First report of green tobacco sickness in Arapiraca, Alagoas state, Brazil, 2007

Introduction: Green Tobacco Sickness (GTS) is an acute intoxication caused by dermal absorption of nicotine from tobacco leaves, and is characterized by weakness, headache, nausea, vomit and dizziness. In the Arapiraca region, a seasonal increase in cases of acute intoxications has been noted during August-September since 2004.  This is tobacco leaf harvest season, during which pesticide use is reduced; hence we suspected the occurrence of GTS. Methods: We conducted a 1:1 matched case-control study among persons who had contact with tobacco farming. Cases were persons diagnosed with acute intoxication (dizziness, nausea, vomit, weakness, headache) between August 1^st-September 25^th, 2007). Controls were persons from cases’ home or neighborhood who had contact with tobacco farming and did not present symptoms during the seven days preceding interview. Urine samples are collected for cotinine testing by High Performance Liquid Chromatography. Results: Of 107 cases, 57 (53%) were male; median age was 21 years (range: 8-58 years).  Principal signs and symptoms were dizziness (90%), weakness (88%), vomit (83%), nausea (82%) and headache (58%). On logistic regression, factors independently associated with illness were male sex (OR=2.1; 95%CI=1.1–4.0), non-smoker (OR=7.0; 95%CI=2.6–19.1) and working in the harvest phase of tobacco (OR=2.7; 95%CI=1.2 – 6.0). Among non-smokers, median urine cotinine concentration was 288ng/ml (range: 18-6.313) in cases, and 156ng/ml (range: 0-1,908) among controls (p=0.006). Conclusions: Epidemiologic and laboratory data indicate the occurrence of GTS in the Arapiraca region, most commonly among less educated men. Risk factors associated with illness were male sex and involvement in tobacco harverst phase and not smoking. We recommend enhancement of surveillance for intoxications in the tobacco farming region and increasing use of personal protective gear during the harvest season.