Indian J. Prev. Soc. Med. Vol. 40 No.3& 4,2009

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1 Indian J. Prev. Soc. Med. Vol. 40 No.3& 4,2009 EPIDEMIOLOGICAL PROFILE OF OP POISONING CASES TREATED AT PRAVARA HOSPITAL, LONI, INDIA Somasundaram K.V. 1, Ashok Patil, 2, Shukla S.K 3 ABSTRACT Since January 2006, suicides by farmers have been reported by the media in various parts of India. Although the phenomena is similar in Ahmednagar district it has neither drawn the attention of the media nor the policy makers. The present study aims to fill this gap. The four-year ( ) retrospective hospital based study carried out at PRMCH located in agrarian setting of Maharashtra covered 428 patients treated for Organophosphorous (OP) poisoning. Of the total 428 patients, nearly two thirds were males. The mortality rate was 12.1%. Majority were farmers and farm labour and were at a young age (male:33 Years; Female: 25.8 years). Overall there was an annual increasing trend of poisoning cases, sowing and harvesting seasons registered the highest number of suicidal attempts. Demethoate was the most commonly abused poison, followed by Endosulphen, Betox. Nearly 50% reached hospital within one hour and 82% (84 male & 79 female) were treated in ICU as acute poisoning. The study clearly highlights the severity of the farmers' suicidal attempts in Ahmednagar district of India. Key Words: Poison, Organophosphates (OP), farmers, suicide. INTRODUCTION Pesticide poisoning from occupational, accidental and intentional exposure is a leading public health problem of the developing world. 1 Millions of people are exposed to danger by hazardous occupational practices and unsafe storage. 2 Over hundred thousand peasants committed suicide in the past seven years in India. It was unfortunate that they have poisoned themselves by consuming pesticides/insecticides meant for their crops. Today the rate at which these suicides occur has risen to one in every 8 hours! 3 These suicides point to a greater crisis in the agrarian system as a whole where the suicide is a symptom of a greater malaise that threatens millions of farmers and the landless agricultural labourers in the sub-continent. However it is the deliberate self poisoning that causes the great majority of morbidity and mortality which put pressure on already overburdened hospital services particularly in Asia. 4,5 In developed countries, the rate of mortality from poisoning is 1% to 2% but in India it varies between 15 to 30%. 6 Poisoning is the fourth most common cause of mortality in rural India. 7 The nature of poisoning varies from one region to another depending upon the poison availability and the knowledge of local population regarding poisonous properties. OP insecticides are used extensively in horticulture and agriculture. According to WHO, 3 million people consume these compounds resulting in 40,000 deaths annually. 8 but there is a huge human tragedy of national proportions behind them. These sounds like cold statistics 1. Professor & Head, Dept. of Medical Informatics, Rural Medical College, PIMS-DU, Loni 2. President, International Association of Agricultural Medicine & Rural Health, Sweden 3. Asso. Professor, Dept. of Medical Informatics, Rural Medical College, PIMS-DU, Loni Corresponding author: Professor & Head, Department of Medical Informatics, Rural Medical College, Pravara Institute of Medical Sciences, (Deemed Univeristy), Loni, Taluka- Rahata, Dist.- Ahmednagar, Maharashtra, India, Pin Indexed in : Index Medicus (IMSEAR), INSDOC, NCI Current Content, Database of Alcohol & Drug Abuse, National Database in TB & Allied Diseases, IndMED, Entered in WHO CD ROM for South East Asia.

2 MATERIAL AND METHODS A hospital based retrospective study where 428 patients of OP poisoning admitted in Pravara Rural Hospital from Jan 2003 to Dec were included. The relevant data of the patients was collected from Medical Records. The data (variables) collected using a proforma include age, sex, geographical area, occupation, type of poison consumed, time interval between poisoning and admission, length of stay in the hospital. The data have been analyzed using simple statistical methods including rates, ratios, ranges, averages, time series analysis, correlation coefficient (r), and tests of significance (χ 2 test). RESULTS During the 48 months period of study a total of 428 patients were admitted in the Hospital with the diagnosis of OP poising and they constituted 0.90 per cent of total admissions. Of the 428 cases admitted, 52 cases or 12.14% succumbed to the poisoning. The total OP cases admitted in the hospital have shown a marginal-increasing trend from 104 in 2003 to 115 in 2006, with an annual average of 107. There is a strong negative correlation (r = ) in the annual growth in male and female from 2003 to The number of male patients admitted decreased from 75 in 2003 to 58 in 2005 and then increased to 72 in 2006, on the other hand, the number of female patients increased from 29 in 2003 to 47 in 2005 and then decreased to 43 in On the other hand, the percentage of deaths has shown a marginal decreasing trend from 13.5% in 2003 to 10.4% in 2006 (Table 1). Table-1 : Trend of OP poisoning cases admitted and died Year Male Female Total Admitted Deaths No. Ave./m No. Ave./m No. Ave./m No. % Total Table- 2: Seasonal trend of OP poisoning The sex wise distribution of cases reveals that more than two thirds of the patients were male. Nearly 48% were admitted during harvesting (March-April) and Sowing Season (June-Aug). The number of patients admitted varies from 27 in November/December to 44 in June (male: 16 in January to 34 in June; female 7 in May to 20 in April) (Table-2 ). Month Total OP poisoning cases Grand Male Female Total January February March April May June July August September October November December Total Indian J. Prev. Soc. Med Vol. 40 No.3 & 4 185

