The relationship between pesticide exposure and neuropathy in farmers in Wuluhan district

Introduction: Farmers rely heavily on pesticides to protect crops from pests. Pesticides exposure will inhibit the acetylcholinesterase enzyme and will cause cholinergic symptoms which manifest as neuropathy. Methods & Materials: The research was conducted in March-April 2023 in Wuluhan District, Jember Regency. Pesticide exposure was evaluated through interviews using a pesticide exposure questionnaire, while neuropathy was evaluated through interviews and physical examination using the Diabetic Neuropathy Symptom Score-Indonesian version (DNS-Ina) and Diabetic Neuropathy Examination-Indonesian version (DNE-Ina) questionnaires. Univariate data analysis and bivariate analysis using the Chi-Square test. Results: The results of this study showed that most of the study subjects had worked >10 years, the frequency of using pesticides ≤2 times per week, the duration of using pesticides ≤3 hours per day, the use of PPE is lacking. Bivariate analysis showed that neuropathy occurred in the farmer group, and there was a significant relationship between length of service and neuropathy, as well as the completeness of PPE use and neuropathy. However, there was no relationship between the frequency of pesticide use and neuropathy and the duration of pesticide use and neuropathy. Conclusion: The conclusion of this study is that the variable length of service and the completeness of the use of PPE have


INTRODUCTION
Jember Regency has the largest number of farmers in East Java, namely 426,584 farmers (BPS, 2019).One of the sub-districts in Jember Regency, namely Wuluhan District, is ranked 4th with a total of 21,117 workers in the agricultural sector (BPS, 2021).Pesticides have an important role in increasing agricultural production (Mossa et al., 2018).However, exposure to pesticides continuously without proper use of personal protective equipment (PPE) can cause various diseases for its users.Neurological dysfunction is reported as the most common disease due to exposure to pesticides (Rastogi et al., 2010).
Organophosphates, organochlorines, carbamates, and pyrethroids are types of pesticides that often cause neurological dysfunction (Li et al., 2014).This is because organophosphates, organochlorines, carbamates, and pyrethroids have a high affinity for binding to the acetylcholinesterase enzyme.When there is no acetylcholinesterase enzyme, acetylcholine cannot be broken down into acetate and choline, so acetylcholine will accumulate in the synapse.This results in cholinergic symptoms such as fatigue, muscle weakness, and numbness (Rahayu and Solihat, 2018).These symptoms are symptoms that often appear in neuropathy.If not followed up immediately, complications can occur in the form of muscle atrophy, paralysis, and gangrene (Hammi and Yeung, 2022).
In Indonesia, the prevalence of neuropathy due to exposure to pesticides is not clearly stated.However, several studies have shown that exposure to pesticides can cause neurotoxic symptoms.Research conducted by Gusti and Desnizar (2017), reported that 69.3% of farmers in Solok complained of numbness in their hands or feet.Another study conducted by Setyopranoto et al (2020), stated that 59.2% of farmers experienced symptoms of neuropathy.
The purpose of this study was to determine the relationship between exposure to pesticides and neuropathy as assessed by years of service, frequency of use of pesticides, duration of use of pesticides, and completeness of use of PPE on farmers in Wuluhan, Jember.

METHODS & MATERIALS
This type of research is observational analytic, with a case control study design.The sample used was farmers as the exposed group and non-farmers as the unexposed group in Wuluhan, Jember.The research sample was obtained from a population that fulfills the inclusion criteria, i.e farmers with a minimum working period of 1 year, using pesticides, male, and aged 15-64 years.The minimum number of research samples in each group is 30 samples.
Structured interviews were conducted to obtain pesticide exposure data.Furthermore, interviews and physical examinations were carried out to obtain neuropathy data.The aspects assessed on the physical examination were the achiles reflex, sensation of the index finger, and sensation of the big toe.The tools needed are a reflex hammer, 128 Hz tuning fork, monofilament, and cotton.
Data were processed using univariate and bivariate analysis using Chi-Square.Furthermore, contingency correlation analysis was carried out to determine the strength of the relationship between pesticide exposure and neuropathy.This research has received approval from the Ethics Commission of the Faculty of Medicine, University of Jember in accordance with ethical license no.17.63/H25.1.11/KE/2023.www.jurnal.us.ack.id/jks

RESULT
The characteristics of the research sample divided into groups of farmers and non-farmers were assessed based on gender, age, and level of education can be seen in Table 1.Neuropathy data was assessed by group of farmers and non-farmers.The distribution of neuropathy data was carried out to determine the number of neuropathy in each group which is shown in Table 2. Based on the Table 2, the number of neuropathy in the farmer group is higher than the non-farmer group.Furthermore, bivariate analysis was carried out using the Chi-Square test to determine the comparison of neuropathy in farmers and not farmers.There was a difference between the farmer and non-farmer groups on neuropathy.Then, the distribution of data on farmer groups is assessed from years of service, frequency of use of pesticides, duration of use of pesticides, and completeness of use of PPE can be seen in Table 3.
Based on the Table 3, a relationship was found between length of service and completeness of using PPE with neuropathy.The frequency of use of pesticides and the duration of use of pesticides have no relationship with neuropathy.Contingency correlation analysis was used to determine the close relationship between pesticide exposure and neuropathy, which can be seen in Table 4. Variable length of service and completeness of the use of PPE have a moderate relationship with neuropathy.All variables have a positive relationship with neuropathy.The variables of working period and completeness of PPE use have a relationship with neuropathy, while the variables of frequency and duration of use of pesticides have no relationship with neuropathy.

