Therapeutic Management of Paraquat Poisoning at Colonial War

Final Technical Report
for
Research Project
Therapeutic Management of Paraquat Poisoning at
Colonial War Memorial Hospital.
Principal Investigator: Shayna Khan (Fiji National University:
College of Medicine, Nursing and Health Sciences)
2014.26.FNRERC.20.SU
July 2015
Final Technical Report
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THERAPEUTIC MANAGEMENT OF PARAQUAT
POISONING AT COLONIAL WAR MEMORIAL
HOSPITAL.
PHM 700: MAJOR RESEARCH PROJECT
FOR BACHELORS IN PHARMACY PROGRAM
DEPARTMENT OF HEALTH SCIENCES
Compiled By
Shayna Khan
S110351
Supervisor
Mr Arnold Ram
TOWARDS PHARMACY PROGRAM
COLLEGE OF MEDICINE, NURSING AND HEALTH SCIENCES
FIJI NATIONAL UNIVERSITY
SUVA, FIJI.
NOVEMBER 2014
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DECLARATION
This research project titled “Therapeutic Management of Paraquat Poisoning at Colonial War
Memorial Hospital” was carried out in partial fulfilment of Bachelors in Pharmacy Program. I
declare that this project does not contain any information or materials that have already been
published in order to graduate in another university or institution. To my knowledge, no
information or opinion that has already been published or written by other writers, were used
in the compilation of this project. All information and materials used are owned by the writer.
Materials taken from other sources are quoted as such and noted in the reference list.
3rd November 2014
Suva
……………………………
Shayna Khan.
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ACKNOWLEDGEMENT
The compilation of this Major Research Project entitled “Therapeutic Management of
Paraquat Poisoning” would not have been accomplished without the help of the following
people:
1. Mr Arnold Ram, my research supervisor, for his profoundly valued and constructive
suggestions towards the planning and completion of this research work.
2. The doctors, pharmacists and nurses for their participation in this study.
3. Health Information Unit (Ministry of Health) for providing data, to enable
completion of this study.
4. Mrs Eve De Silva, who enabled liaison with Mental Health Alliance of Fiji.
3rd November 2014,
Suva,
Shayna Khan
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TABLE OF CONTENTS
Topic Page
Declaration……………………………………………………………………………….2
Acknowledgement………………………………………………………………………..3
Table of contents…………………………………………………………………………4
Abstract…………………………………………………………………………………..5
CHAPTER 1: INTRODUCTION
1.1. Background Information…………………………………………………………….6-7
1.2. Statement of Problem……………………………………………………………….7-9
1.3. Aim …………………………………………………………………………………10
1.4. Objectives…………………………………………………………………………...10
1.5. Advantages …………………………………………................................................10
CHAPTER 2: LITERATURE REVIEW………………………………………………...11-16
CHAPTER 3: RESEARCH METHODOLOGY
3.1 Study type and variables………………………………………………………….….17
3.2 Sampling …………………………………………………………………………….17
3.3 Data collection……………………………………………………………………….18
3.4 Data Processing and analysis……………………………………………….………..18
3.5 Ethical Issues………………………………………………………………..……….19
CHAPTER 4: RESULTS
4.1 Results……………………………………………………………….……………….20 – 27
4.2 Discussion…………………………………………………………….………….......28 – 29
4.3 Conclusion…………………………………………………………….……………...30
4.4 Recommendation and Limitations………………………………….…………….…..31
APPENDIX
1. Annex 1 – References…………………………………………………………………..32-34
2. Annex 2 – Information Sheet…………………………………………………………...35-36
3. Annex 3 – Consent Form……………………………………………………………….37
4. Annex 4 – Data Collection Tool (Questionnaires, Table Form)………………………..38-39
5. Annex 5 – Approval Letter……………………………………………………………...40-42
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ABSTRACT
BACKGROUND: Paraquat is a very effective herbicide that has been marketed since 1962 by
a company called Syngenta. In Fiji paraquat is available as a concentrated solution and is sold
under the brand names Gramoxone®, Royal®, Gramoxone Extra® and Agazone®. These
preparations are then diluted and sprayed in plantations.
AIM: To determine the therapeutic management of paraquat poisoning at Colonial War
Memorial Hospital.
OBJECTIVES: To determine the gender, ethnicity and age groups of the patients diagnosed
with paraquat poisoning in Fiji from the year 2009-2013. To determine how paraquat poisoning
is diagnosed. To determine the treatment options available for paraquat poisoning patients
reporting to Colonial War Memorial Hospital.
METHODS: A non-experimental descriptive cross-sectional study was conducted where
convenient sampling was done of doctors, nurses and pharmacist. A total of 20 self
administered questionnaires were distributed and 14 were received. Data regarding gender,
ethnicity and age groups of paraquat poisoning patients in Divisional hospitals from the year
2009-2013 was sourced from Health Information Unit of Ministry of Health. Additional data
was sourced from Mental Health Alliance of Fiji.
RESULTS: It was found that the gender, ethnicity and age groups most susceptible to paraquat
poisoning were males, Indo-Fijians and in age group of 26 years and over respectively.
Paraquat poisoning patients at Colonial War Memorial Hospital are diagnosed by clinical
symptoms and information provided by relatives. These patients are treated using fullers Earth,
activated charcoal and mannitol.
CONCLUSION: The fact that paraquat poisoning does not have an antidote, coupled with the
toxicity of paraquat, pose a challenge in the management of paraquat poisoning patients. There
is a need for more reliable diagnostic tests and further research is needed to determine the
possibility of banning paraquat use.
