Document Type: Original Article

Authors

1 Department of Medicine, Sylhet M.A.G. Osmani Medical College, Sylhet, Bangladesh

2 Department of Gastroenterology, Sylhet M.A.G. Osmani Medical College, Sylhet, Bangladesh

Abstract

Background:The pattern of poisoning has a regional variability. This study was carried out to describe the epidemiological profile of acute poisoning in northeastern Bangladesh and to evaluate the mortality.
Methods:In this retrospective cross-sectional study, medical records of poisoned patients treated at department of medicine of Sylhet M.A.G. Osmani Medical College Hospital, Sylhet, Bangladesh during 1st January 2008 to 31st December 2011 were reviewed. Patients aged 10 years and above with diagnosis of acute poisoning were included. Data collected were gender, age, place of residence, type of poison and intention of poisoning.
Results:A total of 4435 (58.7% men) were included. Patients aged 21 to 30 years were the most common age group involved with poisoning (41.6%). The majority of patients (55.4%) lived in rural areas. Commuter poisoning (43.3%) was the most frequently occurring type of poisoning in both men and women in all 4 years followed by OP poisoning (25.7%). Men were found to be significantly more affected in commuter, organophosphate and alcohol poisoning (P < 0.001). Intention of poisoning in the greatest number of patients (54.5%) was suicidal followed by 1919 patients (43.3%) who were poisoned by homicidal/stupefying intents. Among the homicidal cases, men were significantly more victimized (67% vs. 33%, P < 0.001). Overall, 224 patients (5.1%) died. The highest number of deaths was due to OP poisoning (46.9%) followed by commuter poisoning (45.5%). Case fatality rate was the highest in the snakebite victims (23.3%) followed by alcohol poisoning (11.4%).
Conclusion:Commuter or travel-related poisoning is an emerging public health threat in this part of Bangladesh. Public awareness should be raised and school-based educational programs should be emphasized regarding the commuter poisoning and the consequence of accepting and eating food from strangers.

Keywords

How to cite this article: Bari MS, Chakraborty SR, Alam MMJ, Qayyum JA, Hassan N, Chowdhury FR. Four-Year Study on Acute Poisoning Cases Admitted to a Tertiary Hospital in Bangladesh: Emerging Trend of Poisoning in Commuters. Asia Pac J Med Toxicol 2014;3:152-6.

Introduction

Acute poisoning is a global problem which has steadily increased over the past few years in developing countries and has become as one of the major causes of morbidity and mortality in these countries (1,2). According to the World Health Organization, 99% of the fatal poisoning cases occurred in developing countries (1). Developed countries also face the problem of acute poisoning. In the UK, it accounts for 10-20% of all acute medical admissions (3).

Deliberate self-poisoning has reached epidemic proportions in some parts of the developing world where the toxicity of available poisons and limited medical facilities create a high fatality rate (4). Recent extrapolations of data from a few countries in the Asia suggest that there may be 300,000 suicides by deliberate ingestion of pesticides annually in this region alone (5,6). Poisoning is a serious threat in Bangladesh as it comprises around 44% of all deaths among adult females and around 8 to 10% of overall mortality in medical wards of tertiary healthcare settings (7). Common types of poisoning in this country are organophosphate (OP) poisoning, poisoning with unknown substances especially in commuter (travel-related) poisoning; poisoning with sedatives, corrosive agents, rodenticides, kerosene/petrol and alcohol, and snakebite (7,8). Of them, poisoning in commuters (commuter poisoning) has become a major toxicological issue in Bangladesh in the recent years (9). Some unusual forms of poisoning, such as copper sulfate and puffer fish poisoning are also occurred in some regions of the country (7,10,11).

The pattern of poisoning varies from one country to another and may vary among different regions of a country. Epidemiological data on this important health issue are, however, scarce in northeastern part of Bangladesh. This study was carried out to describe the epidemiological profile of acute poisoning in northeastern Bangladesh and to evaluate the mortality.

