You are on-duty in the emergency room in a rural hospital. At about 10:30 PM, a white male is brought into the ER by his wife who says, "He’s real sick. I had to get all over him to make him come to the emergency room. He couldn’t even drive himself. I’m scared." The wife tells you he has vomited six times in the last three hours and can’t keep anything down. The patient complains of nausea, dizziness, weakness and being shaky. He says he feels awful. The patient denies chest pain and has no history of heart trouble.

On exam the patient is a 33 years old male, approximately 5’10" tall, muscular and about 20 pounds overweight. His jeans and tee shirt are sweat-stained and very dirty. His vital signs are: HR 120 bpm, regular and strong, BP 140/88, no orthostatic changes, respirations 24/min and regular, temperature 98.0 ^oF. Pupils are equal and appropriately reactive. Retinas are normal, no bulging disks, and no nystagmus. There is a mild tremor and weakness of peripheral muscles. When you ask him what’s wrong, he repeats his chief complaints, that he can’t stop throwing up; is weak; dizzy; shaky; has a head ache; and is having trouble breathing. He denies alcohol intake and is on no medications. He has no past medical history and his wife states he is normally healthy and hasn’t seen a doctor in six years. On questioning, you find the patient has been harvesting tobacco all that day from about 8 a.m. to about 6 p.m. and the day before. It is a hot humid day and there had been scattered thunderstorms earlier in the day. He felt fine all day. The nausea, headache and dizziness began approximately four hours ago and the vomiting began three hours ago. He tells you he thinks it might be the pesticide, MH30 sucker dope, he sprayed on the crop two weeks ago. As you are about to continue your exam the patient vomits on you and the floor. The vomitus is a clear yellow fluid with no apparent blood.

Green tobacco sickness is an occupational illness of tobacco harvesters. It is caused by dermal absorption of nicotine from contact with the tobacco leaf. It has been reported in the states of Kentucky, North Carolina and Florida. Additionally it has been reported in India and Japan. The true incidence of this occupational illness is not known. However, one study by the National Institute for Occupational Safety and Health (NIOSH) estimated a crude incidence as 10 cases per 1,000 workers. This would effectively mean as many as 600 patients annually seek medical care for green tobacco sickness in Kentucky alone. (MMWR) A recent study of Hispanic migrant workers in North Carolina suggests that this estimate may be significantly underestimating the true incidence of green tobacco sickness (Quandt, et al).

Two  problems with green tobacco sickness are there may be: 1) a lack of awareness of the syndrome by the farm workers and, 2) some confusion in the patient as to the cause of the illness. Without an awareness of the cause, the workers may fail to take effective precautions when handling green tobacco. Migrant workers, without previous experience in tobacco harvesting, may be unaware of the dangers. Additionally, local farmers and health care workers may confuse these symptoms with heat exhaustion or pesticide poisoning, especially if pesticides have recently been applied to the crop.

Knowledge of the labor involved in tobacco harvesting may help us understand both the close skin contact workers have with tobacco and the origin of the disease. Burley and flue-cured are the two primary varieties of tobacco produced in the US. For both types of tobacco the flower must be removed from the growing plant (topping) to cause greater root growth, leaf weight and nicotine content at harvest. To do this workers walk down the rows of 4 to 6 foot high tobacco plants and break off the flowers at the top. There is nearly constant contact with the leaves as they walk down the rows and reach into the plants to break off the flowers. Topping is usually completed in the first two weeks of July, but can be delayed if the planting season was delayed. Production research has determined that more closely spaced rows increase the production poundage. This also results in greater contact between the plants and the workers.