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CHAPTER 1: INTRODUCTION
1.1 BACKGROUND INFORMATION
Paraquat is a very effective herbicide that has been marketed since 1962 by a company called
Syngenta. In Fiji paraquat is available as a concentrated solution and is sold under the brand
name Gramoxone® which contains 20% w/v paraquat dichloride(1). Other brands of paraquat
used in Fiji include Royal® brand paraquat, Gramoxone Extra® (contains 27.6%w/v of paraquat
dichloride) and Agazone®. These preparations are then diluted and sprayed in plantations.
Other brands of paraquat include Crisquat®, Dextrone®, Herba-xone®, Ortho Weed®, and
Spotkiller®[23]. Paraquat and its salts are listed as poisons under part II of the poisons list in the
third schedule of the Pharmacy and Poisons Act.
Initially death from paraquat resulted from accidental ingestion. However, as the toxicity of
paraquat became known, deaths due to intentional paraquat poisoning began to arise(2). In order
to hinder ingestion, some preparations of paraquat contain an emetic, or a laxative and some
contain a malodorous agent. In developed countries, paraquat poisoning is not widely utilised
as a method of inflicting self harm however, in developing countries like Fiji intentional
paraquat poisoning is relatively common. This is because paraquat is a widely used herbicide
in Fiji. It is easily accessible to people; it may be bought from most hardware stores (only
licensed storekeepers are allowed to sell specific poisons such as paraquat) or from the various
agriculture departments representing the Ministry of Agriculture.
A dose of 10 to 15mL of the concentrate (20%w/v) is considered to be lethal
(3)
. Clinical
manifestations of paraquat poisoning include convulsions (CNS involvement), jaundice (liver
toxicity), gastro-intestinal ulceration and bleeding, respiratory distress (due to pulmonary
oedema), hypovolaemic shock, hypotension and cardiac failure which eventually lead to
death(2).
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In addition to being highly toxic when ingested, prolonged exposure of skin to concentrated
solution of paraquat while spraying the herbicide can also be fatal. Paraquat becomes safe
when it comes into contact with soil thus fullers’ earth is one of the treatment options
administered to paraquat poisoning patients.
1.2 STATEMENT OF THE PROBLEM
1.2.1 The Research Problem
The number of attempted suicide and suicide fatalities are increasing every year in Fiji. With
each suicide attempt individuals are stigmatised, families are devastated, economies lose
productive workers, and the health sector incurs extra costs for providing care. Extensive
research has been conducted regarding suicide in Fiji generally; however, there is a lack of
research that explores the individual methods of self-harm separately.
This research will explore paraquat as a method of self-harm as seen from the health care
perspective. The research is based on intentional paraquat poisoning in Fiji focusing in
particular on the therapeutic management of paraquat poisoning patients reporting to the
Colonial War Memorial Hospital.
1.2.2 The Solutions
One solution that had been tried internationally for preventing paraquat use and sale was the
launch of the pesticide action networks (PAN) Dirty Dozen Campaign in 1985(4). PAN
international is a company based in the United Kingdom and it had come up with a list of
extremely hazardous pesticides. Paraquat was among this list and the company was advocating
that all pesticides contained within the list should be banned, or its sale restricted and safer
pesticides be used as alternatives.
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Furthermore, non-governmental organisations of Asia, America and Europe had launched the
‘Stop Paraquat’ campaign in 2002(5). The campaign targeted Syngenta a company based in
Switzerland that supplies pesticides to many countries. The stop paraquat campaign was aimed
at preventing production of harmful pesticides by Syngenta. As a result of this campaign,
Malaysia became the first Asian country to ban paraquat use and sale. According to Watts (6)
“in 2006 Malaysia reversed the ban and allowed its use in oil palm plantations. In 2007 the
Malaysian government announced that the ban was postponed until further notice”. The
situation in Malaysia teaches us that banning paraquat might seem to be the best solution;
however, it failed to eradicate the problem. This is because trade in paraquat is still rife even
in countries that have banned paraquat.
One solution that had been tried locally was increasing public awareness. However, the
publicity of paraquat as a suicide agent seemed to exacerbate the problem. The addition of an
emetic and stenching agent to paraquat to make it less palatable failed to decrease paraquat
induced suicides in Fiji
(7)
. Efforts to use an alternative to paraquat proved futile as the
alternative was more expensive than paraquat. In addition to this banning the import of paraquat
has not received much approval as paraquat is the major pesticide utilised in the sugar industry
in Fiji.
According to a fact sheet prepared by the Pesticide Action Network Asia and the Pacific(8), as
of February 2012 paraquat is banned in a total of 36 countries. Unfortunately Fiji is not part of
these 36 countries; however, Fiji has been listed among the countries that have restricted
paraquat use.
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1.2.3 Relevance of the Problem to National/Local Activities
Paraquat ingestion can become fatal very quickly as it is extremely toxic to humans. Finding
out about the therapeutic management of paraquat poisoning will help ascertain the different
types of treatment available and the expertise required by health care staff when providing
treatment.
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1.3. AIM OF THE RESEARCH:
To determine the therapeutic management of paraquat poisoning at Colonial War Memorial
Hospital.
1.4. OBJECTIVES:
1. To determine the demographic details (such as gender, ethnicity and age groups) of the
patients diagnosed with paraquat poisoning in Fiji from 2009-2013.
2. To determine how paraquat poisoning is diagnosed.
3. To determine the treatment options available for paraquat poisoning patients reporting
to Colonial War Memorial Hospital.
1.5. ADVANTAGES:
The results may be used to review the therapeutic management of paraquat poisoning in other
hospitals around the country. The results may also be used in future should Fijian policy makers
consider banning paraquat imports altogether instead of just restricting its use.
