Journal of Agromedicine

Pesticide Exposure and Cholinesterase Levels in Migrant

Farm Workers in Thailand
Anamai Thetkathuek a​​ , Pornthip Yenjai a​​ , Wanlop Jaidee b​​ , Patchana Jaidee b​​ , and Poonsak
Sriprapat c​

a​
Department of Industrial Hygiene and Safety, Faculty of Public Health, Burapha University, Chonburi, Thailand;
b​
Department of Public Health Foundation, Burapha University, Chonburi, Thailand; c​​ The Office of Disease Prevention
and Control 6, Muang, Chonburi, Thailand

ABSTRACT

Objectives​: In this study, we examined the effects of pesticides in migrant farm workers
from Cambodia after workplace exposure on fruit plantations in eastern Thailand.

Methods​: We studied 891 migrant farm workers employed on pineapple, durian, and
rambutan plantations in Thailand. Data were collected via a detailed questionnaire
survey and measurements of serum cholinesterase level (SChE).

Results​: The majority of subjects was male (57.7%), with an average age of 30.3 years.
Most subjects (76.8%) were moderately aware of good industrial hygiene practices.
SChE level was divided into four groups based on the results. Only 4.4% had normal
levels of cholinesterase activity, 20.5% had slightly reduced levels, 58.5% had markedly
reduced levels and were “at risk,” and 16.6% who had highest levels of cholinesterase
inhibition were deemed to be in an “unsafe” range. SChE was classified into two groups,
SChE value of 87.5 was “normal” and <87.5 units/mL “abnormal.” For the multiple
logistic regression analysis of the abnormal SChE levels, the variables entered in the
model included gender, period of insecticide use, the total area of plantation, frequency
of spraying, period of daily insecticide spraying, and insecticide spraying method. The
results indicated that the aOR (adjust odds ratio) for male migrant farm workers (95%
confidence interval [CI]) was 1.58 (1.14, 2.17). The OR for farm migrant workers who
worked on larger plantations of more than 39.5 acres (95% CI) was 2.69 (1.51, 4.82).
Finally, the OR for the migrant farm workers who used a backpack sprayer (95% CI)
was 2.07 (1.28, 3.34).

Conclusions​: These results suggest that health screening should be provided to

migrant farm workers, especially those who spray pesticides on plantations of >39
acres, use a backpack sprayer, or have a low level of compliance with accepted
industrial hygiene practices. These three classes of workers are at increased risk of
chemical exposures and developing acute or chronic illness from pesticide exposures.

KEYWORDS ​Carbamate effect; migrant farm workers; organophosphate effect;

