Illnesses From Bug Bombs (Total Release Foggers): 10 States, 2007–2015

Summary

• Total release foggers — "bug bombs" — are pesticide products that fill a room to kill insects. After an earlier study showed they cause acute illness, the Environmental Protection Agency (EPA) required improved labels on foggers made after September 2012.
• From 2007 to 2015, 3,222 fogger-related illnesses were found in 10 states. In the first 3 years after the new labels, there was no significant drop in the overall illness rate.
• The two most common causes: not leaving the premises while the fogger ran, and going back in too soon. Not leaving and using too many foggers were linked to more severe illness.
• Needed: integrated pest management, better ways to get people to read and follow labels, and foggers redesigned so they cannot go off unexpectedly.

How cases were found

Cases came from three sources: the SENSOR-Pesticides surveillance programs in 10 states (California, Florida, Louisiana, Michigan, Nebraska, New York, North Carolina, Oregon, Texas and Washington), the California Department of Pesticide Regulation, and poison control centers in Florida, Texas and Washington. A case needed exposure to a fogger with known active ingredients, at least two related signs or symptoms, and no suicide attempt or intent to harm. Of 7,441 people exposed, 3,222 unique cases remained after exclusions and removal of duplicates. Rates were compared before the new labels (2007–2012), in 2013 (when many old-label products were likely still on shelves), and in 2014–2015.

Who was hurt, and how

• Rates: 27.0, 26.3 and 29.5 cases per 10 million people in 2007–2012, 2013 and 2014–2015 — no significant change after adjustment.
• People: median age 40; 5% were children 5 or younger and 14% adults 60 or older; 56% female.
• Where: 92% in private homes; 91% not work-related.
• Symptoms: mostly respiratory (cough, throat or airway irritation, shortness of breath) and digestive (vomiting, nausea, stomach pain).
• Severity: 78% low, 21% moderate, 0.7% high; four people died.
• Chemicals: about 93% involved pyrethroids (78%) or pyrethrins (24%).

Trends by cause: illness from not leaving rose in 2014–2015 (adjusted rate ratio 1.39), while illness from using too many foggers fell (0.43).

Worse illness was more common among males, people over 60, people with asthma, and those who didn't leave or used too many foggers.

Why the labels didn't do more

The EPA's labels use pictures and stress leaving the premises for at least 2 hours, ventilating for another 2 hours or until no odor remains, and not using more foggers than needed. But case reports suggest many people didn't read or follow them:

• Many left the room but not the premises.
• People went back in shortly after setting it off — to turn off smoke alarms, fetch pets or forgotten items. Some were exposed going in to open windows; labels don't say how to do that safely.
• Some ventilated for the full time or longer and still fell ill, suggesting the recommended time may be too short.
• Some were sprayed because of a faulty nozzle or setting it off pointed the wrong way — a case for better nozzles and a label picture showing how to set one off.

Why overall illness didn't fall is unknown: old-label products may still have been in use, or the new labels may need more time. But the fall in illness from too many foggers suggests simple statements and pictures on that point worked. Going back in early usually meant a brief exposure and mild illness; not leaving or over-using meant longer or heavier exposure and worse illness. The asthma link suggests labels may need an asthma warning; an earlier EPA review found no link between these chemicals and asthma, but a later study found asthma symptoms more common after pyrethrin or pyrethroid exposure than after other pesticides.

Limits

• Reporting is passive, and many mild cases never see a doctor, so illness is undercounted.
• Symptoms are not specific, so some cases may have had other causes.
• The number of fogger users is unknown, so rates use the whole population — trends would mislead if use grew faster than population.
• Only 10 states, possibly not representative.
• Only 3 years after the new labels, with data missing from four states in 2014 or 2015 — though sensitivity analyses gave essentially the same results. The findings are preliminary.

Sources

Based on Ruiling Liu, Walter A. Alarcon, Geoffrey M. Calvert and others, "Acute Illnesses and Injuries Related to Total Release Foggers — 10 States, 2007–2015," MMWR, Centers for Disease Control and Prevention; a work of the United States government in the public domain.