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CHAPTER 2: LITERATURE REVIEW
Suicide is defined as death due to intentional self-inflicted injury. Attempted suicide is defined
as intentional self-inflicted injury not resulting in death(9). According to the World Health
Organisation(10), approximately one million people commit suicide each year worldwide which
is about one death every 40 seconds or 3000 per day. ‘Suicide is among the three leading causes
of death among those aged 15-44 years in some countries, and the second leading cause of
death in the 10-24 years age group’(10). At one point, the suicide rates of Fiji were considered
to be the second highest in the world behind rural China (11).
Statistics released in the year 2010 reveal that hanging, ingesting poisons and drug overdose
are the most common methods of committing suicide in Fiji(12). This fact is reciprocated in a
study done by Hanson(13). In this study, cases of hospitalised clients who were referred to the
Pacific Counselling and Social Services of Fiji were reviewed. Out of all the cases reviewed,
2.7% represented cases of attempted suicide. Among these cases, the most common method of
attempted suicide was intentional self poisoning (78.4%) followed by hanging, strangulation
and suffocation (10.5%).
Studies conducted by Peiris John(14) and Aghanwa(15) explored the substances used in
intentional poisoning. In the study conducted by Peiris-John(14), it was found that substances
used for intentional poisoning included chemicals (41.2%), drugs (35.3%) and pesticides
(23.5%). One limitation of this study was that the records did not state the specific chemicals,
drugs and pesticides used.
The study conducted by Aghanwa(15), however, did not have this limitation. In the study
conducted by Aghanwa, deliberate self poisoning patients were examined in CWM hospital.
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Thirty one (31) patients with deliberate drug overdose and 27 patients with self poisoning were
compared. The study found that Paracetamol (35.5%) and Paraquat (29.7%) were the most
commonly used agents in self poisoning.
In most cases, paraquat poisoning is ascertained by the containers brought in by relatives of the
patient. This is also used to determine the amount of paraquat ingested. At times the containers
are not brought in but the doctor is just informed by the relatives and he takes their word for it.
Mistakes in identifying the poison have occurred as a result of this.
A case report in one study (17), highlighted this fact. ‘A 27 year old woman was sent to a local
hospital after ingesting 30mL of herbicide. According to her relatives, she had ingested
glyphosate, and she was therefore treated with gastric lavage, atropine and fluid administration.
The patient was given oxygen before it was clear that the herbicide was paraquat.’ In paraquat
poisoning, administration of oxygen exacerbates the problem. In the above case, the patient
had survived, however, misdiagnosis can prove fatal to patients.
A test that can be used to diagnose paraquat poisoning is the bicarbonate and sodium dithionate
urine test. ‘In alkaline medium, sodium dithionite reduces paraquat to a blue radical. If the urine
paraquat concentration is more than 1mg/L, the urine will appear blue and this finding alone
indicates a very poor prognosis’(16) .
Plasma paraquat concentrations are also measured but these require quantitative analysis using
complex machines and techniques such as spectrophotometry and HPLC, which is beyond the
scope of local hospital laboratories.
The search for an antidote for paraquat poisoning is still on-going. Since there is no antidote,
standard treatments are often altered according to the patients’ needs in an effort to obtain a
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better prognosis. It is suggested that part of the lethality of paraquat is due to the lack of
effective treatment (10,20).
‘There is no specific treatment for paraquat poisoning and the immediate aim is to remove or
inactivate the paraquat’(3). Initially treatment involves removal of contaminated clothing and
irrigation of eyes and skin that is exposed. A precaution to be taken is to avoid giving oxygen
to the patient initially as it accelerates pulmonary toxicity of paraquat (3).
In a study conducted by Winchester(2), four main aims for management were listed: to prevent
gastro-intestinal absorption, extract paraquat from blood, prevent cellular damage by oxygen
radicals and in some cases to suppress the immune system. The study then elaborated on the
specific agents used to achieve these aims. ‘Fuller’s earth, bentonite and activated charcoal are
usually
administered
to
prevent
gastrointestinal
absorption.
Haemodialysis
and
haemoperfusion are conducted in order to remove paraquat from blood. Antioxidants such as
vitamin C & E, salicylic acid and N-acetylcysteine are used to prevent further cellular damage.
In addition to this glucocorticoids (cyclophosphamide, methylprednisolone, dexamethasone)
are used to suppress the immune system and prevent the acute inflammatory response from
occurring.’
In some studies, patients are given a cocktail of treatments covering all the bases, that is to
prevent GI absorption, prevent generation of oxygen radicals, immunosuppression, and
removal of paraquat from blood while some studies investigate the superiority of certain
methods of treatment over others.
In a study conducted by Sandhu(18), 17 patients were studied over a 5 year period. All these
patients received the same standard treatment: gastric lavage using tap water (5mL/kg body
weight), activated charcoal (1g/kg dissolved in 250-400mL of water), hydrocortisone injection
100mg IV 6 hourly for 3-5 days, Vitamin C 500mg twice daily and Vitamin E 400mg twice
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daily. The study recorded a 35% mortality rate using this regimen. The causes of mortality in
these patients were attributed to respiratory failure, multi-organ failure and shock.
In a study done by Li et al (19) a review was done to assess the effects of glucocorticoid with
cyclophosphamide on mortality in patients with paraquat induced lung fibrosis. Only RCTs
were included in this review. All patients were to receive standard care, plus the intervention
or control. The intervention was glucocorticoid with cyclophosphamide in combination versus
a control of a placebo, standard care alone or any other therapy in addition to standard care.