DISCUSSION
These results are similar to research conducted by Firdaus and Nur (2021), in that study a significant relationship was found between neurobehavioral disorders and exposure to pesticides in tea plantation workers at PT. X Cianjur Regency (Firdaus and Nur, 2021).The results of another study conducted by Li et al also found a relationship between exposure to pesticides and symptoms of numbness or prickling sensation among farmers in China (Li et al., 2014).
Research conducted by Boostani et al states that exposure to pesticides is associated with neuropathy.The symptoms found were paraesthesia with a stocking-glove pattern (37%), decreased sensation of pain and temperature (16%), and weakness of the distal limbs (2%) (Boostani et al., 2014).In addition, research by Setyopranoto et al (2020), stated that 59.2% of farmers experienced symptoms of neuropathy.As many as 6.7% of farmers show symptoms of neuropathy during a physical examination, 8% of farmers experience weakness in the upper extremities, and 5% in the lower extremities (Setyopranoto et al., 2020).
The longer the working period as a farmer, the more frequent the neuropathy.The results of this study are in line with research conducted by Pratama and Setyani (2021), where working period is related to neurological symptoms.This result is also supported by www.jurnal.us.ack.id/jks research conducted by Siregar & Nurfadilah (2022).In that study, it was said that working period was associated with neurotoxic symptoms due to exposure to pesticides in vegetable farmers in Sugiharjo Village, Batang Kuis, Deli Serdang.Research conducted by Meirindany et al (2021) also states that there is a relationship between length of work and neurobehavioral effects on red chili farmers in Beringin District.
From the length of working period, it can be seen how long a farmer has been exposed to pesticides.Farmers with more than 10 years of working experience have a greater risk of health problems due to high exposure to pesticides (Siregar and Nurfadilah, 2022).The longer working period, the greater potential for exposure to pesticides.Furthermore, the more frequently a person is exposed to pesticides, the higher level of poisoning and cause other health problems (Pratama et al., 2021).In addition, the longer working period, the more residual toxic substances that enter the body (Meirindany et al., 2021).
The frequency and duration of pesticide use were not associated with neuropathy.Research conducted by Setyopranoto et al (2020) also found a non-significant relationship between the frequency and duration of pesticide use and neuropathic symptoms in farmers in Magelang, Central Java (Setyopranoto et al., 2020).The results of other studies that are similar are studies conducted by Meirindany et al (2021).In this study, it was found that there was no between spraying duration and neurobehavioral effects on red chili farmers in Beringin District.
The recommended frequency of spraying pesticides is less than twice a week.If farmers do more than that, the risk of pesticide poisoning will be even higher (Ipmawati et al., 2016).The frequency of spraying pesticides will increase when their plants are attacked by pests or diseases.They will spray pesticides as often as possible without regard for personal safety.This is done with the aim of saving plants from pest attacks so that harvest failure does not occur (Suparti et al., 2016).
Based on the Regulation of the Minister of Manpower of the Republic of Indonesia Number PER-03/MEN/1986 of 1986 concerning Safety and Health Requirements in Workplaces that Manage Pesticide, workers who manage pesticides may not be exposed to pesticides for more than five hours a day and 20 hours a week.In addition, a good time to spray pesticides is in the morning before 11.00 and in the evening after 15.00 (Suparti et al., 2016).
The complete use of PPE is associated with neuropathy.The less PPE used, the higher neuropathy.The results of this study are similar to the research conducted by Pratama and Setyani (2021), namely that there is a relationship between the completeness of PPE use and neurological symptoms.Another study conducted by Siregar and Nurfadilah (2022) also stated that there was a relationship between the use of PPE and neurotoxic symptoms in farmers.
PPE is an important factor in work because it can reduce the risk of work accidents and work-related diseases.The PPE needed by farmers includes hats or head coverings, goggles, masks, gloves, long-sleeved shirts, trousers, and boots (Pratama et al., 2021) .The use of complete PPE on farmers can reduce the risk of exposure to pesticides.However, if farmers do not use PPE when using pesticides, the risk of experiencing health problems is even greater (Siregar and Nurfadilah, 2022).
Most farmers only use hats or head coverings, long-sleeved shirts, and trousers.Masks and gloves are considered to be a nuisance, so they choose not to use them (Pratama et al., 2021).In addition, farmers only use PPE when spraying pesticides.Supposedly, PPE is also used when dispensing pesticides and washing equipment (Gusti, 2017).Therefore, incomplete use of PPE is associated with neuropathy.

Table 1 .
Characteristics of the research sample

Table 2 .
Neuropathy by occupation and Chi-Square test

Table 3 .
Distribution of farmer group data and Chi-Square test

Table 4 .
Results of Contingency Correlation test analysis