Methods

Setting

Sylhet M.A.G. Osmani Medical College Hospital is the main referral 900-bed tertiary care hospital, in the north-eastern part of Bangladesh with around 10 million population. Department of medicine in this hospital consists of 235-bed that provides specialized services of internal medicine for an average of 25000 patients annually. This hospital is the only public hospital in this region that is receptive for acute poisonings.

Patients and data collection

In this retrospective cross-sectional study medical records of poisoned patients treated at department of medicine during 1st January 2008 to 31st December 2011 were reviewed. Patients aged 10 years and above with diagnosis of acute poisoning were included. Poisoned patients less than 10 years of age were admitted to pediatrics ward and excluded from the study. Patients with incomplete information and those who left the hospital against medical advice were also excluded. Data collected were gender, age, place of residence, type of poison and intention of poisoning. Age of patients was categorizedinto four groups with range of 10 to 20, 21 to 30, 31 to 40 and above 40. The intention of poisoning was categorized to suicidal, homicidal/ stupefying and accidental poisoning.

Ethics and statistical analysis

The study was approved by the ethics committee of Sylhet M.A.G. Osmani Medical College. Confidentiality of patients' information was maintained when the data were obtained from the medical records.

Statistical analysis was done using SPSS version 16 (SPSS Inc., Chicago, USA) and results are presented as frequency and percentage with charts and tables. Analysis of difference between two categorical variables was done using the chi squared test. A p value less than 0.05 was considered to be statistically significant.

Results

Sociodemographic

During the study period, a total of 4435 cases of acute poisoning with mean age of 24.8 ±12.6 years were treated at the department of medicine. The annual number of admissions due to poisoning slightly increased from 1022 in 2008 to 1216 in 2011. The majority of patients were men (2604, 58.7%) and male to female ratio was 1.4: 1. Patients aged 21 to 30 years were the most common age group involved with poisoning (1844; 41.6%) followed by patients aged 10 to 20 years (1736; 39.1%) (Table 1). The majority of patients (2455, 55.4%) lived in rural areas.

Table 1. Socio-demographic features of patients

 

Total (n = 4435)

Male (n = 2604)

Female (n = 1831)

Age groups (years); n (%)

 

 

 

 

10-20

1736 (39.1)

1041 (60)

695 (40)

 

21-30

1844 (41.6)

1176 (63.8)

668 (36.2)

 

31-40

445 (10.0)

303 (68.2)

142 (31.9)

 

40 <

410 (9.3)

257 (62.6)

153 (37.3)

Place of residence; n (%)

 

 

 

 

Urban

1300 (29.3)

698 (53.7)

602 (46.3)

 

Semi-urban

680 (15.3)

349 (51.3)

331 (48.6)

 

Rural

2455 (55.4)

1252 (51)

1203 (49)

 

Table 1. Year-wise distribution of various types of poisoning in northeastern Bangladesh

Study year

Type of poisoning

Total

Commuter poisoning1

OPC2

Sedatives

Harpic3

Rat-killer

Corrosive agents4

Alcohol/ Methanol

Kerosene/ Petrol

Paracetamol

Snakebite

Others

2008

438 (42.9)

260 (25.5)

122 (11.9)

86 (8.4)

35 (3.4)

31 (3.0)

9 (0.8)

6 (0.6)

6 (0.6)

4 (0.4)

25 (2.5)

1022

2009

487 (46.7)

223 (21.4)

113 (10.9)

95 (9.1)

33 (3.2)

25 (2.4)

12 (1.2)

4 (0.4)

9 (0.9)

5 (0.5)

35 (3.3)

1041

2010

451 (39.0)

336 (29.1)

130 (11.2)

65 (5.7)

45 (3.9)

40 (3.5)

12 (1.0)

7 (0.6)

5 (0.4)

15 (1.3)

50 (4.3)

1156

2011

543 (44.6)

321 (26.4)

117

 (9.7)

67 (5.5)

60 (5.0)