pesticide poisoning; Thailand fruit plantations.
Introduction

In the nations of Southeast Asia, including Thailand, a large segment of the population
works in agricultural production.​1​–​3 ​Although 41.1% of the Thai population worked in
agriculture in 2011, because of labor shortages,​4 ​migrant workers were needed to
maintain production. Data from the Office of Foreign Workers Administration for 2015​5
indicate that 232,250 foreign workers were employed in the eight eastern provinces of
Thailand (primarily Chonburi and Rayong provinces). The largest groups of migrant
farm workers were from Myanmar, Cambodia, and Laos.
Employment of migrant farm workers in the agricultural sector in Thailand is divided
into two categories: those working throughout the year and those working seasonally.​6
Migrant farm workers in Thailand perform many tasks, including digging and cutting
grass on corn and fruit plantations.​7​,​8 ​On fruit farms, the migrant farm workers are
usually employed to raise and harvest specific crops such as durian, mangosteen,
rambutan, or longan, and these fruit farm workers may be either permanently employed
for several years straight or may be limited to seasonal employment. They all may have
occupational exposure to pesticides, especially organophosphates (OP) and
carbamates (CM), during the growing seasons, which generally entail two crops per
year.​9
By law, migrant workers in Thailand are expected to obtain work permits from the
Department of Employment of the Ministry of Labor. Migrant workers who come to work
in Thailand are classified into four types: (1) general laborers (migrant workers who are
skilled and positioned quite highly in the workforce), (2) permanent workers (migrants
who have been issued a work permit under the Article 10 of Decree No. 322, (3)
Notification of Work (migrant workers who entered the Kingdom legally on a temporary
basis), and (4) nationality proof (migrants who escaped from Myanmar, Laos, and
Cambodia).​10 ​Migrant workers are required to undergo a medical examination before
entering and obtaining employment in Thailand. The Ministry of Public Health is the
primary institution in Thailand that deals with medical examination fees, health
insurance protection, control of epidemic diseases, and administering the process of
issuing work permits. Migrant workers who have obtained a medical certificate then
have to pay a license fee (1,910 Baht) at the provincial counter service for a work
permit.​11
 Organophosphate (OP) and carbamate (CM) pesticides are widely used to control
insects and other agricultural pests in Thailand.​6​,​9 ​Migrant farm workers who are
exposed to these pesticides can develop toxic effects from inhibition of
acetylcholinesterase (AChE). In both mammals (humans) and insects, this enzyme
inhibition causes accumulation of excess acetylcholine (ACh) at neural synapses and
neuromuscular end plates, and subsequent toxic cholinergic effects.​12​– ​16 ​This can lead
to unpleasant symptoms such as dizziness, nausea, vomiting, sweating, stomach pain,
diarrhea, bradycardia, and dyspnea.​17​–​19 ​There are also indications that the use of OP
insecticide may cause neurotoxicity.​20​– ​25
Blood tests for cholinergic effects in Thai farm workers were carried out in 2012,
2013, and 2014.​26 ​The results indicated that almost a third of farm workers had unsafe
exposures to these cholinesterase inhibitors as tested by reactive paper (in 2012,
30.94% of 244, 822 farm workers were at unsafe levels; in 2013, 30.54% of 314,805
were at unsafe levels, and in 2014, 34.25% of 317,051 were at unsafe levels). However,
there are no published results relating insecticide exposure to health effects among
migrant farm workers in Thailand.
A number of factors contribute to the suppressed cholinesterase levels in farm
workers. Male workers have been shown to develop effects from pesticides more than
their female counterparts.​27 ​Age and level of education also affect likelihood of pesticide
effects, with a
higher degree of education reducing the risk of developing signs or symptoms.​28
Kachaiyaphum et al.​19 ​reported that farmers who are single, separated, divorced, or
widowed had increased risk of health effects from pesticide use than married workers.
Ohayo-Mitiko et al.​29 ​stated that longer duration of working hours with pesticides
increased the risk of toxic effects, and Matchaba-Hove and Siziya​30 ​reported that good
personal hygiene, including hand washing before eating or smoking, can decrease the
development of toxic effects in workers in pesticide formulation and packaging factories
in Harare, Zimbabwe. Finally, Chakrabotry et al.​31 ​reported that farmers who did not
wear gloves, masks, and shoes had increased risk of OP and CM insecticide exposure
than those who wore personal protective equipment (PPE).
In agricultural workers, plasma cholinesterase (PChE) and erythrocyte cholinesterase
(AChE) activity can be used as an indicator of OP and CM effects.​32​–​35 ​Cholinesterase
activity can be analyzed by several methods, including spectrophotometry,​25 ​the EQM
Testmate,​36 ​and assessment using a reactive paper test kit.​19 ​In developing countries,
reactive paper kits are most commonly used for health screening of farmers, as this
technique is affordable and convenient.
 Beyond the required pre-employment health examination instituted by the Ministry of
Health in 2003,​37 ​which provides for disease screening before the workers have
workplace exposures; the health of migrant farm workers is not monitored, and no
ongoing health surveillance of migrant farm workers is provided. There are no
guidelines for health screening in migrant workers in Thailand for health hazards
resulting from pesticide exposure. Health surveillance is needed for the migrant farm
workers, using similar blood cholinesterase screening protocols as are used for Thai
farm workers.​19​,​38​–​41
Although several studies have examined exposure to OP and CM pesticides among
Thai farmers,​19​,​26​,​38​–​41 ​the effects of such exposures have not been reported in migrant
farm workers in Thailand. Therefore, this study was designed to gather preliminary data
on this issue, concerning health care and surveillance needed for the migrant farm
workers in eastern Thailand. Such data should help to illuminate the nature of work
place pesticide exposures and be used for mitigation efforts.

Materials and methods

Study population

This cross-sectional study was conducted in both male and female Cambodian foreign
migrant farm workers on fruit plantations in Thailand, whether they were registered with
the Labor Department or not. The annual work cycle of the fruit plantations is
continuous, as there are two seasonal crops. A large amount of pesticides such as
chlorpyrifos, methomyl, and cypermethrin are applied in December–January for the
April–May harvest, and then in June–July for the second harvest. The present study
was conducted among the migrant farm workers on plantations in an area of
concentrated tropical fruit production, in three adjacent coastal provinces (Chonburi,
Rayong, and Chanthabuti) of south-east Thailand near the Cambodian border. Data
were collected for 3 months from November 2015 to January 2016.

