Research Article
A Prospective Multicentre Study of Pesticide Poisoning Cases Admitted to South
Indian Tertiary Care Hospitals
Kiran Nagaraju*1, Nagappan Kannappan2
1.Karpagam College of Pharmacy, Karpagam University, Coimbatore, Tamilnadu, India. 2.Department of Pharmacy, Annamalai University, Tamilnadu, India.
ABSTRACT
Background: India is predominantly an agriculture country with about 60%-80% of the rural population is with agricultural occupation. The easy availability of highly toxic pesticides in the homes of farming communities has made pesticides, the preferred means of suicide with extremely high cases of fatality. It has been reported that an estimated 1 million to 5 million cases of pesticides poisoning occur every year, resulting in 20,000 fatalities among agriculturalist. Aim: The aim of our study was to determine the epidemiological profile of pesticide poisoning in four south Indian tertiary care hospitals. Material and methodology: A prospective study covering the period from March 2011 to March 2014. The data was collected from the patient case sheets into a well-designed data collection form, admitted to medical emergency department. Cases were included according to inclusion and exclusion criteria. Results: Total 2169 patient’s record of pesticide poisoning was analyzed of which, male were 1362 (62.79%) and female were 807 (37.20%). 1046 (48.22%) patients fall under the age limit of 21-40 years. Majority of the patients 1185 (54.63%) consumed pesticides for suicidal attempt. Overall mortality rate during the study period was 386 (17.79%). Conclusion: Widespread use of pesticides in agricultural occupation and easy availability without any policy has made people easy for accessing the pesticides, which has increased the risk of morbidity and mortality. Educating the practitioners for prompt referral to an appropriate facility, creating public awareness, trained staff and timely availability of antidotes can help in reducing the number of deaths.
Keywords: Pesticides, agricultural occupations, developing countries, antidote, awareness
Received 7 Oct 2015 Received in revised form 18 Oct 2015 Accepted 30 Oct 2015
*Address for correspondence: Kiran Nagaraju,
Ph. D. scholar,
Karpagam College of Pharmacy, Karpagam University, Coimbatore, Tamilnadu, India. E-mail: kirantoxicology@gmail.com
INTRODUCTION
Fatal poisoning continues to be a serious problem and it appears that with in recent years, suicide by poisoning is more frequent than death by accidental overdose. [1-3] The cause, pattern and result of poisoning in a particular community depends on a variety of factors such as, the easy availability of a particular poison, the sophistication of the populace, the stress of the environment, and the standard of emergency medical care. [1, 3] The new and easy availability of agricultural chemicals, especially in developing countries, and the lack of sophistication of the populance may result in a pattern of poisoning which is different from that seen in western counties. The possible cause of poisoning in
1990, of which over 75% of whom were from developing countries. [7] World Health Organization (WHO) estimate shows that over 5,00,000 people died from self-harm in Southeast Asia and western Pacific during 2000 alone. [8] Pesticides are the short important method of self-poisoning in many rural regions and are associated with a high death rate. [4,6] In an extrapolation from very limited data, WHO estimates that there are millions pesticide poisoning cases occur worldwide every year, with 2,22,000 death, most of which are intentional. [1, 9-11] In developing countries, the rate of mortality from poisoning is 1% to 2%. But in India, it varies between 15-30%. Poisoning is the fourth most common cause of mortality in rural India out of which organophosphorous (OPs) compound causes the most self-poisoning death in southern and central India. [12] Till date there is no clear cut evidence regarding the burden of poisoning admission in the intensive care setup of our country. Hence, this study was done with an aim to collect relevant data regarding pattern of poisoning in the medical intensive care unit or emergency department of four different tertiary care hospitals.
MATERIAL AND METHODS
Patients who were admitted during the study period from March 2011 to March 2014 into the emergency department of four south Indian tertiary care hospitals with a history and clinical features of pesticide poisoning were prospectively included into the study after the approval from the respective institutional ethical committee of the respective hospitals. Identification of a particular poison was done by the treating physician of the emergency department on the basis of statement of the patient/witness, smell of poisoning agents, brought specimen or clues and the toxidromes due to poisoning. Clothes were removed and body was washed with soap water. Nasogastric tube was passed to decompress the stomach and wash it with normal saline or tap water. All the patients were catheterized to monitor and maintain the urine output chart. The data was collected in a well-designed data
circumstances of poisoning, treatment data, complications, mortality and other relevant data required to draw the conclusion for the study. The patients who are been treated with first aid outside the study centre or those patients, who have been referred to the study centre for observation have been excluded from the study. The literature supporting the study was collected and analyzed. Obtained data were analyzed using percentage method.
RESULTS
poisoning during 6am to 6pm, followed by
unknown time in 263 (12.12%) patients (Table 1).
