Sagar Khadanga

Changing epidemiology of poisoning in Central India: shifting poles from male farmers to young house wives

Gupta R ¹, Baghel PK ², Gupta H ³ , Jain MK ⁴, Khadanga S ⁵, Tagore PK ⁶, Saluja R ⁷, Kesharwani P ⁸

¹Dr Rupesh Gupta, Senior Resident, Department of Medicine, AIIMS Bhopal, Madhya Pradesh, India, ²Dr Praveen Kumar Baghel, Professor, Department of Medicine, SSMC, Rewa, Madhya Pradesh, India, ³Dr Hariom Gupta, Associate Professor, Department of Medicine, SSMC, Rewa, Madhya Pradesh, India, ⁴Dr Mahendra Kumar Jain, Professor, Department of Medicine, LNMC, Bhopal, Madhya Pradesh, India, ⁵Dr Sagar Khadanga, Assistant Professor, Department of Medicine, AIIMS, Bhopal, Madhya Pradesh, India, ⁶Dr Praveen Kumar Tagore, Assistant Professor, Department of Medicine, SSMC, Rewa, Madhya Pradesh, India, ⁷Dr Rohit Saluja, Ramalingaswami Fellow (Scientist D, DBT), Department of Biochemistry, AIIMS, Bhopal, Madhya Pradesh, India, ⁸Dr Priyanka Kesharwani, Dental surgeon, Life care general hospital, Sagar, Madhya Pradesh, India

Address for Correspondence: Dr Sagar Khadanga MD, Assistant Professor, AIIMS Bhopal, Madhya Pradesh, India, Email: sagarkhadanga@yahoo.com

Abstract

Introduction: Acute self infliction of poisoning is very common among young in developing countries. The epidemiology of poisoning changes time to time and varies region to region. In south India, organophosphorus compound poisoning has been more common as compared to Aluminium phosphide poisoning in north India. All over India males are more commonly reported to poison themselves. Poisoning in farmers has been reported more commonly than in any other profession. Madhya Pradesh is situated in central part of India, where agriculture is the predominant source of income. There is a knowledge gap in epidemiology of poisoning in this region. Methods: This is a hospital based observational type cross sectional study over nearly 2 years. Results: Out of the 550 number of study participants about 90% were younger than 40 years. Females were more common than males in all age groups. Poisoning was more common in married population in both the genders. House wives followed by unemployed students were the most vulnerable populations. Farmers constituted only about 10% of total cases. Organophosphorus compounds were the most common type of poisoning contributing to almost one fourth of the total cases followed by Zinc phosphide, Aluminium phosphide, oleander and ethylene dibromide poisoning in decreasing order. The overall mortality was 9.8% (n=54). The case fatality rates of various agro-chemicals in decreasing order were Aluminum phosphide (44.7%), ethylene dibromide (17.6%), and organophosphorus (7%). These 3 poisonings contributed to 92.5% of all deaths. Death was more common when the time lag to hospitalization was > 6 hours. Conclusion: Younger age group, female sex and housewives were the most vulnerable group. The case fatality rate of various poisonings in decreasing order were Aluminum phosphide (Celphos) poisoning followed by EDB and OPC.

Key words: Organophosphorus poisoning, celphos poisoning, zinc phosphide poisoning, farmer suicide, pattern of poisoning in India

Manuscript received: 10th March 2016
Reviewed: 24th March 2016
Author Corrected: 5th April 2016
Accepted for Publication; 19th April 2016

Introduction

Self infliction of toxic substances in human civilization is known since time immemorial. World Health Organization (WHO) estimates more than 3 million cases of acute poisoning and 3 lakh deaths globally per year [1]. The incidence of acute poisoning is rising in India as well as globally. Poisoning is a major unnatural death in developing countries, though the type of poison and the associated morbidity and mortality varies from one place to another. The epidemiology of poisoning usually changes in an area over a prolonged period of time [2]. The epidemiology of poisoning in a region depends on various factors which include availability and accessibility to poison, socioeconomic status of an individual, cultural influences and many more. In developed countries, the rate of mortality from poisoning varies only from 1- 2 % [3-5]. According to the WHO, 99 per cent of the fatal cases seen in developing countries are predominantly among the farmers [6]. Poisoning is the fourth most common cause of mortality specially in rural India where the mortality rate varies from 15- 30% [7,8]. Easy availability and low cost of hazardous chemicals play a major role in poisoning in developing countries [ 9,10].

