A Clinico-Epidemiological Study on Pesticide Poisoning

by Sakina Anwar, Md. Abdul Muqeet, Md. M.A. Majumder, S.M. Arif, M.A. Faiz 

 

Abstract

Contexts: Over the last few decades, agricultural pesticides have become a common household item in rural areas of the developing world. As a result of their easy availability, pesticides have also become commonly used for intentional self poisoning.  World Health Organization (WHO) estimates, around 3 million poisoning cases with 220,000 deaths occur annually. About 99% of these deaths occur in developing countries. So, this study was aimed at to know the clinico-epidemiological aspects and to evaluate the immediate outcome of patients admitted with pesticide poisoning. Methods: This was a crosss-sectional observational study, carried out on 60 victims of pesticide poisoning admitted to one unit of medical indoor department of Dhaka Medical College Hospital, Dhaka. The diagnosis was based on history of pesticide ingestion and clinical features or with evidence of brought specimen. The age, sex, marital status, occupation, cause of intoxication, poison consumed, time elapsed between ingestion and admission to the hospital, signs and severity of intoxication on admission and treatment outcomes were recorded on a predesign case record form. Results: Among the 4378 patients admitted in the unit during this period, total number of poisoning was 796 (18.18%). Number of total deaths was 579 (13.23%), among them 37 deaths was due to poisoning (6.39%). Again, among the poisoning cases, 60 (7.53%) were due to pesticides, and no. of deaths was 13 (2%). Age range of the victims was 13-55 years (mean 23.38 ±1.16 years). Females were 60%, mostly rural (56.7%), married (51.7%) and students (35%). 60(8%) were caused by pesticide, 16(2%) by rodenticide and 8(1%) by fungicide and the rests 711(89%) were caused by other different types of poisoning. the cardinal clinical features of poising were nausea/vomiting (93.33%), myosis (88.33%) and increased sweating (80%) followed by increased salivation (58.33%), hypotension and urinary incontinence (each 51.67%). Majority (93.3%) of the poisoning cases had suicidal intention followed by accidental (5%) and homicidal (1.7%). The suicidal intention was not due  to  any  prior  psychiatric  illness,  rather  due  to  various  tripling issues amongst the family members. Nearly three-quarter (73.3%) of the patients recovered completely, 13 (21.7%) patients died of the condition and the rest 3 (5%) were absconded. Conclusion: It was a simple observational study and though scientific diagnostic measurement was not possible it may not reflect the total pesticide poisoning situation of Bangladesh and much work is needed to tackle the situation. Awareness of the doctors should be created by giving adequate importance of pesticide poisoning in undergraduate curriculum as well as by continued medical education might help to improve the crisis.

 

Indexing words: Clinical & epidemiological factors, Pesticide poisoning

 

 

Introduction:

Pesticides are a group of chemicals used predominantly in agriculture defines a pesticide as any substance or mixture of substances

  1. Indoor Medical Officer, Department of Medicine,

Dhaka Medical College & Hospital, Dhaka

  1. Assistant Professor, Department of Medicine,

Dhaka Medical College & Hospital, Dhaka

  1. Professor, Department of Medicine,

Dhaka Medical College & Hospital, Dhaka

intended for preventing, destroying or controlling any pest1. Organophosphate pesticide poisoning is a major health problem worldwide and is a leading cause of morbidity and premature loss of life in many developing countries of the Asia-Pacific region2.

Over the last few decades, agricultural pesticides have become a common household item in rural areas of the developing world.

As a result of their easy availability, pesticides have also become commonly used for intentional self poisoning. It was estimated that, fourteen of all deaths amongst 10-50 year old women in Bangladesh were due to poisoning, the majority following suicidal ingestion of pesticides3. Bangladesh Health Bulletin under DGHS published in 1998, shows that there is increasing frequency of poisoning cases from 1988-1996 except in 1990 and 19934. In attempted suicide, which is considerably more frequent than completed suicide, pesticide poisoning results in temporary or permanent disability. Intentional and unintentional pesticide poisoning has been acknowledged as a serious problem in many agricultural communities of low- and middle-income countries, including China, India, Sri Lanka, and Vietnam5.

