1. Situation of Common Poisoning in Bangladesh Dr Md Robed Amin Associate Professor of Medicine Dhaka Medical College 05.12.2014

2. Poisoning >600,000 deaths/year in developing world, (Eddleston, Q J Med 2000) DMC- 2 nd cause of admission(After stroke), More than 5000 case per annum since 2008. 2 nd common cause of hospitalization and 9 th common cause of death(DGHS-Health bulletin-2011)

3. Prevalence of top 10 diseases/causes of admission In UHC (DGHS health Bulletin 2014 p49-55) Male (n 762264) Female (n 894425) SerialDiseaseTotal%DiseaseTotal% 1 3 3 4 5 6 7 8 SerialDiseaseNumber%DiseaseNumber% 1Diarrhoea14474218,99Diarrhoea14215715.89 2Assault12589516.52Assault9919611.09 3Peptic ulcer523926.87Peptic ulcer618626.92 4Pneumonia521056.84Pneumonia345673.86 5Enteric267533.51Enteric261082.92 6RTA264553.47Obstructive labour 228972.56 7Bronchial Asthma 234463.08Bronchial Asthma 214992.40 8Viral19 1882.52Anaemia208482.33 9Poisoning186972.45Poisoning196402.20 10HTN103741.36Viral fever184412.11

4. Top 10 diseases/causes of admission in upazila health complexes in 2012 and 2013 (DGHS health Bulletin 2014 p49-55) 2013 2012 Percentage trends DiseaseRanking% %Ranking change Diarrhoea116.32117.74 Assault213.59213.51 Peptic ulcer36.9036,43 Pneumonia45.2346.41 Enteric53.1953.48 Bronchial Asthma 62.7162.51 RTA72.3972.40 Poisoning82.3192.23+1 Viral92.3182.24 Anemia101.79101.56

5. Prevalence of top diseases/causes of admission In District Hospital Male Female SerialDiseaseTotal%DiseaseTotal% 1 3 3 4 5 6 7 8 SerialDiseaseNumber%DiseaseNumber% 1Diarrhoea5895213.53Diarrhoea5319811.79 2Assault392269.00Assault238995.30 3RTA240845.53Peptic ulcer159943.54 4Pneumonia208194.78Pneumonia140743.12 5Peptic ulcer1418823.26Obstructive labour 115712.56 6Bronchial asthma 123502.83Bronchial Asthma 111402.47 7viral115592.65HTN106872.37 8Poisoning90592.08RTA103972.30 9HTN84511.94Viral99232.20 10CVD81861.88Anxiety/de pression 94412.09 11MI80211.84Poisoning93382.07

6. Prevalence of top diseases/causes of admission In Primary, secondary and tertiary care Male Female SerialDiseaseTotal%DiseaseTotal% 1 3 3 4 5 6 7 8 SerialDiseaseNumber%DiseaseNumber% 1Diarrhoea21159114.47Diarrhoea20182712.94 2Assault18349812.55Assault1319878.46 3Pneumonia792615.42Peptic ulcer811575.20 4RTA707254.84Pneumonia537753.45 5Peptic ulcer706424.83Obstructive labour 382902.45 6Bronchial asthma 409012.80Bronchial Asthma 368822.26 7Enteric fever370562.53Enteric fever 347752.23 8Viral fever326772.24Poisoning331052.12 9Poisoning310142.12RTA326822.10 10HTN233071.59Anemia326752.09

9. Mortality report of DGHS (ICD based) in 451 public hospital Name of disease Number Percentage Diseases of the circulatory system 1620633.20 Certain conditions originating in the perinatal period 777915.93 Diseases of the respiratory system 678713.90 Injury, poisoning, and certain other consequences of external causes 45219.26

10. Baseline Survey Baseline survey: 6 months from Sep 2006 - Feb 2007 in 4 hospitals and 7 health centres: (Prof MA Faiz) – 4553 cases (28% pesticide) – 14.5% of admissions – Mortality 4.1% (88% pesticide)

11. Place PesticideSedatives Kerosi ne Snake bite Cu-Sul phate Methan ol Potka fishOthers Total OP Car mate Others Benzod iazepin e Other sedativ e DMCH 27923276018977310251212982318 CMCH 299781119343830313005051390 Coxsbaz ar 9004417000013119 Hathaza ri UHC 26013511600074126 Jenaida4453681713114039537 Sitakun d UHC 290420712010863 Total 11683312373795413943472019374553