Literature search on epidemiology of acute poisoning in India reveals changing pattern over the time [2,7,10-12]. In north India, aluminium phosphide (ALP) is the most common type of poisoning where as organophosphorus compounds (OPC) are more common in south India [13]. There is a lot of hue and cry in recent times regarding the farmer-suicides in India including this locality. There is absolutely a knowledge gap regarding the epidemiology of acute poisoning in central India as there is no published literature from this part of the world. We conducted the study to bridge the gap in knowledge regarding the epidemiology of acute self inflicted poisoning in Central India.

Material and methods

This is a hospital based observational cross sectional study conducted in the region of Rewa, Madhya Pradesh from November 2010 to September 2012.

Inclusion criteria
1. All the suspected poisoning cases (reliable history, presentation of remaining stuff / container by the relatives and clinical suspiciousness)
2. Age more than 15 yrs.

Exclusion criteria
1. Patients with known pre existing co-morbid conditions like diabetes, hypertension, chronic liver disease, chronic renal failure and neurological disorders.
2. Unwilling to give informed consent by patient or patients relatives.

After strict inclusion and exclusion criteria 550 cases were recruited into the study. All the cases undergone detailed clinical examination. They were treated in intensive care unit (ICU) or general ward as per the need. All the patients were investigated for complete blood count, liver function test, kidney function test, serum electrolytes and ECG.

Result

A total number of 550 cases were included in the study. The most common age group of poisoning was noted to be in 15-30 years (72.3%, n=398). Among this age group 181 were male as compared to 217 females. In this age group 48.6% (88/181) of males and 58% (126/217) of females were married. Among all the cases 62.5% (155/248) of males and 69.8% (211/302) of females were married (Table-1). All the patients beyond 30 years were married. The 2nd most common group was in 31-40 years (16.7%). The frequency of poisoning decreased as the age advanced (Table-1). The eldest patient was of 65 years male. Females outnumbered the males in all the age groups (Table-1). Out of the total number of 550 cases 37% were house wives (204/550) of various age groups. Unemployed students were the next most vulnerable group constituting 26.7% (147/550). Farmers constituted only 10.9% (60/550) of the total cases (Table-2). Among all the cases about 75 % belonged to lower socio-economic strata (Table-2). Suicidal intent was identified in 92.1% followed by accidental (5.8%) and alleged homicidal in (2%) cases.

In 29.8% (164/550) of cases the exact type of poisoning could not be identified even after thorough interrogation. OPC were the most common type of poisoning, contributing to almost one fourth of the total cases (23.2%, 128/550). The next most common types were Zinc phosphide (19.6%, 108/550), Aluminium phosphide (15.4%, 85/550), oleander (4.1%, 23/550) and Ethylene dibromide (EDB) (3%, 17/55) (Table-3). All cause mortality of 54 cases (9.8%) were noticed out of the total number of 550 hospitalised cases. Only 3 poisonings viz. Aluminium phosphide (38/54), OPC (9/54) and EDB (3/54) contributed to 92.5% (50/54) of total death. While looking at the case fatality rate of the different poisonings, Aluminium phosphide was having the highest mortality rate (38/85=44.7%) followed by EDB (3/17=17.6%) and OPC poisoning (09/128=7%) in descending order (Table-4). No cases of death was reported in the poisoning due to Zinc phosphide, sedatives, oleander and vermilion poisoning where as 4 cases of death was reported in the unknown poisoning group. While looking at the temporal pattern of time of death, 48.1% (26/54) of death occurred when the cases were hospitalised after 6 hours of ingestion of poison. Early death i.e. within 3 hours of ingestion was observed in OPC, EDB and few unknown poisons (Table-5).

Table 1: Distribution of cases according to age, sex and marital status

Age group in years	Male		Female		Total
Age group in years	Married	Unmarried	Married	Unmarried	Total
15 to 30	88	93	126	91	398
31 to 40	40	00	52	00	92
41 to 50	15	00	16	00	31
>50	12	00	17	00	29
Total	155	93	211	91	550

Table 2: Distribution of cases according to occupation

Occupation	n	%
Housewife	204	37.09
Student	147	26.72
Private worker	92	16.72
Farmer	60	10.90
Businessman	47	8.57
Total	550	100

Table 3: Distribution of cases according to intent of poisoning

Poison	Intent of Poisoning			Total
Poison	Suicidal	Accidental	Homicidal	Total
Unknown	150	07	07	164
Organophosphorus	123	04	01	128
Zinc phosphide	96	11	01	108
Celphos	81	02	02	85
Oleander	19	04	00	23
EDB	15	02	00	17
Barbiturate	14	01	00	15
Vermilion	09	01	00	10
Total	507	32	11	550