Migrant farm workers from randomly selected fruit farms were entered into the study if
they were Cambodian nationals engaged as permanent daily-paid employees on a fruit
farm, and if they had been engaged to work as such for at least 1 year. Additionally,
eligibility was restricted
to workers with self-reported pesticide exposure and whose employer reported OP
and/or CM insecticide use on the farm. All study subjects agreed to cooperate with the
protocol. Permission to recruit study subjects from among the farm workers was
obtained from the employer in advance. All study subjects were permitted to decline
participation or withdraw from the study at any time without consequences. Those who
agreed to cooperate provided written informed consent. The institutional review board of
Burapha University reviewed the study protocol and provided ethical approval for the
research project.

Sample size

The calculation of the sample size for logistic regression analysis was according to the
technique of Hsieh et al.,​42 ​and this led to an estimate of n = 684, which was then
adjusted for covariances:

​ 1⁄4 ð1 ​ R​2​Þ ​when n​p ​is adjusted sample size and n​1 ​is the sample size calculated from
n​1 np _ ​

the formula for simple logistic regression. R​2 ​is the squared multiple correlation

coefficient of the multiple logistic regression; in this study, this score is set at 23% (R​2 ​=

0.23). The size of sample calculated was 888 subjects, and 891 subject workers were

subsequently recruited.

Research tools and data collection

The study utilized an interview questionnaire survey and a single blood sample from
each worker.

Interview questionnaire

An interview questionnaire in Khmer language was used to collect data. The interviews
were conducted by five researchers and two translators for groups of three to seven
workers. Before conducting the interviews, a request letter was sent to the employer
and an appointment was scheduled by telephone. Both the translator and the Thai
interviewer were trained before data collection. The groups of migrant farm workers
were interviewed by both a Khmer-speaking interpreter and a Thai researcher at the
end of a work shift. Interviews had an average duration of 10–15 minutes and were
conducted at their local sub district Health Promoting Hospital. The interview questions
were divided into five parts with 54 items, including

● Part 1: Social demographic data, including gender, age, level of education, average
income (in Thai Baht) per month (4 questions).
● Part 2: Smoking and alcohol consumption, both current and past usage (6
questions).
 ● Part 3: Work history and exposures, on the crop/type of fruit grown, the total period
the farmers have been working (years), the total area of plantation (measured in rai, 1
acre = 2.53 rai), methods used to mix pesticides, the types of pesticides used, the
frequency of pesticide spraying (sessions/week), duration of pesticide spraying
(hours), the PPE available, and the appropriateness of use of PPE (9 questions).
● Part 4: Self-protective behavior, during pesticide preparation, pesticide application
techniques, practices in the warehouse used for pesticide storage and preparation,
and details of pesticide spraying techniques (23 questions). For classification of these
practices, the answers were divided into three levels based on the differences
between the highest and
lowest scores. The self-protective behavior scores were classified into three groups
based on Best’s theory : 1 = low (score <23); 2 = moderate (23–45), and 3 = high
(>45).​43
● Part 5: Knowledge, including that of personal hygiene needed for safe handling of
pesticides, pesticide spraying techniques, and effects caused by exposure to the
pesticides. Each question was written in multiple choice format (12 questions).
Knowledge score: (yes = 1 and no = 0). Knowledge scores were classified into three
groups based on Bloom’s theory.​44 ​Knowledge scores from 12 questions were classified
into three groups: high (>80%; scores >9.60), moderate (60–80%; scores 7.30–9.59),
and low (<60 %; scores <7.30 scores).​44 ​Quality control of the questionnaire was done
to assure validity of the information that was to be gathered. The questionnaire was
reviewed by expert authorities to verify the structure, clarity, and scope of the contents,
as well as the appropriate language for the study population. The expert consultants
included two industrial hygienists and one expert in health behaviors. After reviewing
the suggestions from the experts, the questionnaire was modified as needed and
translated into the Khmer language.
Thirty migrant farm workers who were not study subjects were selected to assist with
preliminary studies designed to validate the questionnaire, to allow us to determine
whether it was applicable to the target population at risk of pesticide exposure. The
preliminary interview questionnaire included two parts on self-protective behavior and
knowledge, and these questions were administered to the test-development population
for rewording questions. The reliability of self-protective behavior was 0.843 and
knowledge was 0.732, respectively. Based on these results, the final adjustments of the
questionnaire were completed.
Participation criteria for study subjects limited them to foreign agricultural workers
employed in the eastern region who worked with OP and/or CM cholinesterase
inhibitors. The subjects participating in this research did so on a voluntary basis. The
research protocol was approved by the institutional review board (IRB) of Burapha
University.

