Construction of a collective report on the causal link between pesticide exposure and illness among vector control workers in Rio de Janeiro

Abstract

Introduction  In Brazil, vector control workers (VCW) are occupationally exposed to multiple pesticides. However, these workers face obstacles in proving a causal link between that exposure and health outcomes.

Objective  To report the experience of a multicenter project in constructing a collective causal link between occupational exposure to pesticides and illness among VCW, in the state of Rio de Janeiro.

Methods  Documentary, epidemiological, clinical, and laboratory analyses were used to establish the causal link between the working process and the VCW illness.

Results  A comprehensive picture of pesticides exposure of different classes was identified, many of them present carcinogenic, neurotoxic, immunotoxic, and endocrine-disrupting properties, and are banned in other countries. Data were consolidated from biomarkers, clinical exams, and self-reported symptoms, revealing a high prevalence of comorbidities consistent with the effects of these substances.

Conclusion  Based on this investigation, a scientifically grounded collective statement was prepared, establishing a causal link between the exposure to pesticides and the observed illness that contributes to the institutional recognition of VCW illness and to support legal actions and public health policies.

Keywords
Endemic Diseases; Pesticides; Agrochemicals; Occupational Exposure; Occupational Diseases; Occupational Health

Resumo

Introdução  No Brasil, agentes de combate às endemias/guardas de endemias (ACE) estão expostos a múltiplos agrotóxicos no exercício de suas funções, contudo, enfrentam obstáculos para comprovar o nexo causal entre a exposição a essas substâncias e os agravos à saúde que os acometem.

Objetivo  Relatar a experiência de um projeto multicêntrico na construção de um laudo coletivo com indicação de nexo causal entre a exposição ocupacional a agrotóxicos e o adoecimento dos ACE do estado do Rio de Janeiro.

Métodos  Análises documentais, epidemiológicas, clínicas e laboratoriais foram utilizadas para o estabelecimento de nexo causal entre o processo de trabalho e o adoecimento dos ACE.

Resultados  Foi identificado um quadro abrangente de exposição a agrotóxicos de diferentes classes, com propriedades carcinogênicas, neurotóxicas, imunotóxicas e desreguladoras endócrinas, proibidos em outros países. Foram consolidados dados de biomarcadores, exames clínicos e autorrelatos, com alta prevalência de comorbidades compatíveis com os efeitos dessas substâncias.

Conclusão  A partir da investigação, foi elaborado um laudo coletivo técnico-científico com indicação de nexo causal, contribuindo para o reconhecimento institucional do adoecimento dos ACE e subsidiando ações judiciais e políticas de proteção à saúde.

Palavras-chave
Doenças Endêmicas; Agrotóxicos; Agroquímicos; Exposição Ocupacional; Doenças Ocupacionais; Saúde do Trabalhador

Introduction

Since the 1950s, the Brazilian State has adopted a model for combating arboviruses/endemic diseases based on eliminating vectors, mainly the Aedes aegypti mosquito. This approach prioritized the intensive use of insecticides in ultra-low volume (ULV) applications, popularly known in Brazil as fumacê, using engine-driven backpack sprayers and spray pumps, as well as larvicides in potential mosquito breeding sites. This “mosquito-centric”¹ and chemical-dependent model, with constant changes of pesticides due to the vectors’ adaptation to the products, has not been able to prevent periodic epidemics, and results in the population and workers being exposed to substances that are harmful to their health¹,².

In this context, the “mosquito killers” play a central role. They are health workers who combat urban vectors, currently known as endemic disease control agents/endemic disease guards (hereinafter referred to as VCW), public servants who occupy positions with different nomenclatures, depending on the organizational structure of the health management bodies, but who have similar functions and similar work processes. Data from the “Projeto Integrador Multicêntrico: Estudo do impacto à saúde de Agentes de Combate às Endemias/Guardas de Endemias (ACE) pela exposição a agrotóxicos no estado do Rio de Janeiro” (Multicenter Integrative Project: Study of the impact on the health of Endemic Disease Control Agents/Endemic Disease Guards [VCW] due to exposure to pesticides from state of Rio de Janeiro) presented in a Technical/Scientific Report from Oswaldo Cruz Foundation (Fiocruz)/Rio de Janeiro State Legislative Assembly (Alerj) Public Hearing³ on June 10, 2024, indicate that this category has been exposed, in their work process, to multiple pesticides, with various harmful effects, since the 1980s. These pesticides can be neurotoxic, genotoxic, carcinogenic, teratogenic, and endocrine disruptors, such as organochlorines, organophosphates, carbamates, coumarins, pyrethroids, and neonicotinoids. Some of which have been banned or restricted in other countries due to their effects on human and environmental health²,³.

Exposure of workers to these substances can cause alterations in laboratory tests and illnesses more frequently than is seen in the population. There is a vast literature on the effects of these pesticides that have been (and still are) used in the VCW work process². Moreover, analyses of genotoxicity, cytotoxicity and immunotoxicity carried out by a team from the Brazilian National Cancer Institute (INCA) and the Federal University of the State of Rio de Janeiro (Unirio) indicated that exposure to pesticides impaired humoral and cellular immune function with adverse consequences for VCW’s health, and damage to genetic material, which can contribute to the development of cancer³.

However, despite the recognized occupational exposure, VCW face great difficulties in formally establishing the causal nexus between their work activity and their illness, which compromises their access to social security and health rights in their entirety.