They reviewed 3 randomised controlled trials with a combined total of 164 patients who had
moderate to severe paraquat poisoning. They calculated the relative risk (0.72) and found that
the group receiving cyclophosphamide and steroids with standard care had a reduced risk of
death of about 28% compared with patients given standard care alone. However, the RCT
conducted were small and one of them was of low methodological quality so the conclusions
drawn from the results have some degree of uncertainty.
Gawarammama(16) suggests that management of paraquat poisoning is determined by two
philosophies. Firstly, when there is no hope of recovery palliative care is provided using lowrisk intervention such as charcoal, IV fluids and maybe an antioxidant. Secondly, when it is
recognised that the outcome is dire and that no treatment is likely to be worse than the disease,
then treatment includes haemoperfusion or haemodialysis, immunosuppresion and a mixture
of treatments.
However, a report by the World Health Organisation(10) regarding clinical management of acute
pesticide intoxication states that the treatment should suit the patient needs.
Studies(10,16,22) suggest that more research is needed to determine effective treatment guidelines
and appropriate therapeutic doses. ‘We would encourage anyone seeing a substantial number
of paraquat poisonings to adopt a consistent strategy for a number of patients, measure the
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paraquat concentration and report their outcomes’(10). ‘There is a great need of additional and
better quality information related both to the extent and nature of pesticide poisoning and its
clinical and public health management’(16). ‘If the occurrence and lethality of pesticide
ingestions cannot be prevented then improved medical management is crucial(22).’
The prognosis of a patient who has ingested paraquat depends on the amount that is ingested.
Winchester(2) classified paraquat ingestion as moderate and severe poisoning. In his study
moderate poisoning was defined as ingesting small quantities (4-30mL of the liquid
concentrate) whereas severe poisoning was defined as ingesting massive amounts (more than
30mL of the concentrate). According to Winchester(2), death in patients who ingest moderate
amounts occurs within one to two weeks whereas death in patients who ingest massive amounts
occurs within several hours to a few days.
The classification and prognosis outlined in Martindale(3) differs slightly from that of
Winchester(2). Martindale(3) suggests that most patients who ingest 7.5 to 15mL of the
concentrate die within 2 or 3 weeks after ingestion. Patients who ingest more than 15mL of the
concentrate die 1-7 days after ingestion.
The study done by Gawarrammana(16) goes on to explain the relationship between the amount
ingested and the prognosis of the patient. Gawarammana(16) explains that ingestion of small
quantities initially affects the kidney and lungs and toxicity of other organs occur gradually,
thus these patients live for a few weeks. Ingestion of large amounts simultaneously affects the
lungs, heart, kidneys, liver and the brain leading to multi-organ failure, thus these patients only
live a few hours or days.
Another study(18) conducted by Sandhu et.al reviewed the outcome of paraquat poisoning
patients admitted in Dayanand Medical College and Hospital in Ludhiana over a 5 year period
(1998-2002). In this study, the degree of poisoning was assessed by number of mouthful of
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paraquat concentrate ingested i.e. <1 mouthful as mild, 1 mouthful as moderate and 2 or more
as severe. In this study, 1 mouthful was equated to approximately 20mL of paraquat.
The different classification methods are creating confusion and differences in classifying
patients among different researchers. The study outlined below is an example reflecting this
confusion.
A study
(17)
conducted in China reporting the successful treatment of patients with paraquat
intoxication, used a different classification to compare its results with. This study utilised a
method that compared the milligrams of paraquat ion ingested per kg of body weight. They
classified mild poisoning as ingesting < 20mg of paraquat ion/kg body weight, moderate to
severe poisoning as ingesting 20-40mg of ions/kg and acute fulminant poisoning as >40mg of
ion/kg body weight. The study then went on to say that since its patients had ingested >20mL
of concentrate, according to the classification above, they categorised it as acute fulminant
poisoning. Their classification was based on mg of ions /kg of body weight, and equating
>20mL of concentrate as fulminant poisoning is contradictory as the measures are totally
different.
Two studies (21,22) (one being a large prospective cohort study consisting of 451 patients and the
other that did a systematic review of 17 studies) highlight the fact that a validated method of
predicting outcome of patients is needed so that appropriate treatment may be selected based
on likelihood of survival. Furthermore, once methods of predicting outcomes are validated, it
may be used to assess the effectiveness of new treatments in improving prognosis.
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CHAPTER 3: RESEARCH METHODOLOGY
3.1. STUDY TYPE AND VARIABLES
A non-experimental descriptive cross-sectional study design was used.
3.2. SAMPLING
Convenient sampling was done of doctors, nurses and pharmacists who were then given
questionnaires.
Personnel
Inclusion Criteria
Wards/ Departments
where selection was
made.
Doctors and nurses working All other hospital staff
working in the wards
in Accidents and
apart from those stated in
the inclusion criteria were
Emergency Ward, Stress
not given the
questionnaire.
Management Ward,
Intensive Care Unit were
included.
Pharmacists working in
inpatients and outpatients
department.
Exclusion Criteria
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3.3. DATA COLLECTION TECHNIQUES
Data collection commenced after written approval was obtained from the Department
Research Committee (DRC), College Research and Ethics Committee (CREC) and the
Ministry of Health: National Health Research Committee (NHRC). Approval was also
obtained from the Medical Superintendent of Colonial War Memorial Hospital before
conducting the research. Data collection commenced on 11th August 2014.
Twenty (20) self-administered questionnaires were distributed to doctors (7), nurses (7) and
pharmacists (6) to obtain data regarding treatment. The questionnaire contained seven
questions and has been enclosed in Annex 4.
De-identified data (regarding gender, ethnicity and age groups) of patients diagnosed with
paraquat poisoning (including data from Labasa, Lautoka and Colonial War Memorial
hospital) was sourced from Health Information Unit of Ministry of Health upon approval. The
data was used for demographic mapping of paraquat poisoning cases in Fiji. Additional data
regarding demographics was sourced from Mental Health Alliance of Fiji.