Assessment of exposure to OP and CM pesticides

After interviewing the migrant farm workers and completing the questionnaire surveys,
the investigators took a fingertip blood sample using standard techniques. The blood
sample was tested for SChE activity using the reactive paper test kit provided by the
Government Pharmaceutical Organization of Thailand. The sensitivity, specificity, and
positive predictive value of the blood test in laboratory analysis were 89.9%, 95.6%, and
94.6%, respectively. When the reactive paper was tested in the field, the sensitivity,
specificity, and positive predictive value of the blood test were 77%, 90.1%, and 90.4%,
respectively.​45 ​Background information on the colorimetric strip method of qualitative
testing for cholinesterase with reactive paper, by Husbumrer and colleagues,​46 ​reported
that the reactive paper was a simple method to use for the early screening of OP and
some CM insecticides.
The reactive paper is made of cellulose filter paper dipped into bromothymol blue (a
color indicator) and Ach chloride (a substrate for cholinesterase). It takes 7 minutes to
complete the determination of cholinesterase activity at 25°C ± 1°C and 70% relative
humidity. The cholinesterase activity as determined by the Biggs method and the
reactive paper method is not significantly different, with a correlation coefficient of 0.56
when the cholinesterase activity is in the range of 20–120 units/mL. The reactive paper
and test kits were supplied by the Bureau of Occupational and Environmental Diseases,
Department of Disease Control, Ministry of Public
Health,
Thailand.​45

Collection of blood samples

Before blood samples were drawn from the farm workers, public health officers and
nurses at the sub district health promoting hospitals in each area were trained to
interpret the results of the blood screening using the colorimetric scale to assess
cholinesterase activity. Blood collection was then conducted and enzyme activity was
measured. Each case required 7–15 minutes for processing. The test result readers
were not blinded to the location where the samples were collected.
Fingertip blood samples for SChE activity were drawn from each subject after
cleaning the site with cotton and alcohol, following a standard protocol.​45 ​The sample
was then collected in a capillary tube and spun in a centrifuge until there was separation
of red blood cells from the supernatant plasma. Then, the reactive paper slip was
placed on a slide by using forceps and one drop of the plasma was placed on the paper,
covered with another clean slide, and incubated for approximately 7 minutes.​45
The results were interpreted according to a colorimetric standard sheet and recorded
as one of four categories: yellow, ≥100 units/mL (normal); yellow-green, 87.5–99.9
units/mL (safe); green, 75.0–87.4 units/mL (at risk); and blue, <75.0 units/mL (unsafe).​32
The test results were further classified into category A (yellow + yellow-green),
considered “normal”; and category B (green + blue), considered “abnormal” (as per the
Bureau of Occupational and Environmental Diseases, Department of Disease Control,
Ministry of Public Health).​45 ​Serum cholinesterase level (SChE) was classified into two
groups: SChE value of 87.5 was “normal” and <87.5 units/mL “abnormal.”​45 ​The data
from these two groups were then used for statistical analysis.

Data analysis

The data were verified, codified, and recorded in a computer spreadsheet, and
statistical analysis was performed using SPSS for PC, version 20 (Statistical Package
for the Social Sciences/Personal Computer; IBM, Armonk, NY, USA). The analysis was
divided into two parts: (1) the descriptive analysis presenting the information on table,
frequency, percentage, average score, standard deviation, median, as well as the
lowest and the highest scores, and (2) bivariate logistic analysis, used to analyze the
association between each independent variable and serum cholinesterase level (SChE)
individually. Significant variables including gender, period of insecticide use (years), the
total area of the plantation (in acres), frequency of spraying (days/week), period of
insecticide spraying (hours/day), and insecticide spraying method were used to identify
the significant variables contributing to SChE, health risks for the migrant farm workers.

