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Background: This qualitative study presents an in-depth evaluation of the contributory psycho-socio-cultural and physical-economic factors related to paediatric poisoning in rural Sri Lanka. Method: The study was conducted at paediatric wards of Anuradhapura teaching hospital (THA) over a period of two years (2012 – 2014). Main methods of data collection were participants’ narrative and focus group discussions (FGDs). All parents of children with acute poisoning were recruited to FGDs. The structure of phenomena was developed based on descriptive phenomenological inquiries and key themes were identified at data analysis stage. Results: 383 parents participated in focus group discussions. Data were categorized to four domains; (1) parental awareness of poisoning risks, (2) presence of child, parent and environment related risk factors, (3) issues related to first aid care and provision of care until child was brought to emergency care unit, and (4) possible measures to prevent further poisoning. Interaction of multiple risk factors was observed in children with both intentional and unintentional poisoning. Accidental poisonings were associated with certain cultural practices, unsafe environment and unsafe storage of poisons. Children with intentional poisoning frequently had disrupted family relationships. Harmful first aid measures and delayed presentation at the primary care unit had negative impact on poisoning related outcomes. Parents believed community education, safe storage of poisons, and safe environment would likely bring down poison related morbidity. Conclusion: Person, poison and environment related risk factors can lead to acute poisoning emergencies in children in rural Sri Lanka. Often multiple risk factors interact to bring about the poisoning event. Avoidance of harmful first aid measures and early presentation at the primary care unit would bring down poisoning related morbidity. Effect of community education, safe storage of poisons and safe environment should be evaluated in the view of preventing poisoning. [ABSTRACT FROM AUTHOR]

Background: Non-accidental poisoning in the paediatric age group is uncommon and international literature on this subject is limited. There are no Sri Lankan paediatric studies on non-accidental poisoning to date. The objective of the current study was to explore the predisposing factors and profile of children less than 12 years in rural Sri Lanka who had non-accidental poisoning. Method: This cross-sectional study was conducted at Anuradhapura teaching hospital for two years (from February 2012 to January 2014) involving all children below 12 years and presented with either a history of acute non-accidental self-poisoning or non-accidental poisoning by another person. Quantitative data were collected using a structured questionnaire and qualitative data to explore the background socio-cultural factors were collected using focused group discussions. Both quantitative and qualitative data were analysed separately in the two groups. Results: Nineteen children with non-accidental poisoning were recruited among 383 acute poisoning admissions over two years. The majority of children were male - 13 (68.4%). All children who had non-accidental self-poisoning were at least eight years of age while the mean age of children poisoned by another person was 4.6 years. Children mostly ingested pesticides (9/14-64.3%) followed by plant poisons and medicinal poisons. No child was reported to have ingested household chemicals including kerosene oil or miscellaneous substances intentionally. Children with non-accidental self-poisoning often had acute psychological distress and an immediate preceding event which resulted in the poisoning event. Verbal abuse by parents, poor family relationships, psychiatric disorders in children and emotional disturbances were often predisposing factors. Four children had morbidity secondary to aspiration pneumonia, respiratory arrest, and cardiac arrhythmias. Case fatality rate was 14.3% among children with non-accidental selfpoisoning. Children with non-accidental poisoning by another person often did not have acute psychological distress prior to the poisoning event. When the perpetrator was one of the parents, those families had major disruptions in family relationships and functioning. Conclusion: Non-accidental poisoning in paediatric age could be either non-accidental self-poisoning or non-accidental poisoning by another person. The risk factors for the two types of non-accidental poisonings are different and multitudinous. These predisposing factors need to be further evaluated through community-based studies. [ABSTRACT FROM AUTHOR]

Background. Acute poisoning in children is a major preventable cause of morbidity and mortality in both developed and developing countries. However, there is a wide variation in patterns of poisoning and related risk factors across different geographic regions globally. This hospital based case-control study identifies the risk factors of acute unintentional poisoning among children aged 1−5 years of the rural community in a developing Asian country. Methods. This hospital based case-control study included 600 children. Each group comprised three hundred children and all children were recruited at Anuradhapura Teaching Hospital, Sri Lanka, over two years (from February 2012 to January 2014). The two groups were compared to identify the effect of 23 proposed risk factors for unintentional poisoning using multivariate analysis in a binary logistic regression model. Results. Multivariate analysis identified eight risk factors which were significantly associated with unintentional poisoning. The strongest risk factors were inadequate supervision (95% CI: 15.4–52.6), employed mother (95% CI: 2.9–17.5), parental concern of lack of family support (95% CI: 3.65–83.3), and unsafe storage of household poisons (95% CI: 1.5–4.9). Conclusions. Since inadequate supervision, unsafe storage, and unsafe environment are the strongest risk factors for childhood unintentional poisoning, the effect of community education to enhance vigilance, safe storage, and assurance of safe environment should be evaluated. [ABSTRACT FROM AUTHOR]