This gap highlights a structural problem: the lack of effective mechanisms for monitoring workers’ health and the under-reporting of work-related illnesses. This report seeks to contribute to the field of Workers’ Health by presenting the construction of a collective report that brings together technical-scientific evidence on the effects of prolonged occupational exposure of VCW to pesticides, with a view to formally recognizing the causal nexus between this exposure and the illness of these workers.

Methods

This is an experience report on the process of constructing a collective report on the effects of prolonged occupational exposure of VCW to pesticides carried out by a multicenter research project linked to the Center for the Study of Workers’ Health and Human Ecology (Cesteh)/Sérgio Arouca National School of Public Health (Ensp)/Fiocruz and partner institutions (described in the Acknowledgements). The project was approved in March 2019 by the Research Ethics Committee (CEP/Ensp), CAAE No. 03323018.4.0000.5240. The study population consisted of VCW from the state of Rio de Janeiro.

The structure of this study is divided into four axes:

1. Retrospective documentary research to identify the pesticides used by VCW in public health campaigns in state and municipality of Rio de Janeiro, using data made available by Rio de Janeiro State Health Department (SES-RJ) and Rio de Janeiro Municipal Health Department (SMS-RJ), from 2000 to 2019, followed by a narrative review of the literature describing the potential harmful effects on humans and the environment⁴.

2. Evaluation of biomarkers: clinical analysis tests carried out at the Laboratory for Diagnostic Support in Pathological Epidemiology (Ladep)/Germano Sinval Faria School Health Center (Csegsf)/Fiocruz; toxicological analyses for biomarkers of oxidative stress, exposure and effect, carried out at the Toxicology Laboratory of Cesteh/Ensp/Fiocruz; sleep pattern assessments by actimetry carried out at Cesteh/Ensp/Fiocruz; audiometric analyses at the Audiology Service of the Cesteh/Ensp/Fiocruz Outpatient Clinic³. The collection of biological material from 127 VCW, as well as sleep and audiological assessments, were carried out between October 2021 and July 2022.

3. Analysis of data collected using a questionnaire comprising 107 questions in six dimensions⁵: (I) Sociodemographic data; (II) Work characterization; (III) Environmental and occupational exposure to chemical substances; (IV) COVID-19 pandemic; (V) Mental health - Self-Reporting Questionnaire (SRQ 20); and (VI) Sleep quality. An online form self-answered by the same 127 VCW was used from August 2020, to July 2022.

4. Documentary analysis of medical records with data on consultations and care at the Cesteh/Ensp/Fiocruz outpatient clinic in the following areas: nursing, social assistance/service, general practice/occupational medicine, neurology, dermatology, physiotherapy, speech therapy, nutrition, pulmonology, and psychology. These analyses took place between March 2023 and June 2024 and included the medical records of the 127 VCW.

The participation of the VCWs was preceded by their knowledge and acceptance of the Free and Informed Consent Form, in digital format, whose agreement was an indispensable condition for access to the questionnaire and, in physical format, for the collection of biological material and care at Cesteh/Ensp/Fiocruz Outpatient Clinic.

Results and discussion

The project was started in 2018 at the request of the VCW who came to Cesteh/Ensp/Fiocruz concerned about illnesses and deaths among workers in this category³. The project was first built through discussion forums with workers, union leaders, researchers and students. The Expanded Research Community (ERC) methodology⁵ was used to build tools that would expand knowledge about the work process and the health situation of this population. In 2019, three lines of research began concurrently: retrospective documentary evaluation of pesticides used by VCW in the Rio de Janeiro Health Departments (SES-RJ and SMS-RJ); analysis of data on sick leave and deaths in the category provided by the Rio de Janeiro State Center (NERJ) of the Ministry of Health (MS) and the construction of a questionnaire to be applied to VCW to provide data reported by the workers themselves. The questionnaire was designed for online self-application, due to the context of the COVID-19 pandemic in 2020.

It was observed that the pesticides reported by the VCW as used in the work process corresponded to those identified in the documentary survey carried out with data from the Rio de Janeiro municipal and state health departments⁴. Multiple pesticides of different chemical classes and toxicity classifications were identified: organochlorines DDT, HCH, and HCB; carbamate bendiocarb; coumarins flucomaphene, coumatetralyl, brodifacoum, and warfarin; organophosphates malathion, temephos, and fenitrothion; pyrethroids bifenthrin, lambda-cyhalothrin, etofenproxy, cypermethrin, alpha-cypermethrin, deltamethrin, permethrin, and pralethrin; pyridyloxypropyl ether pyriproxifem; benzoylureas novaluron and diflubenzuron; neonicotinoids imidacloprid and clothianidin; mixture of spinosyns A and D spinosad; biological larvicide Bti, Bacillus thuringiensis var. israelensis⁴,⁵(Figure 1). It should be noted that these pesticides were not used sequentially in isolation, but concomitantly and increasingly, according to the resistance of the vectors to the substances¹.

Figure 1
(a) Timeline of pesticides used for vector control in Brazil since 1950 and their potential damage to mammalian organisms; (b) Pesticides mentioned by VCW (endemic disease control agents) in a self-administered online questionnaire.

Research into the harmful effects of these pesticides has shown that they have the potential to cause damage to organs and systems in mammals and humans, including oxidative stress, metabolic damage, endocrine disruption, reproductive alterations, and damage to offspring, as well as immunotoxic, hematotoxic, hepatotoxic, nephrotoxic, neurotoxic, genotoxic, cytotoxic, and carcinogenic effects, as detailed in the Multicenter Integrative Project’s Technical-Scientific Report³. Many of them have carcinogenic potential already recognized by the International Agency for Research on Cancer (IARC), linked to the World Health Organization (WHO), and the United States Environmental Protection Agency (US-EPA, such as malathion, cypermethrin, bifenthrin, permethrin, and the metabolite of diflubenzuron, 4-chloroaniline³,⁴,⁶.