Results

Demographic and behavioral factors

Of the 891 migrant farm workers, 57.7% were male. The average age was 30.3 ± 8.5
years, and 46.1% were between 18 and 28. Interestingly, 55.2% did not have a formal
education, and 45.7% had a monthly income of 5,000 to 7,000 Baht (143–200 USD),
with an average of 7390 ± 2133 Baht (211 ± 61 USD). Only 25.5% of the workers were
current tobacco smokers; and 59% of these had a 1–5-pack-year history. Of the
tobacco users, 47.8% smoked 1–5 cigarettes a day. A majority (64.8%) denied lifetime
use of alcoholic beverages, with 33.1% indicating current alcohol usage (see ​Table 1​).
Work environment and history

The work history of the migrant farm workers indicated some overlap, in that 64.2% had
cultivated pineapple, 30.9% durian, and 23.5% rambutan fruit crops. Most of the
migrants (58.8%) had been working for 1–5 years, and 52.2% were employed on
smaller plantations of less than 19.76 acres. The average size of the plantations in the
study was 58.65 ± 127 acres.

TABLE
1

Questions on work practices revealed that 46.1% of the workers mixed several kinds
of pesticides such as chlorpyrifos, methomyl cypermethrin, and nicotine, 43.8% used
solely one type of pesticide, and 73.3% used the type of pesticide supplied by their
employers. Only 26.7% reported following the manufacturer’s instructions and warnings
that were printed on the label of the shipping container or pesticide bottle. The workers
reported spraying the pesticides once or twice a week (46.5 and 41.3%, respectively). In
terms of duration of pesticide spraying, 42.1% reported 4–5 hours and 36.9% reported
1–3 hours of exposure time per session. The study also indicated that the most recent
pesticide use in 407 (46.5%) of the workers was within 3–7 days, whereas in 227
(20.8%) of the workers it was greater than 14 days.
Moreover, 97% of the migrant farm workers reported that they are responsible for
mixing and spraying the cholinesterase inhibitor pesticides. For application of these
agents, 47.9% used cars or motorcycles, 28.2% used a stationary pesticide tank while
spraying, and 23.1% used a backpack sprayer. A plurality of the farm workers (46.5%)
spent 3–7 days applying pesticides during each growing season, whereas 25.9% spent
over 14 days doing these tasks ( ​Table 2​). PPE use by the farm workers was variable:
81% reported wearing long sleeve shirts and long pants, and 67.6% reported wearing
boots, but only 43.3% reported using face masks or respirators during pesticide
preparation ( ​Table 3​).

Strategies for prevention of pesticide exposure

Most of the workers (56.2%) denied smoking while mixing pesticides, but 45.1% did not
read and understand the label instructions before using the pesticides, and 35.5% never
followed all steps in the instructions. The survey also indicated that 21.5% reported
frequently rechecking their equipment before spraying, and an equal percentage
reported occasionally rechecking their equipment before using. Finally, 11.2% reported
drinking water or eating while mixing the pesticides (contrary to label directions).

TABLE
2
TABLE
3

Regarding safety measures taken while spraying the pesticides, 38.7% avoided
touching their skin or eyes, 34.9% did not drink water without washing their hands first,
and 41.3% usually wore boots or the shoes to cover their feet completely. In addition,
25.5% avoided spraying the pesticides when the temperature was high, and 27.2%
stood upwind while spraying the
pesticide
s.
Safety procedures used after spraying pesticides included never disposing of
containers by burying (34.7%), never reusing containers after just washing (33%), and
never washing work clothes worn during pesticide application with other clothes
(25.6%). To protect themselves from pesticide exposure, 43.5% usually changed
clothes after bathing and washing their hair, but only 38.4% reported showering and
washing their hair with soap/shampoo after pesticide application. And only 35.2%
always stored the containers of pesticides so as to prevent contact with children.
Overall, we found that 76.8% of the migrant farm workers used medium-level
measures to prevent pesticide exposure, and 15.7% used only low-level measures,
leaving only 7.5% that used high levels of preventative measures.

Knowledge base for handling pesticides

The majority of the migrant farm workers responded correctly when asked key
questions, especially regarding eating, drinking, and smoking while spraying the
pesticides. In fact, 81.4% realized that there were potential dangers from pesticide
exposures, and 81.9% knew how to protect themselves from exposures while working in
the moving in an upwind direction. Nevertheless, 81.5% wore clothes that did not
provide adequate protection from pesticide exposure. Regarding gaps in knowledge
among the migrant farm workers, 70.5% thought that the different types of pesticides all
have the same effect on their bodies. And 38.9% also thought that they could have
acute toxic symptoms but never develop long-term effects. Finally, 35.1% of the farm
workers believed that they could use higher amounts of pesticides than is stated on the
manufacturers safety instruction sheets. The majority of migrant farm workers (45.7%)
had moderate level of knowledge scores, whereas (36.4%) had low-level scores.
SChE levels in migrant farm workers

The studies of SChE levels in the workers by the colorimetric reactive paper technique
revealed that 4.4% were at normal levels, 20.5% had slightly reduced activity and were
in the “safe group,” 58.5% were in the “at risk group,” and 16.6% were in the “unsafe
group.” The test results were further classified into normal and abnormal categories,
which were 24.9% and 75.1%, respectively.

