Ravindra Fernando

Pesticide poisoning in the developing world—a minimum pesticides list

In parts of the developing world, pesticide poisoning causes more deaths than infectious diseases. Use of pesticides is poorly regulated and often dangerous; their easy availability also makes them a popular method of self-harm. In 1985, the UN Food and Agriculture Organisation (FAO) produced a voluntary code of conduct for the pesticide industry in an attempt to limit the harmful effects of pesticides. Unfortunately, a lack of adequate government resources in the developing world makes this code ineffective, and thousands of deaths continue today. WHO has recommended that access to highly toxic pesticides be restricted--where this has been done, suicide rates have fallen. Since an Essential Drugs List was established in 1977, use of a few essential drugs has rationalised drug use in many regions. An analogous Minimum Pesticides List would identify a restricted number of less dangerous pesticides to do specific tasks within an integrated pest management system. Use of safer pesticides should result in fewer deaths, just as the change from barbiturates to benzodiazepines has reduced the number of deaths from pharmaceutical self-poisoning.

Improvement in Survival after Paraquat Ingestion Following Introduction of a New Formulation in Sri Lanka

Background Pesticide ingestion is a common method of self-harm in the rural developing world. In an attempt to reduce the high case fatality seen with the herbicide paraquat, a novel formulation (INTEON) has been developed containing an increased emetic concentration, a purgative, and an alginate that forms a gel under the acid conditions of the stomach, potentially slowing the absorption of paraquat and giving the emetic more time to be effective. We compared the outcome of paraquat self-poisoning with the standard formulation against the new INTEON formulation following its introduction into Sri Lanka. Methods and Findings Clinical data were prospectively collected on 586 patients with paraquat ingestion presenting to nine large hospitals across Sri Lanka with survival to 3 mo as the primary outcome. The identity of the formulation ingested after October 2004 was confirmed by assay of blood or urine samples for a marker compound present in INTEON. The proportion of known survivors increased from 76/297 with the standard formulation to 103/289 with INTEON ingestion, and estimated 3-mo survival improved from 27.1% to 36.7% (difference 9.5%; 95% confidence interval [CI] 2.0%–17.1%; p = 0.002, log rank test). Cox proportional hazards regression analyses showed an approximately 2-fold reduction in toxicity for INTEON compared to standard formulation. A higher proportion of patients ingesting INTEON vomited within 15 min (38% with the original formulation to 55% with INTEON, p < 0.001). Median survival time increased from 2.3 d (95% CI 1.2–3.4 d) with the standard formulation to 6.9 d (95% CI 3.3–10.7 d) with INTEON ingestion (p = 0.002, log rank test); however, in patients who did not survive there was a comparatively smaller increase in median time to death from 0.9 d (interquartile range [IQR] 0.5–3.4) to 1.5 d (IQR 0.5–5.5); p = 0.02. Conclusions The survey has shown that INTEON technology significantly reduces the mortality of patients following paraquat ingestion and increases survival time, most likely by reducing absorption.

The National Poisons Information Centre in Sri Lanka: The First Ten Years

Introduction: Poisoning is a major health concern in Sri Lanka, which has a very high morbidity and mortality from pesticide poisoning. Poisoning, which continues to be in the first five leading causes of death, accounts for about 80,000 hospitalizations and over 3000 deaths per year. The National Poisons Information Centre in Sri Lanka, the first such centre to be established in South Asia, completed 10 years service in 1997. The 4070 calls received in the first 10 years are analyzed and compared with the national hospitalization pattern. Methods: The recorded data sheets of all enquiries received from 1988 to 1997 were analyzed retrospectively to study (1) purpose of enquiry, (2) category of enquirer, (3) circumstances of poisoning, (4) gender of victim, (5) age of victim, (6) type of poison, and (7) outcome. Items (6) and (7) were compared with the national hospital statistics for 1998. Results: Of the 4070 enquiries, 92% concerned specific patients and 6% were for information on poisons. Almost 90% of the enquiries were from medical or paramedical personnel, 5% from relatives or friends, and 3% from the victims. Nearly 38% of enquiries concerned pesticides compared to 27% of poisoning hospitalizations. Medicinal agents were the subject of 20% of enquiries compared to 13% of hospitalizations. The major discrepancy was for snake bites, accounting for only 6% of enquiries but 42% of hospitalizations. Sex distribution of enquiries showed more males than females. Thirty-seven percent of the victims were young adults—15–29 years age group. Nearly 49% of the enquiries were for suicidal attempts. Seventy-one percent of the victims recovered. Conclusion: Although enquiries to the NPIC averaged only 0.5% of poisoning hospitalizations, they were sufficiently representative of the national pattern to predict that increasing utilization of the NPIC would offer a much needed service, both for children, currently under-represented in telephone inquiries, and for suicidal events where the mortality far exceeds that of other countries.