It was also observed that many pesticides used by VCW are banned in the European Union, such as novaluron, diflubenzuron, flocoumafen, bendiocarb, clothianidin, fenitrotione, temephos, alpha-cypermethrin, permethrin, as well as imidacloprid and praletrin present in the formulation of Cielo®, a product indicated and imported in 2020 by the Brazilian Ministry of Health to combat mosquitoes⁷-⁹.

The data on these pesticides should be enough to ban their use in the country. Following the “Precautionary Principle” incorporated into Brazilian regulations, the use of pesticides with carcinogenic, mutagenic, teratogenic, or endocrine disrupting potential and damage to the reproductive system¹⁰ is not authorized¹¹. However, in reality, there is a growing release and use of pesticides without the necessary precautionary criteria/health care, due to the neoliberal political model that has been gaining ground and changing legislation, making it more permissive¹².

Analysis of data provided by the Ministry of Health Rio de Janeiro State Center revealed an increase in deaths and sick leave, and a expressive number of deaths at working age, with an average age of 55 years, among VCW in the state of Rio de Janeiro, between 2010 and 2018. Considering that the life expectancy of the Brazilian population is approximately 76 years, these workers are dying, on average, 21 years earlier than expected for the general population. It was also observed that the main causes of death among these workers were diseases of the circulatory system (39%) and cancer (15%)¹³.

Based on these findings, and the discussions held at the Multicenter Integrating Project Discussion Forum, it was deemed necessary to investigate the work process, exposure to pesticides, and the current health situation of the category, including sleep quality and screening for common mental disorders (CMD). The workers were then monitored for a year by a psychologist and a psychiatrist from the Psychology Service of the Cesteh Outpatient Clinic, in addition to participating in groups to discuss the relationship between mental health and work. The VCW had complaints prior to the pandemic, such as anxiety, depression, sleep disorders, memory loss/lapses, and attentional difficulties related to the work process. The questionnaires analyzed indicated a high frequency (6.5%) of suicidal ideation, as well as of CMD (43%), considering reference values defined for both sexes⁵.

It is noteworthy that, according to the Occupational Health and Safety Observatory (SmartLab), mental and behavioral disorders, defined based on the International Classification of Diseases (ICD), were the leading causes of accident-related (B91) and non-accident-related (B31) leaves among VCW in Rio de Janeiro in the 2020-2022 period, as well as second and first causes between 2018-2020¹⁴. In addition, the self-reported depression disorder among VCW was 14%, a percentage higher than that observed in the Brazilian population aged 45 to 59 (10%), according to data from the 2019 National Health Survey (PNS)¹⁵.

Because it is closely related to mental health, 68 of the 127 VCW were assessed for quality and the sleep-wake cycle, 60% of whom were classified as having unhealthy sleep; 52% had less than six hours of sleep during the night; and identified an average of 8.6 awakenings during sleep (IQR 5.4-10.8)¹⁶.

Following the work and health assessment process, the 127 VCW took part in the second phase, which consisted of collecting biological samples for clinical and toxicological analysis and interviews. Table 1 summarizes the socio-economic characterization, living conditions, and work process, an important part of the investigation, since collective and individual protection measures are fundamental for minimizing workers’ exposure.

Table 1
Socio-economic characterization, living conditions, and work process of Endemic Disease Control Agents - VCW, Rio de Janeiro, RJ (n = 127)

Age - median (range)	57 years (22-73 years)
Work as VCW - median (range)	31 years (25-45 years)
Contact with pesticides - median (range)	26 years (0-35 years)
Variables	n	%
Sex
Male	98	77
Female	29	23
Color/Race
Brown	63	50
White	36	28
Black	26	20
Age group
20-40 years	1	1
41-50 years	14	11
51-60 years	73	57
61-70 years	36	28
>70 years	3	2
Education
Complete high school	83	65
Complete higher education	19	15
Incomplete higher education	12	9
Postgraduate (specialization, master’s, or doctorate)	4	3
Incomplete high school	3	3
Complete elementary school	3	3
Incomplete elementary school	3	3
Regions of residence in the state of Rio de Janeiro
Metropolitan region	102	80
North of Rio de Janeiro	22	17
Coastal lowlands region	2	2
Green coast region	1	1
Smoking
Never smoked	77	61
Former smoker	40	31
Smoker	10	8
How many cigarettes do you smoke daily?
Less than 10	7	5
From 11 to 20	1	1
21 to 30	1	1
Over 40	1	1
How many years ago did you quit smoking?
1-5 years	2	2
6-9 years	2	2
>10 years	36	28
Consumption of alcoholic beverages
No	69	54
Yes, 1 to 2 times a week	33	26
Yes, 3 to 6 times a week	2	2
Up to 3 times a month	20	16
Daily	3	2
Employment relationships
Active statutory civil servants	122	96
Retired statutory civil servants	2	2
Active civil servants	1	1
Former civil servant	1	1
Contact with pesticides
Current contact	81	64
Previous contact	90	71
Skin contact	98	77
Respiratory contact	70	55
Safety measures
Lack of PPE supply	72	57
Washing work clothes at home	127	100
Lack of training	34	27
Insufficient or inadequate training	50	39
Symptoms of poisoning	103	81
Which symptoms
Headache	60	47
Malaise	52	41
Nose and mouth burning/difficulty breathing	56	44
Skin irritation	48	38
Vomiting, stomach pain, diarrhea, or nausea	31	24
Weakness, dizziness, fainting	23	18
Current occupation
Field agent	73	57
Pesticide applicator	31	24
Supervisor/Coordinator	24	19
Product preparer	23	18
Administrative	22	17
Rodent and mollusc control	15	12
Supply	12	9
Equipment control	11	9
IEC	11	9
Warehouse	2	2
How pesticides are applied
Manual application of larvicide	27	21
ULV	25	20
Spray pump	23	18
Backpack pump	19	15
Nebulizer	9	7