Factors affecting cholinesterase leve​l

The results of multiple logistic regression analysis of the SChE levels indicated that
several independent variables were significantly associated, including gender, period of
insecticide use (years), total area of the plantation (acres), frequency of spraying
(days/week), period of insecticide spraying (hours/ day), and insecticide spraying
method.
The result of the analysis indicated that the aOR (adjusted odds ratio) (95%
confidence interval [CI]) for the male migrant farm workers was higher than that of the
female workers: 1.58 (1.14, 2.17). The aOR (95% CI) for farm workers employed on
plantations of more than 39 acres compared with those from plantations averaging 19
acres, was 2.69 (1.51, 4.82). Finally, the OR (95% CI) for farm workers who used a
backpack sprayer was higher than in those who used stationary pesticide tank while
spraying: 2.07 (1.28, 3.34) (​Table 4​).

Discussion

The results of the present study indicated that during the growing season while
pesticides are being sprayed, 75% of migrant farm workers had abnormal levels of
SChE (16.6% unsafe, 58.8% at risk). These levels are detected by cholinesterase
reactive paper, following the standards of the Bureau of Occupational and
Environmental Diseases, Ministry of Public Health.​45 ​The blood determination for SChE
in this study was done by the same method as used in several previous studies,
including those by Kachaiyaphum et al., Srivorojana et al., Chaikliengnand
Praengkrathok, Chumchuay, and Chomthaisong et al.
This paper technique is simple and convenient for use in the field. However, the
extent of intraindividual variability might be affected by a number of factors, including
disease state (glaucoma or diabetes mellitus) and medications (edrophonium, tacrine,
or pyridostigmine).​45​,​47​,4​ 8 ​These factors may have cross-specificity with the reactive
paper; nevertheless, the specificity of reactive paper tested in laboratory analyses and
in the field is high (95.65% vs. 90.1%).​45 ​The positive predicted value (PPV) of reactive
paper in laboratory analysis and in the field is also high (94.59% vs. 90.38%), making
cholinesterase reactive paper applicable for use in SChE screening in the field.​45
Cholinesterase activity also can be analyzed by standard laboratory methods such as
manometric, potentiometric, titrimetric, photometric, fluorometric, and radioisotopic
techniques, as well as by enzymelinked immunosorbent assay (ELISA).​49​,​50 ​These
methods provide more reliable results than the rapid screening test used in this study.

TABEL 4 Note. Adjusted model: Cox & Snell R 2​ ​= 0.061 and Nagelkerke R 2​ ​= 0.09

