The global distribution of fatal pesticide self-poisoning: systematic review

David Gunnell, Michael Eddleston, Michael R Phillips, Flemming Konradsen, David Gunnell, Michael Eddleston, Michael R Phillips, Flemming Konradsen

Abstract

Background: Evidence is accumulating that pesticide self-poisoning is one of the most commonly used methods of suicide worldwide, but the magnitude of the problem and the global distribution of these deaths is unknown.

Methods: We have systematically reviewed the worldwide literature to estimate the number of pesticide suicides in each of the World Health Organisation's six regions and the global burden of fatal self-poisoning with pesticides. We used the following data sources: Medline, EMBASE and psycINFO (1990-2007), papers cited in publications retrieved, the worldwide web (using Google) and our personal collections of papers and books. Our aim was to identify papers enabling us to estimate the proportion of a country's suicides due to pesticide self-poisoning.

Results: We conservatively estimate that there are 258,234 (plausible range 233,997 to 325,907) deaths from pesticide self-poisoning worldwide each year, accounting for 30% (range 27% to 37%) of suicides globally. Official data from India probably underestimate the incidence of suicides; applying evidence-based corrections to India's official data, our estimate for world suicides using pesticides increases to 371,594 (range 347,357 to 439,267). The proportion of all suicides using pesticides varies from 4% in the European Region to over 50% in the Western Pacific Region but this proportion is not concordant with the volume of pesticides sold in each region; it is the pattern of pesticide use and the toxicity of the products, not the quantity used, that influences the likelihood they will be used in acts of fatal self-harm.

Conclusion: Pesticide self-poisoning accounts for about one-third of the world's suicides. Epidemiological and toxicological data suggest that many of these deaths might be prevented if (a) the use of pesticides most toxic to humans was restricted, (b) pesticides could be safely stored in rural communities, and (c) the accessibility and quality of care for poisoning could be improved.

Figures

Figure 1
Figure 1
Flow diagram for data extraction.
Figure 2
Figure 2
Pesticide suicides in Africa and the Middle East.
Figure 3
Figure 3
Pesticide suicides in Central and South America.
Figure 4
Figure 4
Pesticide suicides in Europe.
Figure 5
Figure 5
Pesticide suicides in South East Asia and Western Pacific regions.