Burly tobacco is harvested as a whole stalk, requiring workers to reach under the large plant (6 to 8 feet tall) and cut the stalk. As the tobacco is cut, each plant’s stalk is impaled on a sharp metal spear placed over the end of a five-foot long wooden stick. The sticks, each with six impaled tobacco plants, are set upright in the field with the plants upside down and arranged in a semicircle around the stick (so each stick of six plants looks like a teepee). After drying in the sun for about three days, the tobacco sticks with the impaled plants attached are passed from the ground to workers on a wagon and then transported to the barn for air curing. Normally tobacco is housed in dry weather. But if the tobacco is ready to be housed and it begins to rain, most farmers will begin loading the wagons and housing the tobacco to prevent it from being rain damaged. When the tobacco is wet, loading the wagons and hanging the sticks in the barn are times of heightened exposure to dermal absorption of nicotine.

Housing the tobacco in the barn is usually done by several workers. Two workers remain on the wagon and pass the sticks up to the next workers perched on the bottom rails just above the wagon. In a typical three tier barn, each worker on the bottom rail takes the sticks, passes two sticks up to the workers on the rails above him, and hangs one stick on his rail. This hanging on the present rail and passing sticks up to the next higher rail continues until the sticks reach the workers perched on the top rails. When the stalks are wet, the nicotine infused water soaks the full body of all the workers. Workers on the lower rails and on the wagon face the most exposure because the tobacco above them continues to drip on them.

Flue cured tobacco is picked one leaf at a time in several stages as the leaves become ripe and may present the greatest opportunity for exposure to wet tobacco leaves. First the bottom leaves are picked. Workers must walk through the rows, reach into the plant and break off the bottom leaves. The picked leaves are held under the arms as more tobacco is picked until no more can be carried. The tobacco is then placed on a cart. The middle leaves are picked in the same manner as they become ripe and finally the top leaves are picked, as they become ripe. This is called priming or cropping the tobacco. Priming is usually begun in July and ended by early to mid September. From 3 to 10 primings are completed for each field.

• The nicotine content of tobacco leaf is approximately 2 % to 8 %.

• Moisture on tobacco leaves from dew or rain may contain as much as 9 mg of nicotine per 100 ml of dew. (Gehlbach, et. al.) This is the rough equivalent of 6 average cigarettes. On a humid day, especially after recent rains, the average field worker during harvesting activities may be exposed to up to 600 ml of dew.

ABSORPTION

PEAK SERUM CONCENTRATIONS

HALF-LIFE

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MECHANISM OF ACTION OF NICOTINE

• NEUROLOGIC

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• DECONTAMINATION

• Intramuscular (IM) dose of 5 to 10 milligrams (1 to 2 milliliters) to control severe nausea and vomiting

or         PROMETHAZINE – Phenergan ®

• The usual intramuscular (IM) or intravenous (IV) dose for the treatment of nausea or vomiting is 12.5 to 25 milligrams, not to be repeated more frequently than every four hours.

• The usual effective oral dose for the treatment of nausea or vomiting is 12.5 to 25 milligrams every 4 to 6 hours. The average dose is 25 milligrams. When oral medications cannot be tolerated, the same dose may be administered by rectal suppository

or           TRIMETHOBENZAMIDE – Tigan ®

• Intramuscular (IM) dose for the treatment of nausea and vomiting in adults is (2 mL) 200 milligrams three to four times daily.

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PATIENT DISCHARGE INSTRUCTIONS.

• Long sleeve shirts and long pants to decrease contact with the skin.

BILINGUAL PATIENT EDUCATION MATERIALS

To download free bilngual (English/Spanish) patient intructions to prevent reoccurance please click below. There are 2 choices. It can be downloaded in Microsoft WORD97 format or in Adobe Acrobat format.
Click Here for the WORD97 version
Click Here for the Adobe Acrobat version

A copy of a bilingual (Spanish/English) photo novel and a narrative simulation exercise for patient/public distribution is available at the University of Kentucky Department of Preventive Medicine and Environmental Health’s Southeast Center for Agricultural Health and Injury Prevention. For more information, please call (859) 323-6836. The simulation exercise is available on-line at http://www/mc.uky.edu.scahip/Pedro.

Written by: Henry A. Spiller, M.S. D.ABAT 8/2004, Revised 5/2007