From this present study, it appears that the prevalence of abnormal SChE was
slightly lower than the prevalence reported in a previous study in 153 Cambodian
vegetable farmers (60.8% at risk, 17% unsafe). In contrast, abnormal SChE levels as
found in this study were more frequent than those reported from several previous
studies from several plantations in Thailand that grow chilies, tomatoes, rice, and
orchids. For chili cultivation, Kachaiyaphum et al.​19 ​reported that 32% of 350 workers
had abnormal SChE. For tomato cultivation, Chomthaisong et al.​41 ​indicated that 66.2%
of 71 seed tomato growers had abnormal SChE (45.1% at risk, 21.1% unsafe), whereas
lower rates were reported for consumption tomato growers (35.1% at risk, 13.0%
unsafe). In a study of rice cultivation workers, Chaiklieng and Praengkrathok​39 ​reported
a prevalence of abnormal SChE of 60% (32.7% at risk, 27.3% unsafe). Finally, in orchid
cultivation, the prevalence of abnormal SChE among farmers was reported as 49.3%
(24.6% at risk and 24.7% unsafe).​38
In the current study, the most recent pesticide use in 407 (46.5%) of the workers was
within 3–7 days, whereas in 227 (20.8%) of the workers it was greater than 14 days.
Therefore, SChE recovery might have occurred prior to testing in some of the workers.
Although acetylcholinesterase recovery occurs at a rate of approximately 1% per day,
SChE regenerates at a more rapid rate (approximately 25% in the first 7–10 days).​51
Therefore, to better follow the effects of cholinesterase inhibitors, enzyme activity
should be determined at two times: for baseline testing to determine the normal SChE
activity in that individual and then a second test should be performed within 3 days of
pesticide application, and/or 30 days or more after the pesticide application period.​19​,​45
The study also documented a number of factors contributing to reduce SChE among
the migrant farm workers. For instance, in this study, men were found to be at higher
risk than women (1.58-fold), consistent with prior studies.​19​,​52​,​53 ​Interestingly, in 2011,
Namwong et al.​53 ​reported that male workers were at higher risk of cholinergic effects
and were more directly exposed to pesticides than female workers during preparation,
spraying, and washing the containers after application to the crops. Thus, it appears
that male migrant farm workers had more risk of exposure, and consequently short and
long illness, than their female counterparts. It would be beneficial to reduce pesticide
use in male farm workers. Preventive interventions to increase perceptions of pesticide
utilization and exposure, as well as increasing the effective use of PPE, providing for
ongoing monitoring of blood cholinesterase among male migrant farm workers,
particularly those who are actively applying pesticides, are suggested.
This is also consistent with the finding that migrant farm workers on plantations larger
than 39.52 acres were more likely to develop abnormal SChE from pesticides (2.69-fold
vs. those working on farms of 19.76 acres or less), which could reflect higher levels of
pesticide usage on larger plantations, with longer periods of spraying required and
without proper PPE use arising the greater risk of abnormal SChE levels.
The prevalence of abnormal SChE levels in the present study was higher than in
several previous studies.​38​–​41 ​This may be attributable to the different types of
plantations that were studied, or the total size of the plantations, which are likely larger
than the farms that raise chilies, rice, tomatoes, or orchard crops. Consequently, some
farm workers on the larger facilities may be exposed more consistently to pesticides
than those who work in smaller plantations; this exposure pattern may reflect use of
different types of pesticides or longer application periods.​54 ​The migrant workers who
work on larger farms with increased or more consistent pesticide exposure should be
managed with modified work practices, such as rotating work duties, to reduce excess
pesticide exposure in small numbers of individuals. Additionally, they should be more
concerned for health screening and health surveillance.
The results of this study also indicate that the use of backpack sprayers increases
risk of over- exposure to pesticides 2-fold compared with use of an on-ground pesticide
container (consistent with the report of Sombatsawat​55​), as the backpack sprayers
produce fine vapors that can be absorbed very easily.​56 ​Therefore, this study suggests
that plantation owners should replace the backpack sprayers with alternative types of
equipment.
Some factors that were not associated with SChE level (self-protection behavior and
knowledge) nevertheless should be enhanced among migrant workers. The study
documented that among migrant farm workers employed on fruit plantations in eastern
Thailand, there was a tendency toward a low level of adherence to good industrial
hygiene practices while applying pesticides, with low level of usage of PPE (13.6%).
The use of PPE among migrant farm workers working on pineapple, durian, and
rambutan plantations indicates that boots, glove, and face masks were the most
frequently used types of PPE during insecticide application, and that goggles, coveralls,
and respirators were used at a much lower frequency. Moreover, even among those
who wear PPE, some still did not use it appropriately. From the focus groups, and
observation, the researchers found that the reason that most of the migrant farm
workers did not wear appropriate PPE (such as chemical resistant PPE) was that the
employers usually did not provide it for them. Additionally, the workers asserted that
they did not wear PPE because of the
hot weather, which made protective garments
uncomfortable.

