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| EDITORIAL |
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| Year : 2023 | Volume
: 21
| Issue : 2 | Page : 79-82 |
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Approach to reducing the burden of pesticide poisoning and improving outcomes in patients with deliberate self-harm
John Victor Peter, Anitha Paul Mampilly
Critical Care Department, Medical Intensive Care Unit, Christian Medical College, Vellore, Tamil Nadu, India
| Date of Submission | 30-Jan-2023 |
| Date of Decision | 31-Jan-2023 |
| Date of Acceptance | 31-Jan-2023 |
| Date of Web Publication | 07-Apr-2023 |
Correspondence Address:
Prof. John Victor Peter
Medical Intensive Care Unit, Christian Medical College, Vellore, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/cmi.cmi_13_23
How to cite this article:
Peter JV, Mampilly AP. Approach to reducing the burden of pesticide poisoning and improving outcomes in patients with deliberate self-harm. Curr Med Issues 2023;21:79-82 |
How to cite this URL:
Peter JV, Mampilly AP. Approach to reducing the burden of pesticide poisoning and improving outcomes in patients with deliberate self-harm. Curr Med Issues [serial online] 2023 [cited 2023 Jun 4];21:79-82. Available from: https://www.cmijournal.org/text.asp?2023/21/2/79/373757 |
The burden of deliberate self-harm (DSH) is high in India, with reports suggesting that there is one farmer suicide every 35 min.[1] The National Crime Records Bureau data show that the incidence of farmer suicides has remained high between 2014 and 2020.[2] When the annual rate of suicide worldwide was 10.5% in 2016, the corresponding Indian data were much higher at 16.5%.[3] According to the analysis of suicides in India,[4] 164,033 suicides were reported during 2021, an increase of 6.2% from 2020. Nearly 50% of the suicides were reported from Maharashtra (13%), Tamil Nadu (11%), Madhya Pradesh (9%), West Bengal (8%), and Karnataka (8%). A systematic review and meta-analysis of data from 2010 to 2020 in the Indian population revealed that pesticides were the main cause of poisoning accounting for 63% of the incidence.[5] In an analysis of data from 108 countries, which included the World Health Organization (WHO) suicide data, it was estimated that there were around 110,000 pesticide self-poisoning deaths each year from 2010 to 2014, which was 13.7% of global suicides.[6] DSH in high-income countries is often with drugs such as analgesics and antidepressants while pesticides are frequently used in middle- and low-income countries. Pesticides are highly toxic in small quantities with a mouthful or 20 ml resulting in case fatality exceeding 40% for some highly hazardous compounds.[7] Fatality is higher in remote areas since patients present late to hospitals which are poorly resourced. Thus, the problem of DSH, which has reached epidemic proportions in India, needs to be tackled on a war footing.
A multi-faceted approach is necessary to address DSH. This would entail the participation of stakeholders from the government, industry (pesticide manufacturers) and healthcare, focusing on the social dimension of loss of life, economic aspect of productivity and medical management of a poisoned patient. Broadly, DSH can be approached as (a) prevention and mitigation, (b) first responder and prehospital care, and (c) hospital care.
| Prevention of Deliberate Self-Harm and Mitigation Strategies | |  |
This involves measures to reduce the burden of suicide, mitigating the impact of poisoning through regulation, modifying formulation and packaging, and safe-storage strategies.
Reducing the burden of suicide
The overall health of a community can be improved through social reform, educational empowerment, and economic development. This is particularly important in communities where poverty and debt are major triggers for suicide.[8],[9] Despite several steps by the Indian government to provide financial assistance to farmers, the suicide rate among them continues to be worryingly high.
Another important factor that contributes to DSH is mental health.[10] The WHO reports that there is an increase in the incidence of mental illness in many countries,[11] particularly of depression in the age group of 15–29 years, which has resulted in suicide being the fourth largest cause of death in this group.[3],[12] The Government of India launched the National Mental Health Program in 1982, keeping in view the burden of mental illness in the community.[13] Strengthening the program is the key to reducing DSH due to mental health problems.