3.4. DATA PROCESSING AND ANALYSIS
EpiInfo software was used to analyse the data collected from the questionnaires. The central
tendencies of this data was also calculated. Microsoft Excel software was used to present the
analysis in the form of graphs and pie-charts.
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3.5. ETHICAL CONSIDERATION
Prior to administering questionnaires, participants were provided with a participant
information sheet (Annex 2) and were required to fill the consent form (Annex 3). All data
obtained during the course of the research was kept confidential. Participant names were not
recorded or revealed. The data collection tools were kept in a file. The file was stored in a
locked drawer.
Furthermore, the analysis of results was kept in a password protected computer in order to
restrict access. Questionnaire answers were coded using the EpiInfo software. The analysis of
the results were presented in the form of graphs and pie charts, therefore no one was able to
connect specific answers to any one individual.
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CHAPTER 4: RESULTS
4.1. RESULTS
Figure 1: Trends of paraquat poisoning cases in past 6 years.
Paraquat Poisoning trends (past 6 years)
60
50
51
49
51
40
39
30
21
20
17
10
0
2008
2009
2010
2011
2012
2013
Explanation: Paraquat poisoning cases in the past 6 years have been increasing except in the
year 2011 when a decrease in cases was reported.
Figure 2: A comparison of Paraquat Poisoning cases between genders.
Paraquat poisoning cases by Gender
35
30
33
32
29
25
23
20
15
10
17
18
16
15
13
5
22
6
4
0
2008
2009
2010
Male
2011
2012
2013
Female
Explanation: In all 6 years, male patients were greater in number than female patients. In
the past 6 years 145 cases (64%) reported were Male whereas 83 cases (36%) reported were
female.
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Figure 3: A comparison between ethnicity of Paraquat Poisoning cases.
Paraquat Poisoning Cases by Ethnicity
100%
0
1
1
0
1
90%
80%
70%
60%
50%
14
40
44
14
43
36
40%
30%
20%
10%
0%
6
9
2
2008
6
2009
2010
I-taukei
8
3
2011
Fijian [Indo]
2012
2013
Others
Explanation: Indo Fijians make up majority of the paraquat poisoning cases. In the past 6
years, cases revealed that 34 (15%) were I-taukei , 191 (84%) were Indo-fijians and 3 (1%)
were Others.
Figure 4: Comparison of paraquat poisoning cases by age group
Distribution of paraquat poisoing cases by age group
35
30
25
20
15
10
5
0
0-16
16-25
2008
2009
2010
2011
26+
2012
2013
Explanation: The highest number of cases reported was in the year 2013 and occurred in
patients 26 years and over. However, reported cases of patients in the 16-25 age group
increased in the year 2009 and 2010. Overall in the past 6 years, 21 cases (9%) were
reported in 0-16 age group, 82 cases (36%) reported for 17-25 year age group, and 125
(55%) cases were reported for 26 years and over age group.
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Figure 5: A comparison between attempted and completed paraquat poisoning cases.
A comparison b/w attempted and
completed paraquat poisoning cases
60
50
40
50
45
30
30
20
18
10
7
10
4
17
1
22
21
3
0
2008
2009
2010
2011
Attempted
2012
2013
Completed
Explanation: The attempted cases of paraquat poisoning has been increasing for the past 3
years. In the past 2 years, a greater number of completed paraquat poisoning cases was
recorded. In total, in the past 6 years 61cases (27%) were reported as attempted suicide,
and 167 cases (73%) were reported as completed suicide cases due to paraquat poisoning.
The percentage of completed suicide cases, reflects the lethal nature of paraquat.
Figure 6: Cases Reported in Divisional Hospitals
Cases Reported in Divisional Hospitals
25
20
15
10
5
0
2009
2010
2011
CWMH
Lautoka
2012
2013
Labasa
Explanation: In the past 5 years Colonial War Memorial Hospital has seen the highest
number-79 (55%) of reported cases of poisoning due to herbicides/fungicides. Lautoka
Hospital reported 20 cases (14%) whereas in Labasa Hospital 44 cases (31%) of poisoning
due to herbicides/fungicides was recorded. Thus poisoning by herbicides/fungicides is not
only confined to the western and northern areas of Fiji, where most of the farming
communities reside. It is also happening in urban areas such as Suva.
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Figure 7. Number of cases observed in a year.
Coded: 2= one-ten cases
3= eleven-twenty cases
7= greater than 50 cases.
Explanation: 85.7% of participants have observed about 1-10 cases in a year. 7.1% of
participants have observed between 11-20 cases in a year whereas 7.1% of the participants
have observed greater than 50 cases.
Figure 8. Diagnosis of Paraquat Poisoning Patients
Explanation: 9 participants said that diagnosis was made according to clinical symptoms. 1
participant said that other biochemical tests were done. Majority (11) participants said that
diagnosis was done according to information provided by relatives.
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Figure 9: Treatment Options Utilised by Colonial War Memorial Hospital (CWMH)
Explanation: The most commonly used treatment option is Fullers Earth (all 14 participants
chose this option), followed by activated charcoal (10 participants) and mannitol (8
participants). 1 participant said that Vitamins C and E may also be given. Analgesics and IV
fluids were also given as answers although these options were not provided in the
questionnaire.