Table 1: Frequencies and study variables (n=2169)
Variables Frequency (%)
Sex
Male 1362 (62.79)
Female 807 (37.20)
Age Category
1 to 20 years 359 (16.55)
21 to 40 years 1046 (48.22)
41 to 60 years 558 (25.72)
Over 61 years 206 (9.50)
Marital Status
Married 1038 (47.85)
Unmarried 784 (36.14)
Divorced 204 (9.40)
Widowhood 143(6.59)
Circumstances of poisoning
Intentional 1185 (54.63)
Unintentional 501 (23.09)
Homicidal 42 (1.93)
Unknown 441 (20.33)
Time of Incidence
6 am to 6 pm 692 (31.90)
6 pm to 6 am 1214 (55.97)
Unknown 263 (12.12)
Time of arrival
1 to 4 hours 237 (10.92)
4 to 8 hours 955 (44.02)
8 to 12 hours 589 (27.16)
Over 12 hours 388 (17.89)
Clues of poisoning
Open containers 932 (42.96)
Empty containers 758 (34.94)
Unknown 479 (22.08)
Outcome
Discharged 1589 (73.26)
Death 386 (17.79)
Discharged against medical advise 194 (8.94) Different types of pesticides
Organophosphorus compounds 736 (33.93)
Carbamate 349 (16.09)
Organochlorines (Endosulfan) 244 (11.25)
Pyrethroid 218 (10.05)
Paraquat 78 (3.59)
Other Herbicides 65 (2.99)
Majority of the patients were farmer laborers followed by housewives, people working in private companies, businessmen, unemployed, and students. After the exposure to pesticide poisoning, by different circumstances, the time of arrival to the study centre was observed and we found that, maximum number of 955 (44.02%) patients took 4 to 8 hours time gap, followed by 8 to 12 hours with 589 (27.16%), over 12 hours were about 388 (17.89%) patients and within 1 to 4 hours, about 237 (10.92%) patients (Table 1). Treating physician requested the caretakers of the poisoned patients to get the clues of poisoning. Out of which 932 (42.96%) patients caretakers brought open containers of pesticides either at home, farm or other places. 758 (34.94%) patient’s attenders got an empty containers around the exposed area and 479 (22.08%) patients attenders couldn’t find any clues (Table 1). About 1589 (73.26%) of the patients admitted to the emergency department were shifted from Intensive care unit (ICU) to wards, recovered and were discharged. However, the mortality rate was reported to have 386 (17.79%) patients. 194 (8.94%) patients took discharge against medical advice due to many reasons like, affordability, less chances of survival of patient, unsatisfaction of treatment.
Compilation of data found that, most exposure substances identified in
emergency department includes
organophosphorous compounds took the highest reports of pesticide poisoning with 736 (33.93%) patients, followed by carbamates with 349 (16.09%), organochlorines (Endosulfan) with 244 (11.25%) patients, pyrethroids with 218 (10.05%) patients, Paraquat with 78 (3.59%) patients, other herbicides with 65 (2.99%) patients. In about 479 (22.08%) patients, it was an unknown poisoning (Table 1).
DISCUSSION
The male clearly outnumbered female patients in the study. Similar finding was obtained in the study done in Andhra Pradesh, two hospitals in Tamil Nadu and
preponderated over male patients. [17-19] This could be because men are more often expose to stress and strain in day to day life, as well as job insecurity. Most of the patients between the age group of 20-40 years have been found to be the most attempted number of poisoning either intentional or unintentional, which was seen in our study as well as in other poisoning studies conducted across globe. [1,16,20] This could be due to more of work pressure, loss of jobs, financial committeemen’s, failure in compatibility with married couples, failure in love affairs in youths, misunderstanding in family. Poisoning with suicidal intent was more common than the accidental one, which was in concordance with the study conducted in Andhra Pradesh, Tamil Nadu, Nepal, Turkey and, Hong Kong, [13-14,18-19,21] In the present study, majority of the patients were farmer laborers followed by housewives, businessmen, unemployed and students. Studies conducted in and outside India, has reported that OPs is the most frequently report pesticide compound in poisoning, which is same in case of our study. [18, 22] The mortality and morbidity is also been recorded high with OPs poisoning. In many cases with acute poisoning, the morbidity/mortality depends on a number of factors such as nature of poison, dose consumed, level of available medical facility and the time of interval between intake of poison and arrival at hospital.
of patients who are risks of suicidal tendencies.
The use of any biological active compound poses potential problems in toxicology. Persons most likely to be affected are those with direct contact, including those who manufacture, formulate, and distribute, but if the material is used in or around households, many more people are affected; it then poses a grave threat to the general population, referred to as the pesticide problem. Studies in developed countries have related long-term pesticide exposure to cancer, adverse reproductive effects and damage to the immune system. The potential health hazard inevitably accompanying the excessive use of pesticides therefore concerns us greatly, but no serious attention has been focused on this issues and no availability of reliable data thus far.
CONCLUSION
Widespread use of pesticides in agriculture results in many short and long-term health problems. Restricting the availability of hazardous pesticides and a general reduction in pesticide usage in agriculture would result in less occupational and environmental exposure for rural farming communities. Sale of insecticide to the public should be strictly controlled by law. Farmers and other people involved in spraying insecticides should be educated regarding prophylactic measures.
ACKNOWLEDGEMENT
Authors would like to thank the medical superintendents, medical staff, nursing staff of all the study hospitals for their cooperation during the collection of data and to make the study successful.
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