3 Table-3: Distribution of patients by age and sex Nearly 75% of the cases were below 35 years. The average age of male was 33 years and that of female was 25.8 years. It was alarming to note that as many as 41% patients were below 25 years and the highest number (37%) of male patients aged between years, and over 52% of female patients aged years. The distribution of the cases as per age and sex was statistically significant (χ 2 = 37.63, p < 0.05). (Table 3). Farmers and farm workers were the prime victims of OP poising as over 95 percent of the patients admitted belong to this occupation. The balance 5% constitutes either working in service sector or students and unemployed. (Table 4). Age Sex of the patient Total ( yrs) Male Female No. % Below Above Total Table- 4: Distribution of the patients by occupation Occupation Sex Total Male Female No. % Farmers Farm workers Service (Salaried) Students Others (unemployed) Total Table -5: Type of OP poison consumed A study of type of OP compound consumed revealed that Demethoate (Rogar) was the most commonly abused poison (50%), followed by Endosulphen (23%), Betox (17%). Various other substances abused in order of frequency are listed in Table 5. Over 50% patients reported to hospital within one hour of poisoning, while another 30% reported between 1-2 hours, which is crucial for improving the outcome of the treatment. Nearly 88% were discharged after improving their condition, while 12% succumbed to poisoning. Type of Poison consumed Total No. % Dimethoate (Rogar) Endosulphen Betox Dichiorovas (Nuvan) Carbomate (Baygon) Diazinon (TK 20) Unknown Total Table 6: Severity of Poisoning Cases Admitted Sex Acute Poisoning Moderate Poisoning Total No. % No. % No. % Male Female Total Nearly 82% of the cases (84 male, 79 female) with acute poisoning were treated in Intensive Care Unit, while the remaining 18 % (16 male, 21 female), who were moderately poisoned treated in normal wards (Table 6 ). Nearly 70% stayed in the hospital for less than 5 days, while 16% undergone treatment for 5 to 10 days. The remaining 14% patients were Indian J. Prev. Soc. Med Vol. 40 No.3 & 4 186

4 treated for more than 10 days in the hospital. The gender wise difference in the average length of stay (5.66 days in male, days in female) of the OP poison cases treated in the hospital is found statistically significant at 5% level { = 9.66, p < 0.05}. DISCUSSION Although hospital data is not true representative of the prevalence of a problem in the community at large, but a phenomenal rise of OP poisoning cases admitted in Pravara Rural Hospital from 47 per year - one per every 8 days ( ) 16 to 107 per year - one per every three and half days ( ) can not be taken lightly. The rise can not be misinterpreted as the concurrent rise in the facilities of the hospital. It should certainly be seen in the light of the current alarming trend of farmer's suicides all over the country. In our study majority of the victims of OP poisoning (95%) were farmers and agricultural labour. Self poisoning is common in agriculturists 12 due to failure of crops, disputes in the process of disintegration of joint families into nuclear families, coupled with easy availability of the poison in their household and whenever there is a precipitating factor one might be tempted to end one's own life. In the present study, the poisoning commonly occurred during harvesting (Mar & Apr.) and sowing season (June-Aug), in which farmer undergoes tremendous stress expecting good results for all the hard work and investment he has put in. Other studies have however shown 12 that a slightly different trend i.e., summer months. In the present study, it was observed that male sex, young age are triggering factors for poisoning, which is in consistent with observations made by other workers. The male predominance, which was observed in our study (65%), is in concurrence with other studies done at Manipal, South Karnataka, Allahabad, Rohtak, and Sri Lanka This male preponderance may be attributed to the reason that males are more exposed to stress and strain associated with monsoon dependent cultivation practices, crop failures, and also to other economic burdens. In this study the most common age group involved was between years, which vary from other studies in India and abroad where the common age group was reported as years. Any inference in this regard has to be drawn looking the problems at a holistic view keeping the other observations like predominance of male sex, farming occupation, and timing of suicides etc. It is very serious matter and frustration due to failure of crops and gainful employment etc. Another important observation was that as many as 50 per cent cases reached the hospital with in one hour and another 30 per cent reached between one to two hours' duration. Reports available from some Asian countries (Pakistan and Sri Lanka) and African countries (Uganda) describe Organophosphates crop sprays and drugs as the commonly abused toxic substances with reported mortality rate varying from 2.0% - 2.1% In India, opium and arsenic were very commonly used poisons in the past, but with the change of time, the commonest cause of poisoning is pesticides, the reasons being agricultural based economy, poverty and easy availability of highly toxic pesticides. 23 The mortality rate in India is between 15-30% 3. In our study, dimethoate was the commonest compound of Organophosphate consumed in 50 per cent of the cases which in consonance with some studies 15, while in some other studies methyl parathion was reported as the commonest 12. In the present study the mortality rate was observed as 12.14%. The mortality in acute poisoning depends upon nature (quality) and quantity of poison consumed, level of available medical facilities and time interval between intake of poison and hospitalization. In the present study more than 80% of the cases reaching the tertiary level teaching hospital explain to some extent the lower mortality rate compared to other studies. Of course, the low mortality rate may also be due to inferior quality of pesticides used which have failed to control the pests and lead to recurrent economic losses to the farmers. Indian J. Prev. Soc. Med Vol. 40 No.3 & 4 187