Figure 10: Guidelines used to treat paraquat poisoning patients
Guidelines Utilised for management
of paraquat poisoning patients
SUICIDE PROTOCOL
1
ANTIDOTE HANDBOOK
1
INTERNAL MEDICINE GUIDELINE
1
TREATED ACCORDING TO CLINICAL PRESENTATION
3
CONSULTATION WITH OVERSEAS POISON CENTRES
1
MARTINDALE
1
EMERGENCY GUIDELINES
6
0
1
2
3
4
5
6
7
Explanation: The most commonly used guidelines utilised is emergency guidelines (6
participants mentioned it), followed by treatment according to clinical presentation (3
participants), other treatments that were mentioned by single (1) participants included using
martindale, consultation with overseas poison centres, using the internal medicine guideline,
using an antidote handbook and following the suicide protocol.
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Figure 11: Change in Treatment
Explanation: Majority of participants (83.3%) said that amount of paraquat ingested did not
change treatment options. The reason given was that there is a set protocol for
management regardless of whether a sip or a gulp of paraquat is ingested. 16.7% said that
treatment options changed according to amount ingested. These participants explained that
significant paraquat poisoning carried poor prognosis and in these patients there are less
treatment options available.
Figure 12: Drug Shortage
Explanation:
Most participants (78.6%) felt that treatment was not hindered by drug shortages. 21.4% of
participants said that there had been drug shortages and Fullers Earth was usually the
treatment short in supply. However, at the time, other treatments such as activated
charcoal were available, so treatment wasn’t necessarily hindered.
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Figure 13: Opinion on Banning Paraquat
Explanation:
Majority (57.1%)
of participants
felt that paraquat
use should be
banned. 42.9% of
participants felt
that paraquat
should not be
banned.
Figure 14: Reasons given by participants saying yes:
Ban paraquat use
33%
34%
Fatal
Commonly abused
Safer alternatives available
33%
Figure 15: Reasons given by participants saying no:
Do not ban paraquat
25%
25%
Others are just as lethal
create awareness instead
farming affected
50%
Explanation: Some
reasons provided for
banning paraquat
were: that it was
fatal (34%), it is
commonly abused
(33%), alternatives
and more
environmentally
friendly herbicides
are available eg.
Roundup-glyphosate
(33%).
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Discussion: Some reasons for not banning paraquat include: other herbicides can also be lethal
(banning one won’t solve the problem) [25%], stringent laws and awareness should be created
instead of banning it [50%], farming will be adversely affected, observed that farmers utilising it don’t
usually abuse it, the people that abuse it just buy it for the sake of suicide [25%].
Comparison between 2 data sets: Mental Health Alliance of Fiji (MHAF)
& Health Information Unit (HIU)
Table 1: Percentage Distribution of paraquat poisoning cases (MHAF)
Variable
Total Finding (past 6 years)
Gender
145 (64%) Male, 83 (36%) Female
Ethnicity
I-taukei 34 (15%), Indo-fijians 191 (84%)
Others 3 (1%)
Age Group
21(9%) aged 0-16 years,82 (36%) aged 17-25
years, 125 (55%) aged 26 years and over
Table 2: Percentage Distribution of Herbicide and Fungicide poisoning cases (HIU)
Variable
Total Finding (past 5 years)
Gender
111 (59%) Male, 76 (41%) Female
Ethnicity
27 (15%) Fijian, 156 (83%) Indo-Fijian, 4
(2%) Others, 0 Rotumans.
Age Group
1 (0.5%) <1 year, 3 (2%) 1-4 years,0 in 5-9
years, 2 (1%) 10-14 years, 30 (16%) 15-19
years, 36(19%) 20-24 years, 37 (20%) 25-29
years, 27 (15%) 30-34 years, 14 (7%) 35-39
years, 8(4%) 40-44 years, 12(6%) 45-49
years, 5(3%) 50-54 years, 3(2%) 55-59
years, 4(2%) 60-64 years, 1 (0.5%)65-69
years, 4 (2%) in 70 years and over.
Discussion: Data from both sources indicate that the gender, ethnicity and age groups most
susceptible to poisoning (either from paraquat or other herbicides/fungicides) was found to
be males, Indo-fijians and in age group of 26 years and over (for paraquat) and between
2529 years (for herbicides and fungicides) respectively.
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4.2. DISCUSSION
The use of paraquat to inflict self-harm is a major concern as the number of paraquat
poisoning cases reported are increasing (figure 1). The results (figure 2, 3 & 4) indicate that
the gender, ethnicity and age groups most susceptible to paraquat poisoning was found to be
males, Indo-fijians and in age group of 26 years and over respectively. These results were
also reflected in cases of poisoning by herbicides and fungicides reported at Divisional
Hospitals (Table 1 & 2).
The results of this study are similar to another study that was conducted by Peiris-John(14),
where the incidence and characteristics of poisoning fatalities and hospital admissions in Viti
Levu among I-Taukei and the Indo-Fijians were compared. The study found that most
intentional poisonings occurred among women (58.3%), over two thirds of poisonings
occurred among people of Indian ethnicity and was most common within the 15-29 year age
group.
The number of completed suicide cases due to paraquat poisoning has been increasing
(Figure 5) which gives an indication about the lethality of the herbicide. Contrary to popular
belief, paraquat poisoning is not only prevalent predominantly in farming communities such
as western or northern divisions, it also exists in urban areas such as Suva (Figure 6).
Therapeutic management of paraquat poisoning patients at Colonial War Memorial Hospital
is initiated in the Accidents and Emergency Department. About 1-10 cases are commonly
observed in a year (figure 7). A diagnosis of paraquat poisoning is mostly made according to
clinical symptoms of the patient and also on information provided by relatives (figure 8).