References

    1. World Health Report 2004. WHO, Geneva; 2004.
    1. Taylor SJ, Kingdom D, Jenkins R. How are nations trying to prevent suicide? An analysis of national suicide prevention strategies. Acta Psychiatr Scand. 1997;95:457–463. doi: 10.1111/j.1600-0447.1997.tb10132.x.
    1. Hawton K. Restriction of access to methods of suicide as a means of suicide prevention. In: Hawton K, editor. Prevention and treatment of suicidal behaviour from Science to practice. Oxford: Oxford University Press; 2005. pp. 279–291.
    1. Conner KR, Phillips MR, Meldrum S, Knox KL, Zhang Y, Yang G. Low-planned suicides in China. Psychol Med. 2005;35:1197–1204. doi: 10.1017/S003329170500454X.
    1. Jeyaratnam J. Health problems of pesticide usage in the Third World. Br J Ind Med. 1985;42:505–506.
    1. Gunnell D, Eddleston M. Suicide by intentional ingestion of pesticides: a continuing tragedy in developing countries. Int J Epidemiol. 2003;32:902–909. doi: 10.1093/ije/dyg307.
    1. 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;42:113–116.
    1. Bertolote JM, Fleischmann A, Butchart A, Besbelli N. Suicide, suicide attempts and pesticides: a major hidden public health problem. Bull World Health Organ. 2006;84:260. doi: 10.2471/BLT.06.030668.
    1. Gunnell D, Ho D, Murray V. Medical management of deliberate drug overdose – a neglected area for suicide prevention? Emergency Medical Journal. 2004;21:35–38. doi: 10.1136/emj.2003.000935.
    1. Eddleston M, Sudarshan K, Senthilkumaran M, Reginald K, Karalliedde L, Senarathna L, de Silva D, Rezvi Sheriff MH, Buckley NA, Gunnell D. Patterns of hospital transfer for self-poisoned patients in rural Sri Lanka? Implications for estimating the incidence of self-poisoning acts in the developing world. Bull World Health Organ. 2006;84:276–282. doi: 10.2471/BLT.05.025379.
    1. Fitzgerald GR, Barniville G, Flanagan M, Silke B, Carmody M, O'Dwyer WF. The changing pattern of paraquat poisoning: an epidemiologic study. Ir Med J. 1978;71:103–108.
    1. Chugh SN, Dushyant , Ram S, Arora B, Malhotra KC. Incidence & outcome of aluminium phosphide poisoning in a hospital study. Indian J Med Res. 1991;94:232–235.
    1. Kinyanda E, Hjelmeland H, Musisi S. Deliberate self-harm as seen in Kampala, Uganda – a case-control study. Soc Psychiatry Psychiatr Epidemiol. 2004;39:318–325. doi: 10.1007/s00127-004-0748-2.
    1. arap Mengech HN, Dhadphale M. Attempted suicide (parasuicide) in Nairobi, Kenya. Acta Psychiatr Scand. 1984;69:416–419. doi: 10.1111/j.1600-0447.1984.tb02513.x.
    1. Eferakeya AE. Drugs and suicide attempts in Benin City, Nigeria. Br J Psychiatry. 1984;145:70–73.
    1. Odejide AO, Williams AO, Ohaeri JU, Ikuesan BA. The epidemiology of deliberate self-harm. The Ibadan experience. Br J Psychiatry. 1986;149:734–737.
    1. Obembe A, Ilechukwu STC, Tunwashe OL, Odukoya O. Self poisoning as seen in Lagos University Teaching Hospital: A Four Year Review. The Nigerian Medical Practitioner. 1986;11:49–53.
    1. Nhachi CF, Kasilo OM. The pattern of poisoning in urban Zimbabwe. J Appl Toxicol. 1992;12:435–438. doi: 10.1002/jat.2550120612.
    1. Tagwireyi D, Ball DE, Nhachi CF. Poisoning in Zimbabwe: a survey of eight major referral hospitals. J Appl Toxicol. 2002;22:99–105. doi: 10.1002/jat.832.
    1. Bahta Y, Fikreyesus Y. Analysis of admissions to the medical intensive care unit of a teaching hospital in Addis Ababa. Ethiop Med J. 1988;26:61–67.
    1. Abebe M. Organophosphate pesticide poisoning in 50 Ethiopian patients. Ethiop Med J. 1991;29:109–118.
    1. Nwosu SO, Odesanmi WO. Pattern of suicides in Ile-Ife, Nigeria. West Afr J Med. 2001;20:259–262.