12. Gender of patients Name of poison/toxic substance PesticideSedativeSnake bite Kerose ne Cu Sul- phate Metha nol OPCarba mate OthersBenzo diazepi ne Other Male6661656391826315 6.9% 86416 15.6%26.5% Female5021767346128119 2.6% 5334 12.7%10.3% Total 1291 28.3% 1675 36.8% 434 9.5% 139 3.0% 720 0.4%

13. Survey in Dhaka Medical College Hospital (DMCH) 2008 5932 total cases of poisoning in DMCH 2108/5929 (35%) female; 3821/5929 (65%) male Median age was 25 years (IQR 19-35 years) Overall mortality was 151/5932 (2.6%)

14. DMC survey 95% sought initial - Government Hospital. Suicidal attempt -43.8% Family disharmony -37.7% stupifying agent (38.2%). Mortality: 105 OP death among 151 herbal medicine-25%, then OP poisoning- 16%., methanol poisoning-11% and copper sulfate poisoning (9%).

15. Major risk factor for mortality rural residence, hindu religion, illiterate, farmer, suicide attempt, deliberate self harm, GCS 100/<60 and abnormal pupils esp constricted or pinpoint.

16. Types of Poison - Deaths

17. Types of Poison - 1 AllSurvivorsDeathsMortality Unknown2061(36%)2050(37%)11 (7%)1% Benzodiazepine / other sedative 714(12%)710(13%)4 (3%)1% Organophosphate / Carbamate 672(12%)567(10%)105 (70%)16% Rat killer382(7%)379(7%)3(2%)1% Snake bite / puffer fish / insect bite / sting 370(6%)366(7%)4(3%)1% Other medication360(6%)360(6%)0(0%)0% "Street"331(6%)330(6%)1(1%)0% Household cleaning chemical183(3%)183(3%)0(0%)0% Kerosine167(3%)166(3%)1(1%)1% Other pesticide / insecticide164(3%)162(3%)2(1%)1%

18. Types of Poison - 2 AllSurvivorsDeathsMortality Other chemical / acid97(2%)90(2%)7(5%)7% Tricyclic/other antidepressant76(1%)76(1%)0(0%)0% Ethanol52(1%)48(1%)4(3%)8% Methanol38(1%)34(1%)4(3%)11% Paracetamol32(1%)32(1%)0(0%)0% Copper sulphate23(0%)21(0%)2(1%)9% Herbal medicine12(0%)9 3(2%)25% Datura plant12(0%)12(0%)0 0% Illicit drugs7(0%)7 0 0% Miscellaneous179(3%)179(3%)0(0%)0% Total574655951513%

19. Predicting Mortality Class of Predictor Substance OPCNon-OPC FactorORPFactorORP Clinical Low GCS (<11)22.7<0.0001Low systolic BP (<80)54.5<0.0001 Low GCS (<11)49.7<0.0001 (Area under ROC curve = 0.81)(Area under ROC curve = 0.87) Clinical and non- clinical Non-muslim4.10.003Economic loss44.03<0.0001 Constricted pupils2.80.045Failure to pass exam10.860.031 Low GCS (<11)1.4<0.0001Low GCS (<11)1.65<0.0001 Low systolic BP (<80)1.04<0.0001 (Area under ROC curve = 0.87) (Area under ROC curve = 0.97) Multivariate analysis

20. Pesticide Poisoning Pesticide poisoning- 39.1% (CI 37.6-40.6%) OPCs- 89.8% ( Malathion was the commonest pesticide used, followed by carbamates) rodenticides- 4.3% carbamates - 4.0% unknown compounds - 1.6% pyrethroids - 0.3% Mortality -72.6% (CI 68.0-76.8) 0.7 deaths per 100,000 population was due to pesticide poisoning Analysis of Recent Situation of Pesticide Poisoning in Bangladesh: Is There a Proper Estimate?..Gourob Dewan APJMT 3;2 http://apjmt.mums.ac.ir June 2014