• PPE: Personal protective equipment; IEC: Information, education, and communication; UBV: Ultra-low volume.
• Source: Own elaboration based on the VCW self-applied questionnaires.

It’s worth noting that the roles of the VCW are not fixed: over the years the workers move around the various activities and functions that are part of the job. It is also important to emphasize that supervisory and administrative positions are not always free from contact with pesticides, as they are often carried out at support points (PAs), places used as a base where they change clothes, eat, as well as store work material and pesticides. These PAs are often located in inappropriate places with inadequate engineering and sanitary infrastructures for storing pesticides, according to the Brazilian Labor Regulatory Standards (NR), increasing the exposure of workers and the population³.

It was possible to ascertain that VCW did not receive adequate training and personal protective equipment (PPE), which is a duty of the federative entity(ies) to which the worker is linked, whether at federal or municipal level. It is important to note that the use of PPE does not replace collective protection measures and that, even when used in accordance with the guidelines of manufacturers and health agencies, there is still a danger of contamination, as they do not completely isolate workers from exposure¹⁷. Furthermore, there are reports from workers, especially older ones from the Superintendence of Public Health Campaigns (Sucam)/National Health Foundation (Funasa), that in the 1980s and 1990s they were instructed by supervisors, among other actions, to add a spoonful of the product Abate® (the trade name for the organophosphate larvicide Temephos) to a glass of water and ingest it in front of residents who showed resistance to the “treatment” in their water reservoirs, in order to convince them that the product did no harm¹³.

After the period of social isolation during the COVID-19 pandemic, blood samples were taken from these 127 VCW for clinical/toxicological laboratory analysis. These results indicated that, in relation to biomarkers for assessing oxidative stress, 50% of the workers had levels of malondialdehyde (MDA) and 21% of carbonylated protein (CP) above the reference value (respectively, 0.23 to 3.94 µmol/L and 0.48 to 0.70 µmol of CP/g of protein). High levels of these biomarkers are found in situations of oxidative stress, with pesticides being one of the factors that potentiate this process¹⁸-²⁰. Oxidative stress is involved in the pathogenesis of several chronic non-communicable diseases, including cardiovascular, autoimmune, and neurodegenerative diseases, including Alzheimer’s and dementia, as well as genetic mutations and cancer¹⁹,²¹-²⁶.

Regarding biomarkers of exposure to organochlorine pesticides (OC) in plasma, it was observed that 52% of VCW had residues of OC metabolites DDT, p,p’-DDE and p,p’-DDT, and 12% of the beta-HCH isomer. In short, a total of 61% of VCW showed residues of OC in plasma.

In Brazil, OC were widely used in public health campaigns until the 1990s. In 1998, the country banned their use in health campaigns by means of Law No. 9.605/1998. However, it wasn’t until 2009 that the manufacture, sale, and use of OC was definitively banned throughout the country by Law No. 11.936/2009. In the self-administered questionnaire in our study, 115 workers reported having had contact with OC, 87% of them until the 2000s, 77% directly in applications during public health campaigns, and 49% also through inadequate storage in the PAs in the same room they used. Although VCW have not had contact with this class of pesticides for many years, it is possible to find residues of OC and their metabolites in the body due to their fat-soluble characteristics, which provide a high capacity for bioaccumulation of these substances in adipose tissue and can be mobilized into the plasma, making detection possible²⁷.

In another study²⁸ carried out in the state of Rio de Janeiro in 2012, 56% of civil servants (n = 471) with a mean age of 51.7 years (SD = 7.9 years) were found to have detectable levels of DDT, with a median of 0.07 ng mL^-1. The median DDT concentration of the VCW in this study was 0.16 ng mL^-1, which is more than double the median of the environmentally exposed population in the state.

We can also compare the plasma levels found in our study with those of the population of Cidade dos Meninos (CDM), a municipality heavily contaminated by an OC factory owned by the Ministry of Health, which was abandoned in the 1960s, leaving an environmental liability of hundreds of tons of these products. In a 2017 study²⁹, it was observed that 73% of the 716 individuals from the CDM evaluated had detectable DDT residues, with a median of 0.98 ng mL^-1. In our study, we found that 17 (13.4%) VCW had median DDT levels equal to or higher than the median of the CDM individuals.

We conclude that the VCW had plasma concentrations of DDT at levels intermediate to those observed in highly exposed populations and in groups with environmental exposure.