The results of this study are consistent with prior studies from several countries,
including Cambodia, that reported that vegetable farmers rarely used goggles (7.1%),
coveralls (0%), or respirators (3.2%), but more frequently used facemasks (66.7%).​18 ​In
contrast, Truong et al.​57 ​reported in a study from Vietnam that the prevalence of using
face masks was only 29.00%. In a study from Iran, it was reported that hats and boots
were commonly used during insecticide application, and that most farmers did not use
gloves, goggles, face mask, coveralls, and respirators with much frequency.​58 ​In Ghana,
it has been reported that the use of PPE was negligible because of economic
limitations.​59
The present study found that most migrant workers had medium level of
self-protection behavior (76.8%), with the remainder at a poor level (25.7%), which is
not consistent with the study of Chaiklieng and Praengkrathok​39 ​on the use of
agricultural pesticides among rice farmers in Thailand, where these behaviors were high
(75.5%) and poor (24.5%), respectively. The results of the current study documented
abnormal SChE levels and are not consistent with the study of Kachaiyaphum et al.,​19
who found that moderate and poor pesticide use behaviors among chili farmers are
associated with abnormal SChE. This study is also not consistent with previous studies
that indicate poor prevention of pesticide exposure causes increased uptake of the toxic
agents during unnecessarily prolonged skin contacts, and this then contributes to
development of cholinesterase inhibition.​52​,​53​,​60
From this present study, a significant percentage of the farm migrant workers (34.8%)
do not bathe immediately after applying pesticides to the crops, or even wash their
hands before eating or drinking. It might be that sufficient water sources or shower
rooms were not provided inside the farms, so that the farm workers could only bathe
after returning home. If this is the case, the employers should provide clean drinking
water, bathrooms, and toilets for these employees. The employers should also be
regulated more rigorously with respect to the health and welfare of the laborers in their
workplace.​61

Additionally, the agricultural employers should adhere to the regulations from the
Ministry of Labor that indicate that the employers must provide access to adequate
clean drinking water to the farm workers, and if the employees live with their employers,
the employers must provide clean and safe accommodations to the employees.​6 ​Clean
water should be available to the workers at all times on the fruit farms, and further, it
should be necessary to provide the migrant farm workers with facilities where they can
shower or bathe as necessary to maintain their health and hygiene.​62
The result of this study found that only 26.7% of farm workers follow the
manufacturer’s instructions and warnings that are printed on the pesticide bottles. From
discussion with migrant farm workers, the researchers found that they are less
interested in reading instructions and pictograms on insecticide bottles because
explanations of the instructions are printed in the Thai language and the pictograms are
too small. Other limitations also might be that many migrant farm workers are not able
to read at all and cannot understand the instructions or pictograms. Most of the migrant
farm workers (55.2%) had low education levels, and that could present obstacles for
their learning processes. But in the present study, worker educational levels and/or
knowledge base were not related to abnormal SChE levels. This is in contrast to the
study of Kachaiyaphum et al.​19 ​who reported that low education level was associated
with abnormal SChE titers. However, these authors had concerns similar to those in the
study that found that vegetable and fruit farmers had higher levels of education and
knowledge than grain farmers but were less willing to reduce pesticide use because of
being anxious about low salary.​63

This study provides evidence that further encouragement of positive behaviors in

pesticide handling, as well as personal hygiene and use of PPE, is needed. It also
indicated that further efforts are needed to inform migrant farm workers about their
pesticide exposure risks, perhaps by providing study materials and safety training
manuals or translated posters, which may facilitate improved work practices in the
migrant farm workers.

Limitation

One limitation of this study is that it only presents data collected early on during the
growing season while pesticide spraying was being done and did not extend later until
harvest time. Therefore, serial studies of the time course of resolution of the
cholinesterase inhibition, as is done clinically to assess patients diagnosed with OP and
CM pesticide effects, was beyond the scope of this study, which was limited to
cross-sectional survey data.

Conclusion

This study indicates a need for health screening and surveillance for migrant farm
workers. It appears that this should be focused on male workers, those who work on
fruit plantations of 39.52 acres or more. In particular, use of back-pack sprayers is of
particular concern. Training to increase knowledge of risks of the cholinergic effects of
the pesticides and how to avoid them, as well as educational materials translated into
the Khmer language, may improve compliance with good industrial hygiene practices.
Educational media about health risks and environmental control of pesticide exposures
should be provided to the migrant farm workers, to decrease the likelihood of
occupational dis-ease, which may have significant long-term consequences for the
individual with chronic exposure.
Moreover, training and advising employers and pesticide retailers to provide end-user
education, as well as improving teaching media, should be instituted so as to enhance
migrant farm workers’ awareness of safe work practices. Pesticide retailers and farm
employers thus could promote appropriate behaviors among migrant farm workers.
Additionally, organic farming should be promoted to employers in order to minimize the
use of pesticides among farm workers.

Funding

This work was financially supported by a research grant from Burapha University
through the National Research Council of Thailand (grant no. 36/2559).

ORCID

Pornthip Yenjai ​http://orcid.org/0000-0002-6076-9343 ​Patchana Jaidee

http://orcid.org/0000-0003-4553-4551 Poonsak Sriprapat
http://orcid.org/0000-0002-4525- 2653
References