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These methods are not very reliable as illustrated by a case report in one study (17). ‘A 27 year
old woman was sent to a local hospital after ingesting 30mL of herbicide. According to her
relatives, she had ingested glyphosate, and she was therefore treated with gastric lavage,
atropine and fluid administration. The patient was given oxygen before it was clear that the
herbicide was paraquat.’
According to figure 9 the most commonly used treatment options utilised are Fullers Earth,
activated charcoal and mannitol. Analgesics and IV fluids are also given for symptomatic relief.
The treatment is given according to clinical presentation and according to protocol outlined in
the Emergency Drug Guidelines (figure 10). Patients are treated in the Accidents and
Emergency department until the patient is in a stable condition. Once the patient is stable, they
are shifted to the stress management ward where the suicide protocol is followed. According
to the suicide protocol the patient is classified as either Severe Suicidal Risk (SSR), Possible
Suicidal Risk (PSR) or Watch Closely (W/C).
The results regarding treatment options and guidelines in this study is consistent with other
studies: “The search for an antidote for paraquat poisoning is still on-going. Since there is no
antidote, standard treatments are often altered according to the patients’ needs in an effort to
obtain a better prognosis. It is suggested that part of the lethality of paraquat is due to the lack
of effective treatment” (10,20).
The treatment options do not change according to the amount of paraquat ingested (figure
11). Furthermore, results reflect that drug shortages have not been implicated in causing
hindrance to treatment of paraquat poisoning patients (figure 12). A solution to paraquat
poisoning could be to ban the use of paraquat. Opinions vary in this regard (figure 13). Both
participants who support the statement that paraquat use should be banned, and those that
oppose the statement have provided valid reasons for their answers (figure 14 & 15).
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4.3. CONCLUSION
The vulnerable patient groups that are commonly involved in paraquat poisoning cases are
males, Indo-fijians, and young people aged 26 years and over. Thus future campaigns regarding
the dangers of paraquat use could be focused mainly on these groups.
The fact that paraquat poisoning does not have an antidote, coupled with the toxicity of
paraquat, pose a challenge in the therapeutic management of paraquat poisoning patients.
This challenge is exacerbated by the rising number of paraquat poisoning cases observed in
recent years.
There is a need for more reliable diagnostic tests and further research is needed to determine
the possibility of banning paraquat use.
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4.4. LIMITATIONS
•
The data only reflects the number of cases that have been reported. The study does not
reflect unreported suicide cases due to paraquat ingestion.
•
Doctors, nurses & pharmacists who were not working in the wards/departments
specified, that may have encountered paraquat poisoning cases have not been included
in this study.
RECOMMENDATION
•
There is a need for more reliable diagnostic tests and further research is needed to
determine the possibility of banning paraquat use.
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APPENDIX
ANNEX 1- REFERENCES
1. Goundar, D.S et.al. Paraquat Toxicity In Man. Fiji Medical Journal, 1984: 74-75.
2. Winchester J. Paraquat Poisoning. UpToDate.Com.[cited 21st January 2013]; Available
from: http://www.fsm.ac.fj/index.php?option=com_wrapper&ltemid=343
3. Sweetman SC,editor. Martindale. 37th ed. London: Pharmaceutical Press: 2011.
4. Pesticide Action Network. Germany.2003. [cited 9th March 2013]; Available from:
<http://www.pan-germany.org/download/fact_paraquat2.pdf>
5. Watts M .Pesticide Action Network Asia and the Pacific. Malaysia.2011 [cited 9th
March 2013]; Available from:
< http://wssroc.agron.ntu.edu.tw/note/Paraquat.pdf>
6. Paraquat in Fiji-What is to be Done. Fiji Medical Journal. 1984;12(5):72-3.
7. Watts M. Pesticide Action Network Asia and the Pacific, Malaysia.2012. [cited 9th
March 2013]; Available from:
<http://www.groundwork.org.za/Resources/FactSheets/PAN%20AP/ pesticidesfactsheet-hhpsparaquat.pdf>
8. Booth H. Gender, Power and Social Change: Youth Suicide Among Fiji Indians and
Western Samoans. The Journal of the Polynesian Society. 1999;108(1):39-68.
9. WHO Suicide Prevention (SUPRE). World Health Organisation. [cited 8th April
2013];
Available
from:
http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/
10. Clinical Management of Acute Pesticide Intoxication: Prevention of Suicidal
Behaviours. Geneva: World Health Organisation; 2008.
11. Smith, M. The Facts of Suicide.The Fiji Times. 1st October 2011. [cited 4th April
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2013]; Available from: http://www.fijitimes.com/story.aspx?id=182096
12. Fiji Facts and Figures. Fiji Bureau of Statistics; 2010.[cited 8th April 2013];
Available from: http://www.statsfiji.gov.fj/releases/FFF2010.pdf
13. Henson C, Taylor A, Cohen J, Waqabaca A, Chand S. Attempted Suicide in Fiji.
Suicidology Online. 2012;3:83-91.
14. Peiris-John R,Kafoa B, Wainiqolo I, Reddy RK, McCaig E, Ameratunga SN.
Population-based characteristics of fatal and hospital admissions for poisoning in Fiji
: TRIP Project-11. 2012 [cited 4th April 2013]; Available from:
http://injuryprevention.bmj.com/content/early/2013/01/24/injuryprev-2012040651.full
15. Aghanwa HS. Attempted suicide by drug overdose and by poison-ingestion methods
seen at the main general hospital in the Fiji Islands: a comparative study. General
Hospital Psychiatry. 2001 ;23(5):266-71
16. Gawarammana IB, Buckley NA. Medical Management of Paraquat Ingestion. British
Journal of Clinical Pharmacology. 2011;72: 745-757.