Mitigating the impact of poisoning through regulation
Pesticides are classified as insecticides, fungicides, herbicides, and rodenticides.[14] They are further categorized based on their chemical structure as organochlorines, organophosphates, carbamates, pyrethroids, bipyridyl compounds, and inorganic salts.[14] The WHO classifies pesticides as Class Ia (extremely hazardous), Ib (highly hazardous), II (moderately hazardous), III (slightly hazardous), and Class U, (unlikely to present an acute hazard) compounds.[15]
There are data demonstrating the beneficial effect of banning the sale of extremely hazardous pesticides through legislation.[16] There is also evidence that mortality is higher in patients who present with Class I WHO organophosphorus (OP) poisoning when compared with Class II and III compounds.[17] A systematic review analyzing the regulations of pesticides and their effect on the prevention of pesticide-related suicides concluded that national bans on highly hazardous pesticides were more effective in reducing pesticide-specific and overall suicide rates and mortality than just restriction on sales.[16] Hence, a worldwide ban on the use of highly hazardous pesticides is likely to prevent tens of thousands of deaths.[16]
National bans on commonly ingested pesticides introduced in low-income countries where pesticide deaths attributed to more than 20% of deaths as in Sri Lanka, Bangladesh, South Korea, and Taiwan resulted in a reduction in pesticide-related mortality thereafter.[16] Sri Lanka's pesticide regulation was estimated to have prevented around 93,000 suicide deaths in a span of 20 years until 2015.[16],[18],[19] In Bangladesh, this was calculated to be around 24%.[20] In South Korea, a ban on Paraquat in South Korea resulted in more than half of the fall in overall suicide-related deaths over 3 years.[21]
The first national ban on pesticides by the Government of India of highly hazardous OP insecticides was the banning of parathion in 1974.[22] Subsequently, the organochlorine endrin was banned in 1990 and monocrotophos, an OP compound, in 2005;[23],[24] another 18 pesticides were banned in 2018 and 2020,[25],[26],[27],[28] including several highly hazardous OP insecticides used in DSH (fenthion, methyl parathion, dichlorvos, phorate, phosphamidon, and triazophos). Despite this, due to poor implementation, compounds such as monocrotophos continue to be available in some regions. This contrasts the implantation of the ban of organochlorine insecticides. In India, when the proportion of suicides due to pesticide ingestion was 20%–30%, the local government restricted the sale, purchase, and storage of endrin. Following this, there was a reduction in endrin-related deaths from 64% (n = 38) to 48% (n = 28) in the two districts studied during the period January 1977 to September 1977.[16] Endrin which was responsible for many deaths in the 1960s–1980s was finally banned in 1990.[22] The banning of endosulfan in Kerala in 2005 and nationwide in 2011[29] has been successful and impactful.
One compound with high fatality in humans continues to be used widely. Paraquat, a compound with a lethal dose of 35 mg/kg, which is less than a mouthful of a 20% solution, has a case-fatality rate of 80%. Paraquat has been banned in over 67 countries and in some states in India. India should seriously consider adding this to the list of nationally banned pesticides. Data suggest that over 1.25 million farmers in low- and middle-income countries successfully produce a range of crops without using paraquat which strongly supports the premise that banning paraquat and using less hazardous alternatives will save lives without affecting agricultural productivity.[30]
There is concern that banning time-tested pesticides can affect crop yield, increase labor cost and cost of pest control using alternative methods. There is also the worry that the newer, less studied pesticides may be more toxic. However, there is evidence that newer insecticides such as pyrethroids, botanical insecticides based on pyrethrum, and neem and natural plant extracts are as effective as the traditional pesticides with lower toxicity to humans.[31],[32],[33],[34]
Mitigating the impact of poisoning through changes in formulation and packaging
Mitigating the impact of poisoning through changes in formulation and packaging can impact fatality due to DSH. In the UK, when there were several deaths due to paracetamol poisoning due to it being sold in bulk in a bottle, the UK Government brought in a move to dispense or sell only blister-packed paracetamol. This reduced lethality since an impulsive suicidal attempt required more effort by the individual to ingest large quantities. Many pesticides in India are sold as concentrated formulations (e.g., 36% monocrotophos and 50% chlorpyrifos) such that the ingestion of even small quantities has the potential to cause severe toxicity. Thus, if dilute pesticide formulations could be mandated by law, this would impact lethality. However, this would result in an increase in manufacturing and transport costs.