32 (2.6)

11 (0.9)

6 (0.5)

9 (0.7)

6 (0.5)

44 (3.6)

1216

Total

1919 (43.3)

1140 (25.7)

482 (10.8)

313 (7.1)

173 (3.9)

128 (2.9)

44 (1.0)

23 (0.5)

29 (0.6)

30 (0.7)

154 (3.5)

4435

1 The majority of commuter poisonings were caused by unknown agents

2 OPC: organophosphate compounds

3 Harpic is a cleaning product mainly composed of 10% HCl

4 Corrosive agents other than harpic

Types of poisons and circumstances of poisoning

Commuter poisoning (1919; 43.3%) was the most frequently occurring type of poisoning in both men and women in all 4 years. Poisoning with OP compounds was the second leading type (25.7%) followed by sedatives (10.8%), harpic (7.1%), rodenticides (3.9%) and corrosives other than harpic (2.9%). Incidence of commuter, OP and rodenticides poisoning were found to have an upward trend-line over the study period (Table 2).

Table 2. Case fatality rate of poisoning in hospital in northeastern Bangladesh during 2008 to 2011 according to poison type

Toxic agents

Total cases

(n = 4435)

Hospital deaths

 (n = 224)

Case fatality rate (%)

Snakebite

30

7

23.3

Alcohol/Methanol

44

5

11.4

OPC*

1140

105

9.2

Commuter poisoning

1919

102

5.3

Corrosive

128

3

2.3

Others

154

2

1.3

Sedatives

482

0

0

Rat-killer

173

0

0

Kerosene/Petrol

23

0

0

Paracetamol

29

0

0

Harpic

313

0

0

Total

4435

224

5.1

* OPC: organophosphate compounds

Considering the gender distribution, variability existed among the different types of poisons used (Figure 1). Men were significantly more affected in commuter (P < 0.001), OP (P < 0.001) and alcohol poisoning (P < 0.001). In addition, poisoning with sedatives and kerosene/petrol was slightly more common in men. On the other hand, women predominated in poisoning with harpic (P < 0.001), corrosive agents, rodenticides and paracetamol, as well as in snakebite.

     

Figure 1. Pattern of different types of poisoning according to gender

Intention of poisoning in the greatest number of patients (2419, 54.5%) was suicidal followed by 1919 patients (43.3%) who were poisoned by homicidal/stupefying intents (Figure 2). Among the homicidal cases, men were significantly more victimized (67% vs. 33%, P < 0.001). Homicidal poisonings  occurred with stupefying agents usually during work-related travels from suburbs to cities or vice versa. Suicidal mode was slightly more common in women (50.7%).

Figure 2. Intention of poisoning according to gender

Outcomes

Overall, 224 patients (5.1%) died with male to female ratio of 1.42:1. The highest number of deaths was due to OP poisoning (46.9%) followed by commuter poisoning (45.5%). Considering the frequency of each type of poisoning, case fatality rate was the highest in the snakebite victims (23.3%) followed by alcohol poisoning (11.4). No death occurred due to poisoning with sedatives, rodenticides, kerosene/petrol, paracetamol and harpic.

Discussion

In this study, a 4-year profile of acute poisoning cases treated at Sylhet M.A.G. Osmani Medical College Hospital, northeastern Bangladesh, was described. Poisoning in men slightly outnumbered women, a finding which was nearly similar to the findings of Sarker et al in Bangladesh, and Prajapati et al and Patil et al in India (12-14). Likewise, two other studies in the country showed that the poisonings are more common in men (15,16). On the other hand, there are findings from some other countries where the woman has a preponderance (17,18). The higher incidence of poisoning in men may be due to the fact that they are more exposed to stress following financial difficulties and work-related pressures. In addition, they are more active outside the house and farms that make them susceptible to outdoor threats (19).