It should be noted that OC have a deregulatory effect on the endocrine and reproductive systems, immunotoxic, hepatotoxic, and neurotoxic effects, as well as mutagenic and carcinogenic potential²⁷,³⁰. Currently, HCH is classified by the IARC as possibly carcinogenic (group 2B), DDT is classified as probably carcinogenic (group 2A), and gamma-HCH (lindane) is classified as proven carcinogenic to humans (group 1)⁹,³¹. Therefore, regardless of the concentration detected, the carcinogenic nature of OC makes them important potentiators for these workers to develop cancer, and there is no safe dose³². Workers exposed to these pesticides should have their health monitored, mainly due to the cumulative effects of these substances with those of other classes of pesticides in recent use³²,³³.

Regarding the biomarker of effect for anticholinesterase pesticides (carbamates and organophosphates), the activity of the enzyme acetylcholinesterase / erythrocyte cholinesterase (AChE) was measured. It should be noted that the baseline (pre-admission) levels of AChE should have been measured before the workers entered the activity of combating endemic diseases for individualized comparison with current levels, but the pre-admission levels were not evaluated, due to a failure to comply with the law on the part of the federal entities to which the VCW are linked. Therefore, for comparison purposes, the reference value found and used at the Cesteh/Ensp/Fiocruz Toxicology Laboratory (560 U/g protein) was used. A total of 45 (35%) of the workers had AChE activity levels below the reference value used, which is a characteristic effect of these pesticides.

According to NR-07 (Labor regulatory on medical control and occupational health program), the baseline levels of activity of this enzyme should have been measured in the pre-admission and monitored through periodic examinations, as well as workers who have contact with anticholinesterase pesticides and have a reduction of 30% or more in the activity of this enzyme should be removed from the occupational exposure situation, guaranteeing the safety and health of the worker³⁴. However, these practices were not followed as they should have been: in some periods, only AChE assessments were carried out, and workers with alterations were temporarily removed, but they were not followed up with periodic examinations for a long time. It wasn’t until April 2025, after many years of struggle by the VCW, that the Ministry of Health started calling for periodic exams for the category.

The Cesteh/Ensp/Fiocruz Outpatient Clinic was an important reference for the study reported here. Specialized in workers’ health, the clinic provided care to the ACEs with a multidisciplinary team. The medical records of the 127 ACE were analyzed. The data was from before the Covid-19 pandemic.

Regarding VCW’s clinical biomarkers (biochemistry, hematology, and thyroid hormones), alterations in metabolic function (total cholesterol or triglycerides) were identified in 73% of the workers; in renal function (urea or creatine) in 47%; liver function (aspartate aminotransferase [AST/TGO], alanine aminotransferase [ALT/TGP], gamma glutamyltransferase [GGT], or alkaline phosphatase [FAL]) in 44%; glucose in 35%; in the erythrogram (red blood cells, hemoglobin, hematocrit, or reticulocytes) by 44%; in total leukocytes by 9%; in platelets by 2%; and in thyroid hormones (TSH or T4L) by 4% (Table 2).

Table 2
Distribution of the vector control workers according to reference levels of clinical analysis parameters, Rio de Janeiro, RJ (n = 127)

Parameters	Sex	Reference values	Below reference levels n (%)	Within reference levels n (%)	Above reference levels n (%)
Red blood cells (M/mm-3)	Men (n = 98)	4.5 to 5.5	18 (18.4)	69 (70.4)	11 (11.2)
	Women (n = 29)	3.8 to 4.8	1 (3.4)	27 (93.1)	1 (3.4)
Hemoglobin (g dl-1)	Men (n = 98)	13 to 17.0	7 (7.1)	89 (90.8)	2 (2.0)
	Women (n = 29)	12.0 to 15.0	4 (13.8)	25 (86.2)	-
Hematocrit (%)	Men (n = 98)	40 to 50	10 (10.2)	85 (86.7)	3 (3.1)
	Women (n = 29)	36 to 46	4 (13.8)	25 (86.2)	-
Reticulocytes (%)	Men and women (n = 127)	0.5 to 1.5	1 (0.8)	100 (78.7)	26 (20.5)
Leucocytes (mm-3)	Men and women (n = 127)	4,000 to 10,000	9 (7.1)	116 (91.3)	2 (1.6)
Platelets (mm-3)	Men and women (n = 127)	150,000 to 400,000	2 (1.6)	125 (98.4)	-
ALT/TGP (u L-1)	Men and women (n = 126)	10 to 37	2 (1.6)	105 (83.3)	19 (15.1)
AST/TGO (u L-1)	Men and women (n = 126)	10 to 37	-	120 (95.2)	6 (4.8)
FA (u L-1)	Men and women (n = 126)	27 to 100	1 (0.8)	111 (88.1)	14 (11.1)
GGT (u L-1)	Men and women (n = 126)	6 to 48	-	89 (70.6)	37 (29.4)
Glucose (mg dl-1)	Men and women (n = 127)	65 to 99	-	82 (64.6)	45 (35.4)
Cholesterol (mg dl-1)	Men and women (n = 127)	< 200	-	53 (41.7)	74 (58.3)
Triglycerides (mg dl-1)	Men and women (n =127)	65 to 150	10 (7.9)	74 (58.3)	43 (33.9)
Creatinine (mg dl-1)	Men and women (n = 127)	0.5 to 1.00	-	69 (54.3)	58 (45.7)
Urea (mg dl-1)	Men and women (n = 127)	15 to 45	-	117 (92.1)	10 (7.9)
Free T4 (ng dl-1)	Men and women (n = 127)	0.70 to 1.48	-	127 (100.0)	-
TSH (μUI ml-1)	Men and women (n = 127)	0.35 to 4.94	1 (0.8)	122 (96.1)	4 (3.1)
AChE (U/g protein)	Men and women (n = 127)	Above 560	45 (35.4)	82 (64.6)	-

• Source: Own elaboration based on the information contained in the medical records of the VCWs treated at the Cesteh/Ensp/Fiocruz outpatient clinic.