17. Zhang Q, Wu W, Lu Y, Wand J, Shang A, Yao F, Chen Y. Successful Treatment of
patients with paraquat intoxication: three case reports and review of the literature.
Journal of Zhejiang University. 2012;13(5):413-418.
18. Sandhu JS, Dhiman A, Mahajan R, Sandhu P. Outcome of Paraquat Poisoning-a five
year study. Indian Journal of Nephrology. 2003;13:64-68.
19. Li LR, Sydenham E, Chaudhary B, You C. Glucocorticoid with cyclophosphamide for
paraquat-induced lung fibrosis (Review). The Cochrane Library. 2012;(7)
34 | P a g e
20. Gunnel D, Eddleston M. Suicide by intentional ingestion of pesticides: a continuing
tragedy in developing countries. International Journal of Epidemiology.
2003;32(6):902-909
21. Senarathna L, Eddleston M, Wilks MF, Woollen BH, Tomenson JA, Roberts DM,
Buckley NA. Prediction of outcome after paraquat poisoning by measurement of the
plasma paraquat concentration. British Medical Journal. 2009;102:251-259.
22. Eddleston M, Wilks M, Buckley N.Prospects for treatment of paraquat-induced lung
fibrosis with immunosuppressive drugs and the need for better prediction of outcome:
a systematic review. British Medical Journal. 2003 November; 96(11):809-824.
23. Santiago C.T. Paraquat. Toxipedia; 2010.[cited 12th June 2014]; Available from:
http://www.toxipedia.org/display/toxipedia/Paraquat
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2. ANNEX 2 – INFORMATION SHEET
Research Topic: Therapeutic Management of Paraquat Poisoning at Colonial War Memorial
Hospital
Description of the research and your participation
You are invited to participate in a research study conducted by Shayna Khan (Year 4
Pharmacy Student at the College of Medicine, Nursing and Health Sciences). The aim of this
research is to determine the therapeutic management of paraquat poisoning patients at
Colonial War Memorial Hospital.
The objectives of this research are to determine how paraquat poisoning is diagnosed and to
determine the treatment options available for paraquat poisoning patients at Colonial War
Memorial Hospital.
Your participation will involve answering a questionnaire which will contain 7 questions.
These questions will explore the frequency of paraquat poisoning cases observed by you,
the treatment options available and your personal opinions regarding issues such as ban of
paraquat in Fiji.
Risks
There are no known risks associated with this research
Potential Benefits
There are no direct benefits associated with this research for the participant. However,
through this research, you will be able to contribute your knowledge and expand the
existing body of research conducted on paraquat poisoning.
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Protection of Confidentiality
The participant details will be kept confidential. Your names will not be recorded and your
responses will be coded and analysed. Thus the responses cannot be traced to any one
individual. Your identity will not be revealed in any publication resulting from this study.
Voluntary Participation
Participation in this research is voluntary. If you wish to withdraw from participating in the
research, you can do so freely at any point in time.
You will not be penalized in any way should you decide not to participate or to withdraw
from this study.
Utilisation of Results
The information obtained from these questionnaires will be analysed first and disseminated
to the lecturers and students of the pharmacy department. It will also be available to the
Ministry of Health.
Contact Information
If you have any questions or queries regarding any aspect of the research, please do not
hesitate to contact me or my supervisor:
Researcher: Shayna Khan
Mobile: 9914580
Email: [email protected]
Supervisor: Mr Arnold Ram
Lecturer of Pharmacology
Mobile: 9273029
Email: [email protected]
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3. ANNEX 3 - CONSENT FORM
Therapeutic Management of Paraquat Poisoning Patients Reporting to Colonial War
Memorial Hospital
This document is to certify that I _____________________(name of participant) have read
the participant information and have been given the opportunity to ask questions. All of my
questions have been answered to my satisfaction. I understand that all data will remain
confidential with regard to my identity. I understand that my participation in this research
project is voluntary and that I am free to withdraw my consent and discontinue participation
at any time.
I freely give my consent to participate in this study.
_________________
Participant’s Signature
_______________
Date
I, the undersigned, have fully explained the research to the above subject.
Researchers Name: Shayna Khan
________________
Signature
________________
Date
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4. ANNEX 4 - DATA COLLECTION TOOLS
Questionnaire
Therapeutic Management of Paraquat Poisoning Patients at
Colonial War Memorial Hospital
Designation:
Doctor
Nurse
Pharmacist
Years of experience at the Colonial War Memorial Hospital _______________
1. On average, in a year how many paraquat poisoning cases do you observe?
None
1-10
11-20
21-30
31-40
41-50
>50
2. Based on your experience, how are paraquat poisoning patients diagnosed?
Based on clinical symptoms
Urine test
Based on information provided by relatives
plasma concentration test
other biochemical tests
3. The following are some drug treatment options for paraquat poisoning. Please place a tick
beside the options utilised at CWM Hospital for paraquat poisoning:
Fullers Earth
Activated Charcoal
Mannitol
Haemoperfusion/Haemodialysis
N-acetyl cysteine
Methyl-prednisolone
Cyclophosphamide
Vitamins C and E
4. What guidelines do you use to determine treatment options for paraquat poisoning patients?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
_______________________________________
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5. Do treatment options change according to the amount of paraquat ingested ?
No Please
Yes
explain.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________
6. In your experience, has treatment of paraquat poisoning ever been hindered due to drug
shortages?
Yes
No
If yes, then which drugs are commonly short of supply?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
_______________________________________
7. “Paraquat use as an herbicide should be banned in Fiji”. Do you support this statement?
Yes
No
Please state your reasons for agreeing or disagreeing with the statement.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________
 Thank You for Your Participation 
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5. ANNEX 5 – APPROVAL LETTERS.
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