The majority of male patients were from the age group of 21 to 30 years which is similar to a study by Chowdhury et al in Bangladesh (7). Studies in other countries also showed similar pattern of age distribution (12,13,20-22). This shows that young adults are more vulnerable to this health problem which might be due to emotional and social disharmony, occupational problems and risk taking behaviors at these ages.

Majority of the patients consumed the poison with suicidal intention with a female to male ratio of 1.02:1 replicating the findings of a study done in southern part of Bangladesh (7).

In this study, commuter poisoning was revealed to be the leading type of poisoning. People in suburban areas need to travel far distances for work. Unemployment is also a problem in Bangladesh which encourages rural people to migrate into bigger cities to find a job. Moreover, northeastern part of Bangladesh is famous for number of religious places and shrines. So, travel of pilgrims from other parts of the country to this part is quite frequent. Thus, all these factors might collectively be responsible for the recent emerging trend of commuter poisoning especially in this part of Bangladesh. This trend is quite similar to the findings of Majumder et al which showed that between2004 and 2006, travel- related poisoning increased from 6.1 to 9.5% of all admissions and represented 46.6 to 55.7% of all admitted poisoning cases at Dhaka medical college hospital (DMCH) in Dhaka at the central part of the Bangladesh (9). Other studies by Howlader et al in 2004 and Sarker et al in 2002 showed similar trend (15,23). Travel-related poisoning is a social and public health emergency in Bangladesh (24). This kind of poisoning is also a health concern in India (25). The agents used for travel related poisoning are reported to be cocktail of stupefying agents and or benzodiazepines commonly lorazepam (9,25).

In the present study, we found OP compounds as the second leading toxic agent used for poisoning. This finding is consistent with two previous studies done in northern and southern parts of Bangladesh (26,27). OP poisoning is a common health dilemma in Bangladesh and in Southeast Asian countries in general (5,8). OP compounds are commonly used with suicidal intention by the poor rural people in the tropical countries as they are low-priced and easy available. Different epidemiological studies in Bangladesh showed that pesticide poisonings are responsible for approximately 39% of total admitted poisoning cases in Bangladesh (8).

A country wide pilot survey in Bangladesh reported sedatives as the leading agent (37.1%) after including travel-related poisonings under this group (11). Common sedatives used for poisoning are benzodiazepines which are easily available without prescription in the country. According to our findings, harpic ingestion was the next important type of poisoning in this part of the country which accounted for 7% of all poisoning cases resembling the findings of Howlader et al (16). Harpic is a common house-hold cleaning staff mainly composed of 10% hydrochloric acid with a pH of 0.5 and it is commonly abused by women. Although snakebite constituted less than 1% of cases in this study, it was responsible for the highest case fatality rate (23.3%). This may be due to the fact that the snakebite is still a neglected health issue in Bangladesh and also the common beliefs of the people that seek traditional healers and methods prior to visiting the healthcare facilities (19,28). Alcohol (especially methanol) poisoning was the second in terms of fatality in this study. In addition to high toxicity of methanol, this is probably due to delayed presentation of victims to the equipped healthcare settings and unavailability of specific antidotes (29).

According to the studies from the high-income countries, analgesics, particularly paracetamol, are the most common cause of deliberate poisonings in adults (20,30,31). But the scenario is different in Bangladesh as our findings in northeastern part and a previous study in southern part of the country demonstrated that less than 1% of acute poisonings are due to paracetamol ingestion (7). It is noteworthy that in the northeastern part of the country no cases of copper sulfate and puffer fish (tetrodotoxin) poisoning were observed which were mentionable causes of poisoning in southern part of Bangladesh (32). The overall mortality rate in this study was 5.1% which is similar to a recent study done at Rangpur Medical College Hospital in northern Bangladesh (14), and close to the findings of national statistics (4.1%) (11).