Table 4: Distribution of cases according to different poison and mortality rates

Type of poison	No of cases	No of death	Case fatality rate in %
Organophosphorus	128	09	7.03
Celphos	85	38	44.70
EDB	17	03	17.64
Zinc phosphide	108	00	0
Sedative	15	00	0
Oleander	23	00	0
Vermilion	10	00	0
Unknown	164	04	2.43
Total	550	54	9.8

Table 5: Distribution of mortality in relation to time lag for hospitalisation

Type of Poison	Total no of death	Time lag for hospitalization
Type of Poison	Total no of death	0-3 hrs	3-6 hrs	>6hrs
Organophosphorus	09	04	04	01
Celphos	38	02	11	25
EDB	03	01	02	00
Unknown	04	02	02	00
Total	54	09	19	26

Discussion

Out of the 550 cases about 90% of cases were younger than 40. To be more specific 72.3% of cases were younger than 30. This is in accordance to different studies carried out earlier [14-16]. Siwach et al. 1995 reported 70 % of poisoning was seen in age group between 15 – 30 years in North India [13]. A similar study from Andhra Pradesh in south India reports 40% of all cases in the age range of 21-30 followed by 11.6% in the age group of 31-40 [17]. This young age presentation has been explained by various authors because of more emotionally liable, financial insecurity, failure in love, peer rivalry, conflicts with parents and spouse. Out of the 248 cases in male 62.5% (n=155) and out of 302 cases in female 69.8% (n=211) were married. Marriage being a social custom, almost similar incidence (57% in male and 73% in female) was reported from an autopsy based study in this region [16]. In our study the females outnumbered the male cases in all age groups (302 Vs 248). Eddleston M et al. 2000 have also reported females comprising 57% of total cases in their case series [18]. Similar findings of female preponderance in acute self infliction of poison found in other places like Istanbul and Japan [19-21]. The female dominance in all these studies have been described because of more labile emotions, illiteracy, ignorance, family conflicts, marital disharmony, economic crisis, unemployment and indifferent approach of family members to their chronic illness. However this finding is in contrast to previous studies from India where males outnumbered the females [2,17, 22,23].

The most common intent of poisoning in our study was suicidal (92.1%) followed by accidental (5.8%). Similar findings were observed by various authors all over the globe [24-27]. Various substances have been used for self infliction of poisoning in various parts of world. It depends on the ease of accessibility and affordability at that region. India being a country of villages where agriculture is the main source of income, various agro-chemicals are the main source of poisoning. Among the various agro-chemicals, OPC remain the most common agent utilized for poisoning [14,15, 26]. This scenario is not different in nearby Asian countries e.g. Sri Lanka and Bangladesh [24,27]. Among the identifiable causes of poisoning, OPC was the single most culprit agent in about 25% of cases in our study. Other agro-chemicals down the list were Zinc phospide in about 20% of cases and Aluminium phosphide in about 15% cases. All the 3 above mentioned agro-chemical compounds are common house hold objectives in agriculture predominant areas. These 3 compounds contributed to almost 60% of poisonings in this study. A recent study in South India showed OPC poisoning in 17.2% cases, drug overdose in 8.4% and unknown poisoning in 7.7% cases which were the 3 most common self inflicted poisons [17]. Aluminium phosphide was the most common poisoning in north India accounting up to 67.8% of cases in one study from Haryana [13]. This regional difference can be explained by following facts. Aluminium phosphide is predominant agro-chemical used for pest control in wheat farming which is the predominant staple food in north India where as OPC are the predominant agro-chemicals of pest control in rice fields of south India where people depend on rice more than wheat. OPC poisoning was the most common agro-chemical poisoning in studies conducted in north India before 1980 when Aluminium phosphide was not easily available [18,19,26].

Overall mortality due to poisoning was 9.8% (n=54) in our study. The case fatality rate was highest in Aluminum phosphide poisoning (44.70%) followed by EDB (17.64%) and OPC (7.03%). Our study was similar to the study from Andhra Pradesh where the overall mortality was 8.3% (n=186).[17] Sheu JJ et al. (1998) in their study of poisoning reported 18 to 23% mortality [31]. Louriz M et al. (2009) observed that mortality associated with Aluminum phosphide poisoning was 49% in Morocco [32]. Mathai et al. (2010) noted mortality of 59.3%.with Aluminum phosphide poisoning [33]. With EDB poisoning mortality of 12% has been reported by Nigam et al. (2010) [34]. In a study on OPC poisoning conducted by Adlakha et al. (1988) mortality was 11% [35]. Uma et al. (2011) in their study on OPC poisoning reported 17% mortality [36]. The varying case fatality rate depends on many factors such as nature of poison, amount consumed, level of available medical facilities and time lag between the consumption and 1st contact with medical care. Most of the mortality in our patients occurred in whom the time lag was > 6 hours for hospitalization. Various studies conducted earlier reported a significant relationship of time lag before hospitalization & mortality in cases of poisoning [36-38]. This association seems self explanatory that early decontamination and appropriate treatment can decrease the mortality.