There were an expressive number of workers with hematometric indices below the reference levels, indicating cases of anemia and leukopenia, as well as workers with indices of liver enzymes, glucose, total cholesterol, triglycerides, urea, and creatinine above the reference levels, indicating liver, metabolic, and kidney damage.

Table 3 summarizes the main medical diagnoses observed in the records of the VCW compared to the Brazilian population, according to the data available in the 2019 National Health Survey¹⁵. It can be seen that the proportions of diseases identified among VCW are higher than in the general population, showing the early illness of these workers.

Table 3
Main diagnoses found in the medical records of the Rio de Janeiro/RJ vector control workers - VCW and in the general population, according to the 2019 National Health Survey

Medical diagnosis	VCW (n = 127) (median age = 57 years)	National Health Survey 201915
High cholesterol/dyslipidemia	59%/58%	45 to 59 years - 19.6% 60 to 74 years - 28.2%
Obesity	39%	45 to 59 years - 36.1% 60 to 74 years - 25.5%
Diabetes	31%	45 to 59 years - 9.4% 60 to 74 years - 19.9%
Hypertension	54%	45 to 59 years - 30.8% 60 to 74 years - 52.5%
Respiratory problems	9%	45 to 59 years -1.6%
Cancer before the age of 60	8%	45 to 59 years - 2.7%

• Source: Own elaboration based on the information contained in the medical records of the VCW treated at the Cesteh/Ensp/Fiocruz outpatient clinic.

Some findings drew attention, such as the fact that several workers had diseases related to carbohydrate and lipid metabolism, as well as the higher prevalence of a history of cancer before the age of 60. It is therefore necessary to carry out further studies on these issues and to monitor the health of these workers, since it is notable that some pesticides used by VCW are associated with this damage²,³,⁶.

Moreover, the female workers reported miscarriages and suspected intoxication of the fetus during pregnancy, leading to the birth of children with neurological and immunological damage. VCW have also reported cases of reproductive damage/alterations without a family history, such as miscarriages, infertility, the death of a premature newborn, fetal malformations, and cases of Down’s syndrome and autism spectrum disorder. In the literature, these effects are related to exposure to pesticides identified in the work of VCW⁶ and require further investigation for this category.

VCWs’ exposure to ergonomic hazards has also resulted in serious health consequences. They face a work routine that involves carrying heavy materials, such as bags, spray pumps, and insecticide boxes, without adequate ergonomic support, leading to physical strainr¹³. We observed illnesses related to this exposure, which require medical monitoring (Table 4).

Table 4
Complaints and illnesses observed in medical, audiology, and neurology evaluations of endemic disease control agents - VCW, Rio de Janeiro, RJ

Diseases diagnosed	n (127 VCW)	%
Cardiovascular diseases (except Systemic Arterial Hypertension)	8	6
Myositis rhabdomyolysis	9	7
Lupus erythematosus	1	1
Thyroid diseases	6	5
Liver diseases	9	7
Gastritis	20	16
Kidney diseases	8	6
Skin allergies	11	9
Herniated spine	14	11
Inguinal/abdominal hernia	13	10
Tendonitis/bursitis	1	1
Plantar fasciitis	1	1
Morton’s neuroma	1	1
Osteoarthritis/osteoarthrosis	3	4
Bladder cancer	1	1
Skin cancer	1	1
Uterine cancer	2	2
Breast cancer	3	4
Thyroid cancer	3	4
Throat cancer	1	1
Audiological assessment	N (68 VCW)	%
Dizziness	29	42
Insomnia	31	46
Tinnitus	35	51
Headache	41	61
Neurological assessment	N (77 VCW)	%
Neurological symptoms	58	75
Tremor and numbness in upper or lower limbs	40	52
Insomnia/irritability/memory loss	38	49
Anxiety	19	25
Headache	12	16
Labyrinthitis/dizziness	11	14
Essential tremor	19	25

• Source: Own elaboration based on the information contained in the medical records of the VCWs treated at the Cesteh/Ensp/Fiocruz outpatient clinic.

The audiological assessment of 68 VCW showed hearing loss that could be attributed to occupational exposure to organophosphate pesticides and noise from the backpack pump³ (Table 4). Among these workers, 39 (57%) had hearing loss, and nine (13%) were referred for otorhinolaryngological assessment³. It should be noted that organophosphate pesticides have ototoxic and neurotoxic properties and are often considered responsible for poisoning workers who handle and apply them³⁵,³⁶. It should be noted that, although the VCW worked with motorized costal equipment, they reported that the requirements of NR-01 and NR-09, on environmental noise monitoring, were not met.

Of the 127 workers, 77 underwent a neurological assessment, with a high prevalence (25%) of essential tremor (Table 4). The scientific literature shows that this prevalence is more frequent after the age of 60, with around 5% in the population over 40³⁷.

Moreover, Azevedo and Meyer³⁸ observed a 3.6 times higher prevalence of essential tremor among the VCW evaluated, when compared to a population not occupationally exposed to pesticides, aged 40 and over, and a 2.6 times higher prevalence compared to a population aged 65 and over. Chronic exposure to pesticides is also associated with other neurological diseases, such as Alzheimer’s disease, parkinsonism, peripheral neuropathy, amyotrophic lateral sclerosis²,³⁹, and Guillain-Barré syndrome⁴⁰.