    1. Scribante L, Blumenthal R, Saayman G, Roos JL. A retrospective review of 1018 suicide cases from the capital city of South Africa for the period 1997–2000. Am J Forensic Med Pathol. 2004;25:52–55. doi: 10.1097/01.paf.0000113862.03302.1d.
    1. Ndosi NK, Mbonde MP, Lyamuya E. Profile of suicide in Dar es Salaam. East Afr Med J. 2004;81:207–211.
    1. Dzamalala CP, Milner DA, Liomba NG. Suicide in Blantyre, Malawi (2000–2003) J Clin Forensic Med. 2006;13:65–9. doi: 10.1016/j.jcfm.2005.08.006.
    1. Langley R, Sumner D. Pesticide mortality in the United States 1979–1998. Vet Hum Toxicol. 2002;44:101–105.
    1. Pan American Epidemiological Association Epidemiological Situation of Acute Pesticide Poisoning in the Central American Isthmus, 1992 – 2000. Epidemiol Bull. 2002;23:1–8.
    1. Puentes-Rosas E, Lopez-Nieto L, Martinez-Monroy T. [Mortality from suicides: Mexico, 1990–2001] Rev Panam Salud Publica. 2004;16:102–109. doi: 10.1590/S1020-49892004000800005.
    1. Tinoco R, Tinoco R, Parsonnet J, Halperin D. Paraquat poisoning in southern Mexico: a report of 25 cases. Arch Environ Health. 1993;48:78–80.
    1. Mahy G. Completed suicide in Barbados. West Indian Med J. 1987;36:91–94.
    1. Hutchinson G, Daisley H, Simeon D, Simmonds V, Shetty M, Lynn D. High rates of paraquat-induced suicide in southern Trinidad. Suicide Life Threat Behav. 1999;29:186–191.
    1. Escoffery CT, Shirley SE. Fatal poisoning in Jamaica: a coroner's autopsy study from the University Hospital of the West Indies. Med Sci Law. 2004;44:116–120.
    1. Accessed 5/1/2007.
    1. Werneck GL, Hasselmann MH, Phebo LB, Vieira DE, Gomes VL. [Suicide attempts recorded at a general hospital in Rio de Janeiro, Brazil.] Cad Saude Publica. 2006;22:2201–2206.
    1. Cole DC, Carpio F, Leon N. Economic burden of illness from pesticide poisonings in highland Ecuador. Rev Panam Salud Publica. 2000;8:196–201. doi: 10.1590/S1020-49892000000800007.
    1. Graafsma T, Kerkhof A, Gibson D, Badloe R, van de Beek LM. High rates of suicide and attempted suicide using pesticides in Nickerie, Suriname, South America. Crisis. 2006;27:77–81.
    1. Jors E, Morant RC, Aguilar GC, Huici O, Lander F, Baelum J, Konradsen F. Occupational pesticide intoxications among farmers in Bolivia: a cross-sectional study. Environ Health. 2006;5:10. doi: 10.1186/1476-069X-5-10.
    1. Abdullat EM, Hadidi MS, Alhadidi N, Al-Nsour TS, Hadidi KA. Agricultural and horticultural pesticides fatal poisoning; the Jordanian experience 1999–2002. J Clin Forensic Med. 2006;13:304–307. doi: 10.1016/j.jcfm.2006.06.011.
    1. Moghadamnia AA, Abdollahi M. An epidemiological study of poisoning in Northern Islamic Republic of Iran. Eastern Mediterranean Health Journal. 2002;8:550–5.
    1. Abdollahi M, Jalali N, Sabzevari O, Hoseini R, Ghanea T. A retrospective study of poisoning in Tehran. Clinical Toxicology. 1997;35:387–393.
    1. Khan MM, Reza H. The pattern of suicide in Pakistan. Crisis. 2000;21:31–35.
    1. Khan MM, Reza H. Gender differences in nonfatal suicidal behavior in Pakistan: significance of sociocultural factors. Suicide Life Threat Behav. 1998;28:62–68.
    1. Saeed A, Bashir MZ, Khan D, Iqbal J, Raja KS, Rehman A. Epidemiology of suicide in Faisalabad. Journal of Ayub Medical College Abbottabad. 2002;14:34–37.
    1. Okasha A, Lotaif F. Attempted suicide. An Egyptian investigation. Acta Psychiatr Scand. 1979;60:69–75. doi: 10.1111/j.1600-0447.1979.tb00266.x.
    1. Michel K, Ballinari P, Bille-Brahe U, Bjerke T, Crepet P, De Leo D, Haring C, Hawton K, Kerkhof A, Lonnqvist J, Querejeta I, Salander-Renberg E, Schmidtke A, Temesvary B, Wasserman D. Methods used for parasuicide: results of the WHO/EURO Multicentre Study on Parasuicide. Soc Psychiatry Psychiatr Epidemiol. 2000;35:156–163. doi: 10.1007/s001270050198.