Conclusion

Pattern of poisoning in Madhya Pradesh, a state in Central India is different from rest of the country. OPC was the most common agent of self inflicted poison, followed by, Zinc phosphide, Aluminum phosphide, yellow oleander and EDB in that order. Intent of poisoning was mostly suicidal like most other earlier studies. Nearly 90% cases were younger than 40 years. Younger age group, female sex and housewives were the most vulnerable group. The case fatality rate of various poisonings in decreasing order were Aluminum phosphide (Celphos) poisoning followed by EDB and OPC. Knowledge and awareness among the public, stringent legislation for sell of agro-chemical compounds with political support, availability of specific antidotes at primary health centers with a quality referral system to tertiary health care center are the need of the hour to lower the rate of poisoning and to improve the outcome.

Funding: Nil, Conflict of interest: None initiated.
Permission from IRB: Yes

References

1. Thundiyil JG, Stober J, Besbelli N, Pronczuk J. Acute pesticide poisoning: a proposed classification tool. Bull World Health Organ 2008;86:205-9. [PubMed]

2. Sharma BR, Harish D, Sharma V, Vij K. Poisoning in northern India: changing trends, causes and prevention thereof. Medicine, science and the law. 2002 Jul 1;42(3):251-7. [PubMed]

3. Evans GJ. Deliberate self-poisoning in Oxford area. Br J Prev Soc Med. 1967;21:97–107. [PubMed]

4. Smith AJ. Self- poisoning with drugs: A worsening situation. Br Med J. 1972;4:57–9. [PubMed]

5. Rygnestad T. A comparative prospective study of self-poisoned patients in Trondheim, Norway between 1978 and 1987: Epidemiology and clinical data. Hum Toxicol. 1989;8:75–82. [PubMed]

6. World Health Organisation Bulletin (1999): Guidelines for Poison Control, WHO, Geneva. [PubMed]

7. Taruni NG, Bijoy TH, Momonchand A. A profile of poisoning cases admitted in RIMS Hospital, Imphal. Journal of Forensic Medicine and Toxicology. 2001;18(1):31-3.

8. Pillay V.V. In: MKR Krishna’s Hand Book of Forensic Medicine and Toxicology, 12th Ed., Paras Publications, Hyderabad,2001: p 276-299.

9. Eddleston M. Patterns and problems of deliberate self‐poisoning in the developing world. Qjm. 2000 Nov 1;93(11):715-31. [PubMed]

10. Batra AK, Keoliya AN, Jadhav GU. Poisoning: an unnatural cause of morbidity and mortality in rural India. Journal-Association of Physicians of India. 2003 Oct 1;51:955-9. [PubMed]

11. Mannaim PF. Pattern of acute intoxication in Florence: A comparative investigation. Intensive Care Med. 1991; 17(1): 24-31. [PubMed]

12. Begum JA, Chowdhury MM. G Ara. A study of poisoning cases in four hospitals of Bangladesh Bangladesh Med J. 1989; 18(2): 64. [PubMed]

13. Siwach SB, Gupta A. The profile of acute poisoning in Haryana. J Assoc Physicians India.1995;13:756–9. [PubMed]

16. Kanchan T,Menzes RG.Suicidal poisoning in Southern India:Gender differences.J Forensic Leg Med 2008;15;7-14. [PubMed]

17. Singh B, Unnikrishnan B. A profile of acute poisoning at Mangalore (South India). J Clin Forensic Med 2006;13:112-6. [PubMed]

18. Nigam M, Jain AK, Dubey BP, Sharma VK. Trends of organophosphorus poisoning in bhopal region an autopsy based study. JIAFM 2004;26:971-3.

19. Kumar SV, Venkateswarlu B, Sasikala M, Kumar GV. A study on poisoning cases in a tertiary care hospital. J Nat Sci Biol Med. 2010;1:35–9. [PubMed]

20. Eddleston M. Patterns and problems of deliberate self‐poisoning in the developing world. Qjm. 2000 Nov 1;93(11):715-31. [PubMed]

21. Zamani J, Aslani A. Cardiac findings in acute yellow oleander poisoning. Journal of cardiovascular disease research. 2010 Mar 31;1(1):27-9.