Background: Snakebite is a major problem affecting the rural poor in many of the poorest countries in the tropics. However, the scale of the socio-economic burden has rarely been studied. We undertook a comprehensive assessment of the burden in Sri Lanka. Methods: Data from a representative nation-wide community based household survey were used to estimate the number of bites and deaths nationally, and household and out of pocket costs were derived from household questionnaires. Health system costs were obtained from hospital cost accounting systems and estimates of antivenom usage. DALYs lost to snakebite were estimated using standard approaches using disability weights for poisoning. Findings: 79% of victims suffered economic loss following a snakebite with a median out of pocket expenditure of $11.82 (IQR 2–28.57) and a median estimated loss of income of $28.57 and $33.21 for those in employment or self-employment, respectively. Family members also lost income to help care for patients. Estimated health system costs for Sri Lanka were $ 10,260,652 annually. The annual estimated total number of DALYS was 11,101 to 15,076 per year for envenoming following snakebite. Interpretation: Snakebite places a considerable economic burden on the households of victims in Sri Lanka, despite a health system which is accessible and free at the point of care. The disability burden is also considerable, similar to that of meningitis or dengue, although the relatively low case fatality rate and limited physical sequelae following bites by Sri Lankan snakes means that this burden may be less than in countries on the African continent. [ABSTRACT FROM AUTHOR]

Acute kidney injury (AKI) is common following glyphosate surfactant herbicide (GPSH) self-poisoning. Serum creatinine (sCr) is the most widely used renal biomarker for diagnosis of AKI although a recent study in rats suggested that urinary kidney injury molecule-1 predicted AKI earlier and better after GPSH-induced nephrotoxicity. We explored the utility of a panel of biomarkers to diagnose GPSH-induced nephrotoxicity in humans. In a prospective multi-centre observational study, serial urine and blood samples were collected until discharge and at follow-up. The diagnostic performance of each biomarker at various time points was assessed. AKI was diagnosed using the Acute Kidney Injury Network (AKIN) definitions. The added value of each biomarker to sCr to diagnose AKI was assessed by the integrated discrimination improvement (IDI) metric. Of 90 symptomatic patients, 51% developed AKI and 5 patients who developed AKIN ≥ 2 died. Increased sCr at 8 and 16 h predicted moderate to severe AKI and death. None of the 10 urinary biomarkers tested increased above normal range in patients who did not develop AKI or had mild AKI (AKIN1); most of these patients also had only minor clinical toxicity. Absolute concentrations of serum and urinary cystatin C, urinary interleukin-18 (IL-18), Cytochrome C (CytoC) and NGAL increased many fold within 8 h in patients who developed AKIN ≥ 2. Maximum 8 and 16 h concentrations of these biomarkers showed an excellent diagnostic performance (AUC-ROC ≥0.8) to diagnose AKIN ≥ 2. However, of these biomarkers only uCytoC added value to sCr to diagnose AKI when assessed by IDI metrics. GPSH-induced nephrotoxicity can be diagnosed within 24 h by sCr. Increases in uCytoC and uIL-18 confirm GPSH-induces apoptosis and causes mitochondrial toxicity. Use of these biomarkers may help to identify mechanism specific targeted therapies for GPSH nephrotoxicity in clinical trials. [ABSTRACT FROM AUTHOR]

