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Poisoning in Sri Lanka: A major health concern

by Prof. Ravindra Fernando, Head, National Poisons Information Centre, National Hospital of Sri Lanka

Considering the high incidence of morbidity and mortality from poisoning the Ministry of Health has declared the week starting from May 14 as the 'National Poisons Prevention Week.' Many activities have been planned to create awareness on prevention of poisoning and to educate the general public on first aid for poisoning.

Sri Lanka and many other developing countries in the world have been made aware of the importance of poisoning as a major health concern in the last few decades. With the improvement of socio-economic status, literacy and health services, especially preventive health services, morbidity and mortality from communicable diseases have shown a decline.

However, morbidity and mortality from non-communicable diseases such as coronary heart disease, diabetes mellitus, hypertension, trauma, accidents and poisoning are increasing.

In Sri Lanka, the leading cause of hospital deaths is ischaemic heart disease or coronary heart disease. Poisoning was the sixth leading cause of death in state hospitals in 2005.

Pesticides are the commonest chemical substances causing poisoning. This is not surprising when one considers the fact that agriculture is the most important sector in Sri Lanka's economy, employing over half the labour force.

The insecticides, organophosphates and carbamates are the most widely used insecticides in Sri Lanka. They have caused 892 deaths in 2005. Other pesticides such as paraquat, chlorophenoxy compounds and glyphosate have caused 378 deaths.

Poisoning with therapeutic drugs, such as paracetamol, salbutamol, aspirin and diazepam, the major concern in developed countries in the West, is also increasing in Sri Lanka.

Other poisons include plants such as Kaneru and Niyangala, industrial chemicals, household chemicals such as disinfectants and cleaners, cosmetics and substances used for abuse.

Suicide rate, which was the highest in Sri Lanka in 1995, has shown a decrease in the last decade due to multiple reasons. However, Police statistics show that 2,941 men and women have committed suicide by taking poisons in 2005. Of this, 2,586 took pesticides.

Pesticide poisoning caused 150 deaths in Kurunegala District and 128 deaths in Badulla District.

It is tragic that these suicide attempts are cries for help, or due to momentary depression or anger, or to scare others such as a boy friend or parents. Almost all of them want to survive and go home once in hospital.

Admissions from snake bites are also increasing. A couple of decades ago those living in rural agricultural districts did not believe that western drugs are effective for snake bites.

However, hospital admissions from snake bites showed a tremendous increase mainly because of the public education campaigns and publications of the Health Education Bureau of the Ministry of Health and the Sri Lanka Medical Association.

In 2005, 36,727 patients were admitted to state hospitals and there were 134 deaths, compared to 27,251 admissions and 164 deaths a decade ago.

The five highly venomous snakes in Sri Lanka are cobra, Russell's viper, common krait, Ceylon krait and the saw-scaled viper.

Accidental poisoning accounted for 33% of enquiries to the National Poisons Information Centre. Most are accidental poisonings at home involving children. It is essential to keep all drugs, pesticides and chemicals in locked cupboards or containers so that children cannot have access to them.

An unusual case of accidental poisoning was an incident of poisoning of about fifty men, women and children in an estate in the Nuwara Eliya district some years ago, where the management of the estate decided to spray an area with a weedicide, to get rid of weeds to replant tea.

A few hours after spraying, the mainly women and small children living in the line rooms became ill. The poisoned patients were admitted to Nawalapitiya and Kandy Hospitals.

What led to this unusual incident of poisoning was quite clear. There was a small stream of water in the sprayed area and this stream supplied the main water tank providing water to the families in the line rooms.

A few hours after spraying the families started using contaminated water and became ill. Fortunately, all patients recovered as the chemical was diluted before entering the body.

Other circumstances of poisoning are occupational poisoning and homicidal poisoning.

Homicidal poisonings, though rare, are reported. A case of homicidal poisoning, where the mother and two daughters died by eating a cake laced with an insecticide was reported some years ago.

There are instances where patients have taken drugs to procure abortions. In one such case, an unmarried young girl, a university student, died of chloroquine poisoning, which she took to procure an abortion.

One specific action that can be taken is to improve the treatment facilities in State hospitals. Lack of intensive care facilities is a major concern.

The Presidential Task Force on formulation of a National Health Policy suggested several in 1993 to reduce the morbidity and mortality from pesticide poisoning. Some of these measures can be used to prevent poisoning from other chemicals as well.

* Strengthening the implementation of the provisions under Control of Pesticides Act by appointing Public Health Inspectors as authorized officers with powers of inspection, obtaining samples, etc.

* Undertaking information, education and communication programmes for pesticide users, the general public, agricultural extension workers, health workers, mass media, producers and suppliers. Adverse effects of pesticide use, safe handling methods in transportation and application of pesticides must be emphasized.

* Ensuring the use of safety measures and protective equipment against accidents and pesticide poisoning through an appropriate pricing and distribution mechanism.

* Encouraging community involvement and popular participation in surveillance of the use of pesticides and safety measures.

* Strengthening the National Poisons Information Centre.

Strengthening the National Poisons Information Centre can provide an efficient 24-hour service for healthcare professionals and doctors, a laboratory back up service to analyse blood, urine and stomach contents to assist doctors in the management of poisoned patients and facilities to supply antidotes to hospitals.

These activities if properly and efficiently implemented can help to reduce the rising incidence of morbidity and mortality from poisoning.

Morbidity and mortality from poisoning will increase causing a tremendous burden to health services in the country. Poisoned patients will require expensive antidotes. They need treatment in intensive care units, which cost several thousand rupees per patient per day.

The cost of poisoning to the health sector has not been properly assessed. Considering a very conservative figure of Rs. 1000 per case of poisoning admitted, the total hospital expenditure is close to a staggering 100 million rupees. Socio-economic costs may be more.

It is high time that the state and all other concerned parties take effective action to reduce the rising morbidity and mortality from poisoning and save thousand of young lives.

Hospital admission and deaths from poisoning - 2005

Total Hospital Admissions Deaths in Hospitals

Pesticides 18180 1270

Drugs 18325 151

Snake Bites 36861 134 Other Poisoning and Toxic Effects (e.g. Plants, chemicals)

17686 230

Total 91052 1785

Preventing skin cancer

Will "Slip Slop Slap," a southern hemisphere campaign to prevent skin cancer, have to be rethought?

The slogan, running especially in Australia and New Zealand, urges the public to slip on a shirt, slop on sunscreen and slap on a hat to protect themselves from ultraviolet (UV) rays that age skin and cause skin cancer.

But, according to a review of the evidence published online Thursday by the British health journal The Lancet, skin protection is a rather more complex business than this.

Wearing thick garments - and avoiding direct exposure to the sun in the first place - are smarter than wearing loose-weave clothing and applying sunscreen, it says. Sun-protection strategies around the world were assessed by Swiss dermatologist Stephan Lautenschlager of Zurich's Triemli Hospital.

His team found that tightly woven, thick clothing made of denim, wool and polyester offers the best protection, while cotton, linen and acetate are far less effective.

Clothes that have shrunk after washing - and thus are denser - are also better than materials which are wet or have been stretched or bleached, according to Lautenschlager's team.

The review says that many people are confused or misinformed about how to use sunscreen, such as how much to apply (a liberal dose is recommended by far) and how frequently to reapply it.

There is not even a standardised method to measure the effectiveness of UV blocking, it says.

This is important, given "our global, outdoor society," it says.

"The sunscreen market - crowded by numerous products - shows various differences worldwide," it notes.

HDN