Limitations

Since it this study was done retrospectively using hospital registry, some of the important parameters including occupation and marital status could not be evaluated. In some cases, mode of poisoning may not have been reported reliably due to concealment of the proper history. Poisoning cases are filed as a police issue in Bangladesh; therefore, people are sometimes afraid of giving proper history. Pediatric cases were not included in this study which may result in missing some important cases of poisoning. Moreover, a facility for toxicological analysis is not available in the catchment area of the study. So, the exact chemical identity of the toxic agents consumed (especially for commuter poisoning cases) could not be identified and the type of poisons reported in this study were solely based on patients' history, police records and bottle labels brought by the patients or their relatives.

Conclusion

Commuter or travel-related poisoning is an emerging public health threat in this part of Bangladesh. Public awareness should be raised and school-based educational programs should be emphasized regarding the commuter poisoning and the consequence of accepting and eating food from strangers.

Legislative measures are required to be strengthened and stringent law enforcement must be ensured on over the counter sale of medications and purchase of poisons in the country. No drugs especially benzodiazepines should be distributed without authorized prescription. Availability of antidotes needs to be ensured in every secondary and tertiary care hospitals of the country. Moreover, prospectively-designed large scale studies are required to provide the evidence-based facts to underpin public health strategies and for implementation of preventive measures.

Acknowledgment

We acknowledge Mr. Zakir Hassan who helped us in collecting the data. We also thank the staff working in the archives division of Sylhet M.A.G. Osmani medical college hospital.

Conflict of interest: None to be declared.

Funding and support: None.

 