Childhood poisoning in Sri Lanka

Poisoning in children is a common accident and poison information services should be aware of the toxic agents responsible for poisoning in the community. A retrospective hospital based study was performed, before-the establishment of the National Poisons Information Centre in Sri Lanka. There were 4,556 admissions of poisoning to the selected hospitals in the Western Province in 1986 and of this, 540 (11.4%) were below 15 years. Males accounted for 66%. Kerosene oil was responsible for 47% of the poisoning cases in less than 5 years age group, while kerosene oil, pesticides and plants/mushrooms were the commonest toxic agents in the 5 to 14 years age group. The case fatality rate was 3.2%.

Suicide by electrocution.

Electrocution is a rare mode of suicide. In Sri Lanka, where the suicide rate is extremely high, ingestion of liquid pesticides is the commonest method used. The case of a 34-year-old labourer of the Electricity Board, who committed suicide using 220–240 volt domestic electricity supply is described. He had been suffering from a depressive illness for some time. Suicide by electrocution has not been documented in Sri Lanka before.

Formulation changes and time trends in outcome following paraquat ingestion in Sri Lanka

Introduction. Deliberate self-harm with pesticides is a significant public health problem in rural Asia. We have previously shown an improved survival of patients with paraquat self-poisoning following the introduction of a new formulation with an increased emetic concentration, an alginate and a purgative in Sri Lanka. Further, formulation changes were introduced in October 2006; this study was designed to assess the impact of these changes on 6-week mortality following paraquat ingestion. Methods. Prospective, cohort study of patients admitted with paraquat poisoning to 10 hospitals across Sri Lanka between September 2006 and September 2008. Results. Overall, there was a significant (p < 0.001) increase in survival in the 533 patients included in this study compared to previous data (44.5 vs. 35.2% before September 2006 and 27.1% before October 2004). Patients ingesting the new INTEON® formulation had a higher survival rate than those ingesting standard formulation (40.2 vs. 31.0%), but this effect was not statistically significant in Coxs proportional hazards model (hazard ratio 0.81, 95% CI 0.61–1.08 (unadjusted) and 1.17, 95% CI 0.82–1.68 (fully adjusted), respectively). Conclusions. This study has confirmed a continued improvement in survival of patients following self-harm with paraquat in Sri Lanka in recent years; however, in contrast to previous investigations, a beneficial effect associated with the INTEON formulation could not be substantiated. This may be partly due to the large number of patients in whom paraquat concentrations were too low for analytical confirmation of the formulation (n = 105) and who had a very high survival rate (86.7%).

Study of suicides reported to the Coroner in Colombo, Sri Lanka

Introduction Deaths from suicide reached a peak in Sri Lanka in 1995. Several interventions reduced the suicide rate of 48.7 per 100,000 in 1995 to 23 per 100,000 in 2006, though it is still a major socioeconomic problem. All suicides have to be reported to the Inquirer of Sudden Death (ISD) or ‘Coroner’, according to the Criminal Procedure Code. Method All deaths where a verdict of ‘suicide’ was given after an inquest at the Coroners Court, Colombo, in 2006 were studied. Close relations or friends who attended the inquest were interviewed by medically qualified research assistants. Age, sex, marital and occupational status, level of education, living circumstances and method and reasons for the suicide were studied. Results During 2006, 151 deaths from suicide were documented, of which 93 (62%) were men. The majority (47%) were aged between 20 and 29 years. One-third of the victims was unemployed. At the time of committing suicide, 75% were living with family; 89 (59%) were married and 46 (31%) were single. Poisoning was the cause of death in 66 (44%), 48 (70%) of which were due to pesticides. Burns caused 51 (34%) deaths. Other common causes of death included hanging (11%), jumping in front of a train (7%) and drowning (3%). The commonest reason for suicide was dispute with the spouse/marital disharmony (30%). Other reasons were dispute with parents (8%), financial matters (7%), organic diseases (7%), alcoholism (7%), psychiatric illnesses (6%) and disputes in love affairs (5%). In 29 cases (19%), no definite reason for the suicide was evident. Discussion Self-poisoning and self-immolation were the commonest methods used to commit suicide. Marital disharmony was the main reason (30%). Psychiatric illnesses were responsible for only 6%. Future interventional activities should include secure access and restriction of the availability of pesticides and drugs, empowering people to manage anger and conflicts, and recognition and treatment of alcoholism and psychiatric illnesses. The success story of the reduction in the incidence of suicides in Sri Lanka should be a lesson to many developing countries where suicide is a major socioeconomic and health issue.