Safe storage
Safe storage like lockable boxes for farmers for the safekeeping of pesticides has been proposed. Unfortunately, this has not been shown to be effective since hazardous pesticides are often carelessly stored near households with easy access to other household members. A randomized trial including 2 lakh people from Sri Lanka did not show effectiveness of improved household pesticide storage by lockable boxes for the safekeeping of pesticides.[35]
| First Responder and Pre-Hospital Care | | |
In those who develop illness, easy and rapid access to health care is crucial. The time lag to seek medical help is sometimes long, particularly in remote areas, resulting in a derangement of physiology that is difficult to reverse. This can place further demands on an already stretched health system. To a large extent time, delays have been addressed in India by the provision of 108 ambulance services that are generally able to reach the patient quickly and transport them to the nearest healthcare facility within 15–20 min.[36],[37] However, at times, when the patient reaches a base hospital, the first responder may not be available or if available ill equipped to manage a sick patient. Facilities may be limited for diagnostics, monitoring, and treatment and the supplies of essential medications may be erratic.
Despite these challenges, appropriate training of the first responder and equipping primary health centres with sufficient stocks of antidotes and medications for resuscitation may be lifesaving. In the US, soldiers who are likely to be exposed to chemical warfare are mandated to carry atropine and pralidoxime vials which they can use immediately if they are exposed to inhalational OP.[38] If we extrapolate this concept of immediate antidotal therapy following exposure, then mandatory stocking of adequate quantities of atropine at the first point of care is important in the management of OP poisoning. This would not only involve primary health care units but also ambulance services. Educating health-care workers to administer atropine as a life-saving measure at first contact would ensure that more patients survive the initial few minutes to hours to be transferred to a secondary or tertiary level care for further treatment.
The recent introduction of poison information centers (PICs) in India with the provision of 24-h teleconsultation services has the potential to impact the management of poisoning.[39],[40] Through this mechanism, the first responder may be able to get valuable input on the immediate management of a poisoned patient. Although we have many PICs in India, including the National PIC, not all poisoning cases are reported and documented, and advice is sought mostly for mildly poisoned patients. A prospective PIC call study from Sri Lanka has shown that mortality was <10% among cases reported to PIC.
| Hospital Care | | |
Hospital care is evolving each day with evidence-based medicine and recent updates on pesticide poisoning. The approach to pesticide poisoning can be categorized as measures to (a) reduce the absorption of the poison through skin and gut by decontamination, (b) neutralize the toxin with antidotes, (c) counteract the effect of the poison (e.g., treatment of seizures), and (d) enhance elimination.
Although gut decontamination by gastric lavage is widely practised, its benefit has not been proven in controlled trials. In clinical practice, it should be considered in patients who present early (<2-h postingestion) with significant ingestion of a compound that is likely to cause toxicity. The risk versus benefit must be weighed prior to subjecting the patient to the procedure. Activated charcoal may have a role in specific poisonings if administered early, although again, a randomized trial failed to show benefit.[41]
Several antidotes are used in toxicology.[42] They act through four different mechanisms: (a) decreasing the active toxin level, (b) blocking the site of action of the toxin, (c) decreasing toxic metabolites, and (d) counteracting the effects of the toxin.[42] The specific antidote, oxime, has not shown a consistent benefit in OP poisoning.[43] Magnesium, fresh-frozen plasma, and N-acetyl cystine have a pharmacological basis in OP poisoning.[44] However, trials in humans have been few and mostly negative. Mesenchymal stem cell therapy in paraquat poisoning showed an anti-fibrotic therapeutic effect on lung injury by reducing oxidative stress and cytokine levels in animal models.[45] Glucocorticoids along with cyclophosphamide is also being studied as an intervention for their immunosuppressive role in lung fibrosis in moderate-to-severe paraquat poisoning, although a Cochrane review suggests the need for future research given limited evidence for benefit.[46] Recently, plasma exchange has been shown to improve survival in rodenticide induced acute liver failure.[47]
Enhancing the elimination of toxins is another attractive treatment modality in poisoning. This can be done by forced diuresis, alkalinisation of urine, or extracorporeal treatment modalities such as hemofiltration, hemodialysis, hemoperfusion, or plasma exchange therapies. Several studies including a meta-analysis support the efficiency of combined hemoperfusion and hemofiltration in treating acute severe OP poisoning.[48] Ultrafiltration and hemoperfusion are used for paraquat poisoning, but evidence is limited.[49]
| Conclusion | | |
The high burden of DSH due to pesticides in developing countries calls for multiple strategies to address this problem, as described above. The incidence of DSH is probably underestimated due to underreporting because of weaknesses in death certification and the stigma associated with suicide, the lack of clinical, and laboratory services to aid diagnosis and the fact that many patients do not come to the hospital for confirmation and documentation. Further careful study of the problem of DSH and formulation of action plans could result in lives saved and improved productivity.
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