedde, L., and Senarathna, L. (2006) Patterns of hospitaltransfer for self-poisoned patients in rural Sri Lanka: implicationsfor estimating the incidence of self-poisoning in the developingworld. Bull. Wrld Hlth Org. 84: 276–282.

Eilrich, G.L. (1991) Tracking the fate of residues from farm gateto the table. In: Tweedy, B.G., Dishburger, H.J., Ballantine,L.G., McCarthy, J. (eds) Pesticide residues and good safety:a harvest of viewpoints. American Chemists Society,Washington, D.C., pp 202–212.

El-Gamal, A. (1983) Persistence of some pesticides in semi-aridconditions in Egypt. Proc. Int. Conf. Environ. Haz. Agrochem.,Alex., Egypt (8–12 November 1983), Vol I: 54–75.

El-Kabbany, S., Rashed, M.M., and Zayed, M.A. (2000) Monitoringof the pesticide levels in some water supplies and agriculturalland, in El-Haram, Giza (A.R.E.). J. Hazard Mater. A72: 11–21.

El-Kady, A.A., Abou-Arab, A.A.K., Khairy, M., Morsi, S., andGalal, S.M. (2001) Survey study on the presence of some pesti-cides and heavy metals in local and imported meat and effect ofprocessing on them. J. Egypt Soc. Toxicol. 24: 81–85.

Ellenhorns, M.J., Schonwald, S., Ordog, G., and Wasserberger, J.(1997) Ellenhorn’s Medical Toxicology: Diagnosis and

REFERENCES 399

Treatment of Human Poisoning. 2nd edn. Maryland: Williams &Wilkins.

El-Nabarawy, I.M., Fouzy, A.S.M., and Sallam, A.A.A. (2001)Determination of some pesticide residues in foodstuff. EgyptJ. Food Sci. 29(1): 63–70.

El-Nabarawy, I.M., Fouzy, A.S.M., Sheble, D.E.A., and Shalby,S.E.M. (2002) Incidence and stability of pesticide residues insome vegetable fruits as affected by food processing. EgyptJ. Food Sci. 30(2): 205–215.

El-Sebae, A.H. (1977) Incidents of local pesticide hazards andtheir toxicological interpretation. Proc. Seminar/Workshop onPesticide Management, UC/AID-Univ Alex, Alexandria, Egypt(5–10 March 1977): 137–152.

El-Sebae, A.H. and Soliman, S.A. (1982) Mutagenic and carcino-genic chemicals in the Egyptian agricultural environment.Basic Life Sci. 21: 119–126.

El-Sebae, A.H., Soliman, S.A., and Ahmed, N.S. (1979) Delayedneurotoxicity in sheep by the phosphorothioate insecticideCyanophenphos. J. Environ. Sci. Hlth B14(3): 3472362.

El-Sebae, A.H., Abou-Zeid, M., and Saleh, M.A. (1993) Status andenvironmental impact of toxaphene in the Third World — Acase study of African agriculture. Chemospher. 27(10):2063–2072.

El-Sebae, A.H., Soliman, S.A., Ahmed, N.S., and Curley, A. (1981)Biochemical interaction of six OP delayed neurotoxicants withseveral neurotargets. J. Environ. Sci. Hlth B16: 463–474.

EOS (1991) Maximum residue limits for pesticides in foods.Egyptian Organization for Standardization and QualityControl, Cairo, Egypt.

Ezzat, S., Abdel-Hamid, M., Eissa, S.A., Mokhtar, N., Labib, N.A.,El-Ghorory, L., Mikhail, N.N., Abdel-Hamid, A., Hifnawy, T.,Strickland, G.T., and Loffredo, C.A. (2005) Association ofpesticides, HCV, HBV, and hepatocellular carcinoma in Egypt.Int. Hyg. Environ. Hlth 208: 329–339.

Fakhri, Z.I. (1993) Cholinesterase assessment as a result of feni-trothion exposure: a survey in a group of public health workersexposed to an organophosphorus pesticide. Occup. Med.(Lond) 43(4): 197–202.

FAO (1983) Compilation of legal limits for hazardous substancesin fish and fishery products. FAO Fishery Circular No. 464, pp5–100.

Farahat, T.M., Abdelrasoul, G.M., Amr, M.M., Shebl, M.M.,Farahat, F.M., and Anger, W.K. (2007) Neurobehavioral effectsamong workers occupationally exposed to organophosphoruspesticides. Occup. Environ. Med. 60: 279–286.

Feinsod, F.M., Allam, I., Ragai, A., and Saah, A.J. (1986)Rodenticide-induced signs simulating Rift Valley fever insheep and goats in Egypt. Vet. Res. 118(10): 270–272.