    1. Thompson JP, Casey PB, Vale JA. Deaths from pesticide poisoning in England and Wales 1990–1991. Hum Exp Toxicol. 1995;14:437–445.
    1. Daeid NN. Suicide amongst the agricultural sector in Ireland; 1982–1994. Journal of the Irish Colleges of Physicians and Surgeons. 1997;26:180–182.
    1. Persson H, Palmborg M, Irestedt B, Westberg U. Pesticide poisoning in Sweden – actual situation and changes over a 10-year period. Przeglad Lekarski. 1997;54:657–661.
    1. Tziafeta SG, Karampelas NA, Papadimitriou E, Ske-parni F. Toxicological aspects of sudden and violent deaths in Southwestern Greece: A three-year review (2001–2003) Review of Clinical Pharmacology and Pharmacokinetics, International Edition. 2004;18:184–185.
    1. Vougiouklakis T, Boumba VA, Mitselou A, Peschos D, Gerontopoulos K. Trends in suicide mortality in the deprived region of Epirus (north-west Greece) during the period 1998–2002. Med Sci Law. 2005;45:39–46.
    1. Parron T, Hernandez AF, Villanueva E. Increased risk of suicide with exposure to pesticides in an intensive agricultural area. A 12-year retrospective study. Forensic Sci Int. 1996;79:53–63. doi: 10.1016/0379-0738(96)01895-6.
    1. Azmak AD. Suicides in Trakya region, Turkey, from 1984 to 2004. Med Sci Law. 2006;46:19–30.
    1. Przybylska A. [Poisoning caused by chemicals for plant protection in Poland in 2001] Przegl Epidemiol. 2003;57:107–116.
    1. Przybylska A. [Poisoning caused by chemicals for plant protection in Poland in 2002] Przegl Epidemiol. 2004;58:111–121.
    1. Fabritius K, Balasescu M. Acute non-occupational intoxications with pesticides in Romania: a comparative study from 1988 to 1993. Toxicol Lett. 1996;88:211–214. doi: 10.1016/0378-4274(96)03739-3.
    1. Iliev Y, Akabaliev V, Doychinov I. Characteristics of adult acute poisoning mortality in a large industrial-agrarian region of Bulgaria during socioeconomic transition and crisis (1990–1998) Vet Hum Toxicol. 2000;42:366–369.
    1. Berecz R, Caceres M, Szlivka A, Dorado P, Bartok E, Penas-LLedo E, Llerena A, Degrell I. Reduced completed suicide rate in Hungary from 1990 to 2001: relation to suicide methods. J Affect Disord. 2005;88:235–238. doi: 10.1016/j.jad.2005.07.005.
    1. Accidental Deaths and Suicides in India 2005. New Delhi: National Crime Records Bureau Ministry of Affairs; 2006.
    1. WHO . Mental Health and Substance Abuse Facts and Figures Suicide Prevention: Emerging from Darkness. South East Asia: WHO; 2007.
    1. Khan N. Poisoning in a medical unit of Dhaka Medical College Hospital in 1983. Bangladesh Medical Journal. 1985;14:9–12.
    1. Heijnen H. WHO Bangladesh: International Programme OnChemical Safety. 2001.
    1. Mode of Suicides – 2005. 2005.
    1. Lotrakul M. Suicide in Thailand during the period 1998–2003. Psychiatry Clin Neurosci. 2006;60:90–95. doi: 10.1111/j.1440-1819.2006.01465.x.
    1. Joseph A, Abraham S, Muliyil JP, George K, Prasad J, Minz S, Abraham VJ, Jacob KS. Evaluation of suicide rates in rural India using verbal autopsies, 1994–9. BMJ. 2003;326:1121–1122. doi: 10.1136/bmj.326.7399.1121.
    1. Prasad J, Abraham VJ, Minz S, Abraham S, Joseph A, Muliyil JP, George K, Jacob KS. Rates and factors associated with suicide in Kaniyambadi Block, Tamil Nadu, South India, 2000–2002. Int J Soc Psychiatry. 2006;52:65–71. doi: 10.1177/0020764006061253.
    1. Bose A, Konradsen F, John J, Suganthy P, Muliyil J, Abraham S. Mortality rate and years of life lost from unintentional injury and suicide in South India. Trop Med Int Health. 2006;11:1553–1556. doi: 10.1111/j.1365-3156.2006.01707.x.