21. Complication of Pesticides atropine toxicity (15.6%) intermediate syndrome (13.6%), acute cholinergic crisis (13.3%) respiratory failure (7.9%), arrhythmia (2.6%) and aspiration pneumonia/hypoxic encephalopathy (1.8%) mortality rate - 5.1% (CI 4.6-5.6) (all poisoning) 72.6% (CI 68.0-76.8) were due to pesticides OPC- 8.9% (CI 7.7-10.4) Carbamates-, 1.4% (CI 0.2-7.7) Rodenticide -3.0% (CI 0.8-10.4) Analysis of Recent Situation of Pesticide Poisoning in Bangladesh: Is There a Proper Estimate?..Gourob Dewan APJMT 3;2 http://apjmt.mums.ac.ir June 2014

23. Estimated doses of different Benzodiazepine were used by miscreants

24. Household poisoning 4.5 % of poisoning cases in Tertiary care hospital. Bleaches, cleaners-commonly consumes Morbidity issue?/stricture Predominantly young groups

25. Miss M, 20 years, admitted with the history of ingestion of Tab. Tryptin 10 mg (amytriptylin) 40 in number and repeat the attempt after recovery with 60 tab. She recovered with ICU support and intensive HCO3 therapy on both occasion. Amitriptiline poisoning

26. ECG

27. Substance Abuse (methamphetamine, YABA ) A-25-year-old Upazilla level officer working in an Upazilla bordering with Myanmar presented with acute confussional state in a private facility having no H/O fever, during workup developed generalized tonic clonic convulsion. Key findings; and investigations gave no clue to diagnosis. Subsequent information from attendants and confirmed by the patient: H/O of multiple substance abuse including amphetamine (‘Yaba’).

28. Unknown Herbal Poisoning

29. Herbal Poisoning Three young friends end up there experiments admitted through ER of a public MCH, following an attempt of gratification by using a cocktail of ?safe herbal concoction (photo of cocktail) having features of GI toxicity and cardiac abnormalities (ECG finding). One of them died, one could be resuscitated, the other left the hospital by their own.

30. ECG Showed Ventricular Tachycardia

31. Aluminium Phosphide Poisoning

32. Aluminum Phosphide Increasing trends in Comilla, Bogura. In DMC 4 yrs (2008-2011) 43 cases and 37 death. Mortality-50%-80% Fatal case series observed in 2008 in DMC ( 7 death within 3 months).

33. Aluminium Phosphide ‘Kari’ or ‘Gas’ Tab First known fatal case of AP poisoning case in Bangladesh: Cardiac, renal, hepatic involvement, hypernatremia, acidosis, haemolysis, thrombocytopenia; Died 8 days after ingestion of single pellete. DMCH (29/08/2004);

34. Methanol Poisoning A 35-year-old previously healthy business executive admitted in an ICU with coma, respiratory distress and features of anion gap acidosis having HO social drinking followed by death of a mate and serious disability in the case with permanent blindness. J MEDICINE 2010; 11 : 212-213 Non contrast axial CT scan of the Head showing bilateral symmetrical hypodense shadows in theregions of putamen.

35. Methanol Poisoning-fatal Case Series In DMC-2008- 8 cases within 4 months Unconsciousness, blindness and metabolic acidosis were characteristics features. None of the patient received antidote or specific supportive measures.

36. Large numbers of patients with neurotoxic poisoning admitted All with history of puffer fish consumption Caused by shipment of fish (41 kg) from Bay of Bengal Exported to Kuliarchar fish depot in Kishoreganj District From there distributed to all affected areas April 2008 Narsingdi & Kishoreganj Districts (1) Port of origin

37. Laboratory investigations (2) Patient samples, Natore District TTX (ng/ml) Sample No. (1–38) Tetrodotoxin concentration in the blood of patients ELISA Fatal outcome

39. Stomach wash room

41. Comment Recommendations of BANTROPTOX (2010 and 2013) is yet to be taken into consideration Is development of treatment guidelines and few training enough to tackle the huge burden of cases of poisoning. Frequent newspaper reports of seizure of ‘Yaba’, ‘Phensedyl’, ‘snake venom’, ‘travel related poisoning of commuters’ are interesting but requires multifaceted serious interventions.

42. Comment Alum phosphide,Methanol and Copper sulphate are raising Scientific diagnosis of poisoning is yet to be made available in public facilities. Available investigations during management and follow up are not considered in most of the cases of poisoning.

43. Acknowledgement Prof MA Faiz Dr. Gourab Dewan Dr. Ariful basher