5 CONCLUSION Agrochemicals poisons, particularly Organophosphates, which are important to sustain crop production, were responsible for suicidal deaths in majority of the cases. Self-poisoning, although a scarcely foreseeable event, it is subject to preventive intervention and hence effective prevention strategies in place reduce its negative impact on the health of the rural population. However, major reforms in micro-economic and agricultural policies, appropriate social security and satisfactory interpersonal relationships through scientific counseling in place can check the high incidence of poisoning in farming community and young people. A detailed regional population based epidemiological research on changing trends of poisoning and their primary causes amongst various occupational groups help understanding the problem and in designing appropriate remedial measures, including equipping the hospitals & health centers. Acknowledgments: The authors wish to thank Department of Medical Records and Computer Department of Pravara Hospital for their help in making the data available. REFERENCES 1. Jayaratnam J. Acute pesticide poisoning. A major global health problem World Health Statistics Quarterly 1990; 43: Karalliedde L., Eddleston M, Murray V. Epidemiology of organophosphate insecticide poisoning In: Karalliedde L, Marrs T, Feldman F, Hentry JA (eds) organophosphate pesticides and human health. London : Imperial College; in press. 3. Nirmalkumar Suryavanshi, "What drives our Farmers to Suicide and how the legal system is partly responsible?" Lawyers Collective, Vol. 21 No. 8, Aug-Sept, Van der Hock W, Konradsen F, Athukorala, Wanigadewa T. Pesticides poisoning: a major health problem in Srilanka. Soc. Science Med. 1998; 46: Eddleston M, Snediff MHR, Hawton K. Deliberate Selflharm in Srilanka : An overlooked trajedy in the developing world. Br. Med. J 1998; 317: Pillay V.V:MKR Krishna's Hand book of Forensic Medicine and Toxicology. 12 th Ed. Paras Publication. Hyderabad: , Taruni NG, Bijoy TH, Momonchand A: A profile of poisoning cases admitted to RIMS Hospital, Imphal, Journ Forensic Med. Toxicology 18:31-33, Sqn Ldr Piplani S, et al Organophosphorous poisoning with intermediate syndrome, Med. J Armed Forces Inst. 2002, 58; Palimar Vikram et all: Spectrum of Organophosphorous Poisoning in Manipal, Medico-legal Update, April-June 2005, Vol. 5. No.2, Unnikrishnan B et. all: Trends of acute poisoning in South Karnataka, Katmandu University Medical Journal (2005), Vol. 2, No. 2, Siwach SB, Gupta A: The Profile of Acute Poisonings in Haryana - Rohtak Study, JAPI 1995, Vol. 43. No Karalliedde L, et. all Acute Organophosphorous poisoning in Sri Lanka, Forens Sci Inter 1988;36: Ashok Patil, "Medical Treatment of Pesticide Poisoning" Journal of International Association of Agricultural Medicine and Rural Health, Vol 21, No.1, Summer Gunnell D. and Frankel F, Prevention of suicide: aspirations and evidence, BMJ 308 (1995), Rihmer Z, Can better recognition and treatment of depression reduce suicide rates? A brief review, Eur. Psychiatry 16 (2001), Tondo L., Isacsson G, and Baldessarini R.J Suicidal behaviour in bipolar disorder, Risk and prevention, CNS Drugs 17 (2003), Nhachi FB Charles, Kasilo MJ Ossy, The Pattern of poisoning in Urban Zuinb above human Exp. Toxicol 1992;14: Seniwirative and Thambipillai Shanthi. Pattern of poisoning in developing agricultural country, Br. J Prev Social Med. 1974; 28; Jamil H. Acute Poisoning. A review of 1990 cases JPMA 1900; 40: Sinha US, et al, A profile of poisoning cases admitted in SRN Hospital, Allahabad, J for Med. Toxicology 1999: 16: Dhattarwal SK, Singh H: Profile of deaths due to poisoning in Rohtak Haryana, Journal of Forensic Med. Toxicol 18:28-29; Senanayake N, Petris H: Mortality due to poisoning in a developing and agricultural country: Trends over 20 years, Hum Exp. T oxicology 14: , Singh D, Jit I, Tyagi S: Changing trends in acute poisoning in Chandigarh Zone. Am J Forensic Pathol 20; , Indian J. Prev. Soc. Med Vol. 40 No.3 & 4 188