Triage and clinical management of patients with acute ...

Clinical Toxicology (2012), Early Online: 1–3 Copyright © 2012 Informa Healthcare USA, Inc. ISSN: 1556-3650 print / 1556-9519 online DOI: 10.3109/15563650.2012.693184

COMMENTARY

Triage and clinical management of patients with acute pesticide self-poisoning presenting to small rural hospitals MICHAEL EDDLESTON1,2,3 & ANDREW H. DAWSON3,4,5 1Clinical

Pharmacology Unit, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK Poisons Information Service – Edinburgh, Royal Infirmary, Edinburgh, UK 3South Asian Clinical Toxicology Research Collaboration, Sri Lanka 4NSW Poisons Information Centre, Children’s Hospital at Westmead, NSW, Australia 5Central Clinical School, Royal Prince Alfred Hospital, Sydney, NSW, Australia

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2National

Acute pesticide self-poisoning is the single most important cause of fatal self-harm worldwide, killing at least 250,000 people every year, the vast majority in rural Asia. However, for many years the problem was little studied and no systematic approach taken to reduce harm and prevent deaths. Eight years ago this changed when the World Health Organization (WHO) proposed an inter-sectoral public health campaign to improve patient management, prevention, knowledge of its epidemiology, and information dissemination. One aim was to improve the triage and acute care of pesticide self-poisoned patients presenting to small rural hospitals with few resources. To this end, a WHO meeting was held in Bangkok at the end of 2007 that developed a protocol for triage and early care that was published online. Unfortunately, this approach has not resulted in dissemination or uptake and, 4 years later, the guidance has not been widely read, critiqued, or used. In this commentary, we describe the basis for the guidance that was produced. We hope it will bring the work to a wider clinical toxicology audience, to ultimately improve management of pesticide poisoned patients, and to encourage clinicians to take part in this important campaign. Future attempts to improve clinical care in rural Asia will need to better understand and utilise methods for influencing policy makers and clinicians in target areas if practice is to be changed. Keywords Other; CNS/psychological; organ/tissue specific; Complications of poisoning; Muscle; organ/tissue specific; Complications of poisoning

work in the community to reduce the risk of self-poisoning. It aimed to support the establishment of sentinel centres to study epidemiology and treatment centres where research could be performed and health workers trained. A further objective was to formulate and disseminate information to guide local policymakers on how best to reduce pesticide self-poisoning.

Introduction Acute pesticide self-poisoning kills an estimated 250– 370,000 people every year.1,2 Jeyaratnam first raised the issue internationally at the end of the 1980s.1,3 However, little was done at that time and subsequent international pesticide treaties, such as the Rotterdam and Stockholm conventions, specifically excluded self-poisoning.4 No attempt was made to systematically address the problem using risk minimisation and harm reduction. Eight years ago, this changed. The World Health Organization (WHO) recognised pesticide self-poisoning to be the single most important means of suicide worldwide and initiated an intersectoral global public health initiative to reduce deaths.5,6 Its objectives were: (1) to improve knowledge of epidemiology by monitoring cases globally at community and hospitals sites, (2) to improve medical and mental health care of pesticide self-poisoned patients by finding better treatments and training health care workers, and (3) to

WHO guidance on acute management At the end of 2007, the WHO brought together a small group of clinicians and public health researchers working on pesticide self-poisoning to discuss the issue in Bangkok. A report was produced from the experts’ technical consensus on the clinical management of acute pesticide intoxication. It was published online by the WHO7 and has been incorporated into the WHO’s current mental health gap (mhGap) program for mental, neurological, and substance use disorders in nonspecialized health settings.8 The guidance (see http://whqlibdoc.who.int/publications/ 2008/9789241597456_eng.pdf) was focused on the most common cause of lethal pesticide self-poisoning worldwide: WHO toxicity class I and II organophosphorus (OP)

Received 30 March 2012; accepted 8 May 2012. Address correspondence to Dr. M. Eddleston, CPU, QMRI E3.20, 47 Little France Crescent, Edinburgh EH16 4TJ, UK. E-mail: [email protected]

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insecticides.2,9 Therefore, the recommendations focused on assessing patients for early signs of OP poisoning. Although many pesticides are used in agriculture that can be used for self-harm, the majority of poisonings with noncholinesterase inhibiting pesticides require only supportive care.10 Such care will usually produce a positive outcome, bar poisoning with paraquat and aluminium phosphide, which both currently have no effective antidotes and case fatalities over 50%. Most preventable deaths from OP insecticide selfpoisoning result from pre-hospital respiratory arrest and the complications (hypoxic brain injury and aspiration) of this event.11 As a result, the guidance focused on early management: preservation of the airway; resuscitation and good supportive care; administration of antidotes; and transfer of patients to hospitals with facilities for ventilation and observation.