Policymaking ‘under the radar’: a case study of pesticide regulation to prevent intentional poisoning in Sri Lanka

Background Suicide in Sri Lanka is a major public health problem and in 1995 the country had one of the highest rates of suicide worldwide. Since then reductions in overall suicide rates have been largely attributed to efforts to regulate a range of pesticides. The evolution, context, events and implementation of the key policy decisions around regulation are examined. Methods This study was undertaken as part of a broader analysis of policy in two parts—an explanatory case study and stakeholder analysis. This article describes the explanatory case study that included an historical narrative and in-depth interviews. Results A timeline and chronology of policy actions and influence were derived from interview and document data. Fourteen key informants were interviewed and four distinct policy phases were identified. The early stages of pesticide regulation were dominated by political and economic considerations and strongly influenced by external factors. The second phase was marked by a period of local institution building, the engagement of local stakeholders, and expanded links between health and agriculture. During the third phase the problem of self-poisoning dominated the policy agenda and closer links between stakeholders, evidence and policymaking developed. The fourth and most recent phase was characterized by strong local capacity for policymaking, informed by evidence, developed in collaboration with a powerful network of stakeholders, including international researchers. Conclusions The policy response to extremely high rates of suicide from intentional poisoning with pesticides shows a unique and successful example of policymaking to prevent suicide. It also highlights policy action taking place ‘under the radar’, thus avoiding policy inertia often associated with reforms in lower and middle income countries.

Pesticide poisoning in the Asia-Pacific Region and the role of a regional information network

Pesticide poisoning is an important cause of morbidity and mortality in many countries in the world. It has been estimated that 95% of fatal pesticide poisonings occur in developing countries, many of which are in the Asia-Pacific region. Agriculture based economies, easy availability of pesticides, poverty related socioeconomic problems, lack of adequate protective clothing, and limited treatment facilities are some of the factors contributing to the high morbidity and mortality. There is a lack of easily accessible information on pesticide related ill health in the countries of Asia-Pacific Region. Although Poison Centers are active in some countries, lack of resources is a major constraint on the provision of an efficient service. There are several intercountry projects and information networks in the region dealing with agriculture and environment but no such information facilities are available concerning pesticide poisoning. A Regional Pesticide Poisoning Information Network for the Asia-Pacific Region could disseminate information on pesticide related illness to any individual or institution via print and electronic media. Such a network could work towards close cooperation between all poisons centers and toxicologists in the region to reduce the rising morbidity and mortality from pesticide poisoning.

An unusual case of fatal accidental paraquat poisoning

Paraquat, a useful contact herbicide is now used in over 130 countries of the world, including Sri Lanka. The number of cases of accidental poisoning reported with paraquat is small, relative to instances of suicide. When a clear history is not available, accidental paraquat poisoning is sometimes difficult to diagnose. A 9-year-old boy was admitted to a peripheral hospital with a history of diarrhoea and vomiting. He later developed abdominal pain, subcutaneous emphysema and difficulty in breathing. Following transfer to a district hospital and then to a teaching hospital, poisoning with paraquat was suspected only on day 11 of the illness. On persistent questioning, on day 13 of the illness the child remembered that the day prior to the onset of illness, on his way from a shop, he felt thirsty and having found an empty bottle of Gramoxone (paraquat) on the wayside he used it to drink water from a water tank. The child died on day 17 and the histology of the lung showed typical changes of paraquat poisoning. This tragic episode emphasises the need for proper disposal of empty containers of all poisonous substances.