Between 2022 and 2024, i.e. in the two years following the collection of tests of our study, among the 127 participants, three workers died. The first died in November 2022, at the age of 61, after suffering from excessive tiredness and shortness of breath, with a compromised heart and lungs and several myocardial infarctions. The cause of death was pneumonia and septic shock.

The second worker died at the age of 59, in May 2023, due to septic shock because of worsening previous illnesses (diabetes and high blood pressure).

The third worker died at the age of 62, in October 2024, due to a complication of pneumonia and gastric ulcer, while being investigated for stomach cancer.

Another worker was diagnosed with leukemia at the age of 58, after 32 years as an VCW. The tests showed a high level of DDT metabolite residue, p,p’-DDE (1.72 ng mL-¹). The worker reported having been exposed to DDT, organophosphates, and pyrethroids.

It was observed that these workers had been exposed for approximately 15 years to several of these and other chemical classes of pesticides in their work,.

The results presented here and the fact that workers have been fighting for health at work for a long time, as well as for recognition of the right to health care and work process surveillance in this activity, refer to the universality of health care contained in the “National Occupational Health and Safety Policy”. However, the right provided for in Brazilian legislation comes up against the reality of many categories of workers in work processes that involve chemical exposure. The VCW category is an example of this paradox, as it has been fighting for decades to guarantee its labor rights, which, in practice, are not being fulfilled, despite the laws and the data known by the federal entities that employ them.

The VCW case is very similar to the emblematic case of the Shell/Cyanamid/Basf company, a manufacturer of pesticides, in which workers were not given any real information about the dangers of the substances they were handling¹¹. On the contrary, they were led to believe that they were completely safe, and after falling ill collectively because of exposure, they were unable to access adequate health information or a causal link report. The difference is that, in that case, it was a private multinational company, while with the VCW, it was public entities, especially the Ministry of Health (over the course of different governments), and the Health Departments of the municipalities where they work.

In Brazil, there are currently three types of causal nexus between the work process and illness:

1. The professional (or occupational) technical nexus is applied for occupational diseases, which are those produced or triggered by a peculiar work to a given activity and included in the respective list drawn up by the Ministry of Labor and Employment (MTE), in lists A and B of Ordinance GM/MS No. 1,999/2023, which updated the List of Work-Related Diseases (LDRT), of the Decree No. 3,048/1999⁴¹.

2. The social security epidemiological technical nexus (NTEP) is applied for work-related diseases, understood as those acquired or triggered because of specific conditions in which work is carried out, and which are directly related to it. It is established by relating diseases (classified by the International Classification of Diseases - ICD) acquired by workers to specific professional activities (classified by the National Classification of Economic Activities - CNAE), based on epidemiological data⁴². The CNAE related to VCWs’ main activity, “Urban Pest Control”, is number 8122-2/00, which falls under risk level 3 and covers specialized services such as dedetection, disinsection, desiccation, and decupinization⁴³,⁴⁴.

However, despite carrying out activities related to the CNAE mentioned above, VCW are incorrectly registered under CNAE No. 8411-6/00, which refers to “public administration in general”, with risk level 1, and not related to any ICD⁴³. This fact is yet another obstacle in establishing the causal link for these workers, preventing them from accessing their labor/social security rights.

Another fact that is important to note is that, at its inception, the decree that established the NTEP presupposed periodic updates to its technical matrix. However, since its creation, no revision has been carried out, which compromises its suitability to the current epidemiological reality and limits its effectiveness in identifying links between health problems and work activities. Furthermore, the regulatory structure of the NTEP-INSS (National Institute of Social Security) itself imposes important restrictions: the system excludes certain CNAE in the private sector, companies included in the Simples Nacional (simplified tax regime for micro and small businesses in Brazil), philanthropic entities and, even more seriously, all public institutions. This means that civil servants, as well as workers hired under the Consolidation of Labor Laws (CLT) in public agencies, are not covered by the NTEP methodology. In practice, this exclusion prevents them from having the causal nexus between work and illness automatically recognized via epidemiological presumption, which contributes to the underreporting of work-related illnesses in this segment and imposes additional obstacles to accessing social security rights and repairing the damage to health caused by pesticide exposure in the work process over decades.

1. The individual technical nexus is applied for diseases equated to work accidents, where the work activity, although not the sole cause, has directly contributed to the worker’s illness. Even if the disease is not listed by the Ministry of Labor , the worker can try to prove that it was aggravated by the work process⁴². However, this is the most difficult causal link to establish for atypical diseases, i.e. health conditions acquired or aggravated due to working conditions or activities, but not considered typical occupational diseases or which are common in the population.

It should be noted that, even with the existence of the lists of work-related diseases (Appendix A), the practical application of establishing causal links between work processes and illness faces major obstacles, as health professionals and experts often encounter difficulties in establishing the causal link – this relationship between exposure and disease - attributing the occurrence to other factors, which may also be associated with most of these diseases not commonly associated with work, due to the multifactorial nature of most chronic non-communicable diseases. The vast technical-scientific literature, the lists of causal links related to pesticides, the high proportions of alterations in laboratory tests and of diagnosed illnesses, as well as the self-reported symptoms by the VCW corroborate the `impact of the highly harmfulness of pesticides on the health of these workers. The lack of workers’ periodic medical examinations over many years makes it difficult to systematically monitor the health of VCW, in addition to the progressive correlation between the exposure to which they are subjected and the illnesses that are observed throughout their working lives.