Gots, R.E. (1992) Toxic risks: Science, regulation, and perception.Lewis Publishers, Florida.

Haley, R.W. and Kurt, T.L. (1997) Self-reported exposure to neuro-toxic chemical combinations in the Gulf War. A cross-sectionalepidemiologic study. JAMA 277(3): 231–237.

Henao, S. and Arbelaez, M.P. (2002) Epidemiological situation ofacute pesticide poisoning in the Central American Isthmus,

1992–2000. Pan American Health Organization (PAHO)PLAGSALUD. Epidemiol. Bull. 23: 5–9.

HRW (2006) Human Rights Watch, Egypt: Underage andUnprotected. http://www.hrw.org/reports/2001/egypt/Egypt01-01.htm

Ibitayo, O.O. (2006) Egyptian farmers’ attitudes and behaviorsregarding agricultural pesticides: implications for pesticide riskcommunication. Risk Anal. 26(4): 989–995.

ILO (1996) Wage Workers in Agriculture: Conditions ofEmployment and Work. Sectoral Activities Programme.TMAWW/International Labour Organization, Geneva.

IPCS/WHO (2004) Epidemiology of Pesticide Poisoning:Harmonized Collection of Data on Human Pesticide Exposurein Selected Countries. International Programme on ChemicalSafety/World Health Organization, Geneva.

Jeyaratnam, J. (1990) Acute pesticide poisonings: A major globalproblem. World Health Statistics Quarterly 43(3): 139–144.

Kamal, A.A., Elgarhy, M.T., Maklady, F., Mostafa, M.A., andMassoud, A. (1990) Serum cholinesterase and liver functionamong a group of organophosphorus pesticides sprayers inEgypt. J. Toxicol. Clin. Exp. 10(7–8): 427–435.

Kashyap, R., Iyer, L.R., and Singh, M. (1994). Evaluation of dailydietary intake of dichloro-diphenyl-trichloroethane (DDT) andbenzene hexachloride (BHC) in India. Arch. Environ. Hlth 49:63–66.

Koh, D. and Jeyaratnam, J. (1996) Pesticide hazards in developingcountries. Sci. Total Environ. 188 (Suppl. 1): S78–S85.

Lu, C., Barr, D.B., Pearson, M.A., and Waller, L.A. (2008) Dietaryintake and its contribution to longitudinal organophosphoruspesticide exposure in urban/suburban children. Environ. HlthPerspec. 116(4): 537–542.

Mansour, S.A. (1993) Usages and problems of pesticides in Egypt.Int. J. Toxicol. Occup. Environ. Hlth 2(2): 46–53.

Mansour, S.A. (2004) Pesticide exposure—Egyptian scene.Toxicology 198: 91–115.

Mansour, S.A. (2006) Monitoring of pesticides and heavy metals inthe western desert lakes of Egypt and bioassaying potential tox-icity of their waters. Proc. 4th Environ. Conf. Pestic. & RelatedOrg. Micropolluts. Environ./10th Symp. Chem. Fate ModernPestic., Univ. Almeria, Almeria, Spain, 26–29 November 2006,pp 113–117.

Mansour, S.A. (2008) Environmental impact of pesticides in Egypt.In: Whitacre, D.M. (ed) Rev. Environ. Contam. Toxicol., vol.196, Springer Verlage, pp 1–5.

Mansour, S.A. and Refaie, A.A. (2000) Xenobiotics interaction. 2.An approach to the use of biochemical data measurements forinterpreting interaction of insecticides in rats. Ad. Pharmacol.Toxicol. 1(1): 1–20.

Mansour, S.A. and Heikal, T.M. (2001) Xenobiotics interaction. 3.A further study on the use of biochemical markers to analyzethe joint action of insecticide mixtures in the rat. J. Egypt Ger.Soc. Zool. 35(E): 31–49.

Mansour, S.A. and Sidky, M.S.M. (2003) Ecotoxicological studies.6. The first comparative study between Lake Qarun and Wadi


El-Rayan wetland (Egypt), with respect to contamination of theirmajor components. Food Chem. 82: 181–189.

Mansour, S.A., Mahran, M.R., and Sidky, M.S.M. (2001)Ecotoxicological studies. 4. Monitoring of pesticide residues inthe major components of Lake Qarun, Egypt. J. Egypt Acad.Soc. Environ. Develop. 2(1): 83–116.

Mansour, S.A., Heikal, T.M., Mossa, A.H., and Refaie, A.A. (2008)Toxic effects of five insecticides and their mixture on albino rats.J. Egypt Soc. Toxicol. 39: 85–94.