    1. Gajalakshmi V, Peto R. Suicide rates in rural Tamil Nadu, South India: Verbal autopsy of 39 000 deaths in 1997–98. Int J Epidemiol. 2007.
    1. Ojima T, Nakamura Y, Detels R. Comparative study about methods of suicide between Japan and the United States. J Epidemiol. 2004;14:187–192. doi: 10.2188/jea.14.187.
    1. Phillips MR, Yang GH. Suicide and attempted suicide in China, 1990–2002. MMWR. 2004;53:481–484.
    1. Phillips MR, Yang G, Zhang Y, Wang L, Ji H, Zhou M. Risk factors for suicide in China: a national case-control psychological autopsy study. Lancet. 2002;360:1728–1736. doi: 10.1016/S0140-6736(02)11681-3.
    1. Maniam T. Suicide and parasuicide ina hill resort in Malaysia. Br J Psychiatry. 1988;153:222–225.
    1. Rajasuriar R, Awang R, Hashim SB, Rahmat HR. Profile of poisoning admissions in Malaysia. Hum Exp Toxicol. 2007;26:73–81. doi: 10.1177/0960327107071857.
    1. Shin SD, Suh GJ, Rhee JE, Sung J, Kim J. Epidemiologic characteristics of death by poisoning in 1991–2001 in Korea. J Korean Med Sci. 2004;19:186–194.
    1. Phillips MR, Li X, Zhang Y. Suicide rates in China, 1995–99. Lancet. 2002;359:835–840. doi: 10.1016/S0140-6736(02)07954-0.
    1. Eddleston M, Sheriff MH, Hawton K. Deliberate self harm in Sri Lanka: an overlooked tragedy in the developing world. BMJ. 1998;317:133–135.
    1. Eddleston M, Eyer P, Worek F, Mohamed F, Senarathna L, von Meyer L, Juszczak E, Hittarage A, Azhar S, Dissanayake W, Sheriff MH, Szinicz L, Dawson AH, Buckley NA. Differences between organophosphorus insecticides in human self-poisoning: a prospective cohort study. Lancet. 2005;366:1452–1459. doi: 10.1016/S0140-6736(05)67598-8.
    1. Eddleston M. Patterns and problems of deliberate self-poisoning in the developing world. QJM. 2000;93:715–731. doi: 10.1093/qjmed/93.11.715.
    1. Srinivas RC, Venkateswarlu V, Surender T, Eddleston M, Buckley NA. Pesticide poisoning in south India: opportunities for prevention and improved medical management. Trop Med Int Health. 2005;10:581–588. doi: 10.1111/j.1365-3156.2005.01412.x.
    1. Eddleston M, Mohamed F, Davies JO, Eyer P, Worek F, Sheriff MH, Buckley NA. Respiratory failure in acute organophosphorus pesticide self-poisoning. QJM. 2006;99:513–522. doi: 10.1093/qjmed/hcl065.
    1. Kamat SR, Heera S, Potdar PV, Shah SV, Bhambure NM, Mahashur AA. Bombay experience in intensive respiratory care over 6 years. J Postgrad Med. 1989;35:123–134.
    1. CropLife International Annual Report 2005/6. Belgium: Croplife International; 2006.
    1. Nesime Y, Lokman B, Akif IM, Gurol C, Basar C, Mustafa K. Acute pesticide poisoning related deaths in Turkey. Vet Hum Toxicol. 2004;46:342–344.
    1. Ganapathi MN, Rao AV. A study of suicide in Madurai. J Indian Med Assoc. 1966;46:18–23.
    1. World Health Organization and IASP International Association for Suicide Prevention . Safer Access to Pesticides: Community Interventions. Geneva: Management of Mental and Brain Disorders, Department of Mental Health and Substance Abuse World Health Organization; 2006.
    1. Konradsen F, Dawson AH, Eddleston M, Gunnell D. Pesticide self-poisoning: thinking outside the box. Lancet. 2007;369:169–170. doi: 10.1016/S0140-6736(07)60085-3.
    1. Konradsen F, van der Hoek W, Cole DC, Hutchinson G, Daisley H, Singh S, Eddleston M. Reducing acute poisoning in developing countries – options for restricting the availability of pesticides. Toxicology. 2003;192:249–261. doi: 10.1016/S0300-483X(03)00339-1.
    1. Eddleston M, Buckley NA, Gunnell D, Dawson AH, Konradsen F. Identification of strategies to prevent death after pesticide self-poisoning using a Haddon matrix. Inj Prev. 2006;12:333–337. doi: 10.1136/ip.2006.012641.