Dissemination and uptake of the guidelines Although a key objective of the meeting was to improve the triage and management of pesticide-poisoned patients, the report has been little read in the clinical and public health toxicology community, in Ministries of Health, or in rural hospitals, and its recommendations never subjected to critique or improvement. The guidance has not been cited by relevant publications and it is not known how many times it has been downloaded from the WHO website. External review and publication might have been helpful as a means of improving dissemination and awareness. In the past 10 years, the validated framework AGREE (Appraisal of Guidelines Research and Evaluation) has evolved to support high quality guideline development.12,13 Within the ‘rigorof-development’ domain, the strengths and limitations of the evidence base as well as external review are important elements. This is highly relevant to clinical toxicology as our specialty’s guidelines often have little evidence base. Once guidelines involve consensus, they require external review to provide necessary confidence to users concerning their validity. A more effective method of increasing uptake of the guidelines might have been performing prospective studies of patient management in target areas before and after implementation. The results could have been published in locally popular journals and publicised to Ministries of Health via the WHO country offices. However, since the guidelines were based on practice that was already implemented in Sri Lanka, such a study was not possible in our own research area. Funding and human resources were not available to carry out such studies elsewhere.

Conclusions Pesticide self-poisoning is the single largest cause of acute poisoning deaths worldwide. Potentially many thousands of lives can be saved with better treatment and prevention. Active participation in the WHO campaign, working at all levels from the individual patient to government legislation,

by clinical toxicologists and public health workers has the potential to make these reductions possible. Use of the triage system in the WHO working group’s guidance for managing pesticide self-poisoned patients offers the possibility of improving care for patients while reducing the need for transfers. However, so far it has not been used, or even critiqued, by relevant decision makers, public health workers, or clinicians in target specialties or areas. These key groupings must be engaged for future efforts in guideline development by WHO and other international groupings to be effective. We hope this article will begin this process among clinical toxicologists, and stimulate involvement of academic clinical toxicology societies in WHO work programmes that are intended to make major relevant global health improvements. Other efforts will need to involve the WHO and the ministries of health and clinicians in rural Asia. The next annual congress of the Asia Pacific Association of Medical Toxicology in Hong Kong will offer the opportunity for review and updating of the guidance. It is vital that steps are taken to widen the involvement of key groups ideally before, but definitely following, that meeting.

Acknowledgements We thank the participants of the meeting: Dr Pattapong Kessomboon, Prof Michael Phillips, Dr José M. Bertolote, Dr Alexandra Fleischmann, Ms Joanna Tempowski, Dr Gregory Larkin, and Dr Peter Loke; and the three Clinical Toxicology referees for insightful comments that improved the article.

Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

References 1. Jeyaratnam J. Acute pesticide poisoning: a major global health problem. World Health Stat Q 1990; 43:139–144. 2. Gunnell D, Eddleston M, Phillips MR, Konradsen F. The global distribution of fatal pesticide self-poisoning: systematic review. BMC Public Health 2007; 7:357. 3. Jeyaratnam J, Lun KC, Phoon WO. Survey of acute pesticide poisoning among agricultural workers in four Asian countries. Bull World Health Organ 1987; 65:521–527. 4. Konradsen F, van der Hoek W, Gunnell D, Eddleston M. Missing deaths from pesticide self-poisoning at the IFCS forum IV. Bull World Health Organ 2005; 83:157–158. 5. World Health Organization. The impact of pesticides on health [cited 2012 May 6]. Available from: URL: www.who.int/mental_health/ prevention/suicide/en/Pesticideshealth2.pdf. 6. Bertolote JM, Fleischmann A, Eddleston M, Gunnell D. Deaths from pesticide poisoning: a global response. Brit J Psychiat 2006; 189:201– 203. 7. World Health Organization. Clinical management of acute pesticide intoxication: prevention of suicidal behaviours, 2008. http://whqlibdoc. who.int/publications/2008/9789241597456_eng.pdf. Accessed 8 March 2012. 8. World Health Organization. mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings. Geneva: WHO; 2010. Clinical Toxicology Early Online 2012

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9. Eddleston M. Patterns and problems of deliberate self-poisoning in the developing world. Q J Med 2000; 93:715–731. 10. Reigart JR, Roberts JR. Recognition and management of pesticide poisonings. Washington, DC: U.S Environmental Protection Agency; 1999. 11. Lotti M. Clinical toxicology of anticholinesterase agents in humans. In: Krieger RI, Doull J, eds. Handbook of pesticide toxicology. Vol. 2. Agents, 2 edn. San Diego: Academic Press; 2001: 1043–1085.

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12. Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: the AGREE project. Qual Saf Health Care 2003; 12:18–23. 13. Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ 2010; 182:E839– E842.