World Health Organization (WHO) estimates, around 3 million poisoning cases with 220,000 deaths occur annually. About 99% of these deaths occur in developing countries. Suicide is an important cause of premature mortality accounting for an estimated 849,000 deaths every year6. In many agricultural communities of low- and middle income countries pesticide self-poisoning accounts for many of these deaths7. In 1985, based on data from Sri Lanka, Jeyaratnam estimated there were approximately 2.9 million cases of acute pesticide poisoning, resulting in around 220,000 deaths each year in the developing world8. More recently, based on the finding that pesticide ingestion accounted for over 60% of suicides in many rural areas of China and South-East Asia, Gunnell & Eddleston (2003)7 estimated that there may be as many as 300,000 deaths each year from intentional poisoning (i.e. suicide by ingestion of pesticides) in these regions alone. This makes it likely that pesticide poisoning is the most frequently used method of suicide worldwide.

To know the clinico-epidemiological aspects and to evaluate the immediate outcome of patients admitted with pesticide poisoning.

Methods:

This was a crosss-sectional observational study, carried out over a period of one year between January 2004 and December 2004. Victims of pesticide poisoning admitted to one unit of medical indoor department of Dhaka Medical College Hospital, Dhaka were enrolled in this study. Proper ethical permission was taken from the authority of Dhaka Medical College Hospital.

The diagnosis was based on history of pesticide ingestion and clinical features or with evidence of brought specimen. Total sixty patients of pesticide poisoning were enrolled.

The age, sex, marital status, occupation, cause of intoxication, poison consumed, time elapsed between ingestion and admission to the hospital, signs and severity of intoxication on admission, treatment. Outcomes were recorded on a predesign case record form.

Results:

Table 1 shows the frequency of the poisoning patients among the other patients admitted in this unit at that period. Among the total 4378 patients, 18.18% patients were admitted due to poisoning. Among 13.23% deaths in this period, 6.39% was due to poisoning.

 

Table 1: Admission and death due to poisoning in one medical unit of DMCH in 2004

Hospital profile Number %
No. of patients admitted 4378
No. of total deaths 579 13.23
Total poisoning cases 796 18.18
Total death due to poisoning 37 6.39
Total pesticide poisoning 60 7.53
Total death due to pesticide poisoning 13 2

Table 2 shows the socio-demographic characteristics of the patients. It was observed that most of the victims were ≤20years. Mean age of the victims were 23.38±1.16 years. They were mostly female (60%) and students (35%).

 

Table 2: Socio-demographic characteristics of the patients

Demographic characteristics Number %
Age (yrs)
≤20 31 51.7
£ 21 – 30 19 31.7
31 – 40 08 13.2
41 – 50 01 1.7
> 50 01 1.7
Mean age = (23.38±1.16) years; range: (13–55) years
Sex
Male 24 40.0
Female 36 60.0
Residence
Urban 26 43.3
Rural 34 56.7
Marital status
Married 31 51.7
Unmarried 29 48.3
Occupation
Student 21 35.0
House-wife 18 30.0
Businessmen 09 15.0
Farmer 04 6.7
Garment’s worker 02 3.3
Maid-servant 03 5.0
Service-holder 01 1.7
Others 02 3.3

Total 796 poisoning cases attended in one medical unit ofq DMCH, 60(8%) were caused by pesticide, 16(2%) by rodenticide and 8(1%) by fungicide and the rests 711(89%) were caused by other different types of poisoning.

 

Pie chart showing types of material used for poisoning
Figure 1:
Pie chart showing types of material used for poisoning

Table 3 shows that the cardinal clinical features of poising were nausea/vomiting (93.33%), myosis (88.33%) and increased sweating (80%) followed by increased salivation (58.33%), hypotension and urinary incontinence (each 51.67%). Other clinical features were not very common.

 

Table 3: Clinical features of the organophos-phorus compound poisoning cases (n= 60)

Clinical features Number %
Nausea / vomiting 56 91.33
Miosis 53 88.33
Blurred vision 27 45.0
Increased sweating 48 80.0
Increased salivation 35 58.33
Increased bronchial secretion 30 50.0
Bradycardia 18 30.0
Hypotension 16 26.67
Urinary incontinence 31 51.67
Abdominal pain 31 51.67
Muscle fasciculation 19 31.67
Headache 19 31.67
Drowsiness 10 16.67
Disturbance in speech 27 45.0
Seizure 5 8.33
Coma 11 18.33

Majority (93.3%) of the poisoning cases had suicidal intention followed by 5% accidental and 1.7% homicidal. The suicidal intention was not due to any prior psychiatric illness, rather due to various tripling issues amongst the family members.