    1. Yang GH, Phillips MR, Zhou MG, Wang LJ, Zhang YP, Xu D. Understanding the unique characteristics of suicide in China: national psychological autopsy study. Biomed Environ Sci. 2005;18:379–389.
    1. Nandi DN, Mukherjee SP, Banerjee G, Ghosh A, Boral GC, Chowdury A, Bose J. Is suicide preventable by restricting the availability of lethal agents ? A rural survey of West Bengal. Indian Journal of Psychiatry. 1979;21:251–255.
    1. Banerjee G, Nandi DN, Nandi S, Sarkar S, Boral GC, Ghosh A. The vulnerability of Indian women to suicide a field-study. Indian Journal of Psychiatry. 1990;32:305–308.
    1. Shukla GD, Verma BL, Mishra DN. Suicide in Jhansi City. Indian Journal of Psychiatry. 1990;32:44–51.
    1. Bhatia MS, Aggarwal NK, Aggarwal BB. Psychosocial profile of suicide ideators, attempters and completers in India. Int J Soc Psychiatry. 2000;46:155–163. doi: 10.1177/002076400004600301.
    1. Aaron R, Joseph A, Abraham S, Muliyil J, George K, Prasad J, Minz S. Suicides in young people in rural southern India. Lancet. 2004;363:1117–8. doi: 10.1016/S0140-6736(04)15896-0.
    1. Lalwani S, Sharma GS, Kabra SK, Girdhar S, Dogra TD. Suicide among children and adolescents in South Delhi (1991–2000) Indian J Pediatr. 2004;71:701–703. doi: 10.1007/BF02730657.
    1. Gururaj G, Isaac MK, Subbakrishna DK, Ranjani R. Risk factors for completed suicides: a case-control study from Bangalore, India. Inj Control Saf Promot. 2004;11:183–191. doi: 10.1080/156609704/233/289706.
    1. Kumar TS, Kanchan T, Yoganarasimha K, Kumar GP. Profile of unnatural deaths in Manipal, Southern India 1994–2004. J Clin Forensic Med. 2006;13:117–120. doi: 10.1016/j.jcfm.2005.10.005.
    1. Mohanty S, Sahu G, Mohanty MK, Patnaik M. Suicide in India – A four year retrospective study. J Clin Forensic Med. 2006.
    1. Sharma BR, Gupta M, Sharma AK, Sharma S, Gupta N, Relhan N, et al. Suicides in Northern India: Comparison of trends and review of literature. J Clin Forensic Med. 2006
    1. Kumar P, Sharma SL. Suicides in rural Punjab. Punjab: Institute for Development and Communication (IDC); 2006.
    1. Tan CT. Suicidal poisoning deaths in Singapore 1975–1984. Ann Acad Med Singapore. 1987;16:300–302.
    1. Thanh HT, Jiang GX, Van TN, Minh DP, Rosling H, Wasserman D. Attempted suicide in Hanoi, Vietnam. Soc Psychiatry Psychiatr Epidemiol. 2005;40:64–71. doi: 10.1007/s00127-005-0849-6.
    1. Yang CC, Wu JF, Ong HC, Hung SC, Kuo YP, Sa CH, Chen SS, Deng JF. Taiwan National Poison Center: epidemiologic data 1985–1993. J Toxicol Clin Toxicol. 1996;34:651–663.
    1. Chan TY, Critchley JA. Hospital admissions due to acute poisoning in the New Territories, Hong Kong. Southeast Asian J Trop Med Public Health. 1994;25:579–582.
    1. Somasundaram DJ, Rajadurai S. War and suicide in northern Sri Lanka. Acta Psychiatr Scand. 1995;91:1–4. doi: 10.1111/j.1600-0447.1995.tb09733.x.
    1. Abeyasinghe R. Psychiatric aspects of pesticide poisoning. In: Smit LAM, editor. Pesticides: Health Impacts and Alternatives Proceedings of a workshop held in Colombo 24 January 2002. Working Paper 45, 12–15. Sri Lanka, International Water Management Institute; 2002.
    1. Chakrabarti K, Devkota KC. Retrospective study of suicide cases admitted in Nepal Medical College Teaching Hospital. Nepal Med Coll J. 2004;6:116–118.
    1. Booth H. Pacific Island suicide in comparative perspective. J Biosoc Sci. 1999;31:433–448. doi: 10.1017/S0021932099004332.
    1. accessed 17/08/2007.

Source: PubMed

Patrocinadores e Colaboradores

Condições médicas

Intervenções de drogas

3
Se inscrever