McCauley, L.A. (2006) Organophosphates and the Gulf WarSyndrome. In: Gupta, R. (ed) Toxicology of organophosphateand carbamate compounds. Elsevier Inc., pp 69278.

Moses, M., Johnson, E.S., Anger, W.K., Buse, V.W., Horstman,S.W., Jackson, R.J., Lewis, R.G., Maddy, K.T., McConnell, R.,Meggs, W.T., and Zahm, S.H. (1993) Environmental equityand pesticide exposure. Toxicol. Indust. Hlth 9(5): 913–959.

Oliveira-Silva, J.J. and Meyer, A. (2003) O Sistema de Notificacaodas Intoxicacoes: o Fluxograma da Joeira. In: Peres, F., Moreira,J.C. (eds) E Venenoou e Remedio? Rio de Janeiro: Fiocruz, p 317

Osorio, A.M., Maza, R., Panagos, H., and Maibach, H. (2002)Evaluation of chemical exposures among papaya industryworkers in Belize: Final Report. International Conference onPesticide Exposure and Health, 8–12 July 2002, Bethesda,MA Society for Occupational and Environmental Health.

PAN (1993) Toxaphene in North Sea Fish. Global PesticideCampaigner. Pesticide Action Network 3(4): 17.

Peiris-John, R.J. and Wickremasinghe, R. (2008) Impact oflow-level exposure to organophosphates on human reproduc-tion and survival. Trans. Royal Soc. Trop. Med. Hyg. 102:239–245.

Recena, M.C.P., Pires, D.X., and Caldas, E.D. (2006a) Acutepoisoning with pesticides in the state of Mato Grosso do Sul,Brazil. Sci. Total Environ. 357: 88–95.

Recena, M.C.P., Caldas, E.D., Pires, D.X., and Pontes, E.R.J.C.(2006b) Pesticides exposure in Culturama, Brazil — knowledge,attitudes, and practices. Environ. Res. 102: 230–236.

Rose, R.L., Hodgson, E., and Roe, R.M. (1999) Pesticides. In:Toxicology. Academic Press, San Diego, pp 663–697.

Salim, A. and Zohair, A. (2004) Effect of acidic natural antioxidanton removal pesticides from some contaminated cereals. J. Agric.Sci. Mansoura Univ. 29(8): 467524683.

Soliman, K.M. (1999) Changes in concentration of some pesticideresidues in potatoes during washing and cooking. J. Agric. Sci.Mansoura Univ. 24(5): 2503–2511.

Soliman, S.A., El-Sebae, A.H., and El-Fiki, S. (1979) Occupationaleffect of phosfolan insecticide on spraymen during fieldexposure. J. Environ. Sci. Hlth B 14(1): 27–37.

Soliman, S.A., Sovocool, G.W., Curley, A., Ahmed, N.S., El-Fiki,S., and El-Sebae, A.H. (1982) Two acute human poisoningcases resulting from exposure to diazinon transformationproducts in Egypt. Arch. Environ. Hlth 37(4): 207–212.

Thai FDA (2003) Establishment of pesticide poisoning databaseon human pesticide exposure: Internal Report. Thai Food andDrug Administration, Nakom-Pathom Provincial Health Office.

Thundiyil, J.G., Stober, J., Besbelli. N., and Pronczuk, J. (2008)Acute pesticide poisoning: a proposed classification tool. Bull.WHO 86(3): 205–209.

Tomlin, C.D.S. (2004) The e-Pesticide Manual. Version 3.1 2004–05. The British Crop Protection Council (BCPC), UK.

U.S. EPA (1990) Pesticide Exposure Study (NOPES), U.S.Environmental Protection Agency, Research Triangle Park, N.C.

UNDP, Egypt (1999) Sustainable Development Documents, EgyptWorkshop Report.

WHO (1993) Pesticides and Health in the Americas. EnvironmentSeries No. 12, Washington, DC: World Health Organization.

WHO (2004) The Impact of Pesticides on Health: PreventingIntentional and Unintentional Deaths from Pesticide Poisoning.Geneva: World Health Organization [http:www.who.int/mental. . ..health/prevention/suicide/en/PesticidesHealth2.pdf].

WHO (2005) The WHO Recommended Classification of Pesticidesby Hazard and Guidelines to Classification: 2004. (NLMClassification: WA 240). World Health Organization, Geneva,Switzerland.

Zheng, T., Zahm, S.H., Cantor, K.P., Weisenburger, D.D., Zhang,Y., and Blair, A. (2001) Agricultural exposure to carbamate pes-ticides and risk of non-Hodgkin lymphoma. J. Occup. Environ.Med. 43(7): 641–649.

REFERENCES 401