 

Showing intension of poisoning
Figure 2:
Showing intension of poisoning

Nearly three-quarter (73.3%) of the patients recovered completely, 13 (21.7%) patients died of the condition and the rest 3 (5%) were absconded.

 

Showing outcome of treatment
Figure 3:
Showing outcome of treatment

Discussion:

Acute pesticide poisoning by organophosphorus compound has been found as a major clinical problem with 8% of poisoning with 22% mortality in an adult medicine unit in Dhaka Medical College Hospital, Dhaka, Bangladesh. In this study, most of the patients were 20 or below 20 years of age (31, 51.7%), 19(31.7%) patients were in between 21-30 years. The study shows that the incidence of pesticide poisoning was highest among the students (21, 35%), the next common group were housewives (18, 30%). Other occupations were businessmen (9, 15%), farmer (4, 6.7%), garment’s worker (2, 3.3%), maid servant (3, 5%) and others 5%. The different source of collection of pesticide in this study shows purchase beforehand for household use 28(46.7%), self purchased poison over the counter 22(36.7%) and left over sample 9(15%). This finding indicates that pesticides are easily available and widely used in our country. The provision of safety handing of pesticide in the community is urgently required for prevention of pesticide poisoning. 98% of our patients were normal, healthy population and only 2% had known prior psychiatric illness. This finding suggests that pesticide poisoning is more common among normal population than population with mental disorders in Bangladesh. On the other hand poisoning by drugs are common in the west having prior mental illness9. In absence of diagnostic laboratory facility for poison detection visual inspection and identification was made in this study. The offending pesticide was brought by requesting the accompanying person to bring the container left in the vicinity of the occurrence or by requesting the victim to bring a similar agent used for the poisoning after recovery. Our study shows that the cause of death was acute cholinergic crisis in 8(62%) cases and respiratory paralysis in 5(38%) cases. The situation could be improved by introducing ICU care to OP poisoning cases.

Conclusion:

It is a simple observational study and though scientific diagnostic measurement was not possible it may not reflect the total pesticide poisoning situation of Bangladesh and much work is needed to tackle the situation like this. Survey in the community is necessary to assess the magnitude of pesticide poisoning in Bangladesh.  National guideline about treatment should be introduced. Awareness of the public should be created for its prevention, for immediate first aid measures and quick hospital admission. Awareness of the doctors should be created by giving adequate importance of pesticide poisoning in undergraduate curriculum as well as by continued medical education. Monitoring and providing immediate prompt advice to physicians and patients.

References:

  1. Food and Agriculture Organization of The United Nations. International code of conduct on the distribution and use of pesticides. Rome, FAO,1986.
  2. Buckly NA, Roberts D, Eddleson M. Overcoming apathy in research on organophosphate poisoning. BMJ 2004; 329: 1231-33.
  3. Yusuf HR, Akhter HH, Rahmam MH, Chowdhury, MK, Rochat RW. Injury-Related deaths amongst Women aged 10-50 years in Bangladesh, 1996-97. Lancet 2000; 355:1220-1224.
  4. Bangladesh Health Bulletin (2001) UMIS, DGHS, Dhaka. 1998-99. Bangladesh Health Bulletin, UMIS, Directorate General of Health Services (2001).
  5. Bertolote JM, Butchart A, Besbelli N. WHO, 2004
  6. World Health Organization. The World Health Report 2002: Reducing Risks, Promoting Healthy Life. Geneva: WHO; 2002.
  7. Gunnell D, Eddleston M. Suicide by intentional ingestion of pesticides: a continuing tragedy in developing countries. International Journal of Epidemiology. 2003; 32:902–909. [PubMed: 14681240]
  8. Jeyaratnam J. Health problems of pesticide usage in the third world. British Journal of Industrial Medicine. 1985a; 42:505–506. [PubMed: 4016001]
  9. Phillips MR, Yang G, Zhang Y, et al. Risk factors for suicide in China: a national case-control psychological autopsy study. Lancet. 2002; 360:1728–1736. [PubMed: 12480425]