  1. Kumar A, Verma A, Jaiswal K, Kumar S, Prasad R. Emergence of entirely new poisoning in rural India; An upcoming health hazard to the community health. Indian J Community Health 2012;24:248-51.
  2. Afsari R, Majdzadeh SR, Balali-Mood M. Pattern of acute poisoning in Mashhad, Iran 1993-2000. J Toxicol Clin Toxicol 2004;42:965-75
  3. Kerins M, Dargan PI, Jones AL. Pitfalls in the management of the poisoned patients. J R Coll Phys Edinburgh 2003;33:90-103.
  4. Eddleston M, Sheriff MHR, Hawton K. Deliberate self-harm in Sri Lanka: an overlooked tragedy in the developing world. BMJ 1998;317:133-5.
  5. Gunnell D, Eddleston M. Suicide by intentional ingestion of pesticides: a continuing tragedy in developing countries. Int J Epidemiol 2003;32:902-9.
  6. Buckley NA, Karalliedde L, Dawson A, Senanayake N, Eddleston M. Where is the evidence for treatments used in pesticide poisoning? Is clinical toxicology fiddling while the developing world burns? J Toxicol Clin Toxicol 2004;42:113-6.
  7. Chowdhury FR, Rahman AU, Mohammed FR, Chowdhury A, Ahasan HA, Bakar MA. Acute poisoning in southern part of Bangladesh - The case load is decreasing. Bangladesh Med Res Counc Bull 2011;37:61-5.
  8. Dewan G. Analysis of Recent Situation of pesticide poisoning in Bangladesh: Is there a proper estimate? Asia Pac J Med Toxicol 2014;3:76-83.
  9. Majumder MM, Basher A, Faiz MA, Kuch U, Pogoda W, Kauert GF, et al. Criminal poisoning of commuters in Bangladesh: prospective and retrospective study. Forensic Sci Int 2008;180:10-6.
  10. Ahasan HAMN, Mamun AA, Rasul CH, Roy PK. Puffer fish poisoning: a clinical analysis. Pak J Med Sci 2003;19:29-32.
  11. Amin MR, Awwal A, Sattar MA, Hasan R, Islam R, Jalil MA, et al. Pilot survey on cases of poisoning and its outcome in different category of hospitals in Bangladesh. J Medicine (Bangladesh) 2009;10:15-7.
  12. Prajapati T, Prajapati K, Tandon R, Merchant S. Acute Chemical and Pharmaceutical Poisoning cases Treated in Civil Hospital, Ahmedabad: One Year study. Asia Pac J Med Toxicol 2013;2:63-7.
  13. Patil A, Peddawad R, Verma VCS, Gandhi H. Profile of Acute Poisoning Cases Treated in a Tertiary Care Hospital: a Study in Navi Mumbai. Asia Pac J Med Toxicol 2014;3:36-40.
  14. Sarkar D, Shaheduzzaman M, Hossain MI, Ahmed M, Nur M, Basher A. Spectrum of acute pharmaceutical and chemical poisoning in northern Bangladesh. Asia Pac J Med Toxicol 2013;2:2-5.
  15. Howlader MAR, Sardar MH, Amin MR, Morshed MG, Islam MS, Uddin MZ, et al. Clinico-epidemiological pattern of poisoning in a tertiary level hospital. J Dhaka Med Coll 2008;17:111-5.
  16. Howlader MAR, Hossain MZ, Morshed MG, Begum H, Sardar MH, Uddin MZ, et al. changing trends of poisoning in Bangladesh. J Dhaka Med Coll 2011;20:51-6.
  17. 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.
  18. 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.
  19. Mondal RN, Chowdhury FR, Rani M, Mohammad N, Islam MM, Haque MA, et al. Pre-Hospital and Hospital Management Practices and Circumstances behind Venomous Snakebite in Northwestern Part of Bangladesh. Asia Pac J Med Toxicol 2012;1:18-21.
  20. Hameed FA, Ansari HK, Al-Najjar FJ. Prevalent Poisonings in Adults and Adolescents in Dubai: A Compendium from Rashid Hospital. Asia Pac J Med Toxicol 2014;3:115-9.
  21. Ramesha KN, Rao KB, Kumar GS. Pattern and outcome of acute poisoning cases in a tertiary care hospital in Karnataka, India. Indian J Crit Care Med 2009;13:152-5.
  22. Zaheer MS, Aslam M, Gupta V, Sharma V, Khan SA. Profile of poisoning cases at a North Indian tertiary care hospital. Health Popul Perspect Issues 2009;32:176-83.
  23. Sarker ZM, Khan RK. Acute poisoning-scenario at a district hospital. Bangladesh J Med 2002;13:49-52 .
  24. Uddin MJ, Shahed FH, Bhowmik SK, Rashid R, Ghose A, Rahman MR, et al. Transport related poisoning-an untapped public health problem. Healer 2003; 8:31-3.
  25. Ravi Ramamurthy H, Jaswal DS, Chaturvedi VP. "Travel travails" - Travel-related poisoning. Med J Armed Forces India 2013;69:409.
  26. Rahman M, Rahman M, Chowdhury AH. Pattern of poisoning in Rangpur Medical College Hospital. North Med J (Bangladesh) 1994;3:15-8.
  27. Bakar MA, Ahsan SMM, Chowdhury PK. Acute poisoning-nature and outcome of treatment in a teaching hospital. Bangladesh Med J (Khulna) 1999;32:19-21.
  28. Sarmin S, Amin MR, Al-Mamun H, Rahman R, Faiz MA. Clinical Aspects of Green Pit Viper Bites in Bangladesh: A Study on 40 Patients. Asia Pac J Med Toxicol 2013;2:96-100.
  29. Chowdhury FR, Bari MS, Alam J. Epidemiological Profile of Methanol Poisoning in Bangladesh (2008-2014) and Clinical Experience of a Single Outbreak. Asia Pac J Med Toxicol 2014;3:S6.
  30. Lau FL. Emergency management of poisoning in Hong Kong. Hong Kong Med J 2000; 6:288-92.
  31. Thomas SH, Bevan L, Bhattacharyya S, Bramble MG, Chew K, Connolly J, et al. Presentation of poisoned patients to accident and emergency departments in the North of England. Hum Exp Toxicol 1996; 15:466-70.
  32. Chowdhury FR, Ahasan HAMN, Rashid AKM, Mamun AA, Khaliduzzaman SM. Puffer fish (Tetrodotoxin) poisoning: A Clinical analysis, Role of Neostigmine and short-term outcome of 53 cases. Singapore Med J 2007;48:830-3.