22. Tufekci IB, Curgunlu A, Sirin F. Characteristics of acute adult poisoning cases admitted to a university hospital in Istanbul. Hum Exp Toxicol. 2004;23:347–51. [PubMed]

23. Yamashita M, Matsuo H, Tanaka J. Analysis of 1000 consecutive cases of acute poisoning in the suburb of Tokyo leading to hospitalization. Vet Hum Toxicol. 1996;38:34–5. [PubMed]

24. Singh S, Sharma BK, Wahi PL. Spectrum of acute poisoning in adults (10 years experience) J Assoc Physicians India. 1984;32:561–3. [PubMed]

25. Singh S, Wig N, Chaudhary D, Sood N, Sharma B. Changing pattern of acute poisoning in adults: Experience of a large North West Indian hospital (1970–1989) J Assoc Physicians India. 1997;45(3):194–7. [PubMed]

26. Van der Hoek W. Analysis of 8000 hospital admissions for acute poisoning in a rural area of Sri Lanka. Clinical Toxicology. 2006 Jan 1;44(3):225-31.

27. Rajasuriar R, Awang R, Hashim SB, Rahmat HR. Profile of poisoning admissions in Malaysia. Hum Exp Toxicol 2007;26:73-81. [PubMed]

28. Mohanty MK, Kumar V, Bastia BK, Arun M. An analysis of poisoning deaths in Manipal, India. Vet Hum Toxicol 2004;46:208-9. [PubMed]

29. Ahmad M, Rahman FN, Ashrafuzzaman M, Chowdhury DK, Ali M. Overview of Organo-phosphorus Compound Poisoning in Bangladesh and Medico-legal Aspects Related to Fatal Cases. Journal of Armed Forces Medical College, Bangladesh. 2009;5(1):41-5.

30. Gupta S, Kumar S, Sheikh MI. Comparative study and changing trends of poisoning in year 2004–2005, at Surat, India. International Journal of Medical Toxicology & Legal Medicine. 2007;10(1):16-20.

31. Murali R, Bhalla A, Singh D, Singh S. Acute pesticide poisoning: 15 years experience of a large North-West Indian hospital. Clinical toxicology. 2009 Jan 1;47(1):35-8.

32. Thapa SR, Lama P, Karki N, Khadka SB. Pattern of poisoning cases in Emergency Department of Kathmandu Medical College Teaching Hospital. Kathmandu University medical journal (KUMJ). 2007 Dec;6(2):209-13.

33. Sheu JJ, Wang JD, Wu YK. Determinants of lethality from suicidal pesticide poisoning in metropolitan HsinChu. Vet Hum Toxicol 1998; 40:332–6. [PubMed]

34. Louriz M, Dendane T, Abidi K, Madani N, Abouqal R, Zeggwagh AA. Prognostic factors of acute aluminum phosphide poisoning. Indian journal of medical sciences. 2009 Jun 1;63(6):227. [PubMed]

35. Mathai A, Bhanu MS. Acute aluminium phosphide poisoning: Can we predict mortality?. Indian journal of anaesthesia. 2010 Jul 1;54(4):302. [PubMed]

36. Nigam M, Godaria I, Varma A, Chaturvedi R. Ethylene di-bromide (EDB)–An underestimated lethal pesticide and its emerging clinico-biochemical trends. Medico-Legal Update. 2010;10(2). [PubMed]

37. Adlakha A, Philip PJ, Dhar KL. Organophosphorus and carbamate poisoning in Punjab. The Journal of the Association of Physicians of India. 1988 Mar;36(3):210. [PubMed]

38. Uma.M.A. et al :Correlation of serum cholinesterase ;clinical score at presentation & severity of organophosphorus compound poisoning MD Thesis ,RGUHS ,2011 Karnatka.

39. Arup KK. Predictors of mortality in organophosphorus poisoning–Hospital based study from suburban West Bengal. J Assoc Physicians India. 2011 Jan;49:91.

40. Ram JS, Kumar SS, Jayarajan A, Kuppuswamy G. Continuous infusion of high doses of atropine in the management of organophosphorus compound poisoning. The Journal of the Association of Physicians of India. 1991 Feb;39(2):190-3.

How to cite this article?

Gupta R, Baghel PK, Gupta H , Jain MK, Khadanga S, Tagore PK, Saluja R, Kesharwani P, Changing epidemiology of poisoning in Central India: shifting poles from male farmers to young house wives: Int J Med Res Rev 2016;4(4):575- 581. doi: 10.17511/ijmrr.2016.i04.17.