Background:Highly hazardous organophosphorus (OP) insecticides are responsible for most pesticide poisoning deaths. As they are removed from agricultural practice, they are often replaced by carbamate insecticides of perceived lower toxicity. However, relatively little is known about poisoning with these insecticides. Methods:We prospectively studied 1288 patients self-poisoned with carbamate insecticides admitted to six Sri Lankan hospitals. Clinical outcomes were recorded for each patient and plasma carbamate concentration measured in a sample to confirm the carbamate ingested. Findings:Patients had ingested 3% carbofuran powder (719), carbosulfan EC25 liquid (25% w/v, 389), or fenobucarb EC50 liquid (50% w/v, 127) formulations, carbamate insecticides of WHO Toxicity Classes Ib, II, and II, respectively. Intubation and ventilation was required for 183 (14.2%) patients while 71 (5.5%) died. Compared with carbofuran, poisoning with carbosulfan or fenobucarb was associated with significantly higher risk of death [carbofuran 2.2%; carbosulfan 11.1%, OR 5.5 (95% CI 3.0–9.8); fenobucarb 6.3%, OR 3.0 (1.2–7.1)] and intubation [carbofuran 6.1%; carbosulfan 27.0%, OR 5.7 (3.9–8.3); fenobucarb 18.9%, OR 3.6 (2.1–6.1)]. The clinical presentation and cause of death did not differ markedly between carbamates. Median time to death was similar: carbofuran 42.3 h (IQR 5.5–67.3), carbosulfan 21.3 h (11.5–71.3), and fenobucarb 25.3 h (17.3–72.1) (p = 0.99); no patients showed delayed onset of toxicity akin to the intermediate syndrome seen after OP insecticide poisoning. For survivors, median duration of intubation was 67.8 h (IQR 27.5–118.8) with no difference in duration between carbamates. Reduced GCS at presentation was associated with worse outcome although some patients with carbosulfan died after presentation with normal GCS. Conclusions:We did not find carbamate insecticide self-poisoning to vary markedly according to the carbamate ingested although the case fatality varied according to the concentration and formulation of the insecticide. Carbamate poisoning did not appear to be much less toxic than poisoning with some liquid OP insecticide formulations, e.g., chlorpyrifos EC40, that we have previously noted in these same hospitals (Lancet 2005, 366:1452–1459; QJM 2006, 99:513–522). Replacement of WHO Class II Toxicity OP insecticides in agriculture with high-strength liquid carbamate formulations may not substantially reduce case fatality after pesticide poisoning and, therefore, global suicide rates. [ABSTRACT FROM AUTHOR]

In 15% to 20% of self-poisoning cases, the pesticides used are purchased from shops just prior to ingestion. We explored how pesticide vendors interacted with customers at risk of self-poisoning to identify interventions to prevent such poisonings. Two strategies were specifically discussed: selling pesticides only to farmers bearing identity cards or customers bearing pesticide 'prescriptions'. Vendors reported refusing to sell pesticides to people thought to be at risk of self-poisoning, but acknowledged the difficulty of distinguishing them from legitimate customers; vendors also stated they did want to help to improve identification of such customers. The community did not blame vendors when pesticides used for self-poison were purchased from their shops. Vendors have already taken steps to restrict access, including selling low toxic products, counselling and asking customer to return the next day. However, there was little support for the proposed interventions of 'identity cards' and 'prescriptions'. Novel public health approaches are required to complement this approach. [ABSTRACT FROM AUTHOR]

Background. Pesticide self-poisoning causes one third of global suicides. Sri Lanka halved its suicide rate by banning WHO Class I organophosphorus (OP) insecticides and then endosulfan. However, poisoning with Class II toxicity OPs, particularly dimethoate and fenthion, remains a problem. We aimed to determine the effect and feasibility of a ban of the two insecticides in one Sri Lankan district. Methods. Sale was banned in June 2003 in most of Polonnaruwa District, but not Anuradhapura District. Admissions with pesticide poisoning to the district general hospitals was prospectively recorded from 2002. Results. Hospital admissions for dimethoate and fenthion poisoning fell by 43% after the ban in Polonnaruwa, while increasing by 23% in Anuradhapura. The pesticide case fatality fell from 14.4% to 9.0% in Polonnaruwa (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.41-0.84) and 11.3% to 10.6% in Anuradhapura (OR 0.93, 95%CI 0.70-1.25; p == 0.051). This reduction was not sustained, with case fatality in Polonnaruwa rising to 12.1% in 2006-2007. Further data analysis indicated that the fall in case fatality had actually been due to a coincidental reduction in case fatality for pesticide poisoning overall, in particular for paraquat poisoning. Conclusions. We found that the insecticides could be effectively banned from agricultural practice, as shown by the fall in hospital admissions, with few negative consequences. However, the ban had only a minor effect on pesticide poisoning deaths because it was too narrow. A study assessing the agricultural and health effects of a more comprehensive ban of highly toxic pesticides is necessary to determine the balance between increased costs of agriculture and reduced health care costs and fewer deaths. [ABSTRACT FROM AUTHOR]

The article presents a clinical trial to determine the efficacy of treating victims of intentional self-poisoning in developing countries with multiple-dose activated charcoal. Intentional self-poisoning has a tenfold higher mortality rate in developing countries due to the greater access to highly toxic pesticides and plants. The trials were conducted with patients at hospitals in Sri Lanka. The mortality rate among patients treated with charcoal did not improve. The authors cite the urgent need for an effective and affordable means of treatment.

Martin Wilks and colleagues compared the outcome of paraquat self-poisoning with the standard formulation against a new formulation following its introduction into Sri Lanka. [ABSTRACT FROM AUTHOR]