After extensive analysis of all the data from laboratory tests and medical records, , in-depth research on the subject of causal nexus related to the work of “Urban Pest Control”, and dialogues between researchers, unions and workers, a technical-scientific report was prepared, adding all the data from the multicenter research project to which this study is linked, into a single document. This report³is instrumental in supporting a movement of struggle in the political/legal fields in favor of recognizing the causal link between occupational exposure to pesticides and the illness of Community Health Agents. The production of this data culminated in a public hearing organized with the Legislative Assembly of the State of Rio de Janeiro (Alerj) and Fiocruz, attended by representatives of the Labor Prosecutor’s Office, the Ministry of Health, the Regional Human Rights Ombudsman’s Office of Rio de Janeiro (DPU/RJ), state deputies, researchers, workers and unions, with a view to making the situation of the VCW visible. with the expectation of recognizing and addressing the health and social security situation of the VCW.Thus, in January 2025, it was possible to file in court the “Laudo do serviço do Cesteh/Ensp/Fiocruz com indicação de nexo causal da exposição a agrotóxicos no processo de trabalho dos Agentes de Combate às Endemias/Guardas de Endemias (ACE) do estado do Rio de Janeiro” (Report from the Cesteh/Ensp/Fiocruz service indicating the causal nexus between exposure to pesticides in the work process of VCW in the state of Rio de Janeiro), a document produced to complement the public civil action regarding the periodic examinations of VCW and signed by the multidisciplinary team from Cesteh/Ensp/Fiocruz. This report shows the establishment of a link between exposure to pesticides from multiple chemical and toxicological classes used in the work process of VCW over the last few decades and the illness of this category of workers.

Conclusion

Drawing up the collective report made it possible to document in a systematized and scientifically grounded way the health problems faced by VCW as a result of prolonged and repeated exposure to different classes of pesticides, involuntarily and without proper protection and knowledge of dangers.

This process represented a milestone in consolidation of evidence for establishing a collective casual nexus, breaking with the individualizing logic traditionally adopted in occupational assessments. It also supported judicial and political strategies in defense of the rights of VCW, contributing to the strengthening of occupational health surveillance.

It should be noted that many of the outcomes observed today result from the use of substances previously considered safe, but which, in the light of more robust recent research and evidence, have been shown to be harmful to health and the environment. It is important to point out that the same toxicological bases that today underpin the condemnation of these substances were also used for their release in the past and continue to guide the approval of new products, which in itself does not constitute a contradiction.

The contradiction is evident, however, when these scientific bases presuppose the existence of safe doses for substances with carcinogenic, neurotoxic, endocrine-disrupting, and reproductive potential, and thus release their use in one country, even though they are already banned in other international contexts for reasons of protecting life and the environment. This reveals a regulatory asymmetry biased by political and economic interests in different countries, depending on their position in the global socio-economic scenario.

As researchers in Collective and Workers’ Health, with social responsibility for human and environmental health, we need to move forward and question the logic of current paradigms, from occupational medicine to occupational health and toxicology, which disregard the country’s social, economic, structural, environmental, and health variables, which, in line with the capitalist economic system, put profit before life, ignoring the principles of prevention and precaution.

Acknowledgments

To the VCWs and their unions; to the doctors, social workers, researchers, and technicians at the Cesteh/Ensp/Fiocruz outpatient clinic responsible for the care and assessment of VCWs; to the Coordination of Cesteh/Ensp/Fiocruz; to the project’s partner institutions (INCA, Unirio and CSEGSF/Ensp/Fiocruz, Fiocruz Pernambuco, EPSJV/Fiocruz); other institutions that supported the project at any stage of this process: Secretariat of Health Surveillance and General Coordination of People Management of the Ministry of Health, National Coordination for the Defense of the Environment and Workers’ Health (CODEMAT)/MPT, Regional Human Rights Ombudsman (DPU/RJ), ALERJ (Science and Technology Commission, Representation Commission for the Follow-up of Laws/Compliance and Health Commission), VPAAPS/Fiocruz, Abrasco, Permanent Campaign Against Pesticides and For Life, National Forum to Combat the Impacts of Pesticides, representatives of the Health Councils that took part in the Public Hearing “Health of Endemic Disease Agents”; and the Labor Inspectorate for their support in the lawsuit.

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  » http://tabnet.datasus.gov.br/cgi/sih/mxcid10lm.htm

• Data availability:
  As this study contains data from clinical examinations with humans, and in accordance with the study’s informed consent form, individual data cannot be made publicly available.
• Statement on the use of Artificial Intelligence:
  The authors declare that no Artificial Intelligence tools were used in the preparation of this article.
• Presentation at a scientific event:
  The authors inform that the study has not been presented at a scientific event.
• Funding:
  Health Surveillance Secretariat/Ministry of Health; master’s, doctoral and post-doctoral scholarships from the Public Health and Environment Program/ENSP/Fiocruz, Fiocruz, Capes, and Faperj Nota 10 and the Fapergs-INOVA-Fiocruz/Rede Saúde-RS Public Notice.

Edited by

• Editors responsible:
  Neice Müller Xavier Faria
  Leila Posenato Garcia

Data availability

As this study contains data from clinical examinations with humans, and in accordance with the study’s informed consent form, individual data cannot be made publicly available.

Publication Dates

• Publication in this collection
  06 Mar 2026
• Date of issue
  2026

History

• Received
  15 May 2025
• Reviewed
  14 Aug 2025